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In cases of smallpox presenting with chills and teeth grinding (teeth clenching), some argue that it is due to excessive heart fire causing tremors, where the extreme heat counteracts itself by generating water-like properties, indicating a pathological heat condition. Others contend: these all belong to cold syndromes, similar to the climate of severe winter, where latent yang within the body cannot withstand the cold, leading to trembling limbs and automatic clenching of teeth; thus, Chen used Yigong San (Isolated Efficacy Powder) with success—if this were not cold, what would it be? Alas! Partially attributing it to either cold or heat fails to grasp the essence of the disease. This syndrome has a sequence of onset, and medication requires distinction between urgency and moderation.

For chills occurring before the seventh day after eruption, it is due to extreme hyperactivity of heart fire, and should be treated as exterior heat. For teeth grinding occurring before the seventh day, it is due to Yangming stomach heat, as the Yangming meridian traverses the upper and lower gums, and should be cleared. If chills occur after the seventh day, it is due to yin condensing upon yang; when the yang aspect is deficient, yin enters the qi pathway causing chills, suitable for treating qi deficiency with large doses of Renshen (Ginseng Radix et Rhizoma), added with Shengjiang (Zingiberis Rhizoma Recens, Fresh Ginger) and Rougui (Cinnamomi Cortex, Cinnamon Bark) to warm the yang aspect. If teeth grinding occurs after the seventh day, it is due to yang sinking into yin; when the yin aspect is deficient, yang enters the blood pathway causing teeth grinding, primarily due to blood deficiency, requiring tonification with large doses of Renshen (Ginseng Radix et Rhizoma, Ginseng Root and Rhizome), added with Xiong (Chuanxiong Rhizoma, Szechwan Lovage Rhizome), Danggui (Angelicae Sinensis Radix, Dong Quai Root), and Heijiang (Zingiberis Rhizoma Preparatum, Prepared Ginger) to solidify yin deficiency.

Symptoms appearing before the seventh day belong to heat and are ominous; symptoms appearing after the seventh day belong to deficiency but may still be treatable. If only chills are present, one should supplement qi while simultaneously nourishing blood. If only teeth grinding is present, one should nourish blood while simultaneously assisting qi. However, yang deficiency and cold naturally cause chills; wind and fire battling each other also cause chills. Yangming stomach heat naturally causes teeth grinding; liver and kidney deficiency-cold also cause teeth grinding. Therefore, it is better to observe the redness or pallor of the rash, the patency or constipation of urination and defecation, the preference for hot or cold drinks, the slowness or rapidity of the pulse, and the ease or difficulty of eruption, so that the nature of cold and heat becomes clear.

Generally speaking, eruptions at the initial stage are mostly due to fire in the heart, liver, and stomach. Because heat toxins cannot fully emerge, they struggle internally with healthy qi, causing the sinews and vessels to tremble; this is an excess-heat syndrome. If eruptions occur at the later stage, it is mostly due to deficiency of both the liver and kidneys. Although there may appear to be heat symptoms, these are false heat. For instance, teeth grinding, red face, thirst, worsening at night indicates yin deficiency; one should freely drink the decoction of Dihuang Wan (Rehmannia Pill). Thus it is said: "Teeth grinding indicates withered teeth." As for cases where the sores are scorched black, consciousness is lost, eyes are closed without spirit, delirium and mania prevail, seeking clothes and picking seams, and the incisors tremble incessantly—these are all signs that qi and blood are nearly exhausted, and toxic pathogens have attacked inward.