寒战咬牙要分明，初热在表羌活从，肺胃有热四物剂，气血两虚参归灵。
[注]
寒战咬牙者，森森若寒，振振摇动，上下牙尖相磨而呜也，
初热时寒战咬牙者，因火毒留于经络之中，邪正相争，欲出不出所致也，
治宜清热透表以羌活汤主之，
如见点后痘色紫赤，大便秘小便涩，烦躁口渴者，此属实热，
是胃热则咬牙，肺热则寒战也，宜加味四物汤主之，
若灌浆时脓包清稀，大便溏小便长，身凉不渴者，此属气血两虚，
是气虚则寒战，血虚则咬牙，宜参归鹿茸汤主之。
(羌活汤)
龙胆草 薄荷 防风 当归 栀子 淡竹叶 羌活 甘草生 川芎 引用生姜水煎服
(方歌)
羌活汤除风热攻，龙胆薄荷共防风，当归栀子淡竹叶，羌活甘草及川芎。
(加味四物汤)
生地 连翘去心 川芎 当归 赤芍 石膏煨 麦门冬去心 川黄连姜炒 木通 水煎服。
(方歌)
加味四物治热盛，寒战咬牙二证并，生地连翘芎芍归，石膏麦连木通共。
(参归鹿茸汤) 方见灌浆证治。
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痘中杂证
倦怠多因气虚弱，或缘滞热困儿脾，虚而无热补中治，食滞伤脾保元医。
[注]
痘中倦怠，固属中气不足，服补中益气汤最为妥协，
然亦有神气本弱，或为食热所困，其现证虽与不足等，
但不可专以虚治，当于补剂中佐以清热之品，
如保元汤加味用之可也。
(补中益气汤) 方见痘顶塌陷。
(加味保元汤) 人参 黄耆生 甘草炙 栀子炒 黄芩酒炒
麦门冬去心 山查 神面炒 陈皮 麦芽炒 引用生姜大枣水煎服。
(方歌)
加味保元食热虚，参耆甘草补厥脾，栀芩麦冬清心热，查麴陈麦消滞宜。
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痘中杂证
寒战和咬牙的症状需要仔细辨别。如果在发热初期出现寒战和咬牙，是因为邪气在表，应使用羌活汤治疗；如果肺胃有热，则使用四物剂（此处指加味四物汤）治疗；如果是气血两虚，则使用参归鹿茸汤治疗。
[注释]
所谓寒战咬牙，是指身体寒冷颤抖，全身振摇晃动，上下牙齿相互摩擦发出声响。
在发热初期出现寒战和咬牙，是因为火毒滞留于经络之中，邪气与正气相争，想要排出体外却未能排出的缘故。
治疗应当采用清热透表的方法，以羌活汤为主方。
如果看到出痘后痘色紫红，大便秘结，小便涩滞，烦躁且口渴，这属于实热证。
这是胃热导致咬牙，肺热导致寒战，宜用加味四物汤治疗。
如果在化脓灌浆阶段，脓包清稀，大便溏薄，小便频多，身体凉爽且不口渴，这属于气血两虚证。
这是气虚导致寒战，血虚导致咬牙，宜用参归鹿茸汤治疗。
(羌活汤)
组成：龙胆草、薄荷、防风、当归、栀子、淡竹叶、羌活、生甘草、川芎。
用法：引用生姜水煎服。
(方歌)
羌活汤能祛除风热攻邪，龙胆草、薄荷与防风同用，当归、栀子、淡竹叶，加上羌活、甘草及川芎。
(加味四物汤)
组成：生地、去心的连翘、川芎、当归、赤芍、煅石膏、去心的麦门冬、姜炒川黄连、木通。
用法：水煎服。
(方歌)
加味四物汤治疗热盛引起的寒战和咬牙两种症状，由生地、连翘、川芎、芍药、当归，以及石膏、麦冬、黄连、木通共同组成。
(参归鹿茸汤) 方剂见“灌浆证治”章节。
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痘疹中的杂症
倦怠乏力多因气虚虚弱，或者是因为食积停滞和热邪困阻脾脏。如果是虚证而无热邪，应用补中益气法治疗；如果是食积损伤脾脏，则用保元汤治疗。
[注释]
痘疹中出现倦怠，确实属于中气不足，服用补中益气汤最为恰当。
然而也有患者神气原本虚弱，或者被食积和热邪所困，虽然表现出的症状与气虚相似，
但不能专门按虚证治疗，应当在补益剂中佐以清热药物，
例如使用加味保元汤即可。
(补中益气汤) 方剂见“痘顶塌陷”章节。
(加味保元汤)
组成：人参、生黄耆、炙甘草、炒栀子、酒炒黄芩、去心麦门冬、山楂、炒神曲、陈皮、炒麦芽。
用法：引用生姜、大枣水煎服。
(方歌)
加味保元汤针对食积、热邪和气虚，人参、黄耆、甘草补益脾胃，栀子、黄芩、麦冬清心热，山楂、神曲、陈皮、麦芽消除积滞适宜。
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痘疹中的杂症
The symptoms of chills (Han Zhan, shaking with cold) and teeth grinding (Ya Ya, grinding teeth) must be clearly distinguished. If these occur during the initial fever stage when the pathogen is in the exterior, Qiang Huo Tang (Notopterygium Decoction) should be used. If there is heat in the Lung and Stomach, Si Wu Ji (Four Substances Formula, referring here to Jia Wei Si Wu Tang) is indicated. If there is deficiency of both Qi and Blood, Shen Gui Lu Rong Tang (Ginseng, Angelica, and Deer Antler Decoction) should be administered.
[Annotation]
"Chills and teeth grinding" refers to a sensation of intense cold, trembling and shaking of the body, and the rubbing together of upper and lower teeth producing sound.
When chills and teeth grinding occur during the initial fever, it is caused by fire-toxin remaining within the meridians, where the pathogenic factor and healthy Qi contend, attempting to exit but failing to do so completely.
The treatment should employ clearing heat and venting the exterior, primarily using Qiang Huo Tang (Notopterygium Decoction).
If, after the eruption of pustules, the lesions are purple-red, accompanied by constipation, scanty or difficult urination, irritability, and thirst, this indicates an Excess-Heat syndrome.
This presents as teeth grinding due to Stomach Heat and chills due to Lung Heat; Jia Wei Si Wu Tang (Modified Four Substances Decoction) is appropriate.
If during the suppuration and filling stage, the pustules are clear and thin, the stool is loose, urination is frequent and long, the body feels cool, and there is no thirst, this indicates a deficiency of both Qi and Blood.
This presents as chills due to Qi deficiency and teeth grinding due to Blood deficiency; Shen Gui Lu Rong Tang (Ginseng, Angelica, and Deer Antler Decoction) is appropriate.
(Qiang Huo Tang / Notopterygium Decoction)
Ingredients: Long Dan Cao (Gentianae Radix), Bo He (Menthae Haplocalycis Herba), Fang Feng (Saposhnikoviae Radix), Dang Gui (Angelicae Sinensis Radix), Zhi Zi (Gardeniae Fructus), Dan Zhu Ye (Lophatheri Herba), Qiang Huo (Notopterygii Rhizoma et Radix), Sheng Gan Cao (Glycyrrhizae Radix et Rhizoma Preparatum), Chuan Xiong (Ligustici Chuanxiong Rhizoma).
Administration: Decoct with fresh ginger water.
(Verse)
Qiang Huo Tang expels wind-heat and attacks pathogens;
Long Dan, Bo He, and Fang Feng work together.
Dang Gui, Zhi Zi, and Dan Zhu Ye,
Combined with Qiang Huo, Gan Cao, and Chuan Xiong.
(Jia Wei Si Wu Tang / Modified Four Substances Decoction)
Ingredients: Sheng Di Huang (Rehmanniae Radix Preparata), Lian Qiao (Forsythiae Fructus, heart removed), Chuan Xiong (Ligustici Chuanxiong Rhizoma), Dang Gui (Angelicae Sinensis Radix), Chi Shao (Paeoniae Radix Rubra), Gao Yao (Gypsum Fibrosum, roasted), Mai Men Dong (Ophiopogonis Radix, heart removed), Chuan Huang Lian (Coptidis Rhizoma, stir-fried with ginger juice), Mu Tong (Akebiae Caulis).
Administration: Decoct with water.
(Verse)
Jia Wei Si Wu treats excessive heat, addressing both chills and teeth grinding;
Sheng Di, Lian Qiao, Chuan Xiong, Shao, and Dang Gui,
Together with Shi Gao, Mai Dong, Huang Lian, and Mu Tong.
(Shen Gui Lu Rong Tang / Ginseng, Angelica, and Deer Antler Decoction)
See "Treatment of Suppuration Stage" for the formula.
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Miscellaneous Syndromes in Smallpox
Fatigue and lassitude (Juan Dai) often result from Qi deficiency and weakness, or may be caused by food stagnation and heat trapping the Spleen. If it is a deficiency pattern without heat, treat with tonifying methods such as Bu Zhong Yi Qi Tang; if it is spleen injury due to food stagnation, use Bao Yuan Tang.
[Annotation]
Fatigue in smallpox indeed belongs to insufficiency of Middle Qi; taking Bu Zhong Yi Qi Tang (Tonify the Middle and Augment the Qi Decoction) is most appropriate.
However, some patients have inherently weak Shen Qi (Spirit and Qi), or are trapped by food stagnation and heat. Although their presenting symptoms resemble deficiency,
one cannot treat exclusively for deficiency. One should add heat-clearing herbs to tonifying formulas.
For example, Jia Wei Bao Yuan Tang (Modified Bao Yuan Decoction) can be used.
(Bu Zhong Yi Qi Tang / Tonify the Middle and Augment the Qi Decoction)
See "Treatment of Collapsed Pustule Tops" for the formula.
(Jia Wei Bao Yuan Tang / Modified Bao Yuan Decoction)
Ingredients: Ren Shen (Ginseng Radix et Rhizoma), Sheng Huang Qi (Astragali Radix), Zhi Gan Cao (Glycyrrhizae Radix et Rhizoma Preparatum), Chao Zhi Zi (Gardeniae Fructus, stir-fried), Jiu Chao Huang Qin (Scutellariae Radix, wine-stir-fried), Qu Xin Mai Men Dong (Ophiopogonis Radix, heart removed), Shan Zha (Crataegi Fructus), Chao Shen Qu (Massa Medicata Fermentata, stir-fried), Chen Pi (Citri Reticulatae Pericarpium), Chao Mai Ya (Hordei Fructus Germinatus, stir-fried).
Administration: Decoct with fresh ginger and Chinese date (Da Zao).
(Verse)
Jia Wei Bao Yuan addresses food stagnation, heat, and deficiency;
Ren Shen, Huang Qi, and Gan Cao tonify the Spleen and Stomach.
Zhi Zi, Huang Qin, and Mai Dong clear Heart heat;
Shan Zha, Shen Qu, Chen Pi, and Mai Ya are suitable for eliminating stagnation.
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Miscellaneous Syndromes in Smallpox