寒战切牙要分明，初热在表羌活从，肺胃有热四物剂，气血两虚参归灵。
【注】寒战切牙者，森森若寒，振振摇动，上下牙尖相磨而鸣也。初热时寒战切牙者，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，是胃热则切牙，肺热则寒战
也，宜加味四物汤主之。若灌浆时脓色清稀，大便溏，小便长，身凉不渴者，此属气血两
虚，是气虚则寒战，血虚则切牙，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（ ） 麦门冬（去心） 川黄连（姜炒） 木通
水煎服。
【方歌】加味四物治热盛，寒战切牙二怔并，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）
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 （生） 甘草（炙） 栀子（炒） 黄芩（酒炒） 麦门冬（去心） 山楂
神曲（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 甘草补厥脾，栀芩麦冬清心热，楂曲陈麦消滞宜。
寒战和切牙的症状需要分辨清楚：如果初热阶段邪气在表，应使用羌活汤；如果是肺胃有热，应使用四物剂；如果是气血两虚，应使用参归灵（即参归鹿茸汤）。
【注】所谓寒战切牙，是指身体感觉寒冷刺骨，全身颤抖摇动，上下牙齿相互摩擦并发出声响。在初热阶段出现寒战切牙，是因为火毒滞留于经络之中，邪气与正气相争，痘毒欲出而不能出的缘故。治疗应当清热透表，以羌活汤为主方。如果见点之后痘色紫赤，大便秘结，小便涩滞，烦躁口渴，这属于实热证，其中胃热导致切牙，肺热导致寒战，宜用加味四物汤治疗。如果在灌浆期脓液清稀，大便溏薄，小便清长，身体凉爽不口渴，这属于气血两虚证，其中气虚导致寒战，血虚导致切牙，宜用参归鹿茸汤治疗。
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
生地、连翘（去心）、川芎、当归、赤芍、石膏、麦门冬（去心）、川黄连（姜炒）、木通。
水煎服。
【方歌】加味四物汤治疗热盛之证，寒战切牙两种症状并见，生地、连翘、川芎、芍药、当归，配合石膏、麦冬、黄连、木通共同组成。
参归鹿茸汤（方剂内容见“灌浆证治”章节）
倦怠多因气虚所致，或者是因为食积郁热困阻脾脏。如果是虚证而无热象，应用补中益气法治疗；如果是食积损伤脾脏，则用保元汤加减治疗。
【注】痘疹中的倦怠症状，固然属于中气不足，服用补中益气汤最为妥当。然而也有患者神气本弱，或被食积郁热所困，虽然现症表现与气虚相似，但不能单纯按虚证治疗，应当在补益剂中佐以清热之品，如加味保元汤即可使用。
补中益气汤（方剂内容见“痘顶塌陷”章节）
加味保元汤
人参、黄芪（生）、甘草（炙）、栀子（炒）、黄芩（酒炒）、麦门冬（去心）、山楂、神曲（炒）、陈皮、麦芽（炒）。
引用生姜、大枣，水煎服。
【方歌】加味保元汤针对食积、郁热和气虚，人参、黄芪、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。
The symptoms of rigors (cold shivering) and teeth grinding must be clearly distinguished. If the initial heat indicates pathogenic factors in the exterior, Qianghuo Tang (Notopterygium Decoction) should be used; if there is heat in the Lung and Stomach, Siwu Ji (Four Substances Formula) should be used; if there is deficiency of both Qi and Blood, Shenguiling (Ginseng and Angelica Decoction, referring to Shen Gui Lu Rong Tang) should be used.
[Note] Rigors and teeth grinding refer to a sensation of piercing cold, trembling and shaking of the body, and the rubbing of upper and lower teeth producing sound. When these occur during the initial heat stage, it is because fire-toxin remains within the meridians, causing a struggle between pathogenic factors and healthy Qi, where the pox toxin desires to emerge but cannot. The treatment should focus on clearing heat and venting the exterior, primarily using Qianghuo Tang (Notopterygium Decoction). If after the appearance of spots the pox color is purple-red, accompanied by constipation, dysuria, irritability, and thirst, this belongs to excess-heat syndrome. Specifically, Stomach heat causes teeth grinding, while Lung heat causes rigors; Jiawei Siwu Tang (Modified Four Substances Decoction) is indicated. If during the suppuration stage the pus is clear and thin, with loose stools, long clear urination, cool body without thirst, this belongs to deficiency of both Qi and Blood. Specifically, Qi deficiency causes rigors, while Blood deficiency causes teeth grinding; Shen Gui Lu Rong Tang (Ginseng, Angelica, and Deer Antler Decoction) is indicated.
Qianghuo Tang (Notopterygium Decoction)
Longdancao (Gentianae Radix), Bohe (Menthae Haplocalycis Herba), Fangfeng (Saposhnikoviae Radix), Danggui (Angelicae Sinensis Radix), Zhizi (Gardeniae Fructus), Danzhuyez (Lophatheri Herba), Qianghuo (Notopterygii Rhizomatis et Radix), Gancao (Glycyrrhizae Radix et Rhizoma [raw]), Chuanxiong (Chuanxiong Rhizoma).
Add fresh ginger, decoct in water and take orally.
[Formula Song] Qianghuo Tang attacks wind-heat, combined with Longdan, Bohe, and Fangfeng; Danggui, Zhizi, and Danzhuye, along with Qianghuo, Gancao, and Chuanxiong.
Jiawei Siwu Tang (Modified Four Substances Decoction)
Shengdi (Rehmanniae Radix Preparata), Lianqiao (Forsythiae Fructus [decored]), Chuanxiong (Chuanxiong Rhizoma), Danggui (Angelicae Sinensis Radix), Chi Shao (Paeoniae Radix Rubra), Shigao (Gypsum Fibrosum), Maidong (Ophiopogonis Radix [decored]), Huanglian (Coptidis Rhizoma [stir-fried with ginger juice], Mutong (Akebiae Caulis).
Decoct in water and take orally.
[Formula Song] Jiawei Siwu treats excessive heat, addressing both rigors and teeth grinding; Shengdi, Lianqiao, Chuanxiong, Shaoyao, and Danggui, combined with Shigao, Maidong, Huanglian, and Mutong.
Shen Gui Lu Rong Tang (Ginseng, Angelica, and Deer Antler Decoction) (See "Treatment of Suppuration Stage" for formula details).
Fatigue is often due to Qi deficiency, or may arise from food stagnation and trapped heat confining the Spleen. If it is deficiency without heat, treat with Bu Zhong Yi Qi method; if food stagnation injures the Spleen, use Baoyuan Tang modified.
[Note] Fatigue in smallpox/variolous diseases indeed belongs to insufficiency of Middle Qi, making Buzhong Yiqi Tang (Tonify the Middle and Augment the Qi Decoction) the most appropriate choice. However, some patients have inherently weak Shen-Qi or are confined by food stagnation and heat. Although their presenting symptoms resemble deficiency, they should not be treated solely as deficiency. Instead, heat-clearing herbs should be added to tonifying formulas, such as Jiawei Baoyuan Tang (Modified Baoyuan Decoction).
Buzhong Yiqi Tang (Tonify the Middle and Augment the Qi Decoction) (See "Treatment of Collapsed Pox Crown" for formula details).
Jiawei Baoyuan Tang (Modified Baoyuan Decoction)
Renshen (Ginseng Radix et Rhizoma), Huangqi (Astragali Radix [raw]), Gancao (Glycyrrhizae Radix et Rhizoma [roasted), Zhizi (Gardeniae Fructus [stir-fried]), Huangqin (Scutellariae Radix [wine-stir-fried]), Maidong (Ophiopogonis Radix [decored]), Shanzha (Crataegi Fructus), Shenqu (Massa Medicata Fermentata [stir-fried]), Chenpi (Citri Reticulatae Pericarpium), Maiya (Hordei Fructus Germinatus [stir-fried]).
Add fresh ginger and Jujube, decoct in water and take orally.
[Formula Song] Jiawei Baoyuan addresses food stagnation, heat, and deficiency; Renshen, Huangqi, and Gancao tonify the Spleen; Zhizi, Huangqin, and Maidong clear Heart heat; Shanzha, Shenqu, Chenpi, and Maiya are suitable for eliminating stagnation.