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The most critical aspect when pustules erupt is that the throat remains clear and unobstructed. If toxic fire flares upward, the throat is affected first, leading to swelling, blockage, narrowing, difficulty in breathing, inability to swallow food or drink, and symptoms such as pain, aphonia (loss of voice), and choking on water. In such cases, one may select from Ru Sheng Yin (Sage Drink), Gan Lu Yin (Sweet Dew Drink), or Shegan Niuzi Tang (Belamcanda and Burdock Seed Decoction). For sore throat caused by blood heat, Zicao Xiaodu Yin (Arnebia Detoxification Drink) is most appropriate.

If there is sore throat accompanied by fever, where the fingertips feel warm initially but become cold after prolonged touching, this indicates Spleen Qi deficiency; Qian's Yigong San (Isolated Efficacy Powder) should be used. If there is sore throat with fever, thirst with desire to drink, and heat in both hands and feet, this indicates Heat in the Spleen channel; Xiehuang San (Drain Yellow Powder) should be used. If loose stools occur and food intake is poor, Baizhu San (Atractylodes Macrocephala Powder) should be used. One must strictly avoid using cold/cooling medicines to prevent damaging the Spleen and Stomach, which could lead to vomiting, diarrhea, or collapse of the pustules.

If there is sore throat with heat in the feet, and scanty, painful, frequent urination, this indicates Deficiency of the Three Yin channels, with rootless fire ascending along the meridians to the throat; Shengliu Junzi Wan (Six-Ingredient Rehmannia Pill with Additions) plus Maidong (Ophiopogon Tuber) and Wuwei Zi (Schisandra Fruit) should be used.

"Choking on water" occurs because the throat gate is congested by toxins, preventing water from entering the esophagus, causing it to overflow into the trachea, leading to reverse flow of Qi and choking. If this appears within six to seven days after eruption, and the pustules are red and purple, it signifies upward congestion of Heat-Toxin. If the pustules are grayish-white and do not rise, it indicates deficiency of Qi and Blood with injury to the Lung and Stomach, a grave omen. Urgent detoxification and appetite stimulation are required; for red color, add blood-cooling herbs; for pale color, add Qi-tonifying herbs. If this symptom appears after seven days, while external pustules are steaming, rising, and lustrous, it is due to internal pustule development causing choking. One need only assist in filling the pustules with pus; once external scabs form, the choking will resolve spontaneously.

Regarding aphonia, it is generally caused by Lung Heat or the presence of pustules in the throat. If seen within seven days, toxic vapors harass and obstruct the Lung orifices, with internal ulcers eroding, leading to respiratory failure; this is difficult to treat. If choking and aphonia appear after seven days, it is due to internal ulcers heating up and then crusting over; Shegan Niuzi Tang (Belamcanda and Burdock Seed Decoction) is indicated. Alternatively, if there were no internal ulcers originally but resulted from excessive consumption of hot medicines, urgent use of Xiaodu Yin (Detoxification Drink) without Jingjie (Schizonepeta), adding Jiegeng (Platycodon Root) and Maidong (Ophiopogon Tuber) is necessary. If redness and heat are severe, add Xijiao (Rhinoceros Horn - *note: substitute with Water Buffalo Horn in modern practice*) and Heishen (Scrophularia Root/Nicotiana Radix contextually often refers to Scrophularia or similar cooling roots here, specifically Scrophulariae Radix); alternatively, Liangge San (Cool the Diaphragm Powder) without Xiaoshi (Mirabilite) and Dahuang (Rhubarb) can be used. If toxic fire harasses the Lung, causing Qi stagnation due to Fire, blocking orifices and causing hoarseness, Daochi San (Guide Out Red Powder) with Jiegeng (Platycodon Root) and Niubangzi (Burdock Fruit) is suitable. If hoarseness is accompanied by vexation, heat, pain, groaning, thirst, desire for cold water, and constipation, this indicates Excess Heat in the Heart and Spleen; urgent cooling and detoxification are required. During midsummer heat, small amounts of cold water may be given to rescue the condition. Zhang Jiegu stated: "If the voice remains unchanged after eruptions appear, neither form nor Qi is diseased. If the voice does not emerge before eruptions appear, form is not diseased but Qi is diseased first. If eruptions appear but the voice does not emerge, both form and Qi are diseased." The treatment principles can be understood from this. Whenever pustules are black, depressed, dry, accompanied by cough and aphonia, vomiting and diarrhea, vexation and thirst, fever with cold limbs, lethargy with poor appetite, profuse phlegm with shortness of breath, chills with teeth grinding, or black depression with dry itching, these are all untreatable conditions. Only by vigorously advancing warming and nourishing agents is survival occasionally possible.