痘出最要咽喉清利。若毒火上熏。咽喉先受。以致肿塞窄狭。呼吸不能。饮食不入。疼痛哑
呛等证。如圣饮、甘露饮、射干鼠粘子汤选用。血热咽痛者。紫草消毒饮最当。若咽痛发热。手
指初捻似热。捻久则冷者。此脾气虚也。钱氏异功散。若咽痛发热。作渴引饮。手足并热者。脾
气热也。泻黄散。若大便溏泄。饮食不进者。白术散。慎勿用凉药。致损脾胃。而变吐泻痒塌也。
若咽痛足热。小便赤涩而频数。此三阴虚。无根之火循经上至咽喉也。生料六味加麦冬、五味。
呛水者。咽门为毒所壅。则饮不得入而溢于气喉。故气逆喷而呛也。若呛水在六七日前见。痘
色红紫者。乃热毒上壅。若痘色灰白不起。乃气血虚弱。肺胃受伤。大为危兆。急宜解毒开胃。色
赤兼凉血。色淡兼补气。若七日后。外痘蒸长光润而见此证。乃内痘起发而呛。只须助其灌浆。外
痘结痂而呛自愈矣。
失音之证。大抵肺热气病。咽喉有痘也。若于七日前见者。毒瓦斯熏蒸。肺窍闭塞。内疮糜烂
。呼吸俱废者。为难治。若七日后呛水失音。乃内疮先热而靥。射干鼠粘子汤。或有内本无疮。
多服热药所致者。急用消毒饮去荆芥加桔梗、门冬。 赤热甚。更加犀角、黑参。或凉膈散去硝、
黄。若毒火上熏于肺。肺受火郁而窍塞声哑者。导赤散加桔梗、牛蒡。若声哑而烦热 痛。呻吟
作渴。欲饮冷水。大便不通者。此心脾实热。急与清凉解毒。夏月盛暑之时。稍与冷水救之。洁
古云。痘疹已出而声音如故者。形气俱不病也。痘疹未出而声不出者。形未病而气先病也。痘疹
出而声音不出形。气俱病也。其治法可领悟矣。凡痘疮黑陷干枯。咳嗽失音。吐泻烦渴。发热肢
冷。昏睡少食。痰多气促。寒颤切牙。黑陷燥痒者。皆为不治。惟猛进温养之剂。间有得生者。
痘疮发出时，最重要的是咽喉保持清利通畅。如果毒火向上熏蒸，咽喉首先受邪，导致肿胀堵塞、狭窄狭小，呼吸不畅，饮食难进，出现疼痛、失音、呛咳等症状。此时可选用如圣饮、甘露饮或射干鼠粘子汤进行治疗。如果是血热引起的咽痛，紫草消毒饮最为适宜。
如果咽痛伴有发热，手指初触感觉发热，但触摸久了反而变冷，这是脾气虚弱的表现，应使用钱乙的异功散。如果咽痛发热，口渴想喝水，手足都发热，这是脾经有热的表现，应使用泻黄散。如果出现大便溏泄、饮食不进的情况，应使用白术散，切记不要使用寒凉药物，以免损伤脾胃，进而引发呕吐、腹泻或痘疮塌陷等变证。
如果咽痛且足部发热，小便短赤涩滞且频数，这是三阴经阴虚，无根之火沿着经络上行至咽喉所致，可用生料六味地黄丸加麦冬、五味子治疗。
所谓“呛水”，是因为咽喉门户被毒邪壅塞，导致饮水无法进入食道而溢入气管，引起气逆喷涌从而发生呛咳。如果在出痘后六七天前出现呛水，且痘色红紫，这是热毒上壅；如果痘色灰白且不起发，则是气血虚弱，肺胃受损，这是非常危险的征兆。此时急需解毒开胃，痘色赤者兼以凉血，痘色淡者兼以补气。如果在七日后，外部痘疮蒸腾隆起、光泽润泽却出现此证，是内部痘疮起发时引发的呛咳，只需帮助其灌浆成熟，待外部痘疮结痂，呛水症状自然痊愈。
关于失音的症状，大抵是由于肺热气盛或咽喉长痘所致。如果在出痘后七日前出现，因毒气熏蒸，肺窍闭塞，内部疮疡糜烂，导致呼吸衰竭，属于难治之症。如果在七日后出现呛水和失音，是内部疮疡先发热而后结痂所致，可用射干鼠粘子汤治疗。或者体内原本没有疮疡，因多服热药所致者，急需使用消毒饮去掉荆芥，加入桔梗、麦冬。如果赤热严重，再加犀角、玄参（黑参）。或者使用凉膈散去硝石、大黄。如果毒火上熏于肺，肺受火郁导致窍塞声哑，可用导赤散加桔梗、牛蒡子。如果声音嘶哑且烦热疼痛，呻吟作渴，想喝冷水，大便不通，这是心脾实热，急需给予清凉解毒之法。夏季酷暑之时，可稍给冷水以救急。张洁古说：痘疹已发出而声音如常的，说明形体和气机都没有病；痘疹未发出而声音不出，是形体未病而气机先病；痘疹发出而声音不出，是形和气都病了。这些治法原理可以由此领悟。凡是痘疮黑陷干枯，咳嗽失音，呕吐腹泻烦躁口渴，发热四肢冰冷，昏睡少食，痰多气促，寒战咬牙，黑陷干燥瘙痒的，都属于不治之症。只有猛进温补滋养的药物，偶尔才有存活的可能。
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.