总括 失音之症古名 ，大抵多因病后成；补泻随时加减用，地黄丸服有音声。
《内经》曰∶舌者，音之机也；喉者，音之关也。小儿卒然无音，乃寒气客于会厌，则厌不能发，发不能出，致其
门阖不启，故无音也。若咽喉音声如故，而舌不能运转言语，则为舌 。此乃风冷之邪克于皮之络，或中于舌下廉泉穴
所致。盖舌乃心之苗，心发声为言，风邪阻塞其经络，故舌不能转运也。若舌本不能转运言语，而喉中声嘶者则为喉 ，
此亦为风冷所客，使气道不通，故声不得发，而喉无音也。然或因风痰阻塞，或因心经气虚，或因脾之络受风，或因风
痰滞于脾之络，或因脾气不足，或胃中清气不升，皆足以致 。大抵此症有禀父肾气不足不能言者；有乳母五志之火遗
儿、熏闭清道不能言者；或儿病津液耗损，会厌干涸不能言者；或肾气不充，虚火上炎，伤肺不能言者；有惊风中风不
能言者。若遗热于津液耗者，用七味白术散；清气不升者用补中益气汤；禀肾不足与虚火伤肺者，用六味地黄丸。若仰
首咳嗽肢体羸瘦，目白睛多，或兼解颅呵欠、切牙等症，悉属肾虚，非地黄丸不能救也。
若患吐泻或大病后，虽有声而不能言，又能咽物，有不能咽者非失音，此肾怯不能上接于阳也，当以参术温补之剂
主之。《保婴集》云，小儿五六岁，心气不足而不能言用菖蒲丸，口噤不能言者，用地黄丸。
三十二问，解颅。仲阳谓生下囟不合，肾气衰也，长必少笑。更有目白睛多， 白身瘦者，多愁少喜也，余见肾虚
症。杨氏曰∶小儿年大，头缝开解而不合者，肾主髓，脑为髓海，肾气有亏，脑髓不足，所以头颅开而不能合也。人乏
脑髓，如木无根，凡得此者不远千日，亦有数岁，乃成废人。故有此症亦不可束手待死也，宜与钱氏地黄丸，仍用天南
星，微炮为末，米醋调敷于绯帛，烘热贴之，亦良法也。
三十三问，囟陷囟填。囟陷者始因脏腑有热，渴饮水浆致成泄泻，久则血气虚损不能上冲脑髓，故囟陷如坑不能平
满，
用狗头骨炙黄为末，鸡子清调敷之。囟填者囟门肿起也，脾主肌肉，乳哺不常，饥饱无度，或寒或热，乘于脾家，致使
脏腑不调，其气上冲，为之填胀，囟突而高，如物堆起，毛发短黄自汗是也。若寒气上冲则牢靳，热气上冲则柔软。寒
者温之，热者凉之。剂量轻重，兼与调气。小儿肝盛风热交攻亦然，此症未易退瘥，或热症用大连翘散主之。有表热症
柴胡散主之，又有封囟散掩之。
论曰∶小儿胃和冲和则脑髓充盛，囟顶渐合。若胃热熏蒸脏腑，则渴而引饮，因致泄利。今脏腑壅热，血气虚弱，
不能上冲脑髓，所以囟陷也，用当归散、地黄丸。
齿迟、语迟、行迟∶齿迟者肾气不足；语迟者心气不足；行迟者禀受不足。
天柱骨倒∶项软者胎气不足。大病后后项软即天柱骨倒也。或吐泻之余，伤寒失表，脾受风热者，速与祛风追热，
及以强筋之剂。
（小儿肌体雄壮，不为瘦瘁，忽然项软倾倒，此名下窜，皆因肝肾气虚，客邪侵入脏腑，传于筋骨，故成此疾。盖
肝主乎筋，肾主乎骨，筋骨俱弱则项软、垂下无力，亦名天柱骨倒，与五软相类，不过调元散、补肾地黄丸。）
〔附方〕
七味白术散 人参 白术 茯苓 藿香 木香 干葛 甘草
补中益气汤 见脱肛症内。
六味地黄丸
菖蒲丸 治心气不足，不能言语。
石菖蒲 赤石脂（各三钱） 人参（五钱） 丹参（二钱） 天冬 麦门冬（各一两）
连翘散 见风毒症内。
柴胡散
封囟散 人参（二钱） 甘草（二钱） 门冬（二钱） 胆草（一钱，酒炒） 防风（一钱） 柴胡（五分）
当归散 见诸泻症内。
地黄丸
调元散 人参 茯苓 茯神 白术 白芍 熟地 当归 黄 川芎 石菖蒲 山药 甘草
补肾地黄丸 见五淋症内。
总括：失音这一病症在古代被称为“喑”，大多是在生病之后形成的；治疗时需根据病情虚实随时进行补泻和药物加减，服用地黄丸后声音即可恢复。
《黄帝内经》说：舌是发声的关键机关；喉是发声的关口。小儿突然不能发声，是因为寒气侵袭会厌，导致会厌开合失灵，气机出入受阻，致使咽喉门户关闭无法开启，所以不能发声。如果咽喉发出的声音正常，但舌头不能灵活运转以言语，这称为“舌喑”。这是由于风冷之邪侵犯皮部络脉，或者中于舌下的廉泉穴所致。因为舌是心的外候（苗窍），心主发声为言，风邪阻塞了经络，所以舌头不能灵活转动。如果舌根不能灵活运转言语，而喉咙声音嘶哑的，则称为“喉喑”，这也是因为风冷之邪客居，使气道不通畅，所以声音发不出来，喉咙无声。然而，有的因为风痰阻塞，有的因为心经气虚，有的因为脾的络脉受风，有的因为风痰停滞在脾的络脉，有的因为脾气不足，有的因为胃中清气不升，这些都足以导致失音。大体上，此症有先天禀受父亲肾气不足而不能说话的；有乳母因五志之火遗留给婴儿、熏蒸闭塞清道导致不能说话的；或者婴儿患病津液耗损，会厌干涸导致不能说话的；或者肾气不充实，虚火上炎，损伤肺脏导致不能说话的；有因惊风或中风导致不能说话的。如果是余热遗留且津液耗损的，使用七味白术散；清气不升的，使用补中益气汤；禀赋肾不足与虚火伤肺的，使用六味地黄丸。如果出现仰头咳嗽、肢体消瘦、眼白睛多，或者兼有解颅、呵欠、磨牙等症状，都属于肾虚，非地黄丸不能救治。
如果在患吐泻或大病之后，虽然有声但不能说话，且能吞咽食物，如果不能吞咽的则不是失音，这是肾气怯弱不能上接于阳气所致，应当以人参、白术等温补的药剂为主治。《保婴集》说，小儿五六岁，因心气不足而不能说话的，用菖蒲丸；口噤（牙关紧闭）不能说话的，用地黄丸。
第三十二问：解颅。钱乙（字仲阳）认为出生后面囟门不合，是肾气衰弱所致，长大后必定少笑。更有眼白睛多、身体瘦弱者，多愁少喜，其余详见肾虚症。杨氏说：小儿年龄较大，头缝开解而不闭合的，肾主骨髓，脑为髓海，肾气有亏损，脑髓不足，所以头颅开裂而不能闭合。人缺乏脑髓，就像树木没有根一样，凡是得此病的，活不过一千年（意指寿命不长），也有活到几岁的，最终成为废人。所以有此症也不可束手待毙，宜给予钱乙的地黄丸，仍配合天南星，微炮制后研为细末，用米醋调匀敷在红帛上，加热后贴敷，也是良法。
第三十三问：囟陷与囟填。囟陷是指开始因脏腑有热，口渴饮水导致泄泻，日久则气血虚损不能上冲至脑髓，所以囟门凹陷如坑，不能平满，可用狗头骨炙烤变黄后研为细末，用鸡蛋清调和敷贴。囟填是指囟门肿起，脾主肌肉，哺乳不规律，饥饱无度，或寒或热之邪乘袭脾家，致使脏腑不调，其气上冲，造成填胀，囟门突起而高，像物体堆起，伴有毛发短黄、自汗等症状。若寒气上冲则囟门坚硬，热气上冲则囟门柔软。寒者用温法，热者用凉法。剂量轻重，兼以调理气机。小儿肝盛，风热交攻亦然，此症不易痊愈，若有热症用大连翘散主治。有表热症的用柴胡散主治，又有封囟散覆盖患处。
论述说：小儿胃气和顺则冲和之气充足，脑髓充盛，囟顶逐渐闭合。若胃热熏蒸脏腑，则口渴引饮，因而导致泄利。如今脏腑壅滞有热，血气虚弱，不能上冲脑髓，所以囟门凹陷，用当归散、地黄丸。
齿迟、语迟、行迟：牙齿长得晚是肾气不足；说话晚是心气不足；走路晚是禀受不足。
天柱骨倒：项颈软弱是胎气不足。大病之后后项软弱即称为天柱骨倒。或者是吐泻之余，伤寒失于发汗解表，脾受风热者，迅速给予祛风追热，以及强筋的药剂。
（小儿肌体原本雄壮，不为瘦弱憔悴，忽然项颈软弱倾倒，此名“下窜”，皆因肝肾气虚，外邪侵入脏腑，传于筋骨，故成此疾。盖肝主筋，肾主骨，筋骨俱弱则项颈软弱、垂下无力，也名为天柱骨倒，与五软相似，不过用调元散、补肾地黄丸调理。）
〔附方〕
七味白术散：人参、白术、茯苓、藿香、木香、干葛、甘草。
补中益气汤：见脱肛症内。
六味地黄丸。
菖蒲丸：治心气不足，不能言语。石菖蒲、赤石脂（各三钱）、人参（五钱）、丹参（二钱）、天冬、麦门冬（各一两）。
连翘散：见风毒症内。
柴胡散。
封囟散：人参（二钱）、甘草（二钱）、门冬（二钱）、胆草（一钱，酒炒）、防风（一钱）、柴胡（五分）。
当归散：见诸泻症内。
地黄丸。
调元散：人参、茯苓、茯神、白术、白芍、熟地、当归、黄芪、川芎、石菖蒲、山药、甘草。
补肾地黄丸：见五淋症内。
General Overview: The condition of aphonia was anciently called "Yin" (loss of voice), and it mostly arises after an illness; treatment requires adjusting tonification and purgation according to the timing and condition, and taking Dihuang Wan (Rehmannia Pill) will restore the voice.
The *Neijing* (Classic of Internal Medicine) states: The tongue is the mechanism of sound; the throat is the gate of sound. Sudden loss of voice in children is caused by cold pathogenic factors invading the epiglottis, causing the epiglottis to fail to open and close properly, blocking the exit of qi, leading to the closure of the throat's gate, thus resulting in no voice. If the voice from the throat remains normal but the tongue cannot move to articulate speech, this is called "She Yin" (tongue aphonia). This is caused by wind-cold pathogens attacking the collaterals of the skin or obstructing the Lianquan acupoint under the tongue. Since the tongue is the sprout of the Heart, and the Heart produces speech, wind pathogens blocking the meridians cause the tongue to be immobile. If the root of the tongue cannot move for speech while the throat sounds hoarse, this is called "Hou Yin" (throat aphonia). This is also due to wind-cold pathogens lodging in the airway, preventing smooth airflow, so the voice cannot emerge. However, some cases are due to wind-phlegm obstruction, some due to deficiency of Qi in the Heart meridian, some due to wind affecting the spleen's collaterals, some due to wind-phlegm stagnating in the spleen's collaterals, some due to insufficiency of spleen Qi, and some due to failure of clear Yang to ascend from the stomach. All these can lead to aphonia. Generally, this condition includes those who cannot speak due to congenital insufficiency of paternal kidney Qi; those whose voices are blocked by maternal emotional fire transmitted to the infant, obstructing the clear pathways; infants who cannot speak due to dryness of the epiglottis from fluid depletion during illness; those who cannot speak due to insufficient kidney Qi with deficient fire flaming upward damaging the lungs; and those who cannot speak due to convulsive winds or stroke. For cases where residual heat damages fluids, use Qiwai Baizhu San (Seven-Ingredient Atractylodes Macrocephala Powder); for cases where clear Yang does not ascend, use Buzhong Yiqi Tang (Tonify the Middle and Augment the Qi Decoction); for congenital kidney insufficiency and deficient fire damaging the lungs, use Liuwei Dihuang Wan (Six-Ingredient Rehmannia Pill). If symptoms include coughing with the head tilted back, emaciation of limbs, prominent white sclera, or accompanying signs such as Jie Lu (splitting fontanelle), yawning, and teeth grinding, all belong to kidney deficiency, which cannot be cured without Dihuang Wan (Rehmannia Pill).
If a child has vomiting and diarrhea or has just recovered from a severe illness, and although they have a voice but cannot speak, yet can swallow food, whereas inability to swallow indicates it is not aphonia, this is due to weak kidney Qi failing to connect upward with Yang. It should be treated primarily with warming and tonifying agents containing Renshen (Ginseng Root) and Baizhu (Atractylodes Rhizome). The *Baoying Ji* (Collection for Protecting Infants) states that for children aged five or six who cannot speak due to insufficiency of heart Qi, use Changpu Wan (Acorus Pill); for those with trismus (lockjaw) unable to speak, use Dihuang Wan (Rehmannia Pill).
Question 32: Jie Lu (Splitting Fontanelle). Zhongyang (Qian Yi) stated that if the anterior fontanelle fails to close at birth, it is due to decline of kidney Qi, and the child will likely laugh less when grown. Those with prominent white sclera and emaciated bodies are often melancholic and rarely joyful; see Kidney Deficiency conditions for details. Yang Shi said: When a child grows older and the cranial sutures remain open and do not close, it is because the Kidney governs marrow, and the brain is the sea of marrow. Deficiency of kidney Qi leads to insufficient brain marrow, causing the skull to split and not close. A person lacking brain marrow is like a tree without roots. Those afflicted with this condition will not live long, though some may survive for several years before becoming invalids. Therefore, even with this condition, one should not wait passively for death. It is advisable to administer Qian's Dihuang Wan (Rehmannia Pill), combined with prepared Tian Nan Xing (Arisaema Rhizome) ground into powder, mixed with rice vinegar, applied on red silk, warmed, and patched onto the area, which is also an excellent method.
Question 33: Sunken and Bulging Fontanelles. A sunken fontanelle initially results from heat in the zang-fu organs, thirst leading to drinking, causing diarrhea, which over time depletes blood and qi, preventing them from ascending to nourish the brain marrow, causing the fontanelle to sink like a pit and fail to fill flat. Treat by roasting dog skull bone until yellow, grinding into powder, and applying mixed with egg white. A bulging fontanelle refers to swelling of the fontanelle. The Spleen governs muscles. Irregular feeding, excessive hunger or fullness, or cold/heat pathogens attacking the spleen cause disharmony of the zang-fu organs. Their qi rushes upward, causing distension and bulging of the fontanelle, resembling a pile of objects, accompanied by short yellow hair and spontaneous sweating. If cold qi rushes upward, the fontanelle feels firm; if hot qi rushes upward, it feels soft. Cold is treated with warmth, heat with cooling. Adjust dosage based on severity and harmonize qi. In children with hyperactive liver wind-heat, the situation is similar; this condition is difficult to resolve. For heat syndromes, use Da Lianqiao San (Large Forsythia Powder). For exterior heat syndromes, use Chai Hu San (Bupleurum Powder), and cover with Feng Xin San (Fontanelle Sealing Powder).
Discussion: When a child's stomach qi is harmonious, chong qi is balanced, brain marrow is abundant, and the fontanelle gradually closes. If stomach heat steams the zang-fu organs, thirst and drinking ensue, leading to diarrhea. Currently, with zang-fu organ heat congestion and weak blood and qi, unable to ascend to nourish the brain marrow, the fontanelle sinks. Use Danggui San (Angelica Sinensis Powder) and Dihuang Wan (Rehmannia Pill).
Delayed Teething, Delayed Speech, Delayed Walking: Delayed teething is due to insufficiency of kidney Qi; delayed speech is due to insufficiency of heart Qi; delayed walking is due to congenital insufficiency.
Tian Zhu Gu Dao (Collapse of the Heavenly Pillar Bone): Weakness of the neck is due to insufficiency of fetal qi. Weakness of the posterior neck after a severe illness is called Tian Zhu Gu Dao. Or, following vomiting and diarrhea, or failure to release the exterior in cold damage, with spleen affected by wind-heat, quickly administer wind-dispelling and heat-clearing agents, along with tendon-strengthening formulas.
(When a child's body is robust and not emaciated, but suddenly the neck becomes weak and collapses, this is named "Xia Cuan" (Descending Creep). It is caused by deficiency of liver and kidney qi, allowing pathogenic factors to invade the zang-fu and transmit to sinews and bones, resulting in this disease. The Liver governs sinews, and the Kidney governs bones. When both sinews and bones are weak, the neck becomes flaccid and hangs down无力, also named Tian Zhu Gu Dao, similar to Wu Ruan (Five Flaccidities), treatable with Tiaoyuan San (Regulate Origin Powder) and Bushen Dihuang Wan (Kidney-Nourishing Rehmannia Pill).)
[Attached Formulas]
Qiwai Baizhu San (Seven-Ingredient Atractylodes Macrocephala Powder): Renshen (Ginseng Root), Baizhu (Atractylodes Rhizome), Fuling (Poria), Huoxiang (Patchouli Herb), Muxiang (Costus Root), Gange (Kudzu Root), Gancao (Licorice Root).
Buzhong Yiqi Tang (Tonify the Middle and Augment the Qi Decoction): See Hemorrhoid Prolapse section.
Liuwei Dihuang Wan (Six-Ingredient Rehmannia Pill).
Changpu Wan (Acorus Pill): Treats insufficiency of heart Qi and inability to speak. Shichangpu (Acorus Tatarinowii Rhizome), Chishizhi (Red Halloysite) (each 3 qian), Renshen (Ginseng Root) (5 qian), Danshen (Salvia Miltiorrhiza Root) (2 qian), Tiandong (Asparagus Tuber), Maidong (Ophiopogon Tuber) (each 1 liang).
Lianqiao San (Forsythia Powder): See Wind Poison Disease section.
Chai Hu San (Bupleurum Powder).
Fengxin San (Fontanelle Sealing Powder): Renshen (Ginseng Root) (2 qian), Gancao (Licorice Root) (2 qian), Mendong (Ophiopogon Tuber) (2 qian), Dancao (Gentiana Root) (1 qian, wine-fried), Fangfeng (Saposhnikovia Root) (1 qian), Chaihu (Bupleurum Root) (0.5 qian).
Danggui San (Angelica Sinensis Powder): See Various Diarrhea section.
Dihuang Wan (Rehmannia Pill).
Tiaoyuan San (Regulate Origin Powder): Renshen (Ginseng Root), Fuling (Poria), Fushen (Poria with Hostwood), Baizhu (Atractylodes Rhizome), Baishao (White Peony Root), Shudi (Prepared Rehmannia Root), Danggui (Angelica Sinensis Root), Huangqi (Astragalus Root), Chuanxiong (Ligusticum Rhizome), Shichangpu (Acorus Tatarinowii Rhizome), Shanyao (Dioscorea Rhizome), Gancao (Licorice Root).
Bushen Dihuang Wan (Kidney-Nourishing Rehmannia Pill): See Five Strangury section.