经云。邪入于阴则喑。人卒然无音者。寒气客于厌。则厌不能发。发不能下。至其开阖不致。
故无音。失音大都不越于肺。然须以暴病得之。为邪郁气逆。久病得之。为津枯血槁。盖暴喑总
是寒包热邪或。本内热而后受寒。或先外感而食寒物。并宜辛凉和解。稍兼辛温散之。消风散用
姜汁调服。缓缓进之。或只一味生姜汁亦可。冷热嗽后失音尤宜。若咽破声嘶而痛。是火邪遏闭
伤肺。昔人所谓金实不鸣。金破亦不鸣也。古法用清咽宁肺汤。今
改用生脉散合六味丸作汤。所谓壮水之主以制阳光也。肥人痰湿壅滞。气道不通而声喑者。二陈
导痰开涤之。一切滋补。皆为禁剂。至若久病失音。必是气虚挟痰之故。宜滋肺肾之化源。非生
脉散下都气丸不可。凡咽干声槁者。润肺为主。生脉散合异功散。若膈内作痛。破瘀为先。代抵
当丸最妥。更有舌喑不能言者。亦当分别新久。新病舌喑不能言。必是风痰为患。类中风例治之。
若肥人舌短不能言。或舌根强硬。导痰汤为主。若久病后。或大失血后。舌萎不能言。大虚挟寒
例治之。要在临证审察病因无误。然中风暴病失音。多缘少阴真气久虚而得。更兼遗尿五绝证见。
不可治矣。若冬月咳嗽。寒痰结于咽喉。语声不出者。此寒气客于会厌。故卒然而喑也。麻杏甘
石汤。或古今录验续命汤选用。若失音不语。已经发散润肺而不应者。生脉散。并童真丸噙化之。
若咳喘气促。而胸中满闷。声喑不出者。肺胃气燥。不能祛散余邪也。紫菀散主之。亦有叫骂声
嘶而喉破失音者。十全大补汤。若肺气虚寒。为厉风所伤。喘咳声嘶。或先伤热。而寒郁热邪声
喑不出者。千金酥蜜膏。又咽痛起于四五日间。或因咳剧而得。或多稠痰结痰而咽喉上 肿痛。
其声虽哑而尚有音破浊。脉大缓而右寸尤甚。此热结于肺也。宜用辛凉之剂。如桔梗汤加葱白、
香豉、荆芥、薄荷。兼有风寒客邪。更须桂枝、芍药、姜、枣、胶饴之类。并以姜蜜制黄柏噙之。
慎不可骤用敛降之药。若暴哑声不出。咽痛异常。卒然而起。或欲咳而不能咳。或无痰。或清痰
上溢。脉多弦紧。或数疾无伦。此大寒犯肾也。麻黄附子细辛汤温之。并以蜜制附子噙之。慎不
可轻用寒凉之剂。二证寒热天渊。不可不辨也。胎前产后失音。另详本门。
石顽治西客王如嵩。触寒来苏。忽然喘逆声喑。咽喉疼肿。察其形体丰盛而饮啖如常。切其
脉象浮软而按之益
劲。此必寒包热邪。伤犯肺络也。遂以麻杏甘石汤。加半夏、细辛。大剂葳蕤。二服喘止声出。
但呼吸尚有微疼。更与二陈、枳、桔、葳蕤之类。调理而安。
王唯一数年前虽有血证。而年壮力强。四月间忽患咳嗽。服发散药后。痰中见血数口。继服
滋阴药过多。遂声飒而哑。时觉胸中气塞。迁延月余。乃兄勤中鼎中。邀余往诊。脉虽沉涩。而
按之益力。举之应指。且体丰色泽。绝非阴虚之候。因论之曰台。翁之声哑。是金实不鸣。良非
金破不鸣之比。因疏导痰汤加人中黄、泽泻方。专一涤痰为务。四剂后。痰中见紫黑血数块。其
声渐出。而飒未除。更以秋石兼人中黄。枣肉丸服。经月而声音清朗。始终未尝用清理肺气。调
养营血药也。
飞畴治郭代工。午日少食角黍。倦怠作泻。曾用消克不效。因圊时跌仆。即昏迷不省。数日
后邀予诊视。六脉虚微欲脱。右臂不能转动。声喑无闻。时有用大黄消克之剂者。予急止之。此
脾肺虚惫。安能任此。今纵有合剂。恐胃气告匮。乌能行其药力。惟粥饮参汤。庶为合宜。所谓
浆粥入胃。则虚者活。遂确遵予言以调之。泻止神宁。声音渐出而苏。能食后。亦惟独参汤调养。
不药而愈。
《黄帝内经》说：“邪气侵入阴分，就会导致失音。”人突然不能发声，是因为寒气客居在会厌部位，导致会厌不能正常开合。当会厌的开阖功能失调时，就会失去声音。
失音大多与肺有关，但需要区分是新病还是久病。新近患病导致的失音，多因邪气郁结、气机逆乱所致；久病导致的失音，多因津液枯竭、血液干枯所致。一般来说，暴发性失音总归是寒邪包裹热邪，或者是体内本有内热而后又感受了寒邪，或者是先外感风寒又食用了寒凉食物。这些情况都适宜用辛凉和解的方法治疗，稍加辛温药物以发散邪气。可以使用消风散，用姜汁调服，缓缓服用。或者单用一味生姜汁也可以。对于冷热交替咳嗽后导致的失音尤其适宜。如果咽喉破损、声音嘶哑且疼痛，这是火邪遏闭损伤肺脏的表现。古人所说的“金实不鸣”（肺气壅实导致的声音不出）和“金破亦不鸣”（肺气虚损导致的声音不出）就是指这种情况。古法使用清咽宁肺汤，现在改用生脉散合六味地黄丸煎汤服用，这就是所谓“壮水之主，以制阳光”（滋补肾阴以制约阳亢）的方法。
体型肥胖的人，若因痰湿壅滞、气道不通而导致失音，应用二陈汤导痰、涤除痰浊。此时一切滋补药物都是禁忌。至于久病失音，必定是气虚夹杂痰湿的缘故，应当滋润肺肾的化源，非生脉散配合下都气丸不可。凡是咽喉干燥、声音枯槁者，以润肺为主，可用生脉散合异功散。如果胸膈内部作痛，应以破瘀为先，代抵当丸最为妥当。
还有舌喑（舌头僵硬不能言语）的情况，也应当分别新病和久病。新病的舌喑不能说话，必定是风痰为患，按照类中风的方法治疗。如果是肥胖之人舌头短缩不能说话，或者舌根强硬，以导痰汤为主治方。如果是久病之后，或者大失血之后，出现舌体萎软不能说话，属于大虚兼寒证，按此例治疗。关键在于临证时要审察病因，确保无误。然而，中风暴病导致的失音，多因少阴真气长期虚弱而引发，如果再伴有遗尿等五绝证候出现，就不可治愈了。
如果在冬季咳嗽，寒痰凝结于咽喉，导致语声不出，这是寒气客居在会厌，所以突然失音。可选用麻杏甘石汤或古今录验续命汤。如果失音不语，经过发散和润肺治疗后无效，可用生脉散，并配合童真丸含化。如果咳嗽气喘、气促，且胸中满闷，声音不出，这是肺胃气燥，不能驱散余邪所致，以紫菀散主治。也有因叫骂导致声音嘶哑、咽喉破损而失音的，用十全大补汤。如果肺气虚寒，被厉风所伤，出现喘咳、声音嘶哑，或者是先受热邪，后又被寒邪郁闭导致失音的，用千金酥蜜膏。
另外，咽喉痛出现在发病四五天后，可能是因为剧烈咳嗽引起，也可能是因为稠痰凝结导致咽喉上部肿痛。此时声音虽然嘶哑但尚有余音，且声音浑浊，脉象大而缓，右寸脉尤为明显，这是热结于肺的表现。适宜使用辛凉药剂，如桔梗汤加葱白、香豉、荆芥、薄荷。如果兼有风寒客邪，更须加入桂枝、芍药、生姜、大枣、胶饴之类。同时可以用姜蜜炮制的黄柏含服。千万不要骤然使用收敛降气的药物。
如果是暴发性失音、声音不出，咽喉异常疼痛，突然发作，想要咳嗽却咳不出来，或者没有痰，或者有清稀痰液上溢，脉象多弦紧，或者数疾无伦次，这是大寒侵犯肾脏所致。用麻黄附子细辛汤温散寒邪，并用蜜制附子含服。千万不要轻易使用寒凉药剂。这两种情况（热结于肺与大寒犯肾），一寒一热，天壤之别，不可不仔细辨别。胎前产后失音，详见本书相关门类。
石顽医生诊治苏州客人王如嵩，此人受寒来到苏州，突然喘息气逆、失音，咽喉疼痛肿胀。观察他形体丰盛，饮食如常，切脉象浮软，但重按更加强劲有力。这一定是寒包热邪，伤及肺络。于是用麻杏甘石汤，加半夏、细辛，重用葳蕤（玉竹）。服用两剂后，喘息停止，声音恢复。只是呼吸时仍有轻微疼痛，再给予二陈汤、枳壳、桔梗、葳蕤之类的药物调理，得以痊愈。
王唯一几年前虽然有咯血病史，但年富力强。四月间忽然患上咳嗽，服用发散药后，痰中带血几口。接着服用滋阴药过多，导致声音飒飒作响而变哑，时常觉得胸中气塞，拖延了一个多月。他的哥哥王勤中、王鼎中邀请我去诊治。脉象虽沉涩，但重按更加有力，轻取应指，而且身体丰腴、面色光泽，绝非阴虚的证候。因此我说：“您的声音嘶哑，属于‘金实不鸣’，确实不同于‘金破不鸣’（虚证）。”于是用疏导痰汤加人中黄、泽泻，专门致力于涤除痰浊。服用四剂后，痰中带出紫黑色血块几团，声音逐渐恢复，但仍有飒飒声。再用秋石配合人中黄，制成枣肉丸服用，经过一个月，声音变得清朗。从头到尾未曾使用过清理肺气、调养营血的药物。
飞畴医生诊治郭代工，端午节吃得少粽子，感到倦怠并腹泻。曾用过消食攻下的药物但没有效果。后来在厕所跌倒昏迷，几天后请我诊治。六脉虚微欲脱，右臂不能转动，失音听不见。当时有人想用大黄等消克攻下的药剂，我急忙制止。这是脾肺极度虚弱，怎么能承受这种攻伐？现在即使有对症的药剂，恐怕胃气已经衰竭，怎能发挥药效？只有米粥饮和人参汤，才比较合适。所谓“浆粥入胃，则虚者活”。于是严格遵照我的建议进行调理。腹泻停止，神志安宁，声音逐渐恢复而苏醒。能进食后，也只用人参汤调养，未用其他药物而痊愈。
The *Huangdi Neijing* (Yellow Emperor's Inner Canon) states: "When pathogenic factors invade the Yin, aphonia occurs." Sudden loss of voice is caused by cold pathogen lodging in the epiglottis (Huìyàn), preventing its normal movement. When the opening and closing function of the epiglottis fails to coordinate, voice is lost.
Aphonia generally involves the Lung, but one must distinguish between acute onset and chronic conditions. Aphonia arising from recent illness is mostly due to pathogenic stagnation and rebellious Qi; aphonia arising from long-standing illness is mostly due to exhaustion of body fluids and dryness of blood. Generally, sudden aphonia is always due to cold enveloping heat pathogen, or internal heat followed by external cold contraction, or external wind-cold attack combined with ingestion of cold foods. These cases are suitable for treatment with acrid-cool harmonizing methods, slightly combined with acrid-warm dispersants. Xiaofeng San (Wind-Dispersing Powder) should be taken slowly, mixed with ginger juice. Alternatively, using only fresh ginger juice is also effective, especially for aphonia following alternating hot and cold coughs. If the throat is damaged, voice is hoarse, and painful, this indicates fire pathogen obstructing and damaging the Lung. As the ancients said, "Metal solid does not ring" (Jin Shi Bu Ming - aphonia due to Lung excess) and "Metal broken does not ring" (Jin Po Bu Ming - aphonia due to Lung deficiency). The ancient method uses Qingyan Ningfei Tang (Throat-Clearing Lung-Calming Decoction); now, Shengmai San (Generate the Pulse Powder) combined with Liuwei Wan (Six-Ingredient Pill with Rehmannia) decocted as a soup is used. This is what is meant by "Strengthening the master of Water to control the sunlight" (Zhuang Shui Zhi Zhu Yi Zhi Yang Guang - nourishing Kidney Yin to subdue hyperactive Yang).
In obese individuals, if aphonia is caused by phlegm-dampness obstruction and blocked airways, Erchen Tang (Two-Aged Decoction) should be used to guide out phlegm and cleanse turbidity. All tonifying agents are contraindicated in such cases. As for aphonia from long-standing illness, it is invariably due to Qi deficiency complicated by phlegm. One must nourish the source of transformation for the Lung and Kidney; Shengmai San combined with Xiadiqi Wan (Lowering Earth Qi Pill) is indispensable. For those with dry throat and withered voice, moistening the Lung is primary; Shengmai San combined with Yigong San (Yi-Gong Powder) is appropriate. If there is pain in the chest/diaphragm area, breaking blood stasis comes first; Daididang Wan (Dai Dang Pill) is most suitable.
There is also "tongue aphonia" (She Yin - inability to speak due to tongue stiffness), which must also be distinguished by new or old onset. New-onset tongue aphonia is definitely caused by wind-phlegm and should be treated according to the pattern of stroke-like disorders (Lei Zhongfeng). If an obese person has a short tongue unable to speak, or a stiff tongue root, Daotan Tang (Phlegm-Guiding Decoction) is the main formula. If after long-term illness or massive blood loss, the tongue becomes flaccid and speechless, it is treated as severe deficiency with cold. The key lies in accurate diagnosis during clinical examination. However, aphonia from stroke or acute disease often stems from long-term deficiency of True Qi in the Shaoyin channel. If accompanied by urinary incontinence and the Five Extinction signs, it is incurable.
If in winter, coughing with cold-phlegm knotting in the throat causes voice loss, this is cold pathogen lodging in the epiglottis, causing sudden aphonia. Maxing Gan Shi Tang (Ephedra, Apricot Kernel, Licorice, and Gypsum Decoction) or Gujin Luyan Xuming Tang (Ancient and Modern Record-Verified Reviving Life Decoction) can be selected. If aphonia persists despite diaphoretic and lung-moistening treatments, Shengmai San and Tongzhen Wan (Virgin Boy Pill) for sucking/melting are used. If cough, wheezing, rapid breathing, and chest fullness occur with voice loss, this is dryness of Lung and Stomach Qi failing to disperse residual pathogens; Ziwan San (Aster Powder) is the principal formula. There are also cases of shouting/cursing leading to hoarseness, throat damage, and aphonia, treated with Shiquan Dabu Tang (Ten Complete Tonifying Decoction). If Lung Qi is deficient and cold, injured by malignant wind, causing wheezing, cough, and hoarseness, or if heat was initially injured and then cold trapped the heat causing aphonia, Qianjin Sumi Gao (Thousand Gold Butter-Honey Paste) is used.
Furthermore, if sore throat appears on the 4th or 5th day, possibly due to severe coughing or thick phlegm knotting causing swelling and pain in the upper throat, the voice may be hoarse but still retain some sound, though turbid. The pulse is large and slow, with the Right Cun position particularly prominent. This indicates heat knotting in the Lung. Acrid-cool agents like Jiegeng Tang (Platycodon Decoction) added with Congbai (Scallion White), Jiangchi (Fermented Soybean), Jingjie (Schizonepeta), and Bohe (Mint) are suitable. If wind-cold pathogen is also present, Guizhi (Cinnamon Twig), Shaoyao (Peony), Shengjiang (Fresh Ginger), Dazao (Jujube), and Jiaoyi (Maltose) should be added. Huangbai (Phellodendron) processed with ginger and honey should be sucked. Astringent and descending drugs must never be used abruptly.
If sudden aphonia with voice loss, extreme throat pain, sudden onset, desire to cough but inability to do so, no sputum, or overflow of clear thin sputum occurs, and the pulse is wiry-tight or rapid and chaotic, this is severe cold invading the Kidney. Mahuang Fuzi Xixin Tang (Ephedra, Prepared Aconite, and Asarum Decoction) warms the condition, and Fuzi (Aconite Root) processed with honey is sucked. Cold-natured agents must not be used lightly. These two conditions (Heat Knotting in Lung vs. Severe Cold Invading Kidney) are as different as heaven and earth; they must be distinguished carefully. Aphonia before and after childbirth is detailed in the respective sections.
Shiwen treated Wang Rusong, a guest from Suzhou, who contracted cold upon arrival in Suzhou. He suddenly developed wheezing, aphonia, and swollen, painful throat. His physique was robust, and his appetite was normal. His pulse was floating and soft but became more forceful upon deep pressure. This indicated cold enveloping heat pathogen injuring the Lung collaterals. Thus, Maxing Gan Shi Tang was used, adding Banxia (Pinellia), Xixin (Asarum), and a large dose of Weirui (Polygonatum/Ophiopogon - specifically Yu Zhu here). After two doses, wheezing stopped and voice returned. Only slight pain remained during respiration. Further treatment with Erchen Tang, Zhike (Aurantium), Jiegeng (Platycodon), and Weirui resolved the issue.
Wang Wei yi had a history of hemoptysis years ago but was young and strong. In April, he suddenly developed cough. After taking diaphoretic medicines, he coughed up blood-streaked sputum several times. Subsequently, excessive intake of yin-nourishing medicines led to a raspy, hoarse voice and a sensation of Qi blockage in the chest, persisting for over a month. His brothers, Wang Qinzhong and Wang Dingzhong, invited me to examine him. The pulse was deep and choppy but became stronger upon deep pressure, and responsive upon light pressure. His body was plump and complexion lustrous, clearly not a Yin deficiency pattern. I stated: "Your hoarseness is 'Metal Solid Does Not Ring' (excess type), certainly not 'Metal Broken Does Not Ring' (deficiency type)." Therefore, a Phlegm-Dredging Decoction was used, adding Renzhonghuang (Human Excrement Cake) and Zexie (Alisma), focusing solely on clearing phlegm. After four doses, purple-black blood clots appeared in the sputum, and the voice gradually returned, though the rasping sound persisted. Later, Qiushi (Stone Urine) combined with Renzhonghuang, formed into pills with jujube paste, was taken. After one month, the voice became clear. Throughout the treatment, no Lung-clearing or Ying-Blood-nourishing herbs were used.
Feichou treated Guo Daigong, who ate little zongzi (sticky rice dumplings) on Dragon Boat Festival, resulting in fatigue and diarrhea. Previous attempts at digestive purgatives failed. He later fell while defecating, becoming comatose. Several days later, I examined him. The six pulses were weak and nearly imperceptible. The right arm could not move, and he was aphonic. Some suggested using Dahuang (Rhubarb) purgatives, but I urgently stopped them. This was extreme deficiency of Spleen and Lung Qi; how could it withstand such attacks? Even if there were correct formulas, the Stomach Qi might be exhausted, rendering drugs ineffective. Only rice gruel and Ginseng Soup were appropriate. As the saying goes, "If gruel enters the Stomach, the deficient will survive." Strictly following this advice, the diarrhea stopped, spirit calmed, voice gradually returned, and he awakened. After regaining appetite, only Ginseng Soup was used for recovery, and he healed without further medication.