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The symptom of mutism (aphasia) can be caused by both internal injury and external contraction. Mutism due to external contraction is known as Jin Kou Shang Han (Cold Damage with Clenched Jaw), a condition that exists in the world but lacks dedicated medical texts, hence this supplementary annotation. Mutism due to internal injury includes cases where the tongue is stiff; in these cases, consciousness remains clear, the mouth can open, but the root of the tongue is rigid, preventing speech. It also includes cases where the jaw is clenched; here, the tongue itself is not diseased, but the teeth are tightly locked, the mouth cannot open, and speech is impossible. Furthermore, there are cases of mutism due to clouded consciousness; the patient does not respond to calls or questions, appearing intoxicated or asleep, thus unable to speak.

There are five types of mutism due to external contraction:
1. At the onset, with aversion to cold and fever, if the exterior pathogen is not released through sweating, the pathogen fails to vent outward, leading to irritability, fever, panting, and thirst. Misidentifying this as interior heat and incorrectly administering cooling agents constitutes one type: mutism with clenched jaw caused by cold-natured herbs suppressing and obstructing the exterior pathogen.
2. Prolonged fever where the heat pathogen is not resolved; if fire-clearing measures are neglected and purgatives are missed when indicated, heat congestion blocks various orifices, preventing speech. This is one type of mutism due to interior heat and cloudiness.
3. If anger and food stagnation occur alongside an external wind-cold invasion, resulting in fever, delirious speech, and thirst without desire to drink water, observers may mistake delirium for interior heat. Consuming bitter, cold drinks causes congealing in the Middle Jiao. Consequently, mutism follows delirium. This is one type of mutism caused by cold-natured substances suppressing and obstructing food qi.
4. Internal accumulation of phlegm-fluids combined with external wind-cold invasion and mistaken consumption of raw/cold foods resembles Shang Han with Food Stagnation. This is one type of mutism caused by cold-natured substances suppressing and obstructing phlegm confusion. In all the above cases, even if constipation presents with indications for purgation, only Mang Xiao (Natrii Sulfas) and Xuan Ming Fen (Mirabilite) should be used to dissolve hardness, avoiding Da Huang (Rhei Radix et Rhizoma) which is heavy, turbid, and cloying.
5. Epidemic alien qi spreads door-to-door; warm toxins and damp toxins, sudden heat and cold, invade the hair follicles, potentially causing epidemic diseases. Sha toxins fail to vent outward, disturbing the Spirit internally, causing confusion of mind and consciousness, patients crossing hands and picking at empty air, with clenched jaws and mutism. This is one type of mutism due to epidemic toxins.

Treatment for mutism due to exterior pathogens: If the body surface is still hot, feet have no sweat, and the six pulses are floating, slippery, rapid, and active, or if pulses are deep, hidden, and indistinct, treatment should employ acrid-warm diaphoresis. During the three winter months in northern regions where the mouth is not dry, Ma Huang Tang (Ephedra Decoction) may be used; if the mouth is dry, Qiang Huo Bai Du San (Notopterygium Decoction for Resolving Toxins) is used. For the other three months, Ma Huang is omitted, and Qiang Huo Bai Du San is used directly, assisted by Shi Chang Pu (Acori Tatarinowii Rhizoma) and Ban Xia (Pinelliae Rhizoma) to open orifices and resolve phlegm. Cold-natured purgatives are strictly prohibited.

Treatment for mutism due to interior heat: If the body surface is not hot, hands and feet often have sweat, the mouth is dry, lips are scorched, and the six pulses are deep and rapid, interior heat should be cleared so that orifices become unobstructed. Dao Chi Ge Ban Tang (Half-Dao Chi Decoction) or Liang Ge San (Cooling the Diaphragm Powder) may be used. If there are indications for purgation, Cheng Qi Tang (Descending the Qi Decoction) should be administered.

Treatment for mutism due to food/qi stagnation: If there is fever and chest fullness, hands and feet may be cold or hot, lips are not scorched, the mouth is not thirsty, and the right pulse is slippery, large, and not rapid, or conversely deep and hidden, first employ emesis. Subsequently, regulate qi stagnation using formulas such as Bao He San (Preserve Harmony Powder) or Zhi Jie Ping Wei San (Bitter Orange and Platycodon Pingwei Powder) added with Shi Chang Pu and Bai Dou Kou (Amomi Fructus Rotundus). Add Gan Ge (Puerariae Radix) and Fang Feng (Saposhnikoviae Radix) if there is no sweat; add Qiang Huo (Notopterygii Rhizoma et Radix) if Tai Yang symptoms appear; add Chai Hu (Bupleuri Radix) if Shao Yang symptoms appear. If exterior pathogens are dispersed, and hands/feet occasionally sweat with constipation and indications for purgation, administer purgatives.

Treatment for mutism due to phlegm confusion: If there is chest/diaphragm fullness, nausea, vomiting, no mouth dryness/thirst, and the right Guan pulse is slippery, deep, wiry, and not rapid upon pressure, treat with Er Chen Dao Tan Tang (Two-Aged Phlegm-Resolving Decoction) combined with Ping Wei San (Calm the Stomach Powder), adding Zhi Ke (Aurantii Fructus Pericarpium) and Jie Geng (Platycodi Radix). Emesis may also be used to induce upward expulsion of phlegm. If exterior pathogens exist, add herbs for dispersing exterior pathogens from respective meridians. If exterior pathogens are dispersed and hands/feet occasionally sweat, take Zhi Lian Er Chen Tang (Gardenia and Coptis Two-Aged Decoction) mixed with Zhu Li (Bambusa Textilis Sap) while hot. If constipation persists with indications for purgation, use Zhu Li Dao Tan Tang (Phlegm-Resolving Decoction with Bamboo Sap) added with Xuan Ming Fen to purge.

Treatment for mutism due to epidemic toxins: First use Bai Du San (Toxin-Resolving Powder) to disperse the exterior. If there is chest fullness, emesis may be used, as emesis contains the principle of dispersion. If there is accumulated heat in the intestines/stomach with deep, rapid pulses, cool and clear toxicity, but do not abruptly use cold-natured herbs. Ancients used Bai Du San for epidemic toxins because heaven-and-earth pathogenic qi enters from outside and must exit via hair follicles; dispersion allows toxin to exit outward, whereas bitter-cold herbs suppress and obstruct the toxin.

Qiang Du Bai Du San (See Fever)
Dao Chi Ge Ban Tang (See Abdominal Pain)
Liang Ge San (See Mania)
Cheng Qi Tang (See Constipation)
Zhi Jie Ping Wei San: Ping Wei San plus Zhi Ke and Jie Geng.
Zhi Lian Er Chen Tang: Er Chen Tang plus Shan Zhi (Gardeniae Fructus) and Huang Lian (Coptidis Rhizoma).
Zhu Li Dao Tan Tang: Dao Tan Tang mixed with Zhu Li.

For mutism due to phlegm knotting, even if fire is present, one must guard against suppression by cold-natured herbs. This formula clears fire without stagnation and resolves phlegm without violent purging.

Qing Wei Tang (Stomach-Clearing Decoction)
Sheng Ma (Cimicifugae Rhizoma), Sheng Di (Rehmanniae Radix), Shan Zhi (Gardeniae Fructus), Huang Lian (Coptidis Rhizoma), Gan Cao (Glycyrrhizae Radix et Rhizoma)

Accumulated heat from rich/greasy foods congests the Middle Jiao, blocking orifices and preventing speech. Thus, this formula clears stomach heat to treat the root cause.