经义
帝曰∶人之卒然忧恚而言无音者，何道之塞？何气出行？使音不彰，愿闻其方。少师曰∶咽喉者，水谷
之道也。喉咙者，气之所以上下者也。会厌者，音声之户也。口唇者，音声之扇也。舌者，音声之机也。悬雍
垂者，声音之关也。颃颡者，分气之所泄也。横骨者，神气所使主发舌者也。是故厌小而疾薄，则发气疾，其
开阖利，其出气易。其厌大而浓，则开阖难，其出气迟，故重言也。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。（《灵枢》）
哲言
虚劳音哑者，喉喑也，由火热熏灼所致。中风音哑者，舌喑也，乃风中廉泉或心、脾、肾之络，以心脉系
舌本，脾脉络舌旁，肾脉循喉咙挟舌本故耳。
风中脏者，心神昏昧而不能言，但噫嘻作声。风痰者，舌本强硬而不能言。风热者，舌纵大满口而不能言。
寒中三阴者，舌短缩而不能言。内虚者，语言蹇涩而不明。劳嗽者，真气损伤，不能上通心肺，而语声不出。
亡血者，三阴脉虚而不能作声。叫
号失音者，风入会厌而不能开阖作声。咳嗽失音者，痰壅肺孔而不能出声。舌喑者，喉中有声而舌不能转掉。
喉喑者，喉不出声而舌能转掉。（《医阶辨证》）
有内热痰郁，窒塞肺金，声哑不出，及久咳气伤而散者，此内因也；有外受风寒，束其内热，嗽而声哑者，
此外因也；有争竞号叫，或歌唱伤气，而声不出者，此不内外因也。（《三因方》）
音声之发，肾主之。肾者，水也。水流则有声，常也。或激之鸣则变矣，如胃中大热而谵语是也。水止则
无声，如重身九月而喑，胞脉闭塞是也。水涸则无声，如肾损失音是也。○室女有无故而喑者，月闭也，亦胞
脉绝也。重身有胞脉绝者，月闭亦有胞脉绝者，皆瘀血阻塞少阴通舌本之道也。不治则成石瘕，可导而下之。（《医参》）
方书将失音与不能言合为一证，岂知失音者，舌能转运，喉中则寂然无声也；不能言者，舌强不能转运，
喉中格格难出，其声自在也。余以无声解之，自难与不能言者混呼矣。（《说疫》）
人有一生不能言者，此肺窍窒塞，肾气不能上通于咽，如管钥之固闭其窍，不能通呼吸之气也。（《见闻录》）
凡五脏之病，皆能为喑。忧思积虑，久而致喑者，心病也。惊恐愤郁，卒然致喑者，肝病也。风寒外袭，
火燥刑金，咳嗽而致喑者，肺病也。饥饱疲劳，致败中气，而喘促为喑者，脾病也。酒色过伤，欲火燔灼，以
致阴亏而盗气于阳，精竭而移槁于肺，肺燥而嗽，嗽久而喑者，肾水枯涸也。舌为心之苗，心病则舌不能转，
此心为声音之主也。声由气而发，肺病则气夺，此肺为声音之户也。肾藏精，精化气，精虚则无气，此肾为声
音之根也。经曰∶言而微，终日乃复言者，此气之夺也。而况无声者乎？是知声音之病，虽由五脏，而实惟心
之神、肺之气、肾之精三者为之主耳。然人以肾为根蒂，由精化气，由气化神，使肾气一亏，则元阳衰弱，所
以声音之标在心、肺，而声音之本则在肾。观之
《经》曰∶阳盛已衰，故为喑也。内夺而厥，则为喑痱。然则肾为声音之根，信非谬矣。○喑哑之病，当知虚
实。实者，其病在标，因窍闭而喑也；虚者，其病在本，因内夺而喑也。窍闭者，有风寒之闭，外感证也；火
邪之闭，热乘肺也；气逆之闭，肝气强也。风闭者可散而愈，火闭者可清而愈，气闭者可顺而愈，此皆实证之
易治也。内夺者，有色欲之夺，伤其肾也；忧思之夺，伤其心也；惊恐之夺，伤其胆也；饥馁疲劳之夺，伤其
脾也。此非各求其属而大补元气，安望其嘶败者复完，而残损者复振乎！此皆虚证之难治也。然犹有难易之辨
者，则辨其久暂，辨其病因，乃可悉焉。盖暂而近者易，渐而久者难；脉缓而滑者易，脉细而数者难；素无损
伤者易，积有劳怯者难；数剂即开者易，久药罔效者难。此外复有号叫歌哭，及因热饮冷，暴吸风寒而致喑者，
乃又其易者也。若是者，但知养息，则弗药可愈。（张景岳）
夫发声之本在肾，其标在肺。病有虚实，由咳嗽而起者居多。或肺有燥火，外感寒邪，火气郁遏而喑者；
有肺金燥甚，木火上炎，咽干喉痹而喑者；有风热痰涎，壅遏肺窍而喑者；有嗔怒叫号，致伤会厌而喑者；亦
有龙相之火上炎，凌烁肺金，久咳而喑者；有内夺而厥，则为喑痱，此肾虚也。金空则鸣，金实则无声，金破
碎亦无声，此三言足以该之矣。有邪者，肺家实也；无邪者，久咳损肺，金碎无声也。治法∶有寒者散寒，有
火者清火，有风痰者则祛风豁痰。若龙相上炎灼肺者，宜金水同治。若暴中之喑，属少阴之虚，宜峻补肝肾，
或兼治痰火。用药总宜甘润，不宜苦燥。（《临证指南》）
失音大都不越于肺，然以暴病得之，为邪郁气逆；久病得之，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。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。治用生脉散合
六味丸，所谓壮水之主，以制阳光也。（张路玉）
风寒之邪，客于肺中，滞而不发，故喑。宜服发散之药，不必治喑。以苏梗、荆芥各二钱，研汁，入酒半
盏和服，效。（《千金方》）
时令病，昏冒不能言语，承气汤主之。《经》云∶大肠之脉散舌下。大肠燥结，热气上蒸心肺，肺与大肠
相表里，以承气汤下去热结，自能言耳。（萧慎斋）
大惊入心，则败血顽痰填塞心窍，故喑不能言。治宜蜜陀僧散、远志丸、茯神丸。（《仁斋直指》）
脉候
搏阴为喑。○心脉搏坚而长，当病舌卷不能言。（《素问》）
选案
一小儿吐泻利，小便过多，以致脾虚不欲饮食。治用益黄散，服效。数日后，忽尔不语，知其脾气已复，
肾气尚虚。投以地黄丸数剂，遂能言。于是益信声音之根出于肾也，不诬。（钱仲阳）
一人力田辛苦，饥食骤饱，倦卧，醒后喑不能言。此劳倦伤脾，饥饱伤胃，阳明之气遏而不升，津液不
行，贲门壅涩，故言语不能出。以补中益气汤与服十剂，偶午睡觉，通身汗出，言语如常。（高鼓峰）
[Scriptural Principles]
The Yellow Emperor asked: When a person suddenly loses their voice due to sudden worry and anger, what pathway is blocked? Which qi mechanism malfunctions? Causing the voice not to emerge, I wish to hear the reasoning. Master Shao answered: The pharynx (throat) is the pathway for water and food. The larynx is the gateway for the ascent and descent of qi. The epiglottis is the gatehouse of sound production. The lips are the fan blades that project sound. The tongue is the pivot of articulation. The uvula is the latch of the voice. The nasopharynx is where divided qi is excreted. The transverse bone is governed by divine qi (shen) to direct the movement of the tongue. Therefore, if the epiglottis is small and thin, qi moves swiftly, its opening and closing are smooth, and exhalation is easy. If the epiglottis is large and thick, opening and closing are difficult, exhalation is slow, hence speech becomes slurred or heavy. Sudden aphonia occurs when cold pathogen lodges in the epiglottis, preventing it from moving; qi cannot ascend or descend properly, opening and closing fail to coordinate, thus no sound is produced. (From *Ling Shu*)
[Philosophical Discourses]
Aphonia caused by deficiency consumption is termed *Hou Yin* (laryngeal aphonia), resulting from scorching by fire-heat. Aphonia caused by stroke is termed *She Yin* (tongue aphonia), occurring when wind strikes the Lianquan acupoint or the collaterals of the Heart, Spleen, or Kidney, because the Heart meridian connects to the root of the tongue, the Spleen meridian runs along the sides of the tongue, and the Kidney meridian follows the throat and flanks the tongue root.
When wind strikes the zang organs, the heart spirit becomes confused, leading to an inability to speak, producing only sighing sounds. Wind-phlegm causes stiffness of the tongue root, preventing speech. Wind-heat causes the tongue to relax and fill the mouth, preventing speech. Cold striking the Three Yin meridians causes tongue retraction, preventing speech. Internal deficiency leads to hesitant and unclear speech. Chronic cough damages true qi, preventing it from ascending to the Heart and Lung, resulting in loss of voice. Blood loss empties the Three Yin meridians, causing inability to produce sound. Excessive shouting causes aphonia by allowing wind to enter the epiglottis, impairing its opening and closing. Cough-induced aphonia results from phlegm obstructing the lung orifices. *She Yin* presents with sound in the throat but an immobile tongue; *Hou Yin* presents with silence in the throat but a mobile tongue. (From *Yi Jie Bian Zheng*)
If there is internal heat and phlegm stagnation obstructing Metal (Lung), causing hoarseness, or if chronic cough damages Lung qi causing dispersion, this is an internal cause. If external wind-cold binds internal heat, causing cough and hoarseness, this is an external cause. If shouting during arguments or singing injures qi, causing loss of voice, this is neither purely internal nor external. (From *San Yin Fang*)
Sound production is governed by the Kidney. Kidney belongs to Water. Flowing water makes sound; this is normal. If stimulated to resonate, it changes, such as delirious speech caused by excessive heat in the Stomach. Still water makes no sound, such as aphonia in the ninth month of pregnancy due to obstruction of the Bao Mai (uterine vessels). Dry water makes no sound, such as aphonia due to Kidney essence depletion. ○ In young women, unexplained aphonia may be due to amenorrhea, also indicating severance of the Bao Mai. Pregnant women with severed Bao Mai, or those with amenorrhea and severed Bao Mai, all have blood stasis blocking the pathway of the Shaoyin meridian to the tongue root. If untreated, this becomes Shi Jia (stone mass); it can be treated with purgative methods. (From *Yi Can*)
Medical formularies often combine aphonia and mutism into one syndrome. However, aphonia involves a tongue that can move but produces no sound from the throat; mutism involves a stiff tongue unable to move, with difficulty articulating despite sound being present. Interpreting aphonia as "no sound" distinguishes it clearly from mutism. (From *Shuo Yi*)
Some individuals are mute from birth due to obstruction of the Lung orifice, with Kidney qi unable to ascend to the pharynx, similar to a locked lock preventing breath passage. (From *Jian Wen Lu*)
Diseases of any of the Five Zang organs can cause aphonia. Long-term worry and rumination leading to aphonia indicate Heart disease. Sudden shock, fear, or depression causing aphonia indicates Liver disease. External attack by wind-cold, with fire-dryness damaging Metal (Lung), causing cough and aphonia, indicates Lung disease. Irregular eating and fatigue damaging Middle Qi, leading to panting and aphonia, indicate Spleen disease. Excess alcohol and sexual activity burning yin, stealing qi from yang, exhausting essence and drying the Lung, leading to chronic cough and aphonia, indicates Kidney water depletion. The tongue is the sprout of the Heart; Heart disease prevents tongue movement, making the Heart the master of voice. Sound arises from qi; Lung disease depletes qi, making the Lung the gateway of voice. Kidney stores essence, which transforms into qi; essence deficiency leads to qi deficiency, making the Kidney the root of voice. The Classics state: "Speaking faintly, requiring a whole day to speak again, indicates qi depletion." How much more so for total silence? Thus, while voice disorders involve the Five Zang, they are primarily governed by the Spirit of the Heart, Qi of the Lung, and Essence of the Kidney. Since the Kidney is the foundation, transforming essence to qi and qi to spirit, Kidney qi deficiency leads to Yuan Yang weakness. Therefore, the manifestation of voice lies in the Heart and Lung, but the root lies in the Kidney. As stated in the *Classic*: "Excess yang followed by decline causes aphonia. Internal depletion with厥 (jue/counterflow) causes Yin Fei (aphonia with paralysis)." Thus, the Kidney being the root of voice is indeed correct. ○ Aphonia must be distinguished as excess or deficiency. Excess cases involve the branch (biao), caused by orifice obstruction; deficiency cases involve the root (ben), caused by internal depletion. Orifice obstruction includes wind-cold (external contraction), fire-pathogen (heat attacking Lung), and qi-reversal (strong Liver qi). Wind obstruction resolves with dispersal; fire obstruction resolves with clearing; qi obstruction resolves with smoothing. These are easy-to-treat excess cases. Internal depletion includes sexual excess injuring Kidney, worry injuring Heart, shock injuring Gallbladder, and hunger/fatigue injuring Spleen. Without tonifying Yuan Qi according to the affected organ, recovery is unlikely. These are difficult-to-treat deficiency cases. Difficulty varies by duration and etiology: recent/acute is easier than chronic; moderate/slippery pulse is easier than fine-rapid pulse; no prior injury is easier than chronic consumptive disease; quick response to herbs is easier than resistance to treatment. Additionally, aphonia from shouting, hot/cold drinks, or sudden wind-cold exposure is relatively easy to treat. Rest alone may suffice. (Zhang Jingyue)
The root of voice is Kidney; the branch is Lung. Diseases vary in excess and deficiency, mostly arising from cough. Causes include: Lung dry-fire combined with external cold; extreme Lung dryness with Wood fire flaming upward; wind-heat phlegm obstructing Lung orifices; anger/shouting injuring epiglottis; Dragon Fire and Ministerial Fire scorching Lung; or internal depletion with jue causing Yin Fei (Kidney deficiency). "Empty metal rings; solid metal is silent; broken metal is silent." This covers the three aspects. Pathogenic presence indicates Lung excess; absence of pathogen after chronic cough indicates Lung damage ("broken metal"). Treatment: Disperse cold, clear fire, expel wind-phlegm. For Ministerial Fire scorching Lung, treat Metal and Water together. For sudden aphonia due to Shaoyin deficiency, strongly tonify Liver and Kidney, or address phlegm-fire. Medications should generally be sweet and moistening, not bitter and drying. (*Lin Zheng Zhi Nan*)
Aphonia rarely exceeds Lung involvement. Acute onset indicates pathogen constraint and qi reversal; chronic onset indicates fluid exhaustion and blood dryness. Acute aphonia is usually cold enveloping heat, or internal heat followed by cold exposure, or external cold followed by cold diet. Treat with pungent-cool harmonization, slightly combined with pungent-warm dispersal. If throat is damaged, hoarse, and painful, it is fire-pathogen constraining Lung ("solid metal does not ring; broken metal does not ring"). Treat with Sheng Mai San combined with Liu Wei Di Huang Wan, i.e., strengthening the master of Water to control Yang. (Zhang Luyu)
Wind-cold lodging in Lung, stagnating without venting, causes aphonia. Use dispersing herbs; do not specifically treat aphonia. Use Su Geng (Perilla Stem) and Jing Jie (Schizonepeta) 2 qian each, crushed to juice, mixed with half cup wine. Effective. (*Qian Jin Fang*)
Seasonal diseases with coma and inability to speak are treated with Cheng Qi Tang. The Classic states: "The Large Intestine meridian spreads under the tongue." Large Intestine dryness causes heat steaming to Heart and Lung. Since Lung and Large Intestine are interior-exterior pairs, using Cheng Qi Tang to purge heat accumulation restores speech. (Xiao Shenzhai)
Great shock enters the Heart, causing bad blood and stubborn phlegm to block Heart orifices, leading to aphonia. Treat with Mi Tuo Seng San, Yuan Zhi Wan, or Fu Shen Wan. (*Ren Zhi Zhi Zhi*)
[Pulse Diagnosis]
Pulsation indicating Yin excess causes aphonia. ○ A Heart pulse that is firm and long indicates disease manifesting as tongue retraction and inability to speak. (*Su Wen*)
[Selected Cases]
A child suffered vomiting, diarrhea, and dysentery with excessive urination, leading to Spleen deficiency and anorexia. Treated with Yi Huang San with effect. Days later, the child suddenly stopped speaking. The physician deduced Spleen qi had recovered but Kidney qi remained deficient. Administered Di Huang Wan for several doses, and speech returned. This confirms the root of voice lies in the Kidney. (Qian Zhongyang)
A man worked hard in fields, ate suddenly when hungry, lay down exhausted, and woke up mute. This was fatigue injuring Spleen, irregular eating injuring Stomach, blocking Yangming qi from ascending, stopping fluid circulation, and obstructing the cardia, preventing speech. Given Bu Zhong Yi Qi Tang for ten doses. Upon waking from a nap, he sweated profusely and speech normalized. (Gao Gufeng)