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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.