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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.