痘疮最要声音清亮，若卒有失音者，凶兆也。先哲云∶疮已出而声不变者，形病也，其病轻。
疮未出而声先变者，气病也，其病甚。疮出而声不出者，形气俱病也。凡此失音之证，大为
痘疮所忌，然亦有吉有凶，须当详辨治之。
一、风寒外袭皮毛，壅闭肺窍，或致咳嗽而偶为失音者，此惟外感之证，宜解散之，
以加减参苏饮，或六安煎加薄荷、桔梗主之。或待风寒解散，其声自出，此固无足虑也。
一、火邪上炎，肺金受制，气道壅闭而声不出者，宜导赤散合甘桔汤加炒牛蒡子主之，或
用甘桔清金散。
一、上焦阳虚而声音低小不出者，此心肺不足之病。盖心主血，肺主气，痘疮稠密则血
气俱损，故声不能出，宜六物煎加麦门冬，或导赤通气散主之。
一、下焦阴虚而声不出者，其病在肝肾。盖肾为声音之根，若证由肝肾而痘疮稠密，则
精血俱为耗竭，水亏则肺涸，故声不能出，速当滋阴益水以救其本，宜大补元煎、五福饮，
或十全大补汤之类，酌宜用之。
一、凡啼哭无声而但见泪出，语言无声而但见口动者，此皆毒瓦斯归肾而内败也。或声
哑如破如梗者，此咽喉溃烂也，皆难治之证。
一、痘后余毒失音，其证有二∶一以咽痛不能言者，此毒瓦斯不净也，宜甘桔清金散加天
花粉。一以肾气虚不能上达而声不出者，宜治如前，或用四物汤加麦门冬、白茯苓。
The most critical aspect of smallpox is that the voice should be clear and bright. If sudden loss of voice occurs, it is an ominous sign. Ancient physicians stated: If the rash has erupted but the voice remains unchanged, it is a disease of the form (Xing), which is mild. If the voice changes before the rash erupts, it is a disease of Qi, which is severe. If the rash erupts but the voice does not emerge, both form and Qi are diseased. All such cases of aphonia are highly contraindicated in smallpox; however, there are both auspicious and inauspicious outcomes, requiring detailed differentiation and treatment.
1. When wind-cold external pathogens invade the skin and hair, obstructing the lung orifices, causing cough and occasional aphonia, this is merely an exterior contraction syndrome. It is appropriate to resolve the exterior using Jiajian Rensu Yin (Modified Ginseng and Perilla Decoction) or Liu'an Jian (Six-Safe Decoction) added with Bohe (Menthae Haplocalycis Herba) and Jiegeng (Platycodonis Radix). Alternatively, once the wind-cold dissipates, the voice will naturally return, which requires no concern.
2. When fire pathogenic factors flare upward, constraining Lung Metal (the Lung organ system associated with metal element), and blocking the airway leading to aphonia, it is appropriate to use Daochi San (Red-Draining Powder) combined with Ganjie Tang (Licorice and Platycodon Decoction) added with Chao Niubangzi (Fried Arctii Fructus), or use Ganjie Qingjin San (Licorice, Platycodon, and Lung-Clearing Powder).
3. When upper Jiao Yang deficiency results in low and faint voice unable to emerge, this is a disease of Heart and Lung insufficiency. Since the Heart governs Blood and the Lung governs Qi, dense smallpox lesions deplete both Qi and Blood, thus preventing voice emission. It is appropriate to use Liuwu Jian (Six-Material Decoction) added with Maidong (Ophiopogonis Radix), or Daochi Tongqi San (Red-Draining and Qi-Unblocking Powder).
4. When lower Jiao Yin deficiency results in aphonia, the pathology lies in the Liver and Kidney. The Kidney is the root of voice. If the condition stems from Liver and Kidney involvement with dense smallpox lesions, Essence and Blood are exhausted. Water deficiency leads to Lung dryness, preventing voice emission. One must quickly nourish Yin and replenish Water to save the root. Appropriate formulas include Dabu Yuanjian (Great Tonify Origin Decoction), Wufu Yin (Five-Favor Infusion), or Shiquan Dabu Tang (Perfect Ten Great Tonifying Decoction), selected according to suitability.
5. Cases where crying produces no sound but only tears flow, or speaking produces no sound but only mouth movements are seen, indicate that toxic vapors have returned to the Kidney causing internal collapse. Hoarseness resembling broken sounds or feeling blocked indicates throat ulceration; these are difficult-to-treat conditions.
6. Aphonia caused by residual toxins after smallpox recovery presents in two types: First, inability to speak due to sore throat indicates incomplete clearance of toxic vapors; treat with Ganjie Qingjin San added with Tianhuafen (Trichosanthis Radix). Second, inability to emit voice due to Kidney Qi deficiency failing to ascend should be treated as described above, or using Siwu Tang (Four-Substance Decoction) added with Maidong (Ophiopogonis Radix) and Baifuling (Poria).