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Yin (loss of voice) is caused by pathogenic factors invading the Yin aspect. The Classics state: "When pathogenic factors contend with the Yin, loss of voice occurs." It also states: "When pathogenic factors enter the Yin and contend, it results in loss of voice." However, there are two main syndromes: one is She Yin (tongue-related loss of voice), which belongs to the type where stroke causes impairment of tongue movement; the other is Hou Yin (throat-related loss of voice), which belongs to the type where chronic coughing leads to hoarseness or aphonia. Generally speaking, She Yin involves only the inability of the root of the tongue to move flexibly to assist speech, while the sound produced by the throat remains normal. Hou Yin involves only hoarseness of the throat, while the root of the tongue can still move flexibly to assist speech.

[She Yin] The Classics state: "Severe stagnation of the Heart pulse leads to loss of voice." It also states: "A firm and long Heart pulse indicates a disease of tongue retraction and inability to speak." Lou Quanshan stated: "When a person's tongue is short and speech is indistinct, it is due to phlegm-fluid obstructing the meridians connected to the root of the tongue." I once treated a middle-aged man suffering from Shanghan (cold damage) with fever. After taking five doses of Shanghan medicine prescribed by another doctor, his condition worsened to stupor and aphasia. I then treated him for constitutional deficiency with phlegm-dampness, using Ren Shen (Ginseng Radix et Rhizoma) 5 qian, Huang Qi (Astragali Radix), Bai Zhu (Atractylodis Rhizoma), Dang Gui (Angelicae Sinensis Radix), and Chen Pi (Citri Reticulatae Pericarpium) each 1 qian, decocted in water, with Zhu Li (Bambusae Caulis in Taenia) and Jiang Zhi (Zingiberis Recens Juice) added. After twelve days, he could utter only one word. After another half-month of treatment, his tongue gradually regained flexibility for speech, the heat subsided, and he recovered. This is because the Foot-Shaoyin Kidney meridian flanks the root of the tongue, the Foot-Taiyin Spleen meridian connects to the root of the tongue, and the Hand-Shaoyin Heart meridian's branch ties to the root of the tongue. When these three meridians are deficient, phlegm-fluid takes advantage of the deficiency to obstruct the meridians, causing the tongue to lose its ability to move and articulate. If blood is lost in these three meridians, the tongue lacks blood nourishment and becomes aphonic. The Classics state: "If the Foot-Shaoyin meridian is punctured causing severe deficiency and bleeding, the tongue will be difficult to move for speech." It also states: "Excessive puncture of the vessels under the tongue leading to continuous bleeding causes loss of voice." Treatment should involve adding blood-nourishing herbs to the previous formula. I also treated a man over fifty who, after vomiting approximately one bucket of blood due to alcohol abuse and ceasing food intake, could not speak but felt thirsty and drank water; his pulse was slightly rapid. I prescribed Dang Gui (Angelicae Sinensis Radix), Chuan Xiong (Ligustici Chuanxiong Rhizoma), Bai Shao (Paeoniae Radix Alba), and Shu Di Huang (Rehmanniae Radix Praeparata) each 1 liang, Bai Zhu (Atractylodis Rhizoma) and Ren Shen (Ginseng Radix et Rhizoma) each 2 liang, Chen Pi (Citri Reticulatae Pericarpium) 1.5 liang, and Gan Cao (Glycyrrhizae Radix et Rhizoma) 2 qian, with Zhu Li (Bambusae Caulis in Taenia), Tong Bian (Infant Urine), and Jiang Zhi (Zingiberis Recens Juice) added. After more than twenty doses, he could speak. If wind-heat invades these three meridians, the meridians become flaccid and lax, causing the tongue to be lax and unable to move, resulting in aphonia. If wind-cold invades, the meridians contract and spasm, causing the tongue to be stiff and retracted, resulting in aphonia. Treatment should follow the methods for treating stroke with hemiplegia. Danxi treated a thirty-five-year-old man who, after shouting continuously due to fatigue, developed malaria. After three attacks following treatment with malaria medicines, he developed fever, tongue retraction, indistinct speech, and rattling phlegm in the throat. His pulse was surging, rapid, and seemingly slippery. I administered Du Shen Tang (Single Ginseng Decoction) with Zhu Li (Bambusae Caulis in Taenia) equivalent to two clam shells. After two doses, he expectorated three pieces of gelatinous phlegm, his tongue root returned to normal, and speech became clear. As other symptoms persisted, I decocted and administered Ren Shen Huang Qi Tang (Ginseng and Astragalus Decoction). After half a month of this, all symptoms receded. He then recovered his ability to stand after two months of dietary supplementation with congee.

There are two acupuncture methods for treating aphonia: First, select the Spleen meridian. The Classics state: "Pathological changes in the Foot-Taiyin Spleen meridian cause stiffness of the tongue root; treat according to excess, deficiency, heat, cold, or sinking conditions." Second, select the Heart meridian. The Classics state: "The branch of the Hand-Shaoyin Heart meridian is named Tongli (HT5), located 1.5 cun above the wrist crease, ascending into the heart and tying to the root of the tongue. In deficiency cases where speech is impaired, select the point 1 cun behind the palm."

[Hou Yin] The *Lingshu Jing* (Spiritual Pivot), chapter "Worry and Anger Without Speech," records: The Yellow Emperor asked Shaoshi: "What causes sudden loss of voice due to worry and anger? Which pathway is blocked? What abnormal qi movement prevents sound projection? I wish to hear the explanation." Shaoshi replied: "The pharynx is the pathway for water and grain. The larynx is the passage for qi ascent and descent. The epiglottis is the door of sound. The lips are the fan of sound. The tongue is the mechanism of sound. The uvula is the gate of sound. The Hangsang (nasopharynx) is where divided qi escapes. The Henggu (hyoid bone) is directed by spirit qi and primarily controls tongue movement. Therefore, if nasal discharge cannot be contained, it is because the Hangsang is not opening, and the function of dividing qi is lost. Thus, those with small and thin epiglottides emit sound quickly, open and close easily, and exhale air readily; those with large and thick epiglottides have difficulty opening and closing, exhale air slowly, and thus speak with a heavy voice. Sudden aphonia occurs when cold pathogen lodges in the epiglottis, preventing it from opening or closing properly, leading to dysfunction of opening and closing, hence no sound." The Yellow Emperor asked: "How to treat with needling?" Qibo replied: "The Foot-Shaoyin Kidney meridian ascends to tie to the tongue, connects to the Henggu, and terminates at the epiglottis. By draining the blood vessels twice, turbid qi is expelled. The epiglottis meridian connects upward to the Ren Mai (Conception Vessel); selecting Tian Tu (CV22) allows the epiglottis to function."

The *Zabing Pian* (Miscellaneous Diseases Chapter) of the *Lingshu* states: When jue qi (rebellious qi) travels to the throat causing aphonia, accompanied by cold extremities and constipation, select the Foot-Shaoyin meridian. Danxi treated Yu Jidao for seminal emission. Due to mistakenly consuming Ren Shen (Ginseng Radix et Rhizoma) and ascending-floating agents, qi became congested in the upper jiao, causing aphonia and inability to vocalize. He used Xiang Fu (Cyperi Rhizoma) soaked in Tong Bian (Infant Urine), ground into powder and taken with liquid, to unblock the upper jiao and treat aphonia. He also prepared pills using Ha Fen (Concha Meretricis) and Qing Dai (Indigo Naturalis) as the sovereign herbs, with Huang Bo (Phellodendri Cortex), Zhi Mu (Anemarrhenae Rhizoma), and Xiang Fu (Cyperi Rhizoma) as minister herbs, to tonify the lower jiao and treat seminal emission. He recovered well after ten days.

From *Shengyin Fang* (Formula for Voice): He Zi (Terminalia Chebulae Fructus) processed and pitted, Mu Tong (Akebiae Caulis) each 1 liang, Gan Cao (Glycyrrhizae Radix et Rhizoma) 0.5 liang. Decoct in 3 sheng of water until 1.5 sheng remains. Add 1 he of Sheng Jiang (Zingiberis Rhizoma Recens) and Di Huang Zhi (Rehmanniae Juice). Boil briefly. Warm and divide into six doses. Take after meals, using half the material daily. Hejian's He Zi Tang (Chebula Decoction): He Zi (Terminalia Chebulae Fructus) descends rebellious qi and breaks stagnation; Mu Tong (Akebiae Caulis) unblocks orifices; Jie Geng (Platycodonis Radix) unblocks Lung qi; Tong Bian (Infant Urine) clears fire and moistens lungs. Hence, these formulas are commonly used together.

Fasheng San (Voice-Unblocking Powder) opens knotted phlegm. *Zhouhou Fang* (Handbook of Prescriptions for Emergencies): Chen Pi (Citri Reticulatae Pericarpium) 5 liang, water 3 sheng. Boil to obtain 1 sheng. Strain and take in one dose to drain stagnant qi and descend phlegm. *Qianjin Fang* (Essential Prescriptions Worth a Thousand Gold) states: "When wind-cold pathogen lodges internally, stagnating and failing to disperse, aphonia results. It is appropriate to use exterior-releasing drugs; there is no need to specifically treat aphonia." Use Zijie Jingjie Gen (Radix Schizonepetae cum Radice) 1 liang, crush and extract juice, mix with wine, warm and take half a zhan at any time. Another prescription: Ou Gen (Nelumbinis Rhizomatis Rhizoma) 2 liang, extract juice, mix with one large zhan of wine, warm and take half a zhan at any time. These all treat wind-cold induced aphonia. In winter, cold-phlegm knots in the throat causing obstruction and aphonia. The Classics state: "Cold pathogen lodging in the Huian (epiglottis) causes sudden muteness." Treat with Yufen Wan (Jade Powder Pill). For evil qi in the lungs, accumulated blood in the chest causing pain and aphonia, use Gejie Wan (Gecko Pill). For sudden cough with aphonia, use Rundao Tongsheng Gao (Moistening Dryness and Unblocking Voice Ointment). Cough with hoarseness is due to blood deficiency with heat. Use Qing Dai (Indigo Naturalis) and Ha Fen (Concha Meretricis), mixed with honey and taken. Huai Hua (Sophorae Flos), roasted on a tile until fragrant, cooled on the ground to remove fire toxicity, taken freely after midnight while lying supine, treats heat-induced aphonia. Xing Ren (Armeniacae Semen Amarum) 3 fen, peeled and tip removed, stir-fried, ground separately into paste, mixed with Gui (Cinnamomi Ramulus) 1 fen. Form a pill size of an apricot pit, wrap in cotton, hold in mouth, swallow saliva slowly. Take 5 times day and 3 times night. Another method: Place Gui Mo (Cinnamomi Ramulus Powder) under the tongue, swallowing saliva is excellent; this treats cold-induced aphonia. Sun Zhao's Koujue says: "Eunuch Cao Dushi built a new house and moved in. Half a month later, after getting heavily drunk, he woke up with aphonia and could not speak. Sun Zhao used Buxin Qi Shuyu Wan (Ginseng and Dioscorea Pill to Tonify Heart Qi), using Xi Xin (Asari Radix et Rhizoma) and Chuan Xiong (Ligustici Chuanxiong Rhizoma) to treat dampness. After ten days, the illness gradually decreased; after twenty days, full recovery. When Cao recovered and saw the Emperor asking who treated him, saying it was Physician Sun Zhao, the Emperor summoned Sun Zhao and asked: 'What disease did Cao suffer?' Sun Zhao answered: 'All wall mud in new houses is damp, and the ground is yin-heavy. When people first arrive, the yin qi has not dispersed. Cao's Heart qi was originally deficient. Getting drunk opened all hair pores, allowing yin-damp qi to enter and attack the Heart meridian. Since the Heart meridian was deficient, dampness took advantage. Thus, he could not speak. I first used Shuyu Wan to strengthen Heart qi, then used Chuan Xiong and Xi Xin to remove dampness, so he could speak.'"

There are two types of Yunqi (Five Movements and Six Qi) induced aphonia: One is heat assisting Heart excess. The Classics state: "In the recurrence of Shaoyin, sudden aphonia occurs; treat with bitter-cold drugs." Two is cold attacking Heart deficiency. The Classics state: "When Year Fire is insufficient, cold dominates greatly, and people suffer sudden aphonia; treat with salty-warm drugs."

Huo Huo (Huohuo disease) with hoarse voice presents with silence, desire to sleep, inability to close eyes, and restlessness.

There are three acupuncture methods for treating aphonia: First, select the Foot-Shaoyin meridian, referring to the two Classic passages cited at the beginning of the chapter. Second, select the Foot-Yangming meridian. The Classics state: "The branch of the Foot-Yangming Stomach meridian is named Fenglong (ST40), located 8 cun above the malleolus, diverging to connect with the Taiyin, descending to link the throat. Its pathology involves rebellious qi causing throat bi and sudden aphonia; select the divergence point." Lou Quanshan treated a forty-nine-year-old man with chronic phlegm-cough. Suddenly, after contracting wind-cold and consuming alcohol and meat, he suffered from jue qi traveling to the throat causing sudden aphonia. He moxa'd Fenglong (ST40) on the Foot-Yangming meridian with three moxa cones on each side, and Zhaohai (KI6) on the Foot-Shaoyin meridian with one cone on each side. His voice immediately returned, confirming the truth of the Sacred Classics. He then used Huang Qin (Scutellariae Radix) as sovereign herb to clear fire, Xing Ren (Armeniacae Semen Amarum), Chen Pi (Citri Reticulatae Pericarpium), and Jie Geng (Platycodonis Radix) as minister herbs to drain jue qi, He Zi (Terminalia Chebulae Fructus) to drain rebellious qi, and Gan Cao (Glycyrrhizae Radix et Rhizoma) as assistant herb to harmonize yuan qi. He recovered well. Third, select the Hand-Yangming meridian. The Classics state: "For sudden aphonia and qi choking, select Futu (LI18) and Sheben (Lianquan/CV23) to induce bleeding. Sheben refers to the Lianquan acupoint."

[Pregnancy Aphonia] The *Suwen* records: The Yellow Emperor said: "Why does a pregnant woman lose her voice in the ninth month?" Qibo replied: "Because the collateral vessels of the uterus are obstructed." The Emperor asked: "Why do you say so?" Qibo replied: "The uterine collaterals are tied to the Kidney. The Shaoyin meridian passes through the Kidney and ties to the root of the tongue, hence the inability to speak." The Emperor asked: "How to treat?" Qibo replied: "No treatment is needed. It will recover in the tenth month. (Wang Bing's commentary: Shaoyin refers to the Kidney meridian. Qi fails to nourish, hence the inability to speak.)"

[Postpartum Aphonia] Chen Shi stated: "Postpartum muteness is due to Heart qi deficiency failing to communicate with the tongue, causing tongue stiffness and inability to speak. It is appropriate to consume Zhenzhen San (Seven Treasures Powder). I should deduce the cause and treat accordingly." Xue Xinpu stated: "The Classics state the Large Intestine meridian scatters below the tongue. It also states pathological changes in the Spleen meridian cause tongue stiffness and inability to speak. It also states the branch of the Kidney meridian enters the Heart system and ties to the root of the tongue; deficiency leads to inability to speak. I believe that for the aforementioned syndromes, if Heart and Kidney qi are deficient, use Zhenzhen San. If Kidney deficiency with wind-heat, use Dihuang Yin (Dihuang Decoction). If Large Intestine wind-heat, use Jiawei Xiaoyao San (Modified Free and Easy Wanderer Powder) plus Fang Feng (Saposhnikoviae Radix) and Bai Zhi (Angelicae Dahuricae Radix). If Spleen meridian wind-heat, use Qin Jiao Sheng Ma Tang (Belamcanda and Ligusticum Decoction). If Liver meridian wind-heat, use Chaihu Qinggan San (Bupleurum Liver-Clearing Powder) plus Fang Feng (Saposhnikoviae Radix) and Bai Zhi (Angelicae Dahuricae Radix). If Spleen qi stagnation, use Jiawei Guipi Tang (Modified Restore the Spleen Decoction) plus Sheng Ma (Cimicifugae Rhizoma). If Liver wood is excessive, use Xiao Chaihu Tang (Minor Bupleurum Decoction) plus Gou Teng (Uncariae Ramulus Cum Uncis). If Spleen suffers from Earth counter-restriction (Wood insulting Earth), use Liu Jun Zi Tang (Six Gentlemen Decoction) plus Sheng Ma (Cimicifugae Rhizoma), Bai Zhi (Angelicae Dahuricae Radix), and Gou Teng (Uncariae Ramulus Cum Uncis). If Liver and Spleen blood are deficient, use Foshou San (Buddha's Hand Powder). If Spleen qi is deficient, use Sijun Zi Tang (Four Gentlemen Decoction). If both qi and blood are deficient, use Bazhen Tang (Eight Treasures Decoction); if ineffective, use Dushen Tang (Single Ginseng Decoction); if still ineffective, urgently add Fu Zi (Aconiti Lateralis Radix Praeparata) to tonify qi and generate blood. Using blood-tonifying drugs directly would be a mistake." Guo Shi discussed that the human Heart has seven apertures and three hairs. Postpartum weakness often leads to retained bloody stasis blocking the Heart apertures, causing unclear spirit and consciousness. Heart qi communicates with the tongue; if Heart qi is blocked, the tongue becomes stiff, causing muteness. Simply consume Zhenzhen San. Hu Shi's Gufeng Dan San (Lone Phoenix Pill Powder) treats postpartum closed-eye muteness. Use Bai Fan (Alumen) finely ground, take 1 qian per dose, mixed with hot water.