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Listen to the patient's five tones (Wu Yin, referring to sounds associated with the five zang organs) to differentiate the disease. The Classics state: "Speaking faintly, only able to speak again after a whole day" indicates Duo Qi (loss of vital qi). If there is excess in the middle and fullness in the zang-fu organs, and the voice sounds as if coming from inside a room, this indicates dampness of the middle qi obstructed by summerheat and sweating, accompanied by vexation, thirst, and panting; yet when quiet, the patient speaks excessively. If the patient does not adjust clothing or bedding appropriately, speaks without distinguishing between good and bad words, and ignores distinctions between relatives and strangers, this indicates chaos of the Shen Ming (spirit/mind). If the patient's five zang organs have been severely depleted, the spirit cannot be retained, and the voice is hoarse, death ensues. If the patient picks at the seams of their clothes and speaks deliriously (Zhan Yu), it is untreatable. In cases of internal injury due to diet and overexertion, the patient has no desire to speak; even if they do, the voice will necessarily be timid, weak, and low, which is evidence of deficiency. In cases of external contraction of wind-cold, speech is necessarily light at first and heavy later, with a high pitch, strong and vigorous sound, which is evidence of excess.

Whenever the voice is hoarse (Sha), and speech sounds as if coming from an urn, light at first and heavy later, raised high and powerful, all are evidence of damage by wind qi causing stagnation. In cough due to phlegm-fire, if hoarseness gradually progresses to aphonia over time, death is inevitable. Hearing that the patient speaks with little strength and greatly lacks the desire to speak, with difficulty in distributing breath, indicates internal injury. If the patient speaks with strength and speaks incessantly without tiring, it indicates external injury. If both yin and yang qi of the patient are exhausted, leading to confusion and inability to speak, death occurs within three days. If the patient speaks wildly and confusedly, or is unable to speak and has no desire to speak, it is generally untreatable; however, if these symptoms occur in heat diseases, they may be treatable. In Shang Han (Cold Damage) disease, manifestations such as wild speech, delirium, solitary muttering, Zheng Sheng (repetitive, low-pitched speech), inability to speak, lack of desire to speak, or continuous wild delirium, all have distinctions between excess and deficiency.

My commentary: At the moment before death from any disease, there is invariably shortness of breath resembling panting, with a sawing sound in the throat, as if there were phlegm sounds, with respiration barely maintaining itself a few cun below the Renying point (ST9). This is because true yin is exhausted below, and lone yang escapes above, resulting in the floating of the hun and falling of the po, a sign of the separation of yin and yang, representing the extreme of shortness of qi. Originally, qi is governed by the Mingmen (Gate of Life) and tied to the right kidney. Exhaustion proceeds from the kidney to the liver, from the liver to the spleen, from the spleen to the heart, and from the heart to the lung. The lung is the gathering place of Zong Qi (Gathering Qi) and all other qi. When Yuan Qi reaches here, the convergence of various qi becomes vigorous and produces sound, just as water and wind interact to create waves. Only when the wind calms do the waves subside; only when the form dissipates due to the scattering of qi does the sound cease. Therefore, life and death depend on the gathering and scattering of qi, which is a necessary principle. Often, physicians at this juncture mistakenly attribute it to excessive fire and rising phlegm, administering Huoluo Niuhuang Wan (Calming Spirit and Resolving Phlegm Pill) and urging others to find it quickly, using drugs to attack phlegm and calm panting without discrimination, merely accelerating death. This is truly lamentable. Furthermore, before death actually occurs, if pulse and complexion indicate deficiency, treatment should focus on rescuing the root, administering Ginseng Radix et Rhizoma (Renshen) and Aconiti Lateralis Radix Praeparata (Fuzi). If the condition does not improve and the patient approaches death with panting, blame is often placed on the physician for mistakenly administering tonifying qi herbs, causing the patient lifelong regret and the physician unjust accusations. Who can clarify that this is the escape of yuan qi upwards, a terminal syndrome resembling panting but not quite panting, resembling phlegm but not quite phlegm? It is common to see patients frequently taking draining agents during illness, only to exhibit panting at the end; whom should one blame then? Do they not know that Renshen and Fuzi are essential herbs for grasping qi? Even when the disease enters a fatal stage but does not immediately cause death, lingering for ten days or more, it is due to the power of these herbs, though most people are unaware. There are also cases where, without prior illness, dizziness of the head and eyes occurs, with throat sounds resembling panting; this is a sudden syndrome of qi deficiency, characterized by a deep and hidden pulse, or fine as a thread. Only by urgently administering large doses of Renshen and Fuzi is survival possible. However, if the six pulses escape upwards, being rapid, slippery, flooding, and large, or wiry, hard, and beating against the finger, combined with closed eyes and open mouth, scattered hands and urinary incontinence, sweating, coarse breathing, flushed face like makeup, exhalation without inhalation, sunken eyeballs, and cold limbs, it is untreatable. There are also cases of sudden syncope with loss of consciousness and silent breathing; waiting briefly allows qi to recover and spontaneous awakening to occur; do not disturb or agitate. This is caused by extreme fatigue or anger leading to failure of middle qi to ascend, not a sign of yuan qi exhaustion. There are also cases of lung injury from wind-cold, with phlegm obstruction causing panting, or locked jaw; if pulse and symptoms match, administering Kaiguan San (Opening Orifices Powder), Suhexiang Wan (Styrax Pill), or Niuhuang Wan (Calming Spirit Pill) to resolve phlegm and smooth qi often leads to recovery. There are also cases of sudden death due to long-term deficiency of true qi, with silent breathing; this is not due to pathogenic factors, but rather the exhaustion of qi and self-severance. Thus, diagnosis through listening to sounds must be carefully differentiated.