Coughing Up Blood Every Year, Phlegm Choking the Throat, Breathless at the Slightest Movement? — Doctor Zhang Xichun Treated Sinking of the Great Qi (da qi xia xian) with Hemoptysis
Patient search terms: spitting blood / coughing up blood / blood in the sputum / too much phlegm / wheezing at the slightest movement / blocked urination / a swollen body / blood in the urine Medical terms: sinking of the great qi · hemoptysis · copious phlegm and drool · qi failing to command blood · blocked urination
Opening: when qi sinks down, why does blood run upward?
We have spent many days on sinking of the great qi (da qi xia xian, 大气下陷), and by now everyone knows its favorite trick: it likes to make trouble downward — the qi sinks, and so you get blood in the stool, blood in the urine. But today Doctor Luo is going to tell two stories that run the opposite way: two middle-aged men in their forties — one who spit blood every year, one whose urine would not flow and whose whole body swelled — and when Doctor Zhang Xichun examined them, the root of both illnesses was sinking of the great qi. Qi is supposed to sink in this condition, so why does blood come out of the mouth instead? In this case, Doctor Zhang Xichun took the principle apart and explained it to the last thread.
Who was the first patient? Forty-something, spitting blood two or three times a year — for four years running
The first patient was in his forties, right at the middle of life. His illness sounds frightening: he spit blood two or three times a year, for four years, and every year it got worse.
💬 Note from Doctor Luo: Here we must first sort out a character. In the old usage, “spitting blood” (tu xue, 吐血) and “coughing up blood” (ke xue, 咳血) were kept separate — generally speaking, “spitting blood” meant blood coming from the stomach; blood from the lungs was called “coughing up blood.” In Doctor Zhang Xichun’s case, reading further, the blood came from the lungs, so this should be counted as hemoptysis — except that in the old days all blood came out of the mouth, so it was all lumped together as “spitting blood.” When you read an old case record with the words “spitting blood,” first ask yourself: is this blood coming from the stomach or from the lungs?
Besides the bleeding, the man also coughed constantly, and he had copious phlegm and drool (tan xian yong sheng) — so much phlegm, in fact, that he wheezed at the slightest exertion, breathless at any movement; he also often felt short of breath, and with a little exercise the qi simply ran out. He dragged on like this for four years before he finally came to Doctor Zhang Xichun.
💬 Note from Doctor Luo: Coughing is mostly caused by external contraction — wind-cold or wind-heat makes you cough. But there is a large category of internal injury coughs as well: liver fire attacking the lungs causes cough; lung yin deficiency with dryness-heat causes cough; even yang deficiency can cause cough — we seldom mention lung yang deficiency, but the lungs’ yang can be insufficient too; and spleen deficiency with dampness, or excessive phlegm-dampness, also produces cough. So internal-injury coughs are extremely common. In this case, “copious phlegm, wheezing at the slightest movement, and frequent shortness of breath” tell you that the upright qi was already severely depleted.
Reading the pulse: deep, slow, faint and weak — with the right cun position especially lifeless — sinking of the great qi
When Doctor Zhang Xichun took the pulse, he found it deep, slow, faint and weak (chen chi wei ruo) — pressed down, the beat was a little slow and extremely faint, and the right cun pulse (which corresponds to the lungs) was especially weak. Doctor Zhang Xichun knew at once: sinking of the great qi.
💬 Note from Doctor Luo: Patients in that era were truly fortunate. Doctor Zhang Xichun was in Shenyang — then called Fengtian — where he had opened China’s very first hospital of Chinese medicine, the Lida Hospital of Chinese Medicine (Li Da Zhong Yi Yuan), and saw patients there. To find him was a stroke of real luck.
The prescription: Shengxian Tang as the base, with long gu, mu li and sheng di huang — three doses stopped the bleeding
Having diagnosed sinking of the great qi, Doctor Zhang Xichun prescribed Shengxian Tang (升陷汤, the Decoction for Lifting the Sunken), but with a small change: he added long gu (dragon bone) and mu li (oyster shell), plus sheng di huang (raw Rehmannia), 6 qian (~18 g) each, and increased zhi mu (Anemarrhena) from the original amount to 5 qian (~15 g). After three doses, the illness was cured. For aftercare, Doctor Zhang Xichun removed the sheng ma (cimicifuga) from the formula and had the patient take several more doses to consolidate — and the case closed.
💬 Note from Doctor Luo: One point worth flagging — the long gu and mu li in Doctor Zhang Xichun’s formula were all raw (sheng) — not the calcined long gu and calcined mu li commonly used today. He himself believed raw dragon bone and raw oyster shell work best. Later he explains in detail why he added these two herbs in this particular case.
At this point Doctor Luo paused to sigh: Doctor Zhang Xichun’s cases are sometimes genuinely hard to lecture on, because they are too simple — the diagnosis is accurate from the start, the prescription goes straight in, and often two or three doses, three or five doses, and the illness is gone. And the cases he compiled name names — he even writes down which organization the patient belonged to, absolutely true. That is why Doctor Luo often says: if every Chinese medicine doctor were like Doctor Zhang Xichun, there would be no such thing as “anti-Chinese-medicine” sentiment — people would be begging you to treat them.
Question one: if the qi is sinking, why does the blood run upward?
The case looks simple, but the real lessons are all in the commentary. At the time, someone asked Doctor Zhang Xichun: in most cases of spitting blood, the qi is moving upward — the qi rebels upward, disrupts the normal mechanism of qi, and only then does the patient spit blood. But this illness is sinking of the great qi — isn’t the qi going down? By that logic it should be blood in the stool, or blood in the urine as we saw earlier — how can the blood run upward to the mouth?
Doctor Zhang Xichun’s explanation had two layers:
Layer one: the lungs lose their nourishment and the lung network is injured. Once the great qi sinks, the lungs lose their nourishment and both heart qi and lung qi become very weak. When lung qi is deficient, the patient coughs constantly — this is a cough born of deficiency; and when coughing goes on long enough, the lung network (fei luo) is injured, and the result is easy bleeding — spitting blood.
Layer two: the great qi is the commander of the qi of the whole body. The great qi dwells in the chest, and it is supremely important — it commands all the qi of the body. When the great qi sinks and weakens, the body’s qi has no commander; the qi runs wild, and sometimes it rebels upward — so although sinking of the great qi sends qi downward, giving blood in the urine and blood in the stool, there are also cases where blood runs upward: some patients bleed from the nose, some cough blood out, and some women have their menses run in reverse — this is called “daojing” (倒经, retrograde menstruation).
💬 Note from Doctor Luo: Remember this: bleeding caused by sinking of the great qi runs both downward and upward. In fact, sinking of the great qi and qi deficiency are the same thing at bottom — qi is the commander of blood; when a person’s qi becomes deficient, the blood loses its commander and runs wild. Look at a qi-deficient woman: her menstrual flow is unusually heavy and pale in color. What does that tell you? It tells you the qi that commands the blood is insufficient — and at that moment you should tonify her qi. So many blood disorders are tied to qi deficiency: bleeding does not always mean fire or heat. Sometimes when the deficiency is deep enough, the blood loses the command of qi and simply comes out on its own.
Question two: if you want to lift the qi, why use long gu and mu li, which pull downward?
Someone else asked: long gu and mu li are astringent herbs — they gather and pull downward. The great qi is sinking, the qi is moving down, and you should lift the qi upward — why instead use these two herbs that draw things inward and down?
Doctor Zhang Xichun’s answer is just as brilliant: yes, the great qi is sinking — but the man is also bleeding. At this point, using only qi-tonifying, qi-lifting herbs alone would likely make the bleeding worse. So the formula lifts on one side — chai hu, sheng ma, jie geng carry the qi upward — while long gu and mu li gather it inward on the other: lift the qi on one side, yet do not let the bleeding get worse, do not let the lifting overshoot.
💬 Note from Doctor Luo: Doctor Zhang Xichun also had a private method here: long gu and mu li have the function of resolving stasis. He used raw long gu and raw mu li partly to gather — but to a large extent to resolve stasis: when you bleed, the blood has left its vessels, which means stasis is forming. At that moment, activating blood and resolving stasis lets the stasis dissolve and the blood return to its proper channels — only then does the bleeding stop. This is Doctor Zhang Xichun’s private method with long gu and mu li; he often added these two herbs to his tonifying formulas.
Bonus master’s method: even Zhu Weiju, when warming yang, paired it with long gu and mu li to “keep a lid on it”
At this point Doctor Luo added a bonus story about a famous doctor — in Republican-era Shanghai there was a renowned physician named Zhu Weiju (祝味菊), a famous master of the yang-warming school (the Fire Spirit school, huo shen pai). When he warmed yang — using fu zi (aconite), gan jiang (dried ginger) and the like — he would often pair them with long gu and mu li.
💬 Note from Doctor Luo: Why did Doctor Zhu Weiju do this? The logic is the same — gathering. I tonify your yang on one side and gather it on the other, so that after the yang is built up, fire does not burst out of the upper body. This is how some masters work. From now on, when you read Republican-era cases and see yang-warming paired with long gu and mu li, you will know the trick.
The second patient: blocked urination, a swollen body, and so much phlegm he could hardly breathe
Now the second case. This patient was also in his forties. What was wrong with him? Blocked urination (xiao bian bu li) — his urine would never flow smoothly; and swelling over the whole body (zhou shen man zhong) — his body was swollen, especially below the waist, where the swelling was worse: when dampness is heavy it moves downward, so the lower body swells badly. At the same time the upper burner was stuffed with phlegm and drool — so much phlegm that it blocked his airway and he could barely breathe. And he coughed blood-streaked sputum, and his urine also had a bloody tinge from time to time.
The illness had dragged on for half a year; doctor after doctor had been called, none had cured it, and the more it was treated the worse it grew. With no other option, he came to Doctor Zhang Xichun’s hospital.
Taking the pulse: slippery and forceful (hua er you li). Doctor Zhang Xichun suspected damp-heat congestion — too much damp-heat in the body. When asked, yes — the man felt heat in his chest. The judgment was right, so the formula was written: heavy doses of hua shi (talc) and bai shao (white peony) to drain damp and seep out the damp-heat; plus a little chai hu (bupleurum) and some ru xiang and mo yao (frankincense and myrrh) to free the movement of qi.
💬 Note from Doctor Luo: Watch the thoroughness of a great doctor — Doctor Zhang Xichun thought: this man has been ill a very long time, so his body must be weak; if I only dredge him a little, I fear his upright qi is insufficient and he cannot withstand the draining. So in every dose he added sheng shan yao (raw Chinese yam), 1 liang (~30 g) — a fairly large amount — for what? To fortify upright qi and tonify the spleen. Copious phlegm and drool is itself a sign of spleen deficiency — when the spleen is deficient, dampness is heavy, so tonifying the spleen hits the mark exactly. At the same time he had the patient take san qi powder (notoginseng), 2 qian (6 g), washed down with the decoction — because the man had both hemoptysis and blood in the urine; san qi activates blood and resolves stasis while also stopping bleeding, gathering the blood back under control.
After a few doses, the heat receded and the bleeding diminished — the damp-heat was being drained out, the blood lessened, the phlegm thinned a little — but the urination was still blocked; it had not completely resolved.
The turning point: gasping through a dozen breaths just to sit up, and Doctor Zhang Xichun had his revelation
Just then something happened. Doctor Zhang Xichun was seeing the patient, who had been lying down and needed to sit up for the pulse to be taken. As he sat up, Doctor Zhang Xichun noticed that he struggled a little, with some effort; once seated, he had to gasp through ten-odd breaths in succession before his breathing slowly settled. Doctor Zhang Xichun looked at this and thought: this is not right — this man is severely deficient too. He took the pulse again — where before it had been slippery, now that the fire had gradually receded, the pulse was turning weak.
And suddenly it clicked: the root of this illness is sinking of the great qi! So he went straight to Shengxian Tang: zhi mu increased to 6 qian — a fairly large amount; plus xuan shen (Scrophularia), 5 qian — a cool, moistening herb that nourishes yin and clears heat; plus mu tong (Akebia stem), 2 qian — to dispel damp-heat, free the urination and clear damp-heat.
The patient took the medicine home: one dose, and his urine flowed again! A few more doses and the illness was completely cured. That illness which had dragged on for half a year was finished off in a few doses.
💬 Note from Doctor Luo: Another clean, crisp case. Look at this patient — he had problems on both fronts: below, blocked urination — after the great qi sinks, the qi moves downward, the qi mechanism of the lower burner gets congested, and problems easily follow: blocked urination, lower-abdominal pain and so on. The swelling over the whole body, worse below, is also evidence of qi moving downward. At the same time, above, the phlegm and drool stuffed the upper burner, with coughing and breathlessness — exactly like the previous case: a person with sinking of the great qi shows upper-burner symptoms, because the lung qi is weak, giving all sorts of throat trouble, lung trouble, cough — and one of them is copious phlegm and drool. So remember: copious phlegm and drool, cough, plus shortness of breath — that too is a symptom of sinking of the great qi.
Two men in their forties, one and the same root
These two patients share a trait: both were in their forties — middle-aged.
💬 Note from Doctor Luo: This is rarer in young people — they have not yet reached that stage. After middle age, the decline of upright qi becomes obvious. Once the great qi sinks and lung qi is insufficient, copious phlegm and drool appears — and especially so in the elderly. Doctor Luo says he meets a flood of people asking health questions every day, and in his mind a large database has slowly formed — in his experience, among people with sinking of the great qi, the elderly are especially numerous: middle-aged people get a lot of sinking of the great qi from work fatigue, and their symptoms are quite obvious; but in the elderly, sinking of the great qi is often hidden behind other symptoms — you see an old person coughing endlessly with a mouthful of phlegm, and you may assume it is emphysema, chronic bronchitis, interstitial pneumonia — you think in those directions. In fact many elderly people have lung qi weakness and upper-burner phlegm caused by sinking of the great qi. So in the course of treatment, keep this in the back of your mind.
Doctor Luo also added a word about phlegm: a doctor who can truly understand phlegm is a very accomplished doctor. Phlegm changes endlessly — especially in the weak and elderly; in northern China you constantly see such patients, spitting enormous amounts of phlegm and coughing without stop. Slowly resolving phlegm matters, but resolving phlegm alone will not do — a great deal of phlegm is caused by deficiency; you hardly need extra phlegm-resolving herbs — slowly fortify the upright qi, and the phlegm will disappear on its own.
What to take away: the more you understand sinking of the great qi, the better you can protect yourself. Two men in their forties, two opposite-looking illnesses — yearly bleeding from the mouth on one side, blocked urination with whole-body swelling on the other — and both turned out to be the same root: the great qi of the chest had sunk. Blood that runs upward can come from qi that has sunk downward, and phlegm that chokes the throat can be the face of lung qi weakness; bleeding does not always mean fire — sometimes the qi is simply too weak to command the blood. And the most important lesson of all, as Doctor Luo says: the point of knowing about sinking of the great qi is not to cure it later — it is to avoid letting your own great qi sink in the first place.
Compiled from Doctor Luo Dalun’s lectures on Doctor Zhang Xichun’s case records, from Medical Records Integrated Chinese and Western Medicine (《医学衷中参西录》, published in installments 1918–1934).