Hoarse for Half a Year, Voice Nearly Gone? Three Cases of Sinking of the Great Qi
The opening: when the great qi sinks, the lungs and throat suffer first
For many days now we have been talking about the sinking of the great qi (大气下陷, da qi xia xian) — the collapse of the vital qi that lives in the chest. When qi sinks downward, which two organs suffer the most obvious damage? One is the heart, the other is the lungs. Today Doctor Luo’s lesson is entirely about the lungs and the throat — because the throat is the channel through which the lungs and the stomach communicate with the outside world. When the great qi in the chest sinks, the lung qi weakens and drifts downward, and the throat above cannot escape the fallout. The three cases today all gather around the lungs and the throat.
💬 Note from Doctor Luo: Let me set out the big picture first: the sinking of the great qi is, in plain terms, a weakening of heart-lung function. The great qi in the chest moves downward, and the lungs feel it — lung qi becomes deficient, and so come cough and wheezing. The throat feels it too — the throat is the passage that links the lungs and the stomach to the outside — and so come a hoarse voice, a tight throat, and speech that sounds different. Today’s three cases walk through this whole chain of symptoms, one by one.
The first patient: a man in his twenties, treated for “tuberculosis” for years
Let’s start with the first case. This man was in his twenties — young, not old at all. What was his illness? He wheezed at the slightest exertion and coughed constantly. The cough lived in the throat and windpipe, and it had to do with the lungs. The doctors before him had treated him for several years — and instead of improving, he got worse and worse. He would gasp at nothing, wheezing with his mouth open, the breath coming up short, feeling as though his airways had narrowed and he simply could not draw a full breath.
The more he was treated, the worse he became, and everyone concluded the same thing: tuberculosis — one of those grave consumptive diseases. So the doctors all backed away and refused to treat him, saying it was incurable. With nowhere else to go, he came to Doctor Zhang Xichun.
💬 Note from Doctor Luo: You often hear me say that people who lived in that era were extraordinarily lucky if they could find Doctor Zhang Xichun. Isn’t that right? No matter how severe the illness, when it reached this man, he solved it. That’s no exaggeration — look at this patient: an illness no doctor would touch for years, and Doctor Zhang Xichun cured it in a few doses.
One touch of the pulse: not thin — “as if it weren’t beating at all”
When Doctor Zhang Xichun took his pulse, he found it was not exactly thin and weak — it presented in a different way: place your fingers on the wrist, and you could hardly feel the pulse moving at all. It was as though you couldn’t even be sure the pulse was still beating.
With that single touch, Doctor Zhang Xichun knew what he was dealing with: sinking of the great qi.
💬 Note from Doctor Luo: Why is it that when the great qi sinks, you can barely feel the pulse? Because after the great qi falls, the upright qi (zheng qi) is insufficient and lacks the strength to drive the pulse. Lay your hand there and you can’t feel it moving. And why the constant cough and wheezing? Because the upright qi is insufficient and the great qi moves downward — the organs hit hardest are the heart and the lungs. When the lungs grow weak, cough and wheeze follow. These are all expressions of a weakened lung.
The prescription: Shengxian Tang plus ren shen and tian dong, cured in a few doses
Based on this pulse, Doctor Zhang Xichun diagnosed sinking of the great qi and wrote a prescription — Shengxian Tang (升陷汤, the Lifting the Sinking Decoction), with ren shen (ginseng) and tian dong (asparagus root) added. What was ren shen for? Tonifying qi. And tian dong? Nourishing yin. Where is the genius in this approach? When you tonify qi, don’t let it run too hot — pair it with tian dong to moisten dryness and hold down the fire. He used three qian (about 9 g) of each.
What was the result? After several doses, he recovered. An illness that years of treatment could not cure — Doctor Zhang Xichun fixed it in a few doses of medicine.
The father’s confession: someone in our family died of this in four years
The patient’s father was overjoyed, and he told Doctor Zhang Xichun something that made the heart sink. He said: “In our family line, someone once suffered this exact illness, with the same symptoms — and four years after falling ill, he passed away. My son has now been sick for three years. I never imagined we would meet you, sir — you have saved my child.” He thanked him again and again.
Gratitude aside, Doctor Zhang Xichun continued: this man’s body is genuinely very weak, and the illness has run so long that a few bowls of decoction cannot be the end of it. So he removed sheng ma (cimicifuga) from the formula — sheng ma lifts the qi upward, and once the patient is well, there is no need to keep lifting — then ground the remaining herbs into powder, mixed it with honey into pills, and had the patient take them slowly for about a month, to consolidate the cure and secure the recovery.
💬 Note from Doctor Luo: Look at that — an illness that no one could cure for years, and Doctor Zhang Xichun put it right in a few doses. What matters most here? Recognizing the pattern accurately. And notice the aftercare thinking: in acute states use decoctions, in recovery use pills. Once the patient is better, don’t stop abruptly — use pills to slowly firm up the root. That is the thoroughness of a great physician.
A question from the audience: what’s the difference between a sinking-qi cough and a lung-qi-deficiency cough?
At this point, a question naturally arises: if the sinking of the great qi causes abnormal heart-lung function and brings on coughing — then what is the difference between that cough and an ordinary cough caused by lung qi deficiency?
Doctor Luo says: the two actually overlap. Lung qi deficiency causes coughing too. That’s why we often say: when a child keeps coughing after a cold, give him some shan yao (Chinese yam) — why? It tonifies the lung and the spleen, and the cough clears up. How? Once the lung qi is replenished, it pushes the residual pathogen out. So lung qi deficiency does cause cough.
But the sinking of the great qi, apart from the cough of lung qi deficiency, hides a far more serious problem behind it: the heart’s function declines as well.
💬 Note from Doctor Luo: Remember the previous case — the patient’s relative died suddenly four years after falling ill. Why? For exactly this reason. When both heart and lung function are damaged, the weakened lungs bring cough and wheezing and so on — but once the heart itself runs into serious trouble, it becomes a matter of life and death. So the cough and wheezing of sinking of the great qi are clearly much more severe. That is the crucial difference between it and a plain lung-qi-deficiency cough.
The second patient: 24 years old, getting worse, with a new symptom
Now the second case. This patient was 24 — also very young, so never assume that young people are safe from this. What were his symptoms? Fullness and oppression in the chest — the breath wouldn’t come up and he had no strength; coughing day and night — why? Sinking of the great qi, weakened lung qi; and on top of that, the pain under his ribs flared badly when he coughed — with each cough, both flanks hurt.
💬 Note from Doctor Luo: Why the pain? Usually, when liver qi is not flowing smoothly, the flanks hurt — that’s the area of the ribs on both sides. It’s a sign of liver qi stagnation, of something stuck. And his pulse? When Doctor Zhang took it, it was even and fairly normal at first — but press deeper and it lost its strength. Push down a little and there was nothing there.
Seeing pain in both flanks and a tight chest, Doctor Zhang Xichun suspected the qi was not moving freely — some qi stagnation, a blockage in the qi mechanism. So he gave a small dose of qi-moving herbs to soothe the liver and free the flow. But being cautious — because the pulse was so weak — he added huang qi (astragalus): if I soothe the liver and move the qi, and you add something to tonify the qi, that should cover all the bases.
What happened? He got worse, not better. After the medicine, the cough and the chest oppression grew heavier, and a new symptom appeared — what symptom? A trembling voice: when he spoke, his voice quivered, shaking as he talked.
💬 Note from Doctor Luo: Friends, this is exactly what we discussed before — when the great qi sinks and the lung qi is weak, the throat and voice get dragged down with them. When a person’s upright qi is insufficient, the quality of their voice changes — you discover this after enough clinical experience. For instance, some people speak normally before an illness, but after a serious sickness their voice changes pitch. Some people are so qi-deficient that the ends of their sentences trail off — say “Have you eaten yet?” A person with strong middle qi puts real force behind the final syllable; a person with weak middle qi, whose great qi has sunk, throws away the ending of every sentence, it’s not a normal sound. I have even seen patients like this: after every sentence they add a long, strange exhale — they can’t finish the last syllable properly, so it stretches into a drawn-out trailing breath that has nothing to do with the words. What is that? Also sinking of the great qi — the throat can’t hold its function. And “a trembling voice” is a phrase recorded in Doctor Zhang Xichun’s own case notes — when the great qi sinks, there is no strength to hold things steady, not enough qi for speech, so the voice begins to shake. This is the sign that the condition has reached a serious degree.
Doctor Zhang admits the mistake: I didn’t ask the full story
Hearing the trembling voice, Doctor Zhang Xichun paused — this doesn’t fit. It looks like a deficiency pattern. So he began to question the patient closely about exactly how the illness began. It turned out: the man was a farm laborer who normally worked the fields. He caught a cold once and had no appetite (lazy eating, 懒食) — but he went out to the fields and worked anyway. From that day on, the illness took hold.
Hearing this, Doctor Zhang Xichun recognized his own earlier mistake — this man was genuinely deficient. Look what happened when he gave him qi-moving herbs: the body rejected them and the illness grew worse. So what was the truth? Earlier I did not question him carefully enough — and he felt ashamed.
💬 Note from Doctor Luo: How did Doctor Zhang Xichun write it in his own records? “幸迷途未远” — fortunately I had not wandered far down the wrong road. He had not gone far astray, and he woke up at once — and shuddered to think what could have happened. So what did he do? He gave the patient Shengxian Tang. In all, only four doses — and the patient recovered. This is why Doctor Zhang Xichun kept insisting, again and again: with this kind of patient, never treat it as an excess pattern and start soothing the liver and moving the qi — no. This is deficiency, and he knew it because he had made the mistake himself.
A lesson for every doctor: don’t be too proud; asking more questions never hurts
For this case, Doctor Zhang Xichun closed with a passage addressed to every physician at the bedside:
💬 Note from Doctor Luo: Take a lesson from this, all doctors at the bedside — never be too proud, never be too sure of yourself, never think “my judgment is right” and skip the careful questions about the details. You can be wrong. Asking a few more questions never does any harm. This is a lesson Doctor Zhang Xichun distilled from his own experience and wrote down specially for everyone. Let me add a little more today, so you can look at it again —
The third patient: a man in his forties, hoarse for half a year, still wearing winter clothes in summer
This patient was a middle-aged man in his forties. What was his illness? 失音半载 — hoarse for half a year. And not the ordinary sort of hoarseness — he had reached the point where he could hardly speak at all. That degree of vocal loss is called aphonia (失音). As the half year of hoarseness went on, he gradually felt his throat growing tight, tighter and tighter; and the throat broke down and ulcerated frequently — what we would today call something like chronic pharyngitis, flaring up again and again, ulcerating again and again.
It looked at first like a common external invasion — but there was more: this man was afraid of wind and severely intolerant of cold. How severe? He was still wearing his winter clothes in the middle of summer. In everyday life I think everyone has met such a person — they dress much more heavily than others; you’re in a T-shirt, and they’re in a jacket.
💬 Note from Doctor Luo: What does that tell us? Insufficient upright qi. What else? His appetite fell — he ate less and less, and as his body grew weaker and weaker, he slid into a consumptive state — by then his body was already severely depleted. He tried treatment after treatment, and the illness only grew worse; every medicine he swallowed did nothing. So Doctor Zhang Xichun was sent for. Every time I tell this part I think: the patients of that era were truly fortunate.
Both cun pulses weak — almost unpalpable: the textbook picture
Doctor Zhang Xichun took his pulse: both cun positions were faint and weak. The pulse positions of the heart and the lungs both live at the cun (the distal position on the wrist). Both cun pulses were faint — not a trace of rising force, no sign of leaping up. Lay your fingers there and both cun pulses seemed almost not to exist.
💬 Note from Doctor Luo: I have explained this before — when the great qi sinks, the qi mechanism moves downward, and the whole pulse position shifts down with it. So the cun pulse becomes especially weak, sometimes unpalpable, while the kidney position seems to have slipped down a little — the entire qi mechanism is descending. With a pulse like this, Doctor Zhang Xichun knew at once: both cun pulses gone — this is textbook. Sinking of the great qi. Straight to Shengxian Tang.
The prescription: Shengxian Tang plus xuan shen, 4 qian — throat no longer tight after two doses
What did he add to the formula? Xuan shen (scrophularia), four qian (12 g).
💬 Note from Doctor Luo: What does xuan shen do? We covered this before — xuan shen draws the fluid of the kidney essence upward to moisten the throat and clear heat in the upper burner. It is a cool, moistening herb that nourishes yin and clears heat. Do you see? Why was this patient’s throat hot? After the great qi sank, the throat was short of qi, blood and fluids — nothing left to moisten it — so it ran a little hot. This heat is deficiency heat, born of insufficient fluids. That is why Doctor Zhang Xichun added xuan shen, to moisten dryness and clear heat.
The result: after two doses, the throat was no longer tight — the constricted feeling was gone. What does that show? The great qi had been lifted back up, the qi mechanism was back in place, and the throat’s function had returned to normal.
At this point Doctor Zhang Xichun removed sheng ma from the formula — why? Because there was no need to keep lifting upward; if you lift too forcefully, it can actually harm the throat. With sheng ma removed, he had the patient continue for more than ten further doses — and all the illnesses were cured. Every one of the symptoms resolved.
Why does the throat feel “tight” when the great qi sinks?
In this case, the patient’s two leading complaints were: loss of voice (hoarseness) and a tight, ulcerating throat. Why tight?
💬 Note from Doctor Luo: After the great qi sinks, the throat is left empty and its function fails — so it gradually feels tight. Doctor Zhang Xichun used a simile like this: an empty bottle — if you pump air hard into it and out of it, the bottle can grow thin, and with a pop it can collapse inward, even crack. So people with sinking of the great qi show a very clear sign — the airway and the throat narrow, and it feels a little blocked. Mind you, it is not truly blocked — it is caused by the sinking of the great qi. At the same time this patient also ran somewhat deficient and cold — with the great qi sunk, there is no strength to sustain the movement of qi and blood through the body, and the qi at the interior and exterior no longer holds firm — so he feared cold and wind, and his hands and feet ran cold. If such a patient also experiences shortness of breath (the feeling that the breath won’t come up), and you connect all these symptoms together, you can be sure it is sinking of the great qi.
What to take away
Today’s lesson extends the symptom picture of the sinking of the great qi once more:
In the lungs: cough and wheezing — problems born of the emptiness in the lung channels caused by the sinking of the great qi.
In the throat: loss of voice (hoarseness), a changed tone of speech, a tight feeling in the throat — in severe cases complete aphonia, unable to speak, sometimes with repeated ulceration, like a touch of throat inflammation.
Shortness of breath: the sensation that the breath will not come up can also be one symptom of the sinking of the great qi.
💬 Note from Doctor Luo: In fact, such people are everywhere in daily life — there are very many people with insufficient upright qi today. How many of them actually have sinking of the great qi? It deserves serious thought. And one more thing: I have written before about Zhang Jingyue’s Zhen Yin Jian (镇阴煎, the Sedate the Yin Decoction), which treats chronic pharyngitis caused by kidney essence deficiency — the “dragon-fire rushing upward” (long huo shang ben). But there is another portion of chronic pharyngitis that is actually caused by the sinking of the great qi — and this is the more dangerous kind, with potentially more severe symptoms, because it affects the heart, and the eventual harm can be especially great. So I am expanding your view on purpose, to help you understand the sinking of the great qi a little better.
Doctor Luo closes: I don’t mind repeating myself, I don’t mind spending the words. If I talk a little more, and you get the chance to hear it, it widens your thinking — seeing from another angle that there is such a problem in our health, and that if you ever meet it, you can protect yourself. If that is achieved, then the talk has been worth something.
Based on Doctor Luo Dalun’s explanation of Doctor Zhang Xichun’s case records, from Yi Xue Zhong Zhong Can Xi Lu (《医学衷中参西录》, published in installments between 1918 and 1934).