Generally speaking, a red tongue with no coating, or even a mirror-like tongue, is considered a manifestation of Yin deficiency and fluid deficiency. According to “Diagnosis of Tongue Quality in Traditional Chinese Medicine,” a tongue that is dark red and moist indicates a condition of excess Yang fire due to internal injury, often accompanied by phlegm-dampness; a red and dry tongue with little fluid indicates excess Yang fire or heart fire alone in cases of internal injury, while a dark red and shiny tongue suggests severe deficiency of stomach and kidney Yin. However, in clinical diagnosis and treatment, a comprehensive consideration should be made. Otherwise, one may fall into the trap of confusing deficiency with excess.
I once treated an 80-year-old woman with a history of coronary heart disease and chronic heart failure. She had been hospitalized for over two months in a certain hospital, receiving various Chinese and Western medicines, yet her condition worsened. The patient was emaciated, had clear consciousness but poor spirit, exhibited shortness of breath, sat up to breathe, could not turn herself, and had severe edema in both lower limbs, with pitting edema upon palpation; she had poor appetite, vomited immediately after eating, had abdominal distension like a drum, and had not had a bowel movement for seven days, despite several enemas, and was currently receiving gastric tube decompression; her tongue was dark red with no coating, dry with little fluid, and shiny like a mirror, while her pulse was slippery and firm, with weak pressure. The diagnosis indicated a deficiency of Yang Qi, water retention obstructing the heart, loss of lung Qi, and stagnation in the intestines. The main pathological mechanism was the severe deficiency of Yang Qi, which failed to transform water, leading to obstruction in the heart and lungs above, and in the muscles and intestines below, causing stagnation in the stomach and intestines, resulting in an inability to pass gas. The previous prescriptions used by other doctors were all nourishing and regulating products, biased towards nourishing Yin and moistening, and the medication was cautious due to her old age and frailty, all seeking to avoid excessive treatment. The treatment should focus on warming Yang, tonifying Qi, promoting water metabolism, and unblocking the intestines to eliminate turbidity. The prescription included: Ren Shen (Ginseng) 10g (separately decocted), Fu Zi (Aconite) 10g (pre-decocted), Zhu Ling (Polyporus) and Fu Ling (Poria) each 15g, Bai Zhu (White Atractylodes) 10g, Ze Xie (Alisma) 10g, Ting Li Zi (Descurainia) 15g, Gui Zhi (Cinnamon Twig) 10g, Gua Lou (Trichosanthes) 10g, Yu Jin (Curcuma) 10g, Hou Po (Magnolia Bark) 30g, Zhi Shi (Bitter Orange) 10g, Da Huang (Rhubarb) 10g, and finally Gan Cao (Licorice) 6g, Chao Xing Ren (Stir-fried Apricot Kernel) 10g, and 6 dates, decocted into a concentrated solution, administered multiple times in small amounts via the gastric tube.
The formula was based on Shen Fu Decoction, Wu Ling San, and Ting Li Da Zao Xie Fei Tang to tonify Qi, warm Yang, promote water metabolism, and transform Yin, thus restoring Yang Qi, reducing water retention, and enhancing the function of the organs. Additionally, Hou Po San was used to directly expel the intestinal stagnation. Upon re-examination the next day, the patient’s shortness of breath had significantly reduced, swelling had noticeably decreased, and she had seven bowel movements of foul-smelling, thin, and sticky stools, with abdominal distension alleviated. The prescription was adjusted by reducing Hou Po to 10g and changing Da Huang to 5g prepared with wine, decocted together with the other herbs, and two more doses were given. The patient’s abdominal distension completely resolved, she had daily bowel movements, her shortness of breath stabilized, she could lie flat, turn herself, and the edema in her lower limbs significantly decreased. She was able to consume a small amount of food without nausea or vomiting, and her tongue quality changed to light red, moist, with a thin white coating appearing on the tongue surface, indicating a gradual recovery of Yang Qi, reduction of water retention, and normal distribution of fluids as Yang Qi transformed the water and fluids.
In general, a red tongue with no coating and dryness is a manifestation of Yin deficiency and fluid deficiency. However, tongue diagnosis is only one part of Traditional Chinese Medicine diagnosis, and thus tongue diagnosis should be considered in conjunction with the overall symptoms of the body. Yin fluids refer to water and fluids, which require Yang Qi to vaporize and circulate in order to be distributed normally. In this patient, the Yang Qi was severely deficient, and the fluids were not following their normal path, leading to obstruction in the heart and lungs above, and in the intestines and muscles below. The red tongue with no coating is not merely a sign of Yin fluid deficiency, but rather a result of Yang failing to transform Yin, lacking the power to vaporize the fluids and causing them to overflow. Therefore, merely nourishing Yin without effect is futile; only warming Yang and transforming fluids can restore normal distribution of fluids, and the tongue coating will naturally appear.
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