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 hyperactivity of heart fire in cases of internal injury, while a bright red and glossy tongue signifies 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 upright to breathe, was unable to turn herself, and had severe edema in both lower limbs, which left indentations when pressed; 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 having a gastric tube inserted for decompression; her tongue was dark red with no coating, dry and lacking fluid, glossy like a mirror, and 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, but they leaned towards nourishing Yin and were overly cautious due to the patient’s advanced age and frailty, 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 (Fried Apricot Kernel) 10g, and 6 dates, decocted into a concentrated solution, administered multiple times in small amounts through 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, thereby restoring Yang Qi, reducing water retention, and enhancing the function of the organs. Additionally, Hou Po San Wu was used to directly expel 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 it should be considered in the context of the overall symptoms. Yin fluids refer to body fluids, which require Yang Qi to vaporize and circulate normally. In this patient, the Yang Qi was severely deficient, and the fluids were not following the normal pathways, leading to obstruction in the heart and lungs above and in the intestines and muscles below. Thus, a red tongue with no coating is not merely a sign of Yin fluid deficiency, but rather a result of Yang’s inability to transform Yin, lacking the power to vaporize fluids and causing them to overflow. Therefore, simply nourishing Yin would be ineffective; it is essential to warm Yang and transform the fluids to restore normal fluid distribution, which will naturally lead to the appearance of tongue coating.
Daoist Fan, Dongming Traditional Chinese Medicine Hospital, Shandong