Daoist Fan, Shandong Dongming Traditional Chinese Medicine HospitalGenerally speaking, a red tongue with no coating or even a mirror-like tongue is a manifestation of Yin deficiency and fluid depletion. According to “Diagnosis of Tongue Quality in Traditional Chinese Medicine”, a tongue that is dark red and moist indicates a condition of Yin deficiency with excess heat in internal injuries, often accompanied by phlegm-dampness; a red and dry tongue with little fluid in internal injuries indicates excess heat due to Yin deficiency or hyperactivity of heart fire, while a bright red and glossy tongue signifies severe depletion 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 in a certain hospital for over two months, receiving various Chinese and Western medicines, yet her condition worsened. The patient was emaciated, had a clear mind but poor spirit, exhibited shortness of breath, was in a sitting position to breathe, could not 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 using a gastric tube for decompression; her tongue was dark red with no coating, dry with little fluid, and glossy like a mirror, while her pulse was slippery and firm, with no strength upon heavy pressure. The diagnosis indicated a deficiency of Yang Qi, water retention obstructing the heart, loss of lung Qi, and stagnation in the intestines. The key pathological mechanism was the 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 the Qi of the bowels to be unblocked. Observing the prescriptions used by previous doctors, they were all nourishing and regulating products, biased towards nourishing Yin and moistening, and the medication was cautious due to the patient’s 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 bowels to eliminate turbidity. The prescription included: Ren Shen (Ginseng) 10g (separately decocted), Fu Zi (Aconite) 10g (pre-decocted), Zhu Ling (Polyporus) 15g, Fu Ling (Poria) 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, thus restoring Yang Qi, reducing water retention, and enhancing the function of the organs. The next day, upon re-examination, the patient’s shortness of breath had significantly reduced, the swelling had noticeably subsided, and she had seven foul-smelling, loose, sticky bowel movements, 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, allowing her to consume a small amount of food without nausea or vomiting. Her tongue quality changed to light red, moist, with a thin white coating, indicating a gradual recovery of Yang Qi, reduction of water retention, and normal distribution of fluids as Yang Qi transformed the fluids. The prescription was adjusted by removing Zhi Shi, Hou Po, and Da Huang, adding Mai Dong (Ophiopogon) 10g and Wu Wei Zi (Schisandra) 15g to nourish Yin and support Yang, restoring her condition. In total, over 20 doses were modified from the previous prescriptions, and the patient was able to get out of bed and take care of herself.In general, a red tongue with no coating and dryness is a manifestation of Yin deficiency and fluid depletion; however, tongue diagnosis is only one part of Traditional Chinese Medicine diagnosis, and thus tongue diagnosis 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, Yang Qi was severely deficient, and the body fluids were not following their normal pathways, leading to obstruction in the heart and lungs above, and in the intestines and muscles below. A red tongue with no coating does not merely indicate a deficiency of Yin fluids, but rather a failure of Yang to transform Yin, lacking the strength to vaporize the fluids and causing them to overflow. Therefore, merely nourishing Yin would be ineffective; only warming Yang and transforming fluids would restore normal distribution of body fluids, and the tongue coating would naturally appear.
