Remain in the Brain
On Forgetfulness
Last month we looked at treating tingling and numbness (má mù), which is a condition that is not uncommon in my practice, but that seldom gets a full differentiation in clinical manuals and acupuncture school courses. Today we’re going to look at a condition similar in its prevalence as well as the paucity of specific discussions regarding its treatment.
Forgetfulness
Forgetfulness (jiàn wàng) is a complaint I hear from many patients. In most cases, it may not be the most urgent complaint, and often can be folded into a more general scenario of something larger like kidney vacuity. But the pathomechanisms behind forgetfulness can be more complex, and it is worth taking some time to unpack them a bit more. As with tingling and numbness, most of the comprehensive clinic manuals in English have no dedicated chapter on forgetfulness, save Maclean et al. (2018). A more specialized guide on my shelf, Chinese Medical Psychiatry by Flaws & Lake (2001), does include an entry on impaired memory. The patterns and treatments in these books are useful, but looking at earlier sources can also give one a broader view or extra insight into the etiology and treatment options for this problem.
Back to the Qīng
To get an idea of where the TCM differentiations that we have today came from, as well as to see which ones didn’t make the cut, so to speak, I am increasingly nosing around Lèi Zhèng Zhì Cái [Differentiation and Classification of Patterns and Treatments, 類證治裁, 1839] by Lín Pèiqín. Here’s the chapter on forgetfulness.
健忘論治
健忘者，陡然忘之，盡力思索不來也。夫人之神宅於心，心之精依於腎，而腦為元神之府，精髓之海，實記性所憑也。正希金先生嘗曰：凡人外有所見，必留其影於腦。小兒善忘者，腦未滿也。老人健忘者，腦漸空也。隱菴云：觀此則知人。每記憶必閉目上瞬而追索之，亦凝神於腦之義。故治健忘者，必交其心腎，使心之神明，下通於腎，腎之精華，上升於腦。精能生氣，氣能生神，神定氣清，自鮮遺忘之失。
Discussion on Treatment for Forgetfulness
Forgetfulness is suddenly forgetting [something], and trying hard to think about it, but it doesn’t come. A person’s shén-spirit resides in the heart, and the essence of the heart relies on the kidney; furthermore, the brain is the palace of the original spirit [yuán shén], the sea of marrow, and is in fact the place on which memory depends. Mister Zhèng Xījīn once said: Generally when people see something outside [themselves], the image of it will remain in the brain. When children are forgetful, [it is because] the brain is not yet full. When the aged are forgetful, [it is because] the brain is gradually becoming empty. Yǐn’ān said: Contemplating this results in knowledge of people. For every memory one must close their eyes to go up for a moment and seek it, and also to focus on its significance in the brain. Thus in treating forgetfulness one must connect the heart and kidneys to cause the bright spirit of the heart to flow freely downward to the kidneys, so the kidney’s florid essence will ascend upward to the brain. Essence can engender qì, qì can engender spirit, spirit stabilizes the qì to make apparent what was lost in one’s recent forgetting.
[Comment: Zhèng Xījīn [正希金] is apparently a misprint of Jīn Zhèngxī [金正希, a.k.a Jīn shēng金聲], a noted Ming scholar. The passage comes from Běn Cǎo Bèi Yào by Wāng Áng (Pan, 2020). Yǐn’ān (隱菴) refers to Zhāng Zhìcōng (張志聰), one of the four great masters of the Sòng-Jīn-Yuán era.]
惟因病善忘者，或精血虧損，務培肝腎，六味丸加遠志、五味。或縈思過度，專養心脾，歸脾湯。或精神短乏，兼補氣血，人參養營湯下遠志丸。或上盛下虛，養心湯。或上虛下盛，龍眼湯。或心火不降，腎水不升，神明不定，朱雀丸。或素有痰飲，茯苓湯。或痰迷心竅，導痰湯下壽星丸。或勞心誦讀，精神恍惚，安神定志丸。或心氣不足，怔忡健忘，辰砂妙香散。或稟賦不足，神志虛擾，定志丸、孔聖枕中丹。或年老神衰，加減固本丸。若血瘀於內，而喜忘如狂，代抵當丸。
Considering the disease etiology of forgetfulness, if it is qì and blood depletion, seek to bank up the liver and kidney, Liù Wèi Wán [Six-Ingredient Rehmannia Pill] plus Yuǎn Zhì [Rx Polygalae], Wǔ Wèi [Fructus Schisandrae]. Or if there is excessive worrying and thought, focus on nourishing heart and spleen, Guī Pí Tāng [Spleen-Returning Decoction]. Or if there is a lack of essence-spirit, simultaneously supplement qì and blood, Rén Shēn Yáng Yíng Tāng [Ginseng Provisioning-Nourishing Decoction] then Yuǎn Zhì Wán [Polygala Pill]. Or if there is upper body exuberance and lower body vacuity, Yǎng Xīn Tāng [Heart-Nourishing Decoction]. Or if there is upper body vacuity and lower body exuberance, Lóng Yǎn Tāng [Dragon’s Eye Decoction]. Or if there is heart fire not descending and kidney water not ascending, and the bright spirit is unstable, Zhū Què Wán [Red Birdie Pill]. Or if there is plain phlegm-rheum, Fú Líng Tāng [Poria Decoction]. Or if there is phlegm confounding the orifices of the heart, Dǎo Tán Tāng [Phlegm-Abducting Decoction] then Shòu Xing Wán [Star of Longevity Pill]. Or if there is taxation of the heart with loud recitation, abstraction of the essence spirit, Ān Shén Dìng Zhì Wán [Spirit-Quieting Mind-Stabilizing Pill]. Or if heart qì is insufficient, with palpitations and forgetfulness, Chén Shā Miào Xiāng Sàn [Cinnabar Mysterious Fragrance Powder]. Or if there is a lack of natural endowment, with spirit-mind vacuity disturbance, Dìng Zhì Wán [Mind-Stabilizing Pill], Kǒng Shèng Zhěn Zhōng Dān [Sagacious Confucius’ Pillow Elixir]. Or if one is elderly with a debilitated spirit, Jiā Jiǎn Gù Běn Wán [Variant Root Securing Pill]; if it appears that there is blood stasis internally, with confusion resembling madness, Dài Dǐ Dāng Wán. [Substitute Dead-On Pill]
We’ll sort through the thicket of formulas below.
附方
Appended Formulas
〔肝腎〕 六味丸。
〔Liver-kidney〕 Liù Wèi Wán.
〔心脾〕 歸脾湯。
〔Heart-spleen〕 Guī Pí Tāng.
〔氣血〕 人參養營湯。
〔Qì-blood〕 Rén Shēn Yáng Yíng Tāng.
[Comment: These formulas are well-known, and I won’t list the ingredients here. Formula modifications given for Liù Wèi Wán are the addition of Yuǎn Zhì and Wǔ Wèi Zĭ. Guī Pí and Rén Shēn Yáng Yíng also contain Yuǎn Zhì, and the latter includes Wǔ Wèi Zĭ as well.]
〔熱煩〕 遠志丸: 遠志 菖蒲 茯苓 茯神 人參 龍齒 蜜丸，辰砂為衣。
〔Heat vexation〕 Yuǎn Zhì Wán: Yuǎn Zhì, Chāng Pú [RzAcori Graminei], Fú Líng [Poria], Fú Shén [Poria Pararadicis], Rén Shēn [Rx Ginseng], Lóng Chǐ [Dens Draconis]; honey pills, coat with Chén Shā [Cinnabaris].
[Comment: An interesting, simple formula. Not strongly heat-clearing but definitely settling. The Yuǎn Zhì + Chāng Pú combination is an important one for brain health, as we have written about before. You will also find it in many of the formulas listed below.]
〔下虛〕 養心湯 參 耆 歸 術 二冬 菖蒲 遠志 茯神 牛膝 熟地 木通。
〔Lower vacuity〕 Yǎng Xīn Tāng: Rén Shēn, Huáng Qí [Rx Astragali], Dāng Guī [Rx Angelicae Sinensis), Bái Zhú [Rz Atractylodis Macrocephalae], Èr Dōng [Rx Ophiopogonis and Rx Asparagi], Chāng Pú, Yuǎn Zhì, Fú Shén, Niú Xī [Rx Achyranthis Bidentatae], Shú Dì [Rx Rehmanniae Praeparata], Mù Tōng [Caulis Akebiae].
[Comment: This is a different formula than any of the formulas with the same name listed in Scheid et al. (2009). Much richer and more supplementing than the formula above, it boosts qì, nourishes blood, enriches yīn, calms the spirit, and opens the orifices. I’m seeing Mù Tōng as a safety valve to keep the heart from accumulating heat from all of the supplementation.]
〔上虛〕 龍眼湯 參 耆 麥冬 草 柴胡 升麻 茯神 丹參 龍眼 遠志。
〔Upper vacuity〕 Lóng Yǎn Tāng: Rén Shēn, Huáng Qí, Mài Dōng [Rx Ophiopogonis], Gān Cǎo [Rx Glycyrrhizae], Chái Hú [Rx Bupleuri], Shēng Má [Rz Cimicifugae], Fú Shén, Dān Shēn [Rx Salviae Militiorrhizae], Lóng Yǎn [Arillus Longan], Yuǎn Zhì.
[Comment: This formula has a very Lǐ Dōngyuán feel to it, though I came up empty when searching for it. Using Huáng Qí, Chái Hú and Shēng Má to raise the qì is a sort of Dōngyuán signature, most notably in Bǔ Zhōng Yì Qì Tāng (Suppement the Center and Boost the Qì Decoction). The formula also has hints of Shēng Mài Sǎn (Pulse-Restoring Powder) and Guī Pí Tāng.]
〔心腎〕 朱雀丸 沉香（一兩） 茯神（四兩） 人參（二兩） 蜜丸。
〔Heart-kidney〕 Zhū Què Wán: Chén Xiāng [Lignum Aquilariae] (1 liǎng), Fú Shén (4 liǎng), Rén Shēn (2 liǎng), honey pills.
[Comment: I swear I did not make up the name “Red Birdie Pill”; it is from the Wiseman dictionary (Wiseman, 2022). It is an interesting combination: Fú Shén and Rén Shēn enter the heart to calm the spirit and sharpen the wits; Chén Xiāng enters the kidney and sinks (chén, hence its name), thus opening up the downward connection between heart and kidney. This is a different pathomechanism from what we usually teach as “heart and kidney not communicating,” which is generally presented as a vacuity of heart and kidney yīn with vacuity heat and treated with formulas like Tiān Wáng Bǔ Xīn Dān (Celestial Emperor’s Heart Supplementing Elixir).]
〔痰飲〕 茯苓湯 參 陳 夏 苓 草 香附 益智（各一錢） 烏梅（一個） 竹瀝 薑汁（各二匙）。
〔Phlegm-rheum〕 Fú Líng Tāng: Rén Shēn, Chén Pí [Pc Citri Reticulatae], Bàn Xià [Rz Pinelliae], Fú Líng, Gān Cǎo, Xiāng Fù [Rz Cyperi], Yì Zhì [Fr Alpiniae Oxyphyllae] (each 1 qián) ; Wū Méi [Fr Mume] (1 count); Zhú Lì [Succus Bambusae], Jiāng Zhī [Succus Zingiberis] (each 2 spoonfuls).
[Comment: This is another variant of Èr Chén Tāng [Two Aged Ingreditents Decoction]; it has additions like Xiāng Fù to course the liver and Wū Méi to astringe coughing. It also contains Yì Zhì Rén which is a mild yang-warming agent but perhaps more importantly is traditionally thought to improve one’s intellect, which is the meaning of the name Yì Zhì.]
〔痰迷〕 導痰湯: 二陳湯再加膽南星、枳實。
〔Phlegm confounding〕 Dǎo Tán Tāng: Èr Chén Tāng with added Dǎn Nán Xīng [Rz Arisaemae Cum Felle Bovis], Zhǐ Shí [Fructus Aurantii Immaturus].
[Comment: A well-known formula, and yes, another Èr Chén Tāng variant.]
〔補攝〕 壽星丸 參 耆 術 草 陳 苓 地 芍 歸 味 桂心 膽星 琥珀 硃砂 遠志 豬心血糊丸。
〔Supplement and contain〕Shòu Xing Wán: Rén Shēn, Huáng Qí, Bái Zhú, Gān Cǎo, Chén Pí, Fú Líng, Dì Huáng, Bai Sháo [Rx Paeoniae Alba], Dāng Guī, Wǔ Wèi, Guì Xīn [Cx Cinnamomi], Dǎn Xīng, Hǔ Pò [Amber], Zhū Shā [Cinnabaris], Yuǎn Zhì; use blood from a pig’s heart to form a paste and make into pills.
[Comment: Another formula comparable to Rén Shēn Yáng Yíng Tāng. This formula contains Hǔ Pò, a potentially interesting choice of medicinal for memory problems; the pieces that have things preserved in them are a sort of metaphor for boosting the brain’s own ability to preserve and store memories.]
〔恍惚〕 安神定志丸 人參 白朮 茯苓 茯神 菖蒲 遠志 麥冬 棗仁 牛黃 硃砂 龍眼 蜜丸。
〔Abstraction〕 Ān Shén Dìng Zhì Wán: Rén Shēn, Bái Zhú, Fú Líng, Fú Shén, Chāng Pú, Yuǎn Zhì, Mài Dōng, Zǎo Rén [Sm Zizyphi Spinosae], Niú Huáng [Calculus Bovis], Zhū Shā, Lóng Yǎn; honey pills.
[Comment: This is an expanded variant of Sūn Sīmiǎo’s Dìng Zhì Wán, cited below. It is increased in its ability to supplement both heart qì and yīn, and is more nourishing to the heart than the original.]
〔怔忡〕 辰砂妙香散。
〔Fearful throbbing〕 Chén Shā Miào Xiāng Sàn.
[Comment: There are no ingredients listed in the text for this formula. I suspect this is a variant name for Miào Xiāng Sàn (妙香散) which appears in the Tài Píng Huì Mín Hé Jì Jú Fāng (Imperial Grace Formulary of the Tài Píng Era, 1078). The ingredients for that formula are Shè Xiāng [Moschus], Mù Xiāng [Rx Aucklandiae], Shān Yào [Rz Dioscoreae], Fú Shén, Fú Líng, Huáng Qí, Yuǎn Zhì, Rén Shēn, Jié Gěng [Rx Platycodi], Zhì Gān Cǎo, Chén Shā. It is found in Scheid et al. (2009) as a variant formula under Dìng Zhì Wán.]
〔虛擾〕 定志丸 人參 茯神 茯苓（各三兩） 菖蒲 姜炒遠志（各二兩） 硃砂一兩半為衣，蜜丸。
〔Vacuity harassing〕 Dìng Zhì Wán: Rén Shēn, Fú Shén, Fú Líng (each 3 liǎng), Chāng Pú, jiāng chǎo [ginger-fried] Yuǎn Zhì (each 2 liǎng); Zhū Shā [1.5 liǎng] to make coating; honey pills.
[Comment: A slightly augmented version of the classic Sūn Sīmiǎo formula. Both Fú Shén and Fú Líng are included.]
〔毓神〕 枕中丹 龜甲 龍骨 遠志 石菖蒲 為末。酒調一錢，日三服。
〔Nurture spirit〕 Zhěn Zhōng Dān: Guī Jiǎ [Carapax Testudinis], Lóng Gǔ [Os Draconis], Yuǎn Zhì, Shí Chāng Pú; make into powder. Mix 1 qián with wine, take 3 times a day.
[Comment: Another Sūn Sīmiǎo formula, from the man who brought us the ghost points. Both this and the previous formula are found in Scheid et al. (2009).]
〔年老〕 加減固本丸 熟地 天冬（各一兩半） 麥冬 炙草 茯苓（各一兩） 人參 菖蒲 遠志 硃砂（各五錢） 蜜丸。
〔Old age〕 Jiā Jiǎn Gù Běn Wán: Shú Dì, Tiān Dōng [Rx Asparagi] (each 1.5 liǎng); Mài Dōng, Zhì Gan Cǎo, Fú Líng (each yī liǎng); Rén Shēn, Chāng Pú, Yuǎn Zhì, Zhū Shā (each 5 qián); honey pills.
[Comment: Chāng Pú and Yuǎn Zhì have been added to the standard Gù Běn Wán prescription, along with Zhì Gan Cǎo and Fú Líng; Shēng Dì Huáng was removed. Strongly enriches yīn and supplements qì, calms spirit, opens sensory orifices and sweeps turbidity. In all these formulas, Zhū Shā must be omitted or replaced by something like Zhēn Zhū Mǔ (Concha Margaritaferae).]
〔血瘀〕 代抵當湯 水蛭（三十個，熬） 虻蟲（三十個炒） 桃仁（二十個） 大黃（酒浸，三兩）。
〔Blood stasis〕 Dài Dǐ Dāng Tāng; Shuǐ Zhì [Hirudo] (30 count, decocted); Méng Chóng [Tabanus] (30 count fried), Táo Rén [Sm Persicae] (20 count), Dà Huáng [Rx et Rz Rhei] (wine-soaked, 3 liǎng)
[Comment: Strongly unblocks blood stasis. Táo Rén is also one of our ghost herbs.]
Conclusion
In terms of medicinals for forgetfulness, the most frequently cited in the chapter are
· Yuǎn Zhì: 12/16 formulas
· Fú Shén and/or Fú Líng: 12/16 formulas
· Rén Shēn: 11/16 formulas
· Shí Chāng Pú: 6/16 formulas
This suggests core treatment principles of supplementing the heart qì, nourishing and calming the spirit, sweeping phlegm-turbidity, and opening the orifices can be found throughout most of the clinical presentations of forgetfulness. Additionally, it may be necessary to enrich yīn, preserve essence, anchor and settle the spirit, and regulate qì and/or blood.
Okay that’s it for now. Thanks for reading.
Note: this publication is for information purposes only and is not intended as medical advice. Please seek the opinion of a health care professional for any specific medical issues you may have.
References
Flaws, B. & Lake, J. (2001). Chinese medical psychiatry: A textbook and clinical manual. Blue Poppy.
Lìn, P. (1839). Lèi Zhèng Zhì Cái. Retrieved January 14, 2024, from https://jicheng.tw/tcm/book/%E9%A1%9E%E8%AD%89%E6%B2%BB%E8%A3%81/index.html.
Maclean, W., Lyttleton, J., Bayley, M., & Taylor, K. (2018). Clinical handbook of internal medicine: The treatment of disease with traditional Chinese medicine. Eastland Press.
Pan, D. (2020). Remembering by heart: Giulio Aleni on the heart, brain, and soul. Dao.
https://doi.org/10.1007/s11712-019-09705-z
Scheid, V., Bensky, D., Ellis, A., & Barolet, R. (2009). Chinese herbal medicine: Formulas & strategies (2nd ed.). Eastland Press.
Tài píng huì mín hé jì jú fāng. (1078). Retrieved February 7, 2024, from https://jicheng.tw/tcm/book/%E5%A4%AA%E5%B9%B3%E6%83%A0%E6%B0%91%E5%92%8C%E5%8A%91%E5%B1%80%E6%96%B9/index.html
Wiseman, N. (2022). Chinese-English Dictionary of Chinese Medical Terms. Paradigm Publications.