The Role of Traditional Herbal Medicine in Modern Japan
By Dan Kenner
Japanese kampo is an important feature of modern medical practice in Japan. Almost all Japanese pharmacies carry the traditional herbal formulas and have a pharmacist on staff trained in the traditional methods of prescription.
The great majority of Japanese physicians -- over 70% -- use at least some kampo formulas in their practice.
The word kampo in Japanese is a generic term for Chinese medicine. The literal meaning of kampo is "Han method," the treatment system of the "Hans," as the Chinese were referred to. Until 1875, when Western medicine became the official medicine, the dominant form of medical practice in Japan was kampo and acupuncture. After legislation was passed in 1875 sanctifying Western medicine as the sole orthodox system of practice, kampo was relegated to an insignificant role.
Herbs used in traditional kampo practice were brought into the realm of laboratory science for research into their pharmacological activity. In 1885, Dr. Nagayoshi Nagai isolated ephedrine from ma huang (ephedra sinica), which had commonly been used in formulas for treating asthma attacks. Ephedrine attained the status of a standard drug for medical practice. Many of the herbs used in kampo were accorded legitimacy in the Western science-dominated medical culture, but it was not until the 1930s before the traditional kampo system of prescription was re-evaluated on its merits as a method of medical practice.
The Modern Era
The most significant historical landmark for traditional herbal practice occurred in the 1960s, when the "kampo boom" emerged resulting from the unconditional demand from the normally docile Japanese public for safer medications with fewer negative effects. Herbal practice began to flourish, and public institutions were forced to respond. In 1972, the Japanese Medical Association took the position that conventional laboratory blood tests were not sufficiently sensitive to ascertain which traditional formula should be used, so the traditional methods of diagnosis based on patient history and examination of the pulse, tongue and abdomen were adopted. The practice of kampo, however, was restricted to physicians and licensed pharmacists who underwent special training.
In the 1970s, Oriental medicine wings of teaching hospitals were established for physician training programs. In these institutions, clinical research was undertaken on how to use traditional kampo formulas for treating various health care problems. Among the first were the Toyama Medical and Pharmaceutical University in Toyama; the Kitazato Institute in Tokyo; and the Kinki University Medical Teaching Hospital near Osaka. At Kinki University, Dr. Shigeru Arichi researched the used of traditional formulas to treat the effects of steroid withdrawal. He also did research trials on the treatment of chronic hepatitis; diabetes; chronic pain; and a variety of other health problems.
Dr. Arichi's research method used measurement of laboratory parameters along with differential diagnosis of formulas by means of traditional physical examination, and often demonstrated during grand rounds for physician trainees and hospital interns who wanted to learn kampo. Dr. Arichi would examine the patient's color; palpate the pulse and abdomen; and perhaps ask a question or two. During grand rounds, Dr. Arichi would examine as many as 60 patients. Even though all of the patients he examined in a hospital ward would have an identical diagnosis, e.g. hepatitis B, he would prescribe a variety of formulas based on their individual diagnostic parameters, i.e. abdomen, pulse, tongue, etc.
This approach was well accepted as a teaching method for physicians learning kampo, but it was less accepted as part of a research protocol. Dr. Arichi got excellent results with hepatitis by individualizing treatment for different patients. Reduction of liver enzymes in the blood was the primary research endpoint and success was high, even with difficult cases that had not responded to other forms of therapy. Critics demanded more "controls" in the research design, which resulted in more tightly controlled research trials, some of which are on Medline. From a traditional viewpoint, however, Dr. Arichi's approach combined the best of both worlds: objective measurement standards and subjective, individualized patient evaluation.
Characteristics of Kampo
Kampo is a classical method of practice based on interpretation of classical literature. The ideal of kampo through most of Japanese history has been to establish a pragmatic clinical medicine that is not excessively theoretical or dogmatic. Practice is built around the practitioner himself as advocated by the Shang Han Lun (Shokanron in Japanese). The main schools of thought in kampo have traditionally eschewed formalized systems of pathology and treatment. In the mid-18th century, Todo Yoshimasu developed the concept of the sho, or symptom-sign pattern. In the concept of the sho, clinical syndromes are identified by patterns of symptoms and signs associated with specific classical formulas. Therefore, the set of symptoms and signs for which cinnamon combination (keishito) would be indicated would be called "keishito-sho," or "cinnamon combination syndrome." This unity of diagnosis and treatment is also seen in homeopathy. Yoshimasu also revived the ancient technique of fukushin, or abdominal palpation diagnosis.
Palpation diagnosis is no less important in kampo than it is in Japanese meridian therapy. The palpation of the abdomen and pulse comprise a vital part of selection of an herbal prescription. This emphasis is an important feature of the Japanese preference of practical application over theory. Kampo theory exists in a rudimentary form. Formulas are classified according to the three yins and three yangs, and also according to the classifications of ki (qi), blood and water formulas. Historically, during every generation there have been new systems and schools of thought based on new permutations of the themes of three yins and yangs; the eight entities; ki; blood and water; and even the five phases, but in Japan, medical theory does not traditionally enjoy a lofty status.
Dr. Iwao Yamamoto, a modern expert on kampo, describes the spirit of kampo succinctly: "A beautifully constructed medical theory is not of much use in the clinic. They (theories) just don't match up to reality. A doctor who doesn't see patients is therefore able to be a scholar and give clear explanations. Scholarship in medical theory has an important role to play, but it is not in the clinic." Dr. Yamamoto also says, "Todo Yoshimasu's thesis on the Shang Han Lun thinks only of treatment strategy. The Shang Han Lun is not a text on theory, but direct observations welding symptoms and signs to the treatment method as two sides of the same coin. He (Yoshimasu) takes the position that if one studies formulas, the patients can be directly perceived as they are with no intermediary steps, and the treatment will match successfully." Because of this emphasis of practice over theory, the method of learning kampo in Japan is through hospital grand rounds, such as Dr. Arichi used to teach.
Pharmaceutical Grade Quality
Since 1992, because many kampo formulas are covered under the national health insurance plan, Japanese manufacturers of kampo medicines have had to conform to the same standards of quality as other pharmaceutical companies. Absolute standardization of formulas is not an attainable goal given the chemical complexity of a single formula. The standard required is to use chemical "markers," which are important pharmacologically active components, to establish the grade or quality.
These chemical markers include such substances as baicalin (from scutellaria baicalensis); glycyrrhizin (from glycyrrhiza uralensis); or saikosaponins (from bupleurum falcatum). According to Gyo Kinoshita, a buyer of crude herbs for a leading Japanese pharmaceutical company, "We can't afford not to get high quality if we're going to stay in business. Because in Japan we have to import so many of our herbs, quality really counts. Bupleurum from one region may have four or five times as many saikosaponins as bupleurum from another region. We can't afford to buy four or five times as much bupleurum for our formulas. We have to have the best crude herbs from the beginning."
In addition to rigorous qualitative analysis, the herbs also undergo tests for any possible contaminants from agricultural pesticides or environmental pollutants, especially heavy metals. Microbial tests for bacteria, yeast and mold are also carried out.
Highlights of Research Results
The results of various clinical and laboratory studies have led to an expanded use of traditional formulas in medical offices and hospitals in the mainstream of Japanese medicine. For instance, the formula shosaikoto (minor bupleurum combination) has been shown to be effective for hepatitis C; prevent liver cancer and fibrosis in hepatitis C patients; increase interleukin-12 production; inhibit the growth and metastasis of malignant melanoma; and more. The formula kamishoyosan has been shown to be effective for most types of menopause symptoms, and for the tremors of Parkinsonism induced by antipsychotic medication. The formula kotosan (gambir formula) was found effective for a number of symptoms in a clinical trial for hypertension treating 120 subjects. It was effective for stiff shoulders in 83.9% of people tested; 81.3% of headaches including periorbital pain; 60.7% of sleep disturbances; 89.5% of patients with dizziness; 36.4% of cases of essential hypertension; and 4.1% of cases of renal hypertension.
Other formulas that have been extensively researched are juzentaihoto (ginseng and tang kuei ten combination) for anemia, fatigue, loss of appetite prevention of infection with candida albicans and general treatment of chronic disease; keishibushito (cinnamon and aconite combination) for rheumatoid arthritis; tokishakuyakusan (tang kuei and peony formula) for menopausal symptoms, leucorrhea and hypothyroidism; hangeshashinto (pinellia combination) for diarrhea; shoseiryuto (minor blue dragon combination) for sinus allergies; and bofutsushosan (siler and platycodon dormula) for its anti-obesity effects, to name only a few of the formulas researched.
Even though this modern approach is based on a conventional Western disease nosology and on conventional immunology, there is much to learn for the validation of traditional methods in a modern biomedical context for the transformation of medicine in this country. Despite the fact that research models used in Japan for studying kampo are relentlessly Western and reductionist, the Japanese medical profession still maintains a great respect for the traditional methods of examination and herbal prescription. In many ways this combination of respect for tradition combined with a modern technological view is quintessentially Japanese.
For more information on kampo, visit the following websites: