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                      JAPANESE ACUPUNCTURE    

 

The development of acupuncture in Japan, with its unique style we recognize today, has been attributed to Waichi Sugiyama, who is known as the "blind acupuncturist." Born into a samurai family in 1610, he went blind at an early age. For the blind in Japan, the primary jobs available were acupuncturist, moxibustionist, or massage therapist. He chose to be an acupuncturist.

At eighteen, he left the country home of his well-to-do parents and traveled to Edo (now called Tokyo), where he met his first teacher, a sighted acupuncturist named Takuichi Yamase. But, his skill did not progress as he had hoped. After five years under his tutelage, Takuichi threw Waichi out, saying his pitiful techniques would forever keep him from being an accomplished acupuncturist. Heartbroken, Waichi began the long journey home, but halfway there, he collapsed from exhaustion in the town of a famous doctor. As fate would have it, this doctor had been Takuichi's mentor and, after regaining his health, Waichi got another stab at being a disciple of an acupuncturist.

With practice, Waichi's needling skills progressed, but, even after a few years of dedication, he still wasn't good enough to practice on others. Desperate for help, he traveled to Enoshima, a small islet about 30 miles from Edo, to pray to Benten for better skill. Benten is the only female deity among the seven Japanese gods of good fortune. She is goddess of language and literature, love and wisdom, music, and the sea. Benten was originally a Hindu goddess (Sarasvati in Sanskrit) later adopted by Buddhists in India. She was enshrined in Japan by the Shogun Yoitmo Minamoto (1147-1199) in support of Buddhism. The Benten figures are usually placed near water's edge to serve as a guardian deity of sea voyages.

The Benten enshrined at Enoshima was reputed for her ability to fulfill the wishes of worshippers, but access to the cave with her statue was restricted to special visitors. In 1600, the Shogun Ieyasu Tokugawa (1542-1616) visited the Enoshima Benten and made the site an official prayer hall for the Tokugawa family, which spurred the faith in Benten. In 1603, the temple/shrine complex was opened to the public. It is now a Shinto shrine.

Waichi stayed at the shrine, fasting and praying in the cave for three weeks. At the story goes, when he came out of the cave after the fast, he stumbled over a stone (see Figure 1). As he fell to the ground, a pine-tree needle stuck deep into his leg. Cursing, he picked it up, and, as he did, he realized that it was sticking out from a reed of bamboo. Inspiration struck: for the acupuncturists, it is a critically important to stick the needle straight down and attain the proper depth: this pine needle in its bamboo cradle had done just that. Upon his return, he began using a small pipe to help guide the acupuncture needle vertically to pierce the patient's skin. That bamboo reed became the basis for a device known as a kudabari¾ a needle insertion guide tube that is now standard equipment for both blind and sighted acupuncturists worldwide.

Waichi's innovation made him a successful acupuncturist; he is credited with having developed 100 acupuncture techniques. Waichi's skill was proven when his acupuncture skill cured Shogun Tsunayoshi Tokugawa (1646-1709) of a serious illness. As an expression of gratitude, the Shogun retained him as his personal physician, conferred the title of Kengyo, the highest official title given to the blind, and he gave Waichi a chunk of land, which became the home to Shinji Koushujo, Edo's first organized school for the blind. In appreciation of his success, Waichi donated a three-story-pagoda in the name of Benten (which was, unfortunately, removed after the Meiji Restoration) and he had 47 mileposts built between Enoshima and Fujisawa, of which 11 are still in existence. He visited Enoshima so often to worship Benten that he was not always available when Shogun Tsunayoshi needed him. To keep Waichi nearby, the Shogun erected a mini-temple sacred to Benten in Waichi's residence.

By the time of his death in 1694, at the age of 84, Waichi had established 45 acupuncture schools for the blind throughout Japan. By having books read to him, he studied and then simplified volumes of ancient medical texts, making a substantial body of knowledge available to the blind on a practical level. The stone Waichi had tripped over at the Benten shrine became known as the "Stone of Good Luck." The Benten statue, to which Waichi prayed, was damaged after being set aside during an anti-Buddhist phase of the Meiji Restoration, and has been reconstructed and is available for viewing at Enoshima, though it serves as a museum piece rather than a sacred artwork due to failure of the reconstruction to match the original.

WAICHI SUGIYAMA AND ABDOMINAL DIAGNOSIS

Waichi Sugiyama, in his teachings, made a significant contribution to the theoretical basis of abdominal diagnosis and influenced the practical method of carrying out the diagnosis. In particular, he relied on study of the Nan Jing to develop a five-element abdominal pattern for detecting imbalances. This pattern involved having the fire element (heart/small intestine) evaluated at the upper part of the abdomen; the water element (kidney/bladder) at the lower part of the abdomen; the wood element (liver/gallbladder) at the left part of the abdomen; the metal element (lung/large intestine) at the right part of the abdomen, and the earth element (spleen/stomach) at the center (see Appendix 1). To perform the diagnosis, he recommended using the palm and finger tips of the left hand to gently touch and palpate the skin surface. There is no deep pressure exerted. The diagnosis proceeds from the center to the left and right, and then from the top to the bottom of the abdomen. Abdominal diagnosis would replace, for the blind, the observational diagnosis of traditional Chinese medicine, such as appearance of the tongue and complexion. Among the features to be felt on the abdomen were temperature variations, tightness or looseness of the skin, tension of the muscles, pain or tensing on light pressure, fluid movements (as occur in the intestines) during palpation, sensation of movement across an abdominal region, and any lumps or swellings.

Soon after Waichi's death, an herb doctor, Todo Yoshimasu (1702-1773; see Figure 2), also gave a substantial boost to the use of abdominal diagnosis. He developed the concept of conformations-symptom/sign complexes-that were to be associated with each of the essential traditional formulas. He assigned the herb formulas to certain diagnostic indicators found by gently palpating the abdomen. Thus, both acupuncture and herb therapy became tied intimately to the abdominal diagnostic method that thereafter dominated the Japanese system for both the blind and sighted acupuncturists.

THE LEGACY OF WAICHI SUGIYAMA

The guide tube approach to needling allowed for thinner needles to be used. This suited the blind acupuncturists who had to be especially careful about using large needles and deep insertion without being able to see the body. In the modern era, Japan is especially known for its use of very thin needles. However, the shift to the finer needles and the tendency to use these with ever more shallow insertion and little or no stimulus, has led some to remove themselves from any connection to physical reality and to corrupt the acupuncture field with therapies that offer no more than the equivalent of a placebo effect (see Appendix 2).

Unfortunately, when Waichi passed away, funding of the acupuncture schools for the blind dried up, and within a couple of decades, all of Sugiyama's schools were forced to close. Blind acupuncture managed to survive as relatively minor profession during the next 180 years, a time when Western medicine was beginning to supplant traditional Japanese medicine. Then, in 1876, the first new private school for the blind (Rakuzen-Kai) was founded, and spawned the modern era of blind education. Within 20 years, three more private schools were providing training for blind acupuncturists and the field opened up again.

Blind acupuncture is a nationally recognized practice in Japan today. Currently, 30 percent of the roughly 90,000 licensed acupuncturists in Japan are blind. These practitioners work among the sighted practitioners at clinics and hospitals, or carry out private practices, and pass on their skills to others like themselves in special schools for the blind. They hold the same licenses, earn the same wages, and charge the same fees as the sighted acupuncturists. There is a national association for blind acupuncturists (Zenshinshikai) to deal with their unique situation. Blake More of Point Arena, California, interviewed blind Japanese acupuncturists and published his report in the 1995 article Acupuncture’s Blind Side, which appeared in the magazine Time Out, published in Tokyo.

Tomoyuki Hoshiyama is a blind acupuncturist who teaches at the Hiratsuka School for the Blind (founded in 1910; it offers kindergarten through high school classes to about 100 students) in Hiratsuka City, south of Tokyo. Hoshiyama began studying acupuncture when he was 19, needling his parents for homework in order to perfect his technique; a sacrifice he describes as "painful for them, difficult for me." He says he went into teaching five years ago because he wanted to help other blind people make positive contributions to society. Hoshiyama's wife of two months, Yoko, also teaches acupuncture to blind students. For the last 11 years, she has been working at her famous alma mater, the School for the Blind at Tsukuba University in Tokyo. One of 14 acupuncture teachers instructing 50 students, Yoko says she got into acupuncture for the same reason most blind people do: necessity. "But then, while I was in the clinical aspect of my studies, I began to understand the benefits of acupuncture. As I watched people experiencing good results, I decided that I wanted to study harder and improve my technique so I could offer even more."

Although satisfied with their jobs, both Yoko and Hoshiyama express frustration over the fact that, like others who went to blind schools all their lives, they chose acupuncture more because it was the thing to do rather than because it was their life-long dream. Explains Yoko, "As blind people, we have few occupations available to us, so almost all blind students think about acupuncture at one time or another, particularly if they hope to be productive members of society. Even today, the only proven avenues we have are acupuncture, massage, and music." At the Osaka Prefectural School for the Blind, the course offering notes that: "According to the traditional culture in Japan, almost all of visually impaired persons have gotten a job doing massage, acupuncture, and moxibustion. But, we have three departments to get newer occupations, which are physical therapy, music, and computer science." The courses are offered after graduation from high school.

The majority of Japan's 69 schools for the blind are almost entirely funded by government sources, that is, they are public schools rather than private. About 600 people like Hoshiyama and Yoko-300 of whom are fully blind-teach acupuncture to visually impaired students in Japan. After graduating from high school and before going on to acupuncture school, students must pass an entrance test just as any sighted student would. Explains Hoshiyama, "Since we all take the same national licensing examination, our acupuncture department offers what sighted universities and colleges do. The main difference is that we use Braille and learn on a special practice model with raised acu-points." But there are some professional limitations: blind acupuncturists can't practice in major hospitals.

Among the leading blind acupuncturists is 85-year-old Kodo Fukushima, known as the "godfather" of contemporary meridian therapy and the force behind the enormous Toyo Hari I Teaching Center in Tokyo. His personality is almost as famous as his acupuncture, and he is described as charismatic, dogmatic, charming, and difficult. The 76-year-old Katsuke Serizaw, a near-blind medical doctor and acupuncturist, is another famous personality. He has written numerous acupuncture books for the blind-some of which are available in English-and has upgraded the overall quality of Japan's blind education system.

Some blind acupuncturists from Japan have visited the U.S. to share their knowledge. For example, Five Branches Institute in Santa Cruz, California offered a seminar by Anryu Iwashina, from Morioka City. He graduated from the Tokyo National School for the Blind with a degree in acupuncture more than 20 years ago, and trained with Kodo Kukushima at the Tokyo Hari Medical Association. He has traveled to the United States several times since 1988 to offer free acupuncture treatments to the Hopi and Dine people, and to assist at several Sundance ceremonies.

APPENDIX 1: Abdominal Diagnosis in the Nan Jing

The Nan Jing (Classic of Difficult Issues) was compiled around the end of the Han Dynasty (ca. 200 A.D.). It is comprised of 81 issues or questions that are concerns arising from the study of the Nei Jing (Inner Classic) that had been compiled during the early Han Dynasty (ca. 100 B.C.). A large portion of the book is devoted to the five elements depiction of disease causation (especially seasonal influences), the associated internal organs (zangfu; see Figure 3), the disease indicators (such as pulse forms), and the use of acupuncture. As is the case with the Nei Jing, herbal medicine is not a concern. An English translation of the Nan Jing, along with commentaries from well-known Chinese doctors who worked during subsequent centuries, was produced by Paul Unschuld.

Waichi studied the Nan Jing extensively, and based his abdominal diagnosis work largely on the contents of the 16th and 56th difficult issues raised in that text. Those sections described movements of qi in the abdomen that corresponded to and preceded (because they were part of the cause) diseases of the five viscera (zang). The implication that he derived from the text was that light touching of the abdomen at the locations indicated in the Nan Jing could detect the moving qi or blocked qi that indicated a disease was developing or already present.

The 16th difficult issue focuses on evidence that localizes a disease to one of the five viscera, to confirm what is felt in the pulse (at the wrist). The information presented can be summarized in a table as follows:

Organ Abdominal Indication Symptoms Reported by Patient External Evidence
Liver Moving qi detected to the left of the navel; if pressed, this region responds with firmness and pain. Swollen and stiff limbs; dripping urine; difficult stools; twisted muscles. Tendency toward tidy appearance; virid complexion; inclination to become angry.
Heart Moving qi above the navel; if pressed, responds with firmness and pain. Uneasiness of the heart; heart pain; the center of the palms are hot; dry vomiting may occur. Red complexion; dry mouth, and tendency to laugh.
Spleen Moving qi at the navel; if pressed responds with firmness and pain. Swollen and full abdomen; food not digested well; body feels heavy; and the joints ache. Yellow complexion; tendency to belch; tendency to ponder; fondness for tasty food.
Lung Moving qi to the right of the navel, if pressed, responds with firmness and pain. Panting and coughing; shivering from fits of cold and heat. White complexion, tendency to sneeze; grief without joy; and an inclination to cry.
Kidney Moving qi below the navel; if press responds with firmness and pain. Feeling of qi moving contrary to its normal course; tension and pain in the lower abdomen; diarrhea feeling as if something heavy was moving down; feeling cold; feeling of reversed qi in the feet and shinbones. Dark complexion; tendency to be fearful; frequent yawning.

In the discussion of the 56th difficult issue, involved with detection of accumulations affecting the internal organs, the Nan Jing states that:

  • Accumulations in the liver are called "fat qi." They are located below the ribs on the left side and resemble a cup turned upside down. They have a head and foot, and they last a long time without healing. They let the afflicted person develop a cough with qi moving contrary to the proper direction and they cause alternating fevers.
  • Accumulations in the heart are called "hidden beams." They extend upward [from the navel] to below the heart and last a long time without healing. They let the afflicted person suffer from a feeling of uneasiness in his heart.
  • Accumulations in the spleen are called "blocked qi." They are located in the stomach and resemble a large bowl turned upside down. They last a long time without healing. They cause the person to be unable to pull in his four limbs and they cause jaundice.
  • Accumulations in the lung are called "rest and run." They are located below the ribs on the right side and are several times the size of a cup. They last a long time without healing. They let the person shiver due to alternating perceptions of cold and heat and they let him cough and develop blockages in the lung.
  • Accumulations in the kidneys are called "running piglets." They develop in the lower abdomen and extend upward to below the heart. Like a piglet, they move up or down unexpectedly. They last a long time without ending. They let the afflicted person pant due to qi moving contrary to its proper direction. They cause the bones to weaken and to have little qi.

To produce a full system of abdominal diagnosis, the limited indications in the Nan Jing had to be expanded. Therefore, Waichi, and those who followed his example, carefully elaborated sensations felt by the diagnostician of the skin and muscles of the different parts of the abdomen.

APPENDIX 2: Excursions into Unreality

Proponents of Japanese acupuncture often point to an advantage that they perceive over the original Chinese system of acupuncture. The latter is portrayed as intolerable to most Americans because of its use of relatively large needles, deeply inserted and strongly stimulated. The Chinese aim is to attain the qi reaction, called deqi, which has a sensation of heaviness, distention, and numbness, often accompanied by an attempt to get transmitted qi: the experience by the patient of the qi sensation propagating from the acupuncture point towards the part of the body where the disease or injury exists. Japanese acupuncture, as promoted in the U.S., is contrasted as involving extremely fine needles, shallowly inserted and not stimulated to get a strong qi sensation for the patient (the acupuncturist, however, likes to feel a slight bobbing of the needle as it is inserted at the point, which is interpreted, instead, as the qi reaction). Indeed, because many Americans have had bad experiences with medical needles-hypodermic needles flushing liquids into the body, stabs of blood sampling needles, IV needles for drawing blood or dripping fluids-they are not drawn to the strong needle sensations, even if not painful, associated with standard acupuncture.

While Chinese acupuncture has been subjected to intensive scientific investigation, Japanese acupuncture is only loosely studied, and its effectiveness, especially when practiced in the very light stimulation forms, is open to question. While practitioners proclaim the benefits they see in their own patients, modern researchers recognize that such observations are often unreliable indicators. Nonetheless, the basic Japanese acupuncture technique is used in Japan by about 90,000 acupuncturists, about 8 times as many acupuncturists as there are in the U.S. So, it is a large field and a good resource for experience.

As some practitioners working in the West attempt to rely on ever more subtle treatments, they begin to develop explanations of how such minor interaction with the patient could possibly have a strong effect on healing. This leads to imaginations about energetics of the body and of the acupuncture needles-concepts that have no known basis in reality and little or no connection to the ancient tradition: they are just projections and guesses. Still, the language of the ancient tradition is used and even the language of modern science is brought in support of the untestable theories and newly devised techniques.

Examples of the corrupting influences are:

  • Omura's bi-digital O-ring diagnostic test developed by Yoshiaki Omura. This is no more than the muscle test developed by a chiropractor a few years back (and thoroughly dismissed by anyone who turns to critical analysis of claims made), shifted from the outstretched arm to the thumb and first finger held together. Omura, now living in New York, has written articles that describe his bizarre and obscure explanations in seemingly scientific terms of how photons interact "bidirectionally" with molecules.
  • Manaka's Ion Pumping Cords, developed by Yoshio Manaka, which not only do not pump ions, but are usually utilized by persons who have may have little or no concept of what an ion is or have little concern about making such a claim. Certainly, the study of ions, electrical transmission, and its potential effects on the body are not subjects in acupuncture colleges. The cords are nothing more than a length of wire with a diode (patented), purportedly to allow the flow of ions to go only one way.

As practitioners are encouraged to leave behind the long-standing tradition in order to take up these bogus diagnostics and therapeutics, they are further led to bizarre theories about how the body works. This move away from respect for a long lineage of scholars and dedicated doctors frequently leads to bragging about therapeutic triumphs, ones that are not properly recorded in any serious medical journal. Such behavior serves as an insult to the hard working practitioner scholars of the past who tried to encourage students to seek after the truth, rather than follow every fad.

March 2002

 


Figure 1:The Stone of Good Luck at the entrance of the Benten shrine.

 


Figure 2:Todo Yoshimasu (1702-1773).

Figure 3:Japanese map of the abdomen, 1685.

 

KAMPO MEDICINE

The Practice of Chinese Herbal Medicine in Japan

Kampo medicine is widely practiced in Japan, and is fully integrated into the modern health care system. Kampo is based on traditional Chinese medicine but adapted to Japanese culture. With only slight modifications, it has been adopted also in Taiwan and exported from Taiwan to the West. This article presents a concise history of Kampo that helps to elucidate the areas of primary concern to Japanese practitioners and reveals how a collection of certain traditional formulas came to dominate the system.

The basic texts of Chinese medicine, such as the Neijing Suwen and Lingshu, and the Materia Medica came to Japan during the 7th through 9th Centuries. This led to publication of the primary historical text about Chinese medical theory and practice in Japan: the Ishimpo. In the Chinese tradition, there are certain scholar-physicians who have become revered for their work, including Zhang Zhongjing and Sun Simiao, whose formulas and theories were incorporated into the Ishimpo. Japan also has its famous contributors from the classical period (15th to 18th Centuries), such as Sanki Tashiro, Gonzan Goto, and Todo Yashimosu, and renowned 20th-Century physicians, such as Keisetsu Otsuka and Domei Yakazu, who helped restore Kampo after several decades of suppression during the rise of Western medicine in Japan.

Kampo (also written Kanpo, Kampo is the older transliteration) literally means the Han Method, referring to the herbal system of China that developed during the Han Dynasty. Although Kampo encompasses acupuncture, moxibustion, and other components of the Chinese medical system, it relies primarily on prescription of herb formulas. Kampo today differs from the practice of Chinese herbal medicine in mainland China primarily by reliance on a different basic collection of important herb formulas and somewhat different group of primary herbs. Thus, for example, one of the most frequently mentioned traditional herb formulas in China is Xuefu Zhuyu Tang (Persica and Achyranthes Combination), a formulation used for treating blood stasis, devised by the reform physician Wang Qingren in the early 19th Century. By contrast, the most frequently mentioned herb formula in Japan for treating blood stasis is Guizhi Fuling San (Cinnamon and Hoelen Formula), a formulation of the Han Dynasty described by Zhang Zhongjing in the 3rd Century. While both formulations originated in China, Xuefu Zhuyu Tang is a relatively new one on the large scale of Chinese medical history, and was devised after Japan had ceased being directly influenced by developments in China. There are certain traditional Chinese medicine books that are relied upon heavily in Japan, providing formulas with a limited number of herbs, while there is a much broader range of sources-texts, herbs, and well-known formulas-relied upon in China.

A factor that has strongly influenced the practice of Kampo during the past 25 years was the formal recognition, by the Japanese Ministry of Health, of certain traditional Chinese herb formulas (and a few formulas of similar nature developed in Japan) as suitable for coverage by national health insurance. These formulas are prepared in factories under strict conditions. As a result, Japanese physicians focus their attention on a small group of formulas: about 80 that are frequently prescribed out of an approved collection of 148 formulas. By contrast, Chinese physicians are not only more likely to work with a larger group of traditional formulas, but also to make entirely new formulations using a diverse array of herbs. Many Chinese herb formulas prescribed by doctors in China are in the form of decoction, and there is no special pricing system in place to direct practitioners towards certain formulations. In addition, China has thousands of patent medicines, many of them introduced before the Chinese government instituted any restrictions on them.

In the West, the practice of Chinese herbal medicine has been strongly influenced by Kampo, because the Japanese approach was introduced early (before licensing of acupuncture was established) and effectively.

INTRODUCING CHINESE MEDICINE TO JAPAN

Cultural contact between China and Japan has occurred since ancient times. There is a story that is frequently told in the Chinese tradition about the first Emperor (reign: 221-210 B.C.) who is said to have sent emissaries by ship on the Eastern Sea to find the herb of immortality; it is suggested that they returned from Japan with ganoderma (lingzhi; Japanese: reishi) in completion of their mission. Some Chinese medical works were introduced to Japan as early as the 4th or 5th Century A.D., coming first by way of Korea, which had adopted Chinese medicine by that time. Historical records indicate that a Korean physician named Te Lai came to Japan in 459 A.D., and that a Chinese Buddhist named Zhi Cong brought medical texts with him to Japan via Korea in 562 A.D. It was also during this period that the Chinese written language was adopted in Japan so that the people could learn from China about Buddhism, Confucianism, governmental organization, and the divination arts, opening the way for study of Chinese medicine.

The first official classes in Chinese medicine in Japan are said to have been given by a Korean physician in 602 A.D. by order of the Empress Suiko (reign: 592-628 A.D.). During her reign, the Japanese court started sending envoys to China. Some of the Japanese visitors to China, being there primarily on diplomatic missions, brought back medical classics of China. In 701, the Taiho Ritsuryo Code (a series of edicts establishing a particular political and academic structure) was compiled and provided for, among many other things, establishment of a ministry of health (Ten'yakuryo; also translated as the Institute of Medicine). This Taiho Code, influenced by two visits to the Tang Imperial Court by the envoy Enichi, included a division devoted to the Chinese concept of yin-yang, one of the foundations of Chinese medical theories and other aspects of Chinese culture. The services of the health ministry were restricted to the royal court and aristocracy, while Buddhist temples took care of the poor, eventually including Chinese medicine. The Empress Komyo (701-760 A.D.) established a dispensary to supply free medicine to the needy in 730 A.D. The dispensary provided local Japanese herbs, but the method of using the herbs was already influenced by Chinese medical principles.

These early contacts and exchanges with Korea and China had only limited implications for medical activities in Japan which, up to that time, had been dominated by shamanism, exorcism, and purifications, with only a slight reliance on herbs, mainly for symbolic use. Widespread interest in Chinese medicine apparently arose as the result of a visit from the Chinese Buddhist priest Jian Zhen (Japanese: Ganjin) who arrived in Japan in 753 A.D. (at the height of the Tang Dynasty in China). Jian Zhen had developed a great knowledge of medicine and herbs. It took five attempts over a period of 12 years before he was able to cross the rough seas to reach Japan. He was blind at the time he arrived, but he was able to accomplish much due to his great generosity. Jian Zhen had come to Japan with medical texts, a collection of herb materials, and a desire to teach. It was said that he had refined his sense of smell so that he could distinguish between true herbs and any false substitutes despite his lack of eyesight. Most importantly, he provided free medical services, which boosted the respect for both Buddhism and Chinese medicine and, along with the charitable act of Empress Komyo a few years earlier, introduced the concept of social medicine to Japan.

A collection of herbs that Jian Zhen and subsequent visitors brought to Japan has been preserved to this day. In the building complex known as the Shosoin (also spelled Seisoyin), resides a collection of herbs that was presented in front of the Buddha statue in the Todaiji Temple at the Imperial Palace (see Figure 1). This collection was dedicated 49 days following the death of the former Emperor Shomu (Seimu Tienno) in 756 A.D. (in the Buddhist system, the determination of rebirth, entry of the spirit into the womb, occurs 49 days after death). The Shosoin has served as a repository and museum for these herbal medicines and miraculously escaped both natural and man-made disasters, making it one of the oldest surviving structures in Japan. The Shosoin had been designed in such a way that it helped prevent the deterioration of the herbs, and it has been ceremoniously aired out for one week each year. According to an inventory record that accompanied the collection, there were 60 different medicinal materials in the original group, though the dispensing of herbs to patients depleted the supplies of 20 of them, leaving 40 of the original samples; there were also 16 herbs that may have been added to the collection after the inventory list was compiled. Scholars have performed analyses of the herb materials to confirm their identity; they have found many of the active ingredients intact after more than 13 centuries.

Following the introduction of Chinese medicine by Jian Zhen, a number of Japanese people took an interest in learning and spreading the tradition in Japan, and they got hold of numerous medical works from China. The Xinxiu Bencao (Newly Revised Materia Medica) also known as the Tang Bencao, Tang Dynasty Materia Medica, 659 A.D.), which had been sponsored by the Tang Imperial Court, became an obligatory text in the study of medicine at the Japanese Health Ministry in 787 A.D. Unfortunately, many of the 844 medicinal substances described in the Materia Medica were not available in Japan at the time.

At the end of the 8th Century, the Japanese physician Ilura Yamanoue traveled to China to study Chinese medicine and wrote a poem, published in a 9th Century anthology, mentioning famous Chinese physicians, such as Bian Que, Hua Tuo, and Zhang Zhongjing. A few medical works by Japanese authors were also written during the 9th Century, such as Datong Leiqi Fang (A Generalization of the Ancient Native Herb Formulas) in 808 A.D. and Jin Lan Fang (Precious Formulas) in 868 A.D. A list of Chinese medical books compiled around 895 A.D. included 166 texts. Around 918 A.D., a Japanese medical dictionary (Honzo-wamyo) was written, quoting from 60 different Chinese medical works.

The growing collection of Chinese works were used as a source of Japan's primary text on Chinese medicine, the Ishimpo (The Essence of Medicine and Therapeutic Methods; Chinese name: Yi Xin Fang). This text of 30 individually titled scrolls was written by Yasuyori Tamba in 984 A.D. and is the oldest Japanese book on the subject to survive to the present. The Ishimpo is a compilation of medical knowledge and medical theories that were prevalent during the Sui Dynasty (589-618 A.D.) and Tang Dynasty (618-907 A.D.), quoting from more than 100 Chinese texts. This period of Chinese medical history was greatly influenced by the work of two earlier medical authorities: Zhang Zhongjing (ca. 150-220 A.D.) and Sun Simiao (581-682 A.D.). Zhang wrote the medical text that was divided into the Shanghan Lun and Jingui Yaolue. Sun Simiao became known in China as the "King of Medicine" or the "Medicine God;" his herb medicine books were the Qianjin Yaofang and Qianjin Yifang (collectively referred to as Qianjin Fang). In turn, Sun Simiao had been influenced, especially with regard to Taoist practices, by the famous alchemist Ge Hong (281-341 A.D.), who published formulas in his book Zhouhou Beiji Fang (ca. 340 A.D.). The Materia Medica guides that were relied upon at the time were the Shennong Bencao Jing (ca. 100 A.D.) in its revised form, Mingyi Bielu by Tao Hongjing (452-536 A.D.), and the Xinxiu Bencao mentioned previously.

Tao Hongjing had classified the herbs of the original Materia Medica of China into three groups: upper, middle, and lower herbs. This grouping had a profound impact on the concepts of medical practice during this era. The upper-class herbs were said to be suited for long-term administration to preserve health and attain long life. While there were numerous plant medicines in this category, the dominant ingredient at the time, the one used most often by Taoist seekers of immortality, was cinnabar (mercuric sulfide). Medicines comprised of large amounts of cinnabar, often with realgar, were popularized by Ge Hong and Sun Simiao, who studied the Taoist arts. Of course, these medicines, considered so valuable for regular intake, were actually poisonous, and both Chinese and Japanese seekers of long life suffered the consequences. The middle- and lower-class herbs were to be used for treating specific diseases, used for a relatively short time, and were deemed to be mildly toxic. In fact, they were often less toxic than cinnabar, but a number of very potent drugs were included, such as genkwa and datura, that supported this classification.

The Shanghan Lun and Jingui Yaolue formulas were mostly comprised of plant materials, and the majority had low toxicity. These plant materials were supplemented by minerals or mineralized compounds, most of which were quite safe: oyster shell, dragon bone, gypsum, and talc, for example, are all calcium materials used in some of the formulas. These ancient formulas soon became one of the principal focal points of Kampo medicine. To this day, many Kampo practitioners study and praise the Shanghan Lun and Jingue Yaolue and prescribe their formulas, such as Minor Bupleurum Combination (Xiao Chaihu Tang), Cinnamon and Hoelen Formula (Guizhi Fuling San), Hoelen Five Formula (Wuling San), Pueraria Combination (Gegen Tang), and Tang-kuei and Peony Formula (Danggui Shaoyao San). These are relatively small formulas (typically 5-9 ingredients) that rely heavily on a small collection of herbs, mainly those categorized in modern texts as surface relieving herbs, heat clearing herbs, moisture draining herbs, and tonics.

Japan entered a period of isolation soon after the Ishimpo was published; the last envoy to China returned in 894 A.D. Although there were some individual visits by Japanese scholars to China, the level of exchange was limited. The formulas of Zhang Zhongjing and Sun Simiao, and the accompanying medical theories and practices of their time, dominated Kampo until the end of the 15th Century.

TWO SCHOOLS OF KAMPO: GOSEIHA AND KOHOHA

The Goseiha School (School of Later Developments in Medicine) evolved from a 12-year visit to China (1486-1498) by Sanki Tashiro (1465-1537). While in China, he encountered the powerful influences of what is known as Jin-Yuan medicine (making reference to two Dynasties of northern tribes, the Jin, which coexisted with the Southern Song Dynasty, and the Yuan, or Mongols, who took control of nearly all China). Jin-Yuan medicine was comprised of four major schools of thought about causes and treatment of disease. Among the leading physicians of the Jin-Yuan period that influenced Sanki Tashiro were Li Gao (aka Li Dongyuan; 1180-1251) and Zhu Danxi (1281-1358), founders of the Spleen/Stomach school and the Nourishing Yin school, respectively, emphasizing the tonification therapies that are denoted in their names (the other two schools focused on clearing heat and on purging evils). In addition to their recommendations for herbal therapeutics, the physicians of the Jin-Yuan period promoted the further development of the five elements system and the associated concepts of the five zang and six fu (yin and yang organs, respectively), and the influence of the environment factors on health. These theoretical components involved considerable speculation about interrelationships within the body and between the body and the environment (as well as between the body and herbs) that came to characterize the thinking of the Goseiha School. This school was also influenced by the neo-Confucianism that was dominating developments in China at this time, largely attributed to the efforts of Zhu Xi (1120-1200).

The Goseiha School began on a small scale, but was spread considerably by several of Tashiro's students and followers during the 16th century; this expansion continued into the 17th century. Perhaps the most important figure in the Goseiha School was Manase Dosan (1507-1594), a student of Tashiro's who wrote the eight-volume work Keitekishu (Textbook of Internal Medicine) and founded the Keiteki-In, a private medical school in Kyoto. He expressed the view that for acute diseases one should rely mainly on the formulas of the Shanghan Lun, but that for chronic diseases, the prescriptions of the Jin-Yuan schools (referring, especially, to the two tonification schools of Li and Zhu) are suitable. He also cautioned that herbal drugs possess some natural toxicity and should be used carefully. Dosan's son, Gensaku, also became an influential Kampo practitioner who wrote Igakutienseiki, a book of clinical cases involving famous personages. The framework of the Goseiha School is sometimes called "Dosan Medicine."

The Goseiha School ushered in the use of a new group of herb formulas. These included those of Li Gao and Zhu Danxi, but even more importantly, those of the Song Dynasty book Taiping Huimin Hejiju Fang (published in 1110). This book, that had been ordered by the Song Emperor, with the project headed up by the Court physician Chen Shiwen, includes a large compilation of formulas. The work was carried out at a time when there was a revived interest in the Shanghan Lun and Jingui Yaolue in China, and, not surprisingly, many of the Hejiju Fang formulas were similar in ingredients and design to those of the earlier works. Among the many traditional Chinese herb formulas heavily relied upon today that come from this text are Four Major Herbs Combination (Si Junzi Tang), Tang-kuei Four Combination (Siwu Tang), and Bupleurum and Tang-kuei Formula (Xiaoyao San). The Hejiju Fang formulas became as widely used as the Shanghan Lun formulas, infusing a new stimulus into the practice of Kampo.

There eventually developed some opposition to the speculative logic associated with the Jin-Yuan teachings. For example, the founder of the Jin-Yuan medical developments, Zhang Yuansu (1151-1234), had proposed that each herb entered one or more specific channels (meridians) to affect the associated organ systems, an idea accepted also by his student Li Gao. This concept, which still appears in modern Materia Medica books (following the listing of the nature and taste of herbs there is usually a listing of affected meridians), has been the subject of objections in both China and Japan. It proposes something that is not considered practical, and that relies too heavily on imposing rigid adherence to the theories of five elements and zangfu without observation of clinical effects. Today, despite the listing of "meridian entrance" of the herbs in the texts, this feature is rarely relied upon in making clinically relevant choices in herbal prescribing.

A new school evolved in Japan, which opposed the Jin-Yuan medical reforms and favored practical knowledge and a return to the earlier teachings (i.e., up to the Tang Dynasty): the Kohoha School (School of Classical Formulas). Proponents of the Kohoha School similarly rejected neo-Confucianism in favor of the original Confucian tenets. This school soon replaced the Goseiha School rather than competing side-by-side with it. Though many in the Kohoha School emphasized the teachings and formulations of the Shanghan Lun (i.e., going back to the most ancient and reliable classic text), others did not stick tenaciously to this source text and remained open to later formularies, such as the Hejiju Fang.

One of the key features of this school was its reliance on what is now known as confirmation theory (also spelled conformation theory): matching a symptom and sign complex (Chinese: zheng) of the patient to a particular ancient formula, with no intervening speculation, such as had been practiced by the Goseiha School using yin-yang and five element analysis. This method is retained by many Kampo practitioners today.

Two specific concepts about disease causation and treatment developed during this period: one based on the problem of qi stagnation; and the other based on the influence of a particular toxin of external origin. An early activist in this School, Gonzan Goto (see Figure 2), placed particular emphasis on the concept that the development of disease is related to stagnation of qi circulation. He noted that some people could remain healthy and unaffected by adverse weather conditions (external disease causes in the Chinese system) and could resist disease due to emotional extremes (internal disease causes in the Chinese system). However, others were readily susceptible to such adverse influences, and this susceptibility, he postulated, was due to qi stagnation. Therefore, he relied on a variety of techniques (not just use of herbs) aimed at overcoming qi stagnation as a means of treating and preventing diseases.

The other specific concept of disease is attributed to the most influential figure of the Kohoha School, Todo Yoshimasu (1702-1773). His understanding was that there was one basic toxin that could enter the body and cause all diseases. He proposed that the differences among diseases and their symptoms were primarily the result of different sites of the body being affected by that same poison. He attached great importance to the Chinese system of abdominal diagnosis that had been all but abandoned in China, stating that the site of the affecting poison could be most easily detected by the condition of the abdomen. Yoshimasu wrote the book Ruijuho (Indications of Kampo Prescriptions) in which he reclassified the formulas of the Shanghan Lun and Jingui Yaolue, believing that the formulas were very valuable, but that the accompanying theory of yin and yang disease types had to be discarded. Many Kampo practitioners still rely heavily on the connections between certain abdominal conformations and the associated formula derived from the Shanghan Lun or Jingui Yaolue. Yoshimasu also wrote Yakucho (Characteristics of Herbs), which remains an important historical work on Kampo.

While both these theories of disease causation were as speculative as those of the Goseiha School, the therapeutic approaches recommended were based on empirical observations and practical methods, so these proposals were not considered an impairment to the fundamental principles of Kohoha. A movement in China similar to that of the Kohoha School (but a century later) was led by Zou Shu (1790-1844), author of Ben Jing Shu Zheng (Materia Medica Classic Commentaries & Testimonials; completed 1837, published 1849). His book was in reaction to the Bencao Shu (published 1700), which he felt contained too much of the Jin-Yuan medical theories, while the practical prescriptions of the Shanghan Lun and Jingui Yaolue and the work of Sun Simiao were neglected. He aimed to blend theoretical and practical information and escape the trend towards increasingly obscure approaches to understanding herbs and formulas.

Another important influence in the Kohoha School, at least for those who did not stick tenaciously to the works of Zhang Zhongjing, was the book by the Chinese physician Gong Tingxian (1522-1619), Wanbing Huichun (1587), written by his student Dai Mangong, who later immigrated to Japan. Another immigrant from China was Ma Rongyu, a scholar of the Neijing; his son studied under Gong Tingxian and helped expound his works.

Gong's prescriptions relied heavily on the framework developed by the Shanghan Lun, Hejiju Fang, and other ancient texts. He made larger formulas that combined the earlier smaller formulas, and then added a number of herbs that were in vogue at the time (mainly herbs for dispelling heat, cleaning toxins, and resolving swellings; he worked during the time when the concept of epidemic warm diseases was evolving). A good example of Gong's formulations is Tang-kuei and Gardenia Combination (Wen Qing Tang), which is an eight-herb formulation comprised of a four-herb formula (Coptis and Scute Combination) from Ge Hong's Prescriptions for Emergencies (340 A.D.) and a four-herb formula from the Hejiju Fang (Tang-kuei Four Combination). Tang-kuei and Gardenia Combination would then serve as a base for a large prescription, such as Gardenia and Vitex Combination (Xigan Mingmu Tang), in which Gong incorporated mentha, schizonepeta, platycodon, gypsum, cassia, and other herbs that were commonly used in heat-cleansing prescriptions.

Gong's formulas were one of the last major imports from China to this system of medicine. Kampo then became a well-established Japanese medical tradition that was independent of China. During this time, Japan did continue to import medical books, including the Bencao Gangmu (Herbal Compendium) by Li Shizhen, first arriving in 1607, but Kampo progressed on its own track. Some new formulas were devised by Japanese practitioners, such as Sohako Asada and his descendents, but the majority of formulas relied upon for Kampo were those introduced from China up through Gong Tingxian's work. Just as Kampo attained its strength and independent status at the end of the 16th Century, Western medicine came to Japan, and eventually caused the decline in practice of Kampo.

DECLINE OF KAMPO MEDICINE AND RISE OF WESTERN MEDICINE

Western medicine was introduced to Japan by the Portuguese around 1590, a few decades after their first landing in Japan in 1543. Additional entry of Western medicine came via Spain during the early 1600s, but this influence of Portugal and Spain was limited to the coastal regions, such as Kyushu (one of the Japanese islands). The Japanese leadership adopted a policy of national isolation soon after the Portuguese and Spanish incursions, allowing trade and interchanges only with the Dutch (among Western powers) starting in 1639, which brought entry of Dutch physicians and medical works.

This foreign medicine took on significance only after Japanese scholars studied it and wrote about it from their perspective. For example, in 1774, Genpaku Sugita published Kaitai-shinsho (The New Book of Anatomy), which greatly enhanced the reputation of Western medicine. Another scholar of Western medicine was Gentaku Otsuki, who pointed out that the two systems of medicine could be complementary, each overcoming the inadequacies of the other. During this time, traditional practitioners began to develop specialization like that found in Western medicine; for example, Genetsu Kagawa (1700-1777; see Figure 3) focused on obstetrics and influenced the field for generations afterward. Seishu Hanaoka (1760-1835; see Figure 4) actively pursued integration of Kampo and Western medicine.

The biggest boost to Western medicine in Japan came with the introduction of smallpox vaccination in 1849, fifty years after it had been developed in Europe. Kampo had no comparable disease prevention techniques and its reputation suffered under the light of the successful vaccination campaign. Kampo then went into a period of severe decline from 1868 to 1902 as the result of efforts by the Meiji government. The government based its actions on the concept that Japan was too weak relative to the Western nations, and took drastic steps to build up the military and to strengthen the internal affairs. As part of this, Western medicine was accepted as the most desirable method of therapy and was fully endorsed by the government, with efforts made to suppress the traditional system as being outmoded and contributing to the weakness of Japan. New medical examinations (starting in 1875) focused on chemistry, anatomy, physiology, pathology, pharmaceutics, internal medicine, and surgery, and ignored traditional medicine dogma, herbs, acupuncture, and other aspects of the ancient medicine. In 1883, the government required passing of the new examination even for those who wished to practice Kampo. The medical studies required for this exam were so intensive as to virtually preclude the opportunity to also study Kampo, even if one wished to do so in this climate.

REVIVAL OF KAMPO

Kampo physicians were appalled by the sudden cut-off of the traditional medical system in 1875. Several of them organized the Onchi-sha Association to defend and preserve Kampo. The principal figures involved were Gyoko Yamada, Shohaku Asada, and Risshi Mori. Beginning in the 1880s they recruited several other Kampo physicians and set up some small hospitals emphasizing Kampo practices. However, by 1887, the organization was disbanded after key members either left the organization due to internal policy dissent or died of old age. In 1895, an attempt to get legislative reform of the medical licensing regulations to allow separate licensing in Kampo failed. Kokkan Azai, one of the main activists in this reform effort died in 1902, with Kampo virtually stamped out.

Despite the highly successful efforts of the Meiji government to eliminate Kampo, a few Kampo physicians remained who continued to promote their tradition as the Meiji gave way to the subsequent Taisho government. Although the Taisho still retained its devotion to Western medicine, some revival became possible after 1902, since Kampo was no longer seen as a potential threat to modernization and there was no need to make it a specific target of suppression. The Kampo physicians wrote about the value of Kampo; for example, Keijuro Wada wrote Ikai-no-tettsui (The Iron Hammer of the Medical World) in 1910 and Tadanao Nakayama wrote Kampo-igaku-no-shin-kenkyu (New Study of Kampo Medicine) in 1927. In addition, a course on Kampo medicine was set up at Takushoku University in 1937 (such a course is currently taught at Toyama Medical and Pharmaceutical University).

After the 1920s, Kampo was promoted not by old doctors from the pre-Meiji era, but by enthusiastic converts from the modern medical profession. Keisetsu Otsuka, who became one of the most famous Kampo practitioners of the 20th Century, told his story of conversion from Western medicine to Kampo:

In 1920, I was a second-year student at Kumamoto Medical School [a Western medicine school]. One day while walking through a park in the suburb of Kumamoto, I saw a sign that said: Chinese Medicine Hospital. I have seen many hospital signs before and since, but have forgotten them all. Only this one can I still picture in my mind's eye. When I looked at the words "Chinese Medicine," I remember feeling only contempt. I didn't know at the time that the hospital dated from the Tokugawa era and was most famous for its Chinese herbal medicine. I thought the sign was merely advertising for an unlicensed practitioner. It was only many years later, as I myself pursued the study of Chinese medicine, that my memory of that time reawakened.

Many people have asked me why I gave up modern medicine to study Chinese medicine, a field at the time ostracized and despised by society. I usually answer: First, I was weak and sickly during my childhood, and treatment with modern medicine proved useless; second, since my entire family consists of doctors, I grew up always surrounded by many books, including those about Chinese herbs as well as other herbs. I truly think that I finally devoted myself to such study because it was destined and not because of the answers that I gave my questioners. Except for chance, I would probably not have devoted myself to the study of Chinese herbal medicine.

Thinking over my career, I can recall numerous times when I have cured fellow doctors with Chinese herbs. All of them took Chinese herbs when sick, yet never took up the study of Chinese medicine. In fact, of the many doctors born into medical families and surrounded by Chinese herbs, only a few, such as myself, have ever given up modern medicine to devote themselves to the study of Chinese herbal medicine.

One morning in March of 1927, as usual before seeing patients, I was reading the literature section of the Tokubai newspaper. There I saw a review of a book entitled A New Study of Kampo Medicine by Tadano Nakayama. After reading the review, I immediately ordered the book. The review mentioned that the autumn edition of the magazine Japan and the Japanese had carried an article by Nakayama "On the Revival of Chinese Herbal Medicine." Because of the sensation it caused, he had expanded that article into this book.

For years I had looked down upon Chinese herbal medicine, but after reading this book I realized that its approach was as clinical and valid as modern medicine. I was ashamed of my ignorance-I had thought it to be only folk medicine. Through reading this book I learned of the classic Shanghan Lun, the oldest book of treatment in the world.

One day, I saw an announcement of the publication of the first volume of a magazine called Kokan Igaku (June 1927). I immediately ordered it. Although not a wealthy man, the herbalist, Yumoto, who later became my teacher, published the magazine himself. After reading it, I decided to devote my life to Chinese herbal medicine.

Yumoto had graduated from Kinzawa Medical School (a Western medical school) in 1901. His attitude towards the value of the medical practices changed, however, and he gave up modern medicine to study Chinese herbal medicine. At the time (around 1920), there were no Chinese herbal specialists left in practice, but some medical doctors had decided to study the subject, even while maintaining their Western medical practice. A licensed medical doctor would be able to prescribe Chinese herbal medicine, but a Kampo specialist lacking Western medical training could not, because he would have no license to practice.

Along with the gradual revival of Kampo medicine via practitioners of modern medicine, another development helped the field to grow: modernization of the dosage form of herbal medicine. In the 1920s, Nagakura, a pharmaceutical company headed by Nagakura Onzo, began developing ways to mass produce Chinese medicine using precision apparatus and scientific methods. This led to the production of dried decoctions in a convenient granular form, commonly called wakan-yaku (Japanese-style classic remedies) that have become a standard method of Kampo medicine administration. In place of a set of small drawers containing a limited number of crude herbs to be selected, weighed, and then sent home with the patient for preparation as a decoction, the manufactured herb formulas were dispensed in a convenient form and simply given to the patient in quantities that would last until the next visit. At about the same time, Tsumora Juntendo, a company founded by Jusha Tsumura in 1893, established a research institute and herbal garden to promote the development of Kampo.

Thus, with some doctors learning Kampo, the publication of some Kampo books and journals, the offering of a Kampo course at a medical college, and production of modern herbal preparations, this field of medicine was ready to expand substantially. Shinichiro Takeyama wrote Kampo-ijutsu-fukko-no-riron (Theories on the Restoration of Kampo Medicine) in 1941, ushering in the new age of Kampo practice.

Then, World War II put the development of Kampo into the background. Modern medicine, especially surgery and antibiotic therapy, was critical during the war years. When Japan was defeated in 1945, it took several years for the country and its industrial and social activities to recover. The medical doctors who had taken up the practice of Kampo formed the Japan Society for Oriental Medicine in 1950 with 98 members. This organization helped lead the way to the current restored form of Kampo; it currently has about 10,000 members. The work initiated in the 1920s to develop prepared forms of Kampo medicine progressed further to allow for large scale production in the 1950s.

In 1967, four Kampo remedies were approved for reimbursement under Japan's national health insurance. In 1976, the Japanese government gave official approval to 82 prescriptions of the Kampo system; these could be purchased under the National Health Insurance System and were available as over-the-counter remedies. In addition, the Department of Pharmaceutical Affairs of the Ministry of Health and Welfare approved 210 herbal formulas (including the 82 already mentioned) for use in medical facilities, where they were also available over-the-counter (but not all of them were approved for coverage by national health insurance). These formulas were adopted as medicines without having to go through the lengthy registration process that was required for modern drugs (and also required for any other herb formulas). Specifically, the long history of use of these formulas was cited as sufficient evidence for their safety, if not for their efficacy, so the accumulation of safety documentation normally required was waived. Today, 148 prescriptions are covered by the national health insurance and more than half of them are the focus of modern Kampo practice.

Aside from the formulas that had been adopted several centuries earlier by the Goseiha and Kohoha schools, a few prescriptions of the Warm Disease school that had developed in China during the 18th Century were also included among the approved formulas. The main influence from this school was the Wenbing Tiaobian (Systematic Differentiation of Warm Diseases; published 1798) written by Wu Jutong (also known as Wu Tang); he presented the popular Lonicera and Forsythia Formula (Yin Qiao San) and Morus and Chrysanthemum Combination (Sang Ju Yin), both used for the wind-heat type of ailment. In addition to the approved formulas, all of the individual herbs that go into making the formulas are also approved for use, so that modified formulations, produced by combining single herbs with base formulas or combining only single herbs to make new formulas, are also available for prescription.

Kampo spread rapidly during the period 1985-1995; after that, the number of practitioners stabilized at a nearly constant level. By 1985, it was reported that about 20-25% of the medical doctors in Japan were including some herb prescribing in their practice. However, as pointed out by Terasawa Katsutoshi, only about 100 or so doctors were routinely prescribing Kampo medicines to their patients. The proportion of doctors that provide some Kampo medicines has risen to about 50% or more by some estimates, with a proportional increase in Kampo specialists (more than 200). In addition, there are about 10,000 pharmacies in Japan that dispense herb formulas. About 2% of total drug expenditures in Japan are herbal medicines, the largest part of them provided by Tsumora Juntendo, with contributions from about 20 smaller manufacturers. Kampo medicine research is conducted at the Toyama Medical and Pharmaceutical University in Toyama, the Kitazato Institute in Tokyo, and the Kinki University Medical Teaching Hospital near Osaka, as well as at other sites. Surveys conducted in Japan have revealed that the main uses of Kampo medicines are treatment of hepatitis, menopausal syndrome, common cold and other upper respiratory tract infections, autonomic nervous dysfunctions, constipation, cough and asthma, skin diseases (mainly eczema and other categories of dermatitis), lumbago and neuralgia, and gastro-intestinal disturbances.

INTRODUCTION OF KAMPO TO AMERICA VIA TAIWAN

Kampo was brought to Taiwan by Dr. Hong-yen Hsu (1917-1991), a native of Taiwan who had studied pharmaceutical science in Japan and became impressed by the Japanese approach to herbal medicine. He also took an interest in the technology that had been developed by Nagakura. On return from Japan, he established the Sun Ten Pharmaceutical Works in Taiwan and began producing Kampo medicines in 1963. Hsu also became director at the Food and Drug Control Division of the National Health Administration. He promoted the scientific study of Kampo by establishing the Brion Research Institute, where several researchers under his direction evaluated the safety and pharmacological actions of the formulas, their individual herb ingredients, and their active components. These researchers also studied the botanical origins of the medicinal materials sold in the Hong Kong, Taiwan, and Japanese markets. Hsu brought the writings of Kampo practitioners to Taiwan, where their methodology was widely adopted at a time when there was virtually no direct communication with the practitioners in mainland China.

The introduction of Kampo to America was also through the work of Dr. Hong-yen Hsu, who emigrated to the U.S. from Taiwan. He set up two organizations in 1975: Oriental Healing Arts Institute (OHAI), to publish translations of Chinese medicine books, and Brion Herbs Corporation, to distribute Kampo medicines and similarly prepared Chinese herb formulas produced by Sun Ten. OHAI published a bimonthly journal (Bulletin of the Oriental Healing Arts Institute; later transformed into a quarterly journal, the International Journal of Oriental Medicine). Many of the journal articles were authored by Japanese doctors, including famous Kampo physicians, such as Keisetsu Otsuka and Domei Yakazu (Oriental Healing Arts provided translation and editorial services).

OHAI also published numerous books about Chinese medicine that were primarily based on the practice of Kampo, such as How to Treat Yourself with Chinese Herbs, Chinese Herbal Medicine and Therapy, and Commonly Used Chinese Herb Formulas with Illustrations. The books presented the formulas used by Kampo practitioners and listed the Kampo indications for their use, which often differed, at least in the specific details, from the indications found in books from mainland China (over time, more information from China was incorporated into the OHAI publications). OHAI published several books that were specifically about clinical experience in Japan by Japanese authors, such as: the clinical guide Natural Healing with Chinese Herbs by Otsuka, Yakazu, and Totoro Shimizu; the collection of case reports in Thirty Years of Kampo by Otsuka; and the book Combined Use of Oriental and Western Medicine by Toyohiko Kikutani. Additionally, OHAI published a translation of the Shanghan Lun that was annotated by Otsuka.

The Sun Ten herb formulas distributed by Brion Herbs Corporation were the same ones used in Taiwan and Japan. In fact, the Sun Ten factory was the only Taiwanese company, out of more than a dozen making similar products, that supplied Japan, having met the very strict import requirements that had been designed to protect Japanese industries. Later, Sun Ten established a factory in the U.S. to produce the formulas. It is the only major manufacturer of Kampo medicines in the U.S. The manufacturing is directed by one of Hong-yen Hsu's sons, Chau-shin Hsu, who also contributed articles and coauthored books published by OHAI. Several other Taiwanese manufacturers of Kampo style remedies now offer their products in the U.S., notably Kaiser Pharmaceuticals and Min Tong, following up on the lead taken by Sun Ten. In addition, Japanese and Korean firms have entered the market (South Korea also utilizes Kampo-style preparations). Translated books about Kampo and herb formulas are distributed to Europe, Canada, Australia, and other areas of the world.

The manufactured herb formulas have become popular in the West because of the convenience and quality of the dried extracts, along with further developments such as encapsulation and tableting, as well as the availability of single herb extracts that can be used to make new formulas. The Kampo-style preparations are a source of formulas commonly used both in China and Japan (e.g., Rehmannia Six Formula; Liuwei Dihuang Wan), while the single herbs are a means of providing individualized prescriptions without having patients go through the process of preparing decoctions. The unique Kampo approach to diagnosis embodied in abdominal diagnosis is not used much in America, but the indications for use and understanding of herb formulas that have developed in Japan have enriched the understanding of Chinese medicine for practitioners here. As a means of broadening interest in the Kampo formulas, some efforts have been made at integrating them into the academic format preferred in China. For example, OHAI published A Comprehensive Guide to Chinese Herbal Medicine, by Zelin Chan and Meifang Chen (physicians from Shanghai), in which most of the formulas listed in the book are from the Kampo system, but formula modifications according to signs and symptoms, typical of what is done in China, are also described.

Ultimately, Kampo in the West is becoming integrated into a broader system capturing the features of Japanese, Taiwanese, and mainland Chinese approaches to traditional Chinese medicine with the intention of combining effectively with modern (Western) medicine. The experience of medical doctors in Japan working with traditional herb formulas offers one model of how the tradition can be utilized as a valuable part of modern medicine.

RESOURCES

This article was derived primarily from secondary sources in English. Among the main resources were:

  • Dawning of Japanese Medicine: Ishimpo; proceedings of the 1984 conference celebrating the 1,000 year anniversary of publication of the Ishimpo, part of the 17th International Congress of Internal Medicine, published with the help of Tsumora Juntendo Co., Ltd. This book was provided by the Oriental Healing Arts Institute.
  • Progress of Oriental Medicine-Proceedings of the Sixth International Congress of Oriental Medicine, 1990, sponsored by the Japan Society for Oriental Medicine.

Articles published in the Bulletin of the Oriental Healing Arts Institute, including:

  • Yasuo Otsuka, The origins of Chinese herbal medicine, 1985; 10(3): 93-99.
  • Yasuo Otsuka, Introduction to Oriental medicine: The theory of Kampo therapy, 1988; 13(4): 217-221.

Books published by the Oriental Healing Arts Institute, especially Thirty Years of Kanpo, by Keisetsu Otsuka, 1984.

The book Oriental Medicine: An Illustrated Guide to the Asian Arts of Healing, edited by Jan Van Alphen and Anthony Aris, Serindia Publications (London), 1995.

The internet web site of Tsumura Juntendo (http://www.tsumura.co.jp/English), which includes access to the articles of the journal Kampo Today.

Table 1: Important Persons and Events Related to Kampo Medicine.

Person Birth/Death;
Chinese Dynasty
Events and Importance to Kampo
Zhang Zhongjing ~150-221 A.D.
Han Dynasty
Revered as the most astute physician in the history of Chinese medicine. He completed his works, later divided into Shanghan Lun and Jingui Yaolue, around 200 A.D. His formulas are considered flawless by many Kampo practitioners.
Tao Hongjing 452-536 A.D.
Six Dynasties
He revised the Shennong Bencao Jing, creating three categories of herbs (upper, middle, and lower), their implications were to strongly influence the early years of Kampo.
Sun Simiao 581-682 A.D.
Sui and Tang Dynasties
Considered to be the God of Medicine, Sun Simiao was the most influential physician to have lived just prior to the introduction of Chinese medicine to Japan. He produced two key works on herbal medicine: Qianjin Yaofang and Qianjin Yifang.
Jian Zhen ~690-760 A.D.
Tang Dynasty
Jian Zhen, a Buddhist priest knowledgeable in medicine, introduced the Chinese tradition to Japan in 753. He may be regarded as the founder of Kampo, as his work led to great appreciation for the value of traditional Chinese medicine in Japan.
Yasuyori Tamba 912-995 A.D.
Northern Song Dynasty
He produced the Ishimpo in 984, a medical text in 30 scrolls, which became the fundamental text of Kampo; it presents traditional Chinese medical theory and knowledge from the Han through to the Tang Dynasty period.
Chen Shiwen ca. 1060-1130
Northern Song Dynasty
He and his colleagues compiled the Taiping Huimin Hejiju Fang (1110) under orders of the Chinese Emperor. It is the source of numerous valuable formulas that are still in use today in both China and Japan. It is second only to the works of Zhang Zhongjing as a source for Kampo formulas.
Sanki Tashiro 1465-1537
Ming Dynasty
This Buddhist priest physician went to China (1486-1498) and learned the methods developed during the Jin-Yuan period, especially influenced by Li Gao and Zhu Danxi, which he then taught upon returning to Japan. His efforts led to the founding of the Goseiha School of Kampo.
Dosan Manase 1507-1594
Ming Dynasty
Studied medicine under Sanki Tashiro, then returned to his home in Kyoto to establish the Keiteki-In Medical Center; helped found the Goseiha School; sometimes called the Dosan School.
Gensaku Manase 1549-1631
Ming Dynasty
Helped spread the teachings of the Goseiha School of Medicine along with Genya Okamoto, Doju Nagasawa, Gyuzan Katsuki, Futei Fukui, and Gensen Tsuda.
Gong Tingxian 1522-1619
Ming Dynasty
Gong Tingxian published Wanbing Huichun in 1587; known as the last major source of Kampo formulas from China.
Saramata Takera 1573-1614
Ming Dynasty
Wrote the first text on abdominal diagnosis in Japan, Essentials of Abdominal Diagnosis (sometimes this book is attributed to his descendent Sarayoshi Takera, with publication in 1706).
Geni Nagoya 1628-1696
Qing Dynasty
Considered the founder of the Kohoha School; he was influenced by Ming Dynasty physicians such as Zhang Jingyue.
Gonzan Goto 1659-1733 A.D.
Qing Dynasty
Influenced formation of the Kohoha School; two of its most active members, Shutoku Kagawa and Toyo Yamawaki were trained by him.
Shuan Kagawa 1683-1755
Qing Dynasty
A student of Gonzan Goto; he wrote two books Ippondo-Gyoigen (Handbook of Medicine) and Ippondo-Yakusen (Handbook of Herbal Drugs). He strongly argued against speculative theories and arbitrary classifications, throwing out the Six Disease Stages concept from the Shanghan Lun.
Toyo Yamawaki 1705-1762
Qing Dynasty
Student of Gonzan Goto and active member of the Kohoha School; he was the first doctor in Japan to carry out a human corpse dissection, with results published in the book Zoshi (Explanation of Internal Organs). This work disproved the traditional theory of five organs and six viscera which was relied upon by the Goseiha School.
Todo Yoshimasu 1702-1773
Qing Dynasty
Criticized the speculative approach of the Goseiha School; stressed abdominal palpation therapy, and the use of strong purging methods. He believed that all diseases came from one poison that could affect different sites to produce various symptoms.
Genetsu Kagawa 1700-1777
Qing Dynasty
Produced a book on obstetrics, Sanron, strongly influencing obstetrics from that time onwards.
Genken Taki 1795-1857
Qing Dynasty
Participated in revival program for reconstituting old texts; leading to printing of Ishimpo in 1859, known as the Ansei version.
Sugita Genpaku 1733-1817
Qing Dynasty
His book, Kaitai-shinsho (New Book of Anatomy, 1774), derived from a Dutch text, helped to introduce Western medicine into Japan; it become the dominant medical system within 100 years.
Seishu Hanaoka 1760-1835
Qing Dynasty
Studied the Kohoha School under Nangai Yoshmasu; also studied surgery and used Kampo for anesthetic in surgical treatments; he created a school of combined Kampo and Western medicine.
Sengen Wuda dates not available
Qing Dynasty
Translated Western texts on internal medicine, producing Selected Essentials of Western Theory of Internal Medicine in 1792.
Sohaku Asada 1815-1894
Qing Dynasty
While he was a practitioner, smallpox vaccination was introduced, leading to decline in Kampo; the Meiji Government restricted entry of Kampo practitioners into medical profession in 1875. Asada helped form the Onchi-sha Association to oppose the restrictions.
Kyushin Yumoto 1876-1941 Researched Kampo remedies and worked to revive Kampo through publications and teachings, focusing on the Kohoha School. His book, Kokan Igaku, influenced many 20th Century doctors.
Wada Keijuro not available His book Ikai-no-tettsui (Iron Hammer of the Medical World; 1910), stressed the clinical value of Kampo and inspired many doctors to look at this medical system.
Kenzo Okumura 1884-1961 He taught Kampo to several medical students from China University. Those students formed a study group; one of the students, Ken Fujihira (1914-1998) taught Katsutoshi Terasawa, who now teaches Kampo at Toyama Medical University.
Jusha Tsumura not available Founded Tsumura Juntendo in 1893 and established the Tsumura Research Institute for Pharmaceutical Science and the Tsumura Herbal Garden in 1924. Tsumura Juntendo would become the largest supplier of Kampo in Japan.
Tadanao Nakayama not available His book Kampo-igaku-no-shin-kenkyu (New Study of Kampo Medicine; 1927) inspired Keisetsu Otsuka and others to take up Kampo.
Onzu Nagakura not available Established the Nagakura Pharmaceutical Company, which developed the process for scientifically prepared dried herb extracts.
Toyoji Naito 1889-1978 Established the Naito Museum of Pharmaceutical Science and Industry in 1971, providing historical information about medicine in Japan. The museum has over 6,000 books, including many ancient scrolls.
Keisetsu Otsuka 1900-1980 Studied herbal medicine under Kyushin Yumoto; started Kampo practice in 1931, founded the Oriental Medicine Research Center at the Kitasato Institute and founded the Japanese Society for Oriental Medicine.
Shiro Hosono 1899- Medical doctor who began study of Kampo in 1934 under Soguru Nietsuma; clinical director and organizing member of the Japanese Society for Oriental Medicine. Established the Hosono Clinic in Kyoto.
Domei Yakazu 1905- He practiced Kampo for over 50 years, became Director of the East Asia Medical Association of Japan, and wrote numerous articles and books on Kampo. He has been the main proponent of the Goseiha School in modern Japan, which is continued now by his son Keido Yakazu (1933-).
Takahide Kuwaki 1916- Well-known clinician and lecturer in Japan, he had been Vice President of the Oriental Medicine International Institute for many years.
Hong-yen Hsu 1917-1991 First Director of the Bureau of Drug Control (Taiwan), founder of Sun Ten Laboratories, Brion Research Institute, Oriental Healing Arts Institute, and Brion Herbs Corporation. Learned Kampo from Keisetsu Otsuka. His son, Chau-shin Hsu, helped translate and edit books and articles on Kampo and manufacture Chinese herb extracts (he is currently in charge of manufacturing in the U.S.).
Arichi Shieru 1922- Studied Kampo under Hosono Shiro; became Professor at the Institute of Oriental Medicine, Kinki University.
Toyohiko Kikutani 1933- He was Director of the Japan Society for Oriental Medicine, lecturer at Showa University, and superintendent at Kikutani Hospital.
Katsutoshi Terasawa 1944- Current Director of the Japan Society for Oriental Medicine, Professor at Toyama Medical and Pharmaceutical University.

Table 2: Examples of Chinese Formulas Frequently Used in Kampo. Most of the two dozen formulas are listed in the Shanghan Lun and/or the Jingui Yaolue, a few are from the Hejiju Fang, and only 3 are from other ancient texts. Pinyin transliteration of the Chinese name, rather than transliteration of the Japanese name is provided because these are the names usually used in the West.

Common Name and Pinyin Ingredients Typical Applications
Bupleurum and Cinnamon Combination
Chaihu Guizhi Tang
bupleurum, scute, pinellia, ginseng, cinnamon, peony, ginger, licorice, jujube Combined internal and surface disorders; mainly respiratory system diseases; also for epilepsy.
Bupleurum and Dragon Bone Combination
Chaihu Jia Longgu Muli Tang
bupleurum, scute, pinellia, ginger, hoelen, cinnamon, ginseng, jujube, dragon bone, oyster shell, rhubarb Disorders involving mental distress or tremors.
Bupleurum and Peony Formula
Jiawei Xiaoyao San
tang-kuei, peony, atractylodes, hoelen, bupleurum, moutan, gardenia, licorice, ginger, mentha Liver diseases and menopausal syndrome; also general damp-heat disorders.
Capillaris and Hoelen Formula
Yinchen Wuling San
capillaris, hoelen, atractylodes, alisma, polyporus, cinnamon Hepatitis, especially with jaundice; edema.
Cinnamon and Hoelen Formula
Guizhi Fuling San
cinnamon, hoelen, peony, persica, moutan Gynecological diseases and numerous symptoms associated with blood stasis.
Coix Combination
Yiyiren Tang
ma-huang, tang-kuei, atractylodes, coix, cinnamon, peony, licorice Arthritis and muscular rheumatism, especially early stage.
Coptis and Scute Combination
Huanglian Jiedu Tang
coptis, scute, phellodendron, gardenia Febrile diseases, inflammation, flushed face, bleeding due to heat.
Four Major Herbs Combination
Si Junzi Tang
ginseng, licorice, hoelen, atractylodes Weakness of spleen/stomach system, indigestion, diarrhea.
Ginseng and Ginger Combination
Renshen Tang
ginseng, ginger, atractylodes, licorice Weakness of the spleen/stomach system, chronic gastritis, chilliness.
Ginseng and Tang-kuei Ten Comb.
Shiquan Dabu Tang
ginseng, astragalus, atractylodes, peony, hoelen, rehmannia, cnidium, cinnamon, licorice, tang-kuei General debility, weak immune system, prolapse of internal organs, poor digestion.
Ginseng Nutritive Combination
Renshen Yangrong Tang
ginseng, atractylodes, astragalus, licorice, tang-kuei, peony, rehmannia, hoelen, cinnamon, citrus, polygala, schizandra Anemia, fatigue, general weakness, poor nutritional status, insomnia, dry skin.
Hoelen Five Formula
Wuling San
hoelen, atractylodes, alisma, polyporus, cinnamon Edema with thirst.
Ma-huang and Apricot Seed Combination
Ma Xing Gan Shi Tang
ma-huang, apricot seed, gypsum, licorice, morus Cough accompanied by sore throat and thirst.
Major Bupleurum Combination
Da Chaihu Tang
bupleurum, scute, pinellia, ginger, chih-shih, peony, rhubarb, jujube Liver and/or gallbladder inflammation, constipation and fullness.
Minor Blue Dragon Combination
Xiao Qinglong Tang
pinellia, ma-huang, cinnamon, peony, schizandra, asarum, licorice Acute ailment with watery sneezing, such as common cold.
Minor Bupleurum Combination
Xiao Chaihu Tang
bupleurum, scute, pinellia, ginseng, ginger, licorice, jujube Alternating fever and chill, digestive disturbance, hepatitis, bronchitis.
Peony and Licorice Combination
Shaoyao Gancao Tang
peony, licorice Muscular tension, especially of the abdomen.
Persica and Rhubarb Combination
Tao He Chengqi Tang
persica, rhubarb, cinnamon, mirabilitum, licorice Abdominal masses, constipation.
Pinellia Combination
Banxia Xiexin Tang
pinellia, ginseng, coptis, scute, ginger, licorice, jujube Diarrhea with frequent bowel movements.
Pueraria Combination
Gegen Tang
pueraria, ma-huang, cinnamon, peony, ginger, licorice, jujube Acute ailments marked by aching in the arms and shoulders, lack of perspiration, sinus congestion.
Rehmannia Eight Formula
Bawei Dihuang Tang
rehmannia, hoelen, alisma, dioscorea, cinnamon, aconite, moutan, cornus Urinary system disorders, impotence, hypertension, back ache.
Siler and Platycodon Formula
Fangfeng Tongshen San
tang-kuei, peony, gardenia, cnidium, forsythia, schizonepeta, siler, talc, mirabilitum, ma-huang, ginger, rhubarb, atractylodes, mentha, platycodon, scute, licorice, gypsum Obesity, skin rashes and eruptions, constipation, edema, hypertension.
Tang-kuei and Peony Formula
Danggui Shaoyao San
tang-kuei, peony, cnidium, atractylodes, alisma, hoelen Pregnancy disorders, anemia, infertility, chilly limbs.
Vitality Combination
Zhenwu Tang
aconite, ginger, atractylodes, hoelen, peony Abdominal aching, usually with diarrhea; cold limbs, poor digestion, lack of vitality.

Table 3. Some Examples of Abdominal Signs and Corresponding Herb Formulas. Abdominal diagnosis (fuku-shin) has a primary function of determining whether there is deficiency or weakness (kyo), or excess, strength, firmness, or fullness (jitsu), to select the type of therapy needed (e.g., tonification or purging). Specific locations of swelling, hardness, fullness, or palpation will help determine which of several potential formulas to consider; the disease and symptoms further direct the selection of prescriptions. The interpretations of abdominal signs vary somewhat among the Japanese specialists.

Abdominal Characteristic Interpretation Formulas
Thick abdominal wall, flexible to touch Firmness confirmation; patient is usually well-set or obese. Major Bupleurum Combination or Siler and Platycodon Formula, to reduce excess.
Thin abdominal wall, lack of flexibility Weakness confirmation; patient lacks qi and blood. Vitality Combination or Ginseng and Ginger Combination, to warm the interior, promote metabolism, and restore qi and blood.
Abdominal distention; resistant to pressure due to distention Firmness confirmation; patient may have constipation and gas. Major Bupleurum Combination, to reduce the excess.
Chest distress; feeling of pressure in area of lower ribs Firmness confirmation if firmness and pain with pressure applied below the sternum; weakness confirmation if soft and not painful with pressure. Use bupleurum-containing formulas; use Major Bupleurum Combination or Bupleurum and Dragon Bone Combination for firm confirmation, Minor Bupleurum for weak confirmation.
Feeling of distress near the heart (sternum and just below sternum) With deep palpation below the sternum, there is resistance, as if there is a swelling. Use pinellia formulas (e.g., Pinellia Combination) or formulas for dampness, such as Hoelen Five Formula or Four Major Herbs Combination.
Tension and stress below the navel or feeling of emptiness and weakness at this site Weakness confirmation associated with kidney deficiency. Use Rehmannia Eight Formula.
Hard swelling in the lower abdomen Indicates blood stasis syndrome. Use rhubarb formulas (e.g., Persica and Rhubarb Combination).
Hardness of central line Feels like a hard substance when palpating the central line of the abdomen. Above the navel, hardness indicates spleen weakness, use Vitality Combination; below the navel indicates kidney deficiency, use Rehmannia Eight Formula.
Umbilical pain Patient reports pain with gentle pressure just above the navel. Indicates muscle tension of an excess confirmation; use Pueraria Combination.
Umbilical weakness Pressing in and around navel, the tissues are loose and there is easy movement, indicating weakness confirmation. Use formulas with ginseng, such as Vitality Combination, Ginseng and Ginger Combination, or Four Major Herbs Combination.
Abdominal muscle tension Rod-like tension on either side of the central line or twitching of abdominal muscles indicates weakness confirmation. Peony and Licorice Combination.

 


Figure 1: Shosoin, the ancient repository for an 8th Century collection of herbs from China.


Figure 2: Gonzan Goto (1659-1733); illustration from the book Portraits of Distinguished Physicians in Earlier Japan.


Figure 3:Genetsu Kagawa (1700-1777), from the Kagawa family collection.


Figure 4: Seishu Hanaoka (1760-1835), on display at the Naito Museum of Pharmaceutical Science and Industry in Kawashima Japan.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Blind Acupuncturists, Insertion Tubes, Abdominal Diagnosis, and the Benten Goddess