KAMPO MEDICINE

The Practice of Chinese Herbal Medicine in Japan

by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

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 7^th through 9^th 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 19^th 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 4^th or 5^th 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 8^th Century, the Japanese physician Ilura Yamanoue traveled to China to study Chinese medicine and wrote a poem, published in a 9^th 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 9^th 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 15^th 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 16^th 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 20^th 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 18^th 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 17^th 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.

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.

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.

Figure 1: Shosoin, the ancient repository for an 8^th 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.