Some reflections on studying Kampo

Some reflections on my studies in Kampo

Tony Todd

I got interested in Kampo around three years ago and decided to study it after having had treatment for a cough which hadn’t responded to other treatments. The formula prescribed to me was Polyporus combination for three days followed by min. Cinnamon and Peony for one week. The cough cleared before I’d finished the first packet and by the time I’d finished the second one I’d decided to sign up for the course. My reason for studying Kampo wasn’t simply that I thought it effective. I’d also had TCM herbs in the past with good results, though in the intervening period I’d moved away from TCM-style syndromes in favour of Japanese meridian therapy in my acupuncture practice. This approach to acupuncture is characterised by an emphasis on palpatory findings over other diagnostic information as well as forming diagnostic patterns around a Sho. Having come to acupuncture originally from Shiatsu, the twin aspects of palpation and Sho within Kampo made it seem like the most obvious choice for herbal study.

An overview of Kampo and its working methods

Much as in the case of acupuncture, traditional herbal medicine was in serious decline throughout the Meiji period (1868-1911) and modern Kampo owes much to figures like Otsuka Keisetsu who, with Yakuzu Domei in 1938, formed the East Asia Society for Medicine in order to unite traditional Doctors in Japan, China and Korea. If the Meiji era is seen as Kampo’s lowest point then its highest could be thought of as the Edo period (1600-1868) when the practice of fukushin abdominal palpation was developed as well as the emergence of the Koho-ha [Classical Medicine faction] school, founded by Geni Nagoya (1628-1696) and Yoshimisu Todo (1702-1773). Yoshimisu’s motto “Do not mention what is invisible” epitomised the contrast with the Gosei-ha [Later Generation faction] school by rejecting the more abstract and esoteric theories and promoting a return to the more simple and practical approach of early Chinese medicine as seen in the writings of Zhang Zhong Jing. Todo discarded the theories of Qi and flavour as well as the theory of channel affinities. His indications for herbs would be in terms of characteristic signs and symptoms derived from cross referencing the patterns they appeared in e.g. Gypsum would be indicated for severe thirst [1] rather than seen in terms as either its Qi or flavour. Though Gosei-ha did not entirely disappear (and in fact later objections to Koho-ha gave rise to an eclectic school, the Secchu-ha in the late Edo period), Kampo today has been influenced by this Koho-ha tendency to a simpler theoretical model grounded in more ‘tangible’ and tactile signs and less inclined to speculate on processes and pathophysiological mechanisms that are not directly experienced. Perhaps this is best expressed in the method of diagnosis by Sho.

Sho [sign/symptom package over syndrome]

The Sho or Akashi [証] is the constellation of signs and symptoms that point to a treatment method or formula. Whereas in other herbal styles one may move from:

signs/symptoms >> syndrome>> treatment

where the syndrome describes some kind of pathophysiological state of the body, and there maybe several treatments possibilities for a given syndrome (different herbs added to or subtracted from a formula, different formulas, different combinations of acupuncture points etc). The method of Sho on the other hand is simply:

signs/symptoms >> treatment

where a given formula (or acupuncture point protocol) will resolve a given a particular combination of signs and symptoms. Nigel Dawes has described this as “formula matching”:

..the practice of composing a formula based on the perceived individual actions of each herb was not discussed in the early classical texts. [2] Prescribing was done on the basis of ‘matching’ an existing formula to a patient conformation, called a SHO in Japanese. The SHO differs from the modern TCM concept of a pathological syndrome in that it includes not only a collection of identifiable signs and symptoms but also pays attention to the patient’s subjective complaints, the constitution, the state of the digestive function and diagnostic specialities such as Fukushin. In Kampo terms each formula is therefore said to have its own unique SHO and the practitioners job is to match the SHO with the patient. [3]

Rather than taking a formula and trying to bend it round to cover all the presenting symptoms, a practitioner will be looking for characteristic patterns within the patients symptoms that point to the use of a particular formula. The use of the formula may resolve the case entirely or in the case of a partial resolution will give rise to a new Sho that is treated with a new formula or possibly combination of formulas. The skill of the practitioner will be seeing the most appropriate Sho in an often confusing set of symptoms, and in knowing how long to prescribe for and what kind of combinations might be needed. In some respects there are similarities with homeopathy, both have a ‘key and lock approach’, matching the remedy to the person/condition. Arnaud Versluys has talked about a ‘Shen Nong’ lineage of practitioners, more concerned with the practicalities of medicine in the field rather than philosophical and theoretical speculation and though Zhang Zhong Jing was clearly a master of Nei Jing theory his book could be used by practitioners as a practical manual. The method of treatment by Sho fits this model; one may of course enquire into the pathophysiology that a Sho represents but it is not the primary object, that of course being to see the Sho and successfully treat the patient. This sensibility runs through Japanese meridian style acupuncture and Shiatsu too, giving rise to the motto ‘the diagnosis is the treatment’.

In practice one can organise Shos into groupings usually around the substances (qi, blood,water), around Shang Han Lun confirmations (tai yang, jue yin etc), or around weak digestion (ichokyojaku). Key signs/symptoms will lead one towards one group or another such as abdominal confirmations for some water or blood formulas, pulse and symptoms for tai yang or jue yin formulas etc. One then matches signs and symptoms with constitution eg a blood formula indication (such as pressure pain in the lower left quarter of the abdomen) could lead to a Persica and Rhubarb Sho for a more full type or Cinnamon and Hoelen for a more medium type constitution. Shos can also be grouped in terms of Outside/Inside [Hyo/Ri], Empty/Full [Kyo/Jitsu], Hot/Cold [Netsu/Kyo] where typically Outside/Surface Shos are treated by Shang Han Lun Yang confirmations and Inside Shos are treated by Shang Han Lun Yin confirmations or formulas from the Jing Gui Yao Lue or later texts, and are themselves typically grouped into qi, blood [Oketsu], water [Suidoku] types. Full and empty includes here the overall state of the patient as well as the nature of presenting symptoms and Hot and Cold to distinguish formulas that have a more heating or cooling effect.

Abdominal palpation

I don’t want to say much about abdominal palpation as it was covered in some detail in the last issue other than to point out that this too is largely derived from Zhang Zhong Jing [4] and exemplifies a sense of immediacy and practicality that runs through Japanese medicine. [5]

Formulas over ingredients

As formulas are seen as the basic building blocks of Kampo, in practice this means that addition or subtraction of ingredients is not common. A formula is given as a unit and then changed to another formula as the presenting pattern changes, similar to peeling layers of an onion. Sometimes more than one formula would be used simultaneously but again in general the formula would be seen as the basic unit. Of course this is not a black and white situation. Even when I first studied Kampo in the UK, modification was not seen as never occurring but simply bottom of the list of things to try, and after considerable experience of using the formula in its original form.[6] While I was in Japan I did see some modification but it was not often and tended to be more combinations of formulas or the addition or increasing of the amount of aconite to boost the warming properties of a formula.

Dosages and preference for classical formulas

The term Kampo could also be used to signify a preference for classical (Han dynasty) formulas. Though this is not exclusive, and there are examples of formulas from the fever schools and from Li Dong Yuan, as well as a few examples of more recent Japanese formulas, one can clearly say that there is a bias towards Zhang Zhong Jing formulas. Another feature is that dosages are smaller than are commonly used in modern Chinese formulas, typically 1/3 of the Chinese dose.

Formulas and the Japanese Health Service

In 1976 the Japanese Ministry of Health and Welfare listed 43 granulated extracts as being covered by the health insurance system. Today there are over 150 formulas, produced by pharmaceutical companies such as Sun Ten and Tsumura for the health system and available from any doctor or pharmacist. Formulas outside of these can also used but cost approximately three times as much for the patient.

My experience of two clinics

I spent time at two clinics in Tokyo in 2008 and 2007, with Dr Tarashi at the Genwado clinic in Ginza and with Dr Watanabe at Keio University. Both practice Kampo in the tradition of Dr Otsuka who’s material the UK course is based on, and this quickly became evident in the formulas they used and in the method of abdominal palpation which was more or less identical with what I studied at home. In both cases I was not the only student present, which in itself helped to shine light on the experience of studying in Japan. In both clinics students (mostly other doctors) would sit in with the doctor and simply observe the consultations and formulas given. Whenever doctors felt there was something especially interesting to point out they would do so in terms of symptom patterns or formulas, or sometimes taking the student over to feel the patient’s abdomen. Other than that there would be little if any formal teaching in the clinic. At Keio there were weekly discussions of new patients amongst the doctors, each discussing what they had prescribed and their assessment of the case. The time I was there this was followed by reading from one of Otsuka’s memoirs, on that occasion it was from a chapter on the action of Hoelen 5 combination and Tang Gui and Peony combination. The students would take it in turns to read and the senior doctors would comment on the text in the light of their experience.

The two clinics I visited were quite different in some ways. Tarashi’s clinic is a ‘family’ clinic that mostly specialises in fertility (though patients once having been

treated tend to also come back for other reasons too), while the Keio clinic is at a prestigious university hospital outpatients department which treats a wide variety of problems. Many of the patients are also simultaneously visiting other university departments, and patient information is kept on a database where formulas are noted alongside blood tests and other findings from other departments. It appears as a very modern integrated health system, with patients either self- referring or coming via other departments. In other ways what actually happens is similar in both clinics, both are very busy seeing around 50 patients in a morning. The importance of a large breakfast quickly became apparent as it could end up being a while before lunch.

The volume of patients is I believe an important factor as to how the art is learned. Unlike more modern western approaches to interactive learning the student is more of a sponge, seeing the patients come in, listening to their symptoms and (if the clinics not too busy) feeling their abdomen/pulse, and seeing the results of the prescription. It is an approach that cuts through intellectual analysis and gradually one begins to associate certain patterns with certain formulas.[7] The key of course is to see a sufficient volume of patients, in the absence of which it is helpful to have other methods of study to rely on.

Doctors in both clinics treated a lot of long term chronic problems, sometimes prescribing for a month or 6 weeks at a time, before checking the patient to either modify or continue with the prescription. At Keio especially, patients were often taking more than one prescription concurrently, in some cases alongside western pharmaceuticals. At Genwado I noted that formulas tended not to be changed according to the different stages of the menstrual cycle as is often taught in the UK (such as supplementing blood and yin before ovulation and warming and boosting yang post ovulation)[8] When I asked Tarashi about this he replied that this idea was introduced into Kampo circles some time ago but never really took root; he believed that formulas treating underlying imbalances take time to adjust the body’s core misalignments and that changing the formula at such regular intervals did not significantly improve results. At Keio, similarly, the changing of formulas though sometimes used is not popular. It would seem to highlight an interesting area of divergence between the use of Kampo and TCM formulas.

Another interesting comment that I heard was that though interest in Kampo amongst doctors has grown dramatically in recent years, actual understanding of Kampo is very poor. Many doctors prescribe quite symptomatically without an appreciation of traditional theory and working methods. The Doctors who were observing with me at Genwado seemed not to know very much traditional theory, though to their credit they were interested in learning Kampo as an alternative approach for their patients that was less likely to produce side effects. At Keio Dr. Nishimura told me that when he began to study Kampo there were very few departments in medical schools. Now over 80 medical schools teach Kampo as part of their core curriculum and there are three post graduate courses in Kampo at Keio, Chiba and Toyama Universities. The Keio course is a three-year course and he feels it is important for doctors interested in Kampo to study to this level.

At Genwado Terashi finds that a high percentage of his patients can be grouped according to the following (approximate) scheme:
FLOW CHARTS

Constitution

strong?

No

See below

Excess water type:

Stephania & Astragalus comb.

Yes

Yes

Yes

No

No

No

Yes

Average / normal constitution?

Large frame?

Kyokyokuman type

Maj. Buplerurum comb. with Cinnamon & Hoelen comb.

Condition worse before a period ?

Average build Oketsu type

Cinnamon & Hoelen comb.

Average build Gassy type:

Abdomen type

Cinnamon & Persica comb.

Constitution strong?

Yes

See above

No

Digestion strong ?

Weak digestion type [ichokyojaku]

Maj. Six comb.

Min. Cinnamon & Peony comb.

No Yes

No

Dizzy? Light headed on standing

Cold type Abdominal pain Dang Gui & Jujube comb.

Yes

Kyo type Blood type

Dang Gui & Peony comb.

These formulas don’t of course account for all the prescriptions though they would seem to form the base from which he would work. In some cases for example he might make use of Rehmannia 8 combination if in addition to the above there was also vacuity below the navel, or combine warming elements of the formula to Tang Gui and Peony for a Dang Gui and Peony Sho with more cold. In an addition to the abdominal patterns I’d previously learned he also saw tightness along both sides of the lower abdomen (superior to the anterior superior iliac spine) as relating to cold and an indication for Dang Gui & Jujube. Another feature of Genwado was the use of raw ingredients for most of the patients, though Keio made use of Tsumura produced granules which is typical of herbal medicine in Japan. The time I spent at the clinics was extremely interesting, it confirmed much of what I’d been taught about the Kampo approach and put it into a wider context, though it left me feeling that there are still too many formulas that I don’t know well enough!

After thoughts

Kampo in the UK is a small part of the Chinese herbal medicine sector. The Kampo society periodically runs introductory courses on a small group basis, with mornings covering theory and afternoons seeing patients. Despite a current lack of study/courses for practitioners who have completed the basic course, there is supervision available from existing practitioners and in some ways this is perhaps closer in spirit to how Kampo is often learned. Studying in Japan is always an option but does require a reasonable level of Japanese. Material is however increasingly becoming available in English. Otsuka’s book is soon to be published in English and there are books by Hong Yen Hsu, Robert Rister, Takahide Kuwaki, Yoshiharu Shibata, as well as several articles and cases published in the North American Journal of Oriental Medicine. Moving beyond what is ‘officially Kampo’, the recent series of lectures by Arnaud Versluys on the Shang Han Lun has for me been an inspiring and useful resource. The Shang Han Lun based working methods not surprisingly share a lot of common ground with Kampo, and though discussion of flavours may not be to Yoshimasu Todo’s liking, the presentation of family formulas I think would get a nod of approval. Of course books and lectures are no substitute for patients. My brief look at the clinics in Japan highlighted some differences in learning and teaching methods as well as clinical reality, since the situation in Japan is much more integrated with conventional healthcare, and driven by doctors with a full pharmacopoeia at their disposal and huge patient volumes. While at Keio I went to a presentation by a representative of Tsumura, the pharmaceutical company that manufacture the formulas used in the Japanese healthcare system. There I was told that the Japanese pharmacopoeia does not contain any aristolochic acid as they use varieties of Asarum and Stephania that are free of it. Perhaps this could be an answer to the restrictions faced by both TCM and Kampo practitioners in the UK?

NOTES

[1] ‘Stroll through Kampo History’, North American Journal of Oriental Medicine, November 2003 #20
[2] Though it has been shown that the architecture of Shang Han Lun formulas is founded on the flavour model of five phase therapeutics [Arnaud Versluys, ‘Shang Han Lun Seminars’, London, Spring 2008], applications of Kampo formulas are not discussed at this level but in terms of objective signs/symptoms (as they are described in Shang Han Lun)

[3] http://www.pacificcollege.edu/alumni/newsletters/summer2003/kampo [4] See The Lantern Vol 3 #2, Vol 3 #3 (articles by Michael Max and Steve Clavey)

[5] Though this trend is rooted in Classical Chinese medicine: see Elizabeth Hsu – Tactility and the Body in early Chinese Medicine. Science in Context 18 (1) 7-34 2005
[6] This was echoed in a recent lecture by Arnaud Versluys (November 2008) who stressed the importance of allowing classical formulas to demonstrate their efficacy before modifying and altering their effects. By not allowing this to happen one is never in a position to understand the effects of these formulas in their normal state and thus is in a even weaker position to be able to make decisions about how to modify

[7] Arnaud Versluys has painted similar descriptions of traditional study methods in the Chinese Shang Han Lun tradition
[8] Jane Littleton, The Treatment of Infertility with Chinese Medicine. Churchill Livingstone 2004