Volume 11, Number 2 | Summer 2016

Integrating Kampo and Evidence-BasedMedicine (6) – Type 5 Cases
Is There a Type 5?
Hiromichi Yasui
Japan Institute of TCM Researchones. These patients do not fall under any of the fourtypes that have so far been introduced, so Dr.
Kashima noted that a Type 5 category should becreated. As an explanation, he then introduced acase example from among a number of cases he has
personally experienced.

Introduction
In this series, I define four types of use of Kampo

Episode 1

medicine in daily clinical practices within Japan’sA 37-year-old male patient began to complain of

unified medical system, and discuss the diseases

malaise, headaches, and joint aches from aroundthat fall under each of these types, by giving relevant

August 3, 2014. On August 16, he came down with acase examples. In the previous issue of this journal,

fever of more than 39°C. As this continued for theI introduced four episodes, and explained that theynext days, he consulted a local doctor. The results offall under the four types of use of Kampo medicine ina blood test showed aberrant values, with a WBC

daily clinical practices. Let me recount them below.

count of 1900/mm3, Plt of 118 × 103/mm3, and an

Type 1: Kampo treatment is better than standard

LDH of 942 U/l. Therefore, on August 26, the patientmodern medical treatment

visited the hospital where Dr. Kashia works, with aType 2: The effects of standard modern medical

referral letter from the local doctor.

treatment and Kampo treatment are both

Height: 165cm; Weight: 72kg (-4kg in 2 weeks)strengthened when the two are used inTemperature: 38.4°C, with alternating chills andcombination

fever and high temperatures from early evening.

Type 3: The side effects of standard modern

The lowering of body temperature is accompanied

medical treatment can be mitigated inby perspiration.

combination with Kampo treatment

Blood pressure: 145/90mmHg; Pulse: 94/min.;Type 4: Circumstances prevent the application of

Respiratory rate: 16/min.

standard modern medical treatment, but

Slight hyperemia in the bulbar conjunctiva; No

treatment is neededswelling of the cervical lymph node; Swollen☆

☆

I introduced the aforementioned four types ofspleen
Pulse examination: String-like and smooth

Kampo use at a certain academic society. Among theTongue inspection: Slightly yellow tongue coating;members was Dr. Masayuki Kashima, a young friend

slightly red tongue bodyof mine whom I respect (a physician in the internal

Abdominal examination: Intermediate abdominal

department at Japanese Red Cross Kumamoto

strength;

Hospital). After listening quietly to my presentation,

hypochondrium region

discomfortanddistensioninhe surprised me, saying “Doctor, I think there is afifth type.” He said that medicine is steadily

Examination findings were as follows.

advancing, and good drugs and new treatment

WBC:1870/mm3; Hb13.7g/dl; Plt120,000; GOT:

methods are being developed one after the other.

111U/L; GPT: 90U/; LDH: 1346U/L;

However, Kampo medicine is extremely useful toCRP:

patients

4420ng/mL; Soluble IL-2 receptor: 2030U/ml;

whocannotreceivesuchexpensive

4.77mg/dL;

TG:

146mg/dL;

Ferritin:treatment. There are patients who are suited toNyelogram (8/29): M/E3.80; Megakaryocyte count:Kampo not from medical reasons, but from economic

16/c.mm; Nucleated cell count:

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

37950/c.mm;

3Volume 11, Number 2 | Summer 2016

Hemophagocytosis caused byhistiocyte wasbut normally, chemotherapy against malignant

observed in places.

lymphoma, administration of a large dose of

Abdominal echo: Hepatosplenomegaly

immunosuppressant, or plasma exchange therapy is

General appearance indicated the patient was not in

attempted in cases of poor reaction to massive

acute distress.

steroid. I administered Shosaikoto in this case based

From the first visit, Dr. Kashima strongly suspectedon Kampo medicine diagnosis. The effect washemophagocytic

dramatic, but even more worthy of mention is thatsyndromeorleukemia,

andrecommended inpatient examination and treatment.

theHowever, the patient did not have health insurance,minimized.”and said hospitalization would pose a large economic

patient’seconomic

burdenwaslargely

The patient did not have health insurance forburden and is therefore impossible.

reasons unknown. If he had been hospitalized toDr. Kashima forewent the use of a steroid, as using

receive standard treatment, it would have cost him

it before diagnosis would make accurate diagnosis

an enormous amount of medical fee.

and the prospect of prognosis difficult later on. Yet,

Thanks to Dr. Kashima’s appropriate judgment,

the patient’s symptoms were strong, and close

the patient’s symptoms were ameliorated by taking

observation was required, so based on Kampo

Kampo, and his medical fee was able to be minimized.

diagnosis, Dr. Kashima administered Shosaikoto

In sum, the patient improved owing to an

and had the patient continue to come in as aninexpensive treatment method, without depending

outpatient.

on expensive standard treatment. For reference, theThe patient began taking Shosaikoto from August

price of a day’s dose of Shosaikoto is approximately

26, and was relieved of his fever by the morning of

230 yen. The patient took the prescription for 15

the 28th. A myelogram taken on the 29th affirmed

days, so it cost him 3,450 yen in total.

the diagnosis of hemophagocytic syndrome, but

Such cases are not necessarily few, but they arebecause the patient’s fever had already subsided andhardly taken up, because most are simply reported

his CRP improved to 1.30 mg/dl on the same day, theas an isolated case. For treatment of serious diseases,same Kampo medicine was continued to be

many people do not believe there are any cases inprescribed on an outpatient basis. Thereafter, thewhich inexpensive Kampo medicine can be superiorpatient’s cytopenia and liver disorder also gradually

to expensive standard medicine. However, this is not

improved, and treatment was deemed complete onnecessarily true in all cases.

September 9 upon confirming normalization in

Shosaikoto will not always improve the symptoms

various examinations. Regular follow-ups wereof hemophagocytic syndrome. Dr. Kashima was able

performed

to prescribe it in this case, because he has abundant

thereafter,butnorecurrence

wasobserved over a year, so the patient was allowed toexperienceintheemergency

outpatient

andterminate his visits.

outpatient internal medicine departments, as well as

Dr. Kashima also said as follows.

deep knowledge of Kampo medicine theory.

“Hemophagocytic syndrome is a life-threatening

It is sufficiently worth discussing whether or notdisease that frequently runs a rapid course and leads

this represents a case in which treatment by

to multiple organ failure. It could be caused by virus

inexpensive Kampo medicine due to economic

infection, drug allergy, a connective tissue diseasereasons improved the patient’s symptoms comparedsuch as SLE, or a malignant disease, but it is known

to standard treatment. In a sense, it does, but as

to be caused mostly by intravascular malignant

there are too many uncertainty factors, it might belymphoma. There is no single method of treatment,

somewhat too early to conclude that this case4

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

Volume 11, Number 2 | Summer 2016

represents Type 5. In terms of the four conventional
types, this case would fall under Type 4.
Episode 2
Let us look at another case, the “Case ofMediastinal Lymphangioma Successfully Treatedwith Kampo Medicine”1), which was published in theJournal of Alternative and Complementary
Medicine by Dr. Keiko Ogawa, a discussion partnerof mine who is in charge of outpatient Kampo
medicine at Kanazawa University Hospital.
The patient is a two-year-old boy who was bornwith a tumors mass in his left axillary fossa. At anage of 1 year and 9 months, he was referred to achildren’s hospital in the region, and was diagnosed
with a mixed type of lymphangioma in the region
from his left axillary fossa and left mediastinum tohis pleural cavity. He was treated at the hospital by
OK-432 sclerotherapy, but to no effect.
The patient’s parents thus requested Kampo
treatment, and took the patient to see Dr. Ogawa as anoutpatient when he was 2 years and 10 months old.

lymphangioma from the left cervix to themediastinum. The MRI findings were as follows.
The left mediastinum was almost wholly affected bylymphangioma, causing a displacement of the liver
and trachea and a deviation of the trachea.
The clinical course was as follows. First, marked
sweating was interpreted as an exterior pattern, andthe patient was prescribed Eppikajyutsuto. The MRI
taken three months after the first visit did not show
any reduction in the size of the lymphangioma. Fivemonths later, the patient developed repeatedbronchial asthma triggered by an infection andaccompanied by hives, and sweated, so Ogikenchuto
was also administered along with Eppikajyutsuto. A
reduction in the lymphangioma was observed in theMRI that was taken after 9 months, and further
reduction after 15 months. The cyst in the cervix
almost wholly disappeared, and a clear reduction insize of the polycystic area, in particular, wasobserved (Figure 1). The cross section also showed areduction of the tumor mass, as well as a return ofthe displacement of the trachea to normal condition(Figure 2). The number of coughing and frequency ofasthma attacks declined, and the same prescription
is still being continued at present.

9 months later
Before first visit15 months later
Figure 1: Changes in MRI findings (1)Before first visit

9 months later

15 months later

Figure2: Changes in MRI findings (2)An MRI examination of the chest
performed
immediately before the first visit to Dr. Ogawa
indicated a partly cavernous to mixed polycystic

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

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Volume 11, Number 2 | Summer 2016

This case report was written in English. Thus,Dr. Hashizume et al. monitored the progress ofpeople around the world were able to read it. A whileeight children (four boys and four girls) withafter the journal was published, Dr. Ogawa received

lymphatic

an email written in English. It was from the U.K. A

Eppikajyutsuto (TJ-28; Tsumura, Tokyo, Japan).

father of a child with the same disease wrote toinquire how he could acquire the drug, because
although Japan’s Kampo prescriptions for medical
use are highly superior, they are not approved as
medicinal drugs in countries other than Japan.
Infantile lymphangioma is caused by a congenital
anomaly of a lymphatic vessel. It is a benign tumor,
but it develops by indistinctly infiltrating themalformations

afterapplying

The result was as follows.
Four of the eight patients had a macrocystic typeof lymphatic malformation, and the other four had amicro-macrocystic mixed type. They were observed
over a period of 75 months, from January 2009 toMay 2014, and were administered the drug over7.2±2.9 months (a scope of 5±12 months). Aftersurrounding organs, and displaces the surrounding

administering Eppikajyutsuto to these patients,organs. There is no known standard treatment, andtheir magnetic resonance imaging (MRI) results

treatment by sclerotherapy using various drugs has

showed a reduction ratio of 54.5±38.3% (73.6±27.0%

becometoday.

among macrocystic types, 35.4±41.5% among micro-Depending on the nature of the lesion, sclerotherapy

macrocystic mixed types). Among the four patientsis not effective, and surgical treatment is thenwith a macrocystic lymphatic malformation, aconsidered. However, because its boundary isconsiderable reduction was observed in one patient,unclear, as mentioned above, removal by surgery

and a moderate degree of reduction was observed inruns the risk of damaging normal tissues around it.

two patients. Among the four patients with a micro-

thefirstchoiceoftreatment

For this reason, it is difficult to completely remove
the tumor in such cases, and treatment runs into abrick wall, so to speak, in many cases.
In this case, sclerotherapy using OK-432 was
already performed, without effect. There was still anumber of possible Western medical treatment
methods, but Dr. Ogawa succeeded in dramaticallyameliorating the young patient’s lymphangioma
using Kampo medicine.
After Dr. Ogawa’s report was published, amacrocystic

mixed

lymphatic

malformation,anoticeable improvement was observed in threepatients. No reaction was observed in the otherpatient. There were no advanced adverse events.
The presentation of this paper after Dr. Ogawa’scase

reportEppikajyutsuto

furtherisdemonstrated

effective

againstthatlymphaticmalformations in a significant number of patients.
Other case reports presented at a number of

number of pediatricians and pediatric surgeons

academicsocieties

heldinJapanesealsosubmitted additional reports one after the other toconspicuously show the drug’s effectiveness against

the effect that the disease was ameliorated by using

lymphatic malformations.

Eppikajyutsuto. Representative of these is theIn the case of this disease, pediatricians and“Clinical Efficacy of Herbal Medicine for Pediatricpediatric surgeons who possess accurate knowledge

Lymphatic Malformations: A PilotStudy”2)by Dr.

of modern medicine can use this prescription under

Naoki Hashizume et al. of Kurume University

their own supervision and obtain results relatively

Hospital, published in Pediatric Dermatology.
Pilot Study by Dr. Hashizume et al.

easily, without making a precise Kampo medicine
diagnosis as in the previous case example. Kampo
medicine is inexpensive. A single day’s dose of
Eppikajyutsuto is around 85 yen, so even a year’s

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The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

Volume 11, Number 2 | Summer 2016

worth costs only approximately 31,000 yen. It is far

Ogawa’s experience as a pediatric surgeon andmore inexpensive and easier to use compared tooutstanding capabilities as a Kampo doctor led hersclerotherapy and operative treatment.

to prescribe Eppikajyutsuto and Ogikenchuto.

When focusing on the fact that in these examples
Kampo was able to ameliorate the patient’s
symptoms at a lower cost to the patient thanstandard treatment, they could perhaps be classified
under Type 5. However, with regard to the fact that
Kampo

providedeffectivetreatment

without

standard treatment, many might say that theyrather fall under Type 1.
☆

☆

Furthermore, Dr. Ogawa’s case report led to thestudy by Dr. Hashizume et al., and generated aneven larger number of case reports.
These case reports and studies show that Kampo
medicine, under certain conditions, is extremely
cost-effective. However, it is too early yet to decide
whether a Type 5 category should be created, basedon their data alone. The views of an even greaternumber of people shall be obtained before making adecision.

The episodes by Dr. Kashima and Dr. Ogawa, andthe pilot study by Dr. Hashizume associated with Dr.
Ogawa all characteristically demonstrate thatReferences1)

Kampo medicine was able to ameliorate patients’diseases in an inexpensive manner, where Western
standard treatment would have cost a large amountof medical fee. Kampo medicine is taken orally, so it
is non-invasive, and is simple and easy for the2)

Keiko Ogawa-Ochiai et al.: Case of Mediastinal
Lymphangioma Successfully Treated with Kampo
Medicine, THE JOURNAL OF ALTERNATIVE ANDCOMPLEMENTARY MEDICINE, Volvme17, Number6,
2011, 563-565
Naoki Hashizume, et al.: Clinical Efficacy of Herbal
Medicine for Pediatric Lymphatic malformations: APilot Study, Pediatric Dermatology, 2016;33(2):191-5

patient to take.
The four types and their characteristics

Diseases subject to treatment
by Kampo medicine

Type 1Treatment is effective
by Kampo treatment
alone

Type 2Treatment effect isincreased in combination
with standard Western
medical treatment

Type 3The side effects of Western
medical treatment aremitigated when combinedwith Kampo treatment

Type 4Situations whereWestsern medicine
cannot be appliled

In the case in Episode 1, Dr. Kashima’s advanced
diagnostic capability regarding Kampo medicine led
him to prescribe Shosaikoto. In Episode 2, Dr.
The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

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