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INTERNATIONAL INSTITUTE OF HEALTH AND HUMAN SERVICES,
BERKELEY
Volume 11, Number 3 ･ Fall 2016

Guest Editorial“Yasui Classification” of the Indications for Kampo Treatment
Yoshiharu Motoo

Integrating Kampo and Evidence-Based Medicine (7)From Reports of Medical Cases from 200 Years Ago
Hiromichi Yasui, Tetsuhiro Yoshino, Ryutaro Arita, Yuko Horiba, Hiroshi Koike, Takuya Hamaguchi, Miwako Ohgishi and Kenji
WatanabeJapanese Acupuncture - Current Research

Japanese Traditional Medicine Text (21) – Industrial Health Field
Kenta Sawazaki

Clinical Report 1 (Acupuncture)
Post Herpetic Neuralgia
Masanori Takashi and Katsuhiko Arai

Clinical Report 2 (Kampo Medicine)

A Case of Acute Exacerbation of Congestive Heart Failure with Chronic Renal Failure Successfully Treated with Goreisan
Takahito Saito, Yoshihiro Furuta, Noriaki Ito, Kazuyoshi Higuchi, Hideo Hirofuji, Norimi Fujita, Hiroyuki Akane and Hiromichi Yasui

Report from Association

A Letter from the 67th General Assembly of The Japan Society for Oriental Medicine
Kazunari Ozaki

ISSN:1559-033X

―The Journal of
Kampo, Acupuncture andIntegrative Medicine(KAIM)
Research on Theory, Practice and Integration

Volume 11, Number 3 ･ Fall 2016

EXECUTIVE EDITOR

Shuji Goto
Chairman, GOTO College ofMedical Arts & Sciences

TA B L E O F C O N T E N T S

Tokyo, JapanEXECUTIVE EDITOR

1 Guest Editorial“Yasui Classification” of the Indications for Kampo Treatment
Yoshiharu Motoo

Shuji Goto
Chairman, GOTO College ofMedical Arts & Sciences
Tokyo, JapanASSOCIATE EDITORS
Shuichi Katai
Ibaraki-ken, Japan

Hiromichi Yasui
Tokyo, JapanEDITORIAL STAFF

Akihiro Souma
Hiromi Sasaki
Hiroshi Tsukayama
Hitoshi Yamashita
Junko Okubo
Kazunari Ozaki
Kengo Nakata
Masayuki Kashima
Naoya Ono
Noboru Mitsuhata
Sayaka Toda
Takao Namiki
Toshiaki Makino
Toshihiro Togo

PUBLISHER

Shuji Goto
International Institute of Health andHuman Services, Berkeley
2550 Shattuck Avenue, Berkeley
California 94704-2724, U.S.A.

2 Integrating Kampo and Evidence-Based Medicine (7)– From Reports of Medical Cases from 200 Years Ago –The Effect of Maoto on Influenza
Hiromichi Yasui, Tetsuhiro Yoshino, Ryutaro Arita, Yuko Horiba, Hiroshi Koike,
Takuya Hamaguchi, Miwako Ohgishi and Kenji Watanabe

17 Japanese Acupuncture - Current Research
Japanese Traditional Medicine Text (21) – Industrial Health Field
Kenta Sawazaki

20 Clinical Report 1 (Acupuncture)
Post Herpetic Neuralgia
Masanori Takashi and Katsuhiko Arai

23 Clinical Report 2 (Kampo Medicine)
A Case of Acute Exacerbation of Congestive Heart Failure with Chronic Renal Failure
Successfully Treated with Goreisan
Takahito Saito, Yoshihiro Furuta, Noriaki Ito, Kazuyoshi Higuchi, Hideo Hirofuji,
Norimi Fujita, Hiroyuki Akane and Hiromichi Yasui

28 Conference Report
A Letter from the 67th General Assembly of The Japan Society for Oriental Medicine
Kazuari Ozaki

MISSIONTo disseminate peer-reviewed information on the use of acupuncture and herbs, and integration with western
medicine, based on research from an international perspective; thereby stimulating further research, applicationof documented therapeutic measures; and facilitating dialogue among health care practitioners worldwide.

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

Volume 11, Number 3 | Fall 2016

Guest Editorial“Yasui Classification” of the Indications for Kampo Treatment
Kampo, traditional Japanese medicine, has been integrated into modern medicine in Japan,
creating a unitary medical system. This system is valuable both for medical professionals andfor patients. Especially, medical doctors should know the indications and limitations of Kampo
medicine in daily practice. Dr. Hiromichi Yasui has a long-term clinical experience in bothwestern and Kampo medicines, in addition to his deep insight into medical history. When we
select Kampo in the decision tree of our daily practice, we should take into consideration the
merits and demerits of western medicine and Kampo medicine. In modern medicine in Japan,
western medicine is overwhelming, and all the medical doctors are educated with western
medicine at medical school and in their residency. However, since the dawn of the 21st century,
Kampo has officially been introduced into medical education system. All the medical students
in Japan are supposed to learn at least the beginning of Kampo medicine. Owing to thisrevolutionary change, almost no sense of resistance is seen in medical doctors of young
generations. On the other hand, not so many doctors prescribe Kampo medicine with Kampo
diagnosis. Sometimes, misuse of Kampo happens. There are two extremes, from “no Kampo”
to “only Kampo” in Japanese medical doctors. These situations are unhappy for patients.
Although various mixed patterns of the above two extremes are present, we need to clarify theindications of Kampo in modern medicine. This is an essential desire of clinicians to provide
the most suitable treatment to each patient, and of course, patients hope it. In this issue of
KAIM, Dr. Yasui clearly classified the indications of Kampo in various situations. This is thefirst attempt in this field, and I would like to name this classification as “Yasui Classification” of
the indication for Kampo medicine in modern medical system. I sincerely hope this classification
is applied to daily practice and clinical research from now on.

Yoshiharu Motoo, MD, PhD, FACP
Professor of Medicine,
Kanazawa Medical University,
Ishikawa, JAPANThe Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

1

Volume 11, Number 3 | Fall 2016

Integrating Kampo and Evidence-Based
Medicine (7) – From Reports of Medical
Cases from 200 Years Ago –The Effect of Maoto on Influenza
Hiromichi Yasui1), Tetsuhiro Yoshino2), Ryutaro Arita2),
Yuko Horiba2), Hiroshi Koike2), Takuya Hamaguchi2),
Miwako Ohgishi2) and Kenji Watanabe
1) Japan Institute of TCM Research2) Center for Kampo Medicine, Keio University
School of Medicine, 35 Shinanomachi, Shinjuku-ku,
Tokyo 160-8582, Japan

These records continued to be read even to thisday. Among them, the ailment that he wrote as"Shang-han lun" seems to be almost the same as the"Shang-han lun" which is listed in the " Shang-han
lun", the original text in which described maoto. And
seen from our modern eyes, this was probably
influenza.

Maoto is currently widely used for influenza. Thisis because this experience of Dr. Yodo ODAI wasearnestly recorded in his "Essay of Medical
Technique".

From medical cases about 200 years ago
This is a story of an experience by a boy born in adoctor's family in a rural area in Japan about 200
years ago.

The composition of maoto"Shang-han lun" lists the compounding anddosing method of maoto as follows.

One day, the people of the neighborhood came toMix ephedra (3 liang, remove stem node), apricot

this doctor’s house saying they wanted him to

seed (70 pieces, remove skin tip), cinnamon twig (2examine a patient. At this time, the doctor was notliang, remove skin), and liquorice (2 liang, scorch)at home, and the grandfather, who was alreadywith 9 sheng of water, first boil the ephedra, reduce

retired, told the doctor's younger brother to "go andby 2 sheng, remove foam, add the other medicines,

examine the patient". And so the boy went andboil down by 2.5 sheng, remove scum, and take 8

examined the patient. The grandfather asked thene warm. In other words, the boiled liquid will beboy what kind of sickness the patient had, and thedivided into 3 equal parts.

boy answered, "The patient's disease is Shang-han,Currently, the following crude drugs are boiled

he has splitting pain in his head, chills, fever,in the following gram amounts to prepare onelabored breathing, pain all over his body, and his

day's dose. The formulation divides this into 3

pulse was floating and strong." To this thetimes.

grandfather replied, "What kind of prescription do
you think to give him?” The boy answered, "howEphedra 3〜5g，apricot seed 4〜5g，cinnamon
twig 2〜4g，liquorice 1〜1.5g

about maoto?” Then the grandfather smiled and said,

Because the amounts are slightly different at"Good job", so he prop 3 doses of maoto and orderedeach pharmaceutical company, there is a range.

him to "give him these doses warm, and make him

Lactose is often used as an excipient, with somesweat a lot" and sent the messenger back. When heformulations using starch.

went back the next morning, the patient had sweat
a lot and said that his suffering had quickly been
alleviated. He still had a slight fever, so he changed
the prescription to shosaikoto, and he recovered inbarely more than a day.
This is a story experienced by Dr. Yodo ODAI(1799-1870) at age 13, who was praised as a great
doctor in his later years, and he wrote of this as being

Maoto as a remedy for influenza
Use of maoto is generally limited to the earlystages of acute fever such as influenza. As statedabove, the indication is the combination of symptoms
such as chills, fever, headache, joint pain, andfloating pulse, with no sweating.

his "first challenge" 1).

2

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

Volume 11, Number 3 | Fall 2016

When administering maoto for influenza, I

be influenza or associated ailments. In recent years,

conduct the following dosing guidance based on the

research from this point of view has progressed anddescription in the "Shang-han lun".

there has been a great deal of clinical research

Patients take an extract formulation of maoto in
hot water. After taking, keep the body warm to help

produced showing that maoto is effective against
influenza.

induce sweating. After the first dose, take 1 dose

There are also many medical reports, theevery 2 hours taking 1 day's worth (3 doses) in 4

prototypical of which is published by Oribe in Vol.1

hours. Subsequently, take some every 3-4 hours, andNo. 1 of this journal.

continue until sweating onsets. After sweating starts,
stop taking at that point. In the original text it isCaution when usingstated that you must not induce too much sweating,Maoto is a formulation with ephedra as its main

but in actuality as long as you quickly change clothes,

ingredient, and the main component of ephedra is

keep warm, and intake an appropriate amount of

ephedrine. For this reason, use in combination withwater.

otherephedra-containing

compounds

and

In some cases the fever may temporarily risecatecholamine formulations requires caution. Side

before subsequently falling. For example, in someeffects caused by ephedrine can be seen includingcase a body temperature of 38.5℃ may rise to 39.3℃

coronary artery disease, arrhythmia, excessive

1 hour after dosing. Normally, the fever will go backperspiration and urinary retention. Also seen are

down after this. In rare cases, palpitation ordigestive symptoms such as a heavy feeling in thetachycardia may occur after dosing. In these cases

stomach and epigastric pain.

temporary stop taking the medicine.

It has also been shown that the absorption of

When the fever starts to go down, there is often

ephedrine raises in pH of the alimentary canal, solarge amounts of sweating, but in a few dozen

absorption is higher when taken internally after

percent of patients, the fever can go down withmeals, and it also has the potential to increase thefrequent urination (urination may occur about 5

likelihood of side effects due to sympathetic nerve

times in 2 hours). In these cases, there is not muchstimulation. For the same reason, taking together

sweating. In extremely rare cases, reduction of feverwith antacid drugs also requires caution 3).

may occur with nosebleeds. When effective, the fever
will drop to about 37.0℃ in 18-36 hours from thestart of dosing.
The amount to use for children depends on theirage and body weight or body surface area
Furthermore, in the series of maoto research
below, the standard method of dosing one day's
worth separated into 3 times is most common.
The diseases for which maoto is indicated in the
text of the "Shang-han lun" belong to taiyang
diseases among diseases called "Shang-han", andthey are "headache and fever, sheng teng lower backpain, bone pain, chills, and panting without sweat".
Thought of in the context of modern notions ofailments, these descriptions of "Shang-han" seem to

Research into maoto for influenza
Influenza virus infection often shows evidence of
maoto, and there have been many reports regarding
the effects of administering maoto. Classified
broadly, we see studies which examine the effects
when adding maoto to commonly used anti-viral
medicines, studies which compare maoto alone with
anti-viral medicines alone, and also case series andcomparative studies which investigate the side
effects and administration methods in addition towhat

happens

before

and

after

maoto

is

administered.
In Japan, continuing from the rapid testing of
influenza viral antigens, in February 2001 theThe Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

3

Volume 11, Number 3 | Fall 2016

National

HealthInsurance

drug

pricesofNote: In Japan, the prices of medicines used with

oseltamivir (Tamiflu®) and zanamivir (Relenza®)

health insurance are controlled by the nation. The

were listed, after which their use expanded

drug price of oseltamivir phosphate is about 640 yen

explosively. In the case of oseltamivir especially, 7080% of its consumption in the world is in Japan, andas a unique phenomenon in Japan it as acquired thestatus of the standard treatment in a short period of

per one day's worth, while maoto is about 60 yen.
Arita et al. preliminarily calculated that using maoto
instead of oseltamivir would result in a reduction intime. Consequently, early-stage clinical researchhealth care costs of 3,000 yen per person or 9 billion

into the results of maoto against influenza virus

yen in Japan overall 5).

infection has no option to not administer the
standard treatment anti-viral medicine, and has

In recent years there have also been reports ofstarted generally as an examination of the effects ofviruses that are resistant to oseltamivir, andmaoto on top of the other medicine.

furthermore

oseltamivir-resistantviruseshave

As the use of oseltamivir expanded, in 2004 ashown cross-resistance with peramivir, a injectablepostscript was added to the package insert of

medicine, as well. There are no reports of resistanceoseltamivir regarding mental and nervous disorders,to maoto, and viewed from the point of view offurthermore about the abnormal behavior of theresistant virus control as well as from the point of

teenage patient, Japan’s Ministry of Health, Labour

view of drug assurance to prepare for pandemics, theand Welfare came to urgently perform a delivery ofsignificance of the existence of Kampo medicine such

safe information in 2007, and the report thatas maoto would seem to be great.

compared the independent groups given maoto withthe oseltamivir came to attract attention. In basic
researches

using

rats,

the

simultaneousadministration of ethanol and oseltamivir has beenreportedtopromoteexcitability,

andsimilarphenomena are predicted in ephedrine as well 4). For
this reason there are opinions that prudence isrequired when using oseltamivir and maoto together.
Furthermore, in 2009 the effectiveness of maoto
against new strains of influenza was investigated,
and this continues today. Compared to oseltamivir,
the National Health Insurance drug cost of maoto isoverwhelmingly low, and it is receiving attention interms of health economics as well regarding whether
or not administering maoto alone has the sameStudies of maoto with standard therapy
Research by Kuroki, et al.
In a comparative study by Kuroki, et al.,oseltamivir was administered to 83 children with
influenza, and in 44 of the 83 cases maoto 0.10.15g/kg/day x 3 was simultaneously administered.
In the group administered oseltamivir alone, nocomplications were seen except 1 case of febrile
convulsions. The time from the first day of fever until
the alleviation of fever was 3 days in the maoto +
oseltamivir group, and 2 days in the oseltamivir only
administration group. The reason maoto wasprescribed was not stated, and it is unclear what the
fever period indicates 6).

effects as oseltamivir.

4

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

Volume 11, Number 3 | Fall 2016(combined administration group) with the combined

Research by Kimoto, et al.
In an open labeled quasi-randomized-controlled

administration group being administered maoto

trial (RCT) conducted subsequently by Kimoto, et al.,(7.5g/day), and the number of days the patientswith the same group, 19 patients diagnosed with

continued to experience a fever of 38℃ or higher,

influenza through clinical condition and rapid

headaches, and full-body fatigue was investigated.

testing from January to March 2004 which did not

The method of assignment into the groups was notmeet exclusion criteria were divided into a group ofstated. The number of days the fever continued was

10 patients (4 men, 6 women, age 24.1±7.72) who

1.7±0.8 days in the single administration group and

were

maoto

1.9±0.6 days in the combined administration group,(7.5g/day×3 days) in the order of examination, and ashowing a significant difference. The number of days

group of 9 patients (5 men, 4 women, age 29.1±4.52)

the headache continued was 2.4±1.0 days in the

who were administered oseltamivir with Western

single administration group and 1.3±0.5 days in the

medicine

andcombined administration group, while the full-bodyclenbuterol hydrochloride or carbocysteine), andfatigue was 2.3±1.2 days in the single administration

their body temperature, appetite, fatigue, andgroup

dizziness after treatment were compared via aadministrationquestionnaire filled out by the patients. All of thedifference. It appeared to be clinical influenza, but incases were type-A influenza. 12 hours after the start

the 6 cases where maoto was administered withoutof treatment, their body temperature showed aa diagnosis via an influenza rapid testing kit, notendency to be lower in the maoto combination group

significant difference in number of days fever,than in the Western medicine combination group.

headache, and full body fatigue continued was foundThe date when the maoto group's fatigue, dizzinesscompared to the combined administration group. No

and lack of appetite scores improved significantly

serious side-effects were observed 8).

administeredoseltamivir(cyproheptadineandhydrochloride

compared to before treatment was sooner comparedto the Western medicine group. Not examples if
increased CRP were observed in the maoto group,
but in the Western medicine group 3 cases of CRP
increase were observed. In the Western medicinegroup reduced WBC, increased RBC, Hb, hematocritand significant increase in ALT and γ-GTP wereobserved. A decrease in albumin was also observedin the maoto group. Including 8 weeks of follow-up
observation,noseriousadverseeventswere

observed in either group 7).

and

1.3±0.5
group,

days

in

the

combinedshowingasignificant

Research by Kubo, et al.
In an open labeled RCT by Kubo, et al., 60 case ofpatients (5 months to 13 years of age) experiencing
fevers of 38℃ or higher, 2 or more of the symptoms
headache, chills, and fatigue, and coughing andnasal inflammation all appearing within 48 hours
were first classified into 2 groups: the group which
was 1 year old or older with a positive rapid testing
result, and the group which was 1 year or less witha positive rapid testing result or a negative rapid
testing result regardless of age. Additionally, thegroup of 1 year and older with positive rapid testing

Research by Fukutomi, et al.
In an open labeled RCT by Fukutomi, et al., 22

results was further assigned randomly into 2 groups,

patients diagnosed with influenza through rapid

with 19 patients being administered oseltamivir

testing within 24 hours of the onset of symptoms(4mg/kg/day) and 17 patients being administered

were

of

12

patients

oseltamivir and maoto (0.06g/kg/day). The group of

only

(the

single24 patients 1 year or less in age with a positive rapid

administration group) and a group of 10 patients

testing result or a negative rapid testing result

who were administered oseltamivir with maoto

regardless of age was administered maoto only.

dividedadministered

into

a

group

oseltamivir

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

5

Volume 11, Number 3 | Fall 2016

Antipyretics were requested not to be internallylack thereof, and the results of these were comparedadministered. The definitive diagnosis of influenza

with the patient information in the electronic charts

was conducted with viral culture or PCR, and among

to confirm the patient backgrounds such as age andthe negative rapid testing group those diagnosed

gender, fever period, and administration of anti-viralwith type A influenza were the only targets ofmedicine and antibiotics or lack thereof. The results

analysis. The method of randomization was notshowed that in the younger ages there was morestated. 3 of the patients with positive rapid testing

administration of maoto alone, while in the higher

resultsofages there was administration together with anti-

oseltamivir and maoto did not internally take maoto

influenza drugs. The average fever period by

and were therefore excluded from analysis. The 2

treatment method was 1.39±0.96 days in the maoto-groups which took maoto orally had significantly

only group and 1.60±1.20 days in the anti-influenza

shorter periods of fever after examination compareddrugs combined use group, with no significant

to those who did not take maoto orally. All patientsdifference observed between the 2 groups. Side

resumed their normal lives and no side effects from

effects were observed in 21 patients (13.1%), and a

maoto

breakdown observing duplicate responses was thatassigned

werecombined

observed.

administrationNo

patients

required13

hospitalization 9).

experienced

Research by Takeya, et al.
In RCT by Takeya, et al., the fever period fromstart of treatment until alleviation of fever wascomparedintwopatients

groups--a

group

that

was

administered both maoto and oseltamivir (23 type A
and 17 type B) and a group that was administeredexperiencedlacknausea/vomitingofappetite,(including

5

while

taking orally), 3 experienced rashes, 2 experienced
diarrhea/watery stools, and 1 each experienced badtemper and edema, respectively, with no significant
difference observed between the groups 11).
Research by Tsuji, et al.

only oseltamivir (59 type A and 86 type B)--targeting

Comparative research by Tsuji, et al. targeted 81

185 patients (age 0-14) selected from children

cases of child influenza patients whose families

examined at 7 hospitals and clinics in Shimane

consented in participation in the study. They wereprefecture

influenza

separated into 3 groups--an anti-influenza medicine

vaccination and who were shown to be type A or typeonly group (oseltamivir 4mg/kg/day or zanamivir

B influenza virus antigen-positive in rapid testing.

8mg/day), a maoto-only group (0.2g/kg/day), and an

The results showed a shorter trend in the combined

anti-influenza + maoto group--and investigated. The

administration group compared to the oseltamivir

method of assignment into the groups was not stated.

only group, but no significant difference wasNo significant difference was observed in the periods

observed 10).

of

who

had

not

receivedaretrospective

comparative

study

by

Yamamoto, et al., 167 cases were investigated via
responses to questionnaires out of 329 cases ofchildren where were diagnosed with new strains ofinfluenza

who

were

administeredmaoto.

A

questionnaire was administered to the guardians of
the target patients regarding the state of oral
ingestion, day of fever alleviation, and side effects or

6continuationorclinical

symptoms

continuation among the 3 groups, however the fever

Research by Yamamoto, et al.
In

fever

continuation

periodandclinical

symptoms

continuation period were both shortest in the
combinedtreatment

administration
withgroup.

anti-influenza

Furthermore,
medicine,clarithromycin (10mg/kg/day), and maoto combinedwith clarithromycin was conducted targeting a totalof 288 other child patients diagnosed with influenza(themaoto-onlygroup and antipyreticgroup

administered group were excluded due to a low

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

Volume 11, Number 3 | Fall 2016

number of cases). The results showed no statisticallystart of ingestion was longer, so it is difficult to comesignificant difference between the groups in theto a conclusion based solely upon this report.

fever continuation or clinical symptom continuation

with almost the same contents targeting 129 childgroups 12).
Studies comparing maoto administered alone andanti-viral medicines administered alone
it

was

not

randomassignment,

Kawamura, who is proactively proceeding withcomparative research, has come to imply thepossibility that the differences in results and side
effects between maoto and oseltamivir are small. 139
child patients with influenza examined in the springof 2007 were divided into a maoto (0.08 ～0.19g/kg/day，maximum of 7.5g in 3 divided doses)
administration

group

and

an

(4mg/kg/day ， maximum 150 ㎎

influenza patients, in addition to similar contents tothe preceding study, the study also investigated thetime passed after onset of fever and after onset of

Research by Kawamura
Although

In a subsequently published report by Kawamura

oseltamivirin 2 divided

doses)administration group as per their parents'
requests, the time of fever alleviation and fever
period, etc. were investigated. The administration
period was 2-8 days in the maoto group and 2-5 daysin the oseltamivir group, with fever alleviation or
improvement of symptoms as criterion in the case ofboth medicines. Antihistamine, antitussives, andexpectorants were also additionally administered asnecessary. In the type A patients no significant
difference was observed in age, maximum bodytemperature, ingested dose of maoto, time fromoutbreak of illness to start of ingestion, time fromingestion until alleviation of fever, time fromingestion until alleviation of general symptoms, andtime of continuation of general symptoms. In thetype B patients, the time of starting ingestion was
significantly later in the maoto group, the time fromingestion until alleviation of fever and time until
alleviation of general symptoms was significantly
faster in the maoto group, and the length of general
symptoms was significantly shorter in the maotogroup 13). In the B group patients, the time fromingestion until alleviation of fever and time until
alleviation of general symptoms was significantly
shorter in the maoto group, but the time until theillness until the start of ingestion, the fever period,
thesymptom

continuation

period,andthecorrelation between the amount of maoto ingested
and the fever period and symptom continuation
period. By and large no correlation was observed, but
a positive correlation between the time of starting
ingestion after onset of fever and fever period wasobserved in the type A influenza oseltamivir groupand in the type B influenza maoto group. No
significant difference in abnormal behavior such as
sleep-talking, auditory hallucinations, and visual
hallucinations was observed between these twogroups 14).
In comparative research conducted by Kawamura
conducted in the following season (2007/08), the timeof disappearance of the influenza virus form thepharynx with maoto and oseltamivir was examined,
and the study implied the efficacy of maoto. 172
patients with type A influenza in the 2007/2008
season were divided into 3 groups--64 patients with
Teikoku's maoto (0.16g/kg/day，maximum 7.5g/dayin 3 divided doses), 61 patients with Tsumura's
maoto (0.16g/kg/day，maximum 7.5g/day in 3 divided
doses), and 47 patients with oseltamivir (average 3.9
mg/kg/day，maximum 150 mg/day in 2 divided doses)by the request of the patients (their parents)--withmaoto administered with 1-6 days with fever
alleviation

as

the

target,andoseltamivir

administered with fever alleviation or 5 days being
the criterion. The average time after ingestion until
fever alleviation was 45.73±35.51 hours, 53.90±39.42
hours，and 30.36±20.96 hours, with the oseltamivirgroup being significantly shorter compared to the 2companies' maoto groups. Similarly, the average
fever

time

was

average

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

67.27±37.88

hours,

7

Volume 11, Number 3 | Fall 201669.57±39.76 hours, and 45.79±21.05 hours, and theA-type, the conservative was significantly younger

time from onset of illness until disappearance ofthan the maoto group. Also, although the fever

symptoms was 70.47±41.99 hours ， 73.95±43.01

period was significantly longer in the conservative

hours，and 48.47± 26.90 hours, significantly shorter.

compared to the maoto group, there was also no

No significant difference was observed in the 3

significant difference observed between the groups

groups in the time after onset of illness until thein the time until coming to the hospital and the time

influenza virus was removed, the time fromuntil alleviation of fever after ingestion. In Soviet A-

alleviation of fever was significantly shorter in the 2type, the time until coming to the hospital as well ascompanies'

thethe time after ingestion until alleviation of fever andoseltamivir group. In a comparison of the Teikoku

fever time were all significantly shorter in the

and Tsumura maotos, a significant difference wasoseltamivir group compared to the maoto group. Also,

observed in the fever alleviation time, fever time,

although the fever period was significantly longer ingeneral symptoms time, and elimination of A typethe conservative compared to the oseltamivir group,

influenza virus from the pharynx 15).

there was also no significant difference observed

maotogroupscomparedto

In comparative research by Kawamura, et al.

between the groups in the time until coming to the

conducted from January to March 2009, eachhospital and the time until alleviation of fever after

subtype of influenza was investigated. 147 patientsingestion. Furthermore, the Soviet A-type had

who came to a hospital within 48 hours of the onset

significantly longer fever time and time until feverof illness, were diagnosed with type A influenza via

alleviation after ingestion compared to the Hongrapid testing kits using nasal swabs and diagnosed

Kong A-type. No significant difference was observedwith a subtype (Soviet A-type H1N1, Hong Kong A-

between the groups in the time until general

type H3N2) were divided into the symptomatic

symptoms were alleviated after ingestion 16).

treatments of oseltamivir 4mg/kg/day and Teikoku
maoto extract 0.2g/kg/day as per the request of thepatients. 1-5 days of oral administration was
conducted depending on the continuing time of thesymptoms, and a comparative investigation of thecontinuation period of fever of 37.5℃ or higher andthe continuation period of general symptoms such as
headaches, fatigue, and lack of appetite wasconducted.

In

SovietA-type,

there

was

an

oseltamivir group of 15 patients (6 male patients，9female patients，age 11.20±16.22), an maoto groupof 63 patients (33 male patients, 30 female patients,
age 7.66±7.25), and a conservativeof 8 patients(1male patients，7 female patients, age 4.53±2.38),
and in Hong Kong A-type there was an oseltamivirgroup of 18 patients (9 male patients ， 9 female
patients, age 12.86±16.20), an maoto group of 34
patients (18 male patients，16 female patients，age
9.24±11.41),and a conservative of 9 patients (2 malepatients，7 female patients, age 7.86±9.40). In Soviet

8

Research by Fukutomi, et al.
In the preceding comparative study by Fukutomi,
et al. which reported the efficacy of combined
administration of maoto, 112 patients of less than 10
years of age diagnosed with influenza via rapid
testing within 24 hours after the onset of illness was
divided into 2 groups--54 patients (average age
4.7±2.1)

administered oseltamivir and 68 patients(average age 5.2±2.7) administered Tsumura maotoextract (7.5g/day) as per the request of the patients-and their body temperatures on consecutive days
were examined. In both groups, the 2nd day of illness
showed a significant decrease in body temperaturecompared to the 1st day of illness, and no difference
was observed between the groups. No serious sideeffects were observed

17).

It was furthermore

reported in a comparative study conducted targeting
41 cases in a different season that no difference wasobserved between the groups. The oseltamivir groupwas 20 patients (average age 4.1±1.8, 10 type A

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

Volume 11, Number 3 | Fall 2016

patients/10 type B patients ， fever of 39.0±0.3 ℃

desired maoto. Moreover, the patients who desired

when coming to hospital), and the maoto group was

maoto from among the group which desired

21 patients (4.1±2.6 age，12 type A patients・9type

neuraminidase

B patients，39.0±0.4℃). In a questionnaire regarding

administered maoto. Furthermore, an investigation

the results of maoto conducted 3 days after thewasadministration of maoto, 66% rated the results very

administered neither anti-viral medication nor

good or good. On the other hand, a large number ofmaoto. The amount of each drug administered was

respondents at 70% responded that it was difficult to

4mg/kg/day for oseltamivir，10mg/day for zanamivir，drink. In spite of the common opinion that it was

and 0.06g/kg/day for maoto. 16 patients weredifficult to drink, only about 3% responded that theyomitted, and only 70 patients were analyzed. No

could not drink it 18).

significant difference was observed in time fromIn a retrospective comparative study by Mori, 19
patients (12 men, 7 women, average age 11±11) out
of 22 patients from amount 291 patients diagnosed
with type A influenza between October andDecember 2009 were administered maoto extract,
and the time it took for their temperature to drop to
36.9 ℃ from examination was investigated. They
ingested 3 packets of Kampo medicine every 2 hours,
and subsequently ingested every 3 hours until
sweating was induced. By comparison, a group of 19
patients (7 men, 12 women, average age 16.5±16.1)
administered oseltamivir and a group of 21 patients
men,

10

women,

into

the

were

additionallypatients

who

were

ingestion to alleviation of fever or time from onset of

Research by Mori, et al.

(11

conducted

inhibitors

averageadministered the drugs in ANOVA. The time from
onset

of

illness

toalleviation

of

fever

was

significantly shorter in all the groups administereddrugs compared to the group administered no drugs.
All patients resumed their normal lives and noside effects from maoto were observed. No patientsrequired hospitalization. Although there were 2
patients in the oseltamivir-only and zanamivir-only
administration groups reported abnormal behavior
respectively, no serious side effects were observed 20).
Research by Saita, et al.

15.4±8.7)

In open labeled RCT by Saita, et al., 45 adult

administered zanamivir were also set up. Regarding

patients (average age 32.4±11.5) who tested positive

the time for the fever to drop to 36.9 ℃ after

for type A influenza in rapid testing were divided

administration,

droppedinto 3 groups--a group of 11 maoto patientssignificantly faster in the maoto group compared to(7.5g/day), a group of 14 oseltamivir patients, athe zanamivir group, no significant difference wasgroup of 9 zanamivir patients and a group of 11

observed between the maoto and oseltamivir

patients who took maoto in combination withgroups19).

oseltamivir. 2 patients in the maoto and combined

althoughtheageillness to alleviation of fever between the groups

fever

administration groups, 1 patient in the oseltamivir

Research by Toriumi, et al.
In the comparative research by Toriumi, et al., 86
patients (aged 5 months to 15 years) who wereobserved to have fevers of 37.5℃ or more and whotested positive for type B influenza were separated
into 3 groups--a group between 1 and 10 years of age
who desired oseltamivir, a group age 6 and older who
desired zanamivir, and a group age 1 year or younger
or who didn't desire neuraminidase inhibitors but

group, and 3 patients in the zanamivir group wereomitted. No significant difference was observed
between the groups in fever after coming to thehospital. The symptoms of joint pain, muscle pain,
headache, cough, and fatigue were evaluated on a 5point scale, with the product of the difference
between the maximum and minimum values of eachpatient and the number of days taken to reach theminimum value from the maximum value as the

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

9Volume 11, Number 3 | Fall 2016

symptom score, which when compared among theno significant difference in the virus isolationgroups was shown to be significantly lower in thepositive ratio or the serum cytokine concentration on

maoto group than the oseltamivir group. 1 patientthe 5th day after the start of administration amongdeveloped nausea due to the odor of the maoto, but

the 3 groups. Mild liver dysfunction was observed in

no serious side-effects were observed 21) 22).

1 patient from the maoto and oseltamivir groups
respectively, but this improved quickly 24).

Research by Nabeshima, et al.
In comparative research by Nabeshima, et al., 20
adult patients who developed a fever of 38 degrees or

Research by Yamagishi, et al.
Althoughretrospective,

Yamagishi,

et

al.,

higher within 48h and tested positive for type A

reported research comparing 130 pregnant women

influenza inrapid testing were divided into a group

who had contracted influenza by whether they hadof 12 patients who desired maoto (7.5g/day) and 8

been administered maoto or now. The assignment

patients who desired oseltamivir. No significant

was by the patients' requests, with 90 patients being

difference was observed between the maoto andadministeredoseltamivir groups in the fever continuation timeadministered no drugs. The group administeredafter coming to the hospital and the symptoms

maoto comprised 70 type A patients and 20 type B

continuation time. The average body temperature

patients, while the group administered no drugs

and headache score on the evening of the first day ofcomprised 32 type A patients and 8 type b patients.

treatment was significantly lower in the maoto

The maoto was administered at 7.5g/day in 3 divided

group

In open labeled RCT subsequently

doses (administration period not stated, antitussives

conducted by Nabeshima, et al., 33 adult patientsand expectorants administered in combination). In

age 20-64 who developed a fever of 38 degrees or

the maoto group, both the type A and type B patients

higher within 48h and tested positive in rapid

had their fevers alleviated significantly faster thantesting were randomly divided into a group of 11

the group administered no drugs. Furthermore theirpatients who were administered maoto (7.5g/day), a

symptoms such as headache, full-body fatigue andgroup of 10 patients who were administeredlackoseltamivir, and a group of 12 patients who weresignificantly faster 25).

23).

administered zanamivir. Ischemic heart disease
patients,

patients

withhyperthyroidism,

enlargement of the prostate, and chronic infections,patients taking steroid/immunosuppressant drugs,
anti-viral drugs, or Kampo medicine, and patients
testing positive for new strains of influenza were
excluded. 1 patient from the maoto group, and 2
patients from the oseltamivir and zanamivir groups
respectively were omitted. The median value of thefever continuation time since coming to the hospital,
which was the primary outcome, was 29h in the
maoto group, 46h in the oseltamivir group, and 27hin the zanamivir group. A significant difference wasobserved between the maoto and oseltamivir groups.
No significant difference was observed between the
3 groups in the influenza symptoms score. There was
10

of

maoto

appetite

and

were

40

patients

observed

to

being

improve

Research by Yaegashi, et al.
In open labeled RCT by Yaegashi, 14 patients
aged 18 and older who had been diagnosed with type
A influenza within 48 hours of developing fever wererandomly

dividedinto

2groups--agroupadministered maoto and shosaikoto in combination(6 patients: 7.5g of maoto extract granules and 7.5gof shosaikoto granules/day in combination, taken for
3 days) and a group administered oseltamivir (8patients: 150mg/day, taken for 5 days). The fever
period from onset of illness, time from onset of illness
until start of treatment, time from start of treatment
until

alleviationoffever,

maximumbodytemperature, amount of antipyretics used, andamount of antitussives used were compared. The

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

Volume 11, Number 3 | Fall 2016

method of assignment into the groups was not stated.

of bronchial asthma as well, the rate of use of

No significant difference was observed between theconcomitant drugs for respiratory organs was 34 out

groups 26).

of 107 (31.8％) in the anti-viral drug group and 9 outof 13.4 (13.4 ％ ) in the maoto group, significantly

Research by Yamauchi, et al.
In comparative research by Yamauchi, et al., childpatients aged 15 and younger diagnosed with
influenza were administered either anti-influenza
drugs (oseltamivir or zanamivir) (166 patients) or
maoto (80 patients) based mainly on the preferenceof their guardians, after which their frequency offollow-up treatment was investigated. The patientswere administered 4mg/kg/day of oseltamivir in 2
divided doses, 20mg of zanamivir in 2 divided doses,

lower in the maoto group. The rate of use ofconcomitant drugs for respiratory organs was lower
in the maoto group. Furthermore, in spite of the factthat the rate of use of concomitant drugs forrespiratory organs was significantly lower the maotogroup in patients without a history of bronchialasthma, the need for follow-up treatment for
respiratory organ complications was low 27).
Research by Suzuki, et al.

and 0.2g/kg/day of maoto in 2-3 divided doses. The

In an open labeled quasi RCT by Suzuki, et al.,anti-viral medicine group and maoto group werechild patients age 1-10diagnosed with type A

further stratified by age (younger than 10, andinfluenza were divided into a group administered

between 10 and 15), history of bronchial asthma or

maoto (0.15g/kg/day，in 3 divided doses) and a grouplack thereof, rate of follow-up treatment foradministered oseltamivir (4mg/kg/day，in 2 divided

respiratory organ complications, and rate of use ofdoses) for 5 days in alternating order of examination.

concomitantorgansFurthermore, the subjects of the study were limited(expectorants, bronchodilators, anti-allergy drugs,

to those with a maximum body temperature of 38.4

and antitussives). The rate of patients requiring～40.1℃ before administration, and who also could

follow-up

organ

be administered one of the drugs within 24 hours

complications was 34 out of 166 (20.5％) in the anti-

after the onset of fever. Child patients who could not

viral drug group and 9 out of 80 (17.8％) in the maoto

be administered maoto were also excluded. A

group, showing no significant difference. In thecomparison of the body temperatures was conducted

patients without a history of bronchial asthma, theat each 6 hour interval. The oseltamivir grouprate of patients requiring follow-up treatment wascomprised 46 patients, while the maoto group

19 out of 107 (17.8％) in the former group and 4 out

comprised 40 patients. No significant differences inof 67 (6％) in the latter group, significantly higher inage, gender, rate of vaccination before contracting

the anti-viral drug group. In the patients with athe illness, maximum body temperature before

history of bronchial asthma younger than age 10, thetreatment, and body temperature at the time ofrate of patients requiring follow-up treatment wasstarting administration were observed between the

15 out of 57 (26.3％) in the anti-viral drug group and2 groups. At 12-30 hours after the start of

4 out of 5 (80 ％ ) in the maoto group, showing aadministration, the temperature in the maoto group

significantly high rate requiring follow-up treatment

was on average 0.15 ～ 0.26 ℃ lower, showing a

in the maoto group, although the number of cases

significantly lower body temperature. Subsequently,

was small. The rate of use of concomitant drugs forthe median value of the body temperatures of the two

respiratory organs in all of the cases was 64 out ofgroups crossed at the 36th hour, after which the

166 (38.6％) in the anti-viral drug group and 12 out

oseltamivir group's body temperature converselyof 80 (15％) in the maoto group, significantly lower

became clearly lower. With having a fever is definedin the maoto group. In the patients without a historyas "37.5 ℃

drugs

treatment

for

for

respiratory

respiratoryor higher", the average ± standard

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

11

Volume 11, Number 3 | Fall 2016deviation of the fever period was 84.8±36.8 hours inreports, all symptoms showed improvement. Sidethe maoto group and 67.0±24.4 hours in theeffects appeared in 2 patients (4.9%), which wereoseltamivir group, showing a significant difference

diarrhea and rashes respectively 29). Iwaki also

between the 2 groups. With "a fever of 37.5℃ or

conducted a similar case series regarding the 2009higher continuing for 24 hours or more after apandemic, in which 12 type A influenza patients (4normal temperature for between 12 and 72 hours "men, 8 women, average age 21.9±11.6) were

defined as diphasic fever, the ratio becomes 4.3％ inadministered Tsumura maoto extract granules in

the oseltamivir group and 20.0％ in the maoto group,

doses of 7.5g per day for adults and 0.2g/kg per day

significantly higher in the former. The average value

for children for a period of 5 days. Results of virusof the number of days of administration was 5.3±1.59

examination via viral isolation and RT-PCR usingdays in the maoto group and 4.6±0.75 days in thenasal swabs and throat swabs as specimens showed

oseltamivir group. Depending on the progress, in thethat all cases were the 2009 pandemic virus (H1N1).

case of maoto, when the fever continued for 5 days or

The average time from onset of illness until initial

more,

there

were

also

cases

where

the

dosing was 15.7 hours, with temperatures at theadministration

waslonger.

Conversely,

intime of arrival at hospital of 38.2 ℃ and a post-

oseltamivir, there were many cases where the fevers

administration fever alleviation time of 18.5 hours.

were alleviated quickly, with a short administration

Regarding the symptoms, upon calculating theperiod not requiring 5 days of administration 28).

average symptom scores (0-3) from the patients'

Case series and comparative studies investigatingside effects, administration methods, etc.

comparingadministration

thesymptoms

preshowed

and

post-

significant

improvement in "sore throat", "muscle and joint

Research by Iwaki, et al.
In a case series by Iwaki, et al., 41 patients (17men, 24 women, age 40.5±13.6) age 20-72 diagnosed
influenza positive (type A and type B) via rapid
testing kits, who had fevers of 38.0 ℃ or higher
before or when coming to the hospital, and who had
been experiencing influenza symptoms for 48 hours
or less were administered maoto,

journals,

and the timefrom administration until alleviation of fever (fever
alleviation time), virus survival time and transitionof clinical symptoms were investigated. The resultspain", fatigue and tiredness" and "headache". An
examination of the virus survival rate conducted on
average on the 5th day after the start ofadministration showed 6 patients positive, for asurvival rate of 50.0%. Harmful events observed
were 1 case each of abnormal behavior and diarrhea,
with the abnormal behavior starting on the first dayof administration and ending the following day andbeing deemed "unrelated" to the maoto 30).
Research by Ihashi, et al.

showed that the overall average fever alleviation

Although it is not comparative research, the casetime was 27.4 hours, of which it was 25.9 hours withseries by Ihashi et al. contains reports of results oftype A and 33.7 hours with type B. Furthermore, theseriously ill child patients with new strains offever alleviation times of type A by subtype were 24.9

influenza and pneumonia requiring hospitalization

hours with H1N1 and 26.5 hours with H3N2. The

who were administered maoto in combination withsurvival

after

neurominidase inhibiters. The subjects were 70 childadministration was 22.6%, with type A H1N1 having

patients (average age: 7.3±3.7; gender: 46 male anda survival rate of 30.0%, type A H3N2 0%, and type24 female; bronchial asthma: 25 with and 45

B 20.0%. Regarding the progress of the clinicalwithout; administration of anti-influenza drugs as

symptoms, upon calculating the average body

outpatients: 21 yes and 49 no) who were hospitalized

temperatures and symptom scores from the patientwith new strains of influenza and pneumonia from

12

rate

of

the

viruses

5

days

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

Volume 11, Number 3 | Fall 2016

June 2009 to January 2010 with no serious

time for group II's fevers to drop to 36.9℃ after

underlying illnesses. The anti-influenza drugs

administration. There are no statements regarding

selected for treatment after hospitalization werecomparisons between group Ⅰ

oseltamivir for 64 patients and zanamivir for 6

group, or between group Ⅰ and group II. No serious

patients. Regarding the administration of maoto, theside-effects

administration dose was 0.2g/kg in 3 divided doses,

observed32).

the administration method was every 2-3 hours on
the first day and 3 divided doses from the 2nd day
onwards (before or after morning, noon, and evening
meals), and the administration period was 5.0 dayson average (95％CI：4.7～5.2 days). The main subjectof the paper was to suggest the importance ofadministering

neuraminidase

inhibiters

beforehospitalization via multiple regression analysis, buteven regarding treatments where maoto wasadministered to seriously ill patients, no side effects
were observed 31).

due

to

Kampo

and the control
treatment

were

Research by Mori, et al.
In a case series by Mori, et al., where early-stage
administration of Kampo medicine was conducted
before seeing a doctor, treatment via early-stage
administration of Kampo medicine was conducted on
10 patients (5 men, 5 women, average age 13.2±12.1)
who exhibited flu-like symptoms between October toDecember 2009 and for whom treatment with the
Kampo internal medicine on hand was insufficient,
after which they went to hospitals and werediagnosed with type A influenza, and the results
thereof were examined. Upon arrival at the hospital

Research by MoriMori's open labeled quasi RCT, which examinedthe evidence was reconfirmed, and in cases where it

unique administration methods of maoto, divided

fit it was continued, while in cases where it differedcases of maoto administration from November 2007

the method was changed.

through March 2008 into 2 groups and examined the

1.5-2 times the normal does was administeredadministration(groupfrequently (every 2-3 hours), with the treatment

administered maoto every 3 hours): Patients withbeing ended at the point when the fever, generalevidence of maoto up to January 31were dosed withcondition, and respiratory tract symptoms improved.

methods.

Group

Ⅰ

maoto every 3 hours when the maoto administration
was started (no administration during sleep). GroupⅡ(group administered maoto every 2 hours):

Patients

with evidence of maoto After February 1

were dosed with maoto every 2 hours when the
maoto administration was started, taking 1 day
worth (3 packets) every 3 hours, and subsequently
continued to take it every 3 hours until the onset ofsweating(no administration during sleep). Afterthey started sweating, the dosing was halted(Hiromichi Yasui's method). Among those treatedwith Kampo, group Ⅰ was 17 patients (average age
6.7) and group II was 11 patients (average age 6.7).
Furthermore, 13 patients treated with oseltamivir
who did not use antipyretics served as the control
group. Examining group II and the group treatedwith oseltamivir shows that it took significantly lessDuring fevers, a dose of

The results showed that the time from coming to thehospital until alleviation of fever was 17.0±17.0
hours, the number of days from coming to thehospital until recovery was 1.8±0.6 days, and thenumber of days from early-stage administration
until recovery was 2.5±0.7 days. The early-stage
Kampo administered before going to the hospital
was keishi-to maoto for 4 patients, keishito for 3
patients, maoto for 2 patients, and saiko keishito
shoken-chu-tofor1

patient,

with

1-5

administrations, with 5 patients' Kampo fitting theevidence and 4 of the remaining 5 leaving earlystage administration prescriptions and combining
with

other

comparison

compounds.
oftheFurthermore,

Kampo

in

a

medicine/anti-viral

medicine combined administration group and the
Kampo-only group, no significant difference was

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

13

Volume 11, Number 3 | Fall 2016

observed in the number of days from start ofgroup from age 0 to 2, the good group was about 32

administration before going to the hospital until

hours while the poor group was about 48 hours,

recovery,ashowing a significant difference. In the type B

significantly shorter fever alleviation time andinfluenza, the fever alleviation time of the goodnumber of days from going to the hospital until

compliance group was about 28 hours while the poor

recovery 33).

compliance group was about 56 hours, showing a

but

the

Kampo-only

group

had

significant difference. In (2), the fever alleviation time
Research by Nishimura, et al.

of the maoto administration group was about 26

In a case series by Nishimura, et al., wherein

hours, which was significantly shorter than in (1)there is a unique report of using a maoto suppository,

where it was about 40 hours. In the zanamivir

a comparison is conducted on the body temperatures

administration group it was about 32 hours. However,before administration and until 24 hours afterin (2), a pharmacist proactively conducted interfusedadministration of a maoto suppository in pediatrics

flavoring agent guidance for the maoto. The results

department between June 2006 and April 2007 on 21

were that milk coffee, cocoa, orange juice, Calpis andpatients (from 10 days old to 9 years and 9 months

other flavors resulted in good medication compliance,old) with fevers of 38.9℃ or greater. There were 17

with (2) being the good medication compliance grouppatients whose body temperature were possible tosignificantly increasing from (1)'s 69.9% to 93.9%,

track. The temperature of these patients decreased

while in the age 0 to 5 group the good medication

significantly. No side-effects were observed 34).

compliance group significantly increased from (1)'s
59.4% to 100% 35).

Research by Tabata, et al.
In open labeled comparative research by Tabata,This concludes the discussion of the state of

et al., in addition to the clinical results of maoto andmaoto's use in Japan as a treatment for influenza

zanamivir, the influence of interfused flavoring

and the current state of its research. It is currently

agent guidance by pharmacists as an idea to increase

commonly used in combination with anti-viralpatient compliance in taking medicine was compared

medications, but in some circumstances it is also

over 2 seasons. (1) In the 2006-2007 season, maotoused alone. It is used especially often in the field of

was administered to 63 child influenza patients (37pediatrics.

type A, 26 type B). (2) In the 2007-2008 season, maoto

The fact that the text cited in the first paragraph

was prescribed for all cases of children 5 years or

which was written in "Shang-han lun" is connectedyounger, while for children of 5 years or older either

to the treatment by a 13 year old boy almost 200

maoto or zanamivir were administered after informed

years ago is a testament to the very high level ofconsent and the parents choosing one of them, with 49

research that "Shang-han lun" was in Japan. The

patients (all type A patients) being administeredKampo medicine of Japan even today continues tomaoto and 32 patients (31 type A patients and 1 type

carry on this tradition.

B patient) being administered zanamivir. The time
until alleviation of fever was scored, and theNote: One way of looking at maoto is that veterinary

compliance with taking the medicine was also

surgeons are focusing on the prescription. They

examined split into a good group and poor group.

discovered maoto’s effect on avian influenza during

maoto was taken 0.18g/㎏/day in 3 divided doses for 3

their research. Currently they are aggressively

days, and zanamivir was inhaled 2 blisters (10mg) per

proceeding with the study 36). A vast amount of researchtime, twice per day for 5 days. In the good medication

reports in future.

compliance group of type A influenza in (1) in the
14

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

Volume 11, Number 3 | Fall 2016

Reference Literature
1) Yodo Odai: 『 Hogi zasshi 』 (Essay of Medical
Technique) 1871. (in Japanese)
2) Kazuhiro Oribe: Maoto Demonstrated as Highly
Effective for the Treatment of Influenza, The
Journal of KAIM, vol.1 No.1, 18-19, 2006.
3) Yasufumi Sawada: Change of pH – Diet (antacid)and maoto, The Journal of Practical Pharmacy
Additional Volume, 55: 115, 2004. (in Japanese)4) Yukitoshi Izumi et al.: Neuroexcitatory actions ofTamifluandits
carboxylate
metabolite
Neuroscience Letters, 426 (2007) 54-58
5) Arita R, et al. National cost estimation of maoto, a
Kampo medicine, compared with oseltamivir forthe treatment of influenza in Japan, Kampo andTraditional Medicine, vol. 3, no. 1 pp. 59-62, 2016.
6) Haruro Kuroki, Hiroshi Kimoto: Experiences with
East-West integrated medicine for pediatricinfluenza and rubeola, Journal of the CHIBAMEDICAL ASSOCIATION, vol. 55, no.10, pp 12091212, 2003 (in Japanese)
7) Hiroshi Kimoto, Haruro Kuroki: Effects ofoseltamivir phosphate combination therapy withmaoto for influenza, comparison of effects in adults
when combined with western drugs, Science of
Kampo Medicine, vol. 29, no. 4, pp. 166-169, 2005
(in Japanese)8) Osamu Fukutomi, Toshiyuki Fukao, Eiji
Matsukuma. et al.: Experiences where the use of
maoto effectively alleviated influenza symptoms,
Science of Kampo Medicine, vol. 29, no. 5, pp. 228230, 2005. (in Japanese)
9) Kubo T, Nishimura H: Antipyretic effect of Mao-to,a Japanese herbal medicine, for treatment of type
A influenza infection in children, Phytomedicine,vol. 14, no. 2-3, pp. 96-101, 2007.
10) Takeshi Taketani, Jyoji Hayashi, Takeshi Kasai, etal.: Investigation of the effectiveness of maoto forpediatric influenza, Child Health, vol. 11, no. 2, pp.
114-118, 2008. (in Japanese)11) Katsusuke Yamamoto, Takehisa Yamamoto,
Yoshimi Mizoguchi, et al.: Effects of maoto
administration for new influenza types inpediatric outpatients, Kampo and Immunology /Allergy, vol. 24, pp. 55-59, 2011. (in Japanese)12) Yuichiro Tsuji, Kohji Morita, Izumi Ichihashi,Kazuo Itabashi: Effects of maoto in combination

therapy for pediatric influenza, Science of Kampo
Medicine, vol. 35, no. 2, pp. 158-160, 2011. (inJapanese)13) Kenichi Kawamura: Investigation of theeffectiveness of maoto for influenza patients,
Journal of the Japan Physicians Association, vol.
22, no. 4, pp. 435-438, 2007. (in Japanese)
14) Kenichi Kawamura: Investigation of theeffectiveness of maoto for influenza patients,
Japanese Journal of Pediatrics, vol. 61, no. 5, pp.
1057-1062, (in Japanese)
15) Kenichi Kawamura: Investigation of the time until
elimination of type A influenza virus from thethroat, Journal of the Japan Physicians
Association, vol. 23, no. 4, pp. 418-422, 2008. (inJapanese)16) Kenichi
Kawamura,
Yoshinobu
Miwa:
Investigation of the effectiveness of oseltamivir
and maoto in patients with type A influenza(Soviet type A, Hongkong type A), Journal of theJapan Medical Association, vol. 138, no. 7, pp.
1391-1396, 2009. (in Japanese)17) Osamu Fukutomi, Hideo Kaneko, Hidenori Onishi,
et al.: Investigations of the effects of maoto forpediatric influenza and the choice of therapy,
Kampo and Immunology / Allergy, vol. 22, pp. 2333, 2008. (in Japanese)18) Osamu Fukutomi, Takahide Teramoto, Michio
Koseki, et al.: Investigations of the usefulness of
maoto for the treatment of pediatric influenza,

Journal of Japan Pediatric Oriental Medicine
Society, vol. 24, pp. 11-15, 2010. (in Japanese)19) Yoshio Mori: Experiences with Kampo treatment
for a new type of influenza, Journal of Kampo
Medicine, vol. 57, no. 10, pp. 1655-1662, 2010. (inJapanese)20) Yoshitaka Toriumi, Kohji Murata, Tsutomu
Kamei: Investigation of the effects of maoto for thetreatment of pediatric type B influenza, Research
Report for 2009. The Japanese Society forComplementary and Alternative Medicine (inJapanese)21) Mizue Saita, Toshio Naito, Soushin Boku, et al.:The efficacy of ma-huang-tang (maoto) against
influenza, Health, vol. 3, no. 5, pp. 300-303, 201122) Mizue Saito, Toshio Naito, Soshin Boku, et al.:Investigation of the effectiveness of maoto for

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

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Volume 11, Number 3 | Fall 2016

influenza, Kampo and Immunology / Allergy, vol.
23, pp. 17-26, 2010. (in Japanese)23) Nabeshima S, Kashiwagi K, Ajisaka K, et al.: A
comparison of oseltamivir with maoto, a
traditional herbal medicine, for the treatment of
adult seasonal influenza A, Journal of Traditional
Medicines, vol. 27, no. 4, pp. 148-156, 2010.
24) Nabeshima S, Kashiwagi K, Ajisaka K, et al.: A
randomized, controlled trial comparing traditional
herbal medicine and neuraminidase inhibitors in
the treatment of seasonal influenza, J InfectChemother, vol. 18, no. 4, pp. 534-543, 201225) Yuka Yamagishi, Koji Izumi, Hiroshige Mikamo:
Effects of maoto in women suffering from influenza
during pregnancy, Recent Progress of KAMPOMEDICINE in Obstetrics and Gynecology, vol. 04,
no. 27, pp. 89-92, 2010. (in Japanese)
26) Hironobu Yaegashi: Efficacy of Coadministrationof maoto and Shosaikoto, a Japanese Traditional
Herbal Medicine (Kampo Medicine), for theTreatment of Influenza A Infection, In Comparison
toOseltamivir,
Japanese
JournalofComplementary and Alternative Medicine vol. 7,
no. 1, pp. 59-62, 2010. (in Japanese)27) Toshihiko Yamauchi, Akio Kanno, Keiichi
Ichimura; Effectiveness of maoto in the treatmentof pediatric influenza, Kampo Medicine, vol. 62, no.
4, pp. 556-558, 2011. (in Japanese)
28) Eitaro Suzuki, Kiyoshi Ichihara: Comparison of
the effects of oseltamivir and maoto in thetreatment of type A pediatric influenza as seen inchanges of the fever pattern, The Journal of
Ambulatory and General Pediatrics of Japan, vol.
14, no. 3, pp. 248-253, 2011. (in Japanese)29) Norio Iwaki, Naoki Kawai, Osamu Tanaka, et al.:The Japanese Journal of Clinical andExperimental Medicine, The Japanese Journal of
Clinical and Experimental Medicine, The

Experimental Medicine, vol. 87, no. 12, pp. 17891793, 2010. (in Japanese)31) Mai Ito, Takehisa Yamamoto, Katsusuke
Yamamoto, et al.: The influence of a combination
therapy with oseltamivir and maoto duringhospitalization because of influenza pneumonia on
the clinical course in children after discharge,
Kampo and Immunology / Allergy, vol. 24, pp. 6068, 2011. (in Japanese)32) Yoshio Mori: Experiences with Kampo therapy
over the period from 2003 until 2008, Kampo &Newest therapy, vol. 18, no. 4, pp. 313-320, 2009.
(in Japanese)33) Katsumi Mori, Mizuaki Miyazaki: Early initiationof Kampo monotherapy for a new influenza type,
Journal of Kampo Medicine, vol. 57, no. 8, pp.
1295-1307, 2010. (in Japanese)
34) Nishimura N, Doi N, Uemura T, et al.
[Pharmaceutical analysis and clinical efficacy of
Kampo medicine, maoto, extract suppository
against pediatric febrile symptoms], Yakugaku

Zasshi Journal of the Pharmaceutical Society ofJapan, vol. 129, no. 6, pp. 759-766, 2009.
35) Yuichi Tabata, Yuji Arasiki: Investigation of theclinical effects of oseltamivir and maoto on
pediatric influenza infection;
investigation of
the two seasons 2006/2007 and 2007/2008,
Japanese Journal of Pediatrics, vol. 62, no. 10, pp.
2219-2225, 2009 (in Japanese)36) Miyazaki T.: Pathogenesis of Influenza and Effects
of Herbal Medicines on the Inhibition of Influenza
Virus Replication, Kampo Medicine, 63(6), 363-368,
2012.

Japanese Journal of Clinical and Experimental
Medicine, vol. 86, no. 12, pp. 1713-1718, 2009. (inJapanese)30) Norio Iwaki, Yutaka Wakasa, Osamu Tanaka, etal.: Investigation of the therapeutic effectivenessand safety of maoto during the pandemic (H1N1)
in 2009, The Japanese Journal of Clinical and

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Volume 11, Number 3 | Fall 2016

Japanese Acupuncture - Current Research
Japanese Traditional Medicine Text (21)Industrial Health Field
Kenta Sawazaki

1. Current Status of Clinical Studies in Japan andOverseas
A search in PubMed for papers related toindustrial health and acupuncture yielded 44 results
as of November 2010, and indicated the existence ofa small accumulation of studies. Randomized
controlled trials (RCT; 4 cases) have begun to appear
from around 1993, which mostly assessed rotator
cuff tendinitis and apoplexy in terms of visual analog
scale (VAS), Short Form 36 (SF-36), and activities ofdaily living (ADL), against a control group of shamexercise,physicaltherapyandoccupational therapy.
A study by Szczurko et al.1) examined andcompared rotator cuff tendinitis in postal workers in
a prospective RCT, by randomly dividing the
subjects into an acupuncture treatment group andphysicaltherapygroup.

Work-related

musculoskeletal disorders have one of the highest
incidence rates in the field of industrial health, andare a major cause of sick leaves2). Compounded with
the increase in medical expenses under healthinsurance,

establishingmeasures

for

their

prevention is an important issue not only forenhancing workers’ health and quality of working
life (QWL), but also for preventing work loss andmaintaining high productivity2). An economicallyeffective means is therefore sought to address such
sick leaves and increases in medical expenses.
Acupuncture treatment could be one such means, as
it is less expensive compared to conventional healthcare in terms of facilities and consumables. However,studies have hardly been made on the economic
assessmentofacupunctureindustrial health field.

Studies in Japan(a) Studies in the industrial health field in Japan
There are few full-fledged studies of the industrial
health field in Japan, but a paper on “TheA. Industrial Healthacupuncture,

2. Present State and Future Prospects of Clinicaltreatmentinthe

Possibilities of Acupuncture in the Workplace”3) waspresented at the Industrial Health and Alternative
Medicine symposium sponsored by the Japan Society
for Occupational Health in 2003. In it, a study by
Sawazaki4) et al. is introduced in reference to theeconomic assessment of acupuncture treatment in
the industrial health field.
In the study, acupuncture treatment was provided
to 117 blue collar workers from a certain workplace
who complained of pain in their neck and shoulders,lower back, or knee. The pain lessened by half insome 80% to 90% of the subjects, and the Profile ofMood States (POMS) before and after treatment also
showed a significant decrease in total score.
Furthermore, the numbers of subjects and thenumber of days that the subjects visited a medical
institution due to a musculoskeletal disorder halved
during the period they received acupuncture
treatment, and the medical expense they paid underhealth insurance decreased to roughly one-third.
The same examination was conducted at anothersimilar workplace, but there was no conspicuous
difference

regardingthefactors

relatedtomusculoskeletal disorders. In a study5) of lumbago
patients, a significant decrease was seen in theirpain, POMS, and medical expenses under healthinsurance. These studies suggest that acupuncture
treatmentiseffective

againstwork-related

musculoskeletal disorders in the industrial healthfield. Moreover, the improvement of POMS indicatesthe possibility of increasing QWL and productivity,and is thought to be widely economical, combinedwith the decrease in medical expenses.
Workers’ work postures and actions are diverse.
Work-related
seriousissue

musculoskeletalin

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

bothdisordersindustrialized

are

a

and

17

Volume 11, Number 3 | Fall 2016industrializing countries alike6), and individualized
approaches must be made to each work action in thepossible, to ensure neutrality.
4) Analysis method

workplace. In related studies, acupuncture treatment

In recent years, it is considered important to haveis applied based on M-Test7), 8). M-Test is thought toknowledge

be useful as an individualized method for preventing

subjective health-related QOL and satisfaction.

work-related musculoskeletal disorders, as it indexes

Therefore, proper analysis of cost effectivenesseach individual’s physical symptoms according toand cost utility based on patients’ subjective

action. The M-Test is discussed in detail under “C.

views is expected in the future.

ofhealthcare

quality,suchasSpecial Diagnostic Techniques” in Chapter 4.
3. Conclusion(b)

Prospectsoffuturestudies(economic

Studies in the field of industrial health will beassessment)

needed in the future, as a means for demonstrating

1) Subjects

the roles of acupuncture treatment in society.

It is not easy to determine who shall be included

Toward this end, a steady improvement in theamong the subjects, but it is necessary to find newquality of studies and investments in studies in thissubjects from diverse occupations.

field are desired.

2) Design
Prospective studies by RCT are thought to be best

References

at present, but as such studies are costly and take1) Szczurko O, Cooley K, Mills EJ, et al.:time, public investment is necessary to also

Naturopathic treatment of rotator cuff tendinitis

ensurebyamong Canadian postal workers: a randomized

Sawazaki et al. is a case-controlled retrospective

controlled trial. Arthritis Rheum 61(8): 1037-1045,

study of medical expenses under health insurance

2009

neutralassessment.

The

study

within the design of a before-and-after trial.

2) Itani, Toru and Norihide Tachi: “Prevention ofRealistically speaking, it is most easy to set a

Work-related

Musculoskeletal

control group, but various biases must be

Situation in Japan and International Trends.”

considered. It is ideal to conduct an economic
assessment based on a perfect design, but from a

Igaku no Ayumi (Journal of Clinical andExperimental Medicine), 173(13): 970-971, 1995.

practical perspective, it is also necessary to3) Iwa, Masahiro and Tadashi Yano: “Possibilities of
the Application of Acupuncture in the Workplace.”

accumulate partial assessment data.
In the study by Sawazaki et al., there was a

SangyoEiseigaku
Zasshi(Journal
Occupational Health), 45: 114-115, 2003.

decrease in medical expenses under health4) Sawazaki, Kenta, Fujihisa Kinoshita, Osamu

3) Assessment (Result)insurance,

after

applying

treatment.

The

Hirano,etal.:Effectsof“Study

of

the

of

TreatmentofMusculoskeletal

assessment of medical expenses may produce

Acupuncture

different conclusions depending on from whose

Symptoms in Corporate Workers and Theirstandpoint it is analyzed, also in consideration ofRelationship to Medical Expenses.” Zen Nihon

expenses paid by the patient and the patient’s
family. As the standpoints of evaluators are

Shinkyu Gakkai Zasshi (Journal of the Japan
Society of Acupuncture and Moxibustion), 51(4):diverse, it is preferable to conduct an assessment

492-499, 2001.

from a broad social standpoint as much as

18

Disorders-

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

Volume 11, Number 3 | Fall 20165) Sawazaki K, Mukaino Y, Kinoshita F, et al.:Acupuncture can reduce perceived pain, mood
disturbances and medical expenses related to low
back pain among factory employees. Ind Health46(4): 336-340, 2008
6) Itani, Toru: “Voluntary Activities for thePreventionofWork-related

Musculoskeletal

Disorders.” Ningen Kogaku Senmonka Bukaiho(CPEJ Newsletter): 7:1, 2006.
7) Yoshito

Mukaino,TatsuroHonda,

Kenta

Sawazaki, et al.: Illustrated manual of M-Test,
Ishiyaku Publisher, Inc. 20128) Yoshito

Mukaino,TatsuroHonda,

Kenta

Sawazaki, et al.: Sports Acupuncture, The
Meridian Test and its Applications, Eastland
Press, 2008

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

19

Volume 11, Number 3 | Fall 2016

Clinical Report 1 (Acupuncture)
Post Herpetic Neuralgia
Masanori Takashi1) and Katsuhiko Arai2)
1) Tokai University Oiso Hospital,
2) Tokai University School of Medicine

and antiviral medication was provided. Bladders
disappeared two months later. However, burning andtingling ache still remains. Pain occurs when clothes
rub against the affected area. The patient was diagnosed
as PHN by a dermatologist. Painkiller was administered
but the pain still remained. The patient wished forIntrodution
Herpes zoster is developed through the reactivationof the varicella zoster virus and subsequent recurrent
infection, which is caused by the weakened immune
system of the body due to aging, strain, overstress,
and/or use of immune-suppressing drugs. The
varicella zoster virus is infected latently at the dorsal
root ganglion or the cerebral ganglia after contracting

acupuncture treatment, and a dermatologist referred her
to my acupuncture clinic.
Other symptoms include light sleep, constipation,
heat, and fatigability.
[Past history]
Lumbar disc herniation (age of 50), Operation for
gastric neoplasm (age of 43), Bronchial asthma (agevaricella. The virus causes inflammation in theof 55), Osteoporosis (age of 70). The patient sought

ganglion cells and/or neural fiber, and then result in

medical advice for lumbago at an acupuncture clinic

exanthema on the skin. Since herpes zoster has

five years ago, and was diagnosed with kidney yin

higher incidence with aging, one out of 5-10 cases isvacuity. The patient was cured after treatment.

supposedly develop the disease in the Japanese aging

Thereafter, the patient continued therapy once asociety of recent years. Generally, a rash appears atmonth for health maintenance.

primary neural regions on one side. The rash can be[Present status]

cured by providing antiviral medication for 2-4 weeks,

Height 155cm, Weight 40kg. Pulse is deep, string-

however the rash part may leave lingering pains. This

like, rapid pulse. Dark red tongue, cracked with apain is called herpes zoster pain. NSAIDs are effective

whitish coating. The pain VAS is 80mm. The patient

to relieve the pain. However, approximately 10-15

has "slow smarting pain from the inside" andpercent of the cases of herpes zoster and herpes zoster"superficial pain on the skin". Cutaneous discoloration

pain can transition to post herpetic neuralgia (PHN)

is observed from the left-side back to the side abdomen.

1）. Many researcuuhers have reported acupuncture is

Allodynia was observed in the side abdomen. Heat in

effective to this pain. We have treated many cases ofthe lower legs was felt. Constipation was observed.

this kind. One case is introduced here:[TCM diagnosis][Case] 77 years old, Female, Retired[Chief complaint] Pain in the right-side back and theright-side of abdomen

Blood stasis, Deficiency of both Qi and yin of Kidney[Therapeutic principle]
Active blood and resolve stasis, Nourish yin andtonify the kidney[Present Illness]
In late June this year, the patient received urgent
treatment for a back pain. On the previous day, thepatient felt a pain in the right-side of her back aftergardening. A bladder was observed in part, so
treatment by dermatologist was suggested. The[Acupoint selection] TE-6, GB-34, LV-14, LV-3, Ouch
point (around the discolored part), SP-6, BL-17, Lowfrequency waves (Low frequency 3Hz and Highfrequency 30Hz, for 10 minutes) are irradiated at theboth side points of the spine from Left TH10-12., BL-23

dermatologist diagnosed the patient with herpes zoster,

20

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

Volume 11, Number 3 | Fall 2016

[Explanation]

Seventh session: The pain VAS became 60mm. The

Pain is produced at lesser yang tripple energizer

number of treatment was reduced to once a week.

channel and reverting yin liver channel in the legs.

Eighth session:

Therefore, "clearing the liver, regulating Qi andblood and resolve stasis” was strengthened by

unblocking the meridian" was done combining LV-14,

practicing pricking bloodletting therapy at the point. Then purgation with twirlingof tenderness. The patient had got a sense of relief.

was practiced at the Triple Energizer Meridian

Tenth session: The sense of relief continues. The pain(TH6) along the rib to heal the pain. . Unblock the

VAS has become 30mm. The area of allodynia had

meridian by needle pricks surrounding the discolored

become 1/3.

part of the skin. Furthermore, promote blood flow and

Twelfth session: The pain VAS became 15mm. The

free the network vessels by purgation with twirlingarea of allodynia further dwindled.

on SP-6 and BL-17 to strengthen “active blood andThirteenth session: Pain and allodynia almost

resolve stasis”. The both side points of the spine weredisappeared. ST-36, KI-3, and CV-4 were added totreated in the nerve field where rash developed. I

tonify the kidney.

thought that this would stimulate the nerve field

Fourteenth session: The pain VAS has become 0mm.

which is defined in Western medicine.

The color of skin was improved. Allodynia disappeared.

Needles Used: Seirin-made sterilized acupuncture

So treatment ended. Monthly treatment is being

needle, length 1cun6fen, No. 1

provided for health maintenance.

[Course] Treatments are planned twice a week.

[Discussion]

Second session: Pain was relieved immediately after

Herpes zoster has been recognized from ancient times.

treatment, but it reoccurred in the evening of the

Several different aliases exist. The representative

same day.

name is "Fire Band Rash (火帯瘡)". In a book written

Third, fourth and fifith session: No obvious changes

inwere observed.

Treatments" (part of surgery), it says "The liver fire

Sixth session: The pain VAS was 70mm. The slow

is overwhelming. It flows into the bladder, and it issmarting pain from the inside was gradually relieved.

clad with the belt vessel. Therefore it looks like

The area of allodynia had become 2/3.

bundled bands." This might have implied herpes

LV-3, and GB-34

１)

２)

1602,

titledNo changes were observed. “Active"StandardsofPatterns

andzoster. Even in this case, a rash was observed in the

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

21

Volume 11, Number 3 | Fall 2016

liver meridian and the belt vessel at the beginning.

Reference

The case was considered to be suffering from the1) LI Shi-zhen: Clinical Elaboration of the Common

same disease mentioned in the old book.
A book titled "The Diagnosis and Therapy of TCM
with Symptoms (Part 2)" mentioned that herpes zoster
has the excess pattern of "the heat exuberance anddampness stagnation" and "the heat toxin burns thenatural aspect”, along with the deficiency pattern of"the spleen deficiency with dampness" and "the Qi
deficiency and blood stasis." Now that two months

Shu

Points,p.749-758,

People’s

MedicalPublishing House Co., LTD, 1985 (in Chinese)
2) Textbook of practical acupuncture, p125, Tianjin
Science and Technology Press, 1995 (in Chinese)3) LI Shi-zhen: Clinical Elaboration of the Common
Shu

Points,p.420-430,

People’s

MedicalPublishing House Co., LTD, 1985 (in Chinese)

have passed since herpes zoster developed in this4) Textbook of the Acupuncture Prescriptions, p87-

case, and the acute period had passed, it is supposed

88, China Press of Traditional Chinese Medicine,that deficiency of both Qi and yin of Kidney occurred2005 (in Chinese)in the body and the state of blood stasis appeared.

5) The Diagnosis and Therapy of TCM with

So high-frequency stimuli including the practice ofSymptoms (Part2), p.421-422, Ryogenshoten,"activate blood and resolve stasis" were given at the1998 (in Japanese)

local route; thus, the symptoms were successfully
relieved.
Additionally, the number of patients referred bydermatologists has increased after this case. I believethat acupuncture treatment has a considerable role
within the general medicine.

6) Sugawara, Masaaki, Yoshikawa, Keiji: Effect ofElectric Acupuncture Therapy for Post Herpetic
Neuralgia, The Japanese journal of acupuncture&

manualtherapies,65:

39-46,

2006(inJapanese)* This case study is based on the report published inthe Vo. 56 No.1 2009 issue of "The Journal of Kampo
Medicine" (Japanese version), and then the contents
have been slightly modified and translated into
English.

22

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

Volume 11, Number 3 | Fall 2016

Clinical Report 2 (Kampo Medicine)
A Case of Acute Exacerbation of Congestive Heart Failure with
Chronic Renal Failure Successfully Treated with Goreisan
Takahito Saito1)2), Yoshihiro Furuta2), Noriaki Ito2)
Kazuyoshi Higuchi2), Hideo Hirofuji2), Norimi Fujita2),
Hiroyuki Akane2) and Hiromichi Yasui2)
1) Medical Corporation Tomidahama Hospital,
2) Oriental Medicine Study Group of
Yokkaichi Medical Association

Abstract
An 85-year-old man suffered from chronic renal
failure and congestive heart failure since about 2
years ago. On May 12th in 2015, he admitted to this
hospital due to acute exacerbation of congestive heart
failure presenting exertional dyspnea and thirst.
Together with resting on bed and oxygen inhalation,a new diuretics, tolvaptan, was taken in addition tohis conventional diuretic drugs. However, about 2
weeks later, tolvaptan was stopped because ofworsening renal function. Then, targeting to thirstand oliguria, goreisan was given for relieving clinicalsymptoms since June 3rd. Subsequently dyspnea andpoor appetite diminished at the end of June andbetter general condition continued more than one
month around the end of July.
We report a case of congestive heart failure
combined with chronic renal failure, successfully
treated with goreisan. In this case, goreisan improved
both acute exacerbation of the congestive heart
failure and the renal dysfunction with regulatingwater imbalance in body. Furthermore, it is very
important that his prognosis was prolonged withhighly quality of life.
Keywords: congestive heart failure, chronic renal
failure, goreisan, water balance regulation
Introduction
The pathologic condition of chronic renal failure
represents "water intoxication". Regardless ofwhether before or after dialysis, based on clinicalsymptoms like edema, dry mouth, vertigo, lassitude
and gastrointestinal symptoms etc. as well as
abdominal diagnosis, goreisan is the drug of first
choice1). Here the formula is expected to help not only

to regulate water metabolism in the body, e.g.,
improve the condition of water intoxication, but also
blood pressure and delay the onset of dialysis2).
Congestive heart failure too, is also considered torepresent "water intoxication". In addition to rest andrestriction of salt intake western diuretics or
cardiotonic drugs are used for the treatment. To
rectify blood pressure or edema western diuretics(mainly loop diuretics like Furosemide or
Spironolactone) are the standard therapy forcongestive heart failure3,4,5). However, an inattentive
increase in the dosage of loop diuretics may easily
lead to a deterioration of kidney function and thus
adversely affect the endogenous water balance.
Recently a new vasopressin receptor antagonists (adiuretic called Tolvaptan) has been added to thewestern diuretics, allowing to comparatively easily
achieve improvements of edema and congestion6).
On this occasion an elderly patient treated withloop diuretics was hospitalized because of a sudden
exacerbation of chronic renal failure complicated bycongestive heart failure. The patient was first treatedwith Tolvaptan, which was expected to improve theedema and congestion, but the drug was not
sufficiently effective. After switching to goreisan,
however, the effects were even better than expected.
The here presented valuable case report indicates,that the diuretic action of goreisan could beconsidered due to it correcting the endogenous waterbalance and thereby improving various symptoms
including renal function.
Case: age 85, man
Chief complaint: exertional dyspnea, dry mouth
Past history: in 2002: fracture of left tibia and rightankle
Clinical course 1 (until admission):
Treatment for chronic renal failure complicated bycongestive heart failure on an outpatient basis was
initiated approximately 2 years earlier. On May 12,2015 exertional dyspnea developed. On May 15 hevisited our hospital and was admitted for treatment
because of an acute exacerbation of the chronic renal
failure complicated by congestive heart failure.

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Volume 11, Number 3 | Fall 2016

Western medical findings:
Alert, height: 153 cm, weight: 56.5 kg, facial edema,
body temperature: 36.4°C, SpO2: 91%, BP: 137/71,
HR: 101/min, regular, cardiopulmonary: systolicmurmur, pulmonary rales, abdomen: flat, soft; edemaof the legs;
Oriental medical findings:
Subjective symptoms: exertional dyspnea, dry mouth;
Objective signs: inspection: poor complexion, earthen
colored; edema of face and lower extremities; pulse
diagnosis: deep, thin, weak; tongue diagnosis: thinwhite coat with dental impressions and engorgedsublingual veins; abdominal diagnosis showed lack ofstrength and softness of the lower abdomen.
Hyochondrial fullness and tenderness as well as
epigastric clapotage.
Examination results:
Blood examination:
white count: 3,500, hemoglobin: 7.4 g/dl, CRP: 0.61
mg/dl, urea nitrogen: 77 mg/dl, creatine: 5.02 mg/dl,eGFR: 9.3 ml/min/1, NT-proBNP 1,383 pg/ml,
albumin: 3.3 g/dl;
chest x-ray: enlarged cardiac shadow, bilateral
pleural effusion, pulmonary congestion
Clinical course 2 (after admission): Figure 1

24

After admission the medication, including thewesternloop
diuretics(FurosemideandSpironolactone) prescribed during the treatment as
an outpatient were continued. In conjunction withrest and initiation of oxygen inhalation the diuretic
Tolvaptan was added to the regimen on May 16, theday following admission. Yet, the dyspnea continued
and renal function deteriorated further. On May 29
administration of Tolvaptan was discontinued. Afterconsultation with the patient and his family it was
decided not to initiate dialysis and insteadconservative treatment, including palliative care,chosen.
From
June
3goreisan(KotaroPharmaceutical Co., Ltd., 6 g/day) was added to theotherwise unchanged regimen in order to improve thesubjective symptoms of dyspnea, dry mouth and lackof appetite, targeting the dry mouth and decreased
urine volume. Later, body weight gradually
decreased and the pleural effusion decreased too. By
the end of June the dyspnea, dry mouth and lack ofappetite had improved. After a while, over a period
of about 1 month until the end of July, the generalcondition stabilized. By the end of August thepatient's general condition deteriorated because of
an infection and he died of multiple organ failure.

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

Volume 11, Number 3 | Fall 2016

Discussion

is precisely the manifestation of water intoxication.

Goreisan is comprised of the five crude drugs

Endogenous water balance in renal failure is marked

Alisma rhizome, Polyporus umbellatus, Poria cocos,
Atractylodes lancea rhizome and cassia bark. It is
widely used as a diuretic for intermediate conditions
between deficiency and excess with water
intoxication as its indication. In the classic Shan
Han Lun the pathologic condition is specified as thelesser yang disease state and the formula widelyused for dry mouth, diabetes, acute or chronic
nephritis, nephrosis, edema, uremia etc.1,2).

by an imbalance between the water of the blood andOn the other hand, western diuretics are used todisrupted water equilibrium in the body and should

reduce the preload, but even increase urine volume
when there is edema in the presence of dehydration.
In case of elderly people dehydration, electrolyte
anomalies, hypotension and similar conditions caneasilycomplicate

thesituation,

so

that

the

administered dose must be carefully considered3).
Taking the side effects of western diuretics like
Furosemide into account, in particular in case oflong-term administration, the dehydration may
possibly lead to renal dysfunction or cerebrovasculardisorders. Short-term combination with goreisan
while carefully observing the pathologic condition, or
else switching to goreisan to increase the diuretic
effect, is also considered to be effective. When taking
the side effect dehydration into account, it is possible
to optimally utilize the advantage of goreisan topromote diuresis only in the presence of edema,possibly decreasing the side effects of western
diuretics.
Moreover, if a dose increase of the western
diuretics is in certain cases difficult due to thegeneral condition, combination with diuretic Kampo
formulas like goreisan can be effective. However,recently the western diuretic Tolvaptan has made its
debut on the clinical scene. Edema and congestion
can now comparatively easily be alleviated, the drugcauses only minor blood pressure fluctuations and issaid to be safer than western loop diuretics6). Some
reports have described the ease of water control
during the initial stage of dialysis7).
The pathologic condition of chronic renal failure

the water compartment outside of blood vessels. In
other words, the equilibrium between tissues andbody cavities has been disrupted. Moreover, while
there is excess water in the tissues and body cavities,
it cannot moisten the blood. goreisan adjusts thiscondition, supplies cells and the blood with waterand since it lowers osmotic pressure, during strong
inhibition of the diuresis, it ameliorates thetherefore be understood not to be simply a diuretic.
Regarding this property its effect can be expected todelay the the timing of dialysis initiation in cases ofrenal failure complicated by congestive heart failure.
Also, in cases of organic renal diseases it is by virtue
of its properties given priority over treatment withwestern diuretics and the guidelines pertaining
chronic renal failure as a chronic renal disease havebeen adjusted8).
Then again, congestive heart failure as apathologic condition too represents a true form ofwater intoxication. It is marked by progressive
intravascular dehydration and an excess of water in
the alimentary tract.
In case of organic disease, similar to organic renal
diseases, based on its properties, this formula should
be given priority over western diuretics. The details
have been arranged in form of the treatment
guidelines divided into acute and chronic cardiac
insufficiency6,7).

Cardiacdiseases

that

are

indications for Kampo medicines are functional
disorders associated with cardiac neurosis. Again,
not so much the acute phase but rather the chronic
phase is the disease stage at which treatment isadministered. In case the western diuretics are
insufficiently effective, Kampo formulas are often
administered as required to alleviate symptoms,
promote diuresis and stabilize the general condition.
Moreover, in case a right heart insufficiency isobservedwhenconsidering

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

Kampo

treatment25

Volume 11, Number 3 | Fall 2016

mokuboito (Mu Fang Yi Tang9)) may be one of thealso said to exert its effects via aquaporin6). In thischoices that can be used. To alleviate the symptoms

case Tolvaptan could not sufficiently exert its effects

of edema or cold pattern Kumibinroutou10) is also

because of the deteriorating renal function, but

said to be useful. Goreisan is often used in cases ofgoreisan was conceivably effective because ofheat pattern associated with a decrease in urine

differences between the two agents on the molecularvolume and edema. It can also be used for anasarca

level. A new disease concept "aquaporin disease" hascaused by cardiac insufficiency as well as a diuretic

been

in cases of pleural effusion due to congestive heart

diuretics, seems to be a formula with brightfailure during the still comparatively acute phase. It

prospects regarding its ability to prevent "waterismoving into directions generally not allowed".

consideredtocorrect

theintravasculardehydration and reduce the amount of excessive
water within the alimentary tract11,12).
This patient was a case of acute deterioration of

acute exacerbation of congestive heart failure or1.

2.

Goreisan on the other hand does not only improvein patient s hospitalized with worsening heart
failure: a randomized controlled trial. JAMA
2004; 291: 1963-1971
3.
4.

excess water into the blood vessels, it increases renal

diuretics through its regulation of the water balance

5.

delaying the timing of initiation of dialysis. We areexacerbation of chronic renal failure complicated by

6.

goreisanregulates

waterbalancevia

aquaporin13,14,15). Similarly, the diuretic Tolvaptan is

26

instruction

applicable

in

the

of

patient

relatedto

Kampo

Series;Kampo

future'Evidence based Clinical Practice Guidebook for

Treatment Guidelines for Acute Cardiac Failure(2011

revisedEdition);The

Japanese

Circulation Society
7.

Treatment Guidelines for Chronic Cardiac
Failure (2010 revised Edition); The Japanese
Circulation Society

8.

Ryukichi Matsui, Shotai Kobayashi: A case ofeffective treatment of recurrent pleural effusion

congestive heart failure will be a promising therapy.
Isohama is conducting research indicating thatcompliance'Practicedisease; 2013; Japanese Society of Nephrology

hoping that the comparatively early addition of

goreisan to the regimen in this kind of acute–

Diagnosis and Treatment of Chronic Kidney

and was therefore considered to contribute toimprovements of clinical symptoms, ADL as well as

Trialogue

Medicine and Pharmacology: 2008; 16: 2-10

their effects. Thus, the diuretic effect of goreisan
improves the responsiveness to western loop

Masayuki Kashima, Hoko Amakata, Saori
Sakai:

Since it promotes the inflow of unevenly distributed

making it easier for western diuretics to recover

Shinichi Tashiro: Diuretic actions of goreisan;
Kidney and Dialysis (Supplement); 1989; 26: 34-37

the edema and congestion, but also renal function.

blood flow, which can be interpreted as helping

Gheorghiade M, Gattis WA, O’Connor CM, et al:
Effects of tolvaptan, a vasopressin antagonist,

correlation called cardiorenal coupling. In spite ofdecreased renal function not very effective.

Sadayoshi Ito: Pharmacodynamics, mechanisms ofcardiorenal coupling; Circulation 2012; 2: 6-15

The heart and the kidneys maintain a close

diuretic Tolvaptan was probably due to thegoreisan, unlike westernactions, and usage of diuretics considering

acute exacerbation of chronic renal failure alone.

the presence of edema or pulmonary congestion theandReferences

chronic renal failure complicated by congestive heart
failure and not a single organ acute exacerbation like

proposedwith goreisan. Kampo Medicine 2006; 57: 339-334
9.

Hideki

Hashimoto:Aofcardiacfailuremanifesting anasarca effectively treated withgoreisan. Journal of The Japan Society for
Oriental Medicine 2006; 57: 566

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

Volume 11, Number 3 | Fall 2016

10. Yoichiro Isohama: Water channel function
regulation

using

Kampo

medicinesforinflammation / water intoxication; Kampo andLatest Therapies 2008; 17: D27-35
11. Yoichiro Isohama: Water regulation by goreisan
via aquaporin and inhibition of inflammatory
reactions; Kampo Medicine 2013; 37: 40-43
12. Yoichiro Isohama: The mechanism of regulation
by goreisan via aquaporin;

Kampo Medicine

2011; 35: 186-189
13. Toshihiro

Shigehara,

MarutoMurakami,

Takashi Araki et al.: Effective long-term
treatment of one dialysis patient with chronic
renal failure using Tolvaptan; Journal of theJapanese Society for Dialysis Therapy 2014; 11:691-696
14. Osamu Kinoshita: Usefulness of Boiogito forrefractory cardiac failure; Kampo Medicine
2004; 28: 73-75
15. Nobuyasu Sekiya, Mitsutoki Chino, Hirzo Goto
et

al.:

Indication

andapplication

ofKumibinroutou; Journal of The Japan Society
for Oriental Medicine 2006; 57: 333-338

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

27

Volume 11, Number 3 | Fall 2016

Conference Report
A Letter from the 67th General Assembly of The Japan
Society for Oriental Medicine

Kazunari Ozaki

Departement of Geriatric Medicine
Itami City Hospital

Key words: The Japan Society for Oriental Medicine(JSOM), The 67th General Assembly of the Japan
Society for Oriental Medicine, Kampo medicine,International Organization for Standard (ISO)

1. Introduction
Kampo medicine is a medical system that has
been traditionally practiced in Japan, based on
ancient Chinese traditional medicine. The Japan
Society for Oriental Medicine (JSOM) is the largest
and one of the most active medical societies on
Kampo medicine in Japan. As of June, 2016, theJSOM has a total of more than 9000 members. It
was established to improve the quality of life (QOL)of the people by sharing research results on health,welfare, and medical science, functioning as aworldwide network to realize the aim. It became amember of the Japanese Association of Medical
Sciences in 1991(1).
The 67th General Assembly of the JSOM took
place June 3-5, 2016 at Sunport Hall Takamatsu,
Kagawa International Conference Hall, and JR
Hotel Clement Takamatsu in Takamatsu, Japan(2).
The General Assembly was organized by JSOMand supported by the Japan Medical Association,
the Japan Dental Association, the Japan
Pharmaceutical
Association,
the
Japan
Acupuncture and Moxibustion Association, theJapan Society of Acupuncture and Moxibustion,
Tokushima Medical Association, Kagawa Medical
Association, Kochi Medical Association, Ehime
Medical Association, Tokushima Pharmaceutical
Association, Kagawa Pharmaceutical Association,
Kochi Pharmaceutical Association, and Ehime
Pharmaceutical Association. The conference wasattended by 2509 researchers, acupuncturists andphysicians from all over the world – primarily
28

from Japan – who exchanged opinions andpresented studies on diverse Kampo medical
research fields in over 100 sessions including 14
symposiums, 13 training sessions, 5 workshops
and 25 seminars(3).
2. Sessions
This General Assembly is designed forresearchers and scholars to present various
studies on its theme, which is “The inheritance of
Kampo paradigms and its paradigm-shift --Bridging Kampo, Science, and Practice”. The
conference was a great success with somestandees on the section of general lectures and of
acupuncture and moxibustion. There were someeducational seminar on Kampo for physicians,
acupuncturists and pharmacists.
In the afternoon session on June 3rd, there wasa clinical symposium on traditional medicine,which theme was “The Kampo paradigms and its
paradigm-shift from the standpoint of history”. Dr.
Tatsuhiko SUZUKI (Teikyo Heisei Univ, Chiba,
Japan / Oriental Medicine Research Center,
Kitasato University, Tokyo, Japan) has given a
speech on “From Sanki TASHIRO to Dosan
MANASE--- The dawning of Kampo medicine (ofGoho-ha school) from the view point of theinheritance of the drug theories for the diagnosis
and use of crude drugs”. Dr. Masakazu
YAMASAKI(Kampo-Kyoguchimon
Clinic,Hiroshima, Japan) has made a lecture on “On aParadigm Shift of Kampo Medicine by Todo
YOSHIMASU”.
Dr.
Yoshihide
YAKAZU(Department of Anesthesiology, Tokyo Medical
University, Tokyo, Japan) has made apresentation on “On a Paradigm Shift of Kampo
Medicine by Dr. Domei YAKAZU and Dr. Keisetsu
OTSUKA”. There were some meetings including
the annual general meeting of members.
In the morning session on June 4th, there was apresidential lecture on traditional medicine, whichtheme was “The effectiveness of Kampo medicine
for extension of healthy life expectancy and antiunhealthy-aging. --- focusing especially on

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

Volume 11, Number 3 | Fall 2016

experimental research---”. Prof. Hiroshi SHIMIZU(The University of Tokushima, Tokushima, Japan /Toyo Hospital, Tokushima, Japan) has given alecture on the relation between kidney deficiency(腎虚) and hypothalamo-pituitary-adrenal system.
At “The Japan-Korea academic symposium on
Kampo medicine and traditional Korean medicine”,
which theme was clinical use of goshakusan (五積散<jp>, Powder of five kinds of Stagnations, Wu-JiSan), Dr. Takashi SEKI (Division of GeriatricBehavioral Neurology, Tohoku University CYRIC,
Sendai, Japan) has made a lecture on “Kampo andtraditional Korean medicine extract formulation
for prescription in Japan and Korea”, and Prof.
Dongwoo NAM (Depertment of Acupuncture andMoxibustion Medicine, College of Korean Medicine,
Kyung Hee University, Seoul, Korea) has made apresentation on “Introduction of Ojeoksan usage in
Korean clinics”. Furthermore, Prof. Sung-Yoon Kim(Depertment of Acupuncture and Moxibustion
Medicine, College of Korean Medicine, Kyung Hee
University, Seoul, Korea) has given a speech on“Introduction of Ojeoksan studies in Korean”, andDr. Masao OGAWA (Kanazawa Medical University,
Uchinada, Ishikawa, Japan) has presented on “Ongoshakusan ( 五 積 散 <jp>, Powder of five kinds ofStagnations, Wu-Ji-San) configuration and on thehistory of the change of secret oral teachings in the
Kampo-sects by the masters”.
In the afternoon session on June 4th, there wasa symposium, which theme was “Who is ‘the
Globalization of Traditional Medicine’ for? (What
Kind of Traditional Medicine do Patients Desire inglobalism?)”, by the International Committee andthe Terminology Committee of the JSOM. Prof.
Shuji YAKUBO (Department of Medicine, Nihon
University School of Medicin, Tokyo, Japan) has
introduced on “Who is ‘ICD-11’ for?”, and Prof.
Yukihiro GODA (National Institute of Health
Sciences, Tokyo, Japan) has presented on “Activityof the Western Pacific Regional Forum for the
Harmonization of Herbal Medicines (FHH)”.
Furthermore, Prof. Takao NAMIKI (Department ofJapanese-Oriental (Kampo) Medicine, Chiba

University Graduate School of Medicine, Chiba,
Japan) has given a speech on “Status Quo andprospect of ISO/TC 249”, and Dr. Maiko TANOUE(School of Law, Senshu University, Tokyo, Japan)
has made a presentation on “International trends
with respect to protection of the traditional
intellectual property and impact on Japanesetraditional medicine”.
In the morning session on June 5th, there wasan invited lecture. Prof. Carl-Hermann HEMPEN(the Technical University Munich for Traditional
Chinese Medicine, Munich, Germany) has
introduced on “Education and practice ofTraditional Chinese Medicine in Europe”.
In the afternoon session on June 5th, there weresome Kampo seminars for medical instructors in
Kampo medicine, residents who were going to beboard certified specialties of Kampo medicine, andpharmacists who specialize in Kampo medicine.
And there was a symposium, which theme was“Restoration of acupuncture and moxibustion”. Dr.
Kazu MURAI (Kazu clinic, Wakayama, Japan) has
presented on “Personal clinical experience on themarvelous clinical effects of acupuncture andmoxibustion”, and Prof. Hitoshi YAMASHITA(Morinomiya University of Medical Sciences,
Osaka, Japan) has introduced on “Evidence Based
Medicine and Acupuncture and Moxibustion: theStatus Quo and Problems”. Furthermore, Prof.
Akira KAWASHIMA (Tokyo Ariake University of
Medical and Health Sciences, Tokyo, Japan) has
given a speech on “How can we save Japan by
prevention of disease?: the Status Quo andProblems of Acupuncture and Moxibustion in
Medical Environments”, and Prof. Ikurou
WAKAYAMA (Kansai College of Oriental Medicine,
Osaka, Japan) has made a presentation on “Future
Approaches of Acupuncture and Moxibustion”.
In the morning session on June 4-5th, there
were four acupuncture and moxibustion seminars
for physicians.
3. Concluding remarks and about the upcoming
congresses.

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

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Volume 11, Number 3 | Fall 2016

All the participants agreed that the General
Assembly was an academic event of Kampo
medicine with high level and standard. The
researchers, pharmacists, acupuncturists andphysicians of the Kampo Medicine have obligation
to improve the quality of life (QOL) of people allover the world by sharing study results on health,welfare, and medical science.
There will be the 68th General Assembly of The
Japan Society for Oriental Medicine (JSOM) in
Nagoya, Japan (June 2-4, 2017) (4). The theme ofthis future conference will be “Establishment of
Kampo medicine. --- Strive for development of
Kampo medicine and cooperation among Kamposects”. In view of JSOM’s long experience inorganizing important events and of the city’s main
congress facilities, the 68th General Assembly of
the JSOM 2017 will be sure not to disappoint.
1

Homepage of the Japanese Association of
Medical Sciences. http://jams.med.or.jp/memberss/87.html [the last date of access September18,
2016]
2
Homepage of the 67th General Assembly of theJapan Society for Oriental Medicine.
http://www.pcojapan.jp/jsom67/ [the last date ofaccess September18, 2016]30

3

Abstracts of the 67th General Assembly of theJapan Society for Oriental Medicine. Kampo
Medicine (extra issue), 2016; 67: 1-394.
4
Homepage of the 68th General Assembly of theJapan Society for Oriental Medicine.
http://www.ccs-net.co.jp/touyo68/ [the last date ofaccess September18, 2016]

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