Volume 2, Number 1 | Spring 2007

Kampo Medicine - Current Research
Use of Kampo Medicine in Treatment of Influenza
Hiromichi Yasui
Japan Institute of TCM Research

the vital principle, occurring because of the invasion ofwind-cold with predominance of cold.
Thesorethroat accompaniedby pharyngeal

erythema is the result of heating within the bodycaused by wind-cold. Regardless of whether or not

1. Introduction

internal heat is present, this heating is assumed to be

Influenza is one of the most common conditions

intrinsic within the disease-causing element itself.

encountered in a clinical setting. The disease isWhen there is a cough beginning in the early stages ofwidespread during the winter months, sometimes

illness, that cough is judged to be a manifestation ofreaching pandemic proportions. Vaccination against

the characteristics originally present in this element.

influenza has become commonplace in the developed

That is to say, the element that causes influenza

nations in recent years, which has led to a reduction inshould not be considered as a simple cold element, but

flu epidemics,. With the development of medications

insteadsuch as oseltamivir phosphate (Tamiflu®) that arecharacteristically generates heat as soon as it enters

particularly effective against the influenza virus, thethe body and directly invades the lungs. Although thisperiod required for recovery from influenza infection

element has the intensified characteristics of cold, it

can be considerably shortened. Nevertheless, an

can be considered a type of "epidemic pathogen", aninfluenza infection can be quite serious for the afflicted

element of infectious disease similar to the pestilence.

asan

influenza-specificelement

thatpatients, frequently requiring several days' absence
It is also possible that a particularly virulent form

3. Are “Cold Damage” and Influenza the same
condition?

of influenza causing a cytokine storm, such as theKampo treatment for influenza very commonly

Spanish Flu in 1918, could again reach pandemic

utilizes “Shang Han Lun (Treatise on Cold Damage

proportions and cause worldwide panic. In fact, thatDiseases)” formulations. These formulations areprobability is actually quite high. If we are ever faced

effective in most cases. However, the conditions of "coldwith such a pandemic, Kampo should prove to beinjury" and influenza, although similar, are notparticularly useful because of its long history as anidentical.

effective intervention for the treatment of influenza

associated with sore throat, and is not necessarily

even during major epidemics.

accompanied by coughing. Other symptoms are very

from work or school.

Here we introduce the use of Kampo medicine in
the treatment of ordinary influenza, and discuss
responses to a new and potentially more virulent
influenza epidemic.

"Coldinjury"

isnotfundamentally

similar to those for influenza, so "cold injury" ispresumed to be a special form of influenza.
The preface to Shang Han Lun (On Cold Damage)notes, "I had a very large family, over 200 people.
However, within 10 years after the start of the Jian'an

2. The Disease-Causing Elements of Influenza

Era (196 AD), two-thirds of them had died, and seven

The textbook description of influenza symptoms

out of 10 of those deaths were due to 'cold damage'." In

generally includes high fever, accompanying severe

other words, during a ten-year period about 100 people

chills, headache, and joint pain, along with sore throat,in that family died from "cold damage". That would

pharyngeal erythema, and sometimes a severe cough.

mean about 10 deaths per year would be ordinary.

From a Kampo perspective, the symptoms of chills,

However, if there were 50 deaths per year for twofever, headache, and joint pain are the result of anyears, that would be a pandemic.

intense battle between disease-causing elements and8The same virus can manifest with different

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

Volume 2, Number 1 | Spring 2007

symptoms depending on the area and season ofResearch by Kawamura [3]contagion. It is also unlikely that antigenicity will be

Kawamura selected 129 patients (0.5 to 14.6 years

absolutely the same in different locations and duringof age) who tested positive with the influenza rapid

different seasons. In Japan in 1918, the "Spanish flu"

diagnosis kit between February 22 and June 13, 2007.

generally started out with "chills and shivering,

These patients were divided into four groups forfollowed quickly by fever, with the simultaneous

treatment: type A-flu oseltamivir group, the type A-flu

development

asmaoto group, type B-flu oseltamivir group, and typepharyngeal erythema, pain, and cough." [1] At the

B-flu maoto group. Kawamura's results showed maoto

same time, Keegan (JAMA, Vol. 71, No. 8) states thatto be as effective as oseltamivir, and to be particularly

the early-stage pharyngeal symptoms may be omitted,effective against type B influenza.

with the patient simply showing a fever and general

Research by Kubo and colleagues [4]oflocalizedsymptoms

suchsymptoms, and that this is considered characteristic of

Kubo and colleagues treated 49 patients fiveinfluenza in the United States [1], indicating thatmonths to 13 years of age (24 boys and 25 girls) who

when viewed on a worldwide scale influenza manifests

had influenza-like symptoms including fever of 38°C orwith a wide diversity of symptoms. The contents ofabove, divided into an oseltamivir monotherapy group

Keegan's report are very similar to descriptions in the(18 patients), a maoto + oseltamivir concomitant use“Shang Han Lun”. As will be discussed later,group (14 patients) and a maoto monotherapy group

formulations that are used for "cold injury" are also

(17 patients), and investigated the effects of treatment

extremely effective against influenza.

in each group. Of these patients, those one year of age

A useful book for reference in this area is Johnor older who had been diagnosed with influenza using

Barry's “The Great Influenza”, which details thea means such as the rapid diagnosis kit, werestories of patients during the Spanish flu epidemic of1918. "Patients cried from joint pain. They sufferedfrom high fever and chills, shaking under theirblankets. They complained of abdominal pain, andvomited repeatedly." (From the Japanese translation,retranslated into English) [2].
This description is very similar to the “Shang HanLun”, which states that "Greater Yang Disease, with orwithout fever, but always with chills, complaints ofpain in areas such as the joints, vomiting, and tense
pulse, is termed 'cold injury'". Given this, it seems
likely that the "cold injury" described by Zhang
Zhong-jing in the preface to the “Shang Han Lun” wasa variation of influenza.

randomly allocated between: (1) the oseltamivir (tradename Tamiflu) group (4 mg/kg/day, divided into twodaily doses), (2) maoto （Tsumura & Co., Ltd., Tokyo,
Japan）0.18g/kg/day, divided into three daily doses) +oseltamivir concomitant use group. Patients less than
1 year old, for whom oseltamivir is not indicated, andpatients who tested negative for influenza with therapid

diagnosis

kit,

wereplacedin,(3)maoto

monotherapy group. The parent or other caregiver was
asked to provide information about any medications
being used and records of body temperature, and thetime from the start of treatment until the fever wasresolved (body temperature of 37.2°C or below) was
compared among these groups. There were nodifferences among the groups with regard to patient

4. Research into the Treatment of Influenza with
Kampo Medicine

characteristics such as mean age at the start ofExperientially, influenza responds well to Kampo

first treatment, degree of fever, or history oftherapy, and considerable clinical research is currentlypreventative inoculation. Meantime, resolution ofunderway or has been completed. Some typical

fever was 31.9 hours in the oseltamivir monotherapy

examples are described below.

group, 21.9 hours in maoto + oseltamivir group, andtreatment, male/female ratio, duration of fever before

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

9Volume 2, Number 1 | Spring 200717.7 hours in maoto monotherapy group. No adverse

administration of both agents. The research by Kubo

drug reactions or other adverse events were observedand colleagues, which found maoto monotherapy to bein any of the groups treated.

more effective than treatment either with oseltamivir

Research by Kuroki [5]alone or oseltamivir + maoto, also showed that theKuroki investigated the effects of concomitant use

effectiveness of such treatment was increased if theof oseltamivir and maoto in the treatment of influenza

agent was administered very early in the course ofduring three influenza seasons from 2003 throughillness. Maoto was used in these studies because the2005. Results showed excellent improvement inmajority of researchers performing the studies wereclinical symptoms in the concomitant therapy group,pediatricians.

but the change in the amount of time required to

Maoto is more commonly indicated for use inrelieve fever was not as significant.

children than in adults. As can be seen from theResearch by Fukutomi and colleagues [6]research reported here, maoto does not require careful

Fukutomi and colleagues enrolled 24 patients whoselection of patient conditions, and is safe for use as

were diagnosed with influenza based on findings fromlong as it is administered as instructed. Maoto is a

the rapid diagnosis kit. Those patients were divided

typical agent that resolves fever by warming the body.

into two groups and treated as described above. Their

Its primary ingredient is Ephedra Herba, which

results showed a significant reduction in the number

contains ephedrine. maoto is used in the treatment ofof days of persistent headache and general malaise inchills, fever, headache, arthralgia, and myalgia in

the group treated with oseltamivir + maoto incases where the patient shows no spontaneouscomparison to the group treated with oseltamivir only.

sweating and has a floating and tense pulse. TheResearch by Kimoto and colleagues [7]method of administration is in accordance with theFrom January through March of 2004, Kimoto andchapter on maoto in the “Shang Han Lun”. After

colleagues administered oseltamivir to patients who

administration, the patient should be covered and kept

were diagnosed with influenza on the basis of findings

warm. Treatment is generally repeated every two

from the rapid diagnosis kit, and compared the clinicalhours until sweating begins, but is usually effective

course for those patients receiving concomitanteven if given only every three to four hours. After

treatment with maoto in comparison to patientsadministration there will be a transient rise in bodyreceiving ordinary concomitant therapy in the context

temperature, and the patient should be monitoredofmedicine.

Feverwasresolved

closely for the development of febrile seizures and12soonerinmaoto

impaired consciousness. Administration should beconcomitant use group than in the Western medicine

discontinued as soon as the patient begins to sweat.

concomitantThis is because sustained sweating can lead toWesternapproximately

usehours
group,andfatigue,

thedizziness,lightheadedness, and anorexia also tended to bedehydration.

improved more rapidly in the maoto group. Elevated

The ordinary course of treatment is as described

CRP was noted in three patients in the Westernabove. In most cases, children show the diagnostic

medicine concomitant use group. There were no such

criteria of maoto chapter when they first develop

adverse events in the maoto concomitant use group.

influenza. However, caution is advised because there

These studies show that maoto, although its

are rare instances of lesser yin disease, in which there

mechanism of action is completely different from thatis no chilling, and also influenza can develop withof oseltamivir phosphate, provides a very similar levelmanyof clinical effectiveness, and that the effectiveness ofmonotherapy is not always the optimal choice fortreatment is further potentiated by concomitanttreatment.

10elementsofThe Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

warm

disease,somaotoVolume 2, Number 1 | Spring 2007

Adults tend to show a wider variety of influenza

with gingyosan or a similar agent to cool fever andtypes than seen in children. Symptoms may be more

eliminate surface elements of disease. gingyosan is notsevere than in children, the condition may beavailable in extract formula of ethical use, but nearlyaccompanied by a sore throat and severe cough, andthe same effects can be obtained by substituting

patients who cannot be cured early may lose appetite

seijobofuto or keigairengyoto.

and waste away. Mori and Miyazaki conducted

According to announcements and releases available

research in adult patients who were allocated into

to date, Japanese influenza tends in most cases to be oftreatment groups depending on Sho diagnosis.

the wind-cold type, and wind-heat variations are rare.
However, there have been some reports of influenza of
the warm-disease type.

Research by Mori and Miyazaki [8]Mori and Miyazaki enrolled influenza patients whocame for treatment between January and April 2005,
allocated those patients into three groups (Groups I, II,and III) for treatment, and determined the number ofdays until recovery occurred in each patient. The
results were as follows.
Group I (oseltamivir + Kampo concomitant usegroup, 20 patients). Time to recovery: 3.4 days
GroupII(oseltamivir+Kampo,escalated

dose/frequency of administration group, 25 patients).
Time to recovery: 2.0 days

5. Closing Remarks
This article has viewed influenza from a number ofangles based on a Kampo medicine perspective. A
variety of medical procedures are available for theprevention and treatment of influenza, from basic
preventative measures such as wearing face masks
and gargling to vaccination and the administration ofantiviral agents such as oseltamivir. We feel thatKampo medicine offers unique advantages in thisGroup III (oseltamivir monotherapy + concomitantcontext, and that its inclusion among the medical

Western medical treatment group, 29 patients). Timetreatment options will provide additional security into recovery: 6.3 days

the treatment of influenza, particularly in the event of

In adults, shoseiryuto is generally indicated for thea pandemic.

early stages of influenza. Agents that may beprescribed other than maoto and daiseiryuto include

keishimaoukakuhanto,keishinieppiichito,

keishinimaoichito,

maobushisaishinto.

Forcasestransitioning into lesser yang disease, agents such as

saikokeishito and shosaikoto may be considered. If thecondition transitions to yang brightness disease,

byakkoto chapter may develop. In cases of severe
cough, makyokansekito or chikujountanto should beconsidered. Deficiencies in both qi and yin frequently
develop during the recovery period, so the use of

bakumondoto and shakanzoto, which are beneficial forthe lung, may be useful. Since very few Western
treatment modalities address this stage in therecovery process, these Kampo formulations canprovide a valuable contribution to patient healing. If
warm disease develops, the patient should be treated

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

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Volume 2, Number 1 | Spring 2007

5) Kuroki H: Using maoto in the treatment ofReferences
1) Barry, J (author), Hirasawa M (translator): The
Great Influenza, Kyodo Tsushinsha, 2005
2) Former Bureau of Public Health, Ministry ofinfluenza. 6th Japan Convocation on Kampo in
Pediatric Applications, 2005
6) Fukutomi O, et al.: Using maoto to effectivelyrelieve influenza symptoms. Kampo Igaku 29(5):Interior, eds.: Influenza, 1920
3) Kawamura K: Using maoto in the treatment of28-30, 2005

influenza patients. 39th Annual Meeting of the7) Kimoto H, Kuroki H: Effects of concomitant use ofJapanese Society for Pediatric Infectious Diseases,

oseltamivir phosphate and maoto in treating2007

influenza. Kampo Igaku 29(4): 16-19, 2005

4) Kubo T, Nakata H: Effectiveness of maoto in8) Mori K, Miyazaki Z: Therapeutic effects ofpediatric influenza infection. Proceedings of theconcomitant use of oseltamivir and Kampo in the56th Annual Meeting of the Japan Society fortreatment of influenza. Journal of Kampo Medicine

Oriental Medicine, 204, 2005

53(12), 11-20

12The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)