Volume 5, Number 1 | Spring 2010

Kampo Formula Developed in Japan (1)Otsujito (“B”Character Decoction)
Hiromichi Yasui
Japan Institute of TCM ResearchOtsujito(“B”CharacterDecoction)

was aformula invented about 200 years ago in Japan by
Nan-yo Hara (1752-1820). He created several new
formulae and four of them have names startingwith Chinese Zodiac, Ko(A), Otsu(B), Hei(C), andTei(D). Otsujito is the most well known formula ofthem all. After this, Sohaku Asada (1815-1894)
modified the otsujito and the modified formula isnow called otsujito.
The formula is now available in the extract
form and often used as a specialized prescription
for hemorrhoids (piles) in clinical sites. The
constituents of the prescription are as follows:
Angelicae Acutilobae Radix 6 g

Bupleuri Radix

5g

Scutellariae Radix

3g

Glycyrrhizae Radix

3g

Cimicifugae Rhizoma
Rhei Rhizoma

1g

1g(In the original prescription made by Nan-yoHara, Japanese angelica Root was not used but
instead Chinese Date and Fresh Ginger werecontained.)[Efficacy] Cooling and activating the blood andelevating qi[Indications] Blood heat, blood stasis, falling qi[Drug actions] Angelicae Acutilobae Radix
activates the blood and its circulation. Bupleuri
Radix frees qi movement in the triple energizers
and Cimicifugae Rhizoma enhances sunken qi.
Combined use of these three kinds of drugs
resolves obstructed network vessels (meridian)caused by qi binding in the lower energizer.
Scutellariae Radix clears heat generated by qi
stagnation and blood stasis. Rhei Rhizoma enters24

the qi system and the blood system, clears theheat and purge the fire and cool the blood andthen expels toxins. Glycyrrhizae Radix has theactions of harmonizing various drugs as well asclearing heat and resolving toxins.
Clinical application
Otsujito is used for various types ofhemorrhoids and its use is especially suitable forthe relatively acute condition in which there areconstipation, pain and small amounts of bleeding.
Otsujito is also used for prolapsed hemorrhoids inthe initial stage.
1. Hemorrhoids
Yoshio, et al. administered otsujito 6.0g to 98
patients with hemorrhoids for 8 weeks to compare
subjective symptoms (pain, bleeding, prolapse)
and objective symptoms (bloating, size ofhemorrhoid) before and after the administration.
They report the results of the overall
improvement rate that markedly improved
accounted for 28.6%, improved 39.6%, andslightly improved 23.5%. For the rate of
usefulness, extremely useful accounted for 22.4%,
quite useful 41.8%, and slightly useful 21.5% withthe recurrence rate of 15.2% after thediscontinuation of administration. The recurrence
timing was after 2.5 to 7 months after thediscontinuation of administration1).
When this prescription is clinically used forhemorrhoids, generally it is not used by itself but
it is often used in combination with otherprescriptions. For example, keishibukuryogan(Cassia Twig and Tuckahoe Pill) is combined if
blood stasis is complicated; hochuekkito(Middle-Reinforcing and Qi-Benefiting Decoction)
if there is distinguished qi deficiency; yokukansan(Liver-Inhibiting Powder) if there is marked liverqi depression; and orengedokuto (Coptis
Detoxificating Decoction) if there is an excess
heat toxin.

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

Volume 5, Number 1 | Spring 2010

Case 1: Hemorrhoid
The patient was a male of 27 years old. He
had been suffering hemorrhoids since his schooldays. Recently, an anal fissure (bleedinghemorrhoid) and internal hemorrhoids of afinger-tip size became inflamed like attacks
several times a year so that the patient was
somewhat neurotic. Although his doctor
recommended a surgery, he could not be awayfrom work for hospitalization for as many as aweek. So he did everything he did but thecondition did not improve at all. He felt likeusing “Kampo Medicine” and visited the clinic.
He was quite healthy except for the affectedarea although there was the sho of blood stasis.
Therefore, the decoction of otsujito wasadministered for continuous two months without
effects. Since there were no reasonableconditions for changing the prescription and thepatient said that it took a lot of trouble toprepare the decoction, I decided to use theextract tablet of otsujito and keishibukuryogan
as a drug for dispelling blood stasis.
Three weeks later, the bleeding stopped andpain was also relieved. After continuous use forsix months, an examination indicated that theinternal hemorrhoids reduced to the size of apiece of soybean and the symptom of blood stasisof the face and the lower abdomen disappeared.
Two years passed without the medication.
However, there has been no recurrence.
(Akira Ishihara, Two Cases in Clinical Trial on
Otsujito, The Association of East-Asia
Medicine Vol.12 3-go p61, 1965)
Case 2: Hemorrhoidal bleeding
Patient: Female of 34 years old
Chief complaint: Bleeding
Current medical history: When constipated, she
had bleeding and the toilet bowl became bright
red, which began to happen several years ago.
Whenever bleeding occurred, the patient used

over-the-counter suppositories. As bleeding
became severe four days ago and did not stopwith suppositories, she visited our clinic.
Findings at the initial visit: There were threeinternal hemorrhoids in the 3 o’clock, 7 o’clock,and 11 o’clock positions. From the internal
hemorrhoid in the 7 o’clock position, rupturesand bleeding were observed. The internal
hemorrhoid was positioned in the 1 o’clock
direction.
Treatment: otsujito (Tsumura & Co., Ltd.,Tokyo, Japan) were used with orengedokuto(Tsumura & Co., Ltd., Tokyo, Japan) Extract
Granules (for ethical use). On the 2nd day of theadministration, the bleeding disappeared. Afterone month of administration, a proctoscopic
examination showed the bleeding stopped andthe internal hemorrhoids changed in color frombright red to dark red.
(Tomonori Kawai, Jishitu ni taisuru Kampo
Seizai Heiyo Ryoho, Kampo Shinryo Vol.7, 2-go,p50, 1988)
Case 3: Bleeding hemorrhoids and pain
Patient: Female of 59 years oldChief complaints: Bleeding and pain
The patient had a medium physicalconstitution and no anemia with slightly darkcomplexion. Appetite and sleep were normal.
Bowel movements were diarrhea-constipation.
She was sensitive to cold (+) with no dry mouth,and no sweat. The abdominal sho was shown in
Figure 1. There were two hemorrhoids with thesize of a piece of soybean in the 7 o’clock position.
After three months of administration ofotsujito 8.0 + hochuekkito 6.0 (per day), nobleeding was observed. After five months, thepatient complained pain only sometimes. A cure
was achieved within eight months.
(Shigeru Tanaka, Jishitu to Kampo Chiryo,Kampo Shinryo Vol.5, 1-go, p42, 1986)

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

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Volume 5, Number 1 | Spring 2010

1. Prolapsed hemorrhoid
Otsujito works to recover the qi movementbound in the lower energizer. So this formula isalso used for prolapsed hemorrhoids. Bupleurum
Root and Cimicifuga Rhizome contained in theprescription enhance stagnant qi movement by
their action of raising qi and drooped organs
caused in conjunction with lowering qi. The
prolapsed hemorrhoids which are the symptom ofdeficiency are often accompanied by spleen
deficiency, in which case hochuekkito, forexample, is used in combination.
Case 4: Prolapsed hemorrhoid and pain
Patient: Female of 45 years old
Chief complaints: Prolapsed hemorrhoid andpain
Sometimes hemorrhoid prolapsed during abowel movement, which began to happen severalyears ago. Pain was added and became
persistent from two months ago.
The patient face was pale but did not haveanemia. The lower half of her body was cold.
Appetite and sleep were normal. Bowel
movements were once/day with one slightly softstool. The dry mouth condition was (+) withsweat (-). The overall abdomen was weak andsoft without resistance. The affected area: Thehemorrhoid with a size of a finger tip was in thestate of an everted flower and the surrounding
tissues were congested and swollen. Intense pain
was felt intense in palpation. “shiunko” wasapplied and then the hemorrhoid was pushed
back. Shiunko was used as an external
medication.
I judged that an intense sensation of cold withnormal appetite was the symptom of deficiencyof qi and blood. On the basis of this, Prepared
Aconiti Radix Processa 1.5g + shikunshito 8.0g
(per day) were administered for two months.
Then the prolapsed hemorrhoid became able toretract somehow. Therefore, the medications

26

were changed to otsujito 7.0g + hochuekkito 7.0g
(per day). For constipation the patientcomplained of, mashiningan 4.0g (as needed)
was used after dinner. Further two months later,
prolapsing was reduced to only a little during abowel movement. Further three months later,
subjective symptoms relieved. The medications
were suspended again for further two months.
(Shigeru Tanaka, Jishitu to Kampo Chiryo,Kampo Shinryo, Kampo Shinryo Vol. 5, 1-go, P39,1986)
1. Itching around the anus
Anal itching is often caused by damp-heat in
the lower energizer. This prescription has theaction of recovering qi movement in the lower
energizer and concurrently dispelling damp-heat,by which the itchy sensation in the anus and theanterior pubic region can be relieved.
Case 5: Bleeding hemorrhoids and itching aroundthe anus
Patient: Male of 38 years old。
Initial visit: July 30, 1983
Present medical history: The patient had been
complaining of bleeding from the anus anditching around the anus for about two years.
Present condition: The patient was of large
build, fatigable, and unable to have sufficient
sleep with pale complexion. The patient was aheavy sweater (whole body). The anus felt nopain but there were bleeding and an itchy
sensation around the anus. Bowel movements
were once a day with one stool and there was asensation of residual stool. Appetite was good.
The tongue was covered with thin white furs andmoist. Pulse was floating with strength. The
abdomen was generally soft with a slight bloating
feeling in the chest and hypochondrium on rightand left sides, and there was a slight tension over
the abdominal muscles in palpation.

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

Volume 5, Number 1 | Spring 2010

[Treatment and course]
During the administration of otsujito(without
Rei Rhizoma), subjective symptoms graduallyimproved. By the end of the 100 day
administration, they become resolved.
(Genpo Ogata, Kampo Chiryo Shorei-Senshu (1)P236, Gendai Shuppan Planning Co., Ltd. 1988）

3)

Akagi K, et al.: Ninshin/Sanjyoku no Komon
Shojyo eno Otsujito no Toyo Koka, Kampo
Shinryo Vol. 15 No. 3, P41-42, 1986

1. Hemorrhoidal disease during puerperium
Pregnancy and child birth delivery haveadverse influences on the development ofhemorrhoids and its worsening. There is adocumentation reporting that otsujito wassuccessfully applied to these problems.
Honda said that 58% of puerperal women
become affected with hemorrhoids, 30% of thewomen develop hemorrhoids after delivery
although they did not have hemorrhoids during
pregnancy, and 60% of the women who had
hemorrhoids during pregnancy do not have relief
within one month after delivery and rather tend
to have exacerbated symptoms such as bleeding,prolapse, and pain during the period of
one-month-after delivery. He administeredotsujito to 30 patients with hemorrhoids observedon the 1st day of the puerperium, reporting theresults of significant improvements in four
symptoms of “painful bowel movements,”“bleeding,” “prolapse,” and “swelling,” slightlyeffective in 11 patients (36.7%), and quite
effective (36.7%) with the overall effectivenessrate of 73.3%2). Akagi, et al. also administeredotsujito
foranalsymptoms
duringpregnancy/puerperium and obtained mostly
similar results3).
1) Yoshio T, Yanagida K, Sumiyama Y, et al.:Naijikaku ni taisuru Otsujito no Rinsho
Koka, Journal of New Remedies and Clinics
40:2087-2096, 1991
2) Honda T, et al.: Fujin to Ji-shikkan-sono 4 –Kampo (Otsujito) no Koka – Bosei-Eisei, Vol.
31 No. 1, 1990

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