Volume 11, Number 1 | Spring 2016

Integrating Kampo and Evidence-Based
Medicine (5) – Type 4 Cases
Kampo Treatment for Patients to Whom Standard
Treatment Cannot Be Applied
Hiromichi Yasui
Japan Institute of TCM Research

Congress of Oriental Medicine (ICOM) held in 2014,
he gave a keynote speech as president of theorganization, in which he introduced an interestingcase example of using Kampo medicine on a patientto whom standard treatment cannot be applied.
Patient: 32-year-old man, 173 cm, 58 kg

Introduction

Chief complaint: The patient has hey fever, but

In this series, I define four types of use of Kampo
medicine in daily clinical practices within Japan’scannottakeantiallergenics

becauseofhypersomnia.

unified medical system, and discuss the diseases

First visit: Mid-April 20XX

that fall under each of these types, by giving relevant

History of present illness: The patient began tocase examples. In the previous issue of this journal,

experience sneezing, a runny nose, and nasal

I introduced four episodes, and explained that theycongestion since four years ago. He was diagnosed

fall under the four types of use of Kampo medicine inwith hey fever and received treatment through an

daily clinical practices. Let me recount them below.

antiallergenic. However, he became so sleepy soType 1: Kampo treatment is better than standard

that he could not work. Therefore, he took the drug

modern medical treatment
Type 2: The effects of standard modern medical

only before going to bed, but this undermined theeffectiveness of the treatment.

treatment and Kampo treatment are both

The patient is skinny and pale. An abdomen

strengthened when the two are used in

examination revealed a weak abdominal wall andcombinationsplashing sound in epigastric region.

Type 3: The side effects of standard modern

After an intermittent administration of 6.75 g/day

medical treatment can be mitigated inof shoseiryuto with processed aconite extract, thecombination with Kampo treatment
Type 4: Circumstances prevent the application ofstandard modern medical treatment, but
treatment is needed

patient’s rhinitis symptoms improved without anantiallergenic1).
The patient has hey fever. Because he would
become sleepy after taking an antiallergenic, he

Here, we shall take a close look at Type 4 cases,in which patients require treatment, but standard
modern medicine cannot be applied. As it is difficult
to present evidence and data for this type, however,visited Hosono Clinic, where Dr. Nakata is the
director, seeking a different type of treatment.
Judging by the fact that “The patient is skinny andpale. An abdomen examination revealed a weak

I shall introduce a number of case reports.

abdominal wall and splashing sound in epigastricEpisode 1

processed aconite extract. Hosono Clinic has its

Dr. Keigo Nakata, a friend of mine, is a skilled
Kampo doctor in modern Japan. He inherited theacademic lineage of Sohaku Asada, who was a
representative physician in Japan more than 210
years ago, and wields full command of prescriptions
based on this school. At the 17th International

2

region,” he was prescribed a shoseiryuto withown drug formulation factory, and produces all
extract formulations used by the clinic since 1950.
It produces extract for approximately 400 types ofprescriptions and approximately 170 types ofmonovalent crude drugs. The shoseiryuto withprocessed aconite that was prescribed to the above

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

Volume 11, Number 1 | Spring 2016

patient is also among the formulations made byheadaches occurred in the same way when

Hosono Clinic itself.

climbing a high mountain. In terms of time of day,

Shoseiryuto is effective against allergic rhinitis, as

they seemed to commonly occur in the earlyhas been found in a number of clinical studies.

mornings.

Among these studies, Prof. Baba’s paper on a double

The patient tried a number of analgesics up to now,

blind comparative study, which proved the effect ofbut because she has a weak stomach to begin with,shoseiryuto against perennial allergic rhinitis,

any analgesic would upset her stomach, and she

stands out2). Processed aconite was added to the

could not continue to take it.

above patient’s formulation, probably because theShe had high blood pressure and experienced

cold pattern was particularly notable.

multiple cerebral infarctions, and was still

Shoseiryuto contains ephedra, and has a slightreceiving treatment for them at a different

stimulant effect. For this reason, no sleepiness is felt.

hospital. She also complained of seeing things in

It is considered a perfect prescription for allergic

double, low motivation, listlessness, loss ofrhinitis.

appetite, and lower back pain. She came to Tokai
University Hospital as an outpatient after beingreferred to by a friend.

Episode 2
Dr. Makoto Arai, an associate professor at Tokai

Present symptoms: Height 156 cm, weight 53 kg,

University Hospital, is similarly a good friend ofblood pressure 156/88 mmHg. She had gray hair,mine. He is a young researcher who provides Kampo

but she had a clear complexion for her age. Her

medical care at the hospital and always gives me

pulse is floating and weak. She has white coating

reports of wonderful case examples. He writes aonseries of articles on case examples in the long-

abdominal strength was neither strong nor weak,standing Journal of Kampo Medicine (in Japanese),

and was tense within measure. In terms ofand introduced the following case3).

abdominal

hertongue,andpattern,decreased

there

gums.

was

Her

slighthypochondriac tenderness on the right side, butPatient: 79-year-old female physician

there was nothing else of particular mention. No

Chief complaint: Headache

bloating or coldness was observed in her legs.

History of past illnesses: Nothing in particular

Progress: I had just read a research paper that

History of present illness: Since around three years“goreisan is good for headaches that occur before aago, the patient began to experience intermittent

rainy day,” and had been waiting for an outpatient

headaches, although they did not trouble her

so I could immediately replicate the study at themuch at the time.

first opportunity. It so happened that the patient

Around springtime of last year, however, thecame to our hospital at just this time.

headaches and dull head pain intensified. The

In reference to the paper, the patient’s headacheheadaches were characterized by a throbbing pain

was of a type that could be treated with goreisan,

at the back of the eyeballs, but did not accompany

judging by how the headache tended to occur. I

nausea. They occurred when atmospheric pressure

therefore prescribed 7.5 g/day of goreisan extract

dropped before a typhoon or an approaching low-

(Tsumura Pharma, Ltd., Tokyo, Japan) with highpressure system. On close hearing, it was foundexpectations. A week later, the headaches hadthat the headaches intensified most on the day

lightened to almost six-tenths of their original

before a rainy day, but mysteriously abated whenintensity. A month later, intense headaches thatit began to rain steadily. Furthermore, thekept the patient in bed stopped occurring. Unlike

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

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Volume 11, Number 1 | Spring 2016

how it was with analgesics, the patient’s stomach

antiviral drugs have facilitated influenza treatment,

remained in good condition, and her sense of

but this is not to say that the use of such drugs is not

fatigue began to improve.

without its problems.

Two months have passed since the patient began
taking goreisan. Her headaches steadily alleviatedInstructions

for

using

Tamiflu

includethefollowing type of warning.

to two-tenths of their original intensity. However,

There have been reports of teenager cases have displayed

no changes have occurred in her complaints of stiff

abnormal behavior after taking this drug, although theshoulders and seeing things in double.

causal connection with Tamiflu remains unclear, and haveresulted in falls and other such accidents. For this reason,

Dr. Arai prescribed goreisan to this patient

teenager patients should, in principle, refrain from using thisbecause he had read Dr. Haimoto’s paper. For

drug, except in cases where they are judged to be high-risk

information on this paper, please see the paper I

patients with a complication or a history of past illnesses.

introduced in Vol. 1 No. 1 of this journal4). It

As a preventive measure against any possibility of an

essentially discusses how goreisan is particularly

accident occurring among pediatric and minor patients once

effective against headaches and migraines thattreatment by Tamiflu begins, explain to the patient and theoccur when atmospheric pressure drops.

patient’s family that (1) there is the possibility that theThis case report is valuable in terms of the factpatient may display abnormal behavior, and (2) guardians ofthat it substantiates the abovementioned research

the pediatric or younger patients should take care not to leave

paper, but it is not for this reason that I introduced

the patient alone for at least two days when recuperating at

it here. Take note of the passage, “The patient tried

home.

a number of analgesics up to now, but because she

Similar symptoms have been reported with regard to

has a weak stomach to begin with, any analgesic

influenza-associatedwould upset her stomach, and she could not continue

explanations should also be given as above in the case of suchto take it.” If the patient were able to alleviate her

illnesses.

encephalopathy,

so

the

same

headaches by taking an analgesic, she may havebeen able to live each day comfortably. However, her

On a certain day in 2007, a young girl came to my“constitution” made her stomach feel poorly after

clinic with a high fever. An examination using ataking this type of drug, so could not take it.

rapid antigen test revealed that she had influenza

Fortunately, not only did the patient’s headaches

type B. The progress of her illness was as follows.

improve after taking goreisan as prescribed by Dr.
Arai, but her stomach also regained its health as an

Patient: 11-year-old girladded benefit.

First visit: March 5, 2007, 10 a.m.
Chief complaint: Fever

Episode 3

History of present illness: The patient got a fever ofAn outbreak of influenza always occurs during

38°C at night on March 3. On March 4, she madewintertime in Japan. Although vaccination isan emergency room visit. The rapid antigen test

encouraged, many people nevertheless contract

was negative for influenza. She was prescribed an

influenza every year. Normally, influenza is not anantipyretic, which she took right away. At night,

illness of poor prognosis, but as it accompanies highher temperature was still 38°C.

fever, headaches, joint pains, and general pains.

In the next day morning (March 5), she came to

Many patients consult a hospital. The developmentof Tamiflu ○R (oseltamivir phosphate) and other4

my clinic and her temperature was 37.5°C.
Chills (-), heat sensation (+), headache (+), sore

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

Volume 11, Number 1 | Spring 2016

throat (+), nasal congestion (+), nasal discharge

The patient had contracted influenza B, but at the(+), coughing (+), sputum (-), dry mouth

time she made an emergency outpatient visit to the(-),sweating (-).

municipal hospital on March 4, it was yet too early
to make a diagnosis, and she was sent home after

Present condition: Temperature of 37.5°C
Pulse: Sunken, thin and rapid; slight tension.

prescribing an antipyretic. Her fever had not abated

96/min.

by the next day, so she visited my clinic. At this time,

Tongue: Light red, red at the tip, slight coating

she was able to be diagnosed with influenza B, but(white)because she was only 11 years old, she was

Diagnosis: Diagnosed with influenza (B) based on anaccompanied by her mother, who said she did notwish to use Tamiflu. Thus, the patient was

examination using a rapid antigen test
Prescription: 1.3g of keishito extract (Kotaro

instructed to take a dose of 1.3g of keishito extractof(Kotaro Pharma, Ltd., Osaka, Japan) + 1.0g of

makyokansekito extract (Osugi Pharma, Ltd.,makyokansekito extract (Osugi Pharma, Ltd., Osaka,

Osaka, Japan) for 1 dose

Japan) every two hours. These two prescriptions

Pharma,Ltd.,

Ossaka,Japan)+

1.0g

Progress: On the morning, the patient took the

together can mimic daiseiryuto, which is out of listprescription every two hours at her home. In thefrom commercially available Kampo extracts. The

late afternoon, her temperature was in the lower

patient was instructed to take the prescription every

37°C. She did not develop much sweating, but thetwo hours, based on instructions written in Shang

frequency of urination increased. She went to bed

han lun. By taking the prescription every two hours,in this condition. She had bowel movement, softshe developed some sweating and a large amount ofstool.

urination, and her condition improved. (It is not rare

In the next morning, the patient had a temperature

to see a large amount of urination during the declineof 36.5°C. Chills (-), heat sensation (-), headache (-),

of a fever. In such cases, there is only a small amountappetite (+), nasal congestion (+), sputum (+). Heroftemperature was 37.2°C in the later afternoon. I

disappeared by taking 6.0g of shosaikoto extractprescribed the abovementioned prescription for(Kracie Pharma, Ltd., Tokyo, Japan) + 4.5g of

three days.

makyokansekito extract (Osugi, Pharma, Ltd.,March 7: Her temperature was 36.7°C. Slight

Osaka Japan) three times a day.

sweating.)The

coughingthatremainedcoughing (-), Cogged sputum (-), Nasal congestion

In most cases, I prescribe a single administration(+). Pulse: fine and rapid. Tongue: Slight whiteof Kampo medicine to influenza patients andcoating (in the middle). Slight decreased appetite

patients exhibiting symptoms that suggest influenza,(-), Dry mouth (-), chills (-), heat sensation (-),

in consultation with the patient. In my office, I

headache (-).

prescribe a Kampo extract formulation that I think

Prescription: 6.0g of shosaikoto extract (Kracie

is best on a test basis. Then I give the patient a day’s

Pharma,ofdose after confirming it is alright, and have themakyokansekito extract (Osugi, Pharma, Ltd.,patient come in again the following day to see the

Osaka, Japan) 3 times/day

result. It is normal for patients to display the type of

The patient’s condition improved the following day,progress as seen in this case.

Ltd.,

Tokyo,

Japan)+and her symptoms disappeared thereafter.

4.5g

Pediatric patients frequently have indications for
maoto, while adults have indications for daiseiryuto,
keishinieppiichito,

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

keishimaokakuhantoand5Volume 11, Number 1 | Spring 2016

maobushisaishinto.

Persistent

coughing

that

The above three patients could not be treated bycontinues after the decline of a fever is frequently

standard Western medical treatment for respective

treated with chikujountanto, bakumondoto, andreasons. I sometimes encounter people like them inshosaikoto + makyokansekito as in the above casedaily practice, although they are not large in number,example5).

and tend to be glad that I have knowledge of Kampo
medicine.

The four types and their characteristics

Diseases subject to treatment
by Kampo medicine

Type 1Treatment is effective
by Kampo treatment
alone

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

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

Type 4Situations whereWestsern medicine
cannot be appliled

In this issue, we took a look at a number of Type 4 case examples. This type includes all sorts of cases, as
shown by reports of diverse cases. Here, we introduced three cases: a case where antiallergenic agents were
not able to be used due to their potential to induce sleep, a case where antipyretic analgesics such as
NSAIDs were not able to be used due to a gastrointestinal disorder, and a case where antiviral drugs were
not able to be used due to the danger of inducing abnormal behavior.
In the future, if the number of reported case examples increase, the role of Kampo medicine for patientsfor whom standard treatment cannot be applied shall become much clearer.

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

Volume 11, Number 1 | Spring 2016

References[List of prescriptions]

1) Keigo Nakata: The Role of Kampo Medicine, 17th ICOM

shoseiryuto 小青竜湯Keynote Speech 2014.

Baba, Takasaka Tomomi, Inamura

goreisan 五苓散

Naoki, et al. Double-blind clinical trial of Sho-keishito 桂枝湯

seiryu-to (TJ-19) for perennial nasal allergy.

makyokansekito 麻杏甘石湯Jibiinkoka Rinsho (Practica otologica); 88: 389–405

maoto 麻黄湯2) Shunkichi(in Japanese with English abstract) 1995.
3) Arai, Makoto: “Goreisan for Headaches that Occur on the
Day before Rain.” Journal of Kampo Medicine Vol. 47-12,
59-66, (in Japanese) 2000.
4) Hiromichi Yasui: Efficacy of “Poria Powder with Five
Herbs” for Headache ― An epidemiological research study
on the relationship between chronic headache anddaiseiryuto

大青竜湯keishinieppiichito 桂枝二越婢一湯
keishimaokakuhanto

桂枝麻黄各半夏湯

maobushisaishinto 麻黄附子細辛湯chikujountanto 竹茹温胆湯bakumondoto, 麦門冬湯

atmospheric depression ― The Journal of KAIM Vol.1
No.1, 7-11 2006.
5) Japan Institute of TCM Research, ed.: “Kampo Treatment
for Influenza.” Japanese Journal of Traditional Chinese

Medicine, (in Japanese) 2007.

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

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