世界７ヶ国の専門家が集まり１７件の発表と討論が行われ、現地の新聞とＴＶで紹介されました。資料Ａ４、５頁（論文集表紙、新聞、会議構成委員、プログラム）
Kazuhiko Horiguchi* and Kiichiro Tsutani**
*School of Health Sciences, Faculty of Medicine, the
University of Tokyo, Tokyo, Japan
**Dept. of Clinical Pharmacology, Div. of Information Medicine,
Medical Research Institute, Tokyo Medical and Dental University,
Tokyo, Japan
Initiated because of the great interest in complementary and alternative (CAM) medicine in the U.S., the concept of CAM is spreading around the world. Japan has had a long history of using "traditional" medicine, which is currently being re-categorized as CAM due to the fascination with this new concept. Many Japanese traditional practitioners do not welcome this new categorization. It is not easy to define CAM, but it can be said that Japanese traditional medicine fits its implied definition in that it complements modern (or bio-) medicine in providing certain healing techniques lacking in modern medicine. Nevertheless, as modern medicine coexists with traditional medicine in Japan, both ancient and modern medicine can be said to complement each other: consumers to use and experience them both, relative to their individuals' own cultural contexts and medical preferences. In this paper, we review the social characteristics of the culture that shaped traditional Japanese medicine. Traditional Japanese medicine has been used for 1,500 years and includes Kampo-yaku (herbal medicine), acupuncture and shiatsu (a special massage technique). We also compare today's Japanese traditional medicine and the Traditional Chinese Medicine (TCM) from which it evolved. We also discuss current public awareness and behavioral study of Japanese traditional medicine in urban Japan. Finally, we point to cultural and philosophical factors that play a role in the new categorization of Japanese traditional medicine as a "complementary and alternative" medicine.
★ 3 Graphs (Figure 1 - 3 : 19KB)
1. Introduction
Eisenberg previously evaluated and reported the use of complementary and alternative medicine (CAM) in the United States in two articles published in 1993 and 1998. These studies revealed that the frequency of CAM use is far higher than previously thought and that the economic impact is considerable. Reflecting this level of use, a National Center for Complementary and Alternative Medicine (NCCAM) was established in the United States, at the National Institutes of Health in October 1998.
The categorization as CAM of traditional health systems is due to the considerable progress of modern medicine (biomedicine), which has become prominent in the world. However, in many countries with a rich history and culture going back several thousands of years, there have been well established traditional systems of health that have been utilized for long time. There are many instances where these traditional systems are also being used in conjunction with biomedicine, hence their classification as CAM. However, for the professionals of these traditional systems and for their users, the terminology of "CAM" is unnecessary and perhaps inappropriate as it places their system in a subordinate position relative to biomedicine. Going beyond the issue of terminology, we should earnestly focus on the fact that CAM, which includes mostly traditional systems of health, has been utilized by billions of people throughout the ages.
The Japanese people have had a long history of using traditional medicine, Kampo-yaku, acupuncture and massage shiatsu for 1500 years. Below we describe the culture and history that fostered the origin of Japanese traditional medicine and how it has survived over the centuries. We compare today's Japanese traditional medicine and the Traditional Chinese Medicine (TCM) through data documenting medical status in Japan. We also discuss the public awareness and behavioral study of Japanese traditional medicine in urban Japan.
Ancient Chinese medicine developed around 3000 years ago and reached a coherent codified form approximately 2000 years ago with the compilation of medical manuscripts and drug books which are still in use today. In the development of Chinese medicine, it was traditional and characteristic for the ancient authorities - well-known doctors, researchers and philosophers - inherited their predecessor's writings, tested their techniques and, in turn, added their own experience and knowledge that they transmitted to posterity.
For example, the original text of the oldest Chinese materia medica, the Materia Medica of Shen Nong "神農本草経", compiled in c.a. 200 AD, has not been preserved. Instead, its contents are known through 6 materia medicas that were compiled later. The latest, the Materia Medica of Li Zi zhen "本草綱目" was formed in 1590 with the text of Materia Medica of Shen Nong. Thus, Chinese physicians examined and used drugs for more than 1000 years to confirm their usage and therapeutic effects, and they added their own clinical observations to the original information before transmitting it for posterity. Currently, the Chinese Materia Medica "中葯大辞典" contains information on approximately 5000 crude drugs. It reflects ancient traditional knowledge as well modern scientific chemical and pharmacological information.
In the 5th century A.D., the Yamato Imperial Court, the first government of Japan, eagerly sought to adopt the medical system from the kingdoms of Hyakusai (Pekche), Silla and Kokuryo in the Korean Peninsula. Historical records indicate that famous Korean physicians visited Japan and met with the Japanese Emperors. In the next century, as Buddhism was spreading to Japan, diplomatic relations between this country and its neighbors in the Korean Peninsula strengthened, and medical books were imported into Japan along with Buddhist images and sacred books.
In those days, the people in countries of the Korean peninsula were practicing and using the Chinese medicine of the Latter Han dynasty, "後漢" (A.D. 25-220). The books of Chinese medicine that were introduced into Japan from the Korean Peninsula were manuscripts of Chinese medicine written in classical Chinese. By the 7th century A.D., official diplomatic relation between China and Japan were established, and the Yamato Imperial Court of Japan sent messengers to the Chinese courts of the Sui dynasty, "隋" (A.D. 589-618), and the Tang dynasty, "唐" (A.D. 618-906), to borrow models from the Chinese political and social systems to use to rule their own country.
The health care system of the Yamato Imperial Court was established and adopted the Tang medical system. Healthcare education to train and certify medical doctors, acupuncturists and masseurs was derived from that in effect during the Tang dynasty, and the textbooks used by the medical professions in the Yamato period were those utilized in China during the Tang dynasty. Crude drugs came along with the medical books. Some of the crude drugs were deposited at the Shosoin Repository in the Todaiji temple, along with information concerning Buddhism culture in the middle of the 8th century. Scientific analysis has indicated that some of these drugs likely came from countries in Tropical Asia and the Middle East. This gives us valuable information concerning the international trade of those days, as well as on the medicinal use of these imported plants.
Although Chinese medicine was imported into Japan and integrated into the Japanese medical system as mentioned above, it was only reserved to the nobility and others close to power. The common people did not yet use Chinese medicine at that time.
Since the first introduction of Chinese medicine in the 6th century A.D., the latest medicine was always eagerly taken into Japan from China, and was immediately accepted and used virtually without any modifications. But it was not until the Edo era in Japan (1603 -1867) that Chinese medicine was modified to become a unique Japanese version of Chinese medicine, called "Kampo", which means "Chinese way" in Japanese. Kampo medicine was traditional Japanese medicine, which included herbal medicine, acupuncture and shiatsu.
During the 11th century A.D., during the so-called Song dynasty "宋" period in China (A.D. 960-1279), printing technology was developed by leaps and bounds, and many manuscripts were published, in particular a large number of medical books. The official trade between Song dynasty China and Japan led many of them to find their way into Japan. Medical manuscripts of the Jin period '金' (between the Song and Yuan dynasties, c. A.D. 1115-1260), and the Yuan '元', or Mongol, dynasty (1260-1368) led to increased influence of the theories of Traditional Chinese Medicine (TCM), which were brought into Japan by the trade at that time. The trade between Ming dynasty China '明' (A.D. 1368-1644) and Japan continued to flourish, and so medical knowledge was continuously exchanged.
The large quantity of medical knowledge that had been introduced from China was accumulated steadily in Japan, and it was during the Edo era that Kampo medicine flourished and became a unique Japanese brand of Chinese medicine. This consolidation of uniquely Japanese medical principles and practices occurred in part as a consequence of the distinct cultural and social characteristics of the feudal Edo period under the Tokugawa Shogunate, with respect to the principle of simplicity, which led physicians to respect practices more than theories. Political and philosophical attitudes were largely changed to be less ideological and simple against the Neo-Confucian doctrines, and developed the pragmatic approach, which was very characteristic of Japanese thinking. Thus, the influence of Chinese theories waned somewhat, and native Japanese practices were developed and strengthened.
The Tokugawa government enforced a policy of national isolationism, and diplomatic relations were only maintained with the Netherlands, China and Korea via trade continued only through the port of Nagasaki. The uniqueness of native Japanese culture matured in the Edo period, which was in part fostered by technological advances and use of the printing press that became widespread in Japan during that period. As a result, many Chinese medical manuscripts were translated into Japanese, explanatory notes were added, and they were published and widely circulated in Japan.
Kampo medicine became widespread in Japan, clinical studies were done frequently, and many superior and famous researchers and doctors were produced. The Koho-ha School (the classical school) "古方派" focused on a concise and practical medicine and used Shang han lun "傷寒論" as a single classical medical book. Because the book was very practical and rational without complicated theory of disease causation and preventive medicine. They wanted to de-emphasize the concept of Yin and Yang, and of the Five Elements Theory of the Su wen "素問". The Koho-ha School received excellent clinical evaluations, and many doctors at that time approved their approach. They are still influential and play a significant role in Japanese traditional medicine today. The Secchu-ha School (the "Compromise" School) "折衷派" integrated the Chinese medical concepts of the Jin and Yuan dynasties "金元医学", and the surgical techniques of Dutch medicine, with the concepts of the Koho-ha school. The Koshou-ha school (the Historical Investigation School) "考証派" compiled and organized an enormous number of classic medical manuscripts, and to this school can be attributed the highest contribution to the educational basis of Kampo medicine.
Special doctors for acupuncture became popular in the Azuchimomoyama period (A.D. 1573-1602, just before the establishment of the Tokugawa Shogunate), and in the Edo era, and they formed influential schools of acupuncture. The efficacy of their treatments, which they dispensed to all, from the common people to the successive Tokugawa Shoguns, or generals, gave them fame and a high reputation in Kampo medicine.
A renowned blind acupuncturist of Waichi Sugiyama (1556-1635) invented the Kanshin-ho (the needling method using a guide tube) "管鍼法", a special method of using a tube for inserting an acupuncture needle. This method enabled the practitioner to reduce the pain due to needle insertion, and to treat a patient with a number of acupuncture needles in a short time. This was the origin of the Japanese style of acupuncture today.
As discussed above, in the Edo era, the influence of the cultural characteristics of practical and rational, and technical ideas of the Japanese people gradually modified the medicine that had been introduced from China for more than a thousand years. It was developed as Kampo, which came to be used by most of the Japanese people, and was supported by the Japanese medical system of the period.
In the Meiji era (1868-1912) following the Edo era, Kampo medicine that had formed the mainstay of Japanese medical care during the Edo period was suppressed by the new government which adopted western values and way of life to enhance the wealth and the military strength of Japan. In 1895, the Japanese parliament, the Diet, announced that only those who learned Western medicine would be qualified to treat patients.
Japan competed with the international military powers at that time, and gradually strengthened its army. In the armed forces, Western medicine rapidly supplanted traditional medicine, because of its superior performance in surgery, which would be the most useful on battlefields. Although Western medicine became the standard of official medical care, Kampo medicine survived in national medical care as specialized medications, acupuncture treatments and shiatsu massage treatment. Drugs used in Kampo treatments were called Kampo-yaku (Kampo drugs), and were supplied by pharmacies and drugstores. Specially trained individuals (acupuncturists and shiatsu practitioners) continued to administer acupuncture and shiatsu in their private offices. During the Edo era, blind acupuncturists and shiatsu practitioners contributed to the development of their disciplines, following in the footsteps of Waichi Sugiyama. Under the repression in the Meiji period, Kampo was practically divined into 3 categories of herbal medicine, acupuncture and shiatsu. It is a main reason why Kampo means just medication of Kampo-yaku (herbal medicine) today.
During World War II, the Japanese people experienced restrictions of food and medical supplies. In these hard times, they remembered Kampo medicine, because they could easily obtain materials of Kampo drugs and moxa (an herb used for acupuncture) locally. Notably, an Oriental medicine department responsible for teaching Kampo medicine was established in a university to train practitioners to meet the general population's needs.
Thus, from the Meiji era to World War II, Kampo medicine was officially suppressed, but the Japanese population sought out and used Kampo medicine, thereby disregarding the government's official policy. Paralleling this trend, Kampo practitioners, pharmacists and acupuncturists kept up the skill they had received from predecessors in their Kampo medical family line.
Just after the War, under control of the General Headquarters (GHQ), the Japanese government changed laws and policies and turned towards building a new nation. Although there were no major changes in the health care system, the American General Douglas MacArthur of the GHQ planned to issued a ruling prohibiting acupuncture in 1947, because this practice was considered to be barbaric and unhygienic, and to lack supporting scientific evidence. However, the ruling was reversed following the immediate objection formulated by the acupuncture professional organizations (including the associations of blind acupuncturists), and this opened the way to the scientific study of efficacy and safety of acupuncture.
In 1961, when Japan had been reconstructed and its economy had greatly strengthened, complete coverage of the National Health Insurance was realized. In 1967, health insurance began to cover acupuncture treatments for 5 diseases recommended by physicians and delivered by acupuncturists. The same year, health insurance began reimbursing 4 formulations of Kampo drugs prescribed by doctors (147 formulations in 1987).
The production of ethical Kampo drugs increased, paralleling the Japanese economy's remarkable growth, and so did the medical insurance coverage of Kampo drugs (Figure 1. Changes in the amount of money spent on Kampo drug production.) This phenomenon indicates that many physicians who were not trained in Kampo medicine prescribed Kampo drugs abundantly, like administering vitamins and supplements, as part of the Kampo medicine boom among the Japanese people. The production of ethical Kampo drugs began decreasing after 1992, after a side effect of Xiao-chai-hu-tang (Formula bupleuri minor) "小柴胡湯", a Kampo drug, was reported in Japan, and Japanese economic recession started. On the other hand, the production of OTC Kampo drugs, which are sold at pharmacies, moved up gradually and after 1992 decreased slightly.
As mentioned above, Kampo medicine, which was on the verge of the extinction at certain times in the past, is now part of Japanese health care again. A well-known Kampo specialist, Dr. Yasuo Otsuka, proposed reasons for Kampo's popularity to be on the rise:
(1) Reaction to the serious side effects of modern medicine
(2) Modern medical doctors being too specialized
(3) Relationship between patients and western-style physicians is
impersonal
(4) The patterns of illness has changed in recent years (chronic
illnesses, for which western medicine is not so effective, have
increased)
The People's Republic of China was founded in 1949. During World War II, Western medicine was used in the medical care system, under the influence of the occupying Japanese army. In 1956, the new government led by Mao Zedong suggested that Chinese medicine should be utilized as the standard of medical care.
There were various schools of Chinese medicine at that time in China. The schools of Chinese medicine were integrated to establish an educational system of Chinese medicine. A new medical theory and approach was built up involving the integration of those schools and named as Traditional Chinese Medicine ("TCM"). National collages for TCM were established subsequently all over the country. Medications with crude drugs, acupuncture, massage manipulation, Qigong and dietary treatments are taught currently at those collages in China.
As mentioned above, the theory of Traditional Chinese Medicine was unified forcibly a little in China. But in Japan, a unification theory of Japanese traditional medicine has not been established.
In medication of Kampo drugs, a theory on the basis of Shang han lun of the Koho-ha school that gained power in the Edo era is still the mainstream in Japanese traditional medicine. Abdominal diagnosis by palpation are performed more often than pulse diagnosis, but Japanese practitioners generally tends to check by symptoms and name of disease and choose a most suitable formulation of Kampo drugs ("随証療法"). Less than 200 formulations are commonly used without any addition of crude drugs. Kampo extract (extract of herbal medicine) is more popular than Kampo decoction now. On the other hand, in China pulse diagnosis is generally conducted and Chinese practitioners choose some crude drugs and make a special formulation for a patient ("弁証療法").
In acupuncture treatment, the meridian treatment theory that taking in Yin-Yang and the Five Elements Theory was established in the Showa era (1926 -1989). By this treatment method they grasp a state of viscera and meridians by pulse diagnosis, and improve the condition by regulating the circulation of meridians with acupuncture stimulation. They tried to apply acupuncture treatment to various illnesses in addition to pain diseases.
A medical theory for the treatment of febrile diseases called "Wen bing xue" ("温病学") was established in Traditional Chinese Medicine, but not in Japanese Kampo. This fact is reflected in the following examples. For treatment of the flu or a cold, Ge-gen-tang (Formula puerariae) "葛根湯" is used frequently in Japan, but, in China, Yin-qiao-san (Pulvis forsythiae et lonicera) "銀翹散" is generally preferred. Ge-gen-tang (Forsula puerariae) is the prescription that doctors of the Koho-ha School of the Edo period used frequently, and its source is the Shang han lun, which is a sacred book of the school originally brought from China. On the other hand, Yin-qiao-san (Pulvis forsythiae et lonicera) is the prescription newly created in China from an original idea of the Wen bing xue theory. Wen bing xue is a theory that was completed in the latter period of the Qing "清"dynasty (A.D. 1636 -1912) in China, while Japan was in the early Meiji era, just after the disturbance of the late Tokugawa period. The Wen bing xue theory was not accepted in Japan because of the rapid Japanese adoption in the late nineteenth century of Western medicine, in conformity with the policies of the new Meiji government, in particular to modernize and end cultural isolation.
Another difference between Kampo and TCM can be seen in the dosages of drugs. Generally, dosages of Japanese Kampo drug are equivalent to one quarter to one third of Chinese ones. It is related to the regulation of the production authorization of Kampo drugs by the Japanese government, and to the difference in quality and type of crude drugs as raw materials.
Japanese traditional medical workers who are practitioners of Kampo medicine are classified into doctors, pharmacists, acupuncturists and shiatsu practitioners.
A qualification of medical doctor is given to the person who has mastered 6-year university education on the basis of Western medicine and passed the national examination. The rule of the qualification is almost same as that of the Meiji era. Students in medical schools are not required to take a lesson of Kampo. There are several universities where a lecture of Kampo medicine is taken in as an elective subject, and some of the universities have set up Kampo medical examination and treatment section at their hospitals (6 universities). At such universities, students get a chance to learn Kampo as residents at bedside.
Pharmacists are educated at university for 4 years on the basis of Western medicine. And Kampo is not a required subject, but an elective subject. There are a very few opportunities for pharmacists to receive an occupational education of Kampo. But there are some pharmacists who have successfully mastered Kampo. They have consultation directly from patients and offer Kampo drugs to patients.
Qualifications of acupuncture and massage shiatsu are given to the person who completes education of an acupuncture vocational school (26 schools) or an acupuncture university (1 university) for 3 years and has passed the national examination. An inconvenient person of an eye can receive education of acupuncture and massage shiatsu in a school for the blind and qualified by passing the national examination. In acupuncture vocational schools, Kampo whole (general idea, diagnosis, clinical), Traditional Chinese Medicine (just general idea) and anatomy and pathology of Western medicine are taught as required subjects.
The number of medical workers of doctors, pharmacists, acupuncturists and massage shiatsu practitioners are about 211,498, 95,642, 125,971 and 94,150, respectively. But we cannot make sure of the precise number of medical workers engaged in Kampo specially. It is simply because there are not the data counting number of Kampo experts in doctors and pharmacists.
On the other hand, there are 1718,000 doctors totally in China, according to the data of Chinese medical worker number in 1989, and TCM doctors are 370,000 in the number.
The Tokyo Metropolitan Government conducted a survey using a questionnaire in order to know public awareness and behavior of using Japanese traditional medicine in 1989. Data were collected from 2293 residents in Tokyo.
As the result, the number of persons who had experience with taking Kampo drugs was 1115 (48.6%). (Figure 2. Experience with taking Kampo drugs and acupuncture.) The reasons of taking Kampo drugs were obtained from the experienced persons by choosing more than one answer. The high rank reasons as follows: "because there was no side effect"(38.7%), "Because Kampo drugs were effective against chronic disease"(27.3%) and "because there was uneasiness in health" (27.0%). In terms of effectiveness of Kampo drugs, 25.8% of the experienced persons felt that "it was very effective", and persons of 45.8% replied it that "it was effective". (Figure 3. Effectiveness of Kampo drugs and acupuncture.)
On the other hand, citizens experienced with acupuncture treatments in Tokyo were 682 out of 2293 persons (29.7%). (Figure 2. Experience with taking Kampo drugs and acupuncture.) In evaluation of acupuncture effectiveness, 39.6% of the experienced persons replied that " it was very effective," and 35.3% of those "that it was effective ". (Figure 3. Effectiveness of Kampo drugs and acupuncture.)
There is a characteristic of Japanese traditional medicine in having been developed by the introduction of Chinese medicine with Japanese unique culture and historical background. The Kampo medicine, which was Japanese traditional medicine established in the Edo era, is still the mainstream of Japanese traditional medicine, and characteristic of today's Japanese traditional medicine. Table 1. shows the summary of difference between Traditional Chinese Medicine and Japanese traditional medicine.
Table 1. The summary of difference between Traditional Chinese Medicine and
The characteristic of Japanese traditional medicine is to
eliminate a complicated, philosophical and abstract theory in
Chinese traditional medicine, and to adopt the pragmatic approach
with a practical and rational theory. This is due to Japanese
cultural tradition and also Japanese medical care system. It is
another important factor affecting the characteristic. For health
insurance coverage of Kampo drugs and acupuncture treatment,
medical doctors need to make diagnosis and prescribe in the way
of modern medicine. The reimbursement of Kampo drugs and
acupuncture treatments are 147 formulations and 5 diseases,
respectively.
There is another characteristic that Japanese traditional
medicine practitioners are consist of some medical doctors and
some pharmacists, acupuncturists and shiatsu, and they practice
independently. As for the Japanese traditional medicine, a theory
of each treatment methods is not unified like Traditional Chinese
Medicine. Therefore, those practitioners in Japanese traditional
medicine cannot cooperate theoretically, and hardly make
diagnosis and treatment as a team.
The Japanese traditional medicine faced the crisis of
continuation historically, but conquered it by dividing the
technique practically into herbal treatment, acupuncture and
shiatsu. It caused such a theoretical lack of unity in Japanese
traditional medicine.
Eisenberg DM, Kessler RC, Foster C, et al. Unconventional
medicine in the United States. N Engl J Med. 1993;328:246-252.
Japanese traditional medicine
China
Japan
Practitioners
TCM doctor
pharmacist
acupuncturist
tuina
PCH providermedical doctor
pharmacist
acupuncturist
shiatsu massager
Education
collage
high school
short time trainingcollage
vocational school
System
formal TCM theory
mainly Western diagnostic
Diagnostic exam.
pulse
abdominal palpation
Prescription
individual formulation
ready-to-use formulation
Dose
45-200g
15-50g
Acupuncture
twirl needling
guide tube needling
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Eisenberg DM, Kessler RC, Foster C, et al. Trends in alternative
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Lock M. East Asian medicine in urban Japan : varieties of medical
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Lock M. The impact of Chinese medical model on Japan or, how the
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