Western medicine and Japanese Kampo medicine are in a complementary relationship — Stillness and movement are beautifully harmonized in Japanese Kampo medicine

This review is a general outline to have a proper understanding of Japanese Kampo medicine from my point of view.


INTRODUCTION
This review presents an overview of the present position of Japanese Kampo medicine in my experience. Coexistence with Japanese Kampo medicine fills gaps of western medicine by its complementary approach. For understanding Kampo medicine, both western and Kampo medical understanding of Kampo medicine are required. I appreciate the chance the organizers of the First International Symposium on Kampo medicine have given me to state my thoughts regarding Kampo medicine. Kampo prescription should be considered in terms of static and dynamic, since we human beings are living with stillness and movement. In this review I have revised the title of the review to "Western medicine and Japanese Kampo medicine are in a complementary relationship" and have added the subtitle -"Stillness and movement are beautifully harmonized in Japanese Kampo medicine"which is the same as the title of my talk in the symposium.
THE GREAT WAVE OFF KANAGAWA, A KATSUSHIKA HOKUSAI WOODBLOCK PRINT Figure 1 shows The Great Wave off Kanagawa produced by Hokusai. What came to Hokusai's mind? We have to imagine what Hokusai would have pictured in his mind during the production process of this wood print. In his work stillness and movement are beautifully harmonized. Rough waves are movement. In contrast, Mt. Fuji is looking at us very quietly regardless of rough waves.
Japanese Kampo medicine is a harmonious medical practice, always creating a clear insight into the combined static and dynamic states in patients. We need practical wisdom to carry out a harmonious medical practice. We need judgment, which is integration ability to promote Kampo medicine in a proper manner.
Stillness is an ideal state of our physicians. Our physicians should be Mt. Fuji. Stillness means physicians should make a tacit judgment with a calm heart in a world where the bioenergy is moving. Our physical condition moves dynamically, and inevitable aging always adds pathological change to our human beings. Each person has a genetic constitution, that is stillness. Environmental factors always affect stillness, that is movement. We have to judge the combined physical and mental conditions from the point of view of stillness and movement. A doctor who understands Kampo medicine well could set up like Mt. Fuji and perceive the patient's dynamic change. On the other hand, a doctor who only knows western medicine may only capture the patient's dynamic change in snapshots. This means the principle of Kampo medicine perceives not only disease but also the whole patient. Kampo medicine sees the patients (human beings), not the disease of the sick. In other words, based on Kampo medicine, though the good doctor treats the disease, the best doctor treats a patient with the disease, as the famous Dr William Osler mentioned.

WESTERN MEDICINE AND JAPANESE KAMPO MEDICINE ARE IN A COMPLEMENTARY RELATIONSHIP
In Japanese medical care, on the basis of its coexistence with western medicine Kampo medicine fills gaps of western medicine by its complementarity. Western medicine and Kampo medicine are in a complementary relationship. In order to understand Japanese Kampo medicine, we need both western and Kampo medical understanding, since our medical education spends almost 99% of its time on western medical education. When they graduate from medical school, physicians do not know what Kampo medicine is.
Hearty doctors realize the need of Kampo medicine during the process of seeing many patients with whom F I G U R E 1 The Great Wave off Kanagawa, a Katsushika Hokusai woodblock print retrieved from http://www. 21j.jp/freef36/. western medicine cannot deal. We should think analytically about Kampo medicine. We have to fuse one's clinical experience with the wisdom of ancestors.

WHAT IS MEDICAL CARE?
What is the basis of medical care? The answer is how to capture the signals emitted by the living body. However, the way to capture the signals is different between western and Kampo medicine. In western medicine, a disease name diagnosis is required for medical therapy to acquire a medical insurance reimbursement. In contrast, a pathophysiological diagnosis is required for Kampo therapy. Western medicine is a science of disease, while Kampo medicine is a science of indication. In other words, western medicine is searching to find a drug that works, while Kampo medicine is pursuing how to make medicine work. Japanese Kampo medicine originally comes from classic Chinese medicine. This framework was introduced to Japan around the 5th to 6th centuries; after that, while inheriting past experience, repeating verification anew, and progressing in search of new developments, Kampo medicine has been developing. Japanese Kampo medicine is established by combining with the perspective of modern western medicine, and looks for what appropriate therapy is in accordance with the Kampo medical syndromes. Japanese Kampo medicine is a harmonious medical practice. In clinical practice the best way would be to fuse western medicine and Kampo medicine (Figure 2).
One of the predecessors of present-day Kampo medical practice, Takeshi Itakura, summed up the medical situation pretty well in a straightforward manner in 1928, one hundred years ago. He said western medicine is a science of disease, while Japanese Kampo medicine is a science of indication. Western medicine is searching to find a drug that works. In contrast, Kampo medicine is pursuing how to make medicines work. Western medicine and Kampo medicine stand in a different position.

TREATMENT TO AIM FOR JUST ENOUGH
The treatment principle of Kampo medicine is to aim for just enough. If patients show a shortage of energy, treatment attempts to make up for the shortage, that is, supplement. In contrast, if patients show a surplus energy, treatment is directed at removing the excess, that is, scratch (Figure 3).

ANALYTICAL CONSIDERATION OF HOCHUEKKITO
Hochuekkito, a traditional Japanese herbal medicine, has been used to treat persons with poor physical strength who are out of energy with a decline of gastrointestinal function and tend to become tired easily. If we prescribe hochuekkito, we should pursue how to make hochuekkito work. We would like to think of hochuekkito analytically. Hochuekkito is a collection of 10 crude drugs ( Figure 4): Atractylodes, ginseng root, Astragalus root, Citrus unshiu peel, Angelica acutiloba, Actaea simplex, Bupleurum root, licorice, ginger, and jujube.
Hochuekkito includes the crude drugs of ginseng root and Astragalus root. Kampo medicines including these two crude drugs are called ginseng root and Astragalus root drug groups, which aim to get rid of fatigue. Ginseng root, Astragalus root and Citrus unshiu peel make up for the energy shortage and distract the energy. Hochuekkito includes these three crude drugs. We may expect hochuekkito can make up for the energy shortage and distract the energy.
Actaea simplex, Bupleurum root and licorice exhibit anti-inflammatory effects. Hochuekkito includes these three crude drugs. Patients with poor physical strength who are out of energy usually have low-grade inflammation in the body. We may expect hochuekkito to exert anti-inflammatory effects and get well patients who are out of energy and tend to become tired easily.
The effects of hochuekkito on the inflammatory and nutritional states were examined in chronic F I G U R E 2 The fusion of western medicine and Japanese Kampo medicine.
obstructive pulmonary disease (COPD) patients [1,2] ( Figure 5). The left panel shows the relationship between high-sensitive C-reactive protein (CRP) and the degree of pulmonary obstructive impairment in targeted COPD subjects. This shows that when pulmonary obstructive impairment get worse, the blood level of high-sensitive CRP goes up. In the right panel, hochuekkito was administered to COPD patients for six months in the study group. The control group received the same treatment before participating in the study. In this study, high-sensitive CRP slightly decreased by treatment with hochuekkito for six months, suggesting that hochuekkito improves low-grade inflammation in COPD. It could be that the three crude drugs mentioned above are as effective as anti-inflammatory ones.
Similarly, the relationship between nutritional status expressed as pre-albumin and body mass index was examined. Pre-albumin is one of the indexes which directly reflects the nutritional status. The blood levels of pre-albumin are related to the body mass index. Body mass index was below 20 in around half of the subjects. This thinness stands out in COPD patients. In this study, in the study group pre-albumin increased after six months. We expect that three crude drugs, namely ginseng root, Astragalus root and Citrus unshiu peel, would be effective for improvement of nutritional status.
Other crude drugs included in hochuekkito show multidirectional effects such as improvement of fluid abnormalities, blood flow and gastrointestinal functions. Atractylodes improves fluid abnormalities. Ginger and jujube improve gastrointestinal functions. Angelica acutiloba improves blood flow. To summarize the effects of hochuekkito, it exerts pleiotropic effects, as shown in Figure 6. The principal aim of hochuekkito in Kampo medicine is to make up for the energy shortage when a patient is thin and weak. Treatment aims for just enough. Hochuekkito is a collection of 10 crude drugs, and each crude drug has its own effects. Hochuekkito exerts comprehensively its action through scientifically proven effects.

BASIC RESEARCH REVEALS UNKNOWN EFFECTS OF HOCHUEKKITO
Hochuekkito has been shown to be a virus entry inhibitor in rhinovirus-infected airway epithelial cells [3]. F I G U R E 5 The effects of hochuekkito on inflammatory state in chronic obstructive pulmonary disease (COPD) patients. After Shinozuka et al., 2007 [2]. CRP, C-reactive protein.
F I G U R E 6 Actions of crude drugs included in hochuekkito.
Hochuekkito contains Astragalus root and Bupleurum root. These two crude drugs have been shown to exhibit antiviral effects. Yamaya et al. [3] demonstrated the antiviral effects of hochuekkito. Airway epithelial cells were infected by rhinovirus R14, and a high concentration of hochuekkito was administered before rhinovirus infection in an in vitro study. Viral release in supernatants of human tracheal epithelial cells was measured. The change of viral titer was measured over time. This study shows that hochuekkito suppresses rhinovirus propagation.
In the process of establishing a rhinovirus infection, rhinovirus first binds to adhesion molecules (ICAM-1) in airway epithelial cells. To search for the mechanistic explanation of suppressing rhinovirus propagation, ICAM-1 mRNA and sICAM-1 protein were measured in infected airway epithelial cells. Hochuekkito suppresses rhinovirus receptor expression.
Hochuekkito exerts defense mechanisms against rhinovirus infection in multiple stages. Hochuekkito suppresses virus attachment, acid endosome, RNA replication, and inflammatory cytokine release.

CONCLUSION
Japanese Kampo medicine is a harmonious medical practice. Clinical practice with an investigative mindset is continuously required. We have to think at the same time about the disease name diagnosis in western medicine and the pathophysiological diagnosis from the Japanese Kampo medicine perspective. We have to judge the combined physical and mental conditions from the point of view of stillness and movement, since as human beings we are living with stillness and movement.