Reflections on Chinese Medicine's Future from the Trajectory of Japanese Kampo
Japanese Kampo medicine is the traditional medicine of Japanese character that grew out of Chinese medicine and pharmacy nursed in Japanese culture. It once flourished, but is now in gradual decline. Those of us in the Chinese-medicine world ought to study the reasons for that decline and take its lessons to heart — to avoid the same fate.
The rise and fall of Kampo
As early as the Sui-Tang period, Chinese medicine and pharmacy had been transmitted to Japan; by the 8th-century Nara period it was set as Japan's orthodox medicine. Over the next 1,200 years, under Japanese cultural nursing, it gradually formed into Kampo, with its own Japanese character; a number of famous physicians and lasting works emerged, exerting no small influence on later Kampo and Chinese medicine alike.
Yet through the more than hundred years since Japan's Meiji Restoration, as Western culture and science were transmitted in, Japan saw a strong tendency to slight and reject traditional culture. From 1873 onward, a series of laws and policies were enacted with the aim of wholly denying Chinese traditional culture and science — cutting Kampo off at the root. From then on Kampo failed to rally, shrank from its leading status, and went into difficulty and decline.
In recent years, with the return to nature wave, Kampo began to revive after the 1980s: more practitioners doing clinical and experimental research, research institutes formed, and especially a fast-growing Kampo-pharma industry on high-tech foundation — Japanese Kampo products take the bulk of global TCM-product exports. But for a Kampo that had been gutted, full recovery is far from easy. Among many Japanese, "Kampo doctor" is a past-tense notion — a distant memory. I once visited a city in northwest Japan; among more than twenty hospitals, not one Kampo hospital, not one Kampo pharmacy. I saw a shop with a Kampo XX banner and walked in eagerly — it turned out to be a health-product store. When I asked colleagues in the field about Kampo, I got either blank looks or apologetic shakes of the head. Public recognition, practitioner recognition, and society-wide popularization are the basic gauges of whether a thing is thriving. What I saw was only a local slice — a not-small slice — but it reflects part of Kampo's actual state.
Reasons for Kampo's decline
No doubt the entry of Western medicine and the down with Kampo, up with the West policies of the past hundred years' Japanese governments brought disaster — the direct cause. But the deeper cause, I believe, lies in problems within Kampo itself.
1. Emphasizing the practical, slighting the theoretical — drugs survive, medicine dies. Chinese culture is vast and deep; the TCM theory built under its guidance is the basis on which Chinese medicine lives and thrives. Japanese culture started later; the medical-figures' command of literary Chinese was limited; the true meaning of Chinese culture and TCM was hard to grasp. So from the start, Japanese physicians absorbed therapeutic experience while neglecting fundamental theory; over the next thousand-plus years of Kampo development this never broke free. Many of the most influential Japanese medical figures' works contain no discussion of zàng-fǔ (storehouses), jingluo, etc., focusing solely on disease treatment. The Tanba Yasuyori Ishinpō, Wake Hiroyo's Yakukei Taiso, Abe Manao's Daidō Ruijuhō, Kajiwara Shōzen's Ton'ishō and Man'anpō, and the like, were mostly compiled with reference to Chinese formula books. Yoshimasu Tōdō, the Edo-period figure later raised as Kampo's banner — a representative of the Ancient-Formula school — went further: he slighted medical theory, denied the existence of jingluo and qi, denied the disease-causing role of the six excesses, the seven affects, diet, and overwork. Given his immense influence, this thinking sowed deep trouble for Kampo's development.
Theoretical medicine is the basis of clinical medicine; without scientific theory to guide, any clinical practice is blind and without future. The thinness and rootlessness of medical theory is the deep cause of Kampo's decline. The contempt for theory caused TCM's life-giving foundational theory to wither in Japan; what remained was only formulas and drugs, both alienated from their root. Drugs survived; medicine died.
**2. Emphasizing "formula-symptom matching," slighting biàn zhèng lùn zhì — losing the very ground of being.** Biàn zhèng lùn zhì (pattern-discernment and treatment) is the basic character of Chinese medicine, the root of its excellent results, the fine tradition of millennia. To throw it away is, in fact, to throw away Chinese medicine at its root.
From the late 16th century, Kampo gradually split into three schools — Ancient-Formula, Later-Generation, and Eclectic. The Ancient-Formula school has held the lead from then to now, mainstream in Kampo. It advocates exclusive reverence for Zhang Zhongjing, the use of ancient formulas, and formula-symptom matching as its basic clinical thinking. But the symptom (zheng) of which they speak has nothing to do with TCM's authentic zheng (pattern): it contains no element of cause or mechanism — only a symptom or a cluster of symptoms, a "syndrome." Nor is it Zhongjing's decoction-pattern concept. Their "formula-symptom matching" is in no way TCM's discern the pattern, seek the cause, treat by the cause — only the selection of a formula by symptoms, with herb-additions by symptoms. Far from what Zhongjing built. In the past fifty years, Japanese scholars have advanced from "formula-symptom matching" to formula-disease matching, pushing Kampo deeper into a zone that on the surface looks half-TCM and half-Western, but in substance is neither. If Chinese medicine treats disease without pattern-discernment, what character does it have left? Without its root of being, how can it sustain itself? No wonder some scholars say: the regression from "formula-symptom" to "formula-disease" is Kampo's "last supper" — pushed into the non-Chinese-non-Western zone.
3. Emphasizing political contention, slighting self-improvement — putting the cart before the horse. A natural science's revival and development have close ties to its social and political surroundings, but the decisive driving force comes from within the discipline. External propping cannot last.
After Meiji-era Japan's Westernize, eliminate Kampo policies, Kampo did not respond by defending the scientific frame that TCM's foundational theory had set — a frame that Western medicine cannot replace. It did not contend academically over TCM's scientific character. It did not deeply self-reflect on its own development problems and turn course to fit a developing society. Instead, in the posture of defeated troops, it launched petition after petition, hoping by political means to restore its lost orthodox status, and resolved to compete in treatment with Western medicine head-on. This cart-before-horse approach did not win back former glory; it ended with "without government approval, no Kampo physician may use Kampo formulas" — tragic indeed.
Worth deep thought: Chinese TCM
A hundred-year history of Japanese Kampo's rise and fall is, for us, a thought-provoking textbook. Domestic colleagues ought to reflect deeply. Some of what happened to Kampo yesterday is quietly creeping in among us.
Since founding, the state has set down a series of correct guiding policies — e.g., the 1980s constitutional clause on developing modern medicine and our traditional medicine; the 1990s health-work guideline of equal stress on Chinese and Western medicine — all giving TCM strong protection, with marked results in inheritance and development. But to avoid Kampo's fate, TCM must hold self-respect, self-regard, self-strengthening — and keep raising its theoretical level and clinical capacity. As things stand, some young TCM doctors disdain TCM foundational theory; in the clinic they reach for new Western drugs; faced with a difficult case, they do not seek a path through biàn zhèng lùn zhì but instead circle within Western methods. The result is neither-Chinese-nor-Western. If it goes on, how will TCM's academic theory and clinical experience be carried forward? If our TCM hospitals are full of such doctors, where is TCM character? The future of TCM as a whole — does it not give serious concern?
A second worrying trend is the runaway development of TCM proprietary medicines. In recent years thousands of horses charge in at once, new patent medicines pour out, ads cover the sky. By one report: 1,020 TCM proprietary-medicine enterprises in 1998, output 33.49 billion yuan, more than 8,000 product specifications. Behind the cheer the question is: can a proprietary medicine fit a clinical picture that is complex and changing? Many proprietary medicines even claim to "treat many diseases without pattern-discernment." How much TCM spirit of biàn zhèng lùn zhì is left in that? How is it different from Japan's formula-symptom matching? More worrying still: driven by commercial interest, some ads exaggerate efficacy unaccountably — this can only erode society's confidence in TCM, lower people's trust and recognition. The final state will be no different from Kampo's.
Science's continuing development has been steadily proving TCM theory scientific. So TCM research methods should not be limited to Western-medicine verification; we should use modern science's new thinking, new theory, and new methods to study traditional TCM theory and rich clinical experience. To try, with a single Western-research method, to probe traditional TCM theory and to fit TCM theory and clinic into a Western frame — that is exactly one of the main causes of Kampo's fall. Yet at present, this method is not only used by Western medicine to study TCM; some TCM people also use it as their main basic-theory research method. To require, after clinical practice has repeatedly verified effectiveness, that animal experiments be done in reverse — does that not put cart before horse? To research TCM, with its complex multi-herb compounds, by the method designed for single-component Western drugs, may well not be ideal. The time has come to change course on TCM research methods.
TCM's development needs government support and society's help — but should not rely on them. TCM must self-respect, self-regard, self-strengthen, take Kampo's fall as warning. Value the inheritance and sorting of traditional theory and clinical experience; with new thinking, new methods, new technologies, conduct comprehensive research. If TCM colleagues unite, work hard with clear aim, a bright tomorrow is sure to come.
Originally in China TCM News, 31 March 2003
Chinese Physician Edition, Issue 5