SEO
Search Engine Optimization. This is the golden lotus of internet marketing, the key to Google’s heart, the way to float yourself up to the top of page one on Google. If you have been in business for more than a year, then no doubt you’ve received phone calls from services that will “take you to the top” of a Google search. Or perhaps you have had a web developer try to sell you “optimization services” for your website. Or you have had confused conversations with friends about “this SEO thing” and worried yourself over if you are doing it right or not. Truth is, SEO is important. It is also true that paying attention to the most important 20% will get you 80% of Googliousness you are looking for.

What you don’t need
If you are selling some commodity on the internet, then yes, you do need to pay close attention to A/B testing results and whether a red “buy this” vs an orange “let’s do this” purchase button brings better results. But,  you are in business to create a relationship. You are not selling products, you are offering solutions to problems. You are not looking to make an impulse sale, you are looking to create a sustained connection. So you don’t need copy writing hype, you need to create an open door to the people who are already looking for you.

What it takes
There might still be a few people that use the yellow pages to find the services or products they want. But, even in the heyday of yellow pages, most people relied on connections and referrals for medical care. They still do. But, they also ask Uncle Google. And you don’t need a high priced company to make that introduction. With a minimal amount of effort, you can do it yourself. And I’m not talking about using Adwords or any of the other “pay for play” services that lure the hook of “first page of Google.”

Here are the three keys to page one of Google:

• A website with a blog
• Articles written plain English, directed at the kinds of people you want to treat
• Your address with postal code at the bottom of the page

The website
Wordpress is one of the leading platforms for building both websites and blogs. It’s free. It’s easy to use. It’s continually being developed and improved and it is very Google friendly. In another post we will take a look at the basics of setting up a WordPress site, but for now let’s just assume you use WordPress if not f your site, then at least for your blog. This is where you are going to draw the most interest anyway.

Important point– you want a domain of your own for blog and/or website. Blogspot, weebly, –need more free sites– are a problem for two reasons. First, because when you do step up to your own domain you will lose every bit of Google-juice you have worked so hard to build up. Secondly, you want your own domain because it looks professional. Part of being a pro is acting like one. And nothing says “amateur” like a free web address. Ever get a business card from someone and on the back it says “you too can get free business cards.” How did that make you feel about them as a professional? For less than the cost of a box of brochures you have your own domain. Do it!

The blog
Blogs run the gamet from angst ridden teenage tirades, to cardboard corporate attempts  at communication, to technical dissertations on someone’s unique area to interest, to insightful and informative articles on how Oriental medicine is the key to unlocking the conundrum of certain obstinate health issues. We will be looking at the latter.

Basically, when someone types certain key words into a search engine like Google, it is wanting to serve up websites that it thinks are relevant, worthy and useful to the reader. In service of this, search engines are constantly updating their lists of websites using a number of factors. These are:

• Keywords
• Frequency of postings
• Some other geeky stuff like “backlinks” that keeps certain people up at night, but for you and I, these can be dispensed with for the time being.

Worthwhile content is key
Search engines see sites that post often as having a certain amount of authority. Sites with authority get higher rankings. The more you write and post on your blog, the more search engines like Google will come to your site up date their records, and the more likely you are to show up in a search.

Now, it is one thing to get a good place on Google, and it is yet another to be a site worth reading. Ever stumble across a site you thought might contain the information you were looking for, only to find a page of half legible copy and links that point to nothing but ads? Welcome to the link farm! This is not what you want, and not what the people looking for you want either. So, the first thing to keep in mind is your reader. Once they get to your page, you want to be sure to provide them with content that is worth their time and attention. The key to doing this is to:

Choose a particular and narrow scope for your article
When writing avoid empty phases like “uses of acupuncture,” or “benefits of Chinese herbs.” Instead be specific and focused, “acupuncture for menstrual pain,” “Chinese medicine solutions for sinus headaches,” or “acupuncture in the treatment of diabetic neuropathy.” You want specific topics as the people searching for you will no doubt be typing these terms into their Google search. If you are also using these terms in your both your article and title, there is a better likelihood they will find you.

 Noteworthy point: You are NOT trying to get the top of Google with something like the word “acupuncture.” While that might bring more people to your site, it will not necessarily be bringing you the people that are actually seeking your services. Quality trumps quantity when it comes to getting patients via the internet. You are aiming for being at the top of the “acupuncture for acne” page in your area. That is where the fish are biting!

Provide useful on topic information
One of the best ways to create a connection with someone is to be helpful. Even if you have never met face to face. If you can create a connection and help them in some way, then a relationship has already begun to form. When you write on blog, be sure to include some useful how-to information along with what ever else you are writing. People seeking help want to feel like their practitioner is knowledgeable and available. Writing blog posts that both inform and give away some methods or ideas that can help them to stay out of your office sends a message that you are an expert in the field and in this to serve.

Stand in your patient’s shoes
If you were looking for help for a certain issue, what words would you be tappity-tapping into a search engine? Make a list of those words and be sure they get used 2-3 times in the article you write. Again, we are not looking for one of those mechanic reading pages that tells us nothing and leaves us cold with the feeling of wasted time. Write as if you were talking to the person for whom your blog post is intended. Ideally in your own voice, and with a focus how your skills and methods can help reader. Do not look to “sell” acupuncture, look more toward offering a solution to the patient’s problem.

How often should I post to my blog?
Ideally, once a week or at least twice a month. Ever clicked on what seemed like a promising link only to have it land on a website that was last updated toward the end of the previous decade? This tends to leave the reader with a sense that the owner of the website either does not care, or is not reliable. That is NOT the impression you want to give to the people searching for you. Regularly published fresh content not only tells the reader that you know your stuff and are generous in sharing it, but it also encourages Google and the other search engines to visit your site with their update robots more often. This means better ratings for your site. Fresh content = Authoritative website in Google’s book, and that means higher ranking.

In addition to all this, the more you write on your blog about the kinds of issues that you can help people with, the easier it will be for those potential patients to find you. Like fishing, you need to use the right bait, and the right bait on the internet are the keywords people type into a search engine in hopes of finding a solution to their problem. Write those blog posts and they will come!

In a nutshell, when it comes to SEO, focusing on the most important 20% will yield you 80% of the results you are looking for. That 20% involves these key items:

•  Have website with blog and update that blog on a regular basis
• Write articles that include the keywords that people would use when searching for you
• Write those articles in your own voice, and be sure to include some advice on how people can help themselves
• Be sure that your contact information is at the bottom of every page of your website.

Following this simple process not only floats you toward the top of page one of Google for a search that includes the keywords in your blog posts, but also has a tendency to make your phone ring with people seeking an appointment.

Junkyarddaist.com caught up with her recently over a glass of red wine to discuss meridian energetics and practical approaches to practicing the art.

Preface

Patients, colleagues and students often ask me how Kampo (also written Kanpo) 漢方 (lit. “The Chinese Method”) differs from other parallel traditions co-existing within the broad spectrum of East Asian Medicine (EAM), a term I have respectfully appropriated from a landmark text in the field of East Asian Studies (Lock, M., 1980).

My most concrete response is to explain that the term refers to both its cultural and textual origins deriving from Han Dynasty China (206 BCE – 220 CE), as well as to its discreet 1500-year practical evolution as a traditional medical system unique to Japan. Undoubtedly the most fertile and progressive of these historical currents of evolutionary development occurred during the Edo Period 江戸時代 (Tokugawa Shogunate, 1603-1868). It has, however, successfully re-emerged in the modern era as a significant force in contemporary mainstream Japanese healthcare, in spite of the most formidable challenge to its survival, Cosmopolitan Medicine (CM) [1] , whose ascendancy was triggered by the arrival of the first European anatomical texts in the 18th CE. For a more detailed historical account of this remarkable evolutionary process, refer to: Chinese Traditional Medicine In Japan (Otsuka, Y., in: Asian Medical Systems. Leslie, C., 1976).

In Japan itself, common terms of reference for Kampo have included: “Classical Chinese Medicine”, “Classical Formula Medicine” and even “Shang Han Lun Medicine”, (in reference to the herbal formulas predominating in Kampo practice which mainly derive from the Shang Han Za Bing Lun 傷寒雜病論 (Discussion of Cold Damage and Miscellaneous Disease) by Zhang Zhong Jing (150-219 CE). For the purposes of this discussion, I will simply refer to Kampo as: “Traditional Sino-Japanese Herbal Medicine”.

Of note, however, is that the term Kampo was originally used in the broadest sense to refer to any and all traditional medical practices deriving from the transmission, study and adaptation of traditional medicine from the Chinese mainland. This fact is illustrated in the pages of the oldest surviving Japanese medical classic, the Ishinpo 醫心方 (The Essentials of Medicine in Ancient China and Japan) by Yasuyori Tamba [2] , an extraordinary 30 volume account of all the many branches of Chinese Medicine that had reached Japan by its first publication in 984 CE. In contemporary Japan, however, the term Kampo is used to define the practice of herbal medicine in particular, having come to differentiate itself markedly from contemporary herbal practice in mainland China, which is generically referred to these days as Traditional Chinese Medicine (TCM) [3].

These differences are evidenced both in diagnostic methodologies and treatment styles. Thus, the aim of this article’s focus on some of the more salient characteristics that constitute such differences, and in so doing identify some of the more unique characteristics of the Kampo tradition.

Abstract

What is Kampo? What characterizes its contemporary and historical place within the pluralistic tradition of EAM as a whole? How does it differentiate, and identify, itself from, and with, the dominant current of the more enduring of these systems, namely TCM?

This short article is directed at these questions, and will identify methods of thinking, practice, and diagnosis unique to the Kampo tradition, as they differ substantially in style, content and emphasis from other traditions within the field of EAM.

In addition, this article highlights concrete examples of Kampo methodology from the perspective of a Kampo practitioner’s daily experience in the clinic. It attempts to identify key elements of the subjective process by which he or she goes about the business of collecting, privileging and interpreting clinical evidence that ultimately results in the selection of specific formulae for treatment.

Examples of essential practical components of this process include, but are not limited to:

1. The extensive and hierarchically privileged use of Fukushin (abdominal diagnosis) [4] in exercising clinical evaluation and judgment, and its critical role in formula selection and differentiation.
2. A strong diagnostic emphasis toward the inclusion of differential analysis of the patient’s Taishitsu (constitution) [5] alongside and often in hierarchical preference to that of the illness itself.
3. A deliberate, rigorous pursuit of empirical evidence, (in the form of signs and symptoms), used either to confirm or exclude a match between the unique clinical narrative of a given patient with that of a known classical formula “unit”[6] .
4. A bias for privileging empirical data derived from the practitioner’s direct sensory experience, as well as the patient’s own subjective account, expressed explicitly in the concrete language of signs and symptoms [7].

Cultural and Personal Bias

In reflecting on the perennial question of what exactly defines Kampo, I am increasingly aware that, despite its long, uninterrupted, and well documented role in Japanese medical history, (and more recently internationally), many aspects of contemporary Kampo theory and practice remain unfamiliar to even the most seasoned contemporary EAM scholars and practitioners, whatever their ethnic origin. In fact, misconceptions and erroneous assumptions abound. These include attempts to inaccurately define Kampo as, “Japanese patent medicine”, or, “allopathic herbal medicine”, or to explain its salient principles of practice through incorrect phrases like, “Kampo doesn’t modify formulas or use raw herbs”, or, “It operates like herbal homeopathy”. Such attempts are more likely to perpetuate myths rather than uncover truths about the nature of Kampo as a distinct and unique tradition within the pluralistic spectrum of EAM.

Certainly this phenomenon might in some way be accounted for by the historical chronology, and at times random manner by which many of the disciplines associated with EAM have come to penetrate other cultures, especially in the West. In Europe, as in the United States, acupuncture only began to trickle into the popular culture from the 1950’s, and has taken 60 years to claim a modicum of credibility and acceptance. As for the diverse practices of herbs and nutrition, bodywork, and the martial, movement, meditation, and geomancy arts, which have formed an integral part of EAM for centuries, these have only more recently begun to gain currency as potentially legitimate forms of healthcare and maintenance in the West.

The frequently anecdotal, and painfully slow transmission process of established traditional medical practices from East Asia into Western cultures is really quite remarkable. One only has to consider, for example, the appendectomy performed on one of Nixon’s aides, which involved the use acupuncture in the recovery process during the then US president’s historic visit to China in 1972, and its resulting impact on an amazed, skeptical and subsequently curious American public, to appreciate just how arbitrary this process of transmission has been.

In spite of a rich, scholarly tradition of textual translations of predominantly Chinese literature on the subject, notably by influential German and French authors dating from the early 19th CE, the impact of two millennia of documented clinical evidence and scholarly work in the field of EAM has largely been overlooked in the West. Even the unparalleled contributions to the field by the British historian, sinologist, and scientist, Joseph Needham, through almost the entirety of the 20th century, have done little to inspire any significant curiosity within medical or scientific circles about EAM and its potential implications for contemporary CM practice. Ironically, it has been in the social sciences during the last 40 or so years that such an interest has flourished and it has been the work of sinologists, amongst them philosophers, psychologists, sociologists, historians and medical and cultural anthropologists, who have offered the most noteworthy and stimulating insights into Asian medical systems. Significant examples include the multiple essays in: (Leslie, C., 1976) and (Leslie and Young, 1992) or in texts by: (Porkert, M., 1974) and (Unschild, P., 1988).

In the following discussion on Kampo diagnosis, I also point to aspects of inevitable bias necessarily associated with certain accepted terms. For example, the term Kampo 漢方(Han Fang) does not, and cannot, ever claim to have defined a single, homogenous thread of Sino-Japanese herbal medicine. From its very earliest beginnings in the 6th CE, differing currents of Japanese herbal theory and practice have evolved, some finding expression in major Tokugawa Jidai 江戸時代 (Tokugawa Period) movements, and others in schools such as the Koho-Ha 古方派 (Classical School), the Gosei-Ha 後世派 (Later Generation School ) or the Chusei-Ha 中世派 (Middle Way School). In more recent times, some M.D.’s and pharmacists, seeking to integrate traditional and modern understandings of medical practices, have trained and been licensed to practice Kampo in contemporary Japan.

There have been historic disputes between various camps over issues broad and specific. Broad, as in which textual sources should ideally inform clinical theory, and which styles of practice can claim more efficacy. Specific, as in whether or not Mengen (Healing Crisis) [8] is a necessary or avoidable part of treatment, whether Di Huang (Rehmannia Radix) even deserves a place in the herbal drawers [9], or whether detailed knowledge of meridians, flavors and the perceived energetics of individual herbs is even relevant to clinical outcome [10] . In identifying my own bias in this particular context I will note here that my views are mostly synonymous with those of the Modern Koho-Ha school of Kampo, in as much as my own training has predominantly been in this lineage, (specifically associated with that of Otsuka Keisetsu [11]).

Another source of bias is related to what I perceive as the limited sense in which I use the term Shin Dan 診断 (Diagnosis). I am only referring in this article to the Kampo diagnostic process, and more specifically to that deriving from the Koho-Ha Kampo tradition. This inevitably represents a rather narrow definition of only a single current of practice within Kampo, but more significantly it only pertains to the field of clinical practice itself. By that I mean, it does not refer in any way to a far broader potential definition of “diagnosis”, which might otherwise, and in other contexts, imply a far richer interdisciplinary, and intercultural, connotation.

The existence, extent and nature of these types of biases have only recently been brought to our attention in the clinical sciences by social, cultural and medical anthropologists, medical historians, clinical psychologists, and others working in the allied health fields. As the field of East Asian Studies expands, and that of EAM in particular, in the West, it seems to me a matter of critical importance for students, educators, and clinicians to pursue a more inclusive, inter-disciplinary approach to teaching, research, and practice as our profession matures. This is undoubtedly a topic for future research if we truly have the best interests of our patients at heart.

In the meantime, a quote from Arthur Kleinman, a prolific, and well-regarded cross-cultural psychiatrist, summarizes this point rather eloquently:

“Clinicians tend to be simplistic about clinical practice. Their tendency towards positivistic scientism and atheoretical pragmatism discourages attempts to understand illness and care as embedded in the social and cultural world. Their reliance on “Common Sense” often masks ignorance of relevant behavioral and social science concepts that should be part of the foundation of clinical science and practice. This is the reason social science needs to be brought into medicine and psychiatry as a clinically applied science that systematically analyzes the clinical relevance of sociocultural determinants on sickness and care.”
Kleinman, A. (1980). Patients and Healers in the Context of Culture. Berkley / Los Angeles: University of California Press, preface pp.xii.

The Kampo Diagnostic
漢方の診断 (Kampo No Shin Dan)

One might assume that in all medical traditions, a universal aim is to achieve sufficient understanding of, and compassion for, the patient, such that the practitioner might increase the chances of alleviating the patient’s suffering. Each tradition has sought to achieve this through its own complex and varied social and cultural mores.

In the field of Kampo, the practitioner focuses his or her skills in 2 primary clinical areas that ultimately form an inseparable bond between the arts of diagnosis and treatment. These two primary elements in the clinical process are symbolized by the patient, and by the formula prescribed to treat them. Both are linked in practice by the Sho (Proof) [12], perhaps the most fundamental of all guiding principles in Kampo practice. At the same time, they are distinguished from one another in that one is a known variable in the clinical interaction, the other is not, as we are about to see.

But before that, a quote from one of modern Kampo’s pre-eminent exponents will serve to underscore both the definition and the particular interpretation of the critical term Sho within the scope of the Kampo tradition:

“Simply speaking, the term sho can be added to the name of a Kampo recipe as a suffix, telling us in which instances a certain herbal recipe should be used. It is the correct sho that we seek in order to determine the treatment. In western medicine the name of the disease is determined according to symptoms, tests and lab findings, yet the naming of the disease does not decide which treatment is called for. Using Kampo methodology, one diagnoses on the basis of certain subjective and objective symptoms. In western medicine the name of the disease is diagnosed; in Kampo we diagnose that such and such a patient should be treated by a specific herbal recipe. The sho translates as a method of treatment, and not the disease name, so that determining the sho both labels the dysfunction and points to the appropriate treatment.”
Otsuka K. (2010). Kampo: A Clinical Guide to Theory and Practice. Oxford: Churchill Livingstone, pp.11

In this last part of the quote we can glimpse the most fundamental defining characteristic of clinical methodology in Kampo practice: that of simultaneously equating the discreet clinical signs and symptoms of the formula “unit” with both the treatment strategy and the diagnostic evaluation.

Let us now look at the two most critical, related, but, distinct expressions of clinical evidence or “proof” mentioned above.

Formula Proof
藥証 YAKU SHO (Yao Zheng)

The Formula Sho includes the rich gestalt of clinical signs recognizable to the practitioner, symptoms manifested or reported by the patient, as well as the perceived constitutional strength for which the formula is suited, (strong, moderate or weak), and the therapeutic level at which it is primarily known to function, (qi, blood or fluids).

For example, in broad constitutional terms, Gui Zhi Fu Ling Wan (Cinnamon Twig and Poria Pill) is considered a “blood formula for the moderate constitution”, whilst Tao He Cheng Qi Tang (Peach Pit Reorder the Qi Decoction) is a, “blood formula for the strong constitution”, and Si Wu Tang (Four Substance Decoction), “a blood formula for the weak constitution”. Further constitutional differentiations into “dry” types, who tend to be thin, tight and less cold, and “wet” types, who tend to have more lax and atonic adipose tissue, and to be colder, will follow. These differentiations remain, however, within the broad category of “blood formulas” as a whole. The same constitutional differentiation process is followed when considering the qi and fluid categories.

In turn, specific formula family groupings associate with constitutional categories and their sub-groupings. Thus, in the Kampo diagnostic process, empirical evidence derived from the clinical encounter is used to determine a formula for treatment, which in turn matches not only the pattern of disharmony related to that patient’s complaints, but also specifically their particular constitution.

Kampo treatment methodology is rooted in the formula “unit” itself. This “unit” embodies the narrative of perceived etiologic, and patho-mechanistic evidence that supports the practitioner’s proposed treatment principles and methods. In other words, the empirical diagnostic evidence, which constitutes the currency of any intelligent treatment rationale, already finds comprehensive expression in, and is clinically embodied by, a historical extant herbal prescription. This is why in Kampo, diagnosis begins and ends with the formula. It is in this sense that the formula “unit” is considered a “known” quantity. This explains Kampo’s pre‐eminent focus on attributing each formula with its own unique and comprehensive “proof of practice” or Sho (Zheng).

These formula “units”, often referred to as Jing Fang (Classical Formulas), principally derive from Chinese Han Dynasty sources, though also from Japanese Edo period works. What characterizes them most particularly is the thread of material composition and dosage, spun from a single spool and warped from their original textual origins across history and culture where we now find them, essentially unchanged, plied into the fabric of contemporary Kampo clinical practice.

Thus, the formula “unit” is the known variable in the treatment equation based upon its continuous documented clinical use through many centuries, and across several distinct East Asian medical traditions. Such extensive evidence-based knowledge [13] of the therapeutic effects of these formulas amassed over time and amongst varying patient populations, has led to the detailed clinical narrative, or “monograph”, used to characterize each formula in the Kampo repertoire, collectively referred to as the Sho.

Currently the Japanese Health Ministry licenses 148 such formulas, approved for sale by prescription since 1971, and eligible for insurance reimbursement (Watanabe, K., 2011). As part of contemporary mainstream healthcare, the Japanese government has established approved standards of education, clinical practice, and research in Kampo, as well as regulations for Good Manufacturing Practice (GMP) and Good Laboratory Practice (GLP) for Kampo formulas (Ishibashi, A., 2005). These have become the subject of extensive & rigorous clinical trials, and the Japanese Society of Oriental Medicine included 320 clinical trials between 1986 and 2008 in an evidence report of Kampo treatment (JSOM, 2009). These and other developments in the field have added to the widespread appreciation of Kampo amongst both medical professionals and the general public in Japan, thus recent decades have seen a revival of Kampo medicine accompanied by scientific reevaluation of its relevance to modern health care (Terasawa, K., 2004).

Patient Proof
體質証 TAISHITSU SHO (Ti Zhi Zheng)

If the Kampo formula is the “known” quantity, then the patient is the “unknown”, and it remains the task of the Kampo diagnostician to skillfully employ his or her sensory faculties to crystallize the clinical narrative into a match with a pre-existing Formula Sho.

The classics are unequivocal as to the relative clinical merits deriving from the clinician’s various sensory faculties; they agree, by and large, on a certain hierarchy amongst the 4 Diagnostic Methods 四診 (Shi Shin / Si Zhen).

Looking diagnosis 望診
(Bo Shin / Wang Zhen)

Literally, “that which strikes the eye”, is referred to as the “highest” skill in diagnosis. Otsuka Keisetsu in his text, Kampo: A Clinical Guide to Theory and Practice, (Churchill Livingstone. Edinburgh: 2010), describes this skill as the “ability to see beyond the person; to see what they are made for (of).” He continues: “Traditionally it is said that one who knows only by seeing is called a God” (Ibid. pp.15). He quotes the Plain Questions 素問 (So Mon / Su Wen ) as recording, “without fail one must observe the appearance of the patient and whether he is thick or thin (肥痩 Hi So / Hin Shu) to know if he is in the Deficient 虚証 (Kyo Sho / Xu Zheng) or Excess 実証 (Jitsu Sho / Shi Zheng) state” (Ibid. pp.15).

These observational references point specifically to the importance of assessing physical body types as well as affective and behavioral styles, along with other external visual signs including the complexion (Lit. “blood color”) 血色 (Kesshoku / Xue Si) and the spirit (also “mind” “heart” “god”) 神 (Shin / Shen).

In Kampo, the patient is visually assessed as predominantly a Qi Type 気証 (Ki Sho / Qi Zheng), Blood Type 血証 (Ketsu Sho / Xue Zheng) or Water Type 水証 (Sui Sho / Shui Zheng), each differentiated by certain specific observational and behavioral signs too complex for the scope of this discussion. Each category is then further classified into Strong or Healthy (Jobu) 陽証 (Yosho / Yang Zheng), Moderate or Ordinary (Futsu) 中証 (Chusho / Zhong Zheng), and Weak or Non-energetic 虚弱証 (Kyojyakusho / Xu Ruo Zheng).

These constitutional sub-categories, when applied to a given patient, are as significant a diagnostic determinant in Kampo, as patterns of disharmony (Byosho / Bing Zheng) or disease categories are in other traditions of EAM, or CM, respectively. For example, a Kampo practitioner’s primary clinical association with a formula such as Gui Zhi Fu Ling Wan (Cinnamon Twig and Poria Pill) will be, neither to its perceived general traditional therapeutic function (eg: blood cracking) nor to a potential specific allopathic indication (eg: uterine myoma), but rather to the precise constitutional type for which this formula is best suited (eg: moderate to strong blood type). This distinction has already been amply illustrated in Dr. Otsuka’s quote above (pp.9).

I will use myself as an example to make this clinical point. When I catch “cold” I present with the four primary signs and symptoms of the Taiyang Bing 太陽病 (Greater Yang Stage), as detailed in the Shang Han Lun (Treatise on Cold Damage): a floating pulse 浮脈 (fu mai), cold damage 傷寒 (shang han) or wind strike 中風 (zhong feng), heat effusion 发 熱 (fa re), and stiffness and pain in the head and nape (Mitchell, Ye and Weisman, 1999). The appropriate formula choice in Kampo will depend more upon a person’s constitutional strength than it will on any attempt to characterize certain symptoms in terms of their perceived pathogenesis.

For example, in Kampo attempting to differentiate Wen Bing (Warm Disease) from Han Bing (Cold Disease) by symptoms and signs alone is considered clinically unreliable. Comparing wind-cold manifestations with those of wind-heat in tabular format in a text book is all very well (Macioca, G.,1994), but its automatic clinical relevance is flatly rejected in Kampo practice for several reasons. Tongue and abdomen signs are considered unlikely to accurately record the process of acute illness progression, because changes at the Yin level (tissue tonus, color, shape etc) are thought to occur over relatively long periods of time. Similarly, an attempt at differential comparisons between symptoms, such as the relative intensity of the fever, aversion to cold, body aches or sweating, all depend on an accurate analysis of the patient’s constitutional strength, as opposed to some more theoretical framework.

Referring again to my own case as an example, I have found from repeated experience that Gui Zhi Tang (Cinnamon Twig Decoction), or any of its several derivative modifications from the Shang Han Lun (Treatise on Cold Damage), typically master my constitutional type of Tai Yang Stage disease. Even if I present with a pulse that is forceful, tight and floating, extreme joint pain, headache, and lack of sweating, I still am unable to tolerate Ma Huang Tang (Ephedra Decoction) based formulae. If I try, I sweat immediately and profusely, get more chilled, and often experience palpitations and occasional nausea or upper abdominal cramps. Why? Because in Kampo I am a moderate to weak constitution, dry qi type, whilst Ma Huang Tang (Ephedra Decoction) is for the strong constitution, wet qi type. For my constitutional type, Ma Huang (Herba Ephedra) both over-stimulates the yang qi, sending it upward and outward (palpitations and “speediness”), and temporarily dries out the Stomach fluids, (dry heaves and upper abdominal cramps). Interestingly, I can occasionally tolerate Ge Gen Tang (Kudzu Root Decoction) and its derivative formulas, as the Ge Gen (Kudzu root) is moistening for the Stomach, and the relative amount of Ma Huang (Herba Ephedra) is smaller in this prescription.

There are further sub-divisions of constitutional analysis and categorization that can be confirmed by both visual and palpatory examination such as:

Weak Gastro-Intestinal Types (Ichokyojyakusho)
Cold Types (Hiesho)
Counterflow Types (Nobosesho)
Nervous Types (Shinkeisetsusho)
Types who are Weak and Susceptible to TB (Senbyoshitsu)
Types who Tend Toward Excessive Sweating (Asekakisho)
Types who Tend toward Fatigue (Hirosho)

Each of these distinct constitutional sub-sets carries with it a unique symptomatic narrative, or Sho, which carries significant weight in the diagnostic process in Kampo. In fact, this extensive taxonomy of constitutional tendencies operates both within the popular culture in Japan as well as within Kampo circles. It forms an integral part of how illness is perceived, experienced, defined and treated in Japanese society (Ohnuki-Tierney, E., 1984).

This is partially because these classifications represent a broader understanding of the person as a whole: psychological, emotional, behavioral, physical, as well as influences from society and culture. Such detailed observational assessments serve to identify the corresponding formula category likely to best suit the patient’s constitution. The sheer range and variety of contexts in which one could compile empirical evidence to attempt a definition of the term “constitution” requires long-term, sophisticated, inter-disciplinary study and understanding. Relying on clinical “proof” alone will not suffice. This point seems to me critical to the successful realization of any of EAM’s aspirations for contributing to current and future global health initiatives. This is a current research interest of mine and I hope to return to it in future publications.

Touch Diagnosis 切診
(Setsu Shin / Qie Zhen)

One relevant example of Japanese cultural bias, accounting for its enduring significance in the practice of Kampo, is the symbolic significance of the Hara (abdomen) [14] (Ohnuki-Tierney E., 1984). The location of feelings within the abdomen, for example in the phrase hara ga tatsu (the abdomen stands up) meaning to get angry, or the description of character traits, such as hara no ookii (the abdomen being big), referring to someone who has a generous nature. Though sometimes translated as “mind”, the concept of Hara lends symbolic and concrete meaning to the way in which the Japanese privilege direct sensory experience that is, literally, “gut-felt”, rather than the more abstract “heart-felt” common in our own culture. A more morbid association in this regard compares the Japanese form of ritual suicide, in which literally the Hara kiri (the belly is cut), to some forms of suicide in the West, such as a bullet to the head. It also seems appropriate to point out that recent biomedical research regarding the physiology of emotions, long considered the exclusive product of brain chemistry, reveals that certain neurotransmitters are released in the gut, suggesting an interactive rather than an exclusive communication system for the experience of feelings (Pert C., 1997).

Thus, Fukushin (abdominal diagnosis), has come to dominate much of the practical diagnostic process in Kampo, and is perhaps the defining characteristic of this tradition.

The abdomen represents the body’s anatomical center, housing the vital organs as well as forming its myofascial and structural core. In Asian systems of medicine it is also the source of vital energy [15] , acting as a crucible for the mutual transmutation of acquired [16] and pre-natal essences [17]. It also represents a metaphysical cauldron in which the vital organs play a pivotal role, each acting as repository and catalyst for specific manifestations at the psychic and emotional level.

Despite abdominal diagnosis’ pivotal historical role in the development of EAM, its use in the modern clinic has dwindled outside of Japan, where, from the Edo Period [18] , acupuncturists, as well as Kampo and Shiatsu [19] practitioners, have developed highly sophisticated methods of assessing the abdomen in treatment.

In the 20th CE, various systems of abdominal assessment have emerged in modern Japanese EAM practices. In the field of Shiatsu, Masunaga Shizuto developed an abdominal diagnostic protocol and chart first published in Japanese (1974), and then in English (Masunaga, S., 1977). Denmei Shudo also included abdominal palpation references in his Meridian Therapy acupuncture text (Denmei, S., (1990) Meridian Therapy. Seattle: Eastland Press). And one of the very few acupuncture texts to be dedicated uniquely to the abdomen, which surveyed many traditions of clinical uses of the abdomen, but reflecting principally the experience of its authors deriving from the family style teachings of Nagano, Kawai et al. (Matsumoto, K., & Birch, S., (1988). Reflections on the Sea. Taos: Paradigm Publications).

In the field of Kampo, yet another tradition of abdominal palpation with diagnostic and treatment applications is that employed by modern herbalists (mostly MD’s) in Japan. These have included modern Koho-Ha systems, such as the 13 abdominal conformations of Dr. Otsuka Keisetsu (Otsuka, K., 2010), and others including Domei Yakazu and Terasawa Katsutoshi. These systems use detailed, and highly specific forms of abdominal palpation to obtain information directly influencing the selection of herbal prescriptions for treatment. Each Yakusho (formula conformation) in Kampo, therefore, has its own associated specific Fukusho (abdominal conformation), which consists of one or more findings, (including constitutional ones), that pertain exclusively to that formula alone. These modern expressions trace their roots to a primary Edo period source text (Inaba, K., 1800), and ultimately all the way back to the Shang Han Lun (Treatise on Cold Damage) itself.

For an example of such abdominal references related to a specific formula, I quote from Dr Otsuka’s text regarding the Sho (conformation) for An Zhong San (Calm the Middle Powder):

“Used for chronic progressive abdominal pain in a patient with Hiesho (cold constitution) due to Kyosho (weak constitution). The abdominal wall is Fukubu Nanjyaku Muryoku (flaccid and lacking in elasticity), there is evidence of Shin Ka Bu Shin Sui On (epigastric splash sound), as well as trapped gas in the intestines. This is similar to the Sho (conformation) of Da Jian Zhong Tang (Major Construct the Middle Decoction), though the peristaltic uneasiness seen here is not so intense, nor so extreme. In addition there is a rapid Shin Ki (pulsation) around the navel and at times stomach acid vomited up. There are aches and pains, primarily limited to the epigastric area, though there can be pain around the navel, or additionally, pain radiating from the lower abdomen towards the lumbar region characterized by a pulling or dragging sensation.” (Otsuka, K., 2010, pp.35-36)

In the broader context of Kampo practice, the typical language of formula narratives always begins with this kind of constitutional referencing, typically followed by the concrete clinical signs and symptoms characteristic of the Sho as a whole, which always includes abdominal references. So for example Kampo practitioners consider Xiao Jian Zhong Tang (Minor Construct the Middle Decoction) appropriate for the Kikyosho (weak constitution dry qi type) while Si Jun Zi Tang (Four Gentlemen Decoction) is for the Kikyosho (weak constitution wet type). The former will tend to suffer from middle jiao patterns of the yin deficient type, the latter of the yang deficient type. The formula Sho in each case will include its unique constellation of clinical signs and symptoms, which are carefully considered alongside its matching constitutional Sho when prescribing.

The Kampo literature is full of such extensive abdominal references in the clinical narratives of formulas and both patient constitutions and their patterns of disharmony are constantly characterized in terms of their associated abdominal findings. Indeed, amongst the many methodologies in Kampo practice as a whole, it is perhaps the abdomen, and its use in diagnosis and treatment, that most clearly stands out as uniquely Japanese in character.

Conclusion

In this article I have tried to introduce several aspects of clinical thinking and methodology in Kampo practice. In particular I have attempted to highlight ways in which cultural bias in Japan toward empirical over abstract evidence extends very naturally and explicitly into the realm of medicine.

Many of the distinguishing features of Kampo, for example, including the practice of constitutional and abdominal diagnosis discussed in this article, reflect this empirical bias and have tended to subjugate the role of abstract theoretical methods of constructing evidence in the clinical setting.

Additionally, and by way of comparison, TCM emphasizes the traditional concepts of East Asian natural philosophy, such as yin and yang, and five-element theory. Japanese Kampo favors diagnostic methods that directly relate the symptoms to the therapy, bypassing speculative concepts (Watanabe K, 2011).

Perhaps the most concrete example illustrating the unique flavor of clinical methodology in Kampo is the manner in which the formula itself functions as the diagnosis, and serves to identify the etiological and pathological mechanisms through its Sho rather than through abstract philosophical language. This simplifies the process of matching the treatment method to the patient presentation, a fact that not only avoids unnecessary complication for the clinician, but is ultimately more attractive and comprehensible to the patient. The fact that the patient’s subjective complaints, however seemingly obscure, matter to the clinician, and that their constitutional tendencies are factored into the treatment equation, appeal greatly to the suffering individual.

Such a process is less hierarchical, more inclusive, and provides for a much-needed sense of mutual trust and collaboration in the therapeutic interaction. In this sense Kampo offers an individualized system in which empathy and empowerment are considered of equal importance in the healing process as the medicine itself. In these days of insurance-driven, protocol-orientated treatment where we are encouraged to see ourselves as service “providers” and our patients as “consumers”, it is comforting, at least for me, to keep in mind the human and ethical dimension of clinical work, as well as its medical value.

Lest we think such reflections are the exclusive concern of those in the so-called “alternative” medical professions, it is comforting to note that there is equal concern and debate amongst senior clinicians, educators and researchers in the Cosmopolitan Medicine community on just such matters (Hartzband & Groopman., 2011).

Endnotes:

[1] I am co-opting this term to collectively refer to the practice of allopathic medicine internationally, based on a compelling treatment of the subject in the landmark text: Leslie C. (1976). “Asian Medical Systems, A Comparative Study”, in the Introduction (pp. 6-8). Berkley: University of California Press.

[2] Tamba, Y. (1986). Ishimpo: The Essentials of Medicine in Ancient Cina and Japan. Boston: Brill.

[3] Recent history leaves us in little doubt that it has been the People’s Republic of China (PRC) that has most convincingly managed to stamp its particular brand of EAM on the minds of many across the globe. Most people in our field today, no matter their ethnic origins, would likely identify the prevailing contemporary force amongst the diverse range of surviving authentic traditional medical lineages in East Asia, as that of TCM. It remains however the case that this particular iteration of the long tradition to which it belongs, dates only from the early 1950’s. It is indeed in many respects “the new kid on the block”. Others have remarked on the supreme irony in the appropriation of this particular acronym to describe such a recent phenomenon (Scheid, V., 2002 & 2004) and (Freuhauf, H., 1999). Others still have noted the potentially destructive effect on the pluralistic nature of EAM as a whole by the exclusivist pretensions of any single hegemonic force within the field (Fuyuno, I., 2011).

[4] Any and all references to abdominal patterns in this article belong to the modern Koho-Ha (Classical) lineage of Dr. Otsuka Keisetsu (see xi below). His seminal Kampo text (Otsuka, K., 2010) includes a section on Fukushin, though without doubt the definitive reference on this topic since its publication in 1800 remains a text, written in the typically terse style of the Koho-Ha school by Inaba Katsubunrei: the Fuku Sho Ki Ran (Extraordinary Patterns of Abdominal Diagnosis). This text, considered the preeminent neo-classical source for abdominal diagnosis in Japan, systematically identifies an abdominal pattern for each classical formula listed with distinctive Edo Period illustrations. These illustrations were later reproduced in a modern herbal text by a prominent Taiwanese doctor, and student of Dr. Otsuka’s (Hsu, H-Y.,1980).

[5] The concept of Taishitsu (constitution), literally meaning the “root of a person” 体質, is critical to the practice of Kampo. It is referred to variously in terms of yin, yang qi, blood and fluid body types (Otsuka, K., 2010) and strongly influences diagnosis of the patient and formula prescription, each of which is seen as being appropriate for a certain constitutional type. The unique concept of Jibyo (my illness), related to one’s own constitution, is embedded in the Japanese culture at large. It manifests in everyday descriptions characterizing someone’s personality and physiology as for example: ijaku (weak digestion), hirosho (easily tired), hiesho (easily cold), nobosesho (a tendency to flush or become anxious) or shinkeisetsusho (hyper-sensitive), (Ohnuki-Tierney, E., 1984).

[6] Usually referred to as Jing Fang (Classsical Formula). In Kampo this unit is referred to as the Yakusho (Formula Conformation).

[7] This highly pragmatic approach to clinical work in the Kampo tradition has been commented on extensively in the literature and is symbolic of a broader cultural bias toward implicit trust in practical rather than logical evidence. This is clearly exemplified in a familiar Edo period proverb (Buchanan, D., 1987): Ron Yori Shoko (Evidence is more powerful than logic) which functions in some sense as a kind of “mantra” for many of the martial, fine and healing arts of Japan (Dawes, N., 2012).

[8] For more on this topic refer to: Dawes N. (2012). Mengen; Perspectives on the role of Healing Crisis and its place in clinical practice. junkyarddaoist.com, articles.

[9] To appreciate this statement in context, refer to: Otsuka K. (2010). Kampo: A Clinical Guide to Theory and Practice. Oxford: Churchill Livingstone, pp.2.

[10] In the Koho-Ha (Classical) tradition of Kampo these claims are considered overly theoretical and of little practical use in clinical work. This explains Kampo’s preoccupation with classical formula matching as opposed to the compounding of individual herbs in practice. Moreover, the fact that many of the theoretical tenets of TCM, deriving from Daoist and Confucian philosophy are not immediately apparent in Kampo provides further evidence of the philosophy of Ron Yori Shoko (see endnote vi above).

[11] For a biography of Dr. Otsuka and his lineage, refer to: Watanabe K., Notes from Japan. In: Otsuka, K., (2010) Kampo: A Clinical Guide to Theory and Practice. Oxford: Churchill Livingstone.

[12] 証 Sho (Zheng). There are multiple translations for this term including: “Conformation” (Hsu H-Y, 1980), “Pattern” (Kaptchuck T, 2000), “Presentation” (Mitchell et al., 1999) and the ubiquitous “Syndrome” (as used throughout contemporary TCM literature). I prefer the term: “Proof” as in the empirical evidence used to define a given entity eg: Patient proof; Formula proof; Diagnostic proof etc.

[13] There is a wealth of relevant reference material detailing contemporary CM opinion on the topic of Evidence-based Medicine (Sackett, D., 2000) and (Chalmers, I., 2011) and related discussion of the importance of clinician-based empirical judgment alongside and at times in preference to lab-based data (Hoffman, I., 2009), (Hartzband & Groopman, 2011).

[14]  Usually translated as “heart”, “mind” or “belly”, thus symbolizing the totality of human experience on an intellectual, emotional and psychic level.

[15] Seiki 生気 in Japanese (Sheng Qi). According to the Ko Tei Nai Kyo 黄帝内経 (Huang Di Nei Jing) the Yellow Emperor’s Classic of Internal Medicine, this emanates from the “space between the Kidneys”, roughly in the area of the points Ren 6 (“Sea of Qi”) and Ren 5 (Front-Mu point of the San Jiao) on the midline of the abdomen below the navel. The entire lower abdominal area is often energetically referred to as the Tan Den 丹田 in Japanese (Dan Tian in Chinese) meaning literally the “Cinnabar Field”, an alchemic reference to the notion of transmutation, like a furnace or kiln where solids, liquids and gases are exchanged and transformed, a kind of energetic generator or power house. More generally however, both in the martial and healing arts traditions, this area of the lower abdomen as both a physical and psycho-emotional center is referred to as the Hara (Japanese). Often translated interchangeably as “belly”, “mind” or “heart”, in Japan at least, this term is also strongly associated with the corresponding area of the lower back or Koshi, an equally powerful source of vital energy (especially linked with libido and sexual power). Thus, consistent with Oriental Medicine theory, there exist complementary Yin and Yang aspects of this notion of vital energy which, together, are linked with the vital core of the body front and back, internal and external, physical and metaphysical.

[16]  Sometimes referred to as “Post-Heaven Essence”, derived from the combined environmental resources of food (all nutritional substances transformed as part of the digestive process governed by the Spleen/Stomach) and air (primarily oxygen absorbed by the Lungs).

[17] Sometimes referred to as “Pre-Heaven Essence”, derived from ancestral genetic material and housed in the Kidneys.

[18] Edo Jidai 江戸時代 (1603-1867), the so-called “Golden Age” of Japanese culture during which there were many original developments in the field of traditional medicine including extensive research and application of abdominal palpation in diagnosis and treatment.

[19] Shiatsu 指 圧 Literally means “Finger Pressure” in Japanese. Derived from the traditional massage and breathing exercise system of Japan, Do In Ankyo, focusing on the application of static pressure applied to the meridians and points to regulate energetic flow as well as gentle stretches and manipulations that restore harmony to the system.

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