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ORIGINAL ARTICLE Table of Contents  
Ahead of print publication
The influence of Shanghanlun on Japanese Kampo medicine


1 Department of Traditional Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin 301617, China
2 Japan Institute of TCM Research, Mie 510-0091, Japan

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Date of Submission20-Apr-2021
Date of Acceptance21-Jul-2021
 

  Abstract 


Shanghanlun is a classic work in traditional Chinese medicine (TCM), which systematically discusses diagnosis and treatment ideas based on syndrome differentiation and records a large number of highly practical prescriptions. When Shanghanlun was introduced into Japan along with the communication between China and Japan in the Sui and Tang Dynasties, it had a profound influence on the development of Kampo medicine in Japan. By sorting out the works related to Shanghanlun in the medical history literature of Kampo medicine before the Meiji Restoration, this paper discusses the relationship between Shanghanlun and the Koho school of Kampo medicine, as well as the influence of the thought “formula corresponding to pattern identification,” originating from the Koho school, on the development of modern Kampo medicine. The study of Shanghanlun by Kampo medicine nowadays not only attaches great importance to clinical practicality but also has theoretical discussions. It is expected that future medical exchanges between China and Japan will complement each other from the perspectives of both sides and promote the theoretical and clinical development of TCM.

Keywords: Formula corresponding to pattern identification, Kampo medicine, Koho school, Shanghanlun


How to cite this URL:
Zeng LR, Zhang T, Wang HJ, Zhong K, Shao LL, Zhang GJ, Yasui H. The influence of Shanghanlun on Japanese Kampo medicine. World J Tradit Chin Med [Epub ahead of print] [cited 2022 Aug 8]. Available from: https://www.wjtcm.net/preprintarticle.asp?id=344545





  Introduction Top


Shanghanlun (also known as Treatise on Febrile Diseases) is a classic medical work written by Zhongjing Zhang during the late Eastern Han Dynasty. The work was passed down to the present day after compilation by Dr. Shuhe Wang in the Western Jin Dynasty, collection by Dr. Simiao Sun in his work Qianjinyifang in the Tang Dynasty, collation by the Office of Revising Medical Books of the Song Dynasty, and annotation by Dr. Wuji Cheng during the Jin Dynasty. According to Zhongjing Zhang's preface, the original book was 16 volumes of Shanghanzabinglun (also known as Treatise on Febrile Diseases and Miscellaneous Diseases), introducing the treatment of febrile diseases or miscellaneous diseases. Although the original book was lost, thanks to the people who compiled and revised it, the book was later divided into two books named Shanghanlun and Jinguiyaolue (also known as Synopsis of the Golden Chamber), which have been handed down until now. The two books had a profound influence on the medical circle of Japanese Kampo. This paper will discuss Shanghanlun as a theme.

Japanese Kampo medicine has its roots in traditional Chinese medicine (TCM). With the exchange of envoys sent to Sui and Tang Dynasties, more books on TCM were introduced into Japan, laying a foundation for the development of Kampo medicine in Japan. In the mid-16th century, Dozan Manase introduced Chinese medicine from the Ming Dynasty into Japan and spread it widely. At that time, Japanese Kampo medicine was basically consistent with Chinese medicine. However, when later Japanese doctors began to attach importance to Zhongjing Zhang's Shanghanlun, the Gosei School of Kampo medicine, originating from Dozan Manase, was replaced by the Koho School. It was also from the Koho school that the development of Kampo medicine began to distinguish itself from TCM and formed its own characteristics. However, even in its own right, more than half of the prescriptions commonly used in modern Kampo prescriptions were from Shanghanlun and Jinguiyaolue. From the perspective of medical history, this paper will discuss the influence of Shanghanlun on Kampo medicine.

The incoming of Shanghanlun to Japan

In 701 AD, the Japanese government enacted the Great Treasure Decree, which was modeled on the Zhenguan Decree of the Tang Dynasty. The law involves the medical system, on which the “Pharmacopoeia Ryo” (an institution for training medical and health talents) is established, and Xiaopinfang and Jiyanfang are designated as teaching materials for doctors to learn. By 737, the Tang Dynasty designated Shanghanlun as a textbook for medical students, while Japan did not make the same changes.[1] In Nihonkoku Kenzaisyo Mokuroku, written in 898, we can see the record of “Volume nine of Zhongjing Zhang.” Zhongjing Zhang's medical books should have been in Japan during this period. There are several references to Zhongjing Zhang's prescriptions in Ishinho compiled by Yasuyori Tanba in 984, but its relationship with the existing Shanghanlun remains unclear. Thus, we can see that Shanghanlun was not widely known in Japan during this period.

Since the end of the 13th century, the articles of Shanghanlun appeared in Japanese medical books, such as Honzoirohasyo in 1284 and the Book of Mananpo in 1315. The articles of Zhujie Shanghanlun were quoted in the book of Fukudanho, written around 1362. According to these sources, the time at which Shanghanlun was officially imported into Japan should be at the end of the 13th century.

The influence that Shanghanlun booms in China brought to Japan

The first boom led to the publication of Shanghanlun in Japan

The official revision and publication of Shanghanlun and Jinguiyaolue by the Office of Revising Medical Books of the Song Dynasty set off a great upsurge in the reading of Shanghanlun at that time. Subsequently, Anshi Pang's Shanghan Zongbinglun, Gong Zhu's Shanghanleizheng Huorenshu, Shuwei Xu's Shanghanfaweilun, and Wuji Cheng's Zhujie Shanghanlun appeared. After the works of this period were introduced into Japan, they promoted the publication of a series of reproductions.

In 1620, the first edition of Shanghanlun was published in Japan. This edition was based on Jichuan Wang's Zhujie Shanghanlun, which was printed on movable wood. Around 1660, the original text of Shanghanlun was published. The annotated parts were removed and only the original text was retained.

The following is a tabulation of the Shanghanlun published in Japan before the Meiji Restoration[2] [Table 1].
Table 1: Shanghanlun published in Japan before the Meiji restoration

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The second boom kicked off the rise of the Kampo Koho School

The second boom occurred from the late Ming Dynasty to the early Qing Dynasty. During this period, numerous research works were published, including Shanghanlun Tiaobian by Youzhi Fang, a reprinted edition of Zhong Jing Quan Shu by Kaimei Zhao, and Shang Lunpian by Chang Yu. These works were introduced into Japan in the early-to mid-17th century, and with the publication of the Japanese edition, an increasing number of Japanese doctors attached importance to Shanghanlun.

In Japan, in the 16th century, however, the predominant medical philosophy was that of the Jin-Yuan period in China, especially that of Dongyuan Li and Danxi Zhu, as promoted by Dozan Manase. During this period, Kampo medicine followed both the tendency of Chinese medicine at the time to emphasize theory and the use of prescriptions. The latter, after the flourishing of the study of Shanghanlun in the 17th century, laid the foundation for the evolution of the Kampo Koho school and, indeed, of present-day Japanese Kampo medicine.

The forming of the Koho School

Considering the historical background of the formation of the Koho school, we must mention the revival of Japanese Confucianism at that time. The mainstream of Japanese Confucianism in the 16th century was Cheng Zhu Confucianism of the Song Dynasty. At that time, Jinsai Ito, a Japanese Confucian, began to question whether Confucianism of the Song Dynasty violated the original Confucian doctrine. He advocated attaching importance to the ancient meaning of Confucian classics and formed the school of ancient Confucianism, which held up the banner of Confucianism restoring ancient ways. This retrospective trend also affected the medical profession, and medical practitioners began to focus on the Han Dynasty Chinese medical classic “Shanghanlun,” which led to the formation of the Koho school. To show the difference, the previously prevalent Song, Jin, and Yuan medical practitioners are called the “Gosei school.”

The following doctors played an important role from the beginning to the prosperity of the formation of “Koho School.”

Genyi Nagoya: The first medical scholar to study Shanghanlun

Genyi Nagoya (1628–1696) was familiar with the study of ZhouYi and read Chinese medical books throughout the ages. In the same period, when Jinsai Ito raised the banner of Confucianism, Genyi Nagoya was inspired by reading works written by Chang Yu and Yingmao Cheng in the Qing Dynasty and began to attach importance to the classic and study the medical classic Shanghanlun of the Han Dynasty. Genyi Nagoya advocated the medical thought of strengthening Yang and suppressing Yin and attaching importance to Yang qi, which greatly influenced medicine during the middle period of Edo. His representative works include Ihomonyo, Kinkiyoryaku-tyukai, Ikeisokai-syusyo, and Nangyotyuso.[3]

Konzan Goto: The successor of Genyi Nagoya who inspired the younger generation

Konzan Goto (1659–1733) observed the physiological and pathological phenomena of the human body from the perspective of “qi movement” and put forward the theory of “qi stagnate (Ikki-ryutaisetu).” Konzan attached great importance to the clinical experience. In addition to the classical prescription in Shanghanlun, he also used treatment methods such as hot spring and warm moxibustion or medicinal materials such as bear bile, chili, and others. His emphasis on clinical experience influenced his younger students, who were as many as 200. Among them, Shuan Kagawa, Toyo Yamawaki, and others, under the influence of Konzan Goto, emphasized both classic and clinical evidence and became important representatives of the Koho School.[3]

Shuan Kagawa: An animateur who advocated that “Confucianism and medicine are the same (Jyui-ippon)” and popularized Shanghanlun

Shuan Kagawa (1683–1755) studied under Jinsai Ito and Konzan Goto. He followed the former to read Confucius and Mencius, and the latter to read medical classics such as Huangdineijing, Nanjing, and Shanghanlun. It was this learning experience that helped him put forward the theory that “Confucianism and medicine are the same.” After fully understanding the way of Confucius and Mencius, he could also understand the basic principles of medicine. Just like his teacher, Konzan Goto, Shuan Kagawa also attached great importance to clinical practice. He could only accept medical theory and herbal medicine if they were proven to be effective in clinical practice and wrote his own understanding of works such as Ippondo-koyoigen. In 1715, Shuan Kagawa, who attached great importance to medical classics, removed the partial notes and contents about drug processing from Zhujie-Shanghanlun and published Shokoku-Shokanron, which greatly contributed to the popularization of Shanghanlun in the Edo period.[4]

Toyo Yamawaki: A representative of the empirical spirit of the Koho School

Toyo Yamawaki (1705–1762) was an outstanding student of Kozan Goto. Influenced by his teacher, he devoted himself to studying medical prescriptions before the Tang Dynasty, mainly about Shanghanlun. To explore the effective prescriptions of ancient sages, he reproduced Waitai-Miyao and emphasized on clinical experience by using formulas based on the “Shanghanlun,” especially as he had experience with using Sanchengqi Decoction. He also made the earliest academic anatomy in the history of Japanese medicine and wrote the anatomical records into Zoshi and published them. Toyo Yamawaki practiced the empirical spirit of Koho School.[5]

Todo Yoshimasu: The initiator of the idea of “formula corresponding to pattern identification”

Combining the contents of classical medical books with his clinical experience, Todo Yoshimasu (1702–1773) innovatively put forward the application method of prescription in Shanghanlun: A formula corresponding to pattern identification. Influenced by the revival of Confucianism, Todo began to reflect on the popular Jin-Yuan medicine at that time and then devoted himself to the study of the prescriptions in Shanghanlun. Creatively, he reorganized the provisions of Shanghanlun according to the method of “categorizing prescriptions by prescriptions” and wrote a book called Ruijuho, forming the thought of “formula corresponding to pattern identification” (Hosho-Sotai). Based on this idea, Todo wrote Hokyoku (Extremes of Formulas), Yakucho (Effect of Medicine), and other books through the experiences of testifying of the formula's effect by clinical experience (shinshi jikken). He also put forward the idea of “clinical attention to abdominal diagnosis.”[6] These works and ideas promoted the Koho school to flourish and had a profound influence on the development of Kampo medicine in Japan.

A view of Shanghanlun in the first half of the 19th century

The influence of Ruijuho

Todo Yoshimasu's representative work, Ruijuho, was the first to develop the concept of “formula corresponding to pattern identification.” Later, Japanese Kampo no longer attached importance to the analysis of etiology and pathogenesis but began to focus on how to use prescriptions better. Therefore, in the first half of the 19th century, Yodo Odai (1799–1870) added his own clinical experience in the form of notes to the Ruijuho and wrote the book Ruijuho-Kogi, which was also widely used by Kampo doctors as a therapeutic standard because of the expanded application of prescriptions in Shanghanlun.

The view of disease based on Shanghanlun

During this period, Kampo doctors followed the thoughts of the Koho school and still listed Shanghanlun as the most important medical book for study and research. Nanyo Hara (1752–1820), a medical educator at that time, asked his students to memorize the provisions of Shanghanlun and have a good understanding of the treatment of febrile diseases until they could grasp the correspondence between prescriptions and patterns and prescribe flexibly.

At that time, when facing diseases, Kampo doctors kept in mind the syndrome types of “Shanghanlun” corresponding to the diseases they observed and then gave corresponding prescriptions for treatment. Since the rise of the study of “Shanghanlun” in Japan, the view of medical diseases in Kampo has gradually formed.

The emergence of the Setchu school

At the same time, after Nangai Yoshimasu (1750–1813) proposed the theory of qi, blood, and fluid and interpreted his father's theory of “all diseases are due to poison” (Manbyo Ichidoku) closer to clinical application, doctors of Setchu school (a school that integrated the advantages of the Koho and Gosei schools) appeared in the Kampo medical field. They not only paid attention to the ancient prescriptions of Shanghanlun but also applied the prescriptions of Song-Qing dynasties flexibly.[7] Its representative doctors include Tokaku Wada (1744–1803), Nanyo Hara, Seshu Hanaoka (1760–1835), and Sokan Honma (1804–1872), who used a combination of western surgery and Kampo medicine. Sohaku Asada (1815–1894) crossed the Shogun-Meiji period.

Research books about Shanghanlun in Japan

Since the late 18th century, due to the increasing enthusiasm of Japanese medical scholars for the study of “Shanghanlun,” especially after the rise of Koho School, a large number of research works on “Shanghanlun” successively appeared. Among them, there are both practical books on clinical applications and a large number of textual research books. In the late Edo period, the school of textual research (Kosho school) began to be active, as did a number of famous textual research doctors, such as Motoyasu Taki, Mototane Taki, Motokata Taki, Naohiro Kitamura, and Ritshi Mori. They made full use of the well-preserved Chinese classical documents that have been brought into Japan, some of which are of better quality than those in China.[8] These studies of the Kosho school left behind many meaningful research books. The main books are as follows[2] [Table 2]:
Table 2: Research books about Shanghanlun from the 18th century to the Meiji Restoration

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Kampo Prescriptions from “Shanghanlun”

The National Health Insurance of Japan now includes 148 kinds of Kampo prescriptions for medicine, of which half are prescriptions from Shanghanlun and Jinguiyaolue [Table 3], and the rest are prescriptions from Heji Jufang, Wanbing Huichun, or Japanese experience prescriptions.[9] Because of its ease of use and effectiveness, Kampo prescriptions are not only widely used in Japan but have also begun to be used by China and other countries. To explore how the Kampo prescriptions for medicine formed, it should be traced back to the decline and revival of Kampo medicine in the late 19th century.
Table 3: 70 prescriptions derived from the “Shanghanlun” in 148 Kampo preparations for medical use

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The decline of Kampo medicine

In 1868, the Meiji Emperor established a new government. In 1869, the government stipulated the comprehensive westernization of medicine, and Kampo medicine gradually declined. In 1895, the Japanese Imperial Parliament rejected the proposal of “the revision of medical qualification rules” and “the continuation of medical practice by Kampo doctors,” which led to the end of the system of Kampo medicine. However, although Kampo doctors were not allowed to practice medicine at that time, Western medicine doctors were not prohibited from conducting the research, diagnosis, or treatment of Kampo medicine. This laid the foundation for the revival of Kampo medicine in Japan.

The three schools during the rejuvenation period of Kampo medicine

In 1910, Keijyuro Wada published Ikaino-tettsui (The Iron Hammer of the Medical World), which reflected and criticized the etiology theory of Western medicine and discussed the specialty of TCM. The publication of this book initiated the revival movement of Kampo medicine, and Kyushin Yumoto, who read this book, started to study Kampo from then on and formed the Showa Koho School, which interpreted the ancient formulas with the theory of Western medicine. Yumoto's Kokan'igaku and his disciple Yoshinori Otsuka also greatly influenced the study of Shanghanlun in China.

From the late Edo Shogunate to Meiji, there was a Kampo physician named Sohaku Asada who integrated the Koho and Gosei schools successfully. His students, who had learned Kampo and Western medicine, contributed their own strengths around Japan by integrating Western medicine and Kampo medicine. They prescribed formulas based on Shanghanlun or Gosei School with the thought of “formula corresponding to pattern identification.” Thus, Asada's Setchu school was formed and its representative physicians are Hakuso Kimura, Kosho Nakano, and Sogoro Niizuma.

The last important one is the Ikkando School. Its founder, Dohaku Mori, proposed the thoughts of “formula corresponding to pattern identification.” Based on his own clinical experience, he divided the habitus that was usually seen in clinical practice into three types: blood stasis type (Oketsu), viscera toxic type (Zodoku), and detoxification type (Gedoku). Among them, the detoxification type was treated separately according to different time stages of childhood, youth, and adulthood. For different types, the Ikkando school prescribed formulas mainly based on Shanghanlun and Wanbing Huichun, forming a unique habitus medicine of Kampo medicine.[10]

Three schools promoted the use of Kampo prescriptions

The doctors of the three schools helped Japanese Kampo medicine gradually get out of the predicament. The common prescriptions of the three schools, centering on the prescriptions of “Shanghanlun,” were widely used, contributing to the formation of modern Medical Prescriptions of Kampo. According to the data of Japan's “Pharmaceutical Industry Production Dynamic Statistical Yearbook” in 202,[11] the total production value of Kampo prescription preparations in 2019 reached 19.94 billion yen (about 11.9 billion yuan) which was the highest since 1976 when data statistics were available. Of the top ten prescriptions of Kampo preparations for medical use in terms of gross production value from 2013 to 2019, about six are from Shanghanlun. In 2008 and 2011, the Japan Kampo Medicine Manufacturers Association conducted a survey on the use of Kampo preparations. The results showed that about 90% of the physicians used Kampo prescriptions in their daily diagnosis and treatment, and 59% of them chose Kampo prescriptions as their first choice in the face of some diseases. The positive evaluation of the treatment effect and satisfaction also showed an upward trend.[12] Although there is no independent Kampo medical practice system in Japan, a large number of modern clinical experiences have been published through the clinical application of Western medicine, and there are many randomized controlled trials of Kampo formulations.[13] These findings further promote the development of modern Kampo medicines in Japan.

New researches on the Shanghanlun

The new Kampo schools

Before the Meiji Restoration, research on Shanghanlun by Japanese Kampo medicine started in the Koho school and flourished in the Setchu and Kosho schools. When Kampo medicine suffered the impact of Western medicine, a new generation of Kampo doctors formed a new school of Kampo medicine that integrated Western medicine and Kampo medicine. Among them, the most representative is the Showa Koho school, also known as the “Classical Koho school,” which was originated by Kyushin Yumoto.

There are two types of Showa Koho school: one, which was originated by Kyushin Yumoto, which attaches importance to the theory of “poison from qi, blood, and fluid” and illustrates Kampo medicine with western medical theories; another one affected by Todo Yoshimasu and Yodo Odai of Koho school, which attaches great importance to “formula corresponding to pattern identification.” The common points of these two types are (1) starting from Todo Yoshimasu; (2) taking the Ruijuho as an important reference book; (3) prescriptions are mainly based on Shanghanlun; (4) using the theory of “formula corresponding to pattern identification” to prescribe, without thinking about etiology and pathogenesis, based on traditional medical theory.

In the Heisei era, with the increasing number of doctors using Kampo in clinical practice and the further deepening of communication with China, Kampo medicine developed more characteristics on the basis of the Koho, Gosei, Setchu, and Kosho schools. For example, “Heisei Gosei school,” of which doctors integrated with the thoughts of modern TCM by referring to the unified planning textbook of TCM in China; “EB kannpo school,” of which doctors prescribe Kampo medication under the guidance of evidence-based medicine; and “Heisei Koho school,” of which doctors try to reinterpret the medical theory of Shanghanlun from the perspective of flow of qi and blood.

New researches on the Shanghanlun

The “Heisei Koho school,” represented by Yoichiro Ebe, interprets Shanghanlun from a new angle, which opens up a new way of thinking for the clinical application of Kampo in Japan.

Yoichiro Ebe examined clinical symptoms associated with defense qi and specifically expounded on the flow of qi and blood. From the perspective of physiology and pathology, he analyzed important patterns such as the Guizhi decoction pattern and Mahuang decoction pattern using the visual chart method and explained the effects of herbs commonly used in Shanghanlun and Jinguiyaolue from the angle of qi.[14] The publication of volumes 1–6 of Keiho igaku and Keiho yakuron and Keiho myakuron are of great importance to Kampo medicine, which has ignored the theoretical analysis.

Reflection: The influences that Kampo had brought to traditional Chinese medicine

The difference between Kampo medicine and traditional Chinese medicine

Throughout the history of the development of Kampo medicine, which has its roots in TCM, it has been successively passed down and developed by the Gosei school, the Koho school, the Setchu school, and contemporary doctors who switched from Western medicine to Kampo medicine after the Meiji Restoration, forming a therapeutic mindset based on the “formula corresponding to pattern identification,” emphasizing abdominal diagnosis, paying attention to physical constitution and prescriptions, and generally emphasizing the use of prescriptions over theory. TCM has been developed for thousands of years, and under the guidance of the core idea of treatment based on syndrome differentiation, it has a complete system of discriminating theory, method, prescription, and medicine, with a deep theoretical foundation and more flexible clinical application. Kampo medicine and TCM have the same origin but different streams, and the resulting differences are worthy of mutual exchange and discussion.

The influences Kampo had brought to traditional Chinese medicine

Medical communications between China and Japan have always influenced and promoted each other. After seven centuries of evolution, Shanghanlun, a classic Chinese medical book, has exerted a profound influence on Kampo medicine, and the latter, in turn, has influenced the theory and clinical practice of TCM. For example, the Kampo Kosho school has brought supplementary research to Chinese medical history and the thought of “formula corresponding to pattern identification” has inspired the thinking of prescriptions corresponding to habitus in TCM.[15],[16] Just as Professor Zailiang Zhang said after reading Keiho igaku,[17] “The stone from other mountains can be used as an expert on jade. I admire Yoichiro Ebe's efforts in the field of the study of the theories of the Classics and believe that Ebe's Keiho igaku will certainly have a positive impact on the study of the theories of the classics in our country,” we also hope that with the deepening communications, TCM and Kampo medicine can always draw on each other's strengths and bring better development for theoretical innovation and clinical efficacy.


  Conclusion Top


In summary, by sorting out the contents related to Shanghanlun in the history of Japanese Kampo medicine, we can see that the theoretical system of modern Kampo medicine and the mode of application of Kampo preparations originated from the inspiration brought by Shanghanlun to the Koho school of prescriptions. When we discuss how Chinese medicine practitioners nowadays should inherit and carry forward TCM well, reviewing the influence that Shanghanlun had on Japanese medicine may provide some ideas to solve these doubts.

Financial support and sponsorship

Program of “Collection and Arrangement of Ancient Chinese Medical Literature” supported by Tianjin Health Commission(ZX2021021); Undergraduate Teaching Quality Project of Tianjin University of Traditional Chinese Medicine (2021XLYX-20).

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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2.
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Kosoto H. New Edition History of Kampo. Japan: Taisyukan; 2014. p. 190.  Back to cited text no. 7
    
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Kosoto H. New Edition History of Kampo. Japan: Taisyukan; 2014. p. 200.  Back to cited text no. 8
    
9.
Nagase M, Tanaka K, Irie S. Commentary on all Kampo Prescription Available for Insurance. Japan: Tyugai Igakusya; 2018. p. 17.  Back to cited text no. 9
    
10.
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11.
Japan Kampo Medicines Menufactures Association. Pharmaceutical Industry Production Dynamic Statistical Yearbook; 2021. Available from: https://www.nikkankyo.org/serv/serv6.htm [Last accessed on 2021 Mar 19].  Back to cited text no. 11
    
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14.
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Correspondence Address:
Hiromichi Yasui,
Japan Institute of TCM Research, Mie 510-0091
Japan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2311-8571.344545




 
 
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