Toho (emetic remedy) is one of the three distinctive remedies in the traditional Chinese/Japanese medicine as well as kanpo (perspiratory remedy) and kaho (purgative remedy). It is a treatment based on a medical philosophy of taking evacuant to eliminate toxin out of the human body to recover his/her physical condition. We can see its source in the Huangdi-Neijing-Suwen and the Shanghanlun in ancient China, then subsequently in the Jin dynasty (1115-1234), Zhuang-zihe (1156-1228) described it evidently in his Ruwen-shiqin.

In the Edo era Japan, it was one of the most distinctive medical remedies in the traditional Japanese medicine those days, so called “Kanpo”. I have already surveyed it in the other papers [1-12]. In the Edo era Japan, it is alleged that Okumura Ryochiku?1689-1761?is the pioneer of this medical technique, and after him, his disciples Nagatomi Dokushoan?1732-1766?Ogino, Daishu?1737-1806) and Tanaka Hitsudai?1725-1801?trailed him both in practice and theoretical formulations.

At the same time, Emi Sanpaku?1707-1781?implemented it in his own method. However, it was extremely high technique for the followers. Therefore, we cannot find any further practitioners in his school after him then, Nakagami Kinkei?1744-1833?integrating attainments above, established this treatment as one clinical method of his entire treatments. Though his achievement was also enormously high for his apprentices to follow, they efficaciously succeeded just a part of it. He was so much wide open. Kako Kakushu?1776-1832?was one in practice, and Kitamura Ryotaku?18-19 century) was another one predominantly in the treatment of psychiatry and tried a theoretical formulation. Finally, Watanabe Kun’yo?19 century) described those phases almost at the end of the Edo ear in his brief work.

We should learn not only the philosophy but also ingenious techniques from them for our medicine today. Among them Nakagami and his disciple Kitamura’s clinical practice and medical philosophy of this remedy convey us beneficial insight today since their works are full of clinical experiences. Therefore, they are most theoretical and precise among all. Accordingly, I would take their works to perceive the intrinsic essence so that we may adopt their insight to our medicine today.

As I alluded above, Toho (emetic remedy) is one of the three distinctive remedies in the traditional Chinese/Japanese medicine, in the Edo era Japan as well as kanpo (perspiratory remedy) and kaho (purgative remedy). It is over 200years ago that this remedy was adopted in the clinical practice. However, it is not a past memoir. We have much to learn from this classical remedy. Now I will clarify its significance in this modern world first taking Nakagami’s medical works [13-17] first to survey his all-round clinical practice and medical philosophy including Toho as a preliminary one step to Kitamura’s rounding up work of Tohoron [18].

Here I enrolled those materials of Nakagami’s writings Seiseido-zakki (Nakagami’s notes on medical practice and philosophy), Seiseido-yoseiron (Nakagami’s theory of helth care), Seiseido-chiken  (Nakagami’s treatments), Seiseido-itan (Nakagami’s talk on medicine), and Seiseido-shokan’yakugen (Nakagami’s commentary on Shanghanlun) [13-17] , all of which are actually records of Nakagami’s words and teachings noted by his disciples, but are indubitably the most unswerving materials for us to illuminate his remedy and philosophy of medicine. I have taken an overview on them philologically to clarify his remedy practically, then I considered his philosophy of medicine before. Subsequently, precise descriptions on them are omitted here. 

And then, Kitamura, Ryotaku’s emetic remedy is depicted in his work Tohoron (theory of emetic remedy) [18]. In this volume, Kitamura particularly described his implement of this remedy on those patients suffered from psychiatric diseases or neuroses. We can find some medical reason why he could get such prosperous result exclusively in such field of clinical practice. I would describe it afterward.

Consequently, I will take this work to perceive the fundamental idea and the theory of Toho so that we may learn medical philosophy for us today.

Nakagami’s freewheeling, and all-round emetic remedy:

1. Diagnosing a patient as Kyokan (irascible temper), he administrated his “household” for emetic/purgative Kateisan, a formula mainly composed from galenical, Katei (Cucumis melo, calyx of Oriental melon), and traditional Shanghanlun formula for febrifuge/sedative, Byakkoto plus Ninjin (Panax jinseng) and Oren (Coptis rhizome) of neuraxon/restraint.
2. Also for Kyokan, after Kansui (bathing), administrated the Shanghanlun formula for diaphortic, Maoto.
3. For a patient who was running around his home, screaming and bit someone around him, Nakagami took acupuncture and administrated a Shanghanlun formula as a sedative, Tokakushokito.
4. For a patient who got into temper and screamed, he administrated a typical ataractic in the Jinkuiyaolue, Kanbakudaisoto.
5. For a patient who got angry to lie heavy on his stomach and got asphyxiation to clenched his teeth, Nakagami took Shanghanlun formula for ataractic,
6. Diagnosing a patient as Honton (hysterical neurosis), he administrated his own choice of Bukuryokeishikanzodaisokadaioto, and his household intensive, Han’igan found in his own medical notes, Seiseido Nakagami Kahojuku.
7. For a psychoneurotic of Kowakubyo (bewitched by a fox), he administrated Shanghanlun formula for antidiarrheal/intestinal disorders Kanzoshashinto.
8. For a ten-year-old child who was depressed in low spirits, he took Ryokakusan, which is a typical purgative formula for pyretolysis/detoxicant in the Hejijufang plus his own formula of Kingyokugan.
9. For a person with too much laughter, Kateisan.
10. Sometimes he held his patient’s ankle to lift him up in upside down and swing him to cure his depression like symptom as well as emesis and diarrhea.
11. For a three-year-old child of kan no mushi (a peevish), he just supplies him of Usu-gayu (thin gruel).

As we have come this far, we can assert that Nakagami’s remedy is always unrestricted assortments of various treatments mentioned above, that is what he described “unfettered remedy” which “fetter himself away from the fixed rule”. Actually, the fact that we can hardly find the same treatments in his remedy records is evidence that Nakagami’s remedy is unfettered and out of fixed rule. 

For example:

Nakagami took his own formulae no matter which it is single administration or combined with traditional formulae, and sometimes he took some combination of galenical formulae and some other treatments (e.g. bathing, acupuncture, hot plaster and ointment, etc.), and further he adopted some other ways of treatments that did not seem to be “treatments” like: lifting up a patient in upside down and to swing him, strong/thin gruel, and lotus root juice, etc. All above are based on his own discerning diagnoses. This is the reason why he could evolve his own remedies all at will.

At the same time, Nakagami administrated the Shanghanlun formula for evacuant/purgative Daishokito plus Shogushizenju (a lotus root juice) for a patient who got diarrhea, and sometimes he took use of anything good for the patient around him like malted rice, leek,etc. all of which are typical examples of his “unfettered remedy”.

As a parenthetical description, I would add that this kind of remedies peculiar to himself entails the idea of Koho (reinforcement and elimination) which is also peculiar to himself. I will discuss it briefly.

His own idea of Koho is brought about by his own unfettered remedy. The upshot is that Koho is quite an idea of relative modality. For example, a deficiency of Yin is equal to an excessive of Yang. At the same time, a deficiency of Yang is just equal to an excessive of Yin. Consequently, reinforcement or elimination of the one of them is eventually bringing forth the same conclusion. This is what he depicts “Koho, itsu ni kisu”. (Reinforcement and elimination are eventually one thing.) He described it as follows:

Not sticking to reinforcement or elimination, take the best remedy, this is the way of practitioner.

The most valuable issue is not the idea of Koho, but is the discerning eyes of the practitioner. This is Nakagami’s assertion, which entails the idea that he is almost the only medical practitioner who could really understand the true significance of the true essence of traditional Chinese/Japanese medicine. I have explored it at the other place [6-7]. 

Then we would take a look in Nakagami’s earnest disciple Kitamura. He succeeded Nakagami’s clinical practice and his philosophy of medicine, particularly in the Toho area. Today, we have his work Tohoron. In his preface, he depicted that he will describe his emetic remedy in the whole medical segments. However, we would learn proximately that this book is one for emeti remedy for psychic disease or neurological deficiency. It seems that Kitamura tried to write a general survey on his emetic remedy, but on his way, he had to vacate it. Therefore, this work is one for emetic remedy predominantly for psychic disease or neurological deficiency though it initially aimed at the emetic remedy for the whole medical practices.   

Nevertheless, it was seen sometimes in the hospitals those patients of psychic disease or neurological deficiency especially those with depression, having endogastric fluid, tried to vomit him/herself through putting their fingers into their throats to feel better and it is the fact that originally developed for a gastric mucosa microcirculation amelioration, sulpilide was adopted to those of psychic disease or neurological deficiency, especially depression. They are showing us simply that human beings suffering from psychic disease or neurological deficiency feel better after vomiting. It is very simple law of nature. Kitamura undeniably knew these medical phenomena through his clinical experiences, and implemented it into his clinical practice. He described precisely as follows:

When the disease originates from the deep inside of one’s chest having symptom of Kori-no-do (pical pulse) rising to Danchu and Ketsubon both of which are the acupuncture points in chest and neck, it is the time for the Toho. Without pical pulse, never take Toho.

It is really Kitamura’s way of articulate description.

Kitamura describes that the essential formulae for Toho are Kateisan, Niseisan, and Dokuseisan. All of them are evacuants based on the typical purgative galenical Katei (Cucumis melo, calyx of Oriental melon). “But,” he asserts, “The most significant point is the flexibility of application for this medical usage.” This is certainly a way of Kitamura’s. Succeeding his mentor Nakagami’s philosophy of medicine, he adds various clinical description for this usage just in the same way as his mentor. And further, he says in addition that when one could not get these formulae (galenical), we can take Panax ginseng, Kanzo (Glycyrrhiza uralensis), and even salt and senso (Bufo bufo gargarizans) instead for the formulae (galenical), He refers to all 21 alternative medicines. Then, he concludes that we should take the most appropriate one for the patient at the time, never blunder.” He describes it so precisely. 

At the same time, he refers to the preliminary treatment and post-treatment for Toho precisely. These treatments are also proceeded in accordance with each patient’s physical condition. In the traditional medicine, treatments are discriminately proceeded to each one of the patients. Kitamura takes the same traditional way.   

Consequently, he refers to his most favorite Toho to the Kyokan patients--those patients suffered from psychiatric diseases or neuroses (specifically irascible temper or depression), considering all 23 clinical cases to generalize them into theoretical formylation. This is Kitamura’s own exclusive way of medical philosophy.

This theoretical formulation based on his medical practice is the especially noteworthy point that we should learn medical philosophy today from it.

Nakagami’s remedy is always unrestricted assortments of various methods that is what he described “unfettered remedy” which “fetter himself away from the fixed rule”. This is shown by the fact that we can hardly find the same treatments in his remedy records.?For example:

1. Nakagami took his own formulae (single administration or combined with traditional formulae), and
2. Sometimes he took some combination of galenical formulae and some other treatments, and further, he adopted some other ways of treatments that did not seem to be “treatments”.
3. Nakagami administrated the Shanghanlun typical formula for evacuant/purgative plus lotus root juice for a patient who got diarrhea, and
4. Sometimes he took use of anything good for the patient around him like malted rice, leek, etc.

All above are based on Nakagami own discerning diagnoses. This is the reason why he could evolve all his own remedies at will. At the same time, this kind of remedies peculiar to himself entails the idea of Koho (reinforcement and elimination) which is also peculiar to himself. However, the most valuable issue is the discerning eyes of the practitioner.

Succeeding his genius, and so did it so much wide-open mentor, Nakagami, Kitamura struggled to make his own way in his treatment, mainly Toho. He describes that the essential formulae for Toho are Kateisan, Niseisan, and Dokuseisan. All of them are evacuants based on the typical purgative galenical Katei (Cucumis melo, calyx of Oriental melon). “But,” he asserts, “The most significant point is the flexibility of application for this medical usage.” This certainly a way of Kitamura succeeding his mentor Nakagami’s philosophy of medicine. Then, he adds various clinical description for this usage in his way. And further, he says in addition that when one could not get these formulae (galenical), we can take Panax ginseng, Kanzo (Glycyrrhiza uralensis), and even salt and sennso (Bufo bufo gargarizans) instead for the formulae (galenical), He refers to all in 21 alternative medicines. Then, he concludes that we should take the most appropriate one for the patient at the time, never blunder.” He describes it so precisely.  It is also his way of description.

At the same time, he refers to the preliminary treatment and post-treatment for Toho presicely. These treatments are also proceeded in accordance with each patient’s physical condition. In the traditional medicine, treatments are discriminately proceeded to each one of the patients. Kitamura takes the same traditional way.   

Consequently, he refers to his most favorite Toho to the Kyokan patients--those patients suffered from psychiatric diseases or neuroses considering all 23 clinical cases to generalize them into theoretical formylation. This is Kitamura’s own exclusive way of medical philosophy.

This theoretical formulation based on his medical practice is the specially noteworthy point that we should learn medical philosophy today from it.

Now we should learn from Nakagami and Kitamura’s Toho:

1. Those medical facts described in the classic volumes, which are sometimes seem bizarre, after precise explore, have certain ground. To cure diseases, they took emetic remedy. Especially in the psycho-somatic context of medicine, there they had certain confirmation for their treatment through their clinical experiences. Nakagami adopted it all round in his practice. And Kitamura did it in his most favorable medical arena of psychiatry.

I can take another accurate example of this kind of medical fact. That is a short story about a medical practitioner in ancient China. His name was Wenzhi. And it reads:

Qiwang (the king of Qi) was suffering from wei (chronic headache), he sent his men to Song to bring a medical practitioner Wenzhi. Wenzhi came. He saw king’s symptom and said to the prince “I can cure his disease, but when I’m done, he’s sure to kill me. The prince asked “Why?” Answered Wenzhi “I have to make him angry in order to cure his disease. But if I should do so, he’s definitely killing me.” Prince entreated him with his deepest bow, saying “if you should treat him of his disease, I, together with my mother, should dissuade him from it on our lives. He must understand our true will. So please, master, do not worry.” Wenzhi said, “Yes, I’ll try at the risk of my life.”  Then, he made promises to come to king’s place only to go back so many times. The king, Qiwang was already angry. At last, Wenzhi came. He got up on the king’s bed on his shoes on, and trampled down king’s clothes to ask his condition. The king never answered, since he was already angry. Without any response, Wenzhi was getting out of the room. The king got up with outrage. At that time, his disease vanished.

This is a story found in Lushi-Chunqiu compiled in the 3^rd century BC. Wenzhi cured king’s headache making him angry. Put it in other way, Wenzhi cured king’s headache through an endogenous morphine, endorphin which is secreted when a person gets in a violent emotion. He did not know about endorphin, but he knew the fact that anger cures headache through his clinical experiences.

Now we can describe it through our knowledge of endorphin, because we have this theoretical modality, but he didn’t. We have to read this story with deep esteem for he, and those practitioners in such an ancient time, never passed up even seemingly strange facts for their medical practice.

We should never overlook even ostensibly miniscule ones or ancient one. Significant secrets are hiding there. Accordingly, we can assert:

2. Medicine’s goal is not only curing, but make patients feel better both in physically and mentally. Their Toho was actually effective and valuable. Nakagami took it all round and his disciple Kitamura made very good use of it especially on those patients with psychiatric diseases or neuroses (specifically irascible temper or depression). We cannot adopt it just in the same way he did. However we should learn what they were aiming at when they took this Toho. They just tried to make their patients feel better. They did not know anything about endogenous materials nor anything about physical status throughout the psycho-somatic modality. They learnt everything in this daily phenomenal world through their clinical experiences. They were really discerning.

We should make use everything around us, not only drags or medical instruments, but also daily foods, practitioners’ words, healing hands, etc. It goes without saying that we should learn those galenical that they took in their efficiency and usage. However, we should investigate our daily simple phenomena, since valuable secrets are hiding there. Truth is always simple (vertitas semper simplex).

Acknowledgements

Special thanks to: Professor John Li Schroeder

Conflict of interests

None

Funding

None

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