Many American practitioners assume that the only traditional way of preparing Chinese herbs is by decoction, yet this is not true. According to Xu Dachun, the great 18th century Chinese physician, "Decoctions move fast.Their substance is light; their strength quickly subsides and does not stay. The effects of decoctions are especially fast when it comes to illnesses affecting the constructive or protective influences, the intestines and the stomach. In case of all other illnesses, either pills, powders or pastes may be appropriate."1
Only about 30% of the prescriptions found in the Wushier Bing Fang, a formulary from China dating to 168 BC, are decoctions. It was common in China to administer formulas such as the famous xiao yao san in powder. ("San" at the end of a formula means powder, whereas "tang" means decoction and "wan" means pill.) It was also a common practice to make pills by hand. These pills were rolled and mixed with honey.
Each method of administering herbs has its advantages and disadvantages. Thus, practitioners can choose not only the most appropriate formula for their patients, but also the most effective way to administer the herbs.
As the introductory quote suggests, even in China there is a long history of debate about the proper manner for prescribing and taking herbs. Much of the training given to students at American acupuncture schools is in prescribing herbal formulas for decoction. This overlooks a rich history in China of prescribing herbs in either pill, powder, paste or tincture form. A comparison of teas, tablets and tinctures will help practitioners better understand herbal delivery mechanisms.
Teas, because they are composed of individual herbs, allow for a perfect match with the changing condition of the patient. This advantage has severe limitations however, for the practitioner must have access to a well-stocked and well-maintained raw herb pharmacy. It is also difficult and time-consuming to learn this art of prescribing to practice it safely and effectively, not to mention the time required to fill raw herb formulas for patients. Many practitioners feel that by brewing herbal teas, patients are more involved in their therapies. However, the American public does not share the Chinese cultural history of brewing and drinking herbal medicinal teas. Patient compliance is reduced because of the time and mess of brewing the herbs. Most of the formulas have an objectionable taste or smell that many patients do not tolerate. Additionally, dosage levels fluctuate widely, since some patients either overcook or undercook their herbs, or boil off volatile oils by forgetting to cover the pot.
In contrast to teas, herbal tablets are taken easily at any time; they have no objectionable taste, and provide accurate, consistent, controllable dosage levels. Most of the medicinal supplements taken are in pill form, partly because of their convenience. Tableted herbs assure higher patient compliance because Americans are accustomed to receiving their medicines in this form. Dr. Jianfu Jiang, professor at Emperor's College in Los Angeles, has suggested that "Tablets are suitable for treating long-term, chronic conditions where the patient must take herbs over a period time. Teas are especially useful for treating acute conditions."
In China, teas are commonly prescribed during the acute phase of an illness. followed by pills during the chronic phase. One of the drawbacks of tableted herbs is that they are fixed formulas and are difficult to modify. One solution is to supplement by combining two tableted formulas; taking both tea and tablets; or taking a fixed tableted formula with a modifiable tea. A brewed tea may be taken in the morning and at night, and tablets taken during the day. The key to this procedure is to determine which herbs are most suitable for decocting, and which are best in tablet form. Above-ground herbs such as ma huang may be concentrated and added into tablets. Roots such as astragalus and ginseng are best minimally concentrated before tableting.
A large percentage of the practice of most clinicians consists of patients with chronic conditions. Teas and tinctures are useful for these cases, especially at the outset. However, over the long term, tablets are best because of their convenience, higher patient compliance, and sustained dosage. It should be noted that it often takes three to four weeks before a tableted formula will show positive results in many chronic conditions at a normal dosage. A higher dose -- even double or triple -- can yield faster results.
Another form of herbs that is gaining popularity because of its low manufacturing costs is the herbal tincture. Tinctures have a long history in China, with traditional use reserved for blood-activating formulas. Because alcohol enhances the delivery of medicinal effects to the musculoskeletal system, the alcohol format provides rapid uptake and quick results. For most other formulas, tableting is preferable because it provides higher dosage levels and highest absorption at the lowest cost.
The disadvantage of tinctures is that the alcohol precludes their use by many patients. Because of its warming nature, alcohol is contraindicated in many heat conditions, including yin deficiency and excess heat patterns. For example, alcohol could exacerbate Crohn's disease and other inflammatory conditions. Tinctures may also be inappropriate for recovering alcoholics or alcohol sensitive patients. Some practitioners recommend that tinctures be placed in hot water to evaporate some the alcohol before ingestion. This procedure does not remove all the alcohol, but it further dilutes a product that is already quite diluted, making it questionable whether the dosage will be adequate at a reasonable cost to effect a positive outcome.
Cost is an important a consideration as proper delivery mechanism. Tableting, including concentrates of appropriate herbs, generally proves to be the best bargain. The cost to your patient for a therapeutic dosage for high quality tablets is between $2.00 and $3.00 per day. Daily cost for teas is usually between $3.00 to $5.00.
Commercial tinctures use six pounds of herbal matter per gallon of extracting liquid. This translates to 42 grams of herbs per two-ounce tincture. The standard retail cost for a two-ounce tincture ranges from $13.00 to $44.00. This works out to a minimal cost of 31 cents per gram. A typical bottle of pills, however, will contain 90 tablets weighing .75 grams each, for a total weight of 67.5 grams. It should be pointed out that many herbal manufacturers use concentrated herbs, which have an even higher yield. At $16.00 retail per bottle, the cost is 23.7 cents per gram. It should be remembered that a two-ounce tincture is an extraction from 42 grams of herbs before ingestion, whereas tableting provides the herbs directly for ingestion.
There is much more to the prescribing of herbs than just the selection of the proper formula. The form in which the herbs are ingested is an extremely important consideration in the treatment of your patients. This makes the manufacturing process just as important.
While in some cases American practitioners can obtain products manufactured in China, these are generally not recommended because of erratic labeling, poor quality, and the possibility that pharmaceutical drugs may be in these products. Well-known products frequently contain caffeine and antihistamines, while products for arthritis have been discovered to contain various prescription and non-prescription drugs. Stress aids can contain cinnabar, a toxic mercury compound.
The highest quality herbs in China are exported, which is why many practitioners from China are impressed by the herbs obtained in America. As a general rule, products manufactured in the U.S. offer higher quality controls than those manufactured in China, since higher quality herbs are used the dosage is lower. Products manufactured in the U.S. contain pure herbs without fillers, artificial dyes, or other unnatural ingredients.
In this article, arguments have been presented both for and against the various forms of prescribing herbs. However, Sima Qian, physician and commentator of the Han dynasty and author of the Annals of History, should have the last word: "What people suffer from is a multitude of illnesses; what physicians suffer from is a paucity of approaches."
- Unschuld P. Forgotten Traditions of Ancient Chinese Medicine. Brookline, MA: Paradigm Publications, 1990.
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