Agar-35 (a.k.a. Eagleswood-35): Looking at a Tibetan Medical Formula from a Chinese Medical Point of View

by
Bob Flaws, L.Ac., FNAAOM (USA), FRCHM (UK)

Agar-35 is a very commonly prescribed Tibetan ready-made medicine which includes a number of ingredients or close relatives of ingredients which are common to Chinese medicine as well. Agar-35 is used to treat what Tibetan medicine refers to a lung disease complicated by heat and blood (stasis). The Tibetan medical concept of lung corresponds closely to the Chinese medical concept of qi. In particular, these pills are famous for treating anxiety and nervousness. Since this is both a very effective and a safe, gentle formula, I think it might be useful to look at this medicine from the point of view of Chinese medicine.

In Chinese medicine, anxiety disorders are mostly seen as a combination of liver-spleen disharmony resulting in malnourishment of the heart spirit. Thus the heart spirit is bu an or not quiet. This basic disease mechanism is then often complicated by phlegm and heat harassing the heart spirit above. Further, if there is enduring or severe qi stagnation, this may easily lead to blood stasis. This mutual engenderment of blood stasis is all the more likely if the flow of qi and blood is also blocked and obstructed by phlegm dampness. In this case, the phlegm is to any or all of four factors. 1) Due to spleen vacuity failing to move and transform water fluids, these may collect and transform into damp evils. If these damp evils linger and endure, then they congeal into phlegm. 2) liver depression qi stagnation may lead to the collection of water fluids and, therefore, to the congelation of phlegm, remembering that the qi moves water fluids. So, if the qi stops, water fluids stop. 3) Since water fluids and the blood move together, stoppage of one may lead to stoppage and blockage of the other. Hence, blood stasis may lead to phlegm engenderment. And 4) depressive heat due to liver depression qi stagnation may stew the body's juices and cook them into phlegm. In terms of the heat mentioned above, this is where it comes from, liver depression transforming heat. This heat accumulates in the liver and gallbladder, but it is also commonly shifted to the stomach, heart, and/or lungs.

In terms of Chinese medical pattern discrimination, what we then have is a so-called heart-gallbladder qi timidity pattern complicated by heat and possible blood stasis. This is a not uncommonly seen pattern in clinical practice, and it is the main pattern in the contemporary Chinese medical literature associated with general anxiety disorder (GAD), obsessive-compulsive disorder (OCD), and post-traumatic stress disorder (PTSD). The treatment principles for this multi-element patterns are to course the liver and rectify the qi, fortify the spleen and supplement the qi, nourish the heart and quiet the spirit, transform phlegm, clear heat, and quicken the blood. Because it is common to see not only a liver-spleen disharmony but a liver-stomach disharmony as well, we can also add the treatment principles of downbearing counterflow and harmonizing the stomach.

Ingredients:

Aquilaria agollocha (Chen Xiang, Ligunum Aquilariae): Qi-rectifier; acrid, bitter, warm, aromatic; enters the kidneys, spleen, stomach; warms the spleen and kidneys, downbears counterflow, assists the kidneys grasp or absorb the qi.

Terminalia chebula (He Zi, Fructus Terminaliae): Astringing & securing med; bitter, sour, astringent, neutral; enters the lungs, stomach, and large intestine; descends the lung qi, transforms phlegm, astringes and secures the spleen and large intestine qi

Terminalia belerica: Seems to be a qi and phlegm herb

Emblica officinalis: Sour, bitter, and cool; seems to be heat-clearing and damp-eliminating; seems to enter the liver, gallbladder, stomach, and large intestine

Myristica fragrans (Rou Dou Kou, Fructus Myristicae): Astringing & securing med; acrid, warm; enters the large intestine, spleen, and stomach; warms the spleen and stomach, moves the qi, secures the intestines

Bambusa textilis (Tian Zhu Huang, Secretio Silicea Bambusae): Phlegm-transformer; sweet, cold; enters the gallbladder, heart, and liver; extinguishes wind, sweeps away phlegm, opens the orifices, and stops palpitations

Adhatoda vasica: Appears to be a qi and blood moving medicinal something similar to Yu Jin (Tuber Curcumae)

Mesua ferrea: Seems to be a blood-quickening medicinal which is also cooling; may be similar to Chi Shao (Radix Rubra Paeoniae) and Mu Dan Pi (Cortex Moutan)

Saussurea lappa (Mu Xiang, Radix Auklanidae): Qi-rectifier; acrid, bitter, warm; enters the gallbladder, large intestine, spleen, stomach, and triple burner; moves the qi and stops pain, fortifies the spleen and disperses (food) stagnation; therefore, it harmonizes the liver and spleen

Commiphora mukul (Mo Yao, Myrrha): Blood-quickener; bitter, neutral; enters the heart, liver, and spleen; breaks blood (stasis) and stops pain, disperses swelling and engenders (new) flesh (when applied topically)

Picrorhiza kurroa (Hu Huang Lian, Rhizoma Picrorrhizae): Heat-clearer; bitter, cold; enters the liver, stomach, and large intestine; clears heat from both repletion and vacuity, cools the blood, eliminates dampness

Punica granatum (Shi Liu Pi, Pericarpium Punica-granati): Astringing & securing med.; sour, astringent, warm, toxic; enters the large intestine and stomach; secures the intestines and stops diarrhea

Swertia chirata: Bitter, cold; clears heat from the stomach and kills (intestinal) worms; may also harmonize the stomach

Meconopsis horridula: Liver-kidney supplement

Melia composite (Chuan Lian Zi, Fructus Toosendam): Qi-rectifier; bitter, cold, slightly toxic; enters the bladder, liver, small intestine, and stomach; clears heat, rectifies the qi, stops pain

Shorea robusta: A lung and phlegm herb; also has astringent functions (diarrhea and dysentery)

Solms-Laubachia sp.: Seems to be a minor ingredient; a Brassica family plant from Sichuan; so may have some of the same properties and actions as radish

Cinnamomum cecidodaphne (Rou Gui, Cortex Cinnamomi): Interior-warmer; acrid, sweet, hot; enters the heart, kidneys, liver, and spleen; warms and supplements yang, scatters cold, moves the blood

Carthamus tinctorius (Hong Hua, Flos Carthami): Blood-quickener; acrid, warm; enters the heart and liver; quickens the blood and transforms stasis

Rubus idaeopsis (Fu Pen Zi, Fructus Rubi): Astringing & securing med.; sweet, astringent, neutral; enters the kidneys and liver; supplements and enriches kidney yin, secures the essence

Tinospora cordifolia (Kuan Jin Teng, Caulis Tinopsorae): Wind-damp treating med.; bitter, slightly cold; enters the liver; frees the flow of the network vessels and soothes the sinews

Amomum subta (Cao Guo, Fructus Tsao-ko): Aromatic damp-transformer; acrid, warm; enters the spleen and stomach; strongly dries dampness and scatters cold, disperses stagnation and eliminates distention

Amomum rotundus (Bai Dou Kou, Fructus Cardamomi): Aromatic damp-transformer; acrid, warm, aromatic; enters the lungs, spleen, and stomach; diffuses the lung qi, arouses the spleen, warms the center, transforms dampness, penetrates turbidity

Eugenia caryophylla (Ding Xiang, Flos Caryophylli): Interior-warmer; acrid, warm; enters the kidneys, spleen, and stomach; warms the center, harmonizes the stomach, stops hiccup, nausea, and vomiting, invigorates kidney yang

Santalum album: (Bai Tan Xiang, Lignum Santali Albi): Qi-rectifier; acrid, warm, aromatic; enters the lungs, spleen, and stomach; frees the flow of the chest qi, stops pain, harmonizes the stomach to stop hiccup, burping, and nausea

Inula racemosa (Xuan Fu Hua, Flos Inulae): Phlegm-transformer; bitter, acrid, salty, slightly warm; enters the liver, lungs, stomach, and spleen; downbears counterflow, stops vomiting, and stops cough, softens the hard (phlegm) and disperses accumulations, eliminates dampness

Hedychium spicatum: A type of pepper; acrid and warm; warms and harmonizes the stomach, a qi and phlegm medicinal

Chrysanthemum tatsienense (Ju Hua, Flos Chrysanthemi): Exterior-resolver; sweet, bitter, slightly cold; enters the lungs and liver; disperses wind heat, cools and supplements the liver, brightens the eyes, resolves toxins

Pterocarpus santalinus: Red sandalwood; quickens and cools the blood

Pulicaria insignis: A wind and blood medicinal which stops pain

Outer bark of Aquilaria agollocha: Probably a milder qi-rectifier than Chen Xiang; however, it may have a completely different set of properties and actions

Strychnos noxvomica (Ma Qian Zi, Semen Strychnotis): Blood-quickener; bitter, cold, toxic; enters the liver and spleen; frees the flow of the network vessels, stops pain, disperses glomus and swelling

Aconitum spicatum (some relative of Chuan Wu, Cao Wu, or Fu Zi, Radix Aconiti): Interior-warmer; acrid, hot, toxic; enters the heart, kidneys and spleen; rescues yang desertion, supplements the life-gate fire, guides the actions of other medicinal into the 12 channels, dispels cold damp painful impediment

Bos Grunnines Pectus Pectorus: A blood supplement which nourishes and constructs the heart spirit

Musk (She Xiang, Moschus): Aromatic orifice-opener; acrid, warm, aromatic; enters the heart, spleen, and liver; opens the orifices, arouses the spirit, penetrates turbidity, quickens the blood, frees the flow of the channels and network vessels, stops pain

Dosage: 2-3grams daily either in the morning or at night with hot water. Typically, this means 1-2 pills which are chewed in the mouth and then swallowed with hot water.

This formula is called Agar-35 because its main ingredient is Agaru (Sanskrit), A-gar (Tibetan), or Chen Xiang (Lignum Aquilariae) and it contains 35 ingredients altogether. This is a common naming convention for formulas in Tibetan medicine. Because Tibetans lived very spread out in a vast and sparsely populated territory, Tibetan medicine makes heavy use of ready-made pills. This is because Tibetans may only see their doctor once or twice a year. Therefore, Tibetan formulas tend to contain relatively low doses of each ingredient but many ingredients. By administering small doses of many different medicinals which all accomplish a similar group of functions, A) there is less likelihood for side effects from any one ingredient, and B) should the patient's symptoms change over time, one or more ingredients should cover any new symptoms. Further, because of the low doses involved, Tibetan doctors can use some very powerful but otherwise toxic ingredients, such as Ma Qian Zi (Semen Strychnotis). Therefore, such a large formula achieves very comprehensive, rounded effects. In fact, this formula not only treats the liver, spleen, stomach, and heart, but also takes into account secondary relationships between these four main organs and the lungs, large intestine, and kidneys. For instance, the lungs and liver together control the movement of the qi throughout the body, the lungs providing the motivating power and the liver allowing the qi to flow. Similarly, the liver can only do its function of governing coursing and discharge if it is warmed and steamed by kidney yang/life-gate fire. So all in all, this is a very complex and subtle formula when looked at from a Chinese medical point of view which goes beyond standard Chinese formulas for a heart-gallbladder qi timidity pattern, such as Shi Yi Wei Wen Dan Tang (11 Flavors Warm the Gallbladder Decoction).

It is my experience that sometimes Tibetan formulas are able to treat conditions more effectively than Chinese formulas, although they tend to work more slowly over an extended period of time. For instance, the typical course of treatment with Agar-35 is 1-2 months. In any case, I think it is useful to look at Tibetan medical formulas from a Chinese medical point of view in order to gain new insights into the possible practice of Chinese medicine.