Cerebrovascular and Cardiovascular Obstruction - Master Chen Keji’s “San Tong Tang” (Triple-Through Decoction)

15. Cerebrovascular and Cardiovascular Obstruction - Master Chen Keji’s “San Tong Tang” (Triple-Through Decoction)

I. Master Chen Keji, a National Master of Traditional Chinese Medicine, proposed the “Three Through, Two Tonify” clinical philosophy for treating coronary artery disease and angina pectoris. The “Three Through” comprise: invigorating blood and resolving stasis, aromatic warming-activation, and dispersing stagnation to open Yang. The “Two Tonify” comprise: tonifying Qi and Blood, and tonifying Spleen and Kidney. He also created empirical formulas such as Yu Geng Tong Yu Tang (Post-MI Stasis-Resolution Decoction) and Qing Xuan Jiang Ya Fang (Headache-Clearing and BP-Lowering Formula). The research project “Blood Stasis Syndrome and Invigorating Blood and Resolving Stasis” was awarded the First Prize of the National Science and Technology Progress Award in 2003.

Pathogenesis

The fundamental pathogenesis of cardiovascular and cerebrovascular diseases is root deficiency with manifest excess. Insufficient Heart Qi leads to weak propulsion of blood flow; impaired Spleen transport and transformation leads to deficient generation of Qi and Blood; together they constitute the root deficiency. When Heart Yang is not aroused, the vessels lack sufficient warming, blood flow becomes sluggish and gradually forms stasis obstruction; stasis obstructing the collaterals leads to insufficient blood supply to the Heart and Brain, manifesting as chest tightness and palpitations, dizziness and headache, and numbness in the limbs as manifest excess signs. Qi deficiency and blood stasis are causally linked - Qi deficiency aggravates blood stasis, while blood stasis in turn depletes righteous Qi; a prolonged course results in alternating deficiency and excess. Chen Keji emphasized that pure opening-activation depletes Qi, while pure tonification retains stasis; one must apply opening and tonifying together or alternate between the two.

Formula Composition

Composition: Salvia 12g, Chuanxiong 10g, Pueraria 20g, Cinnamon Twig 9g, Honey-processed Licorice 6g, Ginseng 6g, Ophiopogon 6g, Schisandra 6g, White Atractylodes 12g, Poria 12g

Efficacy: Invigorates blood and opens the collaterals, warms and activates Heart Yang, tonifies Qi and nourishes Yin, strengthens the Spleen and promotes transport

Indications: Cardiovascular and cerebrovascular diseases (Heart Qi deficiency with blood stasis obstructing the collaterals pattern), chest tightness and palpitations, dizziness and headache, limb numbness

This formula is a combination of four classical formulas: Tong Mai Yin (Salvia, Chuanxiong, Pueraria) invigorates blood and resolves stasis to open the collaterals, corresponding to the invigorating blood and resolving stasis method among the “Three Through,” unblocking the stasis obstruction of Heart and Brain vessels. Guizhi Gancao Tang (Cinnamon Twig, Honey-processed Licorice) warms and activates Heart Yang, corresponding to the dispersing stagnation and opening Yang method among the “Three Through,” arousing Heart Yang to propel blood flow. Sheng Mai Yin (Ginseng, Ophiopogon, Schisandra) tonifies Qi and nourishes Yin and generates fluids, corresponding to the tonifying Qi and Blood method among the “Two Tonify,” replenishing the driving power of the Heart to circulate Qi and Blood. The intent of Four Gentlemen Decoction (Ginseng, White Atractylodes, Poria, Honey-processed Licorice) strengthens the Spleen and tonifies Qi, corresponding to the tonifying Spleen and Kidney method among the “Two Tonify,” consolidating the middle jiao so that Qi and Blood generation has a source. Each of the four groups of herbs has a specific focus yet they cooperate with one another - blood-invigorating herbs are aided by Qi-tonifying herbs so that blood moves with greater force; Yang-warming herbs are paired with Yin-nourishing herbs so that they warm without being drying; Spleen-strengthening herbs are combined with blood-invigorating herbs so that tonification does not cause stagnation. The entire formula has tonification within opening and opening within tonification, precisely embodying Chen Keji’s intent of “applying opening and tonification together.”

In the formula, Ginseng is a shared herb between Four Gentlemen Decoction and Sheng Mai Yin, serving dual roles - it tonifies Spleen and Lung primordial Qi to assist Qi and Blood generation, and tonifies Heart Qi to assist propulsion. Honey-processed Licorice is also shared between Guizhi Gancao Tang and Four Gentlemen Decoction, warming and arousing Heart Yang while harmonizing all other herbs. These two herbs form the binding links between the four groups, making the entire formula a unified whole rather than a simple stacking of four formulas.

IV. Pattern-Based Modifications

Chen Keji emphasized that warming-activation herbs should not be overused or used for prolonged periods, as the pathogenesis of coronary artery disease and angina pectoris is often root deficiency with manifest excess; overuse of warming-activation easily depletes Qi and Yin. In clinical practice, the ratio of opening to tonifying must be carefully balanced - when stasis obstruction is the primary concern, opening methods should account for 60-70%; when deficiency signs are primary, tonifying methods should account for 60-70%. Opening and tonifying may also be used alternately - opening first then tonifying, or tonifying first then opening - depending on the urgency of the condition.

Summary

San Tong Tang (Triple-Through Decoction) is a combination of Tong Mai Yin, Guizhi Gancao Tang, Sheng Mai Yin, and Four Gentlemen Decoction, corresponding to Chen Keji’s “Three Through, Two Tonify” therapeutic philosophy - invigorating blood and opening collaterals, warming and activating Heart Yang, tonifying Qi and nourishing Yin, strengthening the Spleen and promoting transport. In the formula, Ginseng and Honey-processed Licorice run through multiple groups, unifying the four sub-formulas into a cohesive whole. The entire formula applies opening and tonification together, addressing both root and branch, suitable for cardiovascular and cerebrovascular diseases with root deficiency and manifest excess. In clinical practice, the balance between opening and tonifying must be adjusted according to the proportion of deficiency and excess.

References:

[1] Liu Yang, Jiang Yong, eds. “A Hundred Years of Chinese Medicine: A Hundred Clinical Masters of Traditional Chinese Medicine - National Masters Volume: Guo Ziguang” [M]. Beijing: China Press of Traditional Chinese Medicine (Reference for Chen Keji’s “Three Through, Two Tonify” therapeutic philosophy)

[2] Chen Keji. “Treating Coronary Artery Disease Angina Pectoris with ‘Three Through, Two Tonify’” [J]. Chinese Journal of Integrated Traditional and Western Medicine

15. 心腦血管堵塞不通-國醫大師陳可冀「三通湯」

一、陳可冀國醫大師，提出治療冠心病心絞痛的”三通兩補”臨證思想——“三通”即活血化瘀、芳香溫通、宣痺通陽，”兩補”即補益氣血、補益脾腎，並創制愈梗通瘀湯、清眩降壓方等經驗方。”血瘀證與活血化瘀研究”獲2003年國家科技進步一等獎。

病機

心腦血管疾病的基本病機是本虛標實。心氣不足則推動血行無力，脾失健運則氣血生化匱乏，二者構成本虛。心陽不振則血脈溫煦不足，血行遲滯漸成瘀阻，瘀阻脈絡則心腦供血不足，出現胸悶心慌、頭暈頭痛、肢體麻木等標實之候。氣虛與血瘀互為因果——氣虛加重血瘀，血瘀又耗傷正氣，病程遷延則虛實交織。陳可冀強調，純通則耗氣，純補則留瘀，須通補兼施或通補交替。

方藥組成

組成：丹參 12g、川芎 10g、葛根 20g、桂枝 9g、炙甘草 6g、人參 6g、麥冬 6g、五味子 6g、白朮 12g、茯苓 12g

功效：活血通絡，溫通心陽，益氣養陰，健脾助運

主治：心腦血管疾病（心氣不足、血瘀阻絡證），胸悶心慌、頭暈頭痛、肢體麻木

本方由四個經典方組合而來，通脈飲（丹參、川芎、葛根）活血化瘀通絡，對應”三通”中的活血化瘀法，疏通心腦血脈之瘀阻。桂枝甘草湯（桂枝、炙甘草）溫通心陽，對應”三通”中的宣痺通陽法，振奮心陽以推動血行。生脈飲（人參、麥冬、五味子）益氣養陰生津，對應”兩補”中的補益氣血法，補充心臟推動氣血之動力。四君子湯意（人參、白朮、茯苓、炙甘草）健脾益氣，對應”兩補”中的補益脾腎法，培補中焦使氣血生化有源。四組藥物各有側重又相互配合——活血藥得益氣藥之助則行血有力，溫陽藥得養陰藥之配則溫而不燥，健脾藥得活血藥之佐則補而不滯。全方通中有補、補中有通，正合陳可冀”通補兼施”之旨。

方中人參為四君子湯與生脈飲共有之品，一身兼兩職——既補脾肺元氣以助生化，又補心氣以助推動。炙甘草亦為桂枝甘草湯與四君子湯共有，既溫振心陽又調和諸藥。兩味藥在四組之間形成配伍紐帶，使全方渾然一體而非四方簡單堆疊。

四、隨證加減

陳可冀強調，溫通藥不宜過用久用，冠心病心絞痛病機多為本虛標實，過用溫通易耗傷氣陰。臨床運用時須權衡通補比例——瘀阻為主時通法佔六七分，虛象為主時補法佔六七分，亦可通補交替使用，先通後補或先補後通，視病情緩急而定。

小結

三通湯由通脈飲、桂枝甘草湯、生脈飲、四君子湯四方組合而成，對應陳可冀”三通兩補”治法思想——活血化瘀通絡、溫通心陽、益氣養陰、健脾助運。方中人參、炙甘草貫穿多組，使四方渾然一體。全方通補兼施、標本兼顧，適用於心腦血管疾病本虛標實者，臨床運用須根據虛實比例調整通補分量。

參考文獻：

[1] 劉楊,江泳編.《中國百年百名中醫臨床家叢書·國醫大師卷：郭子光》[M].北京：中國中醫藥出版社（陳可冀”三通兩補”治法思想參考）

[2] 陳可冀.”三通兩補”治冠心病心絞痛[J].中國中西醫結合雜誌