（附∶白散方）
《伤寒论》大陷胸汤后，又有小陷胸汤以治结胸之轻者，盖其证既轻，治之之方亦宜轻矣。
《伤寒论》原文∶小结胸病，正在心下，按之则痛，脉浮滑者，小陷胸汤主之。按心下之处，注疏
家有谓在膈上者，有谓在膈下者，以理推之实以膈上为对。盖膈上为太阳部位，膈下则非太阳部位。且小结
胸之前（百三十九节）谓∶“太阳病重发汗，而复下之，不大便五、六日，舌上燥而渴，日晡所小有潮热，
从心下至少腹，硬满而痛不可近者，大陷胸汤主之，”观此大陷胸汤所主之病，亦
有从下之文，则知心上仍属胸中无疑义也。
【小陷胸汤方】黄连一两，半夏半升汤洗，栝蒌实大者一枚。
上三味，以水六升，先煮栝蒌取三升，去渣，纳诸药，煮取二升，去渣，分温三服。
此证乃心君之火炽盛，铄耗心下水饮结为热痰（脉现滑象，是以知为热痰，若
但有痰而不热，当现为濡象矣），而表阳又随风内陷，与之互相胶漆，停滞于心下为痞满，以杜塞心下经络，
俾不流通，是以按之作痛也。为其病因由于心火炽盛，故用黄连以宁熄心火，兼以解火热之团结，又佐
以半夏开痰兼能降气，栝蒌涤痰兼以清热，其药力虽远逊于大陷胸汤，而以分消心下之痞塞自能胜任有余也。
然用此方者，须将栝蒌细切，连其仁皆切碎，方能将药力煎出。
此证若但痰饮痞结于心下，而脉无滑热之象者，可治以拙拟荡胸汤，惟其药剂宜斟酌减轻耳。
小结胸之外，又有寒实结胸，与小结胸之因于热者迥然各异，其治法自当另商。《伤寒论》谓∶宜治
以三物小陷胸汤。又谓∶白散亦可服。三物小陷胸汤《伤寒论》中未载，注疏家或疑即小陷胸汤，谓系从治
之法。不知所谓从治者，如纯以热治凉，恐其格拒不受，而于纯热之中少用些些凉药为之作引也，若纯以凉
治凉，是犹冰上积冰，其凝结不益坚乎？由斯知治寒实结胸，小陷胸汤断不可服，而白散可用也。爰录其方于下。
【白散方】桔梗三分，巴豆一分去皮心熬黑研如脂，贝母三分。
上三味为散，纳巴豆，更于臼中杵之，以白饮和服，强人半钱匕，羸者减半，病在膈上必吐，在
膈下必利，不利进热粥一杯，利过不止，进冷粥一杯。
按∶方中几分之分，当读为去声，原无分量多少，如方中桔
梗、贝母各三分，巴豆一分，即桔梗、贝母之分量皆比巴豆之分量多两倍，而巴豆仅得桔梗及贝母之分量三
分之一也。巴豆味辛性热以攻下为用，善开冷积，是以寒实结胸当以此为主药，而佐以桔梗、贝母者，因枯
梗不但能载诸药之力上行，且善开通肺中诸气管使呼吸通畅也。至贝母为治嗽要药，而实善开胸膺之间痰
气郁结。至巴豆必炒黑而后用者，因巴豆性至猛烈，炒至色黑可减其猛烈之性，然犹不敢多用，所谓半钱匕
者，乃三药共和之分量，折为今之分量为一分五厘，其中巴豆之分量仅二厘强，身形羸弱者又宜少用，可谓
慎之又慎也。
白散方中桔梗、贝母，其分量之多少无甚关系，至巴豆为方中主药，所用仅二厘强，纵是药力猛烈，
亦难奏效，此盖其分量传写有误也，愚曾遇有寒实结胸，但用巴豆治愈一案，爰详细录出以征明之。
一人年近三旬，胸中素多痰饮，平时呼吸其喉间恒有痰声。时当孟春上旬，冒寒外出，受凉太过，急急
还家，即卧床上，歇息移时，呼之吃饭不应，视之有似昏睡，呼吸之间痰声漉漉，手摇之使醒，张目不能言，
自以手摩胸际，呼吸大有窒碍。延医治之，以为痰厥，概治以痰厥诸方皆无效。及愚视之，抚其四肢冰
冷，其脉沉细欲无，因晓其家人曰∶此寒实结胸证，非用《伤寒论》白散不可。遂急购巴豆去皮及心，炒
黑捣烂，纸裹数层，压去其油（药局中名为巴豆霜，恐药局制不如法，故自制之），秤准一分五厘，开水送
下，移时胸中有开通之声，呼吸顿形顺利，可作哼声，进米汤半碗。翌晨又服一剂，大便通下，病大轻减，脉
象已起，四肢已温，可以发言，至言从前精神昏愦似无知觉，此时觉胸中似满闷。遂又为开
干姜、桂枝尖、人参、浓朴诸药为一方，俾多服数剂以善其后。
如畏巴豆之猛烈不敢轻用，愚又有变通之法，试再举一案以明之。
一妇人年近四旬，素患寒饮，平素喜服干姜、桂枝等药。时当严冬，因在冷屋察点屋中家具为时甚久，
忽昏仆于地，舁诸床上，自犹能言，谓适才觉凉气上冲遂至昏仆，今则觉呼吸十分努力气息始通，当速用
药救我，言际忽又昏愦，气息几断。时愚正在其村为他家治病，急求为诊视，其脉微细若无，不足四至，询
知其素日禀赋及此次得病之由，知其为寒实结胸无疑，取药无及，急用胡椒（辛热之品能开寒结）三钱捣碎，
煎两三沸，徐徐灌下，顿觉呼吸顺利，不再昏厥。遂又为疏方，干姜、生怀山药各六钱，白术、当归各四钱，
桂枝尖、半夏、甘草各三钱，浓朴、陈皮各二钱，煎服两剂，病愈十之八九。又即原方略为加减，俾
多服数剂以善其后。
（附：白散方）
《伤寒论》在大陷胸汤之后，又记载了小陷胸汤，用于治疗结胸证中较轻的病例。大概是因为病情既已较轻，治疗所用的方剂也应当温和轻灵。
《伤寒论》原文说：“小结胸病，病位正在心下（胃脘部），按压时才疼痛，脉象浮滑的，用小陷胸汤主治。”关于“心下”的具体位置，历代注疏家有的认为在膈膜之上，有的认为在膈膜之下。从医理推断，实际上以在膈膜之上更为准确。因为膈上属于太阳经的部位，而膈下则不属于太阳经部位。况且在小结胸证之前（第139节）提到：“太阳病经过重度发汗，又误用攻下法，导致五、六天不大便，舌面干燥且口渴，下午时分有轻微的潮热，从心下直到小腹，坚硬胀满且疼痛剧烈，拒按的，用大陷胸汤主治。”看这段描述大陷胸汤所主治的病证，也有涉及下方的文字，由此可知，“心下”仍然属于胸中范围，这是毫无疑问的。
【小陷胸汤方】黄连一两，半夏半升（用水洗净），栝蒌实（瓜蒌果实）大的一个。
以上三味药，用水六升，先煮栝蒌，取汁三升，去掉药渣，加入其他药物，再煮取二升，去掉药渣，分三次温服。
此证是由于心火炽盛，灼烧消耗心下的水饮，凝结成热痰（脉象呈现滑象，因此知道是热痰；如果仅有痰而没有热象，脉象应当表现为濡象），同时表阳又随着风邪内陷，与热痰互相胶结，停滞在心下形成痞满，堵塞了心下的经络，使其气血不流通，所以按压时会产生疼痛。由于病因在于心火炽盛，所以使用黄连来平息心火，兼以解散火热之邪的结聚；又佐以半夏开通痰结并能降气，栝蒌涤除痰浊兼能清热。虽然这些药物的药力远不如大陷胸汤猛烈，但在分消心下的痞塞方面，自然能够胜任有余。
然而使用此方时，必须将栝蒌细细切碎，连同其仁一起切碎，才能煎出药效。
此证如果只是痰饮痞结在心下，而脉象没有滑数热象的，可以用我拟定的荡胸汤治疗，只是药剂剂量宜斟酌减轻。
除了小结胸证之外，还有寒实结胸证，这与因热引起的小结胸证截然不同，其治疗方法自然应当另行商讨。《伤寒论》中说：“适宜用三物小陷胸汤治疗。”又说：“白散也可以服用。”三物小陷胸汤在《伤寒论》中未收录，注疏家有的怀疑就是小陷胸汤，认为是反治之法。不知道所谓“从治”（顺从病性而治，此处指反佐或引经），如果是纯用热药治疗寒证，恐怕会出现格拒不受的情况，所以在纯热药中少加一点凉药作为引导。如果是纯用凉药治疗寒证，这就好比冰上积冰，其凝结不是更加坚固吗？由此可知，治疗寒实结胸证，小陷胸汤绝对不可服用，而白散是可以使用的。于是将其方录于下方。
【白散方】桔梗三分，巴豆一分（去皮、去心，炒黑研如脂状），贝母三分。
以上三味药研为散，加入巴豆，再在臼中捣匀，用米汤调和服用。体质强壮者服半钱匕，体弱者减半。病位在膈上者必然呕吐，病位在膈下者必然腹泻。如果不腹泻，喝一杯热粥以促进排便；如果腹泻不止，喝一杯冷粥以止泻。
按语：方中“几分”的“分”，应当读作去声，原意并非指具体的重量单位，而是指比例关系。例如方中桔梗、贝母各三分，巴豆一分，意思是桔梗、贝母的分量都比巴豆多两倍，而巴豆仅占桔梗及贝母分量的三分之一。巴豆味辛性热，以攻下为功效，善于破除冷积，所以寒实结胸证当以此为主药。佐以桔梗、贝母的原因，是因为桔梗不仅能载诸药之力上行，而且善于开通肺中的各种气管，使呼吸通畅。至于贝母是治疗咳嗽的重要药物，实则善于开通胸膺之间的痰气郁结。至于巴豆必须炒黑后才使用，是因为巴豆药性极其猛烈，炒至黑色可以减少其猛烈之性。然而仍不敢多用，所谓“半钱匕”，是指三种药混合后的总分量，折算成现在的分量是一分五厘，其中巴豆的分量仅两厘多一点，身形瘦弱的人更应少用，可以说是谨慎到了极点。
白散方中桔梗、贝母的分量多少关系不大，但巴豆作为方中的主药，所用仅两厘多一点，纵然药力猛烈，也难以奏效，这大概是传抄过程中分量有误。我曾遇到一例寒实结胸证，只用巴豆治愈的案例，于是详细记录下来以证明这一点。
有一人年近三十，平时胸中就多痰饮，日常呼吸时喉间常有痰声。正值初春月上旬，冒寒外出，受凉过度，急忙回家，立即卧床休息。过了一会儿，叫他吃饭不应答，查看他似乎昏睡，呼吸之间痰声漉漉，摇动他才醒来，睁眼不能说话，自己用手抚摸胸口，呼吸大有窒碍感。请医生诊治，认为是痰厥，一概使用治疗痰厥的方剂均无效。到我诊视时，触摸他的四肢冰冷，脉象沉细几乎摸不到。于是告知他的家人说：“这是寒实结胸证，非用《伤寒论》中的白散不可。”于是急忙购买巴豆，去皮去心，炒黑捣烂，用纸包裹多层，压榨去除其油（药局中称为巴豆霜，担心药局制作不规范，故自制），称准一分五厘，用开水送服。过了一会儿，胸中有开通的声音，呼吸顿时变得顺利，可以发出哼声，喝了半碗米汤。第二天早晨又服一剂，大便通畅，病情大减，脉象已起，四肢已温，可以说话，但说从前精神昏愦似无知觉，此时觉得胸中有些满闷。于是又为他开具干姜、桂枝尖、人参、厚朴等药组成一方，让他多服几剂以善后调理。
如果畏惧巴豆的猛烈而不敢轻易使用，我有变通的方法，试再举一案来说明。
有一位妇人年近四十，平时患有寒饮，平日喜欢服用干姜、桂枝等药。正值严冬，因为在冷屋中清点家具时间很久，忽然昏倒在地上，抬到床上，她还能说话，说刚才觉得凉气上冲导致昏倒，现在觉得呼吸十分费力气息才通，应当迅速用药救我。说话间忽然又神志昏愦，气息几乎断绝。当时我正在该村为别人治病，急忙求我为她诊视。她的脉象微细若无，不足四至。询问了她平素的体质和此次得病的原因，知道她是寒实结胸无疑。取药来不及，急忙用胡椒（辛热之品能开寒结）三钱捣碎，煎煮两三沸，徐徐灌下，顿时觉得呼吸顺利，不再昏厥。于是又为她处方：干姜、生怀山药各六钱，白术、当归各四钱，桂枝尖、半夏、甘草各三钱，厚朴、陈皮各二钱。煎服两剂，病愈十之八九。随后在原方基础上略作加减，让她多服几剂以善后调理。
(Attached: Baisan Formula)
After the Daxiexiong Tang (Major Scrofula-Resolving Decoction), the Shanghan Lun (Treatise on Cold Damage Disorders) further records the Xiaoxiexiong Tang (Minor Scrofula-Resolving Decoction) to treat mild cases of Jie Xiong (Chest Binding Syndrome). Presumably, because the condition is mild, the treatment formula should also be gentle and light.
The original text of the Shanghan Lun states: "In minor chest binding syndrome, the pathology is located precisely at the Xin Xia (epigastrium/substernal region); it causes pain only upon palpation, and the pulse is floating and slippery; this is primarily treated with Xiaoxiexiong Tang." Regarding the specific location of "Xin Xia," various commentators have argued whether it lies above or below the diaphragm. Reasoning from medical principles, it is actually more accurate to consider it above the diaphragm. This is because the area above the diaphragm belongs to the Taiyang (Greater Yang) channel territory, whereas the area below does not. Furthermore, preceding the discussion on minor chest binding (Article 139), it is stated: "In a Taiyang disease, after severe sweating and subsequent mistaken purgation, if there has been no bowel movement for five or six days, accompanied by a dry tongue and thirst, slight afternoon tidal fever, hardness and fullness extending from the Xin Xia down to the lower abdomen, with severe pain that cannot be tolerated by pressure, Daxiexiong Tang should be used." Observing this description of the disease treated by Daxiexiong Tang, which involves symptoms extending downward, it confirms without doubt that "Xin Xia" still belongs to the chest region.
[Xiaoxiexiong Tang Formula] Huanglian (Coptidis Rhizoma) 1 liang, Banxia (Pinelliae Tuber) half sheng (washed with water), Gualou Shi (Trichosanthis Fructus) one large fruit.
Take the above three ingredients, add six sheng of water, first decoct the Gualou until three sheng remain, remove the dregs, add the remaining herbs, decoct again until two sheng remain, remove the dregs, and divide into three warm doses.
This syndrome arises from excessive fire in the Heart (Heart Fire) scorching and consuming the fluid retention in the Xin Xia, condensing into hot phlegm (the pulse presents as slippery, indicating hot phlegm; if there were phlegm without heat, the pulse would present as soggy/Ru). Simultaneously, the exterior Yang sinks inward following wind pathogens, intermingling with the hot phlegm like lacquer and glue. It stagnates in the Xin Xia, forming a feeling of fullness and obstruction (Pi Man), blocking the meridians in this region and preventing free flow, thus causing pain upon palpation. Since the etiology stems from blazing Heart Fire, Huanglian is used to pacify and extinguish the Heart Fire and resolve the accumulation of heat-fire. Banxia is added to open phlegm obstructions and direct Qi downward. Gualou clears phlegm and clears heat. Although the medicinal power of these herbs is far inferior to that of Daxiexiong Tang, they are fully capable of resolving the obstruction and fullness in the Xin Xia through dispersion and elimination.
However, when using this formula, the Gualou must be finely sliced, including its seeds, to ensure the medicinal efficacy is extracted during decoction.
If this syndrome involves only phlegm-fluid obstruction in the Xin Xia without the slippery-heat pulse indication, it can be treated with my proposed Dangxiong Tang (Draining Chest Decoction), provided the dosage is carefully reduced.
Beyond minor chest binding, there is also cold-solid chest binding (Han Shi Jie Xiong), which is completely different from the heat-induced minor chest binding; thus, its treatment method must be discussed separately. The Shanghan Lun states: "It is suitable to treat with Sanwu Xiaoxiexiong Tang." It also states: "Baisan may also be taken." Sanwu Xiaoxiexiong Tang is not recorded in the Shanghan Lun. Commentators suspect it might be the Xiaoxiexiong Tang, considering it a contrary treatment method. However, they misunderstand the concept of "Cong Zhi" (following/treating according to the nature of the disease, often implying counter-agency or guiding). If pure heat is used to treat cold, fear of rejection (Ge Ju) might arise, so a small amount of cooling herb is added as a guide within the pure heat formula. But if pure cooling is used to treat cold, it is like piling ice upon ice, making the coagulation even harder. From this, we know that for treating cold-solid chest binding, Xiaoxiexiong Tang absolutely cannot be used, but Baisan can be used. Therefore, I record its formula below.
[Baisan Formula] Jiegeng (Platycodonis Radix) 3 fen, Badou (Crotonis Fructus) 1 fen (peeled, heart removed, stir-fried black, ground into paste), Beimu (Fritillariae Bulbus) 3 fen.
Grind the above three ingredients into powder, mix in the Badou, and pound further in a mortar. Mix with rice water (Bai Yin) and administer. For strong individuals, take half a Qianbi (coin-shaped measure); for frail individuals, reduce by half. If the pathology is above the diaphragm, vomiting will occur; if below, diarrhea will occur. If there is no diarrhea, drink one cup of hot porridge to promote evacuation; if diarrhea persists excessively, drink one cup of cold porridge to stop it.
Note: The "fen" in the formula refers to proportion rather than weight. For example, Jiegeng and Beimu are each 3 parts, while Badou is 1 part, meaning Jiegeng and Beimu are twice the quantity of Badou, and Badou constitutes one-third of the quantity of either Jiegeng or Beimu. Badou is pungent and hot in nature, acting primarily as a purgative, and excels at breaking up cold accumulations. Therefore, it serves as the principal herb for cold-solid chest binding. Jiegeng and Beimu are added as assistants because Jiegeng not only carries the medicinal power upward but also opens the airways in the Lung, facilitating respiration. Beimu is an essential herb for treating coughs and effectively resolves phlegm-Qi stagnation in the chest and epigastrium. Badou must be stir-fried black before use because its nature is extremely fierce; charring reduces its ferocity. Nevertheless, it is still not used in large amounts. The term "half a Qianbi" refers to the total combined weight of the three herbs, which converts to approximately 1.5 liang in modern units (note: historical unit conversion varies, here interpreted as small fraction). Within this, the amount of Badou is only slightly over 2 li. For those with weak constitutions, it should be used sparingly, demonstrating extreme caution.
In the Baisan formula, the proportions of Jiegeng and Beimu are not critical. However, since Badou is the principal herb, using only slightly over 2 li (of the total mixture) makes it difficult to achieve efficacy despite its potency. This suggests a transcription error in the dosages. I once encountered a case of cold-solid chest binding cured solely by using Badou, which I record in detail here to verify this point.
A man nearing thirty years of age had chronic phlegm-fluid retention in his chest, often producing rattling sounds in his throat during breathing. In early spring, he went out exposed to cold, suffered excessive chilling, and hurried home to lie in bed. After resting for some time, he did not respond when called for dinner. He appeared to be in a deep sleep, with loud rattling sounds during respiration. He woke only when shaken, opened his eyes but could not speak, rubbing his chest with his hand, experiencing significant respiratory obstruction. Physicians diagnosed him with Tan Jue (Phlegm Syncope) and prescribed various formulas for this condition, all of which failed. Upon my examination, his limbs were ice-cold, and his pulse was deep, fine, and nearly imperceptible. I informed his family: "This is cold-solid chest binding; only the Baisan from the Shanghan Lun will suffice." I urgently purchased Badou, peeled it, removed the heart, stir-fried it black, and ground it. Wrapped in several layers of paper, I pressed out the oil (known as Badou Shuang/Croton Seed Frost in pharmacies; fearing improper preparation, I prepared it myself), weighed exactly 1.5 fen, and administered it with boiling water. After a while, a sensation of opening occurred in the chest, respiration became smooth, he could hum, and drank half a bowl of rice soup. The next morning, another dose was taken, resulting in bowel movement, significant symptom relief, recovery of the pulse, warming of the limbs, and ability to speak. He reported that previously he felt mentally confused and numb, but now felt chest fullness. I then prescribed a formula containing Ganjiang (Zingiberis Rhizoma), Guizhi Jian (Cinnamomi Ramulus), Renshen (Ginseng Radix et Rhizoma), and Houpo (Magnoliae Officinalis Cortex) to be taken for several doses to conclude treatment.
For those who fear the ferocity of Badou and dare not use it lightly, I have an alternative method. I cite another case to illustrate this.
A woman nearing forty years of age suffered from chronic cold-fluid retention and usually preferred taking Ganjiang and Guizhi. During severe winter, after spending a long time in a cold room counting furniture, she suddenly fainted and fell to the ground. Carried to bed, she could still speak, stating that she felt cold Qi rushing upward causing faintness, and now found breathing extremely laborious, requiring great effort to inhale. She urged immediate medication. Suddenly, she became confused again, and her breath nearly ceased. I happened to be treating another patient in her village and was urgently summoned. Her pulse was minute and fine, almost imperceptible, with fewer than four beats per cycle. After inquiring about her constitution and the cause of illness, I confirmed it was undoubtedly cold-solid chest binding. Medication was unavailable in time. Urgently, I used HuJiao (Piperis Longi Fructus) (pungent and hot, capable of opening cold obstructions), 3 qian, crushed and decocted for two or three boils, and slowly administered it. She immediately felt smoother respiration and no further fainting. I then prescribed: Ganjiang and Sheng Huaishanyao (Dioscoreae Hypoglaucae Rhizoma) each 6 qian, Baizhu (Atractylodis Macrocephalae Rhizoma) and Danggui (Angelicae Sinensis Radix) each 4 qian, Guizhi Jian, Banxia, and Gancao (Glycyrrhizae Radix et Rhizoma) each 3 qian, and Houpo and Chenpi (Citri Reticulatae Pericarpium) each 2 qian. After two doses, the illness improved by eighty to ninety percent. Subsequent prescriptions were slight modifications of this formula, taken for several doses to conclude treatment.