譯 1.36.1 Source원문
疳者乾也, 瘦瘁少血也. 兒童二十歲以下曰疳, 二十歲以上曰勞, 皆由氣血虛憊, 藏府受傷. 故有五藏疳, 外有蛔疳ㆍ脊疳ㆍ腦疳ㆍ乾疳ㆍ疳渴ㆍ疳瀉ㆍ疳痢ㆍ腫脹疳ㆍ無辜疳ㆍ丁奚ㆍ哺露, 治之各有方. 其病多因乳哺失常, 肥甘不節, 腸胃積滯而得之. 故其爲證, 頭皮光急, 毛髮焦稀, 腮縮鼻乾, 口淡唇白, 兩眼昏爛, 揉鼻撏目, 脊聳體重, 鬪甲咬牙, 焦渴自汗, 漩白瀉酸, 肚脹腸鳴, 結癖潮熱, 或身多瘡疥, 酷嗜瓜果ㆍ酸醎ㆍ炭米ㆍ泥土, 多飮水者是也. 惟腎疳害人最速, 盖腎虛受邪, 疳奔上焦, 故以走馬爲喩. 初作口臭, 次傳齒黑齦爛, 熱血迸出, 甚則齒脫, 宜急治之. 縱得全活, 齒不復生矣. 《得效》
Translation영역
Gan means dryness: the child is thin and withered and short of blood. In children under twenty years of age it is called gan, and above twenty years it is called taxation, and both come about through qi and blood being vacuous and worn out and the viscera and bowels taking injury. Hence there are the five-viscera gans, and besides them roundworm gan, spine gan, brain gan, dry gan, gan thirst, gan diarrhoea, gan dysentery, swelling-and-distension gan, blameless gan, jeonghae and bomno, and there is a formula for each of them. The disease mostly arises from irregularity in nursing and feeding, from want of restraint with rich and sweet food, and from accumulation and stagnation in the stomach and intestines. Hence its presentation is this: the skin of the head shiny and drawn tight; the hair scorched and sparse; the cheeks shrunken and the nose dry; the mouth tasteless and the lips pale; both eyes clouded and sore; rubbing at the nose and plucking at the eyes; the spine standing up and the body heavy; the nails clashed together and the teeth ground; parching thirst and spontaneous sweating; the urine white and the stools sour; the belly distended and the bowels rumbling; lumps bound up inside and tidal fever; or the body covered in sores and scabies; a craving beyond control for melons and fruit, for sour and salty things, for charcoal, raw rice and mud and earth; and the drinking of much water. Only kidney gan harms a person fastest, for when the kidney is vacuous and receives evil, the gan rushes to the upper burner, and so it is likened to a galloping horse. At first it makes the breath foul; next it passes on to blackened teeth and eroded gums, with hot blood bursting out, and in severe cases the teeth fall out. It must be treated urgently. Even if the child comes through alive, the teeth will not grow again.
Clinical note임상 주석
This passage opens the gan sections, which run on through the five-viscera gans and the long list of named kinds, and it is best read as a framing statement rather than as the description of a single disease. 疳 in children is the malnutrition and chronic-wasting complex: the child who does not grow, with a swollen belly and thin limbs, hair that has changed in colour and texture and comes away easily, an appetite that is either absent or ravenous and disordered, loose or fatty stools, and one infection after another. Modern terms for parts of it are severe acute malnutrition in its two forms, marasmus and kwashiorkor, environmental enteric dysfunction, and micronutrient deficiencies — iron, zinc, vitamin A — each of which contributes its own signs. Intestinal helminths, chronic diarrhoea and tuberculosis sit inside the same picture as cause, consequence or both.
Read that way, the catalogue of signs is accurate and almost all of it is recognisable. The tight shiny scalp with sparse brittle hair, the sunken cheeks, the prominent spine, the distended rumbling abdomen, the sour stools of carbohydrate malabsorption, the recurrent skin sores and scabies, and the tidal fever of a chronic infection are the examination findings of a severely undernourished child. 酷嗜 charcoal, raw rice and earth is pica, which is associated with iron and zinc deficiency and which also brings in more parasites. The clouded, sore eyes are the beginning of vitamin A deficiency, which this chapter will return to. The one inference that fails is the aetiology: 肥甘不節, want of restraint with rich and sweet food, has the direction of causation backwards, and the following passages build on that error.
The kidney-gan paragraph is noma, acute necrotising gingivostomatitis progressing to destruction of the mouth and face — a disease of severely malnourished children which begins with foul breath and bleeding, ulcerated gums and can destroy the jaw within days. The chapter is right that it moves fast, right that it is an emergency, and right that the teeth are lost for good. It describes it again later under its own heading, and the clinical detail belongs there.
譯 1.36.2 Source원문
疳乾ㆍ疳渴ㆍ疳勞ㆍ疳瀉ㆍ疳痢ㆍ疳腫, 皆五疳之危證; 曰蛔疳ㆍ腦疳ㆍ脊疳ㆍ無辜疳ㆍ丁奚疳ㆍ哺露疳, 皆五疳死證. 所以然者, 五藏俱病故也. 《入門》
Translation영역
Gan dryness, gan thirst, gan taxation, gan diarrhoea, gan dysentery and gan swelling are all dangerous patterns of the five gans; while roundworm gan, brain gan, spine gan, blameless gan, jeonghae gan and bomno gan are all fatal patterns of the five gans. The reason is that in these the five viscera are diseased together.
Clinical note임상 주석
The grading is a prognostic list, and the principle behind it — that the condition becomes lethal when it stops being confined to one system — is sound in its own idiom and roughly right in modern terms. A child with chronic undernutrition dies of what it brings with it: persistent diarrhoea with dehydration and electrolyte loss, pneumonia and other infections against an impaired immune response, tuberculosis, and the circulatory and metabolic failure of severe wasting. Those are the pathways the names in the second list stand for. Which named gan a child was assigned to mattered less than how far the wasting had gone, and the chapter is in effect staging severity under the guise of classification.
譯 1.36.3 Source원문
大抵疳病, 當辨冷熱肥瘦. 其初病者爲肥熱疳, 久病者爲瘦冷疳, 冷熱交作者爲冷熱疳, 當分治之. 《錢乙》
Translation영역
On the whole, in gan disease one should distinguish cold from heat and fat from thin. One newly fallen ill is fat-heat gan; one long ill is thin-cold gan; and one in whom cold and heat alternate is cold-heat gan. They should be treated separately.
Clinical note임상 주석
Grading by how long the illness has run and by how much flesh is left is the most useful axis in the whole scheme, and it is close to how a severely malnourished child is assessed now — by weight for height, by mid-upper-arm circumference, by whether oedema is present, and by whether there are complications. The early, better-fleshed, feverish child and the long-ill, wasted, cold child are genuinely different presentations with different outlooks, and the cold, apathetic, hypothermic child is the one in danger. Hypothermia, hypoglycaemia and infection are the three things that kill such children in the first days of treatment, and warming, frequent small feeds and antibiotics are the first steps of management for exactly that reason.
譯 1.36.4 Source원문
疳病因多食肥甘所致, 故命名曰疳. 《正傳》
Translation영역
Gan disease is brought about by eating much rich and sweet food, and that is why it is named gan.
Clinical note임상 주석
This is an etymology doing duty as a cause. 疳 is being read through 甘, sweet, and the sweetness of the word then explains the disease. The direction is the wrong way round: the children this chapter describes were not overfed on rich food but underfed, and the commonest setting for the whole picture was and is too little food of too poor a quality, with repeated infection on top of it. The error is not harmless, because a theory of excess leads to the treatments the later gan sections reach for — purging, draining and restriction — in children whose need is energy, protein, micronutrients and treatment of infection.
譯 1.36.5 Source원문
凡兒大便色白, 小便濁如米泔, 此疳病也. 《回春》
Translation영역
Whenever a child's stools are white in colour and its urine is turbid like rice-washing water, this is gan disease.
Clinical note임상 주석
Both signs are worth keeping. Pale, bulky, greasy stools are steatorrhoea — fat passing undigested — and in a child who is not growing they point to malabsorption: coeliac disease, cystic fibrosis, pancreatic insufficiency, giardiasis or the flattened small-bowel mucosa of chronic undernutrition itself. Stools that are truly chalky white, rather than pale, mean that bile is not reaching the gut and are a different and urgent matter, requiring investigation for biliary obstruction. Cloudy urine is usually of no significance — it is often only phosphate crystals settling out — but it can mean infection, and urinary infection is one of the occult causes of failure to thrive.
譯 1.36.6 Source원문
諸疳皆依本藏補其母. 假令日中發潮熱, 是心虛熱也. 肝爲心母, 法當先補肝母, 肝實而後瀉心. 心得母氣, 則內平而潮熱自愈矣. 《錢乙》
Translation영역
In all the gans, one supplements the mother according to the viscus concerned. Suppose tidal fever breaks out at midday: this is vacuity heat of the heart. The liver is the mother of the heart, and the method is accordingly to supplement the liver, the mother, first, and only when the liver is replete to drain the heart. When the heart has obtained the mother's qi, then the interior is levelled and the tidal fever resolves of itself.
Clinical note임상 주석
This is the five-phase engendering sequence applied as a treatment rule, and it is a correspondence rather than an observation: the midday hour assigns the fever to the heart, the heart's mother is the liver, and the order of treatment follows from the scheme. There is no finding here from the bedside, and the structure would have generated the same answer for any complaint falling in that hour.