2 Traditional Chinese Medicine Understanding of the Pathogenesis of Measles

In traditional Chinese medicine, measles is also known as “Jie,” “Jie Zi,” “Ma Zi,” “Ma Zheng,” “Sha,” “Tang Chuang,” “Fu Zi,” and other names. In ancient China, measles was referred to as “Ban,” later becoming “Pore,” and the distinction between measles and smallpox was long maintained. It wasn’t until the Ming Dynasty, with “Mai Zhen Shi Wei,” that measles and smallpox were treated separately; Gong Xin was the first to introduce the term “measles” in his work “Gujin Yijian.” Ancient medical texts, such as “Jinkui Yaolu,” contained discussions about maculopapular rashes, though the text was brief and descriptions were incomplete. Since the Northern Song Dynasty, records of measles gradually increased; Qian Yi wrote in “Xiao Er Yao Zheng Zhi Jue”: “Children’s pustules appear on the face, cheeks turn red, the eye sockets also turn red, with sneezing and drowsiness, alternating between cool and hot temperatures, coughing and sneezing, hands and feet feeling slightly cold, restless sleep, and pustules—this is a disease of the heavenly cycle.” This was the first description of measles, not only accurately capturing symptoms but also clearly identifying measles as an infectious disease. Later, in “Shanghan Zongbing Lun · Ban Zhen Pore Lun,” measles was distinguished from smallpox. It was believed that “there are two types of this disease: one where pustules appear, commonly called ‘Ma Zi,’ whose toxicity is somewhat lighter.” In “Youke Quan Shu · Yuan Zhen Fu,” further discussions were made regarding the pathogenesis and treatment of measles: “Toxins originate in the spleen, heat flows to the heart, and damage occurs in the viscera, especially in the lungs.” “If the rash appears too late, it’s best to release the exterior; if it appears too early, it’s better to detoxify.” “It seems like a beautiful pattern, yet only 19 times out of 100 succeed; it looks like coal, yet only 1 time out of 100 fails.” “The new book on measles” provided detailed descriptions of measles symptoms: “In the early stages of measles, when the rash hasn’t appeared yet, the body feels hot and cold, with headache and cough, possibly vomiting or nausea, diarrhea or abdominal pain, clear nasal discharge, sneezing and yawning, swollen eye sockets, watery eyes, red cheeks, body aches, irritability…” In the Ming Dynasty, measles and smallpox were still treated separately; “Pian Yu Dou Zhen” even compared measles with milk rash (equivalent to infantile measles). Additionally, valuable experiences were accumulated in the care and prevention of measles. For example, it was said: “When a rash first appears, avoid wind and cold; do not eat fried, spicy, or salty foods—opt for bland flavors. If you accidentally consume sour or salty foods, it will increase phlegm and cough, prolonging the illness and making it difficult to recover; if you accidentally eat fried foods, it will generate heat and toxins, leading to residual heat; if you encounter wind or cold, or if you cough and feel short of breath, or if you experience heat, various complications may arise, making recovery difficult.” The Qing Dynasty physician Xie Yuqiong’s “Mai Zhen Huo Ren Quan Shu” can be considered a comprehensive collection of measles knowledge, offering concise yet profound discussions on the causes and pathogenesis of measles, differential diagnosis, treatment approaches, and medicinal prescriptions: “Measles arises entirely from heat; when the body is not hot, the rash does not appear. When the body is warm and balanced, it’s favorable; if heat is absent, it’s not a good sign.” He pointed out that the cause of measles was “though measles is a fetal toxin, it often occurs during seasonal epidemics, and when the climate is hot and humid, both men and women can contract it.” He also provided detailed discussions on the progression and prognosis of measles: “In the early stages, the fever is similar to that of a cold, with swollen eye sockets and tears flowing continuously, sneezing and yawning, and swollen eye sockets; coughing and loss of appetite, thirst and fever; when you shine a light on the skin, you’ll feel faint heat beneath the surface, and when you touch the muscles, you’ll feel a rough texture; its appearance resembles scabies, its color is like crimson, and after three days, it’s safe to let it go—it appears and disappears, with wheezing and shortness of breath, no cough, no sweating, the rash is hidden, but the roots are swollen; measles is also accompanied by itching, the skin turns red, the rash becomes more like spots, resembling a beautiful pattern, and it heals without medication; but if it’s like coal, then it’s a black mark, and only 1 out of 100 will recover.” He emphasized that “when measles progresses, it’s necessary to observe the situation carefully and make judgments based on the actual conditions.” (2) Traditional Chinese Medicine Understanding of the Pathogenesis of Measles As early as the Song and Yuan Dynasties, there was a theory that “fetal toxins are internally generated.” In “Xiao Er Yao Zheng Zhi Jue,” it was suggested that “a child’s body contains five internal organs’ blood and impurities, and when born, the toxins should be released.” Later, through extensive clinical practice, the theory emerged that fetal toxins could be combined with external pathogens; as noted in “Renduan Lu,” “Although measles is a fetal toxin, it always accompanies seasonal epidemics.” By the Qing Dynasty, it was further recognized that measles occurred because of “seasonal epidemics,” triggered by the “harsh qi,” and external pathogens were acknowledged as the primary causes of measles. As stated in “Mai Zhen Hui Tong,” “Measles is caused by fetal toxins, which are part of seasonal epidemics—caused by hot and humid climates, transmitted through doorways and alleys.” The measles virus entered the body through the mouth and nose, primarily affecting the Lung and Spleen meridians. The Lung governs the skin and hair; when measles attacks the Lung, damaging the Lung’s defensive qi, fever, cough, and runny nose appear. The Spleen governs the extremities and muscles; when heat rises in the Spleen, it manifests as skin irritation, leading to loss of appetite, fatigue, and swollen skin. The Heart governs blood; when measles flows toward the Heart, it collides with qi and blood, creating conflict between the righteous and the evil forces, and toxins are released outward, resulting in a bright red rash. If the evil qi stagnates in the Liver meridian, it rises to the eyes, causing redness and photophobia, with tears streaming down the face. Measles is a Yang poison, generating heat and fire, consuming fluids and injuring fluids, leading to signs of Yin deficiency in the later stages. This is the favorable progression of measles—where the righteous overcome the evil, the rash appears smoothly, and after the rash clears, the evil follows the rash, leading to a better prognosis. However, if a young child is weak and lacks sufficient righteous qi to drive the evil out, or if measles is excessively intense, generating heat and injuring Yin, or if care is inadequate and treatment is improper, causing measles to become trapped within the body, various adverse conditions and complications may arise. If measles attacks the Lung, the Lung’s meridians become blocked, and lung qi fails to descend, coughing and shortness of breath may occur. If measles is intensely aggressive and generates heat, attacking the throat, hoarseness and difficulty breathing may result. If measles blocks the Lung and moves upward to the Pericardium, disturbing the mind and spirit, delirium and confusion may occur. If measles is excessively intense, generating heat and fire, and the heat becomes extreme, causing wind, convulsions may occur in the limbs. If the evil heat seeps into the blood, causing blood to flow abnormally, bleeding may occur, or “black measles” may develop (hemorrhagic measles); if measles moves heat to the Large Intestine, diarrhea may result. If heat scorches the intestinal meridians and causes stagnation and pus formation, purulent stools may appear (post-measles diarrhea). When the righteous are weakened and the evil is rampant, the rash is difficult to come out smoothly, appearing and disappearing repeatedly, with complex changes, leading to a poor prognosis. (3) Differentiation and Classification of TCM Syndrome Types and Herbal Formulas

1. Differentiation and Treatment (1) Evil Attacks the Lung and Defensive Qi (Early Stage): The main symptoms include fever and chills, sneezing and coughing, red and watery eyes, fatigue and drowsiness, and maculopapular rashes on the cheeks. The tongue coating is thin and white or slightly yellow, the pulse is floating and rapid. Treatment focuses on refreshing and cooling the exterior, using Yinqiao San with modifications: 12g of Honeysuckle, 12g of Forsythia, 12g of Burdock Seed, 10g of Water Hyacinth, 10g of Peppermint, 10g of Dried Soybean, 6g of Cicada Slough, 6g of Radix Hedysari, 10g of Kudzu Root. Brew the herbs in water and take one dose daily. (2) Evil Resides in the Qi Meridian (Midst of the Disease): The main symptoms include persistent high fever, burning sensation on the skin, worsening cough, restlessness, thirst and a desire to drink, and the rash appears in a sequential manner, beginning sparsely and reddening slightly, then gradually thickening and merging into larger patches, turning darker red, spreading throughout the body. The tongue is red with a yellow coating, the pulse is洪数. Treatment focuses on clearing heat, detoxifying, and promoting rash clearance, using Qingjie Toubiao Tang with modifications: 15g of Willow Bark, 6g of Cicada Slough, 12g of Kudzu Root, 12g of Burdock Seed, 12g of Honeysuckle, 12g of Forsythia, 12g of Purple Grass Root, 10g of Water Hyacinth, 12g of Radix Ophiopogonis. Brew the herbs in water and take one dose daily. (3) Evil Damages Qi and Yin (Late Stage): The rash appears in sequence according to the order of onset, leaving behind bran-like scales and brownish spots on the skin. The fever subsides, the body feels cooler, appetite increases, or lingering heat and thirst persist, the tongue is red with little coating, and the pulse is fine and rapid. Treatment focuses on replenishing qi and nourishing yin while clearing residual evil, using Shashen Mai Dong Tang with modifications: 15g of Radix Codonopsis, 12g of Ophiopogon, 15g of Rehmannia Root, 12g of Radix Ophiopogonis, 12g of Codonopsis, 10g of White Lily, 12g of Broad Bean.

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Input: Ling Injection, Houtou Injection, Shuanghuanglian Powder Injection, Fufang Kushan Injection, etc. For oral formulations, you can choose Qingkailing Oral Liquid (Capsules), Qing Reheat Detox Oral Liquid (Granules), Shuanghuanglian Oral Liquid, Jinlian Qingre Granules, Kushan Granules, Gegen Qinlian Micro Pills, Meihua Dian She Dan, Zijin Ding, and others.

(3) Blood-activating and stasis-resolving, damp-dispelling and phlegm-clearing types: Suitable for pulmonary obstruction and dyspnea in the progressive stage and severe cases of SARS. Injectable formulations include Danshen Injection, Xiangdan Injection, Chuanxiong Injection, Dengzhan Xixin Injection, etc. Oral formulations include Xuefu Zhuyu Oral Liquid (or Granules), Fufang Danshen Drops, Huoxiang Zhengqi Oral Liquid (Capsules), Houzao San, and others.

(4) Qi-tonifying type: Suitable for patients with deficiency of righteous qi at all stages. Injectable formulations include Shengmai Injection, Shenmai Injection, Shenfu Injection, Huangqi Injection, etc. Oral formulations include Shengmai Decoction, Bailing Capsules, Jinshui Bao Capsules, Ningxin Bao Capsules, Nuodikang Capsules, Liuwei Dihuang Wan, Buzhong Yiqi Wan, and others. Although the treatment principles for severe SARS often involve natural recovery in most patients, approximately 30% of cases are classified as severe, some of which may progress to acute lung injury or ARDS, even leading to death. Therefore, critically ill patients must be closely monitored dynamically, with enhanced care, timely respiratory support, appropriate use of glucocorticoids, strengthened nutritional support and organ function protection, attention to water, electrolyte, and acid-base balance, prevention and treatment of secondary infections, and prompt management of comorbidities.

The traditional Chinese medicine approach to SARS prevention emphasizes “treating disease before it occurs,” meaning that when a particular disease is likely to develop, corresponding medications are used to prevent its onset, progression, and transmission. Based on the TCM understanding that SARS belongs to the category of “epidemic diseases,” the “Fanggan Tang” series of preparations—principled around clearing heat and detoxifying, dispersing turbidity through aroma, and promoting diuresis to clear dampness and open the exterior—were developed to help improve the body’s damp-heat environment, while leveraging the power of exterior-clearing to invigorate the body’s yang energy and resist external pathogenic factors.

For those with significant internal heat and prone to constipation, Fanggan Tang No. 1 can be selected, composed of 10g of Guanzhong, 10g of Wild Chrysanthemum, 15g of Banlan Gen, 10g of Lianqiao, and 5g of Gancao. Take one dose daily for 3 days. Reduce the dosage for children accordingly. Effects: Clear heat and detoxify, resolving excessive heat and toxins within the body, achieving the principle of “the yin is balanced, the yang is secure, and the spirit is healed.”

For those with spleen and stomach deficiency-cold and who sweat easily while being susceptible to external pathogens, Fanggan Tang No. 2 can be chosen, composed of 10g of Huangqi, 10g of Jingjie, 10g of Guanzhong, 10g of Huangqin, 10g of Banlan Gen, and 5g of Gancao. Take one dose daily for 3 days. Reduce the dosage for children accordingly. Effects: Combine clearing with tonification, preventing cold and bitter herbs from harming the middle burner, while utilizing dispelling and uplifting herbs to invigorate the defensive yang and resist external pathogenic factors.

For those who are overweight and prone to dampness due to excessive smoking and alcohol consumption, Fanggan Tang No. 3 can be selected, composed of 10g of Huoxiang, 10g of Peilan, 10g of Guanzhong, 10g of Huangqin, 10g of Lianqiao, 10g of Banlan Gen, 10g of Jingjie, and 5g of Gancao. Take one dose daily for 3 days, reducing the dosage for children accordingly. Effects: Clear heat and transform dampness, opening the exterior to expel pathogenic factors.

A Chinese medicine screening team composed of experts from the China Academy of Traditional Chinese Medicine, Beijing University of Chinese Medicine, and other institutions aimed to alleviate symptoms, control conditions, and reduce mortality by focusing on clinical pathological aspects such as high fever, exudation, fibrosis, and multiorgan failure. They screened 30 traditional Chinese medicines used in clinical treatments in Guangzhou and Beijing, ultimately identifying eight traditional Chinese medicines as potential treatments for SARS: Qingkailing Injection, Houtou Injection, Banlan Gen Granules, Dengzhan Xixin Injection, Fufang Kushan Injection, and Xiangdan Injection. Among these, ① Qingkailing Injection, Houtou Injection, and Banlan Gen Granules have shown good effects in improving acute pulmonary inflammation; ② XinXue Granules and Jinlian Qingre Granules effectively reduce fever quickly and maintain it for a long duration; ③ Qingkailing Injection and Dengzhan Xixin Injection can effectively alleviate acute respiratory distress syndrome; ④ Qingkailing Injection, Fufang Kushan Injection, and Xiangdan Injection demonstrate significant protective effects against multiorgan damage. These eight traditional Chinese medicines played an extremely important role in the treatment of SARS during its early, mid, severe, and recovery phases—roles that could not be replaced by Western medicine. (China Journal of Traditional Chinese Medicine, 2003.6)

Four. Western Medical Treatment (1) General Treatment and Condition Monitoring

Rest in bed, pay attention to maintaining water and electrolyte balance, and avoid strenuous activity or violent coughing. Closely monitor changes in the patient’s condition. In the early stages, provide continuous nasal cannula oxygen therapy.

(2) Symptomatic Treatment

1. For patients with a fever exceeding 38.5°C or severe systemic pain, antipyretic and analgesic medications can be used. In cases of high fever, apply ice packs, alcohol rubs, or other physical cooling methods.
2. For patients with cough and sputum production, administer cough suppressants and expectorants.
3. Patients with impaired cardiac, hepatic, or renal function should receive appropriate treatment.
4. For patients experiencing diarrhea, ensure adequate fluid replacement and correct water-electrolyte imbalances. (3) Respiratory Support Therapy

In severe cases, even at rest, patients may exhibit hypoxia; after activity, a decrease in SpO₂ is an early sign of respiratory failure. Timely provision of continuous oxygen therapy is essential to maintain SpO₂ at 93% or higher. If the oxygen flow rate exceeds 5 L/min or the oxygen concentration reaches 40%, but SpO₂ remains below 93%, or if the respiratory rate exceeds 30 breaths per minute and the respiratory load remains high, consider non-invasive or invasive positive pressure ventilation to alleviate respiratory distress, improve pulmonary oxygenation, and help patients navigate the critical phase.

(4) Use of Glucocorticoids