II. Diagnosis

II. Diagnosis (1) Diagnostic Criteria

1. Epidemiology: Cases often have a history of outbreaks and contact with infected individuals, with peak incidence during winter and spring.
2. Clinical Manifestations: Swelling, hardness, and tenderness centered around the lower anterior part of the earlobes—often bilateral—and not suppurating. Some cases may be complicated by orchitis, myocarditis, pancreatitis, meningitis, and other conditions.
3. Laboratory tests show mostly normal white blood cell counts, with a relative increase in lymphocytes, elevated serum and urinary amylase activity, and mild to moderate elevation of cerebrospinal fluid cells in more than 50% of cases. If necessary, serological tests (neutralizing antibodies, complement fixation, hemagglutination inhibition), inactivated virus skin tests, and virus isolation can be performed to confirm the diagnosis. (2) Differential Diagnosis
4. Suppurative parotitis typically presents on one side, with significant redness, swelling, and pain, often accompanied by fluctuating masses, and a marked increase in white blood cell count and neutrophils, with antibacterial treatment being effective. 117HMo
5. Lymphadenitis of the neck and preauricular region—non-bilateral, with well-defined hard nodules and significant tenderness, often accompanied by inflammation in the surrounding areas (teeth, pharyngitis, ulcers, etc.).
6. Secondary parotid enlargement may occur in patients with diabetes, malnutrition, chronic liver disease, or drug-induced conditions (iodine preparations, hydrocortisone, isoprenaline, etc.), often symmetrically, with soft tissue, and without pain.
7. Other rare cases may present with allergic parotitis (e.g., cases involving other symptoms associated with the disease). With a history of recurrent attacks, the swelling resolves quickly. In adolescent males, there are also cases of simple parotid swelling, but these are less common. To differentiate from duct obstruction, these cases should be carefully evaluated. Integrated Traditional Chinese and Western Medicine Practical Internal Medicine III. Traditional Chinese Medicine’s Understanding and Treatment of Epidemic Parotitis

(1) Historical Medical Views: Terms like “bursting parotitis,” “parotitis with swollen glands,” “beard-like parotitis,” “toad plague,” “swan plague,” “parotitis with swelling,” “ulcerated parotitis,” “ear swelling,” “big-head plague,” “big-mouth plague,” and others all refer to this disease. Among these, the term “making the waist” is undoubtedly referring to this condition; as early as over two thousand years ago, the traditional Chinese medicine text “Suwen · Zhi Zhen Yao Da Lun” recorded similar cases. The Sui Dynasty’s “Zhu’s Collection of Prescriptions” also mentioned: “When Emperor Renzong was in the Eastern Palace, he was afflicted with parotitis and ordered Taoist Zhan Ning to treat him. He took 70 red beans, ground them into powder, applied it, and recovered.” Later Ming and Qing dynasty physicians further clarified the epidemic characteristics and seasonal patterns of this disease. In “Yi Xue Xin Ke,” the author described the disease in great detail: “Due to a sudden outbreak of wind-heat toxins in the throat, jaw, and cheeks, they combined with qi and blood, causing swelling and pain.” In 1020 AD, the disease was already prevalent in Beijing. Li Shizhen’s “Ben Cao Gang Mu,” which included Zhu’s collection of verified prescriptions, also noted: “When Emperor Renzong was in the Eastern Palace, he suffered from parotitis and ordered Taoist Zhan Ning to treat him. He took 70 red beans, ground them into powder, applied it, and recovered.” More clearly, Ming and Qing dynasty physicians highlighted the epidemic nature and seasonal patterns of this disease. In “Wang Re Jing Wen,” it was stated: “When the weather is unfavorable, people are susceptible to infection and transmission.” “Parotitis arises from wind-heat and damp-phlegm, often occurring after winter’s cold and unfavorable weather, when people become susceptible to infection and transmission, leading to swelling and pain in the parotid glands.” Regarding the epidemic characteristics and clinical symptoms and progression of this disease, the records were remarkably accurate. In “Leng Lu Yi Hua,” there were clear records of parotitis complicated by orchitis: “In cases of parotitis… the swelling and pain subside, but the testes suddenly swell, indicating that the toxin has entered the interior and invaded the Jueyin meridian, causing testicular swelling and pain.” “Wang Re Jing Wen” also stated: “After recovery, men experience testicular swelling and abdominal cramps that are unbearable.” These cases all refer to complications such as orchitis. “Yi Xue Zhun,” a classic work on surgery, noted: “When the weather is unfavorable, people are susceptible to infection and transmission, and many cases can recover naturally within ten days without treatment.” Li Dongyuan and Wu Jutong even recommended using the “Pujie Dihua Yin,” a time-honored prescription for treating this disease: “Warm toxins, sore throat, throat swelling, swelling in front and behind the ears, cheek swelling, face turning red. Or, if the throat does not hurt, but the swelling persists, and in severe cases, hearing loss occurs—commonly known as ‘big-head plague,’ ‘shrimp membrane swelling’—Pujie Dihua Yin removes Chai and Sheng.” (Wen Bing Tiao Bian) (2) Traditional Chinese Medicine’s Understanding of the Pathogenesis of Epidemic Parotitis

Regarding the etiology and pathology of this disease, as stated in “Yi Xue Zhun”: “Parotitis arises from wind-heat and damp-phlegm.” Today, it is believed that this disease is caused by the invasion of wind-damp toxins. These toxins enter the body through the mouth and nose, attacking the Shaoyang Gallbladder Meridian; heat toxins accumulate in the meridians, becoming stagnant and obstructed, leading to qi stagnation and blood stasis. Since the Foot Shaoyang Meridian originates at the inner corner of the eye, ascends to the head and angles, then runs down the ear, we see swelling and hardness in the parotid region below the ear. Because the initial stage involves the invasion of lung and stomach, patients often experience chills, fever, headache, and body aches—symptoms of lung-qi imbalance—and throat pain due to gastric heat rising upward. The Shaoyang and Jueyin meridians are in opposition; the Foot Jueyin Liver Meridian runs around the female organs, and when heat toxins move from the Shaoyang to the Jueyin, testicular or ovarian swelling and pain may occur. If the heat toxins are severe and invade the Ying Qi, settling in the Pericardium and affecting the Stomach and Brain, then high fever, headache, vomiting, convulsions, delirium, and limb stiffness may arise (meningitis, encephalitis). In recent years, there may also be depletion of Qi and Yin, leading to heart palpitations, chest tightness, and shortness of breath (complications such as myocarditis). However, most cases are mild, with good prognoses. In summary, the basic pathogenic mechanisms of this disease are as follows: wind-heat rises and obstructs the Shaoyang; gallbladder heat invades the stomach, causing qi and blood to stagnate; intense heat toxins affect the Heart and Liver; qi and blood are deficient, with phlegm and blood stasis remaining; as the toxins recede, the body becomes deficient in Qi and Yin. (3) Traditional Chinese Medicine’s Differentiation and Classification of Syndrome Types and Herbal Formulas

1. Differentiation and Classification of Syndrome Types and Herbal Formulas (1) Wind-Heat Invasion of the Surface: The main symptoms include chills and fever, headache, swelling of the parotid glands, a red tongue with a thin yellow coating, and a floating, rapid pulse. Treatment focuses on dispersing wind, clearing heat, and resolving blockages and swelling. The formula is Yinqiao San with modifications: 12 g of honeysuckle, 9 g of forsythia, 9 g of citrus peel, 9 g of bitter melon, 6 g of lotus leaf, 15 g of indigo woad, 9 g of prunella, 15 g of salvia, 9 g of scutellaria. Brew the herbs in water, one dose per day. (2) Gallbladder Heat Invading the Stomach, Qi and Blood Stagnation: The main symptoms include high fever and thirst, swelling of the parotid glands that are painful to press, irritability, nausea, constipation, dry stools, a red tongue with a yellow coating, and a slippery, rapid, or string-like, or even a deep, rapid pulse. Treatment aims to clear heat and detoxify, while clearing the Liver and benefiting the Gallbladder and activating blood circulation. The formula is Pujie Dihua Yin with modifications: 6 g of bupleurum, 9 g of mulberry, 12 g of forsythia, 6 g of peppermint, 9 g of silkworm moth, 9 g of burdock, 15 g of indigo woad, 9 g of horsehair, 12 g of scutellaria, 9 g of platycodon, 15 g of salvia. Brew the herbs in water, one dose per day. (3) Remaining Toxins Unresolved, Parotid Swelling Still Present: The main symptoms include heat subsiding, swelling gradually fading, or testicular swelling and pain, a red tongue with a yellow, dry coating, and a rapid pulse. Treatment focuses on clearing residual toxins and softening and resolving blockages. The formula uses Xiaolu Wan with modifications: 12 g of prunella, 9 g of rehmannia, 12 g of full luffa, 12 g of fritillaria, 12 g of oyster shell, 15 g of indigo woad, 9 g of large green leaves, 12 g of poppy seeds. Brew the herbs in water, one dose per day. (4) Qi and Blood Deficiency, Phlegm and Blood Stasis: The main symptoms include heat subsiding, mental dullness, phlegm and saliva accumulating, limited limb movement, a pale red or dark purple tongue, a stout body with moist coating, a fine, rough pulse. Treatment focuses on replenishing Qi and activating blood circulation, transforming phlegm and opening the channels. The formula uses Changpu Yu Jin Tang with modifications: 6 g of peony, 6 g of ligusticum, 12 g of salvia, 9 g of poria, 6 g of earthworm, 3 g of angelica, 6 g of kudzu, 12 g of astragalus, 9 g of licorice. Brew the herbs in water, one dose per day. Second Chapter: Infectious Diseases

Yang Jian (Spleen 5) – Stomach and Liver Clearing. Deficiency-formula, replenishing Shen: Ma can treat winter conditions, heart discomfort, poor appetite, sluggishness, a red tongue with a thin yellow coating, a dry yellow coating, a fine, rapid pulse—treatment focuses on replenishing Qi. 6 g of roasted mountain herb, 3 g of licorice. Brew the herbs in water, one dose per day. OB, 9 g of winter, 9 g of poria. 6 g of white atractylodes, 6 g of codonopsis, roasted away the buds, swelling blood Valley of Honghu, Ji; concurrent with the addition of seaweed and kelp; when heat toxins overwhelm, constipation worsens, and rhubarb and cassava are added; when the illness progresses, the formula includes Ni Li, Miao Li, and other herbs. Ji, Miao Li, and other herbs; when complications such as meningitis or delirium occur, add Pei Tun. Children, mT · KN+ILtrt 工 IB

Under the premise of “early theory,” commonly used methods like “pulling out the bottom of the pot” to clear the interior and attack downward—also emphasize using Salvia to clear heat and detoxify, while also utilizing Dan Shen to activate blood circulation and clear blood stasis. Note: ① Avoid eating seafood, shrimp, crab, and other marine products; fish and shrimp are prohibited in the first few days—1st step: diagnose and treat. For initial treatment, use caution when using ascending and warming herbs like Sheng Mai and Xinyuan. ③ Pay attention to using heat-clearing and detoxifying herbs while also incorporating qi-regulating, blood-activating, and blockage-resolving herbs. (4) Traditional Chinese Medicine Resources on the Differentiation and Treatment of This Disease In recent years, specialized formulas have increasingly been used to treat this disease. For example, in a study by Wen Rui, all 40 cases were treated with Chaihu Gegen Tang with additions: Chaihu, Scutellaria, Niu Lao Zi, 8 g of Silkworm Moth, 8 g of Mulberry, 6 g of Sheng Mai, 6 g of Kudzu, 15 g of Radix Rehmanniae, 10 g of Flower Powder, 20 g of Raw Gypsum, 3 g of Licorice; together with Chaihu, Scutellaria, Rehmannia, Coptis, and Red Peony; for cases with constipation, Rhubarb was added. When heat subsided and swelling did not resolve quickly, the formula was modified to include Niu Lao Gan Ju Tang: Niu Lao Zi, Chuan Xiong, Fu Jing, Chen Pi, Flower Powder, Coptis, Red Peony, Su Mu, Licorice, Sheng Mai, and other herbs. Each day, one dose was taken, and after 1–5 doses, all cases were cured, with an average fever reduction of 2.7 days and a 3-day disappearance of symptoms. (Shanghai Journal of Traditional Chinese Medicine, 1988.6) Recently, scholars have begun to treat this disease based on liver and gallbladder differentiation: ① When heat toxins enter the gallbladder and obstruct the meridians, treatment focuses on clearing gallbladder heat and harmonizing the stomach to descend rebellious qi, using Xiao Zhuang Hu Tang with modifications. ② When liver and gallbladder are filled with damp-heat and their function is disrupted, treatment focuses on clearing the gallbladder and liver, using Longdan Xiegan Tang with modifications. ③ When liver wind is rampant and the toxin has settled in the Pericardium, treatment focuses on clearing the liver and extinguishing wind, detoxifying and cooling the blood, using Lingyang Gou Teng Tang with modifications. ④ When gallbladder heat and liver stagnation lead to phlegm and heat accumulation, treatment focuses on clearing the liver and transforming phlegm, regulating qi and resolving blockages, using Huanglian Wen Dan Tang combined with Hai Zao Yu Hu Tang. Wang Ruilong divided cases into mild, moderate, and severe types. Mild cases used Yin Qiao Bai Du San with modifications, moderate cases used Yin Qiao San, and severe cases used Pujie Dihua Yin. For parotid swelling and hardness, add Sheng Mai and Kelp; for high fever and convulsions, add Gou Teng and Whole Scorpion; for testicular swelling and pain, add Citrus Peel, Lychee Kernel, Chuan Lian Zi, and Tian Hu. All cases were treated with external applications of dissolving ointments (200 g of Realgar and Rhubarb each, 100 g of Turmeric, Red Peony, and Rehmannia each, 50 g of Bloodstone and Camphor each, finely ground and mixed with Vaseline to form a paste). All cases were cured. The average fever reduction time was 3.1 days, and the average swelling resolution time was 6.2 days. (Yunnan Journal of Traditional Chinese Medicine, 1990.3) Li Lihua and others reported using a specialized formula: 20–30 g of honeysuckle, 15 g of forsythia, 15 g of reed root, 15 g of indigo woad, 15 g of Sheng Mai, 6 g of peppermint, 9 g of burdock, 10 g of bupleurum, 10–15 g of scutellaria, one dose per day, brewed in water and taken in three doses. For high fever, add Gypsum and Zhi Mu; for throat pain, add Xuan Shen and Ma Bo; for submandibular gland swelling, add Ba Mei, Silkworm Moth, Xuan Shen; for testicular redness and swelling, add Longdan, Lychee Kernel, Chuan Lian Zi, and Tian Hu. Additionally, apply external ointments containing dissolving agents (200 g of Realgar and Indigo Woad each, 50 g of Camphor, finely ground and sieved, mixed with vinegar in appropriate amounts, applied to the affected area 3–5 times daily). Three days constituted one course of treatment. After treating 98 cases for 2–7 days, 75 cases were cured, 21 cases improved, and 2 cases were ineffective. This formula contained 30 g of indigo woad and honeysuckle each, 15 g of forsythia, 15 g of indigo woad, 15 g of Polygonum cuspidatum, 15 g of Chuan Lian Zi, 12 g of scutellaria, 10 g of bupleurum. For high fever, add Gypsum; for headaches, add Chrysanthemum; for vomiting, add Bamboo Root; for thirst, add Flower Powder; for loss of appetite, add Hawthorn; for throat pain, add Xuan Shen and Kudzu; for cough, add Zhebei Mu; for neck pain, add Kudzu; for constipation, add Rhubarb; for red urine, add Ma Gen; for testicular swelling and pain, add Chuan Lian Zi and Lychee Kernel; for long disease courses, add Danpi and Pangolin. One dose per day, two doses per day for severe cases, brewed in water and taken in two doses. For external applications, add 50 g of Realgar, 50 g of Indigo Woad, 50 g of Magnesium Sulphate, 3 g of Camphor, finely ground and sieved, mixed with vinegar in appropriate amounts, applied to the affected area 3–5 times daily. Three days constituted one course of treatment. After treating 98 cases for 2–7 days, 75 cases were cured, 21 cases improved, and 2 cases were ineffective. (Guizhou College of Traditional Chinese Medicine Journal, 1990.4) Cheng Quntai and others reported treating 57 cases of parotitis complicated by meningitis with Pujie Dihua Yin: 15 g of scutellaria and 15 g of rehmannia, 8 g of Chen Pi, 10 g of Licorice and Ma Bo, 12 g of Xuan Shen and Niu Lao Zi, 6 g of Kudzu and Sheng Mai, 20 g of forsythia and Silkworm Moth, 30 g of indigo woad and bupleurum, 3 g of peppermint. These dosages were for children aged 10; other age groups should adjust accordingly. One dose per day, adding 800 ml of water, simmering until 600 ml remained, taken in three doses. Severe cases received two doses per day, every 6 hours; patients with altered consciousness were fed via nasogastric tube, and those unable to eat were treated with supportive therapies. After 3–7 doses of medication (with an average of 5 doses), all cases were cured. (National Forum of Traditional Chinese Medicine, 1991.2)

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