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[Pathogenesis] Caused by wind-warmth seasonal toxins. The pathogenic factor first attacks the Shaoyang (Lesser Yang) channel, and subsequently is affected by sudden cold, leading to disease onset. This is a combined disease of Taiyang (Greater Yang) and Shaoyang yang heat, with symptoms resembling Shanghan (Cold Damage). Because the patient's ears turn yellow, it is named Huang'er Shanghan (Yellow Ear Cold Damage) based on its morphological features. This disease mostly occurs in spring.

[Symptoms] Fever and aversion to cold, stiffness of the spine and straightening of the back, symptoms similar to Gangjing (Stiff Spasm characterized by rigidity of the neck and back and opisthotonos). The earlobes are yellow, with stinging pain in the ears, followed by tinnitus and hearing loss, redness and swelling of the ears with pus discharge. The tongue coating is white with red patches, which later turns entirely red and develops prickles.

[Pulse] The left pulse is floating and wiry; the right pulse is floating and rapid. Shiwan referred to this as Taiyang-like Shanghan, but it is actually external cold interacting with internal heat, belonging to the seasonal toxin of combined Taiyang and Shaoyang diseases.

[Treatment] Internal and external treatments should be applied simultaneously. For internal treatment, Jingfang Baidu San (Atractylodes and Saposhnikovia Decoction for Resisting Toxins) is used with modifications. (The prescription and administration method are recorded in the preceding Yi Miao section.) Use acrid-dispersing methods to scatter wind-toxin and release the exterior; once the exterior is resolved, spasms cease. If Shaoyang ministerial fire remains vigorous and the ears are swollen and painful, Xinjia Mu Zei Jian (Modified Equisetum Decoction) is used next, removing scallion white and adding Lianqiao (Forsythiae Fructum), Niubangzi (Arctii Fructus) (each 2 qian), Daqingye (Isatidis Folium) (3 qian), Sheng Lv Dou (Vigna radiata seed, raw) (1 liang), and Du Chidou (Adzuki bean) (4 qian, decocted together to replace water for brewing other herbs). Use acrid-cool methods to resolve toxins and clear fire. After fire is cleared and toxins resolved, if tinnitus with intermittent blockage persists, Cong'er Dayu Tang (Ear-Opening Decoction for Releasing Stagnation) is used at the end: Dong Sangye (Mori Folium), Xiakucao (Prunellae Spica), Xian Zhuru (Bambusa Textilis Caulis, fresh), Jiao Shanzhi (Gardeniae Fructus, scorched), Biyu San (Jade Green Powder), Xian Shengdihuang (Rehmanniae Radix, fresh) each 2 qian, Nvzhenzi (Ligustri Lucidi Fructus) 3 qian, Sheng Gancao (Glycyrrhizae Radix et Rhizoma) 0.4 qian, and Xian Shichangpu juice (Acori Tatarinowii Rhizoma, fresh) 4 spoons mixed in. This clears residual heat to conclude treatment. For external treatment, Yueshi (Natrii Sulfas) (2 qian) is soaked in boiling water, mixed with Xian Bohe juice (Menthae Haplocalycis Herba, fresh), Kushen (Sophorae Flavescentis Radix), and Qingmuxiang (Aucklandiae Radix) ground juices (each 2 spoons), and instilled into the ears from time to time. This clears fire and resolves toxins to relieve pain.

[Xiu's Commentary] Huang'er Shanghan is not true Shanghan, but a condition resembling Shanghan caused by wind-warmth seasonal toxins. Therefore, Shiwan stated that wind enters the Kidney, speaking from the perspective that the Kidney opens into the ears. The formula used is Xiao Xuming Tang (Minor Continuation Life Decoction) without Fuzi (Aconiti Lateralis Radix Praeparata), adding Jiangcan (Bombyx Batryticatus), Tianma (Gastrodiae Rhizoma), Manjingzi (Vittariae Spora), and Baifuzi (Typhonii Rhizoma) to drive out deep-seated evil wind. Additionally, Kushen and Gusuibu (Drynariae Rhizoma) juices are dripped into the ears to clear fire and relieve pain. Mr. Yu argues that wind-warmth seasonal toxins first attack Shaoyang, speaking from the perspective that the Gallbladder channel also connects to the ears. Inferring his meaning, it is because external cold from the Taiyang channel binds and constrains, causing Shaoyang fire to stagnate and fail to vent, thus invading the ears and causing pain. Yellowing of the earlobes is analogous to damp-heat stagnation in the Yangming channel where heat cannot dissipate through sweat, resulting in body jaundice. The pathological mechanism is the same. Therefore, treatment prioritizes acrid-cool dispersal and wind-scattering toxin resolution, following the *Neijing* principle of "venting fire stagnation." The formulas are clear and agile. Although the legislation is from a shallower level, the symptomatic medication seems more stable than Zhang's method. This is because Ren Shen (Ginseng Radix), Shengjiang (Zingiberis Rhizoma Recens), and Rougui (Cinnamomi Cortex) in Xiao Xuming Tang are difficult to use indiscriminately for seasonal toxin diseases. Later learners should follow Yu rather than Zhang.

[Lian's Examination] During April and May of the Ji-Chou year of the Guangxu reign in the late Qing Dynasty, I encountered seven cases of Huang'er Shanghan, all poor individuals from rural areas. Their symptoms included red, swollen, and bright yellow ears, which were hot and painful to touch; severe redness, swelling, and pain in both cheeks; redness and swelling inside the ears with occasional discharge of yellow saliva; severe pain like insect bites; tinnitus sounding like cicada noise; yellowing of the sclera and eyelids; fever and body ache; aversion to cold and absence of sweating; cramping and radiating pain in the back, stiffness making extension difficult, inability to turn or lie on side; short, dark, and dysuric urine. The right pulse was soggy and stagnant; the left pulse was floating, wiry, and slightly tight. The tongue coating was white, greasy, and yellowish, with red edges and tips. The disease was diagnosed as wind-heat complicated with damp-warmth seasonal toxin, treated as epidemic otitis media. Modified Ma Huang Lian Qiao Chi Xiao Dou Tang (Ephedra, Forsythia, and Adzuki Bean Decoction) was administered: Mi Zhi Ma Huang (Honey-fried Ephedrae Herba) 0.5 qian, Guang Xingren (Prunus armeniaca seed) 3 qian, Lian Xu Sheng Cong Bai (Scallion white with root) 2 pieces, Dan Xiang Chi (Fermented Soybean) 3 qian, Yin Hua (Lonicerae Japonicae Flos), Lian Qiao (Forsythiae Fructum), Niu Bang Zi (Arctii Fructus) each 2 qian, Jiao Shan Zhi (Gardeniae Fructus, scorched), Zi Jing Pi (Pterocarpus indicus bark), Zi Bai Pi (Catalpa ovata bark) each 3 qian. First, Du Chi Xiao Dou (Adzuki bean) 4 qian, Sheng Lv Dou (Vigna radiata seed, raw), and Mian Yin Chen (Artemisiae Scopariae Herba) each 8 qian were decocted to replace water for brewing the above herbs. This was taken with Cong'er Lu Hui Wan (Ear-Opening Aloe Pill): Sheng Shu Chuan Jun (Rhei Radix et Rhizoma, raw and prepared), Lu Hui (Aloe), Qing Dai (Indigo Naturalis), Chai Hu (Bupleuri Radix) each 5 qian; Long Dan Cao (Gentianae Radix), Huang Qin (Scutellariae Radix), Shan Zhi (Gardeniae Fructus), Dang Gui (Angelicae Sinensis Radix), Qing Pi (Citri Reticulatae Pericarpium Viride) each 1 liang; Qing Mu Xiang (Aucklandiae Radix), Du Dan Xing (Arecae Semen cum Myrobalanis) each 2 qian, Dang Men Zi (Moschus) 0.5 fen, formed into pills with Shen Qu (Massa Medicata Fermentata), each dose 0.8 to 1 qian. This employed acrid-cool opening and reaching, wind-scattering cold to release the exterior, bitter-cold clearing and draining, toxin-resolving and fire-purging to treat the interior. Externally, Qing Di Er Du Shui (Ear-Toxin-Cleansing Water) (Peng Suan Borax 2 qian, Yan Bo Halite 1 qian, dissolved in 9 liang boiling water) was used to irrigate the ears. Qing Er Wu Xian San (Five Immortals Powder for Clearing Ears) (Chuan Bai processed with pig bile 1 qian, Du Hong Hua processed with wine 0.3 fen, Zhi Yue Shi prepared Natrii Sulfas 0.7 fen, Bing Pian Borneolum Syntheticum 0.01 fen, Bo He Shuang Menthol 0.02 fen, ground uniformly and stored in porcelain bottles) was insufflated into the ears. Salted duck egg ash mixed with pounded Tian He Ye (Nelumbinis Folia) was applied to the earlobes and cheeks to reduce swelling and inflammation. Such simultaneous exterior-interior resolution and internal-external treatment cured all seven patients within one hour (fast) or two hours (slow).

[Rongzhai's Commentary] The origin of the disease name "Huang'er Shanghan" is unknown. I first saw it in Zhang Shiwan's *Shanghan Xulun*, where he said: "Huang'er refers to stinging pain in the ears and yellowing of the earlobes, indicating wind entering the Kidney; sudden onset of aversion to cold and fever, with spinal stiffness resembling spasm, belongs to Taiyang-like Shanghan." The term "Huang'er" likely originated from the symptom "yellowing of the earlobes," deriving the disease name from the clinical presentation. These symptoms were already recorded in Chao Yuanfang's *Zhubing Yuanhou Zonglun* (General Treatise on the Causes and Manifestations of All Diseases), which stated: "All cases of stinging pain in the ears are due to wind entering the Kidney meridian; if untreated, it flows into the Kidney, causing sudden spinal stiffness and spasm." However, Chao's record lacked "aversion to cold and fever," and thus did not call it "like Shanghan." Currently, I believe the name "Huang'er" seems to have started with Zhang Shiwan, while the symptoms appeared earlier in Chao Yuanfang. There are similarities and differences in their evolution, and further differences from Yu's description. According to the symptoms listed in this section, they correspond to "ear furuncle" and "otitis media" in Western medicine. Western medical texts describe ear furuncle symptoms as: "Intense ear pain, especially severe at night; redness and swelling of the skin at the affected site, potentially spreading to the surrounding auricle; systemic chills and shivering, or high fever." Otitis media symptoms are described as: "Systemic symptoms—often high fever, chills, vomiting, headache, restlessness, similar to other acute infectious diseases. In children, meningeal irritation symptoms may occur, such as hyperesthesia, convulsions, vomiting, delirium, identical to genuine meningitis. Local symptoms—hearing impairment on the affected side, ear pain, tinnitus, pulsating sensation in the ear." (This is a summary, not the original text.) Comparing the symptoms recorded in Chinese and Western medical theories, the name "Huang'er Shanghan" does not seem entirely appropriate. As for treatment, the empirical prescriptions collected by Mr. Yu and Mr. He are sufficient for application.