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Naoju (Brain Carbuncle), commonly known as Duikou (Opposite Mouth), refers to a specific type of carbuncle. Although the sites of onset differ, there are two main etiological sources: those caused by external invasion due to the steaming interaction of dampness and heat are mild; those originating from internal accumulation in the five zang organs manifesting outwardly are severe.

What is the rationale? Damp-heat pathology often arises from climatic irregularities such as unbalanced cold and heat, fluctuating seasonal temperatures, and disharmony of yin and yang. Individuals with deficient constitution are prone to such invasions. The nape region belongs to the Du Meridian (Governing Vessel) and is also the pathway for the Taiyang Cold Water meridian. External pathogens invading this area cause qi and blood stagnation; stagnation inevitably leads to swelling. This constitutes the external invasion etiology. Such lesions initially present with a head, often occurring on acupoints along the midline. Within three to four days, pain typically develops, accompanied by initial aversion to cold and fever. The mouth feels relatively normal but dry. The lesion appears red with a vibrant base, gradually rising in height without spreading widely. Pain comes and goes. Pus formation and sloughing occur easily. Appetite remains intact, and daily activities are normal. Although the external appearance may seem alarming, there are no internal "Seven Evils" (seven critical syndromes indicating poor prognosis). Thus, it belongs to Yang syndrome, caused by external factors, and generally resolves even without treatment.

Conversely, lesions resulting from five-zang accumulation are severe, with five specific origins:
1. The Heart governs blood. Mental agitation and restlessness stir up fire, causing it to boil and flow into the nape, where it stagnates with cold water, leading to swelling. This is the first origin.
2. The Liver governs sinews. Anger injures the liver. The nape is where the three yang meridians govern sinews. Liver injury causes blood vessels to fail to nourish the sinews, leading to condensation and swelling. Consequently, the neck becomes stiff and painful, limiting movement. Before ulceration, the skin is purple-dark, hard, and diffusely swollen. Upon rupture, it bleeds fluid, feels numb and painful, and produces no pus. These symptoms indicate liver qi injury. This is the second origin.
3. The Spleen governs muscles. Overthinking injures the spleen, depleting spleen qi daily. Alternatively, excessive consumption of rich and sweet foods damages the stomach, drying up stomach fluids. This leads to epigastric fullness and obstruction, preventing qi circulation. Qi rebels within the muscles, causing congestion and swelling. The outer skin may slough, but the interior remains hard and un-ulcerated. Symptoms include dry mouth and tongue, loss of appetite, spreading base, and foul, discolored pus. These indicate spleen qi injury. This is the third origin.
4. The Lungs govern the skin and hair. Melancholy injures the lungs. Lung injury closes pores and blocks interstices, hindering smooth qi flow. Qi stagnates in the collaterals, forming swelling. The lesions are flat or depressed, pale and dull. Skin sloughs with lipid discharge, resembling scalds. Symptoms include coarse breathing, shortness of breath, nasal congestion, flaring nostrils, profuse phlegm, and persistent coughing. These indicate lung qi injury. This is the fourth origin.
5. The Kidneys govern bone marrow. Excessive sexual activity injures the kidneys. Kidney injury depletes true yin. Once true yin is depleted, ministerial fire arises spontaneously. This fire rises and falls, moves and rests, simmering the zang-fu organs, consuming body fluids, altering appearance and voice. Lesions appear purple-black. Pulse is rapid and irregular. Symptoms include irritability, dry mouth, and constant thirst despite drinking. These indicate kidney qi injury. This is the fifth origin.

Treatment must differentiate internal deficiency and excess, and external yin and yang, while adhering to seasonal changes and understanding pathology. If the lesion has not formed after seven days, open the orifices and induce sweating to expel pathogens. If the condition is established after seven days, use tonification to support the expulsion of toxins. This prevents internal attack and external transformation. Over-aggressive purgation damages yuan qi, making toxin expulsion difficult. Applying cooling topical agents causes blood and qi to congeal like ice, leading to muscle necrosis and hindering sloughing.

I have treated such cases and early-stage back carbuncles before formation. Using a lancet, I puncture at the apex until pain is felt, draining evil blood and opening the orifice. Then, insert Chan Su Strip (Toad Venom Strip) to the bottom. Cover externally with ointment. Internally administer Wan Ling Dan (Ten Thousand Spirits Pill) or Chan Su Pill to induce heavy sweating, dispersing internal accumulated toxins. The next day, the lesion may swell or not, hurt or not. Continue insertion and application until the apex swells high, the base protrudes, cracks appear around the periphery, and pus flows. Stop insertion then. Mild cases expel hard, indurated roots after nine days. Severe toxic cases may not detach immediately but will gradually slough and form pus. This is an excellent method for turning severe conditions into mild ones. Externally apply Yu Hong Gao (Jade Red Ointment) to promote tissue regeneration. Internally use tonifying and supporting agents to consolidate healing. Recovery occurs soon. For mild Yang syndrome cases, allow natural sloughing without needling. If there is no swelling or pain, and moxibustion does not elicit pain, especially in Yin syndrome cases, moxibustion should be used promptly without delay. This is the major principle of moving deep pathology to the surface.