Segmental Anatomy - The Key To Mastering Acupuncture, Neural Therapy, and Manual Therapy (PDFDrive)

I.
Wancura-Kampik
Segmental Anatomy
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Ingrid Wancura-Kampik
Segmental Anatomy
The Key to Mastering Acupuncture,
Neural Therapy and Manual Therapy
1st Edition
In collaboration with Prof. Dr. med. Jochen Fanghänel, universities Greifswald and Regensburg
Translated by Pola Nawrocki, Munich (†)
Reviewed by Sarah Monz, Brunnen/Switzerland
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Elsevier GmbH, Urban & Fischer Verlag, Lektorat Komplementäre und Integrative Medizin, Hackerbrücke 6, 80335 Munich, Germany
Original edition
Ingrid Wancura-Kampik: Segment-Anatomie
First edition 2009, Elsevier Urban & Fischer Verlag, München, ISBN 978-3-437-57970-7
Second edition 2010, Elsevier Urban & Fischer Verlag, München, ISBN 978-3-437-57971-4
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Foreword
Great Aristotle once mused: “He who sees things grow from the Being an anatomist myself, I was mesmerized by the fact
beginning, will understand them best”. I would like to apply that even older literature can yield new findings for modern
this phrase to segmental anatomy. It can only be understood if day morphology studies, which lead me to support the author
one takes into account the embryological processes and the in her endeavor. Literature teaches us that the old masters of
laws of metamerism. segmental anatomy researched groundbreaking basics that are
The elaborate book by Dr. Wancura-Kampik presents a still valid today, but have sadly become neglected and forgot-
synopsis of segmental anatomy which constitutes the basis of ten.
acupuncture, neural therapy, and manual therapy. As early as 1932, the great neurologist C.S. Sherrington, who
It is the author’s merit to have compiled and reviewed the engaged in these studies, was awarded the Nobel prize.
fundamentals of segmental anatomy, and to have supplement- I wish all interested readers much joy in perusing this richly
ed it with her more than 40 years worth of experience in acu- illustrated volume. May they come to realize that the know
puncture. In doing so, she has brought to light a treasure trove ledge of segmental innervation must not be neglected in all
of literature on segmental anatomy. Of course, some findings kinds of therapy of the body surface.
in older literature will remain to be revised, discussed, and also
completed. Additionally, some sources are to be found embed- Greifswald and Regensburg, April 2012
ded within the works of other disciplines. For this reason, the Prof. Dr. med. Jochen Fanghänel
present volume has come to resemble a kind of almanac.
Author’s note to the 1st English edition
This book is supposed to recall segmental anatomy, this wron- acupuncture and may induce a special fascination with and
gly “forgotten science”, as it is the key to understanding acu adherence to this method, in the 21st century they have ceased
puncture, neural therapy, and manual therapy, and is therefore to suffice as the single explanatory model of acupuncture-
of great importance today. induced reactions.
Segmental anatomy is the prerequisite of understanding and In contrast, training in neural therapy and manual therapy
recognizing the painful points and areas on the body surface has already focused on science in the past.
which resemble algetic and reflex projection signs due to inter- The sinological and psychological overload that has been
actions within the body, and which determine the clinical heaped on acupuncture fails to do justice to its meaning and
aspect of “ill-being”. efficiency as a form of therapy. Instead, a deeper understanding
The basis of these mutual interactions is the spinal vegetative of acupuncture may be facilitated by an analysis from the point
nervous system. of view of the spinal nervous system and the sympathetic.
Like a thread, the spinal nerves connect the parts of a single nervous system.
segment that have, due to embryonic development, come to lie Having immersed myself in the concept of “segments” for
far apart from each other, yet react synchronously (derma- about 40 years, and having collected all accessible literature by
tome, myotome, sclerotome, enterotome), and they therefore the European anatomists and neurologists who, between 1850
make the interrelation between areas of referred pain, skin and 1960, founded segmental anatomy, and after I was able
alterations, and internal diseases understandable. during my studies at the College of Traditional Chinese
Just one example: Since the deep hand muscles, according to Medicine at Beijing University (1975/76 and 1980) to confirm
Braus and Elze, are singularly made up out of C8- and T1 myo- my suspicion that Chinese acupuncture represents a segmental
tomes, and since the caudal part of the latissimus dorsi muscle, therapy, I decided to write a book on this topic.
according to Herringham’s laws of metamerism, is also made Some of the pictures are based on drawings by European
up of C8- and T1-myotomes, a deep stimulation on the back anatomists from 1850–1900. As they are exceptionally precise,
side of the hand (for instance, on acupuncture point SI 3, or I have deliberately kept them in their original form, without
Hand Point 1) can influence the lumbal area. revisions, even if they may not live up to our present-day
The vegetative nervous system, especially the sympathetic optical expectations and requirements.
root ganglia, transforms these spino-segmental interrelations I hope that my own fascination with the subject will, once
into a Gestaltkreis with social and psychosomatic determina- again, prove as “contagious” as it did in the case of our acupunc-
tion by influencing the subconscious facial expression, gesture, ture books (König, Wancura, Maudrich Verlag Vienna) in the
and body language. 70s, and that once again, it will spark an interest in segmental
Another example: while the spinal segments C8/T2 supply the anatomy which represents the most ancient architectural concept
extensor muscles on the upper extremity (triceps C7/C8/T2) with in evolution, determining health and sickness, psyche and soma,
spino-segmental impulses necessary for fighting and defending and resembling the basis of our spontaneous behaviour, our
movements, also the eyes and hackles are activated via the cilio- “vertebrate language”, by way of our unconscious social stimuli.
spinal center (C8/T2), causing the pupils to dilate and the hairs to I would like to thank my husband, Dr. Bernhard Kampik, for
stand on end. Together with the movement of the arms, this his perseverance and his assistance, without which I would
completes the movements of imposing, fighting, and defending. never have either started or finished this book.
With this, movements become gestures, and segmental I thank Prof. Dr. J. Fanghänel for his gracious support and
interrelations can be understood as the evolutionary equivalent his constructive criticism as an anatomist.
of psychosomatic phenomena. I would extend my thanks to Sabine Zieger for her relentless
In this way, knowledge of segmental interrelations can serve patience and diligence in writing the manuscript, and to the
as a map for diagnosis and treatment, with muscular tensions editors, their team, and to the producer.
and pains, posture anomalies and skin alterations, facial At last, I shall not forget to acknowledge the many hints and
expression and gestures leading the way for a segmental thera- clues I already received in the 70s from professors of the
py via acupuncture, neural therapy, and manual therapy. University of Vienna School of Medicine (from university pro-
Furthermore, segmental anatomy can substitute with scientific fessors Dr. Auerswald, Dr. Seitelberger and Dr. Tilscher),
facts the Chinese medical philosophy as the only theoretical which encouraged me to continue on my journey of reinter-
explanation of acupuncture-associated phenomena that has so preting acupuncture from the point of view of segmental ana
often been gravely misunderstood in the West, and knowledge of tomy.
segmental anatomy may even improve the efficacy of this method.
Although the ancient Chinese ways of thinking with their Bayreuth, April 2012
archetypical images have proven quite helpful in the practice of Dr. med. Ingrid Wancura-Kampik
Contents
1 Segmentation and Metamerism . . . . . . . 1 3.2.5 Evolutionary Importance . . . . . . . . . . . . . . . . . 80
What is a Segment? . . . . . . . . . . . . . . . . . . . 1 3.2.6 Sympathetic Nerve Supply to the Head,
The Significance of Segments . . . . . . . . . . . . 12 Neck, and Limbs . . . . . . . . . . . . . . . . . . . . . . . 81
3.2.7 The Efferent Sympathetic Nerves . . . . . . . . . . . 85
2 The Role of the Peripheral Spinal Nervous 3.2.8 The Afferent Sympathetic Nerve Pathways . . . . 114
System in Segmentation . . . . . . . . . . . . . . 15 3.2.9 The Large Sympathetic Ganglia and
2.1 The Spinal Nerve Defines the Segment . . . . . 15 Their Projections onto the Skin . . . . . . . . . . . . 119
2.2 The Spinal Nerves . . . . . . . . . . . . . . . . . . . . . 17 3.3 The Peripheral Parasympathetic Nervous System
2.2.1 The Spinal Nerve and Its Segment . . . . . . . . . . 17 and Its Role in Segmental Theory . . . . . . . . . 124
2.2.2 Cranio-Caudal Arrangement . . . . . . . . . . . . . . 20
2.2.3 Vertical Spinal-Segmental Arrangement . . . . . 22 4 The Dermatomes . . . . . . . . . . . . . . . . . . . . 127
2.2.4 The Root Fibers of the Spinal Nerves . . . . . . . . 23 4.1 Radicular Innervation of the Integument . . . 127
2.2.5 Types of Fibers in the Spinal Nerves and 4.1.1 Clinical Relevance . . . . . . . . . . . . . . . . . . . . . 136
Relationship to the Autonomic 4.2 Parts of a Dermatome . . . . . . . . . . . . . . . . . . 138
Nervous System . . . . . . . . . . . . . . . . . . . . . . . 25 4.3 The Sensory and Autonomic-
2.3 The Branches of the Spinal Nerves . . . . . . . . 27 Motor Dermatomes . . . . . . . . . . . . . . . . . . . . 141
2.3.1 The Three Spinal Nerve Branches as Basis 4.3.1 Sensory Dermatomes . . . . . . . . . . . . . . . . . . . 141
of the Threefold Longitudinal Division 4.3.2 Autonomic-Motor Dermatomes . . . . . . . . . . . 142
of the Body Surface . . . . . . . . . . . . . . . . . . . . 29 4.3.3 Physiological Hyperesthesia . . . . . . . . . . . . . . 143
2.3.2 The Regions Innervated by 4.3.4 The Maximum Points of the Dermatomes . . . . 143
the Spinal Nerves . . . . . . . . . . . . . . . . . . . . . . 32 4.3.5 The Maximum Areas of the Dermatomes . . . . . 148
2.3.3 The Relations of the Metameric 4.4 The Hiatus Lines . . . . . . . . . . . . . . . . . . . . . . 150
Spinal Nerve Branches . . . . . . . . . . . . . . . . . . 36 4.5 Individual Groups of Dermatomes,
2.4 The Branches of the Spinal Nerves and “Autonomic Facial Expression” . . . . . . . 156
in Detail . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 4.5.1 Dermatomes of the Head and Neck . . . . . . . . 158
2.4.1 The Dorsal Branches of the Spinal Nerves . . . . 42 4.5.2 Dermatomes of the Trunk T 1 to T 12 . . . . . . . 169
2.4.2 The Dorsal Branches in Psychosomatic 4.5.3 The Lumbar and Sacral Dermatomes . . . . . . . . 174
Medicine and Evolution . . . . . . . . . . . . . . . . . . . 47 4.5.4 Dermatoses and Segmentation . . . . . . . . . . . . 178
2.4.3 The Ventral and Lateral Spinal Nerve
Branches and Plexuses . . . . . . . . . . . . . . . . . . 49 5 The Myotomes . . . . . . . . . . . . . . . . . . . . . . 181
2.4.4 Plexus Formation from the Point of View of 5.1 Radicular Innervation of the Muscles . . . . . . 181
Segmental Anatomy . . . . . . . . . . . . . . . . . . . . 50 5.1.1 Segment-Identifying Muscles . . . . . . . . . . . . . 181
2.4.5 The Individual Plexuses . . . . . . . . . . . . . . . . . . 54 5.2 Metameric Order of the Myotomes . . . . . . . . 183
2.5 The Preaxial and Postaxial Lines, 5.3 Herringham’s Rules of Location and
Basis of the Meridian “Lines” . . . . . . . . . . . . 68 Distribution of Myotomes in the Muscles . . . 185
5.3.1 Herringham’s First Rule . . . . . . . . . . . . . . . . . 185
3 The Role of the Peripheral Autonomic 5.3.2 Herringham’s Second Rule . . . . . . . . . . . . . . . 185
Nervous System in Segmental Theory . . . 71 5.3.3 Herringham’s Third Rule . . . . . . . . . . . . . . . . . 186
3.1 Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 5.4 The Muscles of the Upper and Lower Limbs
3.2 The Peripheral Sympathetic Nervous and Their Corresponding Myotomes . . . . . . . 189
System and Its Role in Segmental Theory . . . 75 5.5 The Individual Myotome Groups . . . . . . . . . . 191
3.2.1 The Origin of the Sympathetic 5.5.1 The Cervical Myotomes . . . . . . . . . . . . . . . . . 191
Nervous System . . . . . . . . . . . . . . . . . . . . . . . 76 5.5.2 The Thoracic Myotomes (T 1 to T 12) . . . . . . . . 202
3.2.2 Sympathetic Innervation of the Limbs . . . . . . . 77 5.5.3 The Lumbosacral Myotomes . . . . . . . . . . . . . . 208
3.2.3 Sympathetic Effects on the Dilator
Pupillae Muscle and on the Effector Organs 6 The Sclerotomes . . . . . . . . . . . . . . . . . . . . . 215
of the Integument . . . . . . . . . . . . . . . . . . . . . 78 6.1 Radicular Innervation of the Bones . . . . . . . . 215
3.2.4 On the Dimensions of the Sympathetic 6.2 The Spinal Column and Its
Nuclei . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Segmental Relations . . . . . . . . . . . . . . . . . . . 217
VIII Contents
6.3 The Individual Sclerotomes . . . . . . . . . . . . . . 222 10 The Visceral Organs – the Enterotomes
6.3.1 The Sclerotomes of the Upper Limb and from the Viewpoint of Segmental
the Shoulder Girdle . . . . . . . . . . . . . . . . . . . . 222 Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . 279
6.3.2 The Sclerotomes of the Lower Limb and 10.1 The Heart: Algetic and Autonomic Reflexive
the Pelvis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229 Projection Areas . . . . . . . . . . . . . . . . . . . . . . 280
10.1.1 Algetic Signs in Heart Disease . . . . . . . . . . . . 280
7 The Enterotomes . . . . . . . . . . . . . . . . . . . . 237 10.1.2 Autonomic Reflexive Projection Signs in
7.1 Relationships . . . . . . . . . . . . . . . . . . . . . . . . 237 Heart Disease . . . . . . . . . . . . . . . . . . . . . . . . . 286
7.2 “Transformation” of Internal Organs into 10.1.3 Viscero-Visceral Reflexes or Autonomic Organ
Enterotomes . . . . . . . . . . . . . . . . . . . . . . . . . 242 Reflexes in Heart Disease . . . . . . . . . . . . . . . . 289
10.2 Lungs and Bronchi: Algetic and Autonomic
8 Conduction of Impulses between Reflexive Projection Areas . . . . . . . . . . . . . . . 292
Segments . . . . . . . . . . . . . . . . . . . . . . . . . . 243 10.2.1 Algetic Signs in Disorders of the Lungs and
8.1 Multisynaptic, Proprioceptive, and Bronchi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 292
Viscerogenic Reflexes . . . . . . . . . . . . . . . . . . 243 10.2.2 Autonomic Reflexive Projection Signs in
8.2 Differentiation of Direct, Indirect, and Bronchial and Pulmonary Disorders . . . . . . . . 297
Referred Pains . . . . . . . . . . . . . . . . . . . . . . . . 247 10.2.3 Viscero-Visceral Reflexes or Autonomic
8.2.1 Direct Organ Pain . . . . . . . . . . . . . . . . . . . . . . 247 Organ Reflexes in Disorders of Lungs
8.2.2 Indirectly Conducted Organ Pain and Bronchi . . . . . . . . . . . . . . . . . . . . . . . . . . 299
(Projected Pain) . . . . . . . . . . . . . . . . . . . . . . . 247 10.3 The Esophagus: Algetic and Autonomic
8.2.3 Referred Pain . . . . . . . . . . . . . . . . . . . . . . . . . 247 Reflexive Projection Areas . . . . . . . . . . . . . . . 300
10.3.1 Algetic Signs in Disorders of the
9 Referred Pain . . . . . . . . . . . . . . . . . . . . . . . 249 Esophagus . . . . . . . . . . . . . . . . . . . . . . . . . . . 300
9.1 Pain Projected to the Body Surface 10.3.2 Autonomic Reflexive Projection Signs . . . . . . . 300
in Visceral Disease . . . . . . . . . . . . . . . . . . . . 249 10.3.3 Viscero-Visceral Reflexes in Disorders
9.2 Projected Symptoms . . . . . . . . . . . . . . . . . . . 251 of the Esophagus . . . . . . . . . . . . . . . . . . . . . . 300
9.2.1 General Aspects of Projected 10.3.4 Analogies Between Segmental Anatomy
Algetic Symptoms . . . . . . . . . . . . . . . . . . . . . 251 and Acupuncture . . . . . . . . . . . . . . . . . . . . . . 300
9.2.2 General Aspects of Projected Autonomic 10.3.5 Projection of the Digestive
Reflexive Symptoms . . . . . . . . . . . . . . . . . . . . 251 Tract to the Limbs . . . . . . . . . . . . . . . . . . . . . . 302
9.2.3 Synopsis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254 10.4 Stomach and Duodenum . . . . . . . . . . . . . . . 303
9.3 On the Location of Projected 10.4.1 Algetic Signs in Disorders of the Stomach and
Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . 255 Duodenum . . . . . . . . . . . . . . . . . . . . . . . . . . . 303
9.4 Clinical Significance of Projected 10.4.2 Autonomic Reflexive Projection Signs in
Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . 256 Disorders of the Stomach
9.5 Algetic Symptoms . . . . . . . . . . . . . . . . . . . . . 257 and Duodenum . . . . . . . . . . . . . . . . . . . . . . . 307
9.5.1 Hyperalgesia and Hyperesthesia of the Cutis 10.4.3 Viscero-Visceral Reflexes or Autonomic
and Subcutis (Head's Zones) . . . . . . . . . . . . . . 257 Organ Reflexes in Disorders of the Stomach
9.5.2 Hyperalgesia of Muscles and Tendons and Duodenum . . . . . . . . . . . . . . . . . . . . . . . 308
(Mackenzie's Zones) . . . . . . . . . . . . . . . . . . . . 260 10.5 Small Intestine (Jejunum, Ileum) . . . . . . . . . . 310
9.5.3 Comparison of Referred Pain and 10.5.1 Algetic Signs in Disorders
Pseudoradicular Syndromes . . . . . . . . . . . . . . 262 of the Small Intestine . . . . . . . . . . . . . . . . . . . 310
9.6 Autonomic Reflexive Symptoms . . . . . . . . . . 264 10.6 Cecum, Appendix, Ascending and
9.6.1 Autonomic Effects in the Integument . . . . . . . 265 Transverse Colon . . . . . . . . . . . . . . . . . . . . . . 313
9.6.2 Effects on the Head . . . . . . . . . . . . . . . . . . . . 268 10.6.1 The Algetic Signs . . . . . . . . . . . . . . . . . . . . . . 313
9.6.3 Effects in the Shoulder . . . . . . . . . . . . . . . . . . 274 10.6.2 Autonomic Reflexive Projection Signs . . . . . . . 316
9.6.4 Asymmetry of Posture and Movement . . . . . . . 274 10.7 Descending Colon, Sigmoid Colon,
9.6.5 Reflexive and Algetic Spinal and Rectum . . . . . . . . . . . . . . . . . . . . . . . . . . 318
Syndromes . . . . . . . . . . . . . . . . . . . . . . . . . . . 275 10.7.1 Algetic Signs . . . . . . . . . . . . . . . . . . . . . . . . . 318
9.6.6 Asymmetry of Proprioceptive and Multisynaptic 10.7.2 Viscero-Visceral Reflexes or Autonomic
Reflexes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275 Organ Reflexes in Disorders of the Descending
9.6.7 Autonomic Organ Reflexes Colon, Sigmoid Colon, Rectum, and
(Viscero-Visceral-Reflexes) . . . . . . . . . . . . . . . 277 Pelvic Organs . . . . . . . . . . . . . . . . . . . . . . . . . 322
Contents IX
10.8 Kidney, Bladder, Ureter: Algetic and Autonomic 10.11 Prostate Gland: Algetic and Autonomic
eflexive Projection Areas . . . . . . . . . . . . . . .
R 323 Reflexive Projection Areas . . . . . . . . . . . . . . . 332
10.8.1 Algetic Signs in Disorders of the Kidney 10.11.1 Observations from Practical Experience . . . . . . 332
and the Ureter . . . . . . . . . . . . . . . . . . . . . . . . 323 10.11.2 Segmental Relations between Segments
10.8.2 Autonomic Reflexive Projection Signs in of the Lower Limb, Bechterew's Disease,
Disorders of the Kidney, Bladder, and Ureter . . 326 and Prostate Disease . . . . . . . . . . . . . . . . . . . 332
10.8.3 Consequences for Treatment . . . . . . . . . . . . . . 327 10.12 Liver and Gallbladder: Algetic and
10.8.4 Viscero-Visceral Reflexes or Autonomic Organ Autonomic Reflexive Projection Areas . . . . . 334
Reflexes in Disorders of the Kidney, Bladder, 10.12.1 Algetic Signs in Disorders of the Liver
and Ureter . . . . . . . . . . . . . . . . . . . . . . . . . . . 327 and Gallbladder . . . . . . . . . . . . . . . . . . . . . . . 334
10.9 The Genital Tract: Algetic and Autonomic 10.12.2 Autonomic Reflexive Projection Signs
Reflexive Projection Areas . . . . . . . . . . . . . . . 328 in Disorders of the Liver and Gallbladder . . . . 337
10.9.1 Algetic Signs . . . . . . . . . . . . . . . . . . . . . . . . . 328 10.12.3 Viscero-Visceral Reflexes or Autonomic
10.9.2 Autonomic Reflexive Projection Signs Organ Reflexes in Disorders of the Liver
in Gynecologic Disorders . . . . . . . . . . . . . . . . 328 and Gallbladder . . . . . . . . . . . . . . . . . . . . . . . 338
10.10 Testes, Uterus, Ovaries: Algetic and Autonomic 10.13 Pancreas and Spleen: Algetic and Autonomic
Reflexive Projection Areas . . . . . . . . . . . . . . . 331 Reflexive Projection Areas . . . . . . . . . . . . . . . 340
10.10.1 Algetic Signs in Disorders of the Testes, 10.14 Occurrence of Reflexive and Algetic Symptoms
Uterus and Ovaries . . . . . . . . . . . . . . . . . . . . . 331 in Other Disorders . . . . . . . . . . . . . . . . . . . . . 340
10.10.2 Autonomic Reflexive Projection Signs
in Disorders of the Testes, Uterus, Bibliography . . . . . . . . . . . . . . . . . . . . . . . . 347
and Ovaries . . . . . . . . . . . . . . . . . . . . . . . . . . 331
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 351

CHAPTER
1 Segmentation and Metamerism

What is a Segment?
Segmentation and metamerism are a principle of arrangement that characterizes the struc-
tural design of all vertebrates, either visibly (as divisions, or “segments”) or invisibly (as
functional entities).
Segmentation and metamerism also represent the oldest architectural principle of evolu-
tion, detectable from plants to human beings. The structural design of segmentation and me-
tamerism follows laws that are of eminent importance not only from the point of view of
evolution, but also in medicine, even as an “imperative necessity” (von Rynberk 1900).
A segment in vertebrates is defined as the region a spinal nerve supplies in the skin, mus-
culature, bones, and internal organs (dermatomes, myotomes, sclerotomes, enterotomes,
etc.), and is the basis for the interactions between the surface and the inside of the body.
Although during the embryologic developmentthe parts of a segment shift their positions
relative to one another like geological strata, and thus may move far apart – for example,
some of the muscles served by C8 are located in the hand, others at the iliac crest – they retain
a lifelong connection via the same spinal nerve. Thus, pain in one part of a segment can be-
come manifest in widely distant regions.
Understanding the laws of segmentation and metamerism means having a decrypting key
with which the interactions and projection phenomena on the body surface can be inter-
preted in case of illness. It virtually enables one to “see with the hands from the outside of the
intact body into the inside” (Kunert).
In healthy individuals, segmentation and metamerism are not visible to the naked eye. But
in illness they make their appearance in an impressive way.
The laws of segmentation and metamerism are those of the spinal nervous system, supple-
mented by the autonomic nervous system. In comprehensive studies done in the nineteenth
century, European anatomists formulated these laws as “segmental anatomy”.
2 1 Segmentation and Metamerism
In my opinion, however, segmental anatomy is the best Western approach for interpreting
the theories of ancient Chinese acupuncture, since it applies this empirical method in an op-
timal fashion. In my analysis, Chinese acupuncture carries the signature of the spinal and
autonomic nerves; one could say that it is based on the metameric memory of the organism.
An understanding of spinal-segmental interactions and projection phenomena enables the
1 physician to make a “diagnosis”, to “see through” in the literal sense of the term.
Beyond this, the perceptible and visible changes on the surface of the body, which the pa-
tient experiences in a particular way regarding quantity, quality and intensity, can also serve
as a point of departure for personalized medicine, in which the physician can utilize the sub-
jective perception of painful projection signs in diagnosis and treatment.
According to Puttkammer (around 1900),
… the physician of the future should have a thorough command of the facts regarding relation-
ships of the body surface to the organs, enabling him to develop a comprehensive understand-
ing of the value of various treatment measures, so that he may utilize the reflex zone to diag-
nose and treat the diseased organ.
For those of us scientifically trained physicians who use acupuncture, an understanding of
the segmental interactions enables us to dispense with more or less exotic philosophical theo-
ries as the sole explanation of this empirical method.
Segments are equivalent parts of an organism that consists of an external body wall and
internal organs. They are arranged in a metameric fashion, i. e. one after the other, to form
the body. When the segments are arranged in a cranio-caudal series, i. e. metamerically along
the longitudinal axis of the body, the correct terms are
• metameres rather than segments
• metamerism rather than segmentation.
The number of segments corresponds to the number of spinal nerves of the individual.
The arrangement in the right and left halves of the body, corresponding to the right and
left spinal nerves, is referred to as antimerism.
Segmentation und metamerism allow for interactions between the body surface and the internal or-
gans, which can be utilized for diagnosis and treatment.
What is a Segment? 3
The structure of an organism consisting of subdivisions, i. e., “segments” and “metameres”, is

typical for the blueprint of all vertebrate bodies. Segmentation is already evident in very early
stages of development as formation of subdivisions.
Each of these subdivisions consists of
• an area of skin, or dermatome
• a muscular part, or myotome 1
• a skeletal part, or sclerotome
• a visceral part, or enterotome
• a neural part, or neurotome.
All of these “-tomes” (literally: slices, or sections) are parts of a segment and connected by nerves.
Whenever a stimulus touches any part of the segment, an impulse is transmitted via an
afferent pathway to a nerve center in the same segment. From there the impulse is transmit-
ted along an efferent pathway – as a proprioceptive reflex –back to the site of the original
stimulation, or it is transmitted as a multisynaptic reflex to other parts of the same segment.
In the simplest case the impulse “swings” back and forth among the parts of the segment:
• from dermatome to myotome,
• from one part of the myotome to other parts,
• from enterotome to dermatome,
• from enterotome to myotome,
• from one enterotome to another enterotome,
• etc.
Such reflexes put all parts of a segment into a state of nervous excitation.
Since the neurotome is always involved in such excitatory states, diseases of internal or-
gans can elicit pain on the body surface as well as motoric and autonomic reflexes.
Division of the vertebrate body into individual, serially arranged segments begins at a very
early stage of embryonic development.
After completion of the morula and blastula stages, invagination leads to the gastrula
stage, resulting in a double-layered embryonic disk .
The gastrula consists of an external and an internal germinal layer (ectoderm and endo-
1 derm, respectively). These two layers bound the primitive gut, forming the future celiac cav-
ity. The third germ layer, the mesoderm, develops later.
In the third week of gestation, about forty cuboid sections condense from the mesodermal
streaks on either side of the notochord (chorda dorsalis). These sections are referred to as
primitive segments or somites.
These primitive segments give rise later to the myotomes and sclerotomes, and thus to the
definitive segments of the body surface.
Even at this early stage, the stratified architecture of the body wall is apparent.
Proceeding from the outside to the inside, the following layers can be distinguished:
• a dermatome – a skin part
• a myotome – a muscular part
• a sclerotome – a bony part
• a neurotome – a spinal nerve part.
Together they envelop the body contents,
• the enterotomes – the internal organs.
The medullary canal is segmentally related to the mesodermal myotomes and sclerotomes.
Thus the spinal cord too is involved in the metameric arrangement, and remains connect-
ed to parts of the body surface by segmental nerves.
The lateral and ventral parts of the mesoderm and the endodermal gut give rise to the internal organs
(viscera). Although the latter are not segmented, they remain metamerically connected with the seg-
mented dorsal parts of the mesoderm.
That is to say, every organ is, and remains, connected for life to a specific part of the spinal
cord via segmental nerve pathways.
The ectoderm as well is connected to the neurotomes of the spinal cord by segmentally
distinct pathways, thus forming the segmental zones of cutaneous innervation, or derma-
tomes.
From the embryonic stage to adulthood, the human body remains divided into segments
partitioning it into a cranio-caudal, i. e. metameric, manner, each with its own assigned com-
ponents. 1
The subdivision into segments therefore means that dermatomes, myotomes, and sclero-
tomes are all related to an internal organ supplied by the same, shared spinal nerve.
A segment consists of a transverse slice through the body, as in an anatomical specimen
showing only part of the external body wall and some of the visceral organs (› fig. 1.1).
The parts of the segment on the body surface that are supplied by a single spinal nerve are
referred to as the spinal periphery.
The name of the spinal nerve supplying these parts is also applied to the parts of the seg-
ment. For example, the parts of the skin, muscles, and bone supplied by the fifth thoracic
nerve are known as
• dermatome T 5
• myotome T 5
• sclerotome T 5.
Basically, the design of body wall and internal organs corresponds to the segmental body
plan of early evolutionary stages.
A clearly visible vestige of the original segmental construction of the body is therefore the spinal nerve.
Each segment contains a spinal nerve, and all parts of the segment are supplied by the same spinal
nerve.
Thus only the spinal nerve determines what belongs to a given segment.
It conjoins the dermatomes, myotomes, and sclerotomes that it innervates to form a func-
tional unit that reacts synchronously.
The bond between the parts of a segment and its spinal nerve persists throughout life, even
though growth and further development of parts of the segment may result in considerable
shifting and displacement. The interactions between the parts of the segment located in the
integument, and between the body surface and visceral organs are due to the fact that each
spinal nerve internally transmits information about disorders within its own innervation
1 area.
Thus in the event of heart disease, pain may be perceived in the body wall in skin, muscles,
and bones of the segments that are segmentally “related” to the heart.
Conversely, disorders in the spinal periphery, e. g. in case of chronic irritations of corre-
sponding vertebral parts or scars after injury, may lead to pain or functional disorders of
visceral organs.
T4
N. thoracicus
T5
3
T6 IV
4
V
5 Sclerotome T 5
VI
Myotome T 5
6
VII
Dermatome T 5
Enterotome
(Viscerotome) T 5
Fig. 1.1 Schematic drawing of a segment, using T 5 with its dermatome, myotome, sclerotome, enterotome, and spinal nerve with its autonomic portion
to illustrate the interactions and projection phenomena between the body surface and visceral organs. (Modified after Hansen and Schliack)
The spinal nerve is therefore the prerequisite for segmentation and the interactions be-
tween the parts of a segment (› Chapter 9 “Algetic and Autonomic-Reflexive Signs of Dis-
ease”, p. 253).
Segmentation determines the structural design not only of the vertebrate body. Analogous
subdivisions, i. e., segmentations, are found in plants, in lower worms, and through to the
vertebrates. Hence segmentation is the most ancient structural design in the evolutionary 1
process.
Leonardo da Vinci already recognized the architectural design of the spinal nerves and the
areas they supply, as shown by an illustration in his “Canon” (› fig. 1.2).
Fig. 1.2 Sketch from Leonardo da Vinci's “Canon”, showing the precise areas supplied by the spinal nerves on the trunk and extremities and their origins
within the spinal cord (after Brissaud, quoted by van Rynberk).
Note: Leonardo correctly indicates that the face is not innervated by spinal nerves.
As shown in figure 1.3, segmentation occurs

• in plants as grooves, constrictions, and marks. Within these segments, regularly repeti-
tive structures are found, such as leaves, flowers, and buds,
• in lower invertebrates, such as worms, in which vital organs are regularly repeated in in-
dividual segments,
1 • in arthropods, in which limbs or supporting structures develop in the external parts of
each segment.
At this stage of evolution, a single segment is capable of giving rise to a complete organism. A
tree can develop from part of a branch, and a complete earthworm from a fragment. Aristo-
tle made such observations even in ancient times.
• The lancelet fish (Amphioxus), the prototype of all vertebrates, shows subdivisions in the
form of internal segmentation, most obvious in the muscles.
• In higher vertebrates, segmentation is readily apparent only in the axial skeleton and the
spinal nerve system.
The same segmental construction pattern is found in
• fish
• reptiles
• birds and
• mammals.
Functional parts of skin, muscles, and vertebrae, along with parts of a visceral organ unite to
form a segment.
Because of its primitive segmentation, an embryo resembles a worm. In the nineteenth
century, this and other similarities with lower animals led to some peculiar theories about the
origin and development of man, which I would like to summarize briefly here (based on van
Rynberk).
Around 1850, studies of lower worms led to the notion that the segments of these animals
represent tiny units of life with relative capabilities of survival.
Presumably these small units of life, termed “zoonites”, did not develop into a complete
living being until they conjoined and became specialized.
Fig. 1.3 Segmentation in the course of evolution. Externally visible segmentation in plants and lower animals, and hidden internal segmentation
in vertebrates.
This notion fit in well with the nineteenth century philosophies, including political ones, that
led to the theory of “relative individuality” which held that although individual small units
of life are viable to a limited extent, long-term survival is possible only in groups.
In the metameres, i. e., in the serially arranged portions or segments of lower invertebrates,
and especially in their capabilities of regeneration, Haeckel and Gegenbauer saw evidence
1 that growth is based on pullulation and budding.
The notion of budding also gave rise to odd ideas concerning segmentation in the human
body. Brissaud, for instance, hypothesized that segments develop as “bell-shaped offshoots”
(› fig. 1.4).
Haeckel wrote:
“Metamerism therefore can be explained by a process of budding leading to incomplete
products that remain united to form a whole organism.”
The budding theory of Haeckel and Gegenbauer as the basic principle of metamerism is no
longer considered valid.
It is now accepted that primary metamerism in vertebrates originates due to segmental
division of the primitive streak of the mesoderm into somites, or primitive vertebrae (van
Rynberk).
Fig. 1.4 Old schematic depiction of the segmental structure of the trunk and upper extremity (after Brissaud, quoted by van Rynberk).
Incorrect: Notion of segmental budding.
Correct: Reference to a ventral and a dorsal portion of each segment.
Another theory going back to the same period deserves mention because – although long
since disproved – it is still treated as factual in many books: the so-called recapitulation
theory, or biogenetic law.
The recapitulation theory states that segmentation in humans represents a continuous
evolution from previous animal stages, and that human development passes through “am-
phibian, reptilian, and fish stages.” 1
The recapitulation theory too is based on the appearance of the human embryo, which in
its very early stages recalls that of lower vertebrates. This similarity is due mainly to division
of the mesoderm into primitive segments.
The conclusion was drawn that the embryonic development of humans recapitulates, for
example, that of an adult lancelet fish.
This would imply that the segmental construction of the human represents a synthesis of
all body plans on which the emergence of fish, amphibians, reptiles, and mammals are based.
According to this theory, therefore, the embryo passes through the stages of evolution during
its own development, i. e., ontogeny recapitulates phylogeny.
• Ontogeny refers to the development of the individual organism.
• Phylogeny refers to the evolutionary development of all living organisms, from protozo-
ans to human beings.
Although the interpretations and theories of metamerism research in the nineteenth century
have been refuted, the principle that all vertebrates are segmented remains. This notion has
become a fundamental one in scientific medical diagnosis and treatment.
The Significance of Segments
An important question is why the construction principle of segmentation and metamerism

has become so successful.
1 If one looks at segmentation not only from the standpoints of embryology and morpholo-
gy, but teleologically, asking what their biological purpose is, I believe we must look for the
answer to this question in an evolutionarily successful, individual survival strategy.
This applies to lower animals just as to humans:
• Every environmental stimulus that impinges on the protective outer layer of a living or-
ganism is transmitted to the inside – even if only a single-celled organism is involved.
• If it is necessary and advantageous for the existence of the organism, the stimulus may
evoke plasmatic contractions and changes in shape that are sent back to the surface.
If a stimulus affects an organism that is subdivided into metameres, that organism has the
advantage over a diffusely innervated one of being able to react only with the affected part of
its body.
Thus only certain parts, rather than the organism as a whole, must react to the stimulus.
This process, which can be demonstrated in all lower organisms, was also described by Aris-
totle.
The main advantage of segmentation therefore lies in the fact that a stimulus can be modu-
lated and responded to at the segmental level, without affecting the organism as a whole.
In humans and higher vertebrates as well, segmentation and metamerism represent a kind
of individual survival strategy, in that the organism – without involvement of the cerebral
cortex and therefore automatically and reflexively – has developed an effective mechanism
for regeneration and self-healing.
This capability of “survival” in humans as well causes some pathological conditions to af-
fect only certain segments, rather than irritating the body as a whole.
Since body wall and internal organs interact constantly via neural pathways, disorders of
viscera may be influenced in a beneficial way by stimulation of external portions of the cor-
responding segment, e. g. skin, muscles, and bones.
The Significance of Segments 13
Many methods used in folk medicine are based on segmental healing procedures.
Treatment approaches attempting to heal disease by diverting it to the body surface have
played a role throughout the history of medicine. Paracelsus summarized such “detoxifica-
tion via the skin” in a maxim: 1
“The spot where nature causes pain is where it wants to accumulate and (subsequently) get rid
of harmful substances. If this process is obstructed, one must help along.”
Although this train of thought reflects the medical knowledge of past times, its therapeutic
value is still evident, for instance, in the well-known “surface therapies” such as cantharid
plasters, cupping, leech therapy, phlebotomy, Baunscheidt's therapy, but also, to some ex-
tent, acupuncture and moxibustion.1
Such therapies were known in nearly all cultures:
• According to Herodotus, the physicians in southern Russia, the Balkan countries, and
Libya injured the skin artificially in order to heal various conditions.
• Hippocrates and his successors used cauterization of the skin as a method of detoxifica-
tion through the integument.2
• These methods were taken over by Roman physicians, such as Galen.
• In the medicine of the Middle Ages, especially under Arabic influence, cauterization was
a widespread method that was particularly successful in treatment of diseases of the
joints and neuralgic pain.
Of all these therapies, which are based on empirical observation, one fact is still valid today, i. e., that
irritation of a particular part of the integument has a beneficial effect on certain disorders of internal
organs.
Of course, the toxins to be eliminated were defined differently in different times, and the
purely empirical knowledge gave rise to various medical theories.
Today, the theoretical systems are, in most cases, of interest only to medical historians.
However, the empirical knowledge of reflexive interactions still has great practical value.
1 The literal translation of (Chinese) zhen jiu is “to pierce and to burn.“
2 The literal translation of (Greek) καιειν και τεμνειν is ”to burn and to cut.“
Particularly in Chinese acupuncture it is evident that the theory of reciprocal interactions

between the integument and the internal organs basically corresponds to a segmental thera-
py. As I like to put it:
Acupuncture carries the handwriting of the spinal nerves and the sympathetic nervous system.
1
This analysis must be considered in the light of the fact that the conception of Chinese medi-
cine is based on a phenomenological interpretation of disease.
As early as 1983, we (i. e., König and Wancura) collaborated with Professor Auerswald
(Institute of Physiology) to prove this fact and scientifically describe it for the first time. This
view has been adopted by many subsequent authors.
A phenomenological interpretation of illness means that the subjective perception of the
illness by the patient, i. e.
• the site at which the illness is perceived, and
• the quality of the perception
are fundamental to the concept of disease.
Furthermore, an analysis of acupuncture shows that the parameters of “site” and “quality”
of a painful sensation are arranged in a metameric fashion via the autonomic nervous system
(› Chapter 3 “Autonomic Nervous System”, p. 75).
Thus the interactions between the integument and the internal organs are determined not
only
• by spinal-segmental interactions, but also
• by autonomic-reflexive interactions.
As will be discussed later (› page 107), the autonomic-reflexive projection signs give rise to
the qualitative parameters that define illness as a central-nervous processing of the events
of disease. Thus, for example, a feeling of warmth, cold, or sensitivity to drafts is significant
for diagnosis and provides orientation for therapy.
The basis for the segmental interactions and projection phenomena is the peripheral ner-
vous system, which will be described in the next chapter to the extent necessary in order to
understand the segmental interrelationships.
CHAPTER
2 The Role of the Peripheral Spinal

Nervous System in Segmentation
2.1 The Spinal Nerve Defines the Segment
The spinal nerve is the tie that binds segmental parts, to form, like members of a family, a
synchronously reacting functional unit. In this way, parts of the integument, the muscles,
and bones that are innervated by the same spinal nerve relate to each other and to internal
organs via reflexes.
The study of the areas served by the spinal and sympathetic nerves is the basis of segmen-
tal anatomy, which has produced highly interesting results concerning the interactions
among various parts of the body.
Before analyzing the “-tomes”, i. e. the components of each segment, as a synchronously
reacting unit, and interpreting the observations for practical application, the anatomy of
these “-tomes” must be examined separately (› chapters 4, 5, 6, 7).
An understanding of the “neurotome”, i. e., of the spinal nerves and the sympathetic ner-
vous system, is of critical importance for comprehension of segmental anatomy and acu-
puncture.
According to my analysis, the anatomical studies and results reported by van Rynberk, Sherrington,
Voigt, Bolk and others (in 1850 to 1900) agree remarkably well with certain theories and rules of
Chinese acupuncture.
Thus, segmental anatomy provides a scientifically valid possibility of interpretation and a scientifically
valid approach to the phenomenon of acupuncture.
Each spinal nerve is also termed a segmental nerve, because it connects the individual parts
of the segment on the body surface with the viscera to form a functional unit. Its areas of in-
nervation are defined as follows:
• in the skin – the dermatome
• a muscular part – the myotome
• a skeletal part – the sclerotome
• a visceral part – the enterotome
• a neural part – the neurotome
16 2 The Role of the Peripheral Spinal Nervous System in Segmentation
The area of innervation of each spinal nerve determines which structures belong to its par-
ticular segment. The spinal nerve directs and synchronizes the parts of its segment “as if
tuned by a tuning fork” (Head) to achieve the biological cooperation that serves the survival
of the individual organism.
This biological cooperation occurs by way of reflexive interactions of the segmental parts,
which enable a shifting or displacement of disorders between the integument and the visceral
organs.
Since the spinal nerve pairs depart from the spinal cord and the vertebral column in a
regular cranio-caudal, i. e., metameric series, this region represents a clearly visible remnant
2 of the original segmentation and metamerism.
Like Ariadne's thread, which guided Theseus through the labyrinth back to the entrance,
the spinal nerves lead through the labyrinth of scattered parts of the segment, back to the
origin of each spinal nerve in the spinal cord.
For this reason, the spinal nerve was called a “hodoneuromere1” by nineteenth-century
anatomists (van Rynberk), which can be roughly translated as a neural signpost within each
segment.
The close interplay of segmental areas of innervation can be described as “spinal anatomy
and symphony of relationships within our bodies”. It is the basis of our spontaneous body
language, autonomic facial expressions, and unconscious social stimuli as possible causes of
pain, muscular tension, and illness.
For the acupuncturist, the areas of innervation of spinal and sympathetic nerves (› pp. 30
and 86) are not dry anatomy. They reveal interesting insights for understanding the interac-
tions within the body, which Chinese physicians discovered empirically hundreds of years
ago and explained in the context of their times as theory of acupuncture.
In many areas, the agreement between segmental anatomy and acupuncture is so astonishing and
precise that I find it very difficult, after careful study, to support the opinion that the ancient Chinese
physicians did absolutely no post-mortem dissections.
1
óδóϚ (hodos) Greek, “pathway”
2.2 The Spinal Nerves 17
2.2 The Spinal Nerves
The human body contains thirty-one (or thirty-two) nerve pairs, each of which emerges from
a spinal cord segment, and an equal number of segments arranged in a metameric cranio-
caudal series and antimerically on the right and left sides:
8 cervical nerves Nn. cervicales C 1 to C 8

12 thoracic nerves Nn. thoracici T 1 to T 12
5 lumbar nerves Nn. lumbales L 1 to L 5 2
5 sacral nerves Nn. sacrales S 1 to S 5
2 coccygeal nerves Nn. coccygei Co 1 to Co 2
2.2.1 The Spinal Nerve and Its Segment
The spinal nerve serves for a lifetime as a bond between its “own” segmental parts, even
though the events during embryological development may separate them widely, as shown
for C 5 as case in point (› fig. 2.1).
Thus, for example, pain and tension in the C 5 myotome in the shoulder and upper arm
regions may be related to irritation of the C 5 sclerotome. The latter includes the body of the
fifth cervical vertebra and the spinous process of C 4, which is related to the spinal cord seg-
ments C 5|C 6. The spine of scapula also belongs to the C 5 sclerotome.
Furthermore, skin alterations in the C 5 dermatome may be related to irritation in the C 5
myotome.
Similarly, disorders of organs close to the diaphragm may affect the C 4|C 5 myotomes
(diaphragm) and the phrenic nerve (C 4|C 5), giving rise to pain:
• in the shoulder
• in the spinous process of C 4 and the vertebral body of C 5
• in the region of the spine of scapula and
• at the clavicular insertion of the pectoral muscle.
As this example shows, understanding the positions of related parts of a segment, i. e., the knowledge
of spinal relational anatomy, is of immense importance in diagnosis and therapy.
Pain research must therefore always be metamerism research.
The muscles of the shoulder girdle are derived from

• arm muscles that grow back centripetally toward the trunk,
• trunk muscles that grow centrifugally toward the upper limbs, and
• cranio-thoracic muscles that grow from the head toward the shoulder girdle.
2
Fig. 2.1 The C 5 segment (schematic rendition of an original drawing by Bolk): The C 5 dermatome is a con-
tinuous area of skin, whereas the C 5 myotome is divided into separate parts (shoulder muscles, diaphragm),
and the C 5 sclerotome is distributed among various parts of the skeleton (spine of scapula, fifth cervical verte-
bra, humerus). The C 5 spinal nerve with its branch, the phrenic nerve.
2.2.2 Cranio-Caudal Arrangement
According to Elze, the spinal nervous system represents “the most conservative system in
vertebrate organisms”, because its areas of innervation are always arranged in a strictly cra-
nio-caudal order, i. e., in metameric sequence, and because each spinal nerve supplies only its
“own” area.
For example:
During the embryonic period the muscles of the limbs develop from the ventrolateral ab-
dominal wall.
2 Later on in development, the muscles of the limbs “migrate,” i. e., they grow back toward
the trunk and come to lie, like a cervical buffer zone (shown in red) between the thoracically
innervated skin (shown in yellow) and the thoracically innervated intercostal muscles
(› fig. 2.2a).
However, the cervically innervated limb muscles that migrate back likewise come to lie in
a strictly cranio-caudal alignment along the thorax wall, as shown by Bolk (› fig. 2.2b).
One might say: The spinal nerve arranges the muscular parts of its family in a strictly meta-
meric hierarchy in a consistent pattern, so that
• the cranially innervated myotomes are positioned more cranially, and
• the caudally innervated myotomes are positioned further caudally.
This arrangement of the myotomes follows certain laws, which have been summarized by
Herringham (› page 185).
These laws of segmentation and metamerism can be of great help to the pain therapist –
provided he understands the underlying principle of arrangement.
As an indicator within the segment, the spinal nerve is thus also an indicator to areas of
pain, which the patient does not perceive as such primarily and spontaneously, but only
when pressure is applied.
Only a thorough understanding of segmental interrelationships enables the therapist – acupuncturist,

neural therapist, or manual therapist – to search directly for such “hidden” pressure-sensitive points
and to utilize them in treatment.
Fig. 2.2a Congruent arrangement of

the cervical dermatomes and myotomes
C 2, C 3, and C 4 (in red) at shoulder
level. Non-congruent arrangement of
the thoracic dermatomes (in yellow)
with the cervically innervated muscles
that have migrated from the arm to the
trunk beneath them.
Fig. 2.2b Metameric arrangement of

myotomes C 3 to C 8 in the muscles of
the shoulder blade and back (modified
after Bolk).
2.2.3 Vertical Spinal-Segmental Arrangement
The T 6 spinal nerve supplies exclusively the parts of its own segment.
On its pathway from the spinal cord to the periphery its nerve fibers supply only the cor-
responding T 6 myotomes in the deep, autochthonous muscles of the back.
It then passes through the more external layer of cervical muscles – without giving rise to
a single nervous fiber – before innervating the skin of its “own” T 6 dermatome.
In the region of the deep muscles of the back, the T 6 spinal nerve sends motor fibers to
certain parts of the rotator brevis, intertransversarius, multifidus, semispinalis thoracis, and
2 longissimus thoracis muscles.
The diverse localizations of the T 6 myotomes in these muscles form a sort of vertical fan
(› fig. 2.3).
According to Brügger this explains why an irritated vertebral arch joint responds to per-
cussion with radiation of pain in a vertical direction.
This clinical observation and anatomical fact are evidence of a vertical spinal-segmental
arrangement in the trunk.
This example is intended to show early on that acupuncture research must also be metamerism research
if one wants to recognize and understand the vertical arrangement of the trunk as postulated by Chi-
nese physicians.
3
?
4
2
T6
7
?
8
10
Fig. 2.3 The T 6 spinal nerve, its
branches to the various parts of the 11
T 6 myotome in the deep back muscles
(in red), and its terminal branch to the
T 6 dermatome (in yellow) (schemati- 12
cally modified after Brügger). The tho-
racic spinal nerves are identical to the L1
intercostal nerves.
2.2.4 The Root Fibers of the Spinal Nerves
A spinal nerve arises from the union of dorsal and ventral nerve root filaments departing
from the spinal cord in a regular, segmental order (› fig. 2.4).
Dorsal Root Filaments Ventral Root Filaments

The dorsal root filaments form the dorsal The ventral root filaments form the ventral
root. root.
The corresponding nerve cell bodies are lo- They consist of axons whose cell bodies are
2 cated in the sensory spinal ganglion, an located in the anterior and lateral horns of
ovoid thickening at the dorsal root. the spinal cord.
The dorsal root consists of somatic and vis- The ventral root consists of efferent fibers,
ceral-afferent fibers, and a much smaller and a much smaller number of afferent fi-
number of efferent fibers. bers.
Each spinal nerve thus consists of dorsal and ventral root filaments of one spinal segment,
and passes to the periphery as a so-called “mixed” nerve.
“Mixed” means that within the trunk of the spinal nerve, the fibers of the dorsal and ven-
tral roots are distributed in such a way that the dorsal and ventral branches into which the
spinal nerve separates contain both sensory and motor fibers.
Spinal nerves are therefore “mixed” nerves with regard to their nerve fiber composition,
i. e., they contain motor, sensory, and autonomic fibers.
The branches supplying the skin are referred to as sensory nerves and those supplying the
muscles as motor nerves. However, this is a simplified, abbreviated terminology. There are
no cutaneous nerves containing only sensory fibers, and no nerves to the muscles with only
motor fibers; some sensory and autonomic fibers are always present.
In summary: each primitive segment contains a spinal nerve, whose motor fibers supply
the myotome and whose sensory fibers supply the dermatome of the particular primitive seg-
ment.
Posterior root Anterior root

Sympathetic ganglion
Spinal ganglion
Ramus spinalis
Ramus dorsalis
Ramus ventralis
2
Ramus Ramus
communicans communicans
griseus albus
Rami musculares
Ramus
cutaneus Ramus Ramus
lateralis mammarius lateralis cutaneus ventralis
Fig. 2.4 The spinal nerve and its branches (schematic drawing).
2.2.5 Types of Fibers in the Spinal Nerves and Relationship to the

Autonomic Nervous System
The spinal nerves contain all types of fibers that are required for the nerve supply of the body.
In the figure
somato-sensory fibers somato-afferent fibers blue
viscero-sensory fibers viscero-afferent fibers blue broken line
2 somato-motor fibers somato-efferent fibers red
viscero-motor fibers viscero-efferent fibers red broken line
The spinal nerve and its relationship to the autonomic nervous system are depicted
(› fig. 2.5a) as well as the viscero-afferent and viscero-efferent fibers of the spinal nerve in
relationship to the sympathetic nervous system (› fig. 2.5b).
Dorsal root
Spinal ganglionic cell

Ganglion spinale
Para- Relay cells
sympathetic
cell
Ramus duralis
Ventral root
Ramus communicans albus

Ramus communicans griseus
Ganglion trunci sympathici
somato-afferent
viscero-afferent
viscero-efferent
somato-efferent
nerve fibers in the ventral
branch (Ramus ventralis)
Fig. 2.5a The spinal nerve and the types of fibers it contains (modified after Waldeyer).
Spinal cord
Rad. dors.
Spinal ganglion
Ram. dors.
N. spin.
R.com.
albus
2
Ram. com.
gris.
R. ventr. Prevertebral ganglion

Spinal co cord
rd Spinal
Ganglion trunci
sympathici
Ram. interganglion
Ram. visc. Skin
Ram. visc.
Truncus sympathicus Gut
Fig. 2.5b Pathway of the sympathetic fibers (modified after Waldeyer).

Left side: Synapsing of the preganglionic fibers (solid red line) in the sympathetic ganglion to the postganglionic fibers (broken red line). Further transmis-
sion to the periphery is via the dorsal and ventrolateral branches.
Middle: “Passing through”, e. g. the splanchnic nerve on its way to the prevertebral ganglion (solid red line), e. g. the celiac ganglion. Synapsing occurs
here to postganglionic fibers (broken red line) and further transmission to visceral organs, e. g. the intestine.
Right side: Viscero-cutaneous (= viscero-sensory) reflex arc from a visceral organ, e. g. by way of the splanchnic nerve (solid blue line) to the posterior horn,
from there to the anterior horn and finally as preganglionic fibers (solid red line) to the sympathetic trunk, with synapsing to postganglionic fibers (broken
red line) and transmission to the periphery in the dorsal and ventrolateral branches.
2.3 The Branches of the Spinal Nerves
The ventral and dorsal root filaments unite to form the spinal or segmental nerves that leave
the vertebral canal. The trunk of the spinal nerve is relatively short, already dividing into its
main branches within the intervertebral foramen (› fig. 2.6).
Ramus dorsalis (dorsal branch) Supplies the deep muscles and the skin of
the back, and the vertebral joints.
2
Ramus ventralis (ventral branch) The largest mixed branch. Within the an-
terior wall of the trunk, it passes between
the ribs in the thoracic region and be-
tween the abdominal muscles in the ab-
dominal region. Its motor fibers supply
the ventral muscles of the trunk. The sen-
sory fibers (lateral and medial cutaneous
branches) supply the skin of the lateral
and ventral regions of the abdominal wall.
Ramus lateralis (lateral branch) A branch of the ventral branch. Since the
limbs are derived from excrescences of
the ventrolateral wall of the trunk, their
nerve supply comes exclusively from ven-
trolateral branches.
Ramus meningeus (meningeal branch) A small branch containing sensory sym-
pathetic vasomotor fibers. Being unim-
portant for the analysis of acupuncture, it
is only mentioned here.
Rami communicantes These two “connections” form a link to
(communicating branches) the ganglia of the sympathetic trunk, lo-
cated paravertebrally, i. e., next to the ver-
tebral column.
Ramus communicans albus This white, myelinated branch consists
(white communicating branch) mostly of axons of preganglionic sympa-
thetic neurons, which pass from the later-
al columns of the spinal cord to the ante-
rior roots, and from there to the sympa-
thetic ganglia.
Ramus communicans griseus After most of the fibers of the sympathetic
(gray communicating branch) ganglion have been synapsed to the post-
ganglionic neuron, the postganglionic
gray, unmyelinated axons continue within
the ramus communicans griseus to the
spinal nerve, which thus carries the sym-
pathetic axons that supply blood vessels,
glands, etc.
The dorsal, lateral and ventral branches represent the basis of a longitudinal division of the body surface
into thirds.
In figures 2.6a and 2.6b, the regions supplied by these branches are indicated by color. The
regions of supply can already be distinguished in the embryo.
2.3 The Branches of the Spinal Nerves 29
Fig. 2.6a The spinal nerve and its branches, schematically: dorsal branch (red), ventral branch (yellow), lateral
branch (green). This is the basis of a longitudinal division of the trunk into thirds (modified after van Rynberk,
1900)
Spinal cord
Spinal ganglion
Spinal nerve
(sympathetic trunk)
Prevertebral ganglia
(e.g. solar plexus)
Enteric nervous system

(intramural plexuses)
Fig. 2.6b Schematic transverse section through an embryo, showing the areas supplied by the spinal nerve
branches: dorsal branch (red), lateral branch (green), ventral branch (yellow). (Modified after Rohen)
2.3.1 The Three Spinal Nerve Branches as Basis of the Threefold

Longitudinal Division of the Body Surface
The areas innervated by the dorsal, ventral, and lateral branches on the trunk form three
longitudinal strips. These thirds correspond to the long yang meridians2 in Chinese acupunc-
ture (König, Wancura 1978; › fig. 2.7).
The situation in the trunk is as follows:
The area supplied by the forms the dorsal longitudi- corresponding to the blad-
2 dorsal branches nal one-third der meridian, or taiyang
The area supplied by the lat- forms the lateral longitudi- corresponding to the gall-
eral branches nal one-third bladder meridian, or shaoy-
ang
The area supplied by the forms the ventral longitudi- corresponding to the stom-
ventral branches nal one-third ach meridian, or yangming
Since both the head and the limbs are part of this longitudinal arrangement, I believe it is possible to
state that the basic principle of arrangement essential for diagnosis and therapy in acupuncture cor-
responds to the spinal-segmental order, and thus is determined by the spinal nerves and the sympa-
thetic nervous system.
2 Several acupuncture societies have agreed to abandon the term “meridian” in favor of the term “channel”.
2
R. latera
lateR.
R.
v
ralis
en
R. d
lis
tra
lis
orsa
lis
R. ventralis
Fig. 2.7 Areas of innervation of the dorsal (red), ventral (yellow), and lateral (green) spinal nerve branches to
the skin of the trunk, neck, and head (modified after Villinger, 1933).
The division of the trunk into longitudinal thirds was described as early as 1850 by Ross
and Voigt. Ross showed that even at the beginning of evolutionary development, the verte-
brate body is already divided in this way.
Thus, even in the lancelet fish (Amphioxus), the nerve branches supply dorsal, ventral, and
lateral areas, respectively. The innervation areas of the seven cervical, twelve thoracic, and
nine lumbosacral nerves are arranged by thirds.
The areas of innervation are as follows (› fig. 2.8):
in the figure
2
The dorsal branch of the spi- the dorsal longitudinal one- red
nal nerve innervates third
The lateral branch of the spi- the lateral longitudinal one- green
nal nerve innervates third
The ventral branch of the the ventral longitudinal one- yellow
spinal nerve innervates third
Such threefold longitudinal division, which is already present in the lancelet fish (Amphiox-
us), can also be found in man.
A particularly interesting publication was presented by the Viennese anatomist, Voigt,
who in 1850 conducted a “Study on the Branching Areas of the Spinal Nerves” arriving at
conclusions corresponding to those of Ross. Both authors studied and showed the spinal
nerve supply not only to the trunk, but also to the limbs (› fig. 2.9).
Fig. 2.8 First evidence of a longitudinal division of the body into thirds at the lowest evolutionary level of
vertebrate animals, taking the lancelet fish (Amphioxus) as an example (modified after J. Ross).
Fig. 2.9 Overview of the longitudinal threefold division of the human body, showing the areas innervated by the dorsal, ventral, and lateral branches of
the spinal nerves. (Modified after Voigt; the letters are part of the original drawing.)
2.3.2 The Regions Innervated by the Spinal Nerves
The Regions Innervated by the Lateral Branches
The regions innervated by the lateral branches of the spinal nerves comprise the following
(› fig. 2.10; green areas):
in the upper half of the body: • the lateral head and neck regions
• the shoulder region
2 • the extensor region of the upper limbs
in the lower half of the body: • the lateral trunk region

• the lateral hip region
• the anterior part of the thigh
• the tibial part of the lower leg
• the medial ankle and the medial edge of
the foot
• parts of the lateral ankle and the dorsum
of the foot
The lateral branches of the spinal nerves thus innervate
in the upper limb • the extensor muscles and

• the lateral skin area covering them
in the lower limb • the extensor muscles and
• the lateral skin area covering them
On the basis of these anatomical facts, the acupuncturist will immediately notice that the re-
gions innervated by the lateral branches of the spinal nerve correspond
on the upper limb • to the hand shaoyang (triple heater

eridian) and the hand taiyang
m
(small intestine meridian)
on the lower limb • to the foot shaoyang (gallbladder
meridian) and the foot yangming
(stomach meridian)
on the head and trunk • to the shaoyang region
According to my analysis, it is therefore justified to regard the region innervated by the lateral spinal
nerves as equivalent to the shaoyang meridian, the taiyang meridian and parts of the yangming me
ridian.
Fig. 2.10 Regions of the head, trunk, and limbs innervated by the lateral branches of the spinal nerves (indicated in green) (modified after Voigt).
The Regions Innervated by the Ventral Branches
The regions innervated by the ventral branches of the spinal nerves comprise the following
(› fig. 2.11; yellow areas):
in the upper half of the body • a ventral longitudinal third of the trunk
• the medial and radial sides of the upper
limb
2 in the lower half of the body • a part of the buttocks
• the posterior aspect of the thigh and
lower leg
• the region of the lateral ankle and the
sole of the foot
The ventral branches of the spinal nerves thus innervate the following:
in the upper limb • the flexor muscles and

• the skin covering them
in the lower limb • the flexor muscles and
• the skin covering them
Considering these anatomical facts, the acupuncturist will immediately notice that the re-
gions innervated by the ventral branches of the spinal nerves correspond
• on the upper limb, to the hand yangming (large intestine meridian) and
• on the trunk, to the yangming region (stomach meridian).
The changed localization on the lower limb results from its rotation during embryonic devel-
opment, which causes the extensor muscles, originally located dorsally, and the skin covering
them, to move ventrally and laterally.
At the same time the flexor muscles, originally located ventrally, and the skin covering
them, shift to a dorsal position.
Fig. 2.11 The areas innervated by the ventral spinal nerve branches (indicated in yellow) on the skin of the trunk and limbs (modified after Voigt).
The Regions Innervated by the Dorsal Branches
The regions innervated by the dorsal branches of the spinal nerves comprise the following
(› fig. 2.12; red areas):
on the head and back • a dorsal longitudinal third of the skin

• the deep autochthonous muscles of the back
• the vertebral joints
2
The dorsal branches do not innervate the limbs.
On the basis of this anatomical fact, the acupuncturist will immediately notice that the re-
gions innervated by the dorsal branches of the spinal nerves correspond
• on the head and back, to the taiyang (bladder meridian).
2.3.3 The Relations of the Metameric Spinal Nerve Branches
According to Fanghänel, the “lateral, ventral, and dorsal spinal nerve branches have particu-
larly close relations with one another.” This particularly close relationship of the spinal nerve
branches with the adjacent metameres has a histologically proven basis, as shown in figures
2.13 and 2.14.
From the viewpoint of acupuncture, I interpret this comment by Fanghänel to mean that
the close interrelationships of the spinal nerve branches also provide a possible explanation
for the close functional relationships within the meridian axes of:
• triple heater and gallbladder (shaoyang)
• large intestine and stomach (yangming)
• small intestine and bladder (taiyang)
Fig. 2.12 The areas innervated by the dorsal spinal nerve branches (indicated in red) on the skin of the head and trunk (modified after Voigt).
Posterior midline
Spinous pro-
Scapular elevation cesses
Anterior
midline Upper limb
Mammillary elevation
Ribs
Costal
arch
Xiphoid
process
Umbilicus
Iliac crest
Pubic
tubercle
Fig. 2.13 Schematic representation of the histologically verified, particularly close relationship of the dorsal
(red), ventral (yellow), and lateral (green) spinal nerve branches with the neighboring metameres as the basis
of the longitudinal division in thirds.
Note, for example, the lack of contact between the dorsal branch (red) and the lateral branch (green), or be-
tween the lateral branch (green) and the ventral branch (yellow) in the thoracic region. (Modified after Grosser
and Fröhlich, 1902)
2.3 The Branches of the Spinal Nerves 41 Spec
Specia
Spe
Specia
Scapular elevation
Anterior
midline Upper limb
Mammillary elevation
Ribs
Costal
arch
Xiphoid
process
Umbilicus
Iliac crest
Pubic
tubercle
Fig. 2.14 Same statement as in figure 2.13. The individual dermatomes are marked uniformly gray.
Horizontal Order
Fig. 2.15 The horizontal segmental order is determined by the spinal nerves. Color coding: cervical, red; thoracic, yellow; lumbar, blue; sacral, gray
(modified after Hansen and Schliack). Notice that the representation of the foot is not quite accurate, in that the great toe, like the thumb, should be di-
rected cranially (› fig. 2.24).
Vertical Order
Fig. 2.16 The vertical order is determined by the neighboring (metameric) spinal nerve branches.
Color coding: ventral branches, yellow; lateral branches, green; dorsal branches, red.
The right and left spinal nerves divide the body conceptually into horizontal ovoid slices
(› fig. 2.15).
The three branches of all spinal nerves divide the body conceptually into three vertical
strips (› fig. 2.16).
Together, these horizontal and vertical patterns make up a sort of “grid”, i. e., an ar-
rangement principle with extremely important therapeutic and diagnostic implications. To
start with, this is illustrated by two examples:
Example 1
2
A stimulus at acupuncture point LI 4
• affects dermatome C 6 and
• the myotomes C 6 and C 8 (M. adductor pollicis C 6, M. interosseus dorsalis I C 8)
→ horizontal distribution pattern.
• Furthermore, LI 4 also lies in the region supplied by the ventral branches of these seg-
ments (yellow in the figure) → vertical distribution pattern.
An acupuncture stimulus at LI 4 therefore also affects the segments C 6 to C 8 on the trunk,
but only in the area supplied by the ventral branches of these segmental nerves. This means
that it includes the myotomes C 6 to C 8, which are supplied by the ventral branches, in this
case all parts of the pectoral muscle.
The point LI 4 thus affects only the ventral, but not the lateral or the dorsal longitudinal
third.
This corresponds to the tenet in acupuncture practice of the hand yangming affecting the yangming
region of the trunk.
Example 2
A stimulus at acupuncture point SI 3
• affects the dermatome and myotome C 8|Th 1
→ horizontal distribution pattern.
• Furthermore, SI 3 also lies in the region supplied by the lateral branches of these seg-
ments (green in the figure)
→ vertical distribution pattern.
An acupuncture stimulus at SI 3 therefore affects the segments C 6 to C 8 on the trunk, but
only in the area supplied by the lateral branches of these segmental nerves. This means
that it includes the myotomes C 8|Th 1, in this case the caudal parts of the latissimus dorsi
muscle.
The point SI 3 thus affects only the dorsolateral, but not the ventral longitudinal one-third.
2.4 The Branches of the Spinal Nerves in Detail
2.4.1 The Dorsal Branches of the Spinal Nerves
The dorsal branches (in the figures in red) supply the deep autochthonous muscles of the
back and their derivatives in the neck. Additionally, they supply the intervertebral joints and
a band of skin on the back that extends from the vertex along the neck to the tip of the coc-
cyx and the region of the buttocks. Its width varies at different levels (› fig. 2.17 and
› fig. 2.18).
2.4 The Branches of the Spinal Nerves in Detail 45
The Dorsal Branches of the Cervical Nerves
They supply the deep autochthonous muscles of the back, and the skin of the neck and oc-
cipital regions.
• The dorsal branch of the first cervical nerve is composed only of motor fibers. It sup-
plies the short muscles between atlas and axis, and does not give rise to a sensory branch.
For this reason there is no C 1 dermatome.
• The dorsal branch of the second cervical nerve is of mixed composition, i. e., it contains
motor fibers supplying the pharyngeal muscles and sensory fibers for the C 2 dermatome.
Immediately beneath the insertion of the trapezius muscle it passes subcutaneously, 2
breaks down into numerous terminal branches, and is named N. occipitalis major
(greater occipital nerve). This nerve supplies the skin from the occiput to the vertex, and
laterally to the temple regions.
• The dorsal branch of the third cervical nerve is of mixed composition. It supplies a
small stripe of the C 3 dermatome, and is known as N. occipitalis tertius (third occipital
nerve). The motor fibers of the third cervical nerve are involved in the supply of the sple-
nius, longissimus thoracis, transversus occipitalis and transversus spinalis muscles.
• The dorsal branches of the fourth through the eighth cervical nerves are likewise of
mixed composition. They supply the longissimus thoracis and splenius muscles and the
skin with branches of increasing length that run laterally toward the spine of scapula and
the acromion.
Th 1
Th2
Th3
Th4 Th 3
2 Th5 Th 4
Th6
Th 5
Th7 Th 6
Th8 Th 7
Th 8
Th9
Th 9
Th10 Th 10
Th11
Th12 Th 11
L1
L2 Th12
L3
L1
S1
S2
L2
S3
S4
S5
L3
Fig. 2.17 The thoracic dermatomes T 1 through T 12 on the trunk as a horizontal pattern.
Dorsal view (modified after Bolk).
Th 1
Th2
Th3
Th4 Th 3
Th5 Th 4
2
Th6
Th 5
Th7 Th 6
Th8 Th 7
Th 8
Th9
Th 9
Th10 Th 10
Th11
Th12 Th 11
L1
L2 Th12
L3
L1
S1
S2
L2
S3
S4
S5
L3
Fig. 2.18 The thoracic dermatomes T 1 through T 12 on the trunk as a longitudinal pattern with ventral,
lateral, and dorsal longitudinal thirds, determined by the dorsal (red), lateral (green), and ventral (yellow) spinal
nerve branches. (Modified after Bolk)
The Dorsal Branches of the Thoracic Nerves
These nerves supply the deep autochthonous muscles of the back, where they dissociate into
their terminal branches, the medial and lateral branches.
The medial and lateral branches of the dorsal branches of the thoracic nerves are distrib-
uted differently in the upper and lower halves of the thorax. In the upper half, the medial
branches and in the lower half the lateral branches contain both motor and sensory fibers
with which they supply the skin.
2 The medial branch of the dorsal branches- The lateral branch of the dorsal branches-
supplies the cutis and the subcutaneous tis- supplies the cutis and the subcutaneous tis-
sue of the upper half of the back. sue of the lower half of the back.
A virtual line extending from the medial A virtual line extending from the lateral
branches of the dorsal branches marks the branches of the dorsal branches marks the
medial branch of the bladder meridian. lateral branch of the bladder meridian.
As shown in figure 2.17, a cranial shift of dermatomes occurs at the shoulder blade (“scapu-
lar elevation”).
Scapular elevation explains why a needle inserted horizontally and tangentially at the lat-
eral border of the dorsal longitudinal one-third, i. e. at the lateral branch of the bladder me-
ridian, and pointing in the direction of the dorsal midline, can reach and influence several
adjacent dermatomes, and thus very different levels of the spinal cord, via the medial branch
of the bladder meridian.
In this way, the subcutaneous insertion of a single needle connecting the lateral and medial branches
of the bladder meridian can give therapeutic access to several adjacent segments of the spinal cord.
The Dorsal Branches of the Lumbar Nerves
The dorsal branches of the lumbar nerves divide into

• a medial branch supplying the lumbar part of the transversospinal and the spinal mus-
cles, and
• a lateral branch, whose cutaneous branches, the superior cluneal nerves (Nn. clunium
superiores) supply the integument covering the posterior part of the buttocks.
The Dorsal Branches of the Sacral and Coccygeal Nerves
The dorsal branches of the sacral nerves emerge through the posterior sacral foramina, the
coccygeal nerve through the sacral hiatus.
In the skin of the buttocks they form the medial cluneal nerves (Nn. clunium medii).
2.4.2 The Dorsal Branches in Psychosomatic Medicine and Evolution
As shown in figure 2.12, the area innervated by the sensory fibers of the dorsal branches of
the cervical nerves C 2|C 3 extends far cranially, covering the head from occiput to vertex.
Similarly, the area innervated by the sensory fibers of the dorsal branches of the thoracic
nerves extends caudally.
The question arises as to why the sensory fibers of the dorsal branches cover such a large
area on the back side of the body, extending from the occiput to the tip of the coccyx.
Since the dorsal branches of the spinal nerves contain more sympathetic fibers than any
other branches, this musculocutaneous region is a particularly sensitive area of resonance 2
for sympathetic stimuli.
Consequently, excitatory stimuli such as fear or cold may lead to flexion or extension of
the deep autochthonous back muscles, i. e. “bucking” or “revolting”, and may also cause the
hairs on the back to stand on end due to contraction of the sympathetically innervated arrec-
tor pili muscles.
Because erection of the hairs always involves a sensation of cold and shuddering, fear and
cold are perceived above all in this longitudinal stripe covering one-third of the back. In oth-
er words, fear makes the hair stand on end, and this elicits a sensation of cold.
In TCM terminology, this somato-psychological unit, consisting of the dorsal longitudinal
one-third of the body and sympathetic reflexes involving muscles and skin, corresponds to
an outer and an inner pathogenetic factor – cold and fear, respectively.
In my analysis, the neurophysiological basis of this correspondence lies in the rich supply of sympa-
thetic fibers to the dorsal longitudinal one-third and the reaction of sympathetic effector organs in the
integument upon sympathetic stimulation.
In other words: The correspondence or association of a psychological and a climatic factor

with a given area of the body surface can be explained only if one regards the region supplied
by a specific meridian as a perceptive area in which psychological and climatic factors are
perceived with special acuity. This principally applies to all such correspondences (König,
Wancura 1978).
In the above example, “cold” as a climatic factor and “fear” as a psychological factor are
perceived mainly in the region of the back. Therefore, the bladder meridian (taiyang) is as-
sociated with the factors cold and fear.
This has implications for diagnosis as well as therapy: All disorders that are triggered or
exacerbated by cold and fear must receive an acupuncture treatment that increases the circu-
lation in the dorsal one-third and thus elicits a feeling of warmth on the back.
Here the phenomenological aspect of Chinese acupuncture becomes especially clear: The perception of
subjective sensations in specific areas of the body surface is seen as the basis for a system of correspon-
dences.
In the above example, therefore, fear, cold, and the dorsal longitudinal one-third are associ-
ated; they “correspond” to one another.
The psychosomatic aspect of Chinese acupuncture is based to a large extent on these neu-
rophysiological facts. Since these observations are intersubjective, i. e. they occur in all hu-
man beings, independently of the observer, they are also scientific (Pietschmann).
Since the vertebrates possess this special sensitivity due to the rich supply of sympathetic
fibers in the dorsal longitudinal one-third, this region from the top of the head to the tip of
the tailbone may be regarded as a particularly sensitive area of resonance for inner moods.
This pertains both to external stimuli and the “expression” of inner moods:
• The “hair stands on end” in the region of the dorsal branches, but not the hair of the
beard in the region supplied by the corresponding ventral branches (Elze).
• In many vertebrates, bristling of the hair in the dorsal longitudinal third of the body sur-
face is also an expression of readiness to fight and aggression, a message that is correctly
interpreted by other members of the group.
• By contrast, smoothing of the dorsal hair on the back and head signifies submission and
“making oneself smaller”.
Bristling produces an apparent enlargement of the body surface, while smoothing of the hair
appears to reduce it. This example thus illustrates two opposite messages that may be ob-
served in all vertebrates.
Eibl-Eibesfeldt notes that the areas in which “the hair stands on end” are the ones “in
2 which later also manes grow.”
Even in lower vertebrates, this region is accentuated by skin folds.
Certain lizard species have a skin fold on the back that corresponds to the region supplied
by the dorsal branches. This skin fold is particularly sensitive to all external stimuli. Thus,
even in lower vertebrates the dorsal longitudinal one-third of the body surface represents a
particularly sensitive transmitting and receiving station.
This region is also the part of the body surface where autonomic sympathetic reactions are
experienced with the greatest intensity. For instance, “a cold shudder runs down the back” or
fear “makes one's hair stand on end.” (Dobrovolski & Piirainen 2005)
For this reason the dorsal longitudinal one-third of the body is of great significance in psychosomatic
medicine.
2.4.3 The Ventral and Lateral Spinal Nerve Branches and Plexuses
The ventral branches (› figs. 2.11, 2.19a, 2.19b; indicated in yellow) are the largest branches
of the spinal nerves. They pass within the thorax and the anterior abdominal wall and supply
the ventral muscles of the trunk, and the lateral and anterior skin of the abdominal wall. The
lateral branches (› figs. 2.10, 2.19a, 2.19b; indicated in green) are derived from the ventral
branches.
The ventral branches (› fig. 2.11) of the The lateral branches (› fig. 2.10) of the
spinal nerves supply spinal nerves supply 2
a ventral longitudinal one-third of the trunk a lateral longitudinal one-third on the head,
neck, and trunk
a volar and radial area of the upper limb a dorsal and ulnar area of the upper limb
that covers the flexors of the upper limb that covers the extensors of the upper limb
a dorsal area of the lower limb that covers a ventrolateral area of the lower limb that
the flexorsof the lower limb covers the extensors of the lower limb
The ventrolateral branches of the spinal nerves form extensive plexuses:

• the neck plexus, or cervical plexus,
• the arm plexus, or brachial plexus,
• the leg plexus, or lumbosacral plexus.
Recall: The extremities are derived by budding from the ventrolateral thoracic and abdominal wall.
Therefore, they are only supplied by the ventrolateral branches of the spinal nerves. I would like to
emphasize that the dorsal branches of the spinal nerves do not extend to the limbs, but remain in the
back in a strictly metameric order.
2.4.4 Plexus Formation from the Point of View

of Segmental Anatomy
The plexuses are formed by the ventrolateral branches.

Schuhmacher found that the fibers which subsequently give rise to the ventral and lateral
(so-called “dorsal”) branches of the brachial and lumbosacral plexuses, already separate in
the anterior horn of the spinal cord (› figs. 2.19a, 2.19b).
These findings indicate that the separation of the nerve fibers in the brachial and lumbosa-
cral plexuses into ventral and lateral (“dorsal”) branches does not take place within the plex-
2 us, but can be recognized as high up as the points of exit of the anterior roots of the spinal
cord.
Fig. 2.19a Schematic drawing of the ventral (yellow) and lateral (green) branches which are already separate
at their point of origin within the anterior horn (modified after Schuhmacher).
Fig. 2.19b Schematic drawing of the arrangement of the segmental roots within the main trunks of the bra-
chial plexus: Ventral branch of the spinal nerves C 5 to T 1 (yellow), musculocutaneous nerve (C 5, C 6), me-
dian nerve (C 6 to T 1), ulnar nerve (C 8 to T 1), and the dorsally located lateral branch of the spinal nerves
C 5 to T 1 (green), axillary nerve (C 5, C 6), radial nerve (C 5 to T 1). (Modified after Braus and Elze)
By means of plexus formation, there is extensive commingling of nerve fibers from various
roots, forming a peripheral nerve that contains fibers from various neurites (“peripheral in-
nervation”; › fig. 2.20).
Yet each nerve root – despite its separation and mingling with other nerves in the plexus
– supplies a specific area in the periphery (“radicular innervation”; › fig. 2.20).
Fig. 2.20 Schematic comparison of peripheral (dark gray) and segmental (light gray) innervation: Peripheral
disorders, e. g., in carpal tunnel syndrome, are indicated in the patient's right hand (dark gray). Segmental
disorders may be due to mechanical irritation of a nerve root, e. g. by a prolapsed disk (radicular pain), or to
referred pain, shown in the figure as L 5 on the patient's left side, for example in case of disorder of an organ
in the upper abdomen (light gray).
For example
The area of skin supplied by a posterior The muscular area supplied by a single ante-
root rior root
is a dermatome. is a myotome.
In contrast, the area of skin supplied by a The region innervated by a peripheral
peripheral nerve nerve that supplies a muscle
consists of portions of different derma- consists of neurites derived from several
tomes. anterior roots. 2
Thus the trisegmental deltoid muscle is supplied by neurites from the segments C 4|C 5|C 6,
which form the axillary nerve (“peripheral innervation”).
A myotome that was originally a unit is “split into pieces” (Villinger) in the course of its
migration to the periphery, and participates in the formation of several muscles.
For example, portions of the C 8 myotome are found in the caudal part of the latissimus
dorsi muscle, in the caudal part of the pectoral muscle (M. pectoralis), as well as in the deep
muscles of the hand and the ulnar muscles of the arm.
In the peripheral nerves, the neurites of a spinal cord segment change their positions relative to each
other and are bundled together like parts of a braid, but toward their distal ends they regain their
segmental order before reaching their dermatomes, myotomes, and sclerotomes. By contrast, a derma-
tome persists as a unit, and is never “split into pieces.”
Braus and Elze consider the displacement and fragmentation of individual myotome parts to
be the reason for plexus formation, since all muscle and myotome parts are accompanied by
their nerve fibers during migration.
Since displacement and fragmentation of the myotomes is most pronounced in the cervical and lumbo-
sacral regions, plexus formation is a characteristic of the cervical and lumbosacral regions.
In the region of the trunk innervated by the thoracic nerves, no plexus formation occurs. The
intercostal nerves are therefore both radicular and peripheral.
One can imagine and keep in mind this simplified description: Although the ventral and
lateral branches intermingle, the areas they serve are sharply demarcated (“radicular inner-
vation”).
The ventral branches innervate The lateral branches (in the limbs mislead-
ingly termed “dorsal branches”) innervate
in the upper limb in the upper limb
2 the volar (and part of the radial) muscles the dorsal (and part of the ulnar) muscles
and integument and integument
in the lower limb in the lower limb
(due to rotation during embryonic develop- (due to rotation during embryonic develop-
ment) the dorsal muscles and integument. ment) the ventrolateral muscles and integ-
ument.
In contrast, the dorsal branch (of the spinal nerve) remains restricted exclusively to the
back.
Keep in mind: The lateral branches are derived from the ventral branches. For sake of sim-
plicity, I refer to them as “ventrolateral” branches.
2.4.5 The Individual Plexuses
In accordance with the book title “Segmental Anatomy” and for the sake of completeness, the
individual plexuses are described here.
The Ventrolateral Branches of the Cervical Nerves
The Cervical Plexus

2
The cervical plexus originates from the ventrolateral branches of the spinal nerves C 1
through C 4.
The Cutaneous Branches of the Cervical Plexus

The cutaneous branches of the cervical plexus are (› fig. 2.21):
• The lesser occipital nerve (derived from C 2 and C 3) innervates the skin lateral to the
region of the major occipital nerve. It extends toward the mastoid process.
• The great auricular nerve (N. auricularis magnus3, derived from C 3) supplies the back
surface of the external ear and the earlobe, as well as the skin of the mandibular angle and
the retromandibular fossa.
• The transverse cervical nerve (N. transversus colli4, derived from C 3) innervates the
skin in the anterior triangle of the neck.
• The supraclavicular nerves5 (derived from C 3 and C 4) innervate a wide swath of skin
that crosses the suprasternal notch and the manubrium sterni, the clavicle, and the pecto-
ralis major muscle to the nipple and the deltoideo-pectoral triangle, as well as the skin
above the acromion, the spine of scapula, and the dorsal parts of the deltoid muscle.
From the point of view of segmental theory, this area is of special importance because all disorders of
organs close to the diaphragm can by way of the phrenic nerve project pain into this area supplied by
the supraclavicular nerves (› page 60).
3 Various authors give differing information

Vertex-ear-chin line
N. auricularis magnus
N. transversus colli
Nn. supraclaviculares
N. intersostalis I
2 Borderline between lateral and
anterior branches of intercostal nerves
N. cutaneus brachii lateralis

(N. axillaris)
N. cutaneus brachii medialis
N. intercostobrachialis
N. cutaneus antebrachii
posterior (N. radialis)
N. cutaneus
antebrachii medialis
N. cutaneus antebrachii
lateralis (N. musculocutaneus)
N. iliohypogastricus
N. ulnaris, R. palmaris
N. medianus, R. palmaris
N. radialis, R. superficialis
N. medianus, Rr. digitales
N. ulnaris, Rr. digitales
N. genitofemoralis, R. femoralis
N. genitofemoralis,
R. genitalis, u. N. illoinguinalis
N. cutaneus femoris lateralis
N. cutaneus femoris anterior
N. obturatorius
N. cutaneus surae lateralis
N. saphenus
N. peronaeus superficialis
N. suralis
N. peronaeus profundus
Fig. 2.21a The segmental (radicular) areas of innervation of the skin are shown on the right side of the body,
and the areas of peripheral innervation of the skin on the left side. Ventral aspect.
Vertex-ear-chin line
Borderline between dorsal

and ventral branches of
spinal nerves
2
Borderline between
dorsal and ventral
branches of spinal nerves
Rr. dorsales mediales of the

sacral and coccygeal nerves
Fig. 2.21b Same depiction as in fig. 2.21a, dorsal aspect (after Braus and Elze)
The Muscular (Motor) Branches of the Cervical Plexus

• The muscular branches of the cervical plexus innervate the intertransversarii muscles, the
rectus capitis, the longus capitis and longus colli muscles, and the levator scapulae mus-
cle.
The levator scapulae muscle from C 3 and C 4 is particularly important in segmental theory
because, like the trapezius muscle, it receives impulses from the phrenic nerve.
This means: Raised shoulders (“pulling in one's head”) can also be the result of projective
impulses originating from disorders of upper abdominal organs.
• Further branches innervate the sternocleidomastoid (C 2|C 3) and the trapezius
2 (C 2|C 3|C 4) muscles, as well as the diaphragm.
• Motor fibers also innervate the prevertebral muscles, the scalene muscles, and the infra-
hyoid muscles.
The cervical plexus is connected to
• the sympathetic nervous system by way of the Rami communicantes grisei which connect
the stellate ganglion with the phrenic nerve and
• cranial nerves (hypoglossus, accessorius and facial nerves).
The phrenic nerve plays a special role in segmental anatomy regarding the phenomenon of referred
pain.
Since afferent parasympathetic fibers from all organs adjacent to the diaphragm join the
phrenic nerve, disorders of any thoracic or abdominal organs can elicit pain in the original
segments of the phrenic nerve, i. e. in the segments C 3, C 4, and C 5 (shoulder girdle). The
origins of the phrenic nerve differ in various ethnic groups.
How the fibers from these organs reach the phrenic nerve is unknown (Braus and Elze).
According to M. Clara, sympathetic fibers of the phrenic nerve can cause the phenomenon
of referred pain from the thoracic and abdominal organs to the shoulder region (C 3|C 4|C 5)
(› page 276).
In 20 to 25 percent of individuals, the phrenic nerve receives accessory branches from the
lower cervical nerves (C 5–C 6), which are termed accessory phrenic nerve.
The Brachial Plexus
The brachial plexus consists of ventrolateral branches of the spinal nerves C 5 through T 1,
which make up the roots of the plexus. Each ramus ventrolateralis divides into two branches,
a ventral and a lateral (“dorsal”) one (› fig. 2.19b):
The ventral branch (› fig. 2.19b, yellow) is the origin of the
• lateral cord (C 5|C 6|C 7), which in turn gives rise to the musculocutaneus, the brachial
and the medial antebrachial nerves.
The lateral cord supplies the radially located flexor muscles on the volar side of the arm
and receives impulses from the respiratory tract via collateral fibers in the sympathetic 2
trunk.
The ventral branch is also the origin of the
• medial cord (C 8|T 1), which in turn gives rise to the ulnar nerve.
The medial cord supplies the ulnar flexor and extensor muscles of the arm and receives
impulses from the heart, esophagus, and stomach.
The medial and lateral cords jointly give rise to the loop of the median nerve which is
therefore connected to C 6–T 1, and thus receives impulses from the heart, lungs, and
stomach.
The lateral (“dorsal”) branch (› fig. 2.19b, green) forms the
• posterior cord (C 5–T 1), from which the radial and axillary nerves arise.
The latter supply the cervically innervated muscles of the back and receive impulses from
the heart, lungs, and stomach.
The Cutaneous Branches of the Brachial Plexus

The cutaneous branches of the brachial plexus supply
• the volar and radial sides of the arm (ventral branches), and
• the dorsal and ulnar sides of the arm (lateral branches).
The Muscular (Motor) Branches of the Brachial Plexus

The motor branches of the brachial plexus, erroneously termed “dorsal” branches, although
they are actually lateral ones, run to the levator scapulae and rhomboid muscles, to the supra-
and infraspinatus muscles, to the subscapularis and teres minor muscles, to the latissimus
dorsi and the deltoid muscles.
• The ventral branches supply the subclavian and the pectoralis major and minor muscles,
the flexor muscles of the upper arm and forearm, and the muscles of the hand.
• The lateral (“dorsal”) branches supply all extensors of the upper arm and forearm by
way of the radial nerve.
Understanding this nerve supply is important for the following reasons:
• The extensor muscles of the upper arm and forearm are related to the extensor muscles of
the back that have originated in the same segments, but have “remigrated” to the back.
• Pain in this layer of muscles, which extends from the occiput to the iliac crest and covers
the entire back, can therefore mutually interact with the extensor muscles of the upper
arm and the forearm.
Implications for therapy:
• Treatment of pain in the extensor region of the upper arm and forearm
should always involve the needling of acupuncture points on the back
that are located in the region innervated by the “dorsal” (lateral) branches of the brachial
plexus.
Accordingly, for the treatment of backache anywhere from the occiput to the iliac crest, acu-
puncture theory recommends the needling of TH 5 and SI 3 on the forearm and hand, respec-
tively.
This precisely represents a segmental therapy with additional consideration of the vertical
order, i. e., the division into “dorsal” (more properly “lateral”) and ventral branches.

• Treatment of pain in the flexor region of the upper arm and forearm
should always involve the needling of acupuncture points on the chest and abdomen
that are located in the region innervated by the ventral branches of the brachial plexus.
Vice versa, the limb muscles that have remigrated to the back (i. e., the subclavian and pec-
toralis major and minor muscles) and are supplied by the ventral branches, can interact
with the flexor muscles on the upper arm and forearm, which are also supplied by ventral
branches.
2 • Treatment of pain in the region of the pectoral muscles
should always involve the needling of acupuncture points located in the flexor region of
the arm, e. g., P6 or xinpin.
This example too shows that not only the horizontal segmental order, but also the longitudinal order
based on the branches of the spinal nerves is important for classification and treatment.
Digression:
Radicular Pain Symptoms of the Cervical Syndrome (adapted from Hansen und Schliack)
Pain characteristics:
• sudden onset, “electrical”
• segmental radiation
• exacerbation when the head is held in certain positions.
Pain localization:
2
C 3, C 4 • Shoulder pain
• Hypalgesia
C 5 • Pain in the shoulder and upper arm

• Hypalgesia
• Functional impairment of the deltoid and biceps brachii muscles
C 6 • Pain or possibly hypalgesia on the radial parts of the upper arm
and forearm, of the thumb, and the index finger
• Functional impairment of the biceps brachii and brachioradialis
muscles
C 7 • Pain on the radial part of the forearm, radiating to the middle
finger
• Functional (motor) impairment of the pectoralis major, triceps
brachii, and pronator teres muscles, the ball of the thumb, and
sometimes of the long flexor muscles of the finger
C 8 • Pain and sensory impairment in the ulnar part of the hand and
the forearm
• Paresis of the triceps brachii muscle and of the small muscles of
the hand, and atrophy of the hypothenar
The Ventrolateral Branches of the Thoracic Nerves
The ventrolateral branches of the thoracic spinal nerves are also known as the intercostal
nerves (› fig. 2.22a).
• Their ventral cutaneous branches are the terminal branches of the intercostal nerves
(› fig. 2.22b, yellow); they supply the skin of the chest and abdomen from the level of
the nipples to the symphysis and the inguinal region.
• Their lateral cutaneous branches (› fig. 2.22b, green) supply the skin on the lateral
part of the trunk from the armpit and the upper arm to the iliac crest, extending to the
2 trochanter.
• The motor branches (Rami musculares) supply
– the elevator muscles of the ribs (Mm. levatores costarum)
– the serratus posterior muscles (Mm. serrati posteriores)
– the intercostal muscles
– the transversus thoracis and transversus abdominis muscles
– the internal and external oblique abdominal muscles, and
– the rectus abdominis muscle.
In summary:
The ventrolateral branches of the thoracic spinal nerves, i. e., the intercostal nerves, supply
the genuine muscles of the chest and abdomen as well as the skin of the chest and abdomen
down to the inguinal ligament and the hip region. They mark
N.
intercost. VI
R. cutan. lat. of
the N. intercost VII
R. vent. of the R. cutan.
lat. N. intercost VIII
R. dors.
N. intercost.X
N. intercost.XI
N. subcostalis
N. iliahypogastricus
Fig. 2.22a Anatomic representation of the ventral and lateral thoracic spinal nerve pathways, with dermatome
borders indicated (after Clara 1942)
Fig. 2.22b Vertical order resulting from adjacent (metameric) spinal nerve branches.
Color coding: ventral branches are indicated in yellow, lateral branches in green. Ventral aspect.
• a medial longitudinal one-third (ventral branches), and

• a lateral longitudinal one-third (lateral branches).
The medial longitudinal one-third corresponds to the yangming meridian, and the lateral longitudinal
one-third to the shaoyang meridian.
The Ventrolateral Branches of the Lumbosacral Nerves
The Lumbosacral Plexus
The lumbosacral plexus consists of the ventrolateral branches of the spinal nerves T 12
through S 5. Basically it consists of several loops which form the lumbar plexus, the sacral
plexus, the pudendal plexus, and the coccygeal plexus.
The lumbar plexus (T 12 to L 4)

It gives rise to
• the iliohypogastric nerve (T 12 to L 1),
• the ilioinguinal nerve (L 1),
• the genitofemoral nerve (L 1 to L 2),

• the cutaneus femoral nerve (L 2 to L 3).
Additionally, it is the origin of
• the femoral nerve (L 1 to L 4),
• the obturator nerve (L 2 to L 4), which innervates the adductor muscles of the hip, and
• the saphenus nerve (L 1 to L 4), which innervates the skin and muscles of the thigh to the
navicular bone.
The segments of the lumbar plexus thus cover the entire ventromedial aspect of the leg.
Via collaterals in the sympathetic trunk, this supply territory receives impulses from the fol-
2 lowing organs of the upper abdomen: liver, spleen, pancreas, small intestine, and large in-
testine as far as the splenic flexure (› fig. 3.11).
From the point of view of acupuncture, this corresponds to the course of the liver, spleen, and stomach
meridians, all of which relate to the upper abdominal visceral organs.
The sacral plexus (L 5 to S 5)

This plexus supplies with its motor branches the following muscles (among others):
• piriform muscle
• gemellus muscles
• gluteus muscles
(see also appropriate anatomy books).
These muscles are derived from the myotomes (L 4), L 5, S 1, and S 2.
The largest branch of the sacral plexus is the sciatic nerve, which innervates the muscles in
the hip region and on the back of the leg.
Its terminal branches supply the dorsolateral aspect of the leg. Via collaterals in the sym-
pathetic trunk, the sacral plexus receives impulses from the pelvic organs (› fig. 3.11).
From the point of view of acupuncture, this corresponds to the course of the Bladder and the Kidney
meridians, which relate to the pelvic visceral organs.
The pudendal plexus and the coccygeal plexus are of secondary importance in this context.
Origins of the Peripheral Nerves of the Brachial and

Lumbosacral Plexuses
The classification of the muscles of the shoulder and pelvic girdles according to their innervation
by ventral or lateral (“dorsal”) nerve branches from the brachial or lumbosacral plexus, respec-
tively, was established by Paterson (1886) in mammals and is summarized in the following table.
Nerve Branches Innervated Structures

Brachial plexus
Ventral branches 2
Anterior thoracic nerve Pectoral muscles (Mm. pectorales)
Musculocutaneous nerve Pectoral muscles on the inside surface of the humerus,
skin of the outer and anterior surface of the forearm
Median and ulnar nerves Muscles and skin of the anterior surface of the inside of
the forearm and hand
Internal cutaneus nerve Skin of the inside and anterior surface of the upper arm
and the forearm
Lateral (“dorsal”) branches
Suprascapular nerve Muscles of the dorsal part of the shoulder
Short subscapular nerve M. subscapularis
Circumflex/axillary nerve Mm. deltoideus and teres minor
Skin of the dorsal and lateral sides of shoulder and arm
Medial subscapular nerve Mm. subscapularis and teres major
Musculospiral nerve Muscles of the dorsal side of the humerus, the forearm
and the hand
Skin of the dorsal side of the forearm and the hand
Long subscapular nerve M. latissmus dorsi
Lumbosacral plexus
Ventral branches
Crural nerve
Obturator nerve Muscles of the inner thigh, and knee flexor muscles
Internal popliteal nerve Skin and muscles of the posterior part of the leg, and sole
of the foot
Lateral (“dorsal”) branches
Anterior crural nerve Anterior muscles of the thigh and medial muscles of the
leg and foot
Superior gluteal nerve Mm. glutei medius and minimus, M. tensor fasciae latae
External popliteal nerve Muscles and skin of the lateral and anterior surfaces of
the leg and foot
Special Aspects of the Areas Innervated by the Ventral Branches

The cutaneous areas supplied by the ventral branches cover
• the ventrally located flexor muscles of the trunk and
• the flexor muscles of the upper and lower limbs.
In my opinion, the function common to all the ventral branches can be defined as a “protec-
tive flexion reflex”.
Sherrington demonstrated the flexion (bending) reflex triggered by a stimulus to have a
protective function for the organism. Such flexion reflexes can be elicited in all areas inner-
vated by the ventral branches. In contrast, extension (stretching) reflexes can be elicited in all
areas innervated by the lateral branches.
The most important flexion reflex is elicited on the sole of the foot, which is innervated by
the ventral branches. This flexion reflex protects the body from damage by causing the en-
dangered extremity to withdraw from the source of danger as quickly as possible. A person
who has just suffered an injury to the sole of the foot will pull his or her leg away immedi-
ately, or will fall over.
In case of affliction of a visceral organ, the same flexion reflex protects the body or the
trunk by drawing up the bent legs, e. g. in acute appendicitis.
Flexion is originally a life-saving reflex. If it can no longer be elicited, then one “stretches
out all fours”, and dies.
2 This example, too, shows that the branches of the spinal nerves – in this case the ventral
branches – serve a common function, i. e., flexion, and therefore protection.
• The life-saving “flexion function” of all ventral branches is also revealed in the upper
limbs while eating and inserting food into the mouth. This position and posture is char-
acteristic of the original embryonic flexed position of the upper limbs.
• The “flexion function” of all ventral branches is also revealed in the lower limbs, particu-
larly in the corresponding position of the legs during defecation and coitus.
In analogy to this protective flexion function of the regions supplied by the ventral branches, Chinese
medicine assigns the functions of “assimilation and transformation” to the hand and foot yangming.
Special Aspects of the Areas Innervated by the Lateral Branches

The lateral branches resemble offshoots of the ventral branches; they innervate the lateral
walls of the chest and abdomen. The regions of skin innervated by the lateral branches of the
spinal nerves make up
• a lateral longitudinal one-third on head and trunk,
• a dorsal and ulnar region of the upper limb covering the extensor muscles of the arm,
• a ventral and lateral region of the lower limb covering the extensor muscles of the leg.
Taken together, the regions innervated by the lateral branches form a lateral longitudinal one-third of
the body surface and correspond, in my analysis, to the shaoyang region (triple heater-gallbladder
meridians).
The common function of the lateral branches can also be defined, in my opinion, as an “ex-
tensor reflex for defense and fighting”, which also implies “stability” and “stamina” guar-
anteed by the activity of the extensor muscles of the upper and lower limbs.
It is noteworthy that the areas of skin innervated by the lateral branches cover precisely the
myotomes that are still in touch with original sympathetic neurons in the spinal cord (C 8
through L 3), i. e.
• on the arm, C 8 to T 2,
• on the leg, L 2 to L 3.
From the point of view of segmental anatomy, the “aggressive sympatheticotone triad” as-
signed to the extensor muscles – of aggressive movements, determination, and behavior en-
larging the apparent size – originates within the chain of original sympathetic neurons in the
spinal cord.
Put more simply, one might also say: The areas supplied by the lateral branches have direct
access to the sympathetic nervous system.
This mode of innervation and its close ties to the original sympathetic neurons of the spi-
nal cord also imply that in case of disease of visceral organs, referred pain will be perceived
only in the lateral skin areas covering the extensors of the limbs (› page 84).
Referred pain therefore cannot occur in the skin innervated by the ventral branches cov-
ering the flexor muscles of the limb.
For the same reason, referred pain may mitigate or even inhibit the aggressive sympa-
theticotone triad, but has no influence on the protective flexion reflexes.
In other words: Internal diseases irritate the extensor muscles, and may thus inhibit aggression and
attack movements.
Internal diseases do not irritate the flexor muscles, so that the protective reflexes remain intact.
Regarding the projection phenomena and interactions between the body surface and its in-
sides, the ventrolateral branches have another feature which is of great importance in the
theory of segmentation: They are related to the areas of projection of the viscera, namely,
Head's zones.
In the words of Hansen and Schliack, it is a “remarkable, but merely empirical fact, that
Head's zones of the endodermal derivatives are found only in the ventrolateral abdominal 2
wall.”
According to my analysis, the fact that Head's zones do not occur anywhere else but in the ventral and
lateral walls of the abdomen is not a “merely empirical fact”, but one that can be clearly explained from
the point of view of segmental anatomy and neurophysiology.
Nearly all depictions of embryological development are consistent in showing that

• the preganglionic white communicating branches originate in the trunk of a spinal nerve,
but
• the postganglionic gray communicating branches backtrack only to the ventral branch of
the respective spinal nerve.
In other words:
• All information from within the body and from its surface is transmitted along viscero-af-
ferent and somato-afferent fibers entering the posterior horn of the spinal cord and pass-
ing on their impulses to the lateral and anterior horns, and is connected to the sympathet-
ic trunk via the white communicating branches.
• Impulses travelling back along the gray communicating branches reach only the ventro-
lateral branch and never the dorsal branch.
Therefore, Head's zones and referred pain can be found only in the ventral and lateral walls of the trunk.
This fact explains why Head's zones of the endoderm-derived viscera (e. g., the respiratory
and digestive tracts, and the digestive glands) are found only in the ventrolateral parts of the
trunk.
It also explains why Head's zones, as areas of resonance for internal organs, are related to
the limbs, in particular the extensor muscles, since, as shown earlier, the limbs are derived
from the ventrolateral wall of the trunk.
Chinese acupuncture considers this by treating disorders of the respiratory and digestive tracts and the
digestive glands via acupuncture points located within the Head's zones and on the extremities.
In any case, acupuncture points located in the ventrolateral areas of innervation of the spinal
nerves are treated. Treatment is recommended as follows:
• on the lower limbs: for all hollow organs, the lower He/Sea points ST 36, GB 34, ST 37,
ST 39,
• on the upper and lower limbs: the Yuan/Source points for all mesenchymal organs.
In addition, of course, acupuncture points located in Head's zones on the trunk are treated.
This example also illustrates that the choice of points in acupuncture follows the “guidelines” laid out
by the spinal nerves and the sympathetic nervous system.
Implications for Practical Application

The ventrolateral branches have another special feature regarding interactions and projec-
tion phenomena which is highly important for practical application:
The ventral and lateral regions of the head and trunk have a particularly close relationship
to the limbs, since the latter, being derived from the ventrolateral abdominal wall, are inner-
vated only by the ventrolateral branches of the spinal nerves. On the limbs, the ventrolateral
branches of the spinal nerves separate into
• ventral branches supplying the limbs, and
• lateral (“dorsal”) branches supplying the limbs.
2 (These “dorsal” branches innervating the extremities have nothing to do with the dorsal
branches on the back! It would therefore be preferable to refer to them only as lateral branches.)
During embryonic development, the cervically innervated muscles of the limbs “migrate”
or grow back toward the trunk, ending up between the thoracically innervated integument
and the thoracically innervated deep muscles of the trunk.
These interjected muscles with cervical innervation have a characteristic arrangement
(› fig. 5.2):
The muscles position themselves along the wall of the trunk, strictly in accordance with the
atavistic construction principle of the spinal nerves, in the same way as they are positioned
on the limbs.
• The ventrally located flexor muscles shift towards the ventral wall of the thoracic cage.
• The dorsally located extensor muscles shift towards the dorsolateral wall of the trunk.
Both retain their flexion and extension functions in their new locations.
The more cranially located ventrally into the upper half dorsally into the upper half
myotomes C 5|C 6 migrate of the pectoral muscle, and of the back muscles
even further upwards, where (Mm. rhomboideus, supra-
they develop spinatus, and teres)
The more caudally located ventrally into the lower half dorsally into the lower half
myotomes C 7|C 8|T 1 settle of the pectoral muscle, and of the back muscles (caudal
in the caudal regions, where portions of the serratus ante-
they develop rior and latissimus dorsi
muscles)
This has profound implications for therapy:

• Pain in the anterior wall of the thorax requires additional points in the flexor region of
the arm.
• Pain in the region of the back requires additional points in the extensor region of the arm.
Of course, the reverse is also true for pain in the arms:
• Pain located in the ventral region of the arm requires additional points on the anterior
chest.
• Pain located in the dorsal region of the arm requires additional points on the back.
From the point of view of acupuncture, this means that:
• Pain in the ventrolateral walls of the chest and abdomen requires therapy reinforced by
acupuncture points in the region of the flexors (e. g., PC 6, HT 7, LU 9).
• Pain in the back region, i. e., in the region of the muscles that have shifted back from the
extremities to the trunk, requires therapy reinforced by acupuncture points in the region
of the dorsal extensor muscles of the arm (TH 5, SI 3).
The ventrally located flexor muscles of the limbs are therefore connected with the ventrally located
flexor muscles of the trunk.
The dorsally located extensor muscles of the limbs are therefore connected with the dorsally located
extensor muscles of the trunk.
2.5 The Preaxial and Postaxial Lines, Basis of the Meridian “Lines” 71
2.5 The Preaxial and Postaxial Lines,

Basis of the Meridian “Lines”
The dorsal and volar areas of the upper extremity are separated by the so-called pre- and
postaxial lines (› fig. 2.23).
In the embryonic position of the arms,
• the preaxial line runs along the radial side and more cranially, and
• the postaxial line runs on the ulnar side and more caudally.
On the lower extremity, the pathways of the pre- und postaxial lines are somewhat different, 2
due to rotation during the embryonic period (› fig. 2.24):
• the preaxial line runs along the tibial side from the medial side of the foot, the tibia, the
medial condyle of the femur, and the sartorius muscle to the inguinal region.
• The postaxial line runs along the fibular side from the lateral side of the foot to the later-
al malleolus, the head of the fibula and across the lateral and posterior surface of the thigh
to the coccyx.
Between these lines, there are
• on the posterior side of the leg a narrow strip of integument and muscle innervated by
the ventral branches
• on the anterior side of the leg a wider strip of integument and muscle innervated by the
lateral branches.
These pre- and postaxial lines of the upper and lower extremities correspond, at the level of
the deep compartment and at the border of the innervation by the ventral and lateral branch-
es, to the connective tissue space traversed by the nerve-vessel bundle.
Fig. 2.23 Arrangement of the dermatomes in the “embryonic position” displaying the strictly metameric,
cranio-caudal sequence of the segments (after Langmann; › fig. 4.6). The anlages of the thumb and big toe
are pointed upward.
According to my analysis, the pre- and postaxial lines, together with the deeper lying nerve-vessel
bundle (jingluo), correspond to the radial or ulnar, or tibial or fibular meridian “lines” on the skin of
the extremities.
Thus it is possible to define these meridian “lines” as the borderlines of metameric spinal
innervation between
• the ventral and dorsal branches on the extremities and
• the ventral, lateral, and dorsal branches on the trunk (› fig. 2.25).
Fig. 2.24 Preaxial and postaxial lines on the upper and lower extremities, ventral and dorsal aspects (Pansini, quoted by van Rynberk).
Upper extremity: The preaxial lines (radial side) are denoted by a und b, respectively. The postaxial lines (ulnar side) are denoted by a' und b', respectively.
Lower extremity: The preaxial lines (tibial side) are denoted by c and d, respectively. The postaxial lines (fibular side) are denoted by c' and d', respectively.
2.5 The Preaxial and Postaxial Lines, Basis of the Meridian “Lines” 73
The meridian region between these borderlines corresponds to the region innervated by the
corresponding spinal nerve branches.
Fig. 2.25 Metameric spinal nerves: The borderlines separating ventral (yellow) from lateral (green) branches on the extremities and the ventral,
lateral and dorsal (red) branches on the trunk. Ventral and dorsal aspects: A way of interpreting the long yang meridian “lines”.

CHAPTER
The Role of the Peripheral
3 Autonomic Nervous System

in Segmental Theory
In our sensory perception, not only the spinal nervous system, but also the autonomic ner-
vous system plays an important role.
For any stimulation or pain therapy – such as acupuncture, neural or manual therapy –
that proceeds from the body surface to treat distant regions and visceral organs, the role of
the autonomic nervous system and its areas of innervation is an eminently important one.
Therefore, in order to understand the interactions and projection phenomena, a knowl-
edge of the origin, course, and peripheral areas of innervation of the autonomic nervous sys-
tem is essential.
This knowledge helps the therapist
• to locate the site of pain and thus the site of the stimulus;
• to interprete the type of pain and thus the type of stimulus; ;
• to conclude from the intensity of the pain to the intensity of the stimulus. ;
This basic rule was designated by us (König, Wancura 1975) as the ground rule of acupunc-
ture. I am pleased that all German-language acupuncture societies have adopted it as a fun-
damental rule in their training programs.
The autonomic nervous system, particularly the sympathetic trunk, also influences our
unconscious facial expressions and posture and transforms movements into gestures, thus
modifying, in my opinion, the spinal metamerism into a Gestaltkreis determined by psycho-
somatic and social factors.
For the development of symptoms on the surface of the body such as pain and autonomic
reflexive signs of disease, the autonomic nervous system, especially the sympathetic trunk, is
of immense importance.
From this point of view, the autonomic nervous system shall be discussed in the following
chapter.
76 3 The Role of the Peripheral Autonomic Nervous System in Segmental Theory
Fig. 3.1a Autonomic nervous system: Sympathetic trunk with its ganglia and origin in the spinal cord from the
1st thoracic to the 3rd lumbar segment. Preganglionic fibers are indicated as solid lines, postganglionic fibers as
dotted lines. (Modified after Villinger)
3 The Role of the Peripheral Autonomic Nervous System in Segmental Theory The Role of the Peripheral Autonomic Nervous System in Segmental Theory 77
Ggl. ciliare
M. sphincter pupilae
M. ciliaris
Ggl. sphenopalat.
Ggl. lacrimal.
Ggl. otic.
Gld. parotis
Chorda
Ggl. submaxill.
Ggl. sublingual.
Gld. submaxill. 3
Heart
Bronchi
Stomach
Intestine
Liver
Pancreas
Kidneys
Plex. hypogastric.
Rectum
Bladder
N. erigens s.pelvicus
Genitalia
Fig. 3.1b Autonomic nervous system: Parasympathetic preganglionic fibers are indicated as solid lines, post-
ganglionic fibers as dotted lines. (Modified after Villinger)
3.1 Anatomy
Anatomically, the central efferent portion of the autonomic nervous system can be divided
into
• a cranial,
• a thoraco-lumbar, and
• a sacral portion (› fig. 3.1).
The preganglionic neurons of the cranial portion are parasympathetic in nature
(› fig. 3.1b, purple). They originate in the diencephalon, the mesencephalon, and the me-
dulla oblongata, and form the vagal nerve. The vagal nerve supplies the visceral organs to the
splenic flexure of the colon (Cannon’s point).
The preganglionic neurons of the thoraco-lumbar portion are sympathetic in nature
(› fig. 3.1a, red). They originate in the spinal cord segments C 8 through L 3, pass to the
3 ganglia in the sympathetic trunk, then to the peripheral large sympathetic ganglia, the pe-
ripheral nerves, and the integument.
The preganglionic neurons of the sacral portion are parasympathetic in nature
(› fig. 3.1b, purple). They emerge with the 2nd, 3rd, and 4th sacral nerves, and form the pelvic
nerves.
The autonomic nervous system is also known as the visceral or – in German-speaking coun-
tries – as the vegetative nervous system. The word “vegetative” certainly would seem more
appropriate, because its original meaning – “belonging or pertaining to plants” – expresses a
relationship to the basic vital functions, e. g. metabolism, reproduction, respiration, assimila-
tion and dissimilation, which are already evident in plants.
The term “autonomic nervous system” is less accurate, since the sympathetic nervous sys-
tem is by no means “autonomic”, or independent, from the spinal nervous system.*
The distinction between sympathetic and parasympathetic neurons regarding their projec-
tion phenomena is important for two reasons:
• The sympathetic fibers cause algetic and autonomic reflexive symptoms on the surface of
the body.
• The vagal and/or parasympathetic fibers cause only algetic symptoms.
The vagal and parasympathetic neurons cause no concomitant autonomic cutaneous symp-
toms because they lack nerve endings in the integument.
* Despite this, the term “autonomic nervous system” is used in the following text simply because it is firmly
established (translator's comment).
3.2 The Peripheral Sympathetic Nervous System and Its Role in Segmental Theory 79
3.2 The Peripheral Sympathetic Nervous System

and Its Role in Segmental Theory
The center of the sympathetic nervous system is the sympathetic trunk, which is connected to
various parts of the body, i. e.
• by the white communicating branches to the spinal nerves, and through them to the spi-
nal cord;
• by the gray communicating branches to various areas of the body surface.
Spinal ganglion
3
Ramus
communicans
griseus
Ramus
communicans
albus
Fig. 3.2 The spinal nerve and the communicating branches, schematically.
An understanding of the interactions and projection phenomena requires the following

background:
• Knowledge of the origin of the sympathetic nervous system in the spinal cord (› page
81)
• Its ”supplemental role“ in the nerve supply to the head and limbs (› page 85)
• Knowledge of the efferent sympathetic pathways (› page 89):
– Efferent pathways from the spinal cord to the body surface:
– the effects of sympathetic innervation of the skin
– the autonomic reflexive symptoms of disease
– the individual's perception of illness.
– Efferent pathways from the spinal cord to the visceral organs:
(of secondary importance from the viewpoint of segmental theory)
• Knowledge of the afferent sympathetic pathways (› page 113):
– Afferent pathways from the visceral organs to the spinal cord:
3 the “enterotome”, the connection of each visceral organ to its segment.
– Afferent pathways from the body surface to the spinal cord:
the afferent collateral pain pathway
• Knowledge of the large sympathetic ganglia and their projections to the integument
(› page 120).
3.2.1 The Origin of the Sympathetic Nervous System
The cells from which the sympathetic nervous system arises are located in the lateral horn of
the spinal cord in the segments C 8 through L 3.*
Because this location has far-reaching implications for the innervation of the head and
extremities, and beyond this is significant in evolutionary biology, I should like to dwell on it
briefly.
All information that reaches the posterior horn by way of somato-sensory neurons, i. e.,
from the body surface, and by way of viscero-sensory neurons, i. e., from within the body,
also reaches the nuclei that give rise to the sympathetic nervous system.
The sympathetic nervous system is therefore already aware at its point of origin about
what is happening in its segment, both on the surface and within the body.
It distributes and disseminates this information from within the body far and wide to the
body surface, since each preganglionic neuron can transmit information to about twenty
postganglionic neurons.
The region of origin of the sympathetic nervous system in all vertebrates is restricted to the
part of the spinal cord between the brachial plexus and the lumbosacral plexus, no matter
how many segments the individual species may have (Braus and Elze; › fig. 3.3).
* Some authors describe the region of origin of the sympathetic nervous system as extending to L 4.
Oculomotor nucleus
(small-columnar)
Nucleus salivatorius
Nucleus dorsalis vagi
3
Plexus brachialis
Cell line of segmental

autonomic nerve fibers
Sympathetic
cell line
Plexus lumbalis
Fig. 3.3 Region of origin of the sympa-

thetic nervous system in the spinal cord
(red): In all vertebrates, it is located
above the brachial plexus and below the Sacral parasympathetic
nucleus
lumbar plexus. (Modified after Braus
and Elze)
Thus, the sympathetic nervous system originates

• in the human from C 8 to L 3,
• in the cat from T 1 to L 4,
• in the chicken from C 16 to L 3.
3.2.2 Sympathetic Innervation of the Limbs
The crucial fact is that in all vertebrates the following nerves contain sympathetic neurons.
• the last and next-to-last segmental nerves of the brachial plexus and
• the first and second segmental nerves of the lumbosacral plexus.
Braus and Elze describe this as an unexplained fact. In my opinion, this “unexplained fact”
might have some significance in evolutionary biology.
Since the nerves of the brachial and lumbosacral plexuses that pass adjacent to the origin
of the sympathetic nervous system still carry sympathetic neurons, they have a sort of “hot
line” to the sympathetic system.
These segmental nerves supply the extensors of the upper and lower limbs, respectively.
Thus, the extensor muscles of the upper and lower limbs also have a “hot line” to sympa-
thetic impulses.
The Extensor Muscles of the Upper Limb

In humans, the cranially located nuclei of the sympathetic neurons (C 8 to T 1) are related to
the extensor muscles of the arm and the deep muscles of the hand.
When, in certain situations, the arm is extended at the elbow, a fist is clenched, or the deep
muscles of the hand spread the fingers, this may be the result of direct sympathetic signals. It
is not difficult to recognize these gestures as part of the basic position of the upper extremity
in attack and defense, and thus as gestures of aggression – or of enthusiasm.
The Extensor Muscles of the Lower Limb

In humans, the sympathetic neurons of the caudally located nuclei (L 2 and L 3) are related
to the extensor muscles of the leg.
When in a particular situation the leg is extended at the knee joint and rotated somewhat
toward the outside, the result is an “erect, straddle-legged” position. This too may be a direct
signal from the sympathetic system that a man “stands his ground”. Furthermore, “to tread
3 on”, to kick, and “to rise up” are functions of the extensor muscles, and thus a gesture of ag-
gression or threat, but also of enthusiasm.
The Flexor Muscles of the Upper Limb

The flexor muscles of the upper extremity cause bending at the elbow joint and rotation to-
ward the midline, an archaic movement that leads the hand to the mouth, i. e., a protective
gesture with which one “takes something to heart”, but never to attack or fight.
The Flexor Muscles of the Lower Limb

The flexor muscles of the lower extremity cause bending at the knee, and thus “weak knees”,
“buckling knees”, or “falling to one's knees”, a position from which one could never attack or
fight.
In simple terms one might say: The flexor muscles of the limbs do not have a “hot line” to the sympa-
thetic system, as do the extensor muscles, and resemble a sort of combat objector.
3.2.3 Sympathetic Effects on the Dilator Pupillae Muscle and

on the Effector Organs of the Integument
Furthermore it is interesting that in all vertebrates, the dilator pupillae muscle is innervated
by the same first spinal cord segment to contain sympathetic nuclei (› fig. 3.4):
• in the human the 8th,
• in the cat the 9th,
• in the chicken the 16th,
• in the frog the 3rd spinal cord segment.
Thus, the sympatheticotonic, aggressive fighting and defense posture described above is fur-
ther emphasized by the corresponding position of the extremities and the simultaneous acti-
vation of the sympathetic innervation of the dilator pupillae muscle.
The dilator pupillae muscle causes the eye to appear large, terrifying, and threatening, but
also frightened and startled. The enlarged pupil, widened palpebral fissure, and increased
flow of tears come from sympathetic stimulation that, together with the clenched fist, the
outstretched arm, and the typical leg posture, as well as the autonomic reflexive signs, are
part of the “segmental aggressive triad”.
The effect is enhanced by the fact that sympathetic innervation of the erector muscles of
the hairs cause the hairs to stand on end, thus enlarging the surface of the body.
Fig. 3.4 Innervation of the dilator pupillae muscle in all vertebrates by the respectively highest segment of the
spinal cord to contain sympathetic nuclei, e. g., in man C 8, in the frog C 3, in the chicken C 16.
In evolutionary biology, this signifies power and superiority, anger, and readiness to fight.
The middle high German word “bho”* (böse, evil) means both large and evil, pointing to
these sympathetic relationships in our hereditary structure (› page 162).
Enlargement of the body surface is therefore part of the repertoire of threatening signals
and posturing to appear impressive which characterizes the nonverbal body language of all
vertebrates.
The “sym-pathetic” system (from “to feel with”, “to be com-passionate”) may thus also be
regarded as a social communicator, transmuting movements into gestures, connecting the
external bearing to the internal attitude, and thus “speaking” non-verbally.
Because this vertebrate language is understood by all vertebrates and by human beings,
we can use it to attune ourselves and to empathize with others, to act and react reflexively,
spontaneously, and without conscious cerebral reflection. Therefore, from the viewpoint of
evolutionary biology, the sympathetic system resembles the part of the nervous system which
enables individual survival and thus also social survival of the group, by creating the neces-
sary gestures as prerequisites.
3.2.4 On the Dimensions of the Sympathetic Nuclei
The rates of longitudinal growth of the spinal cord and the vertebral column are quite differ-
ent, with the result that the spinal cord is much shorter than the vertebral column.
* cf. English “boo!” as a playful expression to induce fright; translator's comment.

Since the sympathetic nuclei in the spinal cord occur only in the segments C 8 to L 3,
this portion of the spinal cord is even shorter.
If one imagines the portion containing the sympathetic nuclei as projected onto the ante-
rior chest wall, the projection would cover roughly the region between the jugular notch
and the xiphoid process of the sternum.
Further pursuing this line of reasoning, the projection onto the back of the sternum would
represent, as Goethe put it, the “two souls that dwell within our breast”, namely, the con-
scious and the unconscious.
Since the sympathetic system, representing our unconscious nature, consists only of the
segments C 8 to L 3, it would correspond to a headless homunculus with thin little arms (ul-
nar arm region, C 8 to T 1) and thin little legs (L 2 to L 3).
This tiny “autonomic sympathetic dwarf” would lie behind the sternum, from where it
would direct our unconscious, supra-individual, autonomic facial expressions and our earth-
bound instincts.
3 This would make it the center of our vertebrate language, which – without being influ-
enced by the conscious self – is understood by all vertebrate animals. It would also be the
social communicator that triggers the ritualized behavior which enables our social coexis-
tence.
3.2.5 Evolutionary Importance
For several reasons, the fact that the extensor muscles of the upper and lower limbs have a “hot
line” to the sympathetic system is significant from the point of view of evolutionary biology:
Referred pain, i. e., pain transmitted from a diseased visceral organ to the surface of the
body, can occur only in the regions corresponding to the spinal cord segments containing
sympathetic nuclei.
For individual survival, this means that:
• on the extensor muscles of the limbs, referred pain and muscular tension may occur,
causing the extensor muscles to “fail” and rendering fighting or aggressive action difficult
or impossible;
• the flexor muscles of the limbs, i. e., the “non-combatants”, are never affected by re-
ferred pain, because their spinal cord segments lack the sympathetic visceral afferent neu-
rons that would be needed to stimulate them, i. e., they “cannot fail”.
However, this means that “bending the knees”, i. e., the life-preserving flexion reflex, remains
intact and cannot be offset by visceral disease, as is the case with the extensor muscles.
As long as we can “bend”, we are alive; when we can no longer bend, then we “stretch out
all fours and die”. In other words, “flexibility is a characteristic of life”.
From the point of view of behavioral science, the flexion reflex, which causes the “infantile
position” in all vertebrates, leads to a submissive posture (turning onto the back, baring the
belly) that in a social group serves to inhibit aggression in an attacker.
The flexion reflex or submissive posture is detached from sympatheticotonic gestures, and
in social groups leads to an inhibition of aggression and thus to survival of the individual.
This example once more illustrates that from the point of view of evolutionary biology, our
unconscious autonomic facial expressions and gestures are the counterparts of our emotions
and affects.
In any case, the forced social reaction of members of a group may be termed “morally analogous” in
a sense of “good” and “caring”, because they protect the underdog, the one who has already yielded
(Eibl-Eibesfeldt).
3.2.6 Sympathetic Nerve Supply to the Head, Neck, and Limbs
The anatomic fact that the nuclei of the sympathetic trunk in the spinal cord are restricted to
the segments C 8 to L 3* has far-reaching and important consequences, not only for analysis of
acupuncture, but also for any kind of stimulation therapy that proceeds from the body surface.
The restriction to the spinal cord segments C 8 to L 3 implies that all segmental parts of the
body located above or below these segments have to draw their sympathetic nerve supply
from these nuclei in C 8 to L 3 (Hansen and Schliack, Monnier; › figs. 3.5, 3.6):
Supplied by In the figure

Head and neck C 8 to T 3 Green
Arms T3 to T 7 Red
Legs T 10 to L 3 Blue 3
Viscerogenic Irritation Signs on the Limbs
The sympathetic nerve supply to the head, arms, and legs results in the fact that
• pathological impulses from the thoracic organs are conducted to the arms, and
• pathological impulses from the abdominal and pelvic organs are conducted to the legs.
Such diffuse autonomic irritations on the arms (caused by the thoracic organs) and on the
legs (caused by the abdominal and pelvic organs) are also referred to as viscerogenic irrita-
tion signs on the limbs (Hansen and Schliack).
The sympathetic system thus defines areas on the trunk and limbs as its own territory,
which it marks with autonomic reflexive signs.
These autonomic reflexive cutaneous signs are the first evidence of visceral disease, appearing long
before pain or clinically evident changes in the organ itself. For this reason, such autonomic reflexive
signs of disease are particularly important in preventive medicine, representing an early warning system
(› page 251 for details).
* Some authors describe the region of origin of the sympathetic nervous system as extending to L 4.
Fig. 3.5 Schematic drawing of the autonomic nerve supply: “co-supply” of head, neck, and limbs from the
sympathetic system. Head and neck co-supplied by C 8 through T 3 (green), arms co-supplied by T 3 through
T 7 (red), legs co-supplied by T 10 through L 2 (L 3) (blue).
Organ Preganglionic Postganglionic

Upper limbs T 2–T 7 Gangl. stellatum Vasoconstriction
Gangl. thorac. sup. Sudation
Piloerection
Trunk: Skin, vasomotion, T 1–L 2 Sympathetic trunk Constriction, piloe-
pilomotor reaction, sweat rection, secretion
glands
Trunk: Heart T 1–T 4 Gangl. cervic. Tachycardia
Gangl. thorac. Dilation of coronary artery (?)
Trunk: Lung T 2–T 8 Gangl. cervic. inf. Bronchodilation, vaso-
constriction (dilation?) 3
Abdomen: Cardia T 5–T 6 id. Contraction
Abdomen: Stomach T 6–T 9 Plexus coeliacus Inhibition of peristalsis
+ secretion
Vasoconstriction
Abdomen: Liver T 6–T 9 Plexus coeliacus Vasoconstriction
Abdomen: Pancreas T 6–T 10 id. Vasoconstriction ±
secretion
Abdomen: Intestine T 9–T 10 Plexus coeliacus Inhibition of peristalsis
+ secretion
Vasoconstriction
Abdomen: Colon T 12–L 1 Gangl. mesent. sup. Inhibition of peristalsis
(proximal) + secretion
Vasoconstriction
Abdomen: Kidney T 12–L 1 Plexus coeliacus Vasoconstriction
Gangl. renale Inhibition of secretion
Abdomen: Adrenal gland T 10–L 1 Secretion
Pelvis: Colon (distal), L 1–L 2 Gangl. mesent. inf. Inhibition of peristal-
rectum sis
Plexus hypogast. inf. Contraction of anal sphincter
Pelvis: Bladder T 12–L 1/2 Plexus hypogast. inf. Inhibition of M. vesicae
Contraction of internal
sphincter
Pelvis: Genitalia Contraction of prostate
gland and of seminal
vesicles
Pelvis: Uterus T 12–L 1/2 Plexus hypogast. Intrapartal contraction
Lower limbs T 10–L 2 Sympathetic trunk Vasoconstriction, sudati-
(lumbar, sacral) on, piloerection
Fig. 3.6 Table of efferent sympathetic innervation (from M. Monnier; other authors give somewhat differing data).
Viscerogenic Projections to the Head and Neck
By collateral nerves in the spinal cord or in the sympathetic trunk, disorders of all visceral
organs may be conducted to the cilio-spinal center in the spinal cord.
This center is a thickened part of the spinal cord segments C 8 through T 2|T 3.
From here, the head and throat, neck and shoulders receive their sympathetic innervation.
Stimuli from all visceral organs can therefore use this pathway to reach the head, throat,
neck, and shoulders.
The efferent sympathetic neurons from C 8 through T 2|T 3 are related to the sympatheti-
cally innervated dilator pupillae muscle, the smooth muscles of the eye socket, the region
supplied by the trigeminal nerve, and the skin of the head, throat, neck, and shoulders.
Experimental stimuli elicit sweating and piloerection in this region, as well as reactions of
the eye. This explains how, at the start of an illness, increased sweating, erection of the hairs,
a shivering sensation, and increased sensitivity to cold may occur in the face, on the neck,
3 and on the skin of the shoulders as early warning signs long before the disease of visceral or-
gans becomes apparent.
Dilation of the pupil in the eye that is homolateral to the diseased organ is an important early sign of
internal disease.
3.2.7 The Efferent Sympathetic Nerves
The efferent sympathetic nerves are responsible for changes in the skin and for the subjective
perception of the signs of disease or symptoms. They elicit changes in circumscribed areas of
the body surface – especially in the skin – which are referred to as autonomic reflexive signs
of disease.
A distinction is made between:
• neurons that exit the spinal cord through the anterior root, and
• neurons that exit the spinal cord through the posterior root.
Sympathetic Neurons Exiting the Spinal Cord

Through the Anterior Root
Anatomy 3
These neurons enter the paravertebral ganglia of the sympathetic trunk as white communi-
cating branches (› fig. 3.7).
This pathway is known as the preganglionic neuron.
In the sympathetic trunk the neurons are relayed, coming into contact with at least seven
sympathetic trunk ganglia; in this way they disperse and distribute their information.
This makes it possible to elicit autonomic reflexive changes in a large area by the stimula-
tion of a single neuron in the anterior root (experimentally verified several times over).
The neurons in the sympathetic trunk pass
• partly to the viscera, traversing the sympathetic trunk without synapsing; synapsis does
not occur until they reach the large sympathetic ganglia (celiac ganglion, among others),
or the wall of a visceral organ
• partly as relayed, synapsed postganglionic “viscero-somato-motor” sympathetic fibers
within the peripheral nerves and the sympathetic network of the blood vessels to the pe-
riphery.
Classification of the Neurons
The autonomic neurons transmitting impulses from visceral organs to the periphery are
termed viscero-motor neurons, because they leave the spinal cord by way of the motoric
anterior root on their way to the integument, i. e., to
• the vaso-motor,
• the pilomotor, and
• the sudo-motor effector organs.
In case of disease they elicit autonomic reflexive signs in the integument, which consist of
• constriction of the blood vessels,
• erection of the hairs, and
• increased sweat secretion (› page 105)
The patient experiences this subjectively as cold sweat and goose bumps. Such autonomic
signs may affect an entire quadrant of the body, since collateral connections in the sympa-
3 thetic trunk are spread over a wide area.
Each area of skin that corresponds to a spinal cord segment with its sympathetic nuclei is
referred to as an “autonomic dermatome”.
Some authors refer to this part of the integument as a “motoric dermatome” because the
neurons exit the spinal cord through the motoric anterior root.
Furthermore, the autonomic neurons that transmit impulses from the visceral organs to
the periphery also may be referred to as somato-motor neurons. They carry impulses to the
muscles of the body surface, where, for instance, they lead to tonic contractions of the ab-
dominal wall.
Spinal cord
Rad. dors.
Spinal ganglion
Ram. dors.
N. spin.
R.com.
albus
Ram. com.
gris.
R. ventr. Prevertebral ganglion

Spinal co cord
rd Spinal
Ganglion trunci
sympathici 3
Ram. interganglion
Ram. visc. Skin
Ram. visc.
Truncus sympathicus Gut
Fig. 3.7 Diagram of the pathways of the sympathetic neurons (modified after Waldeyer).
Left side: Synapsis of the preganglionic neurons (solid red lines) in the sympathetic ganglia to the postgangli-
onic neurons (dashed red lines); further conduction to the periphery along the dorsal and ventrolateral branches.
Middle: “Transiting nerves”, e. g., the splanchnic nerve to the prevertebral ganglion (solid red lines), e. g., the
celiac ganglion. Here, synapsis to the postganglionic fibers (dashed red line) and further conduction to internal
organs, e. g., the intestines, occur.
Right side: Viscero-cutaneous (= viscero-sensory) reflex arc from an internal organ, e. g., along the splanchnic
nerve (solid blue line) to the posterior horn, then to the anterior horn, and finally as preganglionic fibers (solid
red lines) to the sympathetic trunk with synapsis to postganglionic fibers (dashed red line) and further transmis-
sion to the periphery through the dorsal and ventrolateral branches.
Relationship of Spinal Cord Segments to the Effector Organs in the

Integument
Efferent Sympathetic Nerve Fibers in the Ante

(according to O. Foerster in Foerster & Bum
and the corresponding segmental derm
Orbital Trigemi- Arm
Anterior M. dilatator
smooth nal nerve
roots pupillae
muscles supply C2 C3 C4 C5 C6 C7 C8 T1 T2 T3 T4
C2 × × + O+ O+ O+
1 ×× ×× O+ O+ O+ O+
2 × × O+ O+ O+ O+
3 O O O O O+ O+ O+ O+ O+ O+ O+
– – – – – – –
3
4 O+ O+ O+ O+ O+ O+ O+ O+
– – – – – – –
5 O+ O+ O+ O+ O+ O+ O+ O
– – – – – – –
6 O+ O+ O+ O+ O+ O+ O+ O
– – – – – – –
7 O O O O O O O O
8
10
11
12
L1
L2
L3 Similar to L 2 with individual variations

Orbital Trigemi--
M. dilatator
smooth nal nerve C2 C3 C4 C5 C6 C7 C8 T1 T2 T3 T4
pupillae
muscles supply
O Sudation + Piloerection – Vas
Fig. 3.8 Relationship between spinal cord segments and their anterior roots, and the effector organs in the corresponding dermatomes, as shown by ex-
perimental stimulation (table from “Handbuch der Neurologie” by Foerster and Bumke).
Anterior Roots of Human Spinal Nerves – as far as known

Bumke: Handbuch der Neurologie, Vol. 5)
dermatomes as their target organs in the skin.
Leg
T4 T5 T6 T7 T8 T9 T10 T11 T12 L1 L2 L3 L4 L5 S1 S2 S3 S4 S5

C2
1
3
O+ O– O+ 4
O O O O O O 5
O O O O O O 6
O O O O O O 7
O O O O O O O 8
O O O O O O O O 9
+ – O+ O+ O+ O+ O+ O+ O+ O+ O+ O– O+ 10
– – – – – – –
O O O O O+ O– O+ O– O+ O+ O+ O O O 11
– – – – – – –
O+ O+ O+ O+ O– O+ O– O+ O+ O+ O+ O+ O+ 12
– – – – – – –
O O O+ O+ O+ O– O+ O+ O+ O+ O+ O+ L1
– – – – – – –
O+ O+ O+ O+ O– O+ O+ O+ O+ O+ O+ L2
– – – – – – –
L3
T4 T5 T6 T7 T8 T9 T10 T11 T12 L1 L2 L3 L4 L5 S1 S2 S3 S4 S5
– Vasoconstriction
The table by Foerster and Bumke from the “Handbuch der Neurologie” (› fig. 3.8) shows
the relationship between the spinal cord segments and their anterior roots, and the effector
organs in the corresponding dermatomes, as demonstrated in stimulation experiments.
Figure 3.9 is a graphic version of the same table after Braus and Elze. The two versions cor-
respond to each other.
It shows the regions supplied by all postganglionic neurons that can be stimulated by pre-
ganglionic neurons of the segmental nerves:
• C 8 to T 3,
• T 3 to T 7,
• T 10 to L 3.
In order to understand the location and dimension of the autonomic reflexive signs of disease,
it is necessary to understand these interrelationships, as illustrated in the following example:
3 The Ganglionic Chain of the Sympathetic Trunk

As already described, the sympathetic trunk contains extensive collaterals, which can spread
to up to seven ganglia. This enables the diffusion of sympathetic impulses.
For example:
The preganglionic neurons from the spinal cord segment T 10 are connected to the sympa-
thetic ganglia T 5 through S 2.
Therefore, irritation of the spinal cord segment T 10 may lead to autonomic reflexive signs
anywhere from T 5 (level of the mammilla) to S 2 (posterior surface of the leg).
Irritation of the spinal cord segment T 10 may occur when any organs connected to the
spinal cord segment T 10 become diseased.
Therefore, disease of abdominal and pelvic organs can transmit pathological impulses to
the segments of the body surface from the level of the mammillae (T 5) to the posterior sur-
face of the legs (S 2).
Fig. 3.9 Graphic depiction of the Foer-

ster-Bumke table using the example of
experimental irritation of the sympa-
thetic-efferent neurons of the anterior
root of T 10: Due to the numerous col-
laterals of the sympathetic trunk, auto-
nomic reflexive signs occur in the T 5
region caudally to the mammilla and
throughout the leg S 2 (S 3); in the fig-
ure in the right lower quadrant of the
body. This corresponds to the clinical
situation in case of upper abdominal
visceral disease. (From Braus and Elze)
Conduction of Efferent Sympathetic Impulses to the Trunk
The graphic depiction from Braus and Elze (› fig. 3.9), illustrating the areas innervated by
postganglionic neurons, also shows that the autonomic areas of the body surface – i. e., the
“autonomic resonance zones” in the integument – overlap considerably and may occupy an
entire quarter of the body (› chapter 9):
• The autonomic regions overlap, but
• the algetic areas do not overlap.
The illustration also shows especially the area of the upper abdomen to contain areas of auto-
nomic resonance in which impulses from the viscera in the upper abdomen, the pelvis, and
the thorax overlap.
The well-known acupuncture point CV 12 is located in this region. From the viewpoint of
Chinese acupuncture, it is a point with influence on the organs of the thorax, the upper abdo-
men, and the pelvis, and the most important point of the parenchymal organs (yin organs). A
3 conceivable explanation for this is that this point is located in the overlapping autonomic re-
flexive regions of the thoracic, abdominal, and pelvic organs.
Since the point CV 12 also lies in the ventral midline where the sympathetic and spinal
resonance areas of the left and the right sides meet, it can be significant for the viscera of both
the left and the right sides.
All acupuncture points in the ventral midline (Conception Vessel, or CV) therefore influ-
ence the organs on both the left and right sides.
The same is true of the dorsal midline (Governing Vessel, or GV).
The points of the ventral and dorsal midlines presumably have such widespread effects because here
the cranial and caudal autonomic projection areas overlap, as do the projection areas of the spinal
nerves from the left and right sides.
Conduction of Sympathetic Efferent Impulses to the Limbs
According to Monnier, the sympathetic efferent signals are conducted along the sympathetic
trunk in a “track-like” manner to the limbs. This assertion by Monnier partially contradicts
Hansen and Schliack, who assume a “diffuse” conduction of autonomic signals to the limbs
(› fig. 3.10).
This apparent contradiction can be resolved in the sense that although “the entire arm and
the entire leg are viscerogenically sensitized”, this sensitization affects mainly certain areas:
in disorders of the respiratory predominantly the radial half of the arm (› fig. 10.2)
tract
in disorders of the heart predominantly the ulnar half of the arm (› fig. 10.1)
in disorders of the abdominal predominantly the ventral part of the leg
organs (› figs. 10.3, 10.4, 10.5) 3
in disorders of the pelvic organs predominantly the dorsal part of the leg (› fig. 10.7)
This shall be explained in detail in the following paragraphs. The sympathetic fibers
(› fig. 3.10) starting with
• the 7th ganglion of the sympathetic trunk, are all directed cranially;
• the 10th ganglion of the sympathetic trunk, are all directed caudally.
The sympathetic ganglia of T 8 und T 9 are projected only to the abdominal wall.
These sympathetic neurons arrive in the periphery as postganglionic neurons with the spi-
nal nerves and the blood vessels. This passage, according to Monnier, is not diffuse, but
track-like.
The impulses from the organs also reach the corresponding segments on the trunk:
• from the thoracic organs to the segments (C 8) T 1–T 7,
• from the abdominal organs to the segments T 1–L 1 (L 2),
• from the pelvic organs to the segments T 12–L 3.
Since this transmission is more clearly discernible in the lower limbs, this case shall be dis-
cussed first.
Fig. 3.10 Spinal cord (yellow) contain-

ing the sympathetic nuclei (orange) and
the sympathetic trunk (C 8) T 1–L 2
(L 3), with the large sympathetic ganglia
located cranially and caudally. This
schematic drawing shows the “track-
like” transmission of sympathetic im-
pulses along the sympathetic trunk to
the upper and lower limbs. (Modified
after Monnier)
Lower Limbs
The lower extremity is supplied by preganglionic neurons derived from T 10 to L 3:
• The more cranially derived preganglionic neurons (T 10–L 1) pass through the sympa-
thetic trunk to the lumbar ganglia L 4 and L 5 (› fig. 3.11, blue). This is where the post-
ganglionic neurons begin, which join the lumbar plexus, and finally the femoral nerve.
• The more caudally derived preganglionic neurons (T 12–L 3) pass to the sacral ganglia
S 1|S 2|S 3 (› fig. 3.11, gray). This is where the postganglionic fibers begin, which join
the sacral plexus, and ultimately the sciatic, the tibial and the peroneal nerves.
According to my analysis this “track-like transmission” is of far-reaching implications for
understanding acupuncture:
• The more cranially derived preganglionic neurons (T 10–L 1), which are segmentally
related to the abdominal organs as their enterotomes, reach the lumbar sympathetic
ganglia L 4 and L 5 by way of collaterals, thus conducting information through the lum-
bar plexus to the ventral aspect of the leg.
3
According to Chinese theory, this region corresponds to the course of the meridians of the abdominal
organs (digestive tract and liver-gallbladder, yangming and shaoyang; › fig. 3.11, blue).
• The more caudally derived preganglionic neurons (T 12 to L 3), which are segmentally
related to the pelvic organs as their enterotomes, reach the sacral sympathetic ganglia
S 1|S 2/S 3 by way of collaterals, thus conducting information through the sacral plexus
and the sciatic nerve to the dorsal aspect of the leg.
This region corresponds, according to Chinese theory, to the course of the meridians of the pelvic or-
gans (kidney-bladder, terminal large intestine, taiyang; › fig. 3.11, gray).
Fig. 3.11a, b Schematic depiction of the transmission of sympathetic impulses from the viscera to the spinal
cord, and from the spinal cord via the sympathetic trunk to the plexuses of the upper and lower limbs.
(Left-hand image taken from König, Wancura; right-hand image taken from Monnier)
Fig. 3.11c Areas of resonance of the visceral organs:

On the upper limb, the radial aspect corresponds to the respiratory tract (red), the ulnar aspect to the heart
(red and yellow).
On the lower limb, the tibial aspect corresponds to the upper abdominal organs (blue), the dorsal aspect to
the pelvic organs (gray).
Note: The toes and the thumb point cranially in this depiction.
(Modified schema of dermatomes; after Waldeyer)
Upper Limbs and Head

The upper limb is supplied by preganglionic neurons derived from C 8 to T 7:
• The more cranially derived preganglionic neurons (C 4, C 5, C 6) pass upward through
the sympathetic trunk to the medial cervical ganglion (› fig. 3.11a, cross-hatched red
and yellow). Since this ganglion is related to the spinal nerves C 4, C 5, and C 6, the im-
pulses reach the brachial plexus mainly by way of the lateral bundle (C 5, C 6, C 7), and
then pass to the musculocutaneous and median nerves, which supply the cranially inner-
vated flexor muscles of the upper limb.
• The more caudally derived preganglionic neurons (T 1 to T 7) pass upward to the infer-
or cervical ganglion (› fig. 3.11b, cross-hatched red and yellow). Since this ganglion is
related to the spinal nerves C 7, C 8, and T 1, the impulses reach the brachial plexus main-
ly by way of the medial bundle (C 7, C 8, T 1), and then pass to the ulnar and median
nerves, which supply the caudally innervated flexor and extensor muscles of the upper
limb.
3 Relevance for acupuncture:
• The more cranially derived preganglionic neurons are segmentally related to the en-
terotome of the lung. By way of collaterals in the sympathetic trunk and further passage
through the medial cervical ganglion, they reach the C 4, C 5, C 6 and C 7 dermatomes/
myotomes/sclerotomes in the radial half of the arm, and the accessory respiratory mus-
cles of the trunk, including the diaphragm.
This region corresponds, according to Chinese theory, to the course of the meridian of the respiratory
tract (lung, taiyin; › fig. 3.11a, red).
• The more caudally derived preganglionic neurons are segmentally related to the . en-
terotome of the heart. They reach the C 7, C 8 and T 1 dermatomes/myotomes/sclero-
tomes in the ulnar aspect of the arm by way of collaterals in the sympathetic trunk.
This region corresponds, according to Chinese theory, to the course of the meridian of the heart (sha-
oyin; › fig. 3.11a, red and yellow).
(For details on the segmental relations of the enterotomes › page 244)

Sympathetic Fibers Exiting the Spinal Cord

Through the Posterior Root
But there are also segmental sympathetic fibers which – although cholinergic – are consid-
ered by several authors (Braus and Elze, Foerster and Bumke, Hansen and Schliack, among
others) as belonging to the sympathetic neurons (many also refer to them as parasympa-
thetic). They leave the spinal cord by way of the posterior root (› fig. 3.12), and trigger the
following reactions exclusively in the regions of their segmentally corresponding derma-
tomes:
• vasodilation,
• lack of piloerection,
• reduced secretion of sweat.
In Head's zones, which are irritated by disorders of visceral organs within their own seg-
ments by way of their corresponding spinal cord segments, the following may therefore oc-
cur: either 3
• vasodilation, lack of piloerection, and reduced sweating in a strictly limited region of a
dermatome,
or, as described above,
• vasoconstriction, piloerection, and increased sweating in an entire quadrant of the
body.
The efferent sympathetic neurons leaving the spinal cord by way of the posterior root pass
through the spinal ganglion only, avoiding the sympathetic trunk. This makes it impossible
for their impulses to spread and become distributed throughout an entire quadrant.
The effects of the “posterior root efferences” are thus strictly segmental, since they are not subjected
to the infrastructure of the sympathetic trunk.
Fig. 3.12 Schematic representation of the different types of efferent sympathetic neurons leaving the spinal cord:
From the anterior horn, preganglionic sympathetic neurons enter the sympathetic trunk (solid red lines), where
they join collaterals that enable autonomic reflexive signs of disease, such as vasoconstriction, within a quadrant
of the body.
From the posterior horn, segmental sympathetic fibers (dashed black lines) bypass the sympathetic trunk, en-
abling strictly segmental vasodilation.
(Modified after Braus and Elze)
Sympathetic Effects on the Integument
Irritation of the Anterior Root
Experimental studies by Foerster, Bumke and others show that stimulation of the pregangli-
onic sympathetic neurons, i. e., of the anterior root, elicits vasoconstriction, piloerection,
and increased secretion of sweat on the body surface. Due to the formation of collaterals in
the sympathetic trunk, these sympatheticotonic reactions can become manifest in an entire
quadrant of the body surface.
Irritation of postganglionic sympathetic neurons causes the same autonomic reaction in
a single segment only.
The effects of efferent sympathetic anterior root nerves in the integument are referred to as
autonomic reflexive signs of disease.
• Vasoconstriction is caused by vasomotor alterations of the blood vessels in the skin.
• Piloerection is caused by contraction of the sympathetically innervated erector muscles 3
of the hairs (Mm. arrectores pilorum).
• Increased sweating is caused by the sympathetically innervated eccrine sweat glands.
These autonomic symptoms in the skin occur in visceral disease as projection signs to the
integument. They have been demonstrated many times over in experiments. Due to this sym-
patheticotonic reaction in the integument, the skin of an entire quadrant can be transformed
into pale, moist “gooseflesh”.
In the subjective perception of the patient, the skin in such an area is
• pale, chilly and sensitive to cold,
• sensitive to drafts,
• “goose-bumpy” due to piloerection, described by patients as “shivering”,
• damp and sensitive to moisture.
Irritation of the Posterior Root
However, the sympathetic neurons can also elicit the opposite reaction.
Segmental sympathetic neurons that leave the spinal cord by way of the posterior root
(and are therefore exceptions to the Bell-Magendie law) trigger, within a single segment,
• vasodilation,
• relaxation of the hairs (lack of piloerection),
• reduced secretion of sweat.
This sympatheticotonic reaction causes the skin in a single segment to become flushed, dry,
and smooth.
In the subjective perception of the patient, the skin in such an area is
• reddened and warm,
• dry, smooth and highly sensitive to touch (“thin-skinned”).
The effects of the circulatory centers in the brain and other mechanisms that affect circula-
3 tion go beyond the scope of segmental anatomy and are not discussed here.
The various effects of sympathetic innervation of the skin are summarized in the following
table:
The physician-acupuncturist will recognize in this list the traditional Chinese assignment
of the circulatory symptoms to the “climatic factors”:
• cold – han
• heat – re
• dampness – shi
• dryness – zao
• draft – feng
This example also illustrates the extent to which acupuncture carries the signature of spinal
nerves and the sympathetic system.
Wagner, Poetzschner and Maric presented a very interesting paper at the Jena 2008
DGfAN congress on the feasibility of demonstrating the meridians using an infrared camera
(published together with Maric, Schlebusch and Popp in the DZA), and reported the laser-
supported visualization of the acupuncture meridians.
In my opinion, the phenomena discussed here from the viewpoint of segmental anatomy
depend on the conduction of impulses that travel along segmental sympathetic neurons and
lead to vasodilation.
Tab. 3.1 Effects of the sympathetic innervation of the skin

Sympathetic Symptoms in the Objective Symptoms Subjective Symptoms
Integument
Changes in vasomotion of the cutaneous vessels
Vasoconstriction Cold or chilly skin Sensation of coldness
Boring, deeply perceived pain
Vasodilation Warm or hot skin Sensation of heat
Burning, caustic, stabbing pain
Sweat secretion
Increased sweat secretion Stickiness of the skin Sensation of coldness
Reduced sweat secretiion Dryness of the skin Exquisite sensitivity to touch
Piloerection
“The hairs stand on end” “Goose bumps” “Shivering”
Lack of piloerection Smooth skin Exquisite sensitivity to touch
Clinical Aspects
The efferent sympathetic neurons passing through the anterior root cause moist, pale goose-
flesh in an entire quadrant of the body.
The efferent sympathetic neurons passing through the posterior root cause a reddening,
smoothness, and dryness in the region of a single dermatome.
The skin changes provoked in the experiments basically correspond to the changes that
occur as autonomic reflexive symptoms on the surface of the body when visceral organs be-
come diseased.
• Vasoconstriction triggers a sensation of coldness and a boring, dull pain deep inside.
• Vasodilation triggers a sensation of heat and a burning, piercing pain on the surface.
• Increased sweating leads to stickiness of the skin and a feeling of coldness.
• Decreased sweating leads dryness of the skin and exquisite sensitivity when touched.
• Piloerection causes goose bumps and shivering.
• Lack of piloerection causes smoothness of the skin and exquisite sensitivity when 3
touched.
Patients almost always describe these changes on the body surface in terms of climatic ef-
fects: “It's cold, I'm cold, cold makes me feel worse, it's as if something icy cold were touching
me, the cold penetrates deep inside” etc. (in TCM called yang weakness, yangxu).
The opposite feeling is experienced by a patient when the autonomic changes on the skin
are characterized by vasodilation, lack of piloerection, and reduced sweating. Then the pa-
tient describes feeling thin-skinned and overly sensitive to being touched; he perceives the
body surface as being smooth, thin-skinned, and tense, and reports being particularly sensi-
tive to heat. “The pain is burning, I'm warm, heat makes it worse, massage worsens the pain,
the pressure of clothing is unpleasant“ etc. (in TCM called yin weakness, yinxu).
In many cases, however, the patient does not perceive just a circumscribed area on the
body surface as changed in the way described above, but experiences himself in his entirety,
“with his whole being” as sensitive to cold, drafts, or heat, etc.
The cutaneous sympathetic projection signs therefore transform the spinal-segmental pro-
jection pain into an individual experience of pain with qualitative and quantitative pa-
rameters.
Disease and pain are no longer defined simply by the locality (“where”), but also by quali-
tative parameters (“how, what kind”).
Disease becomes illness, which is not exclusively defined by objectively measurable data,
but rather is subjectively perceived by way of central-nervous processing of the disease as
experience of pain and of consciousness.
A definition of disease according to these criteria, which, in addition to the local symptoms, also consid-
ers the parameters of quality and quantity, is the rule in Traditional Chinese Medicine and the basis for
its concepts of diagnosis and treatment.
Since the patients always describe their complaints in terms of climatic changes – just as in
colloquial language, which also equates “cold” with “a cold” – all symptoms of a disease are
interpreted as causes occurring together. This co-incidence, literally translatable as symp-
tomatology* of a disease, corresponds to the description of disease from the viewpoint of
Chinese medicine (König, Wancura 1983).
This corresponds fundamentally to the Chinese way of thinking, which, according to
L. Abegg, “constructs its entire philosophy, state power, and medicine on the principle of
coincidence, of concurrence, i. e., on what coincides with what else, and not, as in the West,
what causes or triggers something else.”
* Symptom (Greek): coincidence

Chinese medicine is therefore a medicine that is defined according to the principle of coincidence, of
symptomatology, in which the simultaneous, concurrent, and coincidental occurrence of symptoms is
significant.
In this sense, cold is a coincidental, simultaneous cause of a cold and disease.

To be sure, cold is not the cause of the disease. But because it often coincides with the out-
break of the disease, and therefore has symptomatological significance, cold is regarded in
Traditional Chinese Medicine as having caused the disease.
This way of thinking is not based on cause-and-effect logic, such as prevails in Western
thought, but rather on conclusion by analogy.
Because Traditional Chinese Medicine defines a disease according to how it is processed in
the central nervous system (“cold disease”) rather than by its cause (e. g., pneumococcal
pneumonia), as in Western medicine, we (König, Wancura 1983) refer to the concept of Chi-
nese medicine as being based on a phenomenology of disease.
3
Independent Sympathetic Neurons with Particular Relationship to

the Longitudinal Thirds
In addition, and for the sake of completeness, I should like to mention that studies by van
Rynberk, Foerster, and others have demonstrated the existence of neurons that trigger vaso-
dilatory, pilomotor, pigmento-motor and secretory (sudo-motor) effects.
They leave the spinal cord partly through the anterior root, and partly through the poste-
rior root.
These neurons, according to the authors, are present in especially large numbers in certain
branches of the spinal nerves, so that the above-mentioned autonomic changes in each par-
ticular longitudinal third (ventral, lateral, dorsal) are clearly identifiable.
Since this is highly interesting both clinically and in evolutionary biology, and also pro-
vides evidence of autonomic changes in the longitudinal thirds from the viewpoint of TCM, I
should like to examine it briefly in detail.
The Pilomotor Neurons
The pilomotor fibers are sympathetic neurons that cause the hair on our neck and back to
bristle, as well as goose bumps and shuddering associated with fear, cold, or enthusiasm.
The fact that nearly all of the pilomotor neurons are contained in the dorsal branch of the
spinal nerves, through which they reach the dorsal longitudinal third of the body
(› fig. 2.12), might explain why 80 percent of all sympathetic nerves reach the region sup-
plied by the dorsal branches. Fanghänel too considers this a conceivable explanation.
Bristling of the hair on the back and shoulders in the dorsal and adjacent lateral longitudi-
nal thirds always signalizes aggression in man and animals, but it can also mean enthusiasm.
It produces an impressive increase of the body surface and is part of all threatening and im-
posing gestures.
This expression of threatening and imposing gestures has become genetically anchored so
firmly in all vertebrates in the course of evolution that the areas in which the hairs bristle
have subsequently become the spots where manes grow. It is remarkable that manes are par- 3
ticularly conspicuous in male animals, since they use threatening and imposing postures
more often than females do.
In human beings as well, the “man” who wants to look impressive may strive to enlarge his
shoulders with padding or epaulettes, or use feathers to emphasize the shoulder and back
regions, as shown by Eibl-Eibesfeldt (› fig. 4.18).
It is interesting that the term for the dorsal longitudinal third in acupuncture is tai yang, “the greater
yang”, to which the “functions” of extension and stretching are attributed, thus also describing the
function of the dorsally located extensor muscles.
The Pigmento-Motor Neurons
Van Rynberk has studied the pigmento-motor neurons in fish, and recognized that they too
follow the segmental pattern, with most of them being located in the ventral branch of the
spinal nerves.
They are responsible for the whiteness of the fish's belly, expressing an individual survival
strategy, since an enemy swimming below the fish is unable to distinguish the white belly
from the surface of the water above it.
Interestingly, the term for the ventral longitudinal third in acupuncture is yang ming, “the bright, radi-
ant yang”, with which the functions of curling up, assimilation, and protection are associated.
In man, the pigmento-motor neurons have no significance, since they are completely lacking.
Nevertheless, the fact that a light-colored or white belly can provide an advantage for indi-
vidual survival is still firmly anchored in our genes.
Displaying a white, “brighter, innocent” belly, i. e., of the ventral longitudinal third
(› fig. 2.11) signifies submission, child-like characteristics, and ostentative trust towards an
opponent.
Particularly in wolves and dogs, the submissive posture of the “underdog” is apparent
when he turns over onto his back, exposing his belly and throat, and thus thwarts the biting
attack of the “top dog”.
In human behavior as well, displaying the “white belly” is still present, e. g., in the gesture
of “hands up”, in which the abdomen is exposed, thus demonstrating that we will not attack;
likewise, hoisting a “white flag” signifies non-aggression and submission, forcing the attacker
to interrupt his own attack posture.
The Secretory (Sudo-Motor) Neurons
Langley has shown that in cats the areas in which sweat secretion is most pronounced corre-
sponds to the metameric arrangement of the dermatomes, i. e., that the sensory and the se-
cretory integumental regions are congruent.
An increased sweat secretion due to disease or experiments can occur in all dermatomes.
It has no particular relationship to the longitudinal thirds of the body.
The pathway for the sweat gland reflexes corresponds to the one for piloerection and vaso-
constriction:
• Their neurons originating in the lateral horn of the spinal cord pass through the anterior
root and the white communicating branches to the sympathetic trunk.
• From there they pass together with the sensory cutaneous nerves to the effector organs,
the small eccrine sweat glands of the integument.
Thus, each anterior root has “its own” particular dermatomes on the body surface, in which
3 irritation or disease may trigger sweat secretion.
Anatomically, the secretory (sudo-motor) neurons are regarded as sympathetic. Pharma-
cologically they behave like cholinergic fibers, in that they respond to pilocarpin.
For the autonomic reflexive signs of disease they play a prominent role, in that increased
sweat secretion always occurs on the homolateral side of the diseased organ in the autonom-
ic dermatomes supplied by fibers from the same anterior horn.
In visceral diseases, the phenomenon of increased sweat secretion is therefore highly useful in differ-
ential diagnosis.
The Vasodilatory Neurons
Foerster has shown that the posterior root as well contains its own efferent neurons capable
of triggering vasodilation.
This contradicts the Bell-Magendie law, according to which efferent neurons pass only
through the anterior root, and afferent fibers only through the posterior root. Foerster
showed intraoperatively that irritation of the posterior root elicits erythema of the skin in
dermatomes corresponding to the particular root (› fig. 3.12).
Dermatomes in which vasodilation can be triggered by experimental stimuli correspond
to the algetic dermatomes (Foerster).
Foerster was also able to show that thermal irritation (with hot water), mechanical irrita-
tion (pricking, stroking with a matchstick), electrical irritation (faradaic or galvanic current),
or chemical irriation (with mustard oil) cause brisk vasodilation, even after the peripheral
nerves have been severed.
He concluded that the hyperemic reaction after complete separation of the peripheral
nerves would be possible only if a connecting pathway outside the central nervous system
were still present.
Both when the posterior root is severed, and when the peripheral nerves are severed,
“neighborhood reactions”, such as reflective erythema, will occur. This fact leads one to sus-
pect that the neighborhood reactions may involve the vessel's own network of neurons. An
explanation for this vascular reaction may be the peripheral axon reflex, which shall be dis-
cussed later (› pp. 112, 247).
Vasodilation can be elicited in all dermatomes. It has no particular relationship to the lon-
gitudinal thirds.
Vasodilation, Vasoconstriction, and Pilomotor Reaction as “Waves”
Everyone knows from personal experience that there are “vasodilation waves”, “vasocon-
striction waves” and “pilomotor waves”, which correlate remarkably well with the longitudi-
nal thirds on the trunk.
Since the longitudinal thirds on the trunk (the ventral, lateral and dorsal longitudinal
thirds) correspond to the sum of all spinal nerve branches, whereas vasodilation and pilo-
erection (goose bumps) are caused by segmental sympathetic neurons and therefore are trig-
gered only in individual dermatomes, it is logical to conclude that both vasodilation and pilo-
motor waves are triggered by axon reflexes.
Therefore, whenever “flushing” occurs ventrally, or “chills run down one's back”, this is
probably due to the axon reflexes described below.
Morphological studies have shown the horizontal connections among the individual
branches of the spinal nerves to be tighter than the horizontal connection between a dorsal
branch and its lateral branch, or the connection of the latter with the ventral branch of the 3
same spinal level (› fig. 2.13).
This close, anatomically proven longitudinal connection of the spinal nerve branches in
metameric sequence could enable spreading
• of a vasodilation wave in the ventral longitudinal third,
• of goose bumps and
• of piloerection waves in the dorso-lateral longitudinal third.
In analogy to this, Traditional Chinese Medicine assigns
• heat to the ventral longitudinal third,
• cold to the dorsal longitudinal third, and
• cold chills to the dorso-lateral longitudinal third.
The Axon Reflex
Foerster defines an axon reflex as a reflex arc (› fig. 3.13) in which

• the receptors are located in the intracutaneous sensory organs,
• the afferent fibers are located in the sensory cutaneous nerves, and
• the efferent fibers are located in the neurons of cutaneous nerve branches supplying the
cutaneous vessels.
Efferent preganglionic (vasodilator)

fiber
Efferent postganglionic (vasodilator)

fiber
Site of lesion
Sensory axon
Efferent axonal crus
Afferent axonal crus
Plexus of supporting
vessels
Skin
Fig. 3.13 Schematic representation of a peripheral axon reflex (adapted from Foerster and Bumke; the site of
peripheral injury is marked).
An axon reflex is a reflex arc that enables a peripheral pathway and does not involve the spinal cord.
The reflex arc has no ganglionic cells and is never interrupted by synapsing, but passes only
through the ascending and descending parts of the axon. The reflex persists even after the
sensory nerve has been separated from its ganglionic cell, ceasing only when the entire sen-
sory neuron degenerates.
According to Foerster, the wave of vasodilation spreads when a peripheral nerve is stimu-
lated along its pathway to the neurons surrounding the blood vessels. The neurons surround-
ing the blood vessels are independent of the cerebrospinal nerves, and are connected solely to
the sympathetic nervous system.
Foerster also postulates that the spread of the vasodilation wave upon stimulation of a pe-
ripheral nerve might not necessarily be restricted to nerve structures, but might be mediated
by the protoplasmic formations surrounding the vessels.
3.2.8 The Afferent Sympathetic Nerve Pathways
A distinction is made between

• the afferent sympathetic neurons from the visceral organs to the spinal cord, and
• the afferent sympathetic neurons from the body surface to the spinal cord.
3
The Afferent Sympathetic Neurons from Visceral Organs

to the Spinal Cord
Most of the afferent viscero-sensory sympathetic neurons from the viscera are carried by the
various branches of the sympathetic nervous system (cardiac and bronchial branches, major
and minor splanchnic nerves, iliohypogastric nerves, etc.). However, afferent sympathetic
fibers are also contained in the segmental neurons of all spinal nerves (Fanghänel).
After passing through the peripheral branches to the sympathetic trunk, they enter the
posterior horn of the spinal cord.
Some of these neurons accompany the blood vessels in a periarterial network supplying
the viscera (iliac plexus, aortic plexus, etc.). In this way, sympathetic neurons reach the sym-
pathetic trunk directly, “pass through”, and travel along the white communicating branch to
the spinal cord.
Thus, by way of their relationship to certain spinal cord segments, both the sympathetic
and the parasympathetic visceral afferent nerves determine the relationship of visceral or-
gans to the segmental order. For example: Since the ventricles of the heart are connected to
the spinal cord segments C 8 through T 4 by viscero-afferent neurons, the heart belongs to a
C 8–T 4 enterotome (› fig. 3.14).
This relationship determines which dermatomes, myotomes, and sclerotomes will become
painful on the body surface when a visceral organ is diseased.
Regarding the heart, for example, these will be the (C 8) T 1 to T4 dermatomes, myotomes,
and sclerotomes (› fig. 3.14).
Because of the fragmentation and shifting of the myotomes, the nerve impulses from vis-
ceral organs spread over a wide area on the body surface.
The Afferent Sympathetic Neurons from the Body Surface

to the Spinal Cord
(Based on works by Foerster and Bumke, Braus and Elze, Hansen and Schliack, and others)
Some of the afferent sympathetic neurons from the limbs pass through mixed peripheral
nerves (brachial and lumbosacral plexuses) to reach the spinal nerves that supply the upper
and lower extremities (› fig. 3.15, blue line).
Sympathetic Nervous System
T 1 T 2 T 3 T 4 T 5 T 6 T 7
Heart (ventricles), Aorta asc.
Bronchi, Lungs
Esophagus
Stomach
3
Duodenum
Pancreas
Liver, Gallbladder
Small Intestine, Colon asc.
Ureter
Kidney
Bladder
Colon desc., Rectum
Testis, Epididymis
Ovary
Uterus
* according to O. Foerster in Foerster & Bumke: Handbuch der Neurologie, Vol. 5
Fig. 3.14 Afferent sympathetic neurons (based on data from O. Foerster in “Handbuch der Neurologie”, edited by Bumke and Foerster, vol. 5). Some au-
thors also assign segment C 8 to the heart.
T 8 T 9 T 10 T 11 T 12 L 1 L 2 L 3
Heart (ventricles), Aorta asc
Bronchi, Lungs
Esophagus
Stomach
3
Duodenum
Pancreas
Liver, Gallbladder
Ureter
Kidney
Bladder
Colon desc., Rectum
Testis, Epididymis
Ovary
Uterus
The Afferent Sympathetic Nerve Pathways of the Limbs

(Schematic representation based on data from Foerster, Altenburger and Kroll, 1929)
The pain-conducting neurons in the spinal nerves supplying the upper limbs (› fig. 3.16,
left-hand drawing, solid blue lines) reach the sympathetic trunk by way of the brachial plex-
us, partly through the dorsal roots, and partly through the white communicating branches.
Then they pass from the sympathetic trunk via the gray communicating branches to the spi-
nal cord segments C 8 through T 5.
Some of the neurons from the periarterial networks (dashed blue lines) pass through the
spinal nerves, and others pass directly to the sympathetic trunk, reaching the spinal cord seg-
ments T 2–T 5 by way of the gray communicating branches.
The pain-conducting neurons in the spinal nerves supplying the lower limbs (› fig. 3.16,
right-hand drawing, solid blue lines) pass through the lumbosacral plexus, and from there
partly through the dorsal roots, and partly through the white communicating branches to the
sympathetic trunk and then via the gray communicating branches to the spinal cord seg-
ments T 8 through T 12.
Some of the neurons from the periarterial networks (dashed blue lines) accompany the
spinal nerves, whereas others pass directly to the sympathetic trunk, also radiating into the
spinal cord segments T 8–T 12.
This means that from these spinal nerves providing the efferent sympathetic nerve supply
to the upper and lower limbs, also afferent sympathetic fibers arise which enter the sympa-
thetic trunk via the corresponding communicating branches.
In this way, a cuti-visceral influence of visceral organs from the extremities is possible.
As Foerster reports (Handbuch der Neurologie, vol. V), another portion of the afferent
sympathetic neurons reaches the limbs by way of the periarterial networks of the blood ves-
sels.
However, parts of these periarterial networks, instead of following the spinal nerves and
the communicating branches, follow the periarterial networks of the subclavian and iliac ar-
teries and that of the abdominal aorta, to enter the sympathetic trunk directly (› fig. 3.16b).
3
Radix dorsalis
Ganglion spinale
N. spinalis
afferent
efferent preganglionic
efferent postganglionic
Sweat gland Vessel
Skin
M. arrector pilli
Fig. 3.15 Schema of the arrangement of sympathetic neurons in a spinal nerve in cutaneous structures such
as blood vessels, sweat glands, and the erector muscles of the hairs.
The preganglionic efferent sympathetic neuron ends in one of the sympathetic ganglia.
The postganglionic efferent sympathetic neuron runs in the gray communicating branch to the spinal nerve.
The afferent sympathetic neuron passes from the skin through the spinal ganglion to the posterior root.
(Modified after Mitchell 1953)
From the sympathetic trunk, the afferent sympathetic neurons pass through the white
communicating branches back to the spinal nerves, entering the spinal cord mostly by way of
the posterior roots, but also by way of the anterior roots.
Leriche, Lazorthes, Braus and Elze, Hansen and Schliack, and others have corroborated
Foerster's views:
“Thus not only the spinal nerve, but also the sympathetic system is an 'afferent feeder' from the
periphery to the spinal cord.”
Foerster states further:
“… ignorance of the fact that the afferent nerves of the upper limbs also contain sympathetic
neurons which enter the sympathetic trunk partly by way of the communicating branches of
the spinal nerve and partly by way of the periarterial network of the subclavian artery – igno-
rance of this fact has caused surgery to pay a high price. Because it has been tried repeatedly to
combat painful disease processes in the upper limbs by resection of the posterior spinal cord 3
roots belonging to the upper limbs (C 4 to T 2).”
This attempt has been, as he reports, only partially or temporarily successful (› fig. 3.16).
Foerster explains this by the fact – which was overlooked – that some of the afferent neu-
rons of the upper extremity do not at all pass through the posterior root of C 4 to T2 in the
spinal cord; instead, some of the pain-conducting nerves of the arm also pass by way of the
communicating branches in the network surrounding the subclavian artery directly to the
sympathetic trunk, and from there via the thoracic nerve roots to the spinal cord.
This means that the sympathetic pathways are an “afferent secondary line”, whose func-
tion becomes apparent only when the main line is interrupted.
In paraplegics, the sympathetic nervous system can transmit sensory and motor impulses
by way of such paramedullary afferent fibers even if the pathway through the spinal cord is
completely interrupted.
In this way, for example, completely paraplegic patients may perceive a full urinary blad-
der in the occiput, a feeling described as “a peculiar tingling in the back of the head”.
Apparently, some of the afferent pathways from all parts of the body lead through parts of
the sympathetic nervous system.
The sympathetic nervous system therefore consists of mixed nerves containing afferent and efferent
fibers (Foerster und Bumke, and other authors).
Fig. 3.16a Paramedullary afferent pathway via the communicating branches and the sympathetic trunk (from Clara)
Fig. 3.16b Sympathetic innervation of the arm, bypassing the cervical nerve roots via the sympathetic trunk
(after Foerster, quoted in Haywood and Woothall 1953)3
3.2.9 The Large Sympathetic Ganglia and

Their Projections onto the Skin
Due to their location, the large sympathetic ganglia are also referred to as prevertebral gan-
glia.
In contrast, the ganglia of the sympathetic trunk on either side of the spinal column are
also referred to as paravertebral ganglia.
As early as 1900, van Rynberk postulated that “there must be a cutaneous projection of the
large sympathetic ganglia”. Such a hypothesis would be of great practical significance, since
stimulation of the region of such a skin projection would mean that a peripheral stimulus
could replace infiltration of the large sympathetic ganglia, which can be dangerous. The effect
of a relatively small and low-risk stimulus on the body surface could possibly be similar, if
not equally pronounced, to that of deep infiltration of the sympathetic ganglia.
Higier observed that when certain ganglia were subjected to mechanical und electrical
3 stimuli, there was a constant relationship between the stimulus of the sympathetic ganglia
and the spread of pain in certain regions.
He found a relationship
• between the superior cervical ganglion and the face; and
• between the stellate ganglion and the regions of the heart, thorax, and upper arm.
My analysis indicates that points in the region of the hiatus lines, e. g., TH 5, PC 6, SP 6, and
areas in which segmentally different layers of skin, muscle, and bone overlap one another,
represent peripheral regions in which even a small stimulus can affect a large region in the
spinal cord (› page 150).
This would explain why these points on the hiatus lines have such widespread effects.
To (literally) get to the point:
• Stimulation of the acupuncture point GB 20 corresponds to infiltration of the superior
cervical ganglion.
• Stimulation of the acupuncture point CV 17 corresponds to infiltration of the stellate gan-
glion.
• Stimulation of the acupuncture point CV 12 corresponds to infiltration of the celiac gan-
glion.
Stimulation of these points could, in my opinion, influence several metameric spinal cord
segments at once, as well as the visceral organs related to these spinal cord segments.
The Superior Cervical Ganglion
Indirect Stimulation via the Greater Occipital Nerve (GB 20)
The superior cervical ganglion supplies organs of the head (eye, tear glands, salivary glands)
with its postganglionic neurons.
The preganglionic neurons for these organs are derived from the cilio-spinal center (C 8 to
T 3).
The superior cervical ganglion also receives impulses from T 3 to T 7, meaning that infor-
mation from the thoracic organs and the arms can reach this ganglion.
The ganglion is 2 cm in diameter, lies on the transverse processes of the first and second
cervical vertebrae, and extends to the base of the skull.
The superior cervical ganglion is connected to the spinal nerves C 1|C 2|C 3.
The fact that the communicating branches for the spinal nerves C 1|C 2|C 3 branch off in
the region of the superior cervical ganglion means that these spinal nerves are directly related 3
to the superior cervical ganglion.
Therefore I believe that stimulation of the C 1|C 2|C 3 dermatomes*, myotomes, and
sclerotomes is a thoroughly adequate stimulus equivalent to infiltration of the ganglion.
Stimulation of the peripheral nerves of C 1|C 2|C 3 at their points of emergence has a par-
ticularly marked effect on these segments and thus on the superior cervical ganglion. For
example:
• The greater occipital nerve is where the dorsal branch of C 2 emerges.
• The lesser occipital nerve is where the ventral branch of C 2 emerges.
In agreement with these neurophysiological facts, ancient Chinese physicians recommended the acu-
puncture point GB 20 (exit site of the greater occipital nerve) for disorders of the eye, ear, or salivary
glands, and for headache.
The Middle Cervical Ganglion
Indirect Stimulation via the C 4|C 5 Dermatomes, Myotomes,

and Sclerotomes (CV 22)
The middle cervical ganglion is located at the level of the sixth cervical vertebra, adjacent to
the inferior thyroid artery. It has a large communicating branch to the 5th spinal nerve, and is
therefore related to the spinal cord segment C 5, as well as to C 4.
Through the cardiac branch it is connected to the heart. Furthermore, there are connec-
tions to the stellate ganglion, the common carotid artery, and the inferior thyroid artery.
The middle cervical ganglion is thus related to the spinal nerves C 4|C 5. This relationship
makes it possible to influence this sympathetic ganglion indirectly by stimulating its C 4|C 5
dermatomes, myotomes, and sclerotomes.
Notably, the following ought to be stimulated:
• the C 5 myotomes on the back, i. e., the muscles inserting and originating in the region of
the spine of scapula, and
• the caudal region of the clavicle (C 5 myotome) in the region of the pectoral and the sub-
clavian muscles, likewise belonging to the C 5 myotome.
* A C 1 dermatome does not exist.

Indirect stimulation is also possible by inserting an acupuncture needle into the upper half of the ster-
num, i. e., at a point between the jugular notch (CV 22; C 4) and the middle of the sternum (CV 17;
C 5). From the point of view of TCM, this will “influence the heart, the lung, and the thyroid gland”.
Particularly effective, according to the ancient Chinese physicians, is retrosternal needling at CV 22.
By way of the middle cervical ganglion the impulses from thoracic organs (especially the
lung) belonging to more cranially located segments are referred to the radial part of the arm,
i. e., to the segments C 5|C 6 (lateral cord of the brachial plexus; › fig. 3.11), which as “lung
meridian” are related to the respiratory tract.
Another possibility for an indirect stimulation of this ganglion from the body surface is to
stimulate the spinous process of the C 7 vertebra and the adjacent subcutaneous C 5 and C 6
dermatomes. This corresponds to the position of the new point 45 (“suppression of the
coughing reflex”).
3
The Inferior Cervical Ganglion
Indirect Stimulation via the Hiatus Line C 6|C 7|C 8 on the Forearm

(PC 6)
The inferior cervical ganglion nearly always – and in mammals, always – fuses with the first
and second thoracic ganglia to form the stellate ganglion. The inferior cervical ganglion is
located at the level of the lowest cervical vertebra and is connected to the spinal nerves
C 6|C 7|C 8. From its upper end emerges the vertebral nerve, which is the main component of
the network surrounding the vertebral artery.
The inferior cardiac nerve connects the ganglion to the heart. Like the medium cervical
ganglion discussed above, the inferior cervical ganglion is also connected to the vagal trunk
and to the recurrent laryngeal nerve.
The inferior cervical ganglion conducts impulses from the thoracic organs (heart, ventri-
cles, and atria) that are related to the more caudally located segments C 7|C 8|T 1 (medial
cord of the brachial plexus; › fig. 3.11), to the ulnar side of the arm, i. e. as “heart meridian”
is related to the heart.
The Stellate Ganglion
Indirect Stimulation via C 8 to T 7 Dermatomes, Myotomes,

and Sclerotomes in the Anterior Midline (CV 15–CV 12)
These areas cover

• the caudal half of the sternum,
• the costal arches at the epigastric angle, and
• the spinous processes C 7 to T 3|T 4.
The stellate ganglion receives preganglionic neurons from T 3 through T 7; by way of its con-
nection to the inferior cervical ganglion it is also related to the spinal cord segments C 8
through T 3.
Therefore the stellate ganglion, as a link connecting the lowest inferior cervical ganglion
and the uppermost thoracic ganglia, is related to the spinal nerves C 8 through T 7. This con-
nection puts the stellate ganglion in contact with the head, the arms, and the thoracic organs.
Whereas the large sympathetic ganglia supply only the visceral organs with sympathetic
fibers, the stellate ganglion occupies an exceptional position as it supplies both the body sur-
face and the internal organs, i. e., the thoracic organs, simultaneously. Regarding indirect
stimulation of the stellate ganglion, one may follow Mackenzie's instructions and infiltrate or
needle the region of the spinous processes of the vertebrae C 7 to T 3 in order to influence the
heart and the lung (› fig. 6.3).
Celiac ganglion
Indirect Stimulation via T 6 to T 12 Dermatomes and Myotomes in

the Anterior Midline (CV 12)
The splanchnic nerves originate in the 6th through 12th thoracic segments of the spinal cord:
• The greater splanchnic nerve originates from the 6th through 10th thoracic segments of the
spinal cord.
• The lesser splanchnic nerve originates from the 10th through 12th thoracic segments of the
spinal cord.
From the spinal cord segments T 6 to T 12, preganglionic neurons pass through the splanch-
nic nerve, commingle with the aortic plexus and the hypogastric plexus, and form the celiac
ganglion (“solar plexus”).
As shown in the table of M. Monnier (› fig. 3.6) on the efferent sympathetic innervation,
the celiac plexus (celiac ganglion) supplies the cardia, the stomach, the liver, the pancreas, 3
and the intestines. In addition, some neurons also supply the kidney.
The relationship of the celiac ganglion to the spinal cord segments T 6 through T 12 makes
it possible to stimulate this ganglion from the T 6–T 12 dermatomes, myotomes, and sclero-
tomes, thereby influencing the above-mentioned visceral organs from the body periphery.
For centuries, Chinese physicians have empirically utilized this relationship of the celiac ganglion to the
body surface in practice by stimulating acupuncture points in the anterior midline in the regions of the
T 6–T 12 dermatomes and myotomes.
Because the regions innervated by the left and right spinal nerves in metameric sequence
overlap in the anterior and posterior midlines, it is conceivable that the celiac ganglion also
can be therapeutically influenced by acupuncture along the anterior midline between the xi-
phoid process and the umbilicus.
The acupuncturist will immediately think of the points CV 12, CV 10, and CV 6, all of which are known
to influence the upper abdominal viscera and the thoracic organs as well.
Superior Mesenteric Ganglion
Indirect Stimulation via the T12 to L 1 Dermatomes and Myotomes in

the Anterior Midline (CV 4, CV 5, CV 6)
The superior mesenteric ganglion arises from the preganglionic neurons T 12 through L 1
and supplies the cecum, the ascending colon and the transverse colon as far as the left colic
flexure with postganglionic neurons.
In this spinal peripheral region the stimulation via acupuncture points along the anterior
midline in the areas of the T 12 to L 1 dermatomes and myotomes would therefore be equiva-
lent to a neural therapeutic injection into the superior mesenteric ganglion.
The acupuncturist will immediately think of the points CV 4, CV 5, CV 6, and their effect on the above-
mentioned organs which is well known in Chinese medicine.
Inferior Mesenteric Ganglion – Hypogastric Plexus
Indirect Stimulation via the T12|L 1|L 2 Dermatomes, Myotomes and

Sclerotomes along the Anterior Midline (CV 4 and SP 6)
The sympathetic innervation of the pelvic organs, i. e., of the descending colon, the sigmoid
colon, the rectum, the urinary bladder, the genital region, and the uterus, occurs through
postganglionic neurons from the inferior mesenteric ganglion, or hypogastric plexus.
Indirect stimulation of this ganglion can be achieved by stimulating the region of the ante-
rior midline of the lower abdomen and the symphysis (T 12 through L 2).
The acupuncturist will immediately think of the point CV 4.
3 Since impulses from the pelvic organs pass through collaterals within the sympathetic trunk
on their way to the lower sympathetic sacral ganglia S 1|S 2|S 3, they can travel to the
S 1|S 2|S 3 dermatomes, myotomes and sclerotomes of the leg by way of the sacral plexus.
Along the same pathway, stimulation of the inferior mesenteric ganglion and the pelvic
organs would also be conceivable by irritating the medial part of the lower leg and the dorsal
muscles of the leg.
Practical experience from Chinese medicine regarding the stimulation of the acupuncture
point SP 6 (hiatus line between S 1|S 2 and L 4|L 5), and the observed effects on the pelvic
organs support this hypothesis.
Furthermore, due to its relationship with S 1|S 2, the point SP 6 is also connected to the
parasympathetic pelvic nerves supplying the pelvic organs.
Practical Implications
The large sympathetic ganglia are connected by preganglionic neurons not only both to the
spinal cord and to certain visceral organs, but also via the spinal cord segments to certain
regions of the skin, muscles, and bones in the periphery.
Thanks to such connections, needling stimulation in this spinal peripheral region may
therefore also be equivalent to a neural therapeutic infiltration stimulus of one of the prever-
tebral sympathetic ganglia.
The very same effect can be achieved by stimulation along the dorsal midline and in the
paravertebral region adjacent to the spinous processes (hua tuo points).
Stimulation in the region of the anterior and posterior midlines can be enhanced by nee-
dling the hiatus lines of the same segments on the upper and lower limbs.
For example:
• CV 17, CV 15 in combination with PC 6,
• CV 12 in combination with PC 6,
• CV 6, CV 4 in combination with SP 6.
3.3 The Peripheral Parasympathetic Nervous System and Its Role in Segmental Theory 125
3.3 The Peripheral Parasympathetic Nervous System

and Its Role in Segmental Theory
In segmental theory, the parasympathetic system plays a much smaller role in projection
phenomena and interactions than the sympathetic system.
The main difference is as follows: Since the sympathetic system has target organs in the
integument (erector muscles of the hairs, vasoconstrictors in the vessels, and eccrine sweat
glands), not only algetic symptoms, but also autonomic reflexive sympatheticotonic symp-
toms may occur.
Since on the other hand, the parasympathetic system has no target organs in the integu-
ment, it will not elicit autonomic reactions, but only algetic symptoms. These will manifest
within the regions of the body surface connected to the origins of the parasympathetic sys-
tem, or to the nerves joining it with the trigeminal nerve and the C 2 segment, respectively.
The parasympathetic system originates cranially in the mesencephalon and in the medulla 3
oblongata, and caudally in the second to fourth segments of the sacral spinal cord
(› fig. 3.1b). For this reason, the parasympathetic system is also called the cranio-sacral
part of the autonomic nerve system.
Whereas the sympathetic neurons also conduct pain signals, the parasympathetic neurons
conduct most notably organ sensations such as nausea and vomiting, fear, urge to urinate or
defecate, etc.
The afferent and efferent parasympathetic fibers run with the vagal nerve and with the
pelvic nerves. Since the vagal fibers are connected to the trigeminal nerve and also to the seg-
ment C 2, disorders of the organs innervated by the vagal nerve may also lead to hyperalgesia
in the cutaneous regions innervated by the trigeminal nerve as well as in the segment C 2
(Braus and Elze).
As shown in the table by Foerster (› fig. 3.17), vagal nerve fibers are able to elicit hyper-
algesia in parts of the integument, similar to Head's zones: affections of the heart, bronchi,
lungs, esophagus, stomach, liver, gallbladder, ascending and transverse colon, can lead to
pain in the region supplied by the trigeminal nerve (in the face), and in the C 2 region (oc-
ciput).
• Parasympathetic fibers of the phrenic nerve can project affections of the heart, bronchi,
esophagus, stomach and liver-gallbladder to the region of origin of the phrenic nerve
(C 4|C 5|C 6), i. e., to the shoulder region.
• Parasympathetic fibers of the pelvic nerves can project affections of the pelvic organs
descending colon, rectum, urinary bladder, urethra and uterus to their own regions of or-
igin, S 1 through S 5, i. e., to the dorsal part of the legs, and to the surface of the buttocks.
For example:
In case of disease of the urinary bladder, according to its sympathetic innervation, the seg-
ments T 11 through L 3 on the body surface may become painful and exhibit autonomic reac-
tions.
However, in addition, according to the parasympathetic innervation of the urinary blad-
der (by the pelvic nerves), the segments S 2 through S 5 on the body surface may also become
painful.
Therefore, disorders of the urinary bladder may be associated with pain and autonomic reactions on
the surface of the lower abdomen and the medial part of the thigh down to the knee (sympathetic nerve
supply), as well as with pain on the posterior side of the legs (S 2 through S 5) and in the buttocks
(parasympathetic nerve supply).
Parasympathetic Nervous System
N. vagus N. phre- N. pelvinus

(related to) nicus
N. trige- C3, C4
minus C2 (C5 5) S 2-S 5
Heart (ventricles), Aorta asc. Heart (ventricles), Aorta asc.
Bronchi, Lungs Bronchi, Lungs
Esophagus Esophagus
Stomach Stomach
3 Duodenum Duodenum
Pancreas ? ? ? Pancreas
Liver, Gallbladder Liver, Gallbladder
Small Intestine, Colon asc. Small Intestine, Colon asc.
Ureter Ureter
Kidney Kidney
Bladder Bladder
Colon desc., Rectum Colon desc., Rectum
Testis, Epididymis Testis, Epididymis
Urethra Urethra
Uterus ? Uterus
Fig. 3.17 Afferent parasympathetic neurons projecting organ sensations, and corresponding Head's zones (hyperalgetic integumental areas)
(After data of O. Foerster in Handbuch der Neurologie, by Bumke and Foerster, vol. 5.)
CHAPTER
4 The Dermatomes
4.1 Radicular Innervation of the Integument
The cutaneous region influenced by a spinal nerve is called a dermatome.

• A dermatome whose borders are established anatomically by dissection of the spinal
nerve as far as the subcutis, is referred to as a subcutaneous dermatome.
• A dermatome whose borders are based on clinical examination is referred to as an epi-
dermal dermatome.
Since epidermal dermatomes and subcutaneous dermatomes often are not congruent, der-
matomic schemas may differ considerably. This is not due to lack of precision on the part of
the authors, but rather to the fact that the spinal map of the skin has in some cases been de-
termined by anatomists, and in other cases by clinicians.
It is necessary to understand and differentiate this fact in order to assign integumental re-
actions to a given segment in diagnosis, and to consider the often widely separated subcuta-
neous spinal nerve regions in treatment.
For example:
In treatment of pain and skin changes on the radial side of the elbow, not only the epider-
mal dermatomes, but also the corresponding subcutaneous paravertebral lines at the level of
the spinous process of C 7 must be considered.
The well-known dermatomic schemas of Head and Hansen and Schliack are based on sen-
sibility examinations of the skin and observations of herpes zoster eruptions. Their derma-
tomic schemas are therefore epidermal dermatomic schemas:
• According to Head, dermatomes are longitudinal oval areas covering the body surface
like patchwork (› fig. 4.1).
• According to Hansen and Schliack, dermatomes are horizontal rings and linear bands
covering the body, like a globe, with a grid of meridians (› fig. 4.2 and fig. 4.5).
These familiar dermatomes remain invisible under conditions of health, but in case of pathological
disorders they may make an impressive appearance.
128 4 The Dermatomes
Fig. 4.1a Schema of epidermal dermatomes, based on clinical evidence (anterior and lateral views; after Head)
4.1 Radicular Innervation of the Integument 129
Fig. 4.1b Schema of dermatomes, based on clinical evidence (posterior and medial views; after Head)
Fig. 4.2a Schema of dermatomes, based on clinical evidence (anterior view, after Hansen and Schliack)
Fig. 4.2b Schema of dermatomes, based on clinical evidence (posterior, medial and caudal views, after Hansen and Schliack).
Fig. 4.3 Schema of subcutaneous dermatomes, based on anatomical evidence (posterior and anterior views, after Braus and Elze)
Fig. 4.4 Schema of subcutaneous dermatomes, based on anatomical evidence (anterior and posterior views, after M. Clara)
Fig. 4.5a Dermatomic schema, dorsal view: The dermatomes are color-coded according to their spinal innerva-
tion. (Modified after Hansen and Schliack)
Fig. 4.5b Dermatomic schema, ventral view: The dermatomes are color-coded according to their spinal
innervation. (Modified after Hansen and Schliack)
4.1.1 Clinical Relevance
The dermatomic schemas give those capable of reading them the possibility of making a
“projective diagnosis”, enabling them, so to speak “to peer from the outside into the intact
body” (Kunert).
Since changes in the dermatomes which appear in the presence of visceral disease develop earlier than
changes detectable by radiology or other technical diagnostic methods, dermatomic diagnosis repre-
sents a simple and efficient indicator of pathological events within a segment, and thus a genuine
method of early diagnosis.
The subcutaneous dermatomes – in contrast to the epidermal schemas – are not an imagi-
nary grid, but always verifiable markers. The subcutaneous dermatomes have been studied
mainly by Braus and Elze, and by M. Clara (› fig. 4.3 and › fig. 4.4).
Epidermis and subcutis form the “outermost shell” of a segment in which the deeper layers
will “express themselves”. This outer layer is where disorders situated elsewhere in the same
segment (i. e., in muscles, bones, and visceral organs) become visible, palpable, subjectively
4 perceptible and thus directly detectable by the senses.
Reactions in a dermatome are mediated by the spinal nerve and the sympathetic system,
in which the spinal nerve determines “where” these changes will occur, whereas the sympa-
thetic system determines “how” the changes take place.
These reactions, or changes, are termed “algetic and autonomic reflexive symptoms”
(Hansen and Schliack; › page 251).
• The location of the changes in the dermatomes may therefore indicate that deeper-lying
parts of the segment are affected.
• The kind of changes in the dermatomes may indicate the autonomic condition of the
vascular system in the superficial and deeper parts of the segment.
For example:
Cold, pale skin on the lower abdomen and the sacral region is usually related to vasocon-
striction within the pelvic organs.
Whenever a deeply seated disorder becomes manifest in the region of its dermatomes, it is
also “expressing” itself in the sense of communicating to the outside, “sounding alarm”,
“sending a signal”.
This gives the patient a chance, based on his subjective perception, to react instinctively
and usually appropriately.
For example:
In case of subjective feeling of cold in the lumbosacral region, instinctive external applica-
tion of heat results in vasodilation not only in the integument of this region, but also within
the pelvic organs.
In this context, Brügger reported that he very often observed scratch marks on the anterior
wall of the thorax in patients with diseases of the thoracic organs.
The localized pruritus on the thoracic wall in this example signalizes a segmental “expres-
sion” of the diseased internal organ. The repetitive scratching thus corresponds to an instinc-
tive segmental therapy.
Much as vegetation may allow conclusions about the composition of the soil without ne-
cessitating soil samples, changes on the body surface allow conclusions concerning patho-
logical processes deep within the body, without necessarily having to take samples.
The segmental manifestations in the dermatome therefore also signify “ex-pression”
meaning to press out, to divert, i. e., facilitating instinctive self-treatment.
Since the spinal nerve gives rise to numerous collateral branches to the muscles and bones
on its way from the spinal cord to the integument, these segmental-identical parts of myo-
tomes and sclerotomes may develop into “accessory combat zones”.
For example:
On its way to its dermatome, the spinal nerve T 6 gives rise to collateral branches for its T 6
myotome, the parts of which may be located in different muscles, as shown in figure 2.3.
Therefore, a disorder in the T 6 segment may involve not only hyperalgesia, hyperesthesia
or irritation of the skin in the T 6 dermatome, but also pain in the T 6 myotomes of the cor-
responding muscles.
In the integument, however, the spinal nerve is always restricted to “its own” undivided dermatome.
4
4.2 Parts of a Dermatome
Each dermatome consists of three parts: a ventral, a dorsal, and a lateral one. They are inner-
vated by the ventral, dorsal, and lateral branches of the spinal nerves, respectively.
On the trunk, the right and left spinal nerves each form a half of a horizontal ring; the two
halves meet at the anterior and posterior midlines. Since the areas innervated by the spinal
nerves overlap there, it is possible to achieve effects on spinal nerve regions on both the right
and the left sides from the anterior and posterior midlines.
Here, the acupuncturist naturally is reminded of the anterior and posterior midline vessels, CV and GV.
On the limbs, the dermatomes have only ventral and lateral parts, because the limbs are de-
rived from the ventrolateral abdominal wall, which is innervated only by the ventral and
lateral spinal nerve branches.
One must imagine growth of the limb buds from the wall of the trunk as follows
(› fig. 4.6): First the segments C 7|C 8 protrude, and as they continue to grow on either side,
4 they will pull the adjacent segments along with them.
This results in
• a radial aspect, in which the dermatomes C 4 to C 7 “grow into” the limb, and
• an ulnar aspect, in which the dermatomes C 8 to T 2 “grow out of” the limb.
Head refers to these events during the embryonic period as “flowing into the arm and flowing out of
the arm”, which immediately reminds the acupuncturist of the “inward and outward flow of energy”
in traditional Chinese thinking.
Later in this book, it shall be explained in more detail why instead of “energy” one might just
as well say “metamerism”.
At the exit points of the ventral, dorsal, and lateral branches of the spinal nerve on the
trunk and those of the ventral and lateral spinal nerve branches on the limbs, there are cer-
tain spots which are particularly sensitive. These are referred to as the ventral, dorsal, and
lateral maximum points in the dermatome (› fig. 4.10).
The dorsal parts of the dermatomes (more precisely, the subcutaneous dermatomes)
remain localized on the back in the dorsal longitudinal third. They are not involved in limb
development.
The dorsal spinal nerve branches therefore do not participate in the innervation of the
limbs, i. e., their fibers do not reach the brachial or the lumbar plexuses.
The persistence of the dorsal portion of the subcutaneous dermatomes on the back means
that in the dorsal third, from the crown of the head to the tip of the coccyx, the dermatomes
retain their sequential, i. e., metameric, order from C 2 to the coccygeal region. The uninter-
rupted segmental order of the dorsal parts of dermatomes has been demonstrated by dissec-
tion studies of the anatomists Braus and Elze (› fig. 4.7).
The dorsal parts of the dermatomes contain the most sympathetic neurons, since the dor-
sal branch of the spinal nerves consists mainly of sympathetic neurons (80 %). This makes
the dorsal longitudinal third a particularly sensitive area of resonance for sympatheticotonic
impulses and affective emotional states. For the same reason,
• it is the hairs of the neck and back, but not those of the beard or chest, that can stand on
end; and
• cold shudders run down the back, but not the belly (› page 109).
The dorsal parts of the dermatomes are not only the most sensitive, but also the parts in which
sensibility is retained for the greatest length of time. Van Rynberk has shown in animal ex-
periments that after destruction of the dermatome by destruction of the spinal nerve, the dor-
sal portions are the ones that survive longest, i. e., “the dermatome dies from belly to back.”
4.2 Parts of a Dermatome 139
Week 4 of development Week 5 of development

upper limb lower limb upper limb lower limb
preaxial border preaxial border
postaxial border postaxial border
Week 7 of development Week 8 of development
thumb
thumb
preaxial border
preaxial border
4
palmar side
palmar side
postaxial border
postaxial border
preaxial border
large toe
postaxial border palmar side

palmar side preaxial border
large toe postaxial border
Fig. 4.6 Budding of the upper limb (C 5 to T 2, red-yellow) and the lower limb (L 2 to S 2, blue-gray) and the
rotation of the lower limb in various stages of development. (Modified after Bolk, Clara and Netter)
Notice the shifting of the big toe due to rotation (› fig. 2.25).
This also means that neurological disorders leading to hypo- or analgesia in the dermatomes of the
trunk and limbs cause longer lasting symptoms in the dorsal part of the dermatome than in its ventro-
lateral part. One must therefore conclude that in projection phenomena, the algetic changes in the
dermatomes of the dorsal longitudinal third will elicit the most intense pain as well as longest persis-
tence of pain.
The ventrolateral parts of the epidermal dermatomes make up the integument of the limbs
and that of the ventrolateral portions of the thoracic and abdominal wall.
Because the ventrolateral parts of C 5 to T1 are used to form the upper limbs, they are
missing in the ventral part of the trunk, producing a “segmental gap”. This gap is also re-
Fig. 4.7 Schema of the subcutaneous dermatomes in the dorsal longitudinal third, as shown by anatomic
studies (modified after Brügger)
ferred to as a “hiatus”*. It accounts for the “segmental leap” in which, on the ventral aspect
of the trunk, the dermatome C 4 borders on that of T 2 (› fig. 4.14).
Dorsally a segmental leap, according to the notions of Braus and Elze, Clara, and others,
i. e., a “hiatus”, is impossible, because the dorsal parts of the dermatomes remain in meta-
meric sequence on the back from the crown to the tip of the coccyx. This is in opposition to
the notions of Hansen and Schliack.
The ventrolateral portions of the dermatomes contain fewer sympathetic neurons than the
dorsal portions, so that, for example, “cold shudders” on the limbs and in the ventrolateral
parts of the thorax occur only to a slight degree.
Because the ventrolateral portions of L 2 to S 2 are used to form the lower limbs, they are
missing in the ventral part of the trunk. However, this does not lead to a hiatus line.
In contrast to Braus and Elze, Hansen and Schliack postulate a segmental gap, a hiatus
line, on the back as well.
* Latin hiatus = gap, slit, opening

4.3 The Sensory and Autonomic-Motor Dermatomes 141
4.3 The Sensory and Autonomic-Motor Dermatomes
In practice, it is important to differentiate between sensory and autonomic-motor derma-

tomes.
4.3.1 Sensory Dermatomes
The term “sensory dermatome” is applied when the sensory-afferent neurons of the poste-
rior root determine the extent of the dermatome.
The sensory dermatomes are divided into
• algetic dermatomes (pain dermatomes) and
• esthetic dermatomes (tactile dermatomes).
Algetic Dermatomes
The algetic dermatomes are determined by examination of the pain perception (protopathic 4
sensitivity). Head carried out his studies using a stiff-haired brush.
The algetic dermatomes have distinct borders, making them suitable for determining the
segmental borders in the integument.
Because the sensory nerve supply of algetic dermatomes and certain visceral organs is de-
rived from the same spinal cord segment, the algetic phenomena in referred pain are pro-
jected to the corresponding algetic dermatomes.
In other words, when a visceral organ becomes diseased, the corresponding segmental al-
getic dermatomes become overly sensitive to pain (hyperalgesia).
Such dermatomes are named Head’s zones after their discoverer. The dermatomic sche-
mas of Head, Hansen and Schliack, and other authors are based on them.
Esthetic Dermatomes
Esthetic dermatomes are determined by the sense of touch (epicritical sensitivity). They are
also known as tactile dermatomes.
Since the tactile neurons of the posterior root supply a larger area of the integument than
the pain neurons and extend far into the adjacent regions, the tactile dermatomes are both
larger than the pain dermatomes and have gradual, blurred borders. Because of this, the tac-
tile dermatomes are said to “overlap”. Sherrington described the borders of the tactile derma-
tomes as flowing into each other “like the colors of a water color painting” (› fig. 4.8).
The overlapping is important for another function: It enhances the capability of tactile lo-
calization, the so-called tactile gnosis.
For this reason, overlapping of the tactile dermatomes is most pronounced in areas requir-
ing particularly high discriminative localization ability, i. e., at the ends of the limbs, espe-
cially at the fingertips.
The esthetic dermatomes are not suitable for study or determination of the segmental borders. In
segmental theory, they therefore play only a minor role, since they have nothing to do with projection
phenomena.
A single prick in a zone of so-called physiological hyperesthesia (› fig. 4.8, circle) thus irri-
tates not just one, but three spinal cord segments, giving it a much wider range of action than
isolated stimulation of a single dermatome, which affects only one spinal cord segment.
Nerve 1
Nerve 2
Nerve 3
Fig. 4.8 Overlapping of the tactile dermatomes (not the pain dermatomes) (schema after Sherrington)
Zones of physiological hyperesthesia are found, for example, in the radial part of the hand (the area of
4
LI 4, TH 5), in the head region (the area of GB 20) as well as in the areas influenced by points of the
stomach and large intestine meridians.
4.3.2 Autonomic-Motor Dermatomes
The term “autonomic-motor dermatomes” refers to dermatomes, which are determined in

their size and borders by autonomic sympathetic efferent neurons of the (motor) anterior
root.
Autonomic-motor dermatomes are much larger than the algetic dermatomes of the same
segment because the preganglionic sympathetic neurons in the sympathetic trunk give rise to
numerous cranial and caudal collateral branches.
This accounts for the wide expansion of autonomic dermatomes in both the cranial and
the caudal directions. Their extent corresponds to the area influenced by the autonomic sym-
pathetic efferent neurons, as shown in chapter 3 (› fig. 3.8). Their dimensions have been
clinically and experimentally established by Foerster and Bumke, and other authors.
For example:
This difference in the dimensions of algetic and autonomic-motor dermatomes, which is
of great practical importance, can be demonstrated by an example:
• The algetic dermatome of T 10 occupies only a 6 inch wide area at the level of the navel.
• The autonomic-motor dermatome of T 10, in contrast, extends from the level of the
mammillae (T 5) to the medial part of the leg (L 4, L 5) as well as onto the dorsal side of
the leg (S 1, S 2).
Since the algetic dermatomes, the autonomic-motor dermatomes, and the autonomic inner-
vation of visceral organs of the corresponding segment belong to the same spinal cord seg-
ment, the following projections occur in case of visceral disorders:
• Hyperalgetic phenomena appear in the algetic dermatomes.
• Autonomic reflexive phenomena such as vasoconstriction, piloerection and increased se-
cretion of sweat appear in the autonomic dermatomes.
This means that the painful regions, the algetic zones, are amply covered by the autonomic
zones, “tinting” the pain.
For example:
• objectively: cold skin, subjectively: sensation of cold; or
• objectively: piloerection (goose bumps), subjectively: sensation of cold shuddering.
The autonomic-motor dermatomes play a highly important role in segmental theory, because it is
through the autonomic symptoms (vasoconstriction, piloerection, increased sweating) that the algetic
symptoms of a disorder become clinically manifest, i. e., objectively and subjectively palpable and visible.
4.3.3 Physiological Hyperesthesia
Transfer phenomena, or referred pain, involve hyperalgesia and hyperesthesia, i. e., “more”
pain and increased sensitivity.
Neurological disorders involve hypo- to analgesia and hypoesthesia, i. e., “less” pain and
decreased sensitivity.
An increase or decrease of habitual pain or sensitivity is, in any case, an indicator of a segmental dis-
order.
However, it must be pointed out that hyperesthesia may also be normal. Such a “physiologi-
cal hyperesthesia” has been demonstrated by Langelaan. One can imagine its development
as follows: 4
Because each tactile dermatome is innervated by at least three spinal nerves, and the bor-
ders of the dermatomes overlap, the middle of the middle dermatome becomes a particularly
hyperesthetic area.
These hyperesthetic areas represent the basis of physiological hyperesthesia, which has
been demonstrated by Langelaan in the form of streaks and bands at the edges of the derma-
tomes (› fig. 4.9).
Physiological hyperesthesia and overlapping of the skin areas only occur in tactile dermatomes. Al-
getic dermatomes do not overlap.
Physiological hyperesthesia thus is due to summation of the innervation in the tactile derma-
tomes.
From the point of view of acupuncture, these areas are very interesting because needling an acupunc-
ture point in an area of overlapping dermatomes can simultaneously stimulate up to three dermatomes,
and thus three spinal cord segments and their segmental parts in the integument and within the body.
If placed correctly, even a minor, superficial, punctiform irritation can therefore stimulate
several spinal cord segments.
It is especially noteworthy that these areas of physiological hyperesthesia contain acu-
puncture points that have a remarkably wide spectrum of effects.
4.3.4 The Maximum Points of the Dermatomes
The maximum points are particularly sensitive areas of about 3 cm in diameter within the
dermatomes. They correspond to the points where the spinal nerve branches enter the in-
tegument (› fig. 4.10).
In each dermatome on the right as well as on the left side of the body, one can find a ven-
tral, a dorsal, and a lateral maximum point.
Figure 4.10 shows the maximum points on one side. This should not obscure the fact that
corresponding maximum points always lie on the left and right sides (and not, as shown in
the illustration for the sake of clarity, only on one side).
Fig. 4.9 Physiological hyperesthesia, resulting from overlapping tactile dermatomes in healthy individuals (after Langelaan, quoted by van Rynberk)
Fig. 4.10 Maximum points on the trunk, overlying the points where the intercostal nerves emerge.
They correspond to those points at which the ventral, lateral, and dorsal branches of the spinal nerves enter the skin (after Head).
Dorsal Maximum Points
The dorsal maximum points of the dermatomes correspond to the points at which the dorsal
spinal nerve branches penetrate the fascia to reach the integument.
They are located 3 cm on each side of the dorsal midline. However, this is the case only as
far as the level of the navel; further caudally, the cutaneous branches emerge 3 cm more later-
ally (Braus and Elze).*
The dorsal maximum points correspond to the shu points of the bladder meridian, which
Chinese instructions localize “two fingerbreadths laterally to the spinous processes”.
Ventral and Lateral Maximum Points
The ventral maximum points of the dermatomes correspond to the points where the ventral
spinal nerve branches enter the integument.
The lateral maximum points of the dermatomes correspond to the points where the lateral
spinal nerve branches enter the integument.
The ventral and lateral maximum points correspond, in part, to the alarm points.
4
When in the presence of visceral disease, pain is referred to the skin, it is rare for the entire derma-
tomic band to become hypersensitive immediately; usually only one maximum point on the homolat-
eral side of the diseased organ is affected.
Maximum Points as Signals of Disease within a Segment
Often in the event of internal disease, but before a diffuse oversensitivity in a dermatome
becomes noticeable, the corresponding homolateral maximum points are already sensitive to
pain. After resolution of the visceral disorder they may persist for a long time as superficial
painful areas.
Maximum points may therefore be painful harbingers, as well as painful memories, of an illness.
Maximum points are characterized not only by hyperalgesia, but may also stand out due to
hyperpigmentation, or occasionally due to depigmentation.
According to Plügge, pruritus often occurs in a circumscribed area corresponding to a
maximum point, so that scratch marks may also provide a clue to diagnosis.
Whenever a circumscribed area of skin repeatedly exhibits the symptoms described above,
i. e., altered pigmentation, scratch marks, or scaliness, one always ought to consider the pos-
sibility of an irritated maximum point, and subject it to “segmental analysis”.
By studying the electrical conductivity of the skin, Schmid was able to show that the maxi-
mum points actually correspond to the sites where nerve branches enter (or exit) the fascia.
Similar results were obtained by Heine in his anatomical analysis of acupuncture points.
Maximum points are of great importance not only in diagnosis, but also in treatment. It is often pos-
sible to influence pathological segmental processes within the body as well as on the body surface
simply by subcutaneous infiltration at such points.
* In my opinion this corresponds to the points on the inner and outer branches of the bladder meridian.
As already mentioned, pathological processes irritating the posterior root of the spinal cord
can have two kinds of effects:
• On the one hand, they may irritate the root neurons, thus eliciting symptoms of sensory
irritation.
• On the other hand, they may interrupt the afferent conduction of impulses through the
nerve root, thus causing sensory defects (Foerster).
When a posterior root is irritated, pain is referred to the corresponding dermatome
(› tab. 4.1).
If the irritation is severe enough, the pain will affect the entire dermatome. In this way, for
example, irritation of a thoracic nerve root may cause a band-like “girdle pain” encircling the
entire trunk.
Severe irritation of a nerve root supplying a limb may trigger pain which will spread
lengthwise, corresponding to the arrangement of the dermatomes on the limbs.
When the stimulus is not very intense, the pain may be referred to certain relatively cir-
cumscribed points, i. e., the maximum points described by Head and Mackenzie.
In practice, maximum points can always be regarded as “signal points” indicating a disorder of an
entire segment (› tab. 4.1).
4
These so-called posterior root pains play an important role in all herpes zoster eruptions and
in every case of spondylitis, but they also represent an early sign of a visceral disorder, in case
of which pain in a maximum point may be the first and only sign of a projection phenomenon.
Tab. 4.1 Projection of pain into dermatomes (according to Foerster)

Dermatome Pain
C 2 Pain in the occiput
C 3 Ear ache
C 4 Pain in the shoulder region
C 5 Pain on the lateral side of the arm, radiating to the thumb
C 6 Pain radiating to the thumb and index finger
C 7 Pain in all fingers, but sometimes only radiating to the middle finger
C 8 Pain in the 4th and 5th fingers, sometimes radiating only to the little finger
T 1 Pain on the medial side of the forearm
T 2 Pain on the medial side of the upper arm
T 5 Pain in the mammilla and the corresponding region on the back
T 6 Pain below the mammilla and dorsally around the inferior angle of scapula
T 10 Pain in the navel region
T 11
T 12 Pain below the navel
L 1 Pain in the groin and in the trochanter major region
L 2 Pain in the anterior part of the thigh
L 3 Pain in the knee, radiating cranially and caudally from there
L 4 Pain on the medial side of the ankle and in the great toe
Note: In this case the great toe is regarded as belonging to L 4
L 5 Pain in the dorsum of the foot and in all toes
S 1 Pain in the sole of the foot and in the heel
S 2 Pain on the dorsal side of the leg, especially of the knee
S 3 Pain in the gluteal fold
S 4
S 5 Pain in the anus, the penis or in the vulva
Such areas of pain, which may be small and circumscribed, therefore are of great interest in diagnosis
and therapy since sometimes the only option for influencing pathological changes inside the body may
be hypodermic infiltration at the maximum point in the corresponding segment, in the manner of neu-
ral therapy.
4.3.5 The Maximum Areas of the Dermatomes
Quite often, within a dermatome one will not only find single points, but entire areas that
may exceed the borders of the segment, to have become sensitive or visibly changed. In such
cases, subcutaneous edema or flat retractions may be present. Sometimes these areas are
also hyperpigmented, particularly if the subcutaneous tissue firmly adheres to the tissues
beneath it (› fig. 4.11). Schmid has designated such dermatomic regions as “garbage
dumps” of a visceral organ, each organ having its own special “dump”.
Schmid regards such changes in a dermatome as highly important in diagnosis and thera-
py:
When, for example, a patient has headache one should think of a focus in the head.
4 along with changes on the anterior neck as
described above,
When a patient has headache in the pres- one should think of a focus in the stomach
ence of changes in the lower thoracic re- and gallbladder as a possible cause of the
gion as described above, headache.
When a patient has headache in the pres- one should think of a focus in the urogeni-
ence of the changes across the sacral bone tal tract.
as described above,
Flat retractions over the shoulder blades are suggestive of a disorder in the region of
are often associated with paresthesias in the the lungs and bronchi.
arms and
In carpal tunnel syndrome, one finds flat retractions or subcutaneous edema at the medial
margin of the shoulder blade. The location of these changes on the shoulder blade is readily
explainable in terms of segmental theory: At the medial margin of the shoulder blade insert-
ing myotomes belong to the same segment as those of the forearm and the hand, where the
carpal tunnel syndrome occurs (C 5|C 6|C 7 myotomes).
• In heart and stomach disorders, maximum zones may appear over the left posterior tho-
racic region.
• In liver and gallbladder disorders, maximum zones may appear over the right posterior
thoracic region.
• In intestinal disorders, one finds maximum zones in the region of T 10 to L 1.
• In disorders of the urogenital tract, one finds maximum zones mainly in the region of
L 2 and L 5.
• In severe menstrual disorders, and in the early menopause, one finds reflexive zones
with integumental changes over the sacrum and the iliosacral joints.
• In varicose veins, crural ulcers, and predisposition to ankle edema, one finds a retract-
ed, linear zone of about 5 cm in diameter below the iliac crests and parallel to them.
These maximum zones are suitable for various massage methods, but also for subcutaneous infiltration.
Gastric zone
Cardiac zone
Upper biliary zone
Intestinal zone
Menstrual zone
4
Obstipational zone
Venolymphatic zone
Urinary bladder zone
Zone of the head
Zone of the arm
Hypomenorrheal zone
Arterial zone of the leg
Fig. 4.11 Maximum zones as changes in the skin and subcutis that exceed the boundaries of individual dermatomes in visceral disorders (after Schmid)
4.4 The Hiatus Lines
Hiatus* lines, also known as axial lines, are lines originating from the budding of the limbs
during early embryonic development (not to be confused with the preaxial lines on the radial
side, and the postaxial lines on the ulnar side of the arm; › page 71). They are also referred
to as “breaker zones” in which distant dermatomes abut in non-metameric sequence.
Since they play a large role in segmental therapy and in the analysis of acupuncture, I
should like to discuss them in greater detail.
Hiatus lines come into being because of protrusion, or budding, of certain segments in
early embryonic development.
As shown in figure 4.6, the buds that giving rise to the upper limbs are formed in the upper
part of the trunk by segments C 5 to T 2, with C 7|C 8 foremost (week 4 of gestation).
In the same manner, the buds that giving rise to the lower limbs are formed in the lower
part of the trunk by segments L 2 to S 2, with L 5|S 1 foremost (week 5 of gestation).
More precisely, the hiatus line consists of two parts (› fig. 4.12):
In the limbs, budding causes segments to become neighbours, since they no longer follow
the original cranio-caudal sequence, i. e., leading to an “interface” between such segments,
4 for example:
• C 6 next to T1 on the upper limb, and
• L 4 next to S 1 on the lower limb.
Since at the “interfaces” or “borderlines”, i. e. the hiatus lines, several non-metameric seg-
ments meet, a stimulus in the region of the borderlines may cause very widely dispersed ef-
fects.
It is interesting to note that in the region of the and at the interfaces of segments, the word “border”
is part of the Chinese names, e. g. TH 5 wai guan (= “outer border”) on the dorsal hiatus line and PC 6
nei guan (= “inner border”) on the ventral hiatus line, both localized on the forearm.
It would exceed the scope of this book to go into the many Chinese terms for acupuncture
points in this context. I consider them good evidence that the Chinese physicians were aware
of the pathways and regions innervated by the spinal nerves.
On the ventral wall of the trunk, these protruded segments are not present.
After the resulting “gap” (› fig. 4.13) is closed, it forms an “interface” where the seg-
ments C 4 and T 2, which, according to Hansen and Schliack, have remained on the ventral
aspect of the upper trunk, and the segments L 1 and S 3, which have remained on the dorsal
aspect of the lower trunk, now border on each other (› fig. 4.14).
Unfortunately, the data on this topic varies with different authors.
Since the segmental borders at the hiatus lines “skip” metameric sequence, the term “seg-
mental leap” of the hiatus lines is also used.
The hiatus is important in segmental theory for yet another reason. As shown in Head’s
table (› fig. 4.13), which summarizes the relationship between integumental zones and the
visceral organs, the spinal cord segments C 5 to T 1 and the spinal cord segments L 3 to L 5
are separated by a gap, a hiatus, because no sensory neurons from visceral organs enter
these spinal cord segments.
Since these spinal cord segments receive no autonomic fibers from visceral organs, i. e., no
visceral-afferent neurons, it is impossible for reflexive pain, i. e., referred pain, to occur in the
corresponding segmental dermatomes.
The dermatomes C 5 to T 1 and L 3 to L 5 therefore form a gap for the impulses from the
visceral organs, in which Head’s zones and referred pain cannot occur.
* Latin, hiatus = gap, crack

4.4 The Hiatus Lines 151
Fig. 4.12 a) (on top) Hiatus lines between the cervical (red) and thoracic (yellow) dermatomes; ventral and
dorsal views of the upper limb.
b) (at the bottom) Hiatus lines between the lumbar (blue) and sacral (gray) dermatomes; medial and lateral
aspects of the lower limb. (Compare with the pre- and postaxial lines; › pp. 71/72)
Note that various authors describe differing dimensions of L 5 and S 1.
Urinary Bladder (detrusor)
Uterus (contractions)
(mucosa and neck)
Kidney and Ureter
Mammary Glands
Urinary Bladder
Adrenal Glands
Zones
Uterus (cervix)
Prostate Gland
Gallbladder
Stomach
Rectum
Adnexa
Ovary
Lungs
Testes
Heart
Liver
Gut
III. Cervical . . . × × ? – – × – – – – – – – – – – – –
IV. Cervical . . . × × × – – × – – – – – – – – – – – –
? – – – – – – – – – – – – – – – – –
× ? – – – – – – – – – – – – – – – –
× × – – – – – – – – – – – – – – – –
4
× × – – – – – – – – – – – – – – – –
× × – – – – – – – – – – – – – – – –
× × ? – – ? – – – – – – – – – – – –
× × × – – × ? – – – – – – – – – – –
× × × – – × × – – – – – – – – – – –
? × × × – × × – – – – – – – – – – –
– – ? × – × – × – – × – × × – × – –
– – – × – – – × – × × × – – × × – –
– – – × – – – × – × × × – – × × – –
I. Lumbar . . – – – – – – – × – × – ? – – × × – –
II. Lumbar . . – – – – – – – ? – × – – – – ? ? – –
V. Lumbar . . . – – – – – – – – – – ? – – – – – – –
I. Sacral . . . – – – – – – – – – – × – – – – – ? –
II. Sacral . . . – – – – × – – – – – × – – – – – × –
III. Sacral . . . – – – – × – – – × – × – – – – – × –
IV. Sacral . . . – – – – × – – – × – – – – – – – × –
Fig. 4.13 Hiatus lines (according to Head)
According to Braus and Elze, the biological reason for this phenomenon is that regardless
of possible visceral disorders, the limbs will remain partially free of referred pain.
Pain-free limbs would enable an animal to perform life-saving movements such as flight,
defense, or attack movements (› page 252).
Fig. 4.14 The hiatus lines on the trunk marking “segmental leaps” or “segmental gaps” of dermatomes missing due to the budding of the limbs: On
the upper limbs there is a hiatus line between C4 and T2 for the missing C 5 to T 1 dermatomes, and on the lower limbs there is a hiatus line between L 2
and S 2, for the partially missing L 2 to S 2 dermatomes. (Modified after Hansen and Schliack)
Note the differing data from Clara (› fig. 4.4).
The fact that several segments meet at one hiatus line means that one single stimulus on this
line can affect several segments in the periphery, thus influencing several spinal cord seg-
ments, or “neurotomes”, at once.
In this manner, for example, stimulation of the acupuncture point TH 5 will reach the segments
C 6|C 7|C 8 and T 1, thereby influencing the corresponding spinal cord segments, together with parts
of the thoracic organs and the thoracic wall.
The hiatus is important in both segmental theory and in acupuncture in yet another way:
Because needling the points TH 5 and PC 6 affects the spinal cord segments C 6|C 7|C 8 and
T 1, it also influences the stellate ganglion and the middle cervical ganglion, which are related
to these spinal cord segments by way of spinal nerves (› pp. 121/122).
The hiatus line of the arm thus corresponds to the integumental projection zone of the large sympa-
thetic ganglia, i. e., the stellate ganglion and the middle cervical ganglion.
4 As already mentioned, van Rynberk asserted as early as 1900 that there “must be a projection
area of the large sympathetic ganglia onto the skin”. I believe that the hiatus lines correspond
to the integumental projections of the great sympathetic ganglia as predicted by van Rynberk
In the crural region, the hiatus line is located between L 4 and S 2, thus forming the bor-
derline between the areas of influence of sympathetic and parasympathetic innervation:
• L 3|L 4 corresponds to the area influenced by sympathetic innervation, i. e., the inferior
mesenteric ganglion.
• S 1|S 2 corresponds to the area of parasympathetic innervation by the pelvic nerves.
“Since every stimulus in the periphery, no matter how small, can irritate a large region in the
spinal cord” (Elze), one must assume that stimulation of TH 5 and PC 6 on the hiatus lines of
the upper limb can influence the large cervical sympathetic ganglia, and stimulation of SP 6
and GB 39 on the hiatus lines of the lower limb can influence the large caudal sympathetic
ganglia (› fig. 4.15).
This would explain, in my opinion, the wide-ranging effects of the points TH 5 and PC 6, or of SP 6 and
GB 39. Therefore, it is possible to roughly equate the effects of acupuncture at these points with infiltra-
tion of the large sympathetic ganglia.
Gottron and Hauser report that in dermatoses, the hiatus lines will form precise delimita-
tions of integumental alterations.
Experience has shown that hiatus lines may also be erogenous zones in which a minor
stimulus can trigger a large response.
Fig. 4.15 The lumbar (blue) and sacral (gray) dermatomes on the medial aspect of the leg, the plantar aspect
of the foot, and in the anal region. Black jagged lines indicate the hiatus lines. (Modified after Hansen and
Schliack)
Note that various authors give differing data on the position of the dermatomes L 5 and S 1.
4.5 Individual Groups of Dermatomes,

and “Autonomic Facial Expression”
The extent and form of the dermatomes are easier to understand when one imagines the
body proportions and the position of an embryo: large head inclined forward, protruding
belly, arms bent, a thumb pointed toward the mouth, the end of the trunk resembling a fun-
nel with a pointed end, legs bent with the medial aspect and the great toes pointing in a cra-
nial direction.
This embryonic position causes stretching of the integument in some places, and forma-
tion of flexion folds in others.
If this body covering retained its stretched or folded and contracted areas like a layer of
warm rubber, then the form and position of an embryo would still be recognizable in the
adult (› fig. 4.16).
Fig. 4.16a Form and position of the embryo (modified after Netter)
4.5 Individual Groups of Dermatomes, and “Autonomic Facial Expression” 157
Fig. 4.16b Simplified schema for learning the metameric dermatomes in a human in quadruped stance: red =
cervical, yellow = thoracic, blue = lumbar, gray = sacral regions (modified after Waldeyer)
4.5.1 Dermatomes of the Head and Neck
A C 1 dermatome does not exist, since the C 1 spinal nerve lacks a sensory cutaneous branch.
C 2 and C 3 Dermatomes
The C 2 dermatome covers the occiput, the throat, and the neck like a head bandage or a ski-
ing cap. Its shape recalls the great bend of the neck with which “the embryo takes its first
bow” (Blechschmidt).
Also in later life, this region retains its importance for gestures of dominance and submis-
sion, in which notably the autonomic changes in the integument of the head-neck fold en-
hance the facial expression and gestures of dominance or submission (e. g., bristling of the
hair, perking the ears, laying back the ears, etc.).
The inner mood is reflected with particular intensity by the dorsal regions of the upper
cervical dermatomes, where “the hair stands on end”, and from which “cold chills run down
the spine”. This, as already mentioned, is due to the fact that 80 % of the sympathetic neurons
are located in the dorsal parts of the dermatomes.
4 The entire dorsal region in human beings is thus a zone of exceptional sensitivity and ex-
pressiveness.
Toward the face, the upper cervical dermatomes C 2 and C 3 border on the region supplied
by the trigeminal nerve (› fig. 4.17). The borderline between the areas innervated by the
cervical and the trigeminal nerves is also known as the vertex-ear-chin line.
Although the trigeminal areas are not actually dermatomes since their sensory nerve sup-
ply comes from the trigeminal nerve, i. e., from a cranial rather than a spinal nerve, they are
described by many authors as being similar to dermatomes. Leonardo da Vinci already cor-
rectly observed that the face has no spinal innervation (› fig. 1.2).
The shapes of the areas supplied by the three branches of the trigeminal nerve can be eas-
ily memorized with the aid of three catchwords taken from Hansen and Schliack:
• The region supplied by the 1st branch of the trigeminal nerve (V/1) is described as a “half-
mask”, or eye mask.
• The region supplied by the 2nd branch of the trigeminal nerve (V/2) is described as a
“mustache tape”.
• The region supplied by the 3rd branch of the trigeminal nerve (V/3) is described as a
“chinstrap bandage”.
The second spinal nerve corresponds to the greater occipital nerve, which exits 4 cm lateral to
the midline and perforates the trapezius and the semispinalis muscles below the nuchal line.
The C 3 dermatome is shaped like an oblique bandage covering the occiput and the throat
like a scarf with a larger ventral and a smaller dorsal part.
• The third spinal nerve corresponds to the great auricular nerve.
• Its sensory cutaneous branch supplies the C 3 dermatome.
• The shape and extent of the C 3 dermatome resembles a Schanz cervical collar brace.
The vertex-ear-chin line is described differently by different authors: According to Kautzky
it runs closer to the face, but others locate it more dorsally (› fig. 4.17).
Clinical experience has shown Kautzky’s dermatomic classification to be correct, since tri-
geminal neuralgia never affects the tragus and the earlobe. Therefore, the region of the face
supplied by the trigeminal nerve must lie much further ventrally than described, for example,
by Hansen and Schliack (König, personal communication). In the lateral parts of the neck,
the C 2 and C 3 dermatomes overlap.
The C 2 and C 3 dermatomes are common projection areas for disorders of visceral organs.
These are expressed as pain, as typical dermatoses, or as autonomic changes on the vertex,
the occiput, the throat, or the neck.
The neural connections pass through the visceral-afferent neurons from the internal or-
gans, radiate into the posterior root of their respective spinal cord segments, and then pass
cranially, either intraspinally or through the sympathetic trunk, to the ciliospinal center.
From this thickening in the upper cervical spinal cord between C 8 and T 3, which provides
sympathetic innervation for the head and neck, nerve impulses travel through the sympa-
thetic network surrounding the internal carotid artery before reaching their sympathetic ef-
fector organs (pupillodilator muscle, among others) and the dermatomes C 2 and C 3. In
these dermatomes they trigger autonomic reflexive signs, such as changed vasomotor activity
of the cutaneous blood vessels, piloerection and increased sweat secretion, as well as marked
hyperalgesia.
Referred pain in the occiput may also be elicited by parasympathetic fibers of the vagal
nerve.
The fact that the sympathetic and parasympathetic impulses converge in C 2, explains why oversensitiv-
ity on the vertex and the occiput occurs in the presence of many disorders. Symptoms include tingling,
oversensitivity to cold and drafts, and “hair ache”. According to Gottron and Hauser, dermatoses on
the occiput may be due to distant projection of visceral disorders, but likewise to vertebragenic irrita-
tion.
4
C2
C3
C4
Fig. 4.17 The vertex-ear-chin line, according to Kautzky (a); and the C 2 and C 3 dermatomes,
according to Bolk (b).
Of great interest in this context is a phenomenon occurring in completely paraplegic patients:

Even in high paraplegia, these patients perceive the filled bladder as an “irritation at the oc-
ciput” (Grüninger, personal communication).
This illustrates that extramedully conduction of impulses is possible, in which the sympa-
thetic system can take over motor and sensory functions in a compensatory fashion (König,
Wancura 1975).
Stated simply: Visceral disorders are projected onto the vertex, the occiput, the throat, and the neck.
Since patients always experience the autonomic projection symptoms in a subjective way –
e. g., bristling of the hairs as cold chills, vasoconstriction as sensitivity to cold and to drafts –
such symptoms of visceral disorders are felt most commonly on the occiput and the neck.
Bending of the head of the embryo causes a small flexion crease in the lateral part of the
neck, corresponding to the C 3 dermatome.
This flexion crease has long been interpreted as a branchial cleft, or gill slit. It was consid-
ered further proof of the recapitulation theory, in that the branchial cleft was regarded as a
vestige of the fish phase persisting in human embryonic development. Cysts occurring in this
region are still referred to as “branchial (cleft) cysts”. 4
According to Blechschmidt, a great critic of the recapitulation theory, this interpretation is
erroneous.
C 4 and C 5 Dermatomes
The C 4 and C 5 dermatomes cover the shoulders and the acromioclavicular joint like a shawl
collar or a stole (› fig. 4.22).
The dermatome C 5 is also known as the “epaulette dermatome”, because it is located in
the lateral region of the upper arm where epaulettes, or shoulder boards, are worn.
The integument at the shoulder level and on the upper arm, as well as the muscles of the
shoulder girdle, belong to the C 4|C 5 segments. They may become hyperalgetic if organs in
the upper abdomen or the thorax become diseased, causing referred pain in the shoulder.
It is well known from clinical experience that heart diseases may trigger referred pain in the left shoul-
der, and liver and gallbladder disorders may trigger pain in the right shoulder.
The neural pathway is as follows: Impulses from the thoracic and abdominal organs adjacent
to the diaphragm use afferent parasympathetic neurons to reach the phrenic nerve. Since the
phrenic nerve is derived from the spinal cord segments C 4|C 5*, it refers the impulses from
the diseased organs adjacent to the diaphragm to “its own” C 4|C 5 segments in the shoulder
region.
Clinically, this will manifest as hyperesthetic areas of the integument, as well as painful
muscles in the region of the shoulder girdle at C 4|C 5.
Referred, or projected, pain always affects the segment as a whole, i. e., the skin in the
shoulder region and the corresponding myotomes, as well as the origins and insertion sites
of these muscles.
Because the right phrenic nerve is directly connected to the stellate ganglion and to the
vagal nerve, pain can be referred by way of sympathetic and parasympathetic neurons (Braus
and Elze).
* Differing data from various authors.

Due to the influence of sympathetic neurons, a sympatheticotonic reaction takes place in

the skin and the cutaneous appendages, in addition to the hyperalgesia. Therefore, vasocon-
striction, increased sweating, but especially piloerection may occur in the shoulder region.
These autonomic changes play an important role in our unconscious body language, i. e., the auto-
nomic facial expressions. Projection signs thus may indicate not only a disorder of a visceral organ, but
also a disturbance of our inner mood. Both are equally able to influence our gestures and facial expres-
sions. Since this is evident with particular clarity in the C 4|C 5 segments, I should like to comment on
it in more detail.
Bristling of the hair due to contraction of the sympathetically innervated arrectores pilorum
muscles leads to accentuation and enlargement of the shoulder region. In this context, Eibl-
Eibesfeldt mentions that in humans, hair in the shoulder region grows in a cranial direction,
so that bristling of the hair (piloerection) leads to an enlargement of the shoulder region.
This enlargement is enhanced by contraction of the C 4|C 5 myotomes, which elevate the
shoulder girdle (levator scapulae muscle, the rhomboid muscles, supra- and infraspinatus
muscles) and raise the upper arm (deltoid muscle).
Enlargement of the shoulder girdle due to segmental stimuli in C 4|C 5 determines the
4 typical posture in “showing off”, as well as the expression of aggression and readiness to
fight.
Although the mass of body hair is reduced in man, piloerection and the enlargement of the
shoulder region, which it produces in aggression and “showing off”, has remained.
The human male is still inclined, for the sake of appearing dominant, to use fashion to
emphasize his shoulders (› fig. 4.18). This is another example of the extent to which he-
reditary preferences influence humans in their fashion trends.
Beyond making the shoulder region appear larger, piloerection also triggers certain emo-
tions and moods.
In this sense, the autonomic neurons of the phrenic nerves (parasympathetic neurons that
also form part of the solar plexus) trigger “frenetic” enthusiasm. “Big” in our social percep-
tion also usually connotes “bad”.
Since during the course of evolution, our autonomic reflexes have been transformed into
social stimuli (Portmann) determining our unconscious body language, I regard the auto-
nomic, “vegetative” nervous system as i. e., plant-like, as the basis of our nonverbal body
language, in that it can communicate information obliquely, rather than directly as in verbal
language, within a social group.
Fig. 4.18 Emphasis of C 4 and C 5 in the fashion of various cultures (bottom illustration). Growth directions
of body hair (top illustration) and its “counterparts” in fashion and dress (modified after Eibl-Eibesfeldt).
C 6|C 7|C 8 Dermatomes
The C 6|C 7|C 8 dermatomes, together with the upper thoracic dermatomes T 1 and T 2, par-
ticipate in the formation of the arm.
Budding of the segments in formation of the limbs has already been described in the con-
text of the origin of the hiatus lines (› fig. 4.6).
Beyond this, however, the formation of dermatomes by budding of the limbs has a particu-
lar feature that is of great importance in the analysis of acupuncture, since it may also help
explain the ancient Chinese theory of “energy circulation”.
Figure 4.6 shows the budding of each segment in its entirety during the formation of der-
matomes, myotomes, and sclerotomes.
Figure 4.19 concentrates only on the formation of dermatomes of the arm, ignoring the
myotomes and sclerotomes.
Head depicted the C 4 to T 2 dermatomes as flat surfaces, as if each dermatome had been
“ironed flat”.
If one analyzes the budding of parts of these dermatomes into parts of the limbs, there are
remarkable parallels to the notion of “energy circulation” which, according to the ancient
Chinese viewpoint, “circulates” from the trunk to the extremities and then back again from
4 the extremities to the trunk.
If one imagines the skin of the dermatomic zones spread out flat, as Head did (› fig. 4.19),
one finds triangular pieces that change shape successively, thus recapitulating embryonic de-
velopment.
As the lateral portions of the C 4 to C 6 dermatomes protrude in the radial half of the
arm, the lateral portions of the C 8 to T 2 dermatomes on the ulnar half of the arm become
smaller.
In other words: By following the changes in shape of the C 8 to T 2 dermatomes on the ul-
nar aspect of the arm, one can recognize the successive changes they undergo, and how the
lateral portion becomes smaller again.
Formation of the integument on the limbs therefore involves rapid advancement of the
lateral portions of the dermatomes, pulling along the ventral ones as well, whereas the dorsal
portions remain firmly in place on the back.
Head also describes the growth and regression of the lateral portions of the dermatomes
during formation of the limbs as
• “flowing into the arm” (equivalent to spreading from proximal to distal), and
• “flowing out of the arm” (equivalent to regression and simultaneous migration back from
the periphery to the trunk).
In my opinion, this spreading out and growing back, or flowing in and flowing out from the trunk to
the periphery, and from the periphery back to the trunk, is equivalent to the notion in Traditional Chi-
nese Medicine according to which there is a “flow of energy” in both directions.
Looking more closely at these pictures of outgrowth of the dermatomes to the integument of
the arm, I can interpret these events only in the following way:
“Not energy, but metamerism”

is responsible for the 4
“influx and outflux of energy”.
Or more concisely:
Not energy, but metamerism determines the flow of energy from the point of view of
TCM.
The dermatomes C 4|C 5|C 6|C 7 mark the radial half of the arm, which “pulls” distally.
The dermatomes C 8|T 1 and T 2 mark the ulnar half of the arm, which “pulls” in a proxi-
mal direction.
C3
The dermatomes of the neck and shoul-
der level, C 3 and C 4, form triangular
surfaces, each with a ventral, a dorsal,
and a lateral corner; designated V, D,
and L, respectively, in the drawing.
C4
The C 4 dermatome covers the top of
the shoulder and the upper arm. In the
figure, the lateral portion of the derma-
tome is beginning to elongate.
C5
4 In C 5 one can see how the lateral cor-
ner continues to elongate, pulling the
ventral corner with it somewhat. The
position of the dorsal corner remains
unchanged, attached to the trunk.
C6
In C 6, the lateral and ventral sides are
already so spread out that the contact
to the trunk is interrupted, leaving the
smaller, dorsal parts of the C 6 derma-
tome isolated on the back.
C7
In C 7 the formation of two digits, i. e.,
the thumb and the posterior aspect of
the index finger, is already foreshad-
owed in the lateral corner.
Fig. 4.19a The dermatomes of the arm, shown as flattened triangular surfaces, whose gradual change of
shape from C 3 to C 7 recapitulates the embryonic growth sequence (modified after Head).
T 4 and T 5

The T 4 and T 5 dermatomes lie atop the
shoulders like shoulder pads or a collar.
T 3
The T 3 dermatome resembles an al-
most isoceles triangle.
T 2
In the T 2 dermatome, the lateral wings
are becoming smaller.
T 1
In the T 1 dermatome the lateral wing
and its ventrolateral and dorsolateral
portions have become yet smaller.
C 8
In the C 8 dermatome, the lateral wing
splits to form a ventrolateral and a dor-
solateral portion; indicated in the figure
by VL and DL.
Fig. 4.19b The dermatomes of the arm, shown as flattened triangular surfaces, whose gradual change of
shape from C 3 to C 7 recapitulates the embryonic growth sequence (modified after Head).
Overlapping of Tactile Dermatomes
Each tactile dermatome – as described above (› page 141) – overlaps the two adjacent der-
matomes, cross-linking three metameric dermatomes and producing a band of physiologi-
cal hyperesthesia along the middle of the middle dermatome (› fig. 4.20).
It is conceivable that intersegmental reflexes, presumably axon reflexes, might lead to an
increase in sensitivity, which in the radial region should be demonstrable as running from a
proximal in a distal direction, and in the ulnar region from a distal in a proximal direction.
In this way, the zones of physiological hyperesthesia on the radial as well as on the ulnar aspects of the
arm could be superimposed on the lung-large intestine meridians, and the heart-small intestine merid-
ians, respectively, located there.
This overlapping involves only neurons for the touch and temperature percepton. The neu-
rons for pain perception, i. e., the algetic zones of the spinal nerves, do not overlap, but are
sharply delimited.
The inconsistency in this statement regarding the nerves of the extremities, the
4 pain-conducting fibers of which overlap considerably, may be explained by the fact that each
limb nerve contains neuronal fibers derived from several segmental nerves. However, the
pain-conducting fibers of the individual segmental nerves do not overlap, even in the limbs
(Braus and Elze).
Nerve 1
Nerve 2
Nerve 3
Fig. 4.20 Overlapping schema of the tactile dermatomes (not the pain dermatomes). (After Sherrington)
4.5.2 Dermatomes of the Trunk T 1 to T 12
Thoracic Dermatomes
The thoracic dermatomes form horizontal rings (› fig. 4.21). In the abdominal region, these
horizontal rings shift to become oblique and aligned in a caudal direction due to the large
volume of the abdominal organs during the embryonic period.
Because there are right and left spinal nerves, each dermatomic belt has a right and a left half.
At the ventral and dorsal midlines the areas innervated by the spinal nerves overlap somewhat,
making the midlines of both the ventral and the dorsal aspects of the trunk particularly sensitive.
The midline meridians CV and GV therefore receive the sum of the information from the right and the
left sides, i. e., impulses from organs on both sides meet here.
Since each spinal nerve supplies the integumental zones on the trunk with a ventral, a lateral,
and a dorsal branch, the dermatomic bands on each side consist of a ventral, a lateral, and a
dorsal section (› fig. 4.21):
4
Fig. 4.21 The thoracic dermatomes T 1 to T 12; ventral and dorsal views. The shift between the levels of the
dorsal and ventral dermatomes is clearly visible. (Modified after Bolk)
Dorsal aspect: 12 subcutaneous dermatomes between the body of the first thoracic vertebra and the tip of
the coccyx.
Ventral aspect: 12 dermatomes between the clavicula and the symphysis.
• The two ventral portions of the dermatome halves form the ventral longitudinal third.
• The two lateral portions of the dermatome halves form the lateral longitudinal thirds on
either side.
• The two dorsal portions of the dermatome halves form the dorsal longitudinal third of
the trunk.
Dorsally, the dermatomic bands “swing upward” at the level of the scapula. This is known as
“scapular elevation”. In the lumbosacral region as well, a similar upward swing in the path-
way of the dermatomic bands can be identified (› fig. 4.21).
The upward swing makes it possible to influence several dermatomes at once with a single,
horizontally inserted needle, i. e., several spinal cord segments may be affected by one appro-
priate needle stimulation.
In this way a single needle, e. g., at the level of the 12th thoracic vertebra, can influence both
lumbar and thoracic spinal cord segments and their related visceral organs.
The thoracic dermatomes are preferential recipients of sympathetic impulses. This is due
to the fact that the original sympathetic nuclei are contained in the spinal cord segment C 8,
in all thoracic spinal cord segments, and as far caudally as the spinal cord segment L 3.
This has far-reaching implications: Sympathetic impulses in the dermatomes C 8 to L 3 may trigger al-
4 getic and autonomic reflexive reactions on the trunk and, to a lesser extent, on the upper and lower
limbs as well.
This accounts for the occurrence of vasomotor changes in the cutaneous vessels, piloerection
and increased sweating, accompanied by painful areas, in these regions.
In case of irritation of the spinal cord segments C 8 to L 3 by diseased visceral organs – or
more precisely, by their visceral-afferent neurons (› page 84 and › fig. 3.14) – sympathetic
impulses are passed on to the dermatomes C 8 to L 3.
Pictured simply: If a glass – the posterior horn of the spinal cord – is full, it will overflow (into the
dermatomes and myotomes). In this manner, “presensitized areas” (Tilscher) develop in the spinal
periphery, which may react to a “second blow” from the outside, possibly only a minor one, with
muscular pain or skin eruptions. The dermatomes C 8 to L 3 are predisposed as preferential sites of
referred pain and the accompanying autonomic symptoms.
The dorsal longitudinal third on the trunk contains more dermatomes than the ventrolat-
eral longitudinal third (› fig. 4.21), because the dorsal fragments of the dermatomes are
not used in limb formation.
Therefore, the dorsal fragments of the dermatomes form a continuous, uninterrupted
metameric sequence from the crown of the head to the tip of the tailbone, i. e., from C 2 to the
coccyx. Braus and Elze, Clara, and other authors have provided anatomical evidence for this
in the subcutaneous dermatomes.
In contrast, the ventrolateral longitudinal third of the trunk contains only twelve thoracic
dermatomes between the clavicle and the symphysis.
The spinal nerves not only form horizontal reactive units encircling the trunk.
The three branches of the spinal nerves also form three longitudinal reactive units due to
the fact that each of the ventral, lateral, and dorsal regions innervated by the branches is
“closely bound” to the adjacent cranial and caudal neighbouring regions (Fanghänel). This
has been verified by histological studies (Morphologisches Jahrbuch, Grosser and Fröhlich;
› fig. 2.13 and › fig. 2.14).
As early as 1979, we (König and Wancura) were able to show that these longitudinal thirds
on the trunk coincide with the longitudinal thirds known in TCM (› fig. 2.7).
Dermatomes on the Limbs
It is particularly interesting in this context that the ventral and lateral longitudinal thirds on the trunk
continue onto the limbs, since the limbs are derived from the ventrolateral abdominal wall by budding,
as described previously.
The limbs and the ventrolateral abdominal wall therefore have a special relationship to each
other, which is also important for understanding acupuncture therapy.
On the upper limb, shifting of the lateral and ventral portions of the dermatomes of the
corresponding segments takes place as follows:
• The areas innervated by the lateral branches continue onto the dorsal and to some extent
onto the ulnar region of the upper limb (green in the figures) as well.
• The areas innervated by the ventral branches continue onto the volar and to some extent
onto the radial region of the upper limb (yellow in the figures) as well.
Thus, there are interactions between
• the dorsal and the ulnar aspects of the arm and
• the lateral and the dorsal longitudinal third on the trunk (in the language of TCM: shaoy-
ang and taiyang, respectively). 4
Therefore, there are also interactions between
• the volar and the radial aspects of the arm and
• the ventral longitudinal third on the trunk (in the language of TCM: yangming).
Completely consistent with these areas innervated by the lateral and ventral spinal nerve
branches is the selection of points according to Chinese acupuncture:
• For disorders in the ventral longitudinal third of the trunk and in the face, points on the
radial aspect and on the inside of the arm are needled.
• For disorders in the lateral longitudinal third of the trunk and in the lateral parts of the
head and neck, points on the ulnar aspect and on the dorsum of the arm are recommended.
Therefore, corresponding to the “innervation chain” there must also be a “reaction chain” between
the ventral longitudinal third on the trunk (stomach meridian) and the radio-volar region of the arm, as
well as between the lateral longitudinal third of the trunk (gallbladder meridian) and the dorso-ulnar
region of the arm.
On the lower limb, the essentially same shifting takes place in the lateral and ventral derma-
tome portions of the corresponding segments:
• The lateral branches cover the extensor muscles, which originally lay on the dorsal part of the
lower limb, but have shifted ventrally due to rotation in the course of embryonic development.
• The ventral branches cover the flexor muscles, which originally lay on the ventral aspect
of the lower limb, but have shifted dorsally due to rotation in the course of embryonic de-
velopment.
In my analysis, on the upper and the lower limbs
• the innervation areas of the lateral branches cover the extensor muscles,
• the innervation areas of the ventral branches cover the flexor muscles.
Several point combinations in Chinese acupuncture may be explained by this connection of segmental
fragments: For example, TH 5, GB 41, GB 20, and GB 34 each lie in an area innervated by a lateral spinal
nerve branch. Therefore, one can imagine that there is not only an “innervation chain”, but also a “reac-
tion chain” within the entire region innervated by the lateral branches of the spinal nerves. It offers an
explanation for the notion of a meridian axis, in this case the shaoyang axis, in Chinese acupuncture.
In principle, the same applies to the ventral branches as well.

Figures 4.22a and b summarize all dermatomes in a clearly arranged mnemonic schema
after Hansen and Schliack.
N. trigeminus (V)
V/1: "half-mask"
V/2: "mustache binder"
V/3: "chin-sling"
C3: "Schanz' cravat" (or necktie)
C4: "stole" (shawl collar)
T2: "angle brace"
T5: mammillary nipples

T6: epigastric angle
T 7: "tip of the sword" (xiphoid process)
4
9:12 thoracic vertebrae
10–12: "pendulous abdomen"
10: "belt with navel buckle"
L1: "pelvic belt"
L2–L5: "anterior leg quartet"
L2/L3: "duo of the thigh"

L3/L4: "dividing the patella in halves"
L4/L5: "duo of the leg"
L5: "general's stripes"
L4–S1: "trio of the foot" (fan)
Fig. 4.22a Mnemonic schema for the thoracic and lumbosacral dermatomes (anterior view, after Hansen and Schliack)
C2: "monk's skullcap"
C3: Schanz' brace (cravat or necktie)

C4: "stole" (shawl collar)
C5–T2: "five emigrants of the arm"
C5: "epaulets" C5: epaulets

C6: thumb and radial side of forearm
C7: middle finger
C8: hypothenar
T1: ulnar side of forearm and
one half of upper arm 4
T2: "angle brace" C6–C8: "trio of glove",
C6: thenar
C7: middle finger
C8: hypothenar
L5–S3: "posterior quartet

of the leg"
S1: "long outsider"

S2: "long insider"
S3: "short round insider"
S4/S5 "anal rings"
Fig. 4.22b Mnemonic schema for the thoracic and lumbosacral dermatomes (posterior view, after Hansen and Schliack)
4.5.3 The Lumbar and Sacral Dermatomes
As already described (› page 138) in detail for the budding of the segments of the upper
limbs, essentially the same events may be observed in the lower limbs.
In the lower half of the trunk, the segments L 2 to S 2, with L 5|S 1 leading the way, pro-
trude to form the lower limbs.
Here too it must be remembered that the lower limbs, like the upper ones, are derived
only from the ventrolateral abdominal wall, although the ventral portions of the dermatomes
of the lower limb later shift dorsally, and the lateral portions ventrally.
For easier memorization, one must keep in mind the embryonic position of the leg: rotated
toward the outside, at a right angle to the trunk, slightly flexed at the knee, the great toe
pointing in a cranial direction (› figs. 2.23, 2.24).
The dermatome L 2 below the inguinal ligament, covers a band

on the thigh running obliquely in a caudal
and medial direction
The dermatome L 3 like an oblique bandage next to the derma-
tome L 2, covers part of the lateral aspect
4 and the extensor aspect of the thigh as far as
the medial part of the knee
The dermatome L 4 covers the ventral and medial regions of the
lower leg as far as the medial malleolus and
the medial part of the foot
The dermatome L 5 covers the ventral and lateral regions of the
lower leg, the dorsum of the foot, and the
lateral edge of the foot, extending to the toes
The dermatome S 1 marks the transition to the flexor region of
the foot, but reaches the toes from the fibu-
lar side
The dermatomes S 1 and S 2 cover the entire back of the legs, ending in
the sacral region
The S 3|S 4|S 5 and the coccygeal are arranged in concentric circles surround-
dermatomes ing the tip of coccyx (› fig. 4.25)
Fig. 4.23 The dermatomes of the lower limb (modified after Bolk).
Blue: lumbar dermatomes; gray: sacral dermatomes.
Red: areas innervated by the dorsal branches; yellow: areas innervated by the ventral branches.
The thick black lines indicate the hiatus lines on the leg.
Fig. 4.24 The dermatomes of the upper and lower limbs.

The limbs are shown in the position of their growth direction during the embryonic period (based on Lanz and
Wachsmuth, quoted by Clara).
Note the difference in position of the foot compared to that shown in figure 2.24.
Fig. 4.25 The lumbar (blue) and sacral (gray) dermatomes on the ventral and dorsal sides of the legs.
4.5.4 Dermatoses and Segmentation
Dermatomes are the “carriers” of systemic dermatoses whose occurrence and location are
determined by the areas innervated by the spinal and sympathetic nervous systems.
Aside from the well-known example of herpes zoster, systemic dermatoses also include
other congenital and acquired dermatoses, such as eczema, mycoses, urticaria, even seg-
ment-related basaliomas that arise, so to speak, “in previously sensitized terrain”, i. e., when
the corresponding visceral organs have become diseased. Thus they represent a kind of re-
ferred pain that has become visible on the skin.
This implies that the segmental innervation of the skin may play an important role in the
pathogenesis of skin conditions.
Acquired dermatoses may be a consequence of colonization by hematogenously transport-
ed germs, which occur mainly in regions of impaired blood flow in the integument. This, in
turn, as shall be described later in detail, may follow changes in cutaneous vasomotion, which
themselves are due to segmental sympathetic irritation in the presence of visceral disease.
Skin changes may thus occur, for example,
• in heart disease, in the left upper quadrant in the dermatomes C 8 to T 4 (› fig. 4.26a),
• in liver and gallbladder disease, on the right border of the costal arch in the dermatomes
4 T 6 to T 8 (› fig. 4.26b).
Other examples have been described:
• candida infection on the thoracic region in the presence of mediastinal tumors,
• basalioma on the left arm in the presence of heart disease,
• fungal infection (mycosis) of the abdominal skin in the presence of intestinal fungal dis-
ease, and
• urticaria due to a penicillin allergy occurring only in the inguinal region and during men-
struation.
Even congenital dermatoses such as naevi have been described and classified as systemic
dermatoses, because the site of their occurrence followed the segmental distribution of spinal
and sympathetic nerves.
It would go beyond the scope of this book to go into detail here. Literature on the “Nerve
Distribution in the Skin in Relation to Skin Diseases”, was published by Blaschko as a supple-
ment to the Verhandlungen der Deutschen Dermatologischen Gesellschaft in Breslau (1901).
Further publications are available from Hauser, Gottron, Fegeler and Kautzky, Hansen and
Schliack, and other authors.
Fig. 4.26a Schema of the algetic and autonomic reflexive projection zones of the heart.
Fig. 4.26b Schema of the algetic and autonomic reflexive projection zones of the liver and gallbladder.
CHAPTER
5 The Myotomes
5.1 Radicular Innervation of the Muscles
The region influenced by each spinal nerve in the striated muscles is referred to as a myo-
tome. Myotome and muscle are therefore not synonymous terms.
Since nearly all muscles consist of material from several neighboring somites, i. e. are
plurisegmental in origin, they are supplied by several spinal nerves, e. g., the trapezius muscle
by the C 2 to C 4 nerves and by the accessory nerve (› fig. 5.1). Monoradicularly innervated
muscles are segment-identifying muscles (› fig. 5.9a).
Despite this, each individual myotome in a plurisegmental myotomic association form-
ing a muscle is supplied by its own branch from its own spinal nerve.
The branches to the muscles are always only side branches that arise from the spinal nerve on its way
from the spinal cord to its dermatome (› fig.2.3).
5.1.1 Segment-Identifying Muscles
Some muscles have monoradicular innervation, i. e., they are derived from only one, or pos-
sibly two, myotomes.
Segment-identifying muscles are monoradicular muscles that enable identification of a
segmental disorder as such. In this regard they have the same informational value as the
dermatomes.
In case of paralysis or diminished reflexes the segment-identifying muscle may provide a
clue to a radicular disorder, such as a herniated intervertebral disk.
Pain in a segment-identifying muscle and hyperactive reflexes suggest the possibility of
viscerogenic irritation.
Changes in reflex behavior of a segment-identifying muscle therefore reveal the identity of
its spinal nerve (› tab. 5.1).
In acupuncture, segment-identifying muscles are crucial because they are the location of important
acupuncture points.
Tab. 5.1 The most important segment-identifying muscles (according to Hansen and Schliack)
Nerve supply Muscles
C 4 Diaphragm
C 5 Deltoid muscle
C 6 Biceps muscle of the arm, brachial, and brachioradialis muscles
C 7 Thenar muscles
C 8 Hypothenar muscles
L 3 Quadriceps muscle
L 4 Anterior tibial muscle
182 5 The Myotomes
Tab. 5.1 The most important segment-identifying muscles (according to Hansen and Schliack)
(Cont’d.)
Nerve supply Muscles
L 5 Long extensor extensor muscle of hallux
S 1 Long and short fibular muscles
Fig. 5.1 Schema of possible innervation patterns of a muscle (after Braus and Elze):
Monoradicular innervation (yellow), e. g., subclavius muscle (C 5); biradicular innervation (blue and red), e. g., bi-
ceps brachii muscle (C 5, C 6); triradicular innervation (yellow, blue, and red), e. g., deltoid muscle (C 4, C 5, C 6).
Notice the different patterns of “fragmentation” of a muscle into various myotomes, although the cranio-
caudal order is maintained. Plexus formation is the basis of peripheral innervation of the limbs. The pathway of
each root “gets lost” in a plexus or in a peripheral nerve. However, in the effector organ, i. e., the muscle, it
reappears in metameric order, as segmental anatomists have shown (› fig. 5.2).
5.2 Metameric Order of the Myotomes 183
5.2 Metameric Order of the Myotomes
Although the muscle fibers mix and the innervation by the spinal nerves forms a network, it
is still possible to demonstrate territories that are almost exclusively or predominantly sup-
plied by a single spinal nerve, as Bolk has shown for the muscles of the shoulder girdle.
Figure 5.2 illustrates how a spinal nerve supplies its territories in several muscles, dividing
the muscles into horizontal bands arranged in cranio-caudal order. This example also shows
that not only the integument, but also the muscles as well follow the atavistic metameric
construction principle.
The parts of various myotomes within a muscle often have different functions, so that the
muscle may not only form a morphological unit as defined by its peripheral innervation, but
also comes to resemble a functional “multiplicity” as defined by its spinal-segmental innerva-
tion.
This is particularly evident in the trapezius muscle. The shoulder girdle is
• elevated by the descending part (myotome C 2),
• lowered by the ascending part (myotome C 4), and
• drawn toward the midline by the horizontal part (myotome C 3).
Typical restrictions of movement of a muscle are therefore always suggestive of certain
segmental disorders (› tab. 5.2).
A person who is thoroughly familiar with the segmental relationships of muscles and bones, is often
able, on the basis of posture or restrictions of movement alone, to suspect a segmental disorder and 5
define its area at first inspection.
Here too, the spinal nerve serves as a “hodoneuromere” (› page 16, footnote), i. e., as a
“guidepost for diagnosis and therapy”.
Fig. 5.2 Metameric order of the myotomes C 3 to C 8 in the muscles of the scapula and the back (modified
after Bolk).
184 5 The Myotomes
Tab. 5.2 Summary of the segmental muscular functions and possible restrictions (after Netter)
Function Muscles Segments
Inspiration Diaphragm C 3|C 4|C 5
Abduction in the shoulder joint Deltoid muscle C 5
Flexion of the elbow Biceps muscle of the arm and brachial muscle C 5|C 6
Dorsal extension of the wrist Extensor carpi radialis muscles (long and C 6|C 7
short)
Extension of the elbow Triceps muscle of the arm C 7|C 8
Flexion of the fingers Flexor digitorum muscles (superficial and pro- C 8
found)
Abduction and adduction of the Interosseous muscles C 8|T 1
fingers
Adduction of the hip joint Adductor muscles L 2|L 3
Extension of the knee joint Quadriceps muscle L 3|L 4
Dorsal extension of the foot Anterior tibial muscle L 4|L 5
Dorsal extension of the great toe Long extensor hallucis muscle L 5|S 1
Plantar flexion of the foot Gastrocnemius muscle S 1|S 2
Anal closure External anal sphincter muscle S 2|S 3|S 4
5
5.3 Herringham’s Rules of Location and Distribution of Myotomes in the Muscles 185
5.3 Herringham’s Rules of Location and Distribution

of Myotomes in the Muscles
The arrangement of the segmental myotomes in a sort of grid as described by Herringham,

follows certain rules based on three observations.
5.3.1 Herringham’s First Rule
The more superficially a muscle is located, the more cranial its spinal nerve innervation.
The deeper a muscle is located, the more caudal its spinal nerve innervation.
In order to understand this better, one may imagine the myotomes as being layered like win-
ter clothing.
• The deepest layer is an undershirt worn next to the skin. This would correspond to the
autochthonous muscles of the trunk and their more caudally derived, i. e., thoracic, spinal
nerve innervation.
• On top of the undershirt, a sweater that covers the neck, the thorax, the arms, and the fin-
gers is pulled over the head. It would correspond to the cranially derived cervical myo-
tomes that likewise cover the neck, the thorax, and the arms. This more superficially situ-
ated muscle layer is innervated by cranially derived, i. e., cervical spinal nerves. 5
• The trapezius muscle covers these two layers like a large shawl.
The topmost layers are innervated by the spi- e. g., the trapezius mus- C 2 to C 4
nal nerves derived from the most cranially cle (“shawl”)
located segments
The middle layer is innervated by spinal e. g., the cervical arm C 5 to T 2
nerves from segments located further caudally and trunk muscles (“sweater”)
The deepest layer is innervated by spinal e. g., the thoracic au- T 1 bis T 12
nerves from the most caudally located seg- tochthonous muscles of (“undershirt”)
ments the trunk
This has consequences for diagnosis and therapy:

• Superficially perceived and superficially palpable pain in the upper back muscles must call
to mind a cervical segmental disorder, i. e., areas of pain in the cervical spine and the arm.
• Deeply perceived pain and muscular tension that can be palpated in deep layers must
call to mind a thoracic segmental disorder with additional potential pain in the thoracic
spine, and possibly skin irritation in the corresponding thoracic dermatomes.
Since the borders of the metameric territories in the muscles overlap, a defect in the peripheral nerve
supply does not necessarily lead to complete loss of function of a muscle. However, it may cause partial
functional impairment that ought to direct suspicion to a disorder in a particular segment.
186 5 The Myotomes
5.3.2 Herringham’s Second Rule
The closer a muscle is to the spinal column, the more cranial is the segment from which its spinal
nerve supply .is derived.
The further away a muscle is from the spinal column, the more caudal is the segment from which its
spinal nerve supply .is derived.
For example:
The trapezius muscle lies closer to the spinal column than the serratus anterior muscle or
the scapular muscles (› fig. 5.3).
Therefore, the trapezius muscle is innervated by spinal nerves whose origins lie further
cranially (C 1 to C 4) than those of the serratus anterior muscle, which is innervated by spinal
nerves originating further caudally (C 5 to C 8), although both muscles lie at the same level
for much of their length (› fig. 5.3).
Practical significance in acupuncture:
If these facts are regarded from the viewpoint of division into longitudinal thirds in acu-
puncture, then
• pain in the dorsal longitudinal third is always related to spinal nerves that originate fur-
ther cranially, and
• pain in the lateral longitudinal third is always related to spinal nerves that originate fur-
ther caudally, although the pain may be perceived at the same level.
5 This is relevant for point selection.
The same rules apply to the extremities:
• For muscular pain located closer to the spinal column (e. g., in the shoulder or hip re-
gion) the underlying disorder must be sought in segments located further cranially.
• For muscular pain located further away from the spinal column (e. g., in the wrist or the
ankle), the underlying disorder must be sought in segments located further caudally.
For example:
Therapy of any type (needle stimulation, neural therapy injections, chirotherapy manipu-
lation) for muscular pain at the following sites must be carried out
• in the region of the shoulder joint, at C 1 to C 4,
• in the region of the elbow joint, at C 5 to C 7,
• in the region of the wrist and hand, at C 7 to T 5 as well.
The same applies to muscular pain
• in the region of the hip joint, at T9 to L 2,
• in the region of the knee joint, at L 3 to L 5,
• in the region of the ankle joint and foot, at L 5 and at all sacral segments.
Venter occipitaöis m. epicranii
M. semispinalis capitis
M. splenius capitis
M. sternocleidomastoideus
M. levator scapulae
Tendinous part of M. trapezius

M. rhomboideus
M. supraspinatus
Spina scapulae
M. infraspinatus
M. deltoideus
Lateral axillary space,
Medial axillary space
M. trapezius
M. teres major
M. triceps brachii
M. teres major M. latissimus dorsi

5
M. serratus posterior inferior
Proc. spinsosus XII Rib "spikes" of M. latissimus dorsi
M. latissimus dorsi
Origins of M. obliquus externus
abdominis
M. obliquus
externus abdominis
M. obliques internus abdominis
Trigonum lumbale
Fascia thoracolumbalis
Fig. 5.3 Schematic drawing of the metameric order of the myotomes. Left side: trapezius muscle; right side: scapular muscles.
188 5 The Myotomes
5
C5
C6
C7
Fig. 5.4 Herringham's rules governing the arrangement of segmental myotomes applies even to the embryo (modified after Braus and Elze):
Herringham's first rule: The more superficially a myotome is located, the more cranial its spinal nerve supply (red, cervical).
The deeper a myotome is located, the more caudal its spinal nerve innervation (yellow, thoracic).
Herringham's second rule: The closer a muscle is to the spinal column, the more cranial is the segment from which its spinal nerve supply is derived (red).
The further away a muscle is from the spinal column, the more caudal the segment from which its spinal nerve supply is derived (yellow).
Herringham's third rule: here the serratus anterior muscle as an example.
5.3.3 Herringham’s Third Rule
The further cranially a myotome is located in the group of myotomes making up a muscle, the further
cranial its segmental innervation.
The further caudally a myotome is located in the group of myotomes making up a muscle, the further
caudal its segmental innervation.
For example:
The latissimus dorsi muscle is derived from the myotomes C 6 to C 8. The most caudally
located part of the latissimus dorsi muscle therefore belongs to C 8.
In case of pain at the medial iliac crest, other potentially painful regions belonging to C 8
must therefore be sought out, e. g.
• the deep muscles of the hand (SI 3 and hand point 1 for pain at the iliac crest),
• the caudal insertions of the pectoral muscles on the ribs, and
• the muscular region of the cervico-thoracic transition.
Knowledge of the segmentally identical myotomes and their locations therefore gives us additional,
highly important clues for diagnosis and therapy, which could never be provided solely by knowledge
of the peripheral nerve supply of a muscle and the rules of acupuncture.
5
190 5 The Myotomes
5.4 The Muscles of the Upper and Lower Limbs and

Their Corresponding Myotomes
C3 C4 C5 C6 C7 C8 Th 1
Shoulder
Upper arm
Forearm
Hand
Fig. 5.5 Overview of the muscles of the arm and leg, and the position of their motor nuclei in the spinal cord segments (modified after Foerster; varying
data from other authors).
5.4 The Muscles of the Upper and Lower Limbs and Their Corresponding Myotomes 191
Hip
Thigh
Leg
Foot
Ball of the big toe

Ball of the little toe
192 5 The Myotomes
5.5 The Individual Myotome Groups
Fitting in with the book title, “Segmental Anatomy”, the muscles and their myotomes shall be
discussed in detail here. At first an overview of the muscles and their corresponding myo-
tomes is presented in figure 5.5.
5.5.1 The Cervical Myotomes
Taken together, the cervical myotomes resemble a turtle-neck sweater that covers the neck,
the arms and fingers, and the thoracic wall down to the umbilicus.
• C 1|C 2|C 3 participate in formation of the superficial and deep muscles of the throat and neck.
• C 4|C 5|C 6 form the muscles of the shoulder girdle.
• C 5 to T 1 form the muscles of the arms and fingers, as well as the superficial ventral and
dorsal muscles of the thoracic wall.
On the upper limb, the myotomes are arranged in longitudinal bands running in a cranio-
caudal direction, parallel to the thumb and little finger lines (› fig. 5.6). Each myotome of the
arm is covered by a longitudinally oval cervical dermatome belonging to the same segment.
The muscles of the shoulder girdle and rib cage are derived from C 4 to C 8 (T 1). These
myotomes spread out in a fan-like pattern, and their segmental nerve supply is distributed in
such a way that separately located, but synchronously reacting muscle parts are formed.
5 Unlike those of the limbs, the cervical myotomes in the shoulder girdle and the thoracic
wall are not covered by dermatomes from the same segments, but rather by thoracic, hori-
zontally aligned dermatomes (› fig. 5.7 and › page 20).
The cervical myotomes on the trunk are thus not merely copies of the dermatomes cover-
ing them, neither in shape nor in their innervation.
The discrepancy in shape and innervation of the superimposed myotomes and derma-
tomes explains why certain acupuncture points are so effective. Since a vertically inserted
needle reaches both thoracic dermatomes and cervical myotomes, and can thus affect a large
region, a single needle – properly placed and inserted to the right depth – can influence
several spinal cord segments at the same time.
Fig. 5.6 Arrangement of the myotomes on the arm: Schema of segmental relations of the arm and hand muscles (after Schuhmacher).
5.5 The Individual Myotome Groups 193
Fig. 5.7 Congruent alignment of the

cervical dermatomes and myotomes at
shoulder level C 2, C 3, C 4 (red). Non-
congruent alignment of the thoracic
dermatomes (yellow) and of the cervi-
cally innervated muscles beneath them 5
that have migrated from the arm to the
trunk.
This explains the often misunderstood fact that stimulation of a single acupuncture point can
influence an entire visceral organ by way of several spinal cord segments.
In this manner, stimulation of point BL 13 affects

• the dermatomes T 3–T 4,
• the myotomes C 3–C 4 (trapezius muscle),
• the myotomes C 5–C 6 (rhomboid muscles).
In this way, a single needle inserted perpendicularly at point BL 13, the back shu point of the lung, may
affect the spinal cord segments C 3 to C 6 and T 3 to T 4, at the same time influencing all resonance
areas of the lung.
Splitting of the myotomes was a major step in evolution.

Whereas, for example, in the lancelet fish one spinal nerve can influence only one circular
segmental part, in higher vertebrates one spinal nerve can influence several split-up myo-
tomes, each of them partially. In this manner, a single spinal stimulus can influence several
myotomes in various muscles at once, thus affecting a large region and its function in an ex-
pedient way.
For example:
The 5th cervical spinal nerve influences the C 5 myotomes, and thus parts of the auxiliary
respiratory muscles in the shoulder girdle and the diaphragm.
In this biologically efficient manner, a single spinal nerve is able to synchronize all the
scattered parts of the respiratory muscles.
The effects of a spinal nerve on its split-up myotome parts is reminiscent of the physical phe-
nomenon of resonance, according to which each tone causes other bodies with the same natural
frequency to vibrate. Head refers to this phenomenon as “fine-tuned by the spinal nerve”.
194 5 The Myotomes
The Myotomes C 1|C 2|C 3, Throat and Neck
The cervical myotomes C 1|C 2|C 3 participate in formation of the following muscles:

• sternocleidomastoid muscle,
• sternohyoid and sternothyroid muscles,
• trapezius muscle, and
• suboccipital muscles of the neck.
The superficial location of their myotomes makes them readily accessible to segmental therapy.
The more deeply situated autochthonous muscles of the neck are not discussed here, since
they are less important for segmental therapy.
As the superficial muscles are always situated ventrally and dorsally, both sides must be
considered for an efficient pain therapy, e. g., C 2 on the occiput and C 2 in the sternoclavicu-
lar region.
The myotomes C 1|C 2|C 3 determine the position of the head. They stretch, bend, and ro-
tate the head, or draw it inward by elevating the shoulders.
The Sternocleidomastoid Muscle (C 2 to C 4)

This muscle is formed by the myotomes C 2 to C 4.
It originates at the mastoid process and runs obliquely in a caudal and medial direction to
the jugular notch of the sternum and the clavicle close to the sternoclavicular joint.
Function: Contraction causes the head to bend to the homolateral side and the face to turn
5 to the opposite side.
Functional impairment: Unilateral contraction causes tilting of the head and gaze direc-
tion suggestive of an irritation in the sternoclavicular joint and a pressure-sensitive point in
the mastoid region.
Contraction of the muscles on both sides causes the head to bend backward, raising the
angle of vision. This gives rise to a particularly “arrogant posture and haughty gaze”.
The Sternohyoid and Sternothyroid Muscles (C 1 to C 4)

The lower hyoid muscles are formed by the myotomes C 1 to C 4, and extend from the hyoid
bone to the thyroid cartilage and the sternum.
Function: Both depress the hyoid bone and the larynx.
Functional impairment: If these muscles become hypertonic, pain and a “burning” sensa-
tion may be felt in the region of the sternum upon deep inspiration. This might explain the
traditional Chinese diagnosis “heat affecting the lungs”, which is otherwise difficult to under-
stand.
Such pain is often accompanied by pain in the temporal and masseter muscles. In such
cases the patients usually complain of dry cough and a sensation of a lump in the throat.
In these patients, one often finds trigger zones on either side of the hyoid bone that are
readily accessible to neural therapy.
The assignment of the segmental-spinal innervation of the myotomes to the muscles with
regard to cranial and caudal spinal nerves is described quite differently by different authors,
since anatomically there is considerable individual variability. I have tried to do justice to this
situation by using parentheses.
The Trapezius Muscle (C 2 to C 4)

The trapezius muscle forms the topmost layer of the back muscles, and extends from the
spinous processes of all the cervical and thoracic vertebrae to the scapula.
According to Tilscher, the trapezius is the “typical psychological target muscle”, and plays
an important role in neural therapy and in acupuncture.
Pain and myogeloses in this region are found particularly often in patients either overbur-
dened by excessive demands or having to assert themselves in a particularly “headstrong”
and “stiff-necked” manner.
Anatomically and segmentally, the trapezius muscle is divided into three sections, which,
according to Herringham’s rules, are assigned in the following way:
• the cranial portion (descending part) to C 2,
• the middle portion (horizontal part) to C 3, and
• the caudal portion (ascending part) to C 4.
Function: All parts of the trapezius muscle stabilize the shoulder girdle.
• The cranial part (C 2) also elevates the shoulder, whereas
• the caudal part (C 4) depresses it simultaneously.
Functional impairment: Muscular tension and myogeloses are most noticeable when the
arm is actively raised and abducted, or rotated laterally.
Patients with muscular tension and pain in the trapezius muscle tend to hold their arms
close to the body in order to minimize painful movements.
This posture gives the patients a markedly stiff and frozen appearance. Letting the arms
hang down for a while also leads to unpleasant sensations in the shoulder girdle, which ex-
plains why the patients intuitively assume a resting posture with slightly elevated arms in
order to relax the trapezius muscle, especially the descending part (C 2) (Schmid). A patient
with such complaints will often look for a chair with arm rests, because supporting the arm
may relieve the C 2 part of the trapezius muscle.
In case of myogelosis and pain in the C 1|C 2|C 3 myotomes, the most important trigger
points are found on the back 5
• at the insertion of the trapezius muscle on the occiput and
• at the spinous processes of the cervical and thoracic vertebrae through to T 12.
In case of spontaneous pain or tenderness of these areas, the ventral myotomes C 1|C 2|C 3
must be examined, and infiltrated if necessary. This applies in particular to the sternohyoid
and sternothyroid muscles, which correspond to the ventral myotomes of C 1|C 2|C 3.
The Suboccipital Muscles of the Neck (C 1 to C 3)

These muscles belong to the autochthonous muscles of the back.
Their myotomes form the
• rectus posterior major and minor muscles of the head (C 1) and the
• oblique superior and inferior muscles of the head (C 1|C 2).
They extend from the first two cervical vertebrae to the nuchal line on the occiput.
Function: These muscles tilt the head backward and raise the plane of view, giving the
person an arrogant appearance.
Functional impairment: Individuals with functional impairment of the suboccipital mus-
cles of the neck often have muscular tension and tenderness at the transverse processes of the
atlas and at the spinous processes of all the upper vertebrae.
The typical position of the head is also seen in the “sterno-symphyseal stress posture”
(Brügger) as a result of marked kyphosis of the thoracic spine and hyperlordosis of the cervi-
cal spine. This position of the head is also found in elderly bent-over individuals as well as in
patients with spondylitis deformans (Bechterew’s disease).
Often, the origin of the sternocleidomastoid muscle and its insertions on the mastoid pro-
cess and the clavicle are sensitive to pressure.
Irritation and painful areas in C 2|C 3:
• Pain in the occiput and neck
• Pain at the anterior neck
• Difficult swallowing
• Earache
• Sensation of a lump in the throat, dry cough
• Dizziness
196 5 The Myotomes
• Nausea, retching, and agoraphobia-like reactions

• Panic attacks, oscillating blood pressure, and tachyarrhythmia.
Kunert described the autonomic functional disorders accompanying irritation of the seg-
ments C 1|C 2|C 3 as “independent Head’s zones”.
The typical sites of irritation are the external occipital protuberance, the mastoid process,
the transverse process of the atlas, the spinous processes of the C 2|C 3 vertebrae and in the
region of the 2nd cervical vertebra, the hyoid bone, the jugular notch, and the cranial half of
the clavicle.
According to Brügger, these areas of irritation may become even more painful when a
sterno-symphyseal posture is assumed, whereas resumption of erect posture is followed by
immediate pain relief.
The Myotomes C 4|C 5|C 6, Shoulder Girdle
The myotomes C 4|C 5|C 6 participate in formation of the shoulder girdle muscles and those
of the lateral part of the upper arm. The individual muscles are:
• greater and lesser rhomboid muscles
• supraspinatus and infraspinatus muscles
• levator scapulae muscle
• trapezius muscle (ascending part),
• teres minor and major muscles
5 • pectoral muscles
• deltoid muscle
These muscles “encircle” the thorax dorsally and ventrally, just as the myotomes C 2|C 3 in
the previously mentioned muscles cover the neck on the back and the front.
They cover the shoulder, the lateral aspect of the upper arm, and the upper part of the back
down to the 12th thoracic vertebral body like a large triangular shawl that is drawn together
across the sternoclavicular joints.
The muscles of the shoulder girdle are derived from
• arm muscles having grown back centripetally toward the trunk,
• trunk muscles having grown centrifugally from the trunk toward the upper limbs, and
• craniothoracic muscles having grown from the head toward the shoulder girdle.
Although such varied muscles migrate centripetally and centrifugally in opposite directions,
they still remain aligned in strictly cranio-caudal, segmental order in the shoulder girdle, as
shown from Bolk (› fig. 5.2).
As elsewhere in the body, their arrangement follows Herringham’s rules:
• The muscles innervated by the more cranially located spinal nerves are located further
cranially, more superficially, and closer to the midline.
• The muscles innervated by the more caudally located spinal nerves are located further
caudally, deeper, and more laterally.
Between the myotomes C 4|C 5|C 6, i. e., the shoulder girdle and the diaphragm, and the or-
gans located adjacent to the diaphragm, spinal and autonomic reflexive interactions take
place (› page 161).
The interactions occur via parasympathetic fibers of the phrenic nerve, and via sympa-
thetic neurons in the ciliospinal center.
Clothing fashions often emphasize the region of the myotomes C 4|C 5|C 6 in a certain way,
demonstrating once again that inherited preferences influence fashion and apparel.
Masculinity is emphasized by shoulder pads, medals, or fringes, intended to create an im-
pression of dominance. Feminity is emphasized by low, “flowing” shoulders.
Fashion and apparel thus imitate the functions of the C 4|C 5|C 6 myotomes:
• In dominating posture (combat readiness and threatening posture), the shoulder girdle
is stretched dorsally, abducted, and rotated somewhat toward the midline (“male gorilla
posture”).
• In submissive posture, the shoulder girdle is bent slightly forward, the head retracted
and tilted slightly to the side, and rotated. This gives the impression of diminution of the
upper body (“martyr posture”).
By ventral flexion and dorsal extension, the muscles of the myotomes C 4|C 5|C 6 enhance the
function of the more deeply situated autochthonous muscles of the trunk by incorporating
limb movements into this posture.
Flexion of the thorax usually also involves flexion of the upper limbs.
Extension of the thorax usually also involves extension of the upper limbs.
Levator Scapulae Muscle (C 3|C 4|C 5)
The levator scapulae muscle originates from the transverse processes of the four upper cervi-
cal vertebrae and inserts on the superior angle of the scapula.
It elevates the scapula and “draws in the head”, while simultaneously rotating the inferior
angle of the scapula toward the midline.
Lesser Rhomboid Muscle (C 4|C 5)

The lesser rhomboid muscle originates at the transverse processes of the 6th and 7th cervical
vertebrae and inserts at the medial margin of the scapula.
5
Greater Rhomboid Muscle (C 4|C 5)
The greater rhomboid muscle originates at the transverse processes of the four upper tho-
racic vertebrae and inserts at the medial margin of the scapula caudally to the insertion of the
lesser rhomboid muscle. The two muscles have the same function, i. e., they press the scapula
onto the trunk, and can pull it toward the midline (“erect posture”).
The Supraspinatus and Infraspinatus Muscles (C 4 to C 6)

These two muscles originate in the supraspinous and infraspinous fossa, respectively, of the
scapula and pass horizontally to the greater tubercle of the humerus:
• The supraspinatus muscle inserts cranially on the greater tubercle, and
• the infraspinatus muscle inserts caudally on the greater tubercle.
Both abduct the arm. In addition, the infraspinatus muscle causes lateral rotation.
Teres Major Muscle (C 5|C 6|C 7)

The teres major muscle originates at the lateral margin of the scapula, close to the inferior
angle, and passes to the crest of the minor tubercle of the humerus.
Its main function is to rotate the arm backwards and medially (similar to the latissimus
dorsi muscle).
Teres Minor Muscle (C 4|C 5)

The teres minor muscle originates at the inferior angle of the scapula and runs toward the
caudal region of major tubercle. It causes outward rotation of the arm.
198 5 The Myotomes
Deltoid Muscle (C 4|C 5|C 6)
The deltoid muscle consists of three parts. Their segmental affiliation is easier to memorize
when one imagines the arm abducted horizontally.
• The acromial part is situated furthest cranially, and is therefore innervated mainly by C 4.
• The clavicular part and the spinal part are situated further caudally, and are therefore in-
nervated mainly by C 5 and C 6 (Herringham).
Origins and insertions:
• The acromial part originates at the acromion.
• The clavicular part originates at the caudal margin of the lateral third of the clavicle.
• The spinal part originates at the lower margin of the spine of scapula.
All three portions insert at the deltoid tuberosity of the humerus.
The deltoid muscle is the most important abductor of the shoulder joint.
• The chief function of the acromial part is abduction of the arm to a 90-degree angle.
• The clavicular part can additionally rotate the arm inward.
• The spinal part can additionally rotate the arm outward.
Disorders of the C 4 segment lead to pain and restriction of active movements of the arm,
especially abduction or inward rotation.
The action of the C 5 myotome is concentrated much more on the shoulder and the upper
arm than that of the C 4 myotome. The C 5 myotome also influences the rib cage (pectoral
and serratus anterior muscles) and the flexors of the arm (biceps, brachioradialis, and bra-
chialis muscles).
5
The Diaphragm (C 3|C 4|C 5|C 6)*
The main function of the diaphragm is the role it plays in respiration. When respiration is
impaired, pain may develop at the points of insertion of the diaphragm in the region of the
2nd, 3rd, 4th lumbar vertebrae as well as that of the 7th to 12th ribs.
The diaphragm also has considerable influence on blood circulation, on the lumen of the esoph-
agus, on gastrointestinal peristalsis, and on the secretions of the pancreas and the gallbladder.
For this reason, conditions involving abnormal contractions of the diaphragm may involve
impairment of respiration and circulation, cardiac arrhythmias, and esophageal spasms, as
well as influence functions of the gastrointestinal tract, the gallbladder and the pancreas.
Conversely, such disorders may also lead to irritation of the diaphragm by way of reflexive
pathways.
This implies that all the muscular parts of C 4 and C 5 discussed in the previous sections
may be irritated by diseases of those organs, giving rise to potential trigger points whose
identification may be helpful in diagnosis.
The diaphragm is innervated mainly by the phrenic nerve. Through the phrenic nerve and
its parasympathetic fibers, pain may be referred to the shoulder region.
As an important muscle of respiration, the diaphragm is related to the accessory respira-
tory muscles and the radial myotomes of the arm.
This strikingly parallels the notion in Chinese acupuncture according to which the “origin of the lung
meridian” lies inside the abdomen and interacts with the radial half of the arm. The lung meridian
would thus correspond to the segments C 4|C 5|C 6, and its segmental reflexive interactions would
occur between the upper half of the thorax, the diaphragm, and the radial half of the arm (› fig. 2.1)
* Varying data given by different authors.

The Myotomes C 6|C 7|C 8|T 1
The myotomes C 6 to T 1 form

• the ventral and dorsal muscular wall, particularly of the lower half of the thorax, and
• the muscles of the arms.
In the lower half of the thorax, these myotomes encircle the trunk in cranio-caudal order:
• dorsally from the spine of scapula to the iliac crest,
• ventrally from the level of the clavicle to the xiphoid process, and
• laterally parallel to the ribs as far as the 12th rib.
They participate in formation of the following muscles:
• pectoral muscles (C 5 to C 8|T 1),
• serratus anterior muscle (C 5 to C 7),
• latissimus dorsi and teres major muscles (C 6 to C 8|Th 1).
In addition, the myotomes C 5 to T 1 form all of the muscles of the upper limbs.
Just as these myotomes on the trunk are aligned in metameric, i. e., cranio-caudal order,
the same order is also found on the limbs (Schuhmacher).
When the arm is raised to the side at a right angle with the thumb pointed in cranial direc-
tion (“embryonic position”), the myotomes are situated as follows:
• myotomes C 5|C 6|C 7 – cranially, on the radial side and
• myotomes C 7|C 8|T 1 – caudally, on the ulnar side.
From a segmental point of view it is therefore possible, despite plexus and network forma-
tions of the peripheral nerves, to identify a clearly segmental, metameric order of the muscles
of the upper limb. 5
In practice, this makes it easier to classify painful conditions:
Pain in the radial aspect of the arm involves In case of pain in the ulnar aspect of the
spinal interactions with the upper half of the arm, the lower half of the thorax must be
thorax examined and treated
Conversely, this means that in case of pain in Conversely, in case of pain located caudally
the upper half of the thorax (i. e., the shoul- to the spine of scapula, the ulnar region of
der girdle) the radial half of the arm as well the arm as well must be considered in diag-
must be examined, and treated if necessary nosis and therapy
Interestingly, segmental classification reveals an extensive agreement between segmental

anatomy and acupuncture.
Since the limbs are derived from the ventrolateral abdominal wall, they are innervated
only by the ventrolateral branches of the spinal nerves.
The ventrolateral branches of the spinal nerves are distributed on the limbs in a charac-
teristic way:
• The ventral branches of the spinal nerves supply
– the ventral longitudinal third of the trunk and neck, i. e., the “flexor aspect” of the
trunk and neck, and
– the radial and volar halves of the arm, i. e., the “flexor muscles” and muscles causing
inward rotation.
• The lateral branches of the spinal nerves supply
– the lateral longitudinal third of the trunk, head, neck, and shoulder, i. e., the “rotation-
al and extensor aspect”, and
– the ulnar and dorsal aspects of the arm, i. e., the “extensor muscles” and muscles caus-
ing outward rotation.
Put more simply:
• The flexor aspect of the trunk and neck is related to the flexor and inward-rotating mus-
cles of the arm which are derived from the same segments. The biological significance of
this arrangement, in my opinion, probably lies in the “primitive segmental motion of
food intake” – which guides the flexed upper limb toward the ventral longitudinal third
200 5 The Myotomes
of the head, neck, and trunk – or, taking the greater pectoral muscle as an example, is
able to “strike and crush” an opponent in struggle.
• The extensor aspect (lateral and dorsal longitudinal thirds) of the trunk and head is re-
lated to the extensor and outward-rotating muscles of the arm which are derived from
the same segments. The biological significance of this arrangement, in my opinion,
probably lies in the primitive segmental motion of fending off and pushing away an at-
tacker.
Mnemonic aid:
“War and peace” are segmentally realized in the following ways:
The cranially located myotomes C 5|C 6 bend, feed, protect

(the flexor muscles of the arm, ventral
branches)
The caudally located myotomes C 7|C 8|T 1 extend, fight, fend off
(the extensor muscles of the arm, lateral
branches)
Pectoralis Major Muscle (C 5 to T 1)

The greater pectoral muscle originates at three points: the clavicle, the sternocostal region,
and the rectus sheath.
5 These origins correspond to the clavicular part, the sternocostal part, and the abdominal
part of the muscle.
Function: It causes anteversion of the arm, i. e., raising it, and then bringing it down pow-
erfully and quickly. With this “attacking muscle” one can strike a blow. In addition, adduc-
tion and inward rotation make this motion even more dangerous and forceful.
Functional analysis of the pectoral muscle, which effects a downward blow, reveals that
even if we do not use it to strike, the motion is ritualized and reduced to a minimum, but still
present.
For example: The mandating hand movement in a sagittal plane, and even the pointed
index finger further demonstrate the commanding and aggressive character of this muscle.
Even in graphology, this motion leaves traces in strongly accentuated lengthwise strokes in
some handwriting, where they always indicate a dominant personality.
Serratus Anterior Muscle (C 5|C 6|C 7)

The serratus anterior muscle originates at the first to ninth ribs and passes to the medial mar-
gin of the scapula.
It causes elevation of the arm with slight rotation of the trunk. Pressure-sensitive spots in
the lateral thorax following a zigzag pattern corresponding to the origins of the serratus mus-
cle are often found along the first to ninth ribs.
Latissimus Dorsi and Teres Major Muscles (C 6|C 7|C 8)

Both muscles originate at the dorsal midline and pass to the lesser tubercle of the humerus:
• The teres major muscle originates at the inferior angle of the scapula, and
• the latissimus dorsi muscle originates at the spinous processes of the lower thoracic ver-
tebrae, the posterior third of the iliac crest, and partly from the lower ribs.
They draw the outstretched arm toward the back and the trunk and rotate it inward.
These muscles also hold the head of the humerus in its socket.
Patients with tension in these muscles complain that carrying heavy burdens is extremely
painful.
7
5
6
8
7
1
8
Th
a b
Fig. 5.8 a) Arrangement of the myotomes on the arm. The bandlike myotomes are aligned in cranio-caudal
order from radial to ulnar (modified after Bolk).
b) Arrangement of the dermatomes on the arm (after Hansen and Schliack).
The Muscles of the Arms and the Fingers (C 6 to T 1)
From a segmental point of view, the muscles of the arms and the fingers are aligned in longi-
tudinal bands from radial to ulnar (Schuhmacher):
• the radial longitudinal band is located more cranially, and
• the ulnar longitudinal band is located more caudally.
202 5 The Myotomes
The Myotomes C 5|C 6
The myotomes C 5|C 6 form the following muscles:

• biceps brachii and brachialis muscles: Both flex the forearm, i. e., the elbow joint; the bi-
ceps muscle also supinates the forearm;
• brachioradialis muscle: This muscle also bends the forearm, but pronates the hand;
• supinator muscle: This muscle causes supination only.
Tension in the C 5 myotomes causes:
• pain on adduction of the arm (pectoral muscle),
• pain on deep inspiration (subclavius muscle),
• pain beneath the shoulder blade and on the rib cage when the arm is elevated above the
horizontal level (serratus anterior muscle),
• pain on inward rotation of the arm (subscapular muscle),
• pain on bending the elbow joint and supination of the forearm (biceps and brachioradia-
lis muscles, supinator muscle).
The Myotomes C 7|C 8
The C 7|C 8 myotomes

• participate in formation of the triceps muscle and the extensor muscles of the arm,
• cause active extension of the elbow (triceps and anconeus muscles) and flexion of the
5 joints of the hand and fingers (superficial flexor digitorum muscles), and
• participate in formation of the extensor muscles of the wrist and fingers (extensor carpi
radialis, extensor carpi ulnaris, extensor pollicis brevis, extensor pollicis longus muscles).
The Myotome C 8
The C 8 myotome, together with the T 1 myotome, forms the caudal superficial muscles of the
thorax that insert on the iliac crest.
The C 8 and T 1 myotomes participate in formation of the flexor muscles of the hand (pro-
nator quadratus , palmaris longus, flexor carpi ulnaris, flexor digitorum profundus, flexor
pollicis longus muscles, interosseous lumbrical muscles (Mm. interossei lumbricales), ab-
ductor digiti quinti, opponens digiti quinti, flexor brevis digiti quinti muscles, and abductor
pollicis brevis, flexor pollicis brevis, and opponens pollicis muscles).
Impairment of function of C 8 and T 1 is revealed mainly by pain on movement of the
hand.
The Myotomes C 7|C 8|T 1
The C 7|C 8|T 1 myotomes form the ulnar aspect of the arm.

They are innervated by the lateral branches of the spinal nerves and covered by the lateral
dermatomic fragments of the same segments.
Here too, a regular metameric arrangement is evident, in which the more caudally located
segments are situated further laterally (serratus anterior muscle).
Due to “fragmentation” and shifting, the cervical myotomes are found in the superficial
muscle layers of both the trunk and the arm.
5.5.2 The Thoracic Myotomes (T 1 to T 12)
The thoracic myotomes T 1 to T 12 form the deep autochthonous muscles of the trunk. They
are arranged in regular cranio-caudal order, i. e., in metameric sequence.
Each myotome is situated at the level of its sclerotome, i. e., the vertebral bodies and the
ribs.
• In the dorsal region of the shoulder girdle and the thorax, the thoracic myotomes are
covered by cervical myotomes and interact with the thoracic dermatomes.
• In the ventral region between the xiphoid process to the symphysis, the thoracic myo-
tomes T 6 to T 12 form the abdominal wall, where they lie directly beneath their corre-
sponding thoracic dermatomes.
• In the axillary line, the cervically innervated superficial muscle layer meets the thoraci-
cally innervated muscles of the abdominal wall, forming a sort of “surf zone” in a long
zigzag line consisting of
– cervical (C 6|C 7|C 8) and
– thoracic (T 5|T 6|T 7) myotomes.
Pathological signals from the cervical and thoracic segments of the body surface and from the
organs in the thorax and abdomen may therefore cause pain and tension along this zigzag
line.
Conversely, sensitive trigger points on the ribs must always call to mind the possibility of a
disorder of the internal thoracic or abdominal organs, or of irritation in the upper limb.
As the upper and lower limbs are derived from the ventral abdominal wall, there are close interrelation- 5
ships between the upper and lower limbs and the anterior abdominal wall, and also between the limbs
and the projection (or referral) areas of all visceral organs on the anterior abdominal wall.
Therefore the area supplied by the ventral branches, i. e., the anterior longitudinal third of
the trunk, interacts intensively with
• the radial and volar regions of the upper limb, and
• the flexor aspect of the lower limb.
This also implies that
• the flexor muscles of the upper limb (on the radial and volar sides) and
• the flexor muscles of the lower limb (on the dorsal side) have a particularly close rela-
tionship to the anterior abdominal wall.
Likewise, the area supplied by the lateral branches, i. e., the lateral longitudinal third of the
trunk, interacts intensively with both
• the ulnar and dorsal regions of the upper limb, and
• the ventral aspect of the lower limb.
This also means that
• the extensor muscles of the upper limb (on the ulnar and dorsal sides) and
• the extensor muscles of the lower limb (on the ventral side) have a particularly close
relationship to the lateral and to the anterior abdominal wall.
Experience has shown that all diseased visceral organs project signals mainly onto the ven-
trolateral abdominal wall.
The kidneys are an exception from this rule, since signals in case of disease are projected to
the back.
Chinese acupuncturists have utilized this fact in therapy for over 3000 years, by consistently treating
disorders of visceral organs via additional points on the meridians of the arms or legs which correspond
to the previously described longitudinal thirds.
204 5 The Myotomes
Each internal organ has “its own” firmly defined projection (or referral) area in the thoracic
and upper lumbar myotomes and in the corresponding dermatomes covering them.
The location of the projection areas (› chapter 9) is determined by the visceral afferent
neurons, i. e., the sensory afferent impulses are “passed on” by each organ to “its own” spinal
cord segment, and thus to the corresponding dermatomes, myotomes, and sclerotomes on
the body surface.
In order to draw the right conclusions from spontaneously or pressure-sensitive points
regarding possible affections of internal organs, it is therefore important to know the location
of each segment and its corresponding myotomes on the body surface.
These points of muscular tension are known as Mackenzie’s pressure points after their
discoverer (› chapter 9.5.2, table of maximum points).
As with the thoracic dermatomes, the original metamerism of the thoracic myotomes is
clearly evident on the basis of their innervation in cranio-caudal order by the spinal nerves
T 1 to T 12.
This means, for example, that a given part of the rectus abdominis muscle and the derma-
tome covering it are innervated by the same spinal nerve.
As integument and muscles in this region belong to the same segment, reflexive contrac-
tion of the abdominal wall for protection of the internal organs is possible via the shortest
and fastest route (proprioceptive reflex), generally known as guarding or muscular defense
(Kunert, Schmid).
5 The Myotome T 1
The T 1 myotome participates in formation of the ulnar muscles of the arm. In addition, to-
gether with the C 8 myotomes, it forms the deep muscles of the hand.
Pain in the region of the hand therefore requires a therapeutic stimulus paravertebrally in
the vicinity of T 1 and in the region of the spinous process of C 7.
The Myotomes T 2|T 3|T 4
The T 2|T 3|T 4 myotomes participate in formation of the transverse thoracic muscle (T 2 to
T 6), which forms the inner lining of the anterior rib cage.
Tension in this muscle often causes respiration-dependent pain over the sternum, which
can be eliminated by a paravertebral injection at the level of the 2nd to 6th thoracic vertebrae.
The Myotomes T 5 to T 10
The myotomes T 5 to T 10 are particularly important in segmental diagnosis and therapy.
They form the rectus abdominis muscle, i. e., the “straight” abdominal muscle that extends
from the xiphoid process and the 5th to 7th ribs to the horizontal branch of the pubic bone.
It is supplied by the intercostal nerves T 5 to T 10 and lies beneath the dermatome of its
own segment.
The Myotomes T 9 and T 10
The myotomes T 9 and T 10 correspond to the region of the rectus abdominis muscle that is
located a hand above the umbilicus.
Disorders of the liver and gallbladder are projected to the right side of this zone at the cos-
tal arch and at the right margin of the rectus muscle, whereas those of the stomach are pro-
jected to the midline and the left side.
According to observations by Elze and Schmid,

• men in general are more sensitive in the 7th thoracic segment, whereas
• women tend to be more sensitive in the 10th thoracic segment.
Muscular tension in the ventral abdominal wall is found
• in liver and gallbladder disorders on the right side between the umbilicus and the rib
cage, usually on the right margin of the rectus muscle;
• in stomach disorders between the umbilicus and the xiphoid process, in the midline and
on the left side;
• in disorders of the small intestine encircling the umbilicus;
• in disorders of the large intestine at the levels of the ascending, transverse, and descend-
ing colon,
• in case of irritation of the appendix in the right lower quadrant at T 12 (McBurney´s
point).
Rectus Abdominis Muscle (T 5 to T 8)

The rectus abdominis muscle is divided horizontally by tendons, permitting approximate
segmental assignment between the xiphoid process and the umbilicus.
• T 5 and T 6 form the cranial region of the rectus abdominis muscle.
– This is where disorders of the esophagus are projected, but also posterior myocardial
infarctions as well.
• T 7 and T 8 form the middle portion of the rectus abdominis muscle between the xiphoid
process and the umbilicus. 5
– Muscular tension is very often found here on the left side in disorders of the stomach,
and on the right side in disorders of the liver and gallbladder.
For example, the region between the first and second tendinous inscriptions of the rectus
abdominis muscle derives its nerve supply mainly from the 8th intercostal nerve, the roots of
which are closely related to the sensory nerves of the stomach.
Stomach cancer may reveal itself very early to the physician who notices a partial contrac-
tion of the left rectus abdominis muscle, even before any stomach complaints have occurred
(Schmid).
This example too illustrates that the projection of a visceral disorder to the outside is a sort
of early warning system, and therefore the importance for a physician to have a thorough
understanding of segmental relationships between the surface of the body and the internal
organs.
Pancreatitis is often accompanied by painful muscular tension to the left of the midline, in
the region between the xiphoid and the umbilicus.
Obliquus Externus Muscle

The obliquus externus muscle (T 6 to T 8) is located between the fifth rib and the iliac crest. It
originates between the indentations of the serratus anterior muscle and the latissimus dorsi
muscle.
Pain on the iliac crest and at the anterior superior iliac spine may be caused by irritation of
the. obliquus externus and internus muscles (T 6 to T 8 and T 10 to T 12).
Disorders of the abdominal and pelvic organs may therefore irritate not only the lower
thoracic spinal column and the adjacent ribs, but also the iliac crest and the anterior superior
iliac spine.
Transverse Abdominis Muscle

The transverse abdominis muscle (T 7 to L 1) originates at the caudal ribs and extends to the
anterior superior iliac spine and the iliac crest. Since it is covered by the obliquus internus
206 5 The Myotomes
and externus muscles and not directly palpable, it is of secondary importance in segmental
therapy and diagnosis.
Serratus Posterior and Inferior Muscles

The posterior and inferior serratus muscles (T9 to T 12)are completely covered by the latis-
simus dorsi muscle, making them practically inaccessible for direct examination and therapy.
Quadratus Lumborum and Psoas Major Muscles

Sustained contraction of the quadratus lumborum and psoas major muscles (T 12 to L 2)
may lead to backache, and sustained contraction of the greater psoas muscle to pain when the
trunk is raised to an erect position.
The quadratus lumborum muscle (T 12 to L 2) extends vertically from the twelfth rib to
the iliac crest. Painful contraction of the quadratus lumborum muscle causes the lumbar
spine to lean toward the side of the shortened muscle. Furthermore, it may cause tender ar-
eas on the lowermost ribs and the iliac crest.
The psoas major muscle (T 12 to L 2) runs from the lower thoracic and upper lumbar spi-
nal column downward to the lesser trochanter.
Pain on the lesser trochanter must therefore always lead one to suspect an irritation of the
thoraco-lumbar transition. A painfully contracted psoas muscle enhances lordosis of the
lumbar spine and flexes the hip joint, especially when the trunk is raised from a supine posi-
5 tion with the legs stretched.
Myalgic pressure points and reflexive tension in the anterior abdominal wall are readily
palpable and assigned to their respective segments:
• the level of the xiphoid process corresponds to T 5,
• the level of the umbilicus corresponds to T 9|T 10,
• the level of the symphysis corresponds to T 12|L 1.
The region of the abdominal wall contains several muscular pressure points, each of which is
named after its discoverer. All of them, however, are Mackenzie’s pressure points (› chap-
ter 9.5.2, table of maximum points).
Reflexive Tendomyopathy in Disorders of Internal Organs
The thoracic and upper lumbar myotomes play a particularly large role in internal medicine,
since hyperalgesia of these muscles may be caused by disorders of internal organs (› Tab. 9.1,
Mackenzie’s pressure points).
Pressure applied to these muscular maximum points usually provokes reflexive defensive
movements and pain.
› Figure 5.9a:
• Part a gives an overview of the most important muscles of the trunk that may be affected
by visceral disorders. The thoracic organs project mainly to the superficial muscle layers
with cervical innervation (Brügger).
• Part b shows reflexive tendomyopathy in case of right-sided lung disease: Only the mus-
cles with cervical innervation are affected, i. e., the trapezius, deltoid, and serratus anteri-
or muscles.
• Part c shows reflexive tendomyopathy as it occurs in cholecystitis: The obliquus and rec-
tus abdominis muscles, i. e., muscles with thoracic innervation, are affected. In addition,
in cholecystitis tendomyopathy may also occur in myotomes with cervical innervation
(trapezius, deltoid, and serratus anterior muscles).
Fig. 5.9a Commonly observed reflexive tendomyopathies in internal diseases (after Brügger); detailed description see text.
This projection, or referral, occurs by a distant projection of the disease to its cervically
innervated myotomes, which are reflexively related via the phrenic nerve (C 4|C 5|C 6)* to
the organs of the upper abdomen (› page 161).
• Part d shows reflexive tendomyopathy in acute pancreatitis. Only the rectus abdominis
muscle is affected in all three sections above the umbilicus.
Hypertonic and hypotonic muscular portions may alternate within the tendomyopathies.
• According to Brügger, hypotonic muscles are painful on contraction, and cause a sensa-
tion of painful fatigue.
• In contrast, hypertonic muscles are painful when they relax, and cause a sensation of
painful stiffness.
For example, in cholecystitis the muscles in the immediate vicinity of the gallbladder may be
completely atonic, but in the surrounding region reflexively contracted.
The fact that the abdominal muscles are arranged in the same metameric order as the in-
tegument covering them is of immense practical importance.
* Different authors give varying data.

208 5 The Myotomes
Fig. 5.9b Segmentally identical innervation of the rectus abdominis muscle and of the abdominal skin
(T 6–T 12) covering it (from Hansen and Schliack).
This applies particularly to the rectus abdominis muscle and the integument covering it,
both of which are supplied by T 6 to T 12 (› fig. 5.9b). This congruence might also explain
the rapid reaction of the abdominal muscles to irritation from the outside:
When, for example, the skin of the anterior abdominal wall is injured or rapidly chilled,
the muscles contract immediately, becoming hard as a board. This familiar phenomenon
presumably protects the visceral organs within.
The reflex is conducted along the sensory afferent neurons of the abdominal skin to the
spinal cord, and from there to the corresponding segmental muscles.
Thus the reflex arc runs within a single spinal nerve, following the shortest and fastest
pathway to the effector organ.
When a myotome is covered by a dermatome from a different segment, the reflex arc is
longer, i. e., more spinal nerves are necessary in order to conduct a reflex, e. g., to transform
an irritation of the integument covering the gluteal region and the gluteal muscles into a
contraction of the gluteus medius muscle.
5.5.3 The Lumbosacral Myotomes
As on the upper limb, the myotomes on the lower limb are arranged in regular metameric
order that can be easily identified when the legs are spread away from the body at right angles
and rotated so that the great toe points upward (› fig. 2.24).
• The lumbar, cranial myotomes lie in a row from proximal to distal along the great-toe line
(preaxial line), “as if flowing from the trunk into the leg”; and
• the sacral myotomes lie in a row along the little-toe line (postaxial line), “as if flowing
back from the leg to the trunk” (Head).
Studies by van Rynberk have shown that the myotomes of the lower limbs also have a longitudinal
“radial” arrangement, in analogy to Schumacher’s observations on the upper limbs (› fig. 5.6).
This hypothesis is confirmed by the positions of the segment-identifying muscles (› tab. 5.1).
In order to better understand the topography of the myotomes and dermatomes of the leg,
it is useful to imagine the human body in a quadruped position (› fig. 5.10):
When the arms and legs are extended toward the floor at right angles to the trunk, with
thumb and great toe pointing forward:
• The ventral aspect of the lower limb is
– rotated anteriorly and covered by the
– cranial myotomes L 1 to L 4, which form the
– extensor muscles of the lower limb. These muscles are covered by the
– lateral dermatomic parts from the same segment.
• The dorsal aspect of the lower limb is
– rotated toward the back and covered by the 5
– caudal myotomes L 5 to S 2, which form the
– flexor muscles of the lower limb. These muscles are covered by the
– ventral dermatomic parts from the same segment.
Likewise in the quadruped position, the angle of the pelvis is such that:
• the large oval of the pelvic inlet and the horizontal pecten pubis with its muscle origins
and insertions
– opens toward the face, relating it to the
– more cranial myotomes (T 12 to L 3);
• the pointed end of the pelvic funnel with its muscle origins and insertions, in contrast,
– opens toward the back relating it to the
– more caudal myotomes (L 5|S 1|S 2).
For the sake of clarity and to refresh memory:
The position of the myotomes on the lower limb and the pelvic girdle is the result of rotation during the
embryonic period. This process involves shifting of the extensor muscles, which were originally located
dorsally, to the ventral aspect.
For the dermatomes, this means that

• the preaxial line, i. e. the great-toe line, and
• the postaxial line, i. e. the little-toe line,
come to lie on the dorsal aspect of the leg.
In figure 2.25 this corresponds to the two borders between green and yellow, and between
yellow and green on the lower limbs.
As in the upper limb, I find agreement in the lower limb as well between the myotome
groups and their functions:
The most cranial myotomes of the legs flex the hip and adduct the thigh
(L 1|L 2|L 3)
The more caudal myotomes of the legs (L 4|L 5) extend the knee and rotate the leg later-
ally
The most caudal myotomes of the legs (S 1|S 2) flex the knee joint
5
Fig. 5.10 The dermatomes of the upper and lower limbs (drawings above) and their schematic representation on
the human in quadruped position (drawings below) clearly illustrate the correlation of all the “-tomes” (derma-
tomes, myotomes, sclerotomes) of the upper and lower limbs (adapted from Lanz-Wachsmuth, quoted by Clara).
These functions are biologically useful:

• In situations such as struggle and defense, the myotomes L 1|L 2|L 3 first bend the hip,
protecting the belly, whereas extension of the knee (L 4|L 5) enables the leg to thrust out-
ward, potentially saving the life of a vanquished combattant lying on his back.
• For a person standing in an erect position, firmly extended legs that are rotated slightly
outward (myotomes L 3|L 4) signalize readiness to attack and fight as well as intention to
overwhelm an opponent. Furthermore, these myotomes have a “direct line” to the sym-
pathetic system.
• The sacral myotomes (L 5|S 1|S 2) cause flexion and “collapsing knees” in the sense of be-
ing defeated or as a submissive posture.
In addition, these segments are areas of resonance for parasympathetic impulses (› pages
#70 and 139#).
Since each myotome and the dermatome covering it belong to the same segment, these
reactions take place along the shortest pathway, consisting of the afferent sensory neurons
from receptors in the integument and the efferent motor neurons of the myotomes belonging
to the same segment. This is what enables a particularly quick, synchronized reflexive re-
sponse.
5
212 5 The Myotomes
The Myotome L 1
The L 1 myotome participates in formation of the iliopsoas, gracilis, and sartorius muscles.
• The iliopsoas muscle is divided into the psoas and the iliac muscles. It consists of the
myotomes L 1 to L 3, and extends from the inside of the pelvis and the lower thoracic ver-
tebrae to the lesser trochanter. It flexes the thigh and rotates it slightly outward.
• The sartorius muscle extends from the anterior superior iliac spine to the medial aspect
of the tibia. It consists of the myotomes L 1 to L 4, flexes the hip and knee joints, and ro-
tates the leg inward.
• The gracilis muscle has a similar function and course. .
In sum, the myotome L 1 radiates to the thigh and causes flexion of the hip and knee joints
and inward rotation of the leg.
The Myotomes L 2 and L 3
The L 2 myotome participates in formation of the adductor muscles (L 2 to L 4) and the quad-
riceps femoris muscle.
The myotomes L 2 and L 3 adduct the leg and extend the lower leg.
The Myotome L 4

5
The L 4 myotome participates in formation of the tensor fasciae latae muscle, the middle and
small gluteal muscles, the posterior and anterior tibial muscles. Its main action is abduction
of the thigh. Patients with disorders in the L 4 myotome often complain of pain upon walking
uphill or climbing stairs.
With the anterior and posterior tibial muscles, the L 4 myotome reaches the foot, which
with the aid of these muscles may be flexed either in a plantar or a dorsal direction.
The tensor fasciae latae muscle extends from the anterior superior iliac spine to the ilio-
tibial tract. It belongs to the segments L 4|L 5, and flexes the thigh.
The gluteus medius and minimus muscles originate on the outer aspect of the iliac crest;
both insert on the greater trochanter. These two muscles stabilize the pelvis on the weight-
bearing leg during standing or walking.
The quadriceps femoris muscle is made up of the myotomes L 2 to L 4. It extends the leg
at the knee joint.
The Myotome L 5
The muscles belonging to the L 5 myotome are located laterally and dorsally on the thigh and
lower leg. The individual muscles are as follows:
• The gluteus maximus muscle (L 5|S 1|S 2) originates in the posterior part of the iliac
crest and from the lateral face of the sacrum, and extends with a broad tendon to the fas-
cia lata. It inserts at the ischial tuberosity. It extends the pelvis into the erect position and
prevents the trunk from falling over when standing.
• The semitendinosus, semimembranosus, and biceps femoris muscles cover the wide
area at the back of the thigh down to the knee (L 5|S 1|S 2). They extend the thigh and flex
the lower leg.
• The outward rotators, the piriformis, internal obturator, gemelli and quadratus femo-
ris muscles, likewise belong to the segments L 5|S 1|S 2.
In sum, the functions of the 5th lumbar segment are mainly:
• extension of the thigh and trunk (gluteus maximus, semitendinosus, semimembranosus,
biceps femoris muscles), and
• outward rotation of the thigh (piriformis, quadratus femoris, gemelli, and internal obtu-
rator muscles).
On the lower leg, the crural muscles belonging to the myotomes L 5|S 1|S 2 are the peroneus
longus and brevis muscles. Their contraction causes plantar flexion, abduction, and prona-
tion of the foot.
5
The Myotomes S 1 and S 2
The S 1 and S 2 myotomes have dorsal muscle parts on the thigh and lower leg. In addition to
the gluteal muscles mentioned above and the ischiocrural muscles, they include the gastro
cnemius muscle, the soleus muscle, and the plantar muscles of the foot.
The myotomes of the lower limb are covered by dermatomes from the corresponding seg-
ments. This fact becomes particularly clear in the “representatives” of the myotomes, i. e.,
their monoradicular segment-identifying muscles, as shown in figures 5.11a and b (also
› fig. 5.1).
214 5 The Myotomes
M. glutaeus
medius
M. sartorius
M. tensor
fascial latae
M. rectus M. adductor
femoris longus
M. rectus
M. vastus M. vastus femoris
lateralis intermedius M. vastus
lateralis
M. vastus
medialis
Vastus
medialis
M. fibularis
M. tibialis M. gastro-
longus
anterior cnemius
M. tibialis
5 M. extensor anterior
digitorum longus
M. soleus
M. fibularis
brevis
Fig. 5.11a Congruent dermatomes and myotomes L 3 (left drawing) and L 4 (right drawing) using segment-
identifying muscles as examples (modified after Hansen and Schliack)
M. tibialis
anterior
M. fibul.
longus
extensor M. soleus
M. digitorum
longus M. gastro-
cnemius M. fibul.
M. fibularis (medial head)
brevis longus
extensor
M. extensor M. digitorum
hallucis longus longus 5
M. fibularis
brevis
M. extensur
hallucis longus
M. tibialis
anterior
Fig. 5.11b Congruent dermatomes and myotomes L 5 (left drawing) and S 1 (right drawing) using segment-
identifying muscles as examples (modified after Hansen and Schliack)

CHAPTER
6 The Sclerotomes
6.1 Radicular Innervation of the Bones
The term sclerotome refers to the areas of bone innervated by spinal nerves. Parts of various
bones may be innervated by the same spinal nerve.
The parts of segmentally identical sclerotomes that belong together could also be described
as the “segmental-spinal bone framework”.
Segmentally identical sclerotomes are distributed like patchwork across the upper limbs
and the shoulder girdle, as well as across the lower limbs and the pelvic girdle.
The segmentally identical sclerotomes are arranged in longitudinal bands that extend
• from the shoulder girdle to the fingers, and
• from the pelvic girdle to the toes.
The arrangement of the sclerotomes, like that of the myotomes, conforms to the unvarying
rules of the spinal nerve arrangement:
• The bone regions innervated by the more cranial spinal nerves are located further ven-
trally and cranially.
• The bone regions innervated by the more caudal spinal nerves are located further dorsal-
ly and caudally.
However, sclerotomes may become painful projection areas for disorders of internal organs,
i. e., sites of referred pain.
This applies notably to the spinous processes of the vertebrae, in which, according to
Mackenzie, sensitivity to pressure is often the first sign of a disorder of an internal organ be-
longing to the same segment (› fig. 6.3).
Bones, joints, and especially the spinous processes should therefore be examined for spon-
taneous pain and sensitivity to pressure, and the affected segment determined.
Following “Ariadne's thread”, one can find the way to other sclerotomes, myotomes, and
diseased enterotomes from the same segment.
In addition to the sclerotomes, Bolk distinguishes sclero-zones which he defines accord-
ing to the origins or insertions of segmentally identical myotomes.
Bolk sees the same consistent arrangement in the sclero-zones as in the sclerotomes and
the myotomes:
• The myotomes supplied by the more cranial spinal nerves have their origins or insertions
in the sclero-zones located further cranially and ventrally.
• The myotomes supplied by the more caudal spinal nerves have their origins or insertions
in the sclero-zones located further caudally and dorsally.
An interesting question is whether the sclero-zones are derived from the same somites
(primitive segments) as the myotomes inserting on them. Animal experiments have shown
the answer to be “yes”, because the muscle insertions on the skeletal parts follow each other
in regular sequence, according to the order of segmental innervation of the muscles them-
selves.
According to van Rynberk, the realization that sclero-zones exist is “proof of the consistent
architectural metameric blueprint of the body of vertebrates and of man”.
For example:
The pelvis is divided into several sclero-zones (› fig. 6.1).
218 6 The Sclerotomes
The gluteus maximus muscle (L 5|S 1|S 2) lies further dorsally and caudally than the glu-
teus medius (L 4|L 5|S 1) and the gluteus minimus muscles (L 3|L 4|L 5).
Therefore the insertion of the gluteus maximus muscle on the greater trochanter is also
located further dorsally and caudally, and the insertions of the gluteus medius and minimus
muscles are correspondingly further ventrally and cranially.
In any case, the spinal nerve passes like a connecting thread from the sclerotome of the
point of origin through its myotome to the sclerotome of the insertion.
In this manner, the sclero-zones originate as segmentally identical bands within which, in
case of disease, a targeted search for other pressure-sensitive points is indicated, e. g. at the
anterior superior iliac spine or the horizontal branch of the pubic bone, that may be utilized
in therapy.
Fig. 6.1 The sclero-zones of the pelvis (from Bolk). The more cranial myotomes, L 1 to L 5, “occupy” the pelvic inlet, and the more caudal ones, S 1 and
S 2, “occupy” the pelvic outlet.
6.2 The Spinal Column and Its Segmental Relations 219
6.2 The Spinal Column and Its Segmental Relations
In the segmental arrangement of the spinal column, the vertebrae and their spinous pro-
cesses are particularly important. They each correspond to a sclerotome in which the inter-
vertebral disk represents the center of a bony segment (Hansen and Schliack; › fig. 6.2).
Since the spinal column is the last clearly recognizable remnant of the segmental order, it
is easy to imagine that each vertebra with its spinous process is assigned its own spinal nerve,
or, as mentioned above according to Hansen and Schliack, two of them.
Pressure-sensitive points located next to an irritated vertebra may give a clue as to which
segment is affected. Such pressure-sensitive points are about 1 cm in diameter; the pain is
piercing and always perceived in the vicinity of a joint, in the case of the vertebrae close to the
facet (or zygapophyseal) joints.
Such pressure-sensitive points occur, for example, with an “arthrogenous dysfunction” or
“blockade” of a facet joint, which are described in detail in textbooks of manual medicine.
Paravertebral pressure points suggest irritation not only of a vertebra, but also of a sclero-
tome from the same segment on the limbs.
In this sense, irritation of the body of the 5th cervical vertebra should prompt testing for
possible pressure-sensitive points on the spine of scapula or on the radial epicondyle, all of
which belong to the C 5 sclerotome.
6
Fig. 6.2 The arrangement of vertebrae

and intervertebral disks in the sclero-
tome (modified after Hansen and Schli-
ack). Each intervertebral disk, together
with the cranially and caudally adjoining
halves of the adjacent vertebrae, forms
a sclerotome centered around the inter-
vertebral disk in the middle.
6
The spinous processes are even more important in diagnosis than the vertebrae. Their sen-
sitivity to pressure, as already mentioned, may be a first indication of a diseased internal or-
gan. Interestingly, in such cases the temperature of the spinous processes is elevated
(Schmidt) and they are sensitive to pressure, although this is evident only when the pressure
is very firm (Heesch).
In contrast, injuries, inflammation, and periosteal disease of the vertebrae and spinous
processes are usually spontaneously painful, so that even slightest touch is perceived as ex-
tremely painful.
When the vertebrae and spinous processes signal an internal disorder, the integument covering the
spinous processes very often shows alterations such as local skin blemishes, scratches, or pressure
marks. Such signs are usually unilateral, indicating an organ disorder on the left or right side.
For the purpose of diagnosis and treatment, a simple and highly practical schema of the as-
signment of vertebrae to internal organs was designed by Mackenzie (› fig. 6.3):
• Disorders of the heart (and the lung) are projected to the cranial thoracic vertebrae,
where they elicit pain in an area extending approximately to the level of the spine of scap-
ula (› fig. 6.3, ellipse A).
• Disorders of the stomach (and duodenum) are projected to the thoracic vertebrae be-
tween the spine and the inferior angle of the scapula (› fig. 6.3, ellipse B).
• Disorders of the liver and gallbladder are projected to the thoracic vertebrae between
the inferior angle of the scapula and the lowest thoracic vertebra (› fig. 6.3, ellipse C).
• Disorders of the rectum and urogenital tract are projected to the region between the
lowest lumbar vertebra and the cranial half of the sacrum (› fig. 6.3, ellipse D).
Fig. 6.3 The spinous processes and

their relationship to disorders of internal
organs (Mackenzie's schema): disorders
of the heart (ellipse A), disorders of the
stomach (ellipse B), disorders of liver
and gallbladder (ellipse C), disorders of
the descending colon, rectum, and uro-
genital tract (ellipse D).
Mackenzie's assignment of disorders of internal organs to certain vertebrae and their spinous
processes is, in my opinion, easier to understand if one considers the positional relationships
between the spinous processes and the spinal cord segments, as Tandler has done (› fig. 6.4).
• In disorders of the heart (ventricle), the spinal cord segments C 8 to T 4 are irritated by
visceral-afferent neurons. However, referred pain is perceived in the spinous processes of
the vertebral bodies C 6 to T 2, which are located somewhat further cranially; they be-
come sensitive to pressure and have a slightly elevated temperature (› fig. 6.3, el-
lipse A).
• In disorders of the stomach and duodenum, the spinal cord segments T 6 to T 8 are irri-
tated by visceral-afferent neurons. In such cases, the spinous processes of the vertebrae
T 4 to T 5, which are located somewhat further cranially, become sensitive to pressure
and have a slightly elevated temperature (› fig. 6.3, ellipse B).
• In disorders of the liver and gallbladder, the spinal cord segments T 8 to T 11 are irri-
tated by visceral-afferent neurons. The spinous processes of the vertebrae T 6 to T 8, as
the corresponding sclerotomes, may become painful (› fig. 6.3, ellipse C).
• In disorders of the rectum and the urogenital tract, the spinal cord segments T 11 to
L 3 are irritated by visceral-afferent neurons. The spinous processes of the vertebrae T 8
to T 10, as the corresponding sclerotomes, may become painful (› fig. 6.3, ellipse D).
According to Mackenzie's observations, rectum and uterus have their own projection area,
located in the region between the 5th lumbar vertebra and the upper half of the sacrum with
the adjacent ilio-sacral joints (› fig. 6.3, ellipse D).
Just how important it is to understand the relationships of the sclerotomes and their inter-
actions with internal organs was underscored by Mackenzie in a very illustrative example:
“Because of great sensitivity of the 6th and 7th thoracic vertebrae and hypersensitivity of the left
upper quadrant of the abdomen, a patient was treated with a plaster body cast.
However, the subsequent autopsy revealed stomach cancer, so that the pain in the bodies of the
6
6th and 7th thoracic vertebrae was actually referred pain from the stomach cancer.”
Surely this treatment mistake would not have been made, if present-day methods of diagnosis had been
available. Nevertheless, this example shows that no therapist should regard patients with pain in the
vertebral bodies and spinous processes solely as “backache patients”, but must always consider the
possibility of a viscero-vertebragenic component in complaints related to the spinal column.
Fig. 6.4 Schematic overview of the levels of the spinal cord segments, the corresponding vertebrae,
and the levels at which the spinal nerves emerge. Lateral view (modified after Tandler).
Note: The difference in levels increases caudally.
6.3 The Individual Sclerotomes
6.3.1 The Sclerotomes of the Upper Limb and the Shoulder Girdle
The segmentally identical sclerotomes of the upper limb form longitudinally oval areas.
Their shapes resemble those of the “their” corresponding dermatomes and myotomes.
As already described for the dermatomes and myotomes, the same principles apply to the
sclerotomes:
• The further cranially the origin of the spinal nerve supply,
• the more radially the sclerotome is located.
• The further caudally the origin of the spinal nerve supply,
• the more ulnarly the sclerotome is located.
According to Bolk and van Rynberk, these rules show “how firmly the segmental principle of
body architecture is anchored in the human organism”.
6
6.3 The Individual Sclerotomes 225
The C 2 and C 3 Sclerotomes
The C 2 and C 3 sclerotomes are located on the occiput and in the upper region of the clavicle.
The C 4 Sclerotome
The C 4 sclerotome comprises the clavicle (› fig. 6.5).
The C 5 Sclerotome
On the scapula, the C 5 sclerotome comprises the cranial half, the coracoid process, and the
spine of scapula. On the upper arm, it includes the lateral margin of the humerus, the lateral
epicondyle, and the olecranon (› fig. 6.6).
The C 6 Sclerotome
On the scapula, the C 6 sclerotome includes the acromion and a strip of the scapula that runs
obliquely from the acromion in a medial-caudal direction. On the upper arm, it includes the
ulnar side of the humerus down to the medial epicondyle and the olecranon, the radial side of
the radius with the head and styloid process of the radius (› fig. 6.7).
The C 7 Sclerotome

6
On the scapula, the C 7 sclerotome comprises the lowest band, which extends dorsally onto
the upper arm as far as the ulnar and radial epicondyles. On the forearm, it forms the dorsal
and ulnar parts of the radius, and the dorsal and radial parts of the ulna. The C 7 sclerotome
also includes the thumb, the index finger, and the middle finger (› fig. 6.8).
The C 8|T 1 Sclerotome
The C 8|T 1 sclerotome comprises a small dorsal region at the distal end of the humerus. On
the forearm, it includes the distal half of the ulna, the wrist bones on the ulnar side, and the
4th and 5th fingers (› fig. 6.9).
The cervical sclerotomes (C4 to C 8), like the cervically innervated “myotome cape”, ventrally and
dorsally embrace the bony torso formed by ribs, vertebral column, and sternum.
Fig. 6.5 Components of the C 4 sclerotome; see text for details (modified after Cushid).
6.3.2 The Sclerotomes of the Lower Limb and the Pelvis
As in the upper limb, the segmentally identical sclerotomes of the lower limb also form band-
like, longitudinally oval areas. Their shapes also resemble those of their corresponding der-
matomes and myotomes. To the sclerotomes of the lower limbs, the same principles apply as
have been described for the upper limb:
• The more cranially the supplying spinal nerve originates,
• the further tibially and proximally the sclerotomes are located.
• The more caudally the supplying spinal nerve originates,
• the further fibularly and distally the sclerotomes are located.
In adults, the sclerotomes of the pelvis and of the lower limb are distributed as follows:
The L 2 Sclerotome
The L 2 sclerotome consists of

• the anterior superior iliac spine, the ventral part of the iliac crest, and a narrow part of the
ischiadic (or sciatic) spine, and
• a narrow strip along the femur that corresponds roughly to the insertion of the adductor
muscles (› fig. 6.10).
The L 3 Sclerotome
The L 3 sclerotome consists of

• a narrow strip of the iliac bone, six inches below the iliac crest, which
• extends anteriorly toward the symphysis and the pubic tubercle.
6
• It runs dorsally along the entire length of the iliac crest, which is curved slightly toward
the outside, then continues along the inside of the femoral neck to the medial region of
the femur.
• Viewed from ventrally, the sclerotome covers the entire wide anterior femoral region and
the patella, continuing along the medial epicondyle to the tibial tuberosity (› fig. 6.11).
The L 4 Sclerotome
The L 4 sclerotome covers a large area:

• Viewed from ventrally, it includes the deepest part of the “pelvic funnel”, half of the fem-
oral neck, and the entire head of the femur, and extends to the upper part of the femoral
shaft.
• Viewed from dorsally, the L 4 sclerotome then covers the lateral side of the femur down
to the lateral epicondyle, and continues to the upper half of the medial margin of the tibia
(› fig. 6.12).
The L 5 Sclerotome
The L 5 sclerotome comprises:

• the caudal part of the iliac wing and the entire ischial tuberosity,
• the greater trochanter at the most cranial part of the femur, and
• the head and shaft of the fibula (› fig. 6.13).
Fig. 6.10 Components of the L 2 sclerotome; see text for details (modified after Cushid).
Fig. 6.14 Components of the S 1 sclerotome; see text for details (modified after Cushid).
Fig. 6.15 Components of the S 2 sclerotome; see text for details (modified after Cushid).
The S 1 Sclerotome
The S 1 sclerotome comprises:

• on the pelvis: a linear region between the superior and inferior posterior iliac spines, ex-
tending to the dorsal side of the acetabulum, and from there to the ischial tuberosity
• on the femur: a narrow strip between the head and neck of the femur
• on the lower leg: viewed from dorsally, the fibular margin of the tibia, and the plantar
sides of the 1st to the 5th toes
• on the dorsum of the foot: it crosses the 2nd to 4th toes, the fibular part of the ankle and
the distal end of the fibula (› fig. 6.14).
The S 2 Sclerotome
• In the pelvis, the S 2 sclerotome is adjacent to the S 1 sclerotome near the posterior inferi-
or iliac spine.
• On the lower leg, it forms the distal part of the fibula and the bony ray of the 5th toe
(› fig. 6.15).
Extensive account of sclerotomes and sclero-zones is given in the works of Bolk, who as early
as 1880 analyzed shoulder girdle and humerus as well as pelvic girdle and femur very pre-
cisely and was able to show extremely interesting relationships: His insights regarding the
“sclero-zones of the shoulder girdle and humerus, and the pelvic girdle and femur” make the
development of the upper and lower limbs understandable.
6
CHAPTER
7 The Enterotomes
7.1 Relationships
If one defines an internal organ by the relationship of its autonomic, visceral afferent nerves
to the spinal cord segments, it is termed an enterotome (or viscerotome).
The arrangement of the visceral organs is not primarily segmental; only their sensory nerve supply con-
nects them to the segmental order of the body. Since the sensory nerve supply of the visceral organs is
derived from the sympathetic and parasympathetic systems, these autonomic connections define the
segmental assignment of the visceral organs to the spinal cord and the spinal periphery.
In the human, the pathways of the efferent neurons supplying the visceral organs have not
been studied as thoroughly as those of the efferent neurons supplying the body surface.
In the integument it is possible, for example, to test the effects of efferent sympathetic neu-
rons by irritating the anterior root and observing the effects on sweat glands, erector muscles
of the hairs, and the blood vessels of the skin.
In the visceral organs, such observations are not as easy.
Studies on other mammals therefore permit only inferences regarding the situation in
man.
Furthermore, isolation of the efferent neurons by dissection is practically impossible be-
cause of their extensive formation of networks and extremely delicate branching (Braus and
Elze).
Better information is available on the afferent pain-conducting neurons supplying the
visceral organs.
However, comparison of experimental findings on mammals allows the conclusion that in
humans as well, most efferent neurons follow the same pathways as the afferent neurons
(Foerster, Braus and Elze, and others).
Depending on the viscero-sensory afferent sympathetic connections of the internal or-
gans to the spinal cord, specific spinal cord segments are irritated, which then pass on the
impulses in “afferent-appropriate form” to the spinal periphery of the body surface. In this
manner, pain is referred to the trunk regions (C 8 to L 3) (› page 244).
The visceral-afferent and visceral-efferent sympathetic neurons of the internal organs
simply “pass through”, according to Fanghänel, i. e., instead of undergoing synapsis in the
sympathetic trunk, they do not do so until they reach the large sympathetic ganglia or the
wall of an internal organ.
Many of the viscero-sensory parasympathetic neurons of the internal organs are con-
tained in the vagus nerve.
240 7 The Enterotomes
Parasympathetic
Nervous System
N. vagus N. phre-
(related to) nicus
N. trige- C3, C4
minus C2 (C5 5) T 1 T 2 T 3 T 4 T 5 T 6 T 7
Bronchi, Lungs
Esophagus
Stomach
Duodenum
Pancreas ? ? ?
Liver, Gallbladder
Ureter
Kidney
Bladder
Colon desc., Rectum
Testis, Epididymis
Urethra
7 Uterus
Fig. 7.1 Afferent neurons of the sympathetic system in the roots of the spinal nerves and afferent neurons of the parasympathetic system with their cor-
responding Head's zones (after O. Foerster; also › pp. 126 and 244).
7.1 Relationships 241
Parasympathetic
Nervous System
N. pelvinus
T 8 T 9 T 10 T 11 T 12 L 1 L 2 L 3 S 2–S 5
Bronchi, Lungs
Esophagus
Stomach
Duodenum
Pancreas
Liver, Gallbladder
Ureter
Kidney
Bladder
Colon desc., Rectum
Testis, Epididymis
Urethra
? Uterus 7
Since fibers of the vagus nerve are connected to the spinal roots of the trigeminal nerve and
the nuclei in the posterior column of the spinal cord segment C 2, these nerves may elicit pain
in the regions supplied by the trigeminal nerve and C 2.
This explains why disorders of organs supplied by the vagus nerve may be accompanied by
referred pain in the face (trigeminal nerve) and the occiput (C 2|C 3).
Other viscero-sensory parasympathetic neurons of the internal organs pass through the
phrenic nerve, and enter the spinal cord at the level of C 4|C 5.
This enables interactions between the internal organs and the shoulder region (C 4|C 5).
Other viscero-sensory parasympathetic neurons of the internal organs pass through the pel-
vic nerves (S 1 to S 5).
This enables interactions between the pelvic organs and the dorsal aspect of the legs (S 1 to S 5).
Pathological changes of internal organs may thus affect cervical, thoracic, and sacral segments of the
spinal cord.
The segmental relations of individual internal organs to the body surface are summarized in
a table (› fig. 7.1):
These segments of the spinal cord conduct the impulses received from the internal organs
to the surface of the body.
In this way, they project a disorder of an internal organ onto the areas of the body surface
derived from the same segment.
This projection or revealing of an internal organ disorder is called “referral” (› chapter
9.1).
The segmental assignment of the internal organ will only be revealed, when considering its
relationship to the body surface by way of the corresponding spinal nerves, as I would put it.
7
Since the segmental relationship of the internal organs to their corresponding segments in the integu-
ment and the muscles is permanent, it is possible to use changes on the body surface as a basis for
indirect deductions regarding disorders of internal organs.
• The visceral-afferent sympathetic neurons conduct pain sensation, and

• the visceral-afferent parasympathetic neurons conduct organ perception, such as nausea,
urinary urgency, etc.
An overview of the sympathetic and parasympathetic innervation of the internal organs is
depicted in figure 7.2 (original table).
7.1 Relationships 243
Overview of the Segmental Supply of Internal Organs (according to Foerster: Handbuch der Neurologie, Vol. 5, 1936)
Spinal Segments
Organs
Sympathetic Nervous System N. vagus Nn. pelvici N. phremicus
Heart and Aorta ascendens T1–T4 (T5) C2, face (C2) C3, C4 (C5)
Lungs and Bronchi (T1)T2–T5(T4–T9) C2, face (C2) C3, C4 (C5)
Esophagus T9 T5 (T6) C2, face
cardia (T5) T6, T7 (C2) C3, C4 (C5)
Stomach body T7, T8 C2, face
pyloric portion T8, T9
Small Intestine and Colon ascendens (T9)T10–L1 C2, face
Appendix T12, L1 (ride side)
Colon descendens and Rectum L1–L8 S2–S5
Liver and Gallbladder (T7)T8–T11 C2, face (C2) C3, C4 (C5)
Pancreas T8 (left side)
Kidney T10–L1
Ureter (T8)T9–L2
Urinary Bladder T11–L1 (L2, L3) S2–S5
Testis and Epididymis (T11)T12–L3
Ovary and Adnexa (T12)L1–L3
Uterus (T12)L1–L3 S2–S5 (?)
Mamma T5–T6
Fig. 7.2 Overview of the segmental nerve supply of the internal organs (from Foerster).
7
7.2 “Transformation” of Internal Organs

into Enterotomes
The visceral-afferent sympathetic and parasympathetic neurons define the respective organs as seg-
mental enterotomes, disorders and diseases of which are manifested on the surface as referred pain.
• The heart (ventricle), due to its sympathetic, visceral-afferent neurons that are connected
to the spinal cord segments C 8 to T 4, belongs to the enterotomes C 8 to T 4 (T 5).
• The lungs, due to their sympathetic, visceral-afferent neurons that are connected to the
spinal cord segments T 2 to T 5, belong to the enterotomes T 2 to T 5.
• The esophagus, due to its sympathetic, visceral-afferent neurons that are connected to the
spinal cord segments T 4 to T 5, belongs to the enterotomes T 4 to T 5.
• The stomach and the duodenum, due to their sympathetic, visceral-afferent neurons that
are connected to the spinal cord segments T 6 to T 9, belong to the enterotomes T 6 to
T 9.
• The pancreas, due to its sympathetic, visceral-afferent neurons that are connected to the
spinal cord segment T 8, belongs to the enterotome T 8.
• Liver and gallbladder, due to their sympathetic, visceral-afferent neurons that are con-
nected to the spinal cord segments T 8 to T 11, belong to the enterotomes T 8 to T 11.
• The small intestine and ascending colon, due to their sympathetic, visceral-afferent neu-
rons that are connected to the spinal cord segments T 9 to L 1, belong to the enterotomes
T 9 to L 1.
• The ureter, due to its sympathetic, visceral-afferent neurons that are connected to the spi-
nal cord segments T 9 to L 2, belongs to the enterotomes T 9 to L 2.
• The kidneys, due to their sympathetic, visceral-afferent neurons that are connected to the
spinal cord segments T 10 to L 1, belong to the enterotomes T 10 to L 1.
• Urinary bladder, descending colon, and rectum, due to their sympathetic, visceral-affer-
ent neurons that are connected to the spinal cord segments T 11 to L 3, belong to the en-
terotomes T 11 to L 3.
• Uterus and ovaries, due to their sympathetic, visceral-afferent neurons that are connected
7 to the spinal cord segments L 1 to L 3, belong to the enterotomes L 1 to L 3.
Ovaries and testes receive additional innervation by neurons from T 10, since they are orig-
inally located far cranially, and migrate caudally (i. e., descend) in the course of embryonic
development. Despite this, they retain their original segmental relations to T 10.
The phenomenon of referral is discussed in more detail in chapter 9 (› chapter 9.2).
CHAPTER
8 Conduction of Impulses
between Segments1
Before discussing the clinical significance of the enterotomes in detail (› chapter 10), it is
necessary to understand how impulses are conducted between segments. The next chapters,
“Conduction of Impulses Between Segments” (› chapter 8) and “Referred Pain” (› chap-
ter 9) are devoted to this topic.
8.1 Multisynaptic, Proprioceptive,

and Viscerogenic Reflexes
Since the architecture of the human body is dominated by the principle of segmentation and
metamerism, the segments, or metameres, in all vertebrates must be related to each other by
basically similar neural connections.
In this way, all parts of a segment (dermatome = integumental part, myotome = muscular
part, sclerotome = skeletal part, angiotome = vascular part, enterotome = visceral part, neu-
rotome = spinal and autonomic part of the nervous system) are linked to one another by
neural connections.
When a stimulus acts on any one of these parts, a wave of excitation is conducted along an
afferent pathway to the nerve center in the same segment, from which it is sent back to the
originally irritated area along an efferent pathway.
This describes a proprioceptive reflex, in which, for example, information is conducted
from one myotome to another myotome belonging to the same segment.
This is of immense importance in pain therapy and in the analysis of acupuncture, since in the course
of development the myotomes of a segment become split apart, and are later found in widely sepa-
rated parts of the body.
Irritation in the myotome of one muscle also causes irritation of other muscles belonging to
the same myotome.
For example, irritation of the myotome C 6 of the brachioradialis muscle likewise irritates
the parts of the serratus anterior muscle that are derived from the C 6 myotome.
Thus, when pain is felt in the radial epicondyle of the elbow (C 6), the lateral margin of the
costal arch (C 6) is likely to be oversensitive to pressure.
A stimulus from one myotome to another myotome, or from one sclerotome to another
sclerotome, is therefore a proprioceptive reflex.
A stimulus from a dermatome to a myotome is a multisynaptic reflex (e. g., plantar reflex,
cremaster reflex, conjunctival reflex, etc.).
Reflexive relationships between parts of a segment (› fig. 8.1, I–III) may therefore be
• proprioceptive reflexes (e. g., from one myotome to another; › fig. 8.1, II), or
• multisynaptic reflexes (e. g., from dermatome to myotome; › fig. 8.1, I).
1 Based on Rein and Schneider, Dittmar and Dobner, and Hansen and Schliack
246 8 Conduction of Impulses between Segments
Reflexive relationships are possible not only between peripheral parts of the same segment,
but also between enterotomes and areas of the integument to which they are segmentally re-
lated.
These reflexive relationships are termed
• viscerogenic reflexes (e. g., from enterotome to myotome; › fig. 8.1, III).
An irritation originating in the enterotome and influencing the dermatomes and myotomes
from the same segment leads to a
• viscero-cutaneous reflex.
The viscero-cutaneous reflex (› fig. 8.1 and › fig. 8.2) passes
• through afferent neurons of the autonomic system and the sympathetic trunk to the pos-
terior horn,
• from there by way of the lateral horn to the anterior horn, and then
• after synapsis in the sympathetic trunk along with the sympathetic neurons in the spinal
nerve to the integument.
The extensive formation of collateral connections in the ganglia of the sympathetic trunk
enables a stimulus to spread to at least seven other sympathetic ganglia, thus passing through
at least seven spinal nerves to the periphery before reaching the sympathetic target organs in
the integument.
This means that a viscero-cutaneous reflex may elicit autonomic reflexive signs of pathol-
ogy in a large area of the skin, even on an entire quadrant of the body.
A reflex initiated by stimulation of a dermatome or myotome and affecting the enterotome
belonging to the same segment is referred to as a
• cuti-visceral reflex.
A reflex originating in a diseased visceral organ and conducted to an initially healthy visceral
organ is referred to as a
• viscero-visceral reflex.
The reflexes described above put all parts of the segment, including the neurotome, i. e., the
corresponding section of the spinal cord, into a state of nervous excitation.
Posterior root
Spinal
ganglion
Sympathetic trunk
8 I Dermatome
Anterior root
R. comm. II Myotome
R. comm. griseus
albus
Visceral nerve III Enterotome
Fig. 8.1 Reflexive relationships between segmental parts (modified after Hansen and Schliack; also › fig. 9.1).
I Multisynaptic reflex from dermatome to myotome
II Proprioceptive reflex from myotome to myotome
III Viscerogenic reflex from enterotome to myotome
The last leg to the muscle is the same in all cases.
8.1 Multisynaptic, Proprioceptive, and Viscerogenic Reflexes 247
This causes excitation of

• the sensory nuclei in the posterior horn,
• the motoric nuclei in the anterior horn, and
• the autonomic nuclei in the lateral horn,
resulting in
• pain phenomena in the integument,
• motor reflex symptoms, and
• autonomic reflex symptoms.
The possible reflexive relationships between the periphery and the internal organs are sche-
matically shown in › figure 8.2.
Fig. 8.2 Overview of possible reflexes between periphery and internal organs (after Rein and Schneider)
Line 1 (solid black line): Conduction of pain and temperature sensations from the integument to the posterior
horn of the spinal cord.
Line 2 (broken black line): Sympathetic neurons from the lateral horn to the integument with synapsis in the
sympathetic trunk.
Line 3 (broken red line): Sympathetic neurons from the lateral horn to the visceral organs that do not undergo
synapsis in the sympathetic trunk, but synapse subsequently in the prevertebral ganglia, e. g., celiac ganglia.
Line 4 (broken green line): Afferent neurons from visceral organs, passing without synapsis to the posterior
horn.
Line 5 (coarsely dashed black line): Peripheral axonal reflex between visceral organs and the integument, by-
passing the spinal cord.
Viscero-cutaneous reflexes pass through line 4 to line 2.
248 8 Conduction of Impulses between Segments
• Line 1 shows the pathways of neurons conducting pain and temperature sensations from
the integument to the spinal cord (somato-sensory afferent neurons).
• Line 2 shows the sympathetic neurons to the skin. They run from the lateral horn through
the anterior horn, undergo synapsis in the chain of sympathetic ganglia, and proceed
with the spinal nerves to the integument (autonomic efferent neurons).
• Line 3 shows the sympathetic neurons to the visceral organs, which pass through the an-
terior horn, the anterior root and the sympathetic trunk without interruption; in the large
sympathetic ganglia they undergo synapsis, and then pass to the enterotomic parts be-
longing to the same segment (viscero-sensory efferent neurons).
• Line 4 shows the afferent neurons of the autonomic system, which pass without interrup-
tion from the internal organs through the sympathetic trunk to the posterior horn (vis-
cero-sensory afferent neurons).
• Line 5: peripheral axonal reflex between visceral organs and the integument, bypassing
the spinal cord.
Viscero-cutaneous reflexes follow line 4 and line 2.
8
8.2 Differentiation of Direct, Indirect, and Referred Pains 249
8.2 Differentiation of Direct, Indirect,

and Referred Pains
Accurate discrimination of direct and indirect pain in an organ from referred pain is essential. This re-
quires precise definitions, since mix-ups and misleading commentaries are very common.
8.2.1 Direct Organ Pain
Direct organ pain is perceived as a dull pain, located deep inside and only at the site of the
disorder.
The patient is able to describe the site and quality of the pain only imprecisely and vaguely.
Depending on its intensity, direct organ pain may give rise to reflexive defense movements
or elevated blood pressure.
8.2.2 Indirectly Conducted Organ Pain (Projected Pain)
Indirectly conducted organ pain occurs when pathological processes spread to the peritone-
um or the surroundings of the organ.
It spreads only along the peripheral spinal nerves, e. g., the intercostal nerves, the ilioin-
guinal nerve, the iliohypogastric nerve etc.
In English, this type of pain is called “projected pain”, which unfortunately often gives rise
to confusion.
The similarity of the terms “projected” (= conducted) and “projection” of internal disor-
ders onto the body surface (= referred pain) often leads to confusion and misleading com-
mentaries regarding descriptions of organic pain.
8.2.3 Referred Pain
Referred pain spreads only within a segment and not along peripheral nerves.
It is not perceived at its site of origin, but rather in the segments on the body surface cor-
responding to the diseased organ.
Not until an internal organ causes referred pain does it reveal its identity as an enterotome 8
(or viscerotome).
Referred pain has a characteristic quality which patients describe as “somewhat strange
sensation” or discomfort.
Referred pain is a basic interaction between the body surface and its insides. It plays a central role in
neural therapy, acupuncture, and manual therapy. For this reason it will be discussed in detail in the
following chapter.

CHAPTER
9 Referred Pain
9.1 Pain Projected to the Body Surface
in Visceral Disease
Disorders of internal organs may become symptomatic by causing pain in far-distant areas of
the body surface, independently of whether the pain is conducted directly or indirectly from
the organ or not. Such pain is termed:
Referred pain = transferred pain = projected pain.
In diagnosis and therapy, this means that disorders of visceral organs may become noticeable
on the body surface as a painful sensation, even when they have not yet caused pain at the
actual site of the disorder, i. e., are “silent”, or at most lead only to vaguely perceived discom-
fort in the affected organ itself.
Referred pain is strictly and specifically assignable to a particular side and segment, and causes pre-
cisely defined and differentiated pain qualities (“where”, “what kind”, “how strong”).
The changes occurring in the integument, the muscles, and the bones in the presence of inter-
nal disorders therefore constitute an early warning system, since they may also be found
before direct organ pain develops.
In the case of projection, or referral, of a disorder in an internal organ, the body surface
shows
• algetic signs of disease and
• autonomic reflexive signs of disease.
Autonomic reflexive signs of disease may include vasomotor changes in the integument, pi-
loerection, altered sweat secretion, etc. Hansen and Schliack consider them to result from
viscerogenic stimulation that remains below the threshold of perception, but is nonetheless
part of the pain mechanism.
The projection phenomena, i. e., the algetic and autonomic reflexive signs of disease, occur
not only on a particular side and related to a particular segment, but also synchronously
with the changes inside the body.
For example, when a typical stomach pain occurs after eating cold food too quickly and
hastily, the changes in the gastric mucosa are likely to involve vasoconstriction, i. e., a sym-
patheticotonic reaction.
At the same time, vasoconstriction of the cutaneous blood vessels and the muscles also
occurs in the regions of the body surface corresponding to the same segments. In this way,
the stomach articulates its complaints within its segmental region on the body surface using
the same “vocabulary”, i. e., vasoconstriction, as in the gastric mucosa.
Conversely, local application of heat to the abdominal wall from the outside causes local
vasodilation on the body surface and simultaneously in the gastric mucosa. These events
have been demonstrated in many studies.
252 9 Referred Pain
As already mentioned (› chapter 8), in visceral disorders, depending on the sensory
nerve supply to the various internal organs by neurons from the sympathetic system, the va-
gus nerve, the phrenic nerve, and the pelvic nerves, hyperalgetic zones occur in the following
areas:
• Corresponding to the origins of the sympathetic system in C 8 to L 3, disorders of any
internal organs may give rise to hyperalgetic zones in C 8 to L 3, i. e., on the trunk and on
the extensor aspects of the limbs.
• Corresponding to the areas of the spinal cord into which the phrenic nerves radiate at the
level of C 4|C 5, disorders of organs adjacent to the diaphragm may cause pain in the seg-
mental regions of C 4|C 5, i. e., in the shoulder girdle.
• Corresponding to the areas of the spinal cord into which the pelvic nerves radiate at the
level of S 2 to S 5, disorders of the pelvic organs may lead to hyperalgetic zones in the re-
gion of the dorsal aspect of the legs and on the buttocks, i. e., in S 2 to S 5.
• Corresponding to the connections of vagal fibers with the trigeminal nerve and C 2, dis-
orders of organs innervated by the vagus nerve may lead to hyperalgetic zones in the face
and the occiput, i. e., in C 2.
As this list shows, certain segments are not involved in projection, so that referred pain is impossible in
those segments.
These spinal cord segments represent so-called “gaps” (Head) in information from the vis-
ceral organs (› fig. 4.13).
According to Head,
• the upper gap lies between C 4|C 5 and C 8|T 1, and
• the lower gap lies between L 2|L 3 and L 5.
These gaps, remaining unaffected by irritation of visceral organs, correspond to the spinal
cord segments from which the nerve supply of the limbs is derived.
• The spinal cord segments C 4|C 5 to C 8|T 1, which correspond to the upper gap, supply
the upper limb.
• The spinal cord segments L 2|L 3 to L 5, which correspond to the lower gap, supply the
lower limb.
However, this discovery by Head must be further qualified.
Since formation of the limbs also involves segments containing the sympathetic nuclei in
the spinal cord, parts of the limbs are involved in projection after all. On the
• upper limbs this applies to the segments C 8|T 1|T 2, and on the
• lower limbs it applies to the segments L 2 and L 3.
Analysis of the muscles supplied by these segments reveals that
• the extensor muscles of the elbow and the knee are the ones affected. Their functions in
attack, defense, fighting, and escape are essential, but may be impaired.
9
• In contrast, the flexor muscles are not involved in projection, so that the life-saving
flexor response remains intact even in the presence of visceral disorders (› page 152).
9.2 Projected Symptoms 253
9.2 Projected Symptoms
9.2.1 General Aspects of Projected Algetic Symptoms
Projected algetic symptoms are

• more pronounced in acute conditions than in chronic ones,
• more pronounced at the start of a disorder than during the healing phase, and
• of changing intensity during the course of an illness.
Head mapped the precise topography of regions and areas of referred pain in disorders of
specific visceral organs. The zones of referred pain as related to the individual enterotomes
are named “Head's zones” in honor of his work.
Mackenzie expanded this concept by adding muscular pressure points to Head's schema.
Such pressure points are designated “Mackenzie's zones” after him.
The pathogenesis of projected, or referred, pain is still not completely understood.
A schematic representation, based on Hansen, of the possible origins of referred pain in
the presence of visceral disorders is presented here (› fig. 9.1; also › fig. 8.1).
For example:
A diseased visceral organ, e. g., the pancreas, sends viscero-sensory, sympathetic afferent
impulses to the posterior horns of the spinal cord segments T 7 to T 9, where they lead to a
“field of irritation”.
When additional somato-sensory afferent impulses from the segments T 7 to T 9 in the
periphery enter this “field of irritation” of the posterior horn, the stimuli of organ pain and
the input from the periphery add up to produce a “cumulative impulse”.
In practice this means that an impulse which by itself would be too weak to elicit an effect
in the corresponding dermatome can overstep the threshold in the presence of an organ dis-
order, thus becoming perceptible as pain and revealing which dermatome is affected.
The “cumulative impulse” mentioned above is conducted to the cerebral cortex by way of
the spinothalamic tract.
Animal experiments have shown that projected, or referred, pain can be elicited even in
decapitated dogs, identifiable on the basis of muscular contractions.
Since the periphery of the body is more strongly represented in the cortex than the visceral
organs, the cerebrum interprets the pain as coming exclusively from the body surface.
Furthermore, impulses from the diseased internal organ give rise to reflexive muscular
tension by way of synaptic transmission to the nuclei in the anterior horn (“somato-motor
effects”).
Transmission to the sympathetic nuclei in the lateral horn results in autonomic reflexive
symptoms such as vasoconstriction, piloerection, altered sweat secretion, etc. (“viscero-mo-
tor effects”) in the periphery.
Organ pain is always projected in an afferent-suitable form to the corresponding segment,
9
e. g., pain in the pancreas to the spinal cord segments T 7 to T 9.
In this manner, the dermatomes and myotomes T 7 to T 9 become “sensitized”, so that an
additional stimulus from the outside may cause them to become hyperalgetic, i. e., identifi-
able as Head's or Mackenzie's zones.
Therefore these regions also offer a possible therapeutic approach in which the internal
organs may be influenced from the outside.
9.2.2 General Aspects of Projected Autonomic Reflexive

Symptoms
Projected autonomic reflexive symptoms always occur, even if no (or not yet any) projected
algetic symptoms are present. They may appear long before algetic symptoms develop.
There is an interesting and diagnostically important temporal order regarding visceral dis-
orders and their projection onto the body surface:
254 9 Referred Pain
Referred pain
ain
lp
a
er
c
Vis
Afferent signals to
the skin
Hyperalgesia
Afferent signals
to muscles
Hyperalgesia
Reflexive tension
T7−9
Fig. 9.1 Schematic representation of the development of referred pain (modified after Hansen, as quoted by Monnier).
The cumulative impulses from viscero-sensory and somato-sensory afferent neurons of a single segment lead to a ”field of irritation“ in the posterior horn.
The visceral disorder is “misunderstood” by the cerebral cortex and erroneously interpreted as coming from the periphery, since the cortical representation
of the segments in the integument is considerably greater than that of the visceral organs. In this way, areas of referred pain occur on the surface of the
body, as a sort of “cortical error”.
• First to occur are autonomic reflexive symptoms (altered vasomotion, piloerection, and
sweat secretion) in the corresponding segmental areas of the integument.
• Next, the algetic symptoms in the corresponding segmental areas develop. Although re-
ferred pain may be lacking, the autonomic reflexive symptoms of visceral disease are al-
9
ways present.
• Not until the end of this sequence does perceptible, direct organ pain develop.
All in all: Even in the absence of direct organ pain,
• algetic symptoms are common, and
• autonomic reflexive symptoms can always be found.
• Organ pain felt deep within prompts the whole patient to rest and avoid exertion.
• Referred organ pain prompts the patient to avoid movement and to protect parts of the
musculoskeletal system.
The autonomic reflexive symptoms are usually based on a sympatheticotonic stimulus serv-
ing as a signal, in more or less the same way, in all vertebrates. Facial expressions, gestures,
posture, i. e., the entire nonverbal body language, send a message:
• Body hair stands on end or lies smoothly, the body stretches or makes itself smaller.
• Cold causes shivering, heat causes restlessness.
• The eyes become enlarged and widened, anxious or fearsome, etc.
9.2 Projected Symptoms 255
These autonomic signs form an “autonomic facial expression” (Dittmar) which provokes a
spontaneous, archaic behavioral response in an opponent and gives rise to a sym-pathetic
“fellow-feeling” in which members of a group instinctively (must) behave appropriately:
• The small, anxious, shivering individual is spared,
• the hot, restless individual is avoided,
• widened eyes are interpreted as a warning, etc.
As I see it, this means the following:
• The autonomic reflexive symptoms that occur as the first sign of a disorder trigger ap-
propriate social behavior in members of a group.
• The algetic symptoms, the second sign of a disorder, lead to painful guarding and protec-
tive posture in localized regions of the musculoskeletal system, and thus to a correspond-
ing individual behavior.
• The deep organ pain developing at last causes the entire individual to retreat. An animal
with a diseased organ goes into hiding.
The autonomic signs may also be interpreted as “pre-conscious” symptoms that elicit an
“un-conscious” behavioral response in the individual and the members of a group:
• For example, the “pre-conscious”, or autonomic reflexive, symptoms trigger vasocon-
striction and increased sweating.
• This gives rise to a perception of the disorder involving a feeling of coldness, fear of cold,
and hypersensitivity to cold.
• This in turn leads to unconscious, but appropriate measures and therapy-analogous be-
havior to counteract coldness, whether by reducing the body surface or by shivering,
which generates heat, or by application of a hand, or of heat in any form.
When the segmentally corresponding visceral organ is diseased, algetic symptoms such as
hyperalgesia and hyperesthesia develop in the skin and muscles (› chapter 9.5.1).
The biological significance of this algetic and autonomic reflexive symptom is likewise un-
mistakable:
As already mentioned, in a segmented organism, stimulation of an external portion of a
segment may have a beneficial effect on the internal portions, preventing the organism as a
whole from falling ill, which would be likely in an unsegmented organism.
Such segmental reflexive events may also be interpreted as a sort of prophylactic therapy
performed by the body itself, using postural changes and certain intuitive applications to the
body surface etc. in an unreflected, but reflexive manner to achieve therapy-analogous ef-
fects from the outside to the inside and to give an appropriate answer to the signals from a
diseased visceral organ.
I would define it this way:
In transmitting visceral organ signals from the inside to the outside of the body, the spinal nerves and
the sympathetic system are more attuned to events within the body than the consciousness.
9
For example, vasoconstriction within the body leads to certain movements (articulations) on
the body surface, as if the body were “expressing itself”. In this sense,
• pain perceived deep within leads to inactivity and withdrawal behavior, whereas
• superficial, precisely localized pain leads to actions such as fight or escape.
Visceral organs presumably express themselves on the body surface because the tissues of the
visceral organs, which are derived from entoderm, are much less supplied with pain-con-
ducting neurons than the tissues of the superficial organs, which are derived from mesoderm
or ectoderm.
Pain in internal organs is therefore expressed in the superficial regions derived from meso-
derm and ectoderm.
256 9 Referred Pain
9.2.3 Synopsis
The algetic symptoms include:

• hyperalgesia of the integument (Head's zones) and
• hyperalgesia of the muscles (Mackenzie's zones).
The autonomic reflexive symptoms include:

• changes in the integument of head, trunk, and limbs (vasomotor changes in the skin, pi-
loerection, altered sweat secretion, etc.),
• changes in the face (tense facial muscles),
• changes of the eyes (dilation of the pupils, widened palpebral fissure, protrusion of the
eyeball, glossy eye, etc.),
• asymmetrical posture and body movements,
• autonomic organ reflexes (viscero-visceral reflexes), e. g. polyuria following tachycardia
(› chapter 9.6.7).
9
9.3 On the Location of Projected Symptoms 257
9.3 On the Location of Projected Symptoms
Algetic and autonomic reflexive symptoms are nearly always projected to the homolateral
side relative to the diseased organ.
The algetic symptoms of
• the left-sided organs, such as the heart, stomach, left lung, and left kidney, cause pain on
the left side of the trunk, whereas those of
• the right-sided organs, such as the liver, gallbladder, right lung, and right kidney, cause
pain on the right side of the trunk.
The algetic symptoms of
• the thoracic organs are projected onto the thorax,
• the abdominal organs are projected onto the lower thorax and the abdomen,
• the pelvic organs are projected onto the lower abdomen and the pelvis.
The autonomic reflexive symptoms of
• the left-sided organs cause autonomic changes on the left side of the head, trunk, and
limbs, whereas those of
• the right-sided organs cause autonomic changes on the right side of the head, trunk,
and limbs.
The autonomic reflexive symptoms of
• the thoracic organs are projected onto the thorax, upper limbs, and head,
• the abdominal organs are projected onto the abdomen, upper and lower limbs, and
head,
• the pelvic organs are projected onto the abdomen, head, and lower limb.
In total, the appearance of algetic and autonomic reflexive symptoms on the body surface is based on
the existence of a regular, segmental-spinal and segmental-sympathetic relationship between certain
visceral organs and certain areas of the body surface.
Therefore, the algetic and autonomic reflexive projection areas are specifically related to each side and
each segment. Normally, they go unnoticed, but in states of illness or disorder they become apparent.
9
258 9 Referred Pain
9.4 Clinical Significance of Projected Symptoms
Projected, or referred, symptoms play an important role in clinical practice: in diagnosis and
differential diagnosis as well as therapy.
For example:
Algetic and autonomic symptoms such as homolateral dilation of a pupil often occur dur-
ing the latent period of a disease.
They may be found in a pain-free interval in cholecystolithiasis, in nephrolithiasis, or in
stomach disorders. Furthermore, such projected symptoms may provide a clue to organic
disorders that cause no pain, such as liver disease, since an algetic zone of integument or
muscle and homolateral pupillary dilation are usually present in such conditions.
Another example is described by Dittmar:
Inflammation of a cranially displaced and adherent appendix may cause rebound pain to
shift to the right epigastric region, leading to an erroneous diagnosis of acute cholecystitis or
duodenal ulcer.
However, when changes in autonomic phenomena, such as sweat secretion, piloerection,
and vasoconstriction are examined in the corresponding segmental regions, they are found
to occur in the proper places, i. e., in T 11 to T 12, despite displacement of the appendix.
The fact that the autonomic phenomena in gallbladder disorders also occur in the right
upper quadrant, but in this case in the regions of T 5 to T 10, enables clear clinical differen-
tiation between appendicitis and cholecystitis.
This shows that in diagnosis autonomic symptoms are more important than deep palpation (Dittmar).
The symptoms projected onto the body surface may also be an important aid to therapy, es-
pecially for the acupuncturist:
• The type of autonomic symptoms, the “quality”, e. g., vasoconstriction – vasodilation,
etc., determines the kind of pain, and thus for acupuncture treatment the kind of stimu-
lus.
• The intensity of the pain determines the intensity of the stimulus.
9
9.5 Algetic Symptoms 259
9.5 Algetic Symptoms
The hyperalgetic areas

• in the integument (Head's zones) and
• in the muscles (Mackenzie's zones)
are the expression of the total of impulses coming, on the one hand,
• from the skin, the subcutis, the muscles, and the tendons; and on the other hand,
• from the visceral organs belonging to the corresponding segments.
Since the projected (or referred) pain in the cutis, subcutis, and muscles can trigger second-
ary symptoms in the vertebral joints of the corresponding segments, there must also be con-
duction and interactions within the segment in the periphery, i. e., from myotome to sclero-
tome, and vice versa.
As mentioned at the beginning of this book (› page 3), an impulse can “oscillate” within
a segment:
• from one part of a myotome to another, e. g., from the deep muscles of the hand to the la-
tissimus dorsi muscle at the iliac crest (myotome C 8), as in heart disease;
• from changes in a vertebral joint to other sclerotomes, e. g., from the vertebral joint
T 12|L 1 to the anterior third of the iliac crest and the anterior horizontal branch of the
pubic bone (sclerotome T 12|L 1), as in intestinal disorders;
• from the sclerotome of the fifth cervical vertebra to the sclerotome of the spine of scapula
(C 5), as in respiratory disorders.
According to Dittmar, oscillation is also possible between the myotomes and sclerotomes of
a single segment, e. g., when irritation of a vertebral joint capsule leads to pseudoradicular
propagation to corresponding myotomes and sclerotomes.
9.5.1 Hyperalgesia and Hyperesthesia of the Cutis and Subcutis

(Head's Zones)
Hyperalgesia and hyperesthesia of the cutis and subcutis may be found in many visceral dis-
orders in segmentally corresponding areas of the integument of the trunk as acute sensitivity
to pain and touch.
Head, with whose name this phenomenon is inseparably coupled, recognized that certain
zones of the integument correspond to certain visceral organs, and was the first to map them.
Furthermore, he recognized that these areas of the integument do not correspond to their
peripheral nerve supply, but rather are arranged segmentally.
The Head's zones are specific to a certain segment and side.

9
The painful skin areas usually occur ventrally, sometimes ventrolaterally on the trunk
(› fig 9.2).
• The abdominal organs usually project ventrally onto the skin of the abdomen, whereas
• the pelvic organs project ventrally, and the kidneys dorsolaterally onto the lower back.
These hyperalgetic zones may manifest as areas as wide as 6 inches, as linear areas, or small
spots only 1 cm in diameter as maximum points located ventrally and/or ventrolaterally.
Characteristically, Head's zones do not become acutely oversensitive to pain until a second stimulus is
added from the outside.
At first, these zones are sensitized only by a pathological stimulus from the corresponding
diseased visceral organ, or – as Head expressed it – “they resonate as if struck with a tuning
fork.” They are, so to speak, “premorbid territory” or “presensitized terrain” (Tilscher).
260 9 Referred Pain
Diaphragm
(C 4)
C4
T3 and
T4
Heart
(T 3 and 4)
T5
T8
Esophagus (T 4 and 5)
T9
T 10 Stomach (T 8)
Liver and Gallbladder

T 11
(T 8 and 11)
Small Intestine (T 10)
T 12
Large Intestine
(T 11–L1)
L1 Urinary Bladder
(T 11–L1)
Kidneys and Testes
(T 10–L1)
Fig. 9.2 Head's zones (referred pain) on the ventrolateral wall of the trunk: Head's zones are painful areas of
skin (and muscles) that may reveal disorders of a certain visceral organ on the basis of their stringent relationship
to the side and segment of the individual visceral organs.
Not until a second stimulus, as a sort of “double-whammy”, e. g., a cold draft or the pres-
sure of a coat collar or a belt buckle, impinges onto the viscerogenically presensitized area of
the integument, do these areas become clinically manifest, i. e., noticeable to the patient and
9
verifiable by the physician.
This fact is the basis of Head's examination methods, which can be quickly and easily per-
formed in practice. For identification and delimitation of the areas, Head used the follow-
ing tests:
• If the skin is stroked gently with the blunt end of a needle in a cranial-to-caudal direction,
in the sensitized segmental area the blunt, soft stroke is suddenly perceived as acutely
painful.
• If cutis and subcutis are raised in a fold, rolled, and lightly pressed at the same time – as
in the Kibler fold test – the patient perceives the light pressure in the region of the irritat-
ed segment as “chafing and being beaten” (Dittmar). This is referred to as a “painful
pinch fold”.
• A cold stimulus, easily applied by touching with a cold metal object, is not perceived as
coolness, but rather as a “penetrating, freezing pain”.
• A warm stimulus is not perceived as heat, but as a “burning, caustic pain”.
The heightening of perception is therefore not quantitative, i. e.

• cool does not become cold, and
• warm does not become hot.
Instead, there is a qualitative change in touch perception:
• coolness becomes a penetrating, freezing pain; and
• warmth becomes a burning, caustic pain.
Another one of Head's methods was the examination of the increased tension in the cutis
and subcutis:
• If, for example, the skin of the back is gently stroked with the flat, outstretched hand or
finger in a tangentially upward direction, the turgor of the skin on the affected side is per-
ceptibly greater than on the healthy side (“connective tissue stroking according to Bergs-
mann”).
9
262 9 Referred Pain
9.5.2 Hyperalgesia of Muscles and Tendons (Mackenzie's Zones)
Hyperalgesia of muscles is named after its discoverer, Mackenzie.

“Deep hyperalgesia in the trunk corresponds roughly to the Head's zones, so that a dermatome
corresponds roughly to a myotome.”
This was the viewpoint of Mackenzie, Hansen and Schliack, and others.
In my opinion, however, these authors fail to consider that, for example, cervically or lum-
bo-sacrally innervated myotomes lie beneath the thoracic dermatomes of the trunk.
Therefore myotomes and dermatomes from the same segment are not (!) necessarily superimposed.
Another important aspect is the fact that the myotomes, due to separation and shifting dur-
ing embryonic development, may be widely scattered, so that in case of pain in one myotome
of the musculoskeletal system all the other myotomic parts innervated by the same spinal
nerve must be considered, although they may be far apart.
Effective pain therapy is therefore possible only if pain and tension are identified in all the myotomic
parts.
For example, in case of pain at the thoraco-lumbar transition, i. e., at the pars iliaca of the la-
tissimus dorsi muscle (myotome C 8), it is important to look for tenderness at the ends of the
7th and 8th ribs (sclero-zone C 8), or for pain in the deep muscles of the hand (myotome C 8),
or for pain at the spinous process of the seventh cervical vertebra (sclerotome C 8).
These considerations, I am sorry to say, I have not found in any of the textbooks of seg-
mental theory or in any books on neural therapy or acupuncture.
Pain therapy, whether by acupuncture, neural therapy, or manual therapy, cannot be particularly effec-
tive unless the therapist knows and considers all the distantly separated, but connected parts of the
myotomes and sclerotomes.
This explains the “centripetal” radiation of “joint conditions” described by Brügger; he de-
scribes complaints in the basal joint of the thumb as radiating centripetally to the shoulder.
Such radiation, in my opinion, which is based on the viewpoint of segmental anatomy, is
due to synchronous reaction of the C 6 myotomes, which are located between the basal joint
of the thumb and the deltoid muscle.
Accordingly, the “centripetal radiation of joint conditions” referred to by Brügger is basi-
9
cally an oscillation of the pain from one myotome to another in the manner of a propriocep-
tive reflex, or between a myotome and a dermatome or sclerotome in the manner of a multi-
synaptic reflex.
Mackenzie's zones become clinically apparent more often than Head's zones.
Often, the Mackenzie's zones are palpable only deep within as painful points or as rope-like
or string-like strands of muscle. Such muscle strands may be as thin as a straw (Dvorak), and
are found especially in the region of the gluteal muscles.
The clinically well-known trigger points in visceral disease, such as Boas' pressure point,
McBurney's point, etc., are deeply situated Mackenzie's maximum points. They are summa-
rized in the table above.
Since several or all myotomes belonging to a segment may be hypersensitive even though
their locations are widely separated, I believe this may be the basis of the “generalization” of
Tab. 9.1 Maximum points of hyperalgesia (Mackenzie)*

Maximum Topographical location Segmental Disorder
point location
Boas To the left of the 7th to 10th thoracic vertebral spi- T 7 to T 9 Gastritis
nous processes Gastric ulcer
To the right of the 12th thoracic vertebral spinous T 9 Duodenal ulcer
process Cholecystitis
Cholelithiasis
Katsch In the epigastrium to the left of the midline, and T 8 Acute pancreati-
to the left of the 7th to 10th thoracic vertebral spi- tis
nous processes
Kohlrausch Just to the right of the 7th cervical vertebral spi- C 6 and C 7 Tracheal and me-
nous process diastinal diseases
Directly adjacent to the 3rd to 5th thoracic verte- T 3 to T 5 Heart diseases
bral spinous processes
2 fingers to the right or left of the 5th to 7th tho- T 5 and T 6 Lung diseases
racic vertebral spinous processes
2 fingers to the right of the 6th to 8th thoracic ver- T 6 and T 7 Gallbladder dis-
tebral spinous processes eases
2 fingers to the left of the 8th thoracic vertebral T 7 Stomach diseases
spinous process
Just to the right or left of the 10th thoracic to 2nd T 9 and T 10 Intestinal diseas-
lumbar vertebral spinous processes es
To the left of the 2nd to 5th lumbar vertebral spi- T 12 Female genital
nous processes diseases
Just to the right of the coccygeal bone S 4 and S 5 Diseases of the
sigmoid colon
and rectum
Libmann Below the left external ear C 3 Angina pectoris
McBurney On the line joining the umbilicus to the right ven- T 10 and Acute appendici-
tral iliac spine, about 5 cm from the latter T 11 tis
Mussy-Westphal In the supraclavicular fossa next to the insertion C 3 Pneumonia
of the sternocleidomastoid muscle, right or left, Pleuritis
depending on the side of the visceral disorder Cholelithiasis
Angina pectoris
Rosenstein With the patient lying on the left side, about T 11 and Acute appendici-
5 cm medially to and 3 cm below the right ven- T 12 tis
tral iliac spine
* After Dittmar and Dobner; other authors give varying information.
9
pain reported by many patients. For example, the complaint by a patient that “meanwhile my
whole back hurts”, suggests from a segmental point of view that all parts of the segment C 8
are affected: The pain may have been restricted to the cervico-thoracic transition (sclerotome
C 7|C 8) at first, but in the further course it spread to the iliac crest (myotome C 8, latissimus
dorsi muscle at the iliac crest), thus affecting practically the entire back.
Mackenzie's zones may be examined by raising a fold of skin and simultaneously attempt-
ing to palpate the muscle bundles beneath it. One may also press two fingertips deeply and
cautiously onto the painful spot, or tap it gently with bent fingers (Dittmar).
Painful muscular tension may be an expression of a visceral disorder, but of course it may
also occur unrelated to the internal organs. It is important to distinguish whether painful
muscular tension is due to
• referred pain, i. e., pain projected onto the trunk, or to
• pseudoradicular muscular tension.
It has been mentioned several times that referred pain can occur only in those segments of
the integument whose corresponding spinal cord segments are irritated by sympathetic vis-
264 9 Referred Pain
Fig. 9.3 Differential diagnosis of referred pain: Segmental radiation of “projected” pain in visceral disease,
with strict assignment to a side and a segment of the skin (and muscles) on the trunk (conclusions analogous
to those in › fig. 9.2).
cero-sensory neurons. Only in certain areas, i. e., on the trunk in the segments C 8 to L 2|L 3,
is it possible for visceral disorders to be projected onto the body surface (› fig. 9.3).
9
9.5.3 Comparison of Referred Pain and Pseudoradicular
Syndromes
Pseudoradicular pain on the limbs, e. g. from a joint capsule, as shown schematically
(› fig. 9.4), may also occur without being related to a diseased visceral organ.
Referred pain and pseudoradicular pain may, of course, be superimposed on each other. In
my opinion, the most important clinical differences between pseudoradicular pain and re-
ferred pain are these:
• Pseudoradicular pain is perceived as “naked” pain. The patient describes it as “simply”
painful, but without any specific qualities.
• Referred pain is perceived by the patient as a “tinged” pain, inasmuch as the patient
nearly always describes it as penetrating, caustic, burning, cold-sensitive, heat-sensitive,
etc.
Pseudoradicular pain on the limbs manifests as trigger points (see references in Irnich, 2009).
Fig. 9.4 Differential diagnosis of pseudoradicular pain (after Brügger, Lewit, and Hansen and Schliack): Many
of the pains radiating to the head, the trunk, and the limbs are not of radicular origin. Such so-called pseudo-
radicular syndromes (Brügger) are largely expressions of a disorder in a joint and its corresponding, reflexively
influenced muscles, regardless of whether a vertebral or a peripheral joint is involved.
9
266 9 Referred Pain
9.6 Autonomic Reflexive Symptoms
Autonomic reflexive symptoms are autonomic projection phenomena that may occur with
disorders of visceral organs.
As already explained, a disorder of a visceral organ can express itself
• as organ pain,
• as referred pain, and
• as a wide variety of reflexive symptoms.
Autonomic reflexive symptoms are firmly related to enterotomic disease. They usually pre-
cede the actual illness, often occurring in the absence of any specific organ pain. Since they
occur in the same segment as the algetic symptoms, it is justified to assume that the neural
pathway of the autonomic reflexive symptoms is substantially the same as the neural path-
way of the algetic symptoms.
The autonomic reflexive symptoms thus start with propagation of viscero-sensory impuls-
es along the sympathetic trunk to the posterior horn, the lateral horn, and the anterior horn;
from there they are conducted through preganglionic neurons back to the sympathetic trunk,
where the neurons form collaterals, and then spread via postganglionic neurons that form
the basis for the wide dissemination of the viscero-sensory information.
Finally, the impulses travel along the spinal nerve and the sympathetic perivascular net-
work to the integument, where they set the stage for the autonomic reflexive symptoms. This
route is known as the viscero-cutaneous reflex pathway.
The viscero-cutaneous reflex pathway is the basis for the manifestation of sympathetically mediated
effects on the body surface.
The autonomic reflexive symptoms are usually very ephemeral, subtle signals that a diseased
organ sends to the integument.
They require a very subtle examination by the physician, i. e., “palpation with the eyes and
visualization with the hands” (Kunert).
Such fleeting and subtle signals to the body surface elude technical methods such as x-ray,
CT-scan imaging or laboratory studies, and are accessible only by means of immediate ex-
amination with the eyes and hands.
It is of interest that the Chinese word for “to diagnose” may be literally translated as “to see
the disease” (kan bing).
In the preceding chapter (› chapter 8) it was explained that
• the algetic projection zones largely adhere to the segmental borders, whereas
• the autonomic projection zones, due to formation of collaterals in the sympathetic gan-
glia, clearly extend beyond the segmental borders and may occupy an entire quadrant of
9
the body.
When algetic and autonomic projection zones are superimposed within a segment, the pa-
tient is able to describe “where” (location), “how” (quality) and “how strong” (intensity) the
pain is.
Outside of this zone in the autonomic projection area, the patient describes mainly quali-
tative parameters, i. e., “how” – the kind of pain. Apparently the patient experiences hyperal-
gesia, as Head puts it, as being “blurred” by the hyperesthesia which is also present.
I would put it this way: “The algetic zone is stretched out and attenuated to cover the autonomic zone.”
Here too it is clear that in visceral disease the projection phenomena on the body surface cor-
respond to a phenomenology of the disease, in that they fulfill all criteria of a sensory expe-
rience (“where” – “how” – “how intense” – “since when”).
9.6 Autonomic Reflexive Symptoms 267
These parameters are the four polar pairs (ba gang) which represent the basis of the diag-
nostic and therapeutic pathway in acupuncture (König, Wancura 1978).
As brilliant as this acupuncture concept appears, especially considering that it was discovered empiri-
cally, its scientific explanation lies in segmental anatomy, which was pioneered by European anato-
mists.
The autonomic reflexive symptoms include:

• Changes in the integument which may affect an entire body quadrant and may be made
visible by simple provocation tests: vasomotoric symptoms such as dermographism, pilo-
erection, hyperhidrosis.
• Changes on the head, triggered by the sympathetic ciliospinal center: mydriasis, widen-
ing of the palpebral fissure, glossy eye, protrusion of the eyeball, tense muscles of facial
expression, hyperalgetic and hyperesthetic zones on the head.
• Changes on the shoulder, triggered by sympathetic and parasympathetic neurons
(phrenic and vagal nerves).
• Asymmetrical posture and movements.
• Reflexive and algetic vertebral column syndromes.
• Asymmetrical proprioceptive and multisynaptic reflexes.
• Autonomic organ reflexes (viscero-visceral reflexes).
9.6.1 Autonomic Effects in the Integument
As experimental studies by Foerster have shown, autonomic effects in the integument occur
in an entire quadrant of the body, but are unevenly distributed:
• In Foerster's experiments, changes in vasomotion, piloerection and increased sweating
occur together only on the limbs.
• On the trunk, in contrast, piloerection and increased sweating may occur alone, without
vasomotoric changes (› fig. 3.8).
This is in agreement with the clinical observation that pale-blue, livid, “mottled” skin as a
sign of vasoconstriction is usually seen only on the limbs, whereas gooseflesh and profuse
sweating are found on both the trunk and the limbs.
Autonomic changes in the integument can be triggered only by sympathetic neurons,
since they are the only ones to have adrenergic target organs in the skin, i. e., arrector pilo-
rum muscles, eccrine sweat glands, and the terminal blood vessels.
The result is that in projection phenomena in the skin
• the sympathetic neurons cause algetic and autonomic symptoms, whereas
• the parasympathetic neurons cause only algetic, but no autonomic symptoms. 9
The autonomic symptoms on the skin are caused by
• sympathetic neurons from the anterior root, which lead to pale, damp gooseflesh (vaso-
constriction, piloerection, and sweating), and
• sympathetic segmental neurons from the posterior root, which lead to reddened, dry,
smooth skin (vasodilation, lack of piloerection, and reduced sweating).
In the first case, the patient subjectively perceives the skin in the segmentally irritated region
as being
• cool and sensitive to cold,
• damp and sensitive to dampness,
• goosefleshy, and therefore sensitive to drafts.
In the second case, the patient subjectively perceives the skin in the segmentally irritated re-
gion as being
• warm and sensitive to heat,
• dry and smooth, and therefore sensitive to touch (› tab. 3.1).
268 9 Referred Pain
The acupuncturist will immediately recognize the polar pair han-re (cold – hot), which encompasses all
qualitative parameters, and in Chinese diagnosis and therapy is very important for the selection of the
right kind of stimulus.
Vasomotion
In visceral disease, vasoconstriction and vasodilation occur fairly often in the skin of the
homolateral quadrant of the body. Their magnitude is variable and inconstant, and of course
depends on the prior degree of dilation of the blood vessels.
Here, within the context of segmental anatomy, only the regulation of the peripheral circu-
lation shall be discussed, not the circulatory centers in the brain or other mechanisms of cir-
culatory regulation.
Vasomotor changes will usually manifest as vasoconstriction in a circumscribed, but ex-
tensive area that appears pale and livid, and may also be hyperalgetic.
Such cutaneous anemic zones within a segment correspond to the hyperalgetic zones de-
scribed by Head. If such a zone increases in size to cover a larger area, the patient takes care
to avoid any exposure to cold whatsoever, and expresses fear of cold. The affected area feels
objectively cooler, and measurement of the axillary temperature may reveal slight differences
in temperature between the right and left sides.
Spontaneous vasodilation without an external stimulus is fairly rare in segmental regions.
In the head region it may occur in patients with unstable circulation and during the climac-
teric as “hectic” red spots or “hectic” blushing of the cheeks.
With the aid of certain provocation tests it is possible to elicit vasodilative and vasocon-
strictive responses that regularly occur in an irritated segment and may be visible to the na-
ked eye.
When an electric heating pad is applied for a short time, one can see that the irritated seg-
mental area of skin becomes clearly more reddened than that of the contralateral segment.
This simple and effective test for identification of the irritated segment can easily be carried
out in practice.
Heightened localized dermographism is another expression of altered vasomotion within
the skin of a segment. In the dermographic test, an intensified or diminished vertical ery-
thematous line may appear on the skin of an irritated segment, e. g., on the back.
During cupping massages in our practice, we quite often observe a gap in the erythema as conspicuous
pallor in an irritated zone.
Histamine wheals develop more quickly in an irritated segment and are more pronounced.
Wheals that develop, for example, following intracutaneous injections of procaine in a hyper-
9
algetic region also regress more quickly, due to the faster absorption attributable to increased
permeability in the segmentally irritated zone.
Cantharide plasters have a more pronounced effect in Head's zones: It has been shown
that the exudate is increased in amount and contains elevated numbers of leukocytes and
monocytes for as long as the disorder of the internal organ continues (Schmidt, Dittmar, and
others).
Skin erythema after UV exposure occurs earlier in viscerogenically sensitized segments.
Petechial bleeding occurs even when the skin is subjected to only mild suction, e. g., when
cupping glasses are applied.
In contrast to the gap described above as a paler area of skin in part of an irritated segment,
cupping may lead to increased petechial bleeding, thus revealing the viscerogenically sensi-
tized segment. Sometimes patients also report enhanced sensitivity to pain caused by appli-
cation of a cupping glass to this region, although the degree of vacuum is the same.
In other words: Even before pain occurs in a viscerogenically sensitized segment, i. e., when the seg-
ment is still algetically “silent,” vasomotor changes may lead to the cutaneous symptoms described
above, thus providing an initial sign of an incipient disorder of a visceral organ.
By microscopic examination of capillaries in disorders of internal organs, Dittmar was able

to distinguish spastic, atonic, and hypertonic changes in the capillaries of the skin in segmen-
tally corresponding areas of the body surface.
Conversely, Wernoe's animal experiments demonstrated as early as the second half of the
19th century that experimentally provoked localized cutaneous hyperemia always leads to
reflexive vasodilation in the segmentally corresponding enterotome.
Cold stimuli and pain, on the other hand, cause vasoconstriction in both the internal and
external parts of the segment, as Wernoe found in animal experiments.
Segmental vasoconstriction or vasodilation is particulary important in the occurrence of
skin diseases.
According to Hauser and Gottron, the changes in blood flow in the capillary system of the
irritated region are conducive to colonization by hematogenically transported pathogens
(› page 178).
Therefore, the insights provided by segmental anatomy are indispensable for diagnosis and for causal
treatment of generalized skin diseases, as an affected visceral organ belonging to the same segment
must be treated first or simultaneously.
Sweating (Hyperhidrosis)
Hyperhidrosis is a less common autonomic phenomenon most often seen in patients with
coronary infarction, pleuritis, or pneumonia. It is particularly marked on the forehead,
cheeks, and lips.
When the forehead of such a patient is gently wiped dry, it is possible to observe that drops
of sweat reappear more rapidly and profusely on the affected side than on the healthy side,
sharply separated at the midline.
On the body, the regions of increased sweating are also sticky. The patients perceive the
hyperhidrosis as a cold sensation, and seek to keep out any coldness by adding blankets and
wrapping themselves up.
Piloerection
Homolateral and segmental piloerection results from contraction of the sympathetically in-
9
nervated, smooth arrector pilorum muscles. Piloerection can occur in circumscribed areas or
in a wide swath.
Mild cold stimulation always causes piloerection. This is most easily observed upon throw-
ing back the bed covers when the patient is not expecting it.
Piloerection may also be provoked by gentle mechanical stimulation, such as touching or
stroking the skin with a needle. In practice, gently stroking the presumed area of segmental
irritation with a fingernail has proved useful. Subjectively, the patients perceive elicitation of
piloerection as “shivering” or as “cold shudders”.
In my opinion, the feeling of cold shudders which may be elicited by acupuncture is also related to this
phenomenon.
270 9 Referred Pain
Clinics
An interesting experiment was described by Mackenzie, who was able to trigger cold shivers
on the limbs by briskly rubbing the muscles of the thorax at the level of the mamillae.
Other authors report that in the same experimental setup with monkeys they observed pi-
loerection of the facial hairs. These experiments show that an autonomic reflexive reaction
may be triggered not only by a viscero-cutaneous pathway, i. e., from “inside to outside”, but
also “from outside to inside”.
I believe this is due to conduction of impulses within the segment, whereby the impulse oscillates from
myotome to dermatome and vice versa as in a multisynaptic reflex.
The reflex pathway for sweat secretion, piloerection, and vasoconstriction is always the
same. It is mediated by sympathetic neurons originating in the lateral horn, which then pass
through the anterior root, the sympathetic trunk, the sensory nerves, and the perivascular
network to the target organs in the integument.
The reflex pathway for diminished sweat secretion, diminished piloerection, and vaso-
dilation is different: It is mediated by segmental-sympathetic neurons that likewise originate
in the lateral horn, but exit the spinal cord by way of the posterior root, circumvent the sym-
pathetic trunk, and follow the peripheral nerves to the integument. Their effects on the end
organs are therefore always strictly segmental and never involve an entire quadrant of the
body (Foerster; › page 103).
The table in chapter 3 (› fig. 3.8) shows the relations between stimulation of the anterior
spinal nerve root and the dermatomes in which changes in vasoconstriction, piloerection,
and sweat secretion occur.
If equal stimulation of both sides is followed by piloerection on only one side, one can always assume
the presence of pathology in the segmentally corresponding, homolateral internal organs.
Piloerection may be triggered especially by a mechanical or cold stimulus placed on a hiatus

line. As already mentioned (› chapter 4), hiatus lines are also always erogenous zones, so
that the shudder caused by stimulation always has an erotic component.
For the analysis of acupuncture it is particularly noteworthy that the acupuncture points recommended
for disorders of visceral organs are always located in the corresponding projection areas of the auto-
nomic reflexive symptoms.
9
9.6.2 Effects on the Head
Eyes
Dilated pupils, a widened palpebral fissure, glossy eyes, and protruding eyeballs often occur
in combination.
Dilation of the pupil is a very constant sympatheticotonic symptom that accompanies
nearly all visceral disorders. It is a regular finding in painful heart conditions, lung and pleu-
ra afflictions, cholecystolithiasis, and kidney disease, as well as in the so-called “C 8 syn-
drome” which involves atrophy of the hypothenar and the adductor pollicis muscles (myo-
tome C 8) together with dilation of the homolateral pupil.
Dilation of the pupil is a very subtle sign that is often noticed only when one knows what to
look for.
Unilateral mydriasis is most easily identified in a darkened room, or when the hands are
used to shield the eyes from light. Another possibility for identifying it is to surprise the pa-
tient, e. g., by asking an unexpected question, such as “How much is 17 times 18?” Out of
surprise, both pupils become dilated, but the changes are much more pronounced in the eye
on the side which is homolateral to the affected organ.
Homolateral mydriasis results from a reflex mediated by the ciliospinal center, which conducts impulses
from the entire body by way of the perivascular network surrounding the internal carotid artery to the
sympathetically innervated dilator pupillae muscle.
Widening of the palpebral fissure is triggered by the same pathway, the target organ in this
case being the sympathetically innervated orbicularis oculi muscle. When stimulated experi-
mentally, mydriasis and the widening of the palpebral fissure nearly always occur together.
The autonomic symptoms in the eye may also be elicited by applying pressure to the homo-
lateral supraclavicular fossa.
Exophthalmos and the glossy eye caused by excessive lacrimation likewise represent re-
sults of sympathetic reflexes, but they are usually subtle.
When all of these eye symptoms develop simultaneously, the first impression they convey
is that of a unilateral Basedowian eye or a unilateral expression of fear or fright.
The sympatheticotonic signs in the eye are based on a special feature: In all vertebrates, the
dilator pupillae muscle is always innervated by the highest spinal cord segment containing
preganglionic sympathetic neurons, i. e., in man the 8th, in the cat the 9th, in the chicken the
16th, and in the frog the 3rd spinal cord segment (› page 82).
Sympatheticotonic reactions are involved in attack, aggression, fright, and fear. Not only
do they cause an increased tonus of the extensor muscles in the limbs, make the hair stand on
end, and lead to increased sweating, especially on the extensor aspects of the limbs; they also
cause the pupils to dilate. Dilation of the pupils as a sign of fright and readiness to attack is an
expression consciously or unconsciously familiar to all human beings.
In the behavioral sciences as well, a “dark eye spot” (i. e., a marking resembling a dilated
pupil) signals fright or readiness to fight. As the behavioral scientist, E. König, explains in his
book, such dark “eye spots” play a role in the mimicry of many lower animals, e. g., on the
wings of butterflies or on the tail of certain caterpillars, where they are apparently under-
stood as a threat announcing willingness to fight. When an animal displays such an eye spot
suddenly, it frightens any pursuer.
Such a “moment of recoil” gives a weaker animal under attack a better chance to escape
due to the time gained before the attacker can react.
Human beings have “borrowed” from evolution the dark eye spot symbolizing an enlarged
pupil as a sign of willingness to fight and defend, displaying its image on house doors and
ship prows.
9
It is noteworthy that the changes in the eye are always accompanied by changed or at least
increased tonus of the extensor muscles of the arms and the flexor muscles of the hand (C 8,
T 1).
A widened palpebral fissure expressing fright, an outstretched arm, and a clenched fist are signs of
aggression, defense, and struggle; when they occur together, they demonstrate a reflex-like, segmental
event that is mediated by the segment C 8 and the ciliospinal center in the spinal cord.
Muscles of Facial Expression
Tension of the muscles of facial expression is another symptom of autonomic reflexive chang-
es on the head. It may lead to asymmetry of the face, although this is usually very subtle.
272 9 Referred Pain
Usually one finds more marked wrinkling of the forehead on one side, or unilaterally deep-
er facial creases. In a woman wearing makeup, this may lead to irregular distribution of the
latter.
The nasolabial crease may be pronounced, as if the nose were being turned up, together
with a unilateral elevation of the upper lip. This conveys an impression of arrogance and ex-
pectant scepticism.
The cheek on the “expressive side” of the face appears somewhat contracted and elevated
due to tension.
According to my observations, the tension also affects the homolateral sternocleidomas-
toid muscle, causing the head of the patient to turn. Usually the head deviates toward the
painful side, whereas the line of sight is directed toward the middle. This observation may
also be made on injured animals. A dog with an injured paw usually looks away from the in-
jured side and toward the healthy side, possibly to distract from the injury.
In humans, when the changes in the eyes occur together with unilateral tension of the
muscles of facial expression and deflection of the head, the patient often gives the impression
of being “painfully embarrassed”. It is interesting that the word “pain” is derived from the
Latin “poena”, which means both punishment and pain.
Sometimes one also finds cyanotic pallor of the face, which, as observed by Head, occurs
only when circulation is impaired in some parts of the trunk. Therefore sympatheticotonic
effects in the head are most likely when symptoms such as projected pain are present on the
trunk.
This implies that conduction or oscillation between dermatome, myotome, and sclerotome on the body
surface is possible not only from “inside to outside”, but also from “outside to outside”.
Hypersensitive and Hyperalgetic Zones
Hypersensitive and hyperalgetic zones in the homolateral regions of the head are very com-
mon in visceral diseases. Hypersensitivity is revealed on palpation of the exit points of the
trigeminal nerve in the face and the segmental regions C 3 and C 4 on the neck and throat.
The painful areas on the head differ considerably in extent, and their assignment is inter-
preted in various ways by different authors.
According to Dittmar,
• diseases of the heart are projected to the left of the sagittal suture and the left dermatome
C 4,
• diseases of the stomach are projected to the left temple and the left dermatome C 4,
• diseases of the liver are projected to the region above the right eyebrow and the right
dermatome C 4.
9
My own experience corroborates Dittmar's observations, but quite often I have also observed
a few additional projections:
• diseases of the heart are also projected to the vertex and the forehead,
• diseases of the abdominal organs are projected to the parieto-temporal and the maxil-
lary regions,
• diseases of the pelvic organs are projected to the occipital and mandibular regions.
The projection of the pelvic organs onto the occiput is in agreement with observations on
paraplegics: Even completely paraplegic patients perceive an overfilled bladder as a painful,
tingling sensation at the back of the head.
In our opinion (König, Wancura), this sensation must be mediated by the sympathetic
system, which is capable of vicariously taking over sensory and motor functions when the
spinal cord is severed.
The relationship of the perivascular sympathetic network surrounding the arteries and
painful areas in the galea has been experimentally verified by Auberger.
Since pathological impulses from diseased visceral organs are conducted to the ciliospinal
center along the sympathetic trunk as well as intraspinally, it is conceivable, in analogy to the
dilation of the pupil described earlier, that a sympatheticotonic reaction might originate
along the blood vessels of the head, and thus be interpreted as “transmission of visceral dis-
ease to the blood vessels of the galea”.
Headaches would therefore be an autonomic reflexive sign of disease conducted along distinct path-
ways, rather than diffusely, and can give rise to pain in the head (e. g., “migraine biliaire”) in case of
visceral disease.
Between the site of a headache and the diseased internal organ there is a certain correlation,
according to Head: Headaches may be triggered by the vagus nerve (› fig. 9.5; also › fig.
3.17).
As Head and Foerster have reported, pain from the thoracic and abdominal organs may be
transmitted by way of the vagus nerve to the face and the occiput, where they appear as
Head's head zone.
Other authors (Hansen and Schliack) question the existence of such a transmission path-
way, since the vagus nerve mediates only organ reflexes, not pain.
Referred headache, according to Hansen and Schliack, can be triggered only by vascular
reflexes, i. e., by the same sympathetic viscero-motor reflexes that are also involved in my-
driasis, widening of the palpebral fissure, and increased lacrimation.
Projection of disorders of visceral organs takes place when viscerogenic impulses from
all segments are conducted in a cranial direction along intraspinal tracts to the ciliospinal
center.
From there, reflexive vasomotor stimuli, such as vasoconstriction, are transmitted further
along certain pathways, where they may induce headache (Auberger).
Interactions between Zones of the Head and Visceral Organs
Head emphasized that he most often found tender, pressure-sensitive areas on the head and
spontaneous headaches when a sensitive zone on the skin of the thorax had appeared previ-
ously. Regardless of whether such a thoracic zone was due to disease of the stomach or of the
lung, it apparently was able to provoke the zone of the head, so to speak “from outside to
outside”.
Head observed that these zones on the head develop later and disappear earlier than the
ones on the trunk.
Headaches may therefore develop as distant projections of visceral disorders (› figs. 9.6a, b):
• The thoracic organs, i. e., heart and lung, affect the entire head. 9
• The abdominal organs, i. e., stomach, liver, and gallbladder, are projected mainly
– to the medial part of the forehead (“fronto-nasal”),
– to the lateral parts of the forehead (“fronto-temporal”) and
– to the lateral parts of the head (“temporal-vertical-parietal”).
• The pelvic organs, i. e., ovaries, intestines, and sometimes the liver too, are projected
mainly to the back of the head (“occipital”).
Interactions between Head, Trunk, and Organs
Headaches may also develop due to interactions between the painful segmental zones of the
trunk and the zones of the head, as shown in the following table (› fig. 9.6b).
274 9 Referred Pain
Midorbital
Frontonasal Frontotemporal
Rostrall Temporal
Maxillary
r
Nasolabial
Mental
Supralaryngeal
C3 Infralaryngeal
C4
Vertical
Parietal Midorbital Parietal
Fronto-
temporal
Occipital Occipital
Rostral Hyoid
Temporal bone
C3
Mandibular Supra-
laryngeal
Infra-
laryngeal
C4
Fig. 9.5 Projection zones in the head and shoulder regions (after Head; see text).
Summary
The painful zones in the upper thorax (T 1 to T 7) that are triggered by disorders of the lung
and heart project mainly to the region of the forehead and temples.
The painful zones in the lower thorax (T 8 and T 9) that are triggered by disorders of the
stomach, liver, gallbladder, or small intestine project mainly to the temporal and vertex re-
gions.
Aorta and Heart/ Gall-

Zones Lungs Stomach Gut Liver Testis Ovary
Ventricles Atria bladder
rostral
frontonasal
midorbital
fronto-
temporal
temporal
vertical
parietal
occipital
Fig. 9.6a Relationships between zones of the head and visceral organs (after Head)
Segmental Zone on Related Zone on Specific Connections between these Zones and Organs
Head and Trunk the Head
C3 Frontonasal Lung (apex), Stomach, Liver
C4 Frontonasal
Th 2 Midorbital Lung, Heart (ventricles), Aorta (ascending part)
Th 3 Midorbital Lung, Heart (ventricles), Aorta (arch)
Th 4 Doubtful Lung
Th 5 Frontotemporal Lung, Heart (occasionally)
Th 6 Frontotemporal Lung (inferior lobe), Heart (ventricles)
Th 7 Temporal Lung (basal segments), Heart (ventricles), Stomach (cardia)
Th 8 Vertical Stomach, Liver, Small Intestine (superior part)
Th 9 Parietal Stomach (pyloric portion), Small Intestine (superior part)
Th 10 Occipital Liver, Gut, Ovaries, Testes
Th 11 – Gut, Fallopian Tubes, Uterus, Bladder (contractions)
Th 12 – Colon, Uterus etc.
Fig. 9.6b Relationships between the segmental zones of the trunk, the zones of the head, and the visceral organs (after Head)
9
The lowest painful zones of the thorax (T 10 to T 12) that are triggered by disorders of the
pelvic organs, intestines, uterus, or urinary bladder project mainly to the occipital region.
These areas of projection of visceral disorders on the head – to some extent – resemble the
meridian relationships in Traditional Chinese Medicine:
The thoracic organs, including the stomach project to the forehead and temple regions
and duodenum from a segmental stand- (yangming)
point
The abdominal organs project to the temple and parietal regions
(shaoyang)
The pelvic organs project to the occiput (taiyang)
276 9 Referred Pain
9.6.3 Effects in the Shoulder
In addition to genuine and vertebragenic radicular or pseudoradicular shoulder pain, vis-

cerogenically activated shoulder pain is also possible.
The latter occurs when diseased organs adjacent to the diaphragm in the thorax or abdo-
men give rise to impulses in the parasympathetic neurons of the phrenic nerve projecting to
the segments of the phrenic nerve (C 4|C 5).
Such projected pain is called referred shoulder pain.
Referred shoulder pain is specifically unilateral:
• Organs on the left side, e. g., the stomach or the left lung, project to the left shoulder.
• Organs on the right side, e. g., the right lung, the duodenum, the liver or the gallbladder,
project to the right shoulder.
Referred shoulder pain is often also accompanied by autonomic reflexive symptoms in the
integument of the shoulder girdle, e. g., vasoconstriction, piloerection, and increased sweat
secretion, which the patient experiences as sensitivity to cold and drafts.
However, since such autonomic reflexive symptoms cannot be caused by parasympathetic
stimulation, there must also be pain referral via sympathetic neurons.
According to Hansen and Schliack, these sympathicotonic reactions in the integument oc-
cur via formation of collaterals in the sympathetic trunk, in which impulses from the dis-
eased organs adjacent to the diaphragm are conducted along the phrenic nerve from C 4|C 5
in the spinal cord to the ciliospinal center (C 8 to T 3). From there they travel via sympathetic
neurons in the corresponding spinal nerves to the shoulder, where they elicit the autonomic
reflexive symptoms mentioned above in the integument of the shoulder (› page 162).
9.6.4 Asymmetry of Posture and Movement
As mentioned above (› page 265), asymmetry of posture and movement are autonomic
reflexive signs that may reflect disease of an internal organ on the outside of the body. Strict
separation of algetic and autonomic reflexive symptoms is not possible in this context.
Posture and position of the patient usually indicate clearly which side of the body is af-
fected:
• The body is bent toward the affected side.
• The shoulder on the affected side is often raised.
• The head is slightly inclined toward the raised shoulder.
The flexion of the affected parts of the spinal column is due to segmental homolateral muscu-
lar tension.
In Brügger's analysis, the muscular tension of the trunk is a regular feature of certain vis-
ceral disorders. It causes immobility which provides relief to the affected organ and contributes
to its recovery. Brügger termed such muscular tension a nociceptive somato-motor effect.
9
The curvature of the affected portion of the vertebral column is always
• convex on the healthy side, and
• concave on the affected side.
One finds
• scoliosis of the thoracic spine in the presence of disease of a thoracic or abdominal organ, and
• scoliosis of the lower thoracic and lumbar spine in the presence of disease of an abdomi-
nal or pelvic organ.
In simple language: “The body bends around the focus.”
Similarly, it is often possible to identify an asymmetrical respiration by placing both
hands on the patient's thorax.
Functional scoliosis has been found in gastric ulcer, gastritis, gastroptosis, stomach can-
cer, cholecystolithiasis, and nephrolithiasis. An important distinction between congenital-
idiopathic and acquired-reflexive scoliosis is that the patient is able to compensate reflexive
scoliosis voluntarily.
9.6.5 Reflexive and Algetic Spinal Syndromes
Reflexive and algetic syndromes of the spinal column do not permit a strict distinction be-
tween algetic and reflexive causes.
Segmental tension of the back muscles may give rise to circumscribed pain in the thorax
and abdomen, or to neuralgia in the arms and legs. These symptoms are often coupled with
localized circulatory impairment, resulting in a feeling of coldness or in livid cyanosis.
Spinal nerve root irritation causing these symptoms may result from a disorder in a vis-
ceral organ belonging to the corresponding segment (viscero-vertebral transmission).
Conversely, primary irritation of a spinal nerve root may result in functional and morpho-
logic impairment of a visceral organ from the corresponding segment (vertebro-visceral
transmission).
Kunert and Brügger have found functional and morphologic disorders caused by irritation
of the spinal nerve roots to be especially common in
• precordial pain and angina pectoris, due to irritation in the region of the upper thoracic
spine,
• cervical hypertension, due to irritation of the upper cervical spine,
• paroxysmal tachycardia, due to irritation in the region of the sternocostal joints (Tietze's
syndrome),
• gastrointestinal disorders, due to irritation of the lower thoracic spine, and
• diarrhea and constipation, due to irritation in the region of the iliosacral joints.
Extensive documentation on the spinal column in conjunction with visceral disorders is pro-
vided by Kunert and Brügger.
9.6.6 Asymmetry of Proprioceptive and Multisynaptic Reflexes
The proprioceptive reflexes on the affected side are more pronounced than those on the
healthy side. For example, the biceps, triceps, and radioperiosteal reflexes as well as the patel-
lar and Achilles tendon reflexes are more easily elicited on the same side where the disease is
located.
The multisynaptic reflexes on the affected side are weaker. For example, the conjunctival
and corneal reflexes, the abdominal reflexes, the plantar and cremaster reflexes are always
less pronounced on the side where the disease is located.
Proprioceptive and multisynaptic reflexes in the areas of projection thus undergo typical changes as
referred symptoms of disease. They may provide easily recognizable clinical signals that give clues as
to which side is diseased, and possibly even indicate the level of the segment to which the diseased
enterotome belongs.
9
For example, if a patient's patellar reflex is found to be more pronounced on the right side
than on the left, while at the same time the plantar reflex on the right side is weaker than that
on the left, these reflex changes provide a clue that an organ on the right side of the body,
whether in the abdomen or the pelvis, may be impaired.
The most important proprioceptive and multisynaptic reflexes in clinical practice are sum-
marized in the following table (› tab. 9.2).
In contrast, in radicular disorders, e. g. due to herniation of an intervertebral disk, the
proprioceptive reflexes may be attenuated or even absent; in addition, hypalgesia or even
analgesia may develop in the corresponding dermatome.
For further details, see textbooks of neurology.
278 9 Referred Pain
Tab. 9.2 Clinically important proprioceptive and multisynaptic reflexes (after M. Clara)
Name Triggered by Reaction Location in the
spinal cord
Clinically important tendon reflexes (proprioceptive reflexes)
Biceps reflex Tap on the biceps ten- Flexion of the forearm C 5–C 6
don
Triceps reflex Tap on the triceps ten- Extension of the fore- C 6–C 8
don arm
Patellar reflex (knee-jerk Tap on the quadriceps Extension of the lower L 2–L 4
reflex) tendon leg
Achilles tendon reflex Tap on the Achilles ten- Plantar extension of the L 5–S 3
(ankle-jerk reflex) don foot
Clinically important cutaneous reflexes (multisynaptic reflexes)
Abdominal reflex Gently stroking the skin Contraction of the ab- T 8‑T 12
of the abdomen dominal muscles with
resulting retraction of
the belly
Cremaster reflex* Gently stroking the skin Contraction of the cre- L 1–L 2
on the medial aspect of master muscle, resulting
the thigh in elevation of the testi-
cle
Plantar reflex Stroking the sole of the Flexion of the toes S 1–S 2
foot
* The cremaster reflex is actually the lowest abdominal reflex, since the cremaster muscle is derived from
the most cranial portion of the internal oblique abdominal muscle.
In proprioceptive reflexes, the reflexogenic zone is located in a muscle, whereas in multisynaptic re-
flexes it is located in the skin or mucous membranes. The final leg is the same in both cases, and always
affects a muscle (› fig. 8.1 and › fig. 8.2).
9
9.6.7 Autonomic Organ Reflexes (Viscero-Visceral-Reflexes)
When a visceral organ undergoes pathological changes, the algetic and autonomic reflexive
phenomena described above for the body surface are also accompanied by reflexive disorders
of function in other organs that are basically healthy.
Such co-reaction of other, basically healthy organs is termed an autonomic co-reaction, an
autonomic organ reflex, or a viscero-visceral reflex.
Knowledge of these organ reflexes is important in diagnosis, because the co-reacting organ
itself is not necessarily diseased.
Clinically, such autonomic organ reflexes have long been known, e. g.:
• reflexive vomiting
– in stone colic of the kidney and gallbladder
– in pneumonia and angina pectoris
– in appendicitis
• reflexive diarrhea and constipation
– in acute disease of thoracic or abdominal organs
• reflexive anuria or polyuria
– in pneumonia, pulmonary infarction, coronary infarction, and appendicitis
• the reflexive epigastric syndrome
– in coronary infarction (gastrocardiac or Roemheld symptom complex).
Often one also finds mutual reflexive interactions between the uterus and the large intestine,
such as occur in premenstrual syndrome or during menstruation.
The autonomic organ reflexes, unlike the projection phenomena on the body surface described ear-
lier, show no lateral or segmental specificity.
In acupuncture these autonomic organ reflexes are likewise familiar and known as “co-reaction
of fundamentally healthy organs”.
In this sense,
• diseased thoracic organs cause co-reaction of abdominal and pelvic organs, and
• diseased abdominal organs cause co-reaction of thoracic and pelvic organs.
Unlike Western medicine, in which the autonomic organ reflexes are regarded only as clues
in differential diagnosis, Traditional Chinese Medicine concludes pragmatically that in the
presence of autonomic organ reflexes, the segments on the body surface corresponding to the
co-reacting organs also must be included in the acupuncture schema:
• In disorders of the thoracic organs, the algetic zones of the co-reacting abdominal or-
gans (CV 12) and the co-reacting pelvic organs (ST 25) must also be treated.
• In disorders of the abdominal organs, the algetic zones of the co-reacting pelvic organs
(CV 4, CV 6) must also be treated.
9
• Since the pelvic organs always co-react, diseases of visceral organs in the thorax and the
abdomen always also require a point related to the pelvic organs (SP 6, algetic zone of the
pelvic organs S 1|S 2) to be treated.

CHAPTER
The Visceral Organs – the
10 Enterotomes from the Viewpoint

of Segmental Anatomy
Internal, or visceral, organs project their disorders to the sympathetic and parasympathetic
nuclei of their innervation. It is thus a fact that visceral organs “transmit” the disorders to the
spinal cord segments from which their sympathetic and parasympathetic innervation is de-
rived.
In this way, they transmit information about diseases and disorders to the dermatomes,
myotomes, and sclerotomes on the body surface belonging to the same segment, where they
lead to pain and muscular tension, i. e., “algetic signs” and/or “autonomic symptoms”.
The occurrence of palpable and visible changes elicited on the body surface by “projection” follows
certain rules so precisely that it is possible, on the basis of quality and location of their manifestation,
to deduce which organ is affected, i. e., to “dia-gnose” or “see through” the body.
Remember that the Chinese word for “to diagnose” and “to treat” also translates as “to see, or
to perceive, the disease” (kan bing).
282 10 The Visceral Organs – the Enterotomes from the Viewpoint of Segmental Anatomy
10.1 The Heart: Algetic and Autonomic Reflexive

Projection Areas
Because of their relations to the cranial sympathetic ganglia, the innervation of the thoracic
organs, i. e., the heart and lungs, is from a segmental point of view somewhat more complex
than that of the abdominal and pelvic organs. For this reason they shall be discussed here in
more detail.
Segmental Relations
• The ventricles are derived from the segments located further cranially.
– Therefore they are related, via their sympathetic afferent and efferent neurons, to the more crani-
ally located spinal cord segments C 8 to T 5.*
• The atria are derived from the segments located further caudally. The reason for this is that the
ventricles, which are related to the more cranial segments, are formed first in the aortic tube of the
embryo, i. e., before the atria, which are related to the more caudally located spinal cord segments.
– Therefore the atria are related to the more caudally located spinal cord segments T 5 to T 7.
Atria and ventricles thus retain their segmental relations despite the rotation of the heart
during embryonic development.
Diseases and functional disorders of the heart are therefore projected as follows:
• disorders of the ventricles mainly to the dermatomes, myotomes, and sclerotomes C 8 to
T 5, and
• disorders of the atria mainly to the dermatomes, myotomes, and sclerotomes T 5 to T 7.
Regardless of the cause of disease, whether it be angina pectoris or heart muscle failure, the
algetic symptoms remain the same.
All projected signs are located on the same side as the affected visceral organ, i. e., in case
of heart disease on the left. Therefore
• algetic signs on the trunk are found in the segments C 8 to T 7 on the left side,
• autonomic signs are found on the left side of the thorax and in the left arm,
• distant projections are found on the head and the left shoulder (› fig. 10.1).
10.1.1 Algetic Signs in Heart Disease
Algetic Signs on the Trunk and Limbs
On the trunk, the Head's zones corresponding to the heart are located in the segments (C 8)
T 1 to T 4 (T 5) homolaterally on the left side in the region of the mammilla, and are about the
size of the palm.
This zone corresponds to the maximum points from T 1 to T 4 (exit points of the ventral
branches of the spinal nerves).
Maximum points are particularly sensitive areas which develop in the dermatomes, myo-
10 tomes, and sclerotomes when enterotomes of the same segment become diseased.
In my analysis, the metameric arrangement of the maximum points corresponds to the Head's zones of
the particular organ. The same consideration applies to all organs discussed in the following text.
* T 4 and/or T 5; differing data from different authors.

10.1 The Heart: Algetic and Autonomic Reflexive Projection Areas 283
The segmental myotomes of the heart, i. e., C 8 to T 4 (ventricles) and T 5 to T 7 (atria) may
cause pain and tension in an extensive muscular region, particularly in the intercostal mus-
cles. The tension in the intercostal muscles makes the patient feel “as if the heart is being
squeezed in a vise”.
Such tension often gives rise to a sensation of “feeling one's own heartbeat”. According to
Kunert, this may be an early symptom of heart problems. By way of the segments T 2 to T 5
or T 7, the left-sided sternocostal joints and the left side of the sternum may become painful
and tender (Tietze's syndrome).
Quite often, chronic heart conditions, no matter what their cause, are accompanied by
itching and enhanced ticklishness in response to the slightest touch, e. g., by clothing, in the
corresponding projection areas on the left side of the thorax (Plügge). As a reaction to this
spontaneous itching and ticklishness, subtle scratch marks, altered pigmentation, and skin
blemishes are often found, which should prompt suspicion that a cardiac disorder may be
present.
10
Diaphragm (C 4)
T4 Heart
(T3 and
T4)
Esophagus
T8
(T4 and
T5)
Stomach
T10 (T8)
T12 (T8−T11)
Small Intestine
(T10)
T1
Large Intestine
(T11)
Bladder
(T11−L1)
Kidney and Testis
(T10−L1)
10
Fig. 10.1a The heart: schema of the algetic and autonomic reflexive projection areas of the heart, which are
specific to dorsal and ventral segments on the left side.
Red: zone of referred pain of the heart (C 8 to T 7)
Dark red, ventral aspect: “Head's zone” in the region of referred pain, corresponding to the maximum points
of the affected dermatomes (myotomes, sclerotomes)
10
Fig. 10.1b Dark red, dorsal aspect: painful spinous processes (› fig. 6.3, Mackenzie's schema)
Light red: viscerogenically sensitized regions on the trunk and limbs (hyperesthesia and hyperalgesia), more
pronounced on the ulnar aspect, but also occurring on the radial aspect
Blue outline: autonomic reflexive projection area in the entire quadrant (vasomotion, piloerection, and sweat
secretion, including pupillary dilation, zones of the head and shoulders).
On the limbs some of the myotomes belonging to the same segments as the heart (C 8 to
T 2) are located on the ulnar aspect of the arms.
On the trunk some of the myotomes from the same segments as the heart are located in
the caudal parts of the pectoral muscles, in particular at their insertions onto the ribs, and in
the caudal parts of the latissimus dorsi muscle at its insertion onto the iliac crest.
Whereas pain in the ulnar aspect of the arm is a familiar projection phenomenon in heart disease, pain
in the latissimus dorsi and pectoral muscles is less well-known, although it is a common irritation in
heart conditions and must be considered in diagnosis and therapy.
Algetic Signs on the Spinous Processes
Regarding the spinous processes, Mackenzie noted that the first sign of cardiac irritation is
achiness and tenderness of the spinous processes C 7 to around T 3 (› fig. 10.1b, ellipse).
This sensitivity involves enhanced vasodilation on the tips of the spinous processes.
I should like to add on to Mackenzie's observation by mentioning the fact that the subcu-
taneous dermatomes C 8 to T 1, which are located next to the spinous processes, may show
a paravertebral swath of pitting edema (› fig. 4.7).
The region from the vertebrae C 7 through T 3 to approximately the level of the spine of the
scapula may thus reflect early signs of heart problems, being especially painful and somewhat
swollen on the left side.
Of course, this region may also reflect an irritation at the ulnar aspect of the wrist and the
ulnar region of the elbow, both of which belong to the segments C 8|T 1.
As an advance reference, let me add that the atria of the heart have the same segmental
relations as the stomach, the cardiac part of the stomach, and the duodenum, i. e., T 5 to T 7.
In consequence, viscero-visceral reflexes may cause disorders of the heart to give rise to
symptoms resembling those of stomach disorders (nausea, retching, dull pain).
Tenderness of the spinous processes between the spine of scapula and the inferior angle (› fig. 6.3,
ellipse B), which Mackenzie states are related to the stomach, may therefore indicate a disorder of ei-
ther the heart (ventricle) or the stomach.
Distant Projections in Heart Disorders
Headache
Via parasympathetic and sympathetic neurons, a disease or a disorder of the heart may also
project to the region C 2 (occiput) and the trigeminal region (face).
These projections elicit characteristic pain in the regions of the C 2 dermatomes, myo-
tomes, sclerotomes, and in the face:
10 • toothache-like symptoms in the mandible,
• pain on swallowing,
• pain in the sternocleidomastoid muscle, especially at its origin and insertion, i. e., in the
mastoid process and at the sternoclavicular joint,
• pain in the occipital region.
Very often pain is found in the region of the 2nd cervical vertebra, which in our experience is often irri-
tated when the patient complains of heart or vascular disease, e. g., high blood pressure, vertigo, and
sleep problems.
Headaches occurring in heart conditions, which may be interpreted as distant projections,

are located above all in the region of the forehead and the eyes and at the vertex, from where
they may radiate to the temple regions (› fig. 9.6a).
Head and Schmid localize the hyperalgesia in heart disease as follows:
In diseases of the ventricles and the aorta pain is located above all cranially, in the
frontonasal, midorbital, and frontotem-
poral regions
In diseases of the atria (especially in ar- pain is located in the frontotemporal, tem-
rhythmia) poral, vertical, and parietal regions
In diseases of the aortic valve hyperalgetic zones are often found in the
forehead, nose, and eyes
In diseases of the mitral valve pain is located in the temporal, vertical,
and parietal regions
The projection of heart and lung conditions to the trigeminal region is reflected by the term
“trigemino-cardio-pulmonary reflex”.
Shoulder Pain
By way of parasympathetic neurons in the phrenic nerve, disorders in organs adjacent to the
diaphragm may project signals to the shoulder girdle (segment C 4|C 5).
Since the phrenic nerve originates in the spinal cord segments C 4|C 5 and comes into
contact with all organs adjacent to the diaphragm, the organs may use this pathway to cause
irritation in the spinal cord segments C 4|C 5, leading to projection to the C 4|C 5 myotomes,
dermatomes, and sclerotomes, i. e., to the shoulder region (› page 60).
• Organs located on the left side, e. g., the heart or stomach, elicit pain in the left shoul-
der, whereas
• organs located on the right side, e. g., the liver or gallbladder, elicit pain in the right
shoulder.
In this context, let me point out again that the caudal region of the trapezius muscle, which
originates on the lower thoracic spine down to T 12, is a myotome related to C 4.
Pain in the shoulder region (related to C 4) may therefore trigger pain in the lower half of
the thoracic spine, especially in the spinous processes.
In particular, the thoraco-lumbar transition between T 12 and L 1 may be perceptibly irri-
tated, regardless of whether by distant projection or by pain originating in the shoulder itself.
The trapezius muscle (myotomes C 2–C 4) I would therefore regard as a preferential area of projection
for irritated organs adjacent to the diaphragm.
Pain and tension in the trapezius muscle must therefore be interpreted not just as being due
to a vertebrogenic disorder, but should also make one consider a disorder of an organ adja-
cent to the diaphragm as a possible cause. 10
Naturally, in the opposite direction, tension in the trapezius muscle may also provoke ir-
ritation of the organs adjacent to the diaphragm.
The example of the trapezius muscle shows particularly well that a thorough understand-
ing of segmental anatomy can be very useful in practice: Procedures that relax the trapezius
muscle, e. g., cupping, neural therapy, or acupuncture, may have a beneficial effect on all or-
gans adjacent to the diaphragm.
This amounts to a genuine prevention of disease in organs adjacent to the diaphragm and is also of
great significance as a treatment of such diseases in remission.
10.1.2 Autonomic Reflexive Projection Signs in Heart Disease
The upper limbs receive their sympathetic nerve supply from the spinal cord segments T 3 to
T 7, and the head is supplied from C 8 to T 3 (ciliospinal center).
This sympathetic nerve supply enables both the head and the upper limbs to be affected by
autonomic reflexive changes brought on by disorders of the thoracic organs (› figs. 3.5,
3.6).
Disorders of the heart and the aorta thus project symptoms to the left arm, the left side of
the head, and the entire left side of the chest, i. e., autonomic reflexive signs affect the entire
upper left quadrant.
Autonomic Reflexive Symptoms in the Integument
The autonomic reflexive symptoms in the integument consist of:
• vasoconstriction, These signs give rise to pallor, stickiness

• piloerection, and and goose bumps of the skin, and affect an
• increased sweat secretion entire quadrant of the body
Due to segmental-sympathetic neurons exiting the spinal cord through the posterior roots
from
• the segments C 8 to T 4 for the ventricles and
• the segments T 5 to T 7 for the atria,
the opposite reactions are possible, i. e.:
• vasodilation, These signs give rise to erythema, warmth

• lack of piloerection, and and dryness of the skin, and are segmental-
• decreased sweat secretion ly restricted to the algetic zones.
Such changes may be established objectively.

In practice, however, such examinations are laborious and time-consuming.
In my experience, it is simpler and more efficient to ask the patient about his or her subjec-
tive perceptions:
• Ask about (over)sensitivity to cold or preference for warmth, affecting mainly the left
side.
→ An affirmative answer suggests vasoconstriction.
• Ask about occurrence of goose bumps and cold shudders at being touched even slightly,
or efforts to avoid drafts.
→ An affirmative answer suggests piloerection.
• Ask about increased sweating noticed predominantly on the left side of the face and in
the left armpit.
10 → An affirmative answer suggests enhanced sweat secretion.
In all visceral disorders, the symptoms in the corresponding autonomic projection areas are
marked enough so that the patient usually feels compelled to describe them in detail, and is
also in need of appropriate understanding on the part of the attending physician.
I regard questions about subjective perception to be better suited for analysis of autonomic changes
than temperature measurements or ninhydrin testing, at least in large practices.
Autonomic Reflexive Changes in the Face
The left side of the face often shows subtle signs of tension, as if the patient were “embar-
rassed”. Furthermore, the left half of the face is somewhat paler, and there is increased sweat
secretion on the left upper lip.
Sometimes there are more skin blemishes or an altered pigmentation on the left side of the
forehead.
But consistently, the pupil of the left eye is unmistakably dilated, the left eye is glossy, and
the left eyeball protrudes slightly.
Posture
The body is deflected to the left, i. e., “the body bends toward the focus”.
Often the trunk is rotated slightly, with the left shoulder deflected backward.
I have observed that many patients with disorders or diseases of the heart perceive pres-
sure and contact in the ventral part of the thorax as very unpleasant. The patient may even
recoil from a palpating finger.
In contrast, massaging, cupping, and treatment on the dorsal part of the thorax are de-
scribed as very pleasant.
My interpretation of this phenomenon is that referred pain becomes manifest above all in
the skin and muscles of the ventral region, since the Head's zones are located mainly in the
anterior longitudinal third, i. e., in the areas supplied by the ventral branches of the spinal
nerves.
Naturally, pain in the ventral region of the thorax may also be exclusively of vertebral ori-
gin. In this case, however, it does not usually involve autonomic reflexive symptoms.
Differentiation between Angina Pectoris and Pseudo-Angina Pectoris
Differentiation without an electrocardiogram is difficult. Some help may be provided by the

following observations.
Angina Pectoris
Before, during, and after an angina pectoris attack, the following symptoms may appear on
the body surface in the segmental areas related to the heart:
• A sensation of prickling, of lameness and of motor weakness is felt in the left arm.
• An unpleasant burning, jabbing, or tingling is felt on the left side of the chest and the left
side of the face.
• The pressure exerted by clothing, especially suspenders, a belt, or a brassiere, is perceived
as very unpleasant.
• In addition, the regions of the C 8 to T 4 dermatomes, which are related to the irritated
segments, are unusually “ticklish”.
Whether vasomotor effects are due to autonomic projection or not is easily ascertained in 10
practice by analyzing the changes provoked by cupping on the back.
Circumscribed petechial bleeding to the point of fluid loss to the surroundings is always a segmental
clue to a possible disorder within the body.
Another typical sign of altered vasomotion is an extended time to restoration of warmth after
cooling: After both arms are held in cold water and then removed, the left arm remains cool
for a much longer time and requires longer time to become warm again.
Pseudo-Angina Pectoris
Attacks of pseudo-angina are usually precipitated by a faulty position or movement, e. g., by

lying on a pillow that is too flat or too high, or by certain faulty positions of the head, espe-
cially rotation or bending it backward, e. g., while riding a bicycle with low-slung handlebars,
at the hairdresser's, or during shaving. In this context, the “belly sleeper” must also be men-
tioned, who may lie for hours with the cervical spine bent in any possible direction.
Sometimes pressure on a single vertebra in the upper thoracic spine may suffice to trigger
pseudo-angina pectoris. Such observations were reported by various authors long before
Head's zones were discovered.
For differential diagnosis, experience has shown that analgesics and sedatives provide re-
lief in pseudo-angina pectoris, whereas nitrites show practically no effect (for further read-
ing, see Schmid and Kunert, among others).
In patients with chronic stenocardial complaints and heart disease, herpes zoster tends to
occur in the segments T 5 and T 6 on the left side. In my experience, skin blemishes are also
found quite often in this region.
Of course, pain projection to the heart region may also be caused by
• pathology in the cervical spine,
• irritation of the gallbladder (Wenckebach), or
• diseases of the stomach or esophagus.
Among the disorders of the stomach and esophagus, reflux symptoms and aerophagia (Ro-
emheld's disease) are the most important (viscero-visceral reflexes).
Patients who experience cardiac problems such as tachycardia, blood pressure instability,
and marked restlessness when lying down after a heavy evening meal may therefore be treat-
ed better by addressing their digestive problems, e. g., by advising them to eat less or not at all
in the evening, than by giving them antihypertensive or heart medication.
Symptoms more pronounced during an attack than outside of the attacks are (according
to Hansen and Schliack):
• exophthalmos,
• narrow palpebral fissure, on the left side only
• mydriasis,
• pain on deep palpation in C 3 and C 4,
• superficial hyperalgesia of the skin (dermatomes C 4–C 6, T 2–T 6),
• generalized vasospastic skin pallor (only during an attack),
• reduced muscle tone in the left shoulder and arm,
• enhanced reflexes in the biceps and triceps muscles of the left arm,
• enhanced electrical excitability of the deltoid, biceps, supinator, superficial flexor digito-
rum muscles of the left arm,
• analgesia and anesthesia of the palm and back side of the left hand, C 6 and C 7,
• analgesia without anesthesia in a small strip of skin on the hand between C 6 and C 7.
10
10.1.3 Viscero-Visceral Reflexes or Autonomic Organ Reflexes in

Heart Disease
Heart, Gastrointestinal Tract, Lower Urinary Tract
In heart conditions, autonomic organ reflexes occur mainly in the gastrointestinal tract and
the lower urinary tract.
Clinically familiar reflexive symptoms include, for example:
• vomiting, singultus, bloating (meteorism), and constipation, especially in angina pectoris,
but also in other heart conditions; furthermore
• the gastro-cardial symptom complex (Roemheld), in which aerophagia and reflux symp-
toms may trigger tachycardia and tachyarrhythmia.
The abdominal symptoms are often present as a reflexive sign in early heart disease.
Sometimes, particularly during an acute attack of angina pectoris, the abdominal symp-
toms may be so pronounced as to lead to an erroneous diagnosis, such as ileus, perforated
ulcer, kidney or gallstone colic, or pancreatitis. Wrong diagnosis is especially common if the
abdominal wall on the left side is tense, which in angina pectoris often occurs between the
navel and the left upper quadrant.
An important aid to differential diagnosis in such ambiguous cases is the occurrence of
bradycardia or tachycardia:
• For example, bradycardia often occurs at the beginning of an angina pectoris attack.
• In contrast, perforated ulcer, pancreatitis, kidney or gallbladder colic, and inflammatory
abdominal diseases never involve bradycardia, but tachycardia is nearly always present.
Later in the course of angina pectoris, however, tachycardia and tachyarrhythmia predomi-
nate.
Another well-known clinical finding is polyuria (urina spastica), which occurs especially
following paroxysmal tachycardia or an attack of angina pectoris.
The reason why basically healthy organs react in this way is not completely understood.
Most authors seek the cause in the fact that the organs have the same viscero-afferent and
viscero-efferent connections. For instance, the heart and esophagus have the same viscero-
afferent innervation in the segments T 2 to T 5, which might also explain the tachycardia and
hypertension accompanying gastro-esophageal reflux disease.
My observations indicate that during acute attacks, mainly sympathetic organ reflexes (constipation
and anuria) are found, whereas after the attack, parasympathetic organ reflexes (diarrhea and polyuria)
predominate.
Worthy of mention is Mackenzie's observation that left-sided reflexive phenomena, espe-

cially in the presence of tachycardia, may shift toward the right. This occurs especially if
tachycardia has led to liver congestion, as Hansen and Schliack as well as Kunert have cor-
roborated.
Following resolution of the liver congestion, their descriptions indicate that the right-
sided reflexive phenomena disappeared, leaving only the left-sided ones related to the heart.
Also worth mentioning is the fact that many patients with stenocardia report that attacks 10
may be precipitated by certain arm and shoulder movements, but also by rotating the head.
This relationship is understandable from the viewpoint of segmental analysis, and must be
considered in therapy by integrating the shoulder-arm muscles into the treatment.
The interrelationships may be imagined as follows:
• Irritations of the heart (ventricles, atria, and aorta) are related to the spinal cord segments
C 8 to T 7.
• Sympathetic efferent impulses from these segments are conducted in a cranial direction
by the sympathetic trunk to the middle cervical ganglion and the stellate ganglion, and by
way of the spinal nerves C 5 to T 1 to the brachial plexus.
The Influence of Superficial Segments on the Heart
Conversely, irritations in the myotomes C 5 to T 1 on the trunk (i. e., the shoulder girdle, the
latissimus dorsi and pectoral muscles) and the arm may precipitate malfunction in a patho-
logically stimulated heart. This explains why raising the arms and shoulders, especially on the
left side, via the brachial plexus and the middle cervical and stellate ganglia, may irritate the
spinal cord segments C 8 to T 7, eliciting heart disturbances via the somato-visceral pathway.
Here it must also be underscored that a healthy organ can never be irritated by an “illness of the body
surface”, but that most certainly a pathologically stimulated heart may overreact to certain movements
or irritations on the body surface.
Awareness of these interrelationships is of practical relevance, since therapy on the body sur-
face, e. g., by infiltration of the corresponding trigger points or by loosening tight muscles on
the arm and shoulder, plays the most important role in all such cases.
Whereas in Western medicine the viscero-visceral reflexes play an – albeit important – part only in di-
agnosis, they are considered very much practically in acupuncture theory, as in acupuncture and neural
therapy the projection areas showing signs of irritation by autonomic organ reflexes are always treated
concomitantly, e. g., in heart conditions the Head's zones of the stomach and/or the kidney.
Implications for Therapy
The therapeutic consequences described in the following text basically apply to all other or-
gans as well.
The algetic and autonomic reflexive projection areas of the diseased organs contain cir-
cumscribed, larger or smaller areas which are sensitive to pressure or spontaneously painful
and may serve as starting points for acupuncture, for neural or manual therapy.
This corresponds to classical segmental therapy in the periphery, which disables the peripheral
nociceptive afferent neurons so that fewer disruptive impulses are conducted to the spinal cord.
Such painful areas occur mainly:
• at the exit points of the ventral spinal nerve branches, the ventral maximum points,
• in the region of the spinous processes,
• in the regions of scattered myotomes that are segmentally related to the particular affect-
ed organ,
• in painful zones of the head, and
• in painful zones of the shoulders.
Painful Areas at the Exit Points of the Ventral Branches: Ventral Maximum
Points
10 The Head's zones of all organs are located, in my analysis, in the region supplied by the ven-
tral branches, because the gray communicating branches enter only the ventral branches,
transmitting their pathological information, above all, through the latter.
A particularly tender spot in the region supplied by the ventral branches should not im-
mediately be subjected to further irritation by local therapy. Instead, it is preferable to con-
centrate on treating the dorsal segmental areas, and involve the ventral points (CV 17, CV 15,
CV 12) only after improvement has set in.
This corresponds to the ancient Chinese rule that particularly sensitive areas should be treated only very
gently (bufa) or not at all.
Painful Areas in the Region of the Spinous Processes
These projection areas were described by Mackenzie in his reports and are clearly depicted in
figure 6.3.
These segmental projection areas may be influenced by infiltration, or by stimulation
through acupuncture.
Painful Areas in Segmentally Related Scattered Myotomes

In such cases it is best to systematically examine the origins and insertions of the myotomes
for painful tender points, and to include in treatment any that are found.
Other painful areas and points of departure for segmental therapy are located in the seg-
ment C 2, since disorders of all organs may give rise to “Head's zones” (according to Foerster)
or to hyperalgetic regions by way of afferent parasympathetic neurons (i. e., the vagus nerve)
in the regions related to C 2 and the trigeminal nerve.
The typical locations of painful areas in the C 2 region are at the origin and insertion of the
sternocleidomastoid muscle, i. e., the sternum, the clavicle, and the mastoid process.
Painful Zones of the Head

Painful zones of the head play only a minor role in segmental therapy (Schmid). They are
important mainly in diagnosis.
Painful Zones of the Shoulder

Painful zones of the shoulder develop via parasympathetic neurons in the phrenic nerve,
which project irritations occurring in organs adjacent to the diaphragm to the segments
C 4|C 5.
Here as well, the projection of pain is homolateral to the affected organ, e. g., in case of the
heart on the left, and in case of the gallbladder on the right side. In practice, one may observe
that shoulder pain is often related to an extraordinary oversensitivity to cold and touch, so
that the patient describes even the pressure of clothing as unpleasant.
Particularly significant for all visceral organs is the trapezius muscle, because it is often viscerogeni-
cally irritated when an internal organ is diseased.
For the heart itself, the therapeutic implications for acupuncture treatment regarding the ar-
eas innervated by the ventral and lateral branches are as follows:
• The ventral branches affect the parts of the ventral forearm and ventral thorax belong-
ing to the same segment (e. g., xinpin for pain in the pectoral muscle, HT 7, CV 17).
• The lateral branches affect the parts of the dorsal forearm and the back (e. g., SI 3 for
lumbago, BL 15, TH 5).
10
Both the xinpin point and SI 3 are located in segment C 8.
• The xinpin point, due to its location in the region of the forearm innervated by the ventral
branches, affects only the anterior thoracic region supplied by ventral branches, i. e., in
the anterior longitudinal third. The xinpin point is never effective in lumbago.
• The SI 3 point, in contrast, due to its location in the region of the forearm innervated by
lateral branches, affects only the parts of the back supplied by the lateral branches, and is
never effective in stenocardia.
10.2 Lungs and Bronchi: Algetic and Autonomic

Reflexive Projection Areas
Segmental Relations
The lungs and bronchi are related to the spinal cord segments T 2 to T 5 by way of sympathetic viscero-
afferent neurons.
10.2.1 Algetic Signs in Disorders of the Lungs and Bronchi
Algetic Signs on the Trunk
Sympathetic-afferent neurons from the lungs and bronchi extend to the cells of the poste-
rior horn of the spinal cord segments T 2 to T 5.
Algetic signs are therefore found on the trunk in the segments T 2 to T 5, namely
in the dermatomes T 2 to T 5 as skin irritations and itching

in the myotomes T 2 to T 5 as pain in the intercostal muscles
in the sclerotomes T 2 to T 5 as pain in the spinous processes, the verte-
bral bodies, and the costovertebral, sterno-
costal, and sternoclavicular joints
10
10.2 Lungs and Bronchi: Algetic and Autonomic Reflexive Projection Areas 295
Algetic Signs on Limbs
At the exit points of the ventral branches of the spinal nerves T 2 to T 5, i.e, the ventral maxi-
mum points, painful areas may develop that form the Head's zones of the lungs and bronchi,
and are always located on the ventral thorax.
• Sympathetic-efferent neurons from the lungs and bronchi are derived from the lateral
horns of the spinal cord segments T 2 to T 5, leave the spinal cord via the anterior roots of
these segments, and pass as
• preganglionic neurons (white communicating branches) to the sympathetic ganglia of
T 2 to T 5.*
• In the sympathetic trunk they form extensive collaterals, extending cranially as far as the
middle cervical ganglion (C 4|C 5|C 6).
Here, the preganglionic neurons undergo synapsis, emerging as
• postganglionic neurons (gray communicating branches) with the spinal nerves
C 4|C 5|C 6 and T 2 to T 5 that run to the periphery.
Therefore, algetic signs are found on the limbs in the
• C 4|C 5|C 6 dermatomes, myotomes, and sclerotomes, where they cause irritation
mainly on the radial side (M. Monnier) (› fig. 10.2).
10
* The sympathetic nerve supply of the organs is not described here in detail.
Diaphragm (C 4)
T4 Heart
(T3 and
T4)
Esophagus
T8
(T4 and
T5)
Stomach
T10 (T8)
T12 (T8−T11)
Small Intestine
T1 (T10)
Large Intestine
(T11)
Bladder
(T11−L1)
Kidney and Testis
(T10−L1)
10
Fig. 10.2a Lungs. Schema of the algetic and autonomic reflexive projection areas of the right lung, specific
for each side and segment; ventral and dorsal views.
Red: zone of referred pain of the right lung in T 2 to T 5
Dark red, ventral aspect: “Head's zone” in the region of referred pain, corresponding to the maximum points
of the affected dermatomes (myotomes, sclerotomes)
10
Fig. 10.2b Dark red, dorsal aspect: painful spinous processes (Mackenzie's schema, › fig. 6.3)
Light red: viscerogenically sensitized regions on the trunk and limbs (hyperesthesia and hyperalgesia), more
pronounced on the radial aspect
Blue outlined: autonomic reflexive projection areas in the entire quadrant (vasomotion, piloerection, and
sweat secretion, including pupillary dilation, head and shoulder zones).
This means that pain and muscular tension may develop not only in the upper half of the
chest (T 2–T 5, in the dermatomes and in the deep autochthonous muscles of the trunk), but
also in the cervically innervated muscles of the limbs and in the cervically innervated
muscles that have migrated back to the trunk (C 5|C 6).
This concerns mainly
• on the arm: the biceps, brachial, and brachioradial muscles, as well as the extensor and
flexor carpi radialis muscles, located on the radial aspect, and
• on the thorax: the parts of the pectoral muscles and the muscles of the shoulder girdle
belonging to the segment C 5|C 6, i. e., the cranial portion of the pectoral muscle and the
shoulder muscles (rhomboid muscles, supraspinatus and infraspinatus muscles, teres
major and minor muscles). These cervically innervated muscles are the accessory muscles
of respiration.
In addition, neurons from the spinal nerves C 5 and C 6 extend to the diaphragm (C 5|C 6
myotomes).
In disorders affecting the entire respiratory tract, our practical experience has shown again
and again a remarkable sensitivity to tapping and pressure in the spinous process of T 3,
even in the presence of paranasal sinusitis.
For example, in allergic rhinitis consideration of the spinous process of T 3 in diagnosis and therapy has
led to improvement even in therapy-resistant cases.
Distant Projections in Pulmonary Disorders
Headache
By way of a connection between the vagus and the trigeminal nerves, pulmonary and heart
conditions may be accompanied by an effect known in clinical practice as reflexive erythe-
ma, caused by a trigemino-cardio-pulmonary reflex.
Furthermore, connections between the vagus nerve and the dermatomes, myotomes, and
sclerotomes , of C 2 may lead to pain and other effects in the occiput and the mandible.
According to Head, pulmonary and bronchial diseases may be accompanied by headache
located mainly in the frontonasal, frontotemporal, and rostral regions.
Of course, pain in these regions must also lead to suspicion of sinus disease.
Shoulder Pain
Via parasympathetic neurons in the phrenic nerve, pulmonary and bronchial disorders may
project to the dermatomes, myotomes, and sclerotomes of C 4|C 5|C 6.
This may lead to pain in the entire shoulder girdle, which is observed especially homolater-
ally to the affected organ.
• The parasympathetic neurons in the phrenic nerve give rise only to hyperalgesia.
• The sympathetic neurons, which by way of collaterals in the sympathetic trunk may also
10 irritate the integument in segments C 4|C 5|C 6, thus leading to autonomic-sympathetic
effects, elicit autonomic reactions in addition to the hyperalgesia in the integument of
the shoulder girdle.
Such autonomic effects may in turn lead to a marked feeling of cold in the patient, which can
be verified objectively. In the region of the painful shoulder the skin is damp and sticky, and
will react to the slightest touch with gooseflesh.
C 4 neurons may conduct impulses from the lungs and bronchi as far away as the caudal
region of the trapezius muscle (C 3|C 4 myotomes), since the ascending part of the trapezius
muscle extends to the 12th thoracic vertebra. Therefore, the lower thoracic vertebrae and their
spinous processes may be remarkably sensitive to pressure.
In such patients, the corresponding intercostal muscles and the ventral dermatomes T 10
to T 12, i. e., those at the level of the 12th vertebra, may be noticeably oversensitive, some-
times to the extent that neither acupuncture nor infiltration will be tolerated.
Failure to consider this fact may lead to needle shock.
10
10.2.2 Autonomic Reflexive Projection Signs in Bronchial and

Pulmonary Disorders
Segmental Relations
• The
head receives its sympathetic nerve supply from the spinal cord segments C 8 to T 3.
• The
limbs receive their sympathetic nerve supply from the spinal cord segments T 3 to T 7.
However, since these spinal cord segments also give rise to the sympathetic nerve supply of the heart,
lungs, esophagus, stomach, and duodenum, disorders of the latter organs may be accompanied by
autonomic reflexive effects on the head and the integument of the trunk and limbs, i. e., on an entire
quadrant of the body.
Autonomic Reflexive Symptoms in the Integument of

an Upper Body Quadrant
Autonomic reflexive signs of disease in the integument are

• vasoconstriction,
• piloerection, and
• increased sweat secretion.
These effects always occur on the side homolateral to the diseased organ, i. e., for the right
lung on the right side, for the left lung on the left side. In consequence, the skin in this reflex-
ively affected region feels cooler to the touch than that of the opposite side; the patient may
feel very cold inside and constantly strive to cover himself with blankets or dress warmly:
• The slightest touch on the side of the disease leads to piloerection (goose bumps), which
the patient perceives as coldness and cold shudders.
• Increased sweat secretion occurs mainly in the armpit, the half of the face and the upper
lip, always on the side homolateral to the affected organ.
However, segmental-autonomic neurons leaving the spinal cord through the posterior roots
may also cause opposite effects, namely
• vasodilation,
• absence of piloerection, and
• reduced sweat secretion.
These effects occur in a strictly segmental distribution pattern in the algetic zone of the lung.
In such cases, the patient experiences a localized burning or heat sensation, and the skin is
hot and dry to the touch. In practice, one may notice that patients affected in this way per-
ceive massages and cupping as extremely unpleasant, and will often reject such treatment.
Autonomic Reflexive Signs in the Face
Nearly always, homolateral mydriasis, a widened palpebral fissure, and a glossy eye are pres-
ent, as well as other classical autonomic reflexive phenomena, such as tense facial muscles,
pallor, or cyanosis of the facial skin, likewise on the homolateral side.
10 The autonomic reflexive signs in the face can be elicited or enhanced by applying pressure
on the Mussy's point in the clavicular region.
Other Reflexive Signs
Other reflexive signs in disorders of the lungs and bronchi consist of changes in posture.
In the sitting patient, bending to one side at the waist (described by Hansen and Schliack)
may often be observed on the homolateral side, i. e., the body bends around the focus. Usu-
ally the head is tilted to the right or left side toward the painful shoulder. During breathing,
the affected shoulder lags somewhat, accentuating the asymmetry. This abnormal position
also often leads to narrowing of the intercostal spaces. When lying down, the patient often
lies spontaneously on the affected side in order to relieve it during respiration.
Chronic disorders are often accompanied by herpes simplex on the homolateral side of
the mouth and nose.
Of course, shoulder pain is not necessarily an expression of a visceral disorder. For differ-
ential diagnosis, a distinction is often possible, since in referred shoulder pain other homo-
lateral segments are usually affected as well, e. g., the segment C 2 and the area supplied by
the trigeminal nerve or the abdomen.
Such distant projections and viscero-visceral reflexes occur only in projected, or referred, shoulder pain,
but never in genuine or vertebrogenic shoulder pain.
10

Disorders of Lungs and Bronchi
In pulmonary disease, autonomic organ reflexes affect predominantly the gastrointestinal

tract. Clinically, especially in pediatrics, pneumonic pseudo-appendicitis is a well-known ex-
ample. In differential diagnosis, it is easy to identify because McBurney's point at T 11 does
not show rebound tenderness in pneumonic pseudo-appendicitis. In addition, patients with
pneumonia are usually cyanotic, whereas those with abdominal disorders are usually pale.
Pulmonary embolism is also often accompanied by abdominal symptoms triggered by
viscero-visceral reflexes.
Several authors have mentioned that referred pain and autonomic reflexive signs in the
face (e. g., pupillary dilation and a widened palpebral fissure) may also be early signs of a
malignant tumor.
In cancer of the bronchi, lungs and pleura these signs have been found long before the
radiologic evidence.
“So-called intercostal neuralgia or therapy-resistent pain in the costal region in conjunction
with autonomic reflexive signs must therefore always also call to mind the possibility of a ma-
lignant tumor in the corresponding segmental region.”
(Kunert)
The spread of pain across the thorax, the arm, and the face (upper body quadrant) also
leads to a remarkable oversensitivity of the entire homolateral side. Characteristically, the
patient expresses the wish not to have any injections on the affected side, since “the whole
side already hurts”.
As if to relieve it, the patient turns the affected side away from the observer. Although the
head is inclined toward the affected shoulder, the patient's gaze is still directed away from the
affected side.
A noteworthy parallel is described in veterinary medicine: A dog will always look away from an injured
limb and “toward the healthy side” (personal communication from Martin Kampik).
In tuberculosis patients, Neumann (Vienna) described the occurrence of pupillary dilation

and pressure sensitivity of the homolateral Mussy's pressure point as constant findings, like-
wise the more intense tuberculine reaction on the side homolateral to the disease.
Not only the viscero-cutaneous signs and reactions, but also the cuti-visceral ones are im-
portant. In animal experiments it has been shown that repeated applications of chemical ir-
ritants to the right side of the back of a depilated rabbit led to inflammatory reactions in the
left lung. Furthermore, hyperemia of the homolateral stellate ganglion was found. It was also
shown in laboratory animals that after hematogenic infection with tuberculosis the changes
in the right lung were greater if the right-sided dermatomes on the back had been previously
treated as described above (Kunert).
10
10.3 The Esophagus: Algetic and Autonomic Reflexive Projection Areas 303
10.3 The Esophagus: Algetic and Autonomic Reflexive

Projection Areas
Segmental Relations
• The upper half of the esophagus is related to the spinal cord segments T 2 to T 5, and
• the lower half of the esophagus is related to the spinal cord segments T 6 to T 8
by way of sympathetic viscero-afferent neurons.
10.3.1 Algetic Signs in Disorders of the Esophagus
The algetic signs of esophageal disorders therefore occur

• retrosternally, in the upper half of the chest, and
• in the epigastric angle in the lower half of the chest.
The projection signs of the cranial half of the esophagus correspond to those of the segmen-
tally related lung. Their maximum point is located at T 5 in the midline, sometimes on the
right side.
The caudal half of the esophagus projects to the epigastric angle. This projection area coin-
cides with that of the stomach, which likewise belongs to the segments T 6 to T 8.
On the back, the spinous processes of T 6 and T 7 between the shoulders are often sensitive
to pressure.
The autonomic reflexive projection signs correspond to those of the stomach and duodenum
(› chapter 10.4)
10.3.3 Viscero-Visceral Reflexes in Disorders of the Esophagus
Viscero-visceral reflexes occur mainly between the lungs, the heart, and the esophagus. Like
all other viscero-visceral reflexes, they are based on involvement of the spinal cord segments
from which the affected organs, in this case the lung, heart, and esophagus, receive their
nerve supply.
As an example from clinical practice, a breathing condition resembling asthma is known
to occur in reflux esophagitis, especially at night. Similarly, heart conditions, especially
tachycardia and sometimes hypertension as well, have been reported in patients with reflux
disease, especially on lying down after a heavy meal.
The complaints resolve when the patient sits erect, or when he sleeps with the head and
chest elevated, and refrains from lying on the right side.
Often the sterno-symphyseal stress posture described by Brügger (enhanced thoracic ky-
phosis and lack of lumbar lordosis) is accompanied by disorders of the esophagus and the
stomach, involving cramp-like pain and heartburn. 10
It is certainly not easy to determine whether a vertebro-visceral or viscero-vertebral inter-
action predominates, since patients with sensitive stomachs always are bent forward in a
typical relief posture.
10.3.4 Analogies Between Segmental Anatomy and Acupuncture
The upper half of the esophagus and the lungs share viscero-afferent neurons relating them
to the spinal cord segments T 2 to T 5.
Tab. 10.1 Segmental relations between the individual parts of the digestive tract, based on the
embryogenic development
Embryology Digestive Tract Spinal Cord Segments Projection Areas
Foregut Esophagus T 4–T 5 Ventral thoracic wall
Stomach T 6–T 8 and upper limb
Duodenum T 6–T 8
Midgut Jejunum T 7‑T 11 Abdominal wall
Ileum T 7–T 11
Hindgut Cecum T 10–T 12 Lower abdominal wall
Ascending colon T 9–T 12 and lower limb
Transverse colon T 8–L 1
Descending colon L 1–L 3
Rectum T 11–L 3
This fact explains why both organs have their maximum pain in the same algetic zones. In
this sense, there is an area in the T 5 region approximately in the middle of the sternum
which may be spontaneously painful or sensitive to pressure in both cases (CV 17).
Furthermore, I believe that the macroscopic similarity of the trachea (lung) and esophagus
(foregut) is another reason why in acupuncture the lung (trachea) and part of the gut (esoph-
agus) are considered to be related (lung-large intestine; see below).
The fact that both organs, via the sympathetic trunk and conduction of their impulses to
the segments C 5|C 6, are able to trigger viscerogenic irritation in the region of the radial as-
pect of the arm is an additional concordance that makes the interconnection between trachea
and esophagus plausible from the viewpoint of acupuncture.
In my opinion, the term “big gut” (da chang) substantiates this assumption, which Poll-
mann recently referred to.1 According to him, the “big gut” represents the esophagus and is
related via reflexive interactions to the trachea (lung).
To start with: The “little gut” (xiao chang), i. e., the duodenum, is in my opinion related to the heart
because this part of the gut is derived from the same segments as the heart, specifically the atria.
In disorders of the gastrointestinal tract, algetic and autonomic reflexive projection signs oc-
cur from head to toe. On the trunk, they are projected as algetic zones along the ventral mid-
line.
The segmental assignment and relational interpretation of the individual parts of the digestive tract are
easier to understand if one divides the latter on the basis of its embryonic development. This reveals
the concordance of spinal metamerism, embryology, superficial algetic zones, and acupuncture theory.
10
1 from Ärztliche Praxis, 2007

10.3 The Esophagus: Algetic and Autonomic Reflexive Projection Areas 305
10.3.5 Projection of the Digestive Tract to the Limbs
Before discussing the individual organs of the digestive tract and their typical algetic zones, I
should like to mention the role of the limb muscles in the occurrence of projected, or re-
ferred, pain:
• The foregut (esophagus, stomach, duodenum) projects not only to the upper ventral
third of the chest, but also to the radio-volar aspect of the upper limb.
• The midgut (jejunum, ileum, and colon down to the left flexure) projects not only to the
middle ventral third of the abdominal wall, but also to the ventrolateral aspect of the
lower limb.
• The hindgut (descending and sigmoid colon, rectum) projects not only to the lower ven-
tral third of the abdominal wall, but also to the dorsal aspect of the lower limb.
Involvement of the limbs is due to the typical formation of collaterals in the sympathetic
trunk:
• The preganglionic neurons from C 8 to T 7 (related to the thoracic organs and the stom-
ach) run cranially in the sympathetic ganglia via formation of collaterals, extend to the
sympathetic middle cervical and stellate ganglia, and then pass through the spinal nerves
C 5 to T 1 into the brachial plexus.
In this way, they elicit algetic and autonomic reflexive signs in the upper half of the trunk and
upper limbs.
• The preganglionic neurons of T 8 and T 9 (related to the upper abdominal organs)
reach only the intercostal muscles of T 8 and T 9. Therefore they give rise to algetic and
autonomic reflexive signs only in the epigastrium.
• The preganglionic neurons of T 10 to T 12 (related to the upper abdominal organs) run
caudally in the sympathetic ganglia via formation of collaterals, extend to the sympathetic
ganglia L 4|L 5, and then pass through the spinal nerves L 1 to L 4|5 to the lumbar plexus
(L 1 to L 4), and thus to the ventral aspect of the lower limb.
Therefore, they provoke algetic and autonomic reflexive signs in the lower abdomen and
lower limbs.
• The preganglionic neurons of T 12 to L 3 (related to the pelvic organs) likewise run cau-
dally, via collaterals in the sympathetic trunk, extending to the sympathetic ganglia
S 1|S 2|S 3 and passing through the spinal nerves S 1|S 2|S 3 to the sacral plexus and from
there to the dorsal aspect of the lower limb.
The segments S 1|S 2|S 3 are also related to the parasympathic neurons of the pelvic nerves,
which in case of pelvic organ disease may cause hyperalgesia in the dermatomes, myotomes,
and sclerotomes belonging to S 1|S 2|S 3.
Therefore, the dorsal region of the leg, i. e., the flexor muscles on the dorsal aspect of the
leg and the ischiocrural muscles, must be regarded as resonance areas of the pelvic organs.
In my analysis, this relationship corresponds precisely to the specifications of acupunc-
ture, according to which
• the upper abdominal organs project to the ventrolateral aspect of the leg, whereas
• the pelvic organs project to the dorsal aspect of the leg.
Like all other visceral organs, those of the digestive tract project to the anterior midline of the
trunk, between the sternum and the symphysis.
The descriptions of the projection areas given by various authors are fairly well in agree- 10
ment. Whereas Hansen, Staa, Schliack, and Schmid give highly differentiated projection ar-
eas for the individual parts of the digestive tract, the descriptions provided by Foerster and
Bumke are simplified.
In my own experience, Foerster's descriptions correspond best to the painful areas en-
countered in actual practice, which is why I adhere to them.
10.4 Stomach and Duodenum
Segmental Relations
Stomach and duodenum are related by way of sympathetic viscero-afferent neurons to the spinal cord
segments T 6 to T 8.
10.4.1 Algetic Signs in Disorders of the Stomach and Duodenum
Algetic signs occur in the epigastrium between the xiphoid process and the umbilicus.
Pain is projected mainly to the left of the midline, with maximum points at T 6 to T 8 on
the ventral aspect.
The maximum points in stomach disorders in the segments T 6 to T 8 correspond to the
Head's zone of the stomach.
Here too it is evident that the stomach, which is derived from the entoderm, projects to the
region supplied by the ventral branches, like all other organs derived from the primitive gut.
The segmentally identical organs, i. e., stomach and duodenum, differ above all from each
other as to whether they project to the left or right side of the midline:
• Stomach disorders lead mainly to reflexive signs on the left side, whereas
• duodenal disorders lead mainly to reflexive signs on the right side.
Mackenzie found
• hyperalgesia in the upper part of the epigastric region in conjunction with irritation of the
cardial portion of the stomach,
• hyperalgesia in the middle part of the epigastric region in conjunction with ulcers in the
middle part of the stomach, and
• hyperalgesia in the lowest part of the epigastric region in conjunction with an ulcer in the
pylorus.
Mackenzie also found
• hyperalgesia and pressure-sensitive points on the left border of the rectus abdominis
muscle in disorders of the stomach, and
• hyperalgesia and pressure-sensitive points on the right border of the rectus abdominis
muscle in disorders of the duodenum.
On the upper limb, signs of viscerogenic irritation appear mainly on the ulnar side, since
conduction of the impulses from the caudally located organs (stomach and duodenum, T 6
to T 8) within the sympathetic trunk proceeds mostly through the caudal part of the brachial
plexus, i. e., in the region of the ulnar nerve and the segments C 8 to T 1 (› fig. 10.3).
Spinous Processes
According to Mackenzie, the spinous processes in the region between the spine of the scap-
10 ula and the inferior angle are sensitive to pressure if the stomach or duodenum is diseased.
Similarly, the Berlin physician, Boas, reported around 1900, that in patients with stomach
ulcers a pressure-sensitive point was present on the left side adjacent to the 10th to 12th tho-
racic vertebrae (Boas' pressure point).
It must be emphasized that the pressure-sensitive spinous process is located further crani-
ally than the hyperalgetic dermatome.
Therefore, for example, in case of disorder in the T 6segment, the hyperalgetic dermatome
is located further caudally than the pressure-sensitive spinous process T 5 (Kunert).
10.4 Stomach and Duodenum 307
Distant Projections in Disorders of the Stomach and Duodenum
Headache
Patients with diseases of the stomach or duodenum often have temporal and parietal head-
aches. Head observed that such headaches usually occur if previously already referred pain
had been present in the thoracic region between T 5 and about T 10. This finding implies that
pain can be transmitted not only from the internal organ, but also from the body surface to
the head.
Shoulder Pain
Like all the other conditions associated with the gastrointestinal tract, shoulder pain is elic-
ited by parasympathetic fibers running with the phrenic nerve in the segments C 4|C 5|(C 6),
which in stomach disorders is perceived in the left shoulder.
The distant projection in these segments also leads to pain in the region of the lower tho-
racic spine, since the C 4 myotome extends from the caudal part of trapezius muscle to the
12th thoracic vertebra.
Localized overlapping of several segments, i. e., the 12th thoracic vertebra (T 12 sclero-
tome) with its caudal insertion of the trapezius muscle (C 4 myotome) and the T 8 derma-
tome covering it (Head's zone of the stomach), explains the widespread effectiveness of the
shu points B 20 and B 21, and of the alarm point GV 12.
10
Diaphragm (C 4)
T4 Heart
(T3 and
T4)
Esophagus
T8
(T4 and
T5)
Stomach
T10 (T8)
T12 (T8−T11)
Small Intestine
T1 (T10)
Large Intestine
(T11)
Bladder
(T11−L1)
Kidney and Testis
(T10−L1)
10
Fig. 10.3a Esophagus and stomach. Schema of the algetic and autonomic reflexive projection areas of the esophagus and stomach,
specific for each side and segment; ventral and dorsal views.
Red: zone of referred pain of the esophagus in T 5 to T 6 and of the stomach in T 6 in T 8
Dark red, ventral aspect: “Head's zone” in the region of referred pain, corresponding to the maximum points of the
affected dermatomes (myotomes, sclerotomes)
10
Fig. 10.3b Dark red, dorsal aspect: painful spinous processes (Mackenzie's schema; › fig. 6.3)
Light red: viscerogenically sensitized regions on the trunk and limbs (hyperesthesia and hyperalgesia), more pronounced on the ulnar aspect
Blue outlined: autonomic reflexive projection areas in the entire quadrant (vasomotion, piloerection, and sweat secretion, including pupillary dilation,
head and shoulder zones).
10.4.2 Autonomic Reflexive Projection Signs in Disorders

of the Stomach and Duodenum
Integument of the Upper Body Quadrant
In stomach disorders on the left side, in duodenal disorders on the right side, the skin of an
entire upper quadrant of the body will display the familiar signs:
• altered sweat secretion.
Especially in case of stomach disease, the patient's description of subjective symptoms is so
characteristic that one must suspect autonomic effects in the skin, especially in the algetic
zones.
In the presence of stomach irritation, gastritis, or ulcer symptoms, the patient nearly al-
ways complains of pain in the epigastric region that is relieved by application of heat (e. g., a
hot-water bottle) and pressure to the epigastrium.
Posture
Since patients with stomach disorders typically bend forward slightly, i. e., bend the body
around the focus, and since the typical stomach patient perceives warmth and pressure as
very pleasant, they remind one of “Tailor Boeck”, described by the 19th century German hu-
morist Wilhelm Busch:
“Because a hot flat iron, pressed on the cold abdomen, made it well again.”
In my courses and lectures on acupuncture, I have compared the disease entities as defined
in Chinese medical theory again and again with descriptions of diseases and characters from
literary works in order to make them better understandable.
Changes in Segmentally Corresponding Regions
In veterinary medicine, Wernoe conducted experiments which proved that changes in vaso-
motion between the Head's zones on the body surface and the corresponding gastrointestinal
regions proceed synchronously.
Wernoe's endoscopic studies on animals show that pain and cold stimulation in the region
of T 7 to T 9 in the ventral midline led to vasoconstriction of the vessels in the parts of the gut
corresponding to these segments, whereas application of heat led to vasodilation in the cor-
responding parts of the gut. These endoscopic studies showed synchronized vasomotion
within segmentally corresponding regions on the body surface and inside the body.
In simplified terms:
• vasoconstriction on the outside – vasoconstriction on the inside, and
• vasodilation on the outside – vasodilation on the inside.
10 Naturally, the same applies in the opposite direction, e. g., when ice-cold or hot drinks are
ingested.
It is known from practice, and we have observed in many patients, that even after an ulcer
or gastritis have healed, the irritated condition in the corresponding segmental regions on
the body surface may persist.
For example, the region of the 12th thoracic vertebra and the T 8 dermatome often remain
overly sensitive, both in the dorsal and in the ventral regions, after the ulceration and gastri-
tis have healed long since.
In such cases, acupuncture or neural therapy, i. e., a stimulus in the corresponding algetic
projection areas is the treatment of choice.
Autonomic Reflexive Signs in the Face
Just as the heart and the lungs via the trigemino-cardio-pulmonary reflex may repeatedly
cause erythema in the face, the same reaction is also very typical in the presence of stomach
complaints. In the latter case the appropriate term would be trigemino-cardio-pulmonary-
gastric reflex, elicited by the ciliospinal center, from which the sympathetic nerve supply of
the face and neck is derived.
Such distant projection of autonomic reflexive signs to the face in the presence of stomach
irritation is a common observation in patients, particularly females, with unstable circula-
tion. They repeatedly develop a marked, usually sharply demarcated erythema in the trigem-
inal region after intake of coffee or alcohol, which stimulate the flow of gastric juices.
In my opinion, this distant projection, which most certainly was also observed by ancient Chinese
physicians, is the reason why the stomach meridian is located in the face.
In addition, I should like to point out a characteristic sign that may be observed in algetic
projections to the ventral midline: During pressing, the umbilicus is temporarily diverted
toward the affected side, i. e., in gastritis or stomach ulcer toward the left, and in duodenal
ulcer to the right (Kunert).
In the face, there is always homolateral tension of the facial muscles, a markedly “fed-up”
facial expression. “Fed-up” describes clearly the facial expression and the corresponding full-
ness of the stomach.
Another observation fitting into this context is the fact that skin irritations and herpes
zoster develop on the left side in stomach disorders, and on the right side in duodenal disor-
ders.

Disorders of the Stomach and Duodenum
As already described for the esophagus, there are viscero-visceral reflexes, i. e., autonomic
organ reflexes between organs related to the same spinal cord segment by way of sympa-
thetic visceral-afferent and efferent neurons. Here, the organs are the stomach, the duode-
num, the caudal part of the esophagus, and the atria of the heart.
Heart symptoms, in particular arrhythmias, which may dominate the clinical aspect in
stomach conditions, are common.
Case history
We observed a characteristic and exemplary case in our practice: A female patient, 70 years old, had
been treated for two years for heart symptoms, especially tachyarrhythmia.
We found a pressure-sensitive area to the left of the anterior midline at the level of the T 8 and T 9
segments, as well as marked pressure sensitivity of the spinous process of the 12th thoracic vertebra.
There were also changes in the region of the external ears on both sides, corresponding to the stomach
region, and the tongue was coated, especially in the middle. The patient felt tired and weak, but had 10
lost no weight.
Solely on the basis of these projection signs and the typical findings in the left upper quadrant of the
abdomen, we ordered an endoscopic study, which led to discovery of a carcinoma in the posterior wall
of the stomach.
Serving as an example for many similar cases reported by other authors, this case is intended
to show that projection signs on the body surface may always also be an indication of malig-
nant disease in the corresponding segment. According to Hansen and Schliack as well as
Kunert and other authors, projection signs may occur even before there is any endoscopic
evidence of malignant transformation. Even x-ray studies may fail to reveal any pathology,
although the projection signs on the body surface may already be present as “early warning
symptoms”.
Not to be ignored are vertebrogenically triggered gastric symptoms. Since the vertebrae,
like the corresponding myotomes and dermatomes, are considered part of the body surface
(spinal periphery) and thus are capable, in a wide sense, of eliciting “cuti-visceral” reflexes,
even functional disorders of the thoracic spine, e. g., functionally blocked vertebrae or weak
ligaments, they are also capable of giving rise to disorders of the stomach and duodenum in
the corresponding segmental regions. For example, stomach complaints involving nausea,
retching, and possibly shoulder pain may develop after sitting in an inappropriate position
during a long automobile trip. Usually such stomach trouble resolves quickly after relief of
the thoracic spine and performance of compensatory exercises.
10
10.5 Small Intestine (Jejunum, Ileum) 313
10.5 Small Intestine (Jejunum, Ileum)
Since the duodenum is related to the same segments as the stomach, here the jejunum and
the ileum shall be discussed as representatives of the entire small intestine.
Segmental Relations
Jejunum and ileum are related to the spinal cord segments (T 9) T 10 to T 12 by way of sympathetic
viscero-afferent neurons.
10.5.1 Algetic Signs in Disorders of the Small Intestine
Algetic Signs in General
The algetic signs in small intestinal disorders appear in the umbilical region.
In most cases, there is a zone of muscular tension and above all of hyperalgesia of the skin
(Head's zone) on both sides. The sections of the rectus abdominis muscle between T 9 and
T 12 contain pressure-sensitive areas.
The maximum points are located on T 9 and T 10, likewise on both sides.
This corresponds to the practical observation that enteritis, the most common form of
disease in the jejunum and the ileum, causes pain around the umbilicus.
A highly differentiated report on pain projection of the individual sections of the small in-
testine was given by Porkes.
He identifies in disorders Correspondingly, on the back there are

in disorders
of the jejunum the maximum pressure of the jejunum pressure-sensitive areas to
point on the left side at the level of the the left of the 1st lumbar vertebra
umbilicus (T 10)
of the ileum the maximum pressure point of the ileum pressure-sensitive areas to
on the right side at the level of the umbili- the right of the 2nd lumbar vertebra
cus (T 10 to T 11)
Because abdominal typhus and typhoid fever are hardly encountered anymore, practical ex-
perience with the Head's zones of the jejunum and ileum has gradually disappeared.
Nonspecific enteritis usually leads to pain and tension in the entire abdomen, but espe-
cially in the umbilical region (› fig. 10.4).
10
Diaphragm (C 4)
T4 Heart
(T3 and
T4)
T8 Esophagus
(T4 and
T5)
T10 Stomach
(T8)
T12 (T8−T11)
Small Intestine
T1 (T10)
Large Intestine
(T11)
Bladder
(T11−L1)
Kidney and Testis
(T10−L1)
10
Fig. 10.4a Small Intestine. Schema of the algetic and autonomic reflexive projection areas of the small intestine, specific for segments in the middle
and on the right side; ventral and dorsal views.
Red: zone of referred pain from the small intestine in segments T 9 to T 12
Dark red, ventral aspect: “Head's zone” in the region of referred pain (at the level of the umbilicus), corresponding to the maximum points of the affected
dermatomes (myotomes, sclerotomes)
10.5 Small Intestine (Jejunum, Ileum) 315
10
Light red: viscerogenically sensitized regions on the trunk and limbs (hyperesthesia and hyperalgesia), more pronounced along the tibia
Blue outlined: autonomic reflexive projection area in the entire quadrant (vasomotion, piloerection, and sweat secretion, including pupillary dilation,
10.6 Cecum, Appendix, Ascending and Transverse Colon
Autonomic innervation:
• Sympathetic: As far as the splenic flexure, the colon receives its sympathetic nerve supply
from the lesser splanchnic nerve and the inferior mesenteric ganglion.
• Parasympathetic: This is derived from branches of the vagus nerve (Cannon's point, at
the border between the areas innervated by the vagus nerve and the sacral parasympa-
thetic nerves in the vicinity of the left colic flexure).
Segmental Relations
Via sympathetic viscero-afferent neurons the cecum, the appendix, and the ascending and transverse
colon are related to the spinal cord segments T 11, T 12 and L 1.
10
10.6 Cecum, Appendix, Ascending and Transverse Colon 317
10.6.1 The Algetic Signs
Algetic Signs in General
The algetic signs occur in the corresponding segments in the lower abdomen and homolater-
ally to the diseased organs, i. e., on the right side.
Maximum points and Head's zones:
• for the appendix are located:
– ventrally in the right lower quadrant at T 11 (McBurney's point), and
– dorsally to the right of the 2nd lumbar vertebral body
According to Dittmar, the projection area in appendicitis, i. e., McBurney's point, is lo-
cated on the right side even in the presence of a situs inversus.
• for the cecum and the ascending and transverse colon are located:
– ventrally on the right at T 10 to L 1 in a line between the umbilicus and the symphy-
sis, and
– dorsally to the right of the 2nd lumbar vertebral body.
Intestinal disorders often lead to pain in the region of the psoas muscle, making it painful to
extend the leg on the affected side.
According to Knotz, McBurney's appendix point may also be regarded as a psoas pressure
point, since it is located at a site where the psoas muscle is particularly easy to palpate through
the abdominal wall.
For this reason, pressure sensitivity at McBurney's point is not only a symptom of appen-
dicitis, but may also reflect a taut, shortened, and therefore tender psoas muscle due to a
disorder of the right-sided female adnexa or renal colic.
In surgery it is known that in appendicitis a pressure-sensitive site develops approximately in the middle
of the anterior tibial muscle on the right leg (personal communication from Professor Bauer, Gmunden,
Austria). This experience from practical surgery proves that the abdominal organs related to the seg-
ments T 10 to L 1 must elicit a distant projection even in muscles innervated by the lumbar plexus. These
observations from surgical practice agree remarkably well with the location of the “appendix point” in
Chinese acupuncture.
10
Diaphragm (C 4)
T4 Heart
(T3 and
T4)
Esophagus
T8 (T4 and
T5)
Stomach
T10 (T8)
(T8−T11)
T12
Small Intestine
(T10)
T1
Large Intestine
(T11)
Bladder
(T11−L1)
Kidney and Testis
(T10−L1)
10
Fig. 10.5a Large Intestine (proximal to the left flexure). Schema of the algetic and autonomic reflexive projection areas of the large intestine,
specific for segments in the middle and on the right side; ventral and dorsal views.
Red: zone of referred pain from the large intestine in segments T 11 to L 1
Dark red, ventral aspect: “Head's zone” in the region of referred pain in the affected dermatomes (myotomes, sclerotomes)
10
Light red: viscerogenically sensitized regions on the trunk and limbs (hyperesthesia and hyperalgesia), more pronounced along the tibia
Blue outlined: autonomic reflexive projection area in the entire quadrant (vasomotion, piloerection, and sweat secretion, including pupillary dilation, head
and shoulder zones).
To refresh the reader's memory: As mentioned previously, distant projection from the ab-
dominal organs to the lower limbs must be imagined as follows:
• Pathological impulses from the abdominal organs derived from the segments T 10 to L 1
turn caudally by way of collaterals in the sympathetic trunk, then enter the lumbar gan-
glia L 4|L 5 of the sympathetic trunk.
• According to M. Monnier, they then pass through the lumbar ganglia L 4|L 5 of the sym-
pathetic trunk by way of the spinal nerves L 4|L 5 to the lumbar plexus, and from there to
the femoral nerve.
In other words, there is a “track-like” connecting pathway between the abdominal organs
and the ventrally situated myotomes on the lower leg, i. e., the quadriceps femoris and ante-
rior tibial muscles.
Here too there is agreement between segmental anatomy and Chinese acupuncture, in both of which
the organs of the upper abdomen have their areas of resonance and of therapeutic approaches on the
anterior, ventral aspect of the legs. This is also where the long yangming meridian is located, which
comprises all the projection areas of the digestive tract on the body surface.
Autonomic reflexive signs from all abdominal organs are found to extend cranially to T 5
(level of the nipples) and caudally to the entire lower limb.
The autonomic reflexive effects (vasoconstriction, piloerection, and changes in sweat se-
cretion) are therefore found on the entire leg, on the same side as the diseased organ. Chang-
es in sweat secretion are found particularly in the homolateral region of the abdominal wall
from the level of the nipples to the groin.
By way of connections between the vagus with the trigeminal nerve and the segment C 2,
hyperalgetic areas develop in the facial and occipital regions when diseases of the upper ab-
dominal organs are present.
According to Foerster, there are no connections between the intestinal tract and the
phrenic nerve. This explains why intestinal disorders do not involve distant projection to the
myotomes of the phrenic nerve (C 4|C 5, shoulder).
In addition, the furcal nerve is important for understanding the projections of the abdom-
inal organs and the pelvic organs (which will be discussed later).
The furcal nerve is the spinal nerve L 4. The area it supplies extends from the abdominal
wall to the leg.
The cranial part of the furcal nerve extends T 12 to L 5

from
The caudal part of the furcal nerve extends S 1 to S 3
from
The spinal nerve L 4 is related by its cranial to the upper abdominal organs
part (T 12 to L 5)
10
and by its caudal part (S 1 to S 3) to the pelvic organs
Knowledge of this spinal-segmental order is essential for understanding the topographic lo-
cations of the projection areas, i. e.
of the abdominal organs in the ventral region of the legs, and

of the pelvic organs in the dorsal region of the legs.
Only in this way one can explain the therapeutic value of the insertion areas, by way of the Chinese
acupuncture points located there.
Summary: The spinal nerve L 4, like the tines of a fork (hence the name: furcalis = fork), con-
nects the abdominal wall to the lower limbs, such that
• the organs of the upper abdomen are related to the ventral aspect of the leg (innervated
by the femoral nerve), and
• the pelvic organs are related to the dorsal aspect of the leg (innervated by the sciatic
nerve).
10
10.7 Descending Colon, Sigmoid Colon, and Rectum
From the point of view of its segmental relations and autonomic innervation, the caudalmost
section of the digestive tract is an organ of the true pelvis.
Coincidentally, in TCM this section is assigned to the organ symbolizing the pelvis, i. e.,
the kidney.
Segmental Relations
Descending colon, sigmoid colon, and rectum are related by way of sympathetic viscero-afferent neu-
rons to the spinal cord segments T 11 to L 2.
10.7.1 Algetic Signs
The algetic signs on the trunk are located in the lower abdomen, in the sacral region, and on
the anus.
The maximum points and Head's zones are located:
• on the ventral side
– for the descending colon, 3 fingers above the symphysis on the left side (T 12), and
– for the sigmoid colon and the rectum, to the left of the symphysis (L 2)
• on the dorsal side
– for the descending colon, on the left side of the upper half of the sacral bone, and
– for the sigmoid colon and the rectum, on the left side of the lower half of the sacral
bone and on the coccygeal bone.
Viscerogenic projection signs on the lower limbs, which may appear as hyperalgetic zones in
the skin and muscles, are found in S 1|S 2|S 3 (dorsal side of the legs and the buttocks).
Such projection develops via viscero-afferent parasympathetic neurons (pelvic nerves)
that originate in the sacral part of the spinal cord between S 1 and S 3 and may give rise to
hyperalgetic Head's zones in the corresponding segments on the dorsal side of the legs.
Projection to the lower limb is a feature shared by the descending colon and rectum with
the kidney, ureter, urinary bladder, and urethra, as well as the uterus, all of which count as
pelvic organs and are derived from the same segments (› fig. 10.6).
Apart from these parasympathetically elicited hyperalgetic areas, autonomic reflexive ef-
fects such as vasoconstriction, piloerection, and altered sweat secretion may also be triggered
by sympathetic neurons that run in a caudal direction from T 11 to L 2 through the sympa-
thetic trunk to the sacral sympathetic ganglia S 1|S 2|S 3, from which they pass through the
sacral plexus to join the sciatic nerve.
Via sympathetic neurons, algetic and autonomic effects manifest on the skin of the groin,
the buttocks, and the dorsal region of the legs.
10
The parasympathetic neurons only conduct pain impulses without triggering autonomic effects.
Clinically, the sympathetic autonomic reflexive reactions on the buttocks, in the lumbar re-
gion and the groin, on the dorsal side of the legs, and on the soles of the feet include an ex-
treme oversensitivity to cold, which is nearly always reported by patients with disorders of
the kidney, urinary bladder, uterus, or the caudal region of the digestive tract.
This also includes an item commonly reported in the personal history, i. e., that after sit-
ting on cold surface, walking barefoot on cold tiles, or swimming in cold water, symptoms of
bladder irritation, a gynecological complaint, or defecation problems reappeared.
10.7 Descending Colon, Sigmoid Colon, and Rectum 323
Distant Projections in Disorders of the Descending Colon, Sigmoid

Colon, and Rectum
Distant projections in disorders of the descending colon, sigmoid colon, or rectum to the
head or shoulder have not been previously described by other authors.
However, in my own observations and experience, patients do report pain in the occiput
and neck in conjunction with disease of the pelvic organs.
In this context it would seem logical that the parasympathetic neurons of the pelvic nerves,
which resemble the afferent pathways to the spinal cord segment T 11, also reach the sympa-
thetic afferent and efferent nerves related to the liver and gallbladder (segment T 10), and
follow this pathway along the phrenic nerves to the segments C 4|C 5 in the shoulder region
(› fig. 10.6).
This relationship, in my opinion, would explain why a strong stimulus in the region of the
S 1|S 2|S 3 segments is able to affect the C 4|C 5|C 6 myotomes in the shoulder region.
This may explain the effects of GB 39 (S 1|S 2) and those of ST 38 (L 4|S 1|S 2) on shoulder pain.
10
Diaphragm (C 4)
T4 Heart
(T3 and
T4)
Esophagus
T8 (T4 and
T5)
Stomach
T10 (T8)
(T8−T11)
T12
Small Intestine
(T10)
T1
Large Intestine
(T11)
Bladder
(T11−L1)
Kidney and Testis
(T10−L1)
10
Fig. 10.6a Large intestine (distal to the left flexure). Schema of the algetic and autonomic reflexive projection areas of the large intestine,
specific for segments in the middle and on the right side; ventral and dorsal views.
Red: zone of referred pain from the large intestine in segments T 11 to L 1
10.7 Descending Colon, Sigmoid Colon, and Rectum 325
10
Light red: viscerogenically sensitized regions on the trunk and limbs (hyperesthesia and hyperalgesia), more pronounced on the dorsal side of the leg
(projection areas of the parasympathetic pelvic nerves)
Blue outlined: autonomic reflexive projection area in the entire quadrant (vasomotion, piloerection, and sweat secretion, including pupillary dilation, head
and shoulder zones).

Disorders of the Descending Colon, Sigmoid Colon, Rectum, and
Pelvic Organs
Viscero-visceral reflexes among all the pelvic organs are well known from clinical practice,
e. g., premenstrual constipation, the effect of an enema on kidney stones, retention of urine
and stool in ileus, etc.
The myotomes that are segmentally related to the pelvic organs (L 5|S 1|S 2) are also in-
volved in formation of the flexor muscles of the leg.
An imaginary line connecting the hyperalgetic projection areas on the trunk (among
which those of the kidney may also be located dorsally) to the dorsal aspect of the leg corre-
sponds to the foot taiyang (bladder meridian). This line runs along the region of the postaxial
line of the leg from the little toe (or the sole of the foot) to the pelvic outlet.
This region corresponds to the caudal innervation area of the furcal nerve (spinal nerve
L 4).
This connection enables impulses from the dorsal part of the legs to travel as far cranially
as segment T 11, i. e., approximately to the level of the umbilicus in the abdominal wall, and
from there via collaterals in the sympathetic trunk to the regions supplied by the phrenic
nerve (i. e., the shoulder region).
Not until these spinal and autonomic segmental relationships became clear was it possible to explain
the interactions between the lower limb, the abdominal wall, and the shoulder region. They prove the
existence of segmental connections within the longitudinal thirds of the body.
10
10.8 Kidney, Bladder, Ureter: Algetic and Autonomic Reflexive Projection Areas 327
10.8 Kidney, Bladder, Ureter: Algetic and Autonomic

The sympathetic nerve supply of the urogenital tract and the lower intestinal tract distal to
the left colic flexure comes from the lower thoracic and upper lumbar sections of the spinal
cord. Therefore, only a disorder in this spinal cord region can cause irritation of these organs.
Segmental Relations
• The kidney and the ureter are related by sympathetic viscero-afferent neurons to the spinal cord
segments T 10 to L 2.
• The urinary bladder is related by sympathetic viscero-afferent neurons to the spinal cord segments
T 11 to L 1.
10.8.1 Algetic Signs in Disorders of the Kidney and the Ureter
On the ventral side of the trunk: On the side of the diseased organ, algetic zones are found
from the level of the umbilicus (T 10) to the groin and the adjacent thigh (L 2).
Likewise, pain may occur in the region of the testes (L 2).
Maximum points and Head's zones:
• They are located in the lower abdominal region (T 10 to T 12) and extend to the symphy-
sis (L 2).
• Irritation in the segment L 2 may lead to contraction of the cremaster muscle (L 2 myo-
tome).
• According to Hansen and Schliack, the kidneys also have Head's zones on the back.
On the dorsal side of the trunk: Algetic zones are found above all in the area between the
second lumbar vertebral body (T 10) and the iliac crest (T 12). The 11th and 12th ribs may be
particularly painful at their free ends
For this reason, intracutaneous injection in the corresponding Head's zones is very often
recommended for treatment of kidney diseases (ranging from kidney stones to pyelitis).
About ten intracutaneous wheals should be injected along the 11th and 12th ribs, particularly
at their ends (› fig. 10.7).
10
Diaphragm (C 4)
T4 Heart
(T3 and
T4)
Esophagus
T8 (T4 and
T5)
Stomach
T10 (T8)
(T8−T11)
T12
Small Intestine
(T10)
T1
Large Intestine
(T11)
Bladder
(T11−L1)
Kidney and Testis
(T10−L1)
10
Fig. 10.7a Kidney, urinary bladder, and ureter. Schema of the algetic and autonomic reflexive projection areas of the kidney, urinary bladder, and
ureter, specific for segments in the middle, on the left side and the right side, respectively; ventral and dorsal views.
Red: zone of referred pain from the kidney, bladder, and ureter in segments T 10 to L 2
10
Fig. 10.7b Dark red, dorsal aspect: painful spinous processes (Mackenzie's schema; fig. 6.3)
Light red: viscerogenically sensitized regions on the trunk and limbs (hyperesthesia and hyperalgesia), on the leg more pronounced on the dorsal aspect
(projection area of the parasympathetic pelvic nerves)
Blue outlined: autonomic reflexive projection area in the entire quadrant (vasomotion, piloerection, and sweat secretion, including pupillary dilation,
Pain in the region of the right kidney and the right ureter may lead to fixed flexion of the
leg, causing symptoms resembling those of appendicitis. Of course, the symptoms of appen-
dicitis are much less pronounced, and do not include the vegetative shock that often occurs
in renal colic.
For differential diagnosis, laboratory data and further tests are required.
Herpes zoster at T 10 to L 2 is often found on the same side as the diseased organ.
Highly characteristic in the presence of intense renal pain is a right- or left-concave sco-
liosis of the spine (“the body bends around the focus”). The asymmetrical posture of the pa-
tient and the asymmetrical respiratory movements accompanying renal disease are due to a
reflexively increased tone of the deep muscles on the homolateral side of the trunk. Accord-
ing to Dittmar, they resemble a regular feature in intensely painful renal disease.
The algetic signs on the lower limbs are described in chapter 3.
10.8.2 Autonomic Reflexive Projection Signs in Disorders of the

Kidney, Bladder, and Ureter
The integument of the entire lower body quadrants shows the usual familiar symptoms:
Autonomic distant projections to the face occur almost regularly as homolateral mydriasis
and tense facial muscles. However, sweating attacks in the face tend to occur on both sides.
Distant autonomic projections from the pelvic organs include those described by Lähr-
Sölder, i. e., to perioral regions.
Distant algetic projections to the head and shoulders in the presence of disorders of the
kidney, urinary bladder, and ureter have not been previously described by any other authors.
In a practice setting, however, one encounters again and again patients describing reflexive relation-
ships between the bladder, the kidneys, the genital region, and the lower limbs, especially the dorsal
aspect of the legs, the soles of the feet, and the buttocks, i. e., precisely the sacral segments which are
the projection areas of these organs via the pelvic nerves.
Via sympathetic autonomic reflexes, vasoconstriction, piloerection, and altered sweat secre-
tion occur, which particularly in the region of the lower limbs involve an extreme oversensi-
tivity to cold.
Thus patients often report that sitting on a cold surface, and feeling cold on the soles of the
feet make their bladder or kidney disorders return.
In addition, there has been the significant observation that in the presence of urogenital
tract disorders, pain, susceptibility to cramps in the calf muscles, and paresthesias, particu-
larly a burning sensation in the heel and the toes, may be due to a “distant sacral reflex”,
especially if magnesium and potassium supplementation fail to bring about improvement.
Often, there are also skin reactions, such as dermatosis or simply an itching and changes in
10 pigmentation, which appear on the dorsal and medial parts of the thighs, in the groin, and in
the perianal region and may be a clue to an irritation of the urogenital tract.
According to Mackenzie, the first projection sign chiefly consists of the spinous processes
of the 8th to 10th thoracic vertebrae becoming very pressure-sensitive. Their temperature is
also elevated, which would correspond to a vascular zone. Furthermore, markedly painful
areas due to paravertebral muscular tension are found. The algetic and autonomic reflexive
signs thus correspond to the Head's zone T 10 to L 2.
Kunert pointed out that in all patients with progressive scoliosis and the main curvature in
the lumbar spine, the kidney function and that of the urinary tract collection system should
be subjected to a thorough examination.
The reflexive changes described above are found not only in the presence of kidney stones,
but also in pyelitis, renal cysts, kidney tuberculosis, and tumors of the kidney.
In my practice, I observed a patient who had undergone surgery ten years previously for a
malignant renal tumor. She reported having developed syringe abscesses several times after
intramuscular injections performed by her family doctor, but only on the side of the opera-
tion, although the injection was placed alternately on the right and on the left side.
This example also shows that segmental hypersensitivity in the spinal periphery may persist, even if the
original cause was removed long before.
10.8.3 Consequences for Treatment
In addition to injecting intracutaneous wheals along the 11th and 12th ribs as already de-
scribed, paravertebral injections of procaine or lidocaine in the T 12 to L 2 region are indi-
cated as therapy.
Cuti-visceral influence on renal secretion is also known from practical experience: Particu-
larly in nephrolithiasis and pyelonephritis, increased renal secretion may be observed after
provocation of localized hyperemia in the corresponding segments T 10 to L 2 on the trunk.
At the same time, an increase in excretion of uric acid was observed (Gleisner).
It is common knowledge that urination is facilitated by applying heat to the lower half of
the body, whereas application of cold to this region hampers it.
Since the lumbosacral segments in the regions of the heel, sole of the foot, and the dorsal
part of the leg can give rise to distant projections, a further question occurs to me as to
whether the painful heel observed in Bechterew's disease of the lower spine (considered to be
an early symptom of Bechterew's disease), may be regarded as an autonomic reflexive dis-
tant projection of an irritated pelvic organ which, like all autonomic reflexive signs, may oc-
cur long before the actual disease develops.
In our practice we have noticed that painful heels, calcaneal spurs, and even achillodynia
occur mostly in patients with urogenital problems. We have observed this even in patients
with prostate carcinoma and those with uterine fibroids.

Disorders of the Kidney, Bladder, and Ureter
Viscero-visceral reflexes mainly affect the parts of the large intestine distal to the splenic
flexure which are segmentally related to the kidney, the bladder, and the ureter. They nearly
always lead to disruption of intestinal motility. In addition, reflexive paralytic ileus with
blockage of flatulence and stools as well as reflexive urinary retention is possible.
Since it is a familiar fact that in nephrolithiasis the intensity of pain is not directly propor-
tional to the size of the stone (even tiny stones may cause intense pain), the projection signs
described above are of great diagnostic relevance.
Usually the entire abdominal wall on the homolateral side is markedly rigid, the corre- 10
sponding side of the chest lags during respiration, and the diaphragm is nearly always elevat-
ed on the affected side.
10.9 The Genital Tract: Algetic and Autonomic Reflexive

Projection Areas
When diseased, the ovaries, the adnexa, and the testes evoke algetic and autonomic reflexive
signs in the same parts of the body surface as the kidneys, bladder, and ureter; but their seg-
mental relations are described differently by various authors. For this reason, I have summa-
rized them in the following table.
Tab. 10.2 Segmental relations of the pelvic organs as described by various authors (from Hansen
and Schliack)
Head Foerster Braus and Elze
Urinary bladder T 11–L 2, S 2–S 4z T 11–L 3, S 2–S 5 (T 11–T 12), L 1–L 3,
S 3‑S 4
Testes T 10 T (11) T 12–L 3 T 10, T 12–L 3
Epididymis T 11–T 12 (L 1)
Prostate T 10–T 12, (L 5) S 1‑S 3
Ovaries T 10 (T 12) L 1–L 3 T 10–L 3
Adnexa T 11–L 1
Uterus T 10–L 1, S 2‑S 4 (T 12) L 1–L 3, T 10–T 12, S 1–S 4
(S 2–S 5?)
Rectum S 2–S 4 L 1–L 3, S 2–S 5 T 11–L 3, S 2–S 5
10
10.9 The Genital Tract: Algetic and Autonomic Reflexive Projection Areas 333
10.9.1 Algetic Signs
The chief complaint of patients with gynecologic disorders is “low back pain”. Low back pain
is very common in premenstrual syndrome, retroflexion and prolapse of the uterus, endome-
triosis, the so-called pelvic congestion syndrome, but also in tumors of the uterus or the
ovary (› fig. 10.8).
In our practice, we were able to observe that disorders of the urogenital tract were accom-
panied by pressure sensitivity of the iliosacral joints and the greater trochanter (L 5, S 1, S 2),
as well as of the ventral aspect of the iliac crest and the symphysis (T 12, L 1, L 2).
Likewise, therapy-resistant pain in the medial region of the knee (L 3) should always sug-
gest the possibility of a disorder in the urogenital tract.
This would correspond to the “premorbid territory” or the “presensitized terrain”
(Tilscher) related to a disorder of a visceral organ.
Naturally, pain in the lumbosacral region may also be caused by many other factors, such
as degenerative arthritis of the hip, difference in leg length, lumbar hyperlordosis, or flatten-
ing of the lumbar lordosis in the sterno-symphyseal stress syndrome, to mention a few.
10
in general
dorsal ventral
in case of retro-
flected uterus
dorsal ventral
tubal pregnancy left ovarian endometriosis
unilateral
10
dorsal ventral
Fig. 10.8 Algetic zones in gynecologic diseases (after Kunert)

10.9 The Genital Tract: Algetic and Autonomic Reflexive Projection Areas 335
10.9.2 Autonomic Reflexive Projection Signs in Gynecologic

Disorders
Regarding the signs and sites, these projectional manifestations are identical to those already
described for urological diseases.
Since the pelvic organs related to the segments T 10 to L 2 communicate largely via collat-
erals in the sympathetic sacral ganglia (S 1|S 2|S 3), and these segments may also become
Head's zones of the urogenital tract by way of parasympathetic neurons from the pelvic
nerves, autonomic changes, pain, and muscular tension may develop in the corresponding
segmental areas on the body surface (feet, especially the soles, as well as the dorsal part of the
leg, and the buttocks).
The most striking symptom is oversensitivity to cold surroundings, which often leads to a
marked “fear of the cold”. It is a regular finding that such patients will, due to to their fear of
the cold, prefer very warm underwear as a precautionary measure, be slightly bent forward at
the lumbar spine, and very often will place their hands on the lower abdomen or the inside of
the thighs. I find it noteworthy that such patients seek out a warm, soft surface to sit on.
10
10.10 Testes, Uterus, Ovaries: Algetic and Autonomic

Segmental Relations
Testes, uterus, and ovaries are connected by sympathetic viscero-afferent neurons to the spinal cord
segments T 10|T 11|T 12.
The testes and ovaries are located much further cranially during embryonic development
than later on. Despite this, they retain their relatively high segmental association with T 10 to
T 12, even though in the course of embryonic development they shift in a caudal direction,
the testes as far as the region supplied by S 2 and S 3, i. e., segments from which they likewise
receive autonomic neurons (descent of testes).
Testes, uterus, and ovaries project to the skin particularly clearly in the T 10 dermatome.
Therefore, chronic eczema of the navel (T 10) should always also be considered under the
aspect of a possible disorder of these organs.
10.10.1 Algetic Signs in Disorders of the Testes, Uterus and

Ovaries
These are located in the region of the 2nd lumbar vertebra, in the region of the symphysis, and
as tender subcutaneous puffiness at the level of the umbilicus.
Additionally, I would like to mention that differences of temperature and sweat secretion
between the right and left soles of the feet should always remind us of the fact that unilateral
anhidrosis often occurs in conjunction with peripheral nerve paralysis, e. g., due to metasta-
sis or to Hodgkin's disease, which may irritate the peripheral nerves of the lumbosacral plex-
us, thus leading to anisohidrosis (Hansen and Schliack).
The algetic signs on the lower limbs are described in chapter 3 (› page 102).

Testes, Uterus, and Ovaries
On the skin of the entire lower body quadrant and of the face, these correspond to those of all
pelvic organs, including the Lähr-Sölder projection areas.
10
10.10 Testes, Uterus, Ovaries: Algetic and Autonomic Reflexive Projection Areas 337
10.11 Prostate Gland: Algetic and Autonomic Reflexive

Projection Areas
Segmental Relations
According to Head, the prostate gland belongs to the segments T 10 to T 12 and projects to the midline.
Algetic signs of prostate disease are projected to the lower abdomen and to the area of the
thoraco-lumbar transition on the back. In addition, however, Head has also found algetic
signs in the segments L 5|S 1|S 2|S 3.
In this case too, segmental anatomy provides an explanation for pain occurring in the legs
and on the buttocks.
As in those of the testes and ovaries, disorders of the prostate likely lead to transmission of
pathological impulses to the sacral ganglia L 5|S 1|S 2|S 3, which in turn produce algetic symptoms
in the corresponding segments in the spinal periphery (dorsal side of the legs and the buttocks).
10.11.1 Observations from Practical Experience
In this context, let me refer to an observation from our practice: In patients with prostatitis or
conditions such as a prostate adenoma or carcinoma, we have, again and again, observed
mycotic infection of the nail of the great toe (L 5)*.
Chronic fungal infection of the nail affecting only the great toe should therefore also call to
mind that a prostate condition possibly may be involved.
A connection between such changes on the great toe and prostate disease must be consid-
ered above all when, in addition, the 5th lumbar vertebra is painful to palpation, or pain de-
velops in the myotomes and sclerotomes of the pelvic region belonging to the segments
L 5|S 1|S 2, i. e., in the region of the pelvic outlet with the muscles originating or inserting
there (the piriformis muscle, the rotator muscles, and the gluteus maximus muscle).
One may observe that men with disorders in the prostate region often assume a sitting
position that is more typical of women.
When sitting, women usually draw their thighs together, whereas men, especially younger
ones, tend to sit with their thighs apart and turned outward, a position corresponding to the
“display of the genitals in monkeys” (Franz de Waal).
This typical masculine sitting position is often replaced in patients with prostate com-
plaints by a feminine one.
My own explanation of this is that in patients with disorders of the organs in the true pel-
vis, outer rotation and abduction as functions of the segments L 5|S 1|S 2|S 3 may be im-
paired, so that another sitting position is assumed spontaneously.
Characteristic of irritation of the spinal cord segments T 10, T 11, T 12 is also pain in the region of the
lowest ribs, especially at their free ends. In Chinese medicine, this area is designated as the alarm point
of the kidney, i. e., of the organ symbolizing the pelvis.
10
* The segmental relations of the great toe are described differently by various authors: L 4 only, L 5 only, or
both L 4 and L 5.
10.11.2 Segmental Relations between Segments of the Lower

Limb, Bechterew's Disease, and Prostate Disease
In addition to the remarks in chapter 10.7, I should like to dwell more on Bechterew's disease
in the context of the segments T 10 toT 12.
Several older publications (Schmid, among others) suggest that chronic prostatitis may be
the most important cause of Bechterew's disease, or spondylitis deformans. Other authors
discern a connection with urethritis and intestinal disorders. All of these organs are related to
the segments T 10 to T 12 and have algetic distant projections to L 5 to S 3, i. e., the heel, the
dorsal part of the leg, and the buttocks.
Strikingly, all authors describe Bechterew's disease as beginning in young adult men, i. e.,
at an age in which prostatitis is common as well.
The projection areas of prostate conditions are the thoraco-lumbar transition and the seg-
ments L 5 and S 1, S 2, S 3, i. e., the areas in which Bechterew's disease becomes evident in
very early stages.
The best-known early symptom is pain in the heel. That fits in well with a distant projec-
tion to the segments L 5|S 1|S 2, i. e., to the sole and heel.
Bolk refers to the insertion points of the myotomes L 5 to S 2 as the “sclero-zones” L 5 to
S 2 of the pelvis. These sclero-zones would correspond to the lower, sacral location of the
Bechterew's disease.
The somewhat bent-forward posture assumed by Bechterew patients may be explained by
the fact that the insertion of the Achilles tendon on the calcaneus is relieved by bending the
knee slightly, thus reducing the pain in the heel.
The other familiar causes of the bent-forward posture develop during the further course of
Bechterew's disease.
It would surely be interesting to analyze the early symptoms of Bechterew's disease, such as pain in the
heel, with regard to early occurrence of reflexive distant projection to the corresponding segments. In
many cases this should lead to consequences not only for diagnosis, but also for therapy and even
prevention.
10
10.12 Liver and Gallbladder: Algetic and Autonomic Reflexive Projection Areas 339
10.12 Liver and Gallbladder: Algetic and Autonomic

Even without having studied segmental anatomy, every physician knows from experience
that all disorders of the gallbladder project pain to the right upper abdominal quadrant, the
right shoulder, the right side of the back, and especially to the right shoulder blade.
It is noteworthy that in cholecystolithiasis, even during an asymptomatic interval, pain
may occur in the region of the right shoulder blade. However, the pain is much milder than
that in acute disease.
In liver disorders as well, e. g., hepatitis, cirrhosis, and even subphrenic abscess, and in
liver congestion, pain and autonomic signs develop on the right side.
Of course, such pain may also be an early prodromal sign of a carcinoma of the liver, the
gallbladder, or the bile ducts.
Segmental Relations
Liver and gallbladder are related to the spinal cord segments T 8, T 9, T 10, (T 11) via sympathetic
viscero-afferent neurons.
10.12.1 Algetic Signs in Disorders of the Liver and Gallbladder
Algetic zones on the trunk appear in the upper right quadrant of the abdomen at T 8, T 9, and
T 10, especially at the right costal arch and the right border of the rectus muscle, here often as
a particularly painful point persisting long after the cause of the disorder has been removed.
This phenomenon is often misinterpreted by the patient as an imminent relapse.
Via parasympathetic neurons in the phrenic nerve, pain and muscular tension may be
triggered on the affected side, i. e., in the right shoulder (C 4, C 5, C 6 myotomes, correspond-
ing to the spinal nerve fibers that form the phrenic nerve).
Usually a patient in great pain will press the right arm against the trunk, so that the body
curls around the focus on the right side, bending at the waist. This position of the arm helps
the patient avoid motion of any kind, since co-reaction of the C 4, C 5, C 6 myotomes with
movement of the right shoulder and the right arm would be painful (› fig. 10.9).
10
Diaphragm (C 4)
T4 Heart
(T3 and
T4)
T8 Esophagus
(T4 and T5)
Stomach
T10 (T8)
(T8−T11)
T12
Small Intestine
T1 (T10)
Large Intestine
(T11)
Bladder (T11−L1)
Kidney and Testis
(T10−L1)
10
Fig. 10.9a Liver and gallbladder: Schema of the algetic and autonomic reflexive projection areas of the liver and gallbladder,
specific for segments in the middle and on the left side; ventral and dorsal views.
Red: zone of referred pain from the liver and gallbladder in segments Th 8 to Th 11
10
Light red: viscerogenically sensitized regions on the trunk and limbs (hyperesthesia and hyperalgesia), on the leg more pronounced tibially
Blue outlined: autonomic reflexive projection areas in the entire quadrant (vasomotion, piloerection, and sweat secretion, including pupillary dilation,
Algetic Signs on the Head
Via innervation by the vagus nerve, hyperalgesia occurs in C 2 and in the trigeminal region,
in which the algetic zones of the head are typically found in the temporal and parietal regions.
According to Head's observations, this is due to the fact that hyperalgesia of the middle
part of the thoracic wall, i. e., the Head's zones of the liver and gallbladder, may cause projec-
tion of the algetic zones to the head. Regardless of whether the pain in the thoracic wall is
judged to be vertebrogenic or projectional in origin, painful tension of the intercostal mus-
cles at T 5 to T 11 may lead to homolateral headache in the temporal and parietal regions.
Projection to the head may therefore also proceed “from the outside to the outside”, and not only from
“the inside to the outside”.
Algetic Signs on the Lower Limbs
As in the other upper abdominal organs with the same segmental relations, i. e., T 8, T 9, and
T 10 (T 11), here too the impulses are conducted along collaterals in the sympathetic trunk to
the lumbar sympathetic ganglia L 4 and L 5, traveling from there to the lumbar plexus, and
further to the femoral nerve (L 1 to L 4), which supplies the myotomes L 4|L 5 in the anterior
tibial muscle and the peroneal muscle group.
This pathway enables projection of upper abdominal complaints emanating from the liver
and gallbladder to the homolateral lower limb. In the lower limb, therefore, it is chiefly the
right anterior tibial muscle and the right peroneal muscle group that become painful, i. e.,
areas in which the acupuncture points ST 36, ST 37, and GB 34 are located.
Experience has shown that irritation of L 4 and L 5 causes the following areas of the foot to
be particularly sensitive:
• in disorders of L 4: the medial malleolus and the medial border of the foot, and
• in disorders of L 5: the lateral malleolus and the great toe.
This coincides with the peripheral course of the liver and gallbladder meridians on the foot (GB 40,
GB 41, LI 3).

The skin of the entire lower body quadrant to the mammillary line shows the familiar signs
of
10 Autonomic sympathicotonic reactions appear in the face as clenched muscles of facial ex-
pression on the right side, with the right corner of the mouth drawn upward, and homolat-
eral mydriasis.
This example as well illustrates how the autonomic facial expression and posture indicate
which side is affected.
Painful spinous processes are described by Mackenzie on the vertebrae T 10 to T 12.
The T 9 and T 10 dermatomes on the affected right side often show changes of the skin and
pigmentation, especially if the patient has repeatedly applied a hot-water bottle to the abdo-
men. In such cases, it may be seen that the hot-water bottle or a heating pad, applied to the
middle of the abdomen, led to the described changes in pigmentation mainly on the affected
right side. As this particular example shows, changes in vasomotion of the irritated cutane-
ous blood vessels therefore lead to altered permeability of the capillary walls within these
segments, resulting in pigmentation changes and mottling of the skin as a sign of visceral
disease.
As in disorders of the other upper abdominal organs which may irritate the spinal cord
segments T 9, T 10, and T 11, the 11th and 12th ribs become pressure-sensitive in disorders of
the liver and gallbladder as well. However, it is important for differentiation to know the side
on which the last two ribs become tender:
• in liver and gallbladder conditions on the right side,
• in stomach and intestinal conditions on the left side, and
• in renal conditions on the free ends of the homolateral ribs.
In chronic disorders of the liver and gallbladder, herpes zoster lesions are located chiefly in
the T 8, T 9, and T 10 dermatomes on the right side.
Deep hyperalgesia occurs not only in the region of the clavicle (Mussy's pressure point),
but also in the region of the deltoid muscle and as the “upper cervical point” (point cervical
supérieur) on the right side at the level of the transverse process of the 3rd cervical vertebra
(Kunert, Schmid).
According to Kunert, the 7th thoracic ganglion of the sympathetic trunk on the right side is
most important in sympathetic innervation of the gallbladder, whereas the influence exerted
on the gallbladder by the 8th and 9th thoracic ganglia of the sympathetic trunk apparently is
less.
Finally I should like to recall that in disorders of the liver and gallbladder, the 6th to 8th thoracic vertebrae
are painful, particularly their spinous processes. An intradermal injection between the spinous pro-
cesses of T 6 and T 7 may stop a painful attack. Just like infiltration between the spinous processes,
paravertebral injection in the region from T 6 to T 11 may be therapeutically successful.
Just as in the abdominal region a viscero-motor reflex may cause rigidity of the abdominal
wall, a viscero-motor phrenic nerve reflex may lead to elevation of the diaphragm on the
right side. If this is accompanied by elevated temperature and singultus attacks, the possibil-
ity of a right-sided subphrenic abscess must be considered.
From the viewpoint of segmental anatomy, disorders of the liver and gallbladder are diffi-
cult to distinguish from those of the duodenum, particularly duodenal ulcer, because they are
related to the same side and the same segments.
For this reason, before gallbladder surgery gastroscopy is usually done in order to rule out
a duodenal ulcer.
Whenever pain in known disorders of the liver and gallbladder is also projected toward
the left side, one must consider the possibility of complications relating to the pancreas.

Disorders of the Liver and Gallbladder
Viscero-visceral reflexes in gallbladder disorders may manifest in different ways, but they are 10
usually quite intense.
Gallstone colic may involve vomiting and severe disorders of intestinal activity, in extreme
cases with meteorism and reflexive paralytic ileus.
In the colic-free interval, in contrast, the patients often complain of stomach-ache. Pre-
sumably, this is due to the considerable increase in motility of the gastrointestinal tract ac-
companying bile duct disease.
Functional impairment of the bile ducts has been described in hepatitis, liver cirrhosis,
ulcers, and gastroduodenitis, as well as in pancreatitis.
Wenckebach has made reference to the reflexive influence on the heart in gallbladder con-
ditions, related to the common segmental innervation of the gallbladder and the atria of the
heart (T 6 to T 8).
My observations indicate that all visceral organs in the segmental region of T 6 to T 10 are capable of
eliciting tachyarrhythmias and changes in blood pressure as well. This is also based on the common
sympathetic viscero-afferent nerve supply of the upper abdominal organs and the atria.
Wenckebach interprets cases of therapy-resistant extrasystoles as being caused by reflexes, as

many such cases resolved after removal of a chronically inflamed gallbladder.
10
10.14 Occurrence of Reflexive and Algetic Symptoms in Other Disorders 345
10.13 Pancreas and Spleen: Algetic and Autonomic

Typical of disorders of the pancreas is a marked oversensitivity or pruritus of the skin re-
lated to the thoracic segment T 8 on the left side. In segmental anatomy this is considered one
of the most important pancreatic signs. Other typical signs are dilation of the pupil and in-
creased rigidity of the left rectus abdominis muscle.
In definitively diagnosed disease of the pancreas, Hansen and Schliack state that without
exception there is projection to the left side, and the algetic and autonomic reflexive signs of
disease are restricted to the segments Th 6 to T 9.
Autonomic reflexive signs and hyperalgetic projection areas in disorders of the pancreas are identical
to those in disorders of the spleen and the jejunum.
The segmental projection area of the spleen, like that of the jejunum and the pancreas, is lo-
cated in the zone of T 6 to T 11, with the segments T 8 and T 9 on the left side being particu-
larly sensitive.
As with pancreas and jejunum, homolateral mydriasis and pain sensitivity in the homolat-
eral shoulder are also characteristic signs of diseases of the spleen.
10.14 Occurrence of Reflexive and Algetic Symptoms in

Other Disorders
In conclusion, I should like to mention that other disorders also may trigger reflexive and
algetic symptoms. According to Hansen and Schliack, lumbago and sciatica, thrombosis,
dental diseases, tonsillar abscess, granulomas, and otitis, as well as migraine headaches are
the most important conditions to produce reflexive signs with pupillary dilation and cramp-
ing of the muscles of facial expression, in addition to homolateral vasomotor phenomena in
the skin, i. e., piloerection and alterations of sweating. This we can confirm from many years
of experience in our own practice.
My observations indicate that most notably disorders of the head and limbs will elicit ho-
molateral autonomic reflexive symptoms, thus mimicking and overlying disorders of inter-
nal organs.
Thus, pain and changes on the body surface may not only irritate internal organs or trigger disease in
a pathologically sensitized internal organ. It is also possible that pain and changes on the body surface
merely simulate an internal disease.
10

347
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351
Index
A adnexa, segmental relations 332 ––hyperalgesia 255, 256

abdominal and pelvic organs, pathological advantage of segmentation 12 ––hyperesthesia 255
impulses to the legs 85 afferent fibers ––individual behavior 255
abdominal diseases/disorders ––axon reflex 112 ––location 257
––inflammatory ––dorsal root 24 ––parasympathetic fibers 78
–– – tachycardia 291 ––ventral root 24 ––parasympathetic neurons 267
––sensitization of the ventral part of the afferent neurons ––parasympathetic system 125
leg 97 ––pain-conducting 248 ––pelvic organs 257
abdominal muscles, internal and external ––parasympathetic 240, 242 ––referred pain 253, 254
oblique 64 ––somato-sensory 248 ––sympathetic fibers 78
abdominal organs ––sympathetic 113, 114, 117, 239, 240, 242 ––sympathetic neurons 267
––algetic symptoms 257 ––viscero-sensory 248 ––sympathetic system 125
––algetic zones afferent sympathetic pathways 80, 113, ––thoracic organs 257
–– – CV4/CV6 279 115 ––vagal fibers 78
––areas of resonance 101, 320 agoraphobia-like reactions, C2/C3 ––vertebral column syndromes 267
––autonomic reflexive symptoms/ irritation 196 anal region, hiatus lines 155
signs 257, 320 alarm points, maximum points of analgesia 277
––diseases 320 dermatomes 146 ––angina pectoris 290
––Head’s zones 259 algetic dermatomes 141 anconeus muscle, C7/C8 202
––preganglionic neurons 99 ––algetic phenomena 141 anesthesia, angina pectoris 290
––projections ––Head’s zones 141 angina pectoris 289
–– – furcal nerve 320 ––hyperalgetic phenomena 142 ––and pseudo-angina
–– – to the temporo-parietal region ––referred pain 141 –– – differential diagnosis 290
(shaoyang) 275 ––T10 142 ––bradycardia 291
–– – ventral region of the leg 320 ––vasodilation 110 ––hyperalgesia 290
––track-like connecting pathway 320 algetic projection zones/areas ––irritation of the thoracic spine 277
abdominal reflex 277, 278 ––gallbladder 180 ––maximum points of hyperalgesia 263
abdominal skin, fungal infection 178 ––heart 179, 284 ––pain on deep palpation 290
abdominal symptoms, heart disease 291 ––liver 180 ––polyuria 291
abdominal typhus 313 algetic signs ––reflexive vomiting 279, 291
abdominal wall ––appendix/cecum 317 ––tachycardia/tachyarrhythmia 291
––guarding 204 ––bronchial/pulmonary disorders 294, 295 ––vasomotor effects 289
––hard as a board 208 ––dental diseases 345 ankle edema, maximum zones of derma-
––muscular defense 204 ––descending colon/sigmoid and tomes 148
––muscular tension 205 rectum 322 ankle-jerk reflex, see Achilles tendon reflex
––myalgic pressure points 206 ––endometriosis 333 anterior horn, efferent sympathetic
––reflexive tension 206 ––esophageal disorders 303 neurons 104
abductor digiti quinti muscle, C8 202 ––granulomas 345 anterior root (see also ventral root)
abductor pollicis brevis muscle, C8 202 ––gynecologic disorders 333 ––effector organs
abscess, subphrenic 339, 343 ––heart disease 282 –– – skin 94
accessorius nerve 60 ––kidney/ureter disorders 327 ––irritation
accessory phrenic nerve 60 ––liver/gallbladder disorders 339, 340 –– – sympathetic neurons 105
Achilles tendon reflex 277, 278 ––migraine headaches 345 ––spinal cord
achillodynia 331 ––on the head –– – sympathetic neurons 89
acupuncture –– – liver/gallbladder disorders 342 anterior thorax pain, flexor region of
––ground rule 75 ––on the limbs the arm 70
––inward and outward flow of energy 138 –– – liver/gallbladder disorders 342 antimerism 2
––neurotome 15 ––on the trunk anuria, reflexive 279
––psychosomatic aspect 49 –– – liver/gallbladder disorders 339 aortic valve diseases
––relation of esophagus and gut 304 ––otitis 345 ––hyperalgesia 287
––segmental anatomy 2 ––small intestinal disorders 313 appendicitis
––segment-identifying muscles 181 ––spinous processes ––flexion reflex 68
––spinal nerves 14 –– – heart disease 286 ––maximum points
––sympathetic nervous system 14 ––stomach/duodenal disorders 306 –– – hyperalgesia 263
acupuncture points ––testes/uterus and ovaries 336 ––McBurney’s point 263, 317
––in the flexor region of the arm ––thrombosis 345 ––reflexive anuria 279
–– – pectoral pain 62 ––tonsillar abscess 345 ––reflexive polyuria 279
––on the back 61 ––urogenital tract 332 ––reflexive vomiting 279
––on the chest and abdomen 62 algetic symptoms 253–259 appendix
––on the trunk 44 ––abdominal organs 257 ––algetic signs 317
acupuncture stimulus on the trunk 44 ––cumulative impulse 253 ––Head’s zone 317
adductor muscles, L2–L4 212 ––dermatomes 136 ––intestinal disorders 317
352 Index
––irritation, muscular tension, abdominal autonomic reflexive signs/symptoms 104, ––enterotomes 244
wall 205 247, 251, 253, 254 ––parasympathetic innervation 125
––maximum points 317 ––abdominal organs 257, 320 ––segmental relations 327, 332
––segmental relations 316 ––asymmetrical posture/movements ––sympathetic innervation 125
appendix point, acupuncture 317 256, 267 bladder meridian (taiyang)
areas of resonance, visceral organs 101 ––asymmetrical proprioceptive/multisynap- ––cold and fear 49
arm(s) tic reflexes 267 ––dorsal branches 30, 38, 48
––acupuncture points 171 ––body surface 257 blastula stage 4
––extensor muscles 199 ––dermatomes 136 blockade, facet joint 219
––flexor muscles 199 ––early warning system 85 blood pressure oscillations, C2/C3
––increased extensor muscle tonus ––eyes 256 irritation 196
–– – with changes of the eyes 271 ––face 256 location/disorder 263
––inward rotation 199 ––head 267 Boas’ pressure point
––muscles 201 ––headaches 273 ––gastric ulcer 306
––myotomes 201 ––integument 256, 267 ––location/disorder 263
––outward rotation 199 ––location 257 body language
––pain 199, 286 ––of disease 89 ––autonomic reflexive symptoms 254
––radial half ––organ reflexes 256, 267 ––autonomic (vegetative) nervous
–– – dermatomes 164, 165 ––pelvic organs 257 system 162
––ulnar half ––piloerection 251 body surface
–– – dermatomes 164, 165 ––preconscious 255 ––and visceral organs
arrectores pilorum muscles 162 ––referred pain 254 –– – interactions and projection phenomena
arrector pili muscles 49 ––referred shoulder pain 276 6
arrogant posture 194 ––restlessness by heat 254 ––location of segments 204
arthrogenous dysfunction 219 ––secretory (sudo-motor) neurons 110 ––myotomes 204
arthropods, segmentation 8 ––shivering by cold 254 ––vasoconstriction 251
ascending colon 304, 317 ––shoulder 267 ––vasodilation 251
––enterotomes 244 ––skin 105 bone framework, segmental-spinal 217
asthma-like breathing condition, reflux eso- ––social behavior 255 bone regions, see sclerotomes
phagitis 303 ––sweat secretion 251 borderlines, hiatus lines 150
asymmetrical respiration, referred ––thoracic organs 257 brachial plexus 51, 61, 67
pain 276 ––vasoconstriction 255 ––cutaneous branches 61
atlas ––vertebral column syndromes 267 ––lateral cord 61
––transverse processes autonomic-motor dermatomes 142 ––main trunks 53
–– – tenderness 195 axillary line 203 ––medial cord 61
atria, segmental relations 282 axillary nerve 53, 55, 61, 67 ––motor branches 61
atrial diseases, hyperalgesia 287 axon reflex 112 ––posterior cord 61
auricular nerve ––peripheral brachialis muscle 198
––great (N. auricularis magnus) –– – vasodilation 110 ––C5/C6 202
57, 158 brachioradialis muscle, C5/C6 198, 202
autonomic fibers, spinal nerves 24 B bradycardia, angina pectoris 291
autonomic nervous system back muscles, segmental tension 277 branchial cleft 161
––cranio-sacral part 125 back region Braus and Elze, schema of subcutaneous
––interactions 75 ––pain dermatomes 132
––parasympathetic fibers 77 –– – acupuncture points 70 bristling of the hair 50
––peripheral 75 ––referred pain 70 ––C2 dermatome 158
––projection phenomena 75 backache, acupuncture treatment 61 bronchi, segmental relations 294
––sympathetic trunk 76 basalioma, heart disease 178 bronchial branches (sympathetic) 113
autonomic neurons, classification 90 Basedowian eye 271 bronchial disorders, see pulmonary disor-
autonomic organ reflexes Bechterew’s disease 331, 338 ders
––bronchial/pulmonary disorders 302 behavior budding 10
––colon/rectum/pelvic disorders 326 ––individual ––limbs, stages of development 139
––heart disease 291 –– – algetic symptoms 255 budding theory, metamerism 10
––kidney/bladder/ureter disorders 331 ––social buttocks
––liver/gallbladder disorders 343 –– – autonomic reflexive symptoms 255 ––hyperalgetic zones
––stomach/duodenum disorders 311 Bell-Magendie law 110 –– – pelvic nerves 252
autonomic reflexive phenomena, autonomic biceps brachii muscle, C5/C6 198, 202
dermatomes 142 biceps femoris muscle, L5–S2 213 C
autonomic reflexive projection signs/ biceps reflex 278 C 2 and C 3 sclerotomes 225
symptoms big gut (da chang) 304 C 4 sclerotome 225
––esophageal disorders 303 biogenetic law, see recapitulation theory C 5 dermatome 19
––heart disease 288 birds, segmental construction pattern 8 ––irritation 17
autonomic reflexive projection zones BL 13 193 ––skin alterations 17
––gallbladder disease 180 bladder C 5 myotome 17, 19
––heart disease 179 ––disorders/disease 125, 330, 331 ––irritation 17
––liver disease 180 –– – distant algetic projections 330 ––pain and tension 17
Index 353
C 5 sclerotome 19, 219, 225 cold (han) 106, 268 ––lateral 48, 64
––irritation 17 ––as climatic factor 49 ––ventral 64
C 6 sclerotome 225 ––as pathogenetic factor 49 cutaneous projection, sympathetic
C 7 sclerotome 225 ––as cause of disease 108 ganglia 120
C 8|T 1 sclerotome 225 ––oversensitivity 159 cutaneous reflexes, clinically impor-
calcaneal spurs –– – gynecologic disorders 335 tant 278
––Bechterew’s disease 331 ––subjective feeling cutaneus nerve, internal 67
––urogenital disease 331 –– – lumbosacral region 136 cutis, see skin or integument
Cannon’s point 78, 316 cold chills CV 4 123, 124, 279
cantharide plasters 268 ––dorsal longitudinal third 111 CV 5 123
cardiac branch, middle cervical ganglion ––dorsolateral longitudinal third 111 CV 6 123, 124, 279
121 ––upper cervical dermatomes 158 CV 10 123
cardiac branches (sympathetic) 113 coldness, autonomic reflexive sym- CV 12 96, 123, 124
carotid artery, internal 159 ptoms 255 ––celiac ganglion 120
carpal tunnel syndrome 54 cold shudders, piloerection 269 ––disorders of thoracic organs 279
––flat retractions 148 cold stimulus, penetrating freezing ––influence on upper abdominal and thoracic
––subcutaneous edema at the shoulder pain 260 organs 123
blade 148 collapsing knees 211 CV 15 124
cauterization 13 colon CV 17 122, 124
cecum 304 ––up to splenic flexure ––stellate ganglion 120
––Head’s zones 317 –– – autonomic innervation 316 CV 22 122
––maximum points 317 colon/rectum disorders cyanosis 277
––segmental relations 316 ––altered sweat secretion 322
celiac ganglion 91, 123 ––hyperalgetic zones 322 D
––CV12 120 ––oversensitivity to cold 322 da chang (big gut) 304
cervical ganglion ––parasympathetic neurons 322 dampness (shi) 106
––inferior 122 ––pelvic nerves 322 deltoid muscle
––middle 121, 154 ––piloerection 322 ––abductor of the shoulder joint 198
––superior 120, 121 ––projection signs ––C4–C6 198
cervical hypertension, irritation of the cervi- –– – lower limbs 322 deltoideo-pectoral triangle 57
cal spine 277 ––sympathetic neurons 322 dental diseases 345
cervical nerves ––vasoconstriction 322 depigmentation, maximum points 146
––dorsal branches 45 communicating branches 28 dermatome(s) 3, 4, 5, 53, 127, 136, 138
––ventrolateral branches 57 ––and superior cervical ganglion 121 ––algetic symptoms 136
cervical plexus 51, 57 ––gray 28, 69, 79, 115 ––algetic, see algetic dermatomes
––cutaneous branches 57 ––postganglionic gray 69 –– – vasodilation 110
––muscular (motor) branches 60 ––preganglionic white 69 ––arm 166, 167
cervical syndrome 63 ––white 28, 69, 79, 89, 115, 117 ––autonomic reflex phenomena 142
cervical vertebrae Conception Vessel, ventral midline 96 ––autonomic reflexive symptoms 136
––spinous processes conduction of impulses between seg- ––autonomic 142
–– – tenderness 195 ments 245 ––autonomic 90
cervically innervated muscles conjunctival reflex 245 ––autonomic-motor 142, 143
––arrangement 70 constipation ––bronchial/pulmonary disorders
––pain and muscular tension 298 ––heart disease 291 295
changes of the eyes 256, 270, 271 ––irritation of iliosacral joints 277 ––C2 158, 160
child-like characteristics 109 ––reflexive 279 ––C3 158, 160, 166
Chinese medicine 108 coolness, penetrating freezing pain 261 ––C4 161, 166
chinstrap bandage, trigeminal nerve branch coronary infarction ––C5 161, 166
V/3 158 ––gastrocardiac symptom complex 279 ––C6 164, 166
cholecystitis 206, 263 ––hyperhidrosis 269 ––C7 164, 166
cholecystolithiasis 258, 270, 276, 339 ––reflexive anuria/polyuria 279 ––C8 164, 167
cholelithiasis 263 ––reflexive epigastric syndrome 279 ––cervical
cholinergic fibers, secretory (sudo-motor) ––Roemheld symptom complex 279 –– – shoulder level 21
neurons 110 cranial nerves, cervical plexus 60 ––changes/reactions
ciliospinal center 88, 159, 271, 276, 288 cremaster reflex 245, 277, 278 –– – spinal nerves 136
cirrhosis, right-sided pain 339 crural muscles, myotomes 213 –– – sympathetic system 136
Clara, schema of subcutaneous derma- crural nerve, anterior 67 ––clinical relevance 136
tomes 133 crural ulcers, maximum zones of derma- ––coccygeal 174
climatic factor(s), cold 49 tomes 148 ––congruent myotomes 214, 215
climatic factor(s), symptoms 106 cumulative impulses 254 ––dorsal 138
cluneal nerves cutaneous blood vessels, vasoconstric- –– – sympathetic neurons 138
––medial (Nn. clunium medii) 48 tion 251 ––embryonic position 71
––superior (Nn. clunium superiores) 48 cutaneous branches ––epidermal, see epidermal dermatomes
coccygeal nerve(s) 48 ––brachial plexus 61 ––esthetic 141
––dorsal branches 48 ––cervical plexus 57 ––extent 156
coccygeal plexus 65 ––intercostal nerves 64 ––flowing into the arm 165
354 Index
––flowing out of the arm 165 ––Head’s zones 322 ––lower limbs 175
––form 156 ––maximum points 322 ––lumbar nerves 48
––head and neck 158 detoxification via the skin (Paracelsus) 13 ––medial branch 48
––kind of changes 136 diagnosis ––pilomotor neurons 109
––L2 174 ––projective ––psychosomatic medicine 49
––L3 174 –– – dermatomic schemas 136 ––sacral nerves 48
––L4 174 diaphragm 198 ––sensory fibers 49
––L5 174 ––abnormal contractions 198 ––spinal nerves 44, 138
––limbs 138 ––adjacent organs ––sympathetic fibers 49
––location of changes 136 –– – disease prevention 287 ––thoracic nerves 48
––lower limbs 171, 175, 176, 210 ––myotomes C5/C6 298 ––trunk 72
––lumbar 174, 175, 177 ––phrenic nerve 198 dorsal root (see also posterior root)
––lumbosacral 172, 173 ––respiratory disorders 298 ––afferent fibers 24
––maximum areas/zones 148 diarrhea ––efferent fibers 24
–– – massage 148 ––irritation of iliosacral joints 277 dorsal root filaments 24
–– – subcutaneous infiltration 148 ––reflexive 279 ––spinal nerves 24
––maximum points 138, 143, 146 digestive glands, Head’s zones 69 draft (feng) 106
––mnemonic schema 171 digestive tract, Head’s zones 69 ––oversensitivity 159
––motoric 90 dilator pupillae muscle 82, 83 dryness (zao) 106
––non-metameric sequence 150 disease(s) dryness of the skin, decreased
––parts 138 ––algetic signs 251 sweating 106, 107
––posterior root 53 ––autonomic reflexive signs 251 duodenal disorders
––quadruped position schema 210 ––caused by cold 108 ––algetic signs
––S1 and S2 174 ––concept 14 –– – epigastrium 306
––S3 to S5 174 ––definition 107 –– – upper limbs 306
––sacral 174, 175, 177 ––events of 14 ––altered sweat secretion 310
––schema after Braus and Elze 132 ––of the abdominal organs, projection to the ––autonomic organ reflexes 311
––schema after Clara 133 parieto-temporal region 272 ––distant projections 307
––schema after Hansen and Schliack ––phenomenology 108, 266 ––headache 307
130, 131, 134, 135 ––processing in the central nervous ––hyperalgesia 306
––schema after Head 128, 129 system 108 ––painful spinous processes 306
––segmental manifestations 136 ––to diagnose (kan bing) 266, 281 ––piloerection 310
––sensory 141 disorders ––reflexive signs
––simplified schema in quadruped ––algetic symptoms 255 –– – right-sided 306
stance 157 ––autonomic reflexive symptoms 255 ––related vertebrae 221, 222
––spinal nerves 137 ––of internal organs ––shoulder pain 307
––subcutaneous 127 –– – Mackenzie’s schema 221 ––spinal cord segments 222
––subcutaneous 136, 138 –– – sclerotomes 217 ––vasoconstriction 310
––T1 167 ––of organs close to the diaphragm ––vertebrogenic 312
––T2 167 –– – phrenic nerve 57 ––viscero-visceral reflexes 311
––T3 167 –– – supraclavicular nerves 57 duodenal ulcer 263
––T4 167 ––perception of 255 duodenum
––T5 5, 6, 167 ––preconscious signs 255 ––enterotomes 244
––T6 22 ––shifting between integument and visceral ––projection areas 304
––tactile 141 organs 16 ––referred pain 305
–– – overlapping 141, 142 displacement of disorders 16 ––segmental relations 306
––thoracic 172, 173 distant projections ––spinal cord segments 304
–– – horizontal pattern 46 ––bronchial/pulmonary disorders 298 dysfunction, arthrogenous 219
–– – longitudinal pattern 47 ––heart disease 286
––trunk 138 dizziness, C2/C3 irritation 195 E
––upper cervical dominance or submission gestures, C2 earache, C2/C3 irritation 195
–– – cold chills 158 dermatome 158 early warning system
––upper limbs 171, 176, 210 dominating posture 196 ––autonomic reflexive signs 85
––ventrolateral 140 dorsal branches 43, 51 ––internal disorders 251
–– – limbs 139 ––bladder meridian (taiyang) 30, 38 ––projection of visceral disorders 205
–– – trunk 139 ––cervical nerves 45 ––referred pain 251
––vertex-ear-chin line 158 ––coccygeal nerves 48 ectoderm 4
dermatomic schemas, projective diagnosis ––deep autochthonous muscles of the ––connection to neurotomes 5
136 back 38 eczema 178
dermatoses 158, 178 ––evolution 49 edema
––acquired 178 ––extremities 72 ––subcutaneous
––congenital 178 ––hair standing on end 49 –– – maximum areas of dermatomes 148
dermographism, localized 268 ––innervated areas/regions 30, 38 efferent fibers
descending colon 304, 305 ––lancelet fish 32 ––axon reflex 112
––disorders 323, 326 ––lateral branch 48 ––dorsal root 24
––enterotomes 244 ––longitudinal division of the body 28 ––ventral root 24
Index 355
efferent neurons epigastric region eye

––autonomic 248 ––hyperalgesia ––changes, see changes of the eyes
––sympathetic 116 –– – differential diagnosis 306 ––sympathicotonic signs 271
––visceral organs 239 epigastric syndrome eye spots, dark 271
––viscero-sensory 248 ––reflexive, coronary infarction 279
efferent sympathetic nerves 89 epigastrium, algetic signs 305 F
efferent sympathetic pathways 80 erector muscles of the hairs 82 face
––impulses to the limbs 97 erect posture 197 ––autonomic distant projections 311, 330
––impulses to the trunk 96 erogenous zones, hiatus lines 154 ––autonomic reflexive signs/symptoms
elbow, extensor muscles 252 esophageal disorders 303 256
electrical conductivity, maximum ––algetic signs 303 –– – heart disease 289
points 146 ––algetic/autonomic reflexive projection ––fed-up expression 311
elevation, scapular 170 areas 308 ––hyperalgetic zones 252
elevator muscles of the ribs (Mm. levatores ––autonomic reflexive projection signs 303 ––superior cervical ganglion 120
costarum) 64 ––enhanced thoracic kyphosis 303 ––ventral longitudinal third
embryo, primitive segmentation 8 ––lack of lumbar lordosis 303 –– – arm points 171
embryologic development, segments 1 ––muscular tension facial creases, unilateral deeper 272
embryonic disk, double layered 4 –– – abdominal wall 205 facial erythema, stomach disorders 311
embryonic position 156 ––painful spinous processes 303 facial expressions
––dermatomes 71 ––referred pain 308 ––autonomic 156, 162
––postaxial lines 71 ––sterno-symphyseal stress posture 303 ––autonomic reflexive symptoms 254
––preaxial lines 71 ––viscero-visceral reflexes 303 ––muscles 271
endoderm 4 esophagus facial nerve 60
endodermal derivatives ––acupuncture 303 faulty position/movement, pseudo-angina
––Head’s zones, ventrolateral abdominal ––enterotomes 244 pectoris 290
wall 69 ––projection areas 304 fear
endometriosis 333 ––referred pain 305 ––as pathogenetic factor 49
enteritis 313 ––segmental anatomy/relations 303 ––as psychological factor 49
enterotome(s) 239 ––spinal cord segments 304 femoral nerve 66, 321
––C8 to T4/T5 exophthalmos, angina pectoris 290 ––cutaneus 66
–– – heart 244 extension reflex 67 feng (draft) 106
––internal organs 244 extensor carpi radialis muscle, C7/C8 202 fighting and defense posture, aggressive
––L1 to L3 extensor carpi ulnaris muscle, C7/C8 202 sympathicotonic 82
–– – uterus/ovaries 244 extensor muscles fighting or aggressive action, extensor
––referred pain 244 ––aggressive sympathicotone triad 68 muscles of the limbs 84
––T2 to T5 ––dorsolateral wall of the trunk 70 finger muscles 201
–– – lungs 244 ––elbow 252 fish, segmental construction pattern 8
––T4/T5 ––irritation by internal diseases 69 flexion crease, C3 dermatome 161
–– – esophagus 244 ––knee 252 flexion function
––T5 6 ––lateral branches of spinal nerves 34 ––lower limbs 68
––T6 to T9 ––lower limbs 82 ––upper limbs 68
–– – stomach/duodenum 244 –– – lateral branches 51 flexion reflex
––T8 ––of the arm 202 ––appendicitis 68
–– – pancreas 244 –– – lateral branches 68 ––infantile position 84
––T8 to T11 –– – supply 61 ––life-preserving 84
–– – liver/gallbladder 244 ––of the leg ––life-saving 68
––T9 to L1 –– – lateral branches 68 ––protective function 67
–– – small intestine/ascending colon 244 ––of the limbs ––sole of the foot 68
––T9 to L2 –– – relationship to the lateral and anterior ––submissive posture 84
–– – ureter 244 abdominal wall 203 flexor aspect of trunk and neck 199, 200
––T10 to L1 ––of the limbs and trunk 70 ––ventral spinal nerve branches 199
–– – kidneys 244 ––preganglionic neurons 102 flexor brevis digiti quinti muscle, C8 202
––T11 to L3 ––referred pain 68 flexor carpi ulnaris muscle, C8 202
–– – bladder/descending colon/rectum ––upper limbs 82 flexor digitorum muscles
244 –– – lateral branches 51 ––deep (profundus), C8 202
enthusiasm ––wrist and fingers 202 ––superficial
––frenetic extensor pollicis brevis muscle, C7/C8 202 –– – C7/C8 202
–– – phrenic nerves 162 extensor pollicis longus muscle, C7/C8 flexor muscles
epaulette dermatome 161 202 ––of the arm 199
epicritical sensitivity 141 extensor reflex 68 ––of the hand 202
epidermal dermatome(s) 127, 139 extensor region of the arm ––of the limbs
epidermal dermatomic schemas ––back pain –– – relationship to the anterior abdominal
––Hansen and Schliack 127 –– – additional points 70 wall 203
––Head 127 ––pain treatment 61 ––of the limbs and trunk 70
epididymis, segmental relations extrasystoles 344 ––of the lower limbs 82
332 extremities, see upper/lower limbs –– – ventral branches 51
356 Index
––of the upper limbs 82 ––Mussy’s point 343 gracilis muscle, L1 212
–– – ventral branches 51 ––painful spinous processes 341, 342 granulomas 345
––preganglionic neurons 102 ––parasympathetic neurons (phrenic greater rhomboid muscle, C4/C5 197
––ventral branches of spinal nerves 36 nerve) 339 great toe, nail infection and prostate di-
––ventral wall of the thoracic cage 70 ––projection to lower body quadrant 342 sease 337
flexor pollicis brevis muscle, C8 202 ––referred pain 340 great-toe line, lumbar myotomes 209
flexor pollicis longus muscle, C8 202 ––reflexive influence on the heart 344 guarding, abdominal wall 204
flexor reflex, visceral disorders 252 ––related vertebrae 221, 222 gynecologic disorders
flexor region of the arm ––shoulder pain 161 ––algetic signs/zones 333, 334
––acupuncture points on chest and ––skin changes 178 ––autonomic reflexive projections 335
abdomen 62 ––spinal cord segments 222 ––fear of the cold 335
––pain in the anterior thorax 70 ––upper cervical point 343 ––low back pain 333
flow of energy, inward and outward 138 ––viscero-visceral reflexes 343
flowing ––waist-bending 339 H
––into the arm gallbladder meridian (foot shaoyang) 171 hair
–– – dermatomes 165 ––lateral branches of spinal nerves 30, 34 ––bristling (piloerection) 49
––out of the arm gallstone colic 343 ––growth directions and fashion 163
–– – dermatomes 165 ganglia ––standing on end 49
foot, plantar hiatus lines 155 ––large sympathetic 120 hair ache, C2 dermatome 159
foot shaoyang (gallbladder meridian), lateral ––paravertebral 120 half-mask, trigeminal nerve branch
branches of spinal nerves 34 ––prevertebral 120 V/1 158
foot yangming (stomach meridian), assimi- ––sympathetic trunk 120 han (cold) 106
lation and transformation 68 gaps of spinal cord segments 252 hand
foot yangming (stomach meridian), lateral ––lower limb 252 ––flexor muscles 202
branches of spinal nerves 34 ––upper limb 252 ––increased flexor muscle tonus
forearm gastric mucosa –– – with changes of the eyes 271
––extensor region ––vasoconstriction 251 hand shaoyang (triple heater meridian) 34
–– – pain treatment 61 ––vasodilation 251 hand taiyang (small intestine meridian) 34
––flexor region gastric symptoms, vertebrogenic 312 hand yangming (large intestine meridian)
–– – pain treatment 62 gastric ulcer 263 36, 44
––pain ––scoliosis 276 ––assimilation and transformation 68
–– – cervical syndrome 63 gastritis 311 Hansen and Schliack
foregut ––maximum points of hyperalgesia 263 ––schema of epidermal dermatomes 130,
––projection areas 304 ––scoliosis 276 131
––referred pain 305 gastrocardiac symptom complex, coronary ––table of segment-identifying muscles 181
––spinal cord segments 304 infarction 279 haughty gaze, dysfunction of the sternoclei-
forehead gastrocnemius muscle, S1/S2 213 domastoid muscle 194
––and temple regions (yangming), thoracic gastrointestinal disorders head 256, 257, 265–273, 276
disorders 275 ––algetic zones ––and visceral organs, relationships 275
––unilateral wrinkling 272 –– – ventral midline 304 ––autonomic reflexive symptoms 267
freezing pain, cold stimulus 260 ––irritation of the thoracic spine 277 ––dermatomes 158, 159
functional unit, synchronously reacting 5 gastroptosis, scoliosis 276 ––disorders
fungal infection (mycosis) gastrula stage 4 –– – arm points 171
––abdominal skin 178 GB 20 121, 171 ––extensor aspect 200
––intestinal 178 ––superior cervical ganglion 120 ––Head’s zones 273
furcal nerve 320 GB 34 171 ––hyperalgetic zones 267, 272
GB 39 154 ––hypersensitive zones 272
G ––shoulder pain 323 ––painful areas 272
Galen 13 GB 41 171 ––projection areas/zones 274, 275
gallbladder gemelli muscles, L5–S2 213 ––segmental zones and visceral organs 275
––algetic/autonomic reflexive projection genital tract, algetic/autonomic reflexive ––trunk and visceral organs
zones 180 signs 332 –– – relationships 275
––enterotomes 244 genitofemoral nerve 66 headache
––segmental relations 339 girdle pain 147 ––duodenal disorders 307
gallbladder colic, tachycardia 291 glossy eye 267, 270, 271 ––heart disease 286
gallbladder disorders/diseases gluteal muscles 208 ––projection of visceral disorders 273
––algetic signs 339, 341, 342 gluteal nerve, superior 67 ––pulmonary/bronchial disorders 298
––autonomic organ reflexes 343 gluteus maximus muscle 218 ––referred pain 273
––autonomic reflexive projection signs ––L 5|S 1|S 2 213 ––segmental zones of the trunk 273
342 gluteus medius muscle, L4 212, 218 ––site 273
––Head’s zones 340, 342 gluteus minimus muscles, L4 212, 218 ––spontaneous
––herpes zoster 343 gnosis, tactile 141 –– – sensitive thoracic zone 273
––maximum points of hyperalgesia 263 gooseflesh (goose-bumpy skin), piloerec- ––stomach disorders 307
––maximum zones of dermatomes 148 tion 105, 106 Head’s
––muscular tension gorilla posture 196 ––schema of epidermal dermatomes 127,
–– – abdominal wall 205 Governing Vessel, dorsal midline 96 128, 129
Index 357
Head’s zones ––autonomic reflexive signs/symptoms herpes zoster 178

––abdominal organs 259 288 ––eruptions, posterior root pains 147
––algetic dermatomes 141 –– – face 289 ––heart disease 290
––appendix 317 ––basalioma 178 ––kidney/ureter disorders 330
––ascending colon 317 ––bloating 291 ––liver/gallbladder disease 343
––cecum 317 ––chronic ––stenocardial complaints 290
––descending colon 322 –– – enhanced ticklishness 283 Herringham’s rules 188
––digestive glands 69 –– – itching 283 ––first 185, 188
––digestive tract 69 ––constipation 291 ––myotomes 185, 189
––endodermal derivatives 69 ––disorders of the atria 282 ––second 186, 188
––head 273 ––disorders of the ventricles 282 ––third 188, 189
––heart 282, 284 ––distant projections 286 hiatus lines 150, 152
––hyperalgesia/hyperesthesia 259 ––headache 286 ––anal region 155
––independent, C1–C3 irritation 195 ––herpes zoster 290 ––borderlines 150
––kidney/bladder/ureter 328 ––hyperalgesia 287 ––breaker zones 150
––kidneys 259 ––intercostal muscles 283 ––dermatomes 150
––kidney/ureter disorders 327 ––lateral branches 293 ––dermatoses 154
––large intestine 318, 324 ––latissimus dorsi muscle pain 286 ––embryonic development 150
––limbs 69 ––liver congestion 291 ––erogenous zones 154
––liver/gallbladder 340 ––maximum points of hyperalgesia 263 ––forearm
––lungs and bronchi 295 ––nausea 286 –– – inferior cervical ganglion 122
––lungs 296 ––ninhydrin test 288 ––GB39 154
––pain-oversensitive 259 ––pain in the dorsal forearm and back ––interfaces 150
––parasympathetic neurons 240 293 ––limbs 150
––pelvic organs 259 ––pain in the ventral forearm and –– – lower/upper 151, 154
––piloerection 103 thorax 293 ––neurotomes 154
––rectum 322 ––painful head zones 293 ––PC6 154
––referred pain 253 ––painful spinous processes 286, 293 ––plantar foot 155
–– – ventrolateral trunk 260 ––pectoral muscle pain 286 ––segmental borders 150
––respiratory tract 69 ––piloerection 288 ––segmental leaps/gaps 153
––sigmoid colon 322 ––posture 289 ––SP6 154
––small intestinal disorders 313, 314 ––projections 272 ––TH5 154
––stomach 306 ––referred pain 161, 289 ––trunk 153
––sweating 103 ––reflux symptom 290 hindgut 304, 305
––transverse colon 317 ––retching 286 Hippocrates 13
––trunk 69 ––Roemheld’s disease 290 histamine wheals 268
––vasoconstriction 103 ––shoulder pain 287, 293 hodoneuromere 16, 183
––vasodilation 103 ––SI 3 point 293 human male, emphasizing of shoul-
––ventral/ventrolateral trunk 259 ––singultus 291 ders 162
––ventrolateral branches 69 ––skin changes 178 humans, segmentation 11
heart ––stomach disorders 286 hyoid muscles, myotomes C1–C4 194
––algetic/autonomic reflexive projection ––subjective perception 288 hypalgesia 277
areas/zones 179, 284 ––sweat secretion 288 ––cervical syndrome 63
––areas of resonance 101 ––ulnar arm pain 286 hyperalgesia 141, 259
––disorders ––vasoconstriction 288 ––algetic symptoms 255, 256
–– – maximum zones of dermatomes 148 ––vasodilation 288 ––cutis and subcutis 259
–– – related vertebrae 221, 222 ––ventral branches 293 ––Head’s zones 259
–– – sensitization of the ulnar half of the ––ventral thorax pain 289 ––heart disease 287
arm 97 ––viscero-visceral reflexes 286, 291 ––Mackenzie’s zones 262
–– – spinal cord segments 222 ––vomiting 291 ––maximum points 146, 263
––enterotomes 244 ––xinpin point 293 ––of muscles and tendons 262
–– – preganglionic neurons 102 heart meridian, inferior cervical ganglion ––pulmonary disorders 298
––Head’s zones 282, 284 122 ––superficial, angina pectoris 290
––influence of gallbladder disorders 344 heart region, stellate ganglion 120 ––vagal nerve fibers 125
––maximum points 282 heat (re) 106 hyperalgetic phenomena, algetic derma-
––myotomes 283 ––affecting the lung 194 tomes 142
––referred pain 284 ––ventral longitudinal third 111 hyperalgetic zones 252
heart conditions, dilation of the pupil heel pain ––of the head 272
(mydriasis) 270 ––Bechterew’s disease 331, 338 hyperesthesia 259
heart disease(s) 282 ––urogenital disease 331 ––algetic symptoms 255
––abdominal symptoms 291 hepatitis, right-sided pain 339 ––cutis and subcutis 259
––aerophagia 290, 291 herniation of an intervertebral disk, proprio- ––Head’s zones 259
––algetic signs 282 ceptive reflexes 277 ––physiological 141, 142, 143, 168
––autonomic organ reflexes 291 Herodotus 13 –– – overlapping tactile dermatomes
––autonomic reflexive projection signs/ herpes simplex, chronic bronchial/ 143, 144
symptoms 288 pulmonary disorders 301 hyperhidrosis 269
358 Index
hyperpigmentation intercostal nerves 23, 56, 64 ––vasoconstriction 330

––maximum areas of dermatomes 148 ––maximum points on the trunk 145 ––viscero-visceral reflexes 331
––maximum points 146 interfaces, hiatus lines 150 kidney stones (see nephrolithiasis)
hypersensitive zones of the head 272 internal carotid artery 159 ––reflexive changes 331
hypersensitivity to cold, autonomic reflexive internal diseases/disorders kidney tumors, reflexive changes 331
symptoms 255 ––irritation of extensor muscles 69 kind of stimulus, kind of pain 258
hypertension, cervical 277 ––pressure-sensitive spinous processes 221 knee
hypoglossus nerve 60 ––pain projection 251 ––bending 82
hypothenar atrophy internal obturator muscle, L5–S2 213 –– – flexion reflex 84
––cervical syndrome 63 interosseous lumbrical muscles, C8 202 ––extensor muscles 252
intervertebral disk ––therapy-resistant pain
I ––herniation 277 –– – urogenital disorders 333
ileal disorders ––sclerotome 219, 220 ––weak/buckling 82
––enteritis 313 intestinal disorders/diseases knee-jerk reflex, see patellar reflex
––maximum points 313 ––maximum zones of dermatomes 148 Kohlrausch’s point, location/disorders 263
ileum ––maximum points of hyperalgesia 263
––projection areas 304 ––psoas muscle pain 317 L
––referred pain 305 invertebrates, segmentation 8 L 2 sclerotome 231
––segmental relations 313 inward-rotating muscles of the arm 199 L 3 sclerotome 231
––spinal cord segments 304 irritation(s) L 4 sclerotome 231
ileus, reflexive paralytic 343 ––C5 myotome 17 L 5 sclerotome 231
iliohypogastric nerve 65, 113 ––C5 sclerotome 17 lancelet fish
ilioinguinal nerve 65 ––cervical spine ––longitudinal division 32
iliopsoas muscle, L1 212 –– – cervical hypertension 277 ––segmentation 8
iliosacral joints, irritation 277 ––chronic 6 ––spinal nerve branches 32
illness ––typical sites 196 large intestine
––central-nervous processing 14 ischiocrural muscles, S1/S2 213 ––distal to the left flexure
––perception 14 itching, chronic heart conditions 283 –– – Head’s zones 324
––phenomenological interpretation 14 –– – painful spinal processes 325
imposing gestures 109 J –– – projection areas 324
imposing postures 109 jejunal disorders –– – referred pain 324
individuality, relative 10 ––enteritis 313 ––proximal to the left flexure
infantile position, flexion reflex 84 ––maximum points 313 –– – Head’s zone 318
inferior serratus muscle, T9–T 12 206 jejunum –– – painful spinous processes 319
infiltration ––projection areas 304 –– – projection areas 318
––hypodermic ––referred pain 305 –– – referred pain 318
–– – maximum points 148 ––segmental relations 313 large intestine and stomach meridians
––subcutaneous ––spinal cord segments 304 (yangming) 38
–– – maximum zones of dermatomes 148 jingluo (nerve-vessel bundle) 72 large intestine disorders
infrahyoid muscles 60 jugular notch 84 ––muscular tension
infraspinatus muscle, C4–C6 197 –– – abdominal wall 205
innervation K large intestine meridian (hand yangming),
––peripheral 53 kan bing (to see the disease) 266, 281 ventral branches of spinal nerves 36
––radicular 53 Katsch’s point, location/disorder 263 lateral branches 34, 43, 48
––segmental 54 Kibler fold test 260 ––brachial plexus 61, 67
innervation areas kidney ––C7/T1 myotomes 202
––extensor muscles of the limbs 171 ––enterotomes 244 ––dorsal area 51
––flexor muscles of the limbs 171 ––referred pain 328 ––extensor muscles 51
––spinal nerves 6 ––segmental relations 327 –– – of the arm 61
––upper limbs 171 kidney colic, tachycardia 291 –– – of the limbs 203
innervation patterns, muscles 182 kidney disorders/disease 330 ––extensor reflex 68
integument (see also skin) ––algetic/autonomic reflexive projection ––gallbladder meridian (foot shaoyang)
––and internal organs areas 328 30, 34
–– – interactions 14 ––algetic signs 327, 330 ––heart disease 293
––innervation by spinal nerves 136 ––altered sweat secretion 330 ––innervated areas 30, 56, 68
––pain phenomena 247 ––asymmetrical posture 330 ––innervated regions 34, 35
intensity of stimulus, intensity of pain ––autonomic organ reflexes 331 ––lateral longitudinal one-third 51
258 ––autonomic reflexive projection signs 330 ––longitudinal division of the body 28
interactions ––dilation of the pupil (mydriasis) 270 ––lower limb 34
––segments and spinal nerves 7 ––distant projections to the face 330 ––lumbosacral plexus 67
––spinal-segmental 2 ––Head’s zones 327, 328 ––motor and sensory fibers 48
intercostal muscles 64 ––herpes zoster 330 ––shaoyang region 34
––oversensitive ––maximum points 327 ––small intestine meridian (hand
–– – pulmonary disorders 299 ––painful spinous processes 329, 330 taiyang) 34
––tension ––piloerection 330 ––stomach meridian (foot yangming) 34
–– – heart disease 283 ––scoliosis 330 ––sympathetic neurons 68
Index 359
––triple heater meridian (hand shao- liver disorders/diseases ––flexion function of ventral branches 68
yang) 34 ––algetic/autonomic signs 339–343 ––flexor muscles 82
––trunk 72 ––algetic/painful spinous processes 342 ––flexor muscles
––ulnar area 51 ––autonomic organ reflexes 343 –– – relationship to the anterior abdominal
––upper limb 34 ––autonomic reflexive projection signs 342 wall 203
––ventrolateral area 51 ––Head’s zones 340 ––lateral branches of spinal nerves 34
––vertical distribution pattern 44 ––herpes zoster 343 ––lower gap/spinal cord segments 252
lateral cord, brachial plexus 61 ––maximum zones of dermatomes 148 ––lumbar plexus 66
lateral longitudinal one-third of the body, ––muscular tension ––myotomes 209
shaoyang region 68 –– – abdominal wall 205 ––pain-conducting neurons 115
lateral spinal nerve branches ––Mussy’s point 343 ––postaxial lines 71, 72
––extensor muscles of the arm 199, 200 ––painful spinous processes 341 ––preaxial lines 71, 72
––rotational and extensor aspect 199 ––parasympathetic neurons (phrenic ––sacral plexus 66
latissimus dorsi muscle 199 nerve) 339 ––sclerotomes 231, 232, 233, 234, 237, 238
––C6–C8 200 ––projection to the head 272 ––ventral aspect, myotomes 209
––myotomes 189 ––projection to the lower body ––ventral branches of spinal nerves 36
––pain, heart disease 286 quadrant 342 ––ventrolateral dermatomes 140
law(s), biogenetic 11 ––referred pain 340 lumbar lordosis
legs (see also lower limb) ––related vertebrae 221, 222 ––lack of esophageal disorders 303
––hyperalgetic zones ––shoulder pain 161 lumbar nerves, dorsal branches 48
–– – pelvic nerves 252 ––skin changes 178 lumbar plexus 65, 99
––inward rotation ––upper cervical point 343 lumbar spine, scoliosis 276
–– – myotomes 212 ––viscero-visceral reflexes 343 lumbosacral nerves, ventrolateral
––preganglionic neurons 99 ––waist-bending 339 branches 65
–– – more caudal/cranial 99 liver-gallbladder meridians 342 lumbosacral plexus 51, 65, 67
––ventral resonance areas liver meridian, lumbar plexus 66 lumbosacral region, subjective feeling of
–– – abdominal organs 320 longitudinal division, lancelet fish 32 cold 136
lesser rhomboid muscle, C4/C5 197 longitudinal division of the body 32 lump sensation in the throat,
levator scapulae muscle 197 ––spinal nerve branches 30, 33 C2/C3 irritation 195
––C3–C5 197 longitudinal one-third of the body lung(s)
Libmann’s point, location/disorders 263 ––dorsal 170 ––disorders see pulmonary disorders
limbs (see also lower/upper limb) –– – cold 111 ––enterotomes 244
––algetic signs –– – pilomotor neurons 109 –– – preganglionic neurons 102
–– – heart disease 286 –– – subcutaneous dermatomes 140 lung disease
––cervically innervated muscles –– – transmitting and receiving station 50 ––reflexive tendomyopathy 206
–– – bronchial/pulmonary disorders 298 ––dorsolateral ––maximum points of hyperalgesia 263
––dermatomes 138 –– – cold chills 111 lung meridian
––extensor aspect –– – pilomotor wave (piloerection) 111 ––middle cervical ganglion 122
–– – hyperalgetic zones of sympathetic ––lateral 170 ––origin
origin 252 –– – lateral branches 51 –– – C4/C5/C6 segments 198
––extensor muscles –– – shaoyang meridian 65 lung heat 194
–– – fighting or aggressive action 84 ––medial lung(s), segmental relations 294, 300
–– – referred pain 84 –– – yangming meridian 65 lungs and bronchi
––flexor muscles ––ventral 170 ––postganglionic neurons 295
–– – non-combatants 84 –– – heat 111 ––preganglionic neurons 295
––hiatus lines 150 –– – pigmento-motor neurons 109 ––sympathetic efferent neurons 295
––lateral (dorsal) branches of spinal –– – vasodilation wave 111
nerves 70 –– – ventral branches 51 M
––muscles, development 20 –– – yangming 109 Mackenzie’s maximum points 262, 263
––pain-free, life-saving movements 152 ––ventrolateral 170 Mackenzie’s pressure points, muscular
––spinal nerve supply 32 longitudinal thirds tension 204
––sympathetic nerve supply 85, 86 ––vasoconstriction wave 111 Mackenzie’s schema 221
––ventral branches of spinal nerves 70 ––vasodilation wave 111 Mackenzie’s zones 253
––viscerogenous irritation signs 85 low back pain 333 ––hyperalgesia 256, 262
little finger line, cervical dermatomes 192 lower animals, segmentation 9 mammals, segmental construction
little toe line, sacral myotomes 209 lower limb(s) pattern 8
liver ––afferent sympathetic nerve pathways 115 man, impressive look 109
––algetic/autonomic reflexive projection ––dermatomes 175, 176, 210 martyr posture 197
zones 180 ––development massage, maximum zones of
––enterotomes 244 –– – budding 139 dermatomes 148
––lumbar plexus 66 –– – rotation 139 maxim of Paracelsus 13
––segmental relations 339 ––dorsal aspect, myotomes 209 maximum areas/zones of dermatomes 148
––spinal cord segments 222 ––extensor muscles 82 ––flat retractions 148
liver congestion ––extensor muscles ––hyperpigmentation 148
––heart disease 291 –– – relationship to the lateral and anterior ––subcutaneous edema 148
––right-sided pain 339 abdominal wall 203 ––visceral disorders 149
360 Index
maximum points midgut ––restrictions of movement

––appendix 317 ––projection areas 304 –– – segmental disorder 183
––cecum 317 ––referred pain 305 ––superficial
––colon 317, 322 midline –– – cranial spinal nerve innervation 185
––depigmentation 146 ––anterior muscles
––dermatomes 138, 143, 146 –– – celiac ganglion 123 muscular branches, cervical plexus 60
–– – dorsal spinal nerve branches 146 –– – stellate ganglion 122 muscular defense, abdominal wall 204
–– – lateral spinal nerve branches 146 ––dorsal muscular pain, sites and therapy 186
–– – ventral spinal nerve branches 146 –– – Governing Vessel 96 muscular tension 195
––dorsal 138, 146 ––ventral ––Mackenzie’s points 204
–– – shu points 146 –– – Conception Vessel 96 ––painful 263
––electrical conductivity 146 migraine biliaire 273 ––projection of visceral disorders 263
––heart 282 migraine headaches 345 ––pseudoradicular pain 263
––hyperalgesia 146, 263 mitral valve diseases ––referred pain 263
––hyperpigmentation 146 ––hyperalgesia 287 ––reflexive 253
––ileal disorders 313 morula stage 4 ––visceral disorders 276
––jejunal disorders 313 motor branches 64 musculocutaneus nerve 61, 67
––kidney/ureter disorders 327 ––brachial plexus 61 musculospiral nerve 67
––lateral 138, 146 motor fibers, spinal nerves 24 Mussy’s point
–– – alarm points 146 motor reflex symptoms 247 ––autonomic reflexive signs in the face
––posterior root pain 147 movement(s) –– – pulmonary disorders 300
––pulmonary disorders 295 ––asymmetry 256, 276 ––liver/gallbladder disorders 343
––rectum 322 –– – autonomic reflexive symptoms 267 ––location/disorders 263
––sigmoid colon 322 ––restrictions, segmental disorders 183 ––pressure sensitivity in tuberculosis
––signal points 147 multisynaptic reflex(es) 3, 245, 246 302
––small intestinal disorders 313, 314 ––asymmetrical mustache tape, trigeminal nerve branch
––stomach/duodenum disorders 306 –– – autonomic reflexive symptoms 267 V/2 158
––ventral 138, 146 –– – disease location 277 myalgic pressure points, abdominal
–– – alarm points 146 ––clinically important 278 wall 206
McBurney’s point 205 ––reflexogenic zones 278 mycotic infection of the nail, prostate
––appendicitis 317 ––stimulus from dermatome to disease 337
––location/disorder 263 myotome 245 mydriasis 267
medial branches of muscles ––angina pectoris 290
––lumbar nerves 48 ––closer to the spine ––bronchial/pulmonary disorders 300
––thoracic nerves 48 –– – cranial segmental innervation ––homolateral 271
medial cord, brachial plexus 61 186, 188 ––liver/gallbladder disorders 342
median nerve 53, 61, 67 ––deeper ––unilateral 271
––loop 61 –– – caudal spinal nerve innervation 185 myogeloses 195
mediastinal diseases, maximum points of ––functional multiplicity 183 myotomes 3, 4, 181, 185
hyperalgesia 263 ––further away from the spine ––and cervical dermatomes
medicine –– – caudal segmental innervation 186, 188 –– – congruent alignment 193
––Arabic influence 13 ––hyperalgesia 256, 262 ––and thoracic dermatomes
––Middle Ages 13 ––innervation patterns 181, 182 –– – non-congruent alignment 193
––Roman physicians 13 ––morphological unit 183 ––anterior root 53
medullary canal, segmental relation 4 ––of facial expression 271 ––C2–C4 183
meningeal branch 28 ––of respiration ––C5/C6 202
menstrual disorders, maximum zones of –– – accessory 298 ––C6–T1 199
dermatomes 148 –– – diaphragm 198 ––C7/C8/T1 202
meridian lines ––of the arms ––C8 and T1 202
––basis 71 –– – C6–T1 201 ––caudal
––borderlines of metameric spinal –– – spinal cord segments –– – segmental innervation 189
innervation 72 –– – – motor nuclei 190 ––caudally innervated 20
––radial/ulnar 72 ––of the back ––cervical 55, 185, 192, 194
––tibial/fibular 72 –– – autochthonous –– – fragmentation 202
meridians as perceptive area 49 –– – – dorsal branches 44 –– – rib cage 192
mesenteric ganglion –– – – flexion or extension 49 –– – shoulder girdle 192
––inferior 124 –– – – T6 myotome 22 –– – shoulder level 21
––superior 123 –– – – thoracic nerves 48 –– – trunk 192
mesoderm 4 ––of the fingers ––cranial
metameric arrangement, spinal cord 4 –– – C6–T1 201 –– – segmental innervation 189
metamerism 1–11 ––of the leg ––cranially innervated 20
––as survival strategy 12 –– – spinal cord segments ––efferent motor neurons 211
––budding theory 10 –– – – motor nuclei 190 ––groups 192
––pain research 17 ––of the shoulder girdle 196 ––heart 283
––spinal nerve pairs 16 ––of the trunk ––L1 212
meteorism, heart disease 291 –– – T1–T12 203 ––L2 and L3 212
Index 361
––L3/L4 needle shock 299 ––indirect (conducted/projected) 249

–– – congruent dermatomes 214 nephrolithiasis 258 ––referred 254
––L4 212 ––cuti-visceral influences 331 organ perception, visceral-afferent parasym-
––L5 213 ––Head’s zones pathetic neurons 242
––L5/S1 –– – intracutaneous wheals 327 organ reflexes
–– – congruent dermatomes 215 ––pain intensity 331 ––autonomic 279
––L 5–S 2 ––scoliosis 276 –– – acupuncture 279
–– – sclero-zones of the pelvis 338 nerve supply of internal organs 243 –– – projection phenomena 279
––layers 185 nerve-vessel bundle (jingluo) 72 ––autonomic reflexive symptoms 256, 267
––location and distribution 189 nervous system otitis 345
–– – Herringham’s rules 185 ––autonomic, see autonomic nervous system outward-rotating muscles of arm 200
––lower limbs 192 ––sympathetic, see sympathetic nervous ovaries
––lumbar 206 system ––disorders 336
–– – great-toe line 209 ––vegetative 78 ––enterotomes 244
––lumbosacral 55, 209 ––visceral 78 ––segmental relations 332, 336
–– – segment-identifying muscles 209 neural therapy, viscero-visceral ––tumor
––metameric order 183 reflexes 292 –– – low back pain 333
–– – trapezius and scapular muscles 187 neurites 53 overlapping
––of the legs 209 ––peripheral innervation 53 ––tactile dermatomes 143, 144, 168
––on the arm 201 ––segments 55 ––touch and temperature perception 168
––pelvic girdle 209 neurological disorders 139 oversensitivity to pain, Head’s zones 259
––phrenic nerve 17 ––hypo-/analgesia 143
––plexus displacement 55 neurons P
––plexus formation 55 ––afferent, see afferent neurons pain
––plexus fragmentation 55 ––efferent, see efferent neurons ––algetic dermatomes 141
––primitive segments 4 ––sympathetic 247 ––anterior thorax 70
––quadruped position schema 210 neurotome(s) 3, 4, 15 ––arm 199
––S1 and S2 213 ––acupuncture 15 ––back region 70
––sacral ––excitatory states 3 ––burning, piercing
–– – L5–S2 211 ––hiatus lines 154 –– – vasodilation 107
–– – little-toe line 209 new point 45 ("suppression of the coughing ––C5 myotome 17
––segmental 185 reflex") 122 ––cumulative impulse 253
––segmentally identical 189 non-combatants, flexor muscles of the ––deep
––segmental relations of arm/hand limbs 84 –– – muscular tension 185
muscles 192 –– – thoracic segmental disorder 185
––shoulder girdle 196 O –– – vasoconstriction 255
––spinal nerve branches 181 oblique superior/inferior muscles of the ––dull, boring
––splitting 193 head 195 –– – vasoconstriction 107
––T1 204 obliquus externus muscle, T 6–T 8 205 ––extensor region
––T1–T12 203 obliquus internus muscle, T 10–T 12 205 –– – acupuncture points on the back 61
––T2–T4 204 obturator nerve 66, 67 ––flexor region
––T5 5, 6 occipital nerve –– – acupuncture points on the chest and
––T5–T10 204 ––greater (N. occipitalis major) 45, 121, abdomen 62
––thoracic 203, 206 158 ––individual experience 107
––upper limbs 192 ––lesser (N. occipitalis minor) 57, 121 ––in skin and muscles 259
–– – little finger line 192 ––third (N. occipitalis tertius) 45 ––intensity of stimulus 75, 258
–– – thumb line 192 occipital region, muscles and skin 45 ––kind of stimulus 258
––ventral 195 occiput ––left shoulder
––dorsal branches of spinal nerves 49 –– – left-sided organs 287
N ––hyperalgetic zones ––lumbosacral region 333
naevi 178 –– – vagus and trigeminal nerves 252 ––muscular
nasolabial crease, pronounced 272 ––irritation –– – located to the spinal column 186
nausea –– – filled bladder in paraplegia 161 ––muscular tension 253
––C2/C3 irritation 196 ––pain ––neck 195
––heart disease 286 –– – C2/C3 irritation 195 ––occiput 195
neck –– – in conjunction with pelvic diseases ––parameters 266
––dermatomes 158, 159 323 ––pectoral muscles
––disorders ––perception of a full urinary bladder 117 –– – acupuncture points 62
–– – arm points 171 ––taiyang, projection of pelvic organs 275 ––precordial 277
––flexor aspect 199 ontogeny 11 ––pseudoradicular, see pseudoradicular pain
––muscles 44 opponens digiti quinti muscle, C8 202 ––radicular
––myotomes 194, 195 opponens pollicis muscle, C8 202 –– – cervical syndrome 63
––pain, C2/C3 irritation 195 organ pain –– – prolapsed disk 54
–– – in conjunction with pelvic diseases 323 ––autonomic reflexive symptoms 266 ––referred, referred pain
––sympathetic nerve supply 85, 86 ––deep 254, 255 ––right shoulder
––viscerogenic projections 88 ––direct 249 –– – right-sided organs 287
362 Index
––segment-identifying muscles 181 parasympathetic system 125 ––frenetic enthusiasm 162

––site of stimulus 75 ––Head’s zones 240 ––myotomes 17
––superficial paravertebral ganglia 120 ––origins 60
–– – cervical segmental disorder 185 parenchymal organs (yin organs) 96 ––parasympathetic neurons 276, 298, 339
–– – vasoconstriction 255 patellar reflex 277, 278 ––referred pain 60
––sympathetic projection signs 107 PC 6 120, 122, 124, 150, 154 ––segments 60
––tinged 264 pectoral muscle(s) 198, 199 ––shoulder girdle pain 252
––tinting 142 ––greater (major) ––sympathetic neurons 298
––type of stimulus 75 –– – C5–T1 200 ––viscero-motor reflex 343
––ventrolateral walls of chest and ––pain phylogeny 11
abdomen 70 –– – acupuncture points 62 physiological hyperesthesia, see hyperesthe-
––vertical radiation 22 –– – heart disease 286 sia, physiological
pain phenomena, integument 247, 248 pelvic congestion syndrome, low back pigmento-motor neurons, sympathetic
pain qualities 251 pain 333 neurons 109
pain research, metamerism 17 pelvic girdle, myotomes 209 piloerection 105, 159, 269, 270
pain sensation, visceral-afferent sympathetic pelvic inlet, large oval 209 ––abdominal disorders 320
neurons 242 pelvic nerves 242, 322 ––absence
pain therapist, metamerism 20 ––hyperalgetic zones –– – bronchial/pulmonary disorders 300
pain-conducting fibers 168 –– – on the buttocks 252 ––autonomic reflexive symptoms 251, 253,
pain-conducting neurons –– – on the legs 252 254
––afferent ––parasympathetic neurons 305, 325 ––bronchial/pulmonary disorders 300
–– – visceral organs 239 pelvic organs ––cold shudders 269
––lower limbs 115 ––algetic symptoms 257 ––colon/rectum disorders 322
––upper limbs 115 ––algetic zones ––enlargement of shoulder region 162
palmaris longus muscle, C8 202 –– – SP6 279 ––goose bumps 107
palpebral fissure ––areas of resonance 101 ––Head’s zones 103
––narrow ––autonomic organ reflexes 326 ––heart disease 288
–– – angina pectoris 290 ––autonomic reflexive symptoms 257 ––kidney/bladder/ureter disorders 330
––widened in bronchial/pulmonary disor- ––diseases/disorders ––reflex pathway 270
ders 300 –– – pain in the occiput/neck 323 ––sensitivity to touch 107
––widening 271 –– – sensitization of the dorsal part of the ––shivering 107, 269
pancreas, enterotome 244 leg 97 ––stomach/duodenal disorders 310
pancreatitis ––furcal nerve 320 ––sympatheticotonic reaction 162
––acute ––Head’s zones 259 ––viscero-cutaneous pathway 270
–– – maximum points of hyperalgesia ––preganglionic neurons 99 pilomotor fibers, sympathetic neurons 109
263 ––projections pilomotor wave
––muscular tension between xiphoid and –– – dorsal region of the legs 320 ––axon reflexes 111
umbilicus 205 –– – to the occiput (taiyang) 275 ––longitudinal thirds on the trunk 111
––reflexive tendomyopathy 207 ––resonance area pinch fold, painful 260
––tachycardia 291 –– – dorsal region of the legs 305 piriformis muscle, L5–S2 213
panic attacks, C2/C3 irritation 196 ––sacral plexus 66 plantar muscles, S1/S2 66, 213
Paracelsus, detoxification maxim 13 ––viscero-visceral reflexes 326 plantar reflex 245, 277, 278
paralysis, segment-identifying pelvis plants, segmentation 8, 9
muscles 181 ––sclerotomes 231, 232, 233, 234, pleura afflictions, dilation of the pupil
paranasal sinusitis, spinous process of 235, 238 270
T3 298 ––sclero-zones 217, 218 pleuritis
paraplegic patients perception of disorder 255 ––hyperhidrosis 269
––occipital perception of a full bladder perceptive area, supply region of ––maximum points of hyperalgesia 263
117, 161 meridians 49 plexus formation 55
––sympathetic nervous system 117 perforated ulcer as wrong diagnosis of angi- ––myotome 55
parasympathetic fibers na pectoris 291 ––peripheral innervation 53
––afferent 125 periarterial networks 116 ––radicular innervation 53
––algetic symptoms 78 ––sympathetic neurons 113 pneumonia
––efferent 125 peripheral disorders 54 ––hyperhidrosis 269
––pelvic nerves 125 peripheral innervation 55, 58 ––maximum points of hyperalgesia 263
––phrenic nerve 125 petechial bleeding 268 ––reflexive anuria/polyuria 279
––preganglionic/postganglionic 77 phenomenological interpretation of disease/ ––reflexive vomiting 279
parasympathetic neurons illness 14 polyuria
––afferent 126 phenomenology of disease 108, 266 ––angina pectoris 291
––phrenic nerve 276, 298 phrenic nerve(s) 19, 60, 161, 242 ––paroxysmal tachycardia 291
––projection phenomena ––accessory 60 ––reflexive 279
–– – skin 267 ––diaphragm popliteal nerve
––visceral-afferent –– – C4/C5 myotomes 198 ––external 67
–– – organ perception 242 ––disorders ––internal 67
––viscero-sensory –– – of organs close to the diaphragm 57 postaxial lines 71, 72
–– – internal organs 239, 242 –– – of thoracic or abdominal organs 60 posterior cord, brachial plexus 61
Index 363
posterior horn, segmental sympathetic proprioceptive reflex(es) 3, 245, 246 pupillary dilation, tuberculosis 302
fibers 104 ––asymmetrical pupillodilator muscle 159
posterior root (see also dorsal root) –– – autonomic reflexive symptoms 267 pyelitis
––efferences 103 –– – disease location 277 ––Head’s zones
––efferent sympathetic neurons ––clinically important 278 –– – intracutaneous wheals 327
103, 107 ––from one sclerotome to another 245 ––reflexive changes 331
––irritation ––radicular disorders 277 pyelonephritis, cuti-visceral influences
–– – referred pain 147 ––reflexogenic zones 278 331
–– – sympathetic neurons 106 ––stimulus from one myotome to
––pains 147 another 245 Q
posterior serratus muscle, T9–T 12 206 prostate carcinoma 331 quadratus femoris muscle, L5–S2 213
postganglionic neurons 80, 91, 94, 96, 97, prostate disease 337 quadratus lumborum muscle, T12–L2
99, 121, 123 prostate gland, segmental relations 206
––lungs and bronchi 295 332, 337 quadriceps femoris muscle, L2–L4 212
posture prostatitis, Bechterew’s disease 338 quadruped position schema
––arrogant 194 protopathic sensitivity 141 ––dermatomes, myotomes, sclero-
––asymmetry 256, 276 protrusion of the eyeball 256, 267 tomes 210
––autonomic reflexive symptoms pruritus, pancreas disorders 345 ––topography of myotomes 209
254, 267 pseudo-angina pectoris 290 quadruped stance, schema of derma-
––bent-forward pseudo-appendicitis, pneumonic 302 tomes 157
–– – Bechterew’s disease 338 pseudoradicular pain 264
––changes in bronchial/pulmonary ––differential diagnosis 265 R
disorders 300 ––naked pain 264 radial nerve 53, 61
––heart disease 289 ––trigger points 264 radiation of pain
––sitting position pseudoradicular syndromes, differential ––in vertical direction
–– – in prostate disease 337 diagnosis 265 –– – irritated vertebral arch joint 22
––stomach disorders 310 psoas major muscle, T12–L2 206 radicular disorders, proprioceptive
preaxial lines 71, 72 psoas muscle pain reflexes 277
precordial pain, irritation of the thoracic ––intestinal disorders 317 radicular innervation 58
spine 277 psychosomatic aspect of acupuncture 49 raised shoulders, disorders of upper abdomi-
preganglionic neurons 91, 94, 99, 102, psychosomatic medicine, dorsal nal organs 60
121–124 branches 49 Rami communicantes, see communicating
––C8–T7 pudendal plexus 65 branches
–– – digestive tract projections to the lower pullulation 10 Rami musculares, see muscular/motor
limbs 305 pulmonary disorders branches
––cranial 78 ––absence of piloerection 300 re (heat or hot) 106, 268
––lungs and bronchi 295 ––algetic signs 294, 295 reactive units
––sacral 78 ––autonomic organ reflexes 302 ––horizontal
––T8–T9 ––autonomic reactions 298 –– – spinal nerves on the trunk 170
–– – digestive tract projections to the lower ––autonomic reflexive signs 300 ––longitudinal
limbs 305 ––dermatomes 295 –– – spinal nerves on the trunk 170
––T10–T12 ––distant projections 298 rebound pain 258
–– – digestive tract projections to the lower ––glossy eye 300 recapitulation theory 11
limbs 305 ––headache 298 rectum
––T12–L3 ––Head’s zones 295, 296 ––disorders 323, 326
–– – digestive tract projections to the lower ––herpes simplex 301 –– – autonomic organ reflexes 326
limbs 305 ––hyperalgesia 298 –– – distant projections 323
––thoraco-lumbar 78 ––mydriasis 300 –– – related vertebrae 221, 222
premenstrual syndrome 279 ––myotomes 298 –– – spinal cord segments 222
––low back pain 333 ––piloerection 300 –– – viscero-visceral reflexes 326
pressure-sensitive points, irritated verte- ––posture 300 ––enterotomes 244
brae 219 ––referred shoulder pain 301 ––Head’s zones 322
prevertebral ganglion/ganglia 91, 120 ––reflexive erythema 298 ––maximum points 322
prevertebral muscles 60 ––related vertebrae 221 ––projection areas 304
primitive segmentation, embryo 8 ––sclerotomes 295, 298 ––referred pain 305
primitive segments 4 ––shoulder pain 298 ––segmental relations 322, 332
––myotomes 4 ––sweat secretion 300 ––spinal cord segments 304
––sclerotomes 4 ––vasoconstriction 300 rectus abdominis muscle 64
primitive vertebrae 10 ––vasodilation 300 ––intercostal nerve supply 205
projection phenomena 1 ––viscero-visceral reflexes 302 ––partial contraction
––spinal-segmental interactions 2 ––waist-bending 300 –– – stomach cancer 205
projection symptoms ––widened palpebral fissure 300 ––segmental innervation 208
––autonomic pulmonary embolism, abdominal ––T5–T8 205
–– – occiput and neck 161 symptoms 302 ––T6–T12 208
prolapse of the uterus, low back pain 333 pulmonary infarction, reflexive anuria/ rectus posterior major/minor muscles of the
pronator quadratus muscle, C8 202 polyuria 279 head 195
364 Index
referred pain 54, 68, 69, 161, 249, 251 reflexive tension, abdominal wall 206 sclerotome(s) 3, 4, 217–238
––algetic dermatomes 141 reflexive vomiting 279 ––arrangement
––asymmetrical respiration 276 reflux disease –– – in longitudinal bands 217
––asymmetry of proprioceptive/multisynap- ––gastro-esophageal 291 ––bronchial/pulmonary disorders
tic reflexes 277 reflux esophagitis, asthma-like breathing 295, 298
––body surface 251 condition 303 ––dorsal/caudal
––development 254 reflux symptoms –– – more caudal spinal nerves 217
––differential diagnosis 264 ––heart disease 290 ––fibular/distal
––early signs of malignant tumor 302 ––tachycardia/tachyarrhythmia 291 –– – more caudal spinal nerves 231
––early warning system 251 renal cysts 331 ––intervertebral disk 219
––Head’s zones 253 renal secretion, cuti-visceral influ- ––lower limb 231
––heart diseases 284, 289 ences 331 ––pelvis 231
––hyperalgesia/hyperesthesia 143 reptiles, segmental construction pattern 8 ––point of insertion 218
––kidney/bladder/ureter disorders 328 resonance areas/zones ––point of origin 218
––large intestinal disorders 318 ––autonomic 96 ––primitive segments 4
––lateral skin areas 68 ––lung ––quadruped position schema 210
––liver/gallbladder disorders 340 –– – needling of BL13 193 ––referred pain 217
––lung/bronchial disorders 302 ––pelvic organs 305 ––S 1 238
––painful muscular tension 263 respiration ––S 2 238
––phrenic nerve 60 ––asymmetry ––segmentally identical 217
––posterior root irritation 147 –– – referred pain 276 –– – paravertebral pressure points 219
––sclerotomes 217 respiratory muscles ––segmental-spinal framework 217
––small intestinal disorders 314 ––accessory 198 ––shoulder girdle 224
––stomach cancer 222 ––cervical spinal nerve supply 193 ––spinal nerves 217
––stomach/esophageal disorders 308 ––diaphragm 198 ––T5 5, 6
––symptoms 258 respiratory tract ––tibial/proximal
––tinged pain 264 ––areas of resonance 101 –– – more cranial spinal nerves 231
––visceral diseases/disorders 146, 266 ––disorders ––upper limb 224
––viscero-motor effects 253 –– – sensitization of the radial half of the ––ventral/caudal
reflex arc, single spinal nerve 208 arm 97 –– – more cranial spinal nerves 217
reflex pathway ––Head’s zones 69 sclero-zones, arrangement 217
––piloerection 270 restrictions of movement, segmental scoliosis 276
––sweat secretion 270 disorders 183 ––functional 276
––vasoconstriction 270 retching ––idiopathic 276
––vasodilation 270 ––C2/C3 irritation 196 ––progressive
––viscerocutaneous 266 ––heart disease 286 –– – kidney function 330
reflex(es) retractions ––reflexive 276
––autonomic 246 ––carpal tunnel syndrome 148 ––right-/left-concave
––cuti-visceral 246 ––maximum areas of dermatomes 148 –– – renal disease 330
––diminished retroflexion of the uterus secretory (sudo-motor) neurons 110
–– – segment-identifying muscles 181 ––algetic signs/zones 333 segment disorders, signal/maximum
––distant sacral 330 ––low back pain 333 points 147
––enhanced rhinitis segmental anatomy 15
–– – angina pectoris 290 ––allergic 298 ––acupuncture 15
––excitation of segments 3 ribs, trigger points 203 ––Chinese acupuncture 2
––hyperactive Roemheld’s disease, tachycardia/tachyar- ––neurotome 15
–– – segment-identifying muscles 181 rhythmia 291 ––spinal nerves 15
––multisynaptic 3, 245 Roemheld symptom complex, coronary ––sympathetic nerves 15
––proprioceptive 3, 245 infarction 279 segmental arrangement, spinal
––trigemino-cardio-pulmonary 287, 298 Rosenstein’s point, location/disorder 263 column 219
––viscero-cutaneous 246, 247, 248 rotation aspect, lateral spinal nerve segmental construction pattern
––viscerogenic 246 branches 199 ––birds 8
––viscero-visceral 246 ––fish 8
––viscero-visceral, see viscero-visceral re- S ––mammals 8
flexes sacral nerves, dorsal branches 48 ––of the human 11
reflexive erythema, pulmonary and heart sacral plexus 66, 99 ––reptiles 8
conditions 298 sacral reflex, distal 330 segmental disorders 54
reflexive relationships of segmental saphenus nerve 66 ––cervical
parts 245, 246 sartorius muscle, L1 212 –– – superficial pain 185
reflexive response scalene muscles 60 ––movement restrictions 183
––quick, synchronized 211 scapular elevation 48, 170 ––thoracic
reflexive signs scapular muscles, metameric order of –– – deep pain 185
––left-sided myotomes 187 –– – muscular tension 185
–– – stomach disorders 306 scars 6 segmental gaps/leaps
––right-sided Schanz cervical collar brace, C3 158 ––hiatus lines 150, 153
–– – duodenal disorders 306 sciatic nerve 321 ––ventrolateral dermatomes 139
Index 365
segmental innervation 58 ––hyperactive reflexes 181 shoulder pain

––caudal myotomes 189 ––monoradicular pain 181 ––cervical syndrome 63
––cranial myotomes 189 ––paralysis 181 ––heart disease 287, 293
segmental nerve supply, internal segments 1, 2 ––pulmonary disorders 298
organs 243 ––and spinal nerves 2, 5 ––referred 276, 301
segmental nerves, spinal cord 4 ––antimerism 2 ––vertebrogenic 301
segmental order ––arrangement in the body halves 2 shoulder region
––horizontal ––C 8–L 3, sympathetic nuclei 84 ––enlargement
–– – by spinal nerves 42 ––conduction of impulses 245 –– – C4/C5 dermatomes 162
––vertical ––cranio-caudal series 2 –– – piloerection 162
–– – by metameric spinal nerve branches ––dorsal portion 10 ––hair growth in cranial direction 162
43 ––embryologic development 1 shu points, dorsal maximum points
segmental parts ––nervous excitation 246 146
––reflexive interactions 16 ––number of 2 SI 3 44
––reflexive relationships 246 ––significance 12 sigmoid colon
segmental relations ––spinal nerve as neural signpost 16 ––disorders 323, 326
––adnexa 332 ––spinal periphery 5 –– – autonomic organ reflexes 326
––appendix 316 ––state of excitation by reflexes 3 –– – distant projections 323
––atria 282 ––superficial –– – viscero-visceral reflexes 326
––bladder 327, 332 –– – influence on the heart 292 ––Head’s zones 322
––bronchi 294 ––supplying region of spinal nerves 1 ––maximum points 322
––cecum 316 ––ventral portion 10 ––referred pain 305
––colon 316, 322 semimembranosus muscle, L5–S2 213 ––segmental relations 322
––duodenum 306 semitendinosus muscle, L5–S2 213 signal points, maximum points 147
––epididymis 332 sensation of coldness, vasoconstric- skin (see also integument)
––esophagus 303 tion 107 ––autonomic reflexive symptoms 267
––gallbladder 339 sense of touch, tactile dermatomes 141 ––changes in the capillaries 269
––ileum 313 sensitivity ––cutaneous reflexes 278
––jejunum 313 ––algetic dermatomes 141 ––dry, reddened
––kidney 327 ––epicritical 141 –– – sympatheticotonic reaction 106
––liver 339 ––protopathic 141 ––Head’s zones 260
––lungs and bronchi 294 ––tactile dermatomes 141 ––hyperalgesia 259
––lungs 300 ––to cold 88 ––hyperalgetic zones 259, 268
––ovaries 332, 336 sensory experience, criteria 266 ––hyperesthesia 259
––pelvic organs 332 sensory fibers ––irritated segments
––prostate gland 332, 338 ––dorsal branches 49 –– – altered vasomotion 268
––rectum 322, 332 ––spinal nerves 24 ––pale, moist
––sigmoid colon 322 serratus anterior muscle 198, 199 –– – sympatheticotonic reaction 105
––small intestine 313 serratus posterior muscles (Mm. serrati ––projection phenomena
––spleen 345 posteriores) 64 –– – parasympathetic neurons 267
––stomach 306 shaoyang (gallbladder meridian) 38, 65 –– – sympathetic neurons 267
––testes 332, 336 ––lateral branches 30, 171 ––spinal map 127
––ureter 327 shaoyang region 68 ––sympathetic symptoms 106
––uterus 332, 336 ––lateral branches 34 ––turgor 261
––ventricles 282 shi (dampness) 106 ––vasomotoric symptoms 267
segmental-spinal bone framework 217 shivering 88 skin changes 178
segmental sympathetic fibers 103 ––piloerection 105, 107, 269 skin conditions
segmental therapy 14 shoulder ––referred pain 178
segmental zones of the trunk 273 ––changes ––segmental innervation 178
segmentation 1–16 –– – autonomic reflexive symptoms 267 skin diseases
––advantage 12 ––projection zones 274 ––generalized 269
––arthropods 8 shoulder girdle ––segmental vasoconstriction/vasodilation
––as survival strategy 12 ––cervical myotomes 192 269
––biological purpose 12 ––dorsal region skin erythema after UV exposure 268
––in humans 11 –– – myotomes 203 small intestinal disorders 313
––in the course of evolution 9 ––function of trapezius muscle parts ––algetic signs 313
––invertebrates 8 183 ––Head’s zone 313
––lancelet fish 8 ––muscles 18, 196 ––maximum points 313
––peripheral spinal nervous system 15 ––myotomes C4–C6 196 ––muscular tension
––plants 8, 9 ––pain 60 –– – abdominal wall 205
––spinal nerves 7, 16 ––pain radiation small intestine, enterotomes 244
––vertebrates 8, 9 –– – phrenic nerves 252 small intestine and bladder meridians
segment-identifying muscles 181, 209 ––sclerotomes 224, 225, 226, 227, 228, (taiyang) 38
––acupuncture 181 229, 230 small intestine meridian
––diminished reflexes 181 ––ventral region ––lateral branches of spinal nerves 34
––Hansen and Schliack’s table 181 –– – myotomes 203 ––SI3 44
366 Index
small muscles of the hand ––horizontal division of the body 44 ST 25, disorders of thoracic organs 279
––paresis ––horizontal reactive units on the ST 38, shoulder pain 323
–– – cervical syndrome 63 trunk 170 stellate ganglion 120, 121, 122, 154, 161
solar plexus 123 ––indicator to areas of pain 20 ––phrenic nerve 60
soleus muscle, S1/S2 213 ––innervated regions 34, 38 stenocardia triggered by arm-shoulder
somato-afferent fibers, spinal nerves 26 –– – meridian equivalents 34, 36 movements 291
somato-efferent fibers, spinal nerves 26 ––innervation of dermatomes 137 stenocardial complaints, herpes zoster 290
somato-motor effects 253 ––interactions between parts of a seg- sternoclavicular joint irritation 194
––nociceptive 276 ment 7 sternocleidomastoid muscle 60, 194
somato-motor fibers, spinal nerves 26 ––internal transmission of information 6 ––myotomes C2–C4 194
somato-motor neurons 90 ––lateral longitudinal one-third 64 ––pain
somato-sensory fibers, spinal nerves 26 ––medial longitudinal one-third 64 –– – heart disease 286
somites 4 ––metameric borderlines 73 sternocostal joints
SP 6 120, 124, 154, 279 ––metameric sequence 20 ––irritation
spinal column ––metamerism 16 –– – paroxysmal tachycardia 277
––reflexive/algetic syndromes 277 ––more caudal 217, 231 sternohyoid muscle 194, 195
––segmental arrangement/order 219 ––more cranial 217, 231 sterno-symphyseal stress posture 195
––viscero-vertebragenic component of ––motor, sensory and autonomic fibers 24 ––esophageal disorders 303
complaints 222 ––number of 2 sternothyroid muscle 194, 195
spinal cord, metameric arrangement 4 ––projections of the digestive tract 305 sternum, burning sensation 194
spinal cord segments 304 ––reflex arc 208 stickiness of the skin
––anterior roots 94 ––relationship to the autonomic (sympathe- ––increased sweat secretion 106, 107
––difference in levels 223 tic) nervous system 26 stimulus
––effector organs 94 ––respiratory muscles 193 ––intensity of pain 75
––hiatus 150 ––root fibers 24 ––site of pain 75
––lumbar/thoracic ––sclerotomes 217 ––type of pain 75
–– – needling of T12 vertebra 170 ––sclero-zones 217 stole (shawl collar), C4/C5 dermatome 161
––upper/lower gap 252 ––segmentation 7, 16 stomach
spinal innervation, dermatomes 134, 135 ––segments 2, 5, 17 ––enterotomes 244
spinal map, skin 127 ––spinal cord segments 223 ––Head’s zone 306, 308
spinal nerve branches (see also dorsal, ––sympathetic system 30 ––pain 251
ventral and lateral branches) ––terminal branches 23 ––projection areas 304
––adjacent metameres 38 ––types of fibers 26 ––referred pain 305
––dorsal maximum points 146 ––vertical spinal-segmental arrange- ––referred shoulder pain 276
––horizontal segmental order 42 ment 22 ––segmental relations 306
––lateral maximum points 146 spinal periphery 6 ––spinal cord segments 304
––longitudinal division of the body 30 spinal segments, neurites 55 stomach cancer/carcinoma 311
––maximum points on the trunk 145 spinothalamic tract, cumulative im- ––partial contraction of the rectus
––myotomes 181 pulse 253 muscle 205
––neighboring metameres 40 spinous processes ––referred pain 222
––ventral maximum points 146 ––painful 217, 221 ––scoliosis 276
––ventrolateral 199 –– – allergic rhinitis 298 stomach disorders/diseases
––vertical division of the body 44 –– – disorders of internal organs 221 ––algetic signs
––vertical order 65 –– – esophageal disorders 303 –– – epigastrium 306
––vertical segmental order 43 –– – heart disease 285, 286, 293 –– – upper limbs 306
spinal nerve supply –– – kidney/bladder/ureter disorders 329 ––algetic/autonomic reflexive projection
––caudal –– – large intestinal disorders 319, 325 areas 308
–– – deeper muscles 185 –– – liver/gallbladder disorders 341, 342 ––altered sweat secretion 310
–– – deeper myotomes 188 –– – paranasal sinusitis 298 ––and heart disorders 286
–– – muscles away from the spine 186 –– – pulmonary disease 297 ––autonomic organ reflexes 311
––cranial –– – respiratory disorders 298 ––autonomic reflexive signs in the face
–– – muscles closer to the spine 186 –– – small intestinal disorders 315 311
–– – superficial muscles 185 –– – stomach/duodenal disorders 306 ––distant projections 307
–– – superficial myotomes 188 –– – stomach/esophageal disorders 309 ––facial erythema 311
spinal nerve(s) 15 –– – urogenital disorders 330 ––headache 307
––acupuncture 14 ––pressure-sensitive 217, 298 ––hyperalgesia 306, 309
––architectural design 7 ––relation to spinal cord segments 222 ––maximum points 263, 306
––areas of innervation 6, 15, 16, 20, 32 splanchnic nerve(s) 91, 113 ––maximum zones of dermatomes 148
––areas on the trunk 138 ––greater 123 ––muscular tension
––arrangement 217 ––lesser 123 –– – abdominal wall 205
––changes in dermatomes 136 spleen ––painful spinous processes 306, 309
––connection to the superior cervical ––disorders 345 ––piloerection 310
ganglion 121 ––segmental projection area 345 ––posture 310
––cranio-caudal order 20 splitting of myotomes 193 ––projection to an upper quadrant 310
––dorsal/ventral root filaments 24 spondylitis, posterior root pain 147 –– – to the head 272
––effects on split-up myotomes 193 spreading out from trunk to periphery 165 ––referred pain 308
Index 367
––reflexive signs sympathetic ganglia 27, 80, 98 temperature measurements, heart

–– – left-sided 306 ––preganglionic neurons 91 disease 288
––related vertebrae 221, 222 ––projection of T8/T9 97 temporo-parietal regions (shaoyang),
––shoulder pain 307 ––projection onto the skin 120 abdominal disorders 275
––spinal cord segments 222 sympathetic innervation of the skin 106 tendomyopathy
––trigemino-cardio-pulmonary-gastric sympathetic nerves, areas of innervation ––reflexive
reflex 311 16 –– – internal diseases 206, 207
––vasoconstriction 310 sympathetic nervous system tendon reflexes, clinically important 278
––vertebrogenic 312 ––acupuncture 14 tendons, hyperalgesia 262
––viscero-visceral reflexes 311 ––axon reflexes 113 tension
stomach meridian (foot yangming) 171 ––changes in dermatomes 136 ––increased of cutis and subcutis 261
––lumbar plexus 66 ––connection to the cervical plexus 60 tensor fasciae latae muscle, L4/L5 212
––spinal nerve branches 34 ––direct access of lateral branches 68 teres major muscle 199
––ventral branches 30 ––origin 80, 81 ––C5–C7 197
stomach pain 251 ––segmental anatomy 15 ––C6–C8 200
subclavius muscle 202 sympathetic neurons teres minor muscle, C4/C5 197
subdivision into segments 5 ––afferent 113, 239 testes
submissive posture 109, 197 –– – viscero-sensory 239 ––disorders 336
––flexion reflex 84 ––dorsal dermatomes 138 ––segmental relations 332, 336
suboccipital muscles ––dorsal parts of dermatomes 158 TH 5 120, 150, 154, 171
––functional impairment 195 ––efferent 239 thigh
––myotomes 195 –– – anterior root 89, 107 ––extension 213
subscapular muscle 202 –– – posterior root 107 ––outward rotation 213
subscapular nerve(s) 67 ––pain referral 276 thoracic dermatomes
superficial segments, influence on the ––periarterial networks 116 ––horizontal pattern 46
heart 292 ––phrenic nerve 298 ––longitudinal pattern 47
supinator muscle, C5/C6 202 ––pilomotor fibers 109 thoracic kyphosis
supraclavicular nerves, disorders of organs ––projection phenomena on the skin 267 ––enhanced
close to the diaphragm 57 ––secretory (sudo-motor) 110 –– – esophageal disorders 303
suprascapular nerve 67 ––vasodilatory 110 thoracic nerve(s)
supraspinatus muscle, C4–C6 197 ––visceral-afferent ––anterior 67
survival strategy –– – pain sensation 242 ––branches 64
––metamerism 12 sympathetic nuclei, spinal cord seg- ––dorsal branches 48
––segmentation 12 ments 84 ––ventrolateral branches 64
swallowing difficulties, C2/C3 irritation sympathetic origin of hyperalgetic zones thoracic organs
195 ––extensor aspects 252 ––algetic symptoms 257
sweat gland reflexes, pathway 110 ––on the trunk 252 ––autonomic reflexive symptoms 257
sweat secretion/sweating sympathetic pathways, afferent secondary ––CV12 279
––altered line 117 ––pathological impulses conducted to the
–– – colon/rectum disorders 322 sympathetic reflexes, dorsal longitudinal arms 85
–– – kidney/bladder/ureter disorders 330 one-third 49 ––projection to the forehead and temples
–– – stomach/duodenal disorders 310 sympathetic stimuli, area of resonance 49 (yangming) 275
––autonomic reflexive symptoms 254, 255, sympathetic trunk ––reflexive tendomyopathy 206
256 ––collaterals 66 ––ST25 279
––changes ––ganglia 76 thoracic vertebrae/spine
–– – abdominal disorders 320 ––ganglionic chain 94 ––irritation 277
––Head’s zones 103 ––preganglionic/postganglionic fibers 76 ––pressure-sensitive
––heart disease 288 symptoms of climatic factors 106 –– – pulmonary disorders 298
––increased 105, 110 ––scoliosis 276
–– – bronchial/pulmonary disorders 300 T thoracic wall, cervical myotomes 192
–– – stickiness of the skin 107 T 6 dermatome 22 thorax
––reduced/decreased 103 tachyarrhythmia 291 ––lower half, ulnar pain 199
–– – bronchial/pulmonary disorders ––C2/C3 irritation 196 ––painful zones 274
300 tachycardia 291 ––upper half, radial pain 199
–– – dryness of the skin 107 ––paroxysmal 291 thorax region, stellate ganglion 120
––reflex pathway 270 –– – irritation of sternocostal joints 277 threatening gestures 109
––sympathicotonic reaction 271 tactile dermatomes threatening postures 109
sympathetic effector organs 49 ––overlapping 168 throat, myotomes 194
sympathetic fibers ––physiological hyperesthesia 168 thrombosis 345
––algetic symptoms 78 tactile gnosis 141 thumb line, cervical dermatomes 192
––autonomic reflexive symptoms 78 tai yang (greater yang) 109 tibial muscles
––dorsal branches 49 taiyang (bladder meridian) 171 ––anterior/posterior
––dorsal longitudinal one-third 49 ––dorsal branches 38 –– – L4 212
––pathway 27 target muscle ticklishness
––viscero-somato-motor, synapsed postgan- ––psychological ––enhanced
glionic 89 –– – trapezius muscle 194 –– – chronic heart conditions 283
368 Index
Tietze’s syndrome 277, 283 ––vertical segmental order 43 ––autonomic reflexive projection signs
tip of the coccyx 44 ––vertical spinal-segmental arrange- 330
tonsillar abscess 345 ment 22 ––distant projections to the face 330
touch perception, qualitative change 261 tuberculosis 302 ––Head’s zones 327, 328
tracheal diseases, maximum points of hyper- turgor of the skin 261 ––herpes zoster 330
algesia 263 typhoid fever 313 ––maximum points 327
transmitting and receiving station, dorsal ––painful spinous processes 329
longitudinal one-third of the body 50 U ––piloerection 330
transverse abdominis muscle, T 7–L 1 64, ulnar nerve(s) 53, 61, 67 ––referred pain 328
205 upper abdomen ––vasoconstriction 330
transverse colon 304, 317 ––supply territory of the lumbar plexus 66 urinary bladder, see bladder
transverse thoracic muscle, T2–T6 64, 204 ––visceral organs 66 urogenital disorders
trapezius muscle 60, 183, 186, 194 upper abdominal organs, raised shoulder ––distant sacral reflex 330
––functional impairment 195 60 ––maximum zones of dermatomes 148
––metameric order of myotomes 187 upper arm ––related vertebrae 221, 222
––myogelosis and pain 195 ––extensor muscles 61 ––spinal cord segments 222
––myotomes C2–C4 194 ––flexor muscles 61 urogenital problems
––projection area of irritated organs 287 ––pain 17 ––achillodynia 331
––psychological target muscle 194 –– – acupuncture points on the back 61 ––calcaneal spur 331
––viscerogenous irritations 293 –– – cervical syndrome 63 ––painful heel 331
triceps muscle, C7/C8 202 –– – treatment 62 ––therapy-resistant knee pain 333
triceps reflex 278 ––radial part urogenital tract
trigeminal areas, dermatomes 158 –– – hypalgesia 63 ––disorders
trigeminal nerve 158 ––tension 17 urticaria 178
––first branch (V/1) upper arm region, stellate ganglion 120 uterine fibroids 331
–– – half-mask 158 upper extremity see upper limb(s) uterus
––referred pain 242 ––afferent sympathetic nerve pathways 115 ––disorders 336
––second branch (V/2) ––algetic signs 285 –– – projection areas 336
–– – mustache tape 158 ––budding 139 ––enterotomes 244
––third branch (V/3) ––cervical myotomes 192 ––segmental relations 332, 336
–– – chinstrap bandage 158 ––dermatomes 176, 210 ––tumors
trigeminal neuralgia 158 ––dorsal region –– – low back pain 333
trigemino-cardio-pulmonary reflex 287, –– – innervation 171 UV exposure, skin erythema 268
298, 311 ––extensor muscles 81
trigemino-cardio-pulmonary-gastric –– – relationship to the lateral and anterior V
reflex 311 abdominal wall 203 vagal nerve fibers, hyperalgesia 125
trigger points ––flexion function of ventral branches 68 vagus nerve 242
––ribs 203 ––flexor muscles 82 varicose veins, maximum zones of derma-
––visceral diseases 262 –– – relationship to the anterior abdominal tomes 148
triple heater meridian (hand shaoyang), wall 203 vasoconstriction 105
lateral branches of spinal nerves 34 ––lateral branches of spinal nerves 34 ––abdominal disorders 320
trunk ––myotomes C5–T1 199 ––bladder disorders 330
––acupuncture stimulus 44 ––pain-conducting neurons 115 ––bronchial/pulmonary disorders 300
––cervical myotomes 192 ––postaxial lines 71, 72 ––cutaneous blood vessels 251
––dermatomes 138 ––preaxial lines 71, 72 ––deep pain 255
––division into longitudinal thirds 32 ––preganglionic neurons 102 ––gastric mucosa 251
––extensor aspect 200 –– – more caudal/cranial 102 ––Head’s zones 103
––flexor aspect 199 ––radial region ––heart disease 288
––head and visceral organs –– – innervation 171 ––kidney disorders 330
–– – interactions 273 ––sclerotomes 224, 225, 226, 227, 228, ––large intestinal disorders 322
–– – relationships 275 229, 230 ––pain 253
––Head’s zones 69 ––ulnar region ––reflex pathway 270
––hiatus lines 150, 153 –– – innervation 171 ––sensation of coldness 107
––horizontal segmental order 42 ––upper gap/spinal cord segments 252 ––sensation of deep, boring pain 107
––hyperalgetic zones of sympathetic ––ventral branches of spinal nerves 36 ––stomach/duodenal disorders 310
origin 252 ––ventrolateral dermatomes 139 ––superficial pain 255
––muscles 203 ––volar region ––ureter disorders 330
––myotomes 203, 213 –– – innervation 171 vasoconstriction wave, longitudinal
––segmental zones 273 ureter thirds 111
–– – and visceral organs 275 ––enterotomes 244 vasodilation 268
––spinal nerve supply 32 ––segmental relations 327 ––algetic dermatomes 110
––spinal nerves 138 ureter disorders 330 ––body surface 251
––ventral longitudinal third ––algetic signs 327 ––bronchial/pulmonary disorders 300
–– – arm points 171 ––algetic/autonomic reflexive projection ––burning, piercing pain 107
––ventrolateral wall areas 328 ––gastric mucosa 251
–– – Head’s zones 260 ––altered sweat secretion 330 ––Head’s zones 103
Index 369
––over spinous processes ––extremities 51 viscero-motor fibers 26

–– – heart disease 286 ––flexor aspect of neck and trunk 199 viscero-motor neurons 90
––peripheral axon reflex 110, 113 ––Head’s zones 69 viscero-sensory fibers 26
––reflex pathway 270 ––innervation of limbs 28, 70 viscerotome 249
––sensation of heat 107 ––intercostal nerves 64 viscero-visceral reflexes 279
––triggers/irritation 110 ––lumbosacral plexus 65 ––bronchial/pulmonary disorders 302
vasodilation wave ––plexus formation 51, 52 ––colon/rectum/pelvic disorders 326
––axon reflexes 111 ––projection areas 69 ––esophageal disorders 303
––ventral longitudinal third 111 ––projection phenomena and interac- ––heart disease 286, 290, 291
vasodilatory neurons 110 tions 69, 70 ––kidney/bladder/ureter disorders 331
vasomotion 268 ––sympathetic fibers 27 ––liver/gallbladder disorders 343
vasomotor effects, angina pectoris 289 ––thoracic nerves 64 ––neural therapy 292
ventral branches 43, 51 vertebra(e) ––stomach/duodenal disorders 311
––acupuncture stimulus 44 ––irritation vomiting
––borderlines 72 –– – paravertebral pressure points 219 ––heart disease 291
––brachial plexus 67 ––painful 221 ––reflexive 279
––dorsal area 51 ––primitive 10
––extremities 72 ––sclerotome 220 W
––flexion function 68 ––spinal cord segments 223 waist-bending
–– – lower/upper limbs 68 vertebral arch joint ––bronchial/pulmonary disorders 300
––flexor muscles 36 ––radiation of pain 22 ––liver/gallbladder disorders 339
–– – of the arm 200 vertebral column syndromes, reflexive/ wall of the trunk
–– – flexor muscles of the limbs 203 algetic 267 ––dorsolateral
––heart disease 293 vertebrate language 84 –– – extensor muscles 70
––innervated areas 30, 37, 56, 67 ––sympathetic system 83 warm stimulus/warmth
––innervated skin 68 vertebrates, segmentation 8 ––burning, caustic pain 260, 261
––large intestine meridian (hand vertex-ear-chin line 158, 160 Westphal’s point, location/disorders 263
yangming) 36 visceral diseases/disorders
––longitudinal division of the body 28 ––acupuncture points on the arms/legs 203 X
––lower limbs 175 ––early warning system 205 xinpin point, heart disease 293
––lumbosacral plexus 67 ––flexor reflex 252 xiphoid process of the sternum 84
––pigmento-motor neurons 109 ––headaches 273
Y
––protective flexion reflex 67 ––maximum points 146
yang meridians, long 30, 73
––stomach meridian (yangming) 30 ––pain projection to the body surface 251
yang weakness (yangxu) 107
––stomach meridian (yangming region) 36 ––painful muscular tension 263
yangming (stomach meridian) 171
––trunk 72 ––trigger points 262
––functions 109
––ventral longitudinal one-third 30, 51 visceral organs 281
––medial longitudinal one-third 65
––volar and radial area 51 ––and zones of the head 273, 275
yangming region, ventral spinal nerve
ventral root (see also anterior root) ––areas of resonance 101
branches 36
––afferent fibers 24 ––autonomic reflexes 279
yin organs (parenchymal organs) 96
––efferent fibers 24 ––diseases and disorders
yin weakness (yinxu) 107
––neurites 53 –– – projection to the body surface 281
ventral root filaments 24 ––efferent neurons 239 Z
––spinal nerves 24 ––enterotomes 239 zao (dryness) 106
ventricle(s) ––head and trunk 273, 275 zones of physiological hyperesthesia 142
––diseases ––pain-conducting afferent neurons 239 zoonites 8
–– – hyperalgesia 287 ––referred shoulder pain 276
––segmental relations 282 ––viscero-visceral reflexes 279
ventrolateral branches 199 viscero-afferent fibers 26
––brachial plexus 61 viscero-efferent fibers 26
––cervical nerves 57 viscero-motor effects 253

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I.

Notice for the reader

Bibliographic information published by the Deutsche Nationalbibliothek

All rights reserved

Acquisition Editor: Martina Braun, Marko Schweizer, Munich

ISBN Print 978-0-7020-5042-8

Current information by www.elsevier.de and www.elsevier.com

1 Segmentation and Metamerism

The structure of an organism consisting of subdivisions, i. e., “segments” and “metameres”, is

As shown in figure 1.3, segmentation occurs

The Significance of Segments

An important question is why the construction principle of segmentation and metamerism

Particularly in Chinese acupuncture it is evident that the theory of reciprocal interactions

2 The Role of the Peripheral Spinal

2.2 The Spinal Nerves

8 cervical nerves Nn. cervicales C 1 to C 8

2.2.1 The Spinal Nerve and Its Segment

The muscles of the shoulder girdle are derived from

2.2.2 Cranio-Caudal Arrangement

Only a thorough understanding of segmental interrelationships enables the therapist – acupuncturist,

Fig. 2.2a Congruent arrangement of

Fig. 2.2b Metameric arrangement of

2.2.3 Vertical Spinal-Segmental Arrangement

2.2.4 The Root Fibers of the Spinal Nerves

Dorsal Root Filaments Ventral Root Filaments

Posterior root Anterior root

2.2.5 Types of Fibers in the Spinal Nerves and Relationship to the

Spinal ganglionic cell

Ramus communicans albus

Ganglion trunci sympathici

R. ventr. Prevertebral ganglion

Ram. visc. Skin

Truncus sympathicus Gut

Fig. 2.5b Pathway of the sympathetic fibers (modified after Waldeyer).

2.3 The Branches of the Spinal Nerves

Enteric nervous system

2.3.1 The Three Spinal Nerve Branches as Basis of the Threefold

2.3.2 The Regions Innervated by the Spinal Nerves

The Regions Innervated by the Lateral Branches

in the lower half of the body: • the lateral trunk region

The lateral branches of the spinal nerves thus innervate

in the upper limb • the extensor muscles and

on the upper limb • to the hand shaoyang (triple heater

The Regions Innervated by the Ventral Branches

in the upper limb • the flexor muscles and

The Regions Innervated by the Dorsal Branches

on the head and back • a dorsal longitudinal third of the skin

2.3.3 The Relations of the Metameric Spinal Nerve Branches

2.4 The Branches of the Spinal Nerves in Detail

2.4.1 The Dorsal Branches of the Spinal Nerves

The Dorsal Branches of the Cervical Nerves

The Dorsal Branches of the Thoracic Nerves

The Dorsal Branches of the Lumbar Nerves

The dorsal branches of the lumbar nerves divide into

The Dorsal Branches of the Sacral and Coccygeal Nerves

2.4.2 The Dorsal Branches in Psychosomatic Medicine and Evolution

In other words: The correspondence or association of a psychological and a climatic factor

The ventrolateral branches of the spinal nerves form extensive plexuses:

2.4.4 Plexus Formation from the Point of View

The plexuses are formed by the ventrolateral branches.

2.4.5 The Individual Plexuses

The Ventrolateral Branches of the Cervical Nerves

The Cervical Plexus

in the lower half of the body: • the lateral trunk region

in the upper limb • the extensor muscles and

on the upper limb • to the hand shaoyang (triple heater

in the upper limb • the flexor muscles and

on the head and back • a dorsal longitudinal third of the skin

C 5 • Pain in the shoulder and upper arm

• a medial longitudinal one-third (ventral branches), and

• the genitofemoral nerve (L 1 to L 2),