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This is a book of fundamental importance for the acupuncture profession. Most medical acupuncturists will be aware of the concepts of “segmental acupuncture” outlined by Bekkering and van Bussel.1 However, physiotherapists who practise acupuncture may be more familiar with trigger point therapy, and the majority of traditional acupuncturists will have little knowledge of either approach. All will benefit from reading this textbook which, as the subtitle claims, may well be a key to understanding many aspects of acupuncture, neural therapy (a method of treatment using local anaesthetic injections) and indeed manual therapy, in terms of Western anatomy. It will also be useful to other health professionals as an aid to diagnosis.
Dr Wancura is a highly experienced acupuncture practitioner, the co-author of several works on acupuncture since 1974, and involved in the study of the “forgotten knowledge” of segmental anatomy since 1965. The present book is the summation of her own knowledge on the subject, a comprehensive if not all-inclusive review of the extensive literature published in German (around 240 references), in comparison to which that available in English looks very minimal indeed! In fact, only 10 English language publications are listed here, although much of the author’s base material derives from works by Henry Head and James Mackenzie translated into German. (In all, nearly 7% of the references are translations from English. The proportion of papers translated from German in a comparable English textbook would be far less.)
The book is richly illustrated (116 illustrations, many in two or more parts) and divided into 10 chapters: (1) an introduction to the segments and metamerism; (2 and 3) on the role of the peripheral spinal and autonomic nervous systems in the segments; (4–7) on the dermatomes, myotomes, sclerotomes and enterotomes (viscerotomes); (8) on the connections within and between the segments (the latter frequently via the paraspinal sympathetic trunk); (9) on referred pain; and (10) on the areas of referred pain and autonomic reflex symptoms associated with the internal organs.
Each chapter will repay careful study. I particular enjoyed the author’s many segmental insights into psychosomatics and evolution and the role of the sympathetic nervous system in muscle extension, arousal and behaviour (by no means just the usual account of the “fight or flight” response). For the first time, I was also able to appreciate the part the phrenic nerve may play in referred pain (and treatment — as in the use of ST38 or GB39 for shoulder pain), and the importance of the “hiatus lines” where (because of the way the limbs develop in the embryo) the dermatomes do not follow one another in numerical order (metamerically), resulting in a lack of organ-referred pain in the extremities. Wancura considers that the points of intersection of the limb channels (PC6, TE5, SP6, GB39) lie along these lines, which act, as she says, in a way like erogenous zones, where a small stimulus can elicit a large response, so that needling them may well have effects equivalent to infiltrating the associated prevertebral plexi in neural therapy. She does not, however, provide evidence for this statement, other than it being “according to experience”, while her connection between the “guan” of PC6 and TE5 with the “frontier” implicit in the hiatus lines does stretch credibility somewhat.
Wancura’s coverage and illustrations of Head’s “maxima” (as well as her account of the Head zones on the cranium) are also very useful for those unfamiliar with them. This would appear, disappointingly, to be nearly all of us in the anglophone world of acupuncture according to an informal survey I conducted recently. In line with this, although a number of papers on Head’s findings have been published over the years in German, there are very few indeed in English. He published his seminal work in the journal Brain in 1893 and 1894, and it was already available in Germany by 1898. Attention was drawn to his discoveries once again in an influential 1962 textbook on segmental innervation by Hansen and Schliack.2 Here they corrected some of what they perceived as the errors of Head and Mackenzie, emphasising the unilaterality of several of the organ reflexes (T Ots, personal communication, 2009).
Some shortcomings of this book
The author’s style is quite didactic. As a skilled teacher, she knows the value of repetition, but the book could have been much shorter if certain general propositions (for instance, on the autonomic effects of internal organ dysfunction) were clearly stated once and then referred to, rather than being reiterated in full, in each section of each chapter. Dr Wancura is also somewhat dogmatic in her statements about the “ground rules of acupuncture” (for instance, “always use SI3 or TE5 for back pains”, p. 62) and categorical (and not always consistent) in her correlations, as when (p. 34) she states that the SI, GB, ST and TE channels correspond to the areas innervated by the lateral spinal nerve branches, or (p. 73) that in general, the channels on the extremities can be defined as borderlines between the ventral and lateral metameric spinal nerve branches. Sometimes I have the impression that such correlations are rather forced, particularly when she equates Head’s dorsal maxima with points on the BL channel (p. 158), directly contradicted by the illustration (based on Head) that follows. I am also unconvinced by her explanation of the directions of “energy flow” in the limbs in terms of dermatome sequences. This needs to be much more carefully argued. There is usually more than one way to explain one model (that of Chinese medicine) in terms of another (Western anatomy and/or physiology), and it is symptomatic of our Western scientific arrogance that she writes, for instance, that she can only accept with difficulty the generally accepted view that the ancient Chinese did not undertake anatomical dissection (p. 17), or that the scientific explanation of the empirical findings of acupuncture lies in European segmental anatomy (p. 301). Sometimes a model can be unduly persuasive, particularly for those who have immersed themselves in it for many years. Whether it is the model of Western anatomy or that of Chinese medicine, it is easy to get carried away, “playing trains” and making connections according to the system that other people may find it hard to see there. In particular, segment theory can by no means explain all aspects of acupuncture (M Cummings, personal communication, 2009).3
On the other hand, Wancura very rarely criticises her (Western) sources, which are often from an era when the value of replicating research was not appreciated, and not infrequently fails to reference some of her categorical statements. She also occasionally launches into asides that are too speculative or simplistic for a work of this calibre. The result is that the whole beautiful edifice that she has created does at times seem somewhat fragile.
This effect is not helped by an almost complete absence of illustrative scenarios or case histories (the first is on p. 362!). It is a real shame that, despite Dr Wancura’s considerable experience of practice, the book is mostly a collection of generalisations not grounded in her own or other recent clinical observation.
Also lacking is some kind of conclusion to draw together all the disparate information scattered throughout the pages of the book. It is a disappointment, for instance, that the last two chapters projected for the book, assembling Wancura’s insights on “psychosomatic” symptoms and segmental dermatoses, have not been included in this first edition. Tables summarising each chapter could also have been included, for ease of reference.
Surprisingly few specific acupoints are mentioned. Xin min, a non-meridian point, is however. This is not in the usual English language textbooks, and it would have been helpful to include a description of the point’s location.
The illustrations are of very mixed quality, most based on those in earlier publications but with colour overlays. The colours themselves are not always clearly described in the illustration captions (“red” is more like orange, “pink” a light orange), and are occasionally missing (figs 2.7, 2.21). Some illustrations are too schematic to be clear, and lack careful labelling. This may be problematic for those without a good foundation in neurological anatomy, while the absence of clear and detailed illustrations of the muscles of the body will discourage those unfamiliar with the details of muscle anatomy. On the other hand, several illustrations are repeated unnecessarily several times throughout the book.
More seriously, quite a number of authors are mentioned without their works being referenced, or referenced simply as “cited by van Rynberk”. Her account of Head’s maxima owes much to “Schmidt”, for example, but we are not given a source for this (although a “Schmid” is listed). Other authors are quoted but without clearly stating which of their cited works is the source, or giving publication dates that do not match those in the Literatur list. Some items in the list are not referred to in the text.
In addition, there are some errors of cross-referencing, with non-existent headings or the wrong pages and illustrations being given as targets.
However, given what the author has attempted in this very ambitious book, such faults are quite forgivable.
For the majority of readers, the most useful chapters in this book will be the last two, in which patterns of organ-referred pain and cutaneous visceral reflex signs are described in great detail (as well as the interactions between the different levels of each segment), enabling differentiation of healthy and diseased organs, between two different diseased organs, or between organ-referred and muscle or pseudoradicular pain, for example (as in the use of McBurney’s point as an indicator of psoas dysfunction). However, the author emphasises that although the employment of subjective sensory methods to detect the superficial autonomic signs of deeper malaise may provide better — and earlier — diagnostic information in some cases than more objective instrumental measurements, this does require the practitioner to develop a sensitivity to these signs, which may be quite subtle (as is often the case with acupuncture).
I could go on, but this book is so rich, filled with a wealth of information and ideas, that it is impossible to do it justice in a brief review. If you have only a smattering of German, I would encourage you to wrestle with its intricacies, dictionary in hand, and as soon as the current economic recession permits, I very much hope that a revised and possibly simplified version will be published in English so that more of us may benefit from the great learning of Dr Wancura.
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