The same results were found comparing the total number of correctly identified sectors (P< 0.001) and their proportions on the three different parts of the ear.
The conclusions of the above evaluation (submitted for publication) are as follows:
The SG is based on point 0 which was considered by Nogier to be the geometrical center of the ear. It is located on a distinct notch where the horizontal concha ridge meets the vertically rising helix root (see Fig. 5.10). It is noteworthy that the Chinese standardized map has the same denomination (center of the ear) for the root of the helix.
Paul Nogier was principally a clinician but he was also an expert painter and could therefore probably capture both aspects: the geometrical alignment of some points detected on the pinna
and also the effect of their stimulation on the patient's symptoms. To find these alignments he invited students to examine the outer ear carefully, without any preconception, with a spring-loaded probe held vertically, passing gradually from one point to the next and applying the same pressure. When four or five points had been identified, he said, the student would be surprised to find some other tender points on the helix as an extension of the former. Nogier noticed that several alignments crossed the root of the helix in the notch described above, easily identified using the nail of the index finger.18
From the anatomical point of view this notch does not seem to have any particular meaning, except that it is placed in a zone which seems to be subjected to several transformations at the embryogenic stage. It is, for example, interesting that the root of the helix and its ascending branch correspond substantially to the zones which more frequently show the curious fistula auris congenita or 'pitted ear' cited in 'Morphological variables', above.
Perhaps the largest statistical study worldwide on this subject was performed in Japan. In a healthy population of 15 114 elementary and high school students this characteristic was observed in 396 subjects (2.6%). In 74% of the cases the fistula was unilateral and there was a slightly higher incidence in females. The total number of fistulae observed on both ears was 503, and 98.2% of them were located in the area comprehending the pre-auricular region, the prehelix and the crus helix19 (Fig. 3.18). Several authors suppose the fistula to be caused by imperfect fusion of the tubercles derived from the first two branchial arches which could lead to entrapment of the epithelium to form preauricular cysts and preauricular sinuses or fis-tulae. Another interesting hypothesis is reported by Pearson who considered the pit to be caused by a partial retention of the primitive external auditory meatus.20 Nevertheless, besides this bold association with the pits in the ear, anything reasonable may be said about the true sense of point 0.
In his untiring work Nogier was particularly impressed by the anthelix placed on an arch of circumference around this point. Actually the system of radii starting from the center of the ear and traversing the entire pinna helped him greatly in discovering what he called the 'segmental projections' or 'somatotopic organization' of the body. His clinical experience permitted him to say that:
1 = preauricular region (60.4%)
Fig. 3.18 The opening sites of fistula auris congenita and their percentages according to Dr Iida.
all the points on each of these radii are connected in such a way that any therapeutic action performed at the level of the border point and at point Zero (the extreme points of the radius) is transmitted to all points of that radius.
In this way Nogier was able to identify precisely the radii related to some specific vertebrae. He asked students to be very cautious and, for example, not to consider the line RTH8 passing through the vertebral point TH8 as in any way pertaining to the 8th or 9th thoracic nerve18 (Fig. 3.19). But if we look at the case with herpes zoster of the 8th thoracic root reported in Figures 3.20 and 3.21, we can see that the lines proposed by Nogier actually have a meaning and are important for diagnosis and therapy. Through his explanation he perhaps intended stressing the importance of not confusing other structures located on the same line, the innervation of which could in no way be accepted as coincident. For example, in Figure 3.19, the location on the line RTH9 of the somatotopic representation
of the palm of the hand, proposed by Nogier himself, seems unacceptable as its innervation stems from the plexus brachialis (originating from the ventral branches of the last four cervical spinal nerves and most of the ventral branch of the first thoracic spinal nerve). Nevertheless, if we look at the body acupuncture points which are in topographic correspondence to the auricular point TH9 and the palm of the hand, we find respectively point Ganshu (BL18), and point Laogong (PC 8). The former is located 1.5 cun laterally to the border of the spinous process of TH9; the latter is located between the second and third metacarpal bones where the middle finger touches the palm, closing the hand. Beyond the interpretation of these points according to traditional Chinese medicine (TCM), we can limit ourselves to considering only the different groups of therapeutic indications which are reported in the most important acupuncture textbooks. The reader may well be surprised to notice that the two points share overlapping indications, for example of cough, nosebleed and chest pain but also of deep anger and manic-depressive syndrome.21 Therefore, even keeping both feet on the ground and attempting to maintain a scientific approach to auricular diagnosis and therapy, we should nevertheless be prepared to encounter several surprises during our work. The outer ear still holds secrets to be unveiled and no clinical observation, however strange and out of place it might appear, should be rejected.
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