About Rambling Rector

Church of England Parish Priest

Dyspepsia, gut brain and vagus (again)

A few days ago I was lying on a table surrounded by people in masks.

One of them held my head and inserted an object between my teeth to keep the mouth open. A thick rubbery object was then shoved down past my pharynx into the oesophagus. There was much gagging, but I soon got used to it.

Now, dear reader, I don’t know what you’re thinking about the kind of sadomasochistic activity in which I was willingly engaged, but the truth is that I was having a gastroscopy.

The general term for looking into tubes is endoscopy (Greek endon: internal), but yer man didn’t go much further than the pylorus so I’ll stick with gastroscopy. (Actually, Greek gaster meant pretty much anything between chest and pubes, like belly, and I can’t be bothered to find out how it came to be used for the sac where food is digested.)

Boss man, having established that I was not entirely ignorant of medical matters, kept pointing to things on the monitor, telling me where he was and what he could see. This was kind and considerate of him and I would have been eagerly attentive but for the fact that they’d asked me to take off my specs so all I could see was a mass of light pink. It turns out that apart from a somewhat incompetent gastro-oesophageal sphincter leading to reflux, and bit of gastritis with a few erosions, it was all pretty good.

This was a relief. My mother and her father died younger than I am now from abdominal cancer, probably stomach, and in the month or so before the gastroscopy my symptoms (I’ll come to them) had worsened considerably, so in my head I was already rewriting my will and sorting out online passwords for the beloveds. The fact that I consulted the GP speaks volumes.

I’ve only met him once before, a graduate of University College Dublin, so we have mutual acquaintances and had a really good chat about Dublin, Ireland, John Boyne, and life as a non-native in Ireland (me) and England (him). And the state pensions: Ireland’s is much more generous than the UK’s.

For several years I’ve had periodic dyspepsia and belching. Symptoms have gradually worsened and latterly my stomach has taken a great dislike to some foods, sending them back whence they came. My stomach is clearly very clever, since it doesn’t necessarily reject the most recently consumed, but only those it takes exception to. I often feel a queue building up in my oesophagus as if the traffic lights at the pylorus were stuck on red.

Most unpleasant were increasing gassiness, hiccups, and the feeling that unless I made myself vomit – which I had to do frequently – the trapped wind would never get out. Sleep was sometimes delayed and subcutaneous fat lost (no bad thing in itself). There were no signs of liver disease like yellow sclera, pale craps, dark piss, and the latter did not taste sweet so no sugar (not salty either which is astonishing given the amount of salt I consume). But the increasing severity meant that I was no longer able to cope by eating carefully, slowly, little and often, so I was worried. I’m not given to complaining about discomfort: Susan says I’m a stoic and should seek help sooner. But I’m a bloke.

So why such troublesome symptoms in the absence of anything much to account for them?

The GP several times asked me how long this had been going on. Back at home I asked myself when I remembered not having to think about what I ate or how I ate it. 

The answer rather flabbergasted me. It was in Texas just before the great catastrophe of 2015. It is not possible to leave an empty plate at a Texan restaurant, and certainly not Mel’s Country Café in Tomball, if one has belly issues.

Quite astonishingly my symptoms improved from then on – not disappeared, but certainly less aggravating and more manageable. 

Grief, stress, long term niggling anxiety, relief at no evidence of malignancy – all these play a part in the story, together no doubt with food intolerances that have always been there and that I never really noticed because I was so used to them.

Last November I wrote about the vagus nerve: https://ramblingrector.me/2020/11/14/the-vagus-nerve-a-journey/. I mentioned its likely role not only in enabling digestion but also in connecting head brain and gut brain. I alluded to the way in which the psyche and the guts affect one another: gut feelings, gut reactions, feeling gutted, psychiatric state, and more. I never for one moment made that link to account for some of my symptoms until I recalled the last time I didn’t have to be careful about eating. 

On the phone I told the GP of this realization. I asked him if he thought it a likely factor. “Most certainly” he said. “The trouble with you is you know too much. But we’ll do a CT just to make sure there’s nothing sinister further down to account for the weight loss.” 

I am absolutely astonished – and thrilled – at this first hand experience of the importance of the vagus nerve, the nerve of digestion, the nerve of nutrition, the nerve of the yolk sac, and the links between guts and emotions. 

Easter freedom

An Easter homily if I were giving one. It’s based on the Easter sermon preached by Bishop Lancelot Andrewes before King James at Whitehall on Easter Sunday 1609.

The New Testament word for sepulchre, tomb (as in empty tomb) is mnema. It’s the word that gives us memorial, memory, and mnemonics – phrases to help one remember things. The stories in the gospels about Jesus expelling demons from men living in the tombs are for me about freeing them from living in their memories, from living in the past.

People who live in the past cling to resentments, unable to let go, unable to forgive, unable to move on. They are entombed in the past. Think of Miss Havisham in Great Expectations. Think of parents who live through the achievements of their offspring. Think of sad men propping up sports club bars boring all and sundry with tales of their sporting achievements decades ago before their hairy bellies started hanging over their belts.

Now think of the Easter story. Never mind if it’s literally true or not. Never mind if it’s a fable based on more ancient folk tales. It’s utterly psychologically authentic. The stone is rolled away. The contents of the tomb have escaped.

Can you see that this is an invitation for us to let go of the past? If we are to live life abundant then we have to let go and move on. The empty tomb means the past is cleansed. It is forgiven.

Think of people who refused to support Jesus, who deserted him, who told lies about him to save their skins or to curry favour with authority, who joined the chanting mob. How many of the Palm Sunday supporters joined that baying crowd? Now think how shocked they must have been to hear that the man they’d condemned wasn’t dead and gone, but might meet them in the street. It’s like gossiping with a friend about a mutual acquaintance who, just as you’ve made the most utterly bitchy remark, appears round the corner and cheerfully greets you. You want the ground to open up and swallow you.

How does Jesus react when he meets his so-called friends again? Does he berate them? Does he take them to court? Does he arrange for some big fellers from the local pub to kneecap them?

No, none of this. All he says is “Peace”. It’s like he says, “never mind the past, friends, let’s get on—we’ve got work to do.” Forgiveness.

Now, think of those times you’ve gossiped, betrayed, told half-truths to get you out of a tight corner, or blindly followed the crowd. The story is not just about 2000 years ago. It’s about human nature, yours and mine, NOW. It’s about death of pride and ego and self in order that selflessness can ascend. We need to, we must, forgive and let go, otherwise we become entombed in living death. This is not about an afterlife—if there is one—it’s about life abundant before death.

The most difficult person you’ll ever have to forgive is yourself. Some of us like wallowing in it, turning masochism into an art form. But life is to be lived. People make the mistake of thinking that forgiveness will just happen. It won’t. It’s hard work. We have to practise it like we have to practise any skill. We have to keep telling ourselves that we are forgiven. We have to brainwash ourselves. This is important as we get older, for it’s easy to dwell on the past and less easy to imagine the future. At least, I find it so.

Forgiveness doesn’t mean you escape the consequences of your actions, but it helps you to move on and make the best of — that is to say, confront — the hole you’ve got yourself into. It helps you to escape the tomb and see the big wide world: eyes that see shall never grow old.

The penalty for living in the past is that we become wizened, resentful, odious, and mendacious. We risk becoming deeply unattractive miserable gits. If we behave like that, people will avoid us, and rightly so. The only person I harm by living in the past is me.

As Andy and Red say in Shawshank, “get busy living or get busy dying”. The choice is yours.

Happy Easter.

Even my own familiar friend

A repost of a 2019 blog.

Michael Burrows (Cashel, Ferns & Ossory) inspired this reflection and Michael Ipgrave (Lichfield) directed me to Mynheer’s painting. Thank you.

Do you know this picture by Nicholas Mynheer? (used with his permission).

Two women embracing. Look at the background. The artist names the women as the mother of Jesus and the mother of Judas. Such sadness at the death of their sons.

I have a soft spot for Judas, bravado and posturing imploding to catastrophe. I’ve been there. Telling fibs to wiggle out of trouble. I’ve been there too. What was in his mind?

Was Judas disappointed with Jesus? Did they hatch a plot to have Jesus arrested deliberately in order to increase the profile of the “Jesus movement”? If so, it went horribly wrong.

Was Judas angry with Jesus? Perhaps Jesus did not live up to Judas’s expectations of being enough of a political revolutionary? The truth is that we never live up to the expectations of others because they’re not ours.

Was Judas Jesus’ special friend – a second disciple whom Jesus loved? There is no doubt about it, they were friends. And when Judas realised the enormity of his actions he couldn’t live with the shame and guilt. Just think how much hatred came into the world as a result of the way in which the Judas story was written up in the Gospels. I don’t know how the church can live with that shame.

Whatever was in Judas’s mind, his actions liberated Jesus. He started the process that allowed the Christ-imago to break free from the earthed cocoon.

I’d like to give Judas a cuddle. There’s a lot of him in me. Thinking about the distraught and desolate mothers makes me wonder about the fathers. Men grieve too.

You may know this story: the Vicar visiting the school asked, after some discussion of Easter story, “why did Jesus descend into hell?” After a silence, a small voice piped up “to rescue his friend Judas”.

Eyelid and insulation

Devotees of my Facebook page have noted that yesterday and today I changed the images appearing at the top. The confluence of rivers Eden and Eamont near Langwathby has been replaced by the family in 2007, so Hugh is there holding his young daughter, and Christine and I in Trafalgar Square in about 1953 have aged a few years in a portrait taken in (I think) Binns photography department in Carlisle, by which time I was stroppier and hated having my picture taken. Still not keen.

I remember that checked shirt. I remember mother fussing about its collar and my hair. She was a great fusser. Trained as a nurse in Wrightington Hospital and Bradford Royal Infirmary, her approach to motherhood was clinical in the extreme. Everything had to be just so. A woman from the village whom I’d not seen for half a century told me that she’d never seen a boy’s toy cupboard as tidy as mine. She obviously thought this reflected on me and I didn’t have the heart to disabuse her. Having said that, those that know me will understand that I am the tidiest of men: a place for everything and everything in something else’s place. The consequences of a free-spirited lad being thus regimented can for now be left to your imagination, for that is not what today’s billet doux is about.

Should you study the photos of the infant yours truly, you will note that my left upper eyelid droops. The jargon word is ptosis (πτῶσις: falling, dropped). A developing ptosis can point to a number of neurological conditions, and it may even signify a tumour of the apex of the lung which invades the neighbouring sympathetic chain, for the nerve supply to some of the eye apparatus reflects a fascinating evolutionary and embryological history that need not concern us today. In my case, ptosis was present at birth. It is congenital. Yes, girls and boys, I’m a freak, a force of nature.

Why a left ptosis? 

Who knows? Birth injury? Perhaps the forceps happened to press on the wrong place. But I think not. Ever since my left retina “detached” in 2006 and sight on the left deteriorated and then vanished, I’ve concocted another story about my beloved ptosis. 

I think my left eye and eyelid have always been substandard. Vision on the left has always been iffy. Looking back (yes, ha ha, very funny) I’ve always screwed my left eye shut to read. I’ve always had to turn my head more to the left than the right when taking in a view. I’ve never had a good aim in throwing or catching or kicking. Playground fights at Langwathby school never ended well for me so I Iearnt to fight with words.

My lack of hand/foot/eye coordination meant I was the last to be chosen for teams. Mercifully this didn’t happen very often for Miss Metcalfe of truly blessed memory had the extraordinary notion that school was for reading, writing, sums, geography and a bit of history. I have written about her in a previous blog https://ramblingrector.me/2013/07/19/the-happiest-days-of-your-life/

I was therefore hopeless at cricket and football. Penrith Grammar was a rugby school and the only bit of that I even mildly enjoyed, for I had good thighs, was shoving in the scrum – no aim needed once one’s grasp of the opponent’s scrotum was secure. In the main I thought, and think, rugby an incredibly silly game. All those rules – why?

Now, leaving behind the subject of eyes, this set me thinking about why some children are better than others at sporty stuff.

The spinal cord is like an electric cable containing bundles of wires (nerve fibres) each with its own insulation, some carrying impulses from the brain, others to the brain (never, note never, do wires sometimes carry impulses one way and sometimes another – unlike railway tracks that can be signalled bidirectionally). Now, hear this. It takes years after birth for insulation (myelination is the jargon term, myelin being the insulator) to develop fully – indeed in some cases it’s not complete until the late teens. This is one reason why teenagers can be so ungainly and need so much sleep; myelination must be very tiring. Actually, by this reckoning I’m living life backwards. But I digress. 

Here’s my theory, so. If myelination is early, then chances are you’ll be well coordinated early, good at sports and win the victor/victrix ludorum prize, your proud parents donating a cup to be awarded at subsequent sports days for other swaggering toads. If, on the other hand, myelination is later than usual, then you risk having the shit kicked out of you by the jocks for being a clumsy lumbering git.

The vagus nerve: a journey

A former student, now a Head and Neck Surgeon in Liverpool, has asked me to give a talk to his colleagues. Here it is. Even if you’re neither medic nor zoologist you might get something from it, particularly the way that words carelessly used can lead to erroneous inferences. 

This is the story of the tenth cranial nerve and me.

You won’t hear anything useful for your research project or your next paper. This is not likely to result in earth-shattering developments in head and neck surgery. It is rather a series of speculations and insights arising from half a century of asking “why?”.

As a clinical student 1972-75 at King’s College Hospital in south London it gradually dawned on me that medical practice was not to my taste, so in the final year I did some thinking. The things that took my fancy in Cambridge were, first, the introductory anatomy lecture in which the Professor of Anatomy told us about our place in nature with other primates (apes not archbishops); and, second, embryology, that is to say, how we come to be what we are. I guess our medical student cohort was one of the last to study embryology in any depth, examining serial sections of pig embryos every Monday afternoon for a term. 

But the most significant Cambridge influence was the person of Max Bull, the senior non-professorial anatomist, a gifted analytical teacher, and my supervisor. “If that is what an anatomist is and does,” I must have thought, “then an anatomist I shall be”.

In 1976 I started work as Anatomy Demonstrator (Temporary Lecturer) at the new medical school in Nottingham. I stayed for 11 years. In 1988 I took up the Chair of Anatomy at the Royal College of Surgeons in Ireland, which was and remains the biggest undergraduate medical school in Ireland, despite its name. After 16 years I came back to England as the foundation anatomist of the new Nottingham graduate entry medical school sited in Derby.

I was intrigued by a few things throughout this time: for example, the systematic arrangement of brain stem nuclei; that structurally we haven’t changed much since reptiles; and the ways that different species, different chordates even, handle the perception of vibration in the external environment (we call it hearing). But most of all, the vagus.

A motor nerve?

The tenth cranial nerve arises from the medulla by a series of rootlets posterolateral to the olive. The nerve passes through the jugular foramen and runs in the carotid sheath down to the mediastinum. It sends branches to ear, pharynx, and larynx, and forms a plexus around the oesophagus becoming ever more intimately involved with the gut tube as part of the myenteric plexuses of foregut and midgut – all the way to the splenic flexure of the colon.

Good Heavens, this is boring, isn’t it?

I could go on in mind-numbing detail that would have you reaching for the knife with which to slit your throat. But have you noticed that already our view of the vagus is coloured by that textbook account? The brain-to-periphery description implants in our minds the vagus as a motor nerve. 

This is reinforced when we hear physiologists and physicians tell us that vagal impulses slow the heart rate. That is how my undergraduate course first introduced the vagus to me. I heard that it is a parasympathetic nerve (motor), part of the autonomic nervous system that slows the heart (motor).

In 1969 I accepted this without question. After all, I was hearing it from eminent scientists – at least three of them Fellows of the Royal Society, and this 19-year-old freshman from remote Cumberland had other priorities surrounded as he was by the delectable delights of Cambridge.

But the vagus crept up on me. It has a role in the ear. It supplies the lateral line in fish, a system of receptors extending along the side of the body having something to do with picking up vibrations from the aquatic environment. This was intriguing.

Then I saw with my own eyes the asymmetry of the recurrent laryngeal branches – not only in the cadaver but also in serial sections of pig embryos. Thus I came to see how the branchial arch apparatus – fish again – stamped its presence on human anatomy. I began to appreciate that we carry our evolutionary history with us, and much of that history impinges on our structure and function. I began to ponder von Haeckel’s dictum “ontogeny repeats phylogeny”..

Being an Ear, Nose and Throat intern in 1975-76 might have stimulated further interest in the vagus, but keeping on the right side of irascible consultants, looking after patients some of whom I was pumping full of very nasty anti-cancer drugs, and coping with life in general meant there was no time for speculative thinking. Neither was there in Nottingham: I was learning the ropes, interested in university politics, doing a PhD and being a husband and father. 

It was in Dublin from 1988 onwards that I began seriously asking “why?”.

A shifting view

My view of the vagus was changing. I began to see that the vagal functions I’d first been introduced to by physiologists and physicians couldn’t be that important. How could they be when a transplanted heart does perfectly well without any innervation whatsoever? Can you imagine the surgeon suturing tiny strands of nerves and expecting axons to grow down them? So much for cardiac physiology as taught. And then there’s vagotomy (Helicobacter pylori hadn’t been invented then) – how did that affect the distal gut tube? 

You can see I was still in the way of thinking of the vagus as a predominantly motor nerve, reinforced by the appreciation of its role as the nerve of phonation and swallowing. Of course I was aware of its sensory functions, not least because of referred pain to the ear from pharyngeal disease, but they seemed somehow less significant.

I couldn’t see how to put all this together. Phonation, swallowing, external and middle ear, heart, stomach, foregut, midgut? No wonder the vagus is so-called. Why not hindgut? How do we know that vagal fibres go no further than the splenic flexure? In the words of Victor Meldrew, I don’t believe it. Is it merely inference, like so much else? How does it fit with the lateral line? 

Enlightenment

Then one night I had a light-bulb moment as I was soaking in the bath.

What does the heart do? Pumps nutrients round the body.

What do babies use their vocal cords for? To cry for sustenance.

What is the gut tube for? Absorption of nutrients. 

What does the vagus do to the pyloric sphincter? Relaxes it to allow food to move on for digestion.

What do we use our ears for? To pick up vibrations from the environment.

Why? In the search for food and to avoid becoming food for other creatures.

What is the lateral line in fish for? To pick up vibrations from the environment.

Why? Shoaling in the corporate search for food.

What might be the benefits of a slow heart rate?

Post prandial relaxation to aid digestion is one, but think in terms of diving mammals: the slower heart rate allows the dolphins or whatever to stay under for longer, handy when you’re hungry and hunting for the next tasty morsel.

What is the function of the pharyngeal musculature supplied by the vagus? Ingestion, swallowing of food.

The vagus is the nerve of nutrition.

All the structures it supplies are in some way connected to embryonic endoderm derived from the yolk sac. Can the vagus be summed up as the nerve of the yolk sac?

What about sensory?

As a result of teaching histology, I began to think about the myenteric plexuses. My passing interest in invertebrates of the aquatic deeps led me to realise that the plexuses function as a network of mini-brains – a gut brain – coordinating local reflex peristalsis, no motor impulses from the central nervous system being necessary. Also, there must be visceral sensory fibres from gut tube via myenteric plexuses to CNS for coordination and for such as emergency shutdown, and these must be joined by fibres from other abdominal viscera.

I began to see that distal to branches to laryngeal and pharyngeal musculature, the vagus was very significantly a sensory nerve. I had rid myself of the motor obsession. 

The vagus is implicated in a number of common conditions: oesophageal reflux of course, chronic hiccupping, gastroparesis and more. Here are vagal sensory functions working as it were too much or too little. As for the gut brain concept, this has blossomed over recent years. Having been regarded with suspicion as something promoted by sandal-wearing, yoghurt-knitting alternative medicine practitioners, it’s now right up there with the big boys and girls.

We talk of gut feelings, gut reactions. We know that the state of our guts affects our moods and feelings, the inference being that vagal inputs connect to the limbic system. As you may know, this is an up-and-coming research area in psychiatry. Certainly my gut is an effective warning system in all sorts of ways. Unfortunately, we know next to nothing about how visceral sensation in general and vagal inputs in particular are handled centrally – a recurring lament.

What about vagal stimulation for epilepsy? The question is really, I suppose, how do vagal sensory impulses reach the epileptic focus? As I say, our knowledge of visceral sensory central connexions is minimal, and I don’t know the answer. Judging from a survey of online publications, neither does anyone else: there’s a good deal of fudging. Perhaps this treatment regime arose, like many others, from a serendipitous observation.

Odds and ends

I don’t much care for the terms autonomic, sympathetic, parasympathetic, and I’m pleased to note that the US NIH agrees with me. They are pretty harmless when used of functions or modalities, but cause trouble when used, as they sometimes are, of structures – for example “the vagus is a parasympathetic nerve”, giving the impression that it is entirely a motor nerve. Autonomic means visceral motor, cell bodies of presynaptic (a better term than preganglionic) neurons being in the brain stem salivatory nuclei, the dorsal motor nucleus of the vagus, the sacral lateral grey horn, or for sympathetic impulses the lateral grey horn of the thoracolumbar region of the cord. 

So as terms describing modality I can just about live with them. But they lead to error if used of sensory fibres. One can fall into the trap of thinking that there are pre- and postsynaptic sensory fibres, as with visceral motor fibres. Not so. Sensory systems have no peripheral synapses. Primary sensory neurons, no matter what their origin or modality, are morphologically either pseudounipolar or bipolar with cell bodies in sensory ganglia (no synapses) just outside the central nervous system – dorsal root ganglia or the sensory ganglia of those cranial nerves that convey sensory fibres. 

What about the splenic flexure business? Is this really as the books say the limit of vagal gut tube territory? Such statements are often copied from text to text with no sources given. A survey of eighteenth and nineteenth century literature would be interesting to see when the story appeared. But assuming that the tale is true, perhaps the entire distal gut tube is a cloacal derivative with visceral supply from the lateral grey horns of the sacral spinal cord.

I find the sacral spinal cord quite fascinating. Did you know that in birds the terminal (sacral equivalent) spinal cord is separated from the rest of the cord by the glycogen body? Its function remains mysterious. According to Wikipedia (so it must be true) glycogen bodies may also have been present in dinosaurs from which birds are descended. But back to mammals where there is no glycogen body, but where there is nevertheless something different about the sacral cord. It develops not by folding of surface neuroectoderm to form a tube like the rest of the CNS, but by direct in situ differentiation. What to make of this I have no idea except that the sacral cord is peculiar.

Functionally, it is a cloacal brain responsible for sphincters and sex. So if you like, and I do like, we have one brain for controlling gut tube entry, and another brain for controlling gut tube exit. This cloacal brain does not need connexions with the rest of the CNS, as in patients with spinal cord transactions that isolate the sacral cord: it comes into its own with automatic sphincter control. How far back in reptilian/mammalian history this developed I do not know, but given the resonances between mammalian and avian sacral regions, perhaps it has something to do with laying eggs. It would be interesting to know more about the innervation of cloacal derivatives in egg-laying mammals. 

Finally in the nether regions of the trunk, vagal sensory fibres supply the uterus. What for? Why? They might account for the reports of women with spinal cord transection who nevertheless experience orgasm, the vagus being the afferent pathway rather than the spinal cord..

These ruminations lead me to think that we should consider, and teach, the nervous system as it evolves.

When we are simply tubes on the seabed waiting for currents to waft plankton our way for sustenance, we don’t need voluntary muscles at all. We need only the myenteric plexuses to deal with peristalsis. When we need to seek food and avoid being food for other creatures, then we need to move, so the body wall and its limb appendages need muscles and nerves. Thus we have the somatic nervous system.

Instead of teaching somatic first, then visceral, we should teach it as it (in my scheme) evolves. And when it comes to the somatic system, we tend to start with a reflex, so sensory first then motor. But functionally motor is more significant – we have to move to eat – so we should start with that.  But changing the minds of academics who are concerned only with their tiny area of interest is a bit like Northern Irish politics.

Drawing my thoughts together

I hear you say that none of this matters. It doesn’t help patient care, it doesn’t aid my research programme, it doesn’t get me a higher degree. 

It might, though. 

We are so busy scurrying around collecting data about detail that we ignore the big picture stuff. Who knows where seeing connexions might lead? If we’d never speculated about connexions we’d still be scrabbling round in caves, we’d not have penicillin, we’d have no smallpox vaccine, we’d have no theories of relativity. My big picture for the vagus is that it’s the nerve of nutrition, possibly even the yolk sac nerve.

Stepping outside the territory of anatomy, this kind of synthetic big picture thinking has relevance to fetomaternal immunology, still rather mysterious. Why is the fetus, a foreign organism, not normally rejected? One of the factors is that the immunology of the fetomaternal interface has things in common with that of colonial invertebrates that rub up against each other quite happily recognizing their sameness rather than, as in classical mammalian immunology, obsessing about their difference. 

Erroneous perceptions distort our capability for analytical thought. I ask for care in the use of words. As I hope I’ve shown, a lack of precision can so easily lead to fallacious conceptual thinking – for example confusion of fibres and nerves, ganglia and synapses. I hope too I’ve managed to let you see how easily we can be misled by the way information is presented in a text. It’s worth remembering that definitions and concepts are products of the human mind, and the human mind does not always see things clearly. 

As I said I’m probably one of the last generation of medical students to have studied embryology in any detail. I found it quite fascinating and I hope I’ve passed on that enthusiasm to some of my students. Is it useful? Well, it helps answer the “why?” question. It’s a pity that comparative anatomy and embryology have disappeared from undergraduate medical courses, for the more we specialize, the more limited our visual fields become and the more difficult it is to see connexions. We ignore our zoological history to the detriment of broadness of vision.

A plea

We need people who are paid to sit back and think big picture. We need people to make interdisciplinary connexions through blue-sky speculation that our increasingly frenetic research programmes have no time for, driven as they are by the need to satisfy grant-giving bodies, drug companies and the demands of publication. I suppose it’s a kind of academic relaxation I’m asking for – relaxation being something else that the vagus promotes. Regrettably, I don’t see that happening soon.

I have this feeling I was born a hundred years too late. Or too early.

Saints – who needs them?

In the church calendar, it’s All Saints.

I’m not keen on saints. They’re too perfect. The nearest thing to saints I’ve come across are those who live with the most awful grinding problems day by day, hour by hour, minute by minute, yet still manage to keep their heads above water, if only just, smiling and glad to be alive.

Being a saint is not about piety and being seen to do the right thing. It’s about persistence, perseverance, determination, self-knowledge. It’s about disturbing the comfortable and not being swayed from the cause of right. It’s about being real and authentic.

Prophet Micah says do justly, be merciful, walk with humility. Prophet Stanley says Micah is right. One day you’ll be dead, and it could be very soon, so live life to the full: justly, mercifully, humbly. Those who do that, who use their gifts and lives to make the world a better place, are saints in Prophet Stanley’s book.

If you want to be remembered as a saint, forget it. If you don’t care how you’re remembered other than as someone who did their best, then you might be in with a chance—if that matters, which it shouldn’t. 

It’s trite to say that every saint has a past and every sinner a future, but its true. Prophet Stanley goes further and says that you’ve no chance of living life to the full unless you’ve cocked up in the past—cocked up often, and learnt from it. The words of an All Saints hymn “we feebly struggle, they in glory shine” are wrong, wrong, wrong. They shine, and we shall shine, because we have feebly struggled, and continue to feebly struggle.

We are creatures of this earth. From the earth we come and to the earth we return. Nature gathers up particles and atoms and molecules into what you see when you stand with no clothes on in front of the mirror. And when you pop your clogs you disintegrate as molecules and atoms and particles return to the cosmos for reuse. Some might say it’s a kind of reincarnation. Certainly, nothing is wasted.

Earth. Humus. Humility is the key. Feet planted firmly on the ground, living in the here and now, not in some la-la-land of your or someone else’s imagination, or of how things used to be when you were young.

People come, people go, but particles, atoms, molecules remain. And, get this: 

we are never not in the presence of particles, atoms, and molecules of those who’ve been before us; we are never not in the presence of particles, atoms, and molecules of those who will follow us: we are never not in the presence of past and future.

One of my former churches was often visited mid-service by a vagrant. He tended to arrive “tired and emotional” during the sermon. I welcomed him from the pulpit and told him to sit down and shut up. After some chuntering he did. He enjoyed the wine. We chatted afterwards.

That man suffered the slings and arrows of outrageous fortune more than I shall know, for he died recently. He coped with life as best he could without the insulation I enjoy that comes from stable relationships, employment, a roof to sleep under, and a pension. His addictions more often got the better of him than do mine of me. His courage was all the greater. He added colour and earthiness to a narcotic and entitled church community. I shall miss him.

Is there a saint in this story?

NHS encourages irresponsibility?

For Church Magazine, November 2020

You might remember Terry Waite, adviser to a former Archbishop of Canterbury, who was captured and kept in solitary confinement for over three years in Lebanon. He speaks with some authority about how to survive in difficult times. 

He has in no uncertain terms told us to stop being so pathetically wuss (my words not his) about dealing with the privations arising from efforts to stop the spread of covid. We should stop moaning and be constructive about organising our lives. We could read more, be creative, use technology to chat to people. However bad we think it might be, it has to get a lot worse before it compares with being on your own in a Beirut shithole for years. In short, we should take responsibility for ourselves and not expect someone else to come along and sort us out.

Amen, amen.

It applies to every aspect of life, not least health.

Actions have consequences. If you stuff your face with cream cakes from the rising of the sun unto the going down of the same, don’t be surprised if you get fat, develop diabetes, have a heart attack, and suffer from joint disease because your joints weren’t expecting to have to support a ten ton truck.

Part of the blame lies with the NHS—or rather the way we have allowed it to develop. Having it as a safety net is one thing, but now we expect it to deal with the consequences of our stupidity. We think that we have a right to feel as good at 70 as we did at 30. We refuse to take responsibility for ourselves in the expectation that the NHS will sort it out for us.

It’s a bit like praying to a sky-pixie to sort out problems that we have brought on ourselves. Indeed, it is exactly like that. The Dalai Lama has pointed out how silly it is: “humans have created this problem, and now we are asking God to solve it. It is illogical. God would say, solve it yourself because you created it in the first place.” 

And so with health.

Make a weekend visit to a casualty department (after covid, if it ever ends). Wade through the vomit on the floor caused by alcohol overconsumption. Is this what the NHS is for? Why should doctors be non-judgmental? When I was a teenager, my GP told me I was too fat and should do something about it. He was right, and I did. 

None of this is easy to manage. Some of us eat to make us feel better about ourselves. At least the food loves us even if nobody else does. Some of us have genetic predispositions to certain conditions and there is little we can do other than manage them. Life is difficult. We are at the mercy of our obsessions and addictions – and don’t kid yourself that you don’t have any because we all do. Here’s a list.

Nicotine/tobacco. Alcohol. Exercise, Porn. Golf (I’m not old enough to play golf, but I’m told that it’s popular amongst the brain dead). Recreational drugs (cannabis is less dangerous than alcohol; cannabis rice krispie cakes are delicious). Religion: ecstatic trances of mystics are orgasmic, and for some people religion is merely a prop like smoking or drugs or booze to help them get through the day. Some people are addicted to money, power, controlling others, pleasing people, wanting to change people, gambling, internet, social media, books, buying stuff you don’t need, gossiping, criticizing, moaning, being miserable.

We’re all addicted to something—several things in my case. Look at your addictions. If you think you haven’t any, you deceive yourself. We are all in recovery from something.

You hear people compare themselves to others: “if she can eat it, why can’t I?” The sad truth is that as with everything else, our bodies and our metabolisms are unpredictable. We are not all the same. Swallow a handful of paracetamol and see what happens. Some of you will have no detectable symptoms; some of you will die. Or covid: some people have mild or no symptoms, some have serious symptoms that last ages; some die. 

And all of you will die sooner or later. The longer you live, the more likely you are to die. Life is not fair. Life is uncertain. Get over it. 

One of the first things that medical students do is study a dead body. It is a ritual that helps define them as trainee doctors. All their patients will die, and so will they. As a priest, at every funeral I took I pointed to the coffin and said “every single one of you is going to go in a box like that, and it might be later today, so get your affairs in order, make peace with those you need to, and if there’s something you need to do, do it now. And stop moaning”. I had more complimentary remarks as a result of that stark advice than ever I expected.

My reading of Scripture tells me that we are to be responsible for ourselves. You are no good to your neighbour if you don’t look after yourself. The NHS encourages some of us NOT to take responsibility for ourselves, instead remaining as infants expecting nanny (NHS staff) to deal with the consequences of our idiocy.

You could say that the NHS is UNChristian in tolerating irresponsibility.

The British Army: being thirded

Following my blog Avoid the stupid and hardworking about the Prussian Army types that Baron Kurt von Hammerstein-Equord encountered, a friend has written an updated version for today’s British Army. My correspondent is an Army Officer so is well qualified for the task.

Some thoughts from a more modern perspective – about 1952, which is where the Army is stuck. 

The Army is a firm believer in investing in people and maximising talent [pass the sick bag already], which mean that the MOD can pay a consulting firm millions to develop glossy on-message brochures, which they then roll up to sodomise you. The Army’s version of maximising talent is putting the big lads first to act as a human buffer against razor wire. 

The personnel appraisal system has mysteriously endured through successive defence reviews and budget upheavals, I imagine because it is now so entrenched in our language that the thought of changing it would have senior officers reaching for the sal volatile—or the nearest NCO to give him a good lashing. 

We in the Army are “thirded”. Top third, middle third and bottom third. All three are used as a form of introduction, though never in the presence of the subject. “Did you know that Capt Suchandsuch is joining us next month? I’ve heard he’s a solid middle thirder.”

Bottom thirders are referred to in a number of ways. Lizard, melt, creature, and cluster are the most common. In the officer’s cohort insults abound: “I wouldn’t follow him around a supermarket”; “he has all the depth of a car park puddle”; “he has the breaking strain of a soggy kit-kat”. These chaps tend to go to the logistics corps, although there is a smattering of them across the Army. They tend to have utterly unfounded yet deeply held self-belief, and often fall in to the bracket of the dangerously incompetent [von Hammerstein-Equord type 4]. The best thing you can say about a bottom third officer is that he’s bottom third but he knows it. Sadly, a lot of the senior leadership are bottom thirders. They have survived by dint of ‘staying on the log’ – more on that later – and have been promoted simply by remaining alive long enough, but certainly not through merit.

Some of the more progressive, or soft and “caring”, officers have pointed out that “bottom third” is a rather humiliating term – bad for morale – and have suggested alternatives such as “lower third” or “other third”. Needless to say this silly wokery hasn’t caught on, and those who suggest it are shunted off to bottom third jobs where they can’t do any more damage. 

Most people – 90% – constitute the middle third. Synonyms include “won’t set the world on fire”, “bit of a grey man” and “I honestly can’t remember anything he has ever said”. They won’t fuck-up but they bring no glory. They are officers who would make it through a war without firing their weapon or dying. They are generally content with their lot. They aspire to retire on a Lieutenant-Colonel’s pension somewhere in the Cotswolds with a spaniel, a couple of kids at uni and a spouse in a Barbour jacket, Alice band and solid employment. As soldiers, these are the guys you want: reliable, competent, and usually extremely good company. 

Top thirders are either extremely effective or the absolute worst. The worst are the thrusters, those who know how bum-snorkel like a champ, reliably absent when any actual work needs doing, but appearing like a shapeshifter moments before the CO shows up. As officers they epitomise the Sandhurst ethos of “run fast, shout loud”. You can have all the substance of candyfloss, but run fast and shout loud, and well, you’re in the top third, my lad. Thrusters know they are thrusters, and don’t care. They would happily sell their granny for facetime with the boss, and they would just as fast throw that boss under a bus for some crotch-sniffing with a general.

The good top thirders are referred to as genuinely good blokes, gleaming, or golden. They are rare and valuable, both extremely competent and self-aware, and for that reason usually lift the curtain of the Army sooner than most and have all left within six years of joining to earn gazillions in the City. The ones that stay do well, they are the ones who normally make Chief of General Staff level. 

Earlier, I wrote of “staying on the log”. This refers to the log run. On arrival in basic training every recruit is given the necessary kit to survive the impending course, including, ominously, a short length of rope. The purpose of this becomes clear a few weeks in – you knot with another, slip it underneath a horizontal telegraph pole, and as a team, all with your little rope holders, lift the log and run with it forever. There is always a rotating reserve and when your hands begin to bleed or you feel you cannot hold on for much longer, you rotate out and get a bit of a breather, until the next sorry sod raises their hand, at which point you rotate back in. If you fall back or fall over, you get the honour of a place in the jack wagon, the slow moving landrover which follows behind such activity for health and safety reasons. Going in the jack wagon is a heinous sin – you had best be dying, but more likely you are a malingering bottom thirder with an ouchy leg. Staying on the log at the front, setting a ridiculous pace and bellowing “keep it up, chaps” every few minutes is a top thirder’s role, thrusters and good blokes alike. But as long as you are still on the log by the end, even if that means getting out of the jack wagon because your ouchy leg feels a lot less ouchy now the end is in sight, then you pass. Hence the term, stay on the log.

Here ends my correspondent’s text. The parallels with the church are striking.

So there we have it, girls and boys. There are lots of ways to classify people. Perhaps you like von Hammerstein-Equord’s taxonomy. I do. Perhaps you see merit in the Army’s thirding. I do. Perhaps like me you can see lots of overlaps. Invent your own taxonomy. I used to classify people as fxxkers, wankers and buggers. Then I added tossers. But this isn’t really adequate since for me wankers and buggers (as in silly …) are terms of endearment, and none of them sufficiently describes the scabbiest specimens of the species.

In any case, have a good laugh. And for goodness sake, look in a mirror and laugh at yourself.