Advent 2021

I am recovering from a 6-week chest infection (covid negative), the like of which I have not experienced since the 1960s. Childhood memories of standing at the open bedroom window in the middle of the night trying to get air into my lungs. Susan is about a week behind me, as it were.

There are several reasons why I might have fallen victim to this, but what it really tells me is that (a) my lungs are 65 years older than I am in my head, and (b) viruses and other creatures that can take us over will win. It is entirely likely that these “extraordinary” times will last longer than I will. Talk of “post-covid” is well-premature. So, have no expectations other than that you’re gonna die. Get busy living, and as the well-known American theologian Dolly Parton might say, “if you’ve got it, flaunt it” before you lose it.

Susan had her second cataract done early in the year. She can see clearly now the mist has gone. She drives with more confidence. Her hair has turned pink with age. Stanley’s one functioning eye has glaucoma and a mega-cataract. He expects to have said cataract attended to in the next few weeks. Will he be able to drive again? He’s not done so for over 18 months and has no wish to start again. The local taxis take him to the gym and back and – added bonus – he is picking up a smattering of Urdu. His eyesight or lack of same has provoked the great renunciation of giving away most of his sheet music, organ and piano. Liberating in a way. But what if the surgery means he needn’t have done so?

In 6 months’ time Stanley will have outlived father (he outlived mother a few years ago). Susan has yet to reach the age of her mother’s demise. Stanley’s retirement more or less coincided with lockdown 1. “What Is there now to live for?” is the question. Facebook has yielded more people crawling from under the stones of the past, and he’s struck by the number of friends now in their 70s who have said to him that left to their own devices they wouldn’t have made the choices in life that they made – or that were made for them. Him too.

We are of course not often left to our own devices: parental expectations, quirks of circumstance, economic realities, consequences of actions, all conspire to set us on pathways and before we know it we’re too far gone to go back.

Stanley was brought up at a time and in a culture when the man was expected to husband – to father and provide. We made decisions, took the consequences, made the best of it, then another decision had to be made. Repeat ad infinitum. No complaints, no complaining – he’s not – we’re born, we struggle, we die. The molecules that once made us are used again. This cosmic cycle is satisfyingly reassuring. If Stanley had to name one event that marked expulsion from Eden (garden not river though the river is appropriate), it was when he was 5 and his sandpit was tarmacked over. He still feels the outrage. He was never the same again.

Maybe going off into the jungle with a begging bowl is the answer. It might be tolerable in warmer climes, but it’s not for him. His idea of roughing it is running out of ice cubes. He could live in a community of gorillas or orangs, kind of returning whence he came, but there’s still the ice cube problem. Decluttering, giving away possessions (downsizing forces this – it’s very refreshing), having no expectations, living in the moment (eternal life – Jesus was a Buddhist), and being mischievous. Why do people take themselves so seriously? They must think they matter.

Where have we visited this last year? Some of our friends have done so much travelling they must have needed indulgences from The Holy and Blessed Greta. How they can live with the guilt I simply do not know. We in contrast have been models of environmental restraint. Leeds, Derby, Newcastle under Lyme (Susan’s eye) just about sums it up. It’s been thrilling.

We hope to be in Ireland for Christmas, though Dublin is more cautious about covid restrictions than Westminster so we’re not banking on it. It’ll be the first time in two years we’ve seen Vic face to face. Ed visited us a couple of months ago.

In many ways life is like being back in the Eden valley in the 1950s. Small world, don’t go anywhere much, a 4 mile trip to Penrith the highlight of the week. Forced onto one’s own resources. I am now thankful for a solitary childhood that allowed an inner life to grow. Neither of us has a bucket list of places we’d like to see (just as well now) and Susan has long been of the opinion that world heritage sites should be visited only through the pages of the National Geographic.

I’ve been reading a lot. I return to Paul Scott’s Raj Quartet (Jewel in the Crown) and find something new each time. He has a great line about the British in India in the 1940s who “came to the end of themselves as they were”. I feel a bit like that myself. Retirement, sensory loss, lockdown, restrictions, all forcing an end to me as I was – and therefore a beginning. What next?

The phrase is certainly true of our way of life in the west. It is unsustainable. The aforementioned Greta is right, but wrong too – it’s way too late and has been for over a century. We might as well carry on and hasten the end. The sooner we humans are wiped out so that evolution can do its job again, the better. Homo sapiens is an odious species, far from sapiens. I’d like to be reincarnated as either an octopus or one of them sea squirts that come together with their mates to make a tube that glows – pyrosomes. Glowing in the dark is something we’re both used to having been brought up within spitting distance of Windscale (or Calder Hall or Sellafield) in the 1950s.

Two MUST reads: (1) Skyseed by Bill McGuire (he lives in Brassington where I was a curate). (2) The Swarm by Frank Schatzing (he doesn’t).

KBO. Klaatu barada nikto. Happy Advent. Nollaig Shona agus Athbhliain Faoi Mhaise

A story in black and white

Here is a view from the south transept of Carlisle Cathedral looking west into the south nave aisle showing the romanesque arches distorted by settlement in the 1120s*. It’s a meticulously detailed black and white pen and ink essay dated 1970.

The artist, a lovely, gentle man by name Reg Hunt, was a sidesman at the Cathedral and his son Richard and I were choral and in my case organ scholars in the 1960s. Living as I then did twenty miles from Carlisle, the Hunts had me to Sunday lunch week by week between the morning and afternoon choral services. Kindness and generosity of spirit were there in abundance in those heady days of musical exploration and soaking up Round the Horne before heading off for Evensong at 3.

Reg by then was Head of Art at White Close School in Brampton, about 10 miles away. I’d seen some of his work, and when I went to Cambridge in 1969 I asked him if he would be willing to do something for me as a memento of those times and of the Hunt family. I was overwhelmed with this – I was not expecting anything so spectacularly luxurious.

We have moved twelve times since then and this has moved with us – until recently. It’s still in the family, though, now having pride of place at Edward’s in Co Wexford.

I discovered that Reg had once courted a Carlisle woman, Margaret Grainger.  For whatever reason that didn’t work out and he married Margaret Henderson. Together they had John, a writer, and Richard. Margaret Grainger married my uncle Philip Monkhouse, later a tenor Lay Clerk at the Cathedral.

The Eden valley was a small world where rich red sandstone reigns, but Reg had seen more of the big world’s unpleasantness than most for he had been one of the liberators of Bergen-Belsen in 1945. 

* for more information see Dr James Cameron’s excellent and entertaining site: https://stainedglassattitudes.wordpress.com/2018/01/29/carlisle-the-unluckiest-cathedral/

Smells and Middle East memories

I was back in the Middle East recently. Waiting for the taxi to bring me home, I was sat on a huge tyre outside the gym, part of an industrial unit backing on to the railway. The boiling temperature and the smells from the scorching sun beating down on tarmac, cars, rubber and metal, transported me back to the 80s and 90s, to the aromas of Jeddah. 

Some trips were for teaching anatomy to would-be surgeons. I was there for two weeks at a time, with usually a physiologist and a pathologist. Other trips were for examining surgical aspirants – these lasted about a week or so, and were more social in that there were three examiners, two exam administrators, and often spouses.

Some visits took on a political dimension. The college was keen to recruit students and gain hospital management contracts, both of which brought with them substantial government income. I remember several receptions at which we sat round the edges of vast and ornately decorated rooms in palaces waiting for local dignitaries to arrive late, then joining in stilted conversation sipping Arabic coffee and nibbling sweetmeats as the man (never the woman) in the biggest chair continued his conversations with college bosses and advisers. On one occasion in Baghdad, just after the first Gulf War, the important man was a relative of Saddam. I did not consider it wise to be provocative – indeed I might well have said nothing, which was not difficult since smalltalk does not come easily to me unless it involves railways (not trains), organs or churchy stuff. I shut down in the midst of such internal distress, aching to get out. 

Of the places I visited, Amman was without doubt the most wonderful. Lovely people, fascinating places, Roman remains, Biblical sites. I even saw Petra before it was commercialised. By far the worst was Buraydah in central Saudi. I go so far as to declare it the cosmic cloaca. 

Like any remote settlement anywhere, it is conservative. But Saudi takes conservatism to a whole new level. Buraydah is the home of the training college for religious police – the mutawa. These puritans patrol the streets with sticks ensuring that shops close for prayers. They stamp out any hint of public joy. They are on the lookout for bare female flesh that they can whack. Foreigners are not exempt. An Irish female, head to ankle covered in black, had inadvertently allowed a smidgeon of bare foot to be visible. It did not escape the swipe. The mutawa bring to life R S Thomas’s definition of Protestantism: “the adroit castrator of art, the bitter negation of song and dance and the heart’s innocent joy”.

There was thus little incentive to leave the hospital compound. 

In Buraydah we were housed in three-bedroom villas – one each – for the medical staff. They were set around a central scrubby “lawn”. You can see the compound here, with the villas at the bottom of the screen: https://www.google.com/maps/@26.3482938,43.9699666,659m/data=!3m1!1e3

Other than three hours teaching a day there was nothing – and I repeat nothing – to do. It was just like lockdown, only worse. 

Routine activities like cutting one’s nails or scratching one’s backside were scheduled and done very slowly to fill the time. One of the biggest events of the day was cleaning my teeth of a morning. It was ritualized, It became a liturgical event. Running 100 times round the square was eagerly anticipated. Together with a physician teaching physiology, I competed with myself and him. I was never fitter than in those days: Susan said when I returned to Dublin after that fortnight that I looked like a rat. A fit one.

Food was interesting. Each morning we’d fill in a menu putting ticks against our chosen items for lunch and supper. Twice a day except Friday, the meals arrived: always scraggy chicken and rice, no matter where the ticks had been. A good game. There was a supermarket on the compound, fortunately.

I don’t want to give the impression that I sailed through these ten or so middle east trips. I did not. Life at the time was fraught. I found it incredibly difficult to be working and living in Ireland with the two boys at school in England (until 1992). In addition, to be away from Susan and Victoria on these occasions helped to propel me to despair from which it took years to recover – if I have. I was delighted to be able before long to pass these duties to junior staff, and they were happy to oblige.

Baghdad was my first middle east trip. I went twice, the first to examine as part of a team from the London surgical college, and the second, I think (memory is hazy), to discuss the establishment of a new medical school. I liked Baghdad and the Iraqis. Like Jordanians they were down to earth and pleasant. I met a croupier at one of the big Baghdad hotels and wondered why I didn’t have a glamorous and lucrative job like his.

Tragic middle east politics – another cock up of partition overseen by the Brits.

What’s in a name?

I’m a regular reader of the blog Thinking Anglicans (yes, I know there are very few of them ….). It keeps me up to date with the lamentable politics of the Church of England. 

There’s been an interesting discussion about whether contributors should be allowed to use fake names, as some do. The consensus is that real names are ideal but some people must hide their identities for various reasons. For example, a cleric using his/her name might feel obliged to stick to an official church opinion. That never bothered me for so much official church teaching is utterly bonkers and needs to be changed. I rather hoped that I might be hauled up before an ecclesiastical court – it would have been fun – but alas I seemed not to have been offensive enough. Must try harder.

Anyhoo, back to names, I am William after father and his father, Stanley after mother’s father, and Monkhouse because here at present we use the patronymic. Quite why my second name was routinely used I know not. 

I wonder if there is such a thing as a “me” that can be adequately encompassed in just one name.  You see, girls and boys, there are several “mes” living in my body. 

There’s adolescent me discovering things, 6 year old me playing in the sandpit, finger wagging me that gives out shoulds and oughts, 71 year old me that is angrier about injustice and more subversive than ever before (whoever said we get less revolutionary as we age was wrong), dutiful me that serves, eye twinkling provocative me, emotional me, fearful and inadequate me, depressive me that spends money as therapy, and more. 

Add to these the millions of creatures that live in and on me, bacteria, viruses, symbiotes, even maybe parasites, many of which produce chemicals that affect my thoughts and behaviour – we’re all at the mercy of circulating chemicals from whatever source, so is there really free will?

Having three official names to choose from I give different names to these various “mes”: Stanley, Stan, Will, William, Billy, Willy, Monk, Monkey (inevitable school nickname), fat git (used by one of my sons with then some justification). I like all these “mes” and love them even though some cause problems. Interestingly, the “mes” with the problems tend to be creative and good fun, and I wouldn’t be without them. 

As I reflect on these “mes” I return repeatedly to the profound question “would the child I once was be proud of the adult I have become?”

I am put in mind of this exchange on Life of Brian between Stan and his mates.

Stan wants to be a woman called Loretta so he can have babies. 

It is true that many men as they age and lose testosterone develop tits and become more female-like. Changing sex during the life cycle is not unknown in the animal kingdom.

I’m not there yet.

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. 

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.

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.