Lymph 45

Over fifty years ago, during my initial studies in anatomy and physiology, I attended a lecture on the meninges—the protective coverings of the brain and spinal cord, comprising the pia mater, arachnoid mater, and dura mater. In examining the cerebrospinal fluid (CSF) contained within the cerebral ventricles and the subarachnoid space between the pia and arachnoid layers, our lecturer described its chemical composition as akin to a "fortified lymph". It was a striking phrase, and one to which I shall return.

Having previously studied lymphatic fluid and its drainage of clear, spring-water-like fluid from peripheral tissues within the circulatory system, we were accustomed to viewing lymph through that vascular lens. Yet there remains considerable scope to consider the lymphatic system in its own right. On that day, however, our lecturer had provided a vivid visual analogue for CSF, focusing specifically upon its chemical constitution. In his framing, it was "fortified"—implying the presence of additional constituents.

Among our cohort was a Hungarian student whose English, though generally excellent, was not entirely complete. Misinterpreting the lecturer's phrasing, she posed a perplexing question at the conclusion of the session: "Why has this lymph got a number?" Neither the lecturer nor the rest of the class grasped her meaning until she offered by way of clarification, "You said that this was lymph 45." In that moment, the penny dropped; she had misheard "fortified" as "forty-five".

Regrettably, our Hungarian colleague felt foolish and visibly distressed. Happily, our lecturer—ever the gentleman—recognised the misunderstanding and took her aside privately after the lecture to set matters right, an act of graciousness that only enhanced his standing among us.

To return to the characterisation of cerebrospinal fluid as a "fortified lymph", the description remains something of a moot point. Describing CSF in such terms offers a useful conceptual analogy for certain of its protective and physiological functions, but it fails as a literal description of its chemical composition. From a biochemical perspective, CSF is substantially more dilute than peripheral lymph. Indeed, it is more accurately described as an "ultra-purified" fluid, marked by a sparse cellular presence and a dramatically lower protein concentration, thereby maintaining an exquisitely pristine environment around the central nervous system.

The designation "fortified" holds validity only when examining specific electrolyte and nutrient concentrations. Cerebrospinal fluid does possess marginally higher concentrations of sodium, chloride, and magnesium than blood plasma, which aid in regulating neuronal firing. Furthermore, it contains vital micronutrients such as ascorbic acid and folate, directly secreted to nourish cerebral tissue. It appears our lecturer had scrutinised textbook tables of CSF and lymph components and drawn a slightly skewed conclusion: he had observed the specialised additions while overlooking what had been excluded.

Biceps - At shoulder and elbow

The heavy reliance on rote learning and the rigid memorisation of isolated structures present significant pedagogical drawbacks in anatomical education. In one institution where I formerly taught, the curriculum dictated that students dissect a specific topographical region, undergo assessment, and only upon passing, progress to the subsequent area. Consequently, mastering every structure within a rigidly prescribed boundary became the primary imperative. This limitation was starkly illustrated one day when a pair of students requested my assistance. They were dissecting the anterior aspect of the elbow—the cubital fossa—and were unable to identify a particular muscle. Rather than merely supplying the nomenclature, I proposed a more pedagogical, indirect approach. I suggested we first direct our attention proximally, towards the shoulder. Here, the students successfully identified the regional musculature, demonstrating commendable retention of material from their previous assessment. However, because they were operating within a compartmentalised paradigm, they perceived the cubital fossa as a distinct, novel domain where every structure had to be learned anew, despite a clear anatomical continuity staring them in the face. Pointing to a muscle at the shoulder, I asked them to name it. They correctly identified it as the biceps (more precisely, one of its two heads, though the distinction was immaterial for this exercise). I then encouraged them to trace its course distally down the arm. As they followed the biceps into the cubital fossa, they experienced a moment of realisation: the enigmatic muscle at the elbow was merely the distal continuation of the familiar structure at the shoulder. Their failure to make this connection stemmed largely from the department's failure to adopt a systemic, 'joined-up' approach to anatomy—a pedagogical deficiency regrettably reinforced by a dissection manual that championed rigid regionalism over anatomical continuity.

From Psychic to Cephalic

In the first edition of Ann B. McNaught and Robin Callander’s Illustrated Physiology, published in the 1960s, the authors refer to a "psychic phase" in their description of gastric digestion. This phase describes the release of gastric secretions triggered simply by seeing, smelling, or thinking about food prior to eating—a reflex famously demonstrated in Ivan Pavlov’s conditioning experiments. While the specific phrase "psychic phase" has largely vanished from contemporary anatomy and physiology textbooks, the underlying physiological concept remains intact. Modern medical literature overwhelmingly employs the term "cephalic phase" of gastric secretion. This shift in nomenclature, occurring over a relatively brief period, reflects a broader evolution in scientific framing. The legacy designation "psychic phase" (or "psychic secretion") was favoured by early twentieth-century scientists because the trigger was fundamentally mental, originating from the psyche. By contrast, the contemporary preference for "cephalic"—derived from the Greek kephalē, meaning head—privileges anatomical precision over psychological terminology. It underscores that the reflex is governed by the brain via the vagus nerve before food is ever consumed. Notably, the subsequent digestive phases described by McNaught and Callander—the gastric phase and the intestinal phase—have retained their original names.

The central question is whether this terminological replacement represents a genuine improvement. There is a strong case to be made that "cephalic" is less conceptually meaningful than "psychic". While "cephalic" refers merely to the anatomical head, "psychic" pertains directly to the mind. The phase in question operates not merely within the head as an physical location, but within conscious mental experience. Furthermore, the term "psychic" implicitly acknowledges that organisms possessing the necessary neurological apparatus are also subjects endowed with minds. In capturing these cognitive and mental dimensions, "psychic" provides a far more evocative and accurate representation of the phenomenon than the purely localized descriptor "cephalic".

This historical shift in terminology was largely a product of how science evolved throughout the latter half of the twentieth century. When the term "psychic secretion" was coined around the turn of the twentieth century, psychology and physiology remained deeply intertwined disciplines. As the century progressed, however, they diverged into separate, highly specialized academic fields. Concurrently, the word "psychic" underwent a semantic drift in everyday English, becoming increasingly associated with paranormal, supernatural, or telepathic phenomena. Authors of medical textbooks deliberately abandoned the term to insulate medical discourse from any unintended associations with mysticism.

Additionally, modern physiology operates within a strictly physicalist and materialist framework. Empirical science encounters inherent difficulty in isolating, measuring, or physically locating a "thought" or a "mind" in a standardized laboratory setting. Whereas the mind is subjective, the head is physical. Adopting the term "cephalic" grounds the digestive reflex securely within physical anatomy. It delineates a clear structural pathway: tracing the signal from physical sensory receptors on the head (the eyes and nose) to a physical processing centre in the brain, and down a physical nerve pathway via the vagus nerve. Moreover, the cephalic phase encompasses physical chemical and mechanical inputs, such as tasting and chewing. If food is placed in the mouth of a completely distracted individual who is not consciously anticipating a meal, physical contact with the taste buds still triggers this identical gastric response. Because tasting and chewing represent physical, cranial sensory inputs rather than purely mental concepts, "cephalic" emerged as a more biologically inclusive umbrella term.

Nevertheless, in this pursuit of rigid physical precision, modern textbooks risk stripping away the elegant, holistic relationship between human consciousness and bodily function. The original designation "psychic" served as a subtle acknowledgment that neurological pathways belong to sentient beings possessing minds. While avoiding confusion with occult phenomena is an understandable objective, completely excluding reference to "the mind" risks throwing the baby out with the bathwater.

The Radial Pulse

At one time or another, most people have felt their own pulse, or perhaps that of another. Although pulsations can be detected at various anatomical landmarks across the human body, colloquial references to ‘the pulse’ almost invariably denote the one palpated at the wrist. This is the radial pulse, named for the pulsation of the radial artery against the underlying bone.

While veins are categorised into deep and superficial systems, arteries are conventionally classified as strictly deep. In the limbs, arterial vessels track bones closely, cushioned by surrounding muscle and connective tissue. This configuration conveys a clear evolutionary advantage, keeping high-pressure conduits out of harm’s way—barring instances where a fractured bone yields sharp fragments capable of lacerating an adjacent vessel. Whereas a severed peripheral vein, possessing a thinner and more compliant wall, will tend to collapse and allow blood loss to be staunched with external pressure, a severed artery presents a far graver emergency. The thicker, muscular walls of an artery hold the lumen patent even when transected, while the elevated hydrostatic pressure within compounds the haemorrhage.

If arteries are consistently deep structures, how then can the radial pulse be palpated so readily near the skin’s surface? Does this proximity not render the radial artery ‘superficial’ in the same sense as the veins often visible alongside it? The resolution to this apparent paradox lies in a subtle anatomical distinction: although the radial artery is undeniably close to the body’s surface at the wrist, it remains, fundamentally, a deep structure.

This distinction is far from mere semantic wordplay; rather, it reflects a foundational principle of anatomical architecture. The radial artery strictly maintains its deep course along the radius from which it takes its name. As the arm tapers towards the wrist, the overlying muscular tissue transitions into slender tendons, and the superficial fascia thins significantly. Consequently, there are simply fewer anatomical layers intervening between the skin and the vessel. The surface has, in effect, drawn closer to the artery; the artery itself has not migrated towards the surface.

Darwinian Imperatives

In biology and evolutionary theory, the "Darwinian imperatives" broadly denote the fundamental biological requirements for individual survival and species propagation—or, more succinctly, survival and reproduction. Frequently, these imperatives are conceptualised at the population level, or reduced to fluctuating gene frequencies over time, abstracted entirely from the organism in which they reside. The primary concern here, however, is the central place of the individual animal, whether human or non-human.

Of these imperatives, individual survival appears straightforward, encompassing the acquisition of food, water, and shelter. Yet the concept expands naturally to include broader self-care routines, extending even to medical and pharmaceutical intervention—what clinical healthcare designates as activities of daily living. Ultimately, all such actions collapse into the single, essential category of personal survival.

Individual reproduction, by contrast, is far more complex. For higher animals, reproduction is never strictly an individual affair; it mandates a sexual partner, even if contact between the pair is fleeting or non-existent. Because the resulting offspring are genetically distinct from both parents, reproduction is accurately understood not as the replication of an individual, but as the transmission and copying of a recombined subset of genetic information.

Crucially, no animal—other than humankind—consciously sets out to reproduce or foresees the creation of offspring. The outcome is neither anticipated nor intended. Instead, what is biologically ingrained—or "programmed"—within the individual is the execution of a "reproductive act". A clear distinction must therefore be drawn between the evolutionary outcome of reproduction and the behavioural system driving the reproductive act.

This programmed impulse can express itself across diverse orientations. It may be directed towards members of the complementary sex, the same sex, or oneself, and occasionally towards other species or inanimate objects. While only the first orientation yields biological offspring, all these manifestations stem from the selfsame underlying neurological and hormonal drive.

This brings us to the status of the "reproductive system" within anatomical and physiological frameworks. Modern medical textbooks frequently isolate this system, often placing it at the very end as if it were an afterthought. This separation is instructive: unlike every other organ system, the reproductive system contributes nothing to individual homeostatic survival. Furthermore, it functions for only a fraction of the organism's lifespan—dormant throughout prepubescence, non-functional post-menopause in females, and subject to senescent decline in males. Thus, one of the two foundational Darwinian imperatives rests upon a physiological system active for only a limited segment of the individual's life.

Two Quotes

Here are two quotes that I consider worth mulling over:

“The greatest of all the accomplishments of twentieth-century science has been the discovery of human ignorance.”

    Lewis Thomas, physician and essayist, quoted in The Boston Globe, May 18, 1998

“For this, indeed, is the main source of our ignorance—the fact that our knowledge can only be finite, while our ignorance must necessarily be infinite.”

    Karl Popper, philosopher of science, in Conjectures and Refutations, 1960

A Growing Level of Respect

Numerous superlatives can be applied to the act of dissecting a human body. When one remains mindful that a cadaver represents the physical legacy of a living person, concepts such as honour, privilege, and responsibility immediately come to mind. In contemporary medical education, students are actively encouraged to humanise the donor to a far greater extent than was customary during my own formative career between the 1970s and 1990s. This transformation is entirely proper and represents the standard that ought to have prevailed historically. Because early anatomical dissections relied almost exclusively upon executed criminals—performed without consent as an extension of judicial punishment—reverence for the deceased was virtually non-existent. Consequently, when voluntary body donation eventually superseded execution, an ethos of formal respect was slow to take root in the dissecting room.

In my own experience, it was not until the early 1990s that tangible manifestations of deep respect towards the dissected dead began to emerge systematically. Initially, a university chaplain would visit the dissecting room—the place where staff, students and cadavers had met—to deliver a few carefully chosen remarks before work commenced. Within a few years, however, this role was transferred to a retired professor who had returned as an anatomy demonstrator. This transition was likely intended to establish a secular, non-religious atmosphere, accommodating a student body—and a donor cohort—comprising diverse faiths and secular worldviews that permit anatomical donation.

Today, the level of respect demonstrated within my former department is profound. Observing contemporary practices reveals an institutional ethic strikingly distinct from the environment of my earlier years. The institutional attitudes of my generation now feel exceedingly distant, leaving me with the distinct sense of being a product of a bygone era—a conclusion that is, in all likelihood, entirely accurate.