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December 9, 2007

Old Olympus’ Towering Tops
Posted by Jim Macdonald at 11:21 PM * 84 comments

The other day I was chatting with a chum, and the twelve cranial nerves came up.

The cranial nerves are the nerves that don’t come out through the spinal cord. They come directly through the skull. They’re important because (among other things) they can give you a pretty good idea if anything horrible is going on inside the brain, and where exactly that horrible thing is likely to be.

Now suppose you’re in your favorite bar and a big guy dressed in black leather, hung about with chains, walks over and bets you a hundred bucks that you can’t name the twelve cranial nerves. Here’s how you can conquer and win his hundred. Remember this little rhyme:

On Old Olympus’ Towering Tops
A Fat-Ass German Vends Some Hops.

That mnemonic reminds you of:

  • I Olfactory (Sense of smell)
  • II Optic (Sense of sight)
  • III Oculomotor (Eye and eyelid movement)
  • IV Trochlear (Turns eyes downward and to the side; controls superior oblique muscle)
  • V Trigeminal (Controls chewing; touch and pain in the face and mouth)
  • VI Abducens (Turns eye to the side)
  • VII Facial (Controls facial expressions; tears and saliva; sense of taste)
  • VIII Auditory (Sense of hearing; equilibrium)
  • IX Glossopharyngeal (Sense of taste; senses carotid blood pressure)
  • X Vagus (Sense of taste; senses aortic blood pressure; stimulates digestion; slows heart)
  • XI Spinal Accessory (Controls swallowing; trapezius and sterno-cleido-mastoid muscles)
  • XII Hypoglossal (Tongue movement)

Hah, victory! Now suppose that same big guy says, “Double or nothing: Which ones are sensory, motor, or both sensory and motor?”

Another mnemonic springs to your aid: “Some Say ‘Marry Money,’ But My Brother Says Big Breasts Matter More.” (S=sensory, M=motor, and B=both.)

Again you win the bet. You pocket the two hundred bucks. To show that he isn’t a sore loser, the big guy also buys you a beer.

If you want to perform a neurological examination on your Significant Other (kinky foreplay!) here’s how. If you want to see where the cranial nerves are located, what they all do, take a little quiz, and so on, go here.

Just a couple of notes on some of those nerves: Cranial Nerve III (Oculomotor), is the one that controls pupil dilation (among other things). That’s the reason dead people have fixed, dilated eyes. As the brain loses oxygen, the oculomotor nerve is no longer able to constrict the pupils. In a stroke, the pupil can be “blown” by pressure or lack of oxygen on the oculomotor nerve on the affected side. Same thing with head trauma—swelling affects the oculomotor. One pupil that’s sluggish, or fixed and dilated, is a bad sign. It can mean decreased oxygen or increased pressure inside the skull.

Next interesting one is Cranial Nerve V (Trigeminal). It’s both sensory and motor. As its name suggests, it has three roots. The trigeminal covers most of the sensation from the face. One of the most common nerve-pain disorders is trigeminal pain. When it occurs it usually affects women in mid-to-late life; it is usually felt in the maxillary (upper jaw) branch, next most commonly in the mandibular (lower jaw) branch. It’s a sharp, stabbing, sudden-onset pain; frequently mistaken for toothache. It’s often accompanied by a tic-like muscle spasm. Suspect trigeminal pain if the pain stops at the mid-line of the face. There isn’t really anything you can do about this at home: go see your doctor (particularly if the pain is bad enough and frequent enough to put you in danger of malnutrition or dehydration) to rule out other, more serious causes of pain. Trigeminal pain can be controlled with drugs if you catch it early.

Last of the interesting cranial nerves that I want to talk about tonight is Cranial Nerve X (Vagus). This is a long nerve and has a lot of functions, but the one I want to mention is that it controls the heart rate. Rubbing the carotid sinuses (in the carotid arteries, under the angle of the jaw) leads to stimulation of the vagus, which slows the heart (don’t try this at home, kids: if there’s a blockage in the area, and the massage breaks a soft clot loose, you’re looking at a stroke). If someone’s heart rate is too slow due to vagal tone you can whack them up with atropine, which blocks the vagus. (This won’t help with heart transplant patients—the vagus isn’t connected in them.) The last interesting thing is that the vagus doesn’t just innervate the heart: it also hooks up to various parts of the digestive system. Which works out to this: folks on the toilet who are bearing down can stimulate the vagus (which terminates down in the rectum). This has the same effect as carotid massage; the heart slows. Perhaps it slows down far enough that blood pressure plummets. The patient passes out (we call it “vagueing out”), falls off the toilet and cracks his head on the side of the bathtub. Or, the heart slows enough that the old, sick, tired heart says “Okay, I’m done,” and stops beating entirely. This is one reason why so many heart attacks happen while the patent is sitting on the toilet. (We call it “the Elvis presentation.”) If you’re prone to vagueing out (aka vaso-vagal syncope), please consider getting a medic alert tag that says so.


I am not a physician. I can neither diagnose nor prescribe. This post is presented for entertainment purposes only. Nothing here is meant to be advice for your particular condition or situation.


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Comments on Old Olympus' Towering Tops:
#1 ::: xeger ::: (view all by) ::: December 09, 2007, 11:52 PM:

I'd come up with some clever pun about vagueness getting on my nerves, but my cleverness has gone the way of the dodo, with this dire headache...

#2 ::: fidelio ::: (view all by) ::: December 09, 2007, 11:54 PM:

One condition associated with inflammation of the trigeminal nerve is multiple sclerosis--so do not let pain in this nerve's area slide as "just some pain." It was one of the bits of my aunt's medical history that helped support her diagnosis, and that's the reason why I was deeply relieved to find out the pain I was suffering was instead an abcessed tooth.

#3 ::: P J Evans ::: (view all by) ::: December 09, 2007, 11:55 PM:

Trigeminal neuralgia ain't no fun ... I get it (through the eye area) every so often, just often enough to remember I've been here before, but not enough to remember when the last time was.

Heck, no neuralgia is fun to have. Been there, done that, and they don't have tee-shirts for it.

#4 ::: T.W ::: (view all by) ::: December 10, 2007, 12:08 AM:

Vagus is that the left or right side? My arthritis often causes swelling in my neck and jaw.

#5 ::: Teresa Nielsen Hayden ::: (view all by) ::: December 10, 2007, 12:09 AM:

Xeger, I'm sorry to hear that. Feel better soon. What kind of headache is this?

Fidelio, it's a hell of a thing when you're glad of an abscessed tooth.

Jim, you left out vaso-vagal syncope and Bell's palsy.

#6 ::: Paula Helm Murray ::: (view all by) ::: December 10, 2007, 12:11 AM:

The way my vagus nerves run by my ear canals ensure that when I want to clean gently/blot water out of my ear canals I end up gagging myself. It worries my family members, but it's different from the gagging I get when I'm upset. (my situation at work has become so stressful that sometimes I throw up before going to work. Yes, I'm working to effect change. It is just going to take time, mostly because people are worrying about other stuff at the end-of-year.)

#7 ::: A.J. Luxton ::: (view all by) ::: December 10, 2007, 12:22 AM:

Ah! I always wondered about the toilet heart attack thing! I knew it couldn't just be the exertion.

Now I'm wondering about the neurological cause of eyelid twitches (which, to my consternation, I get when I've been suffering low-grade cumulative sleep-dep.)

Damn it, the kitten is trying to type again.

#8 ::: Russell Letson ::: (view all by) ::: December 10, 2007, 12:25 AM:

My problem is this--how do I remember the mnemonic?

#9 ::: Diatryma ::: (view all by) ::: December 10, 2007, 12:33 AM:

I want to come to your bars.

#10 ::: xeger ::: (view all by) ::: December 10, 2007, 12:41 AM:

Teresa Nielsen Hayden @ 5 ... Xeger, I'm sorry to hear that. Feel better soon. What kind of headache is this?

Fortunately it's not a migrane - I think it's a side effect of the sluggish healing of a separated shoulder/whiplash[0]. Weird though - it's like having patches of white hot electricity lashing around different parts of the outside of skull, depending on which part of my shoulder/neck/arm complex is least happy, or under the most stress. All in all, not recommended - and unfortunately persistent.

[0] separate times, but clearly not failing to indulge in feedback between injuries
[1] I am seeing a physiotherapist for this, but job stress isn't exactly helping with the entire process

#11 ::: James D. Macdonald ::: (view all by) ::: December 10, 2007, 12:47 AM:

The vagus runs down both sides. (The cranial nerves go in pairs.) The right and left vagus join in front of the esophagus and continue down from there (with various branches).

I didn't leave out vaso-vagal syncope, Teresa. I just didn't use that exact term. Stimulating the vagus slows the heart, dilates the blood vessels, and lowers the blood pressure. Usually people who vague out are out for less than a minute, don't lose bowel or bladder control, and know where they are the moment they wake up.

There's been some interesting stuff in stimulating the vagus to deal with (some kinds of) epilepsy, (some kinds of) depression, and hiccups.

#12 ::: James D. Macdonald ::: (view all by) ::: December 10, 2007, 01:01 AM:

Teresa: Since you asked about Bell's Palsy, that's caused by a problem with Cranial Nerve VII, the Facial nerve. It isn't life-threatening in itself, or a sign of anything life-threatening (though it is more common among diabetics, it isn't a sign of diabetes).

Not that this is a complete treatise of the anatomy of the cranial nerves and their associated disorders. Generally speaking, if there's something wrong with your body you should go ask someone who passed medical school about it.

#13 ::: Dave Bell ::: (view all by) ::: December 10, 2007, 01:30 AM:

The stuff about the vagus nerve makes me wonder about how my mother fell and broke her leg: the same general situation as the heart attack, and two or three other things that make it a possibility that her blood pressure dropped too low when she stood up.

I have a recollection of the vagus nerve being routinely mentioned by old-time forensic pathologists, and then it almost falling out of fashion as a factor in strangulation. One martial arts type I used to know attributed the Spock Pinch to the blood flow in the carotid arteries, but what I recall she told me makes more sense if the vagus nerve is involved.

Weird thought--does anal sex slow the heart?

#14 ::: Tlönista ::: (view all by) ::: December 10, 2007, 01:47 AM:

Dave Bell @13: There's only one way to find out, and yes, it will lead to you in the checkout at Wal-Mart with stethoscopes, lube, and one confused cashier.

#15 ::: Bob the Mole ::: (view all by) ::: December 10, 2007, 01:48 AM:

Thank you! I have an exam on this on Friday.

#16 ::: James D. Macdonald ::: (view all by) ::: December 10, 2007, 01:56 AM:

I wouldn't know about anal sex, but irregular heartbeat is one of the unwanted side-effects that you have to guard against during manual clearing of fecal impaction.

#17 ::: David Goldfarb ::: (view all by) ::: December 10, 2007, 02:09 AM:

I usually find that mnemonics like this can be useful to remember the order of items in a list, but I have to have the list itself memorized; just knowing the first letter of a list item isn't enough of a trigger to bring the item to mind. That there are numerous mnemonics like this one around suggests I may be unusual in that.

Steven Gould used the vagus nerve interestingly in his novel Reflex, where it figures in the answer to the question, "How do you enslave a teleport?".

#18 ::: Earl Cooley III ::: (view all by) ::: December 10, 2007, 02:22 AM:

From "The Martian Shop" by Howard Fast ---

The voice of Professor Goldman explained, "This frame gave us our key, but we do not claim any clear knowledge of what these inscriptions mean. Medical authorities consulted have suggested that a certain type of irritation of the tri-geminal nerve can result in the most trying pain man knows. The line from Keats is utterly meaningless, so far as we can determine; the reason for its inclusion remains to be explained in the future, if ever. The remaining frames, as you see, are in the hieroglyph."

#19 ::: A.J. Luxton ::: (view all by) ::: December 10, 2007, 02:50 AM:

I have heard the trigeminal nerve also has to do with sneezing.

#20 ::: JamesP ::: (view all by) ::: December 10, 2007, 03:45 AM:

Robertson Davies has a much dirtier version of this mnemonic in THE CUNNING MAN - it goes, as best I remember, "Oh! Oh! Oh! To touch and feel a girl's vagina and hymen!" Which doesn't quite seem to fit, but it's along those lines. Certainly easier for your average medical student to remember, I would remember.

#21 ::: Dave Bell ::: (view all by) ::: December 10, 2007, 04:35 AM:

OK, I expected intriguing answers to my weird thought.

I doubt I shall ever do the experiment, though not because of any strong aversion to the particulat sexual activity. There are other inhibitions.

And getting the grant for the research? "Let me get this straight. You want to wire volunteers up so as to monitor heartrate, blood pressure, and other medical data, while they indulge in deviant sexual practises? Let me remind you. It's an election year, and every gay Republican in Washington will be looking for a distraction like this to point at."

I wonder if I ought to try the Banzai Institute.

#22 ::: ajay ::: (view all by) ::: December 10, 2007, 05:54 AM:

21: I'd imagine that the physical exertion involved would act to speed up the heartrate and increase the bp.

But I think that, if you want to slow someone's heart, splashing water on the face to trigger the diving reflex is probably easier and more convenient for all concerned than what Xopher (IIRC) once memorably described as "hhrghghlhghgling".

#23 ::: Dave Bell ::: (view all by) ::: December 10, 2007, 06:14 AM:

I suppose the obvious experiment design would involve uninhibited young ladies and measurement of their reactions to both vaginal and anal sex.

I fear somebody may already be working on the movie. If so, I don't want my name in the credits.

#24 ::: Connie H. ::: (view all by) ::: December 10, 2007, 06:28 AM:

Dave Bell @21 -- On the up side, it would probably qualify you for an Ignobel.

My 85yo mom finds that her trigeminal neuralgia gets triggered by a blast of cold air on her face, so aside from the drug therapy, her best bet is wrapping up with scarves like an Arctic explorer. I've offered to knit her a ski mask, but so far she isn't going for it.

(The condition seems to have been brought on by shingles, which is another 'interesting' condition that someone :: looks nonspecifically in Jim's direction :: might go into at some point.)

#25 ::: Dave Bell ::: (view all by) ::: December 10, 2007, 07:52 AM:

With my name, do you really think I have any chance of any sort of No Bell prize?

#26 ::: Sue Krinard ::: (view all by) ::: December 10, 2007, 07:58 AM:

Ah, the Ig Nobels... One of their winners was a scientist whose research was about ducks and necrophilia. Really.

#27 ::: Tracey C. ::: (view all by) ::: December 10, 2007, 08:20 AM:

I'll add in that there is some interesting research being done that's looking at the link between vagal nerve tone (via respiratory sinus arrythmia) and emotional resilience.

In a nutshell (and this isn't my research, so some of the details may be off):
RSA = how reactive your heartrate is to your breathing patterns - normally, when you inhale, heartrate increases slightly and decreases when you exhale. People under chronic stress or who have less vagal 'tone' do this less - their heartrate is less reactive to respiration.

Some correlational research has shown RSA to be positively linked to expression of positive emotions, satisfaction with life/well-being, etc.
Research is being done that looks at it in the context of people who are flourishing (vs. depressed or languishing) to see what other factors may be playing a role.

It's theorized that it may be one of the physiological factors underlying the Build aspects of positive emotions (the idea that frequent experiencing of positive emotions builds emotional and physical resources for future need).

Neat stuff. Thanks for posting this!

#28 ::: Beth Friedman ::: (view all by) ::: December 10, 2007, 09:02 AM:

The version I learned in nursing school was "On Old Olympus' Towering Top, A Finn And German Viewed Some Hops."

James P. @20:
I also heard that version, though yours is missing the last two words: "Such Happiness!" Which makes it work with the missing ones.

Unlike many of the things I memorized in nursing school (such as the origin, insertion, function, and innervation of all the human body's muscles), this set has stuck with me permanently.

#29 ::: Ginger ::: (view all by) ::: December 10, 2007, 09:40 AM:

::delurks::

In veterinary school, we learned the mnemonic as "On Old Olympus Towering Top, A Fat Vagrant German Viewed Some Hops", taking into consideration the official name change of "Auditory" to "Vestibulo-Cochlear".

Shingles causes neuropathic pain related to the recrudescence of herpes virus (Varicella-Zoster Virus) from the trigeminal or facial (or other nerves). A shingles outbreak always follows the nerves from which the virus reactivated. For more specific information about it, you can go to the NIH website: http://nihseniorhealth.gov/shingles/aboutshingles/01.html

Bell's Palsy is -- as mentioned above -- related to the Facial nerve, in my patients specifically where it crosses around the external ear canal. In humans, it's a number of causes, including diabetes and viral infections. In some people, the cause of the paralysis is not known. It usually heals slowly, with anti-inflammatory treatment, although the idiopathic variety might not respond to treatment. http://www.nlm.nih.gov/medlineplus/bellspalsy.html

::relurks::

#30 ::: Jon Meltzer ::: (view all by) ::: December 10, 2007, 10:43 AM:

I have had lidocaine for tooth work twice in my life, and both times it has caused vaso-vagal syncope.

The first time, I almost threw up. The dentist sent me home.

The second time, I was having some work done at a dental school. I told the student that giving me lidocaine was probably a Bad Idea. He insisted on doing it ("allergy to lidocaine is extremely rare"), and I thought well, what the hell. Let's find out if I'm really allergic to this stuff.

Nausea, light-headedness, blood pressure drop.

The student hollers for the resident. The resident hollers for the prof. Every non-occupied student on the floor tries to squeeze into the treatment cubicle. They're all staring at me.

Prof: "This is vaso-vagal syncope. It is uncommon but not rare. You will notice that the patient's blood pressure is dropping and that the face looks pale. If you lower the head and allow blood to flow towards the brain ..."

And, eventually they did lower my head and I was fine enough for them to go on.

I suppose I should get some kind of medic alert thing.

#31 ::: Chris J. ::: (view all by) ::: December 10, 2007, 11:46 AM:

Next you'll be posting about the critters of the mediastinum: the ve-goose, the esopha-goose, the thy-moose, and, of course, the Thoracic Duck.

#32 ::: Ingvar M ::: (view all by) ::: December 10, 2007, 12:08 PM:

Jim:
Is vagus nerve trauma the cause of "glass jaw" syndrome? It would, vaguely, fit with what I have seen, though luckily never experienced. I've also seen some palm strikes to the neck area knock people out cold and if it is indeed related, I am relieved that there is a physiological reason to that.

Dave Bell @ 13:

There are many (though not quite infinite) ways of "strangling" someone, varying from applying pressure on the windpipe, both cartoid arteries or by assorted nerve pinching.

In my experience, it's much easier to get either pure windpipe or combined windpipe and cartoid artery strangling to work, since the nerve bundles are tricky to get to (you need to poke fingers in, it's a small target and it's not entirely obvious when you've hit the right spot with an agitated non-cooperating subject), whereas pressure to the arteries and windpipe involves target areas that are small in at most one direction. Yes, martial arts class were, at times, quite interesting, in most senses of the word.

#33 ::: Faren Miller ::: (view all by) ::: December 10, 2007, 12:27 PM:

For some years, I've had what I now find to be trigeminal pain in my left jaw (more in cold weather, I think), but it has never felt quite like a toothache and never seemed very serious. I'd been thinking it might be some occasionally uppety gland in an allergic reaction, so it's good to have a more likely diagnosis. And yup, I'm over 50.

#34 ::: Xopher ::: (view all by) ::: December 10, 2007, 01:36 PM:

Hmm. I have tachycardia and a tendency to be excitable. Is this why I have found pressing just under my jaw calms me?

#35 ::: Lee ::: (view all by) ::: December 10, 2007, 01:44 PM:

Jon, #30: I thought well, what the hell. Let's find out if I'm really allergic to this stuff.

Yikes! You were damn lucky; too many times, that thought turns out to be the precursor to a visit to the ER. My reaction to something like that would be along the lines of, "Okay, bubba, who are you going to believe -- your book, or the patient who damn well knows her OWN MEDICAL HISTORY?" And if he still insisted, then I'd be the one hollering for the resident.

#36 ::: Diatryma ::: (view all by) ::: December 10, 2007, 02:09 PM:

Tracey at 27, I'm glad to know I'm not the only one whose heart does that. I occasionally try sort of meditating and was worried for a while that my heartbeat slowed down so very much when I breathed out.

#37 ::: Jon Meltzer ::: (view all by) ::: December 10, 2007, 03:07 PM:

Lee @35: The reaction I had is not technically an "allergy". The worst that could have happened would have been my throwing up on the dental student (which would have taught him well, I suppose ... ).

The other "explanation" I've heard from dentists is "fear of needles causing anxiety". Never mind that, other than the normal discomfort when having a large, pointy object stuck into one's mouth, I have no problem with injections; and that the only times I've had this reaction have been with the same specific drug. I tell them now to give me carbocaine instead, which actually requires more frequent injections. No side effects there.

I would like to know more about why I did have vaso-vagal from lidocaine, though.

#38 ::: elizabeth ::: (view all by) ::: December 10, 2007, 03:43 PM:

As Jim's posts always are, this is fascinating. I have facial numbness of unknown origin - at least now I have some clue what nerves are playing with me, and I can curse and cajole them into playing nice. Cranial Nerve V, I am *talking to you* here.

I did in fact talk to a Real Live Neurologist about this - she did the battery mentioned in the linked page, and told me to come back if I have any new symptoms. Of any kind. I don't know if that includes talking to my nerves, though.

#39 ::: Xopher ::: (view all by) ::: December 10, 2007, 04:06 PM:

I've heard that Bell's Palsy is sometimes a symptom of HIV seroconversion. Or initial infection; that stuff confuses me. The one person I've known who had it did turn out to be positive some time later.

By the way, it resolved on its own in a week or two.

#40 ::: Diatryma ::: (view all by) ::: December 10, 2007, 04:09 PM:

Xopher, the first time I heard of Bell's palsy was in the context of Lyme disease. I think it's common to a lot of disparate conditions, so it's not diagnostically useful.

#41 ::: Carol Kimball ::: (view all by) ::: December 10, 2007, 05:06 PM:

Mnemonics:
I'm in the "Finn And German Viewed" crowd. I pleaded with my dad to tell me the "naughty little mnemonic" to remember the bones of the wrist, and since I already knew there was one, he obliged:
"Never lower Tilly's pants, Grandma might come home."

Did he clean it up for me?

#42 ::: . ::: (view all by) ::: December 10, 2007, 05:30 PM:

.
[posted from 77.112.18.94]

#43 ::: shadowsong ::: (view all by) ::: December 10, 2007, 05:38 PM:

Carol @ 41: Actually, I think either you remembered it wrong or your father not only cleaned it up but screwed it up. It should be "Some lovers try positions that they can't handle," for "Scaphoid, lunate, triquetral, pisiform, trapezium, trapezoid, capitate, hamate."

#44 ::: Lila ::: (view all by) ::: December 10, 2007, 06:05 PM:

Jim, one of my colleagues (an ex-EMT) uses the term "commode code" for those found in the Elvis presentation.

My favorite mnemonic for the cranial nerves was "Oh, once one takes the anatomy final, a good vacation sounds heavenly." Then they went and changed "auditory" to "vestibulocochlear" and "spinal accessory" to "accessory" and screwed up a good mnemonic.

re weird experiments with the cranial nerves, my favorite involves pouring cold water in somene's ear to induce nystagmus. Also, in patients with "left neglect", this can make the neglect disappear temporarily. Good stuff.

#45 ::: Carol Kimball ::: (view all by) ::: December 10, 2007, 06:44 PM:

#43 ::: shadowsong

Carol @ 41: Actually, I think either you remembered it wrong...

It's most likely my memory from the late 60's. I remember that he pointed to and named the corresponding bones right after the mnemonic, and showed how you ask the person to make the "salt cellar" depression where you check for a fracture. On car trips we used to trace drops of blood through the body (with those tricky pulmonary arteries and veins having the oxygenation backward), go through the alphabet (the valued "xiphoid process" surfaces again here), and so on.

The only other possibility was that there was a nomenclature change, as I prefaced the question with, "When you were in med school..." (during WWII).

#46 ::: Mary Aileen is suspicious ::: (view all by) ::: December 10, 2007, 07:18 PM:

#42 is so generic I got suspicious. The link leads to a billiard site in Polish(?). Spam, or someone who doesn't communicate well in English?

#47 ::: Chris J. ::: (view all by) ::: December 10, 2007, 07:51 PM:

Carol in 41--you've got it right. I was taught all about Tilly's pants in med school, circa 1974.

#48 ::: spc smells comment spam ::: (view all by) ::: December 10, 2007, 08:37 PM:

Mary @ 46: it's spam, spam, baked beans, and spam. Google finds the exact same post on five other blogs already.

#49 ::: James D. Macdonald ::: (view all by) ::: December 10, 2007, 11:00 PM:

The salt cellar depression is also known as the snuff box, I think.

Never Lower Tilly's Pants, Grandma Might Come Home lists the bones in the wrist under their old names:

Navicular, Lunate, Triquetrum, Pisiform, Greater multangular, Multangular lesser, Capitate, Hamate


The new names are Scaphoid, Lunate, Triquetrum, Pisiform, Trapezium, Trapezoid, Capitate, Hamate.

Used to be that the Navicular was the most commonly fractured bone in the human body. Now the Scaphoid is the most commonly fractured bone.

Speaking of the facial nerve (Cranial nerve VII): its terminal branches are Temporal, Zygomatic, Bucccal, Marginal mandibular, and Cervical. The mnemonic is To Zanzibar By Motor Car.

#50 ::: James D. Macdonald ::: (view all by) ::: December 10, 2007, 11:22 PM:

I don't know about vagal stimulation being involved in having a "glass jaw."

I do know that unconsciousness in concussion is caused by a mechanical/chemical disruption of the brain, and that the damage from multiple concussions is cumulative.

I believe that in addition to the classic punch to the jaw, that a sudden downward jerk on an arm can have the same effect.

And I'm told that these days, in student sports, that if a player is knocked out, that he's benched for a minimum of two weeks. If he's knocked out again, he's benched for a minimum of a month. And if he's knocked out a third time, he's benched until next season (the next year).

#51 ::: Robert L ::: (view all by) ::: December 11, 2007, 12:49 AM:

"On Old Olympus’ Towering Tops
A Fat-Ass German Vends Some Hops."

My father used to recite this mnemonic once in a while. He graduated from NYU Medical School ca. 1939. I wonder how far back these mnemonics go.

There are a number of sites that have free downloads of hundreds of medical mnemonics. I don't have that much room on my hard drive right now, so I'm going to wait on that, but I did sample a few. Some, which make reference e.g. to Bob Marley or Randy Travis, are obviously of recent origin. But I suspect there are quite a few that go back a long time.

Incidentally, "Bell's palsy" is itself a mnemonic for its own symptoms:

"BELL'S Palsy:
Blink reflex abnormal
Earache
Lacrimation [deficient, excess]
Loss of taste
Sudden onset
Palsy of VII nerve muscles
· All symptoms are unilateral."

#52 ::: Earl Cooley III ::: (view all by) ::: December 11, 2007, 01:08 AM:

James D. Macdonald #50: I believe that in addition to the classic punch to the jaw, that a sudden downward jerk on an arm can have the same effect.

That's interesting. I wonder if there are any martial arts that use that technique for that specific reason. EMT-fu?

#53 ::: James D. Macdonald ::: (view all by) ::: December 11, 2007, 02:49 AM:

I wonder if there are any martial arts that use that technique for that specific reason.

Since Colonel Fairbairn taught that technique to British commandos during WWII for just that reason, I suspect so.

#54 ::: Ingvar M ::: (view all by) ::: December 11, 2007, 06:01 AM:

James Macdonald @ #50:

Hm. I saw a demonstration on, er, one of the light science shows on British telly, showing a knock-out done with a palm strike to the side of the neck, centred slightly lower than the ear (the camera man wasn't concentrating on getting perfect shots of the impact), with the stricken person having an assortment of brain activity sensors on them and an assisting doctor, showing that the brain activity read-out did indeed indicate that they were completely unconcious. If the footage wasn't edited for time, they seemed to be out for 15-30 seconds.

#55 ::: Nicole J. LeBoeuf-Little ::: (view all by) ::: December 11, 2007, 01:58 PM:

So. Vaguing out. Does that also have something to do with that scary thing that apparently sometimes happens when a guy pees in the woods and it's hella cold out?

This happened to a friend of mine. He was camping. Got up in the middle of the night to take care of business. Next thing he knows he's waking up a minute later unable to move and in pain because he'd passed out, fallen down, and broken his collarbone. (His camping companion was able to get him appropriate help. He's all better now.) Apparently his heart had stopped temporarily, or his blood pressure had simply lowered dramatically, while he was urinating. Something to do with the combination of that bodily process and really cold weather. He told us the medical name for the syndrome, but I can't remember it, or how rare it was said to be.

Remember, kids, always have something to lean on when you're doin' yer stuff!

#56 ::: Dena Shunra ::: (view all by) ::: December 11, 2007, 03:59 PM:

An unfortunate side-effect of reading Making Light in between translation projects (urgent! quick! don't wait a moment!) is I don't necessarily have the time I needed to pursue items of fascination further - in this thread, for example, I didn't yet take the time to connect the menmonic with the object-of-memory.

So I've been walking around for the last 48 hours or so with a sort of mnemonic ear-worm: something about a fat-assed German has been repeating in a sort of sub-volitional way, the rhythm being just about exactly keyed in to something - or maybe, my mind demanding the extra time to close that open circuit. I'll have to take the time to memorize it, or risk insulting nearby Germans (with admirable anatomies and beer-drinking habits).

#57 ::: Steve C. ::: (view all by) ::: December 11, 2007, 04:33 PM:

I have a old friend who would vague out during a good belly laugh. He'd be roaring with laughter, then plunk! backwards in his chair.

#58 ::: shadowsong ::: (view all by) ::: December 11, 2007, 06:27 PM:

Steve @ 57: it could be argued that we have a host who does that as well! not vagus related, granted, and as far as i know she usually falls over INSTEAD of laughing, but still.

#59 ::: Lila ::: (view all by) ::: December 11, 2007, 06:45 PM:

Steve C. @57 and shadowsong @ 58: Indeed, it sounds a lot like cataplexy, which my sister also has.

#60 ::: Steve C. ::: (view all by) ::: December 11, 2007, 06:48 PM:

Ach! I misremembered - my friend Bill didn't faint when laughing, he fainted when he yawned. The doctor told him he was putting pressure on the carotid arteries, but I wonder if he was squeezing the vagus nerve?

#61 ::: Hob ::: (view all by) ::: December 11, 2007, 07:59 PM:

James @ 20: You got it right - that mnemonic fits as long as you file #XI under A for Accessory, rather than S for Spinal Accessory.

When I was in nursing school, the one that went around was nearly the same as the Robertson Davies version, except instead of "and hymen" it just ended in "AH!"

#62 ::: karen ::: (view all by) ::: December 11, 2007, 09:09 PM:

Question: When my father, um, turned into an Elvis impersonator,* we were told (paramedics) it was most likely a stroke, with a handwaving explanation of stimulating the heart to beat faster. Sounded plausible, as he was secretly off his diuretics and other meds. (But also ill so maybe dehydrated and suddenly facing low BP?) So are there two risks to bathroom visits? Or were they mistaken?

* He'd have approved the description, and loved a good grisly EMT story as long as he didn't have to see it.

#63 ::: James D. Macdonald ::: (view all by) ::: December 11, 2007, 09:52 PM:

#60 Steve: (I am not a doctor!)

If I remember correctly, the carotid sinus pressure sensors are connected to Cranial Nerve IX (Glossopharangeal), and from there, after the brain receives the message, Cranial Nerve X (Vagus) gets stimulated to slow the heartbeat to lower blood pressure.

But I could be entirely wrong.

=========

Commentary on cold-induced stuff (I talked about this at length in Cold Blows the Wind Today).

One thing that happens when you get cold is the blood vessels in your extremities contract to keep warm blood in your trunk. That raises your blood pressure. The body does a couple of things about that -- slowing the heart, and dumping water out through the kidneys -- to lower blood pressure. When you get warm again, and the extremity vessels open up, bingo, you're dehydrated.

Other things to think about when going into a cold environment include Mammalian Dive Reflex, when something cold hits you in the face. That can lower heart rate dramatically.

Standing up suddenly from a lying position, can put you into Positional Hypotension. The large vessels of the legs may be more dilated when you're horizontal. Stand up suddenly and the blood flows into them before they can constrict, and suddenly there isn't enough blood to pump all the way to the brain. Down you go. (I'm certain that anyone who's stood up suddenly after lying in a warm bath and felt light-headed knows what I mean by this.) Hard to tell what happened to the guy in the woods. Could be he slipped on the ground, broke his collar bone, and picked up a mild concussion too -- with retrograde amnesia so he doesn't remember the events immediately before the fall. Brief memory loss around the time of the event in head trauma is way common.

Being off your meds can have all kinds of bad effects. Diuretics are often given for high blood pressure, in order to dump fluids. Someone who's off their meds might possibly have dangerously high blood pressure, and here you get into danger of stroke and other badness. Hypertension is all-around not good for you. It puts extra strain on your heart, for example. I'm not a doctor, I can't diagnose nor prescribe, and I darned sure wouldn't even try if I were a doctor -- not from a brief description of a patient I hadn't seen.

In general, on meds, take them as prescribed. If you don't know what they're for, or you think there may be unintended interactions, ask questions of your doctor until you're satisfied that you understand.

Plus, sometimes bad stuff happens without an obvious cause. One thing is certain about this life -- no one gets out of it alive.

#64 ::: Julie L. ::: (view all by) ::: December 11, 2007, 10:29 PM:

ISTR hearing about the weird physiology of one or two people who've actually swum a mile or so in Arctic/Antarctic waters with no further protection than a pair of goggles and an ordinary swimsuit; apparently the circulation from their extremities to the torso gets almost entirely shut down, because otherwise (as with most normal people) the temperature shock to the vital organs would kill them.

(pokes around a bit for their names: Lynne Cox and Lewis Pugh)

#65 ::: Lila ::: (view all by) ::: December 11, 2007, 10:46 PM:

Lynne Cox's book is called Swimming to Antarctica; in it she says the physician who monitored her vital signs (including core temp) during cold water swims felt she had an abnormal physiological response that most of us don't have; whether this was genetic or the result of decades of training wasn't clear.

#66 ::: Marilee ::: (view all by) ::: December 12, 2007, 12:48 AM:

Sometimes when I get tired, the left side of my face feels too long. Now, I'm partially paralyzed on the left side and the first time this happened, I went to look in the mirror and carefully compare sides of my face. The next couple times it happened, I checked again. But apparently my face just feels too long; it doesn't actually change. (I do have an obvious asymmetry to my face -- I have only one dimple. When I was a kid, I used to stick my finger in the matching spot on the other side to try to get one there and then learned they're caused by muscles.)

#67 ::: Dave Langford ::: (view all by) ::: December 12, 2007, 08:17 AM:

I like the mnemonic and fondly remember Robertson Davies's version, but neither of them seems any help in getting e.g. the first three nerves in the right order. "On Old Olympus" is almost an anti-mnemonic in that respect, subtly luring you to put OLfactory in second or third place rather than first.

A related item from Richard Gordon's early "Doctor in the House" books also stuck in my head:

The lingual nerve
Took a swerve
Around the Hyoglossus*;
"Well, I'm mucked**",
Said Wharton's duct,
"The blighter's double-crossed us!"

*Typoed thus in my copy.
**Euphemism suspected, rather than typo.

#68 ::: Lila ::: (view all by) ::: December 12, 2007, 08:47 AM:

Dave, if you think about where the nerves physically emerge from the brain it helps keep the order straight. Or to put it another way, you're starting at the front of the head, going back toward the spine; the nose, being in front of the eyes, comes first.

#69 ::: Dave Langford ::: (view all by) ::: December 12, 2007, 09:56 AM:

Lila #68: Good heavens, they're actually numbered logically? Richard Gordon left me with the clear impression that it had all been made fiendishly arbitrary and irrational for the specific purpose of flummoxing medical students.

#70 ::: Sarah S ::: (view all by) ::: December 12, 2007, 10:06 AM:

Did anyone else learn the slightly more polite version of this mnemonic from reading the Sue Barton, student nurse novels?

#71 ::: CHip ::: (view all by) ::: December 12, 2007, 10:55 AM:

Dave@13: was she hypotense before? That's one of the many family annoyances that I've inherited; 105/65 (typical) combines with Positional Hypotension (per JMD@63) such that I've learned to move cautiously when the conductor tells us to stand up during an evening rehearsal. (Never seems to hit during a concert; I haven't tested myself, but I remember von Karajan got wired up once and found his highest heart rate was \anticipating/ the big moments in a performance -- that might be a protection.)

Jon@30: how long ago was this? My previous (retired) dentist was complaining 30 years ago about the increasing tendency to working on patients that were effectively lying down rather than sitting back; his replacement has done all the (too much) required work with me horizontal. It obviously makes working on the maxilla easier, but may also be a reaction to anesthesia-related syncope.

#72 ::: Jon Baker ::: (view all by) ::: December 12, 2007, 11:19 AM:

speaking of brain science...

bad news.

#73 ::: Ginger ::: (view all by) ::: December 12, 2007, 11:52 AM:

#39 -- Bell's Palsy can be induced by a viral infection, so it isn't specific to HIV.

#74 ::: Jon Meltzer ::: (view all by) ::: December 12, 2007, 12:42 PM:

Chip@71: About two years ago. Tufts Dental in Boston.

I was told that lidocaine was the only thing they had strong enough for what had to be done: removing the decayed remains of a dead tooth. After they lowered my head and allowed me to recover from the syncope, the anesthetic effect did work long enough for them to get the mess out. I was a little annoyed that the remains weren't salvagable; I could have used the dollar (or whatever the going rate is now; when I was ten it was a nickel).

#75 ::: Stefan Jones ::: (view all by) ::: December 12, 2007, 01:31 PM:

#72: Ohhh, that's way sucky. Damn.

#76 ::: xeger ::: (view all by) ::: December 12, 2007, 06:53 PM:

Interestingly enough, the physiotherapist commented (in response to my "Ow! Hurts there!"), that cranial nerve 10 is one of the nerves that follows the described path. He was also more than a bit surprised to have a random patient refer to the memnonics of dubious propriety (the one he knows starts out "Oh! Oh! Oh! ... ")

#77 ::: MagentaGriffith ::: (view all by) ::: December 12, 2007, 08:55 PM:

Interesting to see this discussion right now.

Over the weekend, I went to visit my mother. She complained of eye pain. My brother and I started to take her to the doctor, and saw how her face was drooping on one side. We looked at her, and then each other, and thought, another TIA, or even another stroke. An ER visit followed promptly.

Finding out it was Bell's Palsy was quite a relief. Completely idiopathic, as far as anyone can tell. Two days later, she was mostly back to normal. I think she's paying us back for all those late nights she spent taking care of us when we were sick, and not a few ER visits at 3 am.

#78 ::: xeger ::: (view all by) ::: December 12, 2007, 11:35 PM:

This site of medical mnemonics is guaranteed distraction for hours :)

#79 ::: xeger ::: (view all by) ::: December 12, 2007, 11:46 PM:

It's also full of variations on the cranial nerves ;)

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  • #80 ::: moe99 ::: (view all by) ::: December 14, 2007, 12:12 AM:

    This one may have been mentioned upstream, but it is currently in use with the first year medical students at the Univ. of WA:


    Oh, Oh, Oh, To Touch And Feel Veronica's Giant Vagina And Hymen

    (Olfactory, Optic, Occularmotor, Troclear, Trigeminal, Abducent, Facial, Vestibulocochlear, Glossopharyngeal, Vagus, Accessory, Hypoglossal)

    courtesy of my daughter, class of 2011.

    #81 ::: summer36535 ::: (view all by) ::: March 15, 2009, 04:52 PM:

    Maybe someone can help I have looked everywhere for this. How can you do a cranial nerve test on all 12 in less than 2 minutes, without the person knowing, and no neurological checks?

    #82 ::: James D. Macdonald ::: (view all by) ::: March 26, 2009, 10:37 PM:

    How can you do a cranial nerve test on all 12 in less than 2 minutes, without the person knowing, and no neurological checks?

    I don't know, but if you find out can you tell me?

    #84 ::: Pendrift ::: (view all by) ::: May 19, 2009, 04:58 AM:

    Jim @82: I spotted this question yesterday, and sent it along to a friend who's a rehabilitation physician. Here's what she said:

    Here's my take on this, since I do admit patients who can't follow directions/commands, and I also admit patients who do not need thorough cranial nerve testing (like knee or hip replacement patients for example - they typically don't have anything neuro going on). Typically I state my findings as "cranial nerves II through XII appear intact and symmetric" since cranial nerve I isn't commonly testable by observation.
    I - if pt states he can smell, that's intact; or if he reacts in some way to a conveniently available noxious or strong smell, that's probably intact
    II - if pt can see, that's probably intact
    III, IV, VI - extraocular movements intact, can be observed
    V - am not really sure... that's tested by touching the face. But if pt can be observed to blink in reaction to noxious stimuli in the eye (again, you have to have a conveniently available noxious stimulus like dust blown by the wind) then V should be intact because the blink reflex is cranial nerves V and VII.
    VII - observe facial symmetry while talking, smiling, or even at rest
    VIII - can the pt hear? that's probably intact
    IX, X - if pt talks without dysarthria, and/or can be observed to swallow, that would be intact
    XI - if pt is able to shrug shoulders and move head from side to side (sternocleidomastoid) that's probably intact
    XII - if pt can move tongue adequately to talk clearly, or eat without difficulty that should be intact too (I test this along with inspecting the throat, by asking the patient to say "aah" and stick out his tongue)

    A sudden loud noise or bright light wouldn't count as noxious stimuli for CN V testing - she said it had to touch the eye to test the corneal reflex. Noise would test VIII + VII, bright light II + VII.
    You could pretend to remove a speck of dirt from the face, though.

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