The autonomic nervous system concept at the heart of the matter

I read with great interest Drs Barboi and Macefield's article in the November 15 issue, 2025, of the Journal of Physiology entitled ‘The autonomic nervous system: time for a conceptual reframing?’ (Barboi Popper 1979)’ (page 6726, left column, second paragraph). From the perspective of explaining how the very small SAN and its cells keep doing the job incessantly, why transplantation of a completely denervated heart is possible and the consequences for cardiovascular adaptability and why the heart usually ends up at an IHR of ∼90 beats per minute also in diseases accompanied by severe visceral neuropathies (e.g. diabetes, chronic kidney disease, amyloid neuropathy), it is definitely helpful to discuss the neural input to the SAN as consisting of two limbs of the nervous system with opposing effects. Is the autonomic nervous system (ANS) concept necessary? Or ‘autonomic’? No. Neither is ‘visceral’, which presumably is even further from an intuitively understandable description especially by also including the skin. But the ANS term might be helpful, because it has a long history and might be perceived as familiar and as something outside our control. I do not think it is controversial that we use different descriptions/language when we address patients about the /likely/ mechanism of their symptoms, the therapeutic alternatives and their mode of actions than when we address students, clinicians and scientific experts. The authors write: ‘Clinicians continue to understand visceral integration as automatic, involuntary and separate from somatic and emotional integration’ (p. 6726, right hand column, first paragraph). In my experience this is a pessimistic view underestimating the insights gained at least in cardiology; for example, depression is a risk factor for ischemic heart disease, stress-induced cardiomyopathy (also known as Takotsubo cardiomyopathy and the broken-heart syndrome) mimics myocardial infarction, alarm clocks might trigger arrhythmia in long QT syndrome type 2, and so on. Consequently such insights influence how we deal with our patients’ problems and what we teach our students and aspiring colleagues. Finally is it time to reframe the ANS concept and its opposing limbs? It is probably a matter of the context, but I am not convinced that ‘visceral processing function’ is ‘increasingly accurately descriptive’. That is for the reader to decide. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article. None declared. Sole author. None.