musselmannThe old ones of Auschwitz Birkenau, the survivors, called them the ‘Muselmann’ (german for Muslims); the weak, the inept, the ones who distanced themselves from suffering by giving up.  Deprived of any expectation or hope, they no  longer suffered, they just existed, shuffling along like zombies to the inevitable conclusion;  already dead in spirit.  Any hope had been destroyed together with their humanity and dignity.  . 

Jenny fell passionately in love with a man, who abandoned her.  So she declared War on Want by refusing to submit to her own emotions and with that her need for  sustenance?   This is Jenny’s way. Others use drugs to fill the void left by the loss of hope, others eat or drink too much, others seek sex and others find refuge in illness or madness. In a moment of clarity after the storm, Lear expresses that it is better to lose his mind than to be preoccupied by devastating grief.  

David has been my client for twenty years.  He first came to see me because of persistent abdominal pain and constipation, which he was convinced was caused by a cancer of the bowel that his doctor had failed to diagnose.  No medical tests could convince him that he did not have a disease that would kill him unless promptly and properly treated.  He was very suspicious of any notion of any psychological cause but never stopped coming to see me.  David has never   given up, but he has been a hostage to fortune and he suffers for it.  He clings on to the idea a notion that life has to be fair.  He believes in trust and in spite of everything, retains expectation and hope.  If he were religious, this might give him peace of mind, but he’s not and it doesn’t.  Instead his expectations condemn him to torment of frustration and disappointment as life lets him down yet again.  For David, the pain and mental anguish represents his life force, a continuous grudge against the ineptitude of doctors, the neglect of society and the unfairness of life. . 

It was only recently that he came to the realisation that he doesn’t have to be a victim; the passive recipient of what life delivers. People rarely do what we want. They are much more concerned with their own needs. In that respect, life can never be fair.  It’s a world in which those who shout loudest often get all the prizes.  So if David wants to get what he needs out of life, he has to create the conditions that provide what he needs. 

Those who survived the dreadful conditions in the Nazi concentration camps were the ones who were able to retain a sense of their own identity and adapt to the environment without giving up.  They had no expectation of kindness from the prison guards, but they could gain sufficient life force from a brief glimpse of the mountains, the sound of birdsong, the memory of a melody or composing a poem.  Life is what each of us can make of it.  David’s wife was recently seriously ill with cancer, but this gave him a sense of purpose and worth as he negotiated with the doctors, looked after himself and the house and kept up a email commentary to friend.  .  

Life is never easy,  but we don’t have to submit to its cruelties and injustices. Neither do we have to make ourselves ill by railing against the world and suffering the torment and the illness.  There is a third way.  That is to adapt and take responsibility for our own destiny.


Don Juan, the ambivalent one, the wild man women love to hate or hate to love, the one they want to tame or not, the libertine who liberates sexuality from the everyday shackles of marriage, the maverick who rejects the mores of society to please himself, the nomad who promises freedom but delivers loneliness.  Don Juan epitomises the essential conflict of masculinity, excitement or commitment; constantly on the move, he comes in through the window late at night but does not stay for breakfast. 

But who is Don Juan?  Is he a melancholic, searching for something he can never find and does not wish to?   Inasmuch as we all model future relationships on our first love with our mother, do we imagine little Juan’s mother as a tease, unavailable, the joy of possession snatched away from him leaving the unremitting quest but no trust.  So is the Don predestined to a perpetual  struggle between life and death; does he yearn for the love that will kill him, yet fear it?  His promiscuity embraces death but flees the pain.  Is he Peter Pan, forever in search the Wendy he must reject in place of Lilith, la femme fatale, who will seduce and kill him?  Or can we imagine him unfulfilled, getting old;  a wine soaked depressive regaling all who will listen with of tales of conquest,  sans teeth, his flirtations rendered impotent by repetition?    

Don Juan is complicated; he disturbs us.  On the one hand he represents excitement, power, liberty, joy, orgasm.  On the other he is a coward; fearful that relationships weaken him.  He will never  commit or belong.  He does not wish to possess.  He needs to explore, seek out, live the adventure, continue the quest. 

So what of Don Juan in the 21st century?   In an age when technology has uncoupled sexual urge from reproduction and given women control of their own sexuality, has he been rendered redundant by a tipping of the scales of sexual power?  Is there less risk in seduction and less meaning?  Disconnected from social responsibility, coupling is ruled by the thrill of the moment, the sensation.  So is everybody Don Juan?  Is it a case of every man and every woman for themselves?   We read that community and family are being eroded, less people are entering the commitment of marriage,  more children are raised by single parents who are less available as role models or guides,  young people are exposed to sex and pornography at a precocious age and are more likely to experiment with variations in sexuality.  There’s no mystery any more.   So has the Don not so much disappeared as become normalised, familiar and tamed and well, boring?  Is he just as likely to be gay these days?   Has our sexualised society become lost in adolescent fantasy?   Psychiatrists tell us that more males are phobic of commitment.  Sociologists report that career women cannot find partners to father their children.  At a time when loneliness and depression are the common ailments among the young, has romantic love lost some of its passion?

Anneka is only one year old, but she is bonding with me.  She stares hard at my face, makes eye contact, holds it, then reaches out, touches my nose, my eyes, my ears, scanning each of my features, fixing them in her memory.   Then later when she hears my voice she looks round until she finds the face and smiles.   It seems to me she is not just recognising, she is bonding. 

In the fusiform gyrus, deep in the inferior temporal lobe of the brain, there is a collection of neurones that respond to specific faces.  Damage to this area by a tumour or a stroke leads to the neurological condition, known as proposagnosia – absence of face recognition.  The same region also serves place recognition.  It responds to the features of particular cars in car enthusiasts like Rowan Atkinson, and to characteristics of birds in bird watchers like Simon Barnes.  Indeed Barnes writes about having a giss for a bird, a facility for identification from minimal cues.   If Anneka is played a recording of birdsong, she immediately looks out of the window to see the bird.  Is this the beginnings of giss? 

So is the fusiform gyrus, the site for pattern recognition?  And do people develop a facility for better recognition of patterns that are familiar and interest them, like cars, bird or traction engines?   That would make sense.  After all, Chinese people are better at recognising Chinese faces and find Europeans look very similar.  

But recognition is not the same as familiarity.  The latter is more a function of the amygdala and its emotional connections to the orbitofrontal cortex.   You don’t need recognition in order to form an emotional connection. People with proposagnosia are not autistic.  Some with proposagnosia greet everybody with great familiarity as if every face was a friend.   So do minor forms of proposagnosia lead to indiscriminate affection and intimacy, like the potion poured into Titania’s ear.  Almost anyone will do, even one with the head of a donkey.  Is promiscuity based on a neurological deficit of character recognition? 

Bonding is more enduring than emotional connection.  It requires a specificity, a recognition that is  consolidated by repetition.  Every time you see that person, go to that place, hear that song, a charge of emotion fixes the connection deeper into the memory, like paths through the forest.  It takes time to get to know a person, to trust the consistency of the interaction, to establish that  emotional railroad that makes relationships meaningful.   And once that bond has been produced, it is impossible to sever.  Reinforced by contact, it only declines by degrees when lack of contact and/or disillusion no longer sparks the memory.


Redpolls (Carduelis caberet), fidgeted high in the larch, picked clean Capability’s cones  

 and a few fragile fallow fawns shivered by the guard of red stags.

 Then  with a flash of blue’, the final whistle sounded on the plough, 

 the white swan took flight with a last wheezing of the pipes,

 and I stood in the grove while silent swallows swerved around my knees.


After thirty years, she could stand it no longer.

Her legs would no longer bear the weight

of it. There was no disease;  her numbness

didn’t follow neural logic.  She seemed relieved,


distressed more by  foreign news,

the Nazi’s were rounding up the Jews.

So was her spouse the tyrant, the brooding   

presence in the marriage bed?


Brooklyn Credit’s next in charge,   

the token Hebrew on the payroll, whose 

flaccid hatreds disavow his race 

and persecute his wife.   


Confined in their domestic fortress,

her legs refuse to do her duty,

to withold her infant man,

or bear his burden of suspicion


when that same dark hate forces  old women

to scrub the pavement with a toothbrush.

Lacking support, his despairing heart rages, then stops.  

She stands numb with pity and walks towards him.   


Broken Glass by Arthur Miller stars Anthony Cher and Tara Fitzgerald and is currently playing at the Tricycle Theatre, Kilburn before moving to the Vaudeville in  The Strand next week.  

David Barker is one of those intuitive scientists, a latterday Alexander Fleming who is able to follow up on a chance observation to develop a theory of fundamental importance.  He knows his stuff, he has a prepared mind and the imagination to see the possibilities of a chance observation.

Barker is an epidemiologist.  He became interested in the geographical variation of mortality from so called life style diseases, bronchitis, ischaemic heart disease, stroke, diabetes in various parts of the country and observed that this was related to poverty, impaired nutrition and high infant mortality.   Although nutrition had improved over the years, it  did not seem to prevent death from these diseases.  Barker wondered whether infant mortality and death from life style diseases were somehow connected.  In Hertfordshire, they had kept meticulous records of birth weight from early in the last century.  Barker found that those individuals born underweight and who remained  underweight at one year of age, were much more likely to die of  cardiovascular disease later in life.  These early observations were confirmed in Preston, Burnley, Wakefield and other areas of the UK and also in children born during the Dutch famine of 1944-5.  So was there something about the early intrauterine environment that programmed the infant along a track to life threatening disease?  Subsequent observations showed that low birth weight was often associated with big placentas, but what did that imply?   Did the placenta adapt in some way to try to extract nutrients from the mother or did it hypertrophy to produce growth factors?  Was it the placenta that programmed the infant to conserve nutrients? 

If Barker’s hypothesis has any relevance, it must be in regions like India, Arabia or the Southern Seas, where there is a veritable epidemic of premature diabetes and heart disease.  In India, scientists have found that even in areas where people had a very healthy life style with low fat high vegetable diets and lots of exercise, people still died early of diabetes and heart disease.  Birth weight was low but as they developed children remained thin but had a very high percentage of body fat and early signs of a tendency to diabetes – the thin-fat infants. They had concluded that this tendency was related to micronutrient deficiency and are doing a study in which they are supplementing the diets of pregnant women and comparing their infants with un-supplemented mothers.    

 The foetus is not just inert and passive.  It reacts to stimuli.  Scientists have shown that shaking a rattle by the mother’s abdomen, even through the mother is listening to something else through headphones, produces an alarm response in the some foetuses.  And some mothers will testify how their baby will be calmed by music or even beat time to the rhythm.  There is also evidence that maternal stress may produce a nervous baby and this tendency will continue throughout life. 

‘A day or two old and they’ve already got a personality; this one lies there as stiff as a mummy – a regular banker, the next one is throwing himself all over the place happy as a young horse, the next is Miss Dreary, already worried about her hemline.’    

                                                                     Margaret, scene 10, Broken Glass by Arthur Miller.

Show me the baby and I will show you the man or the woman. 

There is even data to show that male babies born to mothers who survived the bombing and shelling of Berlin, were more likely to become gay. 

The data suggest that neonatal stress can rest the hypothalamo-pituitary-adrenal axis and render the rats more sensitive to stress and therefore more susceptible to stress related but otherwise unexplained illness.  The conditions of one pregnancy may be different from another.  Anxious and busy mothers may beget twitchy babies.

This doesn’t deny the influence of genetics nor the subsequent effects of life events and life style.  Genetics provides the potential to respond to a particular environment in a particular way.  Early life experience will enhance or reduce that tendency and the environment later in life will either realise that life script or suppress it.  So malnutrition early in life will cause a person to over-consume nutrients and store them as fat, increasing the risk of cardiovascular disease and diabetes.  In the same way, emotional deprivation may cause a person to be wary and needy, so that they have less tolerance of solitude and more emotional tension and illness.   Psychotherapy is there to help those people afflicted whose developmental limitations have left vulnerable to the viscissitudes of life.  

So Barker’s hypothesis exhibits the truism that whatever happens to us makes us the person we are and life is like a tree,  the things that influence us early in our existence affect how we grow and develop much more that the events that occur later in life.   

Gone is the time when people believed that medicine could cure all known illnesses and the doctor was the high priest of the arcane rites. The advent of the internet has meant that patients may be as informed about their diseases as their doctor and the medical consultation is more a dialogue between experts than a trip to the Oracle. It’s more about containment and management than cure. Popular acceptance of the healing arts practiced by alternative and complementary therapists has led to a greater understanding of the core relationship between mind and body in the achievement of well being. 

By far the greatest demand for gastroenterological services comes from patients with recurrent or chronic symptoms of dyspepsia, abdominal discomfort and bowel upset and long term conditions such as Irritable Bowel Syndrome, Chronic Liver Disease, Inflammatory Bowel Disease, Coeliac Disease and Barrett’s Oesophagitis. A modern GI service will not only need to respond rapidly to gastrointestinal emergencies, but also to monitor and facilitate  the self care of long term gastrointestinal conditions. 

In the future, more patients will be encouraged to care for themselves while their condition is monitored with simple blood and stool tests in their local health centre. There will be greater emphasis of self help groups, which could  be facilitated by specially trained health care professionals; practice nurses, dietitians and counsellors, and resourced by the third sector; the patient charities (e.g., Core, Coeliac UK, CC(UK) and The IBS Network). The IBS Network, for example, publishes its own self management plan, operates a telephone helpline and offers medical advice by email.

Patients with long term gastrointestinal conditions crave the confidence of a consistent, responsive and reliable service. This may well be better supplied within the patients’ locality, avoiding unnecessary referrals to hospital and allowing gastroenterologists to focus on the increasingly sophisticated and complex diagnostic and therapeutic procedures required for the more life threatening and complicated conditions. 

Freed up from day to day management of chronic conditions, it could be that specialists will adopt a more supervisory and educational role, monitoring the test results of patients with chronic life threatening GI illness through shared websites, responding to email enquiries from local health services, training local health care professionals, advising patient charities, and  preparing educational videos to be disseminated via local television services.

There will be less separation between primary and secondary care in future.  It seems likely that the bulk of gastroenterological services, including diagnostic endoscopy, will be conducted within local hospitals and health centres, which specialists will visit to advise and consult. For example, dyspepsia could be managed in the community with a test and treat approach to H. Pylori, while health teams will be set up to tackle major public health issues such as chronic alcoholic liver disease and obesity.

Population screening will be increasingly important.  It is already here for bowel cancer and it is likely that simple, sensitive and specific biomarkers will become available for other abdominal cancers; pancreas, ovary, liver, stomach and oesophagus as well as coeliac disease, IBD and viral hepatitis.

And as always, the focus of gastrointestinal research will continue to shift with fashion, establishing evidence for changes in health care, improving outcomes, eliciting patient experience, estimating the nature of well being, developing appropriate biomarkers for screening tests, and seeking insight into the relationship between the gut, the mind and the alien within, the all consuming intestinal microbiome. The future may well be not so much orange but beige or brown!

This was the piece I was asked to write to celebrate Core’s 40th anniversary.  Core, previously the Digestive Diseases Foundation, is the charitable limb of the British Society of Gstroenterology.  


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