August 2008

‘I’ve had this pain for months and nobody has been able to help, I’m at the end of my tether with it,’  she complained in a high pitched whine.  The consultant listened carefully, asked her about her pain – when it occurred, what brought it on, whether it was associated with food, posture, sex, exercise, and nodded gravely at her answers.  He then thought for a long while, and then with a grave face told her he wanted to try a completely different type of treatment. He disappeared into the office, only to reappear a few minutes later walking slowly down the ward, holding in front of him a pair of tweezers which grasped a large white tablet.  He dropped the tablet into a glass of water and told the patient to sip the water slowly as soon as the  fizzing had subsided.  


It worked.  The tablet contained little more than vitamin C and some bicarbonate of soda, but through personal gravitas and a little bit of play acting the doctor was able to recruit a therapeutic response in the patient when all other treatments had failed. 


The eighteenth century hypnotherapist, Franz Anton Mesmer, carried this to extremes.  He used to dress up in a purple cloak covered in moons and stars and connect his patients by iron bars to a tub containing dilute sulphuric acid.  By movements of his hands and eyes, he would draw off the sickness and instill energy into the affected part.  This powerful theatre, which resonated with contemporary ideas on electricity and cosmology, rarely failed to cure his patients.   


It helps if the treatment already fits in with ideas that are already prevalent in society.  Yakult, the phenomenally successful probiotic yoghurt, is unproven, but the idea that replacing the bad bugs with good bugs fits with current fears of terrorism and the rise in criminality.  If people can just feel safe inside, then all will be alright. 


For illnesses to heal, we must all have faith in the treatment and in the person who is administering it.  A bit of theatre and make believe can encourage expectation and hugely enhance the therapeutic effect.  Many doctors need to pay more attention to the mechanics of healing; eye contact, active listening, taking time to understand their patients fears and a confident explanation of why the treatment will work. Looking for inspiration on their computer screens and the recantation of rare but serious side effects can be counterproductive.   


But deception is not just important in medicine, it underpins all aspects of life.  Our view of the world is constructed not by what actually exists, but what we think exists, the meaning we ascribe to it and the expectation that we have in it.  These are informed not so much by scientific evidence as by the influence of our parents, our teachers, the friends we had at university, the advertisements on television, a play, an inspiring speech.  


Human beings are story tellers.  We use our imagination to invent a narrative that fits what we perceive.  We convince ourselves it is true, but it is our truth.  There is no absolute truths, only beliefs.  There are no absolute facts, only theories.  But we demand an explanation. We need our narratives, our mythologies in order to make sense of the unknown, to explain the inexplicable,  to tolerate the intolerable.  Traditional healers, like the sangoma in Africa, are story tellers.  They explain the illness and cure it by altering the story.   The same principles are implicit in some types of psychotherapy. 


Many occupations trade in deception; salesmen lie for commercial gain, politicians for ambition, teachers and priests out of conviction, healers out of compassion – actors for dramatic effect.    


Religion is a grand mythology.  The Christian story and the remarkably similar Moslem story have captured the imagination of vast numbers of people for over a thousand years.  They both impart a message of understanding, compassion and self sacrifice, an ethical code essential for the integration of society.  The theatre of the service, the robes, funny hats, rituals, the awe-inspiring edifices all help to consolidate the mythology, maintain the belief and the integrity of the society.  


Our political leaders are also mythic figures; we create Gods out of them.  We need to have faith that they will be strong and determined and live up to our aspirations, while satisfying our needs and dispelling our doubts.  They have to be worthy of our trust in order to gain our votes.  The rhetoric of a charismatic orator such as Barak Obama could unite a nation, inspire half the world.    


Our courts of law attempt to extract truth and justice out of conflicting narratives and deceptions, but in doing so they can create their own mythology which requires the most impressive theatre of bewigged and gowned characters on raised platforms to convey the necessary authority. 


If mythology and delusion were not so crucial to our existence, then literature, poetry, theatre, art, sculpture, song, dance, music would not be so popular.  And because these are representations and not constrained by reality, they possess enormous power to inspire, shock, to bring people together in joy and grief, to demonstrate and teach.  They are outer expressions of our inner world of thought and dream, where every scene is illusion, every act has meaning.   


But if the arts are about expression and representation, what of science?  Science is perhaps the biggest deception of all our institutions; it purports to be about fact, but is nevertheless delusion.  Scientists use assumptions to make the measurements and observations, from which they derive theories that create the ‘laws’ of science and nature.  The only certainties about a scientific fact is that it continues to be supported by observation and has resisted attempts to disprove it, but we know that science is never stable, it changes is according to fashion.  Today’s scientific dogma is tomorrow’s heresy. 


Ask anybody what gives their life purpose and meaning, most would reply that it’s the love of my family, or the love of my spouse or partner.  But isn’t love just a reassuring delusion?  How can we be sure it’s true?  When somebody tells us that they love us, we believe it because we want to believe it.  We need to have somebody special to desire, feel close to; somebody we can invest with our hopes, entrust with our fears, and the expression of love is a kind of password?  Romance is a wonderful  mythology, the cards, the flowers, the romantic dinner for two,  the theatre of the bedroom – the seduction scene.  Romantic couples weave a magic spell, a delusion that convinces them that their love is special and will last for ever.  The Beatles sang,  ‘All you need is love.’  All you need is delusion just didn’t scan!  Even if the relationship is failing, people often hold on to the mythology and the hope it conveys for far too long because the separation and loneliness is just too frightening.     



It’s not what is that’s important, it’s what we think might be.  We can build a better world.  We will never get ill and die.  We will be in love forever.  We will be rich and  famous. God will forgive us. Our children will love us.  Friends will respect us. Human beings tell stories.  It’s built into us.  It’s called imagination.  But imagination involves delusion and self deception.  Our delusions are what inspire us, console us when things go wrong, keep us secure, regulate our behaviour, and generate our desire.  With appropriate self deception we can look back with fond remembrance, and look forward with hope.  Without it, there is no meaning to life.     


By contrast, what serves for reality and is supported by hard evidence,  is dull and tedious, a land of the dead, where there is no meaning and no hope. God does not exist in the ‘real’ world,  love is an illusion, our friends just care for themselves and our employers are only interested in making money.  Life is one long sequence of separations and increasing isolation and when we die we will just disintegrate and nobody will remember who we were. There is no heaven. Beauty is merely a projection.  Happiness is just the release of a chemical in the upper part of the brain stem. Our leaders will always let us down. The world is slowly being poisoned.  We are going to run out of food.  We are just an animal with a capacity for telling stories. 


Phew!  A ray of hope!  Where there’s a story, there’s hope


Rather like patient who is given a ‘placebo treatment’, it is important that people be allowed to keep their delusions (providing they don’t hurt others). Otherwise they run the risk of sliding into a pit of meaninglessness and depression.  Like nineteenth century missionaries, people of strong moral principle can demolish cultural meanings, leading to an erosion of spirit and a decline in health.       


But before I go any further, I should perhaps make it clear that I am not advocating that we should deliberately tell lies, though there are occasions when to conceal the truth is an act of compassion.  Deliberately deceiving another person, keeping secrets from them, not being authentic, can not only devastate their trust, it can also compose  a self script that is so damning, it cannot be edited out.    


Equally so, to be so analytical and introspective that we are fully aware of the extent of our self deception, is not a recipe for happiness.  If we can’t believe in an individual mythology, then we may be destroyed by the reality of the world.  Depression, which is the commonest chronic illness in the western world arises from a depletion, not only of the body and mind but also the spirit – the meaning and purpose of life.


Is there another way?  Is there a philosophy that is more grounded in reality, less dependant of a sustaining mythology, on relationships and material possessions.  Can we become more self reliant?  Can we perhaps find inspiration and peace in the natural world?  It sounds remarkably like Buddhism.  



Comments, feedback on this post would be very welcome.  I feel the message is important, but the style seems a bit too much like a sermon.  What do you think?     

‘I’ve been standing on this bridge all day selling Dr Carter’s pink pills for pale people.  Guaranteed to purify the blood and make the skin like velvet.  Take on an empty stomach and they won’t roll off.  If the pills don’t work, swallow the box.’ 


Did you catch Dr Ben Goldacre’s programmes on Placebos on Radio 4 last Monday and the Monday before?   The messages were uncompromising; the evidence overwhelming.  People who suffer from a variety of illnesses can get better when they are given ‘placebo’ pills that contain an inert sugar or starch compound and no ‘active’ pharmacological agent.  Double the number of placebo pills and the effect increases.  Improve the packaging,  invent a brand name, alter the colour of the pill,  provide a rationale and there are further increments in efficacy.  In other words, it seems that people are not responding to the tablet, they are responding to the idea, the expectation, the belief they have in the treatment. 


Placebo controlled trials indicate that for many illnesses, expectation and belief can provide the bulk of the therapeutic effect.  In patients with unexplained illnesses such as the Irritable Bowel Syndrome, as many as 60% of patients respond to the placebo alone, only a few percent short of those who respond to the active drug.  Thousands of patients are required to prove statistically that this effect could not occur by chance alone.  So are drug companies spending billions of dollars to develop new drugs that are only marginally more effective than inert tablets?   And are we paying for the privilege?      


But it’s even worse than that.  Evidence-based medicine’s holy grail, the randomised, placebo-controlled trial (RCT) is fallible.  The outcomes of RCTs depend on  the patient being unaware of whether they are being given the active drug or the dummy, but this is rarely tested.  Instead, it is assumed that using capsules or tablets that are identical in shape, size and colour and concealing the true nature of the tablet from the prescribing doctor or nurse must make it impossible for the patient to detect the difference. 


That’s not true.  Drugs often taste bitter.  Placebos often taste sweet.  And haven’t we all been trained from childhood that the nasty tasting medicine makes you better?  Even if trial patients don’t detect differences in taste, they almost certainly detect differences in side effects.  Dry mouth, a change in bowel habit, a slight dizziness, drowsiness are all common side effects that would instantly alert the patient that they are taking the active drug. 


Ethical practice for therapeutic trials dictates that patients have to be told that they are taking part in an experiment and that although they may receive the active drug, they may equally well receive a pill that has no pharmacological action on the disease process.  Just imagine what that must be like.  You have suffered a painful disease for years and suddenly you get the chance to test a new drug that promises to solve all your problems, but then you are told that you may not get the new wonder drug, you stand just as much chance of getting the blank.  You would feel so worried that you  would just have to find out whether you were getting the active drug or not.  So you would chew the tablet, break open the capsule, become very sensitive to any tell tale side effects, and even to the complicit gleam in the doctor’s eye, but you wouldn’t let on.   In the few studies where patients have been asked whether they could tell whether they were taking the drug or the placebo, most guessed correctly.  This simple fact must invalidate the results of any RCT at a stroke.


But there’s more.  Although I know of no study that has formally investigated whether the doctor actually knew the true nature of the medication he was administering,  I was involved in research for long enough to realise that such distortions do take place.   Reputations are fragile and ephemeral; medical researchers,  pharmaceutical research coordinators, even multinational executives will do almost anything to protect them.  Sealed codes can be broken, statistics fudged, inconvenient results omitted, negative studies not sent for publication,  studies left out of systematic reviews.     


I’m not intending to blow the whistle on pharmaceutical trials. Many of them, I feel sure, are  conducted meticulously, responsibly according the highest ethical standards.  There are numerous guidelines and safeguards to make sure this is so.  I’m not suggesting that pharmaceutical multinationals are necessarily evil empires that deliberately try to deceive the regulatory authorities.  I am just pointing out the obvious.  Human beings and the organisations they represent are all too – well – human.  And humanity is a broad church.  Politics is about concealment.  Error, distortion, omission and exaggeration all exist in the congregation gathered in the nave of the National Institute for Clinical Excellence.  Indeed, one might be forgiven for asking ‘Excellence in what;  The Arts of Deception?’  


What worries me is that health services now exist in such a state of mutual interdependence with the pharmaceutical industry that it is difficult to see how research can always be conducted and reported with absolute objectivity.    


Some of the drugs that have been developed are truly miraculous and have made enormous differences to our ability to withstand illness and our quality of life – antibiotics, insulin, diuretics, anti-arrhythmics, chemotherapy,  but so many others are probably little more than super-placebos?   


The examples, quoted in Dr Goldacre’s programmes are but a fraction of those that demonstrate the efficacy of placebos.  Human beings are not separated in the neck.  Whatever goes on in our minds has an enormous effect on the ways our bodies work.  Belief can get rid of pain, expectation can cure infections, friendship can cure depression, love can treat tiredness, peace and companionship can prolong life.  Cardiac failure can be treated by a pacemaker that is turned off, angina by an operation in which the skin of the chest wall is opened and closed up again, Parkinson’s disease by an injection of saline,  leprosy by the touch of a King,  epileptic seizures by healers that do little more than place their hands on the heads,  and almost any disease by sipping a solution that is so dilute that the active ingredient cannot possibly exist.    


Drugs are prescribed by serious, responsible and authoritative professionals, who have been trained for five years and apprenticed for a further seven years, who believe in the action of the medication and who understand the way the body works.  With that kind of endorsement, how could we ever doubt the efficacy of drugs.  Drugs are what doctors are about.  Indeed, remove drugs and what would doctors do?      


The idea of  modern drugs;  the notion that there is a pill that can relieve our pain, rectify the gut that has been wrenched out of kilter,  alleviate the burden of backache, make us breathe more freely,  quieten the troubled heart, bring us sleep, render us potent and make us happy, make us life forever, may be deeply reassuring.  We are not alone. There’s always another pill.  There is even a proposal to make Simvastatin available to everybody over the age of 50 so that we don’t die of heart attacks. But our dependence on drugs has stripped people of their self determination.  If we cannot look after our own health without recourse to drugs, how free can we be?  And if we can’t be free from health anxiety,  how healthy can we be?    


I feel sure that our descendants will look back on the millennium as a time when medicine was dominated by pharmaceuticals just as we look back on the ‘enlightenment’ as a time on quack remedies.  The annual UK drug budget is about 7.5 billion pounds.  We urgently need to put our dependany on drugs into perspective.  We must take back responsibility for our own health, realise what living a healthy life means. 


Most illnesses are reversible in their early stages.  The body has remarkable resilience. Rest, shelter, food, exercise, companionship and trust can rectify most illnesses.  It’s only when illnesses are truly life threatening or when the deterioration of bodily function has been compromised beyond repair than we need to turn to drugs. They have their place, but that place is not everywhere.        


It’s time to trust the body to heal itself and learn to give it the best conditions to do so.

It was one of those atmospheric afternoons that can occur in early autumn.  A light mist lent soft focus to the sun as it picked out the greys, greens and russet browns of the Yorkshire fells.  Stone cottages huddled cosily alongside tumbling becks. This was sheep country and I had driven across the high moors to meet Andrea Hunter, a local artist who ‘painted’ in wool.  Her studio adjoined her cottage home in the hamlet of Hardraw, just a mile or two across the fields from where Hawes hunkered down in upper Swaledale.  I climbed the flight of stone steps to a small upper room under a sloping roof of thick slates.  The room was lit by a large window that looked out across field and hillsides dotted with sheep.  It was almost certainly built for weaving. 


Andrea was sitting in front of her drawing board;  a statuesque woman in her mid thirties with ringlets of auburn hair that tumbled like a fleece onto her broad  shoulders. She seemed so much part of the country; I could imagine her striding the moors in dark coat and boots, at home with the long haired sheep that foraged the hillsides.  Her strong face broadened into a wide grin as I walked in, lowering my head in the doorway.  She enquired about my journey in a broad Yorkshire dialect and we chatted about the route and the weather, gauging the safety of our communication.  I soon discerned that Andrea had the easy open confidence of someone at peace with herself and her environment and so I began to ask about her work. 


‘I don’t use wool to make things,’ she told me, ‘I am an artist.  I use it as a medium to ‘paint’ pictures and then I fix the pictures by felting the wool’. Anthea had  discovered the art of drawing with wool through hours of solitary play on her parents sheep farm.       


I asked her to show me and she strode across the room to collect the piece she was currently working on; dark trunks of trees against a light background. ‘Felt’, she explained ‘is what happens to wool when it is heated in water.  There is nothing very difficult about it.  I take two pieces of lightly felted white wool; one with the grain going in one direction, the other with it going in the other direction – like the wrap and the weft.  This is my paper.   Then I paint with the wool.’  She pointed to the skeins of various shades of coloured wool on the shelves by the door.  ‘I would love to work with the wool from local sheep, but it is too coarse.  I get my wool from a flock of Merino sheep on the Falkland Islands.   It comes over in big bales and is dyed at a mill in Bradford.  So this, in effect, is my palette.’  She brought a skein of wool over to show me.   ‘This wool is not spun.  It is just parallel fibres.  That way you can tease it out.’  


‘So I moisten the ‘paper’ with a spray of soapy water and place the wool on top, teasing and spreading the fibres with my fingers.  If I am making a background, a sunset, I use the wool in the same way as a watercolour artist would use colour washes, teasing out the colours and spreading and blending them over the surface.  The good thing about this is that I can adjust and alter the picture as I go along without having to rub out or paint over.   I use a light spray of soapy water to hold the painting in position.  Then when it is done, I felt the layers together.’   


I asked Andrea what happened during the felting process. She replied with the practiced skill of a teacher. ‘Hairs are made up in layers, so the surface of each hair is made of overlapping scales.  When you apply compression and heat to these fibres, the scales interlock forming a mat.  This is ‘felt’.  And once a felt is formed it is impossible to take the picture apart.  So when I have finished a painting,  I moisten it with soapy water and cover in with bubble wrap.  Then I roll it tightly round a cylindrical wooden baton and roll it backwards and forwards.  This compresses the layers and generates heat through friction.  It takes about twenty minutes to fix the painting, but the trick is to do this without the picture moving.  That’s where the spray of soapy water is so important.’  


I looked around the room.  All of her work evoked the atmosphere of The Dales;  the thistle heads, the cotton grass, the horses, the hares and of course the sheep.  ‘I like to do sheep because – well – they are what I grew up with.  I know sheep.  I know how they move, how they stand and look.  I know where they live, the moods of the hills and dales.  I can recreate the wildness of the moors and the strength and hardiness of the beasts.  And there is no better medium than wool for doing this.  I prefer to work in black and white because the natural colours evoke the drama of survival better than anything else.’ 


Andrea Hunter and her work are part of the landscape of Swaledale.  Apart from the time she studied art at Bretton Hall, then part of Leeds University,  she has lived in Hardraw for all her life.  It is in her blood.  Her parents had a farm here.  She married a local shepherd.  She has raised her children here.  The Dales are expressed in her appearance; her hair the dark fleece of the moorland sheep and clouds scudding over the fells; her face the no-nonsense honestly of dalesfolk.  She emanates the strength and peace of a contented soul and transmits this in her work.   

The discs of light danced a violent tango on the thick cream paint of the cabin walls,  backwards and down, forwards and up and then backwards again.     The engine raced, rattling the glass syringes in their boxes and then slowed to a regular thud as the propeller bit into the next wave.  One small dark medicine bottle had broken loose and rattled back and forth across the wooden floor.  Somewhere a door opened and then shut with a bang.  The cabin smelt of Dettol, diesel and fish.  A body,  partly covered in a grey blanket lay on a metal table in the middle of the room.  The lights flashed across his swarthy features, the prominent nose, the high cheekbones, the dark moustache.  His skull, cushioned in pillows, was wrapped in layers of bandage, white except for a faint smudge of blood at the forehead.   His eyes were closed and he slept, oblivious to the world that rattled,  banged, bucked and lurched  around him.  


By the side of the table sat a young woman, dressed in navy slacks and a thick cream coloured Fair Isle cardigan.  She was pretty in a way.  Her brown hair curled loose over her ears.   Her reddened lips were parted to reveal rather prominent teeth with a gap between them.   A scrap of blue paper was screwed tightly in her right hand.  The long fingernails were painted a rich red.   She had been crying, her make-up ran down her face like the rusty stain on the cabin wall she stared at.  She felt sick.


‘You bastard!’   Doris shouted at the sleeping body.  ‘You utter bastard!’   Tears blurred the dancing discs of light as she suddenly got up,  paced back and forth and then tried to push the table to the door.  But it was bolted to the cabin floor and Doris collapsed into her chair, defeated.   The letter was from a girl, a WAAF stationed near Kirkwall.   Doris had read only the first two lines,  ‘Darling, you were so wonderful.  Please come and see me again just as soon as you can’   Just six weeks wed, Doris was completely distraught.  Caught in a blind fury, she just wanted to throw herself, her husband and the whole bloody war into the sea.          


Two years previously,  in that sunny autumn of 1939,  the British government under Neville Chamberlain, declared war on Nazi Germany.  Nothing much happened for the first three months.  In February the following year, the government issued a general call for volunteers.  Wallace, although he was tipped to be a high flyer in his company, had responded without hesitation.  Wrapping his fawn coloured gabardine raincoat around him and holding his dark trilby to his head,  he ran through the squalls to the Navy recruiting office near the top of Park Street in Bristol,  but they were closed for lunch and so he signed up for the RAF a few doors down.  He wasn’t that disappointed – his friends,  Pete and Bryan assured him that the RAF boys got a better class of crumpet.  


That evening he told Doris.  She was frightened;  Wallace couldn’t even drive a car – how on earth could he learn to pilot a plane?  Still, he was so brave and she felt very proud.  Silly with love,  she told her grandmother.   ‘I hope I never live to see you marry that boy’, was her only comment.   But it was war and there was no time to reflect.  Within a few weeks she had left the family; grandma, grandpa, aunts and uncles, her dog Rover, and Daisy, the devoted mother who had lost her husband in another war.   Doris rented a flat in the Victorian town of Clevedon on the Severn estuary; it would be so romantic for her and Wallace when he came home on leave. 


Wallace commenced his pilot training, first in Kidlington north of Oxford, then in Long Sutton in Lincolnshire, before he joined 253 squadron, fighter command, which was assigned to fleet escort duties in Orkney. 


By the spring of 1941, the British army had been defeated and plucked from the beaches at Dunkirk and the Luftwaffe had intensified their bombing raids on London.  The RAF recruited more pilots to respond to the threat of invasion.  Wallace was told that only one in nine of them would survive.   So on the 24th April,  he married Doris at a hurried ceremony in St Luke’s Church.  He wore the blue serge uniform of flight sergeant, his wings proudly sewn to his chest.  Doris clutched her bouquet of white flowers and shivered.  The honeymoon was a weekend in Weston-Super-Mare.  They never left their hotel room. Then Wallace rejoined his squadron.     


Just six weeks later on the 12th of June,  Wallace was on a reconnaissance flight in tandem with his commanding officer.  Witnesses said one engine was making a funny noise. The aircraft had come in from the east over the sea and were heading up a valley on Rousay when they noticed smoke to the south over the hill.  Wallace banked steeply to investigate but was too low to clear the ridge and crashed into a telegraph pole at two hundred miles an hour, cutting off all communication to the island for two weeks.      


Doris had only just got into her office in Clevedon when the call came through.  She left immediately and that same night, took the train to Scotland.  It took her three days. 


Wallace lay in the back bedroom of Mrs Greave’s croft when Doris arrived.     He had broken his back, shattered his right knee, his forehead had been lacerated by the perspex of the broken cockpit and his skull was cracked open.  The MO from the base told her that he had never seen anybody survive such injuries, but Wallace responded to Doris’s devoted nursing and three weeks later was stable enough to be moved to the mainland. 


When Wallace regained consciousness,  he had lost all memory of the accident and the events that had preceded it.  He could not even remember his wedding and he didn’t know who Doris was.  He was childish in behaviour and for a time just talked French.  It was another eight months before he could leave hospital.  Unfit to return to active duty, he spent the rest of the war serving pints in Daisy’s pub in Bedminster.   The daily contact with customers, getting to know the drinks and working out the change rewired his brain.  But he was not the same man.  The damage to his brain had disintegrated his personality.   He had had to reinvent himself.  His sisters remarked many years later that he had gone to war a confident, laughing boy, with everything going for him, and had returned a feckless, middle-aged man, prone to rages and embarrassing behaviour.            


By the end of the war, Wallace was able to return to his work in the same insurance company.  He even passed his professional examinations at the first attempt, but he had lost lacked the emotional containment to take responsibility for even a small  branch office.  He would lose his temper easily.  He drank heavily.  And his behaviour towards women, which had always been very polite, had become openly flirtatious; his innuendo could offend.   


Doris suffered it all, the flirtations, the humiliations, even the drunken rages. They had two young boys and women at that time rarely left a bad marriage.  She stuck it out, but the resentment inside her grew.  She kept the letter as a dark secret and from time to time she would open it and make a solemn vow to herself that if she ever had the chance, she would leave Wallace.  It was only what he deserved.   


They had been married for 18 years when she met Ron.  He had moved into the house next door.  He had recently divorced his wife for adultery, but had retained custody of their 5 year old son.  He and Doris would spend hours talking over the fence while they were both working in the garden. Wallace didn’t seem to notice.  He was hospitable to Ron; he invited him round most evenings – they all went out drinking together.  He even invited him to come on holiday with them.  There was a connection between the two men, a comradeship; during that same war, Ron had served on arctic convoys out of Scapa Floe, the very fleets Wallace had been protecting. 


Wallace never dreamed that Doris could be interested in any other man, let alone a sailor.   But she was.  She was falling in love.  Ron was everything that the old Wallace, the Wallace she had married, used to be – and the reinvented Wallace wasn’t.  He was young, bright, amusing, he had a lively interest in all kinds of things, and he made her laugh.  Wallace’s interests had constricted, become stereotyped by warm beer, laughing women and slow horses and he always seemed angry with her.


Soon Ron and Doris were having an affair.  He would visit her during the afternoons when she knew that Wallace would be safely seeing clients and the children were at school.  They were careful.  They made their plans.  After two years, she left Wallace without any warning.  There was just a note on the kitchen table. She rented a flat in town, hired a man with a van, packed up a few personal items, and left, taking the boys with her. Then she petitioned for divorce on the grounds of mental cruelty. 


Shocked by his wife’s betrayal and furious with the man he had welcomed into his house,  Wallace found the sense of abandonment almost impossible to cope with.  He couldn’t work.  He spent hours in the pub, drinking heavily, buying himself barstool friends by always getting the next round.  His only respite from morbid  preoccupations were the weekly commentaries he composed to his sons; long letters in which he imagined them conducting lives that were always successful and sexually adventurous. 


‘And do they admire you?’  he would ask, as if the continuation of his life depended on their answer.


To what extent, the burden of Wallace’s expectations shaped the lives of his sons is difficult to assess.  They were both successful.  Rory became an artist.  Jack, four years older,  won a  Flying Scholarship with the RAF, obtained his private pilots licence and might have joined the RAF or become a commercial pilot, but those  prospects seemed empty and boring.  So he went to University and pursued a career in zoological research, investigating bird migration.


Flying was Jack’s religion.  He maintained his private pilot’s licence, saved up his money and bought his own aeroplane.  Soaring among the sun-split clouds was the one place he could find peace and inspiration. .      


Jack could not be the happy-go-lucky philanderer that his father wished him to be. He was too shy and introspective.  He never let anybody get too close to him for fear of abandonment.  He had a series of prolonged relationships with women whom he loved, but the inevitable separation always left him with a loss of meaning, that sent him back to the clouds again. 


At length, he married Therese, his research assistant.  In the beginning, they were happy.  Their three children were a joy to them both.  Jack felt, for the first time in his life, that he belonged.  But Therese resented his preoccupation with work and the weekends he took off to go flying.  She grew angry. 


Hurt, Jack had a brief affair with one of his PhD students. Wallace would have been proud of him, but that was little consolation.  It could not negate the guilt he felt.  His girl friend became pregnant.  Jack could not abandon the child, but neither did he want to leave the marriage.  He continued to see his daughter but did not tell his wife, but this strategy was never going to last. After 19 years together, the loss of home, wife and above all, children, was devastating.  It was not an amicable separation.  Therese was furious and took her revenge.  Jack found himself isolated.  His friends deserted him.  It became impossible to continue his work.  He had to find a project, something that would capture his imagination, restore some meaning to his life.   



Wallace, meanwhile, had married a country woman who loved him for the man he had become and understood his losses of memory, supported him through crises of confidence, and guided him to behave in ways that were more appropriate. She became his rock.  He found a contentment he had not known before.  But one bitter February morning in 1994 she collapsed in the bathroom.  Her beloved spaniel also died within the month. 


Wallace lived for another ten years alone in his house on the hill.  His health deteriorated and he suffered being looked after by the carers whom Jack had organised.  It was while he was recovering in a care home from an operation on his hip that he crashed.  He had gone out of his room, without his sticks, on another low flying sortie to visit the ladies when he fell into the door frame, striking his head.  He died later that day in hospital. 



Jack heard the news in Indonesia.  He had left Queensland four days previously  on the third leg of his round-the-world solo flight.  His aircraft, an ancient J3 Piper Cub, had once been WW2 US Army spotter plane, but was very reliable – just a few problems with the carburettor in Australia.  He was island hopping to Singapore before flying on up the Malay Peninsula.  The next day was one of the most dangerous of the whole trip – along the northern peninsula of Sulawesi, then over the sea to Borneo and across the mountains to land in Brunei.  There were storms forecast.  Jack knew he should wait, but if he did that, then he would not get to Singapore the following day and he would not get a flight to England in time for the funeral.  He owed it to his dad. 


He was only an hour or two away from Brunei, flying up the densely wooded valley of the River Sesayao when the mountain ridge ahead was obscured by a tropical storm.  It was getting late.  Unwilling to fly blind into the mountains, he decided to  turn back and try to land by the coast.  He banked steeply towards the wooded hillside.  The cliffs at the side of the gorge were directly ahead of him, lit by a lowering sun that picked out the sparkle of the water cascading down their flanks.  They looked so beautiful,  ‘Oh dad would have loved to see this’  


Tears came into his eyes.  The engine coughed once, twice, three times and stopped. 

There can be nothing as embarrassing and painful as gas. It gurgles and squelches through the intestines during pauses in conversations, sometimes squeaking like a rusty door and sometimes roaring like an express train in a tunnel. It can get trapped by spasms causing pain and such gross bloating and distension that women can look as if they’ve acquired a five month pregnancy within the space of half an hour. It can rise up in the mouth and be expelled with a cavernous belch but worst of all, it can escape downwards, silent and deadly at five paces or with a distinctive sound that instantly identifies your shame.


Doctor Janet Tomlin, who worked in my laboratory, had the dubious privilege of measuring colonic gas expulsion by means of a rectal tube attached to a gas proof bag.  Her ‘normal’ volunteers expelled between 200ml and 2 litres of gas depending on the diet they consumed.  



Most of this gas is generated in the colon by the fermentation of carbohydrate or protein that has escaped absorption in the small intestine. Indeed the colon can be thought of a large fermenting vat of bacteria, converting sugars and starches and some protein to short chain fatty acids (mainly acetic acid, propionic acid and butyric acid), a little alcohol and a lot of gas. Colonic gas is predominantly an explosive mixture of hydrogen and carbon dioxide with variable amounts of methane and some nitrogen.


My first insights into the explosive capabilities of intestinal gas was obtained on camping trip when I was just 14 years of age. During one particular riotous evening, one of my friends, John Bishop, offered to ignite his intestinal gas in exchange for a pint of beer. So later, back at the tent, he prepared himself, his bottom emerging pale like the risen moon from between the tent flaps, while we readied ourselves with the matches. On the muffled order of ‘Now!’, we lit a match and held it close to the pale globe.  There was hiss of gas, a slight flutter, and the field was instantly illuminated by a bright tongue of flame that was just as quickly extinguished.


Pain sensation is not immediate. There was a pause as our eyes adjusted to the dark. This was followed by a scream as a half naked figure rushed from the tent and half ran, half jumped across the field, heading for the river.   


Blowback! So let this be a solemn warning to any who might be tempted to repeat this experiment at home.   



In the early days, explosions were also reported during the endoscopic removal of a rectal polyps using diathermy.  In one such incident, so the story goes, the sigmoidoscope was expelled out the rectum with the force of a rocket,  slamming the surgeon against the opposite wall of the operating theatre.  As the dazed surgeon slid slowly to the floor, the patient raised himself on one elbow, looked round and with wonderful understatement, said, ‘Gee doc, you could do someone an injury doing that.’ 



But for most people the greatest risk of inadvertent gas production is psychological and occasioned by the smell and of course the noise of the escaping gas.


So why should intestinal gas smell so bad? After all, carbon dioxide, hydrogen, methane and nitrogen are all odourless. The answer is that just as water carries the taste of orange juice dissolved in it, so odourless intestinal gases carry small quantities of volatile skatoles, cadaverine and putrescine, which are formed by the bacterial putrefaction of proteins. Intestinal gas also contains very small amounts of hydrogen sulphide, the gas of school chemical laboratories that smells like rotten eggs. In the colon, hydrogen sulphide is generated from the breakdown of sulphur containing amino acids as well as the reduction of sulphite preservatives by populations of sulphide producing bacteria.


And what produces the noise? As we are all aware, the expulsion of gas from the anus can generate a variety of sounds. The farty noise is produced by the floppy walls of a relaxed anal canal behaving like a flutter valve, opening and closing as the gas escapes. As any trumpeter knows, the more tension there is in the muscles surrounding an orifice, the higher the pitch. So if a person is squeezing the anus and trying to stop gas being expelled, any increase in abdominal pressure that might be caused, for example, by getting up from chair or laughing, forces the gas out and creates a loud toot! But this need not always be such a disadvantage.



The entertainer, Joseph Pujol discovered early in life that by exquisitely timed contractions and relaxations of the muscles of his diaphragm, abdomen and anal sphincter, he could suck gas into the rectum and expel it at will. Not only that, but by delicate adjustments in its expulsion, he could play tunes and generate sound effects. His fame spread far and wide and under the pseudonym of ‘Le Petomane’ (‘le pet’ is the French word for ‘fart’) he was soon the star of Le Moulin Rouge, performing before the rich and famous. The King of the Belgians was a notable fan. Pujol’s ‘piece de resistance’, Tchaikovsky’s 1812 Overture complete with cannonade, never failed to bring the house down!


Not everybody is fortunate enough to turn their disability into an art form. But there again, not everybody would want to! Neither are people generally as ‘gung-ho’ about farting as Robbie Burns, who advised his readers, ‘Where’re ye be, let ye’r wind gang free’. Most of us strive to contain our wind in company. Not to do so is indicative of a singular lack of social graces.  So it’s not so much the actual expulsion of wind that is the problem, it is what it represents; loss of control, a lack of social competence, a deficiency of manners and even dirtiness.  Such notions were inculcated in most of us at a very early age!



Farting is frequently associated with intestinal illness, particularly conditions, like celiac disease, pancreatitis, or lactase deficiency, that reduce absorption of carbohydrate or protein.  Indeed, the world’s gasiest man, the pseudonymous Mr Sutalf, had lactase deficiency.  He was recorded to fart 144 times in a single hour, generating enough gas to launch a weather balloon.


Farting is also a source of considerable embarrassment for patients with the Irritable Bowel Syndrome; those with diarrhoea because rapid passage through the gut reduces the absorption of protein and carbohydrate, adding fuel for fermentation; those with constipation because they have a extra large pool of bacteria in the colon, which is fed by the soluble fibre (methylcellulose and isphagula husk) and unabsorbed sugars (lactulose syrup and prebiotics) that are used to treat the symptom. 



So what can be done to reduce or modify the expulsion of gas?  There are three approaches; diet, drugs and behavioural therapy.


Since most gas is generated by poorly absorbed starches and sugars, it would seem sensible to reduce the intake of foods that contain such material.


Beans, beans the musical fruit;

The more you eat, the more you toot!


The flatulent properties of beans have been immortalised in the Hollywood film, Blazing Saddles, but bananas, apples, pears, reheated potatoes, cereal fibre and Jerusalem artichoke are also very gassy. Unfortunately these foods are generally reckoned to be healthy, helping people to lose weight and reduce plasma lipids and blood sugar levels. So everything has its down side. But if it’s the offensive odour is the problem, cutting down the amount of meat in the diet from the diet can also help.



Many products claim to reduce intestinal gas. Charcoal biscuits have been used for many years and claim to adsorb the gas onto the charcoal matrix (  Simethicone (Gas X, Mylicon, Phazyme, Flatulex, Mylanta Gas) reduces the surface tension of gas bubbles in the gut so that small bubbles join to produce big bubbles which are more easily expelled.  Beano is a capsule that contains enzymes break down the starches in beans before they can be fermented in the colon ( By changing the composition of colonic bacteria, probiotics might lead to a reduction of flatulence in some people, but in others they might actually cause more gas.  Capsules containing peppermint (Colpermin or Mintec) may also help, not because they reduce the production of gas but because the gas generated smells more sweetly of peppermint.


There is even a product called Fartypants, tight underwear containing a fart filter of activated carbon ( They are hardly a fashion statement but they may nevertheless be a useful aid to socialisation.  And now, hot from the factory, is ‘GasBGon’, your own personal cushion containing a gas absorbent (  



There is no easy answer for most people with gassy symptoms.  Relaxation and complementary therapies, that help to build confidence, may reduce the sensitivity and reactivity of the colon allowing more gas to be retained and absorbed instead of voided.  


For people who work in an enclosed office, it may be useful to take frequent loo breaks or walks to expel the gas. 


But symptoms frequently express meaning and there can be few more meaningful symptoms than farting.  So for patients whose gas expulsions resist all dietary or behavioural modifications and do not respond to medications,  it can be useful to address the meaning – whether this be fear of company,  the seeking of attention  or even expression of disapproval or anger.   Gas leaks can be dangerous whatever the cause!          





The day after the operation, she was sitting quietly by her bed, reading a magazine, when with a whine, a whirr and a flutter of tire tread, up trundled a Dalek or at least something like it.  The body resembled a self-propelled heavy duty vacuum cleaner and was topped by an adjustable, flat-screen television monitor with the consultants concerned face on it. 


The machine came to a quiet halt in front of Marjorie.  She hadn’t noticed.  She carried on turning the pages of her magazine.   ‘Good morning, Marjorie, it said, how are you feeling today?’


She looked up, stared, seem to give a start, then recognised her consultants face.  She relaxed, smiled knowingly, and replied a little self consciously,  ‘I feel better, thank you.’. 


The face on the monitor then proceeded to ask her specific questions about how much she was eating, her bowels, any soreness.   The machine then focussed in on the results of today’s tests, seemed satisfied,  ‘That’s fine, Marjorie, I’ll see you tomorrow.’  and swivelled round with a whirr and motored on down the ward. 


Asked what she thought of addressing a robot, she smiled and said, ‘Oh it’s just like talking to my husband.  He’s deaf, you know.’


Oh, so not much communication there then!    



But the consultant on the monitor was none other but Lord Darzi of Denham, KBE, perhaps the most eminent doctor in the country, the author of the government’s latest review on the health service and the advocate of a new constitution for the NHS, one that respects and empowers the patient. 


Yet, this same man conducts ward rounds using a Dalek! 


In the introduction to his review, Darzi writes,  ‘I have continued my clinical practice while leading the review nationally.  I have seen and treated patients every week.  Maintaining that personal connection with patients has helped me to understand the changes we still need to make.’   


Personal connection?  With a robot?   


The report continues with high sounding rhetoric. Patients should have control and influence on their own health care.  They should be able to choose which GP practice they attend, they should have access to the best drugs, and those with a chronic illness should have a personalised care plan. 


I suppose patients could also have a say on which colour robot they wanted – something to match their dressing gown, maybe! 


‘All patients want care that is personal to them.’ 


Personal care?  With a robot?   How does C3PO palpate the patient’s abdomen – conduct a rectal examination.  No milord, care by a robot, is hardly personal.  Perish  the thought that it even might be! 


‘High quality care should be as safe and effective as possible, with patients treated with compassion, dignity and respect.’


Compassion is something that can only be conveyed by personal contact.  The patient has to be sure that their doctor really cares.  Sending a robot along really doesn’t do it.   


Dignity?  How could you tell a Dalek about your most intimate symptoms, your deepest worries?  Who else might be listening?  Sending along a robot reduces the status of the patient to that of a machine.       


Respect?  I’m afraid that the use of robots to conduct ward visits conveys the message that their consultant is far too important and busy to see them.  This is hardly respectful.   



Darzi’s robot featured on the television programme, Superdoctors, which was broadcast on Thursday night.   So, to be fair, we don’t know whether the good Time-Lord uses his C3PO routinely or whether this was just for the programme.  Darzi commented that a robot would enable him to maintain continuity of care wherever he was – even from America.  That is true, up to a point.  C3PO might allow Darzi to keep control of his patients, but does it really allow him to administer care? 


Caring is a very human relationship, like loving.  Indeed, it is important that doctors love their patients – not in any romantic sense – but in a compassionate, human sense.  But some patients are difficult to love. I remember one of my teachers, a very wise professor, telling me how he once had to look after a tramp.  ‘He was filthy dirty, drunk, abusive and he smelt like a latrine that hadn’t been cleaned for a month.  He only had one tooth in his jaw, but that tooth seemed to sum up the tragedy of his life,  yet at the same time, his determination to live.  I focussed on that tooth and I began to love it and the more I loved the tooth the more I found I could feel a love for him that overcame my natural revulsion – the more I saw him as a vulnerable person in need of care.’ 


Caring is an essential component of healing, though sadly it seems that medical students are not encouraged to develop either of these essential arts.  The emphasis is on efficiency; diagnostic algorithms, personal care plans and evidence based management.  This has been a developing trend since the nineteen sixties – for as long as I have been in medicine. 


I once remember writing a piece for Northwing, the Sheffield medical student’s magazine, entitled ‘The White Coat Game’.  In it I observed how white coats were originally worn by doctors to protect their suits from the bodily fluids of the patients under their care, but spotless and buttoned up, they seemed to serve another purpose:  to defend the doctor from contamination from the messy emotions of their patients, who were depersonalised in hospital pyjamas and gowns.  The message, ‘Don’t get too close!’  And what did the doctor do when he needed to carry out some messy procedure such as sigmoidoscopy?   He took the white coat off and inspected the rectum in his shirt sleeves!       


Darzi’s robot made me wonder how much of the new NHS constitution is political – offering lip service to an increasingly powerful patient lobby.  Does the strapped-for-time lord not have a public relations assistant?  If he does, they deserve to be fired.  C3PO is appalling PR! 


Healing a patient is like bringing up a child.  It requires intimate personal contact and absolute trust.  95% of human interactions are non verbal.  Touch, eye contact, the flushing or blanching of the skin, involuntary body movements, smell – all of these are important.  They all help to create trust. 


How can you trust a robot?  It may be programmed for a kind of compassion.  The face on the monitor may say reassuring words.  But it is still a robot.  Like television, it is not real!   


And robots are fallible.  What would happen if somebody left a cloth on the floor in front of C3PO, or like ‘Q’s robot in those last few intimate sequences of ‘Live and Let Die’, somebody threw a towel over its head?  What would happen if it took a wrong turning and trundled off down the stairs?  Computers may be great at shopping on line, managing finances, buying theatre tickets, arranging travel, but they are just not  reliable enough to deliver health care.     


And one dreads to think what might happen if the treatments didn’t work and there was no hope.


‘Ex-term-inate! Ex-term-in-ate!




How is it that over 50% of people in this country claim to suffer from food allergy or intolerance yet medical tests establish a diagnosis in less than a tenth of them?   How can elimination of specific foods such as milk or wheat from the diet seem to cure illnesses when there is no objective evidence of allergy or intolerance?   Have doctors just become so immured in their scientific evidence that they are not seeing the broad picture?   Have patients become so fearful of food toxicity and contamination that just the thought of it makes them ill? 


Food intolerance exposes a real clash of cultures.   According to medical criteria, allergy is an immunological hypersensitivity to specific food, like, for example, peanut allergy, while food intolerance requires objective biochemical criteria, such as deficiency of lastase enzyme in milk intolerance.  But many patients and the organizations that represent them tend to define allergy in much the same way as my Chamber’s dictionary, ‘an unnatural reaction to a natural substance’.   So to the doctor, food allergy is relatively rare, but the millions who suffer from reactions to food, it is very common.  Problems arise when people adopt the broad definition of allergy and expect it to be confirmed by immunological evidence or when doctors fail to acknowledge that there are many reactions to food that cannot be validated by immunological tests.  This creates a gap in which private entrepreneurs develop their own allergy tests – leading to exploitation of a vulnerable population.  This was the topic of yesterday’s blog. 


Dr Harry Morrow Brown, emeritus consultant physician and specialist in allergy, has stated that ‘specialization has created barriers to the holistic approach which is essential for the recognition of the diverse illnesses caused by reactions to food and the environment’.  He is correct, because with medical specialization comes the requirement for hard evidence.  Yet food intolerance is more than just a stereotyped bodily reaction to a specific food.  It is the response of the whole person; mind, body and meaning, to his or her environment. 


Surveys have shown that most people with food intolerance have reactions to a variety of foods.  Questionnaires reveal that people with Irritable Bowel Syndrome (IBS) and food intolerance report that between 5 and 22 different foods can provoke their symptoms.  This suggests that it is not the food that is the problem, but their sensitive guts.  It is rather like when you try to put on your shirt after you have been out in the sun for too long.  Your skin feels sore, not because you are allergic to your shirt, but because your skin has became sensitive by being burnt by the sun.  Foods that have rough edges, foods that distend the gut with fluid and foods that are fermented releasing large volumes of gas are particularly likely to cause symptoms.  These include cereal fibre, fruits, vegetables, especially pulses, beer, some fruit juices and onions.  Also implicated are foods that are associated with emotional tension.


We all know how emotion can wrench the gut out of kilter.  If we are tense or we try to eat to quickly or we are worried about what we are eating, then we can get pain and feel sick.  Physiologically, emotional tension increases the activity in the sympathetic nervous system which impairs digestion by drying up secretions,  inhibiting peristalsis, causing spasm and making the gut very sensitive.  As a result, we may end up feeling ‘gutted’.   


Ask me how I feel today.

I feel as unfit as an unfiddle.

And that’s because of a certain turbulence in my mind

And a certain burbulence in my middle.

                                                            Ogden Nash



Sensory signals from the organs of the body are normally damped down in the spinal cord by inhibition from the brain, but if you are anxious, the increased vigilance inhibits that suppression, so that more of the signals reach consciousness as pain and induce gut reactions.  So excessive or unnatural reactions to food can be caused by emotional upset .       


Amanda had ignored how late Rick was coming home and the increasing number of nights he had to spend out of town.  Times were tough for both of them and she knew that Rick was taking on extra jobs so that they could get married and start a family.  So when Rick suggested that they go out for a meal because there was something he had to say to her, she felt thrilled and excited.  The venue was perfect; a little fish restaurant in a village a few miles away.  Rick was attentive as usual but seemed somehow tense and sad.  They chose the ‘salmon with prawns and that delicious buttery sauce’  She had just finished hers when he blurted out that he had been having an affair with Margaret, who worked in the office.  It had been going on for some time.  He still loved her but he loved Margaret too, and well – somehow she had got pregnant.  Amanda listened with mounting horror and dread.   How could this be happening?  Suddenly she couldn’t stay there any more.  She insisted that Rick drive her home, where she was seized with the most violent diarrhoea and vomiting, which continued for three days.  Every time she even thought of food she would be sick.  That was three years ago.  Rick left and married Margaret, but she lost the baby.  Amanda moved to Doncaster, but she continued to be unwell.   Subsequent to the attack of gastroenteritis on that fateful evening, she developed an ‘allergy’ to fish so that  even the smell of fish made her violently ill.  This spread to other foods and even an invitation out made her feel ill. 


Amanda’s gut reaction to Rick’s catastrophic news had been so dramatic that anything that reminded her of that fateful evening made her feel sick.  Her gut has become  conditioned to the associations – going out on dates, nice meals, and particularly fish.   Her doctor has sent her to a gastroenterologist – all the tests were negative.   She has been to an allergist, who carried out tests and advised a very restricted diet.  She was still no better, so in desperation, Amanda went to see a psychotherapist and was able for the first time to talk about what had happened.  Slowly, she gained in self confidence and her symptoms improved.


We all know how the memory of a traumatic events can cause our heart to race,  make us feel faint, cause us to get a lump in our throat or make us feel sick.  What I am suggesting is that if the trauma occurs in association with some particular illness or bodily reaction, then those symptoms persist as a kind of bodily memory triggered by whatever was associated with the event. 


Research on patients with gastroenteritis confirm this conclusion.  Usually,  gastroenteritis or food poisoning only lasts a few days, but in a small percentage of people, the symptoms become chronic and go on for years, even though all traces of the infection are long gone.  Questionnaires administered at the time of the original illness showed that patients who were depressed or anxious about something were more likely to develop persistent symptoms.  It seemed therefore that the gut symptoms had been recruited to express what was going on in the patients’ lives. 


So food allergies may not necessarily be specific immunological or biochemical reactions to particular food components,  but may more usually represent to thoughts and memories associated with a particular food.  In the 1950’s,  patients with severe milk intolerance were fed by gastric tube so they didn’t know what was given to them. The researchers observed that they could tolerate milk quite well when it was given down the tube, but they rapidly developed symptoms if they were told that milk was injected into the stomach irrespective of whether that was true or not.  In other words, it was the idea of the milk that caused the symptoms not the milk itself.      


In other patients the connection between emotion, food and gut symptoms may have been primed early in childhood.  Meals can so easily become a battle ground as foods come to represent a resistance to parental control.  If mum and dad try to make their  little monster eat up his greens, he may get so upset that he is sick and never eats greens again.  The emotion, the food and symptom can establish an aversive loop, which can be very difficult to break it.  I remember that my brother would never eat baked apples.  He complained they gave him stomach ache. This caused mother to become quite exasperated, but then she hit on the idea of calling them ‘Simon’ apples. Immediately he began to view them as a good thing and from that time on would eat his pudding up without getting tummy ache.  Often a specific intolerance bears a closer association with what that food represents for the patient.     


Tracey, a bubbly, pleasantly plump  29 year old,  would only eat chocolate.  Everything else made her sick.  But she was frustrated by her limited horizons of family, her work in the local mill, and a husband who had no ambition apart from supporting the local football team.  She needed more out of life,  more love, more excitement.   The vomiting of the meals she had cooked for the family represented her rejection of the domestic role, while her chocolate consumption represented her desire to have a good time for herself. She never vomited when she went on a girl’s night out.          


 Food is the currency of relationships.  It brings people together and induces feelings of relaxation and companionship.   The primary relationship between mother and infant does not only provide food but also provides warmth, comfort, safety, protection and love.  So from the earliest times of our lives nourishment and nurturing are intimately associated.   Lovers often feed each other like infants.    Going out to dinner is often the precursor of greater intimacy. The family meal is of critical importance in consolidating family ties. Couples invite other couples around for meals to establish a sense of shared experience and empathy. 


The way a person is with food can represent how s/he feels and how s/he is with other people.   People who are wary about what they eat often find it difficult to trust.     Those who suffer from eating food can find relationships and other aspects of life difficult. 


The conviction that food is the cause of the symptoms is more likely to become consolidated when the emotional connection is too shameful or distressing to talk  about.  Psychotherapy can help to make this more accessible, but for Sheila, this was a mixed blessing.   


‘For years, I was so careful about what I ate because I was convinced that my disease was caused by an allergy to food.   At Christmas when I went home, I ate everything and didn’t get any problems with my tummy at all.  Now I’ve come back to the stress and problems of my life here, all the symptoms are back again and I’m watching what I eat.  I guess it must be due to stress.‘


‘But you’re disappointed.’      


‘Yes, because I have no control over the stress.’  



Sounds like more therapy!

Commercial tests for food allergy exploit the fears of vulnerable individuals.  None of them has diagnostic value and what’s more, restricting the diet according to the results of the tests may lead to serious health problems.  Those were the damning conclusions from ‘Which’, the consumer organization, in a report released today.     


‘Which’ carried out its own research.  Four researchers, one with a serious peanut allergy, another with lactose intolerance and two more who had no symptoms of food intolerance assessed 4 different tests.  None of them was experiencing any symptoms of food intolerance at the time of testing.  


The tests used widely differing techniques.  They included analysis of hair samples for vibrational energy (Bionetics) or hair root DNA (Integral Health),  assessment the measurement of changes in muscle resistance caused the proximity of vials containing certain food extracts (kinaesthesiology),  measurement assessment of changes in body conductance when essences of foods are placed in the circuit (Vega),  and analysis of blood samples for circulating antibodies (IgG) to a range of different foods.  They are not cheap.  The cost varies between £45 for the cheapest session of kinaesthesiology to £275 for a full IgG food scan of 113 different substances.      


Each test was evaluated by two researchers, who compared results from two different laboratories or practitioners and in some cases sent duplicate samples under an assumed name.  The results were alarming.  Not only were the tests not replicated by the two different laboratories or practitioners, but analysis of duplicate hair and blood failed to achieve agreement.  None of the tests detected the researcher who had peanut allergy and only one detected the person who was intolerant to milk.  The tests did, however, pick up a whole range of other intolerances.  Kinaesthesiology even claimed evidence for a severe peanut allergy in one of the researchers who ate peanuts with impunity.  The diets recommended by the blood tests excluded up to 39 foods, creating the risk of nutritional deficiency.


The results for hair analysis, kinaesthesiology and body conductance are hardly surprising.  These are exercises in pseudo-science, they have no evidence base and their exponents deserve to be exposed as confidence tricksters, extorting money from vulnerable people under false pretences.  


The data  from the Yorktest and Cambridge Nutritional Services are, however, more worrying.  They measure circulating antibodies to a variety of food substances, their metholodology (ELISA) is scientifically valid, the technicians are trained and, as far is the Yorktest is concerned,  qualified nutritionists are available to offer advice on dietary modification.  The rationale and methods look good, but if they are that good, why is IgG testing not available on the NHS? 



Antibodies did not evolve to protect us against food – they are essential components in our cell wars system against invasion by microorganisms.  Food intolerance is like injury by ‘friendly fire’.    


Antibodies come in various classes.  IgA is secreted into the gut and acts like a fire blanket to immobilize and destroy bacteria before they have a chance to invade.  They are not directly implicated in allergies. 


IgG antibodies circulate in the blood stream.  They recognize and combine with the foreign organism,  tagging it, immobilizing it and rendering it  vulnerable to destruction by the body’s white cells.  They work quietly away all the time, ridding our body of invaders that could take over and damage it.  They, too, for the most part are not implicated in allergies.


IgE exists in the gut wall and attaches itself to highly reactive white cells called mast cells.  Mast cells function like grenades.  The combination of the IgE with a foreign organism pulls the pin on the grenade and the mast cell explodes releasing a cocktail of powerful chemicals, which causes spasms, secretion, inflammation, diarrhea and vomiting – an immediate reaction, which can make the subject feel very ill.  The battle itself is highly destructive, rather like the destruction of Gori in the recent  conflict in the Caucasus.  It is this damaging reaction – the immediate hypersensitivity – that can cause severe allergies.  NHS allergy clinics and immunological laboratories test for immediate hypersensitivity either by injecting small amounts of the food protein under the skin, where, if positive, it causes a wheal and flare or by examining the blood for specific IgE antibodies. 


IgE reactions are highly dangerous and are not deployed often.  Over a lifetime, the body develops a tolerance to most of the foreign substances that it encounters and can deal with these using a quiet combination of IgA and IgG.   The more extreme IgE response is only deployed when the body encounters some rare organism (or protein), that has caused damage before and it has not become tolerant to – like meeting somebody who has previously abused you.  IgE  elicits a rapid protective response that evicts the invader forthwith.  But the body, like a nation state with experience of dealing with other potentially threatening states, usually tends to quieter and more diplomatic means of dealing with the problem. 


Allergies might therefore be regarded as failure of tolerance – the persistent activation of an attack response (in immunological terms a Th2 response), even to food proteins that carry no threat to the body.  Allergy is like an extreme or dysfunctional attitude.  The hygiene hypothesis suggests allergies may be becoming more common because in our sanitized environment, we are less likely to encounter and develop tolerance to the whole range of parasites, bacteria and viruses early in life.  In other words we lack experience, see everything as a threat and over-react – even to the food we eat.   Recent research has shown that worms and helminthes turn the IgE system off.  This allows them to exist in symbiosis with us in our guts, but at the same time, they protect us against allergy.  This has led some to advocate administering worms as a treatment for food allergies.     


But hospital testing reveals that less than 2% of people with symptoms of food intolerance,  have evidence of immunological hypersensitivity – IgE activation.  So there must be something else going on.  So the focus has again swung to IgG. 


The rationale for IgG testing is as follows.  If, for any reason, in a normally tolerant person,  too many proteins get into the body, because – say – the gut has become inflamed and too permeable or the IgA system is defective,  then a  massive IgG response may join with the proteins to produce large clumps which may lodge in the tissues of the joints, the guts, the lungs or the skin causing local inflammation.  An elevation of IgG antibodies to specific foods, therefore, might indicate that enough food proteins are getting across to elicit this type of allergic response.


For the most part, however, raised IgG levels probably indicate quite the reverse – that the body is dealing with the invading protein with normal ‘tolerance’.  This would explain why the York and Cambridge tests detect so many ‘intolerances’ to foods that their subjects can eat without any risk at all.  It would also explain why the most common intolerances are to foods that are most commonly eaten  – there’s just more of them about – and why the results vary according to how much has been consumed.  Finally it would explain why subjects with no symptoms of food intolerance have elevated IgG.           


Several recent studies have shown that raised IgG levels are associated with the development of tolerance to flour in Baker’s asthma,  eggs in egg allergy and foods reintroduced after an exclusion diet. 


The dreadful paradox of all this is that Yorktest and Cambridge Nutritional Services may actually have a test for food tolerance rather than food intolerance.  If that is the case then dietary restriction based on the advice of this test would not only deprive people of what they like to eat but also may risk nutritional deficiency.

Read tomorrow’s blog for a discussion of what food allergies mean.

Dear Dr Dawkins, 


Congratulations.  You succeeded in presenting an authoritative, passionate and convincing account of evolution to a television audience.  ‘The Genius of Charles Darwin’ will stimulate an interest in biological sciences and cause some to reassess their beliefs.  


In last night’s episode, the last in the series, your adversaries were not sixth formers, but their teachers, self styled evangelicals and The Primate of All England, Dr Rowan Williams.  Like you, I was shocked to hear the chemistry teacher declare that he believed that the world was definitely created within the last 10,000 years and saddened at Rowan Williams’ remark that God created the laws of physics.  


There is no doubt in my mind about evolution.  The evidence you presented is quite overwhelming.  Recent investigations in molecular biology have built on Darwin’s observation to create a beautiful and inspiring theory, which is as near to scientific truth as we can possibly get.  John Mackay’s argument that he can’t believe in evolution because he can’t see it happening is patently ridiculous.  Has Mr Mackay seen God?  The sad thing is he might probably say he has! 


But I still feel slightly disturbed by your attack – not so much on belief in God, but on people’s right to believe in their Gods – and even on the belief  in anything that we can’t actually measure.  


I am a also a scientist – and an atheist.  I spent 30 years in medical science.  I published over 500 papers, most of them peer reviewed by other scientists.  I learnt to evaluate evidence and construct a scientific argument.  I, like you, feel passionately about a search for truth, but I am nevertheless all too aware, as you must be, of the limitations of science. 


It all hinges on the nature of evidence.  As I see it, our existence, from a scientific viewpoint, is constructed from three categories of knowledge.  First there are those  aspects we have hard evidence for, like evolution, plate tectonics, the biochemical structure of living matter,  the Laws of Physics, electromagnetism, the benefits of immunisation,  the actions of drugs.   The second category contains knowledge for which the evidence is indirect and much softer, depending often on assumptions and measurements that are in themselves unsubstantiated.  This includes many aspects of theoretical physics – the nature of  subatomic particles, the structure of the universe, the nature of time.  It also includes much psychological theory,  medical epidemiology and even the efficacy of medical treatments since all of these are based on observations of populations and predicated on the assumptions we make in order to group and  separate them and the statistical tests that we apply.  Then, there is a third category, one of acceptance and belief.   This includes many of the cultural and abstract ideas that form our view of the world and condition our social existence, notions like beauty, truth, meaning, love, happiness and belief itself.  This is more the realm of literature, art and music. 


You are a man of culture.  You admitted to Rowan Williams that you love poetry, but… love? ….. poetry?  How do you measure these?  If you are as dyed-in-the-wool a scientist as you can appear to be,  then you must believe that love doesn’t exist and poetry is meaningless,  but I guess you aren’t.   Oh, if challenged, you would bluster on about levels of oxytocin and connections between the limbic system and prefrontal cortex – but this would be sterile and limiting.  It doesn’t capture the essence of human experience in the same way as poetry does.  You might even say that some day we will be able to define the experience of love, or the nature of beauty  by certain types of neurohumoral activity in the brain.  I would have my doubts.      


You may have boxed yourself into a corner by your almost evangelical stance against the creationists, but I would guess that you, like most scientists, hold a balance of knowledge and belief in your mind.  You would have to.  Otherwise you could never say, ‘I love poetry’ or ‘evolution is beautiful’ or ‘that’s patently ridiculous’, because that would immediately challenge your view of love, beauty and meaning – leading you to question the origins of your own beliefs.  Indeed, if I can be so bold, you could never function as Oxford Professor for the Public Understanding of  Science, unless you could use metaphor, yet the very use of metaphor depends on shared cultural narrative, mythology and belief.     


What would you regard as the most important attribute for a scientist – education, perseverance, dedication, a detailed knowledge of statistical method?   I think it is imagination – the ability to dream with your head in the clouds while your feet are firmly planted in terra firma.   Imagination is not about the way things are, it’s about the way they might be.  It’s the stuff of hypothesis, the process scientists use to  convert a belief into a scientific fact,  to make sense of what they can’t understand.    But imagination, surely, is abstract, like beauty or love.  Scientists too have to believe in their mythologies – even though they spend their lives trying to destroy them.            


I am a scientist and a doctor.  I have spent a large part of my life trying to understand the illnesses that medicine has no clear explanation for.  I’ve even written a book on it.  I held professorships in physiology, nutrition and integrated medicine at Sheffield University.   But my epiphany came not with some brilliant physiological breakthough, but with the opportunity to take a Masters degree in psychoanalytical psychotherapy and investigate the meanings of illness.   For years, I had struggled to help my patients, devising new systems of investigation, new methods of treatment, but nothing really worked. 


I am now a better physician.  I integrate the hard facts of  physiology and the softer evidence from psychology and sociology with the meanings, my patients express with their symptoms and ascribe to their treatment.  So, even though there is no scientific evidence that I know of, to support the use of homeopathy, for example, I know that that belief is important to some of my patients and therefore try to work alongside it to bring about the insight that will give confidence and effect a cure.  On the other hand,  I do suggest that they stop taking the drugs that are doing them harm, even though they might be evidence based.  Good medicine, I believe, lies at the hinterland between art and science.  The same applies to good philosophy.    


We all need meaning in our lives, some belief and code of ethics that directs the way we live.  We each need a narrative to make sense of our own lives and a shared cultural mythology to live together in harmony with other people.  Our narratives may well be informed by evidence, but they may not.  But does this really matter – as long as the meaning makes sense to us and our society and doesn’t cause harm.  I suspect – but I have no evidence for it, that the need to create stories, may be part of our genetic heritage – a vital component of our humanity.  


So when I witness you berating recalcitrant sixth formers, beating John Mackay about the head with your arguments or even crossing words with Rowan Williams, I can’t help thinking that you are being a bit of a bully.  After all, you have selected the rules and chosen the weapons.  It is no competition.  They don’t have a chance.  They are coming from a different place.  To be honest,  I find it rather sad that Dr Williams was made to appear as wispy and woolly as his own beard.  I had faith in him as a spiritual leader – but such is the nature of television.        


There is danger in mounting a campaign to disabuse people of their cultural beliefs.  To them, science is as much an abstraction as their belief in God.  Yes, they should be better informed.  By all means educate people about evolution.  Everybody has the right to know where they came from.  But don’t tell them their religious beliefs are rubbish and their Gods don’t exist.  To do that is to be destructive to their soul; it robs them of the meaning of their lives, just like the Christian missionaries were doing in Africa in Darwin’s time.  Freedom of belief is enshrined in all the constitutions of the free world.  Belief is what holds societies together, whether this is belief in God, Allah, Buddah, Oprah Winfrey or Team GB.  It is the variety and quality of our beliefs, irrespective of whether we have evidence for them that enrich our lives.  Science and The Arts work best when they work together.    

The tuna is a magnificent fish.  It has a beautiful streamline shape with sharp serrated dorsal fins and a tail like a scimitar.  The Atlantic Bluefin (Thunnus thynnus) is a dark blue on top shading to a white underneath and can grow to a size of several metres.  It is related to the Swordfish and is much appreciated as a sporting fish by deep sea anglers. 


The tuna is not a single fish but a family, the Thunnuni,  which includes the Skipjack, Yellowfin,  Bigeye, Bluefin and Albacore.  They are pelagic; they range the upper layers of the ocean feeling on smaller fish, crustaceans and squid.  For most of the year, the Atlantic Bluefin forages off the continental shelves of North America and Europe.  When it comes time to spawn, the populations split, one group goes west to the Gulf of Mexico, the other goes east into the Mediterranean.  Once, when they were more widespread and large numbers of tuna fed in the North Sea, schools several miles long could be seen passing through the channel en-route to the spawning grounds. This made them easy to spot and to fish.


But it is in the spawning grounds where the fish are in shallower waters and closer to  human habitation, that most fishing occurs.  This has devastating effects on populations.  A ban of tuna fishing has been imposed in the Mediterranean, but this is difficult to police.  Illegal hunting for tuna still goes on, encouraged by soaring prices.  


As travellers on a continental scale, tuna are strong active fish.  They have to keep on the move; it is their raison d’etre.  If they stop, they die – literally.  Tunas have no mechanism for pumping water over their gills.  Instead, they swim with their mouths open and their forward movement forces water through the gill arches.    


Tuna are able by a combination of muscle activity and swimming in warmer surface waters to keep their muscles at a constant temperature of 30 degrees Centigrade.  Warmer muscles allow the tuna to maintain high swimming speeds for long periods of time and recover quickly after prolonged exertion.  Their dark muscle contains a combination of large numbers of slow twitch fibres adapted for endurance as well as some fast twitch fibres, which provide the necessary burst of speed for the hunter.  It’s perhaps that mix that creates such a tender yet tasty meat.   


Tuna is one of the most delicious fish to eat – so tender with a clean, slightly acidic taste.  It is delicious raw.  Try thin steaks,  basted with spices, coriander seed, cumin, finely chopped garlic and chilli, pepper and sea salt, and seared in a hot cast iron frying pan, until the outside is a light pink, leaving a core of dark red meat inside.  Serve with pok-choi, steamed for a few minutes so that it retains its crisp texture and mustardy flavour, some oriental mushrooms, lightly fried, and a spoon of rice basmati rice with a little soy sauce dribbled over it.  Other recipes recommend marinating the fish in soy and fish sauce and serving with a rocket and parmesan salad with slices of mango, but it is important not to drown the delicate flavour of the meat.  At £4 a steak, this is a meal of rare delicacy, a meal to savour, and you have the added satisfaction of knowing that Tuna contains large amounts of omega-3 fatty acids, which keep your brain, your joints and your arteries flexible.  


At one time, this fish occurred in abundance.  It speed and wide range meant that it was largely fished locally near the spawning grounds. Stocks were sustainable.  For the last thirty years, the demand for tuna in sushi bars and sandwiches has been so high that it is fished on an industrial scale.  According to the World Wide Trust for Nature, the Atlantic Bluefin is on the verge of extinction. 


Had I realised that before I shopped for last nights’ meal, perhaps I would have chosen something else. Gordon Ramsey has taken tuna off the menu in his London restaurants. I also feel slightly guilty at contributing in some miniscule way to the demand for tuna and being prepared to pay the price. But at least I feel that by respecting savouring this beautiful fish, cooking it carefully with the spices and ingredients to set off its unique flavour, I have honoured it. 


Surely it is better to appreciate an endangered fish in this way than to buy it in cans, mash it up in vinegar and pepper and spread it between two slices of plastic bread or to char it to extinction on barbecues.  Does that sound reasonable to you?.  I am not sure I am convinced.  I still feel guilty.        

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