Fergus Shanahan, MD
University College Cork, Ireland
“My brain, it’s my second favorite organ” pronounced Woody Allen.1 For many, it is the seat of the soul, the source of creativity and much more, whereas the heart represents passion, courage, and character. Fondness for other organs
relates to warmth and honesty in the eyes, clarity in the skin, beauty in musculature, and cleanliness in the air inhaled by our lungs. Only the gut is unloved. With its content of gall and bile and linkage with the liver, the gut has long been associated with toxic humors and negative emotions. This persists in colloquial speech, examples of which include: ‘sick with worry’, ‘gut wrenching experience’, ‘bloated with pride’, ‘butterflies in my tummy’, ‘a nervous stomach’, ‘nervous diarrhea’, and the cowardly are still referred to as lily-livered: “How many cowards ... who inward search’d, have livers white as milk” (Merchant of Venice).2
Negative images of the gut and its appendages may account for the obsessiveness with which previous generations purged the bowels of misfortunate patients, regardless of their ills. Many may recall with dread, a time from childhood when there was a vogue for cleansing the bowels with castor oil or other distasteful laxatives. Curiously, the same misguided notions about large bowel hygiene underlie the modern practice of colonic lavage. In the 1994 screenplay of Alan Bennett’s The Madness of King George III early medical attitudes to bowel movements are satirised.3 The eminent Sir Lucas Pepys, one of several bumbling medical consultants called upon to tackle the king’s illness, requests an early view of the king’s motions and recommends an immediate purge, confidently declaring to his colleagues: “I have always found the stool more eloquent than the pulse”.
If art reflects and shapes the way we think, then the portrayal of human organs and their diseases by writers and artists provides an insightful record. Science gives us a way of thinking about disease mechanisms, but only the arts and humanities provide insight and context to the experience of disease. Great works of literature and art have addressed most contemporary scourges, often in a sentimental or romantic context, with disturbances of the heart, mind, and lungs featuring prominently. The gut has not fared so well. Perhaps because of its excretory role, the arts and humanities have found little inspiration in oro-anal transit, and appear to have neglected digestive diseases. The mechanics and mysteries of the alimentary canal have been hidden, but not completely ignored. Fortunately, the works of a few great artistic minds, some prescient, have addressed gut function.
Jonathan Swift alluded to the potential value of extracting material from human excrement in Gulliver’s Travels and heaps scorn on aimless science and the Royal Society as he describes a daft experiment in which a bellows is inserted into the anus for the dual purpose of gaseous extraction or inflation, the latter achieving explosive results.4 This description was of sufficient durability and vividness that two centuries later an image of it would return to the mind of the author Margaret Atwood as she underwent colonoscopy.5
Probing the gut with a scientific instrument also intrigued another Irishman, Leopold Bloom, the fictional hero of James Joyce’s Ulysses, who may have been the first to imagine capsule endoscopy as he ambled along the streets of Dublin over a century ago.6 Joyce dedicated an entire episode (Lestrygonians) of his novel to the gut, in which the rhythm of the prose mimics that of peristalsis.7 Unlike many authors, Joyce was explicit and precise about the everyday functions of the everyman’s digestive tract, from mastication to defecation. This included a phonetic enunciation of the sound of a substantial fart, but his description of swallowing in Finnegans Wake is as beautiful as it is witty: “… the faery pangeant fluwed down the hisophenguts, a slake for the quicklining, to the tickle of his tube and the twobble of his fable”.8
Samuel Beckett’s short play Krapp’s Last Tape deals with isolation in the elderly, and may have been influenced by Joyce as it alludes to an old man’s constipation and obsession with his bowels, a common problem in the elderly.9,10 More recently, harsher realities of bowel disease have found expression in poetry, notably that of Peter Reading11: “My fistulae ooze blood and stink, I vomit puce spawn in the sin, Diarrhoea is exuded. Do not be deluded: Mortality’s worse than you think.” In a more upbeat poem, the renowned scientist JBS Haldane referring to his own rectal cancer begins with the couplet: “I wish I had the voice of Homer, To sing of rectal carcinoma” and includes the comic lines: “So now I am like two-faced Janus, The only god who sees his anus . . . [M]y rectum is a serious loss to me. But I’ve a very neat colostomy.”12
Beauty may be in the eye of the beholder, but appreciation of beauty comes with knowledge and understanding. Access to the innards has revealed exquisite adaptation of structure to function. No longer considered a simple transit vehicle for digestion and excretion, the gut teems with microbial life. When an amateur scientist, Antonie van Leeuwenhoek, turned his home-made microscope on his own stools over three hundred years ago and saw some of God’s smallest creatures, the significance of his findings could not be fully appreciated.13 With more microbes in the gut than human cells in the body and a hundred-fold more microbial genes, the human host is but a minority component of itself! Furthermore, the collective metabolic activity of the gut microbiota is tantamount to that of a hidden inner organ—an organ within an organ.14, 15 This gives new meaning to the popular expression ‘fire in the belly’. Optimal development of the brain and other favoured organs is dependent on microbial signals from the gut; perhaps in time, changing perceptions of this once obscure and neglected organ might see it in its rightful position as the emperor of all organs. Indeed, experimental evidence for the influence of enteric microbes on the brain and animal behaviour should give pause for consideration as to whether we are in control of our microbes or do they control us?16 Who would have thought that transplantation of feces should become a respectable therapy for those with delinquent microbiota?17 A flicker of a smile from Jonathan Swift.
We should mind our microbes and they will mind us. Artists, scientists, and other dreamers will soon be writing of the majesty of the inner tube of life. Unloved? No more.
- Allen W. Sleeper (film) 1973.
- Shakespeare W. The Merchant of Venice, iii, ii. 86
- Bennett A. The Madness of King George III (screenplay) 1994.
- Swift J. Gulliver’s travels. London: Penguin Popular Classics, 1994
- Atwood M. Of the madness of mad scientists: Jonathan Swift’s grand academy. In: Seeing Further. The story of science and the Royal Society. Edited by Bill Bryson. London: Harper Press, 2010, 38-57.
- Shanahan F. Quigley EMM. James Joyce and Gastroenterology. Clin Med 2008 8:632-633.
- Joyce J. Ulysses. London: Penguin, 2000
- Joyce J. Finnegans Wake. London: Penguin, 1992, 319:12-14.
- Logan R. Isolation in time: a cause of suffering in the elderly. Lessons from Krapp’s last tape. Clin Med 2010;10:294-295.
- Beckett S. Krapp’s last tape and other shorter plays. London: Faber and Faber, 2009.
- Reading P. Collected poems. I. poems 1970-1984. Newcastle, UK: Bloodaxe Books, 1995
- Haldane JBS. Cancer’s a funny thing. In: The Oxford Book of Modern Science Writing, edited by Richard Dawkins R, Oxford: Oxford University Press, 2009, 174.
- Dobell C. The discovery of the intestinal protozoa of man. Proc R Soc Med 1920;13 (Sect Hist Med):1-15
- O’Hara AM, Shanahan F. The gut flora as a forgotten organ. EMBO Rep 2006; 7(7):688-93.
- Shanahan F. The gut microbiota-a clinical perspective on lessons learned. Nat Rev Gastroenterol Hepatol 2012;9: 609-614
- Bravo JA, Julio-Pieper M, Forsythe P, Kunze W, Dinan TG, Bienenstock J, Cryan JF. Communication between gastrointestinal bacteria and the nervous system. Curr Opin Pharmacol 2012;12:667-672.
- Kelly CP. Fecal microbiota transplantation – an old therapy comes of age. N Engl J Med 2013;368:474-475.
FERGUS SHANAHAN, MD is professor and chair of the department of medicine, University College Cork, National University of Ireland, and director of the Alimentary Pharmabiotic Centre, a research centre funded by Science Foundation Ireland which investigates host-microbe interactions in the gut and the therapeutic potential of mining the microbiota. His interests include most things that affect the human experience. He has published over 400 scientific articles and several books in the areas of mucosal immunology, inflammatory bowel disease and the microbiota and including several articles relating to the medical humanities.