Gut: the new and revised Sunday Times bestseller
By Giulia Enders and David Shaw
4/5
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About this ebook
WINNER OF THE 2016 AUSTRALIAN BOOK INDUSTRY AWARDS, INTERNATIONAL BOOK OF THE YEAR
SHORTLISTED FOR THE 2016 BRITISH BOOK INDUSTRY AWARDS, NON-FICTION BOOK OF THE YEAR
LONGLISTED FOR THE 2015 GOODREADS CHOICE AWARDS 'BEST SCIENCE & TECHNOLOGY BOOK'
A Sunday Times bestseller
The key to living a happier, healthier life is inside us.
Our gut is almost as important to us as our brain or our heart, yet we know very little about how it works. In Gut, Giulia Enders shows that rather than the utilitarian and — let’s be honest — somewhat embarrassing body part we imagine it to be, it is one of the most complex, important, and even miraculous parts of our anatomy. And scientists are only just discovering quite how much it has to offer; new research shows that gut bacteria can play a role in everything from obesity and allergies to Alzheimer’s.
Beginning with the personal experience of illness that inspired her research, and going on to explain everything from the basics of nutrient absorption to the latest science linking bowel bacteria with depression, Enders has written an entertaining, informative health handbook. Gut definitely shows that we can all benefit from getting to know the wondrous world of our inner workings.
In this charming book, young scientist Giulia Enders takes us on a fascinating tour of our insides. Her message is simple — if we treat our gut well, it will treat us well in return. But how do we do that? And why do we need to? Find out in this surprising, and surprisingly funny, exploration of the least understood of our organs.
PRAISE FOR GIULIA ENDERS
‘A publishing sensation that … sets out to free toilet talk from its taboo’ The Times
‘Enders’ gut manifesto calls on its readers to celebrate their lower bodies’ achievements, rather than apologise for them’ The Guardian
Giulia Enders
Giulia Enders received her medical degree from the University in Frankfurt am Main. She is a resident doctor for Internal Medicine and Gastroenterology. She is a double scholarship holder of the Wilhelm-und-Else-Heraeus-Foundation. In 2012 she won the first prize of the Science Slam in Berlin, Karlsruhe and Freiburg with her lecture ‘Darm Mit Charme’, which became a hit on youtube. Her book Darm Mit Charme has won several awards. Additionally, she was a columnist for Die Ziet.
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Reviews for Gut
434 ratings31 reviews
What our readers think
Readers find this title to be an excellent, informative, and entertaining book. It is intelligently written, funny, and full of valuable information. The author's sense of humor adds to the book's appeal. The book is easy to read and understand, breaking down a complex topic into bite-sized nuggets. Readers appreciate the new and fascinating information it provides about a field of research that concerns us all. Overall, this book is highly recommended.
- Rating: 4 out of 5 stars4/5This was published in 2015 - in the 3 short years since then the literature on the importance of our microbial profile has exploded. This is a good book describing in accessible ways the function and 'entanglement' of our guts with our brains.
- Rating: 3 out of 5 stars3/5reads like a series of essays, often repeating others
- Rating: 5 out of 5 stars5/5Loved it. Very funny, eminently readable, and full of great illustrations.
- Rating: 4 out of 5 stars4/5The more books I read about my gut, the less I seem to know. This book is one of the better ones because it (a) gets into the details of why scientists might think this or that, (b) tells you when the information is somewhat or largely conjectural and should be taken with a grain of salt and (c) takes more of a common sense approach in giving the advice (e. g., saying a certain advice is from her grandmother and, although the scientific backup for it is still a little sketchty, her grandmother was right about a lot of other things...: ) Enders writes in an entertaining and witty way although without the "belly-laughs" I had with Mary Roach's similar book (Gulp). Katy Sobey does a wonderful job turning this excellent writing into the audio format.
- Rating: 4 out of 5 stars4/5This book really makes you appreciate what's going on in your belly. I loved the author's sense of humor. Some of the science was still a little complicated to understand, but she really does break it down as simply as possible.
- Rating: 4 out of 5 stars4/5Good explanation of the importance of the gut, the intestinal system, and particularly the microbiome living there. Many new, exciting medical avenues are opening up, due to microbial research.Read this after being mightily impressed by "Biocode", by Dawn Field and Neil Davies, about all the knowledge flowing from sequencing of human (and other) genomes, including the notion of the microbiome. Truly fascinating.
- Rating: 4 out of 5 stars4/5What do we know about our guts? Alarmingly little, according to Guilia Enders, and after having read her book I certainly agree. This ought to be elementary knowledge for any human being, considering all we know of our heart, lungs, psyche, back etc. Our guts play such a major role in our lives, digestion, metabolism, waste disposal, and influence all the other organs, particularly the brain. We are so easy victims of fraud from the so-called alternative industry because we don't know the basics of our own digestive system, and Enders explains matter-of-factly what is right, wrong and possible. The humour in her writing doesn't always work well in translation, so lucky Germans who get the book in their own language.
- Rating: 4 out of 5 stars4/5Really enjoyed this! Super fun to listen to, only wished it were longer.
- Rating: 3 out of 5 stars3/5If you were ever curious about what goes on down thar yonder here is your book. I was expecting a clinical dissertation from like a medical doctor. What I got was more of an entertaining narrative from what I believe is a medical student. The body works in mysterious ways to most of us but there actually is rhyme and reason behind it all (no pun intended, well maybe). Enders (real name) takes us through the magical mystery tour from the mouth to the exit point detailing all that takes place in quite a process that no computer program could ever duplicate.We are introduced to many bacteria who hang out in our innards invited and uninvited. Some will make their presence known in one way or other. While others do their thing without a peep. Ultimately it seems they run the show. A quite good explanation on what we all deal with on a daily basis, and some good advice to boot. Her sister also adds to the mix with her cartoon depictions of those critters aforementioned.
- Rating: 5 out of 5 stars5/5Loved it. Very funny, eminently readable, and full of great illustrations.
- Rating: 3 out of 5 stars3/5I found it informative and interesting for my age, thankyou
- Rating: 4 out of 5 stars4/5Easy to read and understand, the book is beautifully written and very entertaining.
- Rating: 5 out of 5 stars5/5Excellent book, intelligently written, funny andfull of new (as new as possible) information about a fascinating field of research that concerns us all every day, the whole day! A must read and must follow up.
- Rating: 5 out of 5 stars5/5Excellent read . Takes such a complex system and describes it in wonderful bite size nuggets. Can't pronounce half of the bacterium but still very informative
- Rating: 5 out of 5 stars5/5This book is amazing. I learnt so much and Giulia's sense of humour made this book all the more interesting. I have realised that so much more goes on in our gut than what we realise, and I am making a conscious effort to feed my body with nutritious food to help my little gut bacteria thrive :)
- Rating: 5 out of 5 stars5/5This book by Giulia Enders is superb. For one, she has done ample justice to our most under-rated organ. Second, her writing style is cheerful and entertaining. The book contains much serious information, and a reader must exercise caution. Do not get carried away by the book's breezy style. Read with care, and you will find yourself entertained and informed. The graphics in the book are superb. They supplement the tone of the book.
- Rating: 5 out of 5 stars5/5Amazing book, funny style and valuable information. Definitely recommend it.
- Rating: 3 out of 5 stars3/5This is a jaunty, easily digestible précis of intestinal biology, an enterological cornucopia of facts and figures and buttock-clenching anecdotes. Expect a lot of often fascinating talk about poo and farting, rather like a Monty Python sketch without the punchlines, as well as layman's introductions to the latest research into probiotics, prebiotics, antibiotics, the human biome, and the mysterious relationship between your gut and your brain. I learned a lot. I also made several strategic alterations to my diet, so it clearly connected on that level.The author, Giulia Enders, is still studying for her PhD, and the book came about after a TED-style talk she gave at a Science Slam event went viral in 2012; if you understand German, you can watch it here (she's so young!). She writes about her subject with a smile on her face, fending off embarrassment with a no-nonsense, almost mumsy joviality, leavened with a few judicious euphemisms. It's all rendered into perfect colloquial English thanks to David Shaw's translation, which, at least in this edition, is refreshingly British in idiom. I'm not sure how it compares to Mary Roach's Gulp: Adventures on the Alimentary Canal, which I haven't read, but if you're interested in what you eat, how your body works, or just want to binge on some high-fibre factoids, Gut is a solid pop-science choice.
- Rating: 5 out of 5 stars5/5Makes the function of our second most complicated organ easy to understand even for me. It will give you a good insight into your biology and an appreciation for bacteria.
- Rating: 5 out of 5 stars5/5An excellent look at the way our digestive system works, as well as all the little organisms that help it function. I had hoped to get this kind of information from Mary Roach's book Gulp, but I was rather disappointed. Gut, however, didn't disappoint!As someone else said, there were a few portions that dragged a bit, but overall, I appreciated the way it was told, and there's a lot of surprising information packed into this book.
- Rating: 5 out of 5 stars5/5Outstanding book on how the digestive system of our bodies work, from one end to the other, with up to date information on what we do--and don't--know about these systems. Very readable and charmingly illustrated.
- Rating: 3 out of 5 stars3/5Short, punchily written tour of the third of the big human systems (the others being the heart and the brain), with a lot of poop. Some interesting information, such as the reasons that there are benefits from squatting to defecate, but not particularly enlightening otherwise.
- Rating: 4 out of 5 stars4/5I listened to this as a follow up to I Contain Multitudes knowing full well going into it that it was written to appeal to people generally not interested in science, but I wanted this, to a degree. I was looking for straight-forward information that I could use to apply to my everyday choices. I got both what I was expecting, and what I was looking for. Most of my science reading friends are going to find the writing in this one tedious to the extreme. This is meant to be a very introductory text, and Enders' intended audience knows little to nothing about the hard science of the human body and her generous use of metaphors to help readers along is probably effective, but it nearly drove me up the wall. Katy Sobey, the narrator, did an excellent job: her voice was clear, pleasant and easy to understand, but she sounds young and at times the combination of her youthful sounding voice and the metaphors (and especially when the text used 'tummy' - a word I despise) gave the whole thing a very surreal, children's book vibe, that at the beginning was difficult to take seriously, although I quickly got used to it. While I'd never suggest this book for a Flat Book Society read, I did get a lot out of it; both information I was hoping for (about specific bacteria strains that research has shown useful) and information I wasn't looking for but am thrilled to have found. I know first hand the risk of eating cookie batter; the resulting bout of Salmonella left me with a hefty dose of fear for raw eggs. Gut has taken a world of stress off my shoulders. Specifically, Chickens do not harbour Salmonella naturally; it comes from feeding them cheap grains tainted by reptile feces and it does not exist inside the egg (just the shell). I'm never going to be a raw egg eater, but it's nice to know that if my eggs are sourced from organically fed chickens (mine), and I clean the shells before using them, I can once again dip into the cookie dough - and not be the freaked-out-aunt when my nieces want to lick the spoon! These are the practical types of information I was hoping I'd find in this book, so I'm not at all disappointed. For anyone wanting to know more about how their body works with, and depends on, bacteria and the food they eat, but does not have an interest in the nitty-gritty science-y details, I'd recommend this book happily. It's well-written, easy to understand (if metaphor heavy), balanced and informative.
- Rating: 4 out of 5 stars4/5A really good example of a popular science book that actually takes you to a reasonable level in what would be a hospital specialty.This is a very accessible and fun introduction to the gut and gastroenterology in general. There was plenty of new information, for example with regards to non-coeliac gluten enteropathy. It was written in a fun and engaging style by a German Doctor Who has clearly a fascination with the Gastro intestinal tract.
- Rating: 5 out of 5 stars5/5Excellent. Given the book's popularity and the author's youth, I was half expecting an easy-read potboiler. Not at all. Lively style, some goodish jokes and a driving commitment to enlighten the reader make it very accessible. But it covers a huge range of human biology, much of it entirely new to me (a reasonably well-informed layman). Including that we belong to a class of living things "opisthokonts" (I still can't spell it), which includes fungi as well as homo sapiens. Slight disappointment: the illustrations (by her sister who is meant to be a prize-winning scientific illustrator); they are not very elegant and often unclear what they are meant to show. Intend to re-read the book in German.
- Rating: 4 out of 5 stars4/5Very basic and cute.
- Rating: 2 out of 5 stars2/5I found this book to be poorly organized and not very interesting. I'm also extremely skeptical of much of the medical advice provided. There was a lot of time spent on speculation and not much on backing up the advice that was provided. I would have preferred to see footnote citations rather than the general references section at the end. And I didn't enjoy the attempted comical tone or the illustrations. If you're looking for a more medically minded book with clear evidence pointing to each conclusion and recommendation, this is not the book for you.
- Rating: 4 out of 5 stars4/5i found this very interesting and I also found myself reaching for the probiotics, extra water and some yogurt.I found it a lot of food for thought. Literally and figuratively. I learned a lot I never thought I should or needed to know.
- Rating: 4 out of 5 stars4/5My gut unfortunately fell out with me around 3 years ago, and whatever I did to upset it, clearly it's not forgiving me any time soon. I therefore hoped upon hope that this book would have a "Yes! That's it!" moment for me, but sadly (and not overly unexpectedly) there were no such revelations.Still, it's an interesting, popular science read, and I did learn a number of new things along the way about this most complex of organs and how it works when it's working well. Particularly interesting was the new research which points to the relationship between the health of our gut bacteria and mood / depression.I'd hoped that within these pages would be some new insights of the 'got this symptom? Perhaps check out x, y, z', but this is more of a popular gallop through the gut with a light touch on some general dysfunctions. An interesting read, written in a light and entertaining way, but nothing ground-breaking sadly.3.5 stars - informative but not life-changing.
- Rating: 4 out of 5 stars4/5Offen, witzig und verständlich geschrieben was so alles in uns los ist, insbesondere raus geht. Tolles Buch- tolle Schwesternkooperation.
Book preview
Gut - Giulia Enders
GUT
Giulia Enders is a two-time scholarship winner of the Wilhelm Und Else Heraeus Foundation, and is doing research for her medical doctorate at the Institute for Microbiology in Frankfurt. In 2012, her presentation of Gut won her first prize at the Science Slam in Berlin, and went viral on YouTube.
Jill Enders is a graphic designer whose main focus is communication in science. She received a scholarship from the Heinrich Hertz Society for her work. In 2013, she founded a collaborative network of designers and scientists.
For all single parents who put as much energy and love into bringing up their children as our mother did for my sister and me.
And for Hedi.
Scribe Publications
18–20 Edward St, Brunswick, Victoria 3056, Australia
2 John St, Clerkenwell, London, WC1N 2ES, United Kingdom
Originally published © 2014 by Ullstein Buchverlage GmbH, Berlin
First published in English by Scribe 2015
This edition published 2017
Text and Illustrations copyright © by Ullstein Buchverlage GmbH, Berlin. Published in 2017 by Ullstein Verlag
Translation copyright © David Shaw 2017
All rights reserved. Without limiting the rights under copyright reserved above, no part of this publication may be reproduced, stored in or introduced into a retrieval system, or transmitted, in any form or by any means (electronic, mechanical, photocopying, recording or otherwise) without the prior written permission of the publishers of this book.
The advice provided in this book has been carefully considered and checked by the author and the publisher. It should not, however, be regarded as a substitute for competent medical advice. Therefore, all information in this book is provided without any warranty or guarantee on the part of the publisher or the author. Neither the author nor the publisher or their representatives shall bear any liability whatsoever for personal injury, property damage, and financial losses.
9781925106671 (Australian paperback)
9781911344773 (UK paperback)
9781925113785 (e-book)
CiP data records for this title are available from the British Library and the National Library of Australia.
scribepublications.com.au
scribepublications.co.uk
Contents
Foreword
1 Gut Feeling
How does pooing work? … and why that’s an important question
Are you sitting properly?
The Gateway to the Gut
The Structure of the Gut
The ‘gargly’ oesophagus
The lopsided stomach pouch
The meandering small intestine
The unnecessary appendix and
the bulgy large intestine
What We Really Eat
Allergies and Intolerances
Coeliac disease and gluten sensitivity
Lactose intolerance and fructose intolerance
A Few Facts about Faeces
2 The Nervous System of the Gut
How Our Organs Transport Food
Eyes
Nose
Mouth
Pharynx
Oesophagus
Stomach
Small intestine
Large intestine
Reflux
Vomiting
Why we vomit and what we can do to prevent it
Constipation
Laxatives
The three-day rule
The Brain and the Gut
How the gut influences the brain
Of irritated bowels, stress, and depression
Where the ‘self’ originates
3 The World of Microbes
I Am an Ecosystem
The Immune System and Our Bacteria
The Development of the Gut Flora
The Adult Gut Population
The genes of our bacteria
The three gut types
The Role of the Gut Flora
How might bacteria make us fat?
Three theories
Cholesterol and gut bacteria
The Bad Guys: harmful bacteria and parasites
Salmonellae in hats
Helicobacter: humanity’s first ‘pet’
Toxoplasmata: fearless cat riders
Worms
Of Cleanliness and Good Bacteria
Everyday cleanliness
Antibiotics
Probiotics
Prebiotics
The Gut-Brain Axis
New discoveries
Clever cravings for fermented foods
Acknowledgements
Main References
Foreword
I was born by caesarean section, and was not able to be breast-fed. That makes me a perfect poster child for the intractability of the gastro-intestinal tract in the 21st century. If I had known more about the gut back then, I could have placed bets on what illnesses I would contract in later life. At first I was lactose intolerant. I never thought about why I was suddenly able to drink milk again at the age of five; at some point I got fat, then thin again. Then, for a long time, I was fine. Until I got ‘the sore’.
When I was seventeen, I developed a small sore on my right leg, for no apparent reason. It stubbornly refused to heal, and after a month I went to see my doctor. She didn’t really know what it was, and prescribed me some cream. Three weeks later, my entire leg was covered in sores. Soon they spread to my other leg, my arms, and my back. Sometimes they appeared on my face. Luckily, it was winter at the time, and everyone thought I had cold sores and a graze on my forehead.
No doctor was able to help me — giving me vague diagnoses of some kind of nervous eczema. They asked me about stress and psychological problems. Cortisone helped a little, but as soon as I stopped using it, the sores just came back. For a whole year, in summer and in winter, I wore tights to stop my sores from weeping though my trousers. Then I pulled myself together and started doing some research of my own. By chance, I came across a report about a very similar skin condition. A man had contracted it after taking antibiotics, and I, too, had had to take a course of antibiotics just a couple of weeks before my first sore appeared.
From that moment on, I ceased to treat my skin like that of a person with a dermatological problem, and began to see it as the skin of a person with an intestinal condition. I stopped eating dairy products, cut out gluten almost entirely, swallowed various bacteria cultures, and generally improved my diet. I also carried out some pretty crazy experiments on myself … if I had already been studying medicine at that time, I wouldn’t have dared do half of them. Once, I overdosed on zinc for several weeks, causing me to have an extremely heightened sense of smell for the next few months.
With a few tricks, I finally managed to get my condition under control. This success gave me a lift, and I experienced with my own body the reality that knowledge is power. That’s when I started studying medicine.
In my first semester as a student, I was at a party where I ended up sitting next to a guy who had the smelliest breath I have ever smelled. It wasn’t a typical bad-breath smell — not the scratchy hydrogen-breath odours of stressed-out middle-aged gentlemen, nor the sugary-foetid funk from the mouth of an elderly aunt with too sweet a tooth. After a while, I moved away and sat somewhere else. The next day, he was dead. He had killed himself. I couldn’t get him out of my mind. Could it have been a diseased gut creating that smell, and if so, could a diseased gut also have affected his psychological state?
A week later, I decided to share my suspicion with a good friend. And a few months after that, the same friend contracted a bad case of gastroenteritis, which left her feeling very poorly. The next time we met, she told me she thought there might be something in my theory, as her illness had made her feel worse than she ever had before, psychologically as well as physically. Her comments inspired me to start looking more closely at this subject matter. Soon, I discovered there was an entire branch of medical research investigating the links between the gut and the brain. It’s a rapidly growing field of study. Ten or so years ago, there were hardly any published studies on the subject, but now there are several hundred academic articles covering the field. The influence of the gut on our health and wellbeing is one of the new lines of research in modern medicine! The renowned American biochemist Rob Knight told the journal Nature that the field offered at least as much promise as stem-cell research. I had stumbled upon a subject I found more and more fascinating.
As I continued my medical degree, I realised how neglected, even looked down upon, this area is in the medical world. This is all the more surprising when you consider what an extraordinary organ the gut is. It accounts for two-thirds of our immune system, extracts energy from sandwiches and vegetarian sausages, and produces more than twenty unique hormones. Most doctors learn very little about this in their training. When I visited the ‘Microbiome and Host Health’ symposium in Lisbon in May 2013, the number of participants was modest. About half came from institutions with the financial wherewithal to allow them to be among the ‘pioneers’, including Harvard, Yale, Oxford, and EMBL Heidelberg.
I’m sometimes shocked by the way scientists huddle behind closed doors to discuss their important research results, without informing the public about them at all. Academic caution is often preferable to premature publication. But fear can also destroy opportunities. It is now generally accepted in scientific circles that people with certain digestive problems often suffer from nervous disorders of the gut. Their gut then sends signals to the part of the brain that processes negative feelings, although they have done nothing bad. Such patients feel uneasy, but have no idea why. If their doctors simply treat them as irrational mental cases, it can be extremely counterproductive. And this is just one example of why some research results should be published more quickly.
And that is my aim in writing this book: I want to make new knowledge available to a broad audience, and communicate the information that scientists bury in their academic publications or discuss behind closed doors at scientific meetings, while many ordinary people out there are searching for answers. I know there are many patients suffering from unpleasant conditions who are frustrated by the medical world. I can’t offer any panaceas, and keeping your gut healthy is not a miracle cure for everything. But what I can do is to show, in an entertaining way, why the gut is so fascinating, what exciting new research is currently underway and how we can use this new knowledge to improve our daily lives.
My medical studies and my doctoral research at the Institute for Medical Microbiology have given me the skills to sift and sort scientific data. My own personal experience has helped me develop the ability to communicate this knowledge to people. My sister has given me the support I needed to keep me on the right track — listening to me read aloud from my manuscript and saying, with a charming grin, ‘I think you better try that bit again.’
1
Gut Feeling
The world is a much more interesting place if we look beyond what is visible to the naked eye — there is so much more to see! If we start to look more closely, a tree can be more than a spoon-shaped thing. In a highly simplified way, ‘spoon’ is the general shape we perceive when we look at a tree: a straight trunk and a round treetop. Seeing that shape, our eyes tell us ‘spoon-like thing’. But there are at least as many roots beneath the ground as there are branches above it. Our brain should really be telling us something like ‘dumbbell’, but it doesn’t. The brain gets most of its input from our eyes, and that information is very rarely in the form of an illustration in a book showing trees in their entirety. So it faithfully construes a passing forest landscape as ‘spoon, spoon, spoon, spoon’.
As we ‘spoon’ our way through life like this, we overlook all sorts of wonderful things. There is a buzz of constant activity beneath our skin. We are perpetually flowing, pumping, sucking, squeezing, bursting, repairing, and rebuilding. A whole crew of ingenious organs works so perfectly and efficiently together that, in an adult human being, they require as much energy as a 100-watt light bulb. Each second, our kidneys meticulously filter our blood — much more efficiently than a coffee filter — and in most cases they carry on doing so for our entire lives. Our lungs are so cleverly designed that we use energy only when we breathe in. Breathing out happens without any expenditure of energy at all. If we were transparent, we would be able to see the beauty of this mechanism: like a wind-up toy car, only bigger, softer and more lung-y. While some of us might be sitting around thinking Nobody cares about me!, our heart is currently working its seventeen thousandth 24-hour shift — and would have every right to feel a little forgotten when its owner thinks such thoughts.
If we could see more than meets the eye, we could watch as a clump of cells grows into a human being in a woman’s tummy. We would suddenly see how we develop, roughly speaking, from three ‘tubes’. The first tube runs right the way through us, with a knot in the middle. This is our cardiovascular system, and the central knot is what develops into our heart. The second tube develops more or less parallel to the first along our back, then forms a bubble that migrates to the top end of our body, where it stays put. This tube is our nervous system, with the spinal cord including the brain at the top, and myriad nerves branching out into every part of our body. The third tube runs through us from end to end. This is our intestinal tube — the gut.
The intestinal tube provides many of the furnishings of our interior. It grows buds that bulge out farther and farther to the right and left. These buds will later develop into our lungs. A little bit lower down, the intestinal tube bulges again, and our liver has begun to develop. It also forms our gall bladder and pancreas. But, most importantly, the tube itself begins to grow increasingly clever. It is involved in the complex construction of our mouth, creates our oesophagus, with its ability to ‘breakdance’, and develops a little stomach pouch, so we can store food for a couple of hours. And, last but not least, the intestinal tube completes its masterpiece — the eponymous intestine, or gut.
The ‘masterpieces’ of the other two tubes — the heart and the brain — are generally held in high regard. We see the heart as central to life since it pumps blood around the body; the brain is admired for its ability to create a firework of new mental images and concepts every second. But the gut, in most people’s eyes, is good for little more than going to the loo. Apart from that, people think, it just hangs around inside our bellies, letting off a little ‘steam’ every now and then. People do not generally ascribe any particular abilities to it. It would be fair to say that we underestimate our gut — or, to put it more bluntly, we don’t just underestimate it, we are ashamed of it: more ‘guilt feeling’ than ‘gut feeling’!
I hope this book will change that — by making use of the wonderful ability that books possess to show us more than the world we see around us: trees are not spoons! And a gut feeling is a good feeling!
How does pooing work? … and why that’s an important question
My flatmate wandered into the kitchen one day, saying, ‘Giulia, you study medicine — so how does pooing work?’ It probably wouldn’t be a great idea to begin my autobiography with that question, but that little query did literally change my life. I withdrew to my room, sat on the floor, and was soon poring over three different textbooks. The answer I eventually discovered left me flabbergasted. This unspectacular daily necessity turned out to be far more sophisticated and impressive than I ever would have imagined.
Every time we go to the loo, it’s a masterly performance — two nervous systems working tirelessly in tandem to dispose of our waste as discreetly and hygienically as possible. Very few other animals do their business in such an admirable and orderly manner. Our bodies have developed all sorts of mechanisms and techniques to help us poo properly. The first surprise is the sophistication of our sphincters. The vast majority of people are familiar only with the outer sphincter; the muscle we can consciously control, opening and closing it at will. There is another, very similar, muscle just centimetres away — but this is one we can’t control consciously.
Each of the two sphincters looks after the interests of a different nervous system. The outer muscle is a faithful servant of our consciousness. When our brain deems it an unsuitable time to go to the toilet, the external sphincter obeys and stays closed with all its might. The internal sphincter represents our unconscious inner world. Whether Great Aunt Bertha approves of breaking wind or not is of no concern to the sphincter ani internus. It is only interested in making sure everything is okay inside us. Is the gas pressure rising? The inner sphincter’s mission is to keep all unpleasantness at bay. If it had its way, Great Aunt Bertha would break wind more often. The main thing for the internal sphincter is to keep everything comfortable and in its place.
These two sphincter muscles have to work as a team. When what’s left of our food reaches the internal sphincter, that muscle’s reflex response is to open. But it does not just open the floodgates and let everything out, leaving the outer sphincter to deal with the onrush. First, it allows a small ‘taster’ through. The space between the internal and external sphincter muscles is home to a large number of sensor cells. They analyse the product delivered to them, test it to find out whether it is solid or gaseous, and send the resulting information up to the brain. This is the moment when the brain realises: it’s time to go to the toilet! … or maybe it’s just a bit of wind? It then does what it is so good at, with its conscious awareness: it adapts to the environment we find ourselves in. It compares the information it receives from our eyes and ears to the data in its memory bank of past experiences. In this way, the brain takes just a matter of seconds to make an initial assessment of the situation and send a message back to the sphincter: ‘I’ve had a look, and we’re at Great Aunt Bertha’s, in the living-room — we might get away with breaking a little wind, if we can squeeze it out silently. Anything more solid might not be such a good idea.’
The external sphincter gets the message, and dutifully squeezes itself closed even more tightly than before. The internal sphincter receives this signal from its more outgoing partner and respects the decision — for now. The two muscles work together and manoeuvre the ‘taster’ back into the holding pattern. Of course, it will have to come out sooner or later, just not here and not now. After a while, the internal sphincter will simply give it a try with another little ‘taster’. If by then we’re back within our familiar four walls, it’s ‘full steam ahead’!
Our internal sphincter is a no-nonsense little guy. His motto is, ‘If it’s gotta come out, it’s gotta come out!’ Not much room for argument there. The external sphincter, on the other hand, has to deal with the vagaries of the outside world and its many options: it might, theoretically, be possible to use this stranger’s toilet, but is that a good idea? Have my new girlfriend/boyfriend and I been together long enough for farting in front of each other to be okay — and if so, is it down to me to break the ice and go first? If I don’t go to the loo now, can I wait till this evening, or will I get caught short?
The considerations of our sphincter may not sound worthy of a Nobel Prize, but in fact they are concerned with some of the most basic questions of human existence: how important to us is our inner world, and what compromises should we make to get by in the external world? There are those who clench with all their might to keep the wind in, come what may, eventually struggling home wracked with belly ache. Others get granny to pull on their finger at a family party, making a funny, if slightly vulgar, magic show out of their need to break wind. In the long run, the best compromise is probably somewhere in the middle.
If we suppress our need to go the loo too often or for too long, our internal sphincter begins to feel browbeaten. In fact, we are able to re-educate it completely. That means the sphincter and the surrounding muscles have been disciplined so often by the external sphincter that they become cowed. If communication between the two sphincters breaks down completely, constipation can result.
Even without such defecatory discipline, something very similar can happen to women during labour. Childbirth can cause tearing of the delicate nerve fibres that allow the two muscles to communicate with each other. The good news is that those nerves can heal and reconnect. Irrespective of whether the damage was caused by childbirth or some other way, one good treatment option is what doctors call biofeedback therapy. It teaches the two sphincters to overcome their estrangement and get to know each other again. A machine is used to measure how efficiently the internal and external sphincter are working together. If messages from one to the other get through, the patient is rewarded with a sound or light signal. It’s like one of those quiz shows on early-evening TV, where the whole set lights up and fanfares blare when a contestant gets the answer right — only it’s at a medical practice, not on TV, and the ‘contestant’ has a sensor electrode up their bum. That may seem extreme, but it’s worth it. When the two sphincters are talking properly to each other again, going to the little girls’ or little boys’ room is an altogether more pleasant experience.
Sphincters, sensor cells, consciousness, and electrode-up-the-bum quiz shows — my flatmate was probably not expecting all that in answer to his casual question about pooing. Nor did the group of rather prim female business-studies students who had meanwhile gathered in the kitchen for his birthday tea party. Still, the evening turned out to