An emotional history of face transplants

I am delighted to share the news that I have been awarded a Future Leaders Fellowship by UK Research and Innovation. This was announced on 7 May by the Science and Innovation Minister Chris Skidmore. You can read about the remit of the awards here and what they promise to bring to the future of UK research and innovation.

My project will create a new cultural framework by which we can understand the emotional and ethical impact of face transplants internationally - and in the UK. There have been close to 50 around the world, but none so far in the UK, despite the fact that the UK has long been a leader in facial reconstruction work, and in preparing the ground for face transplants.

More details on my project are available here

One of the most emotionally challenging aspects of the project is the trauma that people receiving face transplants have undergone, and the transformative potential of this extraordinary surgery. The youngest person to receive a face transplant to date is Katie Stubblefield, who was treated at the Cleveland Clinic. Her story was written and documented by the writer Joanna Connors and the photographer Maggie Steber for the National Geographic.

You can learn more about Katie and her journey in the video below.

Please be aware that this video contains images and experiences that you may find upsetting.

interoception and the emotional body. or, how do we know what’s going on inside?

On March 1 2019, I convened a workshop on the visceral bodywith Professor of Psychology, Manos Tsakiris. Exploring the cultures of interiority and interoception (the subjective awareness of what is happening inside the body), papers drew on a wide range of historical, social, psychological, neuroscientific and artistic considerations. They explored the visual history of interiority – from medieval anatomy to 20th-century brain scans – and considered the relationship between subjectivity and objectivity, the meanings of ‘self’ and society, and how the two connect.  

 What struck me, as stories weaved from Jack Hartnell’s account of the 13th-century Abbey of Maubisson to Katerina Fotopolou’s research at the 21st-century London Neuropsychoanalysis Centre, was the different ways bodily subjectivity has been accessed and interpreted objectively. Most notably from the 19th century, with the emergence of scientific medicine, but also through the distancing lens of the other, as I discussed in my own contribution on the heart of Harriet Martineau (see also my book, This Mortal Coil.) Perceptions of emotions are no different. Modern neuroscientific accounts of emotion tend to focus on the brain rather than the heart – replacing the cardiocentric model of emotions that dominated Western medicine for two centuries. But the viscera are back: heart-brain and gut-brain interaction are becoming reintegrated into new interoceptive models.

Interdisciplinary events like these allow us to explore key areas like interception in new and exciting ways. And to consider the ways that historical ideas about medicine and health tend to find their way back into modern analyses. You can download the podcast of the day’s talks here:

I talk more about the emotional body in my forthcoming book with Oxford University Press on the history of Loneliness:, entitled A Biography of Loneliness: The History of An Emotion. Having submitted the monograph last July, the wait has seemed interminable. But copies will be available for pre-order soon, and I’m delighted to be able to share the cover with you at last.


Writing women: World War 2 and the Railways

I haven’t posted for a while. I have been busy with writing and thinking and funding bids. Time has lost its regularity and its meaning as I play the waiting game. So I did what I do when I struggle for inspiration - talk to other writing women about what inspires them. This blog will feature on the History Girls website, for which I write on the 15th of each month.

For today’s blog I spoke to Susan Major, who has written a fabulous book about women working on the railways during World War 2. This book is important because although we know that women took on many traditional men’s roles during the war, very little has been published on women in the railways. Railways were a reserved occupation, so in theory men continued to work on the railways while their counterparts in other industries were sent off to war. In reality, the men working on the railways were often old and disabled. The issues confronted by women workers were those that existed in other activities:  economic, sexual, social and temporal, their lives being changed by the new habits and relationships brought by the war, as well as its ending. Susan’s book is a welcome addition to our understanding of the lives of working women in the Second World War, as well as its gender politics. 

Susan Major completed a PhD with the Institute of Railway Studies & Transport History at the University of York in 2012. Drawing upon material from the National Railway Museum and the British Library, she focused on early railway excursions. Her book based on this research, Early Victorian Railway Excursions, was shortlisted for the Railways and Canal Historical Society Book of the Year Awards 2017. Her latest book, Female Railway Workers in World War II, was published by Pen & Sword in 2018. Susan was a programme consultant for the BBC series Railways: the Making of a Nation, taking part in the episode on leisure. She is retired and lives in York.

Fay: “So Susan, what drew you to the subject of women on the railways?” 

Susan: “Well I completed my doctorate, which later became a book, on Victorian railway excursions. Later, when doing some research about railway voices I discovered the National Archive of Railway Oral History at the Railway Museum, which contains many different  interviews with  people working on and associated with the railways. Quite a lot of this material has been digitised and indexed and transcribed. Among all the men recorded, there were some women and I realised that their voices had not really been listened to. And there were enough women talking about the wartime period, and about working in what were commonly perceived as ‘men’s jobs’, to form the basis of a book. And remember that even so-called ‘women’s’ jobs in those days, like working as a clerk, had been men’s jobs when in the railway context. And I wanted to know not only what everyday life was life for those women, but also how they were looked at by other people, by the companies who were employing the women as well as commentators in newspapers of the time.” 

Fay: “ Are there any particular women that stand out for you?Any stories that were especially memorable?” 

Susan: “There was a female porter at York station, when it was bombed in 1942. A train was also bombed on its way into the station, and these were terrible conditions to work in. The social conditions could be difficult too; she tells a story of a parcel foreman that the female workers had problems with and they sorted him out by giving him some chocolate, which happened to be laxative chocolate.”

Fay: “What can you tell us about the kind of women in these roles, their age or class for instance?”

Susan: “Well it’s a very select sample, dependent on who was chosen to interview. And these women would all have been young at the time, because the older women would have died by the time the stories were recorded. And they described liking the companionship of other women, the responsibility, and, unlike factory, work the variable and different activities involved.”

Fay: “Were the women all unmarried? I’m thinking about other roles of the time, which had very strict union rules”.  

Susan: “Yes. If you got married you had to leave. Most of these women were aged between 16 and 22 and often they met a railway man and got married and that was the last we hear of them. By contrast the newspaper reports were keen to tell readers about those women who might have 12 children and still carried out a role. And there was a sense that a woman wasn’t quite acceptable in publicity unless she had some link to a railway man. Women were not treated as individuals in their own right.” 

Fay: “Were most of these women working class women?”

Susan: “Not necessarily. Many were working class though there were also reports of quite posh women working on the railways. The ones that were interviewed were mainly ordinary women, who had a clear sense of their roles and their relationships with other women and you get a real sense of the culture of the workplace through the stories that they tell. Compared to other work, like factory work, the duties could be varied and interesting”.

Fay: “What do these interviews say about how it was to be a woman in a traditionally male environment?”

Susan: “There is some discussion about workplace harassment, much of which was taken for granted. For instance one of the accounts describes the experience of a typistThey had to go down and check their work with one of the men in the office. She said “And there were never enough chairs. So we used to share a chair with a man. And I think the feminists these days would be horrified. They'd probably be having all the men done for harassment. But we used to call it fun”

[Pause for reflection and a little teeth-gnashing]

Fay: “So these women would have to sit on their boss's lap.” 

Susan: “Yes, or share the chair. And there are a lot of examples of that. And women would talk about how they worked all day while their male supervisors stood around talking about sport. And at the end of the working day the women would get ready to go home and the men would say “overtime now”. And the men got paid more for the overtime, while the women had often families to get home to.There was also this concept of the “railway family”, which other historians have written about. Employees were encouraged to think of the railway as a family, and there were magazines prompting this image. And there was a sense that you could only get a job in the railways if your father put you forward, for instance, and while that wasn’t necessarily so in practice, it was how people thought about the railways as paternalistic employers”. 

Fay: “After the war did these women get sent away from the jobs, as they did in other industries?” 

Susan: “They were dispensed with, yes. Although I’ve focused on women working, the last chapter of my book is called: “and then the men came back”, which draws attention to the way women workers were dismissed. One woman, a guard, was sent a letter thanking her for her service. Only it wasn’t sent to her but to her boss. She had to travel a long way on the train to get to his office after a long shift, where she was shown this piece of paper, which he then kept, before trekking all the way home again”. 

Fay: “Thank you for a fascinating introduction to the book”

If you want to win a copy of Susan’s book, then check out the History Girls website on 15 February, when I will be running a competition for readers.

Railway women. To find out more  click here

Railway women. To find out more click here

The art and science of the heart

I recorded an interview for Radio 4 this week for their upcoming programme on the Art of Living, which looks at the work of artist Sofie Layton and bioengineer Giovanni Biglino at Great Ormond Street Hospital. Sofie and Giovanni worked with patients on visual images and stories about the heart, as an object of science and a metaphor for emotions. As an interdisciplinary art project, The Heart of the Matter is an important intervention into the different ways we look at, and think about the heart as both a pump and something so much more.

In Matters of the Heart: History, Medicine, Emotion published by Oxford University Press in 2010, I explored the reasons why we focus so much on the heart in popular culture - why the heart stands for authenticity, truth, meaning and emotion (especially love) - when it is widely regarded as a pump. The answer lies in the 2,000 years of medical history, when the heart was not only the warming centre of the body under humoral medicine, but also held a significant role in mediating the demands of the soul that worked in and through the physical body.

For the Ancient Greeks, as well as for the Ancient Egyptians and Mesopotamians, a Cardiocentric or heart-centred model of the body predominated. The heart swelled to attract all that was good and contracted to repel all that was evil; an early attempt to account for the sheer physicality of emotions as lived experiences. Not until the 19th century, when the brain was erected as the organ of the self par excellence, did the heart begin to diminish as an explanation of feeling and emotion, though the metaphors have continued, as I discussed in an interview in The Atlantic.

The rise of Cardiology, the parallel rise of Psychiatry and Psychology - as I explored in This Mortal Coil: The Human Body in History and Culture - these were the processes by which the heart’s scientific status was limited to a passive rather than an active organ. The heart responded to the brain’s desires, but it did not have a life-force of its own; it as motivated by reflex rather than the soul.

The origin of these changes can be traced back to the seventeenth century, and the popularisation of the circulation of the blood by the physician William Harvey. I say popularisation because, contrary to popular wisdom, it was an Arab physician, Ibn Al Nafis, who discovered pulmonary circulation in the thirteenth century. This historical oversight reinforces the great man of Western medicine model at the same time as it diminishes the significant impact of Islamic medicine and culture on the West for thousands of years. Yet it took the Renaissance and the flowing of visual arts and books on human anatomy, most notably by the Flemish anatomist Andreas Vesalius, for the idea of circulation to take off in the West.

One could argue that it was not until artists made visible new ways of thinking about and imagining the physical body that physicians were able to see and create alternative narratives of the body and the heart. This is a reminder that science does not simply reflect the body “as it is” but partakes of the wider cultural context in which it takes place. Science works in conjunction with popular narratives and beliefs - such as the well-entrenched idea of the heart as the centre of emotion, feeling and the self - even as it rebuts them. I spoke to one eminent heart surgeon who was unable to contribute to a discussion about the metaphorical heart for a simple reason: it would be impossible to remove the heart from a human chest if it was the site of the self, or love, or emotions. And yet medical students often report anxieties about dissecting the heart - just as they do the brain. Both are weighty organs, after all.

Art and science are always linked, which is what this exhibition makes clear. Part of the reason is the shared languages, metaphors and visual images that provide hooks for our understanding; that help to make the interior visible, and coherent. Hearts are objects of the self and emotions as well as pumps. And after all, though we schematise hearts as pumps versus hearts as metaphorical symbols, physicians are aware of the two-way process between the hearts and the emotions. We do not have to go as far as cellular memory theorists, and the belief that the heart has more neurons than the brain (and is therefore capable of physical memory) to understand the significant ways the heart impacts on feeling. The brain-heart connection is a deep, enduring part of the chemistry of the human body.

That connection is also based in language and metaphor. Hearts were furnaces, now they are pumps. But they are also receptacles of feeling and compassion, and linked to our fears and anxieties around transplantation, and where the limits of the human might be. In other cultures, too, besides the West, hearts matter. The heart (or Anahata) is the fourth Chakra of the body in Hindu, Yogic, Shakta and Buddhist Tantric traditions. The heart Chakra is associated with balance and calmness, as well as truth. In Chinese medicine the heart is a yin organ, that governs joy among other emotions. As in the West, ‘heart’ means more than a mere organ.

Talking about the meanings of the heart is important. It reminds us not only that the body carries symbolism and meaning that is more than the sum of its parts, but also that the stories we tell are also carried along with us. As patients, parents, lovers and friends, as much as artists, philosophers, medics and scientists, we are all curators of an ongoing discussion of what the heart means in the 21st century.


Tending to the lonely body - or when 'social prescribing' might make a difference

As the government turns, piecemeal, to ‘social prescribing’ as a way of countering loneliness, I wrote this piece for the Guardian that emphasises the importance of the body as well as the mind. Tending to the body, I argue, is every bit as important as focusing on talking; after all, it is relatively recently that mind and body were conceived as separate states.


An Interview with Amanda Vanstone at ABC National Radio

I talked recently to Amanda Vanstone, the Australian former politician and ambassador to Italy, now presenter of “Counterpoint” for the Australian Broadcasting Corporation (ABC). Our subject was the neglected history of loneliness. You can listen to and download the programme here.

Why not get in touch to let me know what you think?


Sylvia Plath's Letters, Volume 2

I have just finished reading the second volume of Sylvia Plath's Letters, published by Faber and Faber. They make for sober reading. The first volume, published in 2017, covered the period 1940-1956. In those, a smiling, bikini-clad Plath beams out from the front cover, while the pages are filled with the optimism and hope of youth. There are pockets of doubt and difficulty, the hint of rape and a suicide attempt, but also Plath's growing certainty of herself as a writer, a woman and an equal to the towering figure of Ted Hughes, with whom she is forever linked.

It is evident from the book jacket that the second volume will be a more serious affair. Gone is the summer sun and the happy expression. Viewed from the side and in monochrome, Plath's expression is serious, her hair tied up in a no-nonsense style. In nearly 600 letters, we follow Plath's marriage to Hughes, their movement around the globe and the UK, her library successes and his more immediate recognition, childbirth and child loss, a breaking-down marriage and her suicide at the age of 30.

To Plath, Hughes was a giant, a genius, a literary God. He must be fed steak for breakfast and waited on, his needs tended to. Yet she also resented her domesticity, her entrapment to the demands of her husband - first moving to Devon because he wanted space, searching for childcare in order to write,  and juggling the demands of that writing along babies, cooking, cleaning and tending to Hughes. The marriage was intense. It was also violent. She wrote to her psychiatrist that Hughes beat her when she was pregnant, causing her to miscarry their second child. 

In the foreword to the book, their daughter Frieda meets these claims head on. She writes in defence of her father, justifying his apparent violence towards Sylvia - which is also recorded in Plath's journals - on the problematic grounds that what was meant by 'a beating' is unclear (a hit, a swipe, a push?) and that her mother had been difficult, needy, disruptive. It is difficult to read this perspective, and to compare it with the plaintiveness of Plath's own journals, the constant fretting about existence that hovers at their margins, her need to do right, live right, be right. 

Yet it is clear in Frieda's foreword how difficult it must be to have parents so utterly in the public eye and simultaneously capable of creating division. Plath was better known after her death than in life, with her books The Bell Jar (a semi-autobiographical novel about a nervous breakdown) and her poetry. Her writing is said to have contributed to the development of the confessional style in literature. And yet it is Hughes who is remembered in Westminster Abbey, not Plath.

Plath's final letters were written just a few days before she died by suicide in her London flat. She had successfully moved back to the city after being left by Hughes (he was unfaithful with their tenant Assia Wevill, who, in a terrible mirroring would kill herself and her daughter in the same way that Plath died). Plath seemed to be getting better; she had been knocked by Hughes' infidelity and the subsequent rejection of some friends, and she struggled with Frieda missing her father. She was convinced that her daughter had 'latent schizophrenia', and she fretted constantly about her wellbeing.

It took such effort on the part of Plath to reestablish herself, to find childcare, to push herself back into the London scene, that the exhaustion is apparent on the page. Her letters to people become repetitive as she tells one after another about Hughes' adultery and abandonment, the money he is to pay, his family's turning on her, her living in Yeats' house and how that was fate, and finally, the endless illness, colds and flu of her children. 

In the main, Plath's letters have an enforced jollity even when she is struggling. From time to time she was angry and critical with her mother, but she also felt responsible for her, writing to her sponsor, the American author Olive Higgins Prouty, not to pass on information that might cause Aurelia worry. Prouty had suffered with mental health problems too, so Plath felt she was an ally. Plath was convinced that Hughes wanted her to kill herself, something she refused to contemplate. 

But by the beginning of 1963, despite all her contrived hope and determination, Plath was sleep deprived, unwell, lonely and depressed. On 11 February, having previously convinced herself, and her psychiatrist that she was no longer a suicidal 'type', she left out a snack for the sleeping children, took precautions to seal the kitchen and gassed herself in the oven. 

Two years after her death, Plath's collection of poems Ariel was published by Ted Hughes. These poems, including the eponymous poem written on her 30th birthday, drew on the pain of abandonment and loss that had followed her marriage breakdown. This is the writing for which she is best remembered. 


And now I

Foam to wheat, a glitter of seas.

The child's cry 

Melts in the wall. 

And I

Am the arrow, 

The dew that flies 

Suicidal, at one with the drive 

Into the red

Eye, the cauldron of morning. 

Available from  Faber and Faber

Available from Faber and Faber

Libraries as a lifeline for the lonely

I have been thinking a lot about libraries and their links with loneliness. It seems that often we defend libraries on the basis of their links to literacy and equal opportunity, and I couldn’t agree more.

However libraries are more than spaces filled with books etc. I posted here for the History Girls collective on why libraries are also a lifeline for the lonely.

What do libraries mean to you? What was the first library you visited? Do you still visit the library, and if not, why? I would love to hear from you.


Oswestry library: my childhood saviour 

Suicide and loneliness

For the past couple of years I have been blogging regularly for the History Girls, a collective of bestselling fiction and non-fiction writers who cover every imaginable period of history. This week I blogged about the suicide of Anthony Bourdain, and the ways we talk about suicide in the twenty-first century. You can read that blog post here

One of the reasons I was thinking about Bourdain, aside from the terrible sadness of his death and the challenges we have as a society in framing suicide, was how alone he must have been in his final moments. I have just submitted my history of loneliness for Oxford University Press, in which I explore the meanings of loneliness across cultures and time periods. Being alone - not necessarily physically, but emotionally - recurs time and time again in discussions of suicide.

The language of suicide can be blaming - a person 'commits' suicide because it was a criminal offence until 1961, just like murder or rape. This terminology is outdated and unhelpful and it creates the sense that the suffering person is somehow selfish or wilful, rather than a person whose pain outstrips their coping mechanisms. 

Suicide, like loneliness, is difficult to talk about. Both states carry the whiff of shame because of the way they are talked about in the 21st century. Terms like 'Billy no-mates' or 'loner' create a gulf between the self and others. And like loneliness, suicide is linked with intense depression and a feeling of being shut off from the world; of seeing the world through glass. A population-wide study found close associations between feelings of loneliness and suicidal ideation, or an unusual preoccupation with thoughts on suicide.

Emotional separation, alienation, an unwanted sense of being alone, these are human experiences, but they need not be universal. The 'Time to Change' campaign has highlighted the importance of other people in reaching out to someone who is lonely or depressed. For people who are socially isolated, that is a challenging bind; the separateness from others creates an additional invisible barrier between the self and the rest of the world. 

The campaign to reduce the stigma associated with mental health has been credited with some success. Attitudes towards the mentally ill are harsher in climates of economic instability, however, when the most vulnerable members of society - like refugees - are the most common victims of scapegoating. And there is a limit to the effectiveness of encouraging people to talk while mental health budgets are being slashed. What must be more isolating than being ready to talk, yet finding nobody to hear? 

What Bourdain's death from suicide tells us, like that of the designer Kate Spade just days before, is that external manifestations of success or happiness are no real indicator of emotional contentment. I do not know whether Bourdain or Spade were lonely, though people can be loneliest of all when surrounded by other people. Dying alone, from whatever cause, is a lonely way to go. 

The ways we talk about suicide and loneliness matter. It can isolate people further, or create a welcoming space in which blame has no place. This is especially important when people are disconnected from others, when it seems impossible to talk because there's a gulf of experience, and language. It's not always good to talk; sometimes it's good to listen. 

A Biography of Loneliness will be published by Oxford University Press. 

Samaritans mental health hotline is open 24 hours a day, seven days a week. It can be contacted at any time from any phone for FREE on 116 123. 


Loneliness in history: the case of Queen Victoria

This post also features on the History Girls blog:

Loneliness is a 21st-century problem; an epidemic of global proportions, linked variously to heart problems, mental health crises and dementia among the old. We are social animals, psychologists say; we are supposed to be around other people. Thanks to social media, cuts to social care and a growth in living alone, however, many of us are alone for vast swathes of time.

There are old people who only see another human being once a month, according to some recent studies, and an unknown multitude too shy, too depressed, too unwell or incapacitated to make meaningful social connections. That's the rub, you see: the connections have to be meaningful. Not in an abstract sense, and to other people, but to us, as individuals.

Loneliness has seldom been explored as a historical problem, but it is one. It's all very well to lament the rise of loneliness in the digital age - one of many themes I explore in my forthcoming book on the subject - but people have been lonely, in one sense or another, in earlier times and cultures. One of the chapters in my book describes the loneliness of widowhood and old age, with one of my case studies being Queen Victoria.

Why was Victoria lonely? There have been many literary and visual adaptations of her life, but few have addressed this problematic question. She was lonely because she lost Albert, the man she relied upon in so many aspects of her life, at a relatively young age. And suddenly.

Victoria and Albert had married young - just 21 and 20 respectively, though Victoria had inherited the throne at 18 years old. Together they had nine children, and became inseparable by all accounts; he developed a reputation for public causes such as educational reform and the abolition of slavery, though he had only the role of consort.

When Albert died, aged only 42, Victoria entered a deep state of mourning, and wore black for the rest of her life. It did not matter that due to her rank and status Victoria was one of the least alone women of her age, or that she was attended by a multitude of servants, family members and hangers-on. She missed that special connection she had enjoyed with Albert, the sense that the two of them were unified in their emotional, political, familial and practical lives. Maybe that's why Mr Brown was so important to her; a man she could confide in about anything at all, a man who didn't only see the queen but also a woman.

There is something very specific about losing a husband, Victoria complained when her daughters later married and moved on with their own lives. Nobody could understand it, until they have experienced it. I would extend that further by acknowledging there is something very particular about losing a partner, a perceived 'soul-mate' especially when one imagined growing old with that person; being able to look back on a life lived when one is old and worn.

Queen Victoria wrote in her journal on 20 June 1884: "The 47th (!!) anniversary of my accession. May God help me, in my ever-increasing loneliness, & anxieties'.

Loneliness cares not for status. And it changes over time, depending on our age, networks, expectations, religious belief and health. Concepts of loneliness have also changed, from the 18th century to the present day. So, too, have perceptions of grief, and an appropriate time to mourn.

 Queen Victoria was the subject of considerable criticism in her day about the length of time she spent in mourning, her choice of black garb, her reluctance to be seen in public. She became known nationally and internationally as a sad and lonely figure, even though she regained some public affection in her later years. The loss she felt over Albert's death, as well as her palpable resentment, anxiety and depression about being abandoned, never ended, though Victoria lived to be 81 years old.

In part, Victoria's critics were right. She didn't move on from Albert's death, which was an understandable and conscious choice. For all intents and purposes, the rituals of the household continued as though Albert had not died: from his clothes being laid out each morning to the marble hand, a cold replica of the real thing, that sat on Victoria's bedside table.

On a regular basis, Victoria would get out all the photographs of Albert; the gifts he had given her, sentimentally recalling memories that made her sad and happy in equal measure. She would visit his mausoleum and statutes and speak of him again and again to anyone who would listen. However painful it might have been, Victoria breathed in his absence every day. And perhaps that had a function; keeping the shadow of loneliness about her was the only way to keep Albert alive.

A Biography of Loneliness will be published by Oxford University Press

Victoria ( r. 1837-1901)

Victoria ( r. 1837-1901)

Gender, surgery and silencing women: why the ‘mesh scandal’ is depressingly familiar

On 12 March, BBC News reported on the case of Lucinda Methuen Campbell, a woman who had been treated in 2014 with a mesh implant. Campbell had consulted the surgeon privately, ‘desperate for a solution to the pain’ she was experiencing, linked to ‘complex’ problems with her bowel and womb. She wanted to avoid having a hysterectomy, and a surgical mesh promised a solution.

Campbell’s surgeon, Tony Dixon, was one of the pioneers of the use of a surgical mesh to fix prolapses of the bowel. A mesh is a woven sheet that is used as a permanent or temporary support for internal organs and tissues. Since the 1990s, meshes have been used in a range of reconstruction and repair surgeries, especially for pelvic and vaginal wall reconstructions in women.

Some meshes are intended to degrade in the body and others are more permanent. All are increasingly controversial. Polypropelene meshes in particular have been associated with severe discomfort and internal problems. More than one woman has died from complications linked to the use of vaginal mesh treatment.

Chrissy Brajac, just 42 years old, died of sepsis after repeated, antibiotic resistant infections linked to a mesh that she received. In her case, as in that of thousands of other women, this extreme and dangerous treatment was presented as a solution to minor stress incontinence after childbirth: the kind of condition that can be treated by a course of physiotherapy.  

Because of cases like Brajac’s, the vaginal mesh scandal, also referred to as the 'new thalidomide scandal’ (thalidomide being the anti-sickness medication once given to pregnant women with catastrophic effects) has attracted considerable attention. There are class action suits being brought around the world. An estimated 10,000 women every year in Britain alone receive a mesh implant for prolapse, hernias or incontinence, and despite fears over its safety, the operation is still being performed.

Somewhere between 10 and 40 per cent of women are believed to have experienced problems with mesh implants: not just chronic pain and loss of sex life, but also, as a recent article in The Independent noted, ‘organ erosion, perforation, implants slicing into vaginal walls, debilitating infections’ and more. Women report being dismissed and ignored or treated as hysterical when they draw attention to their suffering; surgeons defending the treatment maintain that no device is perfect, and that they offer patients a 'choice'.

In 2017, Parliament rejected cross-party calls for a suspension to mesh treatment. After a tremendous campaigning effort, the government finally agreed in January 2018 to review all cases of mesh implants (more than 100,000 cases), dating back to 2005.

This story is depressingly familiar. In the 1950s, when silicone implants were developed, they were announced as a saviour for women with breasts that were too small. Indeed, the condition of ‘hypomastia’ or pathologically small breasts was invented by psychiatrists at the same time as male cosmetic surgeons and silicone manufacturers came up with a solution: silicone implants, that could look and feel like the ‘real thing’.

The first woman to receive silicone breast implants, Tammie Jean Lindsey, agreed to be a guinea pig after she went to see cosmetic surgeons about her sticking out ears. The surgeons who were working on the silicone implants – and had successfully implanted them into a dog – offered to pin her ears back for free, provided they could pop in some silicone implants at the same time. Lindsey hadn’t realised her breasts needed enlarging until the surgeons pointed it out to her. She agreed and spent the next few decades  in agony.

Since that time, there have been multiple questions raised about the ethics and safety of implants, including a moratorium on silicone implants in the US, and the PIP scandal in Europe. In the latter case, thousands of women reported psychological and physical problems linked to the implants, which were not made of medical-grade silicone, but the same material used to stuff mattresses. Nevertheless, silicone breast implants continue to be in demand, along with a wide range of cosmetic interventions.

It is not unusual for women’s complaints of ill-health to be rejected. There is a long tradition in medical history of hystericizing women’s experience, or reducing it to psychological causes. The term ‘hysterical’ itself comes the Greek word hysterika, meaning womb. The Ancient Greeks believed that a wandering womb that moved around the body caused a variety of mental disturbances. How often is the term ‘hysterical’ used today to dismiss a woman’s experience? There is more than one book on the history of women’s voices being ignored within medicine.

What the mesh scandal tells us is that yet again women’s health is being risked by a medical procedure that is demonstrably flawed. Women’s stories have been denied and not heard by professionals invested in the continued use of the mesh. It is only now that NHS records acknowledge a 'shocking' rate of failure that the mesh is under scrutiny. A similar neglect for women’s voices has been seen historically in the dismissal of conditions like endometriosis and the over-use of hysterectomies to treat a wide range of ailments.

Time and again in history, women’s bodies have been treated as a series of parts; in the case of urinary and gynaecological complaints, organ removal is often seen as an easy or convenient solution that requires less investment of time, and arguably money, on the part of healthcare providers. Since women are principally viewed through the lens of reproduction, why keep parts that are no longer functional?

There is no better illustration of this, than in the treatment meted out to Lucinda Methuen Campbell. Unbelievably, Dixon is said to have removed Campbell’s ovaries during her operation. He did so without her permission, and apparently without remorse. When she asked why, his justification was simple: she didn’t need them, and they were ‘in the way’. When Campbell expressed shock, the surgeon apparently said he had done her ‘a favour… I thought you know, a woman of your age [she was 54] wouldn’t really need ovaries’.

Ovaries are not merely designed to produce the eggs that lead to babies and women’s function is not entirely to reproduce. Ovaries perform a complex hormonal regulation of the body, and their removal has serious side effects that range from depression and anxiety and a decreased sex drive to premature death. 

How shocking that a surgeon’s convenience should be seen as more important than a patient’s systemic health, as well as her rights over her own body. And how familiar this is to other aspects of invasive medical treatment without consent – including, for instance, the little known but widely practised policy of giving anaesthetised women pelvic examinations for student training purposes.

‘My life is absolutely ruined’, Campbell reported after receiving the mesh. Sadly, she died at home in Swansea on 22 January, leaving two children, according to the South Wales Evening Post. The cause of her death is still being investigated. Dixon has been suspended by the NHS from performing this and related surgeries, and he has been referred to the General Medical Council for investigation.

The mesh scandal reflects an international crisis in confidence around medicine, surgery and women's health. Importantly, this is not a story about the universal indifference of surgeons to the suffering or rights of patients. Many surgeons care deeply about the impact of their work, and about the broader socio-political context in which they engage with women’s health. Which is why we need to hear more from and about these surgeons, especially those who speak out about invasive treatments that are ethically questionable, of unproven efficacy, and potentially damaging to health. 


Why do we send Valentine's cards? Take heart and ask Galen - or a medical historian

Last Sunday I gave a talk to the Sunday Assembly East End, which organised a theme on the heart. This community-focused, heart-warming event used poetry, music and story telling to explore the meanings of the heart in forging relationships. My talk provided some historical context of some of the things we take for granted, including the language of “heart felt feelings”, rooted in the body as well as the mind. The heart is, after all, the first sign of life, detectable in the embryo and heard even before birth, thanks to medical technologies. 

But why is it so ubiquitous in the language of romance? And why do we send Valentine’s cards that are covered in hearts that look nothing like the organ we associate with our heartbeat? To understand this, and the whole world of iconography of the heart in the modern West, we need to know something of its medical and cultural history. For thousands of years, a humoral theory of the body dominated understanding of how emotions, personalities and experiences were formed. The Greek physician Galen, working with the writings of Hippocrates, envisaged the heart as the centre not only of the physical but also the psychological body ("psyche" then meaning soul). Head and heart were not separated, as they are today, into different realms. The heart was the furnace of the body, the place where humours were concocted, and where the soul moved in pursuit of its desires.

That is why the beating of the heart was so fundamental in showing the movement of the soul, and the desires of the individual. The heart was an active organ, pulling the soul towards what was good and away from what was evil. In this humoral landscape, hearts could be hard and soft, warm and cold; hearts and spirits lifted together or were crushed by grief. The iconography of the heart - not as the organ of science and a pump that emerged in the Victorian period, but as a blood-red, symmetrical symbol we now associate with Hallmark greetings cards - has become ubiquitous, especially around Valentine's Day.

St Valentine is usually remembered as a third century Roman priest, killed for marrying couples against the wishes of the Emperor, who believed single men made better soldiers. By the medieval period, the Valentine tradition of 14 February was commonplace, perhaps originating as an effort to Christianise the pagan celebration of Lupercalia, which was held in February. 

The sentimentalism of the Victorians secured modern Valentine’s Day its convention of exchanging greetings cards in order to demonstrate love. Like the one that is depicted here, courtesy of Wellcome Images. And in keeping with the humoral tradition it is the heart that is placed at the centre: the organ that even now, while generally regarded as a pump, retains its traditional status as the organ of the self, personality, emotions and love. 

We may not give much thought to why we celebrate with the heart rather than any other organ. Though the modern separation of mind and body, and the belief that emotions are mostly products of the brain, suggests we might have moved away from the heart to the brain as a cultural symbol of love. Admittedly the results would be rather less aesthetically pleasing. "I brain you" carries a rather different meaning. 

To find out more about the history and cultural meanings of the heart as symbol and organ, why not check out my book, Matters of the Heart, which is available here.  You can also listen to a recent interview on the subject I recorded in Westminster Abbey for Radio 4 here.

Happy Valentine's Day! 


Would you give away your face? The emotional challenges of face transplants

Would you give away your face? The emotional challenges of face transplants

A recent article by leading facial transplantation surgeon Eduardo Rodriguez and others highlights the importance of donor education in transplantation. Motivated by the continual lack of organ donors, researchers argued that educational health campaigns can inform the public and inspire them to act differently. Educating the public might mean that more faces are available for transplant.

It’s an incredibly important issue, and not one restricted to face transplants. There are religious and ethical reasons why some people don’t become organ donors, but how many others decline out of fear or ignorance? Different countries have their own laws on organ donation. Yet there is no doubt that faces make people nervous.

Fifty years ago, when the first successful heart transplant was performed, there was a cultural fear that black people would become spare parts for whites. This was South Africa after all, at the time of Apartheid. Today, there is a cultural fear that old rich people will one day acquire the faces of the young and poor. Like many dystopic fantasies about transplantation, fears of the limits and ethics of science tap into broader concerns about power, the body and identity.

Faces, for good or ill, are supposed to represent the essence of who we are. Stamped on our passports, they define our identity. Consider the political debates about the veil in much of Europe and conflicts in the UK about wearing a veil in court. Smuggled into these debates are anecdotal discussions about honesty, trust, and the importance of faces for social communication. Faces are also visible indicators of our health, wealth, ethnicity, heredity, gender and age. How often do visitors of a newborn declare 'Oh, s/he looks exactly like you!' to titters of delight from the parents? 

It is perhaps understandable, given the varied meanings of the face, that many people would not want to give up the face of a loved one to another, especially since so much misinformation abounds about face transplants, like the myth that a donor would immediately look like the recipient (a myth, no doubt, influenced by John Woo’s movie Face/Off. If John Travolta can become Nicholas Cage in a matter of hours, might somebody else become your beloved husband? 

Would public education help put people's minds at rest? We certainly need to talk about transplantation more than we do. And we need to talk about it earlier; it is traumatic for anyone to be met in the hospital not only with the death of a loved one but also with a request for organs. And yet that it is the burden placed on medical staff. How much more traumatic is it to give up the face of a child, a wife, a brother? To imagine them being buried faceless? Extraordinarily, 3D printers have come to the rescue and donors can now be buried with an almost identical plastic replica of their own face.

The article by Rodriguez et al found that only 52 per cent of people surveyed were willing to donate their own face. After they had watched an educational video, that increased by 18 per cent. Those who changed their minds were influenced not only by learning how the procedure is carried out, but also by understanding the devastating emotional and physical impact of the kind of facial trauma that requires transplantation.

But  - as the considerable proportion of resisters suggests -  people are not only unwilling to give up faces because of a lack of education. It’s also because of what faces mean. It’s also a difficult burden to take on as a recipient. In addition to the pain of surgery, or multiple surgeries, and the need to take dangerous immuno-suppressant drugs for life, acquiring the face of someone else means presuming another, visible, identity of sorts. Not all people are able to cope emotionally with the impact of receiving another person’s face. This is apparent in the story of Isabelle Dinoire, the world’s first face transplant recipient in 2005, as I have written about elsewhere.

More than 40 people have received face transplants since Dinoire’s time, and the number is growing. It is only a matter of time before we have the UK's first. How future generations of face transplant recipients will cope with their inheritance – and how the families of donors will adjust to their complex loss – remains to be seen.

Crucially, there are not yet enough faces to go around. If donor education changes this, what does it mean for the future of the face transplant? Or for the people who acquire a new face?

I am seeking to answer these and related questions through the first major interdisciplinary project into the emotional history and impact of the face transplant. 

Would you give away your face? And would you accept one? What do you imagine the major difficulties might be? Please get in touch through the Contact Me page. Or come to my public lecture at the University of York on 22 January and join in the conversation. 


Loneliness is political, especially at Christmas.

In Saturday’s Guardian, Hadley Freeman challenged readers to reconsider the meanings of having a solo Christmas. Quite rightly, she distinguishes between being alone and being lonely, arguing that living alone can be happy; Christmases alone, moreover, can be voyages of discovery, times spent jetting off to Thailand or breaking the rules for the sake of it. She’s right, too, that people have preconceived ideas about Christmas, and often view the festive period through the multiple, exhausting lenses of modern consumerism: a kind of Charles-Dickens-meets-Christmas-with-the-Kranks orgy of family time, discarded wrapping and tables groaning under the weight of food. Of course, these are not the only kinds of Christmases, or the only kinds of families.

Just as good as family Christmases, maintains Freeman, are those Christmases we can choose to spend on our own – whether lying on ‘a beach in Goa’, binge-watching Christmas movies and eating baked potatoes or visiting India to rediscover the meaning of Christmas: ‘rest, recovery and happiness, and sometimes being alone is the best way to find that’.

I don’t disagree with everything that Freeman says. The tyranny of Christmas means that many people feel alone, and lonely. It is powerful to reclaim its meanings, to celebrate being alone, yes, as well as the quiet and reflection that solitude can bring. There is a difference between loneliness and solitude, of course, and that difference is one between emotional pain and contentment.

But Freeman’s vision of escaping Christmas past is refracted through the lens of a particular kind of economic and social privilege. Many lonely people – even those that choose to spend Christmas alone because they want to differentiate their identity from those crushingly awful childhood patterns – don’t have the money or the time or the mental health to embark on adventurous tours across the globe. Or even to enjoy the thrill of breaking tradition on their own at home. Many people who are most lonely are surrounded by, and responsible for, other people, whether they are carers, estranged and single parents, or experiencing disability and ill-health. These are the people who have, in 21st century Britain, been abandoned and rejected by society, reliant on food banks in the best of times and subject to terrible housing and even worse landlords.  

Loneliness is a major social and emotional and economic and political problem. It is also defined as a health hazard, and a challenge to the basis of humanity in the 21st century. But the experience of loneliness is not one single thing; loneliness means different things to different people and at different points in their lives. The loneliness of a single mum whose baby has colic will not be the same experience as that felt by the newly divorced man propping up the bar at midnight. Or the elderly couple who are disconnected from the world and their heating.

It is right to argue that sometimes loneliness can be indulged and desired and sought after. But please let’s not forget that loneliness, like most things in life, affect old and young, rich and poor, black and white, men and women very differently. While being alone does not always equate with being lonely, and loneliness itself can be a choice, the grim reality is that impoverished and disenfranchised people are amongst the loneliest at Christmas time. This includes those starving themselves to pay for gifts or food for their children, living in bed and breakfasts on or the streets, hiding out in increasingly rare domestic violence shelters, or cast adrift in a world of mental suffering. These aren’t people who can forget everything and jet off to India.

My book on the history and meanings of loneliness will be published in 2018.  

Loneliness is political, especially at Christmas.

Loneliness is political, especially at Christmas.

To resuscitate or not to resuscitate: tattoos, medicine and intent



An ethical medical dilemma made the news this week, which was originally reported in the New England Journal of Medicine. It concerned an unconscious, inebriated patient brought into the University of Miami Hospital with a "Do Not Resuscitate" tattoo on his chest. The 70-year-old man had no identification, and the hospital could not find a next of kin, though the tattoo on his chest was signed, presumably with the man’s own signature.

What should the medics do? Did the tattoo represent a sane, living, up-to-date expression of the patient’s intent, or a joke – a variant of the "insert here" and "cut here" tattoos associated with youthful hi-jinks or an alcohol-fuelled night out? 

Cautionary tales abound, Like the 59-year-old diabetic who went into hospital for an amputation, only to unveil a D.N.R. across his chest. He was questioned by the hospital staff: was that what he wanted? No. If necessary, he wanted the doctors to try to resuscitate him, at least for a reasonable time. The man dismissed suggestions the tattoo was confusing. He didn't think anyone would take it seriously. 

For staff at the University of Miami Hospital, however, a conversation with the patient was not possible. He did not regain consciousness sufficiently for any discussion to take place. What the media coverage of this case failed to note, moreover, was that the patient was not just drunk, but in very bad physical shape. He had lived for some years with obstructive pulmonary disease, diabetes mellitus and atrial fibrillation. 

Though the medical team initially decided to disregard the tattoo, they changed their minds and referred the question to an ethical advisor. Presumably, they took this decision on the basis of the man's general health. And because the medical team was impressed by what they called the 'patient’s extraordinary effort to make his presumed advance directive known'.

Why might the man have wished to be DNR? A DNR order expresses a patient's desire not to receive intubation or Cardiopulmonary resuscitation (CPR) in the event that the heart stops beating. This might seem counterintuitive, but resuscitation can cause numerous ill effects, from broken ribs and ruptured spleens to brain damage. In the case of elderly patients, and those with a serious health condition, the risks might outweigh the predicted quality of life.

However, DNR orders are emotive. This is why some areas of the United States and the United Kingdom use the term Do Not Attempt Resuscitation. Without ‘attempt’, there is an implicit suggestion that resuscitation would definitely succeed. That is an upsetting belief for the patient's family, when resuscitation is not attempted.

Unfortunately, most attempts at resuscitation in the emergency room are unsuccessful. Many doctors I have spoken to admit to attempting resuscitation when they know it is hopeless. This is because CPR is a crucial part of the spectacle of emergency care. Distraught families and friends of patients have seen CPR on medical programmes like ER, and they expect it to be carried out. They are unaware of the damage to the body that can occur, along with the limited likelihood of success. 

DNRs are normally issued after discussion between the medical authorities and the patient and their family. The University of Miami Hospital staff would therefore have been in a particular dilemma. They had a moral duty to save the patient, except if he did not want them to do so. The legal issues were even more pressing. 

Many countries have their own DNR rules. In Saudi Arabia, for instance, patients cannot legally sign a DNR; the decision to resuscitate rests with the physician. In the UK, it is possible to write a living will that predicts whether or not you would want a DNR order in particular circumstances. In the US, DNRs are dealt with differently by different states.

Most relevant here is that the Department of Health for Florida, which covers the University of Miami Hospital, states that a ‘Do Not Resuscitate Order (Form 1896)’ must be printed on yellow paper and signed by the patient and her or his physician. ‘EMS and medical personnel are only required to honor the form if it is printed on yellow paper.’

So, it is easy to understand the hesitation of the medics. There was no legal necessity for them to honour the tattoo, and they could not be certain that the tattoo represented genuine intent on the part of the patient. Yet the ethical advisors decided that the man had taken the time to communicate deliberately, and with forethought, to his caregivers. In respect of that, the writing on the patient's body was given the same moral and legal status as an official DNR statement.

That evening, the man died. The medical team was subsequently 'relieved' to find that there was paperwork to support the tattoo evidence in the patient's case records. They had made a choice, under difficult circumstances, and with all the available evidence. And it turned out to be the right one. 

The usefulness of tattoos in conveying information about a person's health has been debated elsewhere. For there is growing trend, not only if tattoos in general,  but also in people communicating existing health conditions, like diabetes. This reflects other historical usage of tattoos to communicate medical information. In World War 2, for instance, members of the SS similarly carried blood group tattoos on the underside of their left arms. This bears a terrible echo of the Nazi's tattooing prisoners of Auschwitz.

Tattooing the skin clearly provides an indelible signifier that cannot be lost, mislaid or overlooked, in the case of DNR paperwork or medic-alert bracelets. But there remains the question of intent and a change of heart. People do change their minds about being resuscitated. But they may not remove their tattoos in accordance with this re-evaluation. 

I was struck by a number of other ethical and emotional issues when I read about this case. Firstly, the care and consideration exhibited by the medical team. They made an ethical decision to respect a tattoo despite the fact that this was against standard protocol. They recognised that the medical process was not always 'nimble enough to support patient-centred care'. And they wanted to ensure 'respect for patients' best interests', not just to protect the narrow limitations of the law and the hospital. 

It was a brave decision, and presumably not an easy one, given the pressures on individual medics and teams working together against the clock. It was a decision that also reflected the care the patient had taken in signing the DNR statement, as though his body was a legal document. 

I found that detail touching. Of course, the medical team and ethicists did not know for certain that it was the patient's authentic signature. And they must have decided the risk of litigation was reasonably low, balanced against the man's evident health and life expectancy. But the signing of the tattoo transforms what could have been a run-of-the-mill yet subversive challenge to mortality (akin to the tattooing of ‘Y’ incision autopsy scars perhaps) into something more political. 

We don't talk about death enough in life. We leave important decisions about organ donation and resuscitation to others, which leaves time-pressed medical professionals and distressed families and friends, to determine what a person would have wanted, should the worst occur. 

Yes, it's problematic to determine whether a tattoo can be taken as read. They have so many meanings, after all. But tattoos are also historically signs and tokens of resistance; commonly a way for people to stake their claim on their own bodies. They also take on meanings to others. At a time when our identities are increasingly commercialised and commodified, and when medicine in the UK is being privatised and seen not to care, a signed 'Do Not Resuscitate' tattoo takes on the quality of a political statement. 

Transforming the body into text in place of verbal communication potentially shifts the power-balance of the physician-patient relationship. It allows the patient's otherwise silent body - unconscious or anaesthetised, speaking only through a series of objectively measured signs like the heartbeat – to retain an essence of subjectivity: Look at me, it shouts. I am here. Not just a disease, or a body, but a real person, deserving of care.

In that, the unknown man's tattoo is a statement for our time. 






Of legs and letters: fighting for the body of Sylvia Plath

I have been spending a lot of time lately with Sylvia Plath - reading her fiction, poems and journals, exploring her self-representation as a writer, and a woman coming of age in the 1950s. I have even read her undergraduate dissertation:  'The Magic Mirror: A Study of the Double in Two Novels of Dostoevsky', a copy of which is held at the British Library.

Fortuitously, a new edition of Plath's letters has been produced, which covers the early years of her life and ends with her marriage to Ted Hughes in 1956. The Letters of Sylvia Plath volume 1 provides key insights into Plath's relationship with her mother, her memories of her father, and her writing and romantic entanglements before Hughes. Volume 2, which will cover her marriage, breakdown and depression in the years leading up to her suicide in 1963, is due out in 2018.  

There is little contextual information in the Letters, other than an occasional footnote reference t. The significance of the book is not, therefore, its analysis, but in bringing together a vast body of previously unpublished material. Some of Plath's letters have been published before, in a volume published and edited by her mother Aurelia. Letters Home was a sanitised version of Plath's correspondence, removing anything that was uncomfortable to Plath's mother.

This is understandable: Plath's adult journals and letters contain negative and virulent writing about Aurelia; as Plath worked through her therapy, the vampirish 'blood sucking' mother was as important to her self definition as the absent, beloved father. (Otto Plath died when his daughter was eight, from complications linked to untreated diabetes.)

In poems like 'Medusa', and in autobiographical novels like The Bell Jar, Plath raged against the mother whose grip seemed all too tight. Working things out in prose was her way of being. Plath has been treated dismissively as a writer at various points. The term 'confessional' poetry, which Plath helped pioneer, has been used in a denigrating fashion. Her femininity has been linked to hysteria, and her poetry concocted as a 'witches' brew'. 

I wrote in my last blog that Plath is still not remembered in Poets' Corner, unlike her more respectable husband Hughes. Interestingly, Prince Charles, who encouraged Westminster Abbey to have an official memorial to Hughes, has a private shrine to the poet at his own residence. I say 'interestingly', because Prince Charles, like Ted Hughes, has more in common with his friend the poet than you might think: like Hughes, Charles was vilified over his adultery. Like Hughes, Charles' wife remains more popular than he after she died young. Both Princess Diana and Sylvia Plath suffered with mental health complaints, and both Charles and Hughes were accused of contributing to their wives' tortured state. 

Plath is far more than her relationship with Hughes, of course. She was an extraordinarily productive and accomplished writer, whose poems are regarded as some of the best in twentieth-century literature. She wrote a radio play, a children's book, short stories and novels, and won a Pulitzer Prize posthumously for her Collected Poems. Her literary talents were evident from childhood; she wrote poems, won prizes and published in magazines, ever determined to be a successful writer. 

Plath graduated from Smith College in 1955, and won a prestigious Fulbright scholarship to Cambridge, where she met Hughes the following year. As she wrote in her diaries, Hughes 'blasted' all other lovers from her mind, though she also discerned he might be 'a breaker of things and people'. By June 1956 the two were married, moved briefly to America and back to England, where they had two children, Frieda and Nicholas. 

Plath's first collection of poems, Colossus was published in 1960, with her novel The Bell Jar being published in January 1963 under the pen name Victoria Lucas. The book was met by lukewarm reviews. The following month, on 11 February, Plath committed suicide. A single parent living alone, suffering from severe mental anguish, Plath placed her head in the oven and gassed herself. A careful mother to the end, she had first sealed off the kitchen from the rest of the house with blankets and tape, and left food and drink for her sleeping children. 

It's easy to see why there will be a large audience for Plath's published letters. The nature of Plath's early death, her semi-autobiographical writing, her desire to write and to thrive in the male-dominated 1950s, and her dramatic relationship with Hughes, read like threads of a dramatic novel. In 2003 a celebrity-stuffed film was made that conformed to the most common narrative: the brittle but brilliant woman who gave it all for love, and lost. 

These are, of course, just narratives. And Letters has received mixed reviews. Sarah Churchwell in The Guardian isn't sure that they are worth reading, since so much is taken up with Plath's childhood and teenage years, when not much happened, aside from her first suicide attempt, which helped shape the writing of The Bell Jar. I think this is missing the point. We can learn a lot about Plath's self-representation as a daughter, a writer, a lover and a depressive in these letters; themes that I tackle in more detail in my forthcoming book about loneliness. 

What I want to draw attention to here, however, are the ways in which ownership of Plath's body - figuratively, in her writings, but also literally, through the meticulous picking over the bones of her suicide - reflects the pulling apart of the writer as a symbol for so much else: feminism, creativity, motherhood, depression, family trauma and the death of a father. 

Writers argue about whether Plath was co-dependent with her mother, biologically prone to depression, abused by her husband; whether she benefitted or lost out by her creative relationship with Ted Hughes; whether she was loved by him, abandoned by him, killed by him. Some of these claims are easier to prove than others. 

It is interesting that volume 1 of the Letters ends with Hughes, and that this is where volume 2 will begin. Hughes functions as a natural marker because, for good and ill, the two are always linked. I lingered over including a photograph of them both here, rather than Plath on her own. Since I am discussing them both, it seems necessary to include Hughes. There is also something about this portrait - the intimate expression under the public gaze - that seems appropriate. 

Plath had loved other men before Hughes, but the brooding poet absorbed Plath fully after they met at a party in Cambridge. In their marriage, Plath juggled her many roles, as mother, wife, cook, cleaner, academic, novelist, poet, learning to write between the lines, though not always happily since Hughes' career and writing always came first.

Critics have debated the extent to which Plath and Hughes' literary and personal relationship was positive; how far she was his muse, and how far he influenced her writing. Seldom the other way around. In one light, Hughes has been regarded by critics as an inspiration to Plath, a man whose presence impelled her to write, and whose talents sharpened her prose. In another, Hughes seemed to have wrung Plath out, to have taken what he needed and, like any great man of literature, put himself and his needs first.

When they separated, an event usually attributed to Hughes' infidelity with their friend and tenant Assia Wevill, Plath was devastated, and depressed. She was alone when she died, just as she had been alone most of her life. In the 1970s, Hughes was accused of killing Plath, at least through his indifference. Just six years after Plath's death, moreover, Hughes' mistress Wevill also killed herself in eerily similar circumstance. In March 1969, Wevill dragged a mattress into the kitchen of her flat, drugged herself and her four-year-old daughter with sleeping tablets, and turned on the gas stove.

Critics called Hughes a murderer, and repeatedly chiselled Hughes' name off Plath's headstone, incensed too because Hughes had buried Plath in the small village where he himself grew up. Hughes benefitted from Plath's estate after her death since the two were still married, and he destroyed her final journal, claiming he did not want the children to be harmed by it. He also lost Plath's penultimate journal. Hughes had also beaten Plath physically, according to her journals and her letters to her psychiatrist,  one such beating having apparently resulted in a miscarriage.

Yet the polarising of opinion, between Hughes as creator and Hughes as destroyer, has continued. Hughes did not only obliterate Plath's work, it is argued, he also helped created it. It was he who collected poems for the release of Ariel in 1965. In 1981, he also published Plath's Collected Poems. Notably, however, he also profited from the estate and he didn't include anything written before they met. These letters he dismissed as 'juvenilia'. Plath, in Hughes' view, was only born once they met.

Supporters of Hughes cite Plath's mental health problems. They see Plath's suicide as a product of her own instability (or her genetic encoding), rather than the circumstances of her sustained abuse, marital breakdown and abandonment.

Plath's physical body, it seems, provides evidence of her fragile mental state long before Hughes: she lashed her legs in a desperate act of self-harm (and revealed the scars to her mother) before her first suicide attempt. One that occasion, Plath had taken an overdose of her mother's sleeping tablets, and hidden herself away in the crawlspace of the cellar. While a search continued overhead, she lay unconscious for two days before she was found. Her cheek was cut and infested with maggots from where she had bashed her head when waking. She would be self-conscious of the resulting scar for the rest of her life.

Even before Plath met Hughes, then, her body carried the marks of her mental illness. Some critics have gone further in challenging Plath's idolised status; suggesting, for instance that she was jealous and competitive, particularly towards other women. Psychoanalytic concepts - oedipal, neurotic, hysterical - are bandied about as everyday descriptions that summarise Plath's behaviour before sweeping it neatly into a pile. The conclusion is unerringly gendered and tied in a pretty pink bow: she died for love, as so many women do.

Unsurprisingly, it is Plath's children who carry the biggest burden. Her son Nicholas suffered from depression and killed himself in 2009. He was a successful fisheries biologist and an expert in stream salmonid ecology, but that doesn't seem to matter. Nothing can disrupt the linear media narrative: he must be damned by the inevitability of genetics.  

You can understand the frustration and resentment of Plath's surviving daughter Frieda, a successful artist and poet in her own right. She is forever cast in her parents' shadow, and mediates between Plath and Hughes in death, as no doubt she would have been called to do in life, had they both survived. 

Fifty-four years after Plath's death, her body is still fought over. Not only her writings and their interpretation, but also her mental illness, its causation, and its legacy. There is something self-defeating about this struggle, as there is about any attempt at retrospective diagnosis

Plath was an extraordinary writer whose existence and struggles were both universal and particular; she fought for the right to write at a time when women were still defined by their bodies, and by gender. She wrote about her frustration of having been born with breasts and ovaries, rather than a penis, knowing that her sexed identity would imprison her. 

Yet Plath was also a complex individual, with desires and feelings that were a product of her own beliefs, and articulated according to genre. How ridiculous then to dismiss her as self-indulgent, especially when writing in her own journal. Yet this is all too often the fate of autobiographical women.

When Plath wrote, whether in journals, letters or fiction, it was always according to convention. Ever conscious of a potential reader, ever self-conscious about the way she would be read (or come to perceive herself), nothing was unmediated.

The Letters of Sylvia Plath are therefore a wonderful addition to our understanding of the life and experiences of a complex and fascinating woman. But they are no more 'real' than any other source. There is no 'there' there, after all. All we have is text. 



Sylvia Plath and Ted Hughes  

Sylvia Plath and Ted Hughes  

'Gut Feelings': Medicine, Gender and Health


BBC News reported today that gut flora - the trillions of bacteria that live in our digestive system - may ‘boost’ cancer therapy. Scientists in France and the USA tested the microbiome in cancer patients, finding evidence that a diverse biome, composed of a wide range of 'good' bacteria, contributed to the effectiveness of immunotherapy drugs.

This report is part of a more widespread recognition that the biome affects our physical and mental health. Other, recent stories reveal that gut bacteria can stop asthma  and provide a weapon against obesity.  Gut bacteria might, further, influence mental health conditions like anxiety, as well as the trajectory of debilitating diseases like Alzheimer’s. 

This is not the first time the gut has been seen as crucial to the conservation of health.  In 1907 The Abdominal and Pelvic Brain, written by the American physician Byron Robinson, identified the Enteric Nervous System in the gut as equivalent to the Central Nervous System associated with the brain.  Robinson anticipated more the American physiologist Michael F. Gershon's discussion of the gut as a ‘second brain’ in the 1990s.

The reason? The gut contains between 200 and 600 million neurons, the same number as the spinal cord. Moreover, more than two thirds of the body’s immune system can be located in the gut.

In this context, the most recent revelations about gut bacteria influencing immunology drugs makes sense: it is the manifestation of  'cross-talk' between brain and body: and a scientific explanation for ‘gut feelings’; that unproven yet instinctive sense we have about particular events, people and places. 

In the pursuit of health amongst the well, in addition to the sick, maintaining a healthy gut is crucial. Yet most modern Western diets don’t support microbial diversity, which is crucial to our well-being; loss of diversity is particularly linked to obesity. The over-consumption of chemically-produced and enhanced food, in addition to the over-use of antibiotics and antibacterial products, restricts and damages our gut flora, arguably making us more susceptible to allergies, infections and systemic problems.  

We can combat this erosion of healthy gut bacteria by eating probiotics that help defeat 'bad' bacteria, and prebiotics that enable 'good' bacteria to flourish. Naturally fermented foods, organic fruit and vegetables, ‘live’ cultures all point in the right direction. 

There is much that can be said about the militaristic battle lines drawn in the gut, as everywhere else, between the bacteriological forces of good and evil. Crucially, though, for theorising medicine and the mind/body relationship, listening to our guts turns conventional scientific ideas upside down, a theme I have discussed in This Mortal Coil: The Human Body in History and Culture It destabilises the brain from its pedestal as the dominant organ of the body in the neurocentric age, and creates a more holistic vision of the body. 

A focus on the gut challenges the idea that experiences like stress are transmitted just one way, from the brain to the belly, e.g. in conditions like Irritable Bowel Syndrome (IBS). In an alternative model, the  physical condition of the stomach and guts, and their nutritive and hormonal makeup, can be seen to run the show, sending information to the brain and even influencing mental health and brain structures.

As a historian of emotion and the body, I am interested in the imaginative and literary meanings of the body turned upside down. And in the fact that - as with with other anecdotal ideas about the body (like the emotional heart and transplantation) - science often finds material explanations for anecdotal or metaphysical concepts.

Many hormones and chemicals previously thought to exist only in the brain are now identified in the gut. About ninety-five per cent of the body’s serotonin, for instance, a neurotransmitter linked to appetite, sexual behaviour, pain and happiness, is found in the gut. So is dopamine, the 'pleasure hormone'.

If the gut/brain relationship is being re-jigged, however, it is at the expense of gender. We might not think of the gut as being gendered, but it is. Gender, like obesity, age and lifestyle, influences the hormones that are produced in the gut, and therefore the kinds of gut flora that might flourish. Whether or not there are ‘natural’ differences in gut flora is under-researched, though it is likely, given the role of hormonal influence.  It is known, for instance, that taking the contraceptive pill dramatically affects women’s gut bacteria, and that gut bacteria is gendered in BMI-specific ways - could this be a clue to the gender differences in metabolic and intestinal inflammatory disease? 

Why is gender missing from discussions of gut bacteria? And does it matter? Drugs and therapeutics have historically been developed for theoretically genderless (though inherently male) patient. According to the Institute of Medicine, women and men are perceived as different at the level of each individual cell. Each cell line is derived from a single donor and contains 23 pairs of chromosomes. Included in this group are the sex chromosomes, XX (female) and XY (male). Since 5% of the human genome 'resides on these chromosomes - 1846 genes on the X and 454 on the Y' - male and female cells are genetically different, a theme recently explored in the American Journal of Physiology.

Molecular biology is beginning to show how genes expressed on cell chromosomes 'impact cell function, and how they react to all sorts of stimuli'. For instance,female neurons uptake dopamine more quickly than male neurons, and female liver cells may metabolise drugs differently to male.

These cellular differences are rarely considered in medical studies or drug development. Since the 19th-century birth of scientific medicine, there has been a significant gender bias in favour of men. Yet the gender bias affects women's and men's experiences of healthcare in key ways. 

It remains to be seen how much difference gender will make to scientific understandings of the gut. There is a cultural stereotype that women are more able to access 'gut-feelings', though this ability is usually framed as 'intuition'.  Intuition has not historically been regarded credibly, but as evidence of women's connection with the emotional and the mystical (by contrast to men's reliance on reason and logic). Might it one day be re-imagined as a product of bacteria?

Electron micrograph of a common gut flora: Escherichia coli. Image courtesy of Wellcome Images

Electron micrograph of a common gut flora: Escherichia coli. Image courtesy of Wellcome Images