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Pediatric Psychogastroenterology

Bringing together international experts in psychological and behavioral treatments for pediatric
gastrointestinal symptoms, this book provides detailed, evidence-based protocols targeting
gastrointestinal distress and associated mental health concerns for patients and their families.
The first consolidated resource on the topic, Pediatric Psychogastroenterology, gives mental
health professionals access to the most up-to-date clinical knowledge and practice. Taking a
holistic approach, it guides the reader on the treatment and care of pediatric gastrointestinal
(GI) patients, as well as how to work with and support children’s parents and families. The
book is structured around symptom presentation and common challenges, enabling the reader
to focus quickly on the area of need. Each chapter includes clinical pearls of wisdom and 62
developmentally appropriate worksheets for patients and their families to facilitate treatment,
available for download.
This practical, authoritative guide is an essential resource for mental health professionals
who work directly with pediatric cohorts, as well as postgraduate students in health psychology,
behavioral medicine, or social work.

Miranda A.L. van Tilburg is Research Director at Cape Fear Valley Health in Fayetteville,
NC, USA. She also holds professor positions at the University of North Carolina, Marshall
University, University of Washington, and Campbell University. Dr van Tilburg is an expert in
psychogastroenterology.

Bonney Reed is Pediatric Psychologist and Associate Professor of Pediatrics at Emory

University School of Medicine and Children’s Healthcare of Atlanta, USA. In working with
patients and conducting clinical research, she aims to use psychological principles to improve
disease outcomes and quality of life in patients affected by GI conditions.

Simon R. Knowles is Associate Professor and Clinical Psychologist based at the Swinburne
University of Technology, Melbourne, Australia. His clinical and research interests relate to the
biological and psychological interactions of GI conditions and the brain–gut axis.
Pediatric Psychogastroenterology

A Handbook for Mental Health Professionals

Edited by Miranda A.L. van Tilburg,

Bonney Reed and Simon R. Knowles
Designed cover image: © Shutterstock
First published 2024
by Routledge
4 Park Square, Milton Park, Abingdon, Oxon OX14 4RN
and by Routledge
605 Third Avenue, New York, NY 10158
Routledge is an imprint of the Taylor & Francis Group, an informa business
© 2024 selection and editorial matter, Miranda A.L. van Tilburg, Bonney
Reed and Simon R. Knowles; individual chapters, the contributors
The right of Miranda A.L. van Tilburg, Bonney Reed and Simon R. Knowles
to be identified as the authors of the editorial material, and of the authors
for their individual chapters, has been asserted in accordance with sections
77 and 78 of the Copyright, Designs and Patents Act 1988.
All rights reserved. No part of this book may be reprinted or reproduced or
utilised in any form or by any electronic, mechanical, or other means, now
known or hereafter invented, including photocopying and recording, or in
any information storage or retrieval system, without permission in writing
from the publishers.
Trademark notice: Product or corporate names may be trademarks or
registered trademarks, and are used only for identification and explanation
without intent to infringe.
ISBN: 9781032312347 (hbk)
ISBN: 9781032312330 (pbk)
ISBN: 9781003308683 (ebk)
DOI: 10.4324/9781003308683
Typeset in Times New Roman
by Deanta Global Publishing Services, Chennai, India
Access the Support Material: routledge.com/9781032312330
Miranda: This book is dedicated to the countless children, past and future,
whose lives I’ve had the honor to briefly visit. I learned so much from your
grace, grit, and generosity.

Bonney: I dedicate this book to my mentors in pediatric

psychogastroenterology and to my patients.

Simon: I dedicate this book to my parents, Robert and Irene Knowles, who
like all wonderful parents provided a loving and caring environment in which
to learn and grow.
Contents

List of tables  x
List of figures  xi
List of boxes  xii
List of acronyms  xiii
List of contributors  xv
Acknowledgments xxi
List of editors  xxiii
Foreword  xxiv
Preface  xxvi

PART 1
Introduction to pediatric gastrointestinal physiology and conditions,
the brain-gut axis, and working within health care teams 1

1 Gastrointestinal anatomy and physiology  3

JORDAN M. SHAPIRO

2 Stress, psychological factors, and the brain–gut axis  22

JULIE SNYDER CHRISTIANA AND SAMUEL NURKO

3 Common gastrointestinal conditions in pediatrics  35

ASHISH CHOGLE

4 Medical procedures/testing in pediatric gastroenterology  53

SHAUNTE MCKAY AND JOSE GARZA

5 Helping youth manage medical procedures  67

DELANE LINKIEWICH, OLIVIA DOBSON, AND C. MEGHAN MCMURTRY

6 Case conceptualization and assessment  77

MICHELE H. MADDUX AND AMANDA D. DEACY


viii Contents

7 Collaborative, multidisciplinary treatment  87

JENNIFER VERRILL SCHURMAN AND CRAIG A. FRIESEN

8 Working with parents and primary caregivers  101

KARI FREEMAN BABER AND KELLY A. O’NEIL RODRIGUEZ

9 Caring for youth and families with complex medical and

psychosocial concerns  114
BRADLEY JERSON AND AMY E. HALE

PART 2
Psychological approaches in pediatric psychogastroenterology 129

10 Feeding difficulties: Introduction  131

HAYLEY H. ESTREM, JACLYN PEDERSON, AND KAITLIN B. PROCTOR

11 Feeding difficulties: Food refusal  142

MEGHAN A. WALL, ANDREA BEGOTKA, AND CINDY KIM

12 Feeding difficulties: Food selectivity  152

KAITLYN MOSHER, ROBERT DEMPSTER, VALENTINA POSTORINO,
AND T. LINDSEY BURRELL

13 Feeding difficulties: Difficulty swallowing and the fear of aversive

consequences 164
NANCY L. ZUCKER, ILANA B. PILATO, AND SARAH LEMAY-RUSSELL

14 Nausea and vomiting  177

SALLY TARBELL

15 Pain disorders: Introduction, assessment, and psychophysiology  189

LIZ FEBO-RODRIGUEZ AND MIGUEL SAPS

16 Pain disorder interventions: Cognitive behavior therapy and acceptance

and commitment therapy  198
TASHA MURPHY, MIRANDA A.L. VAN TILBURG, AND
RONA L. LEVY

17 Pain disorder interventions: Hypnotherapy  211

ARINE M. VLIEGER
 Contents  ix

18 Constipation and soiling: Infant/toddler  219

CHRISTINA LOW KAPALU AND JOHN M. ROSEN

19 Constipation and soiling: Children and adolescents  228

JACLYN A. SHEPARD AND ALEX C. NYQUIST

PART 3
Transition and future challenges in pediatric
Psychogastroenterology237

20 Chronic illness adjustment and transition  239

SARA L. LAMPERT-OKIN, MEGHAN M. HOWE, ANGELA YU,
KIM GRZESEK, AND RACHEL NEFF GREENLEY

21 Supervision and future challenges in pediatric

psychogastroenterology  252
BONNEY REED, SIMON R. KNOWLES, AND MIRANDA A.L. VAN TILBURG

Index259
Tables

2.1 Developmentally appropriate metaphors to explain the brain–gut connection,

nervous system hypersensitivity, and the concept of chronic GI symptoms  29
3.1 Common GI conditions in youth  36
3.2 Commonly used medications for GI conditions in youth  37
4.1 Common indications for laboratory testing  55
4.2 Summary of common imaging descriptions  57
4.3 Common motility testing indications  62
5.1 Assessment of pain and fear (all measures are freely accessible)  70
6.1 Language adaptations by age and developmental level  79
7.1 Sample roles by patient population (assessment phase)  90
7.2 Role definition and communication strategies for integration of psychology
into GI care  92
7.3 Key strategies to enhance communication and collaboration in
multidisciplinary care  93
7.4 Recommended talking points with administrative leaders  96
11.1 Summary of contributing factors associated with food refusal  144
11.2 Summary of common psychological and behavioral issues and suggested
assessment questions/comments and interventions  149
14.1 Rome IV diagnostic criteria for pediatric nausea and vomiting disorders  178
15.1 FAPD subtypes  191
15.2 Pharmacologic management of abdominal pain  194
17.1 Stages of hypnosis in gut-directed hypnotherapy  212
19.1 Summary table of behavioral issues and suggested interventions  232
20.1 Evidence-based interventions to enhance psychosocial functioning, adherence,
and transition readiness  242


Figures

1.1 The anatomy of the GI tract  4

1.2 Layers of the GI tract  5
1.3 Esophageal phase of swallowing  9
1.4 The role of the lower esophageal sphincter in gastroesophageal reflux disease  10
1.5 Anatomy of the stomach  10
1.6 Sites of absorption of macronutrients and micronutrients along the GI tract  13
1.7 Pancreatobiliary system  14
1.8 Functions of the liver  15
1.9 The anatomy of the anorectal canal  17
2.1 The brain–gut axis  24
3.1 Classification of esophageal atresia 38
4.1 Child performing breath test  56
4.2 Child on tilt table drinking contrast for upper GI X-ray  58
4.3 Child receiving colonoscopy 63
5.1 A longitudinal view of medical procedures 69
7.1 Process map with key elements to consider within each phase 88
10.1 History of PFD and ARFID 134
10.2 Patient ages per diagnostic code use  135
11.1 Bite-size fading  146
12.1 Picky eating and selective eating  153
12.2 Parent–child feeding interaction  155
12.3 Treatment goals for food selectivity  156
13.1 An example of a maladaptive fear gradient following a choking incident  166
13.2 Cycle of somatic avoidance resulting from fear generalization 167
13.3 Throat sensation characters 172
16.1 Impact of child and parent catastrophizing on child and health outcomes 200
16.2 Tension–pain cycle  203
18.1 A vicious cycle: constipation 220


Boxes

3.1 Red flags suggestive of organic conditions  42

8.1 Supporting a 9-year-old in daily medication adherence  104
8.2 Addressing parental overprotection  108
9.1 Discussing refractory symptoms amid reassuring test results  115
9.2 The chicken or the egg? GI symptoms and anxiety disorders  118
9.3 Navigating trauma disclosures  119
9.4 Responding to commonly expressed treatment concerns  120
9.5 Systemic barriers in action  124
9.6 Tips for enhancing treatment collaboration with a school and/or coach  125
10.1 Visualizing antecedent-based challenges  139
14.1 Recommended assessment for NVD  179
14.2 Case example of CVS treatment  184
15.1 Can everyone feel pain?  193
17.1 How to discuss hypnotherapy with youth and parents  215
18.1 Red flags indicating the need for further evaluation  221
18.2 Is toilet training a contributor to constipation?  223
18.3 “Help! I’ll fall in the toilet”  225
19.1 Examples of school accommodations  231


Acronyms

ACE Adverse childhood experience

ACT Acceptance and commitment therapy
AN Anorexia nervosa
ANS Autonomic nervous system
ARFID Avoidant/restrictive food intake disorder
ASD Autism spectrum disorder
BGA Brain–gut axis
BMP Basic metabolic panel
CBT Cognitive behavior therapy
CHS Cannabinoid hyperemesis syndrome
CNS Central nervous system
CRP C-reactive protein
CVS Cyclic vomiting syndrome
DGBI Disorders of gut–brain interaction (formally known as functional gastrointes-
tinal disorders; FGIDs)
EBT Evidence-based treatment
EndoFLIP Endoluminal functional lumen imaging probe
ENS Enteric nervous system
ESR Erythrocyte sedimentation rate
FAP Functional abdominal pain
FGIDs Functional gastrointestinal disorders (now referred to as disorders of gut–brain
interaction; DGBI)
FN Functional nausea
FOAC Fear of aversive consequences
FV Functional vomiting
GI Gastrointestinal
H. pylori Helicobacter pylori bacteria
HPA axis Hypothalamic–pituitary–adrenal axis
IBD Inflammatory bowel disease
IBS Irritable bowel syndrome
IV Intravenous
LGBTQIA+ Lesbian, gay, bisexual, transgender, queer, intersex, asexual, +
NFI Nonretentive fecal incontinence


xiv Acronyms

NG Nasogastric
NVD Nausea and vomiting disorders
OR Observer report
OT Occupational therapist
PFD Pediatric feeding disorder
PFPT Pelvic floor physical therapy
POTS Postural orthostatic tachycardia syndrome
SAM axis Sympathetic-adreno-medullar axis
SDOH Social determinants of health
SLP Speech-language pathologist
SR Self-report
TAs Topical anesthetics
TF-CBT Trauma-focused cognitive behavior therapy
Contributors

Kari Freeman Baber, PhD

Clinical Assistant Professor of Psychiatry, Perelman School of Medicine, University of
Pennsylvania & Psychologist, Department of Child and Adolescent Psychiatry & Behavioral
Sciences and Department of Pediatrics/Gastroenterology, Hepatology & Nutrition, Children’s
Hospital of Philadelphia
Philadelphia, Pennsylvania, USA.

Andrea Begotka, PhD

Assistant Professor, Pediatric Psychologist, Medical College of Wisconsin
Milwaukee, Wisconsin, USA.

T. Lindsey Burrell, PhD

Adjunct Assistant Professor, Departments of Pediatrics, Emory University School of Medicine
& Clinical Psychologist
Atlanta, Georgia, USA.

Ashish Chogle, MD, MPH

Associate Professor, Division of Pediatric Gastroenterology, CHOC Children’s, University of
California-Irvine
Irvine, California, USA.

Julie Snyder Christiana, Psy.D

Assistant Professor of Psychology, Harvard Medical School
Pediatric Psychologist, Boston Children’s Hospital
Boston, Massachusetts, USA.

Amanda D. Deacy, PhD

Associate Professor, Department of Pediatrics, University of Missouri, Kansas City (UMKC)
School of Medicine & Psychologist, Division of Gastroenterology, Hepatology, and
Nutrition, Children’s Mercy Kansas City
Kansas City, Missouri, USA.

xvi Contributors

Robert Dempster, PhD

Clinical Assistant Professor, Department of Pediatrics, The Ohio State University
Program Director, Comprehensive Pediatric Feeding and Swallowing Program, Nationwide
Children’s Hospital
Columbus, Ohio, USA.

Olivia Dobson, MA
PhD student, University of Guelph
Guelph, Ontario, Canada.

Hayley H. Estrem, PhD, RN

Assistant Professor, University of North Carolina Wilmington
Wilmington, North Carolina, USA.

Liz Febo-Rodriguez, MD
Assistant Professor & Pediatric Gastroenterologist, The University of Texas Medical Branch
Galveston, Texas, USA.

Craig A. Friesen, MD
Pediatric Gastroenterologist & Professor of Pediatrics, University of Missouri Kansas City
School of Medicine
Associate Division Director for GI Research, Children’s Mercy Kansas City
Kansas City, Missouri, USA.

Jose Garza, MD
Pediatric Gastroenterology Physician, GI Care for Kids
Atlanta, Georgia, USA.

Rachel Neff Greenley, PhD

Psychologist, Rosalind Franklin University of Medicine and Science
North Chicago, Illinois, USA.

Kim Grzesek, BS
Clinical Psychology Doctoral Student, Rosalind Franklin University of Medicine and Science
North Chicago, Illinois, USA.

Amy E. Hale, PhD

Assistant Professor of Psychology, Harvard Medical School
Pediatric Psychologist, Division of Gastroenterology, Hepatology & Nutrition, Boston
Children’s Hospital
Boston, Massachusetts, USA.
 Contributors  xvii

Meghan M. Howe, BA
Clinical Psychology Doctoral Student, Rosalind Franklin University of Medicine and Science
North Chicago, Illinois, USA.

Bradley Jerson, PhD

Assistant Professor of Pediatrics, University of Connecticut School of Medicine
Pediatric Psychologist, Division of Digestive Diseases, Hepatology, & Nutrition, Connecticut
Children’s Medical Center
Farmington, Connecticut, USA.

Christina Low Kapalu, PhD

Associate Professor & Pediatric Psychologist, Children’s Mercy Kansas City, University of
Missouri
Kansas City, Missouri, USA.

Cindy Kim, PhD, ABPP

Pediatric Psychologist, CHOC Children’s Hospital of Orange
Orange, California, USA.

Simon R. Knowles, PhD

Associate Professor & Clinical Psychologist, Swinburne University of Technology
Melbourne, Victoria, Australia.

Sara L. Lampert-Okin, MS, LPC

Licensed Professional Counselor & Clinical Psychology Doctoral Student, Rosalind Franklin
University of Medicine and Science
North Chicago, Illinois, USA.

Sarah LeMay-Russell, PhD

Clinical Associate & Clinical Psychologist, Duke University Medical Center
Durham, North Carolina, USA.

Rona L. Levy, MSW, PhD, MPH

Professor and Associate Dean for Research, University of Washington
Seattle, Washington, USA.

Delane Linkiewich, MA
PhD student, University of Guelph
Guelph, Ontario, Canada.
xviii Contributors

Michele H. Maddux, PhD

Associate Professor, Department of Pediatrics, University of Missouri, Kansas City (UMKC)
School of Medicine
Licensed Psychologist, Division of Gastroenterology, Hepatology, and Nutrition, Children’s
Mercy Kansas City
Kansas City, Missouri, USA.

Shaunte McKay, MD
Pediatric Gastroenterology Fellow Physician, Ann & Robert H. Lurie Children’s Hospital of
Chicago
Chicago, Illinois, USA.

C. Meghan McMurtry, PhD, C. Psych

Associate Professor, University of Guelph, McMaster Children’s Hospital
Hamilton, Ontario, Canada.

Kaitlyn Mosher, PhD

Clinical Assistant Professor, Department of Pediatrics, The Ohio State University & Clinical
Psychologist, Department of Pediatric Psychology and Neuropsychology, Nationwide
Children’s Hospital
Columbus, Ohio, USA.

Tasha Murphy, PhD

Senior Research Scientist, University of Washington
Seattle, Washington, USA.

Samuel Nurko, MD
Professor of Pediatrics, Harvard Medical School
Director, Center for Motility and Functional Gastrointestinal Disorders, Boston Children’s
Hospital
Boston, Massachusetts, USA.

Alex C. Nyquist, PhD

Assistant Professor of Pediatrics, Cincinnati Children’s Hospital Medical Center
Clinical Child & Adolescent Psychologist
Cincinnati, Ohio, USA.

Jaclyn Pederson, MHI

CEO, Feeding Matters
Phoenix, Arizona, USA.
 Contributors  xix

Ilana B. Pilato, PhD

Medical Instructor & Clinical Psychologist, Duke University Medical Center
Durham, North Carolina, USA.

Valentina Postorino, PhD

Departments of Pediatrics and Psychiatry, University of Colorado, Anschutz Medical Campus,
JFK Partners
Aurora, Colorado, USA.

Kaitlin B. Proctor, PhD

Assistant Professor, Division of Autism & Related Disorders, Department of Pediatrics, Emory
University
Atlanta, Georgia, USA.

Bonney Reed, PhD, ABPP

Associate Professor of Pediatrics, Emory University School of Medicine
Clinical Psychologist, Children’s Healthcare of Atlanta
Atlanta, Georgia, USA.

Kelly A. O’Neil Rodriguez, PhD

Assistant Professor of Clinical Psychiatry, Perelman School of Medicine, University of
Pennsylvania & Psychologist, Department of Child and Adolescent Psychiatry & Behavioral
Sciences and Department of Pediatrics/Gastroenterology, Hepatology & Nutrition, Children’s
Hospital of Philadelphia
Philadelphia, Pennsylvania, USA.

John M. Rosen, MD
Professor & Pediatric Gastroenterologist, Children’s Mercy Kansas City, University of
Missouri
Kansas City, Missouri, USA.

Miguel Saps, MD
Professor & Pediatric Gastroenterologist, Miller School of Medicine
Miami, Florida, USA.

Jennifer Verrill Schurman, PhD, ABPP, BCB

Clinical Psychologist & Professor of Pediatrics, University of Missouri Kansas City School of
Medicine & Section Chief of GI Psychology, Children’s Mercy Kansas City
Kansas City, Missouri, USA.
xx Contributors

Jordan M. Shapiro, MD, MS

Assistant Professor of Gastroenterology, Baylor College of Medicine
Staff Gastroenterologist, Baylor College of Medicine/ Baylor St. Luke's Medical Center
Houston, Texas, USA.

Jaclyn A. Shepard, Psy.D

Associate Professor of Psychiatry and Neurobehavioral Sciences, University of Virginia School
of Medicine & Clinical Psychologist
Charlottesville, Virginia, USA.

Sally Tarbell, PhD

Professor (retired)
Pediatric Psychologist, Northwestern Feinberg School of Medicine
Chicago, Illinois, USA.

Miranda A.L. van Tilburg, PhD

Research Director Cape Fear Valley Medical Center, Professor of Medicine, Marshall
University, Adjunct Professor of Medicine, University of North Carolina, Affiliate Professor
of Social Work, University of Washington
Chapel Hill, North Carolina, USA.

Arine M. Vlieger, MD, PhD

General Pediatrician, St Antonius Hospital Nieuwegein
Nieuwegein, The Netherlands.

Meghan A. Wall, PhD, BCBA

Assistant Professor, Pediatric Psychologist, Medical College of Wisconsin
Milwaukee, Wisconsin, USA.

Angela Yu, BS
Medical student, Rosalind Franklin University of Medicine and Science
North Chicago, Illinois, USA.

Nancy L. Zucker, PhD

Professor & Clinical Psychologist, Duke University Medical Center
Durham, North Carolina, USA.
Acknowledgments

Simon: I wish to thank the patients I have had the honor to work with; your valuable time and
determination to make your life better despite having significant gastrointestinal difficulties
are inspiring. Thank you to the allied and medical health professionals and researchers who
continue to have a significant impact on my work with patients and research in psychogastro-
enterology. Finally, I wish to thank my coeditors, Bonney Reed and Miranda van Tilburg, who
are leaders in psychogastroenterology, and despite significant workloads, agreed to take on this
daunting project with me.

Bonney: I would like to thank my graduate school mentor, Professor Ronald L. Blount, who
first introduced me to GI psychology and my long-time collaborators and supporters including
Dr Jeffery D. Lewis. Only through the support of mentors have I been able to develop a career
in psychogastroenterology. I would also like to acknowledge my GI psychology trainees who
have made my career in psychogastroenterology possible and rewarding, including Dr Grace
Cushman, Dr Sharon Shih, and Dr Kelly Rea. My husband’s steadfast support throughout the
writing and editing of this book, much of which occurred in the evenings, cannot go unacknowl-
edged. Finally, I would like to thank my coeditors, Simon Knowles and Miranda van Tilburg,
both are distinguished experts in the field of psychogastroenterology, from whom I have learned
so much.

Miranda: I would like to honor the scientists and clinicians who laid the foundations of
Psychogastroenterology before such a field was even named. A special thanks to the scientific
mentors in my life: Dr Ad Vingerhoets, Dr Richard Surwit, Dr Bill Whitehead, and Dr Rona
Levy. Thanks for allowing me to stand on your shoulders. I could not have done this without the
amazing pediatric gastroenterologists who accepted me in their midst, at a time when psycholo-
gists were not commonly employed in the field. I especially want to thank Dr Denesh Chitkara
who ushered me in, Dr Nader Youssef who has always been an intellectual sparring partner,
and Dr Miguel Saps who has been there in every step of the way. We are better when we work
together. Finally, I am privileged to have worked with an amazing editorial team. Bonney Reed
and Simon Knowles, I am glad we shared this journey.


xxii Acknowledgments

The editors would also like to acknowledge and thank:

• Mr Maxwell Rapach for his expert research assistant and editing support.
• Mr James Overs for his expert research assistant and editing support.
• Dr Edward Giles (Consultant Pediatric Gastroenterologist at Monash Children’s Hospital,
Melbourne, Australia) for his assistance in reviewing and revising Handout 4.1.
• Professor Carlo DiLorenzo for his very kind Foreword.
• Finally, we would like to thank all the contributors who provided chapters for this handbook.
Each of you is a highly respected clinical expert in your field and consequently providing
your valuable time to provide a chapter was very much appreciated. This handbook was an
enormous challenge made much easier by your professionalism and dedication to this pro-
ject, and your willingness to make changes to your chapters even right up to the end of the
editorial process. Thank you.
List of editors

Dr Miranda A.L. van Tilburg is a Research Director at Cape Fear Valley Health in Fayetteville
NC. She also holds professor positions at the University of North Carolina, Marshall University,
University of Washington, and Campbell University. Dr van Tilburg is an expert in psychogas-
troenterology. She develops and tests brain–gut treatments such as cognitive behavioral therapy
and hypnotherapy, for gastrointestinal diseases particularly for children. Dr van Tilburg has
over 200 publications in her name and has received >$10M in grant funding. She has advised
the FDA, EMA, NIH, and Center for Medicaid/Medicare. Dr van Tilburg was appointed to
the Rome committee, which establishes diagnostic criteria for pediatric disorders of gut–brain
interaction. She is a previously elected council member of the American Neurogastroenterology
and Motility Association and a current elected ethics chair of the North American Society for
Pediatric Gastroenterology, Hepatology, and Nutrition.

Dr Bonney Reed is a Pediatric Psychologist and Associate Professor of Pediatrics at Emory

University School of Medicine and Children’s Healthcare of Atlanta. In working with patients
and conducting clinical research, she aims to use psychological principles to improve disease
outcomes and quality of life in patients affected by GI conditions. She carries an active caseload
of patients, regularly publishes clinical research in peer-reviewed journals, and trains future GI
mental health professionals.

Dr Simon R. Knowles is Associate Professor and Clinical Psychologist based at Swinburne

University of Technology, Melbourne. His clinical and research interests relate to the bio-
logical and psychological interactions of GI conditions and the brain–gut axis. Associate
Professor Knowles has published over 100 peer-reviewed articles, 3 books, including
Psychogastroenterology for Adults: A Handbook for Mental Health Professionals in 2019,
and attained over $5.8(AUD) million in research funding. He has developed multiple online
resources and optimal health programs for gastrointestinal conditions, which have been used by
over 600,000 users to date.


Foreword

Optimal functioning of the gastrointestinal (GI) tract is central to youth’s ability to grow, learn,
and be happy. Yet, diseases and disorders affecting the GI tract impact one in four youth. These
may not only impact biological factors such as appetite or defecation but also are known to
negatively influence children’s psychosocial development. Many children with GI symptoms
are at risk for significant school absence with negative consequences on academic and social
development. Long-term negative outcomes range from job insecurity to imprisonment. The
relationship between psychosocial factors and gastrointestinal health is complex and as a child
grows into adulthood, changes in social, psychological, and biological development can impact
the many facets of the brain–gut axis.
Despite the long recognition of the importance of the brain–gut axis in the development
and impact of many GI disorders and the more recent appreciation of the benefit of multiple
psychological and behavioral treatments, the true integration of mental health professionals in
the treatment of youth with GI diseases is relatively new. Increasingly, the value of a multidis-
ciplinary collaboration to help youth with GI symptoms is recognized and GI practices are look-
ing for ways to incorporate mental health professionals in their care delivery. Also, pediatric
populations present with diverse developmental and emotional needs, requiring a greater range
of therapeutic approaches. In response to such needs, pediatric GI psychology has now become
a highly focused field that requires specialized training. Simply treating general mental health
aspects is no longer deemed sufficient or appropriate for youth with complex GI problems.
A shortage of adequately trained pediatric GI mental healthcare providers has left GI prac-
tices with difficulties in hiring providers with the needed expertise. Until recently, most pedi-
atric GI mental health providers did not have access to training, other than in a few specialized
academic centers, often concentrated in large urban areas, hence excluding access to GI mental
health to many youth, particularly those in rural areas. The current book is the first to pro-
vide comprehensive information needed for any mental health professional entering the field or
established providers looking for an update on recent practices and approaches. Drawing on the
latest research and clinician experience, the authors offer practical advice and evidence-based
strategies for addressing psychosocial issues in youth with GI conditions, aiming to improve
overall health and well-being.
The book includes background information on GI physiology, diseases, and medical assess-
ment/treatment for those new to the field. It provides an in-depth description of mental health
assessment and treatment of the most common GI symptoms such as abdominal pain, constipa-
tion, nausea, and feeding issues. In addition, the book has a very original format with learning


 Foreword  xxv

points, “pearls of wisdom”, practical scenarios, and suggested readings. This book is a pleasure
to read and will be an invaluable resource for any mental healthcare provider encountering
youth with GI issues.
Carlo Di Lorenzo, MD
Chief, Division of Pediatric Gastroenterology
Nationwide Children’s Hospital
Professor of Pediatrics
The Ohio State University
Preface

Pediatric gastrointestinal (GI) conditions are common, and concerns around abdominal pain,
digestion, stooling, and feeding are several of the most common reasons parents seek pediatric
healthcare. Pediatric GI problems are heterogeneous and may include aberrations in meeting
feeding and toileting developmental milestones, disorders of gut-brain interaction (DGBI) such
as irritable bowel syndrome, and pediatric onset of chronic illnesses such as Crohn’s disease.
Particularly DGBI are common: In the Unites States of America 1 out of 4 infants, toddlers,
and children fulfilled criteria for a DGBI. Worldwide, 13.3% of children suffer from functional
abdominal pain [1], likely one of the most common GI conditions. Another common condition
seen in GI practices is inflammatory bowel disease. Although this condition affects only 0.08%
in the US, every single one of these patients needs regular care of a pediatric gastroenterologist.
In addition, the rate of pediatric IBD has increased 133% from 2007 to 2016 with no definitive
explanation [2]. Diagnosis with a pediatric GI disorder places youth and their family at risk of
impaired quality of life [3], missed school/work [4], psychological distress [5], and increased
healthcare costs [6].
As anyone can attest, our brain and gut are intimately connected. Who does not recog-
nize butterflies in one’s stomach or stomach cramps before an important event? The role
of psychosocial factors in pediatric GI symptoms is well established. A sizeable literature
describes associations between GI symptoms and many psychosocial factors such as child’s
and parent’s thoughts, emotions, coping strategies and a history of negative life events [7].
Thankfully, it is increasingly recognized that comprehensive treatment for pediatric GI condi-
tions includes addressing both biological as well as psychological and social factors impact-
ing disease outcomes. It is no longer evidence-based or acceptable to treat a pediatric GI
condition without addressing the social and psychological factors that may be influencing
symptoms directly through an association with their onset and maintenance or contributing to
a patient’s distress through maladaptive coping [8]. This increased recognition has given rise
to a new field of psychogastroenterology.
Psychogastroenterology can be defined as “the application of psychological science and
practice to gastrointestinal health and illness” [9]. It examines how psychosocial factors can
influence GI symptoms, develops and tests psychological treatments for GI disorders, and
examines the crucial role mental health clinicians play in multidisciplinary teams. Although
wide evidence exists for the efficacy and safety of psychological treatments in GI disorders,
these are not available to most patients due to lack of GI-trained mental health care providers,


 Preface  xxvii

low referral rates in the absence of clear psychological distress, and poor insurance coverage
for these treatments. The aim of this book is to develop a compendium of expert opinion on the
practice of pediatric psychogastroenterology. The book aims to serve as a resource for students/
trainees, established mental health practitioners who are new to treating youth with GI disor-
ders, other clinicians interested in psychological treatments of GI disorders, and established GI
mental health providers who desire a state-of-the-art reference book for their practice. Through
education and dissemination, we hope to make psychological treatments available to any pedi-
atric patients in need of psychogastroenterology approaches.

Psychogastroenterology: Development and history

Pediatric psychogastroenterology has a long history. The earliest published literature stems
from the 1950s at a time when Sigmund Freud’s theory on psychosexual development was
widely accepted. Bodily symptoms were often interpreted as repression of unconscious threat-
ening thoughts or emotions. To discover the state of unconsciousness, clinicians interpreted the
patients’ symptoms, behaviors, and language, assigning meaning largely outside of the patients’
own experiences We now know Freud was spectacularly wrong, therefore the examples below
will feel outdated.

(1) Constipation: In 1947 Editha Sterba published a case report of “psychogenic constipa-
tion” in a two year old child [10]. Psychogenic constipation was seen as a normal devel-
opmental stage of the child’s libido during potty training. Children were thought to derive
anal pleasure from bowel movements and constipation was seen as anal eroticism and/or
penis envy. Repeated use of enemas to aid in bowel movements elevated anal libido and
thus constipation. These ideas remained popular even in the mid seventies. For exam-
ple, Dr Glenn [11] published a case report of a young girl with constipation arguing the
girl’s symptoms were due to penis envy, pseudo pregnancy, and a masochistic father. This
despite evidence in 1966 that ‘psychogenic’ constipation can be treated with an enema in
40 out of 56 young patients [12].
(2) Inflammatory bowel disease: In 1958 a report in the Royal Society of Medicine [13]
describes young patients with colitis as dependent upon their parents, having difficulty
expressing emotions, and preoccupation with cleanliness. Although not specifically dis-
cussed, the names of these psychosocial factors clearly are in line with the psychoana-
lytic framework of Freud in which parental sexual jealousy, suppressed emotions, and anal
(erotic) fixations were thought to explain symptoms. Psychogenic causes of IBD where
commonly accepted at that time [14].
(3) Abdominal pain: Although published in 1957 the study by Dr Apley and Naish [15]
on recurrent abdominal pain feels refreshingly modern. The authors relied on empirical
techniques rather than psychoanalytic insights. The authors studied 1000 school children
and found those with recurrent abdominal pain, compared to those who with abdominal
pain, show increased anxiety/timidness as well as increased excitability and fussiness. The
authors relied on reports of mothers and school personnel, rather than psychiatrists’ inter-
pretations of the patient. In addition, their use of concepts such as anxiety and excitability
are more aligned with current conceptualizations rather than their psychoanalytic zeitgeist.
Thus, contrary to their compatriots the authors did not interpret psychological factors as
evidence of repressed feelings being expressed in a physical way. However, not much later
xxviii Preface

the idea that abdominal pain is entirely caused by emotional issues becomes very well
entrenched (for example see the 1970 article by unlisted authors in the British Journal of
Medicine) [16].

Despite these early empirical studies, it was decades before well-designed empirical studies of
psychosocial factors in GI disease become common place. We have to place these studies in
the light of the reigning models explaining health and disease. The biomedical model proposes
that psychosocial factors can play a role in disease in two ways. Psychological factors can be a
consequence of medically explained diseases. It may influence such things as health care seek-
ing. For example, Engstrom observed in 1999 that the well-being of children with IBD depends
on psychological and social complications from the disease [17]. The biomedical model also
predicts that symptoms that are medically unexplained are caused by psychological factors.
If it is not in the body, it must be in the brain. Many case control studies seem to support this
assumption: Anxiety rates were much higher in patients with DGBI than in healthy controls [7].
Yet, Drs Walker and Greene observed no difference in anxiety or depression between children
with medically explained and unexplained GI diseases [18].
The biopsychosocial model (see Chapter 2), proposed in 1977, introduced the idea that psy-
chosocial aspects play a role in all diseases. But it would take several decades for these ideas
to be widely accepted in medicine. We can see this from the timeline of studies (see Figure
0.1) that shows a clear focus of early psychosocially oriented studies on DGBI, disorders that
do not have a clear medical explanation. While early studies in IBD, an inflammatory disease
with a clear medical explanation, focused primarily on the consequence of living with a chronic
disorder. For example, the first trial of cognitive behavioral therapy (CBT) for IBD in 2004 was
aimed at treating comorbid depression. Over time, more blurring of the lines between ‘medically
explained’ and ‘medically unexplained’ occurred, particularly with the recognition of IBS-IBD
overlap. We now know that DGBI have important biological factors in their pathophysiology,
and IBD has important psychosocial aspects affecting disease outcomes.
Although DGBI, particularly IBS/functional abdominal pain, and IBD are still primary targets
for most studies, over time more studies have included other disorders or symptoms such as con-
stipation, nausea, vomiting, feeding issues etc. (see Figure 0.1). These are important developments
making psychogastroenterology far more inclusive and offering much needed psychological care
to children across GI conditions. Furthermore, the type of psychosocial factors examined have
become more diverse (see Figure 0.1). Where the early literature focused primarily on general
anxiety and depression, as either causes of or reactions to GI symptoms, a shift can be observed
towards examining more GI focused concepts such as GI specific anxiety, somatization, pain cata-
strophizing etc. which are stronger predictors of outcomes. Social aspects are also increasingly
studied, and the strongest evidence comes from the social learning literature, showing parents pro-
tectiveness increases the pain and disability of their children. In 2017 this culminated in a novel
trial showing that intervening only with parents can reduce disability in children with DGBI [19].
As evidence for the use of CBT and hypnosis across various pediatric GI disorders was
building (see Figure 0.1), this has increased the number of mental health care providers embed-
ded in pediatric GI clinics. The number of clinicians trained has exponentially increased, but
is still too small to be able to offer care to all patients. Particularly patients living in rural areas
with limited access to mental health care providers. Yet official training does not yet exist for
pediatric psychogastroenterology. Mental health care providers often learn from mentorship of
others in the field.
Figure 0.1 Historic timeline on the rise of pediatric psychogastroenterology.
Preface 
xxix
xxx Preface

The rationale for the book

As identified above, research relating to pediatric Psychogastroenterology has increased at a
rapid rate. The knowledge gained from this research includes the growing understanding of the
brain-gut axis, and its associated bi-directional pathways (brain-gut, gut-brain) in relation to
gastrointestinal conditions and mental health.
Understandably, the evidence-based psychological approaches that are derived from pediat-
ric Psychogastroenterology research are therefore increasingly relevant. While there is a grow-
ing number of publications demonstrating the relevant of psychological interventions in relation
to better outcomes for those youth living with GI symptoms, due to their breadth and number,
for many mental health professionals this area of work can be daunting. Further, despite the
depth of knowledge in relation to the relevance and application of psychological interventions
for youth living with a GI condition, few outside hospital-based university GI clinics have
access to this information. This edited book represents the first attempt to provide mental health
professionals with an evidence-based, practical handbook for working with youth living with a
GI condition.
Due to the nature of the work, mental health professionals need more than the usual set of
skills required when working with youth who present with GI symptoms and associated men-
tal and behavioral difficulties. Basic additional knowledge relating to GI anatomy and func-
tions, and the methods of diagnosis and ongoing management of GI conditions are needed.
Further, knowledge regarding evidence-based psychological interventions, and how to apply
them for youth with GI conditions is essential. To date, there is not a single source for mental
health professionals that provides both a comprehensive introduction to the science of pediatric
Psychogastroenterology and practical “how to” psychological protocols for working with GI
cohorts. We hope that this handbook, written by experts across psychology, psychiatry, and
gastroenterology, helps fill this gap and encourages others to follow.

The structure of the book

It is well established that the experience of psychotherapy leads to successful outcomes when
mental health professionals are unconditionally positive towards patients, utilize microskills
and apply evidence-based interventions. Aligned with successful therapy is the ability and need
for mental health professionals to adapt interventions based on patient presentation, needs, and
resources. To do this in pediatric psychogastroenterology settings, mental health profession-
als also need to be able to adapt their assessment and interventional skillset around a youth’s
condition/s and symptom/s.
Although, the current book aims to produce a handbook that is both comprehensive and
practical, several compromises needed to be undertaken. Given the diversity and number
of pediatric GI conditions, it was not possible to cover each of them. Nor was it feasible to
provide case studies, as this would likely never appropriately reflect the diversity of GI condi-
tions and associated psychological and behavioral presentation seen in pediatric gastroenter-
ology practice. This current book is organized around the most common GI symptoms seen in
pediatric GI youth presentations, namely feeding difficulties, nausea and vomiting, pain, and
constipation and soiling.
Part I of the book is entitled “Introduction to pediatric gastrointestinal physiology
and conditions, the brain-gut axis, and working within health care teams” The chapters
in the first part of the handbook provides essential core aspects to the practice of pediatric
 Preface  xxxi

psychogastroenterology, including GI physiology and common GI symptoms and conditions

(Chapters 1 and 2). This part of the handbook also provides an overview of medical procedures
and testing used in pediatric gastroenterology (Chapter 4) and recommendations to help youth
manage them (Chapter 5). In addition, this part covers important practical aspects of pediatric
psychogastroenterology, including case conceptualization (Chapter 6), how to work and pro-
mote multi-disciplinary approaches (Chapter 7), and working with parents of youth living with
a GI condition (Chapter 8). The final chapter in this part, covers working with complex patients
and psychological concerns (Chapter 9).
Entitled Psychological approaches in pediatric Psychogastroenterology, Part II provides
readers with detailed recommendations and strategies in relation to the assessment and treat-
ment of psychological issues often reported by youth with GI conditions. This part is has four
main sections, broken down by the predominant presentations seen in pediatric GI youth, spe-
cifically feeding difficulties (Chapters 10–13), nausea and vomiting (Chapter 14), pain disorders
(Chapters 15–17), and constipation and soiling (Chapters 18 and 19).
The last part of the book, Part III entitled Transition and future challenges in pediatric
Psychogastroenterology, includes two chapters (Chapters 20 and 21) that explores the process
of adaption to living with a chronic GI condition and recommendations associated with transi-
tioning from pediatric to adult-based care. The final chapter provides recommendations relating
to supervision of psychological trainees and an overview of the future challenges in pediatric
psychogastroenterology.
We hope that this handbook, written by experts, will be an indispensable resource of infor-
mation, guidance, and materials which enhance your knowledge of, and practice in, pediatric
psychogastroenterology.
MvT, BR, and SK
Chapel Hill, Atlanta, and Melbourne
April 2023

References
1. Korterink JJ, Diederen K, Benninga MA, Tabbers MM. Epidemiology of pediatric functional
abdominal pain disorders: A meta-analysis. PloS One. 2015;10(5):e0126982.
2. Ye Y, Manne S, Treem WR, Bennett D. Prevalence of inflammatory bowel disease in pediatric and
adult populations: Recent estimates from large national databases in the United States, 2007–2016.
Inflamm Bowel Dis. 2020;26(4):619–25.
3. Varni J, Bendo C, Nurko S, Shulman R, Self M, Franciosi J, et al. Pediatric Quality of Life
Inventory (PedsQL) Gastrointestinal symptoms module testing study consortium. Health-related
quality of life in pediatric patients with functional and organic gastrointestinal diseases. J Pediatr.
2015;166(1):85–90.
4. Mackner LM, Bickmeier RM, Crandall WV. Academic achievement, attendance, and school-related
quality of life in pediatric Inflammatory Bowel Disease. 2012; 33(2):106–11.
5. Donovan E, Martin SR, Lung K, Evans S, Seidman LC, Cousineau TM, et al. Pediatric irritable
bowel syndrome: Perspectives on pain and adolescent social functioning. Pain Med (United States).
2019;20(2):213–22.
6. Hoekman DR, Rutten JM, Vlieger AM, Benninga MA, Dijkgraaf MG. Annual costs of care for
pediatric irritable bowel syndrome, functional abdominal pain, and functional abdominal pain
syndrome. J. Pediatr. 2015;167(5):1103–8. e2.
7. Newton E, Schosheim A, Patel S, Chitkara DK, van Tilburg MAL. The role of psychological factors
in pediatric functional abdominal pain disorders. Neurogastroenterol. Motil. 2019; 31(6):e13538.
xxxii Preface

8. Reed B, Buzenski J, van Tilburg MA. Implementing psychological therapies for gastrointestinal
disorders in pediatrics. Expert Rev Gastroenterol Hepatol. 2020;14(11):1061–7.
9. Knowles SR, Keefer L, Mikocka-Walus AA. Psychogastroenterology for Adults: A Handbook for
Mental Health Professionals. Routledge; 2019.
10. Sterba E. Analysis of psychogenic constipation in a two-year-old child. Psychoanal Study Child.
1947;3(1):227–52.
11. Glenn J. Psychoanalysis of a constipated girl: Clinical observations during the fourth and fifth years.
J Am Psychoanal Assoc. 1977;25(1):141–61.
12. Salvati EP. Psychogenic constipation. Dis Colon Rectum. 1966;9(4):293–4.
13. Schlesinger B, Platt J. Ulcerative colitis in childhood and a follow-up study. Proc R Soc Med.
1958;51(9):733–5.
14. Kirsner JB. Historical origins of current IBD concepts. World J. Gastroenterol. 2001;7(2):175–84.
15. Apley J, Naish N. Recurrent abdominal pain: A field study of 1000 school children with recurrent
abdominal pain. Arch. Dis. Child. 1958;46:337–40.
16. Recurrent abdominal pain in children. Br Med J. 1970;4(5727):66–7.
17. Engstrom I. Inflammatory bowel disease in children and adolescents: Mental health and family
functioning. J. Pediatr. Gastroenterol. Nutr. 1999;28(4):S28–33.
18. Walker LS, Greene JW. Children with recurrent abdominal pain and their parents: More somatic
complaints, anxiety, and depression than other patient families? J Pediatr Psychol. 1989;14(2):231–43.
19. Levy RL, Langer SL, Van Tilburg MA, Romano JM, Murphy TB, Walker LS, et al. Brief telephone-
delivered cognitive-behavioral therapy targeted to parents of children with functional abdominal
pain: A randomized controlled trial. Pain. 2017;158(4):618.
Part 1

Introduction to pediatric
gastrointestinal physiology and
conditions, the brain-gut axis, and
working within health care teams


Chapter 1

Gastrointestinal anatomy and physiology

Jordan M. Shapiro

Chapter aims
The aim of this chapter is to provide an introduction to the gastrointestinal (GI) tract, spe-
cifically in relation to its key structures and functions, including the mechanical and biochemi-
cal processes associated with normal digestion. The chapter also provides an overview of the
microbiome and immunologic components and their role in the GI tract.

Learning points
• Introduction to key GI anatomy and physiology, including biological, chemical, and physical
processes to break down, move, and absorb nutrients and eliminate waste.
• Introduction to the GI microbiome and immune system as they relate to normal function and
disease states.
• Practical recommendations relating to psychoeducation about the GI tract.

Background
The GI tract is a complex group of organs with functions that range from digestion and absorp-
tion, maintaining fluid and electrolyte balance, immune function, as well as housing and mediat-
ing the interactions between the gut microbiome and human health.

Basic structure and function of the GI system

The GI tract is comprised of a tubular tract running from the mouth to the anus and accessory
organs connected to the tubular structure (pancreas and liver). Each segment is highly special-
ized to carry out specific functions, see Figure 1.1 depicting key structures of the GI tract.
The esophagus facilitates the passage of food from the mouth to the stomach, where it is
mechanically and biochemically broken down into smaller, more digestible components. The
small intestine is made up of three segments – duodenum, jejunum, and ileum – and is the site of
absorption of nutrients. The liver has many functions, such as detoxification, protein synthesis,
energy storage, and cholesterol synthesis, but from the standpoint of digestion, it is primarily
involved in the production of bile, which helps break down fat to help make it more easily digest-
ible. Bile is also stored in the gallbladder to aid in the digestion of meals with higher fat content.
The pancreas has endocrine (i.e., insulin production) and exocrine (i.e., digestive enzymes)
functions. Enzymes are proteins that accelerate biochemical reactions such as digestion. Both

DOI: 10.4324/9781003308683-2
4 Jordan M. Shapiro

Figure 1.1 The anatomy of the GI tract (Source: Christos Georghiou/Shutterstock​.c​om).

 G astrointestinal anatomy and physiology 5

bile and pancreatic digestive enzymes travel in their respective bile and pancreatic ducts and are
released into the duodenum via a common opening – the ampulla of Vater – to mix with and
further digest food. The large intestine, or colon, absorbs water to create formed stools, and the
pelvic floor and anorectal muscles help to hold stool until it is possible to defecate (otherwise
known as “having a bowel movement” or “pooping”).

Layers of the GI tract

The tubular portion of the GI tract consists of four layers (see Figure 1.2):

Figure 1.2 Layers of the GI tract (Source: Dee-sign/Shutterstock​.c​om).

• The mucosa is the innermost layer of the GI tract (i.e., the layer in direct contact with food
contents in the lumen) and consists of several different types of specialized epithelial (or
surface lining) cells with different functions, such as secretion, absorption, or production of
hormones.
• The submucosa is a connective tissue layer beneath the mucosa and contains blood vessels,
lymphatics, and nerves (including the submucosal nerve plexus of Meissner) which provide
both afferent (i.e., receiving signals from the lining of the GI tract and carrying them back to
the central nervous system (CNS)) and efferent (i.e., sending signals to muscles to move or
cells to secrete) innervation to the mucosa and its epithelial cells.
• The muscular layer consists of inner circular muscle and outer longitudinal muscle which
allow the GI tract to contract and move contents from mouth to anus. The myenteric nerve
plexus of Auerbach lies between the circular and longitudinal layers of muscle and regulates
6 Jordan M. Shapiro

these movements, often collectively referred to as “motility”. In addition, the stomach has a
third innermost layer called the oblique muscle layer. A common pattern of movement of the
GI tract is peristalsis, which involves coordinated involuntary smooth muscle contractions
above and relaxations below the food bolus in a sequential fashion to propel the contents of
the GI tract forwards.
• The serosa is the outermost connective tissue covering of the GI tract, consisting of a thin
layer of connective tissue reinforcement of the GI tract and covered by epithelium which
protects the GI tract and reduces the friction of the organs as they move in the abdomen.

Blood supply of the GI tract

Oxygen-rich blood from the lungs returns to and is pumped from the left side of the heart to the
body through the aorta, the largest artery in the body. The aorta rises from atop the heart to form
an arch and then descends through the diaphragm (the large, dome-shaped muscle that flattens
with inspiration to pull air into the lungs and which separates the chest and the abdomen) and
into the abdomen, where three branches supply the GI tract: (1) the celiac artery, (2) the superior
mesenteric artery, and (3) the inferior mesenteric artery. Most blood from the GI tract returns
to the liver through the portal vein, then flows through the liver to the hepatic veins, which
drain into the inferior vena cava, and ultimately back to the right side of the heart before being
pumped to the lungs to pick up oxygen and repeat the cycle. The cycle occurs each heartbeat,
which ranges from 100 to 160 beats per minute in newborns to 60 to 100 beats per minute in
older children and young adults. Blood traveling from the intestines to the liver carries nutrients
for further processing and is used in and by the liver.

The nervous system of the GI tract

The GI tract also includes the enteric nervous system (ENS). The ENS is often referred to as
“the second brain” due to its highly complex organization and function, which includes over 500
million nerves, more than 20 different neurotransmitters, and bidirectional communication with
the central nervous system (i.e., brain and spinal cord) [1]. There are two main nerve plexuses
(i.e., bundles of condensed nerves where many nerves intersect and/or run together) in the GI
tract: the submucosal plexus of Meissner and the myenteric plexus of Auerbach. The former lies
in the submucosa layer, regulates local blood flow and secretion, and contains sensory nerve
fibers to relay information from the gut to the brain. The latter lies between the circular and lon-
gitudinal layers of muscle and is the major player in the motility, or movement, of the GI tract.
Throughout the GI tract, pacemaker cells (interstitial cells of Cajal) generate intrinsic nerve
impulses and cause the GI tract to move. The interstitial cells of Cajal are akin to the pacemaker
cells found in the sinoatrial node of the heart, which initiates each heartbeat.
The ENS can operate largely independently to propel food from the mouth to the anus. A
classic physiology experiment by Bayliss and Starling in 1899 demonstrated that the tubular
GI tract will squeeze a pellet of food from the end of the mouth to the anus with the bowel
completely disconnected from the rest of the body, known as “the law of the intestine”. Despite
its independence, the GI tract is also innervated by the autonomic nervous system, composed
of the sympathetic (“fight, flight, or freeze”) and parasympathetic (“rest or digest”) divisions.
Sympathetic nervous system (SNS) activation diverts blood away from and slows the move-
ment of food contents through the GI tract, while parasympathetic nervous system (PNS) acti-
vation increases blood flow to and movement of food contents through the GI tract. The vagus
nerve (cranial nerve X) is the major nerve involved in carrying efferent (from central towards
 G astrointestinal anatomy and physiology 7

the periphery) signals from the PNS to the GI tract to cause actions such as muscular contrac-
tions of the intestines. However, 85% of the nerve fibers in the vagus nerve are afferent and
carry information from the GI tract back to the brain and brain stem in the central nervous
system. The communication between the brain and the gut constitutes what is referred to as
the brain–gut axis (BGA) and underlies many disorders of gut–brain interaction (DGBI) such
as functional dyspepsia and irritable bowel syndrome (IBS). For more information about the
gut–brain interaction, see Chapter 2.

An integrated review of GI physiology: A journey through the GI tract

Swallowing (mouth and esophagus)
Swallowing, also known as deglutition, is comprised of three phases: (1) oral, (2) pharyngeal,
and (3) esophageal. These phases prepare and carry portions of food from the mouth down the
esophagus to the stomach. Of note, prior to food entering the GI tract, a “pre-oral” phase trig-
gered by the mere thought, smell, and/or sight of food causes salivation to begin in anticipation
of food entering the oral cavity. This so-called “cephalic” (head) phase of salivation was high-
lighted in the infamous psychological research by Nobel Prize winner Isaac Pavlov that led to
the discovery of the behavioral procedure called classical conditioning [1]. In the experiments,
Pavlov paired the salivation that occurred with the sight and smell of food with the ringing of a
bell and then demonstrated the ability to induce salivation without the sight and smell of food
just by ringing the bell.
Oral phase: In the oral phase of swallowing, food and drink enter the oral cavity, where the
tongue and teeth begin to mechanically break food into smaller pieces. Different types of teeth
serve different roles in the chewing process, with incisors cutting, canines tearing, and premo-
lars and molars grinding food. The muscles of mastication (chewing) include the strongest mus-
cle per weight in the body, the masseter, which forcefully closes the jaw to facilitate chewing.
Chewing includes both voluntary and involuntary (reflexive) mechanisms, with stretching of
the muscles of mastication leading to their rhythmic contraction followed by relaxation to grind
up food. In addition, the salivary glands produce saliva, which contains water, mucin (a protein
that contributes to the lubricating, softening, and wetting properties of saliva), and the digestive
enzymes salivary amylase and lingual lipase. The latter contribute to the chemical digestion of
carbohydrates and fats, respectively. Total unstimulated (continuous) saliva production ranges
from 145 ml per day in children to 600 ml per day in adults, with decreases during sleep and
increases with eating and non-nutritive chewing (e.g., gum). The tongue sections off a small por-
tion of the chewed, moistened food into a bolus, forms a ramp with a depression in the midline
by sealing it against the hard palate, and then propels the bolus into the back of the oropharynx.
Pharyngeal phase: When food contacts the highly innervated posterior palatopharyngeal
arch – the more posterior of the two arches visible when looking in the back of the throat – the
bolus enters the pharyngeal phase of swallowing. This marks the last volitional portion of the
entire trip of food through the GI tract until defecation occurs. The food bolus is kept from enter-
ing the nasopharynx by the lifting and closure of the soft palate located on the posterior portion
of the roof of the mouth, which occurs reflexively in response to food touching the posterior
oropharynx. Simultaneously, the epiglottis folds backwards and closes the airway to prevent
swallowed food from entering the lungs, also referred to as “aspiration”. The upper esophageal
sphincter prevents the entry of excessive air into the stomach and the reflux of stomach contents
into the airway. The upper esophageal sphincter is contracted at rest and opens to allow passage
8 Jordan M. Shapiro

of the food bolus into the esophagus, marking the end of the pharyngeal phase of swallowing.
The pharyngeal phase of swallowing is the quickest and lasts roughly one second.
Esophageal phase: As the food bolus enters the esophagus, coordinated muscular contrac-
tions move food down the esophagus by peristalsis, see Figure 1.3.
The speed of transit through the esophagus depends in part on what is swallowed, as liquids
often reach the stomach before the peristaltic wave. Primary peristalsis occurs when a normal
swallow is initiated and the food bolus is moved into and through the esophagus (i.e., from oral
to pharyngeal to esophageal). Secondary peristalsis is an intrinsic capability of the esophagus
to start additional waves of peristalsis in the upper esophagus without the oral or pharyngeal
phases to clear something that should not be there after the initial swallow such as a large food
bolus, sticky foods such as peanut butter, a pill, or acid that has refluxed from the stomach
into the esophagus. The esophageal phase is also contributed to, in part, by gravity. However,
peristalsis of a food bolus through the esophagus and to the stomach can occur even when an
individual is upside down.
The length of the esophagus at birth is 7 in. (18 cm) and in adults is 10–13 in. (25–33 cm),
with widths of 6 mm and 20 mm in newborns and adults, respectively. As food nears the end of
the esophagus, the lower esophageal sphincter (LES) – which is tonically contracted at baseline
– relaxes to allow food to enter the stomach. The LES is contributed to by muscle fibers from
the phrenoesophageal ligament, the diaphragmatic crura, and circular muscle layer of the distal
esophagus. In addition to relaxing in response to a swallow, the LES periodically relaxes in
what is called a transient lower esophageal sphincter relaxation (TLESR). TLESRs also help to
vent gas from the stomach.
TLESRs – not overproduction of acid – are the primary mechanism that leads to gastroe-
sophageal reflux disease (GERD), which manifests as the cardinal symptoms of heartburn
and reflux (see Figure 1.4). Gastroesophageal reflux is common in infants as the LES does
not mature until approximately two years of age. In addition, most infantile reflux is nonacid.
Therefore, most cases of infantile GERD can be managed without the use of acid-suppressing
medications [2].
Belching (burping) is the audible escape of air from the esophagus or stomach. Belching is
a normal physiologic event that can occur dozens of times per day. Belching can be classified
as supragastric (above the stomach) or gastric (from within the stomach). Supragastric belching
involves increased swallowing of air (termed aerophagia) and evacuation of the air prior to it
reaching the stomach. Gastric belching occurs when gaseous distention of the stomach causes
stretch receptors to send signals to the LES to relax and the stomach to contract to force air out
of the esophagus and mouth.

Stomach
As food travels down the esophagus and approaches the stomach, a nerve-mediated reflex
results in receptive relaxation of the upper portion of the stomach (the fundus) to make room for
incoming food (see Figure 1.5). The newborn stomach is approximately the size of a marble
and can hold roughly 30 ml of food. The adult stomach is approximately the size of a canta-
loupe (also known as rockmelon) and holds an average volume of 1 L after meals. However,
it can expand to hold up to 4 L. Once all food has entered the stomach, the lower esophageal
sphincter (inflow to the stomach) and pylorus (ring of muscle that serves as the outflow of the
stomach) contract to close and the stomach begins to rhythmically grind the food against the
antrum (the portion of the stomach closest to the outflow) and pylorus resulting in mechanical
 G astrointestinal anatomy and physiology 9

Figure 1.3 Esophageal phase of swallowing (Source: Blamb/Shutterstock​.c​om).

10 Jordan M. Shapiro

Figure 1.4 The role of the lower esophageal sphincter in gastroesophageal reflux disease (Source: Sakurra/
Shutterstock​.c​om).

Figure 1.5 Anatomy of the stomach (Source: Olga Bolbot/Shutterstock​.c​om).

 G astrointestinal anatomy and physiology 11

digestion of food content. Chemical digestion occurs simultaneously as food is exposed to

gastric juices containing acid and pepsin (a digestive enzyme) made in the stomach, which
begin breaking down proteins. The pH of the human body is 7.4 (slightly alkaline); however,
the pH of the stomach is 1–2 (highly acidic).
The mucosa of the stomach contains many specialized cells which secrete different sub-
stances involved in the digestive process and collectively make up “gastric juices”:

• Parietal cells are in the body and fundus of the stomach and produce hydrochloric acid and
intrinsic factors.
• Acid helps in the digestion of protein, kills bacteria that are ingested, and inactivates sali-
vary amylase. Acid secretion occurs continuously in a basal fashion at about 10–15% of
the maximum capacity. Parietal cells have multiple different receptors for stimuli that can
trigger increased acid secretion: (1) muscarinic acetylcholine receptors are stimulated by
acetylcholine from the parasympathetic nervous system, (2) histamine type 2 receptors
are stimulated by histamine released by enterochromaffin-like cells, and (3) gastrin recep-
tors are stimulated by gastrin released by G-cells in the antrum of the stomach. Gastrin
and acetylcholine directly cause parietal cells to secrete acid. Gastrin indirectly causes
acid secretion by stimulating enterochromaffin-like cells to make histamine, which then
stimulates histamine receptors to cause acid secretion. Histamine potentiates the effects of
gastrin and acetylcholine on parietal cells so that smaller amounts are necessary to increase
acid secretion.
• Intrinsic factor is required for the absorption of vitamin B12 and is the only product of
secretion made by the stomach which humans cannot live without (i.e., supplementation
with vitamin B12 injections is required when the body is unable to produce intrinsic fac-
tor as in autoimmune gastritis, or when the segment of the small intestine required for
absorption of vitamin B12, the ileum, is inflamed, as in Crohn’s disease, or surgically
resected).
• Chief cells produce pepsinogen, the inactive form of the enzyme pepsin. Acid converts pep-
sinogen to pepsin, which is involved in the breakdown of protein.
• Mucus cells produce mucus, which along with bicarbonate, forms a layer that protects the
stomach from acid.
• G-cells are located in the antrum and secrete the hormone gastrin in response to stretch of
the stomach, protein, or increased pH (i.e., less acidity) in the stomach. Gastrin is a major
stimulus of the parietal cells to make acid.
• Enterochromaffin-like cells make histamine which potentiates the effects of the neurotrans-
mitter acetylcholine and gastric hormone gastrin to stimulate parietal cells to make acid.
• D-cells are located in the antrum (as well as the duodenum and pancreas) and release soma-
tostatin, which inhibits gastric secretion, gastric emptying, and intestinal motility in addition
to several other non-GI hormones (e.g., thyroid-stimulating hormone, prolactin, and growth
hormone).

Gastric secretion occurs in three phases:

(1) The cephalic phase, which occurs before food is ingested, accounts for 30–50% of gastric
secretions and is stimulated by special senses such as sight, smell, and thought. Most of
these special senses lead to vagal nerve outputs with acetylcholine-stimulating parietal
12 Jordan M. Shapiro

cells to secrete acid, chief cells to make pepsinogen (which in an acidic environment is
cleaved into the active form pepsin), and enterochromaffin-like cells to make histamine.
Vagal efferents (nerves sending signals away from the central nervous system and towards
the peripheral body) stimulate G-cells using gastrin-releasing peptide (not acetylcholine)
to cause gastrin release. Inhibitors of the cephalic phase include anything that stimulates
the sympathetic nervous system, such as physical or psychological distress.
(2) The gastric phase, which occurs when food enters the stomach, accounts for roughly
40–60% of gastric secretions. Stimuli for the gastric phase of secretion include stretch/
distention and breakdown products from proteins (i.e., amino acids and peptides). Food
entering the stomach stretches the stomach and buffers the acidity (i.e., makes it less acidic
or the pH increase), which both trigger acid secretion. Stretch primarily triggers nerve
reflexes that directly stimulate acid secretion via the vagal nerve. Increased pH triggers
G-cells to secrete gastrin which stimulates acid secretion. D-cells shut down acid produc-
tion by producing somatostatin in response to decreased pH (i.e., increased acidity), which
directly inhibits acid production by parietal cells, histamine production by enterochromaf-
fin-like cells, and gastrin production by G-cells.
(3) The intestinal phase, which accounts for 5–10% of gastric secretions, is triggered by
increased concentrations of partially digested proteins reaching the duodenum where duo-
denal G-cells secrete gastrin and other hormones that simulate gastric acid secretion.

The process of gastric emptying is highly regulated. For example, fatty acids longer than 12
carbon molecules long stimulate the production of a peptide called cholecystokinin (CCK) in
the duodenum which slows gastric emptying by increasing the tone of the pylorus and decreas-
ing contractions of the antrum and fundus. When the food is sufficiently broken down into a
sludge called “chyme”, the pylorus begins to act as a sieve allowing the only particles of food
that are 2–3 mm or smaller to exit the stomach into the small intestine. The stomach usually
empties within 2–4 hours, with liquids emptying more rapidly than solids. Delayed emptying
of the stomach is known as gastroparesis, with youth experiencing symptoms such as nausea,
vomiting, pain, and early satiety.

Small intestine
The small intestine receives partially broken down and digested food from the stomach in the
form of chyme. There are three parts of the small intestine (top to bottom): (1) duodenum, (2)
jejunum, and (3) ileum. The small intestine is the primary site of absorption of both macronu-
trients (proteins, fats, and carbohydrates) and micronutrients (e.g., vitamins and minerals). The
majority of nutrients are absorbed in the duodenum and jejunum. However, the terminal (final
part of) ileum is the site of absorption of vitamin B12, as well as the four fat-soluble vitamins:
vitamins A, D, E, and K (see Figure 1.6). In addition, 95% of bile acids released into the small
intestine are reabsorbed in the terminal ileum and recycled. Normal transit time through the
small intestine is 2–6 hours.
The small intestine is approximately 9–10 ft (270–300 cm) in length in newborns and
15–22 ft (450–670 cm) in adults. The surface area of the adult small intestine is nearly the size
of a tennis court due to not only its length but also small finger-like projections called microvilli
that cover the surface of the small intestine. Each villus contains a capillary and lacteal – small
blood vessel and lymphatic vessel – with glucose and amino acids absorbed into the former and
fatty acids in the latter. Capillaries ultimately drain into the portal vein and then to the liver,
while lacteals drain into the thoracic duct which then empties into subclavian and/or jugular
 G astrointestinal anatomy and physiology 13

Figure 1.6 Sites of absorption of macronutrients and micronutrients along the GI tract (Source: Jordan
Shapiro).

veins on the left side of the chest and neck. Several different contraction patterns occur in the
small and large intestine. Peristalsis is the propulsion of bowel contents forward, segmentation
breaks the contents into smaller portions for easier digestion, and mixing movements cause a
to-and-fro movement of contents to mix chyme with digestive enzymes and maximize contact
with the microvilli.
14 Jordan M. Shapiro

Pancreas
The pancreas releases the enzymes lipase, trypsin (secreted as the inactive trypsinogen and acti-
vated to trypsin which then breaks down protein and activates other pancreatic enzymes), and
amylase to digest fat, protein, and carbohydrates, respectively. Pancreatic enzymes are secreted
into the pancreatic duct which empties into the duodenum via an opening called the ampulla of
Vater (see Figure 1.7).

Figure 1.7 Pancreatobiliary system (Source: TimeLineArtist/Shutterstock​.c​om).

In addition to the production of digestive enzymes (exocrine function), the pancreas also
produces two hormones – insulin and glucagon – which are released into the bloodstream to act
on other organs (endocrine function). These hormones tightly regulate blood sugar levels and
are involved in energy storage and metabolism. Insulin is secreted after meals in response to
elevated blood sugar and facilitates the storage of glucose as glycogen in cells around the body,
reducing blood sugar levels. Glucagon is released in response to a low blood sugar level and
primarily acts in the liver to break down glycogen to release glucose into the bloodstream for
energy.

Liver and gallbladder

The liver has many roles including the production of bile, which acts as a detergent to break fats
into smaller constituents. These smaller constituents are then broken down further by pancreatic
lipase into glycerol and fatty acids, see Figure 1.8. Bile flows down the series of bile ducts within
 G astrointestinal anatomy and physiology 15

the liver, to those from the right and left sides of the liver (the left and right hepatic ducts), and
ultimately to the common bile duct, which empties into the duodenum via the ampulla of Vater,
alongside the pancreatic duct. Bile acts like a detergent, emulsifying fats so that lipase can better
act to break them down into fatty acids and glycerol. Some bile is stored in the gallbladder in
preparation for ingestion of higher fat-containing meals that may require extra bile. Fat in the
duodenum causes the release of the hormone cholecystokinin (CCK), which causes the gallblad-
der to contract and squeeze extra bile into the small intestine.

Figure 1.8 Functions of the liver (Source: Designua/Shutterstock​.c​om).

In addition to the production of bile for fat digestion, the liver has many other vital
functions:

• Protein synthesis (putting amino acid building blocks together into proteins) and degradation
occur in the liver. The liver produces factors that help the blood clot and those that break
down clots, carrier proteins for various other substances, and makes thrombopoietin, the
protein that stimulates the bone marrow to make platelets (a component of blood that helps
with initial clot formation).
• Cholesterol production primarily occurs in the liver (only about 20% of cholesterol comes
from the diet). Cholesterol is a critical component of cell membranes, signaling between
cells, and serves as the chemical precursor for vitamin D and all steroid hormones including
cortisol, aldosterone, progesterone, estrogen, and testosterone.
16 Jordan M. Shapiro

• Detoxification from environmental toxins and drugs by modifying these substances to be

excreted in the urine (water soluble) or stool (fat soluble).
• Storage of nutrients such as glycogen (the storage form of glucose), vitamin A, vitamin D,
vitamin E, vitamin K, and vitamin B12, as well as iron and copper.
• Immune functions of the liver are carried out by its rich supply of immunologically active
cells that help remove bacteria and other pathogens from the blood that flows from the intes-
tines back to the liver.
• Red blood cell production (erythropoiesis) occurs in the liver, spleen, and yolk sac of the
fetus and shifts the bone marrow prior to birth.

Large intestine (colon)

The large intestine is divided into the cecum (portion where the appendix is attached and which
is connected to the end of the small intestine, the ileum), ascending colon, transverse colon,
descending colon, and sigmoid colon. connected to the end of the small intestine (the ileum)
by a valve referred to as the ileocecal valve. The primary job of the colon is to absorb water
and propel feces to the rectum for defecation. However, the bacteria of the colon also produce
several B vitamins, vitamin K, and short-chain fatty acids. The length of the colon is 1.5 ft at
birth (50 cm) and 5 ft (150 cm) in adults. Normal transit time through the colon averages 30–40
hours but ranges from 10 to 59 hours.
Bloating (feeling of abdominal swelling or pressure) and distention (visible increase in
abdominal size) are common symptoms. Excess of these symptoms may occur due to dietary
intake, excessive air swallowing, medications, abnormal sensation (feeling the stretch of the
intestines at normal volumes of gas), overgrowth of bacteria in the small or large intestine,
abnormal motility, or pelvic floor dysfunction preventing normal evacuation of stool. The pass-
ing of gas (flatus) is normal, with an average of 5–15 episodes per day.

Anorectal/pelvic floor muscles

Multiple mechanisms prevent stool from falling out of our bottoms uncontrollably. The ability
of the anus and rectum to feel the subtle differences between solid, liquid, and gas allows for the
passing of gas without accidents. The degree of sensation and coordination required to handle
feces parallels or exceeds that of our hands and fingers. There are two circular sphincter muscles
at the anorectal junction that are contracted (i.e., closed) at baseline (see Figure 1.9) depicting
the anorectal canal. The external anal sphincter is under our voluntary control and can be con-
tracted by squeezing as if to hold in a bowel movement. The internal anal sphincter is controlled
involuntarily. In addition to the sphincters, a sling-like muscle called the puborectalis extends
from the pubic bone posteriorly and around the anorectal junction to form an angle that further
prevents leakage of stool when it is contracted. When the rectum fills with stool, the stretch
causes two things to occur: (1) the urge to defecate, and (2) the relaxation of the puborectalis
and internal anal sphincter muscles so that stool can travel towards the anus. The external anal
sphincter can be contracted until an individual is in an appropriate place to defecate. With all
of the sphincters relaxed and anorectal canal straightened by the relaxation of the puborectalis
muscle, a gentle increase in intraabdominal pressure by contraction of the abdominal wall mus-
cles pushes stool down and out the anus.
 G astrointestinal anatomy and physiology 17

Figure 1.9 The anatomy of the anorectal canal (Source: logika600/Shutterstock​.c​om).

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 Our dear "Minnie's Land" is improving as fast as our poor
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We would be glad if you would ascertain whether a good

agent can be had to procure subscribers in England for it [the
Quadrupeds], or whether a responsible bookseller would buy
the copyright, & a certain number of plates either coloured or
plain.

A few weeks later Audubon wrote also to William Yarrell, hoping

to interest him in the foreign sale of his new publication, but as will
be seen by his friend's reply, now to be given, with indifferent
success:

William Yarrell to Audubon

 [Superscribed by Audubon]
Recd 28 Jany
1843
[Addressed] J. J. Audubon Esqr.
77 William Street
New York
[Superscribed by Yarrell]
single letter.
P. Paid, W.Y.

Ryder Street St. James

London 17th Decr. 1842.

My dear MR. Audubon,

I have this morning received your letter of the 28th. Novr.

last, and as it is strictly a letter of business, I reply to its various
parts immediately.

About a month ago I received a note from Mr. Phillips to say

that he had received the Plates of the first number of your work
on the Quadrupeds of America—would I come and look at them,
and would I exhibit them at the meetings of the Societies I
belonged to for the promotion of Natural History. I went to see
them, and have with pleasure exhibited them at the Linnean
Society on the third Tuesday in Novr. and at the Scientific
evening, as well as the monthly general meeting of the
Zoological Society, both of which occurred early in Decr. and I
then returned the 5 Plates to Mr. Phillips—They were very much
admired but I did not obtain any request for a supply.

In reference to your next request, I must decline any

connection with the sale or publication of this, or indeed any
other foreign work, in this country. The truth is, that having now
 been in the business nearly forty years, I begin to be tired of
work; the last part of my History of British Birds will be
published on the 1st of June 1843; with that part I shall give up
my pen, and write for money no more.

You are kind enough to give me some credit for experience

as a publisher, and some knowledge of the persons who are
likely to be purchasers of works on Natural History here—My
conviction is that you would gain more by paying full
commission to an established Bookseller in London who would
by advertising make your works known, and where they might
be obtained—than you will by the best efforts of any private
friend, even though his kindness should induce him to take all
the trouble for nothing.

You say nothing about your family. I hope they are all well.

I remain, Dear Sir,

Yours very truly
Wm Yarrell.

J. J. Audubon Esqr.
77 William Street.
New York.

In the following letter to Spencer Baird, Audubon was able to

outline more fully his final plans for the western journey:

Audubon to Spencer Fullerton Baird

New York, Nov. 29, 1842.

My dear Young Friend,

It seems to me as if an age had already elapsed since I

have heard from you or your whereabouts. Neither do I know
clearly whether in the way of correspondence, you are in my
debt, or I am in yours. Nevertheless I now write to you, and
request you to read this letter more than once, and think deeply
on the purport of its contents that you may be the [more] able
to form a true Idea of what I intend to say [to] you, and for
yourself to give me a true answer, on which I can depend, no
matter whether it is to my liking or not.

It is now determined that I shall go towards the Rocky

Mountains at least to the Yellowstone River, and up the latter
Stream four hundred miles, and perhaps go across the Rocky
Mountains. I have it in my power to proceed to the Yellowstone
by Steamer from St. Louis on the 1st day of April next; or to go
to the "Mountains of the Wind" in the very heart and bosom of
the Rocky Mountains in the company of Sir William Drommond
Stewart, Baronet who will leave on the 1st of May next also
from St. Louis.

It has occurred to me that perchance you would like to

spare a few months of your life, to visit the great Western
Wilderness, and perhaps again prefer going in my Company in
preference to that of any other person? Of this of course I
cannot Judge without your answer to this. I thought that you
would have been in New York long ere this, but not a Word of
you has reached any friend of yours here for several months. I
have had an abundance of applications from different sections
of the country, from Young Gents who proffer much efficiency,
etc., but I do not know them as I know you, and if the terms
which I am about to propose to you will answer your own
views, I wish you to write to me at once so that I may know
how to prepare myself for such a Journey, and under such
circumstances.
 Would you like to go with me at any rate? By which I mean,
whether by Land, or by Water, and undertake, besides acting
towards me as a friend, to prepare whatever skins of Birds or
Quadrupeds, I may think fit for us to bring home. The Birds, you
might have one half as your own, the Quadrupeds, (should you
wish it) you might have a 4th or every 4th specimen of the same
species, reserving to myself all that is new or exceedingly rare.

I will procure and furnish all the materials for skinning,

preparing, and saving whatever we may find in Ornithology and
in Mammalia, and in all probability (if you think it absolutely
necessary) pay one half your expenses from the time we leave
St. Louis until our return to that city. You will have to work hard,
of course, but then I trust to that the knowledge alone which
you must acquire would prove a sufficient compensation, and as
you already know me pretty well, I need not say to you that I
am not "hard on the trigger."

It will be necessary for you to provide a good double

barrelled Gun, and an excellent Rifle, Shot bag, powder flask,
&c, a good hatchet, and a sufficiency of clothes for something
like a 12 month's Campaign. But if you will write me at once
upon the subject, I can give you a more and a better a/c of all
my intentions, than is at present necessary.

If all goes on as I trust it will go on, we may be back home

by Octr. or Novr. next, 1843.

Do not lose a moment in writing to me in answer to this

after you have thought deeply upon the matter.

Remember me kindly to all your friends, and believe me,

 Yours Always,
John J. Audubon.

77 Williams Street, New York.

Baird was unable to reach a decision in the matter, and Audubon

actually wrote five more letters on the subject and kept a place open
for his young friend for nearly three months. On January 2, 1843, he
said that while it was impossible to determine with any degree of
accuracy the amount of money the journey might require, he could
"safely say that the sum of $500. would prove all sufficient, as our
passages to the Yellow Stone will be granted us free; and the
expenses from here or from Carlisle cannot exceed 50$ to St. Louis,
and may be less." "I have given up," he added, "all Idea of going
South this season, being determined to draw quadrupeds until a few
days of my leaving home for this grand and Last Journey, I intend to
make as a Naturalist." Again, on January 31, he wrote:

It appears from the whole tenure of your letter, that that

rascally article cash is the cause which prevents you from going
along with me to the Yellowstone River and back. Now, it
happens that although we are far from being rich, we are all
desirous that you should go along with me, because we all
know you, and I particularly so. Therefore, if you will go with
me, and assist me all you can, in the way of hunting, measuring
and dissecting Specimens when I am otherwise engaged, etc.
etc. I will furnish you with all that may be necessary for your
expenses, excepting your clothing and your gun or guns, as you
may have them.
 LETTER OF EDWARD HARRIS TO AUDUBON,
REGARDING HIS INTENTION OF JOINING THE
EXPEDITION TO THE UPPER MISSOURI, JANUARY
31, 1843.

From the Deane MSS.

In still another letter, of February 10, Audubon said:

That your kind mother should feel great reluctance in the

premises, does not astonish me, as my own good Wife was
much against my going on so long a Journey; but her Strong
 Sense of what is best for us all, and as well as in myself, the
perfect confidence that our Maker's Will will be done, she has
now no Scruples of any kind, and as for myself I rely as much
as I ever have done in the Support of the Almighty Being who
has supported and secured me against evils of all sorts in my
Various undertakings, and with this Idea at my heart, I feel
confident that although an Old Man, I could undertake any
Journey whatever, and no matter of their lengths or difficulties.
But I wish you would assure your good mother that to go to
Yellow Stone River, in a good Steamer, as passengers by the
courteous offers of the President of the American Fur Company
who himself will go along with us, that the difficulties that
existed some 30 years ago in such undertakings are now
rendered as Smooth and easy as it is to go to Carlisle and return
to N. Y. as many times as would make up the Sum in Miles of
about 3000: Our difficulties (if any there are) will be felt on our
return; when we must come back to St. Louis in one or 2 open
boats in Sepr and part of Octr next. The passage being longer or
shorter accordingly with the state of the Missouri at that
Season.[192]

Young Baird would gladly have accompanied Audubon, but the

fears of his friends for his health and safety interposed, and the
party as eventually made up comprised, beside the naturalist, John
G. Bell, as taxidermist, Isaac Sprague, artist, Lewis Squires, general
assistant and secretary, and his old friend Edward Harris.

Audubon left his home on March 11, 1843, with Victor, who
accompanied him as far as Philadelphia, where a rendezvous was
made before starting west. The party went first to Baltimore, and by
steam cars to Cumberland, then by coach through the Gap, and
across the Alleghanies to Wheeling, where a steamer took them
down river to Cincinnati. On March 19 they reached Louisville, where
Audubon spent four days with his brother-in-law, William G.
Bakewell, and on the 28th they arrived at St. Louis, where the party
completed their outfit. On April 25 they began their ascent to the
Missouri, in the steamer Magnet, a small vessel belonging to the
American Fur Company, with a motley crowd of trappers, employed
by the Company, representing French creoles, Canadian French,
Indians, and other nationalities.

During this journey, which lasted eight months, Audubon kept a

voluminous journal, which was written in a fine hand on large sheets
of linen paper that could be easily rolled and carried in his pocket;
this was afterwards sent to Bachman, was returned, and was lost for
fifty years, or until 1896, when it was recovered from an old
secretary by Audubon's granddaughters, one of whom published it in
1898.[193] It is a highly interesting and spirited narrative from
beginning to end, and abounds in graphic pictures of the Indians
and trappers, the military posts and pioneer settlements, the
abundant bird life and big game, the biggest of which, the buffalo,
was then seen by Audubon in a state of nature for the first time, the
grand and turbulent rivers, and the smiling or frowning face of the
great wilderness so soon to be changed by the devastating hands of
civilized man.

What Audubon thought to be a new finch, discovered near the

Snake Hills in Missouri, was named for Edward Harris, and though it
proved to have been previously described, the bird is still known as
"Harris' Finch"; a few days later a new vireo, Vireo bellii, received
the name of John G. Bell, his taxidermist, and similar honors were
passed to artist Isaac Sprague, to whom was dedicated the little
titlark, Alauda spragueii, now Anthus spraguei.

In those days of river navigation, the frequent tying up for fuel

or necessary repairs, not to speak of grounding in a treacherous
channel, gave almost daily opportunities for the hunters to go
ashore, and these occasions seldom failed to produce something
interesting, new, or rare. In the Indian country, at Bellevue,
Nebraska, where they touched to land a part of their cargo, Audubon
"saw a trick of the trade, which made him laugh. Eight cords of
wood were paid for with five tin cups of sugar and three of coffee—
value at St. Louis about twenty-five cents."

They began to meet with buffalo about the mouth of the James
River, in South Dakota, on May 20; the ground, said Audubon, was
literally covered with their tracks, and the bushes with their hair. On
the same day they discovered "Meadow Larks whose songs and
single notes were quite different from those of the Eastern States,"
and this proved to be the first notice of the Western Meadow Lark,
which later appeared as the Sturnella neglecta in the small edition of
his Birds of America, then in course of publication.

Audubon's opinion of the Indian was modified considerably after

having seen him in the western wilderness, and his confidence in
George Catlin's descriptions was completely shattered; "His book,"
he said, "must, after all, be altogether a humbug. Poor devil! I pity
him from the bottom of my soul; had he studied, and kept up to the
old French proverb that says, 'Bon Renommé vaut mieux que
ceinture doré,' he might have become an honest man—the
quintessence of God's works."

After forty-eight days and seven hours out of St. Louis, on the
12th of June, they reached Fort Union, at the mouth of the
Yellowstone, where the Omega left them and returned down river.
The country proved so interesting that the naturalist remained two
months at the fort, where he occupied the room which had been
used by Maximilian, Prince of Neuwied, when traveling through the
western parts of America ten years before; here Audubon made
many drawings. Buffalo were abundant on all sides, and a favorite
occupation was shooting wolves from the ramparts of the fort. On
June 18 they killed two antelope and two deer before noon, and
"immediately after dinner," he said, "the head of the old male was
cut off, and I went to work outlining it; first small, with the camera
lucida, and then by squares." On the 30th he wrote: "I began
drawing at five this morning, and worked almost without cessation
till after three, when becoming fatigued for want of practice, I took a
short walk, regretting that I could no longer draw twelve or fourteen
hours without a pause, or thought of weariness."

On the 15th of July they started up the shore of the Yellowstone

in a cart. The party soon had had enough of buffalo hunting, and on
one day the naturalist was nearly speared by a charging bull that
had been wounded. "What a terrible destruction of life," he says, "as
it were for nothing, or next to it, as the tongues only were brought
in, and the flesh of these fine animals was left to beasts and birds of
prey, or to rot on the spots where they fell. The prairies are literally
covered with the skulls of the victims, and the roads the Buffalo
make in crossing the prairies have all the appearance of heavy
wagon tracks." Foreseeing the departure of the buffalo, he wrote:

One can hardly conceive how it happens, notwithstanding

these many deaths and the immense numbers that are
murdered almost daily on these boundless wastes called
prairies, besides the hosts that are drowned in the freshets, and
the hundreds of young calves who die in early spring, so many
are yet to be found. Daily we see so many that we hardly notice
them more than the cattle in our pastures about our homes. But
this cannot last; even now there is a perceptible difference in
the size of the herds, and before many years the Buffalo, like
the Great Auk, will have disappeared.

On the 9th of August he added: "I have scarcely done anything

but write this day, and my memorandum books are now crowded
with sketches, measurements, and descriptions." Those who
maintain that a "howling wilderness" is a place that never howls,
should read his note for August 19: "Wolves howling, and bulls
roaring, just like the long continued roll of a hundred drums"; or this
for the 21st: "Buffaloes all over the bars and prairies, and many
swimming; the roaring can be heard for miles."

At Fort Union they built a Mackinaw barge forty feet long, which
they christened the "Union," and on the 16th of August they started
for St. Louis, which was reached in safety on the 19th of October.
There they unloaded, and "sent all things to Nicholas Berthoud's
warehouse." "Reached home," said Audubon, "at 3 p. m., November
6th, 1843, and thank God, found all my family quite well."

When Audubon was returning by the canal route from Pittsburgh

to Philadelphia, he was sought out by a young traveler, who
afterwards related the following incident.[194] The naturalist, he was
told, was under "a huge pile of green blankets and fur," which he
had already noticed on one of the benches, and had taken for the
fat pile of some western trader. Having waived his choice of a berth
in Audubon's favor, he observed that "the green bale stirred a little,
—half turned upon its narrow resting place, and after a while sat
erect, and showed us, to our no small surprise, that a man was
inside of it. A patriarchal beard fell white and wavy down his breast;
a pair of hawk-like eyes glanced sharply out of a fuzzy shroud of cap
and collar." When this stranger, drawn by a sense of irrepressible
curiosity, had ventured near enough to recognize the "noble Roman
countenance" thus obscured, he saw that it was Audubon in his
wilderness dress; he was "hale and erect, with sixty winters upon his
shoulders, and like one of his old eagles, feathered to the heel."
Audubon's conversation, said this writer, was impulsive and
fragmentary, but he showed him with pleasure some of his original
drawings of animals, as well as a living collection of foxes, badgers
and Rocky Mountain deer, which he was bringing home.
 To follow this narrator further:

The confinement we were subjected to on board the canal-

boat was very tiresome to his habits of freedom. We used to get
ashore and walk for hours along the tow-path ahead of the
boat; and I observed with astonishment that, though over sixty,
he could walk us down with ease.... His physical energies
seemed to be entirely unimpaired.... Another striking evidence
of this he gave us. A number of us were standing grouped
around him on the top of the boat, one clear sunshiny morning;
we were at the time passing through a broken and very
picturesque region; his keen eyes, with an abstracted, intense
expression, peculiar to them, were glancing over the scenery we
were gliding through, when suddenly he pointed with his finger
towards the fence of a field, about two hundred yards off. "See!
Yonder is a Fox Squirrel, running along the top rail. It is not
often I have seen them in Pennsylvania." Now his power of
vision must have been singularly acute, to have distinguished
that it was a Fox Squirrel; for only one other person ... detected
the creature at all.

The second Mrs. Victor G. Audubon[195] said that on the day the
naturalist returned, "the whole family, with his old friend, Captain
Cummings, were on the piazza waiting for the carriage to come from
Harlem.... He had on a green blanket coat with fur collar and cuffs;
his hair and beard were very long, and he made a fine striking
appearance. In this dress his son John painted his portrait."[196] This
interesting portrait, which is still in possession of the family, and
which is reproduced by his granddaughter in the work from which
we have just quoted, shows a man whose apparent age, as
suggested by his flowing white hair and grayish white beard,
overshoots the clearer testimony of his smooth face and bright eye;
as already noticed, Audubon had not then attained his sixtieth year.
 Upon his return at this time Audubon is said to have been
mistaken for a Dunker, or member of a sect of Quakers noted for
their ample beards. On November 29 Bachman wrote: "I am glad to
hear that your great beard is now cut off. I pictured you to myself,
as I saw you in my home, when you came from Florida, via
Savannah. You jumped down from the top of the stage. Your beard,
two months old, was as gray as a Badger's. I think a grizzly-bear,
forty-seven years old, would have claimed you as 'par nobile
fratrum.'" Bachman was apparently disturbed about Audubon's
personal habits at this time, for he added in the letter just quoted: "I
am a teatotaler. I drink no wine, and do not use snuff. I hope that
you are able to say the same."[197]

Spencer Baird wrote to Audubon from Washington, November

24, 1843, to congratulate him upon the safe return of his western
party, saying: "From time to time short notices of your whereabouts
and doings appeared in the newspaper and a thousand times I
wished that the fears of my friends had not prevented me from
accompanying you to the scenes of action." Audubon thought that
he might well regret the difficulties that had stood in his way; in
replying he said that he had seen "not one Rattlesnake and heard
not a Word of bilious fever, or [experienced] anything more
troublesome than Moschitoes and of these by no means many"; they
had brought home a Swift Fox, an American Badger, and a live Deer,
which they thought might prove to be new, fifteen new birds, as well
as a certain number of quadrupeds, besides "many of the Birds
procured on the Western side of the Big Rocky Hills by Nuttall and
Townsend." He felt that much still remained to be done, his only
regret being that he was not what he "was 25 Years ago, Strong and
Active, for willing he was as much as ever."

In 1844 Audubon brought to a close his octavo edition of the

Birds by adding seventeen species, eleven of which were new and
represented his discoveries on the Upper Missouri of the previous
year. The 500th plate, and last of the series which marked the end
of Audubon's life-long labors in ornithology, was dedicated to
"Baird's Bunting," Emberiza bairdii. "If a trace of sentiment be
permissible in bibliography," said Elliott Coues,[198] "I should say
that the completion of that splendid series of plates with the name
bairdii was significant; the glorious Audubonian sun had set indeed,
but in the dedicating of the species to his young friend Spencer F.
Baird the scepter was handed to one who was to wield it with a
force that no other ornithologist of America has ever exercised."
 CHAPTER XXXV
FINAL WORK DAYS
Painting the Quadrupeds—Assistance of Bachman and Audubon's sons—Copper
plates of the Birds go through the fire in New York—Audubon a spectator at the
ruins—Bachman's ultimatum—Success of the illustrations of the Quadrupeds—
Bachman's letterpress—Recommendation of Baird—John W. Audubon in London
—Bachman's assistants—His life and labors—Decline of Audubon's powers—Dr.
Brewer's visit—Audubon's last letters—His death at "Minnie's Land."

After 1844 Audubon's remaining energies were devoted

exclusively to his work on the Quadrupeds, in which it is necessary
to discriminate between the large folio of illustrations, which began
to appear, in parts, as early as 1842 and which was completed in
1846; the text, of which he lived to see but one volume finished;
and lastly, the first and only composite edition of both text and
plates, which was published by Victor Audubon in 1854.[199] This
series of works, as already noticed, was produced in collaboration
with the Reverend John Bachman, of Charleston, South Carolina;
Bachman assumed entire responsibility for the text, but owing to his
comparative isolation from large libraries, and to the demands of
professional duties, he depended on the Audubons to supply him
with specimens and books.

Honest John Bachman, whose motto was, "Nature, Truth, and no

Humbug," was suffering sadly, he said, from lack of tools, when he
wrote to Victor Audubon in November, 1844:[200]

The books are to be found in New York and Philadelphia,

but are expensive. I would not have you buy them; but could
you not copy for me such articles as we need?

I enclose my plan. I wish always, a month before the time,

that you would give me notice of the species you intend to put
into the hands of the engraver, and send me, at the same time,
the specimen. I cannot describe without it; I will guess at
nothing.

I find the labor greater than I expected, and fear that I may
break down and, therefore, cry in time, "Help me Cassius or I
sink!" Writing descriptions is slow and fatiguing work. I cannot,
in the careful manner that I am doing them write more than
three in a week. My son-in-law, Haskell, has copied forty-two
closely written pages for me. I cannot shorten the articles,
many of them I ought rather to lengthen. With patience and the
help of all, I hope, however, to get on—the work may be lighter
as we proceed.

The following is my daily practice: I am up at 4 A. M., and

work till breakfast, and recently, when parochial duties would
permit, have kept on until 3 P. M.

The brush of my old friend, Audubon, is a truth-teller. I

regard his drawings as the best in the world. Let us be very
careful to correct any errors of description that have crept in on
the plates—I see a few in the lettering—they can be corrected
in the letter-press; and let us be so cautious as to have nothing
in the future to correct. There is but one principle on which a
just man can act; that is, always to seek the truth and to abide
by it.
 Bachman wrote again on the 29th of that month:

About the little mouse—I cannot see a needle in a haystack;

or give it a name without knowing what it is. Friend,
descriptions cannot be written, as a man works at making Jews-
harps—so many a dozen in a given time. My credit, as well as
your father's, is so deeply concerned, that I will not publish a
day before I am ready....
I have such confidence in you, that I believe that you will do
all that I wish. In doing this, however, you will have your hands
full. Mine are so—God knows! Will not my old friend, Audubon,
wake up, and work as he used to do, when we banged at the
Herons and the fresh water Marsh-hens?

Bachman explained that he was the "schoolmaster," and when

the boys were a little lazy, he would have to apply the whip.

In March, 1844, Spencer Baird sent Audubon a live Pennant's

Marten or Fisher, a rather rare animal even at that time, and now all
but extinct. Said Baird:[201]

It was found in company with an older one, in Peter's

mountain, six miles above Harrisburg about five weeks ago.
After a most desperate resistance the old one was killed, having
beaten off a large pack of dogs, to whose assistance the
hunters were obliged to run. This individual ran up a tree, and
being stoned by the men, jumped off to a distance of forty feet!
when being a little stunned by the leap they ran up quickly and
threw their coats over it, and then secured it. The old one
measured three feet and a half from nose to end of tail, and
was about one third larger than this.... It seems to be in very
good health, and is without exception the most unmitigatedly
savage beast I ever saw. The Royal Bengal Tiger, or the
Laughing Hyena are neither of them circumstances to it.
 Audubon used this marten as the model for his illustration of the
species (shown in natural size, Plate xli of the Quadrupeds); in
noticing its habits later, he said:[202]

We kept this individual alive for some days, feeding it on

raw meat, pieces of chicken, and now and then a bird. It was
voracious, and very spiteful, growling, snarling and spitting
when approached, but did not appear to suffer much uneasiness
from being held in captivity, as, like many other predacious
quadrupeds it grew fat, being better supplied with food than
when it had been obliged to cater for itself in the woods.

Baird also tried to secure for Audubon the "far-famed

catamount" alive, which, from stories related by hunters, he thought
might be different from the young of the panther or puma, and also
a specimen of the true black fox in the flesh; though unsuccessful in
either quest, his efficient aid was greatly appreciated by his friend.
In February, 1845, Baird paid a visit to the Audubons at their Hudson
River home, where he was warmly received; as his biographer
relates,[203] upon leaving he was invited to select any duplicate bird
skins he desired from the naturalist's collection, then at John G.
Bell's taxidermist shop in New York; he accepted this generous offer,
and chose about forty specimens.

It is evident that some trouble-maker had disturbed the serenity

of John Bachman's mind when the following interesting letter was
written by Audubon to balm the feelings of his old friend. It is
evident that Audubon at this time expected to collaborate in the
letterpress of their work, but that plan, according to Bachman's own
statement, was never carried out:
DRAWINGS FOR "THE VIVIPAROUS QUADRUPEDS
OF NORTH AMERICA": ABOVE, AMERICAN
PORCUPINE, DATED "NEW YORK, MARCH 6,
1842," AND PUBLISHED IN 1844; BELOW,
RABBITS.

After the originals in water color in possession of

the American Museum of Natural History, New
York.

Audubon to John Bachman

[Minnie's Land] Jan. 8, 1845.

My dear friend

Never have I been so much astonished as I have been at

reading your letter to Victor, and to which I feel myself bound to
answer at once.

In the first place you must have been most unmercifully

misled by the "mutual friend" of whom you speak, when saying
that through that individual you did understand that I never
used your name as a coadjutor in the work, which is now
publishing on the Quadrupeds of North America under the
names of both I and you—Why you should have taken such a
report or saying as truth is actually beyond my most remote
thought, and again, why did you not long ago, write to me at
once on this mysterious subject.

But to put an end to all this stuff, let me assure you that
nothing of the kind has ever taken place, and this I could well
prove by upwards of one hundred of our last subscribers, all of
whom would be ready to testify that before receiving their
names on my list, I always mentioned your name to each of
them, and many that know you were glad that I had so good
and so learned a man at my elbow—I should amazingly be glad
to know who the "mutual friend" is, as I think I could give him a
lesson on propriety, being a mutual friend, that would serve that
kind gentleman for the residue of his life—But enough of this,
and all that I am sorry for is that you should not have answered
"my short letters," in some of which I particularly requested you
to forward me a fine black bear and one or two wolves, by
which you would have saved me fully fifty dollars as I have had
to pay sixty dollars for two of these vile rascals, and two
hundred dollars for a pair of Elks besides paying the highest of
prices to draw other animals—
 Now my friend I wish you would set in real earnest, and
whenever it is convenient to you in preparing the letter-press for
our work. I have made a beginning and have written Ten
articles already in — days, to wit all the plates of No 1, and the
first of No 2 which are as follows—

Lynx Rufus—Wild-Cat
Arctomys monax—Maryland Marmot
Lepus Townsendii
Neotoma Floridana
Sciurus Richardsonii
Canis (Vulpes) fulvus
The Beaver
The history of the Bison 28 pages
and Fiber Zybethicus (muskrat) 12 pages,
Tamias quadrivittatus

This will shew you that I have not been very Idle since I
began and I should like to know from you, whether you would
like to see what I have said of these, as if you do, I will have
them copied as soon as I receive your letter, and will forward
the whole, and the additional written in the interim, at the same
time. I have a beautiful drawing of a fine male moose, that of
the Elk is already engraved, and next week we will forward to
the engraver no less than five or six drawings of the best
quality. by the way I am sorry that you should look upon the
Texan Skunk as a bad figure. The animal is an ungraceful one in
its Singular Colouring, but it is nevertheless quite true to nature,
with all its specific characters to a T.

Victor wrote to you that I was anxious to have your opinion

about the Title page and I hope you will send me your ideas
forthwith on that subject. I send you now by mail a long article
about our work which I conceive and hope will prove to you that
 the "mutual friend" knew but very little of my feelings or actions
or sayings as regards you—

I really & most truly regret that you should have been put
out, and mis-led about this our work by a third party, who must
to say the least of it [have] abused your credulity to the very
extreme.

However, the sooner forgotten, the sooner mended. it is

with deeply felt regret from every one of my Family that we
read the account in your letter of the condition of your dear
wife, but hope that she will accompany you early next spring to
visit our humble but comfortable residence. Now do Come!
Present our joint regards to every one of your family, and
believe me when I say that none will ever feel more delighted
than I, to hear of the welfare of the beautiful "Rabbit"—

And now that I am exceedingly fatigued, having been

writing for upwards of seven hours, I will wish you good night &
all the blessings that God may grant to [the] good man and to
every member of his family—Do not forget me near your Sweet
heart.

Your ever faithfully attached &

Sincere friend
J. J. A.

In July, 1845, a destructive fire devastated a large section of the

city of New York, including the warehouse in which the copperplates
of Audubon's Birds were stored; many believed that the plates had
been ruined, and one of these was the writer who after witnessing
the event gave the following dramatic account:[204]
 But who had lost most of all that pale crowd that hung like
ghosts around the scene, and gazed with watery eyes, and blue
compressed lips, over the ruin? An erect old man, with long
white hair, glanced his strong bright eye as coldly over the
glowing, smoking desolation, as an eagle would, who watched
the sunrise chasing mists up from the valley. J. J. Audubon looks
over the grave of the labor of forty years!

The Plates of the Birds of America are buried beneath those

smoldering piles! Ye money changers dare not break the
stillness with a sob, though the last cent of your sordid hoards
be gone! ... go away! Ye have lost nothing!... Yet that dauntless
old man is not dismayed; he and Fate knew each other's faces
in battle long ago. Let those who know how to love and
venerate such labors—to sympathize with such grievous
calamities, exhibit it in their prompt patronage of the new work
now issuing—The Quadrupeds of America—and in the care
which shall be taken to preserve the volumes of the Plates of
the Birds, now in existence—the value of which will be five-fold
increased!

When Baird heard the untoward news, he wrote from Carlisle,

August 4, 1845: "It is with sincerest regret that I see by the papers
that your copper plates were injured or perhaps ruined by the fire
which occurred a few weeks ago. Various reports are circulated
respecting your loss, and among so many contradictory ones it is
difficult to get at the truth of the case. Might I ask you to let me
know the truth of the matter." In a postscript to this letter he added:
"I forgot to say that I have been elected professor of Natural History
in Dickinson College. The situation is entirely nominal, nothing to do
& no salary whatever." Audubon replied promptly on the 7th of
August:[205] "You have been too well-informed about the plates of
our large work. They have indeed passed through the great fire of
the 19 ul°; but we are now engaged in trying to restore them to
their wonted former existence; although a few of them will have to
be reingraved for use, if ever that work is republished in its original
size at all."

Bachman, who paid a long visit to the Audubons in the late

summer or early autumn of 1845, said that while he was at "Minnie's
Land," Audubon painted "Le Conte's Pine Mouse" with his usual
facility and skill, but he detected a change in his mental powers. For
a long time Bachman had complained of the want of books, which
the younger Audubons failed to supply, and of lack of specimens,
which no doubt their father wished to retain for use in his own
studies, until at length his patience was gone and he tried another
form of appeal. The following letter[206] to their mutual friend,
Edward Harris, shows that he was then determined to throw up the
responsibility which had been assumed in the Quadrupeds unless
what he regarded as "reasonable requests" were complied with
forthwith:

John Bachman to Edward Harris

Charleston, Decem. 24, 1845.

Friend Harris, you can be of service to me, to the Audubons

& the cause of science. I will tell you how.

I find the Audubons are not aware of what is wanted in the

publication of the Quadrupeds. All they care about is to get out
a No. of engravings in two months. They have not sent me one
single book out of a list of 100 I gave them and only 6 lines
copied from a book after having written for them for 4 years.
When he published his birds he collected hundreds of thousands
of specimens. In his Quadrupeds—tell it not in Gath—He never
collected or sent me one skin from New York to Louisiana along
the whole of the Atlantic States. Now he is clamorous for the
letter press—on many of the Quadrupeds he has not sent me
one line & and on others he has omitted even the geographical
range—I know nothing of what he did in the West having never
received his journal & not twenty lines on the subject. I am to
write a book without the information he promised to give—
without books of reference & above all what is a sine qua non to
me without specimens. In the meantime my name is attached
to the book, and the public look to us to settle our American
species, and alas I have not the materials to do so.

Now this you can do for me. I am willing to write every

description and every line of the book. I do it without fee or
reward. But—1. Books of reference or copies of them he must
obtain. 2. He must publish no species without my approbation.
He has made some sad mistakes already. 3. He must procure
such information as I shall write for. 4. He must send some
person—say when John returns—to make a tour for collecting
specimens through the states of the west especially. I find the
smaller Rodentia differing every 600 miles. Richardson's species
differ from those of New York—ours are once more different
from those of N. Y. Leib [?] found a number of new species in
Illinois. The New Orleans squirrels differ from ours—California
once more new. Now on this last particular—the necessity of
giving me specimens to describe from I wish you to speak to
Audubon. I cannot consent to impose on the public. I cannot
settle the species without specimens. [Tell] him what I have
written and [of what I have] complained. Show him this letter if
you should [think] it will accomplish the end. I shall soon have
the volume finished as well as I am able from the scanty
materials with which I am furnished. Then they will be
clamorous for the second volume. Now I do not like to make
any threats, but if my reasonable requests are not complied
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