20 JANUARY 1961, Page 28

Mind and Body

Intestinal Ethics


LYDG ATE WHATEVER else happens to him, when a patient goes into hospital he can be sure that his bowels will receive passionately close attention. As often as not his induction into the ward community starts with a ritual purge and if he resists it he is often regarded with beady suspicion by the nursing staff throughout his stay. And this is only the initial baptism. While he remains in the ward he is closely watched for signs of backsliding. Each day a fresh-faced junior nurse will mince prettily around the ward with a clip-board conducting a sort of inverted consumer research poll. At the first sign of irregularity the missionaries pounce again with alarming instruments of forcible conversion. The actual phraseology of the daily poll is significant. The patients are rarely asked point blank whether they have had their bowels open. 'Have you been good?' is a favourite usage. It is interesting how few patients take this for anything else but a question about their bowels.

This elaborate programme goes on quite in- dependently of the actual medical treatment and is sometimes even at cross purposes with it. It is the older ward sisters who get most wrapped up in their Augean business, and will even slip in a crafty suppository when the doctor has ruled out such measures only a moment before.

And as for the poor incontinents—these un- fortunate people, often the victims of advanced neurological disease, become damned in an un- relenting system of intestinal ethics. This is not to say that the nurses are actually cruel to such patients; though I have seen this. Indeed they are usually kind and forbearing; but there is without doubt an insidious sense of moral in- dignation in addition to mere physical repulsion.

Nurses are not alone in this preoccupation with the bowels. Doctors themselves may sud- denly go quite gaga over this very issue. It is not so long ago that the great Arbuthnot Lane was shouting for the removal of the large bowel with just a bit more heat than scientific conviction alone would have provoked. The large bowel, he thought, was a great cistern of toxic evil left inside the abdomen by a sanitary oversight. Deep colonic irrigations, laxatives and special break- fast foods all cater for the same irrational anxiety where regularity and ethical purity are so painfully confused. The patients themselves are often very grateful for these personal atten- tions, since lying in a hospital bed will often disturb their personal rhythms. Some of them become quite upset and agitated if they do not revert quickly to their old habits. I remember several women who went in for unaccountable fits of weeping until the sister restored their com- posure with a well-timed enema. I remember asking another patient why he was looking so fretful. He glanced conspiratorially around the ward, whispered darkly that he had not 'bee for three days and leaned back to enjoy the look of shocked amazement which he expected to flood across my face. I flickered not a muscle. I bent towards his ear instead and hissed triumphantly that I had often not 'been' for ten days. He recoiled in horror and would not be persuaded that I had suffered no ill-effects from the stoppage. Perhaps group confessions of this sort would help to dispel this silly guilt; a sort of constipateds anonymous. There is nothing to suggest a physical basis for such a disturbance but it is true to say that the patients who exhibit this petulant, listless behaviour seem to share the same fastidious personality along with a strong sense of thrift and duty. Many psychologists have felt tempted to attribute such personality traits to features in the patient's early bowel training• Of course it is very hard to establish such hypotheses on a firm footing : the variables ate so enormous. However, on first principles alone it would be hard to believe that the elaborate business of Western toilet training would act on the bowels alone. The whole set-up is too fraught with love, aggression, bribery, threats and seduc- tion. It would be very strange indeed if con• tinence were the only result of the experience. In fact one could say that continence emerged as a trivial by-product of the whole noisy transaction.

The small child voids himself automatically and derives considerable pleasure from the re- lieving sense of evacuation. Later on he learns to turn around and look on the product of this pleasurable activity with pride. Then, quite suddenly, as one psychologist has pointed out, he must learn, under pain of losing love, to attach anxiety to excretory materials. He gets involved in a sort of cash nexus in which he learns to barter faeces for affection. He gets acquainted with what must seem to him to be strangely changeable values of bowel produce: here is an object which has high value when deposited in one place only, disgusting when put on the floor. It is not surprising that the child develops a somewhat ambivalent attitude toward this function of his body. In households which focus obsessional attention on the bowels the child is taught to feel ill if he does not eliminate regu- larly. The normal muscular sensations come to be thought of in terms of terrible toxins seeping into the bloodstream. Eventually th9 child is brainwashed into a feeling of guilty lassitude if he does not empty his bowels each day at the right time. Nannies are specially given to this sort of bogus physiology and the child who spends any time in her care will carry her dotty ideas to the grave. At the same time the rest of his emotional apparatus will be geared to this first encounter. This, after all, is his first engagement with the adult world so that by analogy all later situations involving order and restraint will be underpinned by the system of values which he has learnt with so much noise and shouting in the control of his bodily func- tions. SO that it is hardly surprising that thrift, tidiness and other forms of moral continence have a scatological undertow. In this way adult disturbance of bowel action will quite naturally engender the obsessional fretting which the makers of patent medicines must find so profitable.