Original research Med Humanities: first published as 10.1136/medhum-2019-011766 on 30 June 2020. Downloaded from ‘Look under the sheets!’ Fighting with the senses in relation to defecation and bodily care in hospitals and care institutions Sjaak van der Geest ,1 Shahaduz Zaman2 1Faculty of Social and ABSTRact In this essay we will skip a discussion of the Behavioural Sciences, University This essay focuses on sensory aspects of care in long process of growing anthropological attention of Amsterdam, Amsterdam, The for and exploration of sensorial perception and Netherlands situations surrounding defecation in hospitals and 2Brighton, UK other care institutions. Sensory activity does not merely its accompanying emotions. Instead we will move encompass pleasant experiences that enhance healing straight to one particular emotion that involves a Correspondence to and well-being. Anthropologists—and other disciplines wide array of sensory modules and reactions, the Professor Sjaak van der as well—have paid little attention to unpleasant and five conventional senses in Western psychology, Geest, Faculty of Social and disgusting experiences that our senses meet and that as well as the 10 or more that have been reported Behavioural Sciences, University in observations in other cultures.3 This emotion is of Amsterdam, Amsterdam 1012 may rather increase pain and suffering in the context DL, The Netherlands; of care. Our essay therefore reflects on a common but disgust. s. vandergeest@ uva. nl highly uncomfortable aspect of being a—sometimes There is no rigid methodology for this essay as bedridden—patient: defecation. The sensory effects may be required in medical or sociological studies. Accepted 31 March 2020 of human defecation are well known. They affect at Part of the data are based on anthropological partic- Published Online First 30 June 2020 least four of the five traditional senses. But equally ipant observation in Ghana and Bangladesh about repulsive are the social and emotional effects that which the authors have published before. Part defecation in a hospital context has on both patients also derive from self- reflective introspection and and professional and other care providers. The essay is the authors’ personal experiences in Bangladesh, based on anthropological observations and the authors’ Ghana and the Netherlands. We further draw on personal experiences in Bangladesh, Ghana and the scientific publications by other authors as well as Netherlands and covers a wide variety of cultural and fictional sources. Finally, some descriptions were politicoeconomic conditions. It further draws on (scarce) taken from narratives by friends and colleagues in scientific publications as well as on fictional sources. informal conversations. They approved of quoting Extensive quotations from these various sources are their experiences anonymously. Nijhof ’s communi- presented to convey the lived sensorial experience of cation has not been anonymised with his permis- disgust and overcoming disgust more directly to the sion. He had before written about his use of stoma 4 reader. material in his autobiographic essay Sickness Work. http://mh.bmj.com/ DI SGUST: A NEGatiVE EMOTION The intensity of disgust that takes possession of INTRODUCTION the entire body and causes uncontrollable corpo- This essay evolved from a paper presented at a real reactions such as extreme facial expressions conference on the ‘Aesthetics of healing: Working and visceral nausea has long fascinated students with the senses in therapeutic contexts’ which was on September 29, 2021 by guest. Protected copyright. from various disciplines. The search for the ulti- held at the University of Münster, Germany in May mate disgust sensation has produced a large variety 2019. Our intention was to draw attention to the of different—sometimes conflicting, sometimes unaesthetic sensory aspects of care and thereby to complementary—hypotheses. counterbalance the somewhat idyllic assumptions in In 1927, Aurel Kolnai, an Austrian philosopher the conference theme. The subtitle ‘Working with and phenomenologist, produced one of the first the senses’ was thus changed to ‘Fighting with the scholarly studies of disgust, which was republished senses’. in English in 2004 with an introduction by Carolyn The senses received relatively little attention Korsmeyer and Barry Smith. Kolnai lists nine mate- during the early beginnings of medical anthropology, rial sources of disgust: putrefaction, excrement, but this should not be interpreted as a sign of a lack bodily secretions, dirt, certain animals (especially of awareness of their presence in human behav- insects), certain foods, human bodies, ‘exagger- iour, particularly in settings of sickness, suffering, © Author(s) (or their ated’ fertility, disease and deformation. How and healing and care. No one will in earnest deny or employer(s)) 2021. Re-use why these ‘objects’ cause revulsion is harder to pin depreciate the huge impact of sensorial experi- permitted under CC BY-NC . No down, however. Korsmeyer and Smith write that commercial re-use . See rights ence on our lives and on experiences of illness and for Kolnai: and permissions. Published suffering in particular.1 2 Grasping sensorial modal- by BMJ. ities in words and arguments, however, proved a Objects of material disgust share the impression of To cite: van der Geest S, huge challenge to anthropologists struggling with life gone bad, of flesh turning towards death, and of a Zaman S. Med Humanit the ‘mindful body’, which delayed theoretical and primordial and profuse degeneration of life from the 2021;47:103–111. methodological analysis of their observations. muck of decaying organic matter. Things that rot and van der Geest S, Zaman S. Med Humanit 2021;47:103–111. doi:10.1136/medhum-2019-011766 103 Original research Med Humanities: first published as 10.1136/medhum-2019-011766 on 30 June 2020. Downloaded from putrefy become the fuel for maggots and bacteria; insects in swarms aspect: whose matter is it? The answer to the question ‘whose?’ give the impression of excessive, mindless generation, of life “sense- determines the experience of disgust much more than has been 5 less, formless, surging” (p16). suggested by Douglas and all other authors who have written about the cultural meaning of, for example, defecation and It would not be fair to say that Kolnai only looked at mate- faeces. By adding a sociological dimension, we hope to make rial objects that cause disgust. He also included contextual Douglas’s theory of matter out of place more true to life and circumstances and sociocultural interpretations, as Korsmeyer more effective as an interpretative tool (p86).12 and Smith point out. Yet, having said this, it is also true that The strongest feelings of disgust arise in the unwelcome close Kolnai and many scholars after him focused mainly on concrete presence of others, physically or metonymically. Shoes on a table material things and beings that lead to disgust because of what may be dirty, as Douglas writes, but their presence on the table they are. As a result, attempts to explain what disgust is and becomes really uncomfortable if they belong to another person does remained rather static and tended to fall victim to circular with whom we do not want to be intimate in any way. If the reasoning: disgust is caused by disgusting things. shoes are placed right in front of me, they become a disgusting Evolutionist scholars largely followed this material perspec- invasion of my personal territory; they penetrate my ‘social skin’. tive, which still constitutes a dominant vision in psychology, but 6–9 The experience of sexual harassment, the unwanted breach of added a medical reason. They look on the fear and avoidance personal and bodily integrity, causes the same revulsion, but far of dirt as a defence mechanism against sickness and other dangers, more intensely. What is most deeply felt to be out of place is what and postulate a hidden rationality in the seemingly spontaneous invades our most private domain against our will. Apparently, disgust with dirty things and animals. Religious rules about purity the dominant guarantor of social order (to stay with Douglas), at and pollution and taboos on eating certain foods or touching least in Western society, are the boundaries between individual unclean objects or persons are seen as medical prescriptions in people. Transgressing these boundaries results in undesired inti- disguise. Mosaic laws in the biblical texts of Deuteronomy and macy, which is the ultimate dirt. It is no surprise that sexual Leviticus, for example, are perceived as rules for healthy living, harassment is viewed as an extremely disgusting experience and even though some of these rules do not make any medical sense sexual abuse as a hideous crime. today. The following things are najis (impure) in Islam: wine and Our suggestion that concerns about personal privacy and other alcoholic drinks, dogs, swine, dead animals that were not integrity constitute the final and most deeply rooted source of ritually slaughtered, blood, excrement, and the milk of animals disgust does not necessarily reject or disprove the earlier theories 10 whose meat Muslims are not allowed to eat. Disgust ‘is one of mentioned above, but should be added to them to make them the mechanisms crafted by natural selection to keep our distance more convincing and to produce a more plausible interpretation 8 from contagion’ (p22). Faeces, for example, is mentioned as a of sentiments of disgust surrounding defecation in contexts of transmitter of more than 20 diseases. Other people’s breath, lice care. and rats, and sexual organs, all of which score highly for human disgust, are also common sources of infection. It was against these evolutionist and materialist interpre- TWO ETHNOGRAPHIC OBSERVATIONS In 1999 the first author was admitted with cholera to a Ghanaian tations of dirt avoidance that Mary Douglas took a stand. ‘In hospital and put on a drip. Here are a few observations from his chasing dirt’, she wrote, ‘we are not governed by anxiety to diary.