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1 ! Ro man Sieler Postdoctoral Researcher, MESH (Medicine Environment Societies Health) Institut Franc ais de Pondich ery, Pondicherry, India Patient Agency Revisited: Healing the Hidden in South India """""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" It is often argued that biomedicine alienates patients from doctors, from ailments and from understanding treatment processes, while indigenous and alternative healing systems are portrayed as respectful of patients and their experience. Specifically, South Indian siddha medicine has been seen as diverging from biomedicine in empowering its patients. This approach not only assumes biomedicine to be a homogen e ous practice, but also lumps together diverse therapeutic techniques under the labels of "traditional" or "alternative." Analysis of a manual subdiscipline of siddha medicine cautions against such analytic imprecision and active/passive binaries i n physician patient encounters. Practitioners of vital spot medicine claim to "heal the hidden They rarely communicate diagnostic insights verbally and object to auxiliary devices. However, their physical engagement with patients' ailing bodies highlight s the corporeal nature of manual medicine in particular and processual, situational, and reciprocal characteristics of curing in general. [ embodiment manual medicine secrecy siddha medicine South India ] """"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" A long list of scholars, including Parsons (1951), Freidson (1970) and Kleinman (1980), have placed the doctor patient relationship at the center of understanding medicine (Pappas 1990). Aspects of agency, decision making processes, and the scope of action of both sufferers and physicians have th us come to be of central importance for the sociocultural analysis of medicine. Although these are undeniably crucial focal points of medical anthropology and sociology, many studies have tended to perpetuate clichs and dichotomies in this regard. For ins tance, both scholarly writing and popular discourse generally consider patient agency and physician agency as two distinct entities ( see Anderson and Funnell 2010 ; Gafni et al. 1998 ). It is too often and too stereotypically held that, while patients of bio medicine are uninformed about diseases and treatment processes and are therefore passive objects (Illich 1975) patients of complementary and alternative medicine (CAM) and of so called traditional or indigenous healing modalities are active subjects, as t hey are involved in or knowledgeable of therapeutic processes (Barrett et al. 2003). It has become a standard approach to criticize biomedicine for alienating patients from their ailments, from the system of medicine they are treated with (Naraindas 2006), from the physicians conducting treatment (Foucault 1965:202; Rhodes et al. 1999), and from understanding or contributing to healing processes at all (Sujatha 2009; Taussig 1980). S uch binary opposites may be clichs of the West and of the East respectivel y, reiterating stereotypes of the cold, distanced biomedical doctor on the one hand, and a romantic picture of the Oriental physician on the other. Moreover, presenting opposing different therapeutic methods in such a way reveals a high degree of analytic vagueness, since this approach assumes biomedicine to be a homogen e ous practice and lumps together diverse therapeutic techniques under the labels of traditional, alternative, or complementary medicine. Such analytic imprecision results in dualisms, such as that of active/passive patients or physicians, or that of illness /disease, which do not advance our understanding of the dynamics of healing, I argue in this article
2 ! Annemarie Mol (2008), writing on the logics of choice and care in Europe, has similarly criticized generalizing notions of active/passive patients. She ha s noted that treatment is a dialectic process influenced by the logics of choice and of care. Rather than assuming either active or passive patients, it would be more inclusive to analyze the "logic of care" involved (Mol et al. 2010:9). In other words, to adequately understand healing processes, we need to recognize interactions between patients and healers as more complex than simple dualisms suggest. Taking into account the various agencies that influence treatment choices and healing processes also diss olves the problem of patients as active (subject) or passive (object). For Mol, care is not a transaction, but an interaction; care is not a product but "a process: it does not have clear boundaries. It is open ended" (2008:18). In this article, I analyze the particular logic of care involved in a form of indigenous manual medicine in Tamil Nadu, South India, to emphasize its processual and physically reciprocal character. Varma maruttuvam 1 "vital spot medicine," is practiced in the Kanyakumari district of Tamil Nadu, the southernmost part of mainland India. It is generally recognized as a part of siddha medicine, one of the codified indigenous medical systems of India. Sujatha has recently described patients of siddha medicine as "knowing" (2009), since th ey are knowledgeable of and are actively involved in treatment processes ; as such, siddha can be contrasted with biomedicine and its patients. Practitioners of vital spot medicine are called c! They have largely enjoyed a hereditary, noninstitutionaliz ed type of education, which enables them to offer treatments addressing ailments of varmam (i.e. "vital spots," or vulnerable loc ations of the body ) Related therapies include manual stimulations of particular points to retrieve patients from unconscious states, long term treatments for chronic ailments, setting of fractures, and massages. Practitioners of vital spot medicine conduct diagnosis and treatment secretly to avoid observation by witnesses ; they also generally refrain from communicating diagnosti c insights to patients. Rather, c ! s claim to "heal the hidden" and regard vital spots, their locations, and their manipulation as something that should not and cannot be disclosed. This approach to curing calls into question the idea of knowing, emancipa ted, or active patients in siddha medicine. Through tactile attention to their patients' bodies in diagnosis and therapy, c ! s address ailments without any auxiliary devices such as radiographic images, but also without giving verbal explanations to pati ents. "c! s state that their manual, body based therapies cater to the specificities of vital spots, which are physical entities that can be healed by their embodied skills but not communicated. They are unwilling to do so, not only because of the esoteric nature of their practice, but because they also find it difficult to translate their manual techniques and tacit knowledge into language. The practitioner's hands and feet on the one side, and the body of the patient on the other, are brought into intimat e contact, in the process of which diagnosis and treatment are conducted. As will become apparent as the ethnographic narrative unfolds, curing in vital spot therapy rests on this embodied communication between patient and physician. In the case of varma m aruttuvam describing this process of situational and physical reciprocity advances our understanding of curing more than the active/passive binary. Vital S pots and Varma Ma ruttuvam Varmam v ital spots are vulnerable loc ations of the body, which, when affected, may cause ailments ranging from light, even unnoticeable symptoms, to severe pain, or effects as serious as death. Vital spots can be utilized for purposes of combat as well as therapy, and c ! s are frequently exponents of martial arts practices called varma a # i or "hitting the vital spots," as
3 ! well as of varma maruttuvam "vital spot medicine 2 Its therapies are generally recognized as part of siddha medicine (Ir!c!ma i 1996), an indigenous form of health care found mo stly in the southeastern Indian state of Tamil Nadu ( Hausman 1996 ; Weiss 2009), while the corresponding martial arts resemble the better known ka $ arippaya ## u martial art form of Kerala (Zarrilli 1998). Since vital spots may be used to incapacitate opponent s, c ! s generally maintain strict confidentiality regarding their locations and ways of stimulation. For them, to reveal such potentially harmful information would be unethical. Practitioners explain the vulnerability of vital spots as related to the con centration in them of pir! % am a kind of circulating vital force. Any trauma to a varmam for example through physical impacts, inhibits the circulation of this vital force. This, in turn, deranges the three psychophysical functions or t& cam : v! tam (gaseou s/pneumatic), pittam (acidic) and kapam (unctuous), and the five physical structures or t! tu : rasa (chyle), rakta (blood), m sa (muscle), medas (fat tissue), asthi (bone), majj! (bone marrow) and (ukra (seminal fluid) ( see Ir!j#ntira 2006). Vital spot injuries therefore potentially cause detrimental effects to all aspects of psychophysical health. Diagnosing V armam: "Seeing" the P ulse Pulse examination, n # i p! r ttal literally translates as "seeing the pulse" and c onstitutes the main diagnostic method in both vital spot and siddha medicine. Practitioners often emphasize their extraordinary pulse examination skills, which, they say, surpass even modern imaging devices (Narayanaswami 1975:30). c ! s hold that vital sp ots are nonmaterial and hence neither visible nor detectable via dissection. For this reason, they question the value of imaging devices for their practice and may even refuse to look at X ray scans that patients bring along after having been diagnosed els ewhere. As one c ! stated, Varmam can't be seen on these images." It is important to note that seeing the pulse is in fact a tactile diagnostic method that does not depend on vision at all, but consists of sensing the pulsations of patients' radial art eries at the lateral aspect of the forearm below the wrist joint. Here, the t$ cam processes are assessed regarding imbalances, as is the pir! am vital force regarding its circulation, by three fingers of an c ! 's hand. For siddha medicine in general, pu lse examination has been described as a state of equipoise between patient and physician (Daniel 1984; Sujatha 2009). Not only are vitiated processes and blocked vital force detected by this method, but physicians have also become aware of their own pulse while measuring that of their patients. c ! s attempt to modulate their own pulse so that it coincides with that of their patients. This allows for a state of empathy during which they detect imbalances of t$ cam and the flow of pir! am in a patient's body. I was told that in this way c ! s conduct a thorough (tactile) scan of a patient's body, tracing even the most trivial abnormalities. Moreover, p ulse diagnosis is a complex process requiring tactile skill, concentration, and experienc e because seasons and time of day, as well as the age and physico mental state of a patient, must be taken into account. Narayanaswami writes that, "long practice is necessary, for this is more a subjective evaluation of the condition of the body than an o bjective one" (1975:33). Sujatha regards pulse examination as an icon of an allegedly fundamental difference between siddha medicine and biomedicine with regard to their respective processes of knowing an ailment. According to her, biomedicine, being labo ratory centered and following strict disease categories, is comprehensible only to doctors, as "diagnosis, decisions about treatment and its evaluation take place in the language of experts" ( Sujatha 2009:77), while the illness experiences of patients are not included. According to Sujatha (2009), siddha does not create a similar hiatus between patient and practitioner, nor between experience, knowledge and diagnosis, and hence not between
4 ! illness and disease, since it draws on the experiences of both physicians and patients. Since the 1970s, studies in medical anthropology have distinguished "illness" from "disease The former describes the illness exp eriences of patients/laymen, the latter denotes the disease according to doctors'/specialists' understandings and concepts (Good 1996 ; Kleinman 1980 ). Disease is thus seen as an objective, scientific fact in biomedicine, wh ereas illness is seen as an expre ssion of subjective experience and thus is unreliable. That is why biomedicine has been accused of splitting off subjectivity from objectivity and patients from physicians (Taussig 1980:8). 3 However, Mol convincingly argues that it is high time for social scientists to go beyond the illness/disease dichotomy (2002:27). She stresses that diagnosis, in particular, is performatively produced between doctor and patient: In the consultation room, both physician and patient act together to jointly give shape to t he reality of the patients' ailment. This diagnostic acting together of physician and patient can be well illustrated using the example of pulse examination in siddha medicine. In fact, this has been done so before: N # i pulse examination, it has been argu ed, allows for a momentary merger of physician and patient, a state of "consubjectivity" (Daniel 1984; see Sujatha 2009), since tactile experience is a mutual process, consisting of touching and being touched at the same time ( see Van Dongen and Elema 2001 ). In this sense, Sujatha argues that in siddha medicine, "the patient is not merely an object of the physician's investigation through diagnostic equipment" (2009:79). The divide between physician and patient is neutralized and replaced with consubjectivi ty in n # i pulse reading as the siddha physician experiences the suffering and humoral imbalance of the patient T he latter, according to Sujatha, is ultimately a "knower" of diagnosis and treatment (through what she calls "sensory knowing") ( Sukatha 2009:79 ). However, contrasting patients of so called traditional medicine with biomedical patients, with the former imagined as active, emancipated and know ledgeable and the latter as passive, dependent and kept in ignorance, does not advance our unde rstanding of the dynamics of the process of curing. Moreover, although it is true that siddha physicians try to gain in depth understandings of patients' ailments by way of empathy and skilled pulse reading it is necessary to critically examine the notion of these patients as being emancipated and informed. Healing the H idden When I arrived at the small dispensary of Ramachandran, the practitioner was consulting with patients. Not wishing to interrupt, I took a seat outside on the veranda, from wher e I overheard that a teenage patient inside had had a fever for 32 days. The patient's parents were present and lamented that all examinations previously conducted in a hospital had been inconclusive. Therefore, and because the boy had recently been involv ed in a fight, they considered the ailment to be varmam [ related]" and had approached Ramachandran. The c ! after having palpated the patient's neck, pronounced that this was indeed varmam and that the fever would abate after three successive massage s essions, at a total cost of 1,500 r upees. 4 The parents, surprised by this amount, demanded to know what the therapy included. From here on, I cite my field notes: Ramachandran: How dare you question me? Who is the c ! : You or me? Are you going to treat the boy yourself? () If you go to see a doctor in a hospital, will you ask him, How will you treat, or, What does this injection contain? Certainly not! Patient's m other: It's not like that! Don't misunderstand me m y father was also an c !
5 ! R: Then let him cure the boy! If you know about these things, how dare you question me! Vital spots are a secret matter! PM: Yes, we know. But can't you tell us how you will treat our boy, and what it is he is suffering from? R: It's not possible. We are finished. Now go. I was taken aback by the practitioner's angry response to being questioned about his methods. It seemed to me that a medical consultation had been turned into a dispute because of an offended ego. After all, the c ! had virtually kicked out a patient in need of medical care without even attempting treatment, something that appeared to me to be utterly insensitive. Ramachandran later explained that the parent's behavior had been wrong because it was improper to enquire about the modalities of vital spot treatment. A patient visiting him had to consent ( ottakka % um ), otherwise treatment was not possible. I must hasten to assert that uncompassionate behavior is an exception among c ! s, most of whom have great empa thy for their patients. Ramachandran himself struggled to explain his reaction, saying that it was simply not possible to tell patients what the ailment was or how he would treat it. This had to do with the nature of varmam : Such spots, the c ! declared, are potentially dangerous, therefore, since they might be misused, they must be kept secret. Disclosure of locations and stimulation methods of vital spots could damage the lives of persons and the reputations of practitioners. Moreover, there was no sense in explaining the insights of his examination, the nature of the ailment, or the treatment as none of these would be understood: In the words of Ramachandran, what c ! s treat is what is both "kept concealed" and "itself hidden" ( ma ) aitta veccatum ma ) aint appa ## atum ). In other words, vital spots are not only secret because they are not disclosed but also because they are noncommunicable aspects of the physical body. Invisible S pots and T racing the S ecret According to some scholars, the development of diagnostic imaging devices has ensured the primacy of the sense of vision in biomedicine (Foucault 1973; Kember 1991). Soon after the invention of radiography by Wilhelm Roentgen in 1896, images of body struc tures and organs became essential for traumatological diagnostics in Western countries. Besides, the utilization of imaging devices became important in distinguishing legitimate, trained physicians from allegedly unqualified practitioners or "quacks" (Hino josa 2004b:268). But the use of such diagnostic tools in biomedicine "reveals attempts at making an objective diagnosis through clinically isolating the medicalized site," encouraging "the idea that injury can be isolated, captured, and studied at a remo ve from the sufferer" (2004b:282 2 83). It has been argued that such an approach renders patients' experiences and symptoms and even the patients themselves of secondary importance, subordinated to the images produced (Taussig 1980:8), since health, disease and efficient cure in biomedicine are determined by tests, "embodied in a techno legal apparatus and situated entirely outside the felt awareness of the sufferer" (Naraindas 2006:2662). c ! s, on the other hand, dismiss radiography and imaging evidences claiming that diagnosis of vital spots is a highly intricate process, only graspable by experienced practitioners. Admittedly, X ray records can serve a useful purpose with their before and after images of once broken bones, subsequently mended after the rapy, and practitioners may sometimes keep scans that testify to their healing prowess ( see Hinojosa 2002:26). Nevertheless, c ! s generally say that vital spots are hidden and can neither be detected by
6 ! scans nor by the eye, since neither pir! am nor vita l spots are visible. Both categories can only be sensed by practitioners through their own bodies. Another diagnostic modality utilized by c ! s is palpation ( to # u ttal literally "touching" ). A practitioner's hands skillfully palpate body surfaces, caref ully sensing variations in the structure of tissues and vital spots. Physical trauma at a vital spot causes a local blockage of pir! am vital force which can externally be sensed as a localized coldness (Nicivilca 2003:50 ; Chidambarathanu Pillai 1995: 69 ). According to c ! s however, neither patients nor unskilled individuals can locate this because discerning such localized changes in body temperature is a difficult task that depends on detecting pir! am and vital spots in patient's bodies and requires l ong years of practice. To become aware of their own vital force and of that of their patients, c ! s practice exercises that develop abilities to sense pir! am concentrations. These include pir! % y! mam or pir! am regulation," sets of breathing exercises that are mostly known in relation to Yoga, and generally translated as "respiratory control" ( Eliade 1970:53 ). Such exercises consist of deliberate modifications of the rhythm of breath by slowing down and equalizing patterns of inhalation, exhalation and retention of breath. This has a calming effect but also allows for experiencing and influencing pir! am For c ! s, this is required for detecting differentiations in temperature and localizing vital spots when palpating patients. Locating varmam spots th rough palpation therefore requires paying tactile and kinesthetic attention to patients' bodies and to pir! am The corporeal knowledge that underlies this technique is entirely the domain of specialists. c ! s moreover seldom communicate their knowledge and rarely enlighten patients regarding diagnostic insights or their therapeutic procedures. By rejecting diagnostic images that their patients frequently bring along, they underpin their expert authority on vital spot ailments. Curable I ncurable and S igns of D eath It might be argued that a more fitting translation for varmam is "lethal spots" rather than vital spots. 5 Potentially dangerous to life, practitioners have to evaluate every varmam affliction with regard to its being lethal or treatable (Ir!c!ma i 1996:25). In fact, there are signs by which c ! s estimate a condition to be curable, c! ttiyam or incurable, ac! ttiyam The manuscript Varmap*ra + ki ti ) avuk& l mentions symptoms such as "ey eballs falling to one side, emission of urine [and] feces" as "death signs" ( c! ku ) i ) (Nicivilca 2003:52). Some c ! s hold particular loci to be incurable by definition ; hence any impact to these would be potentially fatal. According to Chidambarathanu Pil lai (1994:46), 81 of the total of 108 spots are incurable and 27 are curable. Further, for each vital spots there is a stipulated amount of time during which treatment of an affliction is promising, whereas after its expiration an ailment becomes incurable One of the shortest time spans is given for tilartakk! lavarmam a spot on the forehead. T o save the life of the patient, treatment has to be concluded within 90 minutes of finding this affected spot ( Chidambarathanu Pillai 1994:183). If c ! s assess that a situation is incurable, they administer no treatment. Rather, according to some practitioners, "it is pre eminent to send [the patient] away without administering medical treatment" (Ir!c!ma i 1996:25; see Chidambarathanu Pillai 1995:69). Textual so urces support this view. The manuscript Varmap*ra + ki ti ) avuk& l cautions, "Do not venture to treat" (Nicivilca 2003:52), and the Varmakka %% # i gloomily states, "If [an ailment is] ac! ttiyam [the patient] is sure to die. Beat the pa ) ai [death drum], for hi s life will expire" (Mariyaj$ cap N.d.:27). F or c ! s, an incurable case is not only one where treatment is futile, but one in which a practitioner must not administer treatment. If treated nonetheless, one informant explained, "In case a patient dies, this will be seen as the c ! 's fault." A patient's death may be ascribed to malpractice, not to the original injury, and the reputation of
7 ! a practitioner might be ruined. Alternatively, practitioners may even become victims to (physical) attacks by patients' relatives ( see Sujatha 2009:83). Even signs that are not directly connected to the physical condition of a patient may provide clues about the nature of affliction. These are called la # ca % am "symbol," an aspect not confined to vital spot medicine but foun d in other prognostic and healing procedures in South Asia (Nichter 2008:188). Manuscripts mention that if, for instance, a messenger, bringing a report of an accident, is seen "holding a post or pillar with his right hand or (...) the bar of the roof and standing on a single foot" (Mariyaj$ cap N.d.:39), an c ! can ascertain, even from afar, that therapy is futile and should then not treat the patient. Incurability of ailments is likewise detectable if persons accompanying a patient carry tools, such as a spade ( ma % ve ## i ). A buffalo ( erumai ) crossing the path of a patient who enters a dispensary signals imminent death. 6 Although some practitioners dismiss the idea of rejecting patients on the basis of such signs, I did see one c ! advising a patient suffer ing from a fractured ankle to "go to the hospital and see a doctor." There, he said, the ailment would be taken care of appropriately. I was surprised to hear this, and I i nquired after the patient had left if the c ! honestly thought the patient was bett er off in a hospital. The practitioner demurred, stating that the injury could not be cured at all. He added, "No matter what treatment, there will be problems all his life. If I treat and it doesn't heal, the family will scold me, thinking I'm a bad physi cian. Therefore we should not treat such patients. If I treat him, he will blame me, not his accident!" Such signs, however, appear never to be communicated to patients, who are left unaware of them and their meanings. The practitioner cited explained tha t he would never disclose a diagnosis regarding curability or incurability to patients or their families. "How is it possible," he asked, "to tell anyone that their ailment is not curable?" Such an act would neither meet with comprehension or acceptance, n or would it be in any way helpful. Thus, c ! s do not normally inform patients of their diagnoses regarding the nature and (in)curability of a disease, and this holds true for most aspects of the vital spots. However, although it may not be possible to sp eak of reflectively knowing, active, or empowered patients in the case of vital spot therapy, it is necessary to analyze the particular mode of curing involved. This analysis helps to emphasize the situational, corporeal, processual, and interactional char acter of this manual medicine. Healing the Vital Spots If affliction of a vital spot is assessed and estimated to be curable, most c ! s use external, manual techniques for treatment. These fall into the categories of i $ akkumu ) ai emergency measures, and ta # avumu ) ai specific massage methods. I $ akkumu % ai is a kind of emergency treatment, administered as fast as possible in vital spot injuries. It invariably includes stimulations of a particular category of therapeutic spots called a # a + kal Etymologically, a # a & kal is derived from a # a + ku tal which means "[ t]o obey, () to be subdued; () [t]o cease" ( Tamil Lexicon 1982:34). One c ! referred to the therapeutic spots as "main switch," which had, as it were, to be flicked after an injury. Thus activating a specific therapeutic spot, a varmam affliction is sub dued through regulating the blockage of pir! am vital force in the body. Revived by this method, an unconscious patient regains consciousness. A # a & kal s can also be deployed for giving relief for various ailments, and particular spots may be stimulated acco rding to specific conditions (Ir!j#ntira 2006:364). The general goal of such stimulation of therapeutic spots is to "relax," in Tamil i $ akkutal and hence the overall emergency method is called i $ akkumu ) ai or "relaxing; relaxation method." However, "re laxation" here refers to vital loci and pir! am circulation
8 ! but this is not necessarily perceivable by the patient, nor is it always pleasant. The relaxation method denotes the restoration of a state of bodily equilibrium that has been upset by a varmam af fliction. If a vital spot is traumatized, pir! am circulation gets blocked. To be p recise t his has to be countered by relaxing the afflicted varmam the blocked pir! am vital force and the whole body. By stimulating an a # a & kal a corresponding vital spot is stimulated as well, which effects the slackening of the afflicted spot and the release of pir! am blockage. For each specific case of a spot being affected, one or several adequate a # a & kal s thus have to be known and correctl y stimulated for counteracting an affliction. Practitioners cannot simply press anywhere, since only the complete knowledge of varmam spots and their corresponding a # a & kal loci enables therapy. Moreover, there is no uniform manipulation method: Practitione rs use specific techniques of pressing, turning or pinching, executed by intricate finger positions or wooden sticks for different spots. A # a & kal s are especially concealed and are only handed down within families or closed practitioner lineages, who are reluctant to communicate their locations and usage to outsiders. Many c ! s claim to know "secret therapeutic spots" ( irakaciyam! a a # a + kal ), considered to be most effective, yet unknown to other physicians (Jeyr!j 2007:60). Even close relatives of patient s are sent out of the treatment room when such therapeutic loci are involved in therapy. The concealment of practices finds a spatial expression in the layout of most vital spot dispensaries. At a minimum, a curtain separates the space in which treatment i s conducted from the gaze of even accompanying relatives, contrary to standard procedures in most Indian patient encounters (Halliburton 2002:1127). c ! s have been reported to utilize saris or bedcovers to shield their techniques from the eyes of others ( see Langford 2002:214). Even after a patient is saved from immediate danger, treatment is not complete. Continued treatment of vital spot ailments includes internal medication and, if required, bandaging along with repeated manipulations of limbs, joints and muscles. Vital spot massage method ( ta # avumu ) ai ) consists of stroking and rubbing the body, skin, muscles, joints and tendons, and is almost invariably conducted by using medicated oils or ointments. Such medicinal agents are spread over the whole b ody or confined parts to penetrate the skin and vital spots. As in the emergency treatment described above, the aim of massage is to render a patient's vital spots relaxed or slack. This means that both physiological structures and subtle, physiological pr ocesses return to a healthy condition. Unless there is an immediate problem such as a fracture in the area to be massaged, application of pressure is generally quite strong, consisting of deep, intense massage strokes, which often cause patients to groan in pain. When I experienced this massage, I felt it impossible to relax my muscles, one of the prerequisites or positive effects expected by most Europeans and North Americans from massage. The force applied in vital spot massage, however, causes the reci pient to wince or tighten muscles. Painful or pain like sensations are frequently involved in both localized varmam stimulation and in massages ; patients often experience these as current like sensations. c ! s explain these as vital points being touched a nd released, trigger ing the circulation of pir! am vital force. In massage strokes, c ! s transmit their own pir! am energy to the person being massaged. A requirement for this is an extraordinary control over one's own pir! am which must be experienced a nd channeled by skilled practitioners and transferred through their own limbs into those of a patient. While directing vital force through massage techniques using their hands, feet or other body parts, c ! s not only manipulate their own pir! am but simu ltaneously perceive the vital force of the patient as well. Controlling one's own pir! am allows for effective massage strokes. Detecting a patient's vital force facilitates an assessment of its circulation, by which the type and location of an impacted vital spot can be ascertained, as well as the kind of
9 ! massage required. Thus, pir! am and its control are important therapeutic an d diagnostic tools. Even if patients moan under the pressure, this is no indication of wrong treatment in any way. Pir! am has to be activated in such treatments, and if a patient experiences current like sensations or even pain, th at is a sign of correct manipulation and therapeutic efficacy, not of the wrong treatment. When N ot to T reat In emergency measures and massages, a patient's pir! am and with it the whole body, is supposed to become supple and relaxed. If this doesn't occur, or if the body is regarded as too rigid for manipulation, massage and stimulation are not conducted. For instance, c ! s administer massages during the morning and early afternoon but not in the late afternoon or evening. During these times, bodies are said to be too rig id to receive massages, hence patients are advised to return either the next morning or after three days. A patient's body can also be regarded as too rigid regardless of the respective time of day. Such a state may be due to a functional ( t& cam ) imbalance which may render a body rigid ; in this case manual therapies are avoided. Instead, medical preparations, mainly decoctions ( ka yam ), are given to patients, who are advised to return only after consuming them and observing dietary prescriptions ( pattiya m ) for a number of days. Because of the relaxing effects of medicine and diet, the patient's body is then ready to be massaged. Patients normally expect massage, are unaware that the c ! regards their body as too rigid to apply it, and are thus frequen tly frustrated if they have to forego it. Because patients perceive vital spot therapy chiefly as a form of manual therapy, they connect much of its efficacy to an c ! s' hands and manipulations to their "healing touch," or, literally, to their "lucky hand s," kair! ci Being sent off without having received a massage often disappoints patients, who plead with c ! s to relent and provide one. To one such patient, Velayudhan c ! explained: Velayudhan: You must understand that I cannot massage you now. We have to treat your stiff nerves first. Only after that will I massage. Patient: But can't you massage me just a little bit now? V: No, I can't, that's what I'm telling you. () Look, there's nothing I can give you except decoction, which you must take for three days. After that your body will be ready for massage. P: But if you would just apply some oil, wouldn't that be helpful? V: No! Won't you listen? Take the medicine first. Massage would create problems. I'm giving medicine first, massage only after th ree days. If there is anyone who treats you otherwise, then he's an idiot, who doesn't know varmam Take the decoction and come back after three days. Naming the Secret: Vital Spots and Biomedical Terminologies Despite or rather because of the secret ive behavior of c ! s, patients often seek ways to comprehend and label what ails them. One young man for example, having been unsuccessfully treated by a variety of practitioners and medical systems, decided to consult Velayudhan !c! for an ailment from which he had been suffering for several years. The symptoms included painful coughing and a constantly blocked nose, making his breathing difficult. After examining the patient's pulse, Velayudhan pronounced that it was a vital spot ailment and therefore treatable. Relieved, the patient enquired about the name of his disease. Shaking his head, the c ! replied this simply was varmam Unsatisfied with this and
10 ! mistaking me for a biomedical professional, 7 the young man a sked me to explain his disease. I was u nable to do so, and Velayudhan attempted to console the patient by attempting to describe how pir! am inside his body was obstructed. The patient was apparently not satisfied with this, and continued consulting me, asking, among other things, whether this was a "sinus problem." This case highlights several aspects: It attests to the fact that many patients turn to vital spot therapy as a last medical resort for chronic ailments that have not been cured by biomedical treatment. Nevertheless, the patient, u nsatisfied with the diagnosis of varmam had reverted to biomedical categories. It appears that some c ! s recognize this and employ the lay biomedical language desired by their patients or promote their practices in biomedical terms. With regard to ayurve da in urban India, Harish Naraindas has noted that "efficaciousness, and the very premises of the dialogue, are framed by the language of biomedicine or some pidgin version of it" (2006:2662). There is an increasing deployment of biomedical terminologies t o name vital spot ailments and supposedly to promote related practices. Signboards of dispensaries depict lists of ailments treated by practitioners often including the disease categories of biomedicine instead of, or in addition to, Tamil terms. Even Tamil terms are often simple translations of biomedically defined diseases. These translations may be an attempt to provide options of verbalized explanations of vital spot ailments and treatments. Such labeling of what is otherwise seen as to be kept conc ealed in biomedical terms is aimed at patients who seek to find alternative explanations of varmam than "that which is hidden," or secret. Moreover, in a field of diversified health care practices in India today, generally termed "medical pluralism," the d ominant frame of discourse, credibility, and legitimacy appears to be that of biomedicine and of its language ( see Baer et al. 2003:329). This dominance is visible in biomedical nosologies, through which patients try to gain agency and access to what their healers do. A t the same time, patients partly subscribe to and perpetuate this dominance by adopting references understood in scientific and popular discourse, and by framing what they do in (what they understand as) biomedical terms. This case is also i nteresting as it points to patients as important driving force s in an attempt to produce a correspondence between biomedicine and other therapeutic approaches and in translating one system into another. Previously, s cholars have not acknowledged the role o f patients to the same degree as they have emphasized the agency of professionals in this regard. I t is also intriguing to note that a patient receiving treatment from an exponent of a form of health care described as empowering its patients seeks answers from biomedicine, the therapeutic approach sometimes criticized as disempowering its patients. This case also cautions against perceiving biomedicine as a somewhat homogen e ous practice or system. In fact, what is generally described as biomedicine, and thu s deliberately or unconsciously unified, may consist of widely divergent practices, techniques and notion by professionals and nonprofessionals the world over ( see Lock and Nguyen 2010; Mol 2002). A Somatic Mode of A ttending to Ailing Bodies Manual forms of therapy, though arguably underrepresented in the literature (Oths and Hinojosa 2004:xiii), have been described as a nonverbal, bodily engagement with ailing patients' distress (Hinojosa 2002 2004a 2004b ; Walkley 2004 ). Such a mode of healing parallels what Csordas, drawing on Merleau Ponty (1996  ), calls "somatic modes of attention," which he defines as "culturally elaborated ways of attending to and with one's body in surroundings that include the embodied presence of others" (1993:198; see Csordas 1990 1994).
11 ! Acknowledging the somatic modalities of attention and perception in healing encounters, Servando Hinojosa describes how his informants, Maya bonesetters, physically engage with their patients. They diagnose and treat using their own bodies, thereby achiev ing direct, corporeal links with their patients. Maya bonesetters describe their healing knowledge as located in their hands and claim that their bodies discover disorders by communicating with the bodies of others ( Hinojosa 2004b :265). Since the related knowledge is located in the bonesetter's hands, however, it is not subject to verbalization (Hinojosa 2002:27). Diagnosis and treatment hence are a "body based potentiality" (Hinojosa 2004b:265), as patient's physical ailments are identified only via the bonesetter's body. The diagnostic and treatment modalities of vital spot therapy present a parallel case: c ! s make use of manual techniques, with which they physically engage with their patients' bodies. Their incorporated skills appear to be tacit knowledge; a type of knowledge that according to Michael Polanyi, is a nonlinguistic form of knowledge that "indwells" the body but cannot be verbalized, and which is thus opposed to explicit knowledge, that is, information which can be written down or explained (1967). Maya bonesetters often have "bodily empathy" (Hinojosa 2002:28) with patients because they have suffered from similar ailments as their clients. According to Hinojosa, bonesetters who coexperience their patients' conditio ns are better equipped to respond to bodily suffering. Elisabeth Hsu has contested the widespread biomedical explanation of the efficacy of pain inflictions as counter irritation (2005). According to her, the infliction of acute pain in Chinese acupunctur e techniques creates a social and physical connectedness between patient and healer through sensory attentiveness, which can be of therapeutic value. The observation of the body as a basis for diagnosis and treatment and of a sociality created through pa in infliction holds also true for varmam therapeutic practices. This is apparent from the induction of generally high pressure, triggering pir! am force and causing pain in turn strikingly similar to the painful yet desired effects caused in acupuncture ne edling (Hsu 2005:78 79). In general, when c ! s manipulate spots, acute pain is caused, which, combined with its abating and the ongoing care by practitioners, may be acknowledged to create a physical and social link between patient and healer. V oluntaril y enduring pain at the hands of someone else premises trust which allows for the manual therapies to be administered in the first place. Seen in this light, Ramachandran, the practitioner who, when questioned regarding his methods, had sent away a patient may not have acted merely out of an offended ego but because such questioning had jeopardized his treatment. c ! s acknowledge that they do indeed often refuse or are unable to tell their patients the names of particular ailments the position or importance of vital spots or the forms of therapy they will use To characterize these patients as knowing, emancipated or active can be misleading. However, c ! s pay somatic attention to their patients' bodies, especially to pir! am ci rculation, and this eludes explicit verbalization. Reflecting on how to find a way out of the dichotomy between the knowing subject and objects that are known in medical interventions, Mol has suggested that it would be beneficial "to spread the activity of knowing widely" (2002:50). Instead of talking about subjects knowing objects she suggests talking about enacting reality in practice, a move that circumvents granting doctors or patients subjectivity or objectivity, activity or passivity. In the case o f vital spot medicine, such an analytic approach includes, among others, acknowledging the reciprocal and interactional processes of c ! s' somatic attending to patients and their ailments.
12 ! Conclusion Alth o ugh damage to vital spots causes imbalances a nd disease, health can be restored by therapies addressing the same loci. However, this and other intriguing manual healing modalities have been chronically underrated or misunderstood in scholarly representation. Moreover, touching in medical encounters a nd manual forms of therapy are much devalued and are one reason for the comparably lower status of such practitioners vis vis physically uninvolved physicians all over the world (Hinojosa 2004a 2004b). Human contact in medical settings has been reported to be particularly deprecated, and body workers, nurses and manual practitioners are often merely allowed for auxiliary status, not for medically authoritative opinions (Van Dongen and Elema 2001). One reason for this might be the physical nature of manu al medicine, which may impede verbal and scholarly description on the one hand, but which can provide for a particular healing relationship between practitioner and patient on the other. As I have discussed here manual medical practices such as vital spot therapy allow for a reconsider ation of the concepts of patient and physician agency and the nature of healing. Some have argued that biomedicine alienates patients from their ailments, from the system of treatment, from their physicians, and from unders tanding or contributing to treatment processes. But are patients of other forms of health care emancipated and actively involved in the medical proceedings? And is it legitimate to assume biomedicine to be a somewhat homogen e ous entity and to lump together hugely diverse forms of health care? Examination, diagnosis and treatment of vital spot therapy are secretive processes. Neither diagnostic insights, disease categories, nor aspects of treatment are shared with patients. c ! s claim to heal the "hidden ; varmam loci are not detectable by sight or modern imaging devices, but are only graspable by an experienced practitioner. This projects the romantic image of the Oriental physician gentle and understanding on the one hand, and of the corresponding patien t active and involved on the other. Thus, the idea that the patients of (some) indigenous medicines are knowing, active or emancipated is shown to be more ideological than actual. 8 Active patients of indigenous or alternative medicines may be a clich, a s may be the idea of the passive patient of biomedicine, bereft of autonomy. The fact that such clichs fail to distinguish the many different kinds of alternative medicine, and assume that biomedicine is one monolithic entity should alert us to the fact that they are rhetorical, not descriptive. It is neither justifiable to speak of biomedicine nor of indigenous, traditional, or even complementary medicine as generics when we know that these therapeutic ensembles vary from one geographical / cultural area t o another concerning medical practice, users and patients, social policies, cultural practices, and so on. Moreover, the active subject/passive object binary exhibits a body mind dichotomy with a strong mentalist bias as conscious decisions, plans or the resistance of patients and healers tend to be emphasized, wh ereas somatic circumstances, intersubjective and interactional healing procedures conditions that transcend the actual healing encounter, but nevertheless structure its proceedings are neglected The diagnosing/treating body of the c ! and the diagnosed/treated body of the patient allow for a more precise reflection of the particular type of agency involved: Seeing the body as body cared for and as body caring at the same time ( see Van Dongen a nd Elema 2001:150). The seat of this agency, both patient and practitioner agency, is the body. As argued by Marcel Mauss, the body is at once object, tool and agent (1934). The mode of connection between all, and the object and subject of procedure is to uch. Although it has been argued that "the distinction between touching subject and touched object blurs" (Mazis 1971), this should not lead to believe that there are no distinct agencies of healers and patients in
13 ! vital spot medicine. As in other forms of healing, these are almost always asymmetrical and often shaped by influences outside of the therapeutic encounter (such as health policies, licensing and registration laws, etc.). All vital spot techniques depend on highly intricate corporeal skills of p ractitioners, but also on the patients' physical presence. This does not mean, however, that vital spot therapy empowers patients or that it is an egalitarian exchange. There are distinct hierarchies involved. These are accentuated by specific techniques a nd diagnostic insights that !c! s (sometimes deliberately) withhold from patients and by the fact that practitioners often (have to) go against the wishes of patients, such as when pain is an indication of successful therapy or when !c! s abstain from trea ting. As this article shows, healing may not always involve will and intellect of patients (or that of healers), but this need not lead to the conclusion that patients are unknowing, passive objects. Rather, as the analysis of diagnosis and therapy of vita l spot ailments highlights, healing may take place to large degrees on somatic, multisensorial and preconscious, nonverbal levels. In the case of vital spot therapy, curing can be described as situational: T his is seen in the diagnostic techniques, which in vital spot medicine are highly dependent on individual cases and on the specific situation of any ailment and patient. Curing is processual, as practitioners are not so much concerned with a general category, but with the state or process of an ailment which drive the therapy. Curing is a somatically reciprocal intervention as highlighted by most diagnostic and therapeutic aspects of vital spot therapy, drawing as it does on ca s' incorporated skills, tactility and manual techniques and patients' ph ysical presence and compliance. None of this necessarily diverg es from other forms of health care, but it is more informative than analyzing allegedly opposing and distinct agencies of physicians and patients. Furthermore, as we see at the instance of nam ing varmam in biomedical terms and nosologies, such agencies can hardly be seen as isolated from broader phenomena such as the asymmetrically structured field of healthcare in India, which appears as dominated by the credibility and language of biomedicine We therefore need to understand subjectivity and agency as always socially embedded processes of intersubjective experience (Kleinman and Fitz Henry 2007). As this article shows this applies to the agencies of patients and physicians as well. Taussig ha s emphasized the intersubjectivity of patient and healer: "Health care depends for its outcome on a two way relationship between the sick and the healer. Insofar as health care is provided, both patient and healer are providing it" (1980:10). The case of m anual medicine in general and of varma maruttuvam in particular draws attention to this interactive characteristic of curing as much as to its situational, corporeal, and processual aspects. Notes 1. Original terms, reproduced in italics, are trans literations from Tamil, except where noted otherwise. D ata for this article w ere ga thered throughout 2009 and 2010 using ethnographic research methods of participant observation and interviews combined with apprenticeship learning of varma maruttuvam as part of a doctoral research project fund ed by the German Academic Exchange Service (DAAD) 2. For an account of the relationship between medicine and martial art in varma maruttuvam, see Sieler ( 2012 ). 3. According to Taussig, the social relations that are sign ified in disease symptoms are concealed within the realm of biological signs. Biomedicine, he argues, denies the human relations embodied in ailments and its symptoms, and thus neglects the subjectivity of patients by creating a "phantom objectivity" of di sease and of biomedicine ( Taussig 1980:3).
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