Somatic Lessons (Narrating Patienthood and Illness in Indian Medical Literature)

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In ayurvedic medical practice, the ways in which and the reasons why people become ill are often explained with stories. This book explores the forms and functions of narrative in Ayurveda, India's classical medical system. Looking at narratives concerning fever, miscarriage, and the so-called king's disease, Anthony Cerulli examines how the medical narrative shifts from clinical to narrative discourse and how stories from religious and philosophical texts are adapted to the medical framework. Cerulli discusses the ethics of illness that emerge and offers a genealogy of patienthood in Indian cultural history. Using Sanskrit medical sources, the book excavates the role, and ultimately the centrality, of Hindu religious thought and practice to the development of Indian medicine in the classi- cal era up to the eve of British colonialism. In addition to its cultural and historical contributions to South Asian Studies, the medical narratives discussed in the book contribute fresh perspectives on medicine and ethics in general and, in particular, notions of health and illness.

"Somatic Lessons adds considerably to our understanding of Ayurveda ... the extensive narrative sections of the texts that are Cerulli's primary concern have been consistently undervalued in the scholarly record. Cerulli demonstrates the decisive importance ofthese narrative sections in not only providing a cultural and religious backdrop to these texts, but in showing how they actively regulate the entire system and are important in themselves. This book is highly original in concept and delivery, and intelligently addresses an important area of Indian medical and cultural history:'

"Somatic Lessons is one of the most engaging pieces of scholarship that I have read in recent years. It is well written, clear, and illuminating. The work is a most important piece of scholarship in studies of Sanskrit medical literature and its relationship to Sanskrit brahmanical literature and is almost certain to create much discussion in various academic circles:'

About the Author

Anthony Cerulli is Assistant Professor of Religious Studies and Asian Studies at Hobart and William Smith Colleges.

Introduction

Everyone gets sick. Physical and mental fluctuations between wellness and illness are par for the course of being human. Types of illness are too numerous to count, yet the ways that people ail usually happen in three ways: psychologically, somatically, and psychosomatically. This book is about what happens in the course of becoming ill. In the fol- lowing chapters I ask: In which ways are people different before and after the arrival of disease? What are the processes by which people experience the shift from health into illness? In so doing, I also untan- gle the thorny matter of patienthood: What are some of the character- istics that mark people as so-called patients? These are the significant, framing questions of this book. They invite particular answers insofar as this book is about illness and patienthood in India, Indian medical history, and Sanskrit literature. These areas, too, are quite expansive, so in the chapters that follow I concentrate on a specific type of literary account in Indian history and Sanskrit medical literature to explain why people get sick-namely, narrative discourse. In the literature of India's classical medical tradition, A yurveda, the ways in which, and the reasons why, people become sick are sometimes explained through stories. The stories of A yurveda tend to explain more than just the "hows" of bodily disorders (e.g., how does contaminated water cause diarrhea?). They also address the "whys" of illness (e.g., why me and not someone else? Why now and not the day before?). They are thus valuable lenses through which to study perceived moral and social causes of health and illness in certain cultural domains of Indian history, including of course the medical field, but also religious and political institutions. The medical narratives that I present and analzye here are for the most part mythological, with gods, goddesses, and demons as the central characters. Yet as myths are wont to do, the stories of the gods serve as models or guides for humankind. Indeed, in a Sanskrit medical narrative the activities of heavenly, nonhuman characters invariably exemplify poor decisions that create unhealthy social relations, which eventually lead to the creation of sickness and disease in the world of human beings.

Although this book is primarily about the history of Indian medi- cal literature and religion, the ways the authors of classical ayurvedic literature explain and propose to treat illness offer fresh perspectives on notions of wellness and illness to biomedical ethics and the nascent field of narrative medical studies, both which are largely restricted to the doctor-patient exchange, questions of warrant and moral prin- ciples in medical research, and, in the case of narrative medicine, per- sonal testimonies of illness of patients of American health care. The Sanskrit stories I discuss and analyze in this book speak to theoretical questions about the ethics of illness and what it means to be a patient in South Asia specifically, but they also have cross-cultural relevance. My analysis of the narrative portrayal of somatic change from well- ness to illness in Indian medical literature reveals overlooked moral codes and religious knowledge in Indian history by probing heretofore unobserved associations between cultural institutions and actors in the formation of medical discourse. This hermeneutic approach draws on multiple disciplines in the human sciences, including medical anthro- pology, the history of medicine, literary criticism, and the history of religions. Procedurally, the methodology I present here, not to mention the questions about disease pathology and patienthood asked in the Sanskrit narratives themselves, may be useful to scholars working in narrative medical studies and medical ethics in regions of the world apart from South Asia. At bottom, the present study attempts to eluci- date the ways in which people make use of language in the production of literature. This includes authorial awareness of past and contempo- rary knowledge systems and their corpora, which usually manifests in the Indian context through both subtle and overt intertextual referenc- ing. It also includes language figuration and suggestion, in which case narrative discourse is an especially effective means to convey multiple layers of meaning. When the discursive shift from clinical to narrative discourse occurs in the Sanskrit medical sources, and stories from reli- gious and philosophical texts are adapted to the medical framework- a shift that is apparent because of changes in literary style and subject matter-the topography of the human body ceases to be an organic montage of biophysical items and becomes a medium with which to encode symbols that reflect social mores, assumptions, and fears. As readers of this literature, we follow patients-called rogins in Sanskrit, literally "diseased ones"-along paths ot apparent moral indiscrenon, Our understanding of the ethical attitude of the medical compilers, as B. K. Matilal once wrote about the philosophical opponent in Sanskrit literature, "deepens by our understanding of not so much what it says as what it rejects."! In my reading, the Sanskrit medical narra- tive ultimately denounces the patient's choices and actions, his or her life as lived. This reading marks a noteworthy difference between the work I am doing on illness narratives in the Sanskrit medical idiom and the work on stories of illness in biomedicine over the past two decades by scholars like Rita Charon, Arthur Kleinman, Cheryl Mat- tingly, Martha Montello, and others. For these scholars, as Charon and Montello once put it, "the patients are the true ethicists."? In Sanskrit medical narratives, the compilers of the texts are the ethicists: they aim to generate social (in)action, while the so-called patients are lit- erary contrivances, promoters of straw-man arguments about social, religious, and political behavior. The dramatic changes in the life of the patient in the illness narratives express an ideological conversion that any human being may experience. I argue that the compilers of the Sanskrit medical literature portray the patient in the tradition's narratives as someone who must be transformed from one among the infirm, whose behavior and intentions are flawed, to a healthy person, whose behavior and intentions exhibit social and religious integrity. Ayurveda's medical narratives have a normative thrust, in other words, that attempts to be not only therapeutically effectual but also socially and religiously determinative.

Narrative discourse is a distinctive mode of argumentation in Ayurveda. While there are many narratives in the Sanskrit medical compendia, the majority of these tend to be formulaic mythologies, typically brief honorific and invocatory paeans, rather than £Ull- fledged stories with beginnings, middles, and ends. I am concerned with the protracted narratives, which contribute to our understand- ing of how and why sickness and disease affect humans and which humans are likely to become ill. The stories I discuss also provide us with insight into how the compilers of India's classical medical tradi- tion understood health in general (svasthya), the state of being free from disease (arogya), and possible ways for regaining this state after becoming ill. These stories describe a kind of bioexistential arc of the patient, a life trajectory that accommodates bodily ailment and dis- ease. Disease and bodily dysfunction in these stories are not presented as merely somatic facts to accept and treat. They are portrayed as products of poor decisions, foolhardy actions, and blatant violations of knowledge, knowledge usually pertaining to the Hindu concept of dharma (which fundamentally means "duty," although many scholars have translated the term as law, justice, religion, and righteousness).

What is special about the narrativization of a patient's body in the literature of Ayurveda? And what makes this literary process of linking a human life with disease important? For the most part, the literature of Ayurveda presupposes, rather than explicitly describes, changes from wellness to illness. In the ayurvedic sources available to us today, it is clear that the compilers of the tradition sought to present the nature of health and disease in a concise and matter- of-fact manner. The language of this literature demonstrates a kind of detached, pragmatic rationality useful to clinical reasoning. Even today in ayurvedic clinics, hospitals, and colleges in India this type of discourse serves as the basis for establishing the causes, courses, and treatments of disease and the writing of medical reports. Of course, it is a mode of discourse that is unique neither to Ayurveda nor to India, for it is also common throughout the world wherever medicine is practiced. In a pioneering publication in 1998, "In Search of the Good: Narrative Reasoning in Clinical Practice," Cheryl Mat- tingly labeled this kind of discourse in occupational therapy "chart talk." She described chart talk in contrast to storytelling, which she also identified as a prominent, if informal, vehicle of clinical rea- soning. I contend throughout this book that the standard mode of ayurvedic discourse in the Sanskrit literature resembles what Mat- tingly had in mind when she coined the phrase "chart talk." For Mattingly, chart talk entails a strict impersonal rationality, or at least the presumption of a removed and objective diagnostic point of view that emphasizes pathology, symptomatology, therapy, pharmacology, and the like." Most of ayurvedic discourse involves explicative and diagnostic reasoning rooted in observation, which seeks first to dis- cover and subsequently to explain the underlying causes of disease. Akin to Mattingly's observation of chart talk in contemporary bio- medical discourse, the body in Ayurveda is generally treated as a purely anatomical mechanism, isolable from the person to whom it belongs. The body in other words is separate from we might call the intangible character and qualities that constitute and contribute to the lived experiences of that body. The life the body leads, the very embodiment of the ayurvedic patient, and the ways in which a person actually becomes sick often are not described in the Sanskrit medical sources. But explanations of how people become ill-the processes that lead people from states of presumed wellness into states of pati- enthood-occasionally do crop up in the classical medical literature of India. When the medical authors speak of the transformation from wellness to illness as a lived experience, a discursive shift occurs in the texts when, following Mattingly, the clinical logic of chart talk gives way to the narrative logic of storytelling.

As I treat them here, both types of discourse, chart talk and narrative discourse, are found in the Sanskrit medical compendia, which themselves belong to the genre of textbook or perhaps manual. On the whole, the Sanskrit sources of A yurveda as we have them today are, in the customary meaning of textbook, discursive volumes that conform to a standard or type widely held by theorists. But I also regard the Sanskrit sources, such as the compendia of Caraka, Susruta, and Vagbhata, not as static descriptions or even hard-and- fast instructional manuals for botanical preparations, illness diagnosis, and therapy. Rather, they are generative, meaning-making sources of knowledge. They are meant for training physicians, of course, and accordingly they are knowledge to be taught, consumed and, impor- tantly, re-presented again and again. The ayurvedic "textbooks" we have today, in other words, were composed to shape chart talk in the doctor-patient encounter. The medical narratives in the present study are decidedly different in structure, language, and history; they too are meant to affect the doctor-patient encounter, but in so doing, unlike chart talk, these discourses make room for the integration of other cultural domains in the medical context, such as religion, poli- tics, ethics, and the like. Both forms of medical discourse taken up in this book-chart talk and narrative-are equally vital parts of classical Ayurveda.

A short narrative about the origin of garlic ilasuna) in the Ktisyapasarrzhita, a medical "compendium," samhiia, attributed to the celebrated medical preceptor Kasyapa, is illustrative of the difference between the two types of medical discourse I discuss here. In a chap- ter devoted entirely to the healing properties of garlic, following a perfunctory benediction to Prajapati, Lord of Creatures, we find an origination myth for garlic, which I have summarized here:

The god Indra gave his wife, Indrani, some divine nectar to drink because she had been unable to conceive a child for one hundred years. Upon drinking the nectar, the delicate Indrani promptly belched, and some of the nectar fell out of her mouth and onto the unclean ground. Thereupon Indra declared that Indrani would have many sons. The nectar that fell to the earth became a rejuvenating substance (rasayana) for humankind. Yet because of its inauspicious discharge in the form of a burp, and eventual setting on the ground, the nectar will have a foul smell and twice-borns shall not go near it. On earth its name will be garlic.'

Contents