Charaka Samhita and Sushruta Samhita

by Nayana Sharma | 2015 | 139,725 words

This page relates ‘Medical Attendant’ of the study on the Charaka Samhita and the Sushruta Samhita, both important and authentic Sanskrit texts belonging to Ayurveda: the ancient Indian science of medicine and nature. The text anaylsis its medical and social aspects, and various topics such as diseases and health-care, the physician, their training and specialisation, interaction with society, educational training, etc.

The Medical Attendant

One of the pillars of successful therapeutics, according to our authorities, is the medical attendant. “Paricara”is the term used for the attendant by Caraka[1] while Suśruta uses the terms paricara[2] as well as paricāraka.[3] According to the Amarakośa, a paricāraka is a servant or a slave,[4] while the term paricara implies a guard or an attendant but in the context of military arrangements.[5] Possibly the two terms were used synonymously for medical attendants and there is not really any distinction between them. It has been pointed out that the words used to describe the “assistant” are more commonly used in the context of service. For example, paricara means “one who follows after” in order to serve.[6]

The attendants, according to Caraka, should have the knowledge of attending upon the sick (upacārajñatā), dexterity (dākṣya), loyalty to the maintainer (anurāgāsca bhartari) and cleanliness (śauca).[7] Good moral conduct (śila), cleanliness (śauca), character/good behaviour (ācāra), devotion (anurāga), dexterity (dākṣya) and respectful behaviour (prādakṣinya) are also desirable traits of the attendant. Besides, they should be conversant with the art of attending upon the sick (upacārakuśalan), trained in all the necessary duties (sarva karmasu paryavadātān) and not averse to any kind of work (sarvakarmasvapratikulān).[8]

The term “upacārajñatā” is taken as “knowing how to attend or wait upon someone”,[9] as Cakrapanidatta comments that knowing how to wait upon someone means how to prepare soups and juices, how to massage, how to soothe a person to sleep and so on.[10] The term upcāra, other than “attendance”, also means “medical treatment”. Consequently it can be presumed that attendants with some knowledge of treatment or nursing may have been preferred here. Nonetheless, the duties of the support staff enumerated by Caraka consist of mainly menial tasks, like cooking soup, porridge, etc., (sūpaodanapācaka), giving baths (snāpaka) and massages (saṃvāhaka), lifting patients (utthāpaka), making them lie down (saṃveśaka), and grinding the necessary herbs for drugs (auṣadhapeṣaka).[11] These duties are mentioned by Caraka in the context of the requirements of a hospital or infirmary.

Attendants are a absolute necessity in surgery for no surgical procedure is possible without their presence. Among the requirements of the pre-operative stage (pūrva-karma) of the surgical treatment as mentioned by Suśruta are the attendants.[12] Besides, the physician is always to be accompanied by able assistants on his visits.[13] A good attendant (paricara) for Sūtrasthāna ruta should be affectionate (snigdha), unreproachful (ajugupsur), strong balavān), conscientious about caring for the sick (yukto vyādhitarakṣane), obedient to the clinician’s directives (vaidyavākyakṛda) and tireless (aśrāntaḥ).[14] While describing the pre-operative arrangements, Suśruta calls attendants who are affectionate, steady and strong[15] which implies that nursing was not a specialised profession.

It will be noticed that both the medical authorities mention obedience or devotion of the attendant to the physician as one of the essential attributes. Hence, it may be surmised that they were employed by the physician as his personal staff. However, certain other attributes like dexterity, cleanliness and knowledge of nursing or how to attend upon the sick cited by Caraka do not find a place in Suśruta’s list, who understandably, prefers attendants to be affectionate, strong and tireless. Words of affection and gentle behaviour help to soothe and pacify a patient about to go under the surgeon’s knife. As part of the pre-operative arrangements for removal urinary stone, the patient makes sacrificial offerings while there is chanting of the auspicious texts by priests for his welfare, and the patient is reassured.[16] Here, probably the attendants restore the patient’s confidence by removing his doubts and fears. Again several procedures require that the patient be held firmly as in venepuncture[17] or in removal of urinary stone;[18] hence, the need for well built persons capable of lifting up patients or holding them steady. A case of extremely severe stomach wound causing the intestines to spill out requires delicate and sturdy handling in the following manner:

“The throat of the patient should be tickled by the fingers, or water should be sprayed (over him), or else the patient should be lifted by his hands and feet by strong persons and shaken so that the intestines may get in.”[19]

Two other attributes of the attendants mentioned by Suśruta are very significant: that they should work uncomplainingly and tirelessly, and expectedly so for they need to attend to every need of the patient at any hour. Caraka clarifies that they should be prepared for any kind of work which would include handling of polluting matter. At the same time the attendant would have to be acceptable to the patient. Handling of polluting matter such as blood, pus, faeces, etc., is not specifically mentioned by either of our two medical authors but appears in the list of the duties enjoined upon those who care for the sick in the Mahāvagga. The Buddha explains to the bhikkhus the five qualities which render one incompetent to wait upon the sick: when he is not capable of prescribing medicines; when he does not know what diet is good and what is not for the patient; when he waits upon the sick out of greed, and not out of love; when he revolts from removing evacuations, saliva or vomit; when he is not capable from time to time of teaching, inciting, arousing, and gladdening the patient with religious discourse.[20] That caring for the sick and handling of polluting matter was not easily acceptable to many is also brought forth by the incident which led the Buddha to expound the attributes of nursing. Once the Buddha and Ānanda came across a certain bhikkhu, lying in his own evacuations as he was suffering from disturbance of his bowels with no none to wait upon him. The Master himself with his disciple cleaned the bhikkhu, lifted and lay him down on his bed.[21] Thereupon the Buddha addressed the other bhikkus on the importance of serving the sick:

“Ye, O Bhikkhus, have no mothers and no fathers who might wait upon you! If ye, O Bhikkhus, wait not one upon the other, who is there indeed who will wait upon you? Whosoever, O Bhikkhus, would wait upon me, he should wait upon the sick.”[22]

In the absence of inclusion of these tasks among the duties of the physician’s attendants in our medical treatises, we may only presume that such menial chores were left to persons of the lower castes. From the Buddha’s words it appears that family members were often involved in nursing the sick. We notice that in during the post-operative phase, a phase as important as the procedure itself for the recovery of the patient, Suśruta states that the patient is placed in a recovery room where he is attended upon by affectionate friends who are good conversationalists, and engage him in friendly conversation to help dissipate his pain, and console him in various ways.[23] We may assume that they provide support to the patient by helping him or her to maintain the regimen prescribed by the surgeon to avoid post-operative complications. The assumption that the patient has to obtain his own attendants is plausible if we turn to Caraka’s description of those physicians known as “harbingers of death”. One of the reasons they assign for their failure to cure the sick is that “…the patient lacked in proper equipment, attendance and self control.”[24] This implies that the obligation of making provision for attendants lay on the patient and the possibility of relatives and friends of been engaged in physically handling the patient cannot be ruled out.

Other than attendants associated with nursing, there is reference to other categories of helpers to provide varied services to patients. A hospital also requires helpers well-versed in vocal and instrumental music, panegyrics, recitation, ancient lore, short stories, itihāsa (the Mahābhārata, etc.), purāṇa (mythology), who can grasp inner desires, who are pleasant and who have knowledge of time and place.[25] Thus, many of the attendants” required qualifications are basically entertainment skills needed for diverting the patient’s attention from any discomfort and for dispelling ennui.[26] Caraka also speaks of the need for keeping animals such as lāva (common quail), kapiñjala (grey partridge), śaśa (rabbit), hariṇa (black buck), eṇa (antelope), kālapucchaka (black tailed deer), mṛgamārikā (red deer), urabhra (wild sheep) in the hospital as well as a good tempered healthy milch-cow with calf. Proper arrangements are to be made for her fodder, dwelling and water.[27] It is only expected that there were staff to look after these animals as well.

Female attendants hardly mentioned in the two treatises except at the time of childbirth when Suśruta calls for the services of four dependable elderly women with pared nails and skilled in the procedure of accouchement.[28]

We no information about their remuneration but we get some idea about those on the state pay roll. Kauṭilya informs us that the salary of physician should be 2000 paṇas[29] and of attendants 60 paṇas.[30] Many temples in south India of the early medieval period had provision for hospitals within their premises. The functioning one such hospital (āturaśālā) attached to the Viṣṇu temple at Tirumukkūḍal in the Chingleput district of present day Tamil Nadu is known from the Tirumukkūḍal inscription of Vīarājendra[31] dated the latter half of the 11th century CE.

The hospital with a capacity for fifteen patients was under the supervision of a Vaidya and was staffed by a surgeon, two nurses, a barber, etc. The duty of a nurse was to attend to the patients and administering medicines while the barber had to serve the hospitalised patients, teachers and students. The two nurses were paid 15 kalams of paddy and ½ kāśu each annually. 30 kalam and 1 kāśu each was given as salary to two persons who collected medicinal herbs, supplied fuel and attended to the preparation of medicines. Lowest in the strata was the barber who received 15 kalam of paddy. This head physician, Savarṇan Kodaṇḍarāman Asvatthāmā Bhaṭṭan of Ālappākkam, received annually 90 kalam of paddy[32] and 8 kāśu in addition to a grant of land. The land donated here was probably for residential purpose as it is mentioned in the inscription that he obtained the land which was to be enjoyed by him and his descendants. Besides the physician, there was also a surgeon (challiyakkṛiyai = śalya-kṛiyai) who received only 30 kalam of paddy, i.e., 1/3rd of the remuneration of the principal physician and neither was he allotted any land.

Footnotes and references:


Caraka Saṃhitā Sūtrasthāna 9.8.


Suśruta Saṃhitā Sūtrasthāna 34.24.


Suśruta Saṃhitā Sūtrasthāna 34.15/2.


H.T.Colebrooke (Ed.), Kosha or Dictionary of the Sanskrit Language by Amara Singh with an English Interpretation and Annotations, Delhi, 1989 (Third revised edition reprint), II.X.17. Hereafter Amarakośa.


Amarakośa, II.VIII.30.


J. Leslie, and D. Wujastyk, “The Doctor’s Assistant: Nursing in Ancient Indian Medical Texts”, in P. Holden and J. Littlewood (eds.), Anthropology and Nursing, London, 1991, pp. 25-30.


Caraka Saṃhitā Sūtrasthāna 9.8.


Caraka Saṃhitā Sūtrasthāna 15.7.


J. Leslie and D. Wujastyk, “The Doctor’s Assistant”, pp. 25-30.


J. Leslie and D. Wujastyk, “The Doctor’s Assistant”, pp.25-30.


Caraka Saṃhitā Sūtrasthāna 15.7.


Suśruta Saṃhitā Sūtrasthāna 5.6.


Suśruta Saṃhitā Sūtrasthāna 10.3.


Suśruta Saṃhitā Sūtrasthāna 34.15/2.


Suśruta Saṃhitā Sūtrasthāna 5.6.


Suśruta Saṃhitā Cikitsāsthāna 7.30


Suśruta Saṃhitā Śārīrasthāna 8.8.


Suśruta Saṃhitā Cikitsāsthāna 7.30.


Suśruta Saṃhitā Cikitsāsthāna 2.58/2-60/1.


Mahāvagga 8.26.7.


Mahāvagga 8.26.1.


Mahāvagga 8.26.3.


Suśruta Saṃhitā Sūtrasthāna 19.8.


Caraka Saṃhitā 29.9.


Caraka Saṃhitā Sūtrasthāna 15.7.


Dagmar Wujastyk, Well-Mannered Medicine: Medical Ethics and Etiquette in Classical Ayurveda, New York, 2012, p.62.


Caraka Saṃhitā Sūtrasthāna 15.7.


Suśruta Saṃhitā Śārīrasthāna 10.8.


Arthaśāstra 5.3.12.


Arthaśāstra 5.3.17.


K.V.S.Ayyar, “The Tirumukkuḍal inscription of Vīrarājendra”, Epigraphia Indica, Vol. XXI, pp. 220-250.


@ 3 kuruṇi of paddy and 8 kāśu per day.

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