अथातो महाचतुष्पादमध्यायं व्याख्यास्यामः ॥ १ ॥ इति ह स्माह भगवानात्रेयः ॥ २ ॥
We shall now expound a detailed chapter on the Quadruple of Therapeutics.
Thus, said Lord Atreya.
The present chapter represents details relating to the four aspects of therapeutics described in the preceding chapter. So both from the point of view of its size and contents, this chapter is more important than the preceding chapter. This justifies the nomenclature of the chapter as “Mahachatuspada.”
चतुष्पादं षोडशकलं भेषजमिति भिषजो भाषन्ते, यदुक्तं पूर्वाध्याये षोडशगुणमिति, तद्भेषजं युक्तियुक्तमलमारोग्यायेति भगवान् पुनर्वसुरात्रेयः ॥ ३ ॥
According to physicians, therapeutics has four aspects withch are having sixteen qualities. The same have been stated in the preceding chapter, therapeutics with these sixteen qualities have the capacity to eliminate diseases. “So said Lord Punarvasu Atreya. 
Query regarding the role of therapeutics in the alleviation of diseases
नैति मैत्रेयः, किं कारणं ? दृश्यन्ते ह्यातुराः केचिदुपकरणवन्तश्च परिचारकसंपन्नाश्चात्मवन्तश्च कुशलैश्च भिषग्भिरनुष्ठिताः समुत्तिष्ठमानाः, तथायुक्ताश्चापरे म्रियमाणाः, तस्माद्भेषजमकिंचित्करं भवति, तद्यथा-श्वभ्रे सरसि च प्रसिक्तमल्पमुदकं, नद्यां वा स्यन्दमानायां पांसुधाने वा पांसुमुष्टिः प्रकीर्ण इति; तथाऽपरे दृश्यन्तेऽनुपकरणाश्चापरिचारकाश्चानात्मवन्तश्चाकुशलैश्च भिषग्भिरनुष्ठिताः समु त्तिष्ठमानाः, तथायुक्ता म्रियमाणाश्चापरे । यतश्च प्रतिकुर्वन् सिध्यति, प्रतिकुर्वन् म्रियते; अप्रतिकुर्वन् सिध्यति, अप्रतिकुर्वन् म्रियते; ततश्चिन्त्यते भेषजमभेषजेनाविशिष्टमिति ॥ ४ ॥
Maitreya contradicts and puts a query, what is the cause that some patients managed by proper medicaments, attendants, and well qualified physicians, who are also having selfcontrol soon recover from the diseases. On the other hand in spite of all these some die. ? So therapeutics is of no value (in the eradication of diseases). This is just like a drop of water thrown into a ditch or pond or a handful of dust thrown in a flowing river or on a heap of dust. On the contrary, even without proper medicaments, attendants, good physicians; patients having no self-control recover from diseases, however others in similar situations also die. To sum up: It may be said that therapeutic measures or no therapeutic measures-the results are same. For one taking recourse to therapeutic measures may sometimes succeed in recovering from diseases and may sometimes die as well. Similar is the case with one who does not pay any heed to therapeutic measures. He at times succeeds in recovery from diseases or may sometimes die even. [ 4 ]
The gist of Maitreya’s objection is that it ts Karman, that is the result of the past action, which is responsible for the maintenance of good health or otherwise Therapeutic measures adopted are useful only when ‘Karman’ is favourable. Favourability of Karman may bring about the desired effect even without the prescribed therapeutic measures. In this connection, examples of throwing a drop of water in a ditch or pond; or throwing of a handful of dust in a flowing river or upon a heap of dust, have been cited which go to show ineffective therapeutic neasures could be in the absence of a favourable Karman’. The example of water is from the stand point of elimination or nourishing therapy and that of the dust from the angle of alleviation or reduction therapy. So, it is ‘Karman’ and not the therapeutic measures which brings about the cure of diseases.
Reply regarding the role of therapeutics in the alleviation of diseases:
मैत्रेय ! मिथ्या चिन्त्यत इत्यात्रेयः; किं कारणं, ये ह्यातुराः षोडशगुणसमुदि तेनानेन भेषजेनोपपद्यमाना म्रियन्त इत्युक्तं तदनुपपन्नं, न हि भेषजसाध्यानां • व्याधीनां भेषजमकारणं भवति; ये पुनरातुराः केवलाद्वेषजादृते समुत्तिष्ठन्ते, न तेषां संपूर्णभेषजोपपादनाय समुत्थानविशेषो नास्ति; यथा हि पतितं पुरुषं समर्थमुत्थानायोत्थापयन् पुरुषो बलमस्योपादध्यात्, स क्षिप्रतरमपरिक्लिष्ट एवोत्तिष्ठेत्, तद्वत् संपूर्णभेषजोपलम्भादातुराः; ये चातुराः केवलाद्भेषजादपि म्रियन्ते, न च सर्व एव ते भेषजोपपन्नाः समुत्तिष्ठेरन्, नहि सर्वे व्याधयो भवन्त्युपायसाध्याः, न चोपायसाध्यानां व्याधीनामनुपायेन सिद्धिरस्ति, न चासाध्यानां व्याधीनां भेषजसमुदायोऽयमस्ति, न ह्यलं ज्ञानवान् भिषङ्मुमूर्षुमातुरमुत्थापयितुंः परीक्ष्यकारिणो हि कुशला भवन्ति, यथा हि योगज्ञोऽभ्यासनित्य इष्वासो धनुरादायेषुम स्यन्नातिविप्रकृष्टे महति काये नापराधवान् भवति, संपादयति चेष्टकार्य, तथा भिषक् स्वगुणसंपन्न उपकरणवान् वीक्ष्य कर्मारभमाणः साध्य रोगमनपराधः संपादयत्येवातुरमारोग्येण; तस्मान्न भेषजमभेषजेनाविशिष्टं भवति ॥ ५ ॥
To this Lord Atreya remarks, Oh Maitreya! the conclusion derived by you is not correct. Because, To say that the patients adopting the therapeutic measures having the sixteen qualities die is not borne out by facts; therapeutic measures can never be ineffective in curable diseases. Similarly even in such cases where patients are cured without proper medicines, etc. it should be understood that, had there been proper administration of therapeutic measures the process of cure would have been quicker and better; this can be likened to the lifting of a healthy person who has fallen; he can no doubt get up himself but if he is helped and lifted by another person, he would get up sooner without much difficulty. Such is the case with patients stated to have been cured without adequate therapeutic measures. Then there remains the case where patients die even by taking recourse to adequate therapeutic measures. It is not that all patients taking recourse to therapeutic measures are necessarily cured because all diseases are not curable. The diseases that are curable can be cured only by taking recourse to therapeutic measures. Those which are not curable will certainly not respond to the treatment; not even the ablest physician is capable of curing a moribund patient. Able physicians always proceed with their treatment after proper examination. As an archer having the knowledge and practice ( of archery) throws arrows with the help of his bow and does not commit mistakes in hitting a massive body nearby and thus accomplishes his object, so a physician endowed with his own qualities and other accessories proceeding with the act ( of treatment) after proper examination will certainly cure a curable patient without fail. So it is not correct to say that there is no difference between the application and non-application of therapeutic measures.  In such cases where the patients are cured without taking recourse measures, certainly ‘Karman’ plays a very import
to adequate therapeutic ant role but even there, if proper therapeutic cares are taken, ‘Karman’ and present action would have combined effect in quickening the process of recovery.
Diseases are of two kinds-curable and incurable. The incurable ones can never be cured howsoever proper therapeutic measures are taken. It is only the curable ones which can be cured by taking recourse to therapeutic measures. If such cares are not taken, patients will not survive for the want of proper invigorative action.
Similarly, ‘Karman’ is of two types-strong and weak. The strong Karman is the one which is bound to produce its results at a fixed time and so such a Karman will not but be fatal during a particular period. The weak ‘Karman’ on the other hand does have its effects without any relation to time and so it can be fatal only when proper regimen with regard to diets and medicaments are wanting and not otherwise cf. Vimana 3:35.
Again it is not correct to say that the present state of life in its entirety is predetermined by ‘Karman’ whose action at a particular time is already fixed. It is true that scriptures have established the infallible nature of ‘Kala’ without which nothing happens but as a matter of fact even the Kala, Karman or fate is nothing but a sort of testimony of what worldly activities in the form of performance of rituals or slayings of brahmanas have already been performed. So it is only when something cannot be explained in terms of present worldly action, taking recourse to ‘Karman’ or the results of past action is justified. So long as we can see fire, an established cause of burning, it will be useless to guess an invisible cause for the burn. So, such of the es which are known to have been caused by irregular habits and regimen, can be cured only by means of the fourfold therapeutic measures which are known as their correctives. Otherwise, such diseases are bound to continue uninterrupted-cf. Vimana 3: 33-34.
As to the incurable diseases a competent physician will never make an attempt to treat them. If he does so, this means he is not proficient in the science of medicine.
Examples regarding the principles of treatment establishing the role of therapeutics
इदं च नः प्रत्यक्षं – यदनातुरेण भेषजेनातुरं चिकित्सामः, क्षाममक्षामेण, कृशं च दुर्बलमाप्याययामः, स्थूलं मेदस्विनमपतर्पयामः, शीतेनोष्णाभिभूतमु पचरामः, शीताभिभूतप्रुष्णेन, धातून् पूरयामः, व्यतिरितान् ह्रासयामः, व्याधीन् मूलविपर्ययेणोपचरन्तः सम्यक् प्रकृतौ स्थापयामः; तेषां नस्तथा कुर्वतामयं भेषज समुदायः कान्ततमो भवति ॥ ६ ॥
And we see with our own eyes that we cure a patient by taking recourse to curative therapeutic measures-the depleted with impletion. We give nourishment to those who are weak and emaciated. We administer reducing therapy to the one who is obese. We treat patients afflicted with heat by cooling measures and the one afflicted with cold by heating measures. We adopt proper measures to replenish the deficient dhatus (tissue elements, dosas and malas) and deplenish those that are in excess. We thus bring back the physiological state by treating the diseases with actiopathological antidotes. Thus the group of therapeutic measures gives us the best result in the management of diseases. 
Aetio-pathological antidotes are supposed to be specific in action. Apparently poisonous drugs may not look to be proper antidotes of poisoning but they may be real because of their specific action.
Importance of Prognostic considerations in the management
साध्यासाध्यविभागज्ञो ज्ञानपूर्व चिकित्सकः । काले चारभते कर्म यत्तत् साधयति ध्रुवम् ॥ ७॥ अर्थविद्यायशोहानिमुपक्रोशमसंग्रहम् प्राप्नुयान्नियतं वैद्यो योऽसाध्यं समुपाचरेत् ॥ ८ ॥
A physician who can distinguish between curable and incurable diseases and initiates treatment in time with the full knowledge (about the various aspects of therapeutics) can certainly accomplish his object (of curing the disease). On the otherhand, a physician who undertakes the treatment of an incurable disease would undoubtedly subject himself to the loss of wealth, knowledge and fame and will also earn bad reputation and other royal sanctions or punishments. [7-8 ]
Classification of diseases according to prognosis
सुखसाध्यं मतं साध्यं कृच्छ्रसाध्यमथापि च । द्विविधं चाप्यसाध्यं स्याद्याप्यं यच्चानुपक्रमम् ॥ ९ ॥
साध्यानां त्रिविधचाल्पमध्यमोत्कृष्टतां प्रति । विकल्पो, न त्वसाध्यानां नियतानां विकल्पना ॥ १० ॥
Curable diseases are of two types-one that can be cured easily and the other with some difficulty. Similarly incurable diseases are of two types, viz., one which is palliable and the other which is absolutely irreversible.
Again the curable diseases have three alternants depending on the moderate and excellent devices required to cure them. This alternation is, however, not possible with regard to diseases which are absolutely incurable. [ 9-10]
Even the diseases that are curable require different types of treatment. Some of them can be cured by simple methods, some by moderate ones and the others by the best possible devices. This depends upon the degree of seriousness of the diseases concerned. So apart from the classification of curable diseases as easily curable and curable with some difficulty, another classification has been given from the stand point of treatment as such, viz., diseases that can be cured with only simple devices, those which can be treated with moderate devices and the others which can be cured only by taking recourse to the best possible therapeutic measures. This threefold classification is, however, not possible with regard to the diseases which are absolutely incurable.
Such diseases may, however, be classified according to their effects such as death, deformity, instantaneous death, death after a given period, etc. whatever the means adopted-mild, moderate or excellent, the net result is always incurability in all such cases.
The incurable diseases of palliable variety may of course have the above mentioned threefold classification depending upon their palliation by mild, moderate or excellent means.
Factors influencing the good prognosis
हेतवः पूर्वरूपाणि रूपाण्यल्पानि यस्य च । न च तुल्यगुणो दूष्यो न दोषः प्रकृतिर्भवेत् ।। ११ ।। न च कालगुणस्तुल्यो न देशो दुरुपक्रमः । गतिरेका नवत्वं च रोगस्योपद्रवो न च ॥ १२ ॥ दोषश्चैकः समुत्पत्तौ देहः सर्वोषधक्षमः । चतुष्पादोपपत्तिश्च सुखसाध्यस्य लक्षणम् ॥ १३ ॥
The following are the factors that determine the nature of the diseases which are easily curable:
(1) Causes, premonitory symptoms, and other signs and symptoms are mild;
(2) the qualities of the dhatus involved are not in common with those of the dosas,
(3) the dosas constituting the prakrti (physical and mental constitution) of the patient are also not similar;
(4) the season is not conducive to the growth of the disease;
(5) the geographical and bodily positions are not conducive to the growth of the disease;
(6) Location of the disease is confined to only one system;
(7) the start is recent;
(8) there are no complications;
(9) only one dosa is involved in the pathogenesis of the disease;
(10) the body is amenable to all kinds of medicaments and;
(11) the fourfold therapeutic measures are available. [11-13]
Desa, in the above passage includes both the geographical and bodily location of the disease concerned. For example, if a patient suffering from vataroga is staying in the desert which also predominates in vata, or the one suffering from kapha resides in marshy land predominant with kapha, it will be difficult to cure such patients. Similarly if the vitiation of vata occurs in the colon, which is the site of vata or if disease occurs in vital organs, the treatment will be difficult. any Disease can be located in one or any of the three courses, viz., the sakha, marmasthisandhi, and kostha-cf Sutra 11:48. If the location of the disease is confined only to one of these three courses, it is easier to cure it.
In addition to what has been described in the text above, there are some other factors which indicate the easy curability of the disease. As it has been said, “when jvara (fever) and prameha (obstinate urinary disorders including diabetes) are in qualitative agreement with the seasonal dosas and dhatus (tissue elements) respectively and when the rakta gulma (uterine tumour) becomes chronic, they are said to be easily curable.”
Factors responsible for bad prognosis
निमित्त पूर्वरूपाणां रूपाणां मध्यमे बले । कालप्रकृतिदूष्याणां सामान्येऽन्यतमस्य च ॥ १४ ॥ गर्भिणी वृद्धबालानां नात्युपद्रवपीडितम् । शस्त्रक्षाराग्निकृत्यानामनवं कृच्छ्रदेशजम् ॥ १५ ॥ नातिपूर्णचतुष्पदम् । द्विपथं नातिकालं वा कृच्छ्रसाध्यं द्विदोषजम् ॥ १६ ॥
The following are the factors that determine the nature of the diseases which are difficult to be cured:
1. Causes, premonitory symptoms and other signs and symptoms are of a little serious nature;
2. the qualities of any one of the Kala (season), prakrti (physical including mental constitution) and dhatus (tissue elements) are favourable to the disease ( dosas); the person suffering from the disease be a pregnant woman, old or child; there are also moderate types, of complications; the diseases in whose treatment, surgery, application of alkalies and, cauterization are involved; the diseases that are not new;
7. the diseases occuring in vital parts and joints;
8. diseases involving only one system; but not fully supported by the four-fold therapeutic measures;
9. diseases extending to two systems but not very chronic; and
10. diseases that are caused by the vitiation of two dosas. [14-16]
Factors determining the palliability of diseases:
शेषत्वादायुषो याप्यमसाध्यं पथ्यसेवया । लब्धाल्पसुखमल्पेन हेतुनाऽऽशुप्रवर्तकम् ॥ १७ ॥
गम्भीरं बहुधातुस्थं मर्मसन्धिसमाश्रितम् । नित्यानुशायिनं रोगं दीर्घकालमवस्थितम् ॥ १८ ॥ विद्याद्विदोषजं,
The palliable group of diseases are characterized as follows:
1. As pre-ordained, the patient has survived for a certain period by following the wholesome regimen and as such has enjoyed a little relief; but even a slightest carelessness might instantaneously aggravate the condition; 2. the disease has affected deep seated dhatus;
3. the disease involves a number of dhatus;
4. it affects the vital organs and joints;
5. it affects the patient continuously for a long time; and
6. the disease is caused by the vitiation of the two dosas. [ 17-18 ]
Factors determining the incurability of diseases
तद्वत् प्रत्याख्येयं त्रिदोषजम् । क्रियापथमतिक्रान्तं सर्वमार्गानुसारिणम् ॥ १९ ॥ औत्सुक्यारतिसंमोहकरमिन्द्रियनाशनम् । दुर्बलस्य सुसंवृद्धं व्याधिं सारिष्टमेव च ॥ २० ॥ Likewise, the following factors would determine the absolute
incurability of the disease:
1. Diseases caused by the 2. diseases that transcend all therapeutic devices; 3. diseases which involve all the ( three ) systems; 4. diseases causing excitement restlessness and unconsciousness; 5. diseases which affect the sense organs; 6. the affected patient is usually weak but the disease is sufficiently advanced; and 7. the diseases having bad prognostic signs [ 19-20]
vitiation of all the three dosas;
Importance of thorough examination :
भिषजा प्राक् परीक्ष्यैवं विकाराणां स्वलक्षणम् । पश्चात्कर्मसमारम्भः कार्यः साध्येषु धीमता ॥ २१ ॥ साध्या साध्यविभागज्ञो यः सम्यक्प्रतिपत्तिमान् । न स मैत्रेयतुल्यानां मिथ्याबुद्धिं प्रकल्पयेत् ।। २२ ।।
A wise physician should examine the distinctive features of the diseases beforehand and then he should start his treatment ( only ) of the curable diseases. So a physician who can distinguish between curable and incurable diseases, he, with his right applications will not subscribe to the wrong notions prevailing among the pseudo-physicians like Maitreya, to say, he will certainly succeed in curing diseases. [ 21-22]
तत्र इहौषधं पादगुणाः प्रभवो भेषजाश्रयः । आत्रेय मैत्रेयी मतिद्वैविध्यनिश्चयः ॥ २३ ॥ चतुर्विधविकल्पाश्च व्याधयः स्वस्वलक्षणाः । उक्ता महाचतुष्पादे येष्वायत्तं भिषग्जितम् ॥ २४ ॥
Therapies, qualities of each of the four aspects of therapeutics, their effects, views (in this connection) of Atreya and Maitreya, two different views, the conclusion, four alternants of diseases, characteristics of each-all these are described in this “Detailed chapter on Therapeutics”. Treatment of diseases depends upon these considerations. [ 23-24 ]
इत्यग्निवेशकृते तन्त्रे चरकप्रतिसंस्कृते श्लोकस्थाने महाचतुष्पादो नाम दशमोऽध्यायः ॥ १० ॥
Thus ends the tenth “Detailed Chapter on Quadruple of Therapeutics” of Sutra section of Agnivesa’s work as redacted by Charaka.