नवमोऽध्यायः अथातः खुड्डाकचतुष्पादमध्यायं व्याख्यास्यामः ॥ १ ॥ इति ह स्माह भगवानात्रेयः ॥ २ ॥
We shall now expound on “Brief Chapter on Quadruple of Therapeutics.” Thus, said Lord Atreya. [ 1-2 ]
In the preceding quadrate, regimens for persons possessing normal health have been described. In the present quadrate all the aspects of therapeutics meant both for the healthy persons as well as for those afflicted with diseases are being described. Among these, the four aspects dealing with the physician, drug, etc. occupy an important position which has been discussed in the present chapter. The description in this chapter is in brief as compared to the succeeding one. Hence “it is qualified as khuddaka.” The four aspects described in this chapter are as follows.
(i) Physician (ii) Medicament (iii) Attendant (iv) Patient. (The normal suffix cha indicating the context of the chapter is elided-vide Astadhyayi 5: 2:60)
Quadruple of therapeutics: Chikitsa Chatushpada
भिषद्रव्याण्युपस्थाता रोगी पादचतुष्टयम् । गुणवत् कारणं ज्ञेयं विकारव्युपशान्तये ॥ ३ –
The four aspects of therapeutics are the physician, the medicament, the attendant and the patient. They are responsible for the cure of diseases, provided they have the requisite qualities. 
Among these factors, the physician occupies the most important place, so he has been enumerated first; then comes, in order of merit, the medicament. Third in the order is the attendant but for whom, the preparation and administration of medicines like kalka (paste), decoction, etc. cannot be properly done. Apparently, a patient, being the object of treatment should have been enumerated first. But as a matter of fact these four factors are enumerated here from the point of view of actions leading to the cure of diseases and in that the patient does not play such an important role. So the patient comes last in the order of importance in the present context.
Qualities of these four factors will subsequently be enumerated (Sutra 9:6-9). These factors can succeed in the cure of diseases only when they are actively engaged in the fulfilment of the object. For example, when we say that Devadatta is a cook, we mean that he cooks food by throwing away the chaff and the husk, etc. Simply, the presence of the physician, etc. cannot serve the purpose, even though they might constitute factors for the cure of diseases. Diseases can be cured even without the help of physicians-cf. Sutra 10. 5.
Definition of health and disease :
विकारो धातुवैषम्यं, साम्यं प्रकृतिरुच्यते । सुखसंज्ञकमारोग्यं, विकारो दुःखमेव च ॥ ४ ॥
Any disturbance in the equilibrium of dhatus is known as disease and on the other hand the state of their equilibrium is health. Health and disease are also defined as pleasure and pain respectively. 
In philosophical systems like Samkhya, disturbance of the equilibrium in nature gives rise to sixteen-fold vikaras (eleven indriyas and five tanmatras, i.e. subtle elements). The primordial cause of creation, that is prakrti is nothing but a state of equilibrium of the three gunas, viz.; sattva, rajas and tamas. In the medical science, however, vikara and prakrti are to be taken in a different perspective. Here, dhatus take the place of gunas. Dhatus consist of vata, pitta and kapha; rasa, rakta, mamsa, medas, asthi, majja and sukra; and upadhatus like rajas, etc. Any deficiency or excess in the normal quantity of the dhatus causes vikara or disease. Equilibrium of these dhatus, on the other hand, is prakrti, that is health.
Absolute equilibrium of the dhatus, in fact, is not possible. For example, kapha invariably gets vitiated in the first part of the day and night, immediately after taking food and during childhood. In the similar other circumstances, pitta and vata also invariably remain vitiated. To this extent, an absolute equilibrium of the dhatus is never possible. So arogya, that is health, can be defined as happiness. Happiness again is a relative term to be construed depending upon the conditions varying from individual to individual. For, no worldly happiness can ever be called happiness in absolute terms. As the author will himself say, “All the worldly conditions are tinged with an element of misery”-cf. Sarira 1: 152 So, a slight disturbance in the equilibrium of dhatus as in the cases indicated adove, does not cause any distinct uneasiness in the body and as such it can be called a state of happiness or so. equilibrium of dhatus even includes such conditions where there In other words, is only a slight deviation from normalcy. To sum up: health is a state of happiness or pleasure; vikura or disease, on the other hand, is the cause of misery or pain. Misery itself is not the disease. If it were so, jvara (fever), etc. which are only the causative factors of misery would not be regarded as diseases-cf, Susruta : Sutra 24 : 4.
It may be noted in this connection that while absolute happiness is not possible, absolute misery is a possibility. This has been indicated by the use of the word “samjnaka” in relation to sukha and the emphatic “eva” in relation to duhkha in the text above.
In fact, it is not the disturbance of the equilibrium of dhatus but the outcome thereof which constitute vikara, that is disease. As the author will himself say, “There are multiple groups of vikaras in the body arising out of the disturbance in the equilibrium of one’s own dhatus (Sutra 19: 6.) -cf. Vimana I: 5 and Susruta : Sutra 1:240. Now the problem arises, if the vikara comes out of the disturbance of the equilibrium of the dhatus, what happens to the disturbance of the equilibrium of dhatus itself after it has brought about the vikara? Can it be regarded as a condition of positive health? No. Because positive health implies the possible maintenance of the equilibrium of the dhatus (Sutra 1. 53 )-Can it then be regarded as a disease ? No. Because it is regarded as a causative factor of a disease rather than a disease itself. If on the other hand, it is just a disturbance of the equilibrlum of dhatus and not a vikara (disease), such a condition is not possible, because the moment there is any increase or decrease in dhatus, it is bound to produce a disease with symptomsexcessive or deficient, as the case may be. Then why can’t we accept the disturbance of the equilibrium of dhatus itself as a vikara or disease ? The one advantage of this interpretation would be that the primary meaning of the word “dhatuvaisamya” will remain intact. In that case, such of the texts as described disease, resulting out of the disturbance of the equilibrium of dhatus would be taken as intended for fever, etc., which have manifested themselves fully. And so, the disturbance of the equilibrium of dhatus as well as the effect thereof ( fever, etc. )-both are included under vikaras. Moreover, when there is any deficiency in the dosas, no vikara ( disease) whatsoever is produced; it is only a disturbance of the equilibrium where that particular dosa is deficient-cf. Sutra 17 : 62. So, if it is said that any disturbance in the equilibrium dhatus brings about vikaras ( diseases), even deficiency in dosas would lead to diseases. But it is not so. Those who are determined to accept the effects of the disturbance of equilibrium of dosas as vikara, for them, unless a distinct vikara is produced, an ordinary disturbance of the equilibrium of dhatus as it happens during the course of day, night, etc. is regarded as a normal condition, that is a stage of equilibrium of dhatus.
There are certain diseases (for example black-mole, etc.) which, even though are effects of the disturbance of the equilibrium of dhatus do not appear to be uncomfortable or painful. Even so, they are regarded as diseases because when known, they are painful, if not physically, mentally.
Definition of therapeutics :
चतुर्णां भिषगादीनां शस्तानां धातुवैकृते । प्रवृत्तिर्धातुसाम्यार्था चिकित्सेत्यभिधीयते ॥ ५ ॥
All the efforts of the four Physician, medicament, attendant and patient, possessing requisite qualities, for the revival of the equilibrium of dhatus in the event of their equilibrium being disturbed, is known as therapeutics. 
Effort of a physician includes his judgement about his duties and otherwise; that of the medicament includes therapeutic action when administered; an attendant’s action includes preparation of medicaments and nursing; the effort of the patient lies in following the instructions of the physician and in giving the correct history of his disease.
Qualities of Physician:
श्रुते पर्यवदातत्वं बहुशो दृष्टकर्मता । दाक्ष्यं शौचमिति ज्ञेयं वैद्ये गुणचतुष्टयम् ॥ ६ ॥
Excellence in medical knowledge, an extensive practical experience, dexterity and purity-these are the four qualities. of a physician. 
Excellence in knowledge can be had by attending on preceptors and studying scriptures. Purity in a physician helps the patient by dint of its spiritual force. Reputation as infallible in prescribing medicines is also one of the qualities of a physician which is included in the four qualities mentioned above.
Qualities of Medicaments :
बहुता तत्रयोग्यत्वमनेकविधकल्पना । संपञ्चेति चतुष्कोऽयं द्रव्याणां गुण उच्यते ॥ ७ ॥
Abundance, suitability, multiple form and potency these are the four qualities of medicament. 
There are patients who are averse to the taking of the juice of a drug, some others in paste (kalka) form. Similarly, there are certain diseases where a medicament is required to bo administered in a particular form. For example, decoctions form a special therapy in the treatment of fever. So it is necessary that the medicaments are amenable to preparations according to various pharmaceutical processes. Moreover, medicaments should be potent and free from infections and dampness.
Qualities of Medical Attendant :
उपचारज्ञता दाक्ष्यमनुरागश्च भर्तरि । शौचं चेति चतुष्कोऽयं गुणः परिचरे जने ॥ ८ ॥
Knowledge of nursing, dexterity, affection and purity-these are the four quaiities of an attendant. 
Qualities of Patient :
स्मृतिर्निर्देशकारित्वमभीरुत्वमथापि ज्ञापकत्वं च रोगाणामातुरस्य गुणाः स्मृताः ॥ ९ ॥ च ।
Good memory, obedience, fearlessness and uninhibited expression-these are the four qualities of a patient. 
Even though fearlessness and good memory are regarded as qualities of a patient (for fear, anxiety and such other mental stresses aggravate the disease ), still sometimes terror and loss of memory are prescribed as poiitive treatment for patients, For example, one of the treatments prescribed for a patient suffering from insanity is that he should be got terrified actually by a snake, of course, with its teeth taken out as a measure of safety. Similarly in cases of fever where temperature persists due to the recollection of the time of the onset of fever, there it is necessary to take recourse to certain methods which can weaken his memory.-cf. Chikitsa. 3: 323. But these are exceptions only.
Importance of physician:
कारणं षोडशगुणं सिद्धौ पादचतुष्टयम् । विज्ञाता शासिता योक्ता प्रधानं भिषगत्र तु ।। १० ।।
Though quadruped of therapeutics in all, equipped with sixteen qualities are responsible for success in treatment yet the physician, by the virtue of his knowledge, administrative position and by prescribing capacity, occupies the most important position among them. [ 10 ]
Simile regarding the position of physician:
पतौ हि कारणं पक्कुर्यथा पात्रेन्धनानलाः | विजेतुर्विजये भूमिश्चमूः प्रहरणानि च ॥ ११ ॥
आतुराद्यास्तथा सिद्धौ पादाः कारणसंज्ञिताः । वैद्यस्यातश्चिकित्सायां प्रधानं कारणं भिषक् ॥ १२ ॥
As the vessel, fuel and fire are the helping factors for the cook needs in the process of cooking and for the victory, a conquerer favourable topographical position, army and weapons; similarly in the success of treatment the patient, attendant and medicament are helpers only to the physician. Thus the physician plays the most prominent role in the management. [ 11-12 ]
In the simile of cooking, the patient is likened to the vessel, the attendent to the fuel and the medicament to the fire, and in the victory the patient has been compared with land, the army with the attendant and the weapons with the medicine.
मृद्दण्डचक्र सूत्राद्याः कुम्भका राहते नावहन्ति गुणं वैद्यादृते पादत्रयं यथा । तथा ॥ १३ ॥
Again as the clod of earth, the wheel, the thread, etc. are of no use (in the making of a pitcher) without the help of the potter, so without the physician, other three factors, ( viz., a patient, the attendant and the medicament) do not serve the purpose. [ 13 ]
गन्धर्व पुरवन्नाशं यद्विकाराः सुदारुणाः । यान्ति यच्चेतरे वृद्धिमाशूपायप्रतीक्षिणः ॥ १४ ॥
सति पादत्रये शाशौ भिषजावत्र कारणम् ।
The remaining three factors being similar, the most difficult diseases, required to be treated may soon vanish or it may quickly aggravate like the city of gandharvas, depending upon the quality of the physician. [ 14 ]
Condemnatian of Quackery:
वरमात्मा हुतोऽज्ञेन न चिकित्सा प्रवर्तिता ।। १५ ।।
पाणिचाराद्यथाऽचक्षुरज्ञानाद्भीतभीतवत् । नौर्मारुतवशेवाज्ञो भिषक् चरति कर्मसु ॥ १६ ॥
It is better to die than to be treated by a physician ignorant of the science of medicine. Because, like a blind person moving with the help of his hands or like a boat being driven by the wind, a quack physician applies the course of treatment with apprehension because of his ignorance. [ 15-16]
यदृच्छया समापन्नमुत्तार्य नियतायुषम् । भिषड्यानी निहन्त्याशु शतान्यनियतायुषाम् ॥ १७ ॥
Such a quack physician may cure a few persons by chance, whose span of life is fixed (that is who are likely to get over the ailment automatically) but he is likely to kill in no time, hundreds of patients whose life span is not fixed (that is, who would have survived if treated properly ). [ 17 ]
Definition of Pranabhisara:
तस्माच्छास्त्रेऽर्थविज्ञाने प्रवृत्तौ कर्मदर्शने । भिषक् चतुष्टये युक्तः प्राणाभिसर उच्यते ॥ १८ ॥
A physician duly engaged in the study of the science of medicine, in mastering their actual implications, in the right application of the therapy and having practical experience is known as the Saviour of life ( pranabhisara ). [ 18 ]
Qualities of Royal Physician:
तौलि प्रशमने रोगाणामपुनर्भवे ।
ज्ञानं चतुर्विधं यस्य स राजार्हो भिषकमः ॥ १९ ॥
One who possesses the fourfold knowledge regarding the cause, diagnosis, cure and prevention of diseases is fit to be appointed as a royal physician. [ 19 ]
शस्त्रं शास्त्राणि सलिलं गुणदोषप्रवृत्तये । पात्रापेक्षीण्यतः प्रज्ञां चिकित्सार्थं विशोधयेत् ।। २० ।।
The merits and demerits of a weapon scriptures and water come to light depending upon one who holds them. So, a physician should always purify his intellect for the sake of giving proper treatment. [ 20 ]
विद्या वितर्को विज्ञानं स्मृतिस्तत्परता क्रिया | यस्यैते षड्गुणास्तस्य न साध्यमतिवर्तते ॥ २१ ॥
विद्या मतिः कर्मदृष्टिरभ्यासः सिद्धिराश्रयः । वैद्यशब्दाभिनिष्पत्तावलमेकैकमप्यतः ॥ २२ ॥
यस्य त्वेते गुणाः सर्वे सन्ति विद्यादयः शुभाः । स वैद्यशब्दं सद्भूतमर्हन् प्राणिसुखप्रदः ॥ २३ ॥
The physician, who possesses the six qualities, viz.; knowledge, critical approach, insight into other allied sciences, good memory, promptness and perseverance, he can never miss the target, that is the cure of diseases. Any one of these, viz.; knowledge, intellect, practical experience, continued practice, success in treatment and dependence on an experinced preceptor is enough to justify the use of the word ‘vaidya’ by a physician. The one who combines in him all these good qualities deserves to be called “an excellent physician” who can give comforts to all living beings. [21-23 ]
Repetition of the qualities of the physician in the text has one very useful purpose to serve. It is only the physician who is capable of bringing the other three factors, viz.; the patient, the attendant and the medicament to right usage. Even if, these three factors are deficient in certain qualities, he can, ‘by virtue of his imagination, knowledge and concentration, render them useful. The three factors (even if otherwise useful) may turn out to be completely useless in the absence of a well qualified physician.
Simile regarding the relation of intellect and literature :
शास्त्रं ज्योतिः प्रकाशार्थ दर्शनं बुद्धिरात्मनः । ताभ्यां भिषक् सुयुक्ताभ्यां चिकित्सन्नापराध्यति ॥ २४ ॥
चिकित्सते त्रयः पादा यस्माद्वैद्यव्यपाश्रयः । तस्मात् प्रयत्नमातिष्ठेद्भिषक् स्वगुणसंपदि ॥ २५ ॥
Knowledge of the science of medicine is likened to the light for the purpose of illumination; one’s own mental faculty to the eye (for the purpose of seeing things). A physician endowed with both of them, that is scriptural knowledge and his own intelligence does not commit mistakes during the course of his treatment of a patient.
As the remaining three factors of treatment depend on the quality of the physician, a physician should always try to enrich his own qualities. [24-25]
Knowledge gained from the study of scriptures (vainayaki buddhi) can be fully utilised only when a physician is endowed with good intelligence of his own.
Doctor Patient Relation :
मैत्री कारुण्यमार्तेषु शक्ये प्रीतिरुपेक्षणम् । प्रकृतिस्थेषु भूतेषु वैद्यवृत्तिश्चतुर्विधेति ॥ २६ ॥
Doctor should be sympathetic and kind to all patients, should be concerned with those who are likely to be cured and should feel detached with those who are towards death. These are the four disciplines for physician. 
तत्र लोकौ – भिषग्जितं चतुष्पादं पादः पादश्चतुर्गुणः | भिषक् प्रधानं पादेभ्यो यस्माद्वैद्यस्तु यहुणः ॥ २७ ॥ ज्ञानानि बुद्धिर्ब्राह्मीच भिषजां या चतुर्विधा । सर्वमेतच्चतुष्पादे खुड्डाके संप्रकाशितमिति ॥ २८ ॥
To sum up :
In this brief chapter on Quadruple of Therapeutics, all the four factors of therapeutics-each having four qualities, the importance and qualities of the physician, his knowledge and fourfold spiritual disposition in profession-all these described [ 27-28] are
इत्यग्निवेशकृते तन्त्रे चरकप्रतिसंस्कृते श्लोकस्थाने खुड्डाकचतुष्पादो नाम नवमोऽध्यायः ॥ ९ ॥
Thus ends the ninth brief chapter on the Quadruple of Therapeutics of the Sutra Section of Agnivesa’s work as redacted by Charaka.