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Historical Perspective

Susruta of India, an unrecognized contributor to the historyof exercise physiology

Charles M. TiptonDepartment of Physiology, University of Arizona, Tucson, Arizona

Tipton CM. Susruta of India, an unrecognized contributor to thehistory of exercise physiology. J Appl Physiol 104: 1553–1556, 2008.First published March 20, 2008; doi:10.1152/japplphysiol.00925.2007.—When considering the history of exercise physiology, authors begin withHippocrates and the “Golden Age” of Greece before mentioning Galenand the contributions from Rome. However, this approach has omittedthe information from the ancient civilizations of India which flourishedbefore and during the emergence of Mycenaen cultures. Specificallyignored have been 1) the tridosa doctrine (humoral theory), which asearly as 1500 B.C., emphasized that disease occurred because of adisplacement of one or more of the three humors, with health beingachieved when the humors were in equilibrium and 2) the perspective ofSusruta (Sushruta) who was a 600 B.C. physician who included exercisein his prescriptions to prevent and treat diseases. Susruta not onlyadvocated exercise to maintain equilibrium among the humors, notablykapha, he promoted exercise to minimize the consequences of obesityand diabetes. To be effective, exercise had to be daily and moderate inintensity and never excessive or to exceed the half-maximum limit forexhaustion, because disease or even death could ensue. It is concludedthat Susruta’s concepts pertaining to chronic exercise and to the healthbenefits of exercise were “remarkably modern” and that future authors onthe history of exercise physiology should include contributions fromancient India.

ancient history; health; humors, antiquity

LIKE PHYSIOLOGY (40), the history of exercise physiology beginswith contributions from ancient Greece and Rome (2, 29, 45).Unfortunately, this approach ignores the information fromancient India and the tenets of Susruta (Sushruta, an Indianphysician) concerning exercise physiology and exercise influ-ences on human health and disease. The purpose of thisHistorical Perspective is to acquaint the exercise physiologycommunity with India’s and Susruta’s contributions whileindicating similarities to present day concepts.

BACKGROUND INFORMATION ON ANCIENT INDIA AND THEEXISTENCE OF SUSRUTA

Archeological excavations during the 1920s in the IndusValley pertaining to Mohenjo-Daro (in Sind of now westPakistan) and Harappa (in Punjab of India) revealed the exis-tence of an ancient Indus civilization that noted historians andarcheologists (15, 25, 32, 43) believe existed millenniumsearlier than a carbon dated value of 3300 B.C. (41). Thesefindings support the view that these cities existed during thepre-Susruta era (32) (4000 –900 B.C.) while being contem-porary with civilizations in Egypt, Mesopotamia, and China(1). Excavation results and evaluations of skeletal remainsindicated Hindus living in these regions were focused onmatters of personal hygiene, public health, and sanitation

and had experienced arteriosclerosis, osteomyelitis, cancer,metal poisoning, and infectious diseases (10). The excava-tions also included statues with positions that suggested theinhabitants were familiar with the practice of yoga. With theAryan invasion of �2000 B.C. (42), the Indus Civilizationended but the interest in health and the concern for diseaseremained.

The oldest literature in the world is found in the 1,028sacred hymns of the Rgveda (Rig-Veda) (50 –56). Written inSanskrit, it includes a history of the Aryans, a view ofprehistoric times, requests for benevolence and blessingsfrom various mythological gods and goddesses, and divineremedies for disease and disorders. Within select hymns wasthe belief that disease occurred because of evil spirits thatoriginated from either a god or goddesses or from a living ordeceased enemy (53). When health was mentioned, it wasnot related to disease or recovery from disease, rather it wasa condition that reflected the pleasure or displeasure of thegods (56). It is known that a hymn in the Rgveda makesreference to the existence of the three humors (50, p. 95)that influence health. The dates cited for the Rgveda rangefrom 4000 B.C to 2500 B.C. to 1500 B.C., with the latterdate being most frequently mentioned by historians (21).When the era of the Vedas or the Vedic Period is discussed,a range of dates is also listed with 3000 B.C. to 1000 B.C.being frequently recorded (19).

Of the sacred texts of India, the Atharvaveda (Atharva-Veda) contains the most detailed information dealing withmedicine, health, and disease (15, 16, 48, 49). It includes 20books by multiple authors with 731 hymns and considered bythe Sanskrit scholar Macdonell (26, p. 185) to be a “a heter-ogenous collection of spells” directed against diseases, de-mons, foes, wizards, noxious animals, and oppressors ofBrahmns. Although all authorities agree it appeared after theRgveda, uncertainty reigns as to the date of origination with1000 B.C. being selected by the majority of authors. As in theRgveda, diseases were associated with supernatural forces andas a punishment for evil deeds or for sins against the gods byindividuals, their parents, or by their enemies.

During the late Vedic period (circa 1500–800 B.C.) thetridosa doctrine (also known as the trihautu doctrine andconsidered to be the Indian humoral theory) was formulatedand developed (3, 23). This doctrine was introduced to helpexplain the meaning of life, death, health, and disease whiledescribing how the elements of water, fire, air, earth, and ethercontributed to the formation of the human body. Interactingwithin the body were nutrient particles that were derived fromthe wind, sun, and moon that became transformed into air, bile,and phlegm and were regarded by Susruta as dosas (humors)

Address for reprint requests and other correspondence: C. M. Tipton, Dept.of Physiology, Ina Gittings Bldg., Univ. of Arizona, Tucson, AZ 85704(e-mail: tipton@email.arizona.edu).

The costs of publication of this article were defrayed in part by the paymentof page charges. The article must therefore be hereby marked “advertisement”in accordance with 18 U.S.C. Section 1734 solely to indicate this fact.

J Appl Physiol 104: 1553–1556, 2008.First published March 20, 2008; doi:10.1152/japplphysiol.00925.2007.

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and identified as vayu, pitta (pittam), and kapha (kaphah),respectably (12, 23, 38). However, Susruta considered blood tobe a fourth humor that was capable of influencing interactionsbetween the other humors (38).

According to the tridosa doctrine or the Indian humoraltheory, vayu, pitta, and kapha humors controlled and regulatedall functions of the body (38). When they were in equilibrium,health was present, but if one or more humors were displacedor deranged, health was impaired and illness and death couldoccur (23, 38). In addition to disease, conditions that couldalter the equilibria between the humors were climatic changes,select foods, fatigue, psychic changes, poisons, sedentary liv-ing, and exercise (6, 38).

Susruta’s existence is shrouded in mythology and contro-versy. One version has Dhanwantari, the physician to the godsand reputed Vedic father of medicine, coming to earth tominister to the misery and disease of mankind while extollingthem in the science of life (21). He subsequently migrates toBenares (Varanasi) and meets Susruta as the son of SaintVishvamitra, a disciple of Dhanwantari, and instructs him onthe science of life and the surgery of medicine. Later, Susrutawritings were compiled into a Samhita. Another version hasSusruta being trained by Divodasa, a physician king of Vara-nasai (1, 4). However, this version creates more confusionbecause select authorities consider Divodasa and Dhanwantarito be the same entity.

Regardless, Susruta was a physician who taught surgery andmedicine at the university in Benares (19). With ancient India,there is certainty in the existence of their sacred texts and of thesamhitas associated with Atreya, the world’s oldest record ofmedical practice (15, 43). However, uncertainty prevails con-cerning their dates and whether the samhita attributed toSusruta was from a historical figure or from different physi-cians using a prominent name to give credence to their views(12, 22). When dates are listed for him, they include 1000 B.C.(21, 32), 800–600 B.C. (37), 600 B.C. (27), 600–200 B.C. (1),200 B.C. (15), 1–100 A.D. (33), and 500 A.D. (14). Partialresolution of these uncertainties has been achieved by findingsthat 1) several Vedic hymns were dedicated to him (21), 2) hisdescription of the human skeleton was very similar to the onedescribed in the Atreya samhita (21), 3) his comments on theskeleton were nearly identical to the words included in thecreation of man within Hymn X of the Atharvaveda (17, p.1–4), and 4) a critical analysis of the ancient Bower Manu-script by Hoernle demonstrated Susruta was a historical figureduring 600 B.C. (20). After commenting on what he consideredto be “absurd and amusing theories” that denied the existenceof Susruta, Professor N. H. Keswani of Anatomy at the All-India Institute of Medical Sciences in New Delhi wrote (4, p.7), “Considering all the evidence available today, one comes tothe conclusion that ’the lowest limit of Sushruta’s death is fixedas the sixth and seventh Century B.C., this being the date of theSatapatha Brahmana, while nothing can be said about the upperlimit.” Therefore, 600 B.C. has been selected for the era ofSusruta.

SUSRUTA AND HIS CONCEPTS PERTAININGTO EXERCISE PHYSIOLOGY

He defined exercise as a “sense of weariness from bodilylabour and it should be taken every day” (5, p. 485). When he

described exercise he was referring to movements associatedwith walking, running, jumping, swimming, diving, or ridingand participating in sports such as archery, wrestling, andjavelin throws (5). When prescribed (he was the first phy-sician to prescribe exercise), exercise should be moderate innature or to an intensity that will cause labored breathing.However, before exercise was to be prescribed, the age,strength, physique, and diet of the individual was to beconsidered as well as the season of the year and the terrainof the area (5).

Susruta advocated moderate exercise for ancient Indiansbecause it improved the growth of limbs; enhanced musclestoutness (mass), strength, endurance, tautness (tone), anddevelopment; reduced corpulence; increased digestion; in-creased the resistance against fatigue; elevated temperaturesand thirst while improving appearances and complexions.Moderate exercise was also advocated because it “gives thedesirable mental qualities of alertness, retentive memory, andkeen intelligence” (5, p. 40).

SUSRUTA AND HIS CONCEPTS PERTAINING TO EXERCISE,HEALTH, AND DISEASE

Susruta believed medical practice should direct as mucheffort to the prevention of disease as it devoted to curativeremedial procedure and included physical exercise within hisrecommended hygienic practices. He felt regular moderateexercise provided resistance to disease(s) and “against physicaldecay” and stated “Diseases fly from the presence of a person,habituated to regular physical exercise . . .” (5, p. 486). Hestrongly opposed excessive exercises, which was interpreted tomean continued heavy or maximal exercise (46), because itwould cause diseases and disorders such as consumption, thirstphthisis, asthma, cachexia, hemorrhaging, vomiting, coughing,and fever (5). It is of interest that the concept of excessiveexercise being responsible for a disease state has similarities toa current concept that repeated bouts of strenuous exercise willsuppress the immune system leading to transient disorders ofthe upper respiratory tract (34). Moreover, professional soci-eties who advocate exercise for health reasons should incor-porate this cautionary concern in their 21st century pronounce-ments.

Susruta was a strong advocate for the tridosa doctrine andfor the concepts that 1) disease occurred when the humors werenot in equilibrium and 2) health was present when the dis-placed humors had returned to resting levels. He was con-vinced a sedentary lifestyle that included physical inactivity,sleeping through the day, and consuming excessive food andfluids would sufficiently elevate the kapha humor to a level thatcould disrupt humoral equilibrium resulting in a disease stateand potential death. Consequently, he included exercise in hisrecommendations to prevent the occurrence of kapha diseases(5, 22, 38).

Frequently discussed by historians is whether the tridosadoctrine of India influenced the humoral theory of Greeceattributed to Hippocrates (460 –370 B.C.). Although Alex-ander the Great conquered Greece in 326 B.C. after thedeath of Hippocrates and had Greek physicians within hisArmy, the possibility exists but the issue remains unresolved(15, 43).

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Susruta considered obesity to be a disease that was causedby an increase in the humor vayu because of an elevation inlymph chyle. Obesity was attributed to a sedentary lifestylewhich included “pampering his belly”; sleeping during the day,and being adverse to taking “any sort of physical exercise” (5,p. 135–136). As with other diseases, death could result if hisrecommendations were not followed. Treatment consisted ofremoving the fat that was obstructing the internal channels andby preventing the growth of abnormal fat, which was accom-plished by providing assorted medications and by prescribing“physical exercise” (5, p. 137).

Diabetes was regarded by Susruta as a disease of the urinarytract (prameha) and as an incurable condition (mahu-meha).When diagnosed as prameha, its causes were either congenitalor the result of an injudicious diet, with obesity being a majorcharacteristic of the disease (6). Treatment included dietarychanges and participation in an exercise program that includedlong walks, engaging in sports such as wrestling, and riding ona horse or an elephant (5, p. 377).

Susruta’s sixth century B.C. concept that sedentary livingcould cause obesity, diabetes, disease, and death has similari-ties to the 20th century concept of the Sedentary Death Syn-drome of Professor Frank Booth (9, 24) in that both identifiedinactivity with disease and both included physical activitywithin their prevention regimens (7, 8).

WHY HAVE EXERCISE PHYSIOLOGIST OMITTEDTHE CONTRIBUTIONS OF SUSRUTA?

Susrutra’s contributions to medicine have been extensivelyacknowledged by historians on the history of medicine (15, 35,36, 43) and by authors of articles pertaining to urology, plasticsurgery, and ophthalmology (11, 19, 37). When the History ofPhysiology (40) was published, Rothschuh began with thecontributions from Greece. However, in the United States,exercise physiology did not evolve from physiology; rather, itbegan in the classrooms and laboratories of physical educatorsduring the late decades of the 19th century. Even so, physicaleducation historians have been careful to note the contributionsfrom Persia, India, and China before discussing those fromGreece and Rome (18, 39, 47). Insights can be gleaned fromthe publication in 1553 of the first text devoted to exercisephysiology entitled the Book of Bodily Exercise (33) by theSpanish physician Cristobal Mendez (1500–1541) in that onlyGreek and Roman concepts were used to discuss the fourtreatises emphasized within the book. Sixteen years later(1569), the Italian physician Girolamo Mercuriale (Hierony-mus Mercuralis, 1550–1606 B.C.) published in Latin the firsttext devoted to sports medicine in which sections were devotedto exercise and its physiological concepts; but, only those thathad originated from Greece and Rome with the most comingfrom Galen (31). Several hundred years later in England, or in1807, John Sinclair discussed aspects of chronic exercise(training) for humans and animals (45). Like others, he fol-lowed Mendez’s approach by using observations and conceptsfrom individuals who lived in ancient Greece and Rome(Herodicus, Asclepiades, Celsus, Galen) plus those from the17th century as Sir Francis Bacon and Byran Robinson (45).Since the time of Sinclair there have been �40 first editiontexts published in North America devoted to the science ofexercise physiology. Of those that contain ancient historical

information, all begin with the contributions from Greece andRome.

CONCLUSION

Unlike their history of medicine counterparts, authors on thehistory of exercise physiology have omitted the achievementsfrom ancient India. In doing so, they have missed the contri-butions of a 600 B.C. physician named Susruta (Sushruta;Fig. 1) who was an ardent advocate of the tridosa doctrine(humoral theory), which stated disease was a resultant whenone or more of the three bodily humors (dosas) was displacedand that health occurred when they were in equilibrium. Theantiquity of the tridoasa doctrine is that it was included withinthe oldest of the sacred books of India (The Rig-Veda, circa1500 B.C.) while its importance to exercise physiology wasestablished by Susruta’s belief that exercise could helpprevent the diseases caused by the elevation in the kaphahumor because of lifestyles that included inactivity andexcessive consumption of food and fluid. His idea thatinactivity could lead to a disease state has similarities to the20th century concept of the Sedentary Death Syndrome. Hewas the first physician to prescribe exercise (moderate) forhealth reasons and preceded Greek physicians in discourag-ing individuals from performing “excessive exercise” be-cause of the propensity for health disorders. Susruta re-garded diabetes and obesity as diseases and included mod-erate exercise within his treatment regimens. When hedescribed the physiological effects of chronic exercise, theyhad marked similarities to those currently listed in elemen-tary exercise physiology textbooks.

The collective conclusion is that Susruta was remarkablymodern with his ancient concepts.

Fig. 1. Susruta (Sushruta) of ancient India (circa 600 B.C.) who advocatedexercise to restore the equilibria between the dosas. Reprinted, with permissionfrom Ref. 41a.

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ACKNOWLEDGMENTS

With permission, this is to acknowledge that information pertaining toancient India and to the samhitas of Susruta were included in the APS OrrReynolds Award manuscript entitled “The antiquity of exercise, exercisephysiology, and the exercise prescription for health” (46a).

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