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Introduction

The word Pandu has been derived from "Padi Nashne Dhatu" by adding "Ku" Pratyaya in it, the meaning of which is always taken in the sense of "Nashan" i.e. the loss.[1] As Pandu has been kept under the group which is classified and named according to the change of colour, therefore "Nashan" should be considered in the sense of "Varna" or colour, which is further clarified by Charak with the word Vaivarna. Thus, Pandu is a disease in which there is Vaivarna or Change of normal colour of body. In Sanskrit literature meaning of Pandu is taken as Shweta, Pitasanwalit Shukla, shat Pandu i.e Dhusar. Colour of Pandu can be compared with Sankha, Pakwa adanphala, Ketaki Dhuli (Pollengrains of Ketaki Flower), Apakwa Parushak Phala.[2] This means, while describing the signs and symptoms of different types of Pandu, several types of complexion likeHaritadi Varnaare described, but all of these are dominated by Panduta(Pale -Yellow colour) because of which this disease is called Pandu Roga.[3] So Pandu or Pallor of skin is first observed on the most superficial portion of the body and that is skin. But pallor should also be examined in other parts of the body described by Acharyas, as per them pallorness should be also observed in Eyes, Palate, Tongue, Nose, Lips, Palms, Soles, Nails, Feces and also in urine. These are the important sites to be well examined, complete clinical observations or examine the patients for Panduroga. Means among the diffrent kinds of colours such as Pandu, Haridra and Harita, Pandu being more common among these so this disease is called as Pandu Roga itself. Shveta, Pitabha, Dhusara, Malina and Vivarna are the meanings coined for Pandu by different scholars like Charaka, Sushruta, Vagbhata, Dalhana and Arunadatta. In Sanskrit dictionaries the meaning of Pandu Varna has been found as Pita Samvalita, Shukla, Pitabhagardha etc. In Ashtanga Hridaya, Vagbhata described that perturbed Pitta getting located in between the skin and muscles vitiates Kapha, skin, blood and muscles and lodges within them. As a result, they acquire different colours such as yellowish white, yellow and green. Yellowish white (Pandu) being the most common discoloration, the disease is called the disease of pallor (Pandu Roga)[4]

Etiology of Pandu:

The etiology of diseases are enumerated in Ayurvedic texts under two headings-

1. General etiology.
2. Specific etiology of the individual varieties of diseases.

In some disease, Samanya Nidana of concerned Dosha or group of diseases has been explained and in some disease Vishesha Nidana for that particular disease has been listed. In regard to causative factors of Pandu Roga, only Charaka and Madhava. Nidana has explained in detail, while in Sushruta Samhita, Ashtanga Sangraha and Ashtanga Hridaya etc. the causes of Pandu Roga have not been clearly described. However in these texts, the causative factors provoking Pitta Dosha are described. References of Nidana of Pandu Roga is also available in Harita Samhita. Pandu Roga is considered as Pitta Dosha pradhana. The provoking factors of Pitta can also be taken as a cause of Pandu Nidana of Pandu Roga can be classified into following three categories:

1. Aharaja Hetu
2. Viharaja Hetu
3. Nidanarthakara Roga

The etiological factors of Pandu (Aharaja, Viharaja and Nidanarthakara Roga) are mentioned below in the chart form.

Aharaja Hetu[5] [6]

Food or diet plays an important role in the normal development and maintenance of the different Dhatus of body. Pandu Roga may be caused due to indulgence of food containing more Amla, Kshara, Lavana, Ushna, Rooksha Dravyas. Asatmya Bhojana and Viruddha Bhojana may inhibit normal process by producing Ama and lead to disturbance in the process of digestion and assimilation. If Ushna, Kshara and Amla are used in excess it might be that, they may injure the gastric mucosa and hinder the normal absorption. Intake of Dravays like Nishpav, Tila, Tila Taila, Pinyaka etc, frequently causes Mandagni and Tridosha Prokopa but mainly Pitta Prakopa thereby causing the disease. These factors are harmful to health and may over stimulate the metabolism. Kashaya Rasa as an aetiological factor of Pandu is found only in Harita Samhita. Lavana Rasa as a cause of Pandu is mentioned by Charaka and Sushruta, while Amla Rasa is mentioned by all Acharyas. Amla Rasa has been said to possess the property of Mamsa Vidaha and causes Kaya Shaithilya. Likewise, Lavana Rasa vitiates the Rakta. According to Sushruta, excessive intake of Amla Rasa and Lavana Rasa produces Kayashaithilya and Vaivarnyata. In one word this can also be said that both Amla and Lavana Rasa causes the aggravation of Pitta Dosha which plays the main role in the pathogenesis of Pandu Roga.

Excessive use of wine and spicy materials excites Pitta Dosha and if these substances are continued for long time certain pathological changes in the liver and stomach will be observed in the form of cirrhosis, gastritis or even ulceration which ultimately hampers the normal digestion and assimilation.

Viharaja Hetu [7] [8]: This factors deals with both mental and physical activities of individual. In physical activities Ratrijagarana causes Vata Prakopa and Divasvapna causes Kapha Prakopa, due to Ativyayama, Ativyavaya and Adhika shrama Vata Dosha gets aggravated and it plays a role in the causation of Pandu Roga. Vega are Natural regulators of body functions. Habitual suppression of natural urges leads to Vata Prakopa which ultimately vitiates the other two Doshas and causes Pandu Roga. Climatic changes, disturbance of normal seasonal shifts or abnormal season upset the normal function of the body.In mental activities, Chinta, Shoka, Krodha are important causes of Pandu Roga. These psychological factors vitiate the Dosha in the body, like Chinta and Shoka causes vitiation of Vata Dosha, Krodha causes vitiation of Pitta Dosha etc. These Manasika Bhava are also having their own effect on the Agni as well as Dhatu Poshana.These result in Mandagni and deficient nutrition to Dhatus which are stated to be the causes of Pandu Roga.

Causes related to Nidanarthakara Roga:

In Ayurvedic literature Pandu has been mentioned as either symptom or as Updravas of various diseases. So, all these can be considered as Nidanarthakara Rogas of Pandu Roga. Some of which are Raktatipravartan, Raktarsha, Raktarbuda, Asrigdara, Arsha or Kaphajarsha, Shvasa etc. which directly or indirectly vitiate Vata, Pitta and Kapha singly or in combination. Though Pitta plays a predominant role in the manifestation of Pandu Roga, Vata and Kapha are also involved in the process. In context of, attainment of menarche it has been mentioned that ?Tad varshaat Dwadashaath Kaale Varthamana Asrik Punaha” by Acharya Sushruta, indicating after 12 years of age, the Raja Pravriti starts in females. Thus, with its onset an additional requirement of formation of Upadhatu Artava arises, in view of it, if proper replenishment of Rasa Dhatu is not ensured by proper dietary intake, the adolescent girl may develop Pandu.

Types of Pandu: Acharya Sushruta, Madhava and Bhavaprakasha have mentioned the symptoms of Doshika Pandu.[9] [10] [11]

1. Vataja Pandu Roga:

Due to intake of Vata vitiating factors Vata gets aggravated and causes Pandu Roga. The Lakshanas of Vataja Pandu according to different Acharyas.

2. Pittaja Pandu Roga:

After taking Pitta Prakopaka Ahara-Vihara Pitta Dosha gets vitiated and gets accumulated in the body of the person of Pitta Prakriti, vitiates the Rasa & Rakta along with Mamsa Dhatu and causes Pittaja Pandu Roga. The Lakshanas of Paittika Pandu according to different Acharyas.

3. Kaphaja Pandu:

Due to Kapha aggravating Ahara and Vihara, Kapha gets vitiated and causes Kaphaja Pandu. Madhava, Bhavaprakasha and Vagbhata have described the same symptoms of Kaphaja Pandu as Charaka and Sushruta. In the place of Madhurasyata, Vagbhata has mentioned the symptom Lavana Vaktrata. The Lakshanas of Kaphaja Pandu according to different Acaryas.

4. Sannipataja Pandu Roga:

In person who indulges in Tridosha vitiating Ahara, Vihara, all the three Doshas Vata, Pitta and Kapha get simultaneously aggravated and causes Tridoshaja Pandu, which is showing all the symptoms of Vataja, Pittaja and Kaphaja Pandu. Madhava Nidana and Bhavaprakasha described some special symptoms of Tridoshaja Pandu and mentioned this type of Pandu is Asadhya. The symptoms of Tridoshaja Pandu according to these Acharayas are Jwara, Arochaka, Hrillasa, Chhardi, Trishna, Klama and Rogi becomes Kshina and Hatendriya.

5. Mridbhakashanjanya Pandu Roga:

Acharya Charaka, Vagbhata and Madhava have given this type of Pandu where Mridbhakshana stands as causative factor. The earth or Soil of Madhura Rasa vitiates the Kapha Dosha, the earth or soil of Lavana Rasa vitiates the Pitta Dosha & the earth or soil of Kashaya Rasa aggravates Vata Dosha. It enters Amashaya, dries up the Dhatus and leads to discolouration of the body. ‘Jathragni ’remain unable to digest this and it enters in the Rasavaha Srotas in the same form as it was consumed & obstructs the Srotas and this does not allow any physiologically needful substance to pass through. By this, the Indriyas of the Patient become weaker to receive their own Arthas properly and genuinely. This also damage Saptadhatu (Satva) and Jatharagni.

Samprapti of Pandu Roga: [12] [13] Samprapti is the development of disease including the sequences of process or events from inception to the characteristic development of disease or in short, we can say Samprapti is the Vyadhi Vyapara Parampara. When the Pitta Dosha located in its normal abode gets expelled from its site by the vitiated Vayu, it gets entry into the Hridaya from where it reaches the Dasha Dhamani and is mobilized throughout the body. It gets localized in between the Tvak and Mamsa and vitiates the Kapha, Vata, Asrik, Tvak and Mamsa subsequently causing a variety of colour in the skin such as Pandu, Haridra, Harita etc. This condition is known as Pandu Roga. Sushruta has mentioned that Pandubhava is caused by discolouration of Tvak by the vitiated Rakta due to intake of Ahita Ahara Vihara[14] Vagbhata has mentioned the Samprapti given by Charaka. The pathology of Pandu Roga is mainly concerned with vitiation of Pitta Dosha which in turn vitiates the Rakta, leading to condition of Pandubhava. Thus, Pitta being the Pradhana Dosha or main factor in the causation of Pandu Roga. All functions of it are affected more or less, but as the main seat of the disorganization is the Rakta, the Ranjana function of Pitta is to bear the burn.Ayurveda considers that due to Nidana Sevana the process of Pandu Roga is commenced with the Prakopa of all three Doshas in the Dhatus. The Pitta Dosha takes leading part in the production of Dhatu Shaithilya and Dhatu Gaurava. This leads to Bala Kshaya, Varna Kshaya and Oja Kshaya. Thus, the Pandu Roga is stated to be afflicted with Rakta Alpta, Meda Alpata, Nih Sarata, Vivarnata and Shithilendriyata. Panduta is an invariable feature.

TREATMENT OF PANDU ROGA Snehana: In case of Pandu Roga, there is diminution Snehabhava of Rakta, Meda, Oja etc. and the body becomes dehydrated, emaciated, and deficient in lipid substances which provoke Vata Dosha causing further deterioration in the lipid substances which provokes Vata causing further deterioration in the condition. For performing Snehana Karma, various preparations have been mentioned. For example, Kalyanaka Ghrita, Rajani Ghrita, Triphala Ghrita, Tilvaka Ghrita, Dadimadi Ghrita, Danti Ghrita, Draksha Ghrita, Pancagavya Ghrita, Mahatikta Ghrita, Pancatikta Ghrita etc. They can be used in various types of Pandu according to the predominance of Doshas, variation in pathogenesis and in symptoms. After completing the oleation therapy successfully the signs of which are, the Vata becoming Anuloma, the Jatharagni becoming activated, the stool being unctuous and loose, the body becoming soft and smooth. Shodhana can be performed directly after Snehana as Svedana is contraindicated in Pandu. [15]

Shodhana: Vamana and Virecana Karma both can be performed in Pandu Roga after proper oleation. Commenting on the performance of Vamana Acharya Dalhana has said that while performing Vamana in case of Pandu Roga one should always keep in mind about physical condition of the patients, the climate time and place. Charaka has mentioned Madanaphala as most suitable drug for emesis in case of Pandu.Similarly, for Virecana a long list of drugs has been mentioned in Ayurvedic texts. Sushruta has given more stress on Haritaki in all types of Pandu[16]

Shamana Chikitsa (Palliative treatment): The treatment should be planned.

1. To correct the deficiency of extrinsic factor.

2. To stimulate the production of Intrinsic factor.

3. To stimulate the organs of haemopoiesis.

4. Along with these, treatment for the allied symptoms as a sequel of the pathogenesis should also be done.

The palliative treatment should include – [17]

1. Treatment according to predominance of Doshas

2. Specific treatment.

3. Treatment according to the predominance of Lakshanas (symptomatic treatment).

1. Treatment according to predominance of Doshas:

In cases of Vatika Pandu, the substances having Snigdha Guna, in Paitika the substances having Madhura and Tikta Rasa in Kaphaja Pandu drugs having Ushna Virya and in Tridoshaja Pandu, a mixture of all the above should be prescribed. In Mritikabhakshanajanya Pandu, the mud which may be composed of various indigestible and inaccessible substances obstructs various cannels. Thus, it is necessary to remove it by strong purgation.

2. Specific treatment

Vishishta Aushadhi (Specific Drugs) - As already described that Pandu is predominantly due to lack of blood, or in other words this can also be said that, in Pandu there is diminution of its main constituents which along with other factors play major role in the normal erythropoiesis, causing development of Anemia. Correction in these constituents and other associated factors will naturally be followed in increased blood production and ultimately improvement in Anemia or Pandu.

3.In the treatment of Pandu, single drug or a combination of two or more drugs has been used. A description is given as:

1. Single drug which has been used in Pandu are - Lauha Bhasma, Mandura Bhasma, Pure Kaseesa, Shilajit, Vardhamana Pippali etc.

2. Compound drugs which are of vegetable origin e.g., Triphala, Phalatrikadi Kvatha, Punarnavashtaka Kvath, Vidangavaleha etc.

3. Drug which are a combination of vegetable origin and animal origin e.g.

Mahatikta Ghrita, Pathya Ghrita, Rajani Ghrita, Gomutraharitaki etc.

1. Drugs which are combinations of vegetable and mineral origin e.g., Yogaraja, Shilajatuvati, Navayasa Lauha, Mandura Vataka, Punarnava Mundura etc.

2. Asava and Arishta e.g., Lauhasava, Punarnavasava etc.

In brief the Panduhara Yogas are described in various forms such as Churna, Vati, Asava, Arishta, Avaleha, Ghrita etc.

Discussion

Pandu roga is considered as a Pitta Pradhana Tridosaja and Rasa Pradoshaja Vyadhi which is named on the basis of Pandu Varna which is a main sign of the disease. The etiologies of Iron Deficiency Anemia are having similarities with that of etiologies of Pandu roga. All three forms of Agni viz Jatharagni, Bhootagni, and Dhatvagni are usually affected in the pathogenesis of Pandu roga.

Alpa-Raktata, Nissara, Ojo-kshaya and Alpa-Vyadhikshmatva are generally seen in Pandu roga. Similar features are seen in Iron Deficiency Anemia, where nourishment is hampered leading to reduced immunity and increased morbidity. Kashyapa has specifically mentioned the sites where pallor is evident like Shveta Akshi, Nakha and Vaktra and the term Rudhira Spruha mentioned by him means craving for blood. Hetus like Ruksha, Ushna, Kshara, Katu Rasa Ati Sevana, Anashana, Ativyayama, Chinta, Shoka causes Agnimandya which leads toDhatu Kshaya & Oja Kshaya, later Sthithilendriya, Twak Vaivarnya, Nissaratatakes place & results in Pandu. Also due to Rakta Sravaby Abighataja Hetumay cause Rakta Dhatu Kshaya and cause Pandu.

According to subject the role of Dosha, Dushya in manifestation of Pandu Roga is described as below:[18]

Role of Vata Dosha:Though Pitta is Pradhana Dosha in Pandu Roga, Vata Dosha also plays an important role in manifestation of Pandu Roga. Out of five types of Vata mainly Vyana Vayu is related with the Samprapti of Pandu Roga. Vitiated Vata is responsible for Kampa, Angasada, Gatrashula, Raukshya, Tvaka Parushya, Kati- Uru-Pada Ruk etc.

Role of Pitta Dosha:Pitta is responsible for the normal colour of body but when it vitiates due to the same quality in nature it also vitiates Rakta and causes Pandu Roga which ultimately leads to Panduta of the body.

Role of Kapha Dosha:Kapha seems to play a vital role in the development of Panduta. According to Charaka, Pandu Roga occurs due to vitiation of all three Doshas. Aggravation of Kapha Dosha causes Mandagni which leads to Uttarottora Dhatu Aposhana and ultimately leads to Panduta of the body. It has also been stated that Santarpana which broadly means anabolism, brings about an increase in Kapha which in term may cause the disease by generating Ama and causing Mandagni. Thus, any diet which may increase Kapha Dosha, or any disease associated with increase in Kapha can cause a change in complexion or Panduta. Vitation of Kapha Dosha is responsible for Gaurava, Nidradhikya, Mandagni, Alasya, Alpavak etc. Dushyas of Pandu Roga: Charaka and Vagbhata have mentioned Tvak, Rakta and Mamsa as the dominant Dushyas in Pandu Roga. Dhatus involved in the pathogenesis of Pandu Roga can also be understood by a detailed study of symptoms. The symptoms such as Aruci, Jvara, Panduta, Gaurava and Tandra are indicative of Rasa Dhatu Dushti. Angamarda indicates the involvement of both Rasa and Rakta Dhatu. Karshya is indicative of Mamsa Dhatu Dushti. Atisveda and Svedabhava are suggestive of involvement of Tvaca, Mamsa Dhatu and Medo Dhatu. Shirnalomata is an important indicative of Asthidhatu. The loss of lusture and debility are suggestive of depletion of Ojas.Thus, among Saptadhatus mainly Rasa and Rakta Dhatu are involved in this disease.

 Rasa Dhatu: According to Charaka, Sushruta and Vagbhata, Rasa Dhatu undergoes a change to produce Pandubhava. Charaka and Sushruta have mentioned Panduta as one of the diseases associated with the vitiation of Rasa. Charaka has already stated that vitiated Doshas get lodged in Rasadi Dhatus and produce the disease whereas Sushruta has mentioned that when the vitiated Vata as well as Ama affect the Rasa Dhatu, the disease is produced.

Rakta Dhatu: Charaka and Sushruta have clearly mentioned that the vitiation of all the three Doshas leads to Rakta Dushti and thereby Tvaca becomes pale in color. According to Harita, there is a decrease in the blood volume, as is clearly indicated by “Nayati Rudhirashoshana”. Charaka has mentioned the word Alparakta for this condition.

Conclusion

Pandu roga is considered as a Pitta Pradhana Tridosaja and Rasa Pradoshaja Vyadhi which is named on the basis of Pandu Varna which is a main sign of the disease. The etiologies of Iron Deficiency Anemia are having similarities with that of etiologies of Pandu roga. In pandu roga various types of shamana yoga is maintained according to the predominance of Doshas. Vamana and Virecana Karma both can be performed in Pandu Roga after proper oleation.