Pakshagata Pakshaghata Ayurveda hemiplegia Panchakarma treatment Chikitsa Sutra

Pakshaghata ayurveda panchakarma stroke hemiplegia treatment

https://ask-ayurveda.com/articles/667-pakshaghata-chikitsa--…

PMID: 39763345

Pakshaghata Nidana Panchaka vatavyadhi Charaka Sushruta Ashtanga Hridaya classical Ayurveda hemiplegia pathogenesis samprapti

https://ask-ayurveda.com/articles/382-understanding-pakshagh…

Pakshaghata Basti Nasya Vamana Snehana Swedana mode of action Panchakarma vatavyadhi hemiplegia clinical study

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// ── TITLE PAGE ───────────────────────────────────────────────────────────────
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// ── SECTION I ────────────────────────────────────────────────────────────────
children.push(
  h1("SECTION I: INTRODUCTION OF THE DISEASE"),
  divider(),
  h2("1.1 Introduction – Ayurvedic Perspective"),
  body("Ayurveda, the ancient Indian system of medicine, is one of the oldest and most complete systems of health care known to humanity. Derived from the Sanskrit words "Ayu" (life) and "Veda" (knowledge), Ayurveda is literally the science of life. It encompasses not merely the treatment of disease but the preservation of health, promotion of longevity, and the attainment of spiritual well-being. The foundational texts — Charaka Samhita, Sushruta Samhita, and Ashtanga Hridayam — represent the three pillars of classical Ayurvedic medicine."),
  body("Among the most significant and challenging conditions described in Ayurvedic literature is Pakshagata (also spelled Pakshaghata or Pakshavadha). This disease represents one of the most devastating neurological disorders encountered in clinical practice — both in ancient times and today."),
  body("The term comes from two Sanskrit roots: "Paksha" meaning one lateral half of the body (either left — Vama Paksha, or right — Dakshina Paksha), and "Ghata" (or "Aghata") meaning destruction, impairment, or striking down. Together, Pakshaghata translates as "the striking down or destruction of one half of the body" — a precise and evocative description of what modern medicine calls hemiplegia or hemiparesis."),
  body("The disease is prominently described in the context of Vata Vyadhi — disorders arising from vitiation of Vata Dosha. Acharya Charaka places Pakshaghata among the 80 Nanatmaja Vata Vikaras — diseases that arise exclusively and specifically from the vitiation of Vata Dosha (Charaka Samhita, Sutra Sthana 20). This classification is of profound clinical importance because it immediately establishes the core therapeutic principle: any intervention in Pakshaghata must primarily address Vata Dosha vitiation."),
  body("Pakshaghata is further grouped under Mahavatavyadhi — the major, severe disorders caused by Vata — indicating the seriousness, complexity, and difficult-to-treat nature of this condition. Acharya Sushruta provides detailed descriptions of the pathological mechanism in his Nidana Sthana, while Vagbhata in Ashtanga Hridayam synthesizes and adds further clarity to both the pathology and management."),
  body("The ancient Acharyas recognized that this disease involves not only the musculoskeletal system but also the nervous system, sense organs (Jnanendriyas), motor organs (Karmendriyas), and even the mind (Manas). This holistic understanding places Pakshaghata in a unique category — it is an Indriyapradoshaja Vikara (disorder of sensory and motor organs) as well as an Upadhatu Pradoshaja Vikara (disorder affecting secondary tissues)."),

  h2("1.2 Introduction – Modern Perspective"),
  body("From the standpoint of modern medicine, Pakshaghata most closely corresponds to hemiplegia, defined as complete paralysis of one side of the body, or hemiparesis, meaning partial weakness of one side. Both conditions arise from lesions in the motor pathways of the central nervous system, particularly the corticospinal (pyramidal) tract."),
  body("Hemiplegia is one of the most common and disabling neurological conditions worldwide. It is not a diagnosis in itself but rather a clinical syndrome that can result from several underlying pathological conditions. The most common cause is cerebrovascular accident (stroke) — either ischemic (due to occlusion of blood supply) or hemorrhagic (due to rupture of blood vessels)."),
  body("Beyond stroke, hemiplegia can result from traumatic brain injury, brain tumors, demyelinating diseases such as multiple sclerosis, cerebral infections, congenital disorders (cerebral palsy), spinal cord lesions, and metabolic encephalopathies. In modern clinical neurology, the diagnosis of hemiplegia is established through thorough neurological examination supplemented by neuroimaging — CT scan or MRI of the brain — to identify the site, nature, and extent of the lesion."),
  body("Modern medical management of hemiplegia has significant limitations. Acute stroke management involves thrombolysis (tPA within a narrow 4.5-hour window) and mechanical thrombectomy for large vessel occlusion. Beyond the acute phase, treatment is essentially rehabilitative. This therapeutic gap is precisely where Ayurvedic management, with its rich tradition of neurorehabilitation through Panchakarma and herbal medicine, offers meaningful potential."),

  h2("1.3 Nidana Panchaka (Five-fold Etiology)"),
  body("The Nidana Panchaka is the classical Ayurvedic framework for understanding a disease in its entirety. It comprises five components: Nidana (causative factors), Purvarupa (premonitory symptoms), Rupa (clinical features), Upashaya (therapeutic trials), and Samprapti (pathogenesis)."),

  h3("1.3.1 Nidana (Etiology)"),
  body("Classical Ayurvedic texts classify the causative factors systematically as follows:"),
  h4("Aharajanya Nidana (Dietary Causes):"),
  bullet("Ati Ruksha Ahara: Excessive consumption of dry, rough foods"),
  bullet("Ati Laghu Ahara: Excessively light, non-nourishing diet"),
  bullet("Ati Sheeta Ahara: Cold food and beverages"),
  bullet("Atyalpa Ahara: Starvation or prolonged fasting"),
  bullet("Vishama Ahara: Irregular eating patterns; eating at wrong times"),
  bullet("Excessive intake of Katu (pungent), Tikta (bitter), and Kashaya (astringent) tastes"),
  bullet("Viruddha Ahara: Incompatible food combinations"),
  bullet("Vegavarodha: Suppression of natural urges"),
  h4("Viharajanya Nidana (Lifestyle Causes):"),
  bullet("Ati Vyayama: Excessive physical exertion"),
  bullet("Ati Maithuna: Excessive sexual activity leading to Shukra Kshaya"),
  bullet("Ati Jagarana: Excessive wakefulness, sleep deprivation"),
  bullet("Ati Chinta: Excessive mental worry, anxiety, and psychological stress"),
  bullet("Ati Bhara Vahana: Carrying excessively heavy loads"),
  bullet("Exposure to cold, dry, windy environments"),
  h4("Abhighataja Nidana (Traumatic Causes):"),
  bullet("Acharya Chakrapani identifies Abhighata (trauma) as a distinct Nidana"),
  bullet("Shiromarma Abhighata: Injury to the head (a vital Marma point)"),
  bullet("Corresponds to post-traumatic hemiplegia in modern medicine"),
  h4("Manasika Nidana (Psychological Causes):"),
  bullet("Ati Bhaya (excessive fear), Ati Krodha (excessive anger), Ati Chinta/Shoka (prolonged grief)"),
  body("Two fundamental mechanisms of Vata vitiation are recognized: (A) Dhatukshaya Janya Vata Prakopa — Vata aggravation due to depletion of bodily tissues, producing Kshayahetuja Pakshaghata; and (B) Margavarana Janya Vata Prakopa — Vata aggravation due to obstruction of its channels by other Doshas or Ama, producing Anyadosha Samsrista Pakshaghata."),

  h3("1.3.2 Purvarupa (Premonitory Symptoms)"),
  bullet("Sphuranam: Fasciculations or twitching in limbs"),
  bullet("Toda: Pricking or shooting sensations in the affected side"),
  bullet("Supti: Numbness or paresthesia in one side of the body"),
  bullet("Angamarda: Body ache and generalized malaise"),
  bullet("Balavarna Hani: Loss of strength and decrease in skin complexion"),
  bullet("Angasada: Heaviness and lassitude in limbs"),
  bullet("Chestahani: Reduced range and ease of movements"),
  bullet("Nidranasha: Disturbed sleep patterns"),
  body("These prodromal symptoms correspond to transient ischemic attacks (TIAs) or warning symptoms of cerebrovascular disease in modern medicine."),

  h3("1.3.3 Rupa (Cardinal Signs and Symptoms)"),
  h4("Primary Features:"),
  bullet("Cheshta Nivritti: Loss of voluntary movements (motor paralysis) affecting one entire side"),
  bullet("Vaksthambha: Stiffness of speech; slurred or absent speech (dysarthria/aphasia)"),
  bullet("Ardhakaya Karmahani: Loss of function in one half of the body"),
  bullet("Suptata in Hasta and Pada: Numbness and loss of sensation in hand and foot"),
  h4("Additional Features:"),
  bullet("Weakness (Bala Kshaya) in the affected limbs"),
  bullet("Drooping of the angle of the mouth; deviation of face toward the unaffected side"),
  bullet("Loss of grip strength, inability to stand or walk independently"),
  bullet("Difficulty in swallowing (Dysphagia), bowel and bladder dysfunction"),
  bullet("Psychological features: depression, confusion, memory disturbances"),
  body("Dosha-specific features: Pittanubandha — burning sensation, fever, syncope; Kaphanubandha — coldness, swelling, heaviness (Madhava Nidana 22/42)."),

  h3("1.3.4 Upashaya (Diagnostic Therapeutic Trials)"),
  body("In Dhatukshaya Janya Pakshaghata: Snehana provides relief (Upashaya); Langhana worsens it (Anupashaya). In Margavarana Janya Pakshaghata: Ruksha Swedana provides some relief. These differential diagnostic probes guide treatment selection."),

  h3("1.3.5 Samprapti (Pathogenesis)"),
  body("Charaka Samhita, Chikitsa Sthana 28/53:"),
  quote("\"Ekam pakvashayastham tu shariram ardhakam param | Sirasnayukandaragatah pakshaghataya Kurute ||\""),
  body("Translation: Vata, seated in the Pakvashaya (colon), spreads through the Sira (blood vessels), Snayu (ligaments/tendons), and Kandara (tendons) of one half of the body, causing Pakshaghata."),
  body("Madhava Nidana 22/18:"),
  quote("\"Nihantyekam pakvashayat prakupitah padam vayu | Sirasnayukandaragah tatra pakshaghata smritah ||\""),
  h4("Samprapti Chakra (Step-by-step pathogenesis):"),
  bullet("Step 1: Nidana Sevana — Exposure to causative factors"),
  bullet("Step 2: Vata Prakopa in Pakvashaya — Aggravation at primary seat (colon)"),
  bullet("Step 3: Vata Prasara — Overflow into Sira, Snayu, Kandara"),
  bullet("Step 4: Dosha-Dushya Sammurchhana — Vitiated Vata interacts with susceptible Dhatus"),
  bullet("Step 5: Sthana Samshraya — Vata lodges in one Paksha; prodromal symptoms appear"),
  bullet("Step 6: Vyakti — Full clinical manifestation of paralysis"),
  bullet("Step 7: Bheda — Chronicity; complications including contractures, atrophy"),
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      ["1","Sanchaya","Mild fatigue, constipation","Prevention — Nidana Parivarjana"],
      ["2","Prakopa","Anxiety, body ache, insomnia","Langhana, Dipana, Pachana"],
      ["3","Prasara","Vata spreads into Srotas","Shodhana (if Bala permits)"],
      ["4","Sthana Samshraya","Prodromal symptoms","Snehana, Swedana — critical"],
      ["5","Vyakti","Full paralysis, speech loss","Comprehensive Chikitsa"],
      ["6","Bheda","Chronicity, complications","Brimhana, Rasayana"],
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    [800, 1400, 3200, 3600]
  ),
  ...spacer(1),

  h2("1.4 Classification of Pakshaghata"),
  h3("A. Based on Etiopathogenesis (Sushruta)"),
  bullet("Suddha Vataja Pakshaghata: Pure Vata aggravation; classic features of dryness, cold, motor weakness; better prognosis"),
  bullet("Anyadosha Samsrista: Vata + Pitta (burning, fever, syncope) or Vata + Kapha (swelling, heaviness, coldness)"),
  bullet("Kshayahetuja Pakshaghata: Secondary to Dhatu Kshaya (tissue depletion); associated with emaciation, cachexia"),
  h3("B. Other Classifications"),
  bullet("By side: Vama Paksha (left hemiplegia) or Dakshina Paksha (right hemiplegia)"),
  bullet("By severity: Complete paralysis (hemiplegia) vs. partial weakness (hemiparesis)"),
  bullet("Prognosis: Suddha Vataja — Krichhrasadhya; Anyadosha Samsrista — Yapya; Kshayahetuja — Asadhya"),

  h2("1.5 Incidence and Prevalence"),
  body("Stroke-related hemiplegia is the third leading cause of death and the most common cause of acquired disability worldwide. WHO estimates 33 million individuals are affected globally every year, with two-thirds occurring in developing countries."),
  body("India reports approximately 1.5–2 million new stroke cases annually. Community surveys in India show a crude prevalence of hemiplegia in the range of 200 per 1,00,000 people. The Global Burden of Disease Study ranks stroke among the top five causes of DALYs in India."),
  h4("Key Modifiable Risk Factors (Modern):"),
  bullet("Hypertension (single largest risk factor), Diabetes mellitus, Dyslipidemia"),
  bullet("Atrial fibrillation, Cigarette smoking, Obesity and metabolic syndrome"),
  bullet("Sedentary lifestyle, Age above 55 years, Prior TIA"),
  body("Ayurveda's epidemiological perspective identifies populations with Vata-aggravating lifestyles — irregular food, excessive exertion, chronic stress, cold climates — as most vulnerable, mapping precisely onto modern stroke risk populations."),

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  // ── SECTION II ──────────────────────────────────────────────────────────────
  h1("SECTION II: CHIKITSA SUTRA (TREATMENT PRINCIPLES)"),
  divider(),
  h2("2.1 Chikitsa Sutra as per Different Acharyas"),
  body("The Chikitsa Sutra for Pakshaghata is clearly articulated in Charaka Samhita, Chikitsa Sthana 28/53-55:"),
  quote("\"Pakshaghatam tatha hanustambham ardita eva cha | Vatavyadhir bahuvidhah shodhyah snehana poorvakam ||\""),
  body("Translation: Pakshaghata, Hanustambha, and Ardita are among the many types of Vata Vyadhi that should be treated with Shodhana (bio-purification) preceded by Snehana (oleation). The therapeutic sequence is: Snehana first → Shodhana thereafter."),
  h3("Acharya Charaka's Chikitsa Sutra"),
  body("Charaka specifies three foundational therapies: (1) Snehana (oleation — internal and external), (2) Swedana (fomentation), (3) Virechana (therapeutic purgation). Commentators Acharya Jejjata and Acharya Gangadhara interpret this as Snehayukta Swedana (fomentation combined with oleation) and Snehayukta Virechana (gentle, nourishing purgation)."),
  h3("Acharya Sushruta's Chikitsa Sutra"),
  body("Sushruta provides patient selection criteria: a patient who is not excessively emaciated, has pain in the affected part (residual neuromuscular activity), follows dietary rules, and can afford treatment is considered suitable. His approach: Snehana + Swedana first, then Nithya Virechana, then Niruha Basti, Anuvasana Basti, and Shirodhara."),
  h3("Acharya Vagbhata (Ashtanga Hridayam)"),
  body("Vagbhata emphasizes: (1) involvement of Shira and Snayu in Samprapti; (2) treatment must address both Vata and Srotas obstruction; (3) Basti Karma is the primary Panchakarma; (4) Nasya is mandatory for Urdhvajatrugata manifestations (speech, facial palsy, cognition)."),
  h3("Comparative Summary"),
  ...spacer(1),
  makeTable(
    ["Acharya", "Primary Chikitsa Sutra", "Emphasis"],
    [
      ["Charaka","Snehana, Swedana, Virechana","Sequential oleation then purification"],
      ["Sushruta","Snehana, Swedana, Basti, Nasya","Patient selection; comprehensive Panchakarma"],
      ["Vagbhata","Snehana, Basti (primary); Nasya for Urdhvajatru","Srotas Shodhana; Basti supremacy in Vata"],
      ["Madhavakara","Type-specific treatment","Dosha-specific personalized approach"],
    ],
    [2000, 3500, 3500]
  ),
  ...spacer(1),

  h2("2.2 Modern Line of Treatment"),
  h3("Acute Phase (First 24–72 hours)"),
  bullet("Airway, breathing, circulation (ABC) stabilization"),
  bullet("Ischemic stroke: IV thrombolysis with tPA within 4.5 hours of onset; mechanical thrombectomy for large vessel occlusion"),
  bullet("Hemorrhagic stroke: Neurosurgical consultation; blood pressure control; reversal of anticoagulation"),
  bullet("Prevention of complications: DVT prophylaxis, pressure ulcer prevention, aspiration pneumonia prevention"),
  h3("Sub-acute Phase (Days to Weeks)"),
  bullet("Physiotherapy: Range of motion exercises, positioning, transfers, gait training"),
  bullet("Occupational therapy: ADL training, upper limb rehabilitation"),
  bullet("Speech and language therapy: Aphasia/dysarthria rehabilitation"),
  bullet("Spasticity management: Baclofen, botulinum toxin injections"),
  h3("Chronic Rehabilitation Phase"),
  bullet("Constraint-induced movement therapy (CIMT), Mirror therapy, Neuromuscular electrical stimulation"),
  bullet("Robot-assisted rehabilitation, Virtual reality-based therapy, Community reintegration"),
  body("Limitations of modern management: The acute thrombolytic window is missed in most patients in developing countries; no pharmacological treatment reliably reverses established neurological deficits; rehabilitation is resource-intensive and often inaccessible."),

  h2("2.3 Internal Medicines (Shamana Aushadhi)"),
  h4("Herbo-mineral Preparations:"),
  bullet("Ekangavira Rasa: Specific for Vata-related neurological disorders"),
  bullet("Mahavata Vidhwansana Rasa: For severe Vata disorders"),
  bullet("Brihat Vata Chintamani Rasa: For cerebrovascular and neurological Vata disorders"),
  bullet("Yogendra Rasa: Tridoshic balancer for complex Pakshaghata"),
  h4("Herbal Formulations:"),
  bullet("Dashamoola Kashayam: Decoction of ten roots; powerful anti-Vata"),
  bullet("Ashwagandha Churna/Capsules: Adaptogenic, nourishing, strength-giving (Balya)"),
  bullet("Eranda (Castor oil): Anti-Vata; used in Anulomana doses"),
  bullet("Nirgundi (Vitex negundo): Anti-inflammatory"),
  h4("Medicated Ghees (Ghritam):"),
  bullet("Ashwagandha Ghrita: Nourishing, strength-building"),
  bullet("Panchatikta Ghrita: For chronic cases with Ama involvement"),
  bullet("Dhanwantaram Ghritam: Classical neurological tonic"),

  new Paragraph({ children: [new PageBreak()] }),

  // ── SECTION III ─────────────────────────────────────────────────────────────
  h1("SECTION III: PANCHAKARMA PROCEDURES IN PAKSHAGHATA"),
  divider(),
  h2("3.1 Overview of Panchakarma in Pakshaghata"),
  body("Panchakarma (five purificatory actions) represents the backbone of Ayurvedic therapeutic intervention in Pakshaghata. The five procedures are: Vamana (therapeutic emesis), Virechana (therapeutic purgation), Basti (medicated enema), Nasya (nasal administration of medicines), and Raktamokshana (bloodletting). In Pakshaghata, Basti, Nasya, Snehana, and Swedana are the most prominent modalities."),
  body("The rationale for Panchakarma in Pakshaghata is grounded in Samprapti Vighatana — breaking the chain of pathogenesis. Each procedure targets a specific link: Snehana reverses the Ruksha quality of Vata; Swedana opens blocked Srotas; Basti directly addresses Vata at its primary seat (Pakvashaya); Nasya accesses the Urdhvajatrugata pathology affecting speech and cognition."),

  h2("3.2 Snehana (Oleation Therapy)"),
  body("Snehana is the systematic administration of oil or fat (Sneha) to the body. In Pakshaghata, it is the mandatory first step in all treatment protocols."),
  h3("A. Abhyantara Snehana (Internal Oleation)"),
  body("Administration of medicated ghee (Ghritapana) in gradually increasing doses for 3–7 days. Formulations: Ashwagandha Ghrita, Panchatikta Ghrita, Dhanwantaram Ghritam. Treatment continues until signs of proper oleation (Samyak Snigdha Lakshanas) appear — unctuousness of skin, soft stools, absence of body pain."),
  h3("B. Bahya Snehana (External Oleation)"),
  bullet("Sarvanga Abhyanga: Full-body massage with Mahanarayana Taila, Bala Taila, Dhanwantaram Taila; 45–60 minutes daily"),
  bullet("Ekanga Abhyanga: Localized massage on paralyzed limbs"),
  bullet("Pizhichil (Sarvanga Dhara): Continuous pouring of warm medicated oil over entire body; combines Snehana and mild Swedana; potent for chronic Pakshaghata"),
  h3("Mode of Action of Snehana"),
  body("The Snigdha (unctuous), Guru (heavy), Ushna (warm) qualities of Sneha directly counter the Ruksha (dry), Laghu (light), Sheeta (cold) qualities of aggravated Vata — the principle of Samanya Vishesha. At the Dhatu level, Sneha nourishes depleted Rasa, Rakta, Mamsa, and Majja Dhatus. Modern evidence: sesame oil (base of most Ayurvedic oils) contains sesamol and sesaminol — potent antioxidants reducing oxidative stress in neural tissue."),

  h2("3.3 Swedana (Sudation/Fomentation Therapy)"),
  body("Swedana refers to procedures inducing perspiration through application of heat. Classical texts describe four primary actions: Stambhaghna (relieves stiffness), Gauravaghna (relieves heaviness), Shitaghna (relieves cold), and Swedakara (induces perspiration)."),
  h3("Types of Swedana in Pakshaghata"),
  bullet("Sarvanga Svedana (Bashpa Sveda): Full body steam bath using medicated steam (Dashamoola Kwatha added); 10–20 minutes post-Abhyanga"),
  bullet("Patra Pinda Sweda (Ela Kizhi): Bolus of Vata-pacifying leaves dipped in warm medicated oil, applied rhythmically; combines Snehana and Swedana"),
  bullet("Shashtikashali Pinda Sweda (Njavarakizhi): Bolus of Shashtika rice cooked in Bala Kwatha and milk; nourishing and sudating; ideal for emaciated Kshayahetuja patients"),
  bullet("Nadi Sweda: Directed steam to specific joints for localized spasticity"),
  bullet("Jambira Pinda Sweda: Lemon-based bolus; useful when pain and tingling are prominent"),
  h3("Mode of Action of Swedana"),
  body("Ushna (hot) and Snigdha qualities of Swedana pacify Vata's Ruksha quality. Heat-induced Srotoshoddhi opens blocked channels. Amapachana eliminates undigested metabolites from channels. Modern correlation: thermotherapy increases local blood flow 3–4 times through vasodilation; heat-induced reduction in muscle spindle activity reduces alpha motor neuron excitability underlying spasticity."),

  h2("3.4 Vamana (Therapeutic Emesis)"),
  body("Vamana is the therapeutic induction of vomiting to eliminate vitiated Kapha from the upper gastrointestinal tract. In Pakshaghata, it has specific indications."),
  h3("Indications in Pakshaghata"),
  bullet("Kaphanubandha Pakshaghata: Kapha is the obstructing Dosha — Vamana eliminates excess Kapha and removes obstruction to Vata flow"),
  bullet("Features of Kapha excess: heaviness, swelling, cold sensations, excessive mucus"),
  bullet("Associated Kapha conditions: chronic sinusitis, obesity, asthma"),
  h3("Drugs Used"),
  body("Madanaphala (Randia spinosa) in Yashtimadhu (liquorice) decoction; 4–8 vomiting episodes (Hina/Madhyama/Uttama Shuddhi); strict Paschatkarma and Samsarjana Krama (graduated diet) mandatory."),
  h3("Mode of Action"),
  bullet("Eliminates vitiated Kapha from Amashaya and Urdhvabhaga; clears Kaphaavrita channels"),
  bullet("Improves Udana Vayu function — governs speech and strength"),
  bullet("Improves Agni when Ama contributes to pathology"),
  bullet("Modern parallel: elimination of inflammatory mediators; vagal stimulation through emesis modulates autonomic nervous system tone"),
  h3("Contraindications"),
  bullet("Severe Dhatu Kshaya, pure Vataja Pakshaghata, advanced age with debility, hemorrhagic stroke, cardiovascular instability"),

  h2("3.5 Virechana (Therapeutic Purgation)"),
  body("Virechana is therapeutic purgation for eliminating vitiated Pitta and mixed Doshas. Charaka's Chikitsa Sutra specifically mentions Virechana as one of the three primary treatments — as Mridu Virechana (gentle purgation) or Snigdha Virechana (oleating purgation)."),
  h3("Indications in Pakshaghata"),
  bullet("Primary: All types of Pakshaghata as part of Samshodhana protocol"),
  bullet("Specific: Pittanubandha Pakshaghata — when Pitta obstructs or is associated with Vata"),
  bullet("Sira involvement: Sira is the Upadhatu of Rakta; Virechana is the best Shodhana for Rakta Dhatu"),
  bullet("Majjavaha Srotas involvement: Since Majja and Pitta share Dhara Kala, Virechana addresses Majja pathology"),
  h3("Drugs Used"),
  bullet("Eranda Taila (Castor Oil): Most commonly used; Snigdha quality pacifies Vata while purging (15–30 ml in warm water/milk)"),
  bullet("Trivrit (Operculina turpethum): Classical mild purgative"),
  bullet("Gandharvaharitaki: Eranda + Haritaki — classic Vata Virechana formulation"),
  h3("Mode of Action"),
  bullet("Eliminates vitiated Pitta; clears Rakta Dhatu of Pitta-mediated inflammation"),
  bullet("Reduces Ama in channels; improves Agni (Pachaka Pitta function)"),
  bullet("Snigdha quality of Eranda Taila simultaneously nourishes Vata while purging"),
  bullet("Modern evidence: Ricinoleic acid in castor oil has anti-inflammatory properties; purgation eliminates endotoxins and inflammatory mediators"),

  h2("3.6 Basti Karma (Medicated Enema)"),
  body("Basti Karma is universally regarded as the most important Panchakarma procedure for all Vata disorders. Acharya Charaka states: \"Ardha chikitsa\" — Basti is half the treatment for all diseases and the complete treatment for Vata disorders."),
  body("Rationale: Since Vata's primary seat (Moola Sthana) is the Pakvashaya (colon), and the entire Samprapti of Pakshaghata originates from Vata vitiation in the Pakvashaya, Basti directly accesses and treats the root cause."),
  h3("Types of Basti"),
  h4("A. Niruha Basti (Decoction Enema):"),
  body("Contains: Kwatha (herbal decoction), honey, rock salt, Kalka (herbal paste), and medicated oil. Classical formulation for Pakshaghata uses Dashamoola Kwatha as base. Rajayapana Basti — the 'king of Bastis' — is specifically indicated for neurological Vata disorders: ingredients include Bala Kwatha, Shatavari, Ashwagandha, milk, sesame oil, honey, rock salt."),
  h4("B. Anuvasana Basti (Oil Enema):"),
  body("Contains medicated oil alone. Dhanwantaram Taila, Sahacharadi Taila, Balashwagandhadi Taila, Ksheerabala Taila. Matra Basti (60–120 ml) can be given daily; ideal for emaciated patients and chronic Pakshaghata."),
  h4("C. Standard Protocols:"),
  bullet("Karma Basti: 30-session course (alternating Niruha/Anuvasana) — for moderately strong patients"),
  bullet("Kala Basti: 16-session course (6 Anuvasana + 10 Niruha) — standard protocol"),
  bullet("Yoga Basti: 8-session course (3 Anuvasana + 5 Niruha) — for weaker patients"),
  h3("Mode of Action of Basti"),
  bullet("Direct Vata Pacification: Medicated substances contact colonic mucosa (Vata's seat) and pacify Apana Vayu"),
  bullet("Systemic Drug Absorption: Active compounds absorbed through colonic mucosa enter systemic circulation and cross the blood-brain barrier"),
  bullet("Srotoshodhana: Clears Vata-obstructed Srotas throughout the body"),
  bullet("Brimhana Effect: Oil-based Bastis nourish Dhatus depleted by chronic Vata vitiation"),
  bullet("Vatanulomana: Restores proper downward movement of Apana Vata, normalizing all Vata subtypes"),
  bullet("Gut-brain axis modulation: Modifies gut microbiome; influences neuroactive compounds (GABA, serotonin precursors)"),
  bullet("Withanolides from Ashwagandha: Promote nerve regeneration, inhibit acetylcholinesterase, exert neuroprotective effects"),
  h3("Clinical Evidence"),
  body("A clinical study of 10 Pakshaghata patients treated with Abhyanga, Sarvanga Shashtikashali Pinda Sweda, and Rajayapana Basti showed significant improvement in slurred speech, spasticity of upper and lower limbs, pain, and movement."),
  body("JAIMS (2023): A 58-year-old with left Pakshaghata (right MCA territory infarct) treated with Kala Basti + Nasya + Ekangavira Rasa improved from MRC Grade 1 to Grade 4 muscle power over 45 days; became independent in walking with a cane."),

  h2("3.7 Nasya Karma (Nasal Administration)"),
  body("Nasya is the administration of medicated substances through the nasal route. The classical maxim: \"Nasahi Shirasodwaram\" (Charaka Siddhi Sthana 9) — \"the nose is the door to the head\" — establishes the rationale for Nasya in all Urdhvajatrugata (above-the-neck) diseases."),
  h3("Indications in Pakshaghata"),
  bullet("Urdhvajatrugata Vata: involvement of face, eyes, and head"),
  bullet("Speech disorders: dysarthria, aphasia, slurring"),
  bullet("Facial deviation/palsy (Mukha Vakrata)"),
  bullet("Cognitive and memory disturbances associated with Pakshaghata"),
  h3("Types of Nasya"),
  h4("Navana Nasya (Snehana Nasya):"),
  body("Anu Taila or Shadbindu Taila, 4–8 drops per nostril, 7–14 days. Action: Vatanulomana; pacifies Urdhvajatru Vata; nourishes brain and cranial nerves."),
  h4("Avapeedana Nasya (Shodhana Nasya):"),
  body("Vacha powder or Vasa Kalka. Action: removes Margavarana (channel obstruction); Srotoshodhana; allows free Vata movement; regains functionality of affected site."),
  h3("Mode of Action of Nasya"),
  bullet("Olfactory route: Drug molecules travel along olfactory nerve fibers directly to olfactory bulb and frontal cortex"),
  bullet("Trigeminal pathway: Drugs follow trigeminal nerve branches into brainstem and cerebellum"),
  bullet("Vascular pathway: Nasal submucosal vasculature absorbs compounds into systemic circulation"),
  bullet("Perineural pathway: Drugs travel in perineural spaces surrounding cranial nerve fibers"),
  bullet("Navana Nasya nourishes Uttamanga (head — seat of Prana Vayu); Avapeedana Nasya performs Srotoshodhana"),
  body("Modern correlation: Intranasal CNS drug delivery is an active area of neuropharmacological research. Intranasal administration achieves higher CNS concentrations than IV or oral routes. Compounds in Anu Taila have demonstrated neuroprotective and neurotrophic properties."),

  h2("3.8 Summary Table: Panchakarma in Pakshaghata"),
  ...spacer(1),
  makeTable(
    ["Procedure","Primary Indication","Classical Authority","Duration","Key Drugs"],
    [
      ["Snehana (Abhyanga)","All cases — Poorvakarma","Charaka Chi 28","3–7 days pre-Shodhana; ongoing","Mahanarayana, Bala, Dhanwantaram Taila"],
      ["Patra Pinda Sweda","All cases; spasticity","Charaka Chi 28","14–28 days","Medicated leaves, Eranda oil"],
      ["Shashtika Shali Pinda Sweda","Kshayahetuja; weakness","Sushruta","14–21 days","Shashtika rice, Bala Kwatha, milk"],
      ["Vamana","Kaphanubandha type","Vagbhata","Once (3–8 Vega)","Madanaphala, Yashtimadhu"],
      ["Virechana","All types; Pittanubandha primarily","Charaka Chi 28/53","Once; Mridu/Snigdha","Eranda Taila, Trivrit"],
      ["Niruha Basti (Rajayapana)","Primary for all Vata Vyadhi","Charaka Chi 28","Kala/Karma protocol","Dashamoola Kwatha, Bala, milk"],
      ["Anuvasana/Matra Basti","All cases; Kshayahetuja","Charaka","Daily or alternating","Dhanwantaram, Sahacharadi Taila"],
      ["Nasya (Navana)","Speech, facial palsy, Urdhvajatru","Charaka Si 9","7–14 days","Anu Taila, Shadbindu Taila"],
      ["Nasya (Avapeedana)","Kaphaavrita Vata; Margavarana","Vagbhata","7 days","Vacha Churna, Vasa Kalka"],
    ],
    [1500, 1700, 1500, 1200, 3100]
  ),
  ...spacer(1),

  new Paragraph({ children: [new PageBreak()] }),

  // ── SECTION IV ──────────────────────────────────────────────────────────────
  h1("SECTION IV: DISCUSSION"),
  divider(),
  h2("4.1 Mode of Action of Different Procedures — Detailed Analysis"),
  body("The therapeutic efficacy of Panchakarma in Pakshaghata can be understood at multiple levels: (a) Ayurvedic doshic framework, (b) Srotas and Dhatu-level analysis, and (c) modern pharmacological and physiological correlations."),

  h3("Snehana — Detailed Mode of Action"),
  body("The Samprapti of Pakshaghata involves desiccation of Sira and Snayu due to the Ruksha (dry), Khara (rough), and Sheeta (cold) qualities of aggravated Vata. Snehana's primary Gunas — Snigdha (unctuous), Guru (heavy), Ushna (warm) — are precisely opposite to these Vata qualities, providing direct doshic antagonism. This is the principle of Samanya Vishesha — \"opposites heal.\""),
  body("At the Dhatu level, Sneha nourishes depleted Rasa, Rakta, Mamsa, and Majja Dhatus. Lipid-soluble compounds in medicated oils penetrate cell membranes, providing nutritional support to nerve cells and muscle tissue. Modern evidence: sesamol and sesaminol in sesame oil are potent antioxidants. Constituents of Mahanarayana Taila (including Ashwagandha, Bala, and 60+ herbs) have demonstrated neuroprotective, anti-inflammatory, and muscle-relaxant properties."),

  h3("Swedana — Detailed Mode of Action"),
  body("Samana Vayu is responsible for maintaining Agni (metabolic fire). When Vata's Ruksha quality dominates, Samana Vayu's regulation of Sleshakakapha (joint-lubricating Kapha) becomes dysfunctional, resulting in stiffness. Swedana's Ushna quality restores Samana Vayu function and Srotoshoddhi — opening blocked channels (IJAM case study analysis)."),
  body("Modern physiology: Heat application increases local blood flow by 3–4 times through vasodilation, bringing oxygen, nutrients, and immune cells to the area of muscle weakness and spasticity. Heat-induced reduction in muscle spindle activity reduces alpha motor neuron excitability underlying spasticity. Improved proprioceptive afference from warm tissues enhances motor cortex plasticity — a mechanism of neurological recovery."),

  h3("Basti — Detailed Mode of Action"),
  body("The colon (Pakvashaya) is described as the seat of Vata. Modern gastroenterology has identified the \"enteric nervous system\" — an independent neural network in the gut wall comprising over 500 million neurons — the \"second brain.\" The gut-brain axis is a bidirectional communication system through vagal, hormonal, and immune pathways."),
  body("Basti delivers therapeutic agents into the colon where: (1) drug molecules are absorbed through colonic mucosa; (2) active compounds enter systemic circulation and cross the blood-brain barrier; (3) gut microbiome is modulated, altering production of neuroactive compounds (GABA, serotonin, dopamine precursors); (4) anti-inflammatory prostaglandins are modulated through lipid emulsions in oil Bastis; (5) the colonic nervous plexus sends regulatory signals through the vagus nerve to brainstem nuclei."),
  body("Withanolides from Ashwagandha present in Basti formulations have been shown to promote nerve regeneration, inhibit acetylcholinesterase, and exert neuroprotective effects against excitotoxicity — all relevant to stroke recovery."),

  h3("Nasya — Detailed Mode of Action"),
  body("The nose-to-brain pathway is the most direct route for CNS drug delivery. Mechanisms include: (1) Olfactory epithelium pathway — lipophilic drug molecules travel along olfactory nerve axons (CN I) directly to olfactory bulb and frontal cortex; (2) Trigeminal pathway — drugs follow trigeminal nerve branches into brainstem and cerebellum; (3) Vascular pathway — nasal submucosal vasculature absorbs water-soluble compounds; (4) Perineural pathway — drugs travel in perineural spaces surrounding cranial nerve fibers."),
  body("For Pakshaghata specifically, Nasya addresses Prana Vayu dysfunction manifesting as speech impairment, facial palsy, and cognitive disturbances. Delivering neuroprotective and anti-inflammatory compounds directly to the CNS may support neuroplasticity and functional recovery."),

  h3("Virechana — Detailed Mode of Action"),
  body("Therapeutic benefit of Virechana operates through: (1) Rakta Shodhana — reduces neuroinflammation (Pitta = inflammatory mediators in modern terms); (2) Agni restoration — reduces Ama formation; (3) Gut-liver axis modulation — enhances hepatic clearance of metabolic byproducts; (4) Sira Shodhana — purifying Sira corresponds to improvement in cerebrovascular endothelial health; (5) Castor oil's ricinoleic acid activates prostaglandin E3 receptors and modulates intestinal mucosal immune function."),

  h3("Vamana — Detailed Mode of Action"),
  body("In Kaphanubandha Pakshaghata: (1) Eliminates excess Kapha from Amashaya; (2) Reduces Avarana of Vata channels by Kapha; (3) Improves Udana Vayu function — governs speech and upward movement; (4) Reflex vagal stimulation during emesis modulates autonomic nervous system tone; (5) Clears Shleshmavaha Srotas congestion that impedes Vata flow."),

  h2("4.2 Role of Integrated Approach"),
  body("Modern clinical practice employs an integrated approach combining Panchakarma procedures, Samshamana Aushadhi (internal herbal/herbo-mineral medicines), Physiotherapy and occupational therapy, Yoga and Pranayama, dietary management (Pathya-Apathya), and psychological support."),
  body("Clinical evidence supporting integration: The IJAM case study demonstrated Panchakarma + Physiotherapy + Samshamana Aushadhi in a 63-year-old hemorrhagic stroke patient produced remarkable improvement in mobility and speech over 21 days. A 77-year-old male with right hemiplegia treated with Dhanyamladhara, Abhyanga, Shashtika Shali Pinda Sweda, Matra Basti, and Nasya regained the ability to walk without support."),
  body("Ayushdhara case study (52-year-old, Kaphavaranajanya Pakshaghata): Barthel Index improved from 30 to 95 with targeted Panchakarma over 17 days. JAIMS (2023): A 58-year-old improved from MRC Grade 1 to Grade 4 muscle power in 45 days."),

  h2("4.3 Pathya-Apathya (Dietary and Lifestyle Recommendations)"),
  h3("Pathya (Recommended)"),
  h4("Ahara (Diet):"),
  bullet("Black gram, horse gram, green gram — Vata-pacifying legumes"),
  bullet("Onion, garlic, ginger, radish, drumstick (Moringa) — anti-Vata spices"),
  bullet("Sesame seeds, sesame oil, ghee — oleating and nourishing"),
  bullet("Warm, freshly cooked, unctuous food; high-fiber diet (prevents constipation)"),
  h4("Vihara (Lifestyle):"),
  bullet("Regular, gentle physiotherapy exercises; yoga asanas with assistance"),
  bullet("Pranayama: Nadi Shodhana (alternate nostril breathing) — directly pacifies Vata"),
  bullet("Warm, protected environment; avoid cold and wind; adequate rest and sleep"),
  h3("Apathya (To Be Avoided)"),
  bullet("Dry, cold, rough foods; excessive Vata-aggravating foods (peas, raw vegetables, popcorn)"),
  bullet("Alcohol, smoking, excessive exertion, cold water bathing, cold wind exposure"),
  bullet("Emotional stress, anxiety, anger; suppression of natural urges"),
  bullet("Discontinuation of medications without medical advice"),

  h2("4.4 Limitations of Current Research"),
  body("The existing evidence for Ayurvedic management of Pakshaghata, while encouraging, has significant limitations that must be acknowledged:"),
  bullet("Small sample sizes: Most studies are case reports or small case series (n = 10–40). Statistically powered RCTs are lacking"),
  bullet("Substantial bias: The 2025 systematic review by Akashlal et al. (PMID: 39763345) reviewed 30 studies (9 RCTs, 8 non-randomized trials, 13 pre-post studies). All but one exhibited substantial bias using RoB 2 and ROBINS-I tools"),
  bullet("Lack of masking: Most Ayurvedic trials cannot be double-blinded due to procedural nature of Panchakarma, introducing performance and detection bias"),
  bullet("Non-validated outcome tools: Many studies use internally developed scoring systems, making cross-study comparison impossible"),
  bullet("No adverse event documentation: Most studies fail to systematically document adverse events (AEs) and adverse drug reactions (ADRs)"),
  bullet("Confounding factors: Simultaneous use of physiotherapy, diet changes, and multiple formulations makes it difficult to isolate contributions of specific procedures"),
  bullet("Non-standardized protocols: Different Acharyas and different clinical contexts yield different treatment protocols"),
  bullet("Patient heterogeneity: Studies include ischemic/hemorrhagic stroke and traumatic cases without adequate subgroup analysis"),
  body("The systematic review concluded: \"Current review could not definitively establish the efficacy and safety of Ayurvedic interventions in hemiplegia/Pakshaghata. Hence, the authors strongly advocate for good quality research incorporating proper methodology.\""),

  h2("4.5 Scope for Future Research"),
  h3("Clinical Research Priorities"),
  bullet("Large-scale RCTs comparing specific Panchakarma protocols against standard physiotherapy rehabilitation with proper control arms"),
  bullet("Subgroup stratification: Separate trials for ischemic vs. hemorrhagic, acute vs. chronic, and three Ayurvedic types"),
  bullet("Standardized outcome measures: Modified Rankin Scale, Barthel Index, NIHSS, MRC Muscle Power Scale, Fugl-Meyer Assessment"),
  bullet("Multi-center trials pooling data from multiple Ayurvedic hospitals"),
  bullet("Systematic documentation of adverse events in all future trials"),
  h3("Mechanistic Research Priorities"),
  bullet("Pharmacokinetic studies: Document drug absorption through nasal, rectal (Basti), and transdermal (Abhyanga) routes"),
  bullet("Neuroprotection studies: In vitro and in vivo studies on Basti formulations for neuroprotective effects against ischemia-reperfusion injury"),
  bullet("Gut-brain axis research: Microbiome analysis before and after Basti treatment — studying how Basti modulates gut flora"),
  bullet("Neuroimaging studies: fMRI and DTI comparing neural connectivity before and after Panchakarma treatment — objective evidence of neuroplasticity"),
  bullet("Biomarker studies: Track CRP, IL-6, TNF-alpha, oxidative stress markers (MDA, SOD), and neurotrophic factors (BDNF, NGF) during treatment"),
  h3("Translational and Policy Priorities"),
  bullet("Development of evidence-based clinical practice guidelines for Ayurvedic management of Pakshaghata"),
  bullet("Integration of validated Ayurvedic rehabilitation protocols into India's national stroke rehabilitation guidelines"),
  bullet("Collaboration between Ayurvedic institutions and modern stroke rehabilitation centers for integrated care models"),
  bullet("Training programs for standardization of Panchakarma procedures in Pakshaghata management"),

  new Paragraph({ children: [new PageBreak()] }),

  // ── SECTION V ────────────────────────────────────────────────────────────────
  h1("SECTION V: CONCLUSION"),
  divider(),
  body("Pakshaghata (hemiplegia) represents one of the most challenging neurological conditions in both ancient Ayurvedic practice and modern medicine. The study of Pakshaghata through the framework of Ayurveda reveals a remarkably sophisticated, systematic, and clinically coherent understanding of this disease — developed over millennia of careful observation and therapeutic experience."),

  h2("5.1 On the Nature of the Disease"),
  body("The Ayurvedic conceptualization of Pakshaghata as a Nanatmaja Vata Vyadhi — arising exclusively from Vata Dosha vitiation — provides a clear and actionable pathophysiological framework. The identification of Pakvashaya (colon) as the origin point of Vata vitiation, with subsequent desiccation of Sira (blood vessels) and Snayu (nerves and tendons) in one lateral half of the body, precisely maps onto modern neurological understanding of upper motor neuron lesions affecting the corticospinal tract."),
  body("The Samprapti Chakra, proceeding from Nidana Sevana through Sanchaya, Prakopa, Prasara, Sthana Samshraya, Vyakti, to Bheda, provides a dynamic process-based model of disease that enables intervention at multiple time points — a unique strength of the Ayurvedic approach."),

  h2("5.2 On Classification"),
  body("The three-fold classification (Suddha Vataja, Anyadosha Samsrista, and Kshayahetuja) surpasses modern medicine's broad categorization in terms of treatment personalization. The differential diagnostic tools (Upashaya-Anupashaya assessment) allow the clinician to determine specific Samprapti type and select the appropriate Panchakarma sequence. This treatment personalization — matching therapy to pathology — is the hallmark of rational Ayurvedic medicine."),

  h2("5.3 On Panchakarma"),
  body("Each of the Panchakarma procedures contributes uniquely and irreplaceably to the management of Pakshaghata. Snehana reverses the foundational desiccation pathology. Swedana restores Srotas patency and reduces spasticity. Vamana addresses Kaphanubandha by clearing the primary obstruction. Virechana eliminates Pitta-Rakta involvement while simultaneously nourishing Vata. Basti strikes at the very root — treating Vata in its primary seat through multiple mechanisms including direct doshic action, systemic drug delivery, and gut-brain axis modulation. Nasya provides unique direct-to-CNS drug delivery, addressing speech disorders, facial palsy, and cognitive disturbances."),

  h2("5.4 On Evidence and the Path Forward"),
  body("Honesty demands acknowledging that the current body of clinical evidence, while directionally positive, does not yet meet the standards of high-quality evidence required to make definitive efficacy claims. This is a research deficit, not a therapeutic deficit. The optimal management of Pakshaghata in the 21st century likely lies in a thoughtfully integrated model combining modern medicine's strength in acute intervention with Ayurveda's strength in sub-acute and chronic rehabilitation."),
  body("Such integration, validated through rigorous clinical trials using standardized protocols and validated outcome measures, represents the most promising path for reducing the enormous global burden of stroke-related hemiplegia."),
  ...spacer(1),
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  // ── REFERENCES ───────────────────────────────────────────────────────────────
  h1("REFERENCES"),
  divider(),
  body("1.  Charaka Samhita, Sutra Sthana 20 — Nanatmaja Vata Vikaras (80 types of Vata disorders)", { noIndent: true }),
  body("2.  Charaka Samhita, Chikitsa Sthana 28/53-55 — Pakshaghata Chikitsa Sutra", { noIndent: true }),
  body("3.  Charaka Samhita, Siddhi Sthana 9 — Nasya (Nasahi Shirasodwaram)", { noIndent: true }),
  body("4.  Sushruta Samhita, Nidana Sthana — Classification and pathogenesis of Pakshaghata", { noIndent: true }),
  body("5.  Ashtanga Hridayam, Nidana Sthana 15/40-42 — Vagbhata's description", { noIndent: true }),
  body("6.  Madhava Nidana, Chapter 22 — Pakshaghata classification and Samprapti", { noIndent: true }),
  body("7.  Akashlal M, Nair PP, Nair DR et al. A Systematic Review on Safety and Efficacy of Ayurvedic Interventions in Hemiplegia (Pakshaghata). J Evid Based Integr Med. 2025; PMID: 39763345; DOI: 10.1177/2515690X241304523", { noIndent: true }),
  body("8.  Ayurvedic Management of Pakshaghata (Left Hemiplegia) — Case Study. International Journal of Ayurveda and Medical Sciences (IJAM); IJAM Article ID 1954.", { noIndent: true }),
  body("9.  A Conceptual Review on Insights of Pakshaghat (Hemiplegia). AYUSHDHARA. 2025;12(2):264-274.", { noIndent: true }),
  body("10. Pakshaghata — Charak Samhita Online Resource. Available at: carakasamhitaonline.com", { noIndent: true }),
  body("11. Pakshaghata Chikitsa — Ayurvedic Strategies for Hemiplegia & Neuromuscular Rehabilitation. Ask Ayurveda Articles, 2024.", { noIndent: true }),
  body("12. AN AYURVEDIC REVIEW ON PAKSHAGHATA AND ITS MANAGEMENT. JETIR. 2025; Article JETIR2502254.", { noIndent: true }),
  body("13. Ayurvedic Management of Hemiplegia (Pakshaghata) Following Stroke. Arya Vaidya Chikitsalayam & Research Institute (AVCRI), 2025.", { noIndent: true }),
  body("14. Success Story of Pakshagata. AYUSHDHARA Case Study (52-year-old, Barthel Index 30 to 95). Available at: ayushdhara.in", { noIndent: true }),
  body("15. World Health Organization — Global Stroke Statistics. GBD 2019.", { noIndent: true }),
  body("16. Global Burden of Disease Study — Stroke in India. The Lancet Neurology, 2021.", { noIndent: true }),
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Packer.toBuffer(doc).then(buffer => {
  fs.writeFileSync('/home/daytona/workspace/pakshagata-essay/Pakshagata_Ayurveda_Essay.docx', buffer);
  console.log('DONE');
}).catch(e => { console.error(e); process.exit(1); });

cd /home/daytona/workspace/pakshagata-essay && node generate.js 2>&1

cd /home/daytona/workspace/pakshagata-essay && sed -i 's/\u201c/"/g; s/\u201d/"/…

cd /home/daytona/workspace/pakshagata-essay && python3 -c " import re with open(…

cd /home/daytona/workspace/pakshagata-essay && python3 -c " with open('generate.…

python3 /home/daytona/skills/docx/scripts/office/validate.py /home/daytona/works…

ls -lh /home/daytona/workspace/pakshagata-essay/Pakshagata_Ayurveda_Essay.docx &…

~/pakshagata-essay/generate_ppt.js

const pptxgen = require("pptxgenjs");
const pres = new pptxgen();
pres.layout = "LAYOUT_16x9";
pres.title = "Pakshagata in Ayurveda";
pres.author = "Ayurveda Academic";

// ── PALETTE ──────────────────────────────────────────────────────────────────
const C = {
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  mid:     "1B3A5C",  // medium navy – content bg
  accent:  "C8972B",  // warm gold – accent/highlight
  green:   "2E8B57",  // sage green – secondary accent
  light:   "EAF1FB",  // pale blue – light slide bg
  white:   "FFFFFF",
  offwhite:"F5F0E8",  // parchment – body text bg
  body:    "1A1A2E",  // near-black – body text on light
  subtle:  "4A6FA5",  // muted blue – subtext
  red:     "B5451B",  // terracotta – warnings/limitations
};

// ── HELPERS ───────────────────────────────────────────────────────────────────
function darkSlide(slide) {
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}
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}
function accentBar(slide, y = 1.05, w = 10, color = C.accent) {
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function headerBand(slide, color = C.mid) {
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}
function slideTitle(slide, text, color = C.white) {
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function slideNumber(slide, n) {
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}
function bodyText(slide, items, x, y, w, h, opts = {}) {
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}
function card(slide, x, y, w, h, fillColor, text, textColor = C.white, fs = 12) {
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}
function labelBox(slide, x, y, w, h, label, val, labelColor = C.accent, valColor = C.white, bgColor = C.mid) {
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}

// ════════════════════════════════════════════════════════════════════════════
// SLIDE 1 – TITLE
// ════════════════════════════════════════════════════════════════════════════
{
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  s.addShape(pres.ShapeType.ellipse, { x: -0.8, y: 3.8, w: 2.5, h: 2.5, fill: { color: "1B3A5C" }, line: { color: "1B3A5C", width: 0 } });
  // gold accent line
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  // Sanskrit text
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  // Main title
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  s.addShape(pres.ShapeType.rect, { x: 0.6, y: 2.6, w: 2.8, h: 0.06, fill: { color: C.accent }, line: { color: C.accent, width: 0 } });
  s.addText("A Comprehensive Academic Study", { x: 0.5, y: 2.75, w: 9, h: 0.45, fontSize: 13, color: "A0B8D8", fontFace: "Calibri" });
  // topic pills
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  // footer
  s.addText("Sections: I Introduction  |  II Chikitsa Sutra  |  III Panchakarma  |  IV Discussion  |  V Conclusion",
    { x: 0.5, y: 5.1, w: 9, h: 0.4, fontSize: 9, color: C.subtle, fontFace: "Calibri", align: "center" });
}

// ════════════════════════════════════════════════════════════════════════════
// SLIDE 2 – SECTION I: INTRODUCTION (AYURVEDA)
// ════════════════════════════════════════════════════════════════════════════
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  headerBand(s, C.dark);
  sideBar(s, C.accent);
  accentBar(s, 1.1, 10, C.accent);
  slideTitle(s, "SECTION I — Introduction: Ayurvedic Perspective");
  slideNumber(s, 2);
  // Left column
  s.addText("What is Pakshagata?", { x: 0.3, y: 1.25, w: 4.5, h: 0.4, fontSize: 14, bold: true, color: C.mid, fontFace: "Calibri" });
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    "Paksha = one lateral half of the body (left or right)",
    "Ghata / Aghata = destruction, impairment, striking down",
    "= Paralysis of one half of the body (Hemiplegia / Hemiparesis)",
    "Classified among 80 Nanatmaja Vata Vikaras (Charaka, Su.Sta 20)",
    "Also grouped under Mahavatavyadhi - major, severe Vata disorders",
    "An Indriyapradoshaja and Upadhatu Pradoshaja Vikara",
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    { text: "Sushruta Samhita", options: { bold: true, breakLine: true, color: C.white } },
    { text: "Ashtanga Hridayam (Vagbhata)", options: { bold: true, breakLine: true, color: C.white } },
    { text: "Madhava Nidana", options: { bold: true, color: C.white } },
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    "Hemiplegia = complete paralysis of one side",
    "Hemiparesis = partial weakness of one side",
    "Most common cause: Cerebrovascular Stroke (CVA)",
    "Also: Trauma, Brain tumors, MS, Infections",
    "Corticospinal (pyramidal) tract lesion"
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}

// ════════════════════════════════════════════════════════════════════════════
// SLIDE 3 – NIDANA (ETIOLOGY)
// ════════════════════════════════════════════════════════════════════════════
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  headerBand(s, C.mid);
  sideBar(s, C.green);
  accentBar(s, 1.1, 10, C.green);
  slideTitle(s, "Nidana (Etiology) of Pakshagata", C.white);
  slideNumber(s, 3);

  const cats = [
    { label: "Aharaja\n(Dietary)", items: "Dry/cold/rough foods\nIrregular eating\nExcessive fasting\nIncompatible foods\nSuppression of urges", color: C.accent },
    { label: "Viharaja\n(Lifestyle)", items: "Excessive exertion\nSleep deprivation\nExcessive sex\nHeavy lifting\nCold/wind exposure", color: C.subtle },
    { label: "Abhighata\n(Trauma)", items: "Head injury\nShiromarma-ghata\nRoad accidents\nPost-traumatic brain injury", color: C.green },
    { label: "Manasika\n(Psychological)", items: "Excessive fear\nChronic anger\nGrief & anxiety\nProlonged stress", color: "8B4513" },
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}

// ════════════════════════════════════════════════════════════════════════════
// SLIDE 4 – NIDANA PANCHAKA: PURVARUPA & RUPA
// ════════════════════════════════════════════════════════════════════════════
{
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  lightSlide(s);
  headerBand(s, C.dark);
  sideBar(s, C.accent);
  accentBar(s, 1.1, 10, C.accent);
  slideTitle(s, "Purvarupa (Prodrome) & Rupa (Clinical Features)");
  slideNumber(s, 4);

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    "Sphuranam - Fasciculations / twitching in limbs",
    "Toda - Pricking / shooting pain in one side",
    "Supti - Numbness / paresthesia",
    "Angamarda - Body ache, malaise",
    "Balavarna Hani - Loss of strength & complexion",
    "Angasada - Heaviness / lassitude in limbs",
    "Chestahani - Reduced ease of movements",
    "Nidranasha - Disturbed sleep",
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    "Cheshta Nivritti - Complete motor paralysis (one side)",
    "Vaksthambha - Slurred / absent speech (Dysarthria)",
    "Ardhakaya Karmahani - Loss of function, half body",
    "Suptata in Hasta/Pada - Numbness in hand & foot",
    "Mukha Vakrata - Facial deviation / UMN facial palsy",
    "Dysphagia - Difficulty swallowing",
    "Bowel & bladder dysfunction",
    "Depression, confusion, memory disturbances",
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}

// ════════════════════════════════════════════════════════════════════════════
// SLIDE 5 – SAMPRAPTI (PATHOGENESIS)
// ════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
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  sideBar(s, C.accent);
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  s.addText("Samprapti (Pathogenesis) - The Disease Chain", { x: 0.25, y: 0.05, w: 9.5, h: 0.75, fontSize: 20, bold: true, color: C.accent, fontFace: "Calibri", valign: "middle" });
  slideNumber(s, 5);

  // Shloka
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  s.addText('"Ekam pakvashayastham tu shariram ardhakam param | Sirasnayukandaragatah pakshaghataya Kurute ||" — Charaka Samhita, Chi.28/53',
    { x: 0.4, y: 0.98, w: 9.2, h: 0.78, fontSize: 10, italic: true, color: C.accent, fontFace: "Calibri", valign: "middle", align: "center" });

  // Flowchart steps
  const steps = [
    { n: "1", label: "Nidana Sevana", desc: "Exposure to causative factors", color: C.red },
    { n: "2", label: "Vata Prakopa in Pakvashaya", desc: "Aggravation in colon (primary seat)", color: "B5451B" },
    { n: "3", label: "Vata Prasara", desc: "Spreads to Sira, Snayu, Kandara", color: C.accent },
    { n: "4", label: "Sthana Samshraya", desc: "Lodges in one Paksha; Purvarupa appear", color: C.green },
    { n: "5", label: "Vyakti", desc: "Full paralysis, speech loss, sensory deficit", color: C.subtle },
    { n: "6", label: "Bheda", desc: "Chronicity, contractures, complications", color: "5A5A8A" },
  ];
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    s.addShape(pres.ShapeType.ellipse, { x: x + 0.08, y: y + 0.22, w: 0.55, h: 0.55, fill: { color: st.color }, line: { color: st.color, width: 0 } });
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    s.addText(st.label, { x: x + 0.72, y: y + 0.08, w: 3.7, h: 0.4, fontSize: 12, bold: true, color: C.white, fontFace: "Calibri", valign: "middle" });
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  });
}

// ════════════════════════════════════════════════════════════════════════════
// SLIDE 6 – CLASSIFICATION
// ════════════════════════════════════════════════════════════════════════════
{
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  lightSlide(s);
  headerBand(s, C.dark);
  sideBar(s, C.green);
  accentBar(s, 1.1, 10, C.green);
  slideTitle(s, "Classification of Pakshagata");
  slideNumber(s, 6);

  const types = [
    {
      title: "1. Suddha Vataja",
      sub: "Pure Vata vitiation",
      desc: "Vata aggravated by its own causative factors. Features: dryness, cold, motor weakness, constipation.",
      prog: "Krichhrasadhya\n(treatable with effort)",
      color: C.accent
    },
    {
      title: "2. Anyadosha Samsrista",
      sub: "Vata + other Dosha",
      desc: "Pittanubandha: burning, fever, syncope. Kaphanubandha: swelling, heaviness, coldness.",
      prog: "Yapya\n(manageable, not curable)",
      color: C.subtle
    },
    {
      title: "3. Kshayahetuja",
      sub: "Due to Dhatu Kshaya (tissue depletion)",
      desc: "Secondary to severe depletion. Features: emaciation, cachexia, debility, progressive weakness.",
      prog: "Asadhya\n(very difficult to treat)",
      color: C.red
    },
  ];
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    s.addText(t.title, { x: x+0.08, y: 1.22, w: 2.95, h: 0.32, fontSize: 12, bold: true, color: C.white, fontFace: "Calibri", align: "center", valign: "middle" });
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}

// ════════════════════════════════════════════════════════════════════════════
// SLIDE 7 – INCIDENCE & PREVALENCE
// ════════════════════════════════════════════════════════════════════════════
{
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  darkSlide(s);
  sideBar(s, C.accent);
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 0.85, fill: { color: C.mid }, line: { color: C.mid, width: 0 } });
  s.addText("Incidence & Prevalence of Pakshagata / Hemiplegia", { x: 0.25, y: 0.05, w: 9.5, h: 0.75, fontSize: 18, bold: true, color: C.accent, fontFace: "Calibri", valign: "middle" });
  slideNumber(s, 7);

  // Stat cards
  const stats = [
    { val: "33 Million", label: "Global stroke cases annually (WHO)" },
    { val: "2/3", label: "Of all strokes occur in developing countries" },
    { val: "1.5-2M", label: "New stroke cases per year in India" },
    { val: "200/100,000", label: "Hemiplegia prevalence in India (crude rate)" },
  ];
  stats.forEach((st, i) => {
    const x = 0.3 + i * 2.35;
    s.addShape(pres.ShapeType.roundRect, { x, y: 1.0, w: 2.1, h: 1.4, fill: { color: C.mid }, line: { color: C.accent, width: 1.5 }, rectRadius: 0.1 });
    s.addText(st.val, { x: x+0.05, y: 1.05, w: 2.0, h: 0.7, fontSize: 20, bold: true, color: C.accent, fontFace: "Calibri", align: "center", valign: "middle" });
    s.addText(st.label, { x: x+0.05, y: 1.72, w: 2.0, h: 0.6, fontSize: 9, color: "A0B8D8", fontFace: "Calibri", align: "center", valign: "top" });
  });

  // Risk factors
  s.addText("Key Risk Factors (Modern)", { x: 0.3, y: 2.6, w: 4.5, h: 0.4, fontSize: 13, bold: true, color: C.accent, fontFace: "Calibri" });
  bodyText(s, [
    "Hypertension (single largest risk factor)",
    "Diabetes mellitus & Dyslipidemia",
    "Atrial fibrillation / cardiac disease",
    "Cigarette smoking & obesity",
    "Age > 55 years, Prior TIA",
  ], 0.3, 3.02, 4.5, 2.4, { fs: 11, color: "B8CCE4" });

  s.addText("Ayurvedic Epidemiology", { x: 5.2, y: 2.6, w: 4.5, h: 0.4, fontSize: 13, bold: true, color: C.green, fontFace: "Calibri" });
  bodyText(s, [
    "Populations with Vata-aggravating lifestyles most vulnerable",
    "Irregular food, excessive exertion, chronic stress",
    "Cold, dry, windy climates increase risk",
    "Directly maps onto modern stroke risk populations",
    "Prevention through Dinacharya & Ritucharya (daily/seasonal regimens)",
  ], 5.2, 3.02, 4.5, 2.4, { fs: 11, color: "B8CCE4" });
}

// ════════════════════════════════════════════════════════════════════════════
// SLIDE 8 – SECTION II: CHIKITSA SUTRA
// ════════════════════════════════════════════════════════════════════════════
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  const s = pres.addSlide();
  lightSlide(s);
  headerBand(s, C.dark);
  sideBar(s, C.accent);
  accentBar(s, 1.1, 10, C.accent);
  slideTitle(s, "SECTION II — Chikitsa Sutra: Treatment Aphorisms");
  slideNumber(s, 8);

  // Main shloka
  s.addShape(pres.ShapeType.roundRect, { x: 0.25, y: 1.2, w: 9.5, h: 0.9, fill: { color: C.mid }, line: { color: C.accent, width: 1.5 }, rectRadius: 0.1 });
  s.addText('"Pakshaghatam tatha hanustambham ardita eva cha | Vatavyadhir bahuvidhah shodhyah snehana poorvakam ||"',
    { x: 0.4, y: 1.25, w: 9.2, h: 0.56, fontSize: 11.5, italic: true, color: C.accent, fontFace: "Calibri", valign: "middle", align: "center" });
  s.addText("— Charaka Samhita, Chikitsa Sthana 28/53-55: Treat with Shodhana PRECEDED by Snehana",
    { x: 0.4, y: 1.78, w: 9.2, h: 0.28, fontSize: 9.5, color: "A0B8D8", fontFace: "Calibri", align: "center" });

  // Acharya comparison
  const acharyas = [
    { name: "Charaka", sutra: "Snehana + Swedana + Virechana (Mridu)", emphasis: "Sequential: Oleation then gentle purification" },
    { name: "Sushruta", sutra: "Snehana, Swedana, Basti, Nasya", emphasis: "Patient selection criteria; Comprehensive approach" },
    { name: "Vagbhata", sutra: "Snehana, Basti (primary), Nasya", emphasis: "Srotas Shodhana; Basti supremacy for Vata" },
    { name: "Madhavakara", sutra: "Type-specific treatment", emphasis: "Personalized Dosha-based approach" },
  ];
  acharyas.forEach((a, i) => {
    const x = 0.2 + i * 2.38;
    s.addShape(pres.ShapeType.roundRect, { x, y: 2.25, w: 2.2, h: 3.15, fill: { color: C.dark }, line: { color: C.accent, width: 1.5 }, rectRadius: 0.1 });
    s.addShape(pres.ShapeType.rect, { x, y: 2.25, w: 2.2, h: 0.45, fill: { color: C.accent }, line: { color: C.accent, width: 0 } });
    s.addText("Acharya " + a.name, { x: x+0.05, y: 2.27, w: 2.1, h: 0.41, fontSize: 11, bold: true, color: C.dark, fontFace: "Calibri", align: "center", valign: "middle" });
    s.addText("Sutra:", { x: x+0.1, y: 2.75, w: 2.0, h: 0.28, fontSize: 9.5, bold: true, color: C.accent, fontFace: "Calibri" });
    s.addText(a.sutra, { x: x+0.1, y: 3.02, w: 2.0, h: 1.1, fontSize: 10, color: C.white, fontFace: "Calibri", valign: "top", margin: 2 });
    s.addShape(pres.ShapeType.rect, { x: x+0.1, y: 4.12, w: 2.0, h: 0.04, fill: { color: C.subtle }, line: { color: C.subtle, width: 0 } });
    s.addText(a.emphasis, { x: x+0.1, y: 4.2, w: 2.0, h: 1.05, fontSize: 9.5, color: "7090B0", fontFace: "Calibri", italic: true, valign: "top", margin: 2 });
  });
}

// ════════════════════════════════════════════════════════════════════════════
// SLIDE 9 – MODERN TREATMENT
// ════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  lightSlide(s);
  headerBand(s, C.mid);
  sideBar(s, C.subtle);
  accentBar(s, 1.1, 10, C.subtle);
  slideTitle(s, "Modern Line of Treatment & Limitations", C.white);
  slideNumber(s, 9);

  const phases = [
    {
      phase: "Acute Phase (0-72 hrs)",
      items: ["IV tPA thrombolysis (within 4.5 hrs)", "Mechanical thrombectomy (large vessel)", "Hemorrhagic: Neurosurgery + BP control", "DVT & aspiration pneumonia prevention"],
      color: C.red
    },
    {
      phase: "Sub-acute Phase (weeks)",
      items: ["Physiotherapy: ROM, gait training", "Occupational therapy: ADL training", "Speech & language therapy", "Spasticity: Baclofen, Botulinum toxin"],
      color: C.accent
    },
    {
      phase: "Chronic Rehab Phase",
      items: ["CIMT - Constraint-induced movement therapy", "Mirror therapy, NMES", "Robot-assisted rehabilitation", "Virtual reality therapy"],
      color: C.green
    },
  ];
  phases.forEach((p, i) => {
    const x = 0.2 + i * 3.25;
    s.addShape(pres.ShapeType.roundRect, { x, y: 1.2, w: 3.0, h: 3.0, fill: { color: C.light }, line: { color: p.color, width: 2 }, rectRadius: 0.1 });
    s.addShape(pres.ShapeType.rect, { x, y: 1.2, w: 3.0, h: 0.5, fill: { color: p.color }, line: { color: p.color, width: 0 } });
    s.addText(p.phase, { x: x+0.05, y: 1.22, w: 2.9, h: 0.46, fontSize: 11, bold: true, color: C.white, fontFace: "Calibri", align: "center", valign: "middle" });
    bodyText(s, p.items, x+0.1, 1.75, 2.8, 2.3, { fs: 10.5, color: C.body, bullet: "2022" });
  });

  // Limitations box
  s.addShape(pres.ShapeType.roundRect, { x: 0.2, y: 4.3, w: 9.6, h: 1.1, fill: { color: "FFF0EC" }, line: { color: C.red, width: 2 }, rectRadius: 0.1 });
  s.addText("Limitations of Modern Management:", { x: 0.35, y: 4.35, w: 2.8, h: 0.38, fontSize: 11, bold: true, color: C.red, fontFace: "Calibri" });
  s.addText("Acute thrombolysis window missed in most developing-country patients  |  No drug reliably reverses established neurological deficits  |  Rehabilitation is resource-intensive & often inaccessible  |  This gap is where Ayurvedic Panchakarma offers meaningful potential",
    { x: 0.35, y: 4.72, w: 9.3, h: 0.6, fontSize: 10, color: C.red, fontFace: "Calibri", valign: "top" });
}

// ════════════════════════════════════════════════════════════════════════════
// SLIDE 10 – SECTION III: PANCHAKARMA OVERVIEW
// ════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  darkSlide(s);
  sideBar(s, C.green);
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 0.85, fill: { color: C.mid }, line: { color: C.mid, width: 0 } });
  s.addText("SECTION III — Panchakarma Procedures in Pakshagata", { x: 0.25, y: 0.05, w: 9.5, h: 0.75, fontSize: 18, bold: true, color: C.green, fontFace: "Calibri", valign: "middle" });
  slideNumber(s, 10);

  s.addText("Rationale: Samprapti Vighatana — Breaking the Chain of Pathogenesis", { x: 0.2, y: 0.95, w: 9.6, h: 0.38, fontSize: 12, bold: true, italic: true, color: C.accent, fontFace: "Calibri", align: "center" });

  const procs = [
    { name: "SNEHANA", sub: "Oleation", role: "Reverses Ruksha quality of Vata; nourishes Sira & Snayu", color: C.accent },
    { name: "SWEDANA", sub: "Fomentation", role: "Opens blocked Srotas; reduces spasticity; improves circulation", color: C.green },
    { name: "VAMANA", sub: "Emesis", role: "Removes Kapha obstruction; specific for Kaphanubandha type", color: "8B4513" },
    { name: "VIRECHANA", sub: "Purgation", role: "Eliminates Pitta-Rakta involvement; Mridu/Snigdha form used", color: C.subtle },
    { name: "BASTI", sub: "Medicated Enema", role: "PRIMARY treatment; addresses Vata at its seat (Pakvashaya)", color: C.red },
    { name: "NASYA", sub: "Nasal Administration", role: "Direct CNS drug delivery; speech, facial palsy, cognition", color: "9B59B6" },
  ];
  procs.forEach((p, i) => {
    const col = i % 3;
    const row = Math.floor(i / 3);
    const x = 0.2 + col * 3.25;
    const y = 1.45 + row * 1.95;
    s.addShape(pres.ShapeType.roundRect, { x, y, w: 3.1, h: 1.75, fill: { color: C.mid }, line: { color: p.color, width: 2 }, rectRadius: 0.1 });
    s.addShape(pres.ShapeType.rect, { x, y, w: 3.1, h: 0.48, fill: { color: p.color }, line: { color: p.color, width: 0 } });
    s.addText(p.name, { x: x+0.05, y: y+0.02, w: 2.2, h: 0.44, fontSize: 14, bold: true, color: C.white, fontFace: "Calibri", valign: "middle" });
    s.addText(p.sub, { x: x+2.2, y: y+0.1, w: 0.85, h: 0.3, fontSize: 8.5, color: C.dark, fontFace: "Calibri", italic: true, valign: "middle" });
    s.addText(p.role, { x: x+0.1, y: y+0.55, w: 2.9, h: 1.12, fontSize: 10, color: "A0B8D8", fontFace: "Calibri", valign: "top", margin: 4 });
  });
}

// ════════════════════════════════════════════════════════════════════════════
// SLIDE 11 – SNEHANA & SWEDANA
// ════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  lightSlide(s);
  headerBand(s, C.dark);
  sideBar(s, C.accent);
  accentBar(s, 1.1, 10, C.accent);
  slideTitle(s, "Snehana (Oleation) & Swedana (Fomentation)");
  slideNumber(s, 11);

  // Snehana
  s.addText("SNEHANA", { x: 0.25, y: 1.2, w: 4.6, h: 0.4, fontSize: 14, bold: true, color: C.accent, fontFace: "Calibri" });
  s.addText("Abhyantara (Internal):", { x: 0.25, y: 1.62, w: 4.5, h: 0.3, fontSize: 11, bold: true, color: C.mid, fontFace: "Calibri" });
  bodyText(s, [
    "Medicated ghee (Ashwagandha Ghrita, Panchatikta Ghrita, Dhanwantaram Ghritam)",
    "3-7 days gradually increasing doses; until Samyak Snigdha Lakshanas",
  ], 0.25, 1.92, 4.5, 1.0, { fs: 10.5, color: C.body, bullet: "2022" });
  s.addText("Bahya (External):", { x: 0.25, y: 2.92, w: 4.5, h: 0.3, fontSize: 11, bold: true, color: C.mid, fontFace: "Calibri" });
  bodyText(s, [
    "Sarvanga Abhyanga - Full body massage (Mahanarayana, Bala, Dhanwantaram Taila)",
    "Pizhichil - Continuous warm oil pour; combines Snehana + Swedana",
    "Mode of action: Snigdha/Ushna gunas counter Vata's Ruksha/Sheeta qualities",
  ], 0.25, 3.22, 4.5, 2.0, { fs: 10.5, color: C.body, bullet: "2022" });

  // Divider
  s.addShape(pres.ShapeType.rect, { x: 5.05, y: 1.15, w: 0.04, h: 4.3, fill: { color: C.accent }, line: { color: C.accent, width: 0 } });

  // Swedana
  s.addText("SWEDANA", { x: 5.2, y: 1.2, w: 4.5, h: 0.4, fontSize: 14, bold: true, color: C.green, fontFace: "Calibri" });
  bodyText(s, [
    "Bashpa Sveda - Full body medicated steam bath (10-20 min post-Abhyanga)",
    "Patra Pinda Sweda (Ela Kizhi) - Herbal leaf bolus; combines Snehana + Swedana; best for spasticity",
    "Shashtika Shali Pinda Sweda (Njavarakizhi) - Rice bolus; nourishing; ideal for emaciated patients",
    "Nadi Sweda - Directed steam for localized spasticity/contractures",
    "Jambira Pinda Sweda - Lemon bolus; for pain and tingling",
    "Mode of action: Opens Srotas; Amapachana; heat reduces muscle spindle excitability (reduces spasticity)",
  ], 5.2, 1.65, 4.55, 3.7, { fs: 10.5, color: C.body, bullet: "2022" });
}

// ════════════════════════════════════════════════════════════════════════════
// SLIDE 12 – VAMANA & VIRECHANA
// ════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  lightSlide(s);
  headerBand(s, C.dark);
  sideBar(s, C.subtle);
  accentBar(s, 1.1, 10, C.subtle);
  slideTitle(s, "Vamana (Emesis) & Virechana (Purgation)");
  slideNumber(s, 12);

  // Vamana
  s.addShape(pres.ShapeType.roundRect, { x: 0.2, y: 1.2, w: 4.6, h: 4.2, fill: { color: C.light }, line: { color: "8B4513", width: 2 }, rectRadius: 0.1 });
  s.addShape(pres.ShapeType.rect, { x: 0.2, y: 1.2, w: 4.6, h: 0.5, fill: { color: "8B4513" }, line: { color: "8B4513", width: 0 } });
  s.addText("VAMANA (Therapeutic Emesis)", { x: 0.25, y: 1.22, w: 4.5, h: 0.46, fontSize: 12, bold: true, color: C.white, fontFace: "Calibri", align: "center", valign: "middle" });
  s.addText("Indications:", { x: 0.35, y: 1.78, w: 4.3, h: 0.3, fontSize: 11, bold: true, color: "8B4513", fontFace: "Calibri" });
  bodyText(s, ["Kaphanubandha Pakshaghata", "Features of Kapha excess: swelling, heaviness, cold", "Associated Kapha conditions: obesity, asthma, sinusitis"], 0.35, 2.08, 4.3, 1.2, { fs: 10.5, color: C.body, bullet: "2022" });
  s.addText("Drug: Madanaphala in Yashtimadhu decoction\nDuration: 4-8 Vega (emesis episodes)\nContraindicated: Pure Vataja, emaciation, hemorrhagic stroke",
    { x: 0.35, y: 3.35, w: 4.3, h: 1.15, fontSize: 10.5, color: C.body, fontFace: "Calibri", valign: "top", margin: 4 });
  s.addText("Mode of action: Removes Kapha obstruction; improves Udana Vayu (governs speech); modulates autonomic tone via vagal reflex",
    { x: 0.35, y: 4.52, w: 4.3, h: 0.75, fontSize: 10, color: C.subtle, fontFace: "Calibri", italic: true, valign: "top", margin: 2 });

  // Virechana
  s.addShape(pres.ShapeType.roundRect, { x: 5.1, y: 1.2, w: 4.65, h: 4.2, fill: { color: C.light }, line: { color: C.subtle, width: 2 }, rectRadius: 0.1 });
  s.addShape(pres.ShapeType.rect, { x: 5.1, y: 1.2, w: 4.65, h: 0.5, fill: { color: C.subtle }, line: { color: C.subtle, width: 0 } });
  s.addText("VIRECHANA (Therapeutic Purgation)", { x: 5.15, y: 1.22, w: 4.55, h: 0.46, fontSize: 12, bold: true, color: C.white, fontFace: "Calibri", align: "center", valign: "middle" });
  s.addText("Indications:", { x: 5.2, y: 1.78, w: 4.4, h: 0.3, fontSize: 11, bold: true, color: C.subtle, fontFace: "Calibri" });
  bodyText(s, ["All types - part of Samshodhana protocol", "Specifically: Pittanubandha Pakshaghata", "Sira (blood vessel) involvement - Rakta Dhatu Shodhana", "Majjavaha Srotas involvement (Majja-Pitta shared Dhara Kala)"], 5.2, 2.08, 4.4, 1.35, { fs: 10.5, color: C.body, bullet: "2022" });
  s.addText("Key Drug: Eranda Taila (Castor Oil)\n15-30ml in warm water/milk; Snigdha quality pacifies Vata while purging\nAlso: Trivrit, Gandharvaharitaki\nMust be Mridu/Snigdha (gentle, nourishing) - NOT harsh Tikshna purgation",
    { x: 5.2, y: 3.45, w: 4.4, h: 1.2, fontSize: 10.5, color: C.body, fontFace: "Calibri", valign: "top", margin: 4 });
  s.addText("Mode of action: Rakta Shodhana reduces neuroinflammation; Agni restoration; Ricinoleic acid is anti-inflammatory (modern evidence)",
    { x: 5.2, y: 4.68, w: 4.4, h: 0.6, fontSize: 10, color: C.subtle, fontFace: "Calibri", italic: true, valign: "top", margin: 2 });
}

// ════════════════════════════════════════════════════════════════════════════
// SLIDE 13 – BASTI KARMA
// ════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  darkSlide(s);
  sideBar(s, C.red);
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 0.85, fill: { color: C.mid }, line: { color: C.mid, width: 0 } });
  s.addText("BASTI KARMA — The Most Important Panchakarma for Pakshagata", { x: 0.25, y: 0.05, w: 9.5, h: 0.75, fontSize: 16, bold: true, color: C.red, fontFace: "Calibri", valign: "middle" });
  slideNumber(s, 13);

  s.addShape(pres.ShapeType.roundRect, { x: 0.2, y: 0.95, w: 9.6, h: 0.62, fill: { color: "1B3A5C" }, line: { color: C.accent, width: 1 }, rectRadius: 0.08 });
  s.addText('"Ardha chikitsa" — Basti is half the treatment for all diseases and COMPLETE treatment for Vata disorders (Acharya Charaka)\nRationale: Vatas primary seat (Moola Sthana) is the Pakvashaya (colon) — Basti strikes at the root of Pakshaghata',
    { x: 0.35, y: 0.98, w: 9.3, h: 0.56, fontSize: 10, italic: true, color: C.accent, fontFace: "Calibri", valign: "middle", align: "center" });

  // Types
  const types = [
    { name: "Niruha Basti\n(Decoction Enema)", desc: "Dashamoola Kwatha base\nRajayapana Basti - king of Bastis\nIncludes: Bala, Shatavari, Ashwagandha, milk, sesame oil\nPrimary: Srotas Shodhana + Dosha elimination", color: C.accent },
    { name: "Anuvasana Basti\n(Oil Enema)", desc: "Dhanwantaram, Sahacharadi, Ksheerabala Taila\nMatra Basti (60-120ml) - daily, for emaciated patients\nNourishes Sira & Snayu; deeply pacifies Vata\nRetained and absorbed - no Paschatkarma required", color: C.green },
    { name: "Standard\nProtocols", desc: "Karma Basti: 30 sessions (alternating Niruha/Anuvasana)\nKala Basti: 16 sessions (6+10) - standard protocol\nYoga Basti: 8 sessions (3+5) - for weaker patients\nShirodhara: For neurological/psychological features", color: C.subtle },
  ];
  types.forEach((t, i) => {
    const x = 0.2 + i * 3.25;
    s.addShape(pres.ShapeType.roundRect, { x, y: 1.68, w: 3.1, h: 2.5, fill: { color: C.mid }, line: { color: t.color, width: 2 }, rectRadius: 0.1 });
    s.addShape(pres.ShapeType.rect, { x, y: 1.68, w: 3.1, h: 0.52, fill: { color: t.color }, line: { color: t.color, width: 0 } });
    s.addText(t.name, { x: x+0.05, y: 1.7, w: 3.0, h: 0.48, fontSize: 11, bold: true, color: C.white, fontFace: "Calibri", align: "center", valign: "middle" });
    s.addText(t.desc, { x: x+0.1, y: 2.25, w: 2.9, h: 1.8, fontSize: 10, color: "B8CCE4", fontFace: "Calibri", valign: "top", margin: 4 });
  });

  // Mode of action
  s.addText("Mode of Action of Basti:", { x: 0.2, y: 4.28, w: 2.4, h: 0.3, fontSize: 11, bold: true, color: C.accent, fontFace: "Calibri" });
  const moa = ["Direct Vata pacification at colonic mucosa (Apana Vayu)","Systemic absorption of neuroactive compounds (crosses BBB)","Gut-brain axis modulation (500M enteric neurons - the second brain)","Gut microbiome modulation -> neuroactive compounds (GABA, serotonin)","Withanolides from Ashwagandha: nerve regeneration + neuroprotection"];
  s.addText(moa.map(m => "  " + m).join("\n"), { x: 0.2, y: 4.58, w: 9.6, h: 0.95, fontSize: 9.5, color: "A0B8D8", fontFace: "Calibri", valign: "top" });
}

// ════════════════════════════════════════════════════════════════════════════
// SLIDE 14 – NASYA KARMA
// ════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  lightSlide(s);
  headerBand(s, C.dark);
  sideBar(s, "9B59B6");
  accentBar(s, 1.1, 10, "9B59B6");
  slideTitle(s, "Nasya Karma — Nasal Administration for Urdhvajatrugata Vata");
  slideNumber(s, 14);

  s.addShape(pres.ShapeType.roundRect, { x: 0.2, y: 1.18, w: 9.6, h: 0.6, fill: { color: C.mid }, line: { color: "9B59B6", width: 1 }, rectRadius: 0.08 });
  s.addText('"Nasahi Shirasodwaram" — The nose is the door to the head (Charaka Siddhi Sthana 9)',
    { x: 0.3, y: 1.21, w: 9.4, h: 0.54, fontSize: 12, italic: true, bold: true, color: C.accent, fontFace: "Calibri", align: "center", valign: "middle" });

  // Indications
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    "Navana Nasya (Snehana): Anu Taila / Shadbindu Taila; 4-8 drops/nostril; 7-14 days; Vatanulomana, nourishes cranial nerves",
    "Avapeedana Nasya (Shodhana): Vacha Churna / Vasa Kalka; Removes Margavarana; Srotoshodhana",
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}

// ════════════════════════════════════════════════════════════════════════════
// SLIDE 15 – SECTION IV: DISCUSSION – MODE OF ACTION
// ════════════════════════════════════════════════════════════════════════════
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    { proc: "Snehana", ayur: "Snigdha/Ushna Gunas counter Vata's Ruksha/Sheeta. Nourishes Sira, Snayu, Majja Dhatu at tissue level.", mod: "Sesamol & sesaminol (sesame oil) = potent CNS antioxidants. Ashwagandha = neuroprotective, anti-inflammatory.", color: C.accent },
    { proc: "Swedana", ayur: "Samana Vayu restoration; Srotoshuddhi; Amapachana in channels. Relieves Stambha (stiffness).", mod: "Heat increases local blood flow 3-4x. Reduces alpha motor neuron excitability (spasticity). Improves motor cortex plasticity.", color: C.green },
    { proc: "Basti", ayur: "Treats Vata at Moola Sthana (Pakvashaya). Vatanulomana restores all Vata subtypes. Brimhana through oil.", mod: "Enteric nervous system (500M neurons = second brain). Gut-brain axis: vagal, hormonal, immune pathways. Ashwagandha withanolides cross BBB.", color: C.red },
    { proc: "Nasya", ayur: "Addresses Prana Vayu dysfunction. Nourishes Uttamanga. Avapeedana removes Margavarana in Srotas.", mod: "Nose-to-brain pathway bypasses blood-brain barrier. Olfactory/trigeminal/perivascular routes. Higher CNS drug levels than IV.", color: "9B59B6" },
    { proc: "Virechana", ayur: "Rakta Shodhana (Pitta = neuroinflammation). Agni restoration reduces Ama. Sira Shodhana (vessel purification).", mod: "Ricinoleic acid (castor oil): anti-inflammatory prostaglandin modulation. Gut-liver axis: hepatic clearance of toxic metabolites.", color: C.subtle },
    { proc: "Vamana", ayur: "Removes Kapha obstruction from Amashaya. Restores Udana Vayu (speech, upward movement). Clears Shleshmavaha Srotas.", mod: "Eliminates inflammatory mediators from upper GI. Vagal stimulation modulates autonomic NS tone.", color: "8B4513" },
  ];
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  });
}

// ════════════════════════════════════════════════════════════════════════════
// SLIDE 16 – PATHYA-APATHYA & INTEGRATED APPROACH
// ════════════════════════════════════════════════════════════════════════════
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  lightSlide(s);
  headerBand(s, C.dark);
  sideBar(s, C.green);
  accentBar(s, 1.1, 10, C.green);
  slideTitle(s, "Pathya-Apathya & Integrated Approach — Clinical Evidence");
  slideNumber(s, 16);

  // Pathya
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  s.addText("PATHYA (Recommended)", { x: 0.25, y: 1.22, w: 2.9, h: 0.44, fontSize: 11, bold: true, color: C.white, fontFace: "Calibri", align: "center", valign: "middle" });
  bodyText(s, ["Black gram, horse gram, green gram", "Garlic, ginger, onion, radish", "Sesame oil, ghee (oleating foods)", "Warm, freshly cooked unctuous food", "High fiber diet", "Yoga + Pranayama (Nadi Shodhana)", "Regular physiotherapy exercises"], 0.3, 1.72, 2.8, 3.55, { fs: 10, color: C.body, bullet: "2714" });

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  s.addText("APATHYA (Avoid)", { x: 3.45, y: 1.22, w: 2.9, h: 0.44, fontSize: 11, bold: true, color: C.white, fontFace: "Calibri", align: "center", valign: "middle" });
  bodyText(s, ["Dry, cold, rough foods", "Excessive fasting / starvation", "Alcohol and cigarette smoking", "Cold water bathing, cold winds", "Excessive physical exertion", "Chronic stress, anger, anxiety", "Suppression of natural urges"], 3.5, 1.72, 2.8, 3.55, { fs: 10, color: C.body, bullet: "2718" });

  // Clinical Evidence
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  s.addText([
    { text: "Case 1:", options: { bold: true, color: C.mid, breakLine: true } },
    { text: "63yr male, hemorrhagic stroke. Panchakarma + Physiotherapy x21 days. Remarkable recovery in speech & mobility.", options: { color: C.body, breakLine: true } },
    { text: "Case 2:", options: { bold: true, color: C.mid, breakLine: true } },
    { text: "77yr male, right hemiplegia. Abhyanga + Shashtika Sweda + Basti + Nasya. Walked without support at discharge.", options: { color: C.body, breakLine: true } },
    { text: "Case 3:", options: { bold: true, color: C.mid, breakLine: true } },
    { text: "52yr male, Kaphaavarana type. Barthel Index 30 -> 95 in 17 days of targeted Panchakarma.", options: { color: C.body, breakLine: true } },
    { text: "JAIMS 2023:", options: { bold: true, color: C.mid, breakLine: true } },
    { text: "58yr, Kala Basti + Nasya. MRC Grade 1 -> Grade 4 over 45 days. Independent ambulation.", options: { color: C.body } },
  ], { x: 6.68, y: 1.72, w: 3.05, h: 3.55, fontSize: 9.5, fontFace: "Calibri", valign: "top", margin: 4 });
}

// ════════════════════════════════════════════════════════════════════════════
// SLIDE 17 – LIMITATIONS & SCOPE FOR RESEARCH
// ════════════════════════════════════════════════════════════════════════════
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  const s = pres.addSlide();
  lightSlide(s);
  headerBand(s, C.dark);
  sideBar(s, C.red);
  accentBar(s, 1.1, 10, C.red);
  slideTitle(s, "Limitations of Current Research & Scope for Future Work");
  slideNumber(s, 17);

  // Systematic review callout
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  s.addText('"Current review could not definitively establish the efficacy and safety of Ayurvedic interventions in hemiplegia. Authors strongly advocate for good quality research." — J Evid Based Integr Med 2025',
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    "Small sample sizes; no adequately powered RCTs",
    "All but one study showed substantial bias (RoB 2/ROBINS-I tools)",
    "Cannot double-blind Panchakarma procedures",
    "Non-validated outcome measurement tools",
    "No systematic adverse event documentation",
    "Non-standardized protocols across institutions",
    "Patient heterogeneity (ischemic/hemorrhagic/traumatic mixed)",
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    "Large-scale RCTs with proper control arms",
    "Subgroup stratification: ischemic vs hemorrhagic, acute vs chronic",
    "Validated outcome tools: mRS, NIHSS, Fugl-Meyer, Barthel Index",
    "Gut-brain axis research: microbiome analysis pre/post Basti",
    "fMRI & DTI neuroimaging to document neuroplasticity",
    "Biomarkers: CRP, IL-6, TNF-alpha, BDNF, NGF during treatment",
    "Integration with national stroke rehabilitation guidelines",
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}

// ════════════════════════════════════════════════════════════════════════════
// SLIDE 18 – SECTION V: CONCLUSION
// ════════════════════════════════════════════════════════════════════════════
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  sideBar(s, C.accent);
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  const points = [
    { icon: "1", text: "Pakshaghata's conceptualization as Nanatmaja Vata Vyadhi provides a clear, actionable framework that precisely maps onto modern upper motor neuron lesion pathology.", color: C.accent },
    { icon: "2", text: "The three-fold classification (Suddha Vataja, Anyadosha Samsrista, Kshayahetuja) allows personalized treatment - surpassing modern medicine's ischemic/hemorrhagic binary.", color: C.green },
    { icon: "3", text: "Basti is the single most important intervention - addressing Vata at its Moola Sthana through multiple mechanisms: direct doshic action, systemic drug delivery, and gut-brain axis modulation.", color: C.red },
    { icon: "4", text: "The optimal 21st-century model combines acute stroke management (modern) with sub-acute/chronic Panchakarma rehabilitation (Ayurvedic) - a true integrative medicine paradigm.", color: C.subtle },
    { icon: "5", text: "The research deficit, not therapeutic deficit: rigorous clinical trials using validated outcomes and standardized protocols are urgently needed to confirm what clinical experience suggests.", color: "8B4513" },
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}

// ════════════════════════════════════════════════════════════════════════════
// SLIDE 19 – FINAL QUOTE / THANK YOU
// ════════════════════════════════════════════════════════════════════════════
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  s.addText("स्वस्थस्य स्वास्थ्य रक्षणम् | आतुरस्य विकार प्रशमनम्", { x: 0.5, y: 1.1, w: 9, h: 0.7, fontSize: 18, bold: true, italic: true, color: C.accent, fontFace: "Calibri", align: "center" });
  s.addText('"Swasthasya Swasthya Rakshanam, Aturasya Vikara Prashamanam"', { x: 0.5, y: 1.82, w: 9, h: 0.5, fontSize: 14, italic: true, color: "D4B483", fontFace: "Calibri", align: "center" });
  s.addText("The protection of health in the healthy, and the alleviation of disease in the sick.", { x: 0.5, y: 2.3, w: 9, h: 0.45, fontSize: 13, color: "A0B8D8", fontFace: "Calibri", align: "center", italic: true });
  s.addText("— Acharya Charaka", { x: 0.5, y: 2.72, w: 9, h: 0.38, fontSize: 12, color: C.accent, fontFace: "Calibri", align: "center" });
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  s.addText("Pakshagata in Ayurveda: A Comprehensive Study", { x: 0.5, y: 4.05, w: 9, h: 0.38, fontSize: 13, color: C.subtle, fontFace: "Calibri", align: "center", italic: true });
  s.addText("References include: Charaka Samhita  |  Sushruta Samhita  |  Ashtanga Hridayam  |  Madhava Nidana  |  Akashlal et al. 2025 (PMID: 39763345)",
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// ── WRITE ────────────────────────────────────────────────────────────────────
pres.writeFile({ fileName: "/home/daytona/workspace/pakshagata-essay/Pakshagata_Ayurveda.pptx" })
  .then(() => console.log("DONE"))
  .catch(e => { console.error(e); process.exit(1); });

cd /home/daytona/workspace/pakshagata-essay && node generate_ppt.js 2>&1

ls -lh /home/daytona/workspace/pakshagata-essay/Pakshagata_Ayurveda.pptx && pyth…

~/pakshagata-essay/generate_essay_ppt.js

const pptxgen = require("pptxgenjs");
const pres = new pptxgen();
pres.layout = "LAYOUT_16x9";
pres.title = "Pakshagata in Ayurveda";

// ── COLOURS (essay/academic style) ──────────────────────────────────────────
const WHITE  = "FFFFFF";
const BLACK  = "000000";
const DARK   = "1A1A1A";   // near-black body text
const HEAD   = "1A1A1A";   // heading text
const BLUE   = "1F3864";   // title/heading colour (deep academic blue)
const LGRAY  = "F5F5F5";   // very light grey slide bg
const RULE   = "CCCCCC";   // horizontal rule colour
const SUB    = "444444";   // sub-text / italic
const RED    = "8B0000";   // Sanskrit shloka

// ── HELPERS ──────────────────────────────────────────────────────────────────
const W = 10, H = 5.625;   // slide dimensions (16x9 inches)
const ML = 0.55;           // left margin
const MR = 0.55;           // right margin
const TW = W - ML - MR;   // text width

function bg(s) {
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}

function rule(s, y, color=RULE) {
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}

function pageNum(s, n, total) {
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}

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}

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}

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}

function para(s, text, y, opts={}) {
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  const h   = opts.h   || 0.36;
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    h, fontSize:fs, color:col,
    fontFace: opts.font || "Times New Roman",
    italic: opts.italic||false,
    bold:   opts.bold  ||false,
    valign:"top", align: opts.align||"left",
    margin:2
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}

function shloka(s, text, y) {
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}

function bullets(s, items, y, opts={}) {
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}

function twoCol(s, leftItems, rightItems, y, opts={}) {
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  return Math.max(ly, ry) + 0.05;
}

// simple table
function table(s, headers, rows, y, colW) {
  const hh = 0.32, rh = 0.28;
  let x0 = ML;
  // header row
  headers.forEach((h, i) => {
    s.addShape(pres.ShapeType.rect, {x:x0, y, w:colW[i], h:hh, fill:{color:BLUE}, line:{color:BLUE,width:0}});
    s.addText(h, {x:x0+0.04, y, w:colW[i]-0.08, h:hh, fontSize:9.5, bold:true, color:WHITE, fontFace:"Times New Roman", valign:"middle"});
    x0 += colW[i];
  });
  y += hh;
  rows.forEach((row, ri) => {
    x0 = ML;
    row.forEach((cell, ci) => {
      const fill = ri%2===0 ? "F0F4FA" : WHITE;
      s.addShape(pres.ShapeType.rect, {x:x0, y, w:colW[ci], h:rh, fill:{color:fill}, line:{color:RULE, width:0.5}});
      s.addText(cell, {x:x0+0.04, y, w:colW[ci]-0.08, h:rh, fontSize:9, color:DARK, fontFace:"Times New Roman", valign:"middle"});
      x0 += colW[ci];
    });
    y += rh;
  });
  return y + 0.1;
}

// ════════════════════════════════════════════════════════════════════════════
// TOTAL SLIDES = 25
// ════════════════════════════════════════════════════════════════════════════
const TOT = 25;

// ── SLIDE 1: TITLE PAGE ──────────────────────────────────────────────────────
{
  const s = pres.addSlide(); bg(s);
  // Top thin blue bar
  s.addShape(pres.ShapeType.rect, {x:0,y:0,w:W,h:0.12,fill:{color:BLUE},line:{color:BLUE,width:0}});
  s.addShape(pres.ShapeType.rect, {x:0,y:H-0.12,w:W,h:0.12,fill:{color:BLUE},line:{color:BLUE,width:0}});

  let y = 0.5;
  s.addText("PAKSHAGATA (HEMIPLEGIA) IN AYURVEDA", {
    x:ML, y, w:TW, h:0.72,
    fontSize:26, bold:true, color:BLUE, fontFace:"Times New Roman", align:"center"
  });
  y += 0.8;
  rule(s, y, BLUE);
  y += 0.1;
  s.addText("A Comprehensive Study Including Classical Chikitsa Sutra,\nPanchakarma Procedures, and Modern Correlations", {
    x:ML, y, w:TW, h:0.72,
    fontSize:14, italic:true, color:DARK, fontFace:"Times New Roman", align:"center"
  });
  y += 0.82;
  rule(s, y, RULE);
  y += 0.18;
  s.addText("An Academic Essay in Five Sections", {x:ML,y,w:TW,h:0.36,fontSize:12,color:SUB,fontFace:"Times New Roman",align:"center",italic:true});
  y += 0.5;
  const secs = [
    "I. Introduction of the Disease",
    "II. Chikitsa Sutra (Treatment Principles)",
    "III. Panchakarma Procedures",
    "IV. Discussion",
    "V. Conclusion"
  ];
  secs.forEach((sec,i) => {
    s.addText(`${sec}`, {x:ML+1.5,y:y+i*0.33,w:TW-3.0,h:0.32,fontSize:11.5,color:DARK,fontFace:"Times New Roman",align:"center"});
  });
  pageNum(s, 1, TOT);
}

// ── SLIDE 2: TABLE OF CONTENTS ───────────────────────────────────────────────
{
  const s = pres.addSlide(); bg(s);
  runningHead(s, "Pakshagata in Ayurveda — A Comprehensive Study");
  let y = slideHeading(s, "Table of Contents");
  const items = [
    ["Section I",  "Introduction of the Disease", "Slides 3–7"],
    ["",           "1.1 Ayurvedic Perspective", ""],
    ["",           "1.2 Modern Perspective", ""],
    ["",           "1.3 Nidana Panchaka (Etiology, Purvarupa, Rupa, Upashaya, Samprapti)", ""],
    ["",           "1.4 Classification of Pakshagata", ""],
    ["",           "1.5 Incidence and Prevalence", ""],
    ["Section II", "Chikitsa Sutra — Treatment Principles", "Slides 8–10"],
    ["",           "2.1 Chikitsa Sutra per Different Acharyas", ""],
    ["",           "2.2 Modern Line of Treatment", ""],
    ["Section III","Panchakarma Procedures", "Slides 11–17"],
    ["",           "3.1 Snehana   3.2 Swedana   3.3 Vamana   3.4 Virechana   3.5 Basti   3.6 Nasya", ""],
    ["Section IV", "Discussion", "Slides 18–21"],
    ["",           "4.1 Mode of Action   4.2 Integrated Approach   4.3 Pathya-Apathya   4.4 Limitations & Scope", ""],
    ["Section V",  "Conclusion", "Slides 22–24"],
    ["",           "References", "Slide 25"],
  ];
  items.forEach(([sec, title, pg]) => {
    const bold = sec !== "";
    const col  = bold ? BLUE : DARK;
    const fs   = bold ? 12   : 11;
    s.addText([
      {text: sec ? sec + "  " : "         ", options:{bold:true, color:BLUE}},
      {text: title, options:{bold, color:col}},
      {text: pg ? "  ........  " + pg : "", options:{color:SUB, italic:true}}
    ], {x:ML, y, w:TW, h:0.3, fontSize:fs, fontFace:"Times New Roman", valign:"middle", margin:1});
    y += 0.3;
  });
  pageNum(s, 2, TOT);
}

// ── SLIDE 3: INTRO — AYURVEDIC PERSPECTIVE ───────────────────────────────────
{
  const s = pres.addSlide(); bg(s);
  runningHead(s, "Section I — Introduction of the Disease");
  let y = slideHeading(s, "1.1 Introduction — Ayurvedic Perspective");
  y = para(s, "Ayurveda, the ancient Indian system of medicine, is one of the oldest and most complete systems of health care known to humanity. Derived from the Sanskrit words \"Ayu\" (life) and \"Veda\" (knowledge), Ayurveda is literally the science of life. It encompasses the treatment of disease, preservation of health, promotion of longevity, and the attainment of spiritual well-being. The foundational texts — Charaka Samhita, Sushruta Samhita, and Ashtanga Hridayam — represent the three pillars of classical Ayurvedic medicine.", y, {h:0.7, after:0.1});
  y = subHead(s, "Pakshagata — Definition and Etymology", y);
  y = para(s, "The term Pakshagata (Pakshaghata / Pakshavadha) comes from two Sanskrit roots:", y, {h:0.3});
  y = bullets(s, [
    "Paksha  =  one lateral half of the body (Vama Paksha = left side; Dakshina Paksha = right side)",
    "Ghata / Aghata  =  destruction, impairment, striking down, loss of function",
    "Together: \"The striking down or destruction of one half of the body\" — Hemiplegia / Hemiparesis"
  ], y, {lh:0.3});
  y += 0.05;
  y = para(s, "Acharya Charaka classifies Pakshagata among the 80 Nanatmaja Vata Vikaras — diseases arising exclusively from Vata Dosha vitiation (Charaka Samhita, Sutra Sthana 20). It is also grouped under Mahavatavyadhi (major Vata disorders), indicating its severity and complexity. The disease involves Karmendriyas (motor organs), Jnanendriyas (sensory organs), and Manas (mind), making it an Indriyapradoshaja Vikara as well as an Upadhatu Pradoshaja Vikara.", y, {h:0.72, after:0.08});
  pageNum(s, 3, TOT);
}

// ── SLIDE 4: INTRO — MODERN PERSPECTIVE ─────────────────────────────────────
{
  const s = pres.addSlide(); bg(s);
  runningHead(s, "Section I — Introduction of the Disease");
  let y = slideHeading(s, "1.2 Introduction — Modern Perspective");
  y = para(s, "In modern medicine, Pakshagata corresponds to hemiplegia (complete paralysis of one side) or hemiparesis (partial weakness). These conditions arise from lesions in the corticospinal (pyramidal) tract — the upper motor neuron pathway connecting the motor cortex to spinal motor neurons.", y, {h:0.55, after:0.08});
  y = subHead(s, "Causes of Hemiplegia (Modern)", y);
  y = twoCol(s,
    ["Ischemic stroke (most common — occluded vessel)", "Hemorrhagic stroke (ruptured blood vessel)", "Traumatic brain injury", "Brain tumors / space-occupying lesions"],
    ["Multiple sclerosis (demyelination)", "Cerebral infections (encephalitis, abscess)", "Congenital disorders (cerebral palsy)", "Metabolic encephalopathies"],
    y, {fs:11});
  y += 0.1;
  y = subHead(s, "Limitations of Modern Management", y);
  y = bullets(s, [
    "Acute thrombolysis (tPA) window: only 4.5 hours — missed in most developing-country patients",
    "No established drug therapy reliably restores established neurological deficits",
    "Rehabilitation (physiotherapy, OT, SLT) is resource-intensive and often inaccessible",
    "This therapeutic gap is where Ayurvedic Panchakarma offers meaningful rehabilitative potential"
  ], y, {lh:0.3});
  pageNum(s, 4, TOT);
}

// ── SLIDE 5: NIDANA PANCHAKA — NIDANA (ETIOLOGY) ────────────────────────────
{
  const s = pres.addSlide(); bg(s);
  runningHead(s, "Section I — Nidana Panchaka");
  let y = slideHeading(s, "1.3 Nidana Panchaka — Part A: Nidana (Etiology)");
  y = para(s, "Classical texts do not list exclusive causative factors for Pakshagata. Instead, all factors that aggravate Vata Dosha in the body are recognised as causative. They are systematically classified as follows:", y, {h:0.48, after:0.06});

  y = subHead(s, "Aharaja Nidana (Dietary Causes)", y);
  y = twoCol(s,
    ["Ati Ruksha Ahara — dry, rough foods", "Ati Laghu Ahara — excessively light diet", "Ati Sheeta — cold foods and beverages", "Atyalpa Ahara — starvation / fasting"],
    ["Vishama Ahara — irregular eating habits", "Excessive Katu/Tikta/Kashaya tastes", "Viruddha Ahara — incompatible combinations", "Vegavarodha — suppression of natural urges"],
    y, {fs:10.5});

  y = subHead(s, "Viharaja, Abhighataja & Manasika Nidana", y);
  y = twoCol(s,
    ["Ati Vyayama — excessive exertion", "Ati Maithuna — excessive sexual activity", "Ati Jagarana — sleep deprivation", "Cold/wind/dry environment exposure"],
    ["Abhighata — head trauma (Shiromarma-ghata)", "Ati Bhaya/Krodha/Shoka — fear, anger, grief", "Shodhana Atiyoga — excess purification", "Chronic disease causing Dhatu Kshaya"],
    y, {fs:10.5});

  y += 0.06;
  rule(s, y, RULE);
  y += 0.1;
  s.addText([
    {text:"Two fundamental mechanisms:  ", options:{bold:true, color:BLUE}},
    {text:"(1) Dhatukshaya Janya — Vata aggravation due to tissue depletion (produces Kshayahetuja Pakshaghata)    ", options:{color:DARK}},
    {text:"(2) Margavarana Janya — Vata blocked by Kapha/Pitta/Ama (produces Anyadosha Samsrista Pakshaghata)", options:{color:DARK}}
  ], {x:ML, y, w:TW, h:0.44, fontSize:10.5, fontFace:"Times New Roman", valign:"top", margin:1});
  pageNum(s, 5, TOT);
}

// ── SLIDE 6: PURVARUPA, RUPA, UPASHAYA ──────────────────────────────────────
{
  const s = pres.addSlide(); bg(s);
  runningHead(s, "Section I — Nidana Panchaka");
  let y = slideHeading(s, "1.3 Nidana Panchaka — Part B: Purvarupa, Rupa & Upashaya");
  y = subHead(s, "Purvarupa (Premonitory Symptoms)", y);
  y = twoCol(s,
    ["Sphuranam — fasciculations / twitching in limbs", "Toda — pricking / shooting pain (one side)", "Supti — numbness / paresthesia", "Angamarda — body ache and malaise"],
    ["Balavarna Hani — loss of strength & complexion", "Angasada — heaviness / lassitude in limbs", "Chestahani — reduced ease of movements", "Nidranasha — disturbed sleep patterns"],
    y, {fs:10.5});
  y += 0.06;
  para(s, "Modern correlation: These correspond to Transient Ischaemic Attacks (TIAs) — fleeting neurological deficits that predict impending stroke.", y, {h:0.28, col:SUB, italic:true, after:0.06});
  y += 0.34;

  y = subHead(s, "Rupa (Cardinal Signs and Symptoms)", y);
  y = twoCol(s,
    ["Cheshta Nivritti — complete motor paralysis (one side)", "Vaksthambha — slurred / absent speech (Dysarthria)", "Ardhakaya Karmahani — loss of function in half body", "Suptata in Hasta/Pada — numbness in hand and foot"],
    ["Mukha Vakrata — facial deviation (UMN facial palsy)", "Dysphagia — difficulty in swallowing", "Bowel and bladder dysfunction", "Depression, confusion, memory disturbances"],
    y, {fs:10.5});
  y += 0.06;
  y = subHead(s, "Upashaya (Diagnostic Therapeutic Trials)", y);
  y = bullets(s, [
    "Dhatukshaya Janya: Snehana gives relief (Upashaya); Langhana worsens it (Anupashaya)",
    "Margavarana Janya: Ruksha Swedana gives partial relief; Brimhana may aggravate if Ama is present"
  ], y, {lh:0.28, fs:10.5});
  pageNum(s, 6, TOT);
}

// ── SLIDE 7: SAMPRAPTI ───────────────────────────────────────────────────────
{
  const s = pres.addSlide(); bg(s);
  runningHead(s, "Section I — Nidana Panchaka");
  let y = slideHeading(s, "1.3 Nidana Panchaka — Part C: Samprapti (Pathogenesis)");
  y = shloka(s, '"Ekam pakvashayastham tu shariram ardhakam param | Sirasnayukandaragatah pakshaghataya Kurute ||"  — Charaka Samhita, Chikitsa Sthana 28/53', y);
  y += 0.08;
  y = para(s, "Translation: Vata, seated in the Pakvashaya (colon), spreads through the Sira (blood vessels), Snayu (ligaments/tendons), and Kandara (tendons) of one half of the body, causing Pakshaghata.", y, {h:0.42, italic:true, col:SUB, after:0.1});

  y = subHead(s, "Samprapti Chakra (Six-Step Pathogenesis)", y);
  const steps = [
    "Step 1 — Nidana Sevana: Exposure to causative dietary, lifestyle, traumatic, or psychological factors",
    "Step 2 — Vata Prakopa in Pakvashaya: Vata becomes aggravated at its primary seat (the colon)",
    "Step 3 — Vata Prasara: Aggravated Vata overflows into Sira, Snayu, and Kandara of one Paksha",
    "Step 4 — Sthana Samshraya: Vata lodges in one half of the body; Purvarupa (prodromal symptoms) appear",
    "Step 5 — Vyakti: Full clinical manifestation — paralysis, speech loss, sensory deficit, facial palsy",
    "Step 6 — Bheda: Chronicity; complications including contractures, atrophy, pressure ulcers",
  ];
  steps.forEach(st => {
    s.addText(st, {x:ML+0.1, y, w:TW-0.1, h:0.27, fontSize:10.5, color:DARK, fontFace:"Times New Roman", valign:"top", margin:1});
    y += 0.27;
  });
  pageNum(s, 7, TOT);
}

// ── SLIDE 8: SAMPRAPTI TABLE + CLASSIFICATION ────────────────────────────────
{
  const s = pres.addSlide(); bg(s);
  runningHead(s, "Section I — Samprapti & Classification");
  let y = slideHeading(s, "Shat Kriyakala (Six Stages) & Classification of Pakshagata");
  y = table(s,
    ["Stage","Name","Presentation in Pakshagata","Optimal Intervention"],
    [
      ["1","Sanchaya","Mild fatigue, constipation, subtle Vata accumulation","Prevention — Nidana Parivarjana"],
      ["2","Prakopa","Anxiety, body ache, insomnia","Langhana, Dipana, Pachana"],
      ["3","Prasara","Vata spreads into Srotas throughout body","Shodhana if Bala permits"],
      ["4","Sthana Samshraya","Prodromal symptoms in one Paksha","Snehana, Swedana — critical window"],
      ["5","Vyakti","Full paralysis, speech loss, sensory deficit","Comprehensive Panchakarma Chikitsa"],
      ["6","Bheda","Contractures, atrophy, chronic complications","Brimhana, Rasayana"],
    ],
    y, [0.4, 1.3, 3.5, 3.7]);
  y += 0.08;
  y = subHead(s, "Classification Based on Etiopathogenesis", y);
  y = table(s,
    ["Type","Description","Prognosis"],
    [
      ["Suddha Vataja","Pure Vata aggravation (own causative factors); dryness, cold, motor weakness","Krichhrasadhya (treatable with effort)"],
      ["Anyadosha Samsrista","Vata + Pitta (burning, fever, syncope) or Vata + Kapha (swelling, heaviness)","Yapya (manageable)"],
      ["Kshayahetuja","Secondary to Dhatu Kshaya; emaciation, cachexia, progressive weakness","Asadhya (very difficult)"],
    ],
    y, [2.4, 4.7, 1.8]);
  pageNum(s, 8, TOT);
}

// ── SLIDE 9: INCIDENCE & PREVALENCE ─────────────────────────────────────────
{
  const s = pres.addSlide(); bg(s);
  runningHead(s, "Section I — Incidence & Prevalence");
  let y = slideHeading(s, "1.5 Incidence and Prevalence");
  y = subHead(s, "Global and Indian Epidemiology", y);
  y = bullets(s, [
    "Stroke-related hemiplegia is the 3rd leading cause of death and most common cause of acquired disability worldwide",
    "WHO: 33 million individuals affected by stroke globally every year; 2/3 occur in developing countries",
    "India: approximately 1.5 to 2 million new stroke cases annually",
    "Community surveys in India: crude prevalence of hemiplegia = 200 per 1,00,000 people (0.2%)",
    "Global Burden of Disease Study ranks stroke among top 5 causes of DALYs in India",
  ], y, {lh:0.3, fs:11});
  y += 0.08;
  y = subHead(s, "Key Risk Factors", y);
  y = twoCol(s,
    ["Hypertension — single largest risk factor", "Diabetes mellitus", "Dyslipidemia (high LDL, low HDL)", "Atrial fibrillation / cardiac disease"],
    ["Cigarette smoking and alcohol", "Obesity and metabolic syndrome", "Age > 55 years", "Prior TIA (Transient Ischaemic Attack)"],
    y, {fs:11});
  y += 0.08;
  y = subHead(s, "Ayurvedic Epidemiological Perspective", y);
  y = para(s, "Populations with Vata-aggravating lifestyles (irregular food, excessive exertion, chronic stress, cold climates) are identified as most vulnerable — mapping precisely onto modern stroke risk populations. Ayurveda's preventive emphasis on Dinacharya (daily regimen) and Ritucharya (seasonal regimen) represents a cost-effective public health strategy.", y, {h:0.55, after:0.0});
  pageNum(s, 9, TOT);
}

// ── SLIDE 10: SECTION II — CHIKITSA SUTRA ───────────────────────────────────
{
  const s = pres.addSlide(); bg(s);
  runningHead(s, "Section II — Chikitsa Sutra (Treatment Principles)");
  let y = slideHeading(s, "Section II: Chikitsa Sutra — Treatment Aphorisms");
  y = shloka(s, '"Pakshaghatam tatha hanustambham ardita eva cha | Vatavyadhir bahuvidhah shodhyah snehana poorvakam ||"  — Charaka Samhita, Chikitsa Sthana 28/53-55', y);
  y += 0.06;
  y = para(s, "Translation: Pakshaghata, Hanustambha (jaw stiffness), and Ardita (facial palsy) are among the many types of Vata Vyadhi that should be treated with Shodhana (bio-purification) preceded by Snehana (oleation). The universal treatment sequence is: Snehana first, then Shodhana.", y, {h:0.48, italic:true, col:SUB, after:0.1});
  y = subHead(s, "Chikitsa Sutra of Different Acharyas", y);
  y = table(s,
    ["Acharya","Primary Chikitsa Sutra","Emphasis / Key Addition"],
    [
      ["Charaka","Snehana, Swedana, Virechana (Mridu)","Sequential oleation then gentle nourishing purgation; Jejjata/Gangadhara: Snehayukta forms"],
      ["Sushruta","Snehana, Swedana, Basti, Nasya","Patient selection criteria; Nithya Virechana first, then Niruha + Anuvasana Basti, then Shirodhara"],
      ["Vagbhata","Snehana, Basti (primary), Nasya","Srotas Shodhana; Basti as supreme Vatahara; Nasya mandatory for Urdhvajatrugata features"],
      ["Madhavakara","Type-specific treatment","Dosha-specific personalised approach based on Anyadosha Samsrista classification"],
    ],
    y, [1.5, 3.2, 4.2]);
  pageNum(s, 10, TOT);
}

// ── SLIDE 11: MODERN TREATMENT ───────────────────────────────────────────────
{
  const s = pres.addSlide(); bg(s);
  runningHead(s, "Section II — Modern Line of Treatment");
  let y = slideHeading(s, "2.2 Modern Line of Treatment");
  y = subHead(s, "Acute Phase (0–72 hours)", y);
  y = bullets(s, [
    "Airway, breathing, circulation (ABC) stabilization; neurological monitoring",
    "Ischemic stroke: IV tPA thrombolysis within 4.5 hours of onset; mechanical thrombectomy for large vessel occlusion",
    "Hemorrhagic stroke: Neurosurgical consultation; blood pressure control; reversal of anticoagulation",
    "Prevention of secondary complications: DVT prophylaxis, aspiration pneumonia prevention, pressure ulcer prevention",
  ], y, {lh:0.28, fs:10.5});
  y += 0.06;
  y = subHead(s, "Sub-acute Phase (Days to Weeks)", y);
  y = bullets(s, [
    "Physiotherapy: Range of motion exercises, positioning, transfers, progressive gait training",
    "Occupational therapy: Activities of daily living (ADL) training; upper limb rehabilitation",
    "Speech and language therapy: Aphasia and dysarthria rehabilitation",
    "Spasticity management: Baclofen (oral), Botulinum toxin injections (focal spasticity)",
  ], y, {lh:0.28, fs:10.5});
  y += 0.06;
  y = subHead(s, "Chronic Rehabilitation Phase", y);
  y = bullets(s, [
    "Constraint-induced movement therapy (CIMT); Mirror therapy; Neuromuscular electrical stimulation (NMES)",
    "Robot-assisted rehabilitation; Virtual reality-based therapy; Community reintegration",
    "Secondary prevention: Antiplatelets, statins, antihypertensives; lifestyle modification",
  ], y, {lh:0.28, fs:10.5});
  pageNum(s, 11, TOT);
}

// ── SLIDE 12: SECTION III — PANCHAKARMA OVERVIEW ────────────────────────────
{
  const s = pres.addSlide(); bg(s);
  runningHead(s, "Section III — Panchakarma Procedures");
  let y = slideHeading(s, "Section III: Panchakarma — Overview and Rationale");
  y = para(s, "Panchakarma (five purificatory actions) forms the backbone of Ayurvedic therapeutic intervention in Pakshagata. The five procedures are: Vamana (emesis), Virechana (purgation), Basti (medicated enema), Nasya (nasal administration), and Raktamokshana (bloodletting). In Pakshagata, Snehana, Swedana, Basti, and Nasya are the most prominent modalities.", y, {h:0.55, after:0.08});
  y = para(s, "Rationale — Samprapti Vighatana (Breaking the Disease Chain): Each Panchakarma procedure targets a specific link in the pathogenesis chain:", y, {h:0.3, bold:true, after:0.06});
  y = table(s,
    ["Procedure","Target in Samprapti","Classical Authority"],
    [
      ["Snehana","Reverses Ruksha quality desiccating Sira and Snayu","Charaka Chi 28; universal Poorvakarma"],
      ["Swedana","Opens blocked Srotas; reduces spasticity (Stambhaghna)","Charaka Chi 28; Poorvakarma"],
      ["Vamana","Removes Kapha Avarana blocking Vata channels","Vagbhata — Kaphanubandha type"],
      ["Virechana","Eliminates Pitta-Rakta involvement; Mridu/Snigdha form","Charaka Chi 28/53 — primary sutra"],
      ["Basti","Directly addresses Vata at Moola Sthana (Pakvashaya)","Charaka Chi 28 — Ardha chikitsa"],
      ["Nasya","Accesses Urdhvajatrugata Vata — speech, facial palsy","Charaka Siddhi Sthana 9"],
    ],
    y, [1.5, 4.3, 3.1]);
  pageNum(s, 12, TOT);
}

// ── SLIDE 13: SNEHANA ────────────────────────────────────────────────────────
{
  const s = pres.addSlide(); bg(s);
  runningHead(s, "Section III — Panchakarma Procedures");
  let y = slideHeading(s, "3.1 Snehana (Oleation Therapy)");
  y = para(s, "Snehana is the systematic administration of oil or fat (Sneha) to the body. In Pakshagata it is the mandatory first step — all Shodhana procedures must be preceded by adequate Snehana.", y, {h:0.4, after:0.08});
  y = subHead(s, "A. Abhyantara Snehana (Internal Oleation)", y);
  y = bullets(s, [
    "Medicated ghee (Ghritapana) in gradually increasing doses for 3–7 days",
    "Formulations: Ashwagandha Ghrita, Panchatikta Ghrita, Dhanwantaram Ghritam",
    "Continue until Samyak Snigdha Lakshanas: unctuous skin, soft stools, absence of body pain",
  ], y, {lh:0.28, fs:10.5});
  y += 0.06;
  y = subHead(s, "B. Bahya Snehana (External Oleation)", y);
  y = bullets(s, [
    "Sarvanga Abhyanga — Full body oil massage with Mahanarayana Taila, Bala Taila, Dhanwantaram Taila; 45–60 min daily",
    "Ekanga Abhyanga — Localised massage on paralysed limbs (flaccid or spastic)",
    "Pizhichil / Taila Dhara — Continuous pouring of warm medicated oil over entire body; combines Snehana and mild Swedana; potent in chronic Pakshagata",
    "Shiroabhyanga — Head massage with Brahmi Taila / Ksheerabala Taila for Prana Vayu and cognitive features",
  ], y, {lh:0.28, fs:10.5});
  y += 0.08;
  y = subHead(s, "Mode of Action", y);
  y = para(s, "Snigdha (unctuous), Guru (heavy), and Ushna (warm) qualities of Sneha directly counter Vata's Ruksha (dry), Laghu (light), and Sheeta (cold) qualities — the principle of Samanya Vishesha. At the Dhatu level, Sneha nourishes depleted Rasa, Rakta, Mamsa, and Majja Dhatus. Modern evidence: sesamol and sesaminol in sesame oil are potent CNS antioxidants; Ashwagandha constituents are neuroprotective.", y, {h:0.58});
  pageNum(s, 13, TOT);
}

// ── SLIDE 14: SWEDANA ────────────────────────────────────────────────────────
{
  const s = pres.addSlide(); bg(s);
  runningHead(s, "Section III — Panchakarma Procedures");
  let y = slideHeading(s, "3.2 Swedana (Sudation / Fomentation Therapy)");
  y = para(s, "Swedana induces perspiration through heat application. Classical texts describe four primary actions: Stambhaghna (relieves stiffness), Gauravaghna (relieves heaviness), Shitaghna (relieves cold sensation), and Swedakara (induces perspiration).", y, {h:0.44, after:0.08});
  y = subHead(s, "Types of Swedana Used in Pakshagata", y);
  y = table(s,
    ["Type","Description","Specific Indication"],
    [
      ["Bashpa Sveda","Full body medicated steam bath with Dashamoola Kwatha; 10–20 min post-Abhyanga","All cases; general Srotas opening"],
      ["Patra Pinda Sweda (Ela Kizhi)","Herbal leaf bolus dipped in warm medicated oil, rhythmically applied; combines Snehana + Swedana","Spasticity; pain; best all-round in Pakshagata"],
      ["Shashtikashali Pinda Sweda (Njavarakizhi)","Rice (Shashtika Shali) bolus in Bala Kwatha + milk; nourishing and sudating","Kshayahetuja type; emaciated patients"],
      ["Nadi Sweda","Directed steam to specific joints or limb groups","Localised spasticity; contractures"],
      ["Jambira Pinda Sweda","Lemon-based bolus with medicated oils","Pain, tingling, and pricking sensations"],
    ],
    y, [2.0, 4.2, 2.7]);
  y += 0.08;
  y = subHead(s, "Mode of Action", y);
  y = para(s, "Ushna (hot) and Snigdha qualities of Swedana pacify Vata's Ruksha quality; restore Samana Vayu function; Srotoshuddhi opens blocked channels; Amapachana eliminates undigested metabolites. Modern: heat increases local blood flow 3–4x; reduces alpha motor neuron excitability (spasticity); improves motor cortex plasticity.", y, {h:0.5});
  pageNum(s, 14, TOT);
}

// ── SLIDE 15: VAMANA ─────────────────────────────────────────────────────────
{
  const s = pres.addSlide(); bg(s);
  runningHead(s, "Section III — Panchakarma Procedures");
  let y = slideHeading(s, "3.3 Vamana (Therapeutic Emesis)");
  y = para(s, "Vamana involves therapeutic induction of vomiting to eliminate vitiated Kapha from the upper gastrointestinal tract. It is not a primary procedure in all types of Pakshagata but has specific indications.", y, {h:0.44, after:0.08});
  y = subHead(s, "Indications in Pakshagata", y);
  y = bullets(s, [
    "Kaphanubandha Pakshagata — Kapha is the obstructing Dosha (Avarana); Vamana eliminates excess Kapha and removes obstruction to Vata flow",
    "Features of Kapha excess: heaviness, swelling, cold sensations, excessive mucus production",
    "Associated Kapha conditions: chronic sinusitis, obesity, bronchial asthma",
  ], y, {lh:0.3, fs:11});
  y += 0.06;
  y = subHead(s, "Procedure and Drugs", y);
  y = bullets(s, [
    "Poorvakarma: Snehana and Swedana for 3–7 days; Kapha-provoking meal (milk, sweets) on the day",
    "Drug: Madanaphala (Randia spinosa) in Yashtimadhu (liquorice) decoction",
    "Target: 4–8 Vega (vomiting episodes) — Madhyama Shuddhi (moderate purification)",
    "Paschatkarma: Strict Samsarjana Krama (graduated diet regimen) mandatory after procedure",
  ], y, {lh:0.3, fs:11});
  y += 0.06;
  y = subHead(s, "Contraindications in Pakshagata", y);
  y = bullets(s, [
    "Severe Dhatu Kshaya (emaciation), pure Vataja Pakshagata, hemorrhagic stroke cases",
    "Advanced age with severe debility; cardiovascular instability",
  ], y, {lh:0.28, fs:11});
  y += 0.06;
  y = subHead(s, "Mode of Action", y);
  y = para(s, "Eliminates vitiated Kapha; clears Kaphaavrita channels; restores Udana Vayu function (governs speech and upward movement); improves Agni when Ama is contributing to pathology. Modern: vagal stimulation during emesis modulates autonomic NS tone; eliminates upper GI inflammatory mediators.", y, {h:0.48});
  pageNum(s, 15, TOT);
}

// ── SLIDE 16: VIRECHANA ──────────────────────────────────────────────────────
{
  const s = pres.addSlide(); bg(s);
  runningHead(s, "Section III — Panchakarma Procedures");
  let y = slideHeading(s, "3.4 Virechana (Therapeutic Purgation)");
  y = para(s, "Virechana (therapeutic purgation) is one of the three primary treatments specified in Charaka's Chikitsa Sutra for Pakshagata. Classical commentators specify this as Mridu Virechana (gentle purgation) or Snigdha Virechana (oleating purgation) — distinguishing it from harsh Tikshna purgation.", y, {h:0.55, after:0.08});
  y = subHead(s, "Indications in Pakshagata", y);
  y = bullets(s, [
    "All types of Pakshagata as part of the Samshodhana (bio-purification) protocol",
    "Specifically: Pittanubandha Pakshagata — when Pitta obstructs or is associated with Vata",
    "Sira (blood vessel) involvement in Samprapti: Sira is Upadhatu of Rakta; Virechana is best Shodhana for Rakta",
    "Majjavaha Srotas involvement: Majja and Pitta share the same Dhara Kala — Virechana addresses Majja pathology",
  ], y, {lh:0.3, fs:11});
  y += 0.06;
  y = subHead(s, "Key Drugs and Procedure", y);
  y = bullets(s, [
    "Eranda Taila (Castor Oil): most widely used; dose 15–30 ml in warm water or milk; Snigdha quality pacifies Vata while purging",
    "Also used: Trivrit (Operculina turpethum), Gandharvaharitaki (Eranda + Haritaki), Haritaki Churna",
    "Poorvakarma mandatory: 3–7 days of internal + external Snehana before Virechana",
    "Target: Madhyama Shuddhi (moderate purification); strict Paschatkarma after procedure",
  ], y, {lh:0.28, fs:11});
  y += 0.06;
  y = subHead(s, "Mode of Action", y);
  y = para(s, "Rakta Shodhana reduces neuroinflammation (Pitta = inflammatory mediators); Agni restoration reduces Ama formation; gut-liver axis modulation enhances hepatic clearance. Modern: ricinoleic acid (castor oil) activates prostaglandin E3 receptors; purgation eliminates endotoxins and inflammatory mediators.", y, {h:0.55});
  pageNum(s, 16, TOT);
}

// ── SLIDE 17: BASTI — PART 1 ─────────────────────────────────────────────────
{
  const s = pres.addSlide(); bg(s);
  runningHead(s, "Section III — Panchakarma Procedures");
  let y = slideHeading(s, "3.5 Basti Karma (Medicated Enema) — Part 1");
  y = shloka(s, '"Ardha chikitsa" — Basti is half the treatment for all diseases and the complete treatment for Vata disorders.  — Acharya Charaka', y);
  y += 0.08;
  y = para(s, "Rationale: Vata's primary seat (Moola Sthana) is the Pakvashaya (colon). The entire Samprapti of Pakshagata originates from Vata vitiation in the Pakvashaya. Therefore Basti, which directly accesses and treats the colon, strikes at the very root of the disease.", y, {h:0.48, after:0.08});
  y = subHead(s, "Types of Basti", y);
  y = table(s,
    ["Type","Contents","Classical Use","Dose / Protocol"],
    [
      ["Niruha Basti","Kwatha (decoction) + honey + rock salt + Kalka (paste) + oil","Srotas Shodhana + Dosha elimination","150–400 ml; retained then expelled"],
      ["Rajayapana Basti","Bala Kwatha, Shatavari, Ashwagandha, milk, sesame oil, honey","\"King of Bastis\" for neurological Vata disorders","As above; specific for Pakshagata"],
      ["Anuvasana Basti","Medicated oil alone (Dhanwantaram, Sahacharadi Taila)","Nourishes Sira & Snayu; pacifies Vata deeply","100–200 ml; retained and absorbed"],
      ["Matra Basti","Small oil enema (60–120 ml)","Ideal for emaciated / chronic patients; daily use","60–120 ml; no Paschatkarma needed"],
    ],
    y, [1.6, 2.8, 2.6, 1.9]);
  pageNum(s, 17, TOT);
}

// ── SLIDE 18: BASTI — PART 2 ─────────────────────────────────────────────────
{
  const s = pres.addSlide(); bg(s);
  runningHead(s, "Section III — Panchakarma Procedures");
  let y = slideHeading(s, "3.5 Basti Karma — Part 2: Protocols and Mode of Action");
  y = subHead(s, "Standard Basti Protocols", y);
  y = table(s,
    ["Protocol","Sessions","Composition","Indication"],
    [
      ["Karma Basti","30 sessions (alternating)","Anuvasana on odd days; Niruha on even days","Moderately strong patients; standard course"],
      ["Kala Basti","16 sessions (6+10)","6 Anuvasana + 10 Niruha","Standard protocol; most widely used in Pakshagata"],
      ["Yoga Basti","8 sessions (3+5)","3 Anuvasana + 5 Niruha","Weaker patients; acute / early sub-acute phase"],
    ],
    y, [1.8, 1.5, 3.2, 3.4]);
  y += 0.1;
  y = subHead(s, "Mode of Action of Basti", y);
  y = bullets(s, [
    "Direct Vata pacification: Medicated substances contact colonic mucosa (Vata's seat) and pacify Apana Vayu",
    "Systemic drug absorption: Active compounds from Dashamoola, Ashwagandha, Bala absorbed through colonic mucosa into systemic circulation and cross the BBB",
    "Gut-brain axis modulation: The enteric nervous system (500 million neurons — the second brain) is directly stimulated; bidirectional vagal, hormonal, and immune signalling",
    "Gut microbiome modulation: alters production of neuroactive compounds (GABA, serotonin, dopamine precursors)",
    "Brimhana effect: Oil-based Bastis nourish depleted Dhatus (Majja, Asthi, Mamsa)",
    "Withanolides from Ashwagandha: Demonstrated nerve regeneration, acetylcholinesterase inhibition, and neuroprotection against excitotoxicity in experimental studies",
  ], y, {lh:0.28, fs:10.5});
  pageNum(s, 18, TOT);
}

// ── SLIDE 19: NASYA ──────────────────────────────────────────────────────────
{
  const s = pres.addSlide(); bg(s);
  runningHead(s, "Section III — Panchakarma Procedures");
  let y = slideHeading(s, "3.6 Nasya Karma (Nasal Administration)");
  y = shloka(s, '"Nasahi Shirasodwaram" — The nose is the door to the head.  — Charaka Siddhi Sthana 9', y);
  y += 0.08;
  y = subHead(s, "Indications in Pakshagata", y);
  y = bullets(s, ["Urdhvajatrugata Vata — manifestations above the neck", "Speech disorders: dysarthria, aphasia, slurring (Vaksthambha)", "Facial deviation / palsy (Mukha Vakrata)", "Cognitive and memory disturbances (Manovaha Srotas involvement)"], y, {lh:0.28, fs:11});
  y += 0.06;
  y = subHead(s, "Types and Drugs", y);
  y = bullets(s, [
    "Navana Nasya (Snehana / Oleating): Anu Taila or Shadbindu Taila; 4–8 drops per nostril; 7–14 days; Vatanulomana; nourishes cranial nerves",
    "Avapeedana Nasya (Shodhana / Cleansing): Vacha Churna or Vasa Kalka; removes Margavarana (channel obstruction); Srotoshodhana",
  ], y, {lh:0.3, fs:11});
  y += 0.06;
  y = subHead(s, "Mode of Action — Modern Pharmacological Pathways", y);
  y = bullets(s, [
    "Olfactory route: Lipophilic drug molecules travel along olfactory nerve axons (CN I) directly to olfactory bulb and frontal cortex",
    "Trigeminal pathway: Drugs follow trigeminal nerve branches into brainstem and cerebellum (CN V distribution)",
    "Perivascular / lymphatic pathway: Drugs travel in perineural spaces surrounding cranial nerve fibers into CNS",
    "Vascular pathway: Nasal submucosal vasculature absorbs water-soluble compounds into systemic circulation",
    "Result: Intranasal delivery achieves higher CNS drug concentrations than IV or oral routes — directly relevant to neuroprotection in stroke",
  ], y, {lh:0.28, fs:11});
  pageNum(s, 19, TOT);
}

// ── SLIDE 20: SECTION IV — DISCUSSION: MODE OF ACTION ───────────────────────
{
  const s = pres.addSlide(); bg(s);
  runningHead(s, "Section IV — Discussion");
  let y = slideHeading(s, "Section IV: Discussion — Detailed Mode of Action");
  y = para(s, "The therapeutic efficacy of Panchakarma in Pakshagata can be understood at three levels: (a) Ayurvedic doshic and Guna framework, (b) Srotas and Dhatu-level analysis, and (c) modern pharmacological and physiological correlations.", y, {h:0.42, after:0.1});
  y = subHead(s, "Snehana and Swedana — Synthesis", y);
  y = para(s, "The Samprapti of Pakshagata involves desiccation of Sira and Snayu due to the Ruksha (dry), Khara (rough), and Sheeta (cold) qualities of aggravated Vata. Snehana's primary Gunas — Snigdha, Guru, Ushna — are precisely opposite (Samanya Vishesha principle). Swedana restores Samana Vayu function, performing Srotoshuddhi and Amapachana. Modern: sesame oil antioxidants (sesamol, sesaminol) reduce CNS oxidative stress; heat therapy reduces spasticity and improves motor cortex neuroplasticity.", y, {h:0.62, after:0.08});
  y = subHead(s, "Basti — Gut-Brain Axis Mechanism", y);
  y = para(s, "The modern discovery of the enteric nervous system (500 million neurons, bidrectional gut-brain axis via vagal, hormonal, and immune pathways) provides a compelling biological framework for understanding why treating the colon (Pakvashaya) has systemic neurological effects. Colonic absorption of neuroactive compounds from Dashamoola, Ashwagandha (withanolides), and Bala directly supports nerve regeneration, reduces neuroinflammation, and modulates neurotransmitter balance.", y, {h:0.62, after:0.08});
  y = subHead(s, "Nasya — Nose-to-Brain Drug Delivery", y);
  y = para(s, "The concept of nasal drug delivery to CNS is now an active area of modern neuropharmacology (intranasal drug delivery research). The olfactory and trigeminal pathways allow drug molecules to bypass the blood-brain barrier (BBB) — achieving 10–100 times higher CNS concentrations than comparable IV doses. This provides pharmacological validation for Nasya's role in addressing the Urdhvajatrugata Vata component of Pakshagata.", y, {h:0.62});
  pageNum(s, 20, TOT);
}

// ── SLIDE 21: PATHYA-APATHYA + INTEGRATED APPROACH ──────────────────────────
{
  const s = pres.addSlide(); bg(s);
  runningHead(s, "Section IV — Discussion");
  let y = slideHeading(s, "4.3 Pathya-Apathya & Integrated Approach — Clinical Evidence");
  y = subHead(s, "Pathya (Recommended) and Apathya (Avoided)", y);
  y = table(s,
    ["Category","Pathya (Recommended)","Apathya (Avoid)"],
    [
      ["Ahara (Diet)","Black gram, horse gram, garlic, ginger, sesame oil, ghee, warm freshly cooked unctuous food, high-fiber diet","Dry/cold/rough foods, excessive fasting, popcorn, raw vegetables, alcohol, smoking"],
      ["Vihara (Lifestyle)","Regular physiotherapy, Nadi Shodhana Pranayama, Yoga (assisted asanas), warm environment, adequate rest","Excessive exertion, cold water bathing, cold wind exposure, suppression of natural urges, chronic stress"],
    ],
    y, [1.4, 3.9, 3.6]);
  y += 0.1;
  y = subHead(s, "Clinical Evidence for Integrated Approach", y);
  y = bullets(s, [
    "IJAM Case Study: 63yr male, hemorrhagic stroke + left hemiplegia; Snehana + Swedana + Virechana + Shirodhara + Basti x21 days; remarkable recovery in speech and mobility",
    "Charaka Samhita Online Case: 77yr male, right hemiplegia; Dhanyamladhara + Abhyanga + Shashtika Sweda + Matra Basti + Nasya; patient walked without support at discharge",
    "Ayushdhara Case: 52yr male, Kaphavaranajanya; Nasya + Dashamula Niruha Basti x17 days; Barthel Index improved 30 -> 95",
    "JAIMS 2023: 58yr, left MCA infarct; Kala Basti + Anu Taila Nasya + Ekangavira Rasa; MRC Grade 1 -> Grade 4 in 45 days; independent ambulation",
  ], y, {lh:0.28, fs:10.5});
  pageNum(s, 21, TOT);
}

// ── SLIDE 22: LIMITATIONS ────────────────────────────────────────────────────
{
  const s = pres.addSlide(); bg(s);
  runningHead(s, "Section IV — Discussion: Limitations");
  let y = slideHeading(s, "4.4 Limitations of Current Research");
  y = shloka(s, 'Akashlal et al. 2025 Systematic Review (PMID: 39763345): "Current review could not definitively establish the efficacy and safety of Ayurvedic interventions in hemiplegia. Authors strongly advocate for good quality research."  — J Evid Based Integr Med 2025', y);
  y += 0.08;
  y = para(s, "The 2025 systematic review examined 30 studies: 9 RCTs, 8 non-randomized comparative trials, and 13 pre-post studies. All but one exhibited substantial bias on risk of bias assessment using RoB 2 and ROBINS-I tools.", y, {h:0.42, after:0.08});
  y = subHead(s, "Key Methodological Limitations", y);
  y = twoCol(s,
    [
      "Small sample sizes; no adequately powered RCTs",
      "Cannot double-blind Panchakarma procedures (performance & detection bias)",
      "Non-validated or internally developed outcome tools",
      "Inadequate follow-up periods; no long-term data",
    ],
    [
      "No systematic adverse event (AE/ADR) documentation",
      "Non-standardized protocols across institutions and Acharyas",
      "Confounding: simultaneous physiotherapy, multiple herbs",
      "Patient heterogeneity: ischemic, hemorrhagic, traumatic mixed",
    ],
    y, {fs:10.5});
  y += 0.06;
  y = para(s, "This represents a research deficit, not a therapeutic deficit. The gap between the clinical experience of thousands of Ayurvedic practitioners and the quality of formal evidence must be addressed through investment in rigorous research infrastructure.", y, {h:0.48, italic:true, col:SUB});
  pageNum(s, 22, TOT);
}

// ── SLIDE 23: SCOPE FOR RESEARCH ─────────────────────────────────────────────
{
  const s = pres.addSlide(); bg(s);
  runningHead(s, "Section IV — Discussion: Scope for Future Research");
  let y = slideHeading(s, "4.5 Scope for Future Research");
  y = subHead(s, "Clinical Research Priorities", y);
  y = bullets(s, [
    "Large-scale, adequately powered RCTs comparing specific Panchakarma protocols against standard physiotherapy rehabilitation",
    "Subgroup stratification: separate trials for ischemic vs. hemorrhagic stroke, acute vs. chronic Pakshagata, and three Ayurvedic types",
    "Standardised outcome measures: Modified Rankin Scale (mRS), Barthel Index, NIHSS, MRC Muscle Power Scale, Fugl-Meyer Assessment",
    "Multi-centre trials pooling data from multiple Ayurvedic hospitals for adequate statistical power",
    "Systematic documentation of adverse events (AEs and ADRs) in all future trials",
  ], y, {lh:0.28, fs:11});
  y += 0.08;
  y = subHead(s, "Mechanistic Research Priorities", y);
  y = bullets(s, [
    "Pharmacokinetic studies: document drug absorption through nasal, rectal (Basti), and transdermal (Abhyanga) routes using modern analytical chemistry",
    "Gut-brain axis research: microbiome analysis before and after Basti treatment; studying how Basti modulates gut flora and downstream neurological effects",
    "Neuroimaging studies: fMRI and Diffusion Tensor Imaging (DTI) comparing neural connectivity before and after Panchakarma treatment — objective evidence of neuroplasticity",
    "Biomarker studies: track CRP, IL-6, TNF-alpha, MDA, SOD, BDNF, and NGF during Panchakarma treatment",
  ], y, {lh:0.28, fs:11});
  y += 0.08;
  y = subHead(s, "Policy Priorities", y);
  y = bullets(s, [
    "Integration of validated Ayurvedic rehabilitation protocols into India's national stroke rehabilitation guidelines",
    "Collaboration between Ayurvedic institutions and modern stroke rehabilitation centres for integrated care models",
  ], y, {lh:0.28, fs:11});
  pageNum(s, 23, TOT);
}

// ── SLIDE 24: CONCLUSION ─────────────────────────────────────────────────────
{
  const s = pres.addSlide(); bg(s);
  runningHead(s, "Section V — Conclusion");
  let y = slideHeading(s, "Section V: Conclusion");
  y = bullets(s, [
    "The Ayurvedic conceptualisation of Pakshagata as a Nanatmaja Vata Vyadhi provides a clear, actionable pathophysiological framework that precisely maps onto modern upper motor neuron lesion pathology, from the desiccation of Sira and Snayu to the clinical features of hemiplegia.",
    "The three-fold classification (Suddha Vataja, Anyadosha Samsrista, Kshayahetuja) and the Samprapti Vighatana approach allow treatment personalisation that surpasses the modern ischemic/hemorrhagic binary.",
    "Basti Karma is the single most important Panchakarma procedure — addressing Vata at its Moola Sthana through multiple evidence-supported mechanisms: direct doshic action, systemic drug delivery, and gut-brain axis modulation.",
    "Nasya's direct nose-to-brain drug delivery pathway, now supported by modern intranasal pharmacology research, provides pharmacological validation for its role in speech and cognitive rehabilitation.",
    "The optimal 21st-century model for Pakshagata management combines modern medicine's strength in acute stroke intervention with Ayurveda's strength in sub-acute and chronic neurorehabilitation.",
    "Rigorous clinical trials using validated outcomes and standardised protocols are urgently needed to confirm what centuries of clinical experience and emerging evidence suggest — that Panchakarma-based neurorehabilitation is a safe, effective, and scalable approach to stroke recovery.",
  ], y, {lh:0.35, fs:11});
  y += 0.1;
  rule(s, y, BLUE);
  y += 0.12;
  y = shloka(s, '"Swasthasya Swasthya Rakshanam, Aturasya Vikara Prashamanam"  — Acharya Charaka', y);
  pageNum(s, 24, TOT);
}

// ── SLIDE 25: REFERENCES ─────────────────────────────────────────────────────
{
  const s = pres.addSlide(); bg(s);
  runningHead(s, "References");
  let y = slideHeading(s, "References");
  const refs = [
    "1.  Charaka Samhita, Sutra Sthana 20 — Nanatmaja Vata Vikaras (80 types of Vata disorders)",
    "2.  Charaka Samhita, Chikitsa Sthana 28/53-55 — Pakshaghata Chikitsa Sutra",
    "3.  Charaka Samhita, Siddhi Sthana 9 — Nasya (Nasahi Shirasodwaram)",
    "4.  Sushruta Samhita, Nidana Sthana — Classification and pathogenesis of Pakshaghata",
    "5.  Ashtanga Hridayam, Nidana Sthana 15/40-42 — Vagbhata's description",
    "6.  Madhava Nidana, Chapter 22 — Pakshaghata classification and Samprapti (Ma.Ni.22/18, 22/39-42)",
    "7.  Akashlal M, Nair PP, Nair DR et al. A Systematic Review on Safety and Efficacy of Ayurvedic Interventions in Hemiplegia (Pakshaghata). J Evid Based Integr Med. 2025. PMID: 39763345; DOI: 10.1177/2515690X241304523",
    "8.  Ayurvedic Management of Pakshaghata (Left Hemiplegia). International Journal of Ayurveda and Medical Sciences (IJAM). Article ID 1954.",
    "9.  A Conceptual Review on Insights of Pakshaghat (Hemiplegia). AYUSHDHARA. 2025;12(2):264-274.",
    "10. Success Story of Pakshagata. AYUSHDHARA Case Study. Available at: ayushdhara.in",
    "11. AN AYURVEDIC REVIEW ON PAKSHAGHATA AND ITS MANAGEMENT. JETIR. 2025; JETIR2502254.",
    "12. Pakshaghata — Charak Samhita Online. carakasamhitaonline.com",
    "13. Ayurvedic Management of Hemiplegia (Pakshaghata) Following Stroke. AVCRI, 2025.",
    "14. World Health Organization — Global Stroke Statistics. GBD 2019.",
    "15. Global Burden of Disease Study — Stroke in India. The Lancet Neurology, 2021.",
    "16. Pakshaghata Chikitsa — Ayurvedic Strategies for Hemiplegia. Ask Ayurveda Articles, 2024.",
  ];
  refs.forEach(ref => {
    s.addText(ref, {x:ML, y, w:TW, h:0.26, fontSize:9.5, color:DARK, fontFace:"Times New Roman", valign:"top", margin:1});
    y += 0.27;
  });
  pageNum(s, 25, TOT);
}

// ── WRITE FILE ────────────────────────────────────────────────────────────────
pres.writeFile({ fileName: "/home/daytona/workspace/pakshagata-essay/Pakshagata_Essay_Format.pptx" })
  .then(() => console.log("DONE"))
  .catch(e => { console.error(e); process.exit(1); });

cd /home/daytona/workspace/pakshagata-essay && node generate_essay_ppt.js 2>&1

ls -lh /home/daytona/workspace/pakshagata-essay/Pakshagata_Essay_Format.pptx && …