By Peter J. Koehler

These are the words written in a notebook by French novelist Alphonse Daudet (1840-1897) and published posthumously in a book (La Doulou, 1930, p. 18) with short statements he had made during the 20 years he was suffering from ataxie locomotrice progressive (tabes dorsalis).

As probably most neurologists will know, general paralysis of the insane (GPI, also known as general paresis and dementia paralytica) and tabes dorsalis are the two main neurological manifestations of late neurosyphilis. The first condition was recently discussed by Fiolet and Daey Ouwens in an article on malaria fever therapy and has become relatively rare. (See World Neurology October/November 2020.) The latter disease became very rare during the past decades, and only few living neurologists will ever have observed it.

Shooting Pain

Early 19th-century patient showing wide based gait and hypermetric lifting of right leg. Note the spreading of the arms to keep balance.

In a time that it was much more frequent, a neurological test became associated with it, notably the Romberg Test. It was introduced in a period that this eponymist will not have realized that it was a syphilitic disease. With a latency of between 15 and 30 years after the primary infection, the shooting pain in the legs and abdomen were the most characteristic symptoms, next to signs such as ataxic gait. In old neurological films, these patients are easily recognized by their wide-based gait with hypermetric lifting of the feet.

Another characteristic sign was the Argyll-Robertson pupil. These could be accompanied by absent muscle stretch reflexes of the lower limbs, a sign that was already believed to be of great importance, when the reflexes were described by Westphal and Erb (1875). As would be expected, pathology in these patients was found in the dorsal roots and posterior columns in the lower part of the spinal cord, while, of interest, the exact pathogenesis is unknown.

The Term

The term tabes is quite old, meaning consumption. In the past, the Greek term phtisis was used to indicate consumption, in particular when it was caused by tuberculosis of the lungs. The term dorsalis, as one would expect, does not refer to the dorsal columns, but rather to the affliction of the spinal cord. The neurologist and “neurohistorian” Francis Schiller (1909-2003) noted that it was already referred to in the Hippocratic corpus, where consumption of the spinal cord is mentioned (phtisis notias).

Romberg’s Test

Moritz Romberg (Humboldt-Universität zu Berlin, Universitätsbibliothek).

Probably most neurologists will be acquainted with this test, described in the early 1840s by the Berlin physician Moritz Heinrich Romberg (1795-1873) in his well-known Lehrbuch der Nervenkrankheiten des Menschen. He had observed the phenomenon in patients suffering from tabes dorsalis and wrote:

Isolirt, ohne Verlust des Hautgefühls, zeigt sich die Anaesthesia muscularis, nach meinen Beobachtung, als stete Begleiterin der Tabes dorsualis. Ein einfaches Experiment giebt davon die Ueberzeugung. Man lässt den Kranken in aufrechter Stellung die Augen schließen: sofort tritt ein Schwanken des Körpers ein, und nimmt dergestalt zu, dass derselbe, wenn man ihn nicht hält, umsinkt. ^{2, p.228}

In the English edition of Romberg’s second German edition, this was translated as:

I have observed that anaesthesia of the muscles alone without loss of tactile power, invariably accompanies tabes dorsalis. A simple experiment suffices to determine the fact. If the patient is told to shut his eyes while in the erect posture, he immediately begins to move from side to side, and the oscillations soon attain such a pitch that unless supported he falls to the ground., ^{pp. 226-7}

Romberg believed the sign was pathognomonic:

Auf dieses pathognomonische Merkmal — denn es zeigt sich nach meiner Beobachtung weder bei andern Lähmungen noch in der von Complication freien Amaurose — habe ich schon vor zehn Jahren aufmerksam gemacht …^{2, p.795}

[It is now 10 years since I pointed out this pathognomonic sign, and it is a symptom which I have not observed in other paralyses, nor in uncomplicated amaurosis; since then I have found it in a considerable number of patients, from far and near, who have applied for my advice; in no case have I found it wanting].^{p. 396}

It is interesting to note that Romberg wrote about “paralyses” and inserted the chapter on tabes dorsalis in a section on spinal paralyses.^{2, pp.794-801}

Muscle Sense

Charles Bell (Colour mezzotint by H. Goffey after J. Stevens. Wellcome Collection).

Romberg observed an autopsy at the Berlin Charité hospital, done by his colleague Robert Froriep (1804-1861) and was particularly interested in the atrophy of the caudal part of the spinal cord, including the dorsal columns and the dorsal roots. “Die Marksubstanz der erstern war fast ganz geschwunden, so dass sie wie durchsichtig von graugelber Farbe erschienen”.2^{, p. 799} [The medullary tissue of the former had almost entirely disappeared, so that they were translucent, and of a greyish-yellow colour].^{4, p. 399}

Years before, Romberg had translated English medical books into German, including Scottish surgeon and anatomist Charles Bell’s (1774-1842) The nervous system of the human body (1830). Bell was the person, who gave an early description of proprioception (the sixth sense) in 1826: “between the brain and the muscles, there is a circle of nerves…”

As this subject had also been a part of Romberg’s translations (1832), he was aware of muscle sense, as appears from his textbook: “Verlust des specifischen Muskelgefühls, die Kehrseite des Schwindels, als dessen Grundzug Empfindung von Scheinbewegungen aufgestellt worden, kommt entweder in Verbindung mit Anaesthesia cutanea oder isoliert für sich vor. Von ersterem erzählt Bell ein Paar Beispiele”.^{2, p. 226} [A loss of the specific muscular sensation, the counterpart to vertigo, the fundamental character of which has been stated to be an impression of illusory movement, may occur in connection with anaesthesia cutanea or isolated. Bell relates a few instances of the former].^{3, p. 225}

Thesis of Sigmund Eduard Loewenhard (1817).

The French physician Guillaume BA Duchenne (1806-1875) applied the term ataxia, mentioning the disease “ataxie locomotrice progressive” [progressive locomotor ataxia]. Moreover, he doubted the muscle weakness, as described by Romberg, and emphasized the disorder of balance and coordination that increased in the dark.

Wide-Based Gait and Shooting Pain

Romberg was not the first physician to describe tabes dorsalis. His teacher Ernst Horn (1774-1848) wrote about it in 1813, and some of Horn’s pupils published dissertations on the disease in the early 19th century. De Myelophtisi Chronica Vera et Notha (1817), for instance, was written by Sigmund Eduard Loewenhard (1794-1875) . Like Romberg, they also supposed weakness, but the wide-based gait was the most remarkable feature. They also noted the genu recurvatum or knee hyperextension and were aware of the shooting pain in the limbs, urinary incontinence, and impotence.

Argyll-Robertson Pupil

Douglas Argyll Robertson (Wellcome Collection).

Romberg had already noted the peculiar disorder of the pupils. “in der Tabes dorsualis dagegen habe ich öfters die Pupille bis auf die Größe eines Stecknadelknopſes contrahirt gefunden”^{2, p. 684} [in tabes dorsalis I have found the pupil contracted to the size of a pin’s head]4, p. 299 and “in beiden Augen oder nur in einem, und zwar eine Verengerung mit Unbeweglichkeit”.^{2, p. 797} [one or both eyes, consisting in a contraction with loss of motion]^{4, p. 397}

Scottish surgeon and ophthalmologist Douglas MCL Argyll Robertson (1837-1909) later provided an accurate clinical description of the characteristic, narrow, not completely round pupil that reacted to convergence, but not to light (1869). His students are supposed to have said: “It’s better to be pupil of Argyll Robertson than to have them.”

Charcot’s Contributions

In his early career, Jean-Martin Charcot (1825-1893) in cooperation with Alfred Vulpian (1826-1887) published some cases (1862) and later he described the condition more extensively with his pupil Charles Bouchard (1837-1915), emphasizing the severe pain with the term “douleurs fulgurantes” [shooting pains]. Moreover, he described the arthropathy, later eponymized as Charcot joints, that could accompany the disease.

As for the treatment, he applied suspension therapy, applied 20 years later. He referred to “Dr. Motschutkovsky de l’Odessa,” who had observed a favorable effect on the pain. Charcot, with his pupil Georges Gilles de la Tourette (1857-1904), treated a number of patients by this method, including his rear neighbor the writer Alphonse Daudet. As mentioned in the introduction, book on his disease, in particular the pain, was published posthumously, notably La Doulou (La Douleur/The pain; 1930, English translation in 2002); This is what he noted on this particular treatment:

Je reste jusqu’à quatre minutes en l’air, dont deux soutenu seulement par la mâchoire. Douleur aux dents. Puis, en descendant, quand on me détache, horrible malaise dans la région dorsale et dans la nuque, comme si toute ma moelle se fondait. (La Doulou, 1930^{, p. 23})

[I stay in the air up to four minutes, two of which supported only by the jaw. Pain in the teeth. Then, descending, when they detach me, a horrible malaise in the dorsal region and in the neck, as if the whole cord is melting.]

Intemperance in Baccho et Venere

Hideyo Noguchi.

Interestingly, although the venereal origin of tabes dorsalis was not known in Greek antiquity and the centuries that followed, the association with (excessive) sexual activity and sin was supposed. A relation between sexual activity and the spinal marrow, also known as the encephalomyelogenic spermatology, was assumed. The association has been repeatedly mentioned by persons including Plato (c 427 -347 BCE; Timaeus), Leonardo da Vinci (1452-1519), and the Swiss physician Théophile Bonet (1620-1689).

Herman Boerhaave (1768-1838) wrote about excessive loss of sperm that could produce fatigue, debility, immobility, convulsions, wasting, and drying up, leading to dorsal consumption (tabes dorsalis). The spinal cord had traditionally been linked to the production of semen, and therefore excessive sexual activity was associated with tabes dorsalis by physicians including the Leyden professors Boerhaave and Hiëronymus David Gaubius (1705-1780), to whom the Swiss Samuel-Auguste Tissot (1728-1797) referred in his well-known L’Onanisme (1764).1 In Romberg’s time, it was considered an affliction of men, nearly one eighth of the patients being women. He wrote about physical exercise followed by “Excesse in Baccho et Venere.”

Uebermässiger Aufwand motorischer Kraft durch anhaltendes Stehen in gebückter Stellung, durch forcirte Märsche bei gleich zeitiger Erkältung in ſeuchten Bivouacs etc. und darauffolgende Excesse in Baccho et Venere – wie es so häufig in Feldzügen der Fall ist – spielen in der Aetiologie eine wichtige Rolle, daher die Frequenz der Tabes dorsualis in den ersten Decennien nach den grossen Feldzügen neuerer Zeit. ^{2, p. 800-1}

[When the strength is much taxed by continued standing in a bent posture, by forced marches, and the catarrhal influences of wet bivouacs, followed by drunkenness and debauchery, as is so often the case in campaigns, the malady is rife; this is the reason why tabes dorsalis was so frequent during the first decennia following the great wars of the present century.^{4, p. 400}]

Suspension treatment (from article by George Gilles de la Tourette Nouvelle Iconographie 1889, p. 88-9).

Therefore, long journeys to health resorts, to undergo hydrotherapy as a form of prevention for instance, was dissuaded. The prognosis was believed to be serious without prospect of recovery, although the course could be quite long.

Venereal Disease After All

Due to the long latency between infection and tabes dorsalis (or GPI), it took a long time before the association was proved. Jean-Alfred Fournier (1832-1914), the French dermatologist, who was specialized in venereal diseases, found statistical indications, categorizing both diseases under the term “parasyphilis” (1894). However, he continued the idea of hereditary transmission. Further proof for the association with syphilis was delivered by the German neurologist Wilhelm Heinrich Erb (1840-1921). Biological proof had to wait until 1906, when the Wasserman reaction was described, a year after the discovery by Fritz Schaudinn (1871-1906) and Erich Hoffmann (1868-1959) of the Treponema pallidum. Finally, the Japanese bacteriologist Hideyo Noguchi (1876-1926) demonstrated the spirochete in the brain of a patient suffering from GPI in 1913 and later in the spinal cord of a tabetic patient. •

lphonse Daudet, French writer who suffered from tabes dorsalis

A collaboration between the World Federation of Neurology and Multiple Sclerosis International Federation

By Tissa Wijeratne, Wolfgang Grisold, Rachel King, William Carroll

Wolfgang Grisold

Tissa Wijeratne

World Brain Day (WBD) was launched in 2014. Since then, the WFN, jointly with other international societies, such as International League Against Epilepsy, World Stroke Organization, the International Headache Society, and the Movement Disorders Society chooses a topic with a view to drive home the importance of brain health and promoting better neurological care globally.

Based on this background, the WFN chose the topic of multiple sclerosis jointly with the Multiple Sclerosis International Federation (MSIF) as the topic for WBD 2021. As in preceding WBDs (https://wfneurology.org/world-brain-day-past-years), the aim of WBD 2021 is to alert not only its member societies but also the public on critical neurological issues. The member societies of the WFN will receive a “tool kit,” templates for press releases and also educational PowerPoint presentation sets to assist in their local activity to promote WBD and advocate for patients with MS and their caregivers.

Rachel King

William Carroll, MD

Local press conferences, press coverages (including print, electronic, radio, TV, YouTube channels) are strongly encouraged to reach the public.

Let us spread the key messages from WBD 2021: Stop Multiple Sclerosis through mainstream media, social media platforms, and local, regional, national and international meetings throughout the year. Please see and share our new logo, the web banners, social media images, and other educational material in your country.  We invite our readers to rally around WBD 2021 with the aim to stop multiple sclerosis.

Please make the World Brain day 2021 campaign Stop Multiple Sclerosis an important priority. The educational and promotional material from the WFN-MSIF collaboration will help you to be the best advocates for your patients with multiple sclerosis and their caregivers. •

By Stefan Oberndorfer, MD, Prof, FEAN

Cancer is one of the most important conditions in human health, and due to longer life expectation and improved therapies, survival in cancer patients is also increasing. This has several implications in the management of cancer patients as the longer survival changes the “natural” course of many tumors.

The nervous system, consisting of the brain, spinal cord, the peripheral, and autonomic system is exposed to direct and indirect damage by cancer, which are not only metastatic, but also metabolic, endocrine, inflammatory, and paraneoplastic. In the past decades, besides hematotoxicity, neurotoxicity (for instance, chemotherapy-induced polyneuropathy) was one of the most frequent side effects of anticancer treatment. In recent years, the profile of side effects from cancer therapy is changing from the classical, often dose-related toxicity toward side effects predominantly based on immune mechanisms.

Side effects from these new therapies, including molecular and immunological mechanisms, induce neurological phenomena affecting the brain, spinal cord, and the peripheral nervous system. In clinical practice, the distinction between direct cancer effects, side effects of classical and “newer” therapies, or other cancer effects need to be thoroughly discriminated. This discrimination has a major impact on the therapeutic and diagnostic management of cancer patients.

Conversely to the classic concept of direct damage (e.g. surgery), or toxicity (and chemotherapy), targeted and immune therapies present with an entirely new spectrum of side effects. In clinical practice, where the patient may be affected with tumor progression, concomitant diseases, infections, and side effects of conventional therapies, these emerging therapies pose an additional factor and need to be classified as distinct neurological syndromes.

For the clinical neurologist and neuro-oncologist, it seems sometimes challenging to catch up with all the new anticancer treatments, even with a focus on neurological side effects. Each year, an amazing number of new drugs appear that have been evaluated for toxicity in early phase 1 and 2 trials, and during the registration process. However, their effect in the medium- and long-terms is uncertain, and clinicians are challenged by monitoring these patients.

Recent developments in medical oncology, for example, the therapeutic “revolution” in many cancer types induced by checkpoint inhibitors, show a completely new spectrum of neurological complications such as autoimmune encephalitis, Guillain-Barre syndrome, and myasthenic syndromes. A complete summary of “classical” and “newer” neurotoxicity of anticancer treatment can be found in the book “Side Effects of Anticancer Treatment, co-edited by this author, with many international contributors, focusing on therapy related effects, and providing pragmatic guidance for the differential diagnosis from neoplastic and other causes.

Adequate and immediate response to autoimmune phenomena caused by checkpoint inhibitors (dose reduction, immunosuppression) is crucial for oncologic and neurological outcome. At the same time, symptomatic therapies of neurological side effects have to be applied.  Another example is neuropathic pain, which may be caused by direct or indirect effects of cancer and also as a side effect of therapy. Other examples for the need of symptomatic therapies are disorders of coordination, cognitive disorders, seizures, weakness, which need the expertise of neuro-oncology.

Due to the rapid progress in molecular pathology and genetics, the borders of tumor entities blur and the spectrum of anticancer treatment will become more colourful and personalized in the future. The conventional approach based on surgery, radiotherapy, and chemotherapy will be increasingly complemented by the concepts of targeted therapies and immune therapies, which will increasingly result in a new spectrum of side effects. •

Prof. Oberndorfer is head of the department of neurology at the University Clinic St. Pölten in Austria.

By Lawrence Tucker, MB ChB

Lawrence Tucker

In 2019, Groote Schuur and Tygerberg Hospitals in Cape Town, South Africa, were jointly recognized as the only WFN-accredited, anglophone Regional Training Center (RTC) in sub-Saharan Africa; and one of only four such WFN RTCs on the African continent. It comprises the divisions of neurology of the universities of Cape Town (UCT) and Stellenbosch as well as the Neurology Research Group at the newly established UCT Neuroscience Institute (http://www.neuroscience.uct.ac.za).

Dr. Desmond Koffie

The Cape Town RTC is widely recognized for the quality of its clinical training, commitment to clinical excellence, and meaningful neuroscience research in the African context. This month, Dr. Desmond Koffie, a Ghanian physician, will become the first WFN-sponsored resident to enroll for the four-year career neurology training program in Cape Town. He will join 14 fellow neurology residents from South Africa, Uganda, Libya, Mauritus, and Tanzania on the rotation. Recent graduates from Namibia, Zambia, Kenya, Zimbabwe, and Mozambique have returned to practice neurology in their home countries, resulting in an active network of neurologists across sub-Sahara Africa centered on this RTC.

Groote Schuur Hospital

The Cape Town RTC training program is uniquely placed to provide trainees with an opportunity to diagnose and manage, under expert supervision, a broad spectrum of communicable and non-communicable neurological pathology, while providing comprehensive training in EEG, NCS, and EMG, which includes both “over the shoulder” and Web-based instruction. Over the past two years, more than 500 neurologists, neurology residents, and neurotechnologists from across Africa and beyond have enrolled for the intensive, six-month, EEGonline distance learning program developed at Cape Town’s RTC with seed funding from the WFN (http://studyeegonline.com).

Neurology residents

As from this year, in addition to career neurology resident training, Cape Town will offer one-year, self-funded or independently sponsored clinical fellowships in epilepsy (including epilepsy surgery), infectious neurology, stroke, and neuromuscular disease. These fellowships are primarily aimed at recently qualified neurologists from sub-Saharan Africa (http://www.neuroscience.uct.ac.za/noticeboard/opportunities).

By Drs. Chandrashekhar Meshram, JMK Murthy, Nirmal Surya and U. Meenakshisundaram.

The Tropical and Geographical Neurology Specialty Group of the WFN joined hands with the Indian Academy of Neurology (IAN) to celebrate the Brain Health initiative on Jan. 11, 2021, to raise awareness for the importance of brain health.

A public education and awareness activity in the form of a panel discussion was planned through virtual meeting. The theme of the session was brain health and what happens if brains are not healthy. Dr. Chandrashekhar Meshram, chief coordinator of the program, released the press note.

Dr. JMK Murthy, president of Indian Academy of Neurology and clinical director and chair of the Department of Neurology, CARE Hospitals Hyderabad, inaugurated the event.

Dr. Meshram, in his introductory remarks, emphasized the relevance of this initiative by the World Federation of Neurology. Dr. Sarosh Katrak, past president of IAN, explained the importance of the brain, explained its functions and discussed why brain health is the priority.

IAN Secretary Dr. U. Meenakshisundaram spoke about various brain diseases and when people should consult a neurologist. Dr. Subhash Kaul, past president of IAN, mentioned various risk factors for brain diseases and how a change in lifestyle is important for prevention of neurological disorders.

Marathon runner and neurologist Dr. Anuradha explained how regular physical exercises improve brain health. Dr. Meshram highlighted the misconceptions about diet and stressed the need to shift to a low carbohydrate diet. He said that wrong diet is responsible for the pandemic of metabolic syndrome all over the world.

Dr. Gagandeep Singh, past secretary of IAN, informed about the current status of COVID vaccine. Dr. Sudhir Kothari said that developing hobbies is a good idea to maintain brain health and suggested that there is no age bar to learning new things. Dr. Sudhir Shah explained the positive effects of meditation and yoga on brain health. Dr. Sumit Singh stressed the effects of air pollution on brain health and discussed the sources of air pollution.  Dr. Sudhir Bhave explained the need for sleep hygiene and the role of positive thinking.

The emphasis was on maintaining brain health and prevention of brain diseases.

Dr. Nirmal Surya, IAN president-elect, was the moderator, and he interacted with the panelists. Participants enjoyed the session and the opportunity to interact with the experts during the question-and-answer session. •

By Ani-Osheku Ifeyinwa, Nigeria

Neurology Grand Rounds

In December 2019, I had the utmost privilege to spend four weeks at the neurology department of the Selçuk University in Konya, Turkey. It remains one of the most gratifying moments in my career as a young neurologist.

It has been over a year, yet the memories are ever so fresh. I clearly remember the feeling of excitement as I walked into the massive Selçuk University Hospital and made my way to the “nöroloji poliklinik” where I was greeted with so much warmth by the entire neurology staff. I met Prof. Şerefnur Öztürk, my supervisor, who provided me with the itinerary and a road map of what I was to expect in the coming weeks.

Indeed, it was a four-week period of intense learning in a relaxed and friendly environment. I had the privilege of exploring the world of the practice of neurology by the Turks under the able guidance and excellent mentorship of the neurology team of the Selçuk University Hospital.

Certificate presentation and the new year celebration.

Case after case, I witnessed the translational art of the pathological basis of neurologic diseases from therapeutic theorem to practical strategies using cut-edge technology and evidence-based medicine in the management of various neurologic conditions, including stroke, movement disorders, demyelinating disease (especially multiple sclerosis), neuromuscular diseases, and seizure disorders.

Prof. Öztürk shared with me priceless clinical pearls especially in the area of vascular neurology during the daily morning rounds in the neuro-intensive service as well as in the outpatient service. Her depth of knowledge combined with her wealth of experience has inspired me to push the limits of my career.

It was intriguing watching Prof. Gökhan Özdemir navigate stenosed and occluded vessels inserting stents and retrieving clots and ultimately achieving revascularization.

My experience with the neurophysiology laboratories left quite an impression on me that instinctively I knew I would pursue a fellowship in this area. I participated in carrying out and interpreting several EEGs, needle EMGs, and nerve conduction studies under the supervision of Profs. Gökhan Özdemir, Haluk Gümüş, and Dr. Hakan Ekmekci.

I learned the techniques of peripheral nerve blockade in the management of headaches and this service is one of the treatment modalities currently offered to patients with headache disorders in our neurology clinic. The ease of application coupled with the dramatic improvement has been a rewarding experience.

Lunch with neurology residents

I joined the neurosurgical team in the collaborative management of patients especially those with movement disorders, where I witnessed the usefulness of deep brain stimulation in advanced Parkinson’s disease.

One of the highlights of my stay was the opportunity to speak on “Nigeria, Its People, and Its Health Care System: A Focus on Neurological Diseases.” This lecture was delivered on Dec. 25,  2019, in the Dekanlik Donem 2 Amfisi, and I tagged it “A Christmas to Remember!”

The rich cultural heritage of the Turks makes the city a tourist’s delight. I savored the tastebud tantalizing Turkish foods and enjoyed the sceneries of some of the city’s famous sites, like the famous Mevlâna Museum and Alaaddin Cami.

Despite the numerous challenges the novel Covid-19 pandemic brought, redefining interactions in the health care sector along with restrictions in movements that put a hold on dreams for the physical quest in knowledge acquisition, I have continued to cascade the knowledge so acquired in my time in Selçuk in order to positively impact the lives of patients with neurological needs in Nigeria. I am currently working on various projects that include the transfer of skills acquired, especially relating to headache management and protocols for managing various neurology conditions.

Dr. Ani-Osheku Ifeyinwa giving a lecture

My profound gratitude to the WFN/TNS for this wonderful and innovative collaboration to give young neurologists like me the opportunity to experience the practice of neurology in an advanced society and a chance to improve our skills and broaden our horizons. Plenty of thanks to Mrs. Jade Levy and Mr. Burak for the seamless facilitation of my trip and stay in Konya. My deep appreciation to Selçuk University and  the dean of the College of Medicine for providing the enabling environment for my visit. To Prof. Şerefnur Öztürk, you inspire me in numerous ways to be the best version of myself. Finally, to the exceptional team at the Selçuk neurology department that showed me true friendship, generosity, and ensured I was well integrated, I say thank you!

I had the most amazing time in Konya and established alliances that I believe will go a long way. The lessons learned from my four weeks to Selçuk University will always be a reference point in my career development. •