WHAT DO WE DO WITH ALL THIS TRASH?

 

What do we do with all this trash? With more than 7 billion people consuming, and then disposing of, "stuff" each day, usable space for trash disposal is quickly disappearing. The World Bank estimates that 3 billion people reside within urban areas, producing more than 1.3 billion metric tons of solid waste per year. By 2025 that number is expected to have ballooned to more than 2.2 billion metric tons, forcing governments to task on a garbage problem that many major cities have yet to answer.

 

It is a global problem

It is not a problem of the developing countries only. The Megacities of the world gobble up more water and energy while producing waste astronomically each year. For poor countries, inefficient waste management accelerates the rate of disease as toxins seep into waterways, leading to irreversible environmental pollution.

London churns out too much waste and only 52% goes to recycling. London’s waste disposal companies have increased the recycling rate unburdening the landfill. London’s heavy reliance on primary and secondary industries as the backbone of its economy promotes the consumption of recycled ingredients. The city is blazing the trail in creating a thriving, resilient metro that cuts down waste significantly with a circular economy along with a solid policy framework.

The 7 million perople crammed into Hong Kong's streets produce more than 13,800 metric tons of solid waste a day. That's like tossing an Empire State Building into the waste basket every 27 days. What's worse, of that waste, 3,500 tons-worth comes from scraps of uneaten food, and finding a place to store all of that garbage has proved an insurmountable task. More than 90% of waste is exported for recycling overseas, but that is simply domping poor countries with the waste created by the rich!

One New Yorker dissipates 24 times the electrical energy of a resident in Kolkata, India while spewing 15 times equal solid waste. The city runs a tight ship with aggressive recycling projects that extend outside plastics, paper, and metals to compost food waste. 

Beijing's 20 million plus people produce more than 25,000 tons of garbage a day, a number 4,300 tons beyond what the city can process. The countryside is no better; 40,000 towns and 600,000 villages across the country could not process waste and sewage, leaving more than 300 million tons of waste unprocessed each year.  Chinese government undertook a massive effort to burn trash for energy, constructing hundreds of incinerators to chip away at its trash mountains, but that resulted in large releases of harmful pollutants like dioxin and mercury into the atmosphere.

Manila area produces more than a quarter of all of the garbage in the Philippines, to the tune of nearly 9,000 tons of solid refuse a day. What's worse, only nine of the 16 cities and municipalities that make up the metro Manila area even have a plan to handle all of that waste and 83% og garbage gets collected too.  The trash that does find its way into garbage trucks coalesces into trash cities — towering trash mountains surrounded by shanty towns patrolled by Manila's poorest. Over the years Manila has played host to some of the world's most notorious garbage mountains like Smokey Mountain.

For many years Mexico City's Bordo Poniente held the dubious title of one of the largest landfills in the world. The more than 20 million people of Mexico City's metro area dumped close to 14,000 tons of garbage into the 927 acre site each day. As a result, trash gets dumped everywhere — in rivers, canals, and especially into streets, which are often impassable thanks to the mounds of refuse left behind.

With some 26.7 million people, Jakarta is also one of the world's fastest growing cities. Jakarta produces more than 6,500 tons of waste a day. Most of that waste finds its way to Jakarta's only landfill, Bantar Gebang, a 270 acre trash behemoth that receives 6,250 tons of trash from 800 garbage trucks flowing out of Jakarta each day. The trash clogs waterways during monsoon season, before being sent out into Jakarta Bay and out to sea. 

For hundreds of years the city of Cairo has operated without efficient, government-run trash collection. Instead, for the past 70 years, thousands of trash pickers known as the Zabbaleen have gone door-to-door collecting Cairo's trash for a small fee. The trash-pickers managed to recycle nearly 90 percent of all the garbage that passed through the city, a number that exceeds most Western recycling totals. 

 

The Indian Scenario

India generates 1.7 lakh tons of waste every day. Post Swach Bharat Abhiyan, 90% of the waste is collected and over 54% is processed or treated. Almost 25% of our waste is sent to the sanitary landfills. Now, to this huge man made waste we add the construction and demolition waste, which itself amounts to 15 crore tons a year. If not disposed correctly, which is often the case, it chokes our natural drainage system and cause drains to overflow and monsoon rainwater to cause floods. According to a recent estimate our cities sit atop more than 24 crore tons of legacy waste, spread across 2,400 dumpster, seeping below the surface with every rain, and infecting our groundwater. This leak into our groundwater is called leachate. This is rich in heavy metals, organic pollutants and pathogens contained in the garbage heap. Groundwater near Delhi's Bhalswa landfill has toxic levels of lead and iron and that near Nagpur's Bhandewadi landfill has zinc, copper and cadmium 200% above safe limits. 

New Delhi's tremendous growth has spurned a tremendous growth in refuse, too. The city's solid waste production increased 50 percent over five years, to 9,200 tons of trash a day in 2007, a number that was expected to double by 2024. Three of the four landfills servicing New Delhi are already past capacity, leaving the city starving for additional landfill space. If additional space isn't found these community dumps could spill over into the streets and contribute to a pollution problem that already stretches into the Yamuna river. 

 

Landfills – a necessary evil

Landfills are necessary for the proper disposal of solid waste. They reduce the amount of waste that makes it into the environment, help to prevent disease transmission, and keep communities clean. However, landfills still have significant environmental and social impact. While landfills are a societal necessity, there are practices that can reduce the reliance on landfills and decrease their effects on the biosphere.

Environmental Impact of Landfills

·         The most pressing environmental concern regarding landfills is their release of methane gas from the decomposition of organic waste. Methane is 84 times more effective at absorbing the sun’s heat than carbon dioxide, making it one of the most potent greenhouse gases and a huge contributor to climate change. 

·         Along with methane, landfills also produce carbon dioxide and water vapor, and trace amounts of oxygen, nitrogen, hydrogen, and non methane organic compounds. These gases can also contribute to climate change and create smog if left uncontrolled.  

·         The creation of landfills typically means destroying natural habitats for wildlife.

·         While landfills are required to have plastic or clay lining by federal regulation in the U.S in India these rules are openly flounted. This can result in leachate, a liquid produced by landfill sites, contaminating nearby water sources, further damaging ecosystems. 

·         Leachate can contain high levels of ammonia. When ammonia makes its way into ecosystems it is nitrified to produce nitrate. This nitrate can then cause eutrophication, or a lack of oxygen due to increased growth of plant life, in nearby water sources. Eutrophication creates “dead zones” where animals cannot survive due to lack of oxygen. Along with ammonia, leachate contains toxins such as mercury due to the presence of hazardous materials in landfills.

Social Impact of Landfills

·         Emissions from landfills pose a threat to the health of those who live and work around landfills. A study in New York found that there is a 12% increased risk of congenital malformations in children born to families that lived within a mile of a hazardous waste landfill site.

·         Chronic exposure to leachate contaminated water can cause gastroenteritis, neurological diseases and cancer. 

·         Large landfills, on average, decrease the value of the land adjacent to it. Te quality of life suffers in this region.

·         Landfills bring hazards such as odor, smoke, noise, bugs, and water supply contamination.

·         Minority and low-income areas are more likely to find themselves home to landfills and hazardous waste sites. These areas have fewer resources to oppose the placement of these facilities. This makes them an easier target for landfill placement than higher income areas.

How to avoid landfills

·         Recycle! Continuing to recycle will keep plastic and other materials out of the biosphere and put them to further use!

·         Avoid single-use plastics. Check out this article on single-use plastics and how to avoid them.

·         Compost! Landfills lack the oxygen that compostable items need to fully decompose. By putting biodegradable items into the compost instead of the trash, huge amounts of waste can avoid the landfill.

Landfills help to keep our communities clean, but they also pose serious threats to the health of our environment. Working towards living a zero waste lifestyle will help to reduce our reliance on landfills, their impact on the environment, and their impact on human health and well-being

How do we plan ideal waste management?

It has to be a multi-pronged approach. Waste management should follow the waste hierarchy:

1.      Avoid and reduce waste at the source, starting during the design and procurement phases.

2.      Repair and reuse.

3.      Sort and collect waste separating non-hazardous from hazardous waste.

4.      Recycle.

The treatment and processing system for solid waste include window composting, vermicomposting, pit composting, bio-methanation, organic waste convertors, pelletization, material recovery facilities (MRF), waste to energy plants for electricity generation etc. The ‘waste to energy’ plants are not totally safe as they emit harmful particulate matter in far higher concentration than permissible. So, such plants in Okhla in Delhi and in Jaipur and Hyderabad are not very popular with people living nearby.

So, we should have a proper plan of waste management at every step:

Planning and monitoring

Identify the different types of waste produced, evaluate and record their quantity by volume or weight. Draw up a context-based waste management plan, including sorting, collection, transport, storage, and final disposal. Assess and use local capacities like municipal landfill, informal sector, recycling companies, incineration facilities, etc.

Avoid and Reduce

Encourage procurement and programme teams to avoid and reduce waste at early stage of the project. Evaluate the relevance of each purchase. Engage with suppliers and avoid polluting or single-use items and packaging. Encourage re-usable, recycled, locally repairable and recyclable items with a long lifespan.

Repair and Reuse

Identify items that can be repaired and re-used instead of wasted. Support the necessary infrastructure, for example repair shops, tools or internal workshop. Seek spare parts for the repair process.

Sort and collect

Use separate bins and label them to sort and collect waste. Sort, collect and label hazardous waste separately to avoid any risk or contamination. Adapt the sorting to the existing local recycling opportunities (textile, paper, metals, glass, informal and formal sectors etc). Explore opportunities to mutualise collecting and storage with other actors. Bulk waste generators like malls, hotels, hostels, hospitals must compost and segregate on site. Every ward should have its own compost and segregation site and GPS tagged bins and mobile alerts should be used to track garbage collection.

Recycle

Work with local recycling companies and create employment opportunities. Consider influencing and supporting local governments and decision-makers to improve the recycling infrastructure. Recycled products like tiles, road base material, and prefabricated blocks must be popularised.

Treatment and final disposal

Identify and use legally approved local or regional disposal channels (composting, burial, sealing, controlled landfill, incineration…). Visit the site regularly. Establish partnerships (e.g., incineration in cement plants, energy recovery opportunities) and mutualize equipment like compost pits or collaborate with other actors (NGO’s, health structures, local governments, etc.). Incineration must be disintentivised to avoid contaminating the air with particulate matters.

Staff engagement and Sensitization

Raise staff awareness across all departments and involve them in avoiding waste, sorting, reusing, choosing long lifespan items, and reducing packaging.

 

The onus of mindful waste management cannot be the sole responsibility of the government. Public engagement must be strengthened by teaching waste literacy in schools and colleges, awareness campaigns by icons of the society and celebrating champions of zero waste living.

REMEMBERING PROF. R.P. SAHI BY HIS LECTURE ON MIDLINE SWELLINGS OF THE HEAD AND NECK

 

Prof. R.P. Sahi was our teacher in the Department of Surgery in King George’s Medical College, Lucknow. He was easily the best teacher in the campus. His baritone voice was renowned for its richness, strength and unmistakable quality, making it a defining feature of his aristocratic persona and a major factor in his enduring and universal popularity. This also made him instantly recognizable and command attention every time.

 

As an undergraduate teacher he was matchless because he could sub-divide the most complex subject into easily understandable bits, and once he taught a topic it somehow got imprinted in our brain for life. There was a method in his teaching which invariably simplified problems for even the back-benchers.

 

As a resident in his unit, I found him to be an inspiring leader and an outstanding post-graduate teacher with priceless qualities of a communicator, a disciplinarian, a conveyor of information, an evaluator, a Unit manager, a counselor, a member of many teams and groups, a decision-maker, a role-model, and a surrogate parent all rolled in one. His umbrella of benevolence was so reassuring that trainees got the best opportunity to express themselves. He understood the strengths and weaknesses of his trainees and steered them towards what would be best for them. Looking back, I can understand today how important this individualized approach was in his unit.

 

Prof. Sahi was a very sought after speaker, whether in surgical conferences or on social occasions. He was invariably our first choice for C.M.E and Conference inaugurations as well as after post dinner speeches. He somehow could palpate the mood of the gathering and say exactly what the occasion demanded. When Prof. P.C. Dubey was the Head of the Department of Surgery, Prof. Sahi was entrusted with the responsibility of resident posting and academic scheduling and the Department of Surgery was the best Department of the Medical College by miles. When I was applying for my Microsurgery training fellowship in St. Vincent’s Hospital, Melbourne, he and Prof. N.C. Misra gave me some glowing recommendations.

 

After his retirement he practiced in Krishna Medical Centre and mostly spent his time in academic pursuits. He stays in Hazratganj in his old bunglow wnd enjoys his retired life to the fullest.

 

I came across a lecture he delivered to our batch in 1978 on ‘Swellings of the Head & Neck’. He taught this vast topic in two lectures ‘Midline Swellings of the Head & Neck’ and ‘Lateral Swellings f the Head & Neck’ and this is the first lecture of this series.

  

Introduction

The deep fascia of the neck splits to envelope the Sternomastoid muscles. All swellings situated superficial to it are superficial swellings and all lying deep to it are the deep swellings.

 

Thus superficial swellings at this site are like any other site:

Skin             Epidermoid or Pilar cyst          

Fat               Lipoma

Nerve          Neurofibroma                          

Vessels        Haemangioma

 

The deep swellings of the neck for the purpose of description are sub divided into midline swellings and swellings in the lateral aspect of the neck.

 

Classification by Duration of lesion

1.      Acute: Cellulites, Ludwig’s Angina, Abscess, Carbuncle, Ac. Lymphadenitis

2.      Chronic:

A.    Cystic: Branchial cyst, Thyroglossal cyst, Cystic Hygroma, Cystic adenoma of Thyroid gland, Cold Abscess, Pharyngeal pouch

B.    Solid: Lymph nodes, Submandibular salivary gland, Thyroid tumours, Cervical Rib, Carotid body tumour, Branchogenic carcinoma, Sternomastoid Tumour

C.    Pulsatile: Aneurysm of Carotid artery / Subclavian artery, Aorta, Exophthalmic goiter.

 

Classification of Midline swellings

1.      On the face:

·        Median Angular Dermoid

·        Syncipital Meningocele

·        Fronto-nasal Meningo-encephalocele

·        Lachrymal sac swellings

·        Rhinophyma

·        Symphyseal odontomes

·        Gummata

2.      Submental region

·        Sub mental lymphadenitis

3.      Between menton and Hyoid

·        Ludwig’s Angina

·        Sublingual / Midline Neck Dermoid

·        Ranula / Plunging Ranula

·        Thyroglossal cyst

4.      Between Hyoid and Thyroid Cartilage

·        Sub Hyoid bursitis

·        Osteoma of Hyoid bone

·        Chondritis / Perichondritis

·        Chondroma of Thyroid cartilage

·        Laryngocele

·        Thyroglossal cyst

5.      Between Thyroid and Cricoid

·        Lymph node on crico-thyroid membrane

6.       Between Cricoid and Supra sternal notch

·        Thyroid gland – Goitres

7.      At Supra sternal space of Burns

·        Cold Abscess

·         Lymph nodes

·        Ectopic Thyroid

·        Supra sternal bursitis

·        Neurofibroma

·        Aneurysm of Arch of Aorta

 

Median Dermoids: Can be present at the midline either on the vault or on the floor of mouth or neck. They usually contain skin elements – sebum, hairs etc. They may scallop the skull bones and rarely have intra cranial extension through a gap in the skull. Treatment is excision and repair.

 

Fronto nasal Meningocele / Meningo-encephalocele: Meningoceles are brilliantly trans illuminent, cystic swellings, getting tense on coughing, crying or jugular pressure. Meningomyloceles have ectopic brain tissue in them and so are not trans illuminent. The inter orbital distance is widened – hypertelorism and there are cross fluctuations between it and the fontannele. CT scan demonstrates the gap in the skull and the treatment is excision, replacement of herniated contents, and repair of the bony gap by bone grafts and surgical correction of hypertelorism.

 

Lachrymal sac swellings: These are in the medial canthus of eye, usually inflammatory, and cause by blockage of naso-lachrymal duct with resultant epiphora. Treatment is initially conservative and if unsuccessful a DCR is done.

 

Rhinophyma: Sebaceous cyst adenomatosis affecting the skin of nose. There are multiple sessile nodular elevations over the nasal tip. Treatment is aesthetic rhinoplasty.

 

Gummata: These are seen in the midline in the tertiary stage of Syphilis causing erosion of skin, mucous membrane and bone. Midline structures like palate, hyoid, nasal bone, forehead etc. can be involved. VDRL test clinches the diagnosis. It is getting more and more uncommon in this antibiotic age.

 

Sub mental Lymphadenitis: May be inflammatory or neoplastic and so the entire drainage area – the tip of tongue, floor of mouth, incisors, symphyseal alveolus should be examined for focus of infection or primary tumour. Other lymph nodes should also be examined to rule out a primary Lymphoma.

 

Ranula: Myxomatous or mucoid degeneration of sublingual salivary gland. It appears as a blue-grey domed cyst in the floor of mouth, which is brilliantly trans illuminant. It has a tendency to split the mylohyoid and project in the submental region- plunging ranula. Treatment is excision by oral approach or marsupilization.

 

Sublingual dermoid: Sizable swelling filling and distorting the sublingual space, this dermoid is located within the mylohyoid muscle or the intrinsic muscles of tongue. Treatment is excision by sub mental approach.

 

Ludwig’s Angina: This is a form of cellullitis, which starts in the submandibular region and spreads to the floor of mouth. It produces a diffuse swelling beneath the jaw as well as the floor of mouth, often fixing the tongue. The unyielding deep fascia of the neck pushes the oedema up towards the glottis and down towards the mediastinum. Fatal septicemia, airway obstruction and death may result. Treatment is emergency drainage and broad spectrum anti bacterial coverage for Gram +ve, Gram –ve and anaerobes.

 

Thyroglossal cyst: These are cystic swellings mostly infrahyoid but may be suprahyoid as well and they move both with deglutition and tongue protrusion. The Thyroid develops from the foramen caecum and invaginates down as a tract called Thyroglossal tract to become the Thyroid isthmus. The cyst can occur anywhere along this tract. The cyst can become infected and form an abscess, which can be drained like any other abscess and result in the formation of a fistula. Thyroglossal fistula thus formed is never congenital, always acquired. These cysts are lined by squamous, cuboidal or columnar epithelium and may have lymphoid and thyroid tissue. They can turn malignant. Treatment of cyst and fistula is excision in toto along with the entire tract right up to the foramen caecum, taking the middle 1/3 of hyoid along with.

 

Subhyoid bursitis: Soft fluctuant swelling below the hyoid, it moves with deglutition and cannot be distinguished from Thyroglossal cyst easily.

 

Lymph node on crico thyroid membrane: A secondary deposit from a primary in the larynx, if present an endoscopic laryngeal examination and biopsy is a must. It also moves with deglutition.

 

Laryngocele: A soft, variable, unilateral or bilateral swelling, arising from the upper part of Thyroid cartilage, this is a herniation of the laryngeal mucosa through a gap in the thyrohyoid membrane. The swelling moves with deglutition and is usually seen in musicians playing wind instruments like flute and bagpipes Treatment is excision and repair.

 

Thyroid: This butterfly like endocrine gland straddles the trachea and its isthmus is situated over the 3^rd.and 4^th. tracheal rings. It moves up with deglutition and may have variable shape, size, consistency and tenderness. Lesions in Thyroid can be inflammatory, neoplastic, autoimmune and idiopathic. Lymph nodes on either sides of the neck and features of hypo and hyperthyroidism should always be examined.

 

Thus ended Prof. Sahi’s lecture on Midline Swellings of the Head & Neck. The diagram that he made on the board, every time pops up in my mind, whenever I see patients with midline head and neck swellings. This was once in a lifetime teaching, which has stayed life-long!

BE A PERSUASIVE SPEAKER

 

 

Persuasion is undoubtedly an art form, but have you ever wondered about the secrets of the world’s most persuasive speakers? They are usually tasked with steering an audience to accomplish an explicit action, or to get it to convert to a specific assumption or opinion. A persuasive speaker is someone who effectively convinces their audience to believe or act in a certain way. They use arguments, evidence, and emotional appeals to influence the audience's beliefs, attitudes, values, or behaviors. If you can recollect Martin Luther King Jr.’s “I have a dream” speech or Jawaharlal Nehru’s “Tryst with destiny” speech or Hillary Clinton’s “Women’s rights are human rights” speech or Winston Churchill’s “We will fight on the beaches” speech you will at once understand what I am hinting at.  So, what makes these speakers different?

 

1. They always appear confident

Although the confidence might not be there in reality, a persuasive speaker will always give the impression of confidence. This is one of the most imperative parts of being persuasive. Unsureness on the speaker’s part will be picked up on by the audience, so it’s crucial for a persuasive speaker to have a confident demeanor.

 

2. They always reinforce who they are

The introduction of a speaker is usually the thing that sells the message to an audience before a speech even commences. It is the thing that makes the audience eager to listen to what the speaker has to say.

 

3. Their body language is strong

In order to maximize their interface with an audience, a speaker must exhibit strong body language. Consider how much emphasis is now made on visuals in our culture thanks to technologies such as tablet computers, smart televisions, movies, video games and smartphones. We come to expect the same visual strength from the people we consider to be persuasive.

 

4. They make eye contact

Rather than looking out at the audience as a collective, a persuasive speaker will go that extra mile to ensure that they make eye contact with as many individuals as they can during their speech. In fact, people in an audience tend to expect a speaker to make eye contact with them, and this is a great way of building trust.

 

5. They use an emotional punch

Many highly persuasive speakers include a “grabber” right at the start of their presentations. Examples of a grabber are a declaration, symbol, image or other tool that is employed to immediately grab the audience’s attention. Furthermore, persuasive speakers also use emotions to gain attention and elicit a positive response from their audience.

 

6. They always answer “why” questions

Another technique that persuasive speakers use is to answer a “why” question at the very beginning of a presentation, such as “why is it essential to discuss this subject at this point in time?” Posing such a question, then having the ability to answer it clearly is a demonstration of strong and effective communication skills.

 

7. They are passionate about the topic at hand

In order to persuade or convince an audience, a speaker needs to be passionate, or at least convey passion, about the topic at hand. This has an impact on the audience, which will inevitably pick up on the passion, leaving its members with a sense of obligation that they should accept what they are being told for their own good.

 

8. They speak conversationally

A persuasive speaker will always place emphasis on talking conversationally with their audience, as opposed to giving a speech. This creates an honest and trustworthy perception of the speaker in the minds of the audience members. The Indian Prime Minister, Narendra Modi is a brilliant example. He never lectures in rallies, he establishes a dialogue and uses easily understandable language, the language of regular conversation.

 

 9. They build a sense of truth among the audience

The world’s best actors are prized for their ability to completely involve themselves physically, mentally, and emotionally in the role they are playing. Just try to remember Marlin Brando in Godfather or Anupam Kher in Saransh. A persuasive speaker takes on the same role when in the boardroom or at a conference. The more natural the delivery, the more believable the speaker’s message is.

 

10. They will use repetition for emphasis

Recapping certain points a few times throughout the course of a presentation is the perfect way for a speaker to create greater engagement with the audience. This is especially effective when the speaker goes over the points covered in the presentation immediately after it has been given.

 

11. They share their personal experiences

In order to make themselves more relatable, persuasive speakers will share personal experiences when and where they can as they’re giving their presentation. Doing so brings the message to life, makes the presentation pleasant and wins over the hearts and minds of the audience.

What makes a great and iconic speech? There are numerous examples of brilliant orators and speechmakers throughout history, from classical times to the present day. What the best speeches tend to have in common are more than just a solid intellectual argument: they have emotive power, or, for want of a more scholarly word, ‘heart’. Great speeches rouse us to action, or move us to tears – or both.

REMEMBERING PROF. DEVIKA NAG BY HER LECTURE ON NEUROPATHIES

 

Prof. Devika Nag M.D, F.A.A.N, F.I.A.N.Sc. was our teacher of Medicine, in charge of the Department of Neurolgy in King George’s Medical College in Lucknow. She was a very serious academician and a very good teacher, besides being an extremely graceful lady, and a role model for many Georgians.

 

Prof. Devika Nag lost her father, who was in Army, at young age and later her only younger sister (at UK) due to Subarachnoid Haemorrhage due to ruptured aneurysm. She took good care of her mother till she passed away few years ago. As a child she was keen to become a writer but as destiny desired, she appeared in Premedical test on advice of her mother and topped it. She did MBBS & MD (Medicine) from KGMC and won dozens of awards and medals. Her batch was very bright and gave the Alma mater teachers like Prof. T.C. Goel, Prof. Chandrawati, Prof. A.K. Wahklu and Prof. Indu Wakhlu. She was later trained in Neurology at Boston and other USA & UK institutions.

 

She headed the newly developed Department of Neurology and the department made tremendous progress in all fields, patient care, teaching and research under her leadership. Her consistent efforts led to the start of DM Neurology program in the year 1981, first in state of UP. Prof. Nag served as the Head of the Department from 1977 to 1999 and was a very popular teacher. She later became Professor Emeritus, and served the Department and the speciality in innumerable ways.

 

Neurology and Neurotoxicology were her principal areas of interest and in 1994 the National Academy of Medical Sciences decorated her with their prestigious membership. She served as President of various associations to name a few: Indian Academy of Neurosciences, Neurological Society of India, Indian Academy of Neurology and Indian Epilepsy Association. Her students went on to head various Neorology departments all over the India and even ended up heading their respective institutions as Principals.

She was very punctual, meticulous record keeper, a strict disciplinarian but very soft at heart. Interest of patient was of paramount importance to her. She even declined the offer of becoming the Principal of King George’s Medical College knowing that she will get less time for patient care. She used to take detailed history of all her patients and  perform a proper thorough examination every time. She would take regular evening rounds on Tuesday, the day of her OPD & emergency. This would avoid missing any impending emergency in her newly admitted patients. She was so considerate that she brought home made breakfast for residents sometime when she knew the hostel mess was closed for some reason. She is still serving her patients with devotion even today at Dr KP Singh Memorial (Mayo) hospital at Gomtinagar, Lucknow.

 

There is no better way of remembering a teacher than by remembering what she taught us. This is a one her lectures, on the difficult topic on Neuropathies, which she delivered to our class.

 

The term Neuropathy is short for 'peripheral neuropathy'. It relates to nerve damage suffered by the peripheral nervous system, which is in charge of our nerves outside the brain and spinal cord.   

Causes

Neuropathy is a complication that can be caused by a number of various conditions:

·        Physical trauma

·        Repetitive injury

·        Infections

·        Metabolic diseases

·        Exposure to toxins and some drugs

All these can all lead to peripheral neuropathy. 

 

Signs and symptoms of neuropathy

Neuropathy usually starts as a tingling or burning sensation at our extremities, such as fingers and toes. There is also a loss of sensation at the edge of the nerves that patients have reported feeling like they are wearing a thin stocking or glove on their hands. They can say that the feel pins and needles or ants crawling on their feet. The precise symptoms differ from patient to patient based on the types of nerves affected and how they choose to express themselves.

There are three types of nerves that may be affected by neuropathy, namely sensory, motor and autonomic.

Sensory nerves: Sensory nerves are responsible for collecting sensory information for the body, such as touch, temperature, pain, pressure and vibrations. Neuropathy of the sensory nerves can be expressed as:

·        Spreading numbness and tingling in hands and/or feet (which can spread to the arms and legs)

·        Burning, sharp or electric-like pain

·        Extreme sensitivity to touch

·        Problems with coordination

Motor nerves: Motor nerves are the nerves responsible for activating our muscles and control movements. The involvement of motor nerves present as:

·        Muscle weakness

·        Paralysis

Autonomic nerves: Autonomic nerves are responsible for autonomic functions of the body, such as regulating digestion, heat and blood pressure. Their involvement can present as:

·        Intolerance to heat

·        Problems with digestion, bladder and bowel control

·        Dizziness - brought about by problems with blood pressure.

 

A common cause of neuropathy is Diabetes

Among diabetics, about 50% have minimal neuropathy presenting in some form or the other. They often won't notice the symptoms, and it will stay on a very low level. For the other 50%, however, the symptoms will be unavoidable.

Pain is the most common complaint, usually a 'prickling', 'stabbing' or 'burning' pain, that happens mostly at night. This, along with a numbness that feels as if the limb is 'asleep' - occurs predominantly in the toes, feet and legs. A proper history of the patient’s past illness is mandatory, lest we miss diabetes. Today we end up treating these neuropathy patients with drugs like anti-depressants, anti-convulsants, steroid and cortisone injections, lidocaine and pain killers. These are powerful drugs that address the painful sensations for short and long term relief. However, they have a host of side-effects and must be administered very carefully. Some medical practitioners recommend electrical stimulation of the pain area and of the spine. A lot of research is going on in this area, but progress has been very slow from the medical and drug industry so far.  

 

Natural solutions to neuropathy 

If your patient is suffering from Diabetic neuropathy then you must advice the following:

·        Give up smoking

·        Cut down on alcohol consumption or give it up altogether

·        Maintain a healthy weight

·        Exercise

·        Wear clothing that causes less irritation, such as cotton, covering the sensitive areas with wound dressing or cling film and using cold packs. 

·        Stress relief is also a big help when it comes to neuropathy, and so relaxation techniques such as yoga, and meditation will come in handy.

 

Vitamin therapy

Clinical studies have shown that certain supplements can have a cumulative effect on the symptoms and causes of neuropathy.

1.      Vitamins B1, B2, B6 and B12 Vitamin B deficiency is one of the major causes of neuropathy, and also one of the best natural solutions.

2.      Vitamin B1, usually in its common form of thiamine is helpful. 

3.      Recent natural medications have reverted to using benfotiamine, which has been found to be significantly more effective (almost 3 times) in delivering vitamin B than thiamine.

4.      Stabilized R-Alpha Lipoic Acid (R-ALA) This powerful antioxidant is one of the few, rare materials that can pass through the brain's blood/brain barrier to enter the brain and go directly where it is needed the most.  Most importantly, it has a specific effect on the nerves that eases the pain and numbness associated with neuropathy, and promotes better blood flow and oxygen to the nerves. Recent studies have reported that just by using the R-ALA alone, orally, symptoms of neuropathy were reduced.

Neuropathy support formulas These days, it is common for those suffering from neuropathy to take both medical and vitamin therapies, combining short-term treatment with the cumulative effects of correct nutrition.  The best formulas include vitamins B1, B2 and B12, as well as Vitamin D, R-ALA and materials that relax your nervous system, avoiding over-stimulation.  diabetes patients, this would be a good way to perhaps prevent the onset of neuropathic symptoms.

 

Friends, this was a lecture delivered in 1978-79. Many new things have happened in the field of Neuropathies since then and this field has been much enriched by recent advances. From emerging therapies leveraging stem cells and gene editing to holistic approaches encompassing mind-body techniques and nutritional interventions, the landscape of neuropathy management is rapidly evolving, but the foundation that was laid down by Prof. Devika Nag in our MBBS days has only helped us to understand these recent advances, and not get overwhelmed by them. I have to thank my batch-mate, Prof. Atul Agarwal, who is a retired professor of Neurology from the Department Madam Devika Nag chaired, and an eminent neurologist and epilepsy expert of our country, to help me with this blog.