SLMANEWS
Contents
THE OFFICIAL NEWSPAPER OF THE SRI LANKA MEDICAL ASSOCIATION
April 2013 Volume 06 Issue 04
President's Column It is good to be back with you again. Amongst the many different things that the SLMA is involved in at the present time, one venture was specifically designed not only for existing members but also for prospective Life Members who wish to join the SLMA in the future. What we have managed to secure is a SLMA affiliated dedicated Credit Card from the Hatton National Bank. New members are given the facility of paying the full Life Membership Fee in nine
Page No. Notice board
02
Japanese Encephalitis (JE) and the recent outbreak at Rathnapura 06 Mission on Mercury – Doctors do have a role!
10
Seven Habits of the Ultra Wealthy
12
Introductory Remarks On The “Immunization Handbook – 3Rd Edition Three Words That Create Instant Credibility
13 13
Creativity and Innovation with Dedication -A joy to see in the wilds of Udawalawa
14- 15
E M Wijerama Endowment Lecture - Part 3
16
Adrenal disorders in children
19
“pain” of having to cough up Rs. 10,000/- as the
Women and Stress
22
full Life Membership Fee. In addition, there are
DISCOVER SRI LANKA The Bo-path Ella and Dehena Ella Sabaragamuwa.
23
monthly instalments of Rupees 1111.12 through the card. I believe that it would ease the initial
many other special benefits and concessions afforded to the SLMA members through this card. These include insurance benefits, loan facilities, special concessions, hospital payment plans etc.
Our Advertisers
I do hope that very many doctors would consider availing themselves of these facilities through the
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SLMA.
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We are now in the process of organising Provincial Meetings to take our CPD activities to the periphery. Please do stay tuned to the SLMA for further information. The Programme for the Anniversary Scientific Medical Congress from the 10th to the 13th of July 2013 is almost fully filled up and organised. We
DFCC Vardhana Bank Seylan Bank PLC Guardian Acuity Asset Management Ltd. Tokyo Cement Group Astron Ltd. George Steuart Health Asiri Surgical Hospital Unichem Laboratories LTD. Emerchemie NB (Ceylon) Ltd. GlaxoSmithKline Pharmaceuticals
will let all members know of the completed programme in due course. Let me conclude by wishing one and all, good luck in all your efforts and a VERY HAPPY NEW YEAR.
Official Newsletter of The Sri Lanka Medical Association. Publishing and printing assistance by
Dr B J C Perera President, Sri Lanka Medical Association, No.06, Wijerama Mawatha, Colombo 07, Sri Lanka
This Source (Pvt.) Ltd etc., 236/14-2, Vijaya Kumaranathunga Mawatha, Kirulapone, Colombo 05, Sri Lanka Tele: +94-112-854954 marketing@thissource.com
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Notice Board
April, 2013
SLMANEWS
The 126th Anniversary International Medical Congress of the SLMA “Towards continuing enhancement of quality and safety in healthcare” Inauguration and SLMA Oration : 10th July 2013
126th Anniversary International Medical Congress :11th to 13th July 2013 Day Registration (any doctor)
Full Registration for the Main Congress
: Rs 1500/- per day
Workshop registration (any doctor) : Rs 1000/- per work shop
SLMA member
: Rs 3000/-
Non-member doctors
: Rs 3500/-
Day registration (non-doctors)
: Rs. 1000/- per day
Non-doctors & medical students
: Rs: 1500/-
Sports Medicine Workshop
: Rs 2000/-
(for Doctors, Physiotherapists, Coaches and Trainers)
DISCOUNTED AIRLINE TICKETS FOR THE 126th ANNIVERSARY INTERNATIONAL MEDICAL CONGRESS OF THE SLMA 10th – 13th JULY 2013 Sri Lankan Airlines, the official airline for the SLMA 2013 Congress, has kindly offered all participants and accompanying persons a 15 percent discount on economy class airfare and a 10 percent discount on business class airfare, on the prevailing market fare at the time of ticketing, for purchase of tickets for registered delegates travelling to Sri Lanka from their online stations. The online code for special discount is operational now. All the participants need to do is to send an e-mail to either mice@srilankan.com or thiwanka.dharmapala@srilnkan.com and the airline will make arrangements to provide the discount.
Encourage your colleagues to join SLMA Life membership
: Rs. 10, 000
Ordinary membership
: Rs. 2, 500 (valid for one year)
Overseas Life membership : USD 250
(for those residing overseas)
Membership application could be obtained from http://www.slmaonline.info/index.php/membership.html
Second Speech Craft Programme of SLMA
Due to start from early June 2013 Ten Consecutive Wednesdays
Only 25 persons can be
accommodated
PROGRAMME IS FOR DOCTORS AND MEDICAL REPRESENTATIVES
For further details please contact Jayarani at SLMA Office
(011-2693324) 2
Speech craft Programme I was able to participate in the speech craft programme conducted by the Toastmasters at SLMA, as my Professor diverted his MSc students to this programme from the curricular activities so that we would be moulded as well rounded personalities. Being with Toastmasters is fun and educative. It enabled me to present myself to the public in a refined and assured manner. It relieves stage anxiety and gave me self-confidence to communicate skillfully and in an uncomplicated simple manner. In the long run, it will definitely help me to defend my dissertation with confidence and will also help me to face interviews successfully in the future. I would like to thank the SLMA for giving me the opportunity to participate in the above programme. Thanking you, Yours faithfully, Dr. Samuditha Senarathne (MSc student in Clinical Genetics)
SLMANEWS
April, 2013
Sri Lanka Rapid Response Health Policy Survey You are invited to participate in a short Health Ministry Survey on exploring policies and interventions through community participatory approaches in Sri Lanka. This should take less than 10 minutes of your time! It is a quick ‘tick-box’ style survey and all responses are unlinked and anonymous. Anyone can take this survey, it is not for doctors only. Please go to this link: https://www.surveymonkey.com/s/HealthPolicySurvey2013 Paste the URL in the browser, complete the survey and press send, as simple as that! Please feel free to share with colleagues and within relevant networks as well, please contact Dr Kusal on kusalwijayaweera@yahoo.com if you have any difficulty with the ‘tick box’ survey.
Leprosy in Sri Lanka
Basic biostatistics for clinicians Venue: SLMA Auditorium Date: 7th May 2013
Organized by the Communicable Diseases Committee of the SLMA
Aims of the workshop
11.30 am
To be able to interpret clinical research data.
Success story of leprosy
Dr. Sunil Settinayake Former Director, Anti-leprosy campaign
Time schedule: 9.00 – 9.30 am -
Type of data, summary measures
9.30 – 10.00 am -
Probability & z-score
10.00 – 10.30 am-
Tea
10.30 – 11.00 am
Confidence interval
11.00 – 11.30 am
Statistical tests
11.30 – 12.00 am
Non-parametric tests
12.00 – 12.30 pm
Interpretation of data
12.30 – 1.15 pm
Group exercise
Consultant Dermatologist, Base Hospital, Karawanella
1.15 – 2.15 pm
Lunch
12.30 pm Rehabilitation and orthopedic management
2.15 – 2.45 pm
Sampling methods
2.45 – 3.30 pm
Sample size calculations
3.30 – 4.00 pm
Group exercise
11.45 am
Epidemiology & current status
Dr Nilanthi Fernando Director, Leprosy Focal Point 12 Noon Clinical presentation, complications and multi-drug therapy Dr Indira Kahawita
Dr Narendra Pinto Consultant Orthopedic Surgeon, NHSL
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To understand the basic statistical concepts and steps involved in applying statistics in designing a clinical research.
Resource persons:
Prof Chrishantha Abeysena
Dr B. Kumarendran
12.50 pm
Discussion
(Department of Public Health, Faculty of Medicine, Ragama)
Date
:
Monday 29th April 2013
Course fee
Time
:
11.30 am - 1.00 pm
Contact detail :
Phone- 0112693324 (Ms. Nirmala)
Venue
:
SLMA Auditorium
:
slma@eureka.lk
All are welcome
Closing date
:
3rd May 2013
:
Rs. 1000/= per participant
SLMANEWS
April, 2013
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SLMANEWS
April, 2013
Japanese Encephalitis (JE) and the recent outbreak at Rathnapura From the Symposium on JE held on 20th March 2013 compiled by Prof Jennifer Perera, Chairperson Communicable Diseases Committee SLMA 1.Recent outbreak of Japanese Encephalitis at Ratnapura Dr Sritharan, Consultant Physician, General Hospital, Ratnapura
D
uring last 3 months, from December 2012 to February 2013, 60 encephalitis patients with 9 laboratory confirmed cases and 9 deaths were reported. All 9 were adults over 23 years except one and were not immunised against JE Pathogenesis
JE virus exerts a direct neurotoxic effect on brain cells and prevents the development of new cells from neural stem/progenitor cells. TNFÎą and IL-1 secreted by immune cells is responsible for cerebral oedema. Symptoms and signs
Incubation period is 5 to 14 days, commonly 6-8 days. Only 1 in 250 JE virus infections results in symptomatic illness. When clinical illness is mild it presents as a simple febrile illness with headache which resolves in 5-7 days if there is no central nervous system involvement. Severe clinical illness with encephalitis presents with headache, vomiting, reduced consciousness, twitching of a digit or eyebrow, nystagmus, dull and expressionless faces, generalized hypertonia, cogwheel rigidity and generalized or partial seizures. Some patients with JE infection can present as Guillain-Barre syndrome (GBS) or acute flaccid paralysis (AFP). Therefore during an epidemic, when a patient present with GBS/AFP clinicians should consider JE in the
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differential diagnoses. Investigative findings
There is a leucocytosis initially, which is followed by leucopaenia after 4-5 days of fever. CSF analysis may demonstrate initial neutrophilia and later lymphocytosis. MRI is reported to be more sensitive than CT scan in determining neurological abnormalities. Cerebral oedema is a common finding. During this recent outbreak 42 had cerebral oedema out of 53 encephalitis patients. EEG may show generalized slowing, theta and delta coma, burst suppression, and epileptiform activity. Management
There is no specific antiviral treatment for JE and supportive care is the mainstay of treatment. Reducing intracranial pressure through use of mannitol and optimization of system blood pressure are important. Control of seizures and prevention of secondary complications are also important. During this recent epidemic, 6 had developed seizures on or before admission to the hospital. 12 patients who received antiepileptics prophylactically did not develop seizures during the course of illness. Clinical trials have shown no benefit from interferon alfa-2a or dexamethasone. Most of our patients with encephalitis, received acyclovir due to nonavailability of rapid diagnostic tests to distinguish JE from other infectious encephalites. Outcome
Mortality among encephalitis patients is 30%, and 50% of survivors have severe neurological sequelae.
In our series, most of the complications were related to behavioural abnormalities. The most common sequelae are upper and lower motor neuron weakness. Cerebellar and extrapyramidal signs and severe cognitive or language impairment are less frequent. Patients may continue to have subtle learning or behavioral problems which can be identified on long term follow up. Prognostic indicators
Bad prognostic indicators are multiple, prolonged seizures or status epilepticus, changes in respiratory pattern, flexor or extensor posturing, abnormalities of the pupillary and oculocephalic reflexes, high intracranial pressures, age less than 10 years, low Glasgow coma scale, hypotension, shock and presence of immune complexes in the CSF. High concentration of neutralizing antibodies in the CSF and increased levels of JE virus IgG in the CSF indicate bad prognosis. In general, one third of patients with JE die and 50% of survivors have some sort of disability. All in all two third of affected persons will have an adverse outcome.
2.Epidemiology of Japanese Encephalitis in Sri Lanka & recent changes Dr Paba Palihawadana, Chief Epidemiologist, Epidemiology Unit, Ministry of Health
J
apanese Encephalitis is a communicable disease with a case fatality rate (CFR) of 5-30%. Contd. on page 08
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SLMANEWS
April, 2013
Contd. from page 06
Japanese... JE virus was first isolated in Japan in 1935 and in Sri Lanka at the Medical Research Institute (MRI) in 1968. JE virus circulates in zoonotic cycles involving culecine mosquitoes mainly (Culex tritaeniorhyncus, C.gelidus). Pigs and wading birds serve as reservoirs and amplifying hosts. Man is an accidental dead end host of the disease. First recorded major outbreak occurred in Sri Lanka in 1985-86 in the north central province (385 cases with 64 deaths, CFR of 17%). Two other epidemics have occurred in 1986-87 and 1987-88 too. 1987-88 was the largest reported outbreak (816 cases with 192 deaths, CFR 24%) which spread to adjoining districts (Kurunegala, Puttlam) of the north central province. Immunization with the inactivated JE vaccine was introduced on a
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phased manner in 1988. The target group was children of 1-10 years. Until 2011, JE immunization campaigns were limited to selected 18 high endemic districts. With the replacement of the inactivated JE vaccine with the live vaccine in 2009, JE vaccine became part of the EPI programme, covering the entire country since 2011. Since 2003, only sporadic JE cases have been reported from different parts of the country. 2002-2013 January Gampaha, Vavuniya, Kurunegala, Puttalam, Kegalle and Rathnpura districts reported the highest number of cases. Laboratory confirmed JE cases by MOH areas in Rathnapura district during the epidemic has reported 4 patients from Kuruwita, 2 each from Pelmadulla and Kahawatta and 1 in Nivithigala. During Ratnapura outbreak all were above 23 years except
one child of 2/12. Present increase in wild boar and migratory bird population can act as a reservoir for JE virus. Preventive measures taken during this epidemic were strengthening of acute encephalitis surveillance activities and laboratory confirmation, educating the public regarding the early signs/symptoms and the importance of seeking health care early and ensuring JE vaccination of all children less than 10 years of age. Future plans are to strengthen entomological surveillance activities targeting high risk MOH areas and to vaccinate all pigs in the farms against JE. (Sections on laboratory diagnosis and JE vaccine will continue in the next issue)
SLMANEWS
April, 2013
Mission on Mercury – Doctors do have a role! Dr Jayaindra Fernando, MBBS, MS. Consultant General Surgeon, Lanka Hospital
T
he sequence of anthropogenic green house gas (GHG) emissions causing global warming and climate change have been documented by the Inter-governmental Panel on Climate Change (IPCC) in its 4th Assessment Report published in 2007. Doctors have never seen themselves as polluters contributing to global warming and climate change! However the contribution of GHG emissions as well as other pollutants by doctors and health care providers is not in dispute. Let look at some published figures. The National Health Service (NHS) in the United Kingdom has established its carbon footprint at 549.3 million tons of CO2 equivalents in 2010 while the health sector in the United States emits 8% of the total GHG emissions of the US. The ecological footprint refers to the sum of the carbon footprint, water footprint as well as other footprints such as waste. Every community is responsible for reducing the ecological footprint within their areas of influence. Doctors are not exempt from this responsibility. That being the case, they need to look at two items that are closely associated with doctors and health care. Namely, they are the mercury thermometer and the mercury sphygmomanometer.
is more vulnerable to methyl mercury than is the adult nervous system. Impacts on cognitive thinking, memory, attention, language, and fine motor and visual spatial skills have been observed in children exposed to methyl mercury in the womb. Symptoms of methyl mercury poisoning include, impairment of peripheral vision, disturbances in sensations, lack of coordination of movements, impairment of speech, hearing, walking; and muscle weakness. Andrew Jackson, the seventh president of the United States is suspected by some to have suffered and died of chronic mercury poisoning. It is questioned if this affected his ability to govern. In the traditional hat trade, mercuric chloride was used to make felt.
Organizations such as the SLMA would have to be on the forefront. The steps that need to be taken are clear. These are to, 1. Form a task force in each organi zation 2.
Pledge to phase out mercury
3.
Create a mercury inventory
4.
Substitute mercury containing equipment and
5.
Evaluate success.
More details at http://www.mercuryfreehealthcare.org/Mercury_Elimination_Guide_for_Hospitals.pdf
As time went by most hat makers (hatters) acquired toxic levels of mercury in them and exhibited symptoms of chronic mercury poisoning including effects on the nervous system. This gave rise to the figure of speech “as mad as a hatter”. The hat maker in “Alice in Wonderland” may be an example.
Mercury is the only metal which is a liquid at room temperature. Spilled mercury from damaged thermometers and sphygmomanometers enter the food chain in the form of methyl mercury. Effects of methyl mercury on wildlife can include mortality, reduced fertility, slower growth and development and abnormal behavior that affect survival, effects on endocrine system, development and reproduction of fish.
In an effort to address this issue, the fifth session of the Intergovernmental Negotiating Committee to prepare a global legally binding instrument on mercury (INC5) was held in Geneva, Switzerland in January 2013. At this meeting, governments agreed to such a document thus giving rise to the “Minamata Convention on Mercury”. Among other items, the treaty text mandates an end to the manufacture, import and export of mercury thermometers and sphygmomanometers by 2020. Few weeks later, the Sri Lankan Ministry of Health decided to remove all mercury-containing equipment from use in hospitals in accordance with the global guidelines.
Mercury is neurotoxic to humans. The developing fetal nervous system
For Sri Lanka as a whole to adhere to the Minamata Convention on Mer-
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cury, doctors would need to play an important role.
Mad hatter in Alice in Wonderland
President Andrew Jackson
SLMANEWS
April, 2013
Seven Habits of the Ultra Wealthy By Lewis Schiff
H
ow many times has your success depended on knowing something that most people don't? The survey research I did for my new book, Business Brilliant, uncovered just how frequently highly-successful people think and act differently from the great majority of people with identical levels of education and smarts. There are certain elements of success that everyone agrees on-ambition, hard work, persistence, and a positive attitude. But my survey showed how some people have "business brilliance," a distinctive take on getting ahead that is often at odds with the more pervasive mindset. If you want to get an edge and separate yourself from the common herd, take some cues from the seven beliefs and habits of the most successful people:
1. An equity position is necessary to get wealthy. Ninety percent of the supersuccessful say this is true, versus fewer than half of the masses. More importantly, 80 percent of "business brilliant" people say they already have an equity stake in their work. Just 10 percent of the middle-class have an equity position of any kind, and the vast majority (70 percent) say they're not even trying to get one.
2. I'm always looking to gain an advantage in my business dealings. About 90 percent of "business brilliant" individuals say they are always trying to grab an edge, com-
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pared with just about 40 percent of the middle-class. Gaining even small advantages in a series of deals can have a cumulative effect on your wealth, but since most people aren't even looking for one, they're that much more likely to end up on the disadvantaged side of every deal.
3. Doing things well is more important than doing new things. Getting wealthy usually means you've taken an ordinary idea and executed it exceptionally well. That's what 9 in 10 "business brilliant" people believe. Most other people, though, think that wealth requires a big, new idea. Unfortunately for them, big ideas are rare and risky. Too many people are waiting on the sidelines for the perfect big idea to come along, while the most successful people have jumped in the game, and busily honed their skills at execution.
4. I hire people who are smarter than I am. Exceptional execution requires those who are business brilliant to focus on the two or three things they do very well. So they get their work done by building teams with complementary capabilities. Surveys show that most people, though, would rather learn to do tasks they're bad at than get others to do them. The business brilliant know that you get to the top because of your strengths, not your weaknesses.
5. It's essential I really understand my business
associates' motivations. If you're dependent on other talented employees, you'd best know what makes those talented people tick. That's the belief of about seven in 10 people in my "business brilliant" cohort, compared with fewer than 20 percent of the middle-class. My survey suggests that your willingness and desire to really get to know and understand your business associates is a sure marker of success--and one that most people don't have.
6. I can easily walk away from a deal if it's not right. The "business brilliant" know that bad deals, like bad marriages, can be painful--and costly. So if the deal on the table isn't right, 71 percent say they have no problem cutting bait and moving on. Only about 22 percent of the middle-class say the same. Most people are willing to take their chances on deals that don't seem right from the start, even though it's less risky to walk away.
7. Setbacks and failures have taught me what I'm good at. Those who are "business brilliant" have, on average, more failures than members of the middle-class. But they use those failures to help them succeed on the next attempt. Just 17 percent of the middle-class say they learn from their failures in this way, which is really a shame. Everything worth trying contains an element of risk, after all. If you fall on your face, you might as well learn from the experience to help you succeed on your next try. Excerpt from http://smallbusiness. yahoo.com/advisor/7-habits-of-theultra-wealthy-181131868.html
SLMANEWS
April, 2013
INTRODUCTORY REMARKS ON THE “IMMUNIZATION HANDBOOK – 3rd EDITION Dr Samitha Ginige Consultant Epidemiologist Editor Immunization Handbook -2012
T
he National Expanded Programme on Immunization (EPI ) has an excellent record, with high coverage of all EPI vaccines and extremely low incidence of vaccine preventable diseases. However, unless the country pays attention to key issues of programme quality it could lose the advantages it has gained in disease control over the last 30 years. Due to the rapidly expanding environment in the immunization field, some information published in the previous editions of the Immunization handbook is already out dated. This continues to be a challenge for the National EPI as more new vaccines are approved for use, new vaccine combinations are developed and additional data are available on the immunogenicity and efficacy of vaccines.
The objective of the Immunization Handbook 2012 is to provide updated comprehensive guidelines for health professionals in Sri Lanka on the safest and most effective use of vaccines in their practice. This new Immunization Handbook provides information on epidemiology of vaccine preventable diseases, the vaccines available, and the updated National Immunization Schedule, as well as practical advice and strategies for health professionals immunizing children and adults. These guidelines are based on the best available scientific evidence at the time of writing, from published and unpublished literature. The guidelines will be reviewed periodically when new evidence becomes available. All chapters have been updated and revised since the 2002 edition. In addition, 10 new chapters for Human Papillomavirus, Live Japanese En-
cephalitis, Rabies, Typhoid, Influenza, Varicella, Hepatitis A, Yellow Fever, and Cholera and rotavirus vaccines are included in the new edition. This book could be accessed via www.epid.gov.lk
Three Words That Create Instant Credibility Being a know-it-all is a great way to make people question your common sense. However, the exact opposite is the case. Admitting ignorance makes everything else you say more credible. Admitting ignorance marks you as a person who's not afraid to speak the truth, even when that truth might reflect poorly on you.
W
hen it comes to credibility-building, the three most powerful words in the English language are, "I don't know."
Many salespeople and most managers think that they'll lose credibility if they admit ignorance, especially about something about which they "ought" to know.
Needless to say, the "I don't know" should be followed by a plan to discover the information that's required, if the issue is truly important., you WILL be judged on whether you deliver on that promise. But here's the thing, people dislike a know-it-all. They can often sense, at a gut level, when they're being bull s…..d. Even if they're taken in, when they find out, as usually happens, that they've been bull s…..d, they never trust the bull s…..r again. Excerpt from http://www.inc.com/geoffrey-james/3words-that-create-instant-credibility.html?nav=next
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SLMAN
April, 2013
Creativity and Innovation with Dedication Prof MSA Perera1 MBBS, DFM, MD in Family Medicine, FCGP Dr Shyamalee Samaranayaka2 MBBS, DCH, DFM, MD (Fam Med), MRCGP(Int) 1 Senior Professor and Chair, 2Lecturer, Department of Family Medicine, Faculty of Medical Sciences, University of Sri Jajewardenepura
T
he rapid development of medical science with emphasis on recognition of specialists in one field, lead to dilution of the role of the Generalist clinician who can gather a wealth of information and experience about the people in the community and deliver good quality care. Sri Lanka has a large number of generalist hospitals manned by an equal number of large staff members but with only a few facilities. People bypass these institutions at their doorstep and prefer to go to a larger hospital due to this. Those who are in charge too are generally demoralised with no training, scarce facilities and follow set routines. Hence, they bide their time to get out and go to a better place. Up keep of these institutions must be costing a large sum yielding poor value for money spent. It is only a few who take up the challenge and succeed to bring about a change. It was on our way back from a visit to Padiyathalawa that we visited the Divisional hospital at Udawalawe having heard that one of our students has received a national productivity award
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for the year 2010/2011. A very humble Dr.Wasantha Kumarasiri was overjoyed to see his teachers, and this is his story. A couple of years ago, Udawalawa Rural Hospital was at a point of getting closed up and condemned as useless. Wasantha understood the gravity of the prevailing situation thoroughly, saw the potential of the hospital and decided to develop this hospital up to a lively functioning institute for the sake of the poor people living in the area. He developed a team to collect and share information on how to make his dream real; he put his thinking cap on and made plans, simple but practical. He saw that buildings were in a state of near collapse, equipment lacking, and other facilities to function in a dismal state.
He then identified the resources within the hospital which could be used and prepared the strategies to make use of them in an efficient manner. There is no doubt that the complexity of the situation demanded exceptional creative and innovative skills. The next challenge that he faced was how to carry out his plan. He overcame this successfully by changing the attitudes of his staff and the villagers regarding the hospital. He communicated to them about the fate of the hospital and also the importance of saving it. He made sure that his team was well prepared and supported and was clear about his vision. A born leader, yet a simple and humble human being he put his team together and managed to get
April, 2013
NEWS
-A joy to see in the wilds of Udawalawa the best of their natural talents to surface. During this endeavour he encountered many obstacles which he was able to overcome successfully by using his personal and professional skills. He is a devout Buddhist and maintains that he follows the path of the Buddha. He led by example, never found any job demeaning, and even helping out a labourer when in need. People saw the dedication of this person and were motivated to help him achieve his target. Little by little the standards of the institution were raised, while keeping the misconduct and the negligence at a lowest possible state. He introduced the Japanese 5S system to the hospital in his own way. He included Buddhist philosophy in to it and made it simple and familiar to everyone. He saw to it, ensured functioning of the system. The hospital we saw is functioning beautifully and has gained a good reputation and the people are happy to use it. It is said that even patients from nearby areas also are now coming to this institution to seek medical treatment. There are facilities for 150 out patients at a time. There is a secluded place for a breast feeding mothers. They had built shelter for patients to stay while they await their turn. The drugs are handed over to patients on a tray while they are seated. There are no long queues .Wards are clean and maintained well. The toilets are clean and are being looked after by the patients. A place for worship has been built with the help of the village temple.
organised efficient hospital Udawalawa Divisional Hospital achieved the National Productivity Award for the Best Small Scale Government Institute of the year 2010/2011. How does a single person achieve all this? He does not take credit for it all. He has allocated responsibilities to each member of his staff. As you enter you could see the name board of the person responsible for each activity on display. He is highly appreciative of the roles that his team members play and even remembers the birthdays of each member and gives a small token of appreciation .He works daily with a devotion which is a joy to see in this era where such attitudes are rarely seen. The faculty is indeed proud of this product, who comes from a rural background and is contributing to the good health of people from the village he came from. Dr. Kumarasiri with his dedication to work and his leadership skills paved the path of success for the Udawalawa Divisional Hospital is an inspiration to us all. ‘Full many a gem of purest ray serene The dark unfathomed caves of ocean bear Full many a flower is born to blush unseen And waste its sweetness in the desert air “
Eulogy written in a country churchyard By Thomas grey
He has used the garden of the hospital to grow vegetables fruits and flowers. There is a separate place to produce compost fertilizer by using the degradable waste. Not only he does consultations and curative care, he has also initiated public awareness programmes In fact it has to be seen to be believed! For the excellent management that lead a collapsing institute to a well
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SLMANEWS
April, 2013
E M Wijerama Endowment Lecture - Part 3 Vidyajyothi Prof. Colvin Goonaratna MBBS, FRCP (Lond), FRCP (Edin), FCCP, PhD (Dundee), FNAS, Hon DSc (Colombo), Hony Fellow of the College of Surgeons of Sri Lanka; Hony Fellow of the College of General Practitioners of Sri Lanka
M
y post-internship appointment was to General Hospital Badulla. Badulla suited me fine because the temperature was cooler, the mountain scenery was superb, the people were friendlier, the clinical responsibilities were greater and more diverse, and the Consultants were socially closer to the House Officers. They all attended the regular rollicking parties held at the House Officers’ quarters and contributed generously to the bar and culinary delights. Nurses were invited too, and the Matron and Nursing Sisters who were also invariably invited, appeared to forget, on these occasions , the closing time for nurses to be in their quarters. We greatly appreciated their transient amnesia, and so did the nurses, who went to their quarters only around 3.00 am. In addition to being SHO to the orthopaedic surgeon, Dr T.N Shanmugalingam, I was also appointed Acting J.M.O There was one little snag, and that was that if you were officially designated as J.M.O or Acting J.M.O, in those days, you were not entitled to receive the 25 Rupees for each post-mortem. This problem was neatly solved by the Superintendant Health Services of Uva Province by officially designating me as DMA ( ie District Medical Assistant), but giving me a duty list that covered all forensic duties. You couldn’t do that sort of thing nowadays. Do I hear a few of you snigger at 25 Rupees? If you are, let me tell you that 25 Rupees in 19631965 was in actual real value equal to over Rupees 1000/= today. I have done at least 100 post-mortem
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examinations during my tenure as the so-called DMA at Badulla, and appeared in many cases as expert witness, mostly for cases of grievous or non-grievous hurt at the Magistrate Courts in Badulla and Moneragala , the latter being a Circuit Court for the Badulla Magistrate. Most of the post-mortems were diagnostic ones requested by the Visiting Physician (as they were called then)., the late Dr. K J Nanayakkara. He requested for postmortems in most cases of unexpected or unexplained death. The mortuary in the Badulla General Hospital was primitive, and I certainly did not like having to do so many post-mortems there, Whenever there was a suspicious death in various parts of the Uva Province, the DMO of the area promptly took sick leave to avoid doing judicial post-mortems, because in those days, if you became an expert witness for the prosecution in a murder case, you could not leave the country until it was concluded, which meant usually an appeal to the Supreme Court. This explains why I had to also do many judicial post-mortems. Going abroad had not yet entered my list of ambitions. Field post-mortems were difficult. Often they had to be performed in the open air on makeshift tables constructed by the two policemen on guard duty, with the help of local people, and shielded for propriety by thatched cadjan fencing. This offered little privacy however, and ghoulish chaps used to peer through holes in the thatch at the pitiful naked bodies of the deceased victims being mutilated by the postmortem labourer’s fearsome knives, until these peeping-toms were shooed away by the policemen on duty. I have done open-air field postmortems in Bibile, Buttala, Medagama, Madulsima and Namunukula. The Namunukula post-mortem was at the top of that mountain, where the Namunu-
kula tea estate is situated. The cause of death in that case was drowning. An estate labourer had drowned in a little stream less than 18 inches deep. He was an epileptic on phenobarbitone, who had consumed a lot of illicit alcohol before falling face first into that stream. The relations later sent the customary petition to the then Inspector General of Police stating that the deceased could not have drowned in 18 inches of water, and that he had been held face down underwater by two brothers of his girlfriend. That would not be incompatible with my post-mortem diagnosis of course, but criminal investigation of the circumstances was a Police matter. The Siyambalanduwa post-mortem was done after walking nearly 6 km into a bear and leopard infested jungle. I was accompanied to the site by the coroner, the post-mortem labourer and three Policemen, one of whom carried an ancient looking gun with him, and several rounds of crackers to light to frighten denizens of the jungle to keep away from the footpath. The cause of death in this case was shooting at point-blank range, and the deceased man’s face was blown to bits. The corpse was rotting in the little hut where he had lived with his wife and two little kids, and the awful stench reached us for nearly one kilometre before we reached it. The coroner gave a verdict of suicide because the firearm belonged to the deceased, the shooting was point-blank, and because the young wife said that her common-law husband was an alcoholic subject to fits of deep melancholy. The subsequent petition to the IGP stated that the wife had shot the man on the face when he was sleeping because she was unable to tolerate his alcoholic beatings any longer, and because she had a more tolerable lover, living in a neighbouring chena. Contd. on page 18
SLMANEWS
April, 2013
Contd. from page 16
E M Wijerama... From three riotous years at General Hospital Badulla I was transferred to the Leprosy Hospital at Hendala, from where, as Narada has already told you, I was sent on a disciplinary transfer to District Hospital, Kitulgala. After I had assumed duties there, I discovered that of the 52 employees there, no less than 46 were on disciplinary transfer. So I was among kindred spirits, so to speak. And do you know why DH Kitulgala had such an unusual concentration of chaps on disciplinary transfer? Because it came under Dr. N M Perera’s electorate. The reasoning of the Health Department appeared to be that Dr. N M Perera deserved to have the lot of them under his tutelage. I joined the Department of Physiology of the Faculty of Medicine in Colombo in 1969 and I was selected to be a lecturer there in 1970. My chief, the late Professor K N Seneviratne had decided that I should be sent to a professorial medicine department to read for a clinically oriented PhD. I chose renal physiology. As my luck would have it, Lord Rosenheim who I have mentioned earlier, was visiting Sri Lanka in 1970 as Chief Guest for the annual scientific sessions of the Sri Lanka Association for the Advancement of Science, and also to deliver the inaugural Sir Marcus Fernando Oration, I was appointed his official driver. My duty was to transport him from Galle Face Hotel where he was installed, to wherever he had to go, in my second-hand Ford Prefect. Lord Rosenheim was a chubby and portly man with kindly eyes and a ready smile. On the last day of his stay here he told me that at the request of Professor K N Seneviratne, he had fixed me up in the Unit of Professor Oliver Wrong, Professor of Medicine at the University of Dundee in Scotland. He told me also that Dundee was
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a very cold and bleak place, but that Professor Wrong would soon come to London as the Professor of Medicine at University College Hospital and Medical School within 8 months. Foolishly, I asked Lord Rosenheim how he could be sure about this. And he said, his kindly twinkling eyes smiling, “You want to know how I am so sure? Well, let me tell you, young man, I am sure because I am the one who appointed him” And so it happened that I did my postgraduate studies, for the most part, at UCH Medical School, where both Dr. Wijerama and Lord Rosenheim had also done their undergraduate as well as their postgraduate training. How is that, for serendipity? After I came to University College Hospital Medical School, Lord Rosenheim used to drop in to see Professor Wrong once in a while, and then he never failed to have a kind word of encouragement with me. On a couple of occasions he invited me to supper at his London flat, and I have enjoyed his vintage wines and kindly words of wisdom about how to face the clinicals in the MRCP examination with confidence Lord Rosenheim died of an aortic arch dissection on 12 December 1972.Please bear with me while I show you a picture of University College London, to this day listed as one of the top four Universities in the world, and pictures of something else you will never be able to see in the original – that is a few pages from Lord Rosenheim’s last pocket diary for 1972. On the very first day I met Professor Oliver Wrong in Dundee in September 1970 he took me home for a beer and sandwich lunch and laid out the ground rules, one of which was should put all my endeavour into the PhD degree, and that I should not attempt to sit for clinical exams, because that was not the purpose for which the University of Ceylon had sent me to him. He added that he feared if I tried to do clinical examinations in addition to the PhD, I might flounder, and end up
by failing both. Good advice, but the superb clinics and ward rounds at UCH were really out of this world, and I was beginning to think analytically about clinical problems, perhaps for the first time in my life. And the Wednesday morning clinical case conferences (which are still going on there) in which two complex medical cases are briefly introduced by a Senior Registrar and discussed by top class experts from the UK itself or overseas, are world famous. In 2 years at UCH I had listened carefully to 100 such case discussions. The MRCP Part 1 was simple, but the Final was a different hurdle altogether. Statistics published by the Royal College of Physicians from time to time showed that if you were sitting for the Finals for the first time and you were over 35 years old, the pass rate then was between 5 and 8%. And I was sitting for it at age 36 for the first time in September 1973, but I already had the PhD under my belt, and I had enjoyed the privilege of learning from first-class clinical settings at UCH and its medical school. I managed to pass the MRCP at the first attempt, although I missed ulnar nerve palsy (one of the short cases) and two simple questions at the viva voce.Professor Carlo Fonseka, who had written to me stating that I was a brilliant chap after hearing that I had passed the MRCP, revised his opinion after he had attended just one Wednesday UCH clinical conference with me, when he stayed in my flat in London for a few days on his way to the USA. He said, and I quote: “I know I had written to you earlier saying what a brilliant fellow you are, when I heard that you had passed the MRCP. But after attending this single clinical conference I have had to change my view. If, as you say, you have attended 100 such clinical conferences, and you had failed the MRCP, I would have been compelled to class you as an idiot”.
SLMANEWS
April, 2013
Adrenal disorders in children Dr. Navoda Atapattu MBBS DCH MD MRCPCH Senior Registrar in Paediatric Endocrinology, Lady Ridgeway Hospital, Colombo
A
drenal gland consists of two regions, the cortex which derived from mesenchymal cells, and the medulla which derived from neuroectodermal cells. The cortex consists of three zones; zona glomerulosa , zona fasciculata and zona reticularis which secrete aldosterone, cortisol and androgens respectively. The adrenal medulla produces catecholamines. Disorders in adrenal gland development, defects in enzymatic pathways or tumours result in various disorders which need correct diagnosis and management.
Adrenal insufficiency The adrenal insufficiency could be primary or secondary. Only primary adrenal insufficiency will be discussed as per the topic. Primary adrenal insufficiency can result from 1. Adrenal hypoplasia due to various genetic conditions such as ;SF-1 - Steroidogenic factor 1 mutation, DAX-1- dosage-sensitive sex reversal, adrenal hypoplasia congenital critical region on the X chromosome, gene 1. 2. Adrenal destruction due to autoimmune conditions, infections, haemorrhage, drugs, or a metabolic disorders such as amyloidosis, wolman syndrome 3. Impaired steroidogenesis include either a steroid biosynthetic defect such as congenital adrenal hyperplasia,POR (P450 Oxidoreductase) deficiency,StAR Protein Mutations or a cholesterol biosynthetic defects namely;Smith-Lemli-Opitz Syndrome, abetalipoproteinaemia. Child may present with symptoms of chronic adrenal insufficiency such as weakness, fatigue, anorexia, weight loss, hypotension, hyperpigmentation or acutely with features of adrenal crisis namely shock, weakness, confusion, anorexia, nausea,
vomiting, and hypoglycaemia. A neonate may present with ambiguous genitalia, pigmentation or salt losing crisis. Early morning (8 am) plasma cortisol level lower than 3 μg/dL confirms adrenal insufficiency. Cortisol level higher than 15 μg/dL makes the diagnosis highly unlikely. However if the cortisol level is between 3-15ug/dl synacthen test is needed to confirm the diagnosis. Even if the diagnosis is uncertain it is prudent to treat as adrenal insufficiency after taking blood samples if the clinical features are suggestive. Treatment of primary adrenal insufficiency If hypoglycaemic treat with 10% Glucose - 5 ml/kg bolus followed by infusion: 5% Glucose + 0.9% NaCl IV-Hydrocortison 100 mg/m2 Bolus, then 100 mg/m2/ day (as QDS) ECG-Monitoring and treatment of hyperkalemia Monitor Electrolytes, Glucose Later add fludrocortison, only if hyponatraemia and hyperkalaemia develop
Congenital adrenal hyperplasia (CAH) This is a group of autosomal recessive disorders, each involving a deficiency of an enzyme in the synthesis of cortisol, aldosterone, or both. Salt losing variety can present during 2nd or 3rd week of life with adrenal crisis, hyperpigmentation with or without ambiguous genitalia. Non salt losing variety present later in life with adrenarche ( pubic hair before 8 years in a girl or before 9 years in a boy) ,hypertension or rarely hypokalaemia.
Cushing’s syndrome. Cushing’s disease (Pituitary ACTH dependant) is the commonest cause of Cushing’s syndrome in children over 5 years but in infancy, common-
est cause is adrenal tumours. Major discriminating features from simple obesity are; proximal myopathy, easy bruising, facial plethora, red/purple striae >1cm. Height & body mass index standard deviations provide a sensitive diagnostic discriminator of simple obesity from Cushing’s syndrome.
Primary hyperaldosteronism. Patients can present with hypertension, hypokalaemia, polyuria or alkalosis. Before biochemical tests are performed patient should be prepared according to the guidelines. Complete cure is possible with surgical removal of the tumour. Primary glucocorticoid resistance, glucocorticoid remediable hyperaldosteronism, apparent mineralacorticoid excess and familial glucocorticoid deficiency are rare disorders which can be managed easily with correct diagnosis.
Phaeochromocytoma Phaeochromocytomas are rare in children. It is responsible for 1% of childhood hypertension. 24 h urinary total metanephrines and catecholamines or fractionated plasma metanephrines have a higher sensitivity in the diagnosis. Medical management followed by surgical management is curative. It is important to appreciate that there are four dominantly inherited mutations associated with this condition and appropriate investigations will help to screen family members.
Adrenal tumours These tumours can present with abdominal mass, virilisation, features of cortisol excess. Tumours larger than 100g (or 200cm3) peri-operative tumour spillage/dissemination, increased urinary steroid DHEAS and glucocorticoid hormone levels, Contd. on page 20 hypertension,
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SLMANEWS
April, 2013
Sri Lanka Medical Association Joint Clinical Meeting with the Monaragala Clinical Society
Date : Time : Venue : General
Some snaps from Joint Clinical Meeting with the Hill Country Medical Society held on 19th March 2013
2nd May 2013 8.30 am – 2.15 pm Auditorium, District Hospital, Monaragala
8.30 am National Anthem, Lighting of the oil lamp 8.40 – 8.50 am Welcome address by President Monaragala Clinical Society 8.50 - 9.00 am
Address by President, SLMA
9.00 – 9.45 am
Management of leptospirosis
9.45 – 10.30 am
Non accidental injuries in children
10.30 -10.45 am
TEA
10.45 – 11.30 am
Rational use of antibiotics
11.30 – 12.15 am Fluid management in the surgical patient 12.15 - 1.00 pm Burns – Principles of wound dressing 1.00 - 1.45 pm
1.45– 2.30 pm 2.30 pm
Management of snake bites Early identification of develop mental delay in children LUNCH
Contd. from page 19
Adrenal... delay in diagnosis are poor prognostic factors. Surgery is the primary treatment. Lifelong follow-up is mandatory to exclude contralateral or malignant recurrence. Majority of adrenal disorders are rare. However basic
knowledge on different entities of adrenal disorders is important. It should be emphasized that adrenal insufficiency is a medical emergency and all primary care physicians should be aware of its management.
SLMA monthly Clinical meeting for the month of March was held on 19th March 2013 at the SLMA auditorium. The meeting was well attended. A summary of the review lecture is given above
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SLMANEWS
April, 2013
‘Women and Stress’ A Guest lecture to commemorate International Women’s Day 2013 By theWomen’s Health Committee of the SLMA and Zonta Club 1 of Colombo
T
he Women’s Health Committee of SLMA in collaboration with the Zonta Club I of Colombo organized a guest lecture on ‘Stress and women’ to commemorate the International Women’s day 2013. The lecture was delivered by Professor Nandani de Silva, Emeritus Professor of Family Medicine, University of Kelaniya on 18th of March 2013 at the Lionel Memorial Hall of the Sri Lanka Medical Association. Prof. Chandika Wijeratne the president of Zonta Club 1 and Dr. Nalika Gunawardena the chairperson of the Women’ s Health Committee chaired the session and the lecture was well attended by many interested individuals in the medical as well as the nonmedical fields. The lecture focused on what constitutes ‘stress’, the stress response, how the stress response differs in males and females and the physiological basis for the difference. This was followed by a detailed description of female specific stressors at different stages in the life cycle emphasizing those related to women of reproductive age with Prof. de Silva’s own research. The consequences of chronic stress on physical and psychological well being and how stress could be a contributory factor in heart disease, non communicable diseases and infections was highlighted with evidence from international literature. Methods to manage stress such as mindfulness based stress reduction programmes and cognitive behavior therapy were also discussed. The lecture concluded with instructions on five healthy ways of coping with stresses of daily life which are to Avoid, Alter, Adapt, Accept and to Adopt a healthy lifestyle. A very lively discussion followed the lecture where the participants were exchanging
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their views on individual and group efforts that could be taken to minimize some specific stressors for women such as gender based violence. The
programme was concluded with the vote of thanks which was delivered by Dr. Shamini Prathapan the Convener for the Women’s Health Committee.
SLMANEWS
April, 2013
DISCOVER SRI LANKA
The Bo-path Ella and Dehena Ella Sabaragamuwa. Dr. Philip G. Veerasingam Senior Consultant Surgeon
S
ri Lanka has numerous waterfalls adding to her fairytale charms. The Province of Sabaragamuwa can boast of a large percentage of them. I have chosen this time a trip to see two of these waterfalls near Ratnapura. Leave Colombo around 5 am and proceed to Orugodawaththe and turn at the traffic lights to take the road to Hanwella via Wellampitiya, Kotikawaththa and Kaduwela. For those living close to the High Level Road the route to take is Nugegoda, Maharagama, Homagama, and Pahathgama. Both routes will meet just before Kaluaggala a distance of 33 Kms on the High Level road from Colombo Fort. At the place where both routes meet you will find a memorial erected to Leuke Nilame. The stories of the site of this tomb are explained in the popular ‘Jana Kavi’ etched on the tomb-stone. Pause awhile to read it and ponder on the nuances it implies. Proceeding on the road to Avissawella you will pass Saalawa, Kosgama, and come to Puwakpitiya situated 12 Kms from Kaluaggala. You will be passing the old Kelani Valley Railway station at Puwakpitiya which has the architecture of British Colonial days. Once you pass the level crossing close to the Railway Station, about 200 yards on the right hand
side you will pass a house belonging to a ‘Gam Mulaadaaniya’ of British Colonial days. This was supposedly designed by a Railway Engineer working on the construction of the narrow gauge Kelani Valley Line. A hundred yards further, on the left side, are two places where you could have tea and snacks. They are ‘Freshways’ first and ‘Weerasiri Bakery’ a few yards further on. If you like a Sri Lankan Breakfast you can have it a kilometer further, again on the left side of the highway at ‘Ran Muthu’ or the adjoining ‘Weerasiri Restaurant’. Proceeding further just near the Avissawella Rest House which is again a good place to have your breakfast, you take the road to the right, by-passing Avissawella town on the road to Ratnapura. Proceeding on this road you will pass Getahaththa, Eheliyagoda and enter the approaches to Kuruwita a distance of 35 Kms from Puwakpitiya. At Kuruwita there are two places worthy of a visit. The first is the Delgamuwa Raja Maha Vihara. The approach road is on the right side about 500 Meters before the Kuruwita Police Station. It is a narrow motorable road about a half kilometer long which leads to the temple. The historical artifact of value exhibited
here is a ‘Kurahan Gala’ – a stone mill – inside which the Sacred Tooth Relic of Lord Buddha was hidden and escaped capture by the marauding Portuguese, who ransacked this temple in the latter part of the 16th Century AD. The ‘Kurahan Gala’ at Kuruwita When the Portuguese took the Kingdom of Kotte in the mid 16th Century, Seethawake (present day Avissawella), became the centre of resistance to the Portuguese. King Mayadunne and later King Rajasinghe led the fight against the Portuguese. Contd. on page 24
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SLMANEWS
April, 2013 Contd. from page 23
The Bo-path Ella... The sacred Tooth-Relic of Lord Buddha, kept traditionally by the reigning monarch of Sri-Lanka, was in danger of falling into the hands of the Portuguese. It was smuggled out of Kotte, because Prince Dharmapala of Kotte had converted to Catholicism. According to legend, the Tooth-Relic was taken to the Kingdom of Sithawake. It was installed in Delgomuwa Raja Maha Vihara, in Kuruwita. It was taken in procession in the annual Perahera of Saman Dewale in Ratnapura, successively for ten years. However the danger of a Portuguese raid, to seize the Tooth-Relic remained. The custodians at Delgomuwa Raja Maha Vihara, decided to hide it in a ‘Kurahan Gala’ – a biggish stone mill used to grind ‘Kurahan’ (Kurakkan T) in the household. A biggish version of a ‘Kurahan Gala’, was used to grind coloured stones to be used as paint in Vihares those days. One of these big stone mills was procured and a secret cuboidal chamber was made in the centre of the lower stone. The sacred Tooth Relic was secured there and the upper stone was kept
in place covering the chamber. To all appearances it was a heavy grinding stone mill, left unattended in the
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vihare premises. The Portuguese raided the vihare and ransacked it, but ignored the ‘Kurahan Gala’. Subsequently the Tooth-Relic was transported to Kandy, to be installed in the Dalada Maligawa there. The ‘Kurahan Gala’, which acted as a receptacle to house the ToothRelic in difficult times, is now on exhibition at the Delgomuwa Raja Maha Vihare in Kuruwita and draws a lot of pilgrims annually. It is broken on a side. I took a picture of this some time back. It is mounted on a pedestal and is encased in a glass cage now. Coming back to the main road a few yards further towards Kuruwita near the Police Station is a road on the left side of the highway which leads to ‘Bopath Ella’ named because of the similarity of the waterfall to the leaf of the ‘Ficus religiosa’. This is on a motorable road about 4 kms from the main road. Quite a few lives have been lost at the waterfall by attempt-
ed suicide or trying acts of daring on the slippery rocks on the slopes of the waterfall. As long as any of your party does not attempt to climb the rocks near the waterfall you are safe.
Retracing your path you come back to the main highway to Ratnapura. At Ratnapura there are two places to visit. They are the famous Saman Dewala and a Gem Museum at Batugedara. To reach Saman Dewala you have to turn off at the Moragahayata junction onto the right and take the Ratnapura Panadura highway, a distance of 3.6 Kms. Saman Dewala was the site of a temple situated on a bend of the Kalu Ganga. It was on the old river route to Batugedara and Adam’s Peak in Ratnapura from Kaluthara on the western shore of the Island. A lot of trade passed this way. The Portuguese realized its value. They seized this place, destroyed the temple and built a Fort to guard and collect tax at this point. There are artefacts from this period found in the present Saman Dewala. The original wall of the Fort is still intact. Facing the outer courtyard mounted on a wall facing the entrance is a stone carving depicting a Portuguese soldier with a raised sword astride a fallen figure. Inside the temple is a stone slab depicting the Portuguese Coat-of-arms. Contd. on page 26
SLMANEWS
April, 2013 Contd. from page 24
The Bo-path Ella... The present temple is supposed to have been a temple dedicated to Laxmana brother of King Rama who invaded Sri Lanka in antiquity. Now it is dedicated to the God Saman. Make it a point to see a stone which is said to grow in height slowly over time, exhibited inside the temple premises. On a clear day you can see ‘Sri Pada’ from the entrance to the temple at the top of the steep stone stairway.
Go round the periphery of the stairway to see the Kalu-ganga skirting the temple. There is a lot of bird life there. The following two pictures of a Blue-tailed Beeeater and the Asian Paradise Fly-catcher were taken there by me during a visit to the temple. Retracing your way back to the turn-off to Rathnapura you proceed to Rathnapura and a few miles onto the Badulla road you come to Batugedara a distance of 4Kms from Rathnapura. On the left hand side is a board advertising the Gem Museum owned by Mr. Bodhi Amarasinghe. The workers here will oblige you by showing you round the museum which has a good selection of gems. They manufacture gem studded jewellery for export. You could pick your choice and they will give you a guarantee on the items purchased. Retracing your way back to Rathnapura passing the bridge over the Kalu Ganga, the second turnoff on your right is the road leading to Malwala. At Malwala junction you take the right turn and proceed to Gallella and Hapugasthenna. You pass an iron bridge a Kilometer from Malwala junction on this road. On a clear day you will be able to see Sri-Pada and make out the outline of the white pavilion at the peak summit from the bridge. From Hapugasthenna a few kilometers along beautiful hills, valleys and many small waterfalls you come to the Dehenakandha waterfalls by the roadside a distance of 25 Kms from Rathnapura.
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a Grey Hornbill building its nest in a tree close by at this place. If you go further on this road you will reach Balangoda. The road to the famous Alupola Waterfalls parallels this route. The road further is a scenic wonder but save the trip for another day. Retracing your way back the best place to have a late lunch is at Paradise estate at the French Restaurant next to a petrol shed on the right side. There is another place on a hill by the side of the highway about 400 meters further towards Kuruwita on the left side of the road. You should be back in Colombo by 8 pm. This article was designed, produced and provided by Dr. Philip G. Veerasingam
This waterfall has a small pool built for bathers.
Reproduced with permission from the author and Editor, CoMSAA NEWS
The sound of the denizens of the jungle will thrill you. There is a lot of bird life here. I once photographed
This article was published in CoMSAA NEWS 2013;2(1):17-21