Online edition of Daily News

Prof. Saman Gunatilake, (Head of the Department of Medicine, Kelaniya University) was making his presidential address last week, after he was inducted in office as the 26th President of The Ceylon College of Physicians.

How will our world be in another 25 years? The number of centenarians would be twenty times more. Human sperms and ova would be for sale on-line.

Prof. Saman Gunatilake taking oaths prior to being inducted as President of the Ceylon College of Physicians for the current year. On right is the outgoing President Dr. Anula Wijesundera administering the oath. Prof. Gunatilake is the 26th President of the College.

At least 120,000 babies in the United States alone would have so far been produced not on a bed but in petri dish. It would be the era of designer babies. We would be unravelling the mysteries of the human nervous system with the help of the knowledge we have gained from the human genome project.

Of the 130,000 genes at least 30% direct the growth and development of the nervous system. Discovery of the adult human neural stem cell will revolutionise treatment options. Stem cells will be injected stereotactically into areas of the brain damaged by strokes and stem cell will become the ultimate body-repair kit.

Growing a new brain would still not be possible though growing specific group of cells in the brain would be possible. There will be interventional neurologists injecting highly specific capillary growth factors into the thrombosed cerebral blood vessels to ensure new blood vessel formation and revascularisation to reverse the effects of stroke.

Will we be able to replace our body? Most parts-yes. Nerves, blood vessels, bone and cartilage, heart, liver, kidneys can be regenerated from stem cells. Artificial limbs will be directly wired to the motor cortex and will be controlled by the brain.

The brain has such a wide array of chemical neurotransmitters and their actions can be utilized to treat so many disorders.

Brain may become a super pharmacy. Antenatal genetic diagnosis will be commonplace and devastating conditions like muscular dystrophy in children will be treated by gene correction in the foetus. Now it is known that the fruit fly has a gene that increases its life span by 35%. Will we identify this gene in the human?

The terrorist of the next decade will no longer have to be in prison. He will be on parole with a programmed electronic chip implanted in the amygdala, a part of the brain that controls behaviour. This chip will monitor the electrical activity and when a thought of an antisocial nature occurs, this will be detected and further propagation will be prevented.

Neurosurgeons will be able to visualize the brain tumours through the intact skin, and skull. He will be wearing special goggles through which the image of the tumour will be superimposed three-dimensionally.

Where is all this going to end. Many of us are afraid of the future and cling desperately to the present not realizing that we are already the past. Arthur C. Clarke once said "Advanced technology will eventually be indistinguishable from magic".

To face this magical world, what we require in the coming decade is mature heads on young shoulders and not to get carried away by the gadgets. We should never forget we have the unique privilege of trouble-shooting and repairing the greatest supercomputer of all time, the human brain. Science without compassion is blind; compassion without science is lame. In our anxiety to enter the third millennium let us never forget that we are healers first and technologists later.

With that peep into the future, let us now come back to the present and let us look at us What we do, what we should be doing at times why we don't do what we should doing.

When considering the philosophy of clinical medicine four factors help to define and differentiate the physician from others. These include the focus on the diagnosis, care for sicker patients with complex medical problems, a role as consultant, and intellectual curiosity.

The term that may best characterize a physician is diagnostician. Making diagnoses is what we do best, what we find most stimulating and enjoyable. We delight in the process of problem solving and believe if one knows the diagnosis, then it is relatively easy to determine the most appropriate management strategy. More simply stated, the known treatments for all diseases are there in books.

Thus, we can always look up the treatment and what we need to know is which page in which book to read. These comment are in no way meant to trivialize treatment or management. Clearly these require expertise, skill, and humanism. Rather these comments reflect the philosophical focus of the physician.

Sir William Osler, arguably the finest physician of the last couple of centuries in 1905 best summarized how a physician should practise medicine:

. Act the Golden Rule, as far as in me lay, to ward my professional brethren and toward the patients committed to my care

. To cultivate such a measure of equanimity as would enable me to bear success with humility, the affection of my friends without pride, and to be ready when the day of sorrow and grief came to meet it with the courage befitting a man.

The Physician's focus on diagnostics is consistent with the deductive or scientific approach to patient care we advocate. We are also capable of employing an empiric approach. By listening to the patient's story of the illness (history) and then by examining the patient we come to a probable diagnosis. We know that if properly done, the history and examination provide all the information we need to make a diagnosis in 80 to 90% of cases.

It is also through the history and examination that physicians learn of their patient's life and values, develop a personal relationship, and establish trust.

Technology and tests allows discrimination among the different possibilities. When the diagnosis is not known, tests are chosen that will rule in or rule out the different entitles being considered.

If, on the other hand, the diagnosis is known, tests may be performed for confirmation and to quantify the severity of the condition. Other tests may be ordered to establish a baseline for following the course of the disease or the response to therapy. With this approach all tests are ordered with a specific intent and resource utilization optimized. Once the diagnosis is made, treatments can be initiated. With each intervention, we should ask three questions:

Physicians enjoy the detective work. Understanding how the pieces of the diagnostic puzzle fit together provides the physician great pleasure. To succeed in this method thinking time is essential. After each part of the process, pause and think and revise the diagnosis if new information is available.

Our philosophy of deductive approach helps sort out multiple problems and serves us well in the care of such patients. Because of patients with complex medical problems we tend to spend more time with hospitalized patients and in intensive care units. However we also provide care for the adult patient in a wide variety of settings and deals with most of their non-surgical problems.

Our practice of medicine is patient centred, comprehensive, and integrated. We believe we can relate to patients as individuals, respect them as individuals, and care for the full range of medical and personal problems.

Accordingly, the physician deals with health maintenance and prevention, acute and chronic conditions, and common and uncommon diseases, in ambulatory settings, inpatient services, intensive care units, extended care facilities, and home health and hospice programs. All physicians develop competence through hospital-based training.

Spending time in these settings allows us to appreciate the spectrum of disease severing and learning in these settings translates well into other areas of care delivery. A hospital based physician could easily become a good general practitioner with a little training in the correct attitudes whereas the vice versa may not be true. Therefore in the training of medical students too we must train them well in internal medicine more than in anything else.

Prof. Gunaratna (extreme left) at the Rajagiriya Centenarian Study. The two doctors in the study team Viraj Peramuna and Ranesh Wijesinghe are on the Centenarian Mrs. Margaret Perera's left.

The prestigious medical publication of the Sri Lanka Medical Association - The Ceylon Medical Journal, will carry an article by Prof. Colvin Goonaratna on the medical findings of the Health Watch Centenarian Study in their March issue.

Prof. Goonaratna told this to the study team, when he participated in the Centenarian Study at Rajagiriya last week.

He said from the data collected in this study so far on 25 Centenarians in various parts of the country, the majority over 90 per cent had a clear memory of their past, and a reasonably good memory of the present of their day-to-day events.

A Buddhist monk in Kandy in the study who was 104 years old was found still actively writing books.

One Centenarian in Kelaniya who is 101 plus, was found still able to scrape coconut in a coconut scraper quite easily. He even had gone to the extent of showing the study team that he would still bathe from a well drawing water.

Some of these findings appeared unique for centenarians in this part of the world, and merited to be published in the Ceylon Medical Journal.

Mrs. Sigrid de Silva in her reply to a Daily News (18-01-2002) reader has given the wrong impression that rennet is used in the manufacture of curd. A few vegetarians who have been consuming curd for decades contacted me to verify whether rennet is used in Sri Lanka in the preparation of curd.

It is common knowledge that rennet is an extract derived from rennin, an enzyme present in the stomach of most young animals particularly the calf and the lamb and it causes the main milk protein, case in to precipitate thus allowing the milk to clot. Rennet is sometimes used in the manufacture of cheese. As far as I am aware most of the imported cheese contain rennet.

Dr. Thula Wijewardena, Senior Lecturer in Veterinary Microbiology of the Veterinary Medicine & Animal Science Faculty, Peradeniya University, in an e-mail to the Health Watch with reference to the reply we carried in this page last week on a question on Yoghurt and Curd states:-

"Reference Health Watch Question Box of 18th Jan. 02, to a question raised on how yoghurt and curd differ nutritionally the reply given by Mrs. Sigrid S. de Silva is erroneous.

"Reference the answer to a question raised on how yoghurt and curd differ nutritionally (Health Watch Question Box of Jan. 18) the reply given is erroneous.

Both curd and yoghurt are fermented dairy products obtained from coagulation of milk by the agency of specific strains of lactic acid bacteria referred to as starter culture.

The starter cultures used for preparation of these two products differ in that thermophilic (high temperature) bacteria i.e. Streptococcus thermophilus and Lactobacillus bulgaricus in the ratio of 1:1 serve as the starter for yoghurt while, mesophyllic (low temperature) bacteria such as Streptococcus lactis, Streptococcus diacetyl lactis, Streptococcus cremoris either singly or in combination with Leuconostoc spp are used as starterculture for curd.

These bacteria use lactose in milk for their growth and produce lactic acid which curdles milk.

At the same time they produce by products such as diacetyl, acetaldehyde and similar compounds which contribute to the aroma and flavour of these products.

Therefore the statement on Curd "The coagulation occurs when milk gets treated with rennet" is wrong in that context. Please be good enough to give the correct version of the picture.

Health Watch - We thank Dr. Wijewardena for pointing out the error and correcting it.

The Annual Scientific Sessions of the College of Anaesthesiologists of Sri Lanka will be held tomorrow and on Sunday at the Hotel Lanka Oberoi with two eminent immuno-nutrition specialists of Australia and India as guest speakers.

They are Professor David Bihari, FRCP, FRACP of the University of New South Wales, Australia, and Dr. T. Varsha MSc, PhD (Clin. Nutri.) of the Sri Ramachandra Medical College, India.

The Annual Sessions will be preceded by a workshop on 'Recent Advances in Clinical Nutrition' organised by the College of Anaesthesiologists at the SLMA Auditorium in association with the Sri Lanka arm of Novartis Nutrition of Switzerland, today.

Chairperson of the workshop will be Dr. Neelika Karunaratne (FRCA) Consultant Anaesthesiologist and President elect of the College of Anaesthesiologists.

Dr. Samarasekera last week stressed the urgent necessity for the government to set up a proper Regulating Authority for Private Hospitals to ensure that the people who seek treatment from these hospitals are not exploited.

He said, with health care fast becoming more and more a profit making business, rather than a service to the people, save in the state sector hospitals, and with more and more private health care institutions coming up in this country, a patient could become an exploitable item in health care in the private sector, unless the state had strong Regulating Authority to look into the services provided by these institutions, and draw up proper guidelines for them.

Dr. Samarasekera says that today even the lower middle class people have begun to patronise the private hospitals, thinking that they get a better service there and in the process some of them have had to sell their properties to pay the heavy hospital bills.

One cannot totally blame the private hospitals concerned for this because they are business concerns, part of the blame has to be laid on the state for the failure to workout a realistic national health care plan for the country in keeping with the economic status of the people.

For the present he felt that the present government could at least re-introduce the Private Hospitals Bill that was already in the order paper when the last Parliament dissolved.

Dr. H.B. Jayasinghe (MBBS Ceylon, MCGP Sri Lanka, MDCH London, MBS CH UK, CHT USA) describes how stammering could be cured through clinical hypnotism.

Dr. Jayasinghe who has specialised in this art of curing; which is now recognised by the western medical profession, has initiated a training programme for doctors here in clinical hypnotism, which is being conducted by the College of General Practitioners, Sri Lanka.

The first batch of family practioners who successfully completed this course of training were awarded their certificates by the (CGPSL) in November last year.

Dr. Jayasinghe in this article says "Treatment with hypnosis is likely to be of great value in children and young adults. In older people results are inconsistent. In cases with poor response, hypnosis may be more effective when combined with speech therapy".

He also adds - "Those who spoke once normally and subsequently developed stammer, usually have a better response with hypnotherapy".

A situation, which causes one person to stammer with fright, may cause another to flush with fright or the two may occur simultaneously in the same individual.

Dependent type In stammering, the normal speech rhythm tends to become both inhibited and interrupted. This is particularly seen in certain social situations that tend to produce shyness, embarrassment and uneasiness.

The patient dreads to speak in the presence of other people, especially in the presence of strangers.

Most stammerers are of the dependent type with no self-assurance and find it extremely difficult to assert themselves in the company of others.

Surprisingly enough, most of the stammerers are usually able to sing with no difficulty.

Traumatic Incidence in Childhood Stammering is sometimes precipitated as a result of some traumatic incidence in childhood, and this has to be explored by regression. Faulty parental attitudes can arouse tensions in a child and lead to stammering.

They overreact to child's non-fluent speech with too much of concern or impatience. By correcting him, they make the child conscious that his speech is unacceptable.

He responds by speaking less and less, with the growing fear of failure. Hence, parents should allow the child to develop at his own pace, and his speech should not be judged by adult standards.

Stammering a Neurosis According to Le Cron and Bordeaux, 80 per cent of cases appear before the age of 6 years, and the incidence in males is approximately nine times greater than in females. They consider stammering to be a neurosis, possibly of the compulsive type, and emphasize the difficulty of cure after the age of 30 years.

It is generally accepted that a stammer must be treated as early as possible. Indeed the shorter the duration of the stammer, the greater will be the prospect of success. The prognosis also tends to be favourable when the stammer is associated with subjective feelings of anxiety, for individuals who stammer badly, without becoming anxious or embarrassed rarely seem to improve to any marked extent.

Speaking at a Sept. 20 session on obesity at the AAFP Scientific Assembly in Dallas Dr. Raul Zimmerman said "Obesity could be best viewed in terms of what's known as the - Discordance Hypothesis. The problem is that we have old genes in a new environment.

"Our genetic makeup originated in a harsh environment in which subsistence depended on hunting and gathering. Physical activity was mandatory for survival and periodic famine was the norm.

"The human gene pool, has not changed substantially since then. "Thus in todays environment, where food is more plentiful and in most cases easier to obtain, those same genes favour obesity.

"Using this concept as a starting point, researchers conducting studies of comparative body mass index values among twin pairs and other family members have estimated that genetics contribute to about 40 per cent of obesity variance. "Variations in prevalence according to demographic or social economic factors suggest a model in which susceptibility to obesity is largely a function of genetic, but the environment determines phenotypic expression.