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Late Prof. K. Rajasuriya's bold experiment : 

Intravenous use of Thambili water

This was disclosed last week in Colombo by Prof Nimal Senanayake while delving into the professional life of the late Professor and the bold steps he had taken in the interest of patients, and not sticking by the narrow confines of Medical Science.

Prof. Senanayake Head of the Dept of Medicine Peradeniya Medical Faculty was delivering this year's Prof. Rajasuriya oration at a meeting of the College of Physicians, Sri Lanka.

If you can find the time please send your views and comments on this oration, which we will publish next week.

Excerpts from the oration

King coconut water

Professor Rajasuriya taught us how to analyse any medical problem making the best use of basic knowledge and clinical skills. This does not mean that he shunned new concepts, new knowledge and advances in medicine. No. He was up-to-date. He edited the prestigious CMJ single-handed for many years. He was also a leading clinical researcher in his time. His writings on tropical diseases found their way to international journals and they continue to interest scholars

He always had an open and inquiring mind. He considered every single case presented to him as a new experience. He was never bound by the narrow confines of what we call medical science.

I still remember how he got me to arrange an outside doctor to give a course of acupuncture for one of his ward patients in distress with painful arthritis. He was bold enough to experiment with king coconut water for intravenous use in place of imported potassium solutions. It is in this context that I have chosen the theme for this oration, a concept not often talked about in medical fora, but a concept with great potential to influence scientific thinking; and I have no doubt that the subject would have appealed to Prof. Rajasuriya's analytical mind.

I consider it a singular event in my life to deliver this Professor Kumaradasa Rajasuriya Oration today. Having had the privilege and the good fortune of working as Professor Rajasuriya's Intern and later as his Registrar, I feel that I am fulfilling an obligation that I owe to this great man.

I thank the Council of the Ceylon College of Physicians for giving me this opportunity and bestowing upon me this honour. Professor Rajasuriya's abilities and achievements have been well talked about by several previous orators, and I do not wish to repeat what has been already so well stated. Instead, I'll spend a few minutes recalling my memories of this truly remarkable son of Lanka; my memories as a young medic.

The humanist

Let me take you back in time to the year 1970. Place: ward 28, Kandy Hospital. Event: the Finals. Even today, I have a vivid memory of my long case in Medicine. While my patient was waiting in bed paralysed, anathric, I was waiting, in no better condition, waiting for the viva. The two examiners walked towards me.

One was a Kandy physician. (Not Dr. Hugh Jayasekara, another beloved teacher, whom I am so glad and honoured to see in the audience this evening). My attention was fixed on the visiting examiner walking in front. In his face in spite of his commanding appearance, I thought I noticed a hint of a kind smile.

As the discussion started, I recovered. When the bell rang, for a first time in an exam, I felt rather sad that it ended. I must say, I had the shivers, as a delayed response, when I was told that it was Raj, meaning Professor Rajasuriya, the Professor of Medicine in Colombo. That was my first encounter with this great teacher, brilliant clinician, and above all, the humanist.

That was the event that paved the way for me to go to Colombo for my internship. Thus, I earned the distinction of being the 2nd Peradeniya graduate to be Raj's Intern. Subsequently, he took me back as his Registrar. Although he was away as the DHS for a certain period during this time, these two appointments gave me the opportunity to learn his approach to clinical medicine, and also to see the true personality in him.

Professor Rajasuriya had a genuine concern for his patients, for the profession, and for his country. Having this at heart, he did what he thought was right.

He was bold and courageous in expressing and doing what he thought was right. He could not tolerate hypocrasy; He condemned outright those who shouted slogans in public, but did nothing or did just the opposite when it came to action. Many, obviously, could not understand him, and a good number of them became his enemies.

Only those who were close to him could see the abundance of kindness underneath his stern exterior. eg. How he reprimanded a student but then asked me to find out about his problem.

Although the students were mortally scared of him, I am sure most of them loved him. When I went through my old files, I found a copy of a typed document running into just over a page, Reminiscences of Ward 41, presented to Professor Rajasuriya by a group of students at the end of an appointment.

"We have come to a memorable appointment's end, and to say thank you this poem we send, To you Professor Rajasuriya for all the pains, you took to make us blockheads gain... From syringobulbia to sex-bombs we are well informed..."

Except on an occasion like that, he hardly smiled, but he himself had a superb sense of humour.

Many of you might not have known about his literary talent. Once he penned a poem dedicated to the Kataragama beauty queen-Premawathie Manamperi brutally murdered by the armed forces during the 1971 insurrection. This was a manifestation of his deep commitment to social justice, rising against injustice however powerful or socially acceptable the opposition might be.

His approach to clinical medicine was refreshingly simple and straightforward. He reminded us that common things occur commonly; an uncommon manifestation of a common disease is commoner than a common manifestation of an uncommon disease. History and physical examination come before investigations, irrespective of how modern or high-sounding the latter may be.

Today, we see patients becoming victims of their own investigations; the doctor taking them through a voyage from one investigation to another reminding us of Ulysses, the legendry hero, who was led from one adventure-rather misadventure to another.

Today, we see an emerging brand of modern doctors: who are keen to determine the air entry by auscultation rather than defining the type of breath sounds; who are more keen at producing a long list of differential diagnoses rather than analysing the problem and coming to a straightforward diagnosis; who would rather do an MRI scan than a urine test for sugar to diagnose the cause of coma.

They seem to be more preoccupied with collecting new terms rather than examining concepts and ideals. They use such mod (and often meaningless) terminology as a shield to protect their ignorance and inadequacies. This is the kind of hypocrisy Professor Rajasuriya condemned downright.

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On orthopaedics : The danger in high-heeled shoes

by Dr Mandeep S Dhillon

Fashion trends ensure that millions of women world-wide wear high heels, often without being aware that they may be risking the onset of numerous problems related to their back and maybe hastening the onset of degeneration and arthritis of their knees.

These high heels, especially the stiletto variety, make you walk in a position that is not normal, leading to abnormal strains in the whole skeleton. If you have problems related to the knee and back, these are definitely made worse; if you do not, the potential for you getting these problems is significantly enhanced.

Recently, work done at the Harvard Medical School has pointed out that osteoarthritis (excessive wear and tear in a joint) of the knee is twice as common in women as it is in men. Upon analyzing the contributing factors, they found that the one common thing was wearing high-heeled shoes, and this maybe an important cause of knee or back pain in later life.

Fit women, in their mid 30s, were asked by the researchers, to walk along a special platform in bare feet and then in shoes with heels of 6 cm (2 1/2 inches). Sensors under the platform and cameras recorded the movement of the women's ankle and knee joints; specialized devices allowed the strains on the joints to be measured.

The test results showed that when walking in high heels, there was greater strain between the kneecap and the thighbone and in the inner side of the knee joint, as compared to walking barefoot. The finding of increased strain on the inner side of the knee joint is of particular interest, because osteoarthritis is more common on the inner than the outer side of the knee.

The spinal column is a complex structure, consisting of many vertebrae piled one on top of the other, with some curvatures inherent in the structural assembly. These natural curves are essential for good posture, and if these become abnormal, either due to weak muscles (which happen invariably with ageing and lack of fitness!), then other factors like walking on high heels or improper leg alignment hasten the process of wear and tear. This starts as mild backache, with increased sag of the lower spine to the front and some protuberance of the buttocks; this is further aggravated by walking on high heels, and a vicious cycle is set up, leading to worsening of the situation.

Another problem related to stiletto heels is the fact that the foot has to balance on a small point during gait, compared to the flat surface that is the normal heel. This means that extra muscles at the ankle have to work all the time to prevent minor twists and sprains with each step of the gait cycle. This unnecessarily strains these muscles, leading to fatigue and potential long term damage.

So- are high heels really a good idea? Modern understanding of gait mechanics seems not to think so. So all you ladies out there with plans of wearing stilettos on the weekend should think twice, especially if you have some knee or back pain or if you have a tendency to be overweight. "Sensible shoes" are rightly called so, as they definitely make more sense!

The writer is Senior Consultant Apollo Hospitals, Colombo

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On sesame oil

Now there's evidence that sesame oil can lower blood pressure. It comes in a report to the American Heart Association's annual meeting of the Inter-American Society of Hypertension by Devarajan Sankar, PhD, of Annamalai University, Chidambaram, Tamil Nadu, India.

Sankar and colleagues studied 195 men and 133 women with high blood pressure. All were taking nifedipine (brand names include Adalta, Nifedical, and Procardia), a common blood pressure-lowering drug. Despite this treatment, all patients still had moderate high blood pressure.

Sankar's team asked the patients to switch to sesame oil as the only cooking oil they used. Sixty days later, the patients' average blood pressure dropped into the normal range. It's an impressive finding, agrees Sampath Parthasarathy, PhD, director of gynaecology and obstetrics research at Atlanta's Emory University. Parthasarathy, a biochemist, is a leading expert in antioxidants and lipid/protein metabolism.

"Usually the benefits of these unsaturated fats are measured in terms of cholesterol lowering," Parthasarathy tells WebMD. "Here, the benefit appears to be on blood pressure. That makes the study even more exciting." Parthasarathy says he doesn't think that the PUFAs are involved in the blood-pressure-lowering effect of sesame oil. But he speculates that lower blood pressure may be an indirect effect of sesamin, sesamol, or both.

(E-mailed to us by Ariyasumitra Wijeratne)

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Dr. D. P. Atukorale replies on cardiac problems

Your blood cholesterol level can be controlled

Question on diet, sent by U. de A. Wijesinghe of Panadura. I am a retired government employee 73 years old. About two weeks ago I had a persisting headache and I consulted my family doctor and on his advice I got a cholesterol reading which was 255 and my blood pressure was when checked by the doctor was 160/90. He advised me to take some drugs which he gave me. In the meantime I consulted a family friend, a native doctor who advised me to bring these levels down by diet and exercise, check again after one month.

His recommendation was; - green grams or grams for breakfast, full cup of buffalo curd without the top layer only for lunch, and five string hoppers with vegetables for dinner to fill half the stomach, a piece of papaw only. Four or five cups of plain tea without sugar for a day and walk for about one hour in the morning. Now I am following this and do not take any medicine. I like to have your advice through the column of Health watch at your earliest for the benefit of others too please.

Reply:

As you are being treated by two doctors (your family doctor and a "native-doctor") at the same time, my advice for you is to take treatment from only one doctor as "too many cooks can spoil the soup".

I am not in a position to give any advice regarding the Ayurvedic treatment you are getting for your high blood cholesterol e.g. buffalo curd, papaw, green grams etc. and I don't know the rationale of such treatment.

If you are keen to take western medicine, please have confidence in your family doctor and take his advice. It is not in the interest of your health to take medicine from both doctors at the same time.

Cholesterol lowering drugs

As you are over the age of 70 years, cholesterol lowering drugs are contra-indicated. Your blood cholesterol level of 255mg per cent can be controlled with

(a) low saturated fat, low cholesterol diet;

(b) taking dietary items such as avocado and cashew nuts in moderation as these food items contain very high quantities of monounsaturated fat and moderate amounts of polyunsaturated fat which are known to reduce the level of L.D.L. (bad) cholesterol. Peanuts, soya and gingili too are good for people who have high blood cholesterol.

(c) Consumption of dietary items such as unpolished rice, carrot, beans and fruits such as apples too helps to reduce the level of LDL cholesterol as above foods have soluble fibre.

(d) Frying foods using polyunsaturated vegetable oils such as corn oil, sunflower oil, canola oil and soya oil should be avoided as above vegetable oils which already contain trans fatty acids even at the time you buy from the boutiques and supermarketes produce a large amount of trans fatty acids on frying. As you may be aware trans fatty acids are toxic artificial fats which are worse than cholesterol and are linked with a variety of diseases such as diabetes, cancer, heart disease, multiple scleroses and diverticulosis.

Trans fats also increase the amount of LDL (bad cholesterol) in your blood. So if you want to use a safe oil for frying, use unadulterated coconut oil

(a) which does not produce trans fats on heating

(b) which does not elevate the level of LDL level when consumed as coconut oil is a neutral oil. Coconut oil contains medium chain fatty acids which when consumed in moderation, are metabolized in the liver to produce energy.

A significant number of doctors and dieticians who are not aware of the fact that vegetable oils produce toxic trans fats still advise patients to buy these polyunsaturated oils.

Management for hypertension

There is no indication for drug therapy for your mildly elevated blood pressure (160/90) which can be controlled by

(a) low salt diet

(b) exercise

(c) giving up alcohol if you are already consuming alcohol.

(d) giving up smoking if you are a smoker.

(e) Bringing down your weight if you are obese. When you bring down your weight, your blood cholesterol and triglycerides too come down.

Send your questions on Heart disease and related issues direct to Dr. Atukorale, No. 14, Rajapakse Mawatha, Horton Place, Colombo 7.

Your questions on clinical Hypnotic treatment direct to Dr. H. B. Jayasinghe, Channelled Consultation Centre, 59, Peradeniya Road, Kandy.

Please send copies of your questions to Edward Arambawala, Coordinator Health Page, Daily News, Lake House, Colombo 10.

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Inaugural D. E. Gunatileke Memorial Oration

Dr. Nalin Rodrigo, Consultant Obstetrician and Gynaecologist and Patron of the Sri Lanka College of Obstetricians and Gynaecologists last week delivered the inaugural D. E. Gunatilake memorial oration at Holiday Inn, Colombo.

Dr. Rodrigo is a Fellow of the Asia & Oceania Federation of Obstetrics & Gynaecology - Singapore.

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