My worthy young companion Dr Kumara Kaluarachchi alias Sarasa has recently written an interesting commentary on the management of organophosphate (OP) poisoning. His commentary also referred to his sweet past memories in Peradeniya as a young dental student in the late 1980s. I am glad to be convinced about Dr Kaluarachchi’s vivid memory of toxicology lectures he attended many years ago as a dental student. Although Dr Kaluarachchi and I belong to two different eras as well as generations separated by at least two decades, we both share an intense interest in the bliss of nostalgia. Consequently, there has hardly been any discussion that failed to guide us to take a trip down memory lane, and to tumble upon the nectarine reminiscences of our past times in the Eden of Peradeniya as well as in the citadel of medical education in Colombo. Both institutions, despite being scorned by some weblog-based pseudo-pandits in the recent past, have produced generations of intellectuals with pure eminence whose capacity has been extolled, and jewelled in accolades by the very best academic institutions in the Western world. It is not only a past sensation, but a legend that continues up to date. in his commentary on the management of organophosphate (OP) poisoning, Dr Kaluarachchi mentioned Professor Nimal Senanayake who happened to be one of his remarkable teachers. Let me add a few more lines to his formidable account on the topic.
Professor Nimal Senanayake, Professor Lakshman Karalliedde, Professor Andrew Dawson et al have contributed immensely to the study of organophosphate (OP) poisoning. The type II paralysis (described by Wadia RS, Sadagopan C, Amin RM et al in 1974) also known as Intermediate Syndrome (a term coined by Senanayake N and Karalliede L in 1987) manifests little later when there may be an apparent recovery from the acute poisoning. The term intermediate syndrome refers to the constellation of signs and symptoms that occur between the period of early cholinergic syndrome and the late onset peripheral neuropathy. It is characterised by the weakness of the neck muscles, ocular muscles, bulbar muscles (related to the lower end of the brainstem), proximal limb muscles, and very importantly respiratory muscles.
The recognition as well as the prevention of the onset of intermediate syndrome is vital. In that regard, two points are ever crucial in the management of organophosphate poisoning viz. the clinical appreciation of classical signs in the relevant muscle groups (such as testing for the neck muscle power) for the clinical diagnosis of the intermediate syndrome, and adequate atropinisation for the prevention (not for the treatment) of the intermediate syndrome.
However, the administration of atropine to the wrong patient would create a tragicomedy at the A&E/ETU/PCU. Those who have been to medical wards should know the bizarre neuropsychiatric manifestations of over-atropinised patients (They say fantastic things, and they do wonderful things)! A trial dose of atropine can be recommended in tentative cases that have a diagnostic difficulty if the poison has not been identified reliably.
Sri Lanka, although she could not launch rockets to the Moon, could produce many great academics and professionals of world renowned fame. Dr Kaluarachchi has recently brought to the discussion about the world renowned academic Professor Ranjit Mendis, and then he honoured Professor Nimal Senanayake of that ilk too. Let me mention a few more intellectuals of great academic and professional stature.
Dr J B Peiris
We discussed about acute organophosphate poisoning earlier. There is chronic organophosphate poisoning as well. There is also organophosphate poisoning through the skin. One doctor who has researched and written extensively on the topic is Dr J B Peiris, the pioneer neurologist in Sri Lanka, and indisputably ‘The Father of Neurology‘ in Sri Lanka. Dr Peiris has been an inspiration to several generations, and his students have excelled in many disciplines of Medicine. A gifted and superb clinical teacher, Dr J B Peiris could transform any complicated topic in Neurology into a simple description with his comprehensive understanding and mesmerising demonstrations. Such craft was depicted elegantly in his most readable good old book on Neurology, ‘Short and Sweet – Neurology‘ (the title may be little different to that). It was a worthy reading as much as Patten’s book for juniors.
His name has already been written at least thrice in the history of medicine as the original author of new treatment modalities viz. Clonazepam in the treatment of choreiform activity (Peiris J B, Boralessa H, Lionel N D in 1976), Sodium valproate in trigeminal neuralgia (Peiris J B, Perera G L, Devendra S V, Lionel N D in 1980), and The treatment of Guillain-Barré syndrome by modified plasma exchange: a cost effective method for developing countries (De Silva H J, Gamage R, Herath H K, Karunanayake M G, Peiris J B in 1987).
He has also been honoured for his involvement in describing several disease entities such as Transient Emboligenic Aortoarteritis: Noteworthy new entity in young stroke patients (Wickremasinghe H R, Peiris J B, Thenabadu P N, Sheriffdeen A H in 1978), A delayed onset cerebellar syndrome complicating falciparum malaria (de Silva H J, Gamage R, Herath H K, Abeysekera D T, Peiris J B in 1986), and Non familial juvenile distal spinal muscular atrophy of upper extremity (Peiris J B, Seneviratne K N, Wickremasinghe H R, Gunatilake S B, Gamage R in 1989).
Dr J B Peiris has been a man of tremendous courage and self-confidence. He performed almost impossible tasks with unbelievable ease, for which quality the Institute of Neurology in Colombo, and the highly sophisticated General Hospital of Sri Jayawardenepura would surely speak testimonies.
Professor Milroy Aserappa Paul
One differential diagnosis not to be missed by a physician managing unexplained long lasting fevers (more specifically: pyrexia of unknown origin) especially in the outstations of Sri Lanka, has been the ‘not-so-uncommon’ entity known as ‘Amoebic Abscess of the Liver‘. In the past, physicians believed it was a form of Hepatitis due to Amoeba, thus Rogers in 1922 termed it “Amoebic Hepatitis”.
Professor Milroy Aserappa Paul, who was the founder Professor of Surgery at the Colombo Medical College, and who was qualified both as a physician and a surgeon, had different thoughts about the condition. He suggested that the disease entity described as amoebic hepatitis should be an early stage of amoebic abscess of the liver that presents initially as multiple small liver abscesses. He formulated a theory that states those multiple small abscesses would coalesce to form a large liver abscess at the end. Professor Milroy Paul suggested his theory in an era when there were no sophisticated abdominal imaging techniques such as ultrasound scan, computed tomography etc. to be readily used. But today, with the aid of such advances in imaging, we are convinced Professor Milroy Paul had described the amoebic abscess of the liver so accurately. It was also the era before the wide use of (the drugs such as) metronidazole, tinidazole, diloxanide furoate etc. Therefore, he treated those cases with emetine, and the treatment was a success. Professor Milroy Paul’s description of amoebic abscess of the liver was well recognised internationally as his research paper ‘New Concepts on Amoebic Abscess of the Liver‘ based on over thirty years of experience was published in the British Journal of Surgery in 1960. His name was mentioned in one of the most respected textbooks of Surgery: ‘Bailey & Love’s Short Practice of Surgery‘ originally authored by Hamilton Bailey and McNeill Love, in its 1968 edition. That mentioning is perhaps not found in later editions of the book, but surely it was there in early editions which we used to read (a book with smaller dimensions). Professor Milroy Paul was aptly honoured with the invitation to deliver the prestigious Hunterian Lecture at the Royal College of Surgeons on three occasions (1950, 1953 and 1955). That was a great honour to a great surgeon from Ceylon.
Professor Milroy Paul’s father was Dr Samuel Chellar Paul who was once the First Surgeon to the Colombo General Hospital. The Pauls resided at the Ward Place in proximity to the Borella exit. Their house can still be seen on one’s right-hand-side as one passes the first crossroads on one’s way from Borella to Town Hall. (For my young friend Dr Kaluarachchi’s information: one of Professor Milroy Paul’s three sons became a dental surgeon!)
Professor Arjuna Aluwihare
As usual for many discussions initiated by my dear friend Dr Kaluarachchi, we should come back to Peradeniya before we conclude. Therefore, I selected one of the most respected and beloved teachers, mentors and veteran surgeons around whom many legends have been related. He is none other than the most iconic Professor Arjuna Aluwihare. Those who were fortunate enough to be either his students or his trainees would surely know how to examine the thyroid gland properly, and they would also know the importance of observing from front before going behind! However, the thyroid gland is not what matters here today. It is a congenital anomaly of the lower end of the gastrointestinal tract that makes the topic viz. Imperforate Anus.
The congenital malformation of the lowest end of the gastrointestinal tract resulting in no opening where the anus should be, has been termed imperforate anus. It refers not only to the absence of an anus, but also to the associated malformations of the related muscles and nerves. The last part of the large bowel may remain either close to the perineal skin (lower lesion) or higher up in the pelvis (higher lesion). The differentiation between the two varieties were made classically in the past by measuring the distance between the rectal gas and anal dimple on an abdominal roentgenogram (X-Ray) obtained positioning the newborn infant upside-down for some time (the technique introduced by Wangensteen and Rice in 1930). It is interesting to mention that a coin was placed on the place where the anus was expected to be, so that the place could be identified on the roentgenogram easily!
Professor Arjuna Aluwihare devised a new approach for the correction of imperforate anus, and had successfully practiced it on many patients diagnosed with the condition. Most of those operations were carried out at birth. The perineal approach introduced by Professor Arjuna Aluwihare was proven to be safe and effective. On his tremendously successful contribution to the advancement of operative surgery for the correction of imperforate anus, Professor Arjuna Aluwihare won the opportunity to deliver the prestigious Hunterian Lecture at the Royal College of Surgeons in 1986. Professor Arjuna Aluwihare’s impeccable research work entitled ‘Imperforate Anus in Male Children: A New Operation of Primary Perineal Rectourethroanoplasty‘ found its place in the annals of the Royal College of Surgeons of England in 1989. Professor Arjuna Aluwihare had co-authored the subsection entitled ‘Surgery of Advanced Disease and Late Presentation‘ (under the section 47 entitled ‘Some Special Aspects of Surgery in Developing Countries‘) in the Oxford Textbook of Surgery, in its 2000 edition.
There have been many more distinguished academics and professionals of Sri Lankan origin who have illuminated the world of medicine. Although they have hailed from a country that has not launched rockets to the Moon, nobody other than an unqualified simpleton has ever doubt their supremacy.