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SLMA News Editorial Committee-2015Editor-In-Chief: Prof. Sharmini Gunawardena

Committee:

Dr. Amaya EllawalaDr. Iyanthi AbeyewickremeProf. Deepika FernandoDr. Sarath Gamini De Silva

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September 2015, Volume 8, issue 09

SLMANEWSTHE OFFICIAL NEWSLETTER OF THE SRI LANKA MEDICAL ASSOCIATION

Page No.

CONTENTS

Cover Story

NewsPresident's Message 02

Malaria Count 02

Joint Regional Meeting 03, 04, 06

Childhood Obesity: Why We Should be Concerned 06, 07

The Multiple Sclerosis Association of Lanka (MSAL) 08, 09

An Ageing Man Pleads 10

Nirogi Paadha (Healthy Feet) 12

Seeking the Origins of Forensic Medicine and Charting its Future 14, 16, 18, 20, 22

Sanga our Cricketing Legend 22

Publishing and printing assistance by:

This Source (Pvt.) Ltd,Suncity Towers, Mezzanine Floor,18 St. Anthony's Mawatha, Colombo 03.Tele: +94 117 600 500 Ext 3521Email: [email protected]

Official Newsletter of The Sri Lanka Medical Association.Tele: +94 112 693324 E mail: [email protected]

Professor Jennifer Perera MBBS, MD (Col), MBA(Wales), PgDip MedEd (Dundee), PgDip Women’s Studies(Col).

President, Sri Lanka Medical Association, No 6, Wijerama Mawatha, Colombo 7, Sri Lanka.

Joint Regional Meeting 03, 04, 06

September 2015 SLMANEWSPRESIDENT’S MESSAGE

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We have completed another busy month of work at the SLMA. We have had the regular CPD activities con-ducted by the SLMA: the monthly clin-ical meeting, the regional meeting at Ratnapura, and the CPD programmes conducted by the various SLMA sub-committees in association with other collaborating partners.

We are currently finalising the cor-porate plan for the next five years considering measurable targets. Dur-ing these deliberations the current healthcare needs of the society are being taken into account. The disease paradigms in Sri Lanka have changed resulting in an increase of the health-care consumer expectations on qual-ity and standards.

Plans are underway by the Health Management Subcommittee of the SLMA to organize the annual career guidance seminar. This event which has gained marked popularity among junior doctors is scheduled to be held on 4th October 2015. All specialties, both clinical and non clinical, are rep-resented at this seminar and presen-tations are being made by senior spe-cialists of the respective professional bodies.

Work without play is dull and SLMA is organizing a series of cricket match-es, including soft ball games. The soft ball matches with different profession-al colleges will be held on Sunday the 25th of October 2015 at the University of Colombo grounds. I cordially in-vite all members to join these friendly games which will enable to build ca-maraderie and team spirit. The tradi-tional cricket match with the Bar Asso-ciation of Sri Lanka will be held on 21st November 2015 at the Colts Grounds. If you are willing to play, please come forward and be a SLMA team mem-ber. You can either contact the SLMA office or drop an e-mail to [email protected] for further information.

The SLMA Foundation Sessions will be held jointly with the Anuradhapura Clinical Society from 28th to 30th Octo-

ber 2015. A distinguished panel of ex-patriate speakers has been lined up, and they will travel from UK to enrich these sessions. I extend an open in-vitation to all of you to join us at the Sacred City of Anuradhapura.

The renovation work of the Wijera-ma House is continuing under the su-pervision of our administrative officer, Mr. Rajasingham. It is a costly affair but it has become essential in order to prevent further decay of the house, a generous donation to the SLMA by Dr. E. M. Wijerama, one of our very emi-

nent physicians. The EM Wijerama oration, conducted in honour of this great man, will be delivered by one of our Past Presidents, Dr. Sunil Epa Seneviratne during the Foundation Sessions, which is a tradition that has been followed over many years.

It is my sincere request to all mem-bers to join hands with us in these numerous activities organized by the SLMA, which will strengthen the bonds and team spirit among doctors from all parts of the island.

Professor Jennifer Perera

Dear members,

MALARIA COUNT2015

cases to date

25All are imported!

Let’s keep Sri Lankamalaria free

SLMANEWS September 2015

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By Dr. Shamini Prathapan (Assistant Secretary, SLMA)

The joint regional meeting of the SLMA in collaboration with the Sri Jayewardenepura General

Hospital Clinical Society was held on the 27th of June 2015 at the Sri Jayewardenepura General Hospital.

The President of the Sri Jayewar-denepura General Hospital Clinical Society, Dr. Asoka Jayasena, wel-comed the gathering and delivered the welcome speech. Prof. Jennifer Perera, President of the SLMA, also addressed the gathering and extend-ed an invitation to attend the 128th Anniversary International Medical Congress of the Sri Lanka Medical As-sociation.

The theme of the regional meeting was “New Trends in Medicine” and all speakers adhered to this theme, based on their specialty. It was well attended by medical officers attached to the Sri Jayewardenepura General Hospital and the University of Sri Jayewardenepura. A plaque was un-veiled by the President of the SLMA.

The first session was chaired by Dr. Chula Herath and Dr. Asiri Rodrigo. The panel of speakers comprised of Prof. Aloka Pathirana (Professor and Consultant Surgeon at the Faculty of

Medical Sciences, University of Sri Jayewardenepura), Prof. R. L. Sath-arasinghe (Consultant Physician, Sri Jayewardenepura General Hospital), Dr. Indira Kahawita (Consultant Der-matologist, Base Hospital, Karawanel-la) and Dr. Neelamani S. Rajapaksa Hewageegana (Deputy Director Gen-eral of Health Services (DDG) Plan-ning, Ministry of Health).

Prof. Aloka Pathirana initiated the session with a comprehensive pre-sentation on “Surgery in the 21st Cen-tury”. He commenced his lecture with the history of surgery, which began nearly 7000 years ago and the evolu-tion it has undergone with significant milestones such as the discovery of anaesthesia in 1846, endoscopy in

1809 and flexible fibrescope by Harold Hopkins in 1951 to the Single Incision Laparoscopic Surgery. He stressed that today, due to further evolution Robotic Surgery is playing a key role in the field of surgery, with many ad-vantages such as better magnifica-tion, easier and precise movements, with elimination of fulcrum effects and tremors. He also pointed out the disadvantages of this technique such as the high cost, the requirement of special operating suites and train-ing and especially the fact that there is no long term follow up available as yet. Prof. Pathirana also informed the audience of other modalities currently in use such as augmented reality or 3D simulation; minimize bleeding by use of Bipolar dissectors, Ultrasonic dissectors and High-pressure water jets; control bleeding by surgical cel-lulose, Fibrin glue and Argon plasma coagulation. He concluded his lecture by enlightening the audience about a new trend in surgery, the use of Nano Robots or Nanobots.

Contd. on page 4

JOINT REGIONAL MEETING OF THE SRI JAYEWARDENEPURA GENERAL HOSPITAL CLINICAL SOCIETY AND THE SLMA

September 2015 SLMANEWS

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Joint Regional Meeting...Contd. from page 3

Prof. R. L. Satharasinghe in his lecture on “New Trends in Gas-troenterology” pointed out that there is an increase in infections associated with contaminated endoscopes, such as metallo-be-ta-lactamase (NDM)-producing carbapenem-resistant Entero-bacteriaceae. He also showed evidence that the efficacy of pentoxifylline for severe alcohol-ic hepatitis remains unclear. The diagnostic criteria for hepatore-nal syndrome for the year 2015, was described. He stressed that patients with spontaneous bacterial peritonitis who develop septic shock have high mortal-ity rates, but early initiation of antimicrobial therapy may result in improved outcomes. Another point that he spoke on was that aminotransferase levels predict relapse in autoimmune hepatitis and that there was an increasing prevalence of nonalcoholic fatty liver disease worldwide.

Dr. Indira Kahawita, delivered a lecture on “Leprosy in Sri Lan-ka: Today and Tomorrow”. She emphasized the importance of this lecture as many health work-ers and the public are with the opinion that there are no cases of leprosy in Sri Lanka. Sri Lan-ka achieved the WHO target of elimination of leprosy as a pub-lic health problem in 1997. This meant the achievement of a na-tional point prevalence of less than 1 case per 10,000 popu-lation. With the declaration of elimination, many health work-ers and the general public were left with the idea that there were no more cases of leprosy in Sri Lanka. This resulted in doctors not including leprosy in their dif-ferential diagnosis. At present, there are approximately 2000 new cases reported every year, with about 10% of children below

15 years of age, about 7% with visible disability and only about 40% started on treatment within 6 months of onset of symptoms. She further stressed that Sri Lan-ka is among the top 17 countries reporting over 1000 new cases every year. The highest burden is reported from the Western Prov-ince, while the Eastern Province is the second. She highlighted both the common as well as un-common ways in which patients could present. The theme of the meeting was further reinforced by Dr. Kahawita who explained regarding many new strategies available for reducing the dis-ease burden.

The last lecture for the first session was by Dr. Neelamani S. Rajapaksa Hewageegana on “Communication for Understand-ing”. She began her lecture by saying that one size may not fit all and that although health is for all, there are many better paths to health, with people hav-ing different information needs, keeping in mind that even if they have similar behaviour it does not imply similarity in motivation. It was interesting to note that that up to 80% of patients forgot what their doctor said as soon as they leave the doctor’s room and nearly 50% of what patients do remember is recalled incorrectly.

The second session started off after tea and was chaired by Dr. Lalitha Piyarisi and Dr. Shyama-lee Samaranayake. The panel of speakers comprised of Dr. Duminda Samarasinghe (Pae-diatric Cardiologist, Lady Ridge-way Hospital), Prof. Hemantha Perera (Consultant VOG, Sri Jayewardenepura General Hos-pital) and Dr. Rajitha de Silva (Consultant Cardiothoracic Sur-geon, Sri Jayewardenepura General Hospital) Contd. on page 6


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Joint Regional Meeting...Contd. from page 4

Dr. Duminda Samarasinghe, started the 2nd session with a detailed presen-tation on “New Trends in Paediatric Cardiology: What is Cost Effective for Sri Lanka”. He singled out the chal-lenges of new trends in interventions and continued his lecture by explain-ing the need of such interventions such as 3D Rotational angiography, Hybrid interventions, etc. He ex-plained the developments of cardiol-ogy in Sri Lanka and continued his lecture by explaining the workload for cardiology in Sri Lanka and cost effec-tive methods in cardiology. The latter part of the lecture showed the need of Cardiac Catheterization with new trends in PDA closure.

After a brain storming session on Paediatric Cardiology, Prof. Heman-tha Perera showed another view on maternal mortality in Sri Lanka with his presentation titled “Maternal Mor-tality - Where Are We Going Wrong?” Prof. Perera highlighted on our mor-tality indicators specially emphasiz-ing that Sri Lanka has not reached a single digit on maternal mortality.

With many demographic, socio-economic, quality of antenatal care indicators that are higher than other

countries in the South East Asian re-gion, he was of the opinion that it is not correct to compare our country’s maternal mortality rate with these countries in the region. He continued his lecture by explaining the modes of management that could reduce mater-nal deaths. He concluded by showing the barriers to clinical governance and by explaining how clinical governance can be sustainable.

This was followed by Dr. de Silva’s presentation on “Keyhole Cardiac Surgery”. He emphasized that the trend is towards minimally invasive techniques and that other special-ties have embraced the method with great success and thus the need for keyhole surgeries in cardiac surgery. He explained the indications for Mini-mally Invasive Direct Coronary Artery Bypass (MIDCAB) and explained the procedure. He highlighted the benefits

of MIDCAB which are less pain, less infection, less bleeding, faster recov-ery, faster wound healing, faster return to normal activity and better cosmetic results. He underlined that keyhole surgeries are not only performed for coronary bypass but are also used for aortic valve surgeries, ASD closures, arrhythmia surgeries and even for heart failure. He concluded the ses-sion by emphasizing that hybrid car-diac procedures are the way forward.

The vote of thanks was given by Dr. Shyama Subasinghe, Secretary of the Clinical Society of the Sri Jayewarde-nepura General Hospital, which was followed by a fellowship lunch.

This meeting was sponsored by Kal-be International, A. Baur & Company Pvt. Ltd., Lifeline Pharmaceuticals Pvt. Ltd., CIC Holdings PLC, Ashman Associates, Harcourts Pvt. Ltd. and SMM Halcyon Pvt. Ltd."

Pujitha Wickramasinghe Professor in Paediatrics Department of Paediatrics, University of Colombo

Childhood obesity is well known to be the leading risk factor for the de-velopment of Non Communicable Diseases (NCD) later in life. Although most of the NCD’s develop during adulthood, evidence is quite clear that most of the pathological processes begin during childhood. Obesity which is accumulation of fat in the body with adverse health outcomes is diagnosed

using Body Mass Index. A percentage fat mass of >25% in males and >32% in females is considered as a prudent cutoff. In Sri Lankan children percent-age fat mass associated with the de-velopment of metabolic syndrome is determined to be 28.6% for boys and 32.6% for girls (Wickramasinghe et al, Under-review). BMI for Age >+2SD of the WHO 2007 charts (available in the CHDR) is used as the cutoff to diag-nose obesity in children.

Childhood obesity could affect a child physically as well as psychologi-

cally. Physically it could affect any or-gan or part of body from head to toe, and psychologically it could lead to bullying, alienation, lack of friends and depression. Some of the most impor-tant metabolic complications that have long term consequences are metabol-ic syndrome (MetS) and non alcoholic fatty liver disease (NAFLD). The prev-alence of metabolic syndrome among obese Sri Lankan children is about 20%, but a large population of obese children has at least one or two abnor-mal metabolic components.

CHILDHOOD OBESITY: why we should be concerned

Contd. on page 7


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Childhood obesity...Contd. from page 6

If obesity is not corrected more and more adverse metabolic components gather with more and more children developing metabolic syndrome, thus increasing the risk of cardio vascular disease later in life. Similarly NAFLD incidence is rising with more than 20% of obese children developing non alco-holic steato-hepatitis (NASH). NASH is predicted to be the commonest liver disorder in children which could prog-ress to cirrhosis and hepatocellular carcinoma in early adulthood. Physi-cally disfiguring acanthosis nigricans occurs as a thick dark belt of skin around the neck, axilla and cubital fossa (also in groin) and is related to the degree of insulin resistance. With reduction of weight (reduction of adi-posity), degree of insulin resistance will reduce. This leads to reduction of acanthosis as well as most of the metabolic derangements.

Excessive eating, decreased physi-cal activity and increased sedentary behaviour are the direct contributors to the development of childhood obe-sity. High calorie diets of large portion sizes with low vegetable and fruit con-tent leads to development of obesity. Today children have more opportuni-ties to spend time sedentarily. Most children have very high screen times, ie spend time viewing television, are engaged in computer games or in op-erating smart phones and tablets.

This has contributed immensely to the high physical inactivity. This is further aggravated by their ‘laziness’ which is mostly due to the physi-ological hindrance to physical activ-ity caused by undue increase in core body temperature. Due to the thick fat layer, children cannot dissipate the heat generated inside their body by exercise, thus compelling them to stop continuing physical activity. Physical inactivity is also increased due to lack of space and excessive protection giv-en by parents to their children.

Management of childhood obesity involves taking food comprising all food groups in appropriate propor-tions (starch, vegetables, fruits, dairy products and animal food) with lim-ited consumption of sugar, fat and salt. The amount that should be taken could be guided by food based dietary guidelines published by the Ministry of Health. Water intake has to be in-creased while reducing sweetened beverages as much as possible. High concentrate fruit juices are shown to increase insulin resistance due to high fructose content. Therefore whole fruit squash should be taken (with fi-ber) with no added sugar. Reducing the portion size of meals is the most important. Children should be given every opportunity to engage in physi-cal activity and screen time has to be restricted to not more than one hour each day.

Prevention of NCD’s has to begin from early infancy if not from precon-ception. More than 75% of obese chil-dren become obese adults while less than 10% of normal children end up as obese adults. Therefore the preven-tion of adult obesity, which is a major risk factor for the development of NCD, has to begin early in life. David Bark-er hypothesized that low birth weight children exposed to an adverse envi-ronment later in life, develop NCDs. This adverse environment could be the nutrition transition that occurred with the socioeconomic transition as there has been a rise in incidence of coronary heart disease and diabetes mellitus over the recent past especial-ly in middle income countries. Further research has shown that full term low birth weight babies having acceler-ated growth in early life, leads to the development of NCD later in life.

Therefore it is quite clear that if NCDs’ are to be prevented, it has to begin from a much younger age if not during the antenatal period, by achiev-ing a good birth weight and thereafter

maintaining an appropriate growth rate.

Much analysis has shown that chil-dren who have a rapid growth during early life are more prone to obesity later in life with an increased risk of developing NCDs. This can be seen quite clearly when low birth weight babies gain weight; they mainly do so by accumulation of fat rather than having growth in all compartments of body composition. Increased fat mass leads to the development of obesity. Obese children have more fat cells than their lean counterparts.

During weight losing programmes, fat deposited within adipose tissues decrease, but there is no decrease in the number of fat cells. Therefore when someone is not strict about his/her diet, they could easily become obese again, thus the majority of obese children become obese adults. Therefore many days of fasting could be lost by few days of feasting. This is the reason why many late interven-tions to reduce weight are not suc-cessful and not sustainable. Therefore prevention of NCDs has to take a life course approach and interventions at every stage of life are equally impor-tant.

Childhood obesity is on the rise and related metabolic complica-tions begin from a young age. The most important trigger to develop NCDs appears to be the rapid post natal growth in an individual destined to develop NCD later in life. There-fore in order to prevent NCD, the ideal would be for a healthy mother to give birth to a baby with a desirable birth weight (between 2.5-3.5kg) who is provided with proper nutrition, and allowed to grow along the birth cen-tile, maintaining the same trajectory of growth determined by the birth weight, which is guided by close growth monitoring, irrespective of the state of birth weight (low or normal).


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Dr Enoka Corea President MSAL

The Multiple Sclerosis Asso-ciation of Lanka (MSAL) is an association bringing together

persons with MS, their doctors, care-givers and other well wishers with a view to promoting optimum health and improving the lives of persons with MS.

MSAL was started in 2006 by Dr. Hithaishi Weerakoon and is affiliated to the Multiple Sclerosis International Federation. It is a voluntary organi-zation funded by donations and fund raising activities of the association.

The main aim of the association is to provide support to persons living with MS. Activities of the Association include providing moral support to pa-tients and caregivers through home visits, organizing talks by experts to help patients understand and cope with their disease and by providing fi-nancial assistance, where necessary, for wheelchairs, physiotherapy, pur-chase of drugs and disposables, for travel to MS meetings and for daily living especially in cases where the bread winner has been affected. The association serves as a support group for patients and their families where they can share their day to day prob-lems and solutions. Through the asso-ciation, people round the country are made aware of Multiple Sclerosis and that something can be done about pre-venting permanent disability. The as-sociation hopes to raise funds to build awareness, pay for home based phys-iotherapy, train nurses, attendants and family members, provide rehabilitation accessories, counseling, and support and eventually run a residential home.

MS meetings are held in Colombo and Kandy. These meetings pro-vide an opportunity for MS patients to share their experiences and cop-ing mechanisms with other patients and are open to anyone interested in MS. We have had many speak-ers addressing our meetings includ-

ing international specialists in MS, neurologists, urologists, speech therapists, physiotherapists, social workers, occupational therapists, counsellors and nurses, including nurses specializing in rehabilitation.

We have published articles on MS and interviews with MS patients in the newspapers, in both English and Sinhala, in our effort towards creat-ing greater public awareness and are hoping to have some publicity in the Tamil language newspapers as well.

The latest venture of the association is a programme to conduct a needs assessment of each patient in their own home environment so as to gen-erate recommendations for patient care, physiotherapy, assistive devices and alterations of home infrastructure needed to improve the quality of life of MS patients and their caregivers. The needs assessment is carried out by a trained occupational therapist and his recommendations have been acted

on, using the funds of the MSAL and with the help of other organisations such as the Inner Wheel Club of Co-lombo Midtown.

Since its registration on 19 Sep-tember 2006, the Multiple Sclerosis Association of Lanka has built a mem-bership of over a 100 patients from all over the island, their care givers, fami-ly members, doctors and well wishers.

The MSAL would like to invite all persons with MS to join the MSAL and contribute to its activities. We will be grateful if doctors who care for MS patients would inform patients of this association and its activities and re-fer them to the association or send us the names and addresses of patients. MSAL can be contacted at [email protected] or MS Association, 144 Vipu-lasena Mawatha, Colombo 10, or at the following number 0777319333. More information can be found on our website www.mssrilanka.com.

THE MULTIPLE SCLEROSIS ASSOCIATION OF LANKA (MSAL)

Analysis of some MS Patients in Sri Lanka

This analysis is based on data avail-able on 56 MS patients out of about 104 MS patients listed with the Multiple Sclerosis Association of Lanka (MSAL).

The MS patients whose detailed in-formation is available with MSAL are distributed in 13 districts, with the ma-jority 52 percent from Colombo and 16 percent from Kandy, where the or-ganization is maintaining branches. Expanding the services to patients in other districts with adequate publicity is needed.

Available data show that the majority of patients are in the middle aged groups when diagnosed. It is seen that the av-erage age when MS patients get diag-nosed is 34 years, with a minimum of 6 years to a maximum of 66 years.

Contd. on page 9


The MSAL is a voluntary organiza-tion funded by donations and fund raising activities. Fund raising ac-tivities are held regularly and include benefit shows, movies, jumble sales, sale of Christmas cards and key tags

etc. The association welcomes dona-tions which will be used to further its’ objectives. Donations could be made to The Multiple Sclerosis Association of Lanka, Commercial Bank A/c Num-ber 1100037477.

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The proportion of female MS patients is as much as twice that of male pa-tients. Only one fourth of the patients are reported to be working. Considering gender disaggregation, it is seen that among female patients only 16 percent are working while 44 percent of male patients work. Only one fifth (20%) are the main bread winners of the respec-tive families. Again the gender disag-gregation indicates that among female patients only 5 percent are in this cat-egory while 50 percent of male patients are the bread winners.

When social status of the patients considered it is seen that 64 percent of them are married, 25 percent single, 5 percent divorced and 4 percent wid-owed.

Nearly two third of the patients (62%) are not wheel chair bound but some of them use a walker or walking stick when going out. Bedridden MS patients are about 4 percent. Wheel chair bound pa-tients are about 30 percent.

(Data analysis, tables and charts by Mr Karunasena Jayasinghe)

The Multiple Sclerosis...Contd. from page 8

“Getting the MoSt out of life”


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The smallest print I easily read Aid of lenses there is no need

Roam in the dark I'll give the lead Never grow old, that is my breed

I look too young my patients told Refused drugs, feet getting cold To dye the hair white I was bold

Now hair is grey, but I am not old

The ageing men with raven hair Keep on dyeing with utmost care Forget the ritual don't you dare Overnight greying, a nightmare

Till early morning I sleep well Ready to rise to an alarm bell Waterworks fine, jets like hell Hearing is good, so is smell

Legs are strong, back doesn't ache I can sprint, or even do the shake

Don't feel tired for the stress I take. Aren't I young, for heavens' sake?

Benefits of ageing now I mention Time has come, deadline for action Still feeling fit to continue function Retire early, for a higher pension!

Yet I am always ready for old age To leave in grace the center stage In good trim my every appendage Keep with care my youthful image.

Dr. Sarath Gamini de Silva

AN AGEING MAN PLEADS

Written years ago when a higher pension was offered to those retiring early and when the writer was much younger!


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NIROGI PAADHA (HEALTHY FEET)

Problems of the diabetic foot require special focus on sec-ondary prevention through the

detection of high-risk feet. The unac-ceptable outcomes of this complica-tion include chronic wounds, pro-longed hospital stay, disability and limb loss. A point prevalence study at the National Hospital Colombo in 2006 revealed that 40% of hospital admissions of diabetics was due to foot complications that required in-ward care for an average of 42 days per patient. This aspect of diabetes care in Sri Lanka is sub-optimal.

Patient education on an islandwide basis was initiated by Nirogi Lanka through capacity building of health-care workers, especially nurse educa-tors in 2009. Phase 2 of Nirogi Lanka prioritized further training of medical officers in parallel with community em-powerment. The need for a coordinat-ed islandwide intervention of low-cost footwear was pioneered by the SLMA with the focus on health education re-garding daily care of the diabetic foot.

A national guideline for the man-agement of Diabetic Foot care was compiled in 2013. In order to pilot the implementation of this guideline, the Ministry of Health chose ten special-ist centres committed to a dedicated service for Diabetes supervised by Consultant Endocrinologists. DIA-BETIC FOOT CLINICS to provide holistic care in order to reduce ampu-tations among diabetics was initiated by the Ministry of Health along with the establishment of databases. This model is expected to expand to all District General Hospitals of the coun-try within the next few years. Teach-ing Hospitals that have established

these services include Anuradhapura, Jaffna, Kurunegala, Galle, Kandy, Colombo-South and the National Hos-pital Colombo. Technical support such as hand held Doppler machines were distributed to these centres with local-ly developed monofilaments and other related equipment for foot care along with IEC Materials developed by the NIROGI Lanka Project.

The manufacture of low cost dia-betic footwear was spearheaded by Dr. Palitha Karunapema (Consultant Community Physician and Direc-tor Ragama Rehabilitation Hospital). Training of Prosthetic & Orthotic tech-nicians was initiated through the Sri Lanka School of Prosthetics and Or-thotics (SLSPO), Ragama. 'Training of trainers' programmes in India were arranged for experienced technicians from SLSPO and the D. Samson & Sons (Pvt) Ltd (DSI Group of Compa-nies). Transfer of knowledge and skills to other technicians was arranged by the Ragama Rehabilitation Hospital in collaboration with the Sri Lanka As-sociation of Prosthetics and Orthot-ics (SLAPO). A Memorandum of Un-derstanding was signed between the SLMA and DSI in 2013, followed by the production of low-cost Diabetic shoes by DSI. This novel shoe line com-menced in 2014 and was re-launched under the brand name ‘NIROGI’ on 14th August 2015. Prof. Jennifer Per-era (President SLMA), Mr. Nandadasa Rajapaksa (Chairman DSI) and Prof. Chandrika Wijeyaratne (Chairperson NIROGI Lanka Project), were present for this momentous occasion.

Trilingual health education mate-rial on "How to Care for your Feet" is provided for every customer free of

charge at the point of sale. It is note-worthy that the number of Diabetic shoes purchased in the first seven months reached nearly 4500 in over fifty showrooms islandwide. We are happy and proud that the SLMA has initiated this new trend in health edu-cation through the shoe industry. The NIROGI Lanka Team is engaged in providing on-site foot screening and education facilities for the general public, including Diabetes Day activi-ties at Kolonnawa in conjunction with the NIROGI Diviya. The collabora-tion between Paadha and Diviya has helped to incorporate Health Promo-tion for diabetic foot care. Over 1600 community based patients were screened in NIROGI Diviya of whom a large proportion of high risk patients were detected and referred to special-ist centres.

State of the art equipment for early diagnosis of vascular complications of chronic diabetes was recently pur-chased for the National Hospital. The use of sophisticated equipment alongside continuation of the national project will further enhance service, training and research in the field of Diabetic Foot Care.


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Dr. Sameera Anuruddha Gunawardena Senior Lecturer and Specialist in Forensic Medicine University of Colombo

Prologue

The door opens to reveal a dimly lit room. The faint light falls on the silhou-ette of a bed lying askew in the middle of the room. The bed sheet is drawn back and falls over the edge onto the floor. The pillows are scattered on the ground. Two gentlemen in white over-alls with gloved hands, stand at the edge of the door surveying the room. One considerably older than the other. They duck under the black and yellow vinyl strip reading “crime scene - do not cross” and enter the room.

“Caucasian female approximately 25 years old, lived alone, didn’t report to work this morning. Sister checked on her at around 1500 this afternoon and found this….” reads the younger gent, summarizing the case history from the file in his hand. “Her neigh-bour saw her last night coming home with some guy. Says she looked drunk or high. Saw them go into the room and didn’t hear anything after that”

His senior partner squats beside the body and carefully examines the arbo-rescent pattern of green lines extend-ing across her arms and chest.

“He’s lying! She’s been dead for 24 hours at least. Look at the veins, they’re already green.”

He then looks at the large gaping wound running along the side of her neck and studies the angle and dispo-sition.

“There are definitely two slashes even though it looks like one. From the blood spatter I’d say the carotid is cut. That’s an arterial spurt. She’s broken two finger nails on her right hand. Must have put up a fight. Tell the cops to check if the neighbour has any scratch marks on his body”

“I’ll get the vaginal swabs done and start on the autopsy today itself” says the young forensic protégé eager to please his mentor.

~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ To most of you, this scenario would be a familiar depiction of the mystify-ing abilities of the forensic expert por-trayed through numerous TV shows, films and crime fiction novels. In re-ality however, forensic practice is not as dynamic as depicted in these shows and does not always give rise to the breath-taking deductive skills portrayed by these characters. Many are surprised at how mundane actual forensic practice is. In fact more than three quarters of the cases are actu-ally sudden deaths where in almost all of them, the cause follows a natural event. Violence and crime are only a handful of the workload of a forensic practitioner.

Forensic medicine distances itself from other medical specialties due to numerous reasons. Unlike the clini-cian or surgeon, the forensic practitio-ner cannot always have the patient’s best interest at heart. His primary goal is not the treatment or relief from suf-fering but ensuring that justice pre-vails. Whilst most other specialties race against time to preserve life, the forensic practitioner usually takes over after all hope for life is lost.

This article is not an attempt to en-tice or encourage any reader to take up forensic practice nor is it intended to glorify forensic medicine. It is mere-ly a reflection on the development of forensic medicine with time and an exploration on how forensic medi-cine could evolve to serve a higher purpose within the medical sphere.

Seeking the Origins

Quoting Sir Sydney Alfred Smith, re-garded by many as a legend in foren-sic medicine and famed in Sri Lanka

for his involvement in the enthralling Sathasivam murder case;

“It is justifiable, no doubt, to contend that Medicine originated in the very dawn of human history, when first a cry of pain prompted a fellow-being to experiment with simple forms of as-suagement. Similarly, the Law may be said to have its origins in the earliest sanctions which were doubtless ap-plied to disturbers of the peace in the most primitive communities. We can-not begin to think of forensic medicine as an entity, however, until a stage of civilization is reached in which we have, on the one hand, a recognizable legal system, and on the other an in-tegrated body of medical knowledge and opinion. Furthermore, we can-not know much about such matters until some means of recording them has been achieved, and our earliest records take us back only about five thousand years1.”

In tribal civilizations, the roles of healer and prosecutor were entrusted to a single individual whose judgment would be unquestionably accepted by the community. One can only imagine the dangers of a single person wield-ing such power. With the development of more intricate and cultured com-munities, these roles are likely to have separated out into the medical and legal fractions each forming their own codes of conduct2. Historians believe that the Hammurabi Code dating back to 2200BC is the earliest example of a fundamental legal system within an-cient civilizations3. The code said to have been enacted by the sixth Baby-lonian king Hammurabi also includes a legislation that relates to the topic of medical malpractice. Interestingly even in such early periods in history, liability for improper and negligent medical care was established and penalties ranged from financial com-pensation to cutting off a surgeon’s hand!4.

SEEKING THE ORIGINS OF FORENSIC MEDICINE AND CHARTING ITS FUTURE

Contd. on page 16


Seeking the origins...Contd. from page 14

16

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An Aster DM Healthcare Venture

Egypt, being the earliest civilization known to have an elaborate record of their life and culture provides the earliest evidence of a medicolegal expert; a physician who was officially designated to examine those whose deaths were unforeseen and those where poison was suspected. During the initial periods these examinations would only have been done superfi-cially as dissection of a human body was considered a sacrilegious act5. It is believed that King Ptolemy I who ruled Egypt during 323-283BC, broke this traditional concept and permit-ted dissections in humans. He even established universities in Alexandria to encourage the study of the human body through dissection6. By then Al-exandria was already famous as a hub of learning. Scholars from other regions of the world where dissections were not permitted would come to Alexandria to learn this revolutionary concept7. They later returned to their respective countries with the intention of spreading their new found knowl-edge.

The decline of Egypt coincided with the expansion of the Roman Empire and the name Julius Caesar stood out as arguably the most famous of the Roman Emperors. Through the assassination of Julius Caesar arose one of the earliest recorded medicole-gal autopsies. A surgeon by the name of Antistius examined Caesar’s body and claimed that out of the twenty three stabs, only one; the stab on his left chest between the 2nd and 3rd rib bones, was fatal8,9,10. It is reported that he further concluded this wound to have been caused specifically by the stab inflicted by Senator Gaius Cas-ca, an opinion which would hold very poor ground in modern courtrooms. Given that human dissection was still outlawed, it is unlikely that Antistius actually performed a full autopsy on Caesar’s body. It is more likely to have been an external examination and su-perficial exploration of the stabs using

perhaps a probe. Nevertheless, this ‘autopsy’ is the first recorded instance where a medical expert provided his opinion in a homicide investigation. Some believe that the word ‘forensic’ arose from this incident which in Latin means “before the forum”11.

History shows a strong rivalry be-tween science and religion. Knowl-edge gained through human dissec-tion threatened many of the existing theological concepts and therefore religious establishments retaliated by depriving the academia of the op-portunity to further explore the human body. Diseases and suffering were promoted as resulting from super-natural involvement or atonement for sins. Prayer was advocated over other forms of therapy. Religious extremists portrayed all other forms of healing as heathenism. Dissections on the hu-man body were soon banned and only animal cadavers could be studied. Similarly the clergy also took over the role of investigating suspicious and unnatural deaths12. As was evident in the massive witch hunt that took place during the European plague13, sud-den deaths and even accidents were sometimes believed to be the result of witchcraft and curses for which ‘of-fenders’ were then punished14. It was almost a civilized reenactment of tribal justice. Records exist of a strange and peculiar form of test termed “cru-entation” in murder trials. The dead victim’s body was laid on the ground and the accused person was made to approach the body calling the vic-tim’s name and later stroke the mortal wounds with his hands. If the wounds began to bleed, or if foam appeared at the deceased’s mouth this was re-garded as a sign of divine intervention which confirmed the accused to be the murderer!15

Despite the dominance of religious establishments, many scholars still continued their quest to decipher the human body. One of the most famous physicians to arise during this era was

the Greek physician, Claudius Galen, whose extensive studies on primates popularized medical literature. He served as a physician in the Roman Empire from 162 AD. His work rein-forced ancient Aristotle and Hippocrat-ic teachings that disease was an im-balance of four elements or ‘humours’; blood, phlegm, yellow bile and black bile16. His work persisted through the ages and became the stepping stone to advancement of medicine. Inter-estingly, both Christianity and Islamic religions did not antagonize his work since his teachings maintained the concept of a ‘creator’17.

It wasn’t until the Renaissance peri-od around the 14th century, that schol-ars were finally at liberty to study the human body without having to face the wrath of religious establishments18. Andreas Vesalius was perhaps the most fervent of these scholars and performed numerous dissections un-der the patronage of the Roman Em-peror Charles V. Often regarded as the father of modern Anatomy, he as-cended to the rank of Professor of the University of Padua. His book on “De humani corporis fabrica (On the Fab-ric of the Human Body)” is perhaps still regarded as the first comprehen-sive guide to Human Anatomy19. Many scholars continued to study the human body and immortalized themselves in the medical domain. Gabrielle Fallop-pio, William Harvey, Francis Glisson are some of those famous names that resonate in anatomical texts. Their findings extended beyond the field of medicine and also enchanted many of the renaissance artists including the great Leonardo da Vinci and in later years Michaelangelo who used these dissections to study the human form more elaborately20. In return these art-ists provided wonderful illustrations for many of the anatomical textbooks of this era. This fusion of scientific ex-ploration and art symbolizes the pro-found fecundity of the mind during the Renaissance period21.

Contd. on page 18

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18

Almost two centuries later Giovanni Batista Morgagni followed in the same esteemed rank in the same institution as Vesalius. He too showed a keen in-terest in the dissection of the human body but unlike his predecessor, he focused on exploring the abnormal changes in the body. Until then, very few literary works were available that spoke of the alterations in internal or-gans and tissues following disease22. It is Morgagni’s work that firmly estab-lished the domain of morbid anatomy which indeed is the main cornerstone of what we call Pathology today. The interest grew exponentially. Physi-cians began to realize that by studying the bodies of those that died of dis-ease, one could better comprehend the nature and cause of the disease itself. The signs and symptoms were now explainable. The course of the illness could now be predicted. Treat-ment options became clearer. To para-phrase Sir William Harvey;

“… accumulating knowledge of nor-mal and morbid anatomy through dis-secting the human body not only led to a better understanding of nature, but also defined the identity of the people who engaged in this activity.”23

Ancient chronicles provide a glimpse of well planned legal processes within the pre-colonial Sinhalese kingdoms. There has been in existence a well structured system that dealt with ad-ministering justice. With the king be-ing the ‘supreme’ administrator of jus-tice, powers were delegated to Royal courts, comprising of Royal officials namely Adigars, Disaves, Korales etc and then to smaller organisations such as Gamsabhava, Ratasabhava which undertook legal issues at lower levels. Among these organizations was a tribunal by the name of “Sakki Balanda”, formed by a group of promi-nent individuals within a given area, who were required to investigate into sudden and possibly violent deaths24. It is very likely that many among these prominent individuals were native physicians or Ayurvedic physicians

whose medical expertise would no doubt have played a key role in their judgments. However no religious or archaeological records in Sri Lanka have indicated any form of human dis-section during these early times.

Charting the future

The ease at which we study medi-cine today does not reflect the sacrific-es made by these great patrons who laid the foundations of this wonderful science. It is sad that human dissec-tion no longer reflects the sanctity and fascination experienced by these scholars of yore. Although it is an ideal opportunity to learn, study and reflect on rare and complex diseases and even their management, practicing clinicians rarely get involved in patho-logical or judicial autopsies and there is a declining attitude towards autop-sies among health professionals25,26,27

Perhaps one of the main reasons for this lack of enthusiasm is the limited resources that are allocated to foren-sic work. Accepted recommendations are that mortuary facilities should maintain a Biosafety Level 3 envi-ronment and should be prepared to deal with even biohazard level 4 situ-ations28,29,30. Sri Lanka is yet to have such a mortuary facility. The bulk of the autopsy cases within the country are done in hospital based mortuar-ies. Very few of them have facilities for microscopic study. Obtaining special stains or imunohistochemical studies are virtually impossible. The facilities for quantitative assessment of bio-chemical parameters, drug levels and metabolic abnormalities are extremely limited. Proposals and requests to up-grade these facilities often fall on deaf ears. To a health policy maker there is no observable direct link between au-topsies and health promotion. Rather the primary beneficiaries of forensic services are the courts and other le-gal embodiments such as departmen-tal inquiries and medical boards. The National Maternal Mortality Review is

perhaps the only health related forum to which the forensic practitioners di-rectly provide their expertise. There-fore the state based health authori-ties see no purpose in improving the facilities for forensic medicine. This is a vicious circle that has been plaguing forensic practice in this country for a long period now. Without proper facili-ties for a thorough and comprehensive investigation, forensic practitioners cannot provide unequivocal answers to issues raised. Clinicians and to an extent the public thus tend to lose faith in the necessity and value of the au-topsy process.

Following the Gandhian ideology where in order to elicit change in oth-ers one must first change oneself, it is perhaps time for us forensic experts to rethink our role. At present the death investigation system of our country whether it is a sudden natural death or death following violence, focuses heavily on identifying or excluding cul-pability or any litigious components related to the death. It does not seek to provide a holistic picture of the de-ceased individual. Sometimes patho-logical conditions are identified that could significantly affect the living relatives; transmissible diseases such as tuberculosis, HIV, meningococcal meningitis or, hereditary conditions such as thrombophilias, heart diseas-es, malignancies. Even in such cases our death investigation system is not geared to enforcing a preventive care package for the next of kin. Similarly, when deaths from medical negligence arise, the prime focus is litigation and compensation rather than identifying and correcting the flaws in the health delivery system.

Similarly there is complete dissocia-tion between the legal death investi-gation process and the health statistic monitoring process. Sudden deaths or violent deaths that occur outside the involvement of hospitals are directly investigated through the inquirer into sudden deaths or the magistrate.


Contd. on page 20


1420


These deaths may then be directly brought to the forensic practitioner for autopsy. Even though these autopsies take place within the hospital settings there is no formal process of collect-ing these data for mortality statistics. Even in ward deaths that require in-quests, the hospital authorities have no formal procedure to receive feed-back from the investigating authorities. Forensic practitioners themselves do not provide detailed reports back to the hospital staff and as previously mentioned only the Maternal Death Review demands the forensic practi-tioner’s input as an essential require-ment. In all other cases feedback from the forensic practitioner is mostly lim-ited to scribbling the cause of death on the first page of the Bed Head Ticket.

Today medicine is gifted with tech-nological support that transcends our perceptions into sub-atomic levels. Imagine the mysteries that would have been unraveled if scholars like Galen or Morgagni were provided with such technology. Medicine could be taken to a whole new dimension. Forensic practice in Sri Lanka provides the golden opportunity for in-depth analy-sis into the human body with very few restrictions, yet this facility is grossly underutilized. Perhaps it is because the role of the forensic practitioner has been narrowed towards that of a medi-cal investigator and not towards health advocate or researcher. There have been accusations that medical prog-ress in areas such as cadaveric or-gan transplantation, molecular genetic research has been impeded by the steadfast legal procedures within the death investigation process. Foren-sic practitioners have been accused of basing their opinions on outdated knowledge and personalized expe-rience rather than evidence based information. The veracity of these al-legations is arguable. Nevertheless, it is clear that we need to regain the confidence of the medical fraternity and market our role as a guiding force in medicine. More than half a century

ago, Professor G S W de Saram in his capacity as Professor of Forensic Medicine conducted a study on the temperature cooling of dead bodies and how that can be used to deter-mine time since death. This was a for-midable study which provided one of the earliest population studies which were later used to develop the globally accepted temperature method in as-sessing time since death. Since then, very little pioneering work has arisen from forensic practice in this country. Cadavers are a poorly-utilised re-source in research and experimental studies31,32. The fascination appears to have shifted from the human body towards complex artificial machines with intricate technologies. Hospitals invest millions in equipment like high definition radiographic scanners, se-quential multiple analysers and laser clot blusters which are programmed to detect pre-identified patterns and treat accordingly. But it should be borne in mind that despite their sophistication these machines are only capable of confirming or excluding facts that we already know how to look for whereas the human body has always been the treasure trove of new information.

The more deaths we investigate the more we perceive the frailty of the fabric of human life and ironically, the more answers we find, the more questions we get. It is time we real-ize that we have still only chartered the surface of this vast ocean of the human body and there are still myri-ads of crevasses, abysses, mysteries and secrets waiting to be explored by newer generations of forensic experts.

At the entrance of the Institute of Forensic Medicine and Toxicology for-merly referred to as the Office of the Chief Consultant Judicial Medical Of-ficer, hangs a board; it refers to a Latin quote from Morgagni translated into English;

“Let conversation cease; let laugh-ter flee…

This is the place where death de-lights to help the living”

Allow me to emphasize….where death delights to help the living!

1Smith, S. (1951). History and development of forensic medicine. British medical journal, 1(4707), 599.

2Smith, S. (1954). Development of Foren-sic Medicine and Law-Science Relations, The. J. Pub. L., 3, 304.

3Wecht, C. H. (2005). The history of legal medicine. Journal of the American Acad-emy of Psychiatry and the Law Online, 33(2), 245-251.

4Bal, B. S. (2009). An introduction to medical malpractice in the United States.Clinical orthopaedics and related re-search, 467(2), 339-347.

5Finkbeiner, W. E., Connolly, A., Ursell, P. C., & Davis, R. L. (2009). Autopsy pathol-ogy: a manual and atlas: expert consult-online and print. Elsevier Health Sci-ences.

6Choo, T. M., & Choi, Y. S. (2012). Histori-cal Development of Forensic Pathology in the United States. Korean Journal of Legal Medicine, 36(1), 15-21.

7Von Staden, Heinrich. "The discovery of the body: human dissection and its cul-tural contexts in ancient Greece." The Yale journal of biology and medicine65.3 (1992): 223.

8Fisher, R. S., & Platt, M. (1980). His-tory of Forensic Pathology and related laboratory sciences. Spitz WU, Fisher RS. Medicolegal Investigation of Death. 2nd Edition. Springfield: Charles C Thomas.

9Gradwohl, R. B. H., Camps, F. E., Robin-son, A. E., & Lucas, B. G. (1976). Grad-wohl's legal medicine. J. Wright.

10Hirt, M., & Kováč, P. History of Forensic Medicine.

11http://bambooinnovator.com/2014/03/16/autopsy-report-on-julius-caesars-death-gave-rise-to-the-term-forensic-in-latin-which-means-before-the-forum/

12Butler S. Forensic Medicine in Medieval England. Taylor and Francis 2015

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13Sidky, Homayun. Witchcraft, Ly-canthropy, Drugs and Disease: An Anthropological Study of the European Witch-Hunts. Vol. 70. Wipf and Stock Publishers, 2010.

14Wecht, Cyril H. "The history of legal medicine." Journal of the American Academy of Psychiatry and the Law Online 33.2 (2005): 245-251.

15Brittain, R. P. (1965). Cruenta-tion: In Legal Medicine and in Literature. Medical history, 9(01), 82-88.

16Singer, Charles. "Galen as a Modern." Proceedings of the Royal Society of Medicine 42.8 (1949): 563.

17Shoja, Mohammadali M., and R. Shane Tubbs. "The history of anatomy in Persia." Journal of anatomy 210.4 (2007): 359-378.

18Malomo, A. O., O. E. Idowu, and F. C. Osuagwu. "Lessons from his-tory: human anatomy, from the origin to the renaissance." Int. J. Morphol 24.1 (2006): 99-104.

19Silverman, M. E. (1991). An-dreas vesalius and de humani corporis fabrica.Clinical cardiol-ogy, 14(3), 276-279.

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22Adams E W. "Founders of Mod-ern Medicine: Giovanni Battista Morgagni.(1682-1771)." Medi-cal library and historical journal 1.4 (1903): 270.

23Payne, Linda. "" With much nau-sea, loathing, and foetor": Wil-

liam Harvey, dissection, and dispassion in early modern medi-cine." Vesalius: acta internatio-nales historiae medicinae 8.2 (2002): 45-52.

24Cooray, L. M. (1992). An intro-duction to the legal system of Sri Lanka. Lake House Investments.

25Botega, N. J., et al. "Attitudes of medical students to necropsy." Journal of clinical pathology 50.1 (1997): 64-66.

26Loughrey, M. B., McCluggage, W. G., & Toner, P. G. (2000). The declining autopsy rate and clini-cians' attitudes. The Ulster medi-cal journal, 69(2), 83.

27Charlton, R. (1994). Autopsy and medical education: a review. Journal of the Royal Society of Medicine, 87(4), 232-236.

28Nolte, K. B., Taylor, D. G., & Rich-mond, J. Y. (2002). Biosafety considerations for autopsy. The American journal of forensic medicine and pathology, 23(2), 107-122.

29Sharma, B. R., & Reader, M. D. (2005). Autopsy room: a poten-tial source of infection at work place in developing countries. American Journal of Infection Diseases, 1(1), 25-33.

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31King, A. I., Viano, D. C., & Mizeres, N. (1995). Humanitar-ian benefits of cadaver research on injury prevention. Journal of Trauma and Acute Care Surgery, 38(4), 564-569.

32Cornwall, J., & Stringer, M. D. (2009). The wider importance of cadavers: Educational and re-search diversity from a body be-quest program. Anatomical sci-ences education, 2(5), 234-237.

Sanga our cricketing maestro retired from the game

That brought Srilanka everlasting fame

In golden letters he etched his name

Will Srilankan cricket ever be the same?

Hailing from Kandy’s Trinity famed for its education

He matured fast as a cricketer to represent the nation

Honing his skills with each passing year

In batting or wicket keeping he had no peer

For the national team he was an automatic choice

The selectors agreed all in one voice

Leading by example he inspired the team

And therefore was held in highest esteem

In the international scene he made his mark

Earning well deserved praise as a bright spark

Scoring centuries with ease without any trouble

His prowess with the bat was truly remarkable

While being an active player, a lecture to deliver

A rare honour – ever bestowed before? – never!

In the Mecca of cricket after his lecture on “Spirit of Cricket”

His fame as an orator soared as a rocket

The ICC Chairman described him as a legend of the game

And ‘little master‘ Sunil Gavaskar of everlasting fame

Added to tributes and accolades earned by Sanga

Our cricketing ambassador of the game as ‘real Mega’

Having agreed to play county cricket before retirement

We presume it will be less stressful than international

However the county will be expecting Sanga’s usual commitment

And hope that it satisfies his needs as a professional

Wherever and whatever he does we wish him well

We expect unstinted contribution to county as well

Even after retirement may he live up to expectation

And confirm the fact that he is worth more than the reputation

Dr. Nanda Amarasekara

Colombo

Sanga our cricketing Legend

If undelivered return to :Sri Lanka Medical Association. No. 6, Wijerama Mawatha, Colombo 7

SLMANEWS

Registered at the Department of Post Under No: QD/42/NEWS/2015

THE OFFICIAL NEWSLETTER OF THE SRI LANKA MEDICAL ASSOCIATION

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artner News 2015...ciation of Sri Lanka will be held on 21 st November 2015 at the Colts Grounds. If you are willing to play, please come forward and be a SLMA team mem-ber. You can