their hospital records. Any patient with a medical condition requiring ongoing care would, I am sure, find the means to pay for this booklet if such became available. SYLVIA L. BOSWORTH, OCR
ever, antibiotics alone will be effective in some cases, and we believe that synergistic combinations are indicated. We thank Dr. Gordon Cameron, the attending physician, for his cooperation.
809 Bloomfield Ave., Ste. 702 Outremont, PQ
JULIE RIGHTER, MD, FRCP[C] Microbiologist Department of pathology Toronto East General and Orthopaedic Hospital Toronto, Ont.
Use of synergistic antibiotics in the treatment of infections To the editor: It is well recognized that infections associated with foreign bodies are rarely cured unless the foreign body is removed. Unfortunately, there are many clinical circumstances in which removal is either contraindicated or impossible. The use of synergistic combinations of antibiotics is known to improve the outcome for patients with many infections that are difficult to treat, such as enterococcal endocarditis and Pseudomonas infections in the presence of neutropenia. Infection around a foreign body resembles endocarditis in that it is sequestered from host defences. We believe that in such cases the use of a synergistic combination of antibiotics administered parenterally in the maximum safe dose, may improve the chance of success, as in the following case. A 12-year-old boy with idiopathic intestinal pseudo-obstruction necessitating long-term total parenteral nutrition through a Silastic central venous line presented with fever, chills and cellulitis around the line's insertion site. Cultures of the pus expressed from the subcutaneous tract grew Staphylococcus aureus resistant to penicillin and sensitive to cloxacillin and gentamicin.
Four blood cultures were negative. In view of the anticipated long-term need for parenteral nutrition, it was believed that every effort had to be made to preserve the central venous line. Since the combination of a penicillin and an aminoglycoside is synergistic against many isolates of S. aureus,14 the boy was treated intravenously with cloxacillin, 200 mg/kg every 6 hours,
and gentamicin, 4 mg/kg every 8 hours, every day for 14 days. Administration
of the two drugs was spaced as widely as possible. On two occasions the peak serum concentrations of gentamicin
were 4.1 and 5.0 p.g/ mL. The cellulitis healed completely and the fever abated. Six weeks later the boy was perfectly well with the same central. venous line in place.
There is no doubt that the ideal treatment of such infections includes removal of the foreign body. How-
HAROLD RIcH.utDsoN, B sc, MB, B5, MD, FRcP[c]
Professor and director of medical microbiology Section of laboratory medicine McMaster University Medical Centre Hamilton, Ont.
References
1. WATANAKUNAKORN C, GLOTZBECKER C: Enhancement of the effects of anti-staphylococcal antibiotics by aminoglycosides. Antimicrob Agents Chem-
other 6: 802, 1974
2. STEIGBIGEL RT, GREENMAN RL, REMINGTON JS: Antibiotic combinations in the treatment of experimental Staphylococcus aureus infection. J Infect Dis 131: 245, 1975
3. SANDE MA, JOHNSON ML: Antimi-
crobial therapy of experimental endocarditis caused by Staphylococcu.s aureus. Ibid, p 367
4. WATANAKUNAKORN C, GLOTZBECKER
C: Enhancement of antistaphylococcal activity of nafcillin and oxacillin by sisomicin and netilmicin. A ntimicrob Agents Chemother 12: 346, 1977 5. NORDEN CW: Experimental osteomyelitis. V. Therapeutic trials with oxacillin and sisomicin alone and in combination. J Infect Dis 137: 155, 1978
Return to the art of medicine To the editor: The conversion of the art of medicine to the science of med-
icine, which was already in vogue when I started to practise medicine in 1938, has progressed unopposed and is still in force. While vestiges
of the art of medicine in elements of clinical diagnosis remain, the emphasis on laboratory aids in diagnosis and on the use of synthetic drugs in therapy reinforces this conversion. However, no fact reveals more that the pendulum has reached full height in its swing in this direction than the total rejection of the subjective relief of suffering as an index of a treatment's efficacy. Although a report of an innovative therapy for a serious chronic disease
afflicting 4% of the population may involve 13 000 cases, and despite the
fact that 93% of persons between I and 15 years of age and 67% of
1004 CMA JOURNAL/NOVEMBER 4, 1978/VOL. 119
persons over 15 years of age may have obtained moderate to excellent resolution of symptoms, such a report can be rejected. This rejection occurs because the scientists, who cannot determine relief of suffering by linear, volumetric or mass measurement, pronounce that this degree of relief in such a large number of chronically ill patients was either a figment of imagination or a deliberate lie, in this instance the scientists also make the same assessment of the physician who made such a report. Rejection of the relief of suffering, and therefore of death (which has been the profession's raison d'&re since its beginnings), as a measure of the success of therapy is absolute evidence that scientists, not physicians practising the art of medicine, have assumed control of all research in medicine. This control is now so great that a physician working at the grass roots of medicine without recourse to financial grants-in-aid, and with the severe limits on time imposed by practice, would be foolish to make even preliminary clinical assessments of an innovative therapy and report, even in discussions with associates, on the subjective relief of suffering experienced by his or her patients. In such circumstances the physician would be exposed to criticism and even ridicule by associates who are attuned to the acquiescence of the profession to science and who perceive that scientific control of the advance of medicine provides absolution for their own incapacity to be innovative. These controls on research provide an excuse for the average physician's concentration on volume practice and for the treatment of patients with only prescribed scientific methods, and they afford protection of such practice from persons who would better themselves by being innovative. In my opinion the penalties on health care imposed by the advance of science in medicine can only be balanced by a return to an appreciation of original precepts of the art of medicine. The principal precept is that physicians should listen to their patients and believe them when they say the distress of their disease has worsened, has not changed or has been relieved to some degree. Moreover, the average physician should be encouraged and not penalized for reporting such anecdotal clinical data,
ever, antibiotics alone will be effective in some cases, and we believe that synergistic combinations are indicated. We thank Dr. Gordon Cameron, the attending physician, for his cooperation.
809 Bloomfield Ave., Ste. 702 Outremont, PQ
JULIE RIGHTER, MD, FRCP[C] Microbiologist Department of pathology Toronto East General and Orthopaedic Hospital Toronto, Ont.
Use of synergistic antibiotics in the treatment of infections To the editor: It is well recognized that infections associated with foreign bodies are rarely cured unless the foreign body is removed. Unfortunately, there are many clinical circumstances in which removal is either contraindicated or impossible. The use of synergistic combinations of antibiotics is known to improve the outcome for patients with many infections that are difficult to treat, such as enterococcal endocarditis and Pseudomonas infections in the presence of neutropenia. Infection around a foreign body resembles endocarditis in that it is sequestered from host defences. We believe that in such cases the use of a synergistic combination of antibiotics administered parenterally in the maximum safe dose, may improve the chance of success, as in the following case. A 12-year-old boy with idiopathic intestinal pseudo-obstruction necessitating long-term total parenteral nutrition through a Silastic central venous line presented with fever, chills and cellulitis around the line's insertion site. Cultures of the pus expressed from the subcutaneous tract grew Staphylococcus aureus resistant to penicillin and sensitive to cloxacillin and gentamicin.
Four blood cultures were negative. In view of the anticipated long-term need for parenteral nutrition, it was believed that every effort had to be made to preserve the central venous line. Since the combination of a penicillin and an aminoglycoside is synergistic against many isolates of S. aureus,14 the boy was treated intravenously with cloxacillin, 200 mg/kg every 6 hours,
and gentamicin, 4 mg/kg every 8 hours, every day for 14 days. Administration
of the two drugs was spaced as widely as possible. On two occasions the peak serum concentrations of gentamicin
were 4.1 and 5.0 p.g/ mL. The cellulitis healed completely and the fever abated. Six weeks later the boy was perfectly well with the same central. venous line in place.
There is no doubt that the ideal treatment of such infections includes removal of the foreign body. How-
HAROLD RIcH.utDsoN, B sc, MB, B5, MD, FRcP[c]
Professor and director of medical microbiology Section of laboratory medicine McMaster University Medical Centre Hamilton, Ont.
References
1. WATANAKUNAKORN C, GLOTZBECKER C: Enhancement of the effects of anti-staphylococcal antibiotics by aminoglycosides. Antimicrob Agents Chem-
other 6: 802, 1974
2. STEIGBIGEL RT, GREENMAN RL, REMINGTON JS: Antibiotic combinations in the treatment of experimental Staphylococcus aureus infection. J Infect Dis 131: 245, 1975
3. SANDE MA, JOHNSON ML: Antimi-
crobial therapy of experimental endocarditis caused by Staphylococcu.s aureus. Ibid, p 367
4. WATANAKUNAKORN C, GLOTZBECKER
C: Enhancement of antistaphylococcal activity of nafcillin and oxacillin by sisomicin and netilmicin. A ntimicrob Agents Chemother 12: 346, 1977 5. NORDEN CW: Experimental osteomyelitis. V. Therapeutic trials with oxacillin and sisomicin alone and in combination. J Infect Dis 137: 155, 1978
Return to the art of medicine To the editor: The conversion of the art of medicine to the science of med-
icine, which was already in vogue when I started to practise medicine in 1938, has progressed unopposed and is still in force. While vestiges
of the art of medicine in elements of clinical diagnosis remain, the emphasis on laboratory aids in diagnosis and on the use of synthetic drugs in therapy reinforces this conversion. However, no fact reveals more that the pendulum has reached full height in its swing in this direction than the total rejection of the subjective relief of suffering as an index of a treatment's efficacy. Although a report of an innovative therapy for a serious chronic disease
afflicting 4% of the population may involve 13 000 cases, and despite the
fact that 93% of persons between I and 15 years of age and 67% of
1004 CMA JOURNAL/NOVEMBER 4, 1978/VOL. 119
persons over 15 years of age may have obtained moderate to excellent resolution of symptoms, such a report can be rejected. This rejection occurs because the scientists, who cannot determine relief of suffering by linear, volumetric or mass measurement, pronounce that this degree of relief in such a large number of chronically ill patients was either a figment of imagination or a deliberate lie, in this instance the scientists also make the same assessment of the physician who made such a report. Rejection of the relief of suffering, and therefore of death (which has been the profession's raison d'&re since its beginnings), as a measure of the success of therapy is absolute evidence that scientists, not physicians practising the art of medicine, have assumed control of all research in medicine. This control is now so great that a physician working at the grass roots of medicine without recourse to financial grants-in-aid, and with the severe limits on time imposed by practice, would be foolish to make even preliminary clinical assessments of an innovative therapy and report, even in discussions with associates, on the subjective relief of suffering experienced by his or her patients. In such circumstances the physician would be exposed to criticism and even ridicule by associates who are attuned to the acquiescence of the profession to science and who perceive that scientific control of the advance of medicine provides absolution for their own incapacity to be innovative. These controls on research provide an excuse for the average physician's concentration on volume practice and for the treatment of patients with only prescribed scientific methods, and they afford protection of such practice from persons who would better themselves by being innovative. In my opinion the penalties on health care imposed by the advance of science in medicine can only be balanced by a return to an appreciation of original precepts of the art of medicine. The principal precept is that physicians should listen to their patients and believe them when they say the distress of their disease has worsened, has not changed or has been relieved to some degree. Moreover, the average physician should be encouraged and not penalized for reporting such anecdotal clinical data,
