The love of science

March 1, 2000

Continuing quest for realistic medicine is discussed for the 21st Century.



The love of science

An 8-year-old previously healthy girl was seen by her pediatrician aftertwo days of fever and cough. That was a month ago. She remains in a pediatricintensive care unit, ventilated and on extracorporeal membrane oxygenationbecause of influenza infection complicated by Staphylococcus aureuspneumonia.

A 2 1/2-year-old boy who had never had so muchas an ear infection developed fever, chills, and neck stiffness. Two daysinto the illness he was evaluated at an emergency department and found tohave purpura, disseminated intravascular coagulation, group A streptococcalbacteremia, and a clavicular osteomyelitis. One month later he is stillfebrile, despite appropriate antibiotic therapy.

A 1-month-old full-term infant was noted by his parents to be eatingless and slightly irritable. On physical examination he had apparent painon movement of the right femur. Further evaluation showed osteomyelitisof the proximal femur. The blood culture was positive for Staphylococcusaureus, but the infant has improved only slightly after two weeks ofanti-staphylococcal antibiotics.

We think we know a great deal about why some people become infected withsome organisms. We recognize and think we understand a variety of immunocompromisingconditions—subtle and lethal; congenital, acquired, and developmental.We also think we know about antibiotics—even some antivirals—andhow they work. Most of the time we're pretty good at predicting who is likelyto become infected, how sick they're likely to get, and what the impactof therapy will be. But as these patients illustrate, we don't know enough.There is no reason to believe that any of these three has an identifiableimmunodeficiency— either by history or after laboratory evaluation.Was it the bug? Was it some environmental phenomenon or concomitant viralinfection? Did they have a transient nutritional deficiency? Was there anunfavorable alignment of the planets? And what do we tell their parents?

Twenty-first century medicine just isn't good enough yet to ensure prevention,rapid and effective therapy, or even a reasonable, scientific explanationfor all the bad things that happen. Love of science, personal fears, anda desire to put things in their proper order—all these are importantreasons why the work to understand what happened to these children willcontinue. But perhaps the most important and the most urgent reason to persevereis that we want so badly to have something to tell the people who love them.


Julia A. McMillan, MD, Editor-in-chief of Contemporary Pediatrics,is Vice Chair, Pediatric Education, and Director, Residency Training, JohnsHopkins University School of Medicine, Baltimore.

Julia McMillan. The love of science.

Contemporary Pediatrics