VELOSEF 250 CAPSULES VELOSEF 500 CAPSULES Cephmdhi. capsules VELOSEF 125 FOR ORAL SUSPENSiON VELOSEF 250 FOR ORAL SUSPENSION C.phradln. for Oral Suspension VELOSEF FOR INJECTiON, 500 mg and 1 g Cephradlne for Injection ACTiON: Cephradine Is a semi-synthetic, cephalosporin antibiotic exhibiting bactericidal activity through inhibition of cell-wall synthesis. INDICATIONS: Infections in the respiratory and genitourinary tracts, and in the skin and soft tissues, due to susceptibie organisms. Sensitivity tests should be performed: therapy may be instituted before receiving the results. CONTRAINDICATIONS: Hypersensitivity to the cephalosporin group of antibiotics. WARNINGS: There is evidence of partial cross-allergenicity between the penicillins and the cephalosporins. Therefore, cephradine should be used with caution in patients with known hypersensitivity to penicillins. Antibiotics, including cephradine, should be used cautiously and only when absolutely necessary in patients with a history of allergies, particularly to drugs. Usage during pregnancy and lactation: Safety for use of this product during pregnancy has not besn established. Cephradine is secreted in breast milk. PRECAUTlONS: Patients should be obeerved carefully during therapy. Allergic resctions require discontinuation of VELOSEF and appropriate treatment. Prolonged use of VELOSEF may resuit in overgrowth of nonsusceptible organisms: appropriate measures should be instituted. During long-term therapy, hematological, renal and hepatic functions should be monitored periodically. Patients with known or suspected renal impairment should be observed carefully since cephradine may accumulate in the serum and tissues unless dosage is suitably reduced. Ses DOSAGE AND ADMINISTRATION section. Indicated surgical procedures should be performed in conjunction with antibiotic therapy; e.g., the incision and drainage of abscesses. After treatment with cephalosporins, a false-positive reaction for glucose in the urine may occur, but not with enzymebased tests. A false-positive Coombe test has also been reported. VELOSEF for Injection is not compatible with Lactated Ringer's Solution or other calcium-containing infusion fluids. ADVERSE REACTIONS: Usually limited to gastrointestinal disturbances and occasional hypersensitivity, but may include hematological and hepatobiliary disturbances, as well as elevated BUN, LDH or serum creatinine; superinfection; vaginitis and joint pains. Thrombophlebitis following IV. injection and sterile abscesses after IM. Injection have occurred. Only occasionally severe enough to warrant cessation of therapy DOSAGE AND ADMINISTRATION: The presence of food in the gastrointestinal tract delays the absorption and reduces the peak level but does not affect the total amount of cephradine absorbed. VELOSEF Capaules and VELOSEF for Oral Suspension Adults: Respiratory tract infections: 250 mg, q6h. Pneumococcal lobar pneumonia: 500 mg, q6H. Genitourinary tract infections: 500 mg, q6h. Prolonged therapy is advisable for the treatment of prostatitis and epididymitis. Children: 2510 50 mg/kg/day, divided into four equally spaced doses, e.g.: VELOSEF for Oral Suspension Child's Weight 125 mg/S ml 250 mg/5 ml lOkg(221bs) Atoltsp.q6h 20kg(.lbs) lto2tsp.q6h /ztoltsp.q6h 4Okg(881be) 2to4tsp.q6h lto2tsp.q6h Smaller doses than those indicated above should not be used. For otitis media due to H. influenzae, doses from 75 to 100 mg/kg/dsy are recommended. VELOSEF for Injection: For use in serious and life-threatening infections or where oral therapy is not possible. Average aduit daily dose 1s2 - 4 g, depending on the infection. In children, a daily dose of 50- 100 mg/kg is recommended. All patients; all formulations: Larger doses (up to 1 g q6h in aduits or up to 25 mg/kg q6h in children) may be given for severe or chronic infections: maximum daily dose should not exceed 4 g. Therapy should be continued for a minimum of 48 to 72 hours after the petlent becomes asymptomatic or evidence of bacterial eradication hss been obtained. In Infections caused by hemolytic streptococci, a minimum 10.dsytreatment period Is recommended. Stubborn Infections may require treatment for several weeks with frequent bacteriological and clinical appraisal. A modified dosage schedule in patients with decreased renal function is necessary. Each patient should be considered individually: the following schedule Is recommended ss a guideline. Initial loading doss: 750 mg. Maintenance dose: 500 mg at the time intervals listed below: Crestinine Clearance Time Interval (ml/min/1.73m2) > 20m1/min 6-l2hours 15-19 mI/mm 12-24 hours 10-14m1/min 24-40hours 5-9m1/mln 40-50 hours ( SmI/min 50-70hours DOSAGE FORMS: Capsules of 250 mg and 500 mg in bottles of 50, and bottles of VELOSEF 125 and 250 for Oral Suspension which, after reconstitution, provide 100 ml of pleasantly flavoured suspension containing 25 mg/mI and 50 mg/mI respectively. VELOSEF for Injection is provided as a sterile powder for reconstitution in vials containing 500 mg or 1 g. Consuit Product Monograph for reconstitution procedure. Product Monograph available to physicians and pharmacists on request.

E. R. SQUIBB & SONS LTD. 2365 COTE DE LIESSE, MONTREAL, QUE. H4N 2M7

clinicians, who provided me with these terms in their responses to the questionnaire, and secondly with the literature and history. Dr. Gatfield states that "the protection of society from violent patients is a legitimate function of my profession". Indeed society at times may need this protection, but locked wards and security are not synonymous. Patients abscond from locked wards, just as they do from open ones. Furthermore, as argued in a 1976 debate in The Lancet,1 "ordinary" patients may be exposed to considerable risk through no fault of their own when they are locked up with so-called violent patients. Is not the protection of these patients a legitimate function of Dr. Gatfield's profession? And how would a psychiatric hospital fulfil its role and obligations to the patients, as described by the World Health Organization2 and Sivadon,3 when patients are confined to locked wards? Although papers have appeared supporting his view, Dr. Gatfield should be assured that there is nothing in the literature substantiating his belief that locked wards are therapeutic; there are only the beliefs of others. I agree with Dr. Gatfield that careful assessment and research is required - however, not to discover which patients should be locked up but to develop therapeutically effective methods of treatment in an open, humane milieu. Regarding the wards that are locked, we should try to discover why they are locked, what patients are there, how long they have been there, why they are there and how we can treat them with other, more humane methods. Unfortunately, the statement in an editorial of the Canadian P3ychiatric Association Journal "The psychiatrist has long had the unhappy distinction of being the only medical man to lock up his patients'4 is as true today as it was in 1961. I believe we can do a great deal more than at present to make this statement obsolete. Some of what we can do is outlined in my paper. Finally, my bias could be stated explicitly by quoting from John Connolly: "Restraints are merely a general substitute for the thousand attentions required by troublesome patients".5 G. VoINEsKos, MD Chief, intensive care and crisis unit Clarke Institute of Psychiatry 250 College St. Toronto, ON

References 1. SPENCER DA: who's for the locked ward? (C). Lancet 1: 584. 1976 2. world Health Organization, expert committee on mental health; 3rd report. Tech Rep Ser: no 73, 1953 3. SIVADON PD: Techniques of sociotherapy Psychiatry 20: 205. 1957

4. The open door (E). Can Psychlatr Assoc ,1 6: 55, 1961 5. DEUTSCH A: The Mentally ill In America, 1st ed, Garden City, NY, Doubleday, 1937, p 221

The 5-hour rule To the editor: With reference to the recent correspondence on the "Guidelines for the Minimal Standards of Practice of Anaesthesia" (Can Med Assoc J 114: 986, 1976) there can be no doubt that a 5-hour delay between ingestion of food or drink and administration of an anesthetic is safer than a 4-hour delay, and so on. If one strove for better-than-minimal standards of practice, should one perhaps wait 8 hours? The guideline rightly allows for flexibility and judgement of the individual anesthetist in nonelective procedures situations where sound judgement and assessment of each individual case are of paramount importance. It is a pity that an anesthetist, who has to rely on his own judgement in an emergency situation, cannot be free to exercise that same faculty in an elective case. As to the wisdom of publishing such guidelines I can do no better than quote Dr. Lloyd Grisdale, past president of the CMA: "Guidelines are likely to become rigid rules to the detriment of care J.M. CLARI, FRCP[C] Department of anesthesia Oakville-Trafalgar Memorial Hospital Oakville, ON

Medical education: edifice or edification To the editor: In his editorial "Medical education: edifice or edification?" (Can Med Assoc J 114: 750, 1976) Dr. W. Grant Thompson raised many problems that are of importance both in Canada and elsewhere. It is sad indeed that in most teaching hospitals fragmentation of the practice of medicine has dissociated the complex of the medical practitioner, the laboratory physician, the student and the patient. The laboratory physician is in a unique position, having had training and experience both in the practice of medicine and in pure and applied science. It is regrettable, therefore, that the superspecialization of the teaching hospital has seen the breakdown of the concept of the medical team. Certainly, outside the teaching hospital the laboratory physician is still very much a team member. It is my experience that we are already producing a generation of medical practitioners who are often unable to interpret or implement advances in fields not directly related to their own superspecialties. They are be-

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wildered by advances in technology that have enabled large numbers of laboratory investigations to be carried out in an apparently efficient and well controlled manner. The ability to generate data has led to the geographic separation of the laboratory from the patient, as in the functioning of the "In Common Laboratory" in Toronto1 and the Hamilton district program in laboratory medicine.' This has also led to the undesirable separation of the laboratory physician from the patient, the medical practitioner and the student. By necessity the medical educators are those who have themselves been educated by the previous generation. It is therefore extremely difficult to change attitudes within the profession without educating the educators. Today's students are tomorrow's teachers and it is essential that the laboratory physician of the future be taught to blend with a team that has been prepared for his presence. As discussed previously,3 the solution to this problem of interaction between the different facets of medicine is important to the future practice of medicine and the future entry of medical graduates into the medical sciences. M.L. SALKIE, M SC, MB, B CHIR Medical biochemist University of Alberta Hospital Edmonton, AB

References 1. POLLARD A: The In Common Laboratory, Toronto. Clin Biochem 8: 391. 1975 2. BRAIN MC, HAGGAR RA, Mooaa 5, et al: The Hamilton district program in laboratory medicine: a progress report on integration. Can Med Assoc 1 114: 721, 1976 3. SALKIE ML, MAcLAREN DM: Medical graduates in clinical chemistry. Br Med 1 1: 204, 1975

To the editor: Dr. Thompson makes some valid points in his editorial. His projection of university faculties being based in community hospitals, with recruitment of extra teachers at this level, deserves some comment. He can expect polarizations if community practice patterns are changed; the physicians in private practice will line up against those who are working full-time in the hospital. The concept of the community teaching hospital will work only rarely; it would appear more feasible to adopt the concept of the "teaching practice". Community-based teaching physicians already have outpatient clinics (their offices), which have been built at no cost to the taxpayer. Models such as the Northwestern Ontario Medical Program appear to show that practical teaching in large-volume practices is a useful two-way exercise for the physician-teacher and the student or resident. Few full-time teachers are neces-

sary and the teacher-physician is paid for teaching while the student or resident is in his office. The concept of the teaching community hospital is avoided, as are all the anxieties that this can provoke in the minds of community physicians. Maybe departments of family medicine should decentralize totally. The professor of family medicine in the future would obtain his salary, office and car from the university, and his duties would include supervising dozens of clinical teaching units in private offices. He would recruit new teachers, monitor educational quality in community practices, study ways to improve standards of teaching and health care delivery in the communities and assist in ongoing continuing medical education for his units and the community medical societies containing his units. P.J. NEELANDS, MD Chairman, Northwestern Ontario Medical Program 900 Arthur St. Thunder Bay, ON

To the editor: I am grateful for the interest of Drs. Salkie and Neelands in my editorial. Dr. Salkie expresses regret that laboratory physicians are divorced from the medical team in most teaching hospitals. I am in general agreement with his plea that such physicians play a larger role in medical education, but hope he does not miss my point that active researchers play a role as well. I am afraid Dr. Neelands has overinterpreted my concept of the community teaching hospital. It is precisely the decentralization of medical education that I oppose. When I suggest that our university hospitals must become our medical schools, I mean just that. Patients, teaching facilities and research must all be available at one site. This is no more possible in a small community hospital or doctor's office than it is in a university building. The worst polarizations of physicians have occurred when large institutions have been built with no roots in the community and little attempt to involve local practitioners. The great teaching hospitals in this country have maintained close identification with the people they serve, yet have managed to attract the finest teachers and scientists. It is no more desirable that doctors in training should apprentice like blacksmiths than it is that they should learn the art and science of medicine in an ivory tower like monks sheltered from the foibles of mankind. W. GRANT THoM.PsoN, MD, FRCP[C] Department of medicine Ottawa Civic Hospital and University of Ottawa Ottawa, ON

Inequity in current library regulations To the editor: While it is true that men of great originality, like Thomas Hobbes, read little and knew more, it is also true, as Thomas Carlyle pointed out, that the true university these days is a collection of books - particularly, I might add, for ordinary human beings. It comes, therefore, as a profound shock that, by recent edicts of high unseen powers in many institutional libraries, access to the latest information on medical subjects has become even more unattainable than heretofore. From now on the earliest available data on advances in the healing arts must be at least 5 years old before permission is given for their perusal in medical journals within the quiet sanctuary of one's home. The reason for this ruling is evidently the tendency of some physicians to build up private libraries from the disjecta membra of university collections. Regrettable as this sporadic affliction is, the way to combat it is not to prevent the circulation of journals any more than it would be proper and judicious to try to prevent bank robberies by abolishing legal tender. Moreover, the punishment, well deserved by and proper for a few sinners, should not be inflicted on all and sundry. Students, for example, should not be punished, for the simple reason that they do not read journals. They read lecture notes and compendia. They are therefore not to be found amongst the culprits. Practising physicians do read journals at times and should be cooperative and above suspicion. When they fall from grace they should be compelled by dint of legal action or threat thereof to replace the lost or purloined journal - and, may I ask, is it not infinitely easier to replace a current copy than one that has been out of print for 5 years? True, one can read in the library, but this is often impossible with the congestion created by budding prescribers of pills and nostrums. One can also make copies of articles one wishes to read, but the smudges made by the machines often require the talents of a Champollion for deciphering. It is to be hoped, therefore, that the occasionally justifiable wrath of the librarians will be appeased, that they will reconsider the problem and permit current journals to circulate freely again. We wish to avoid saying, to paraphrase Samuel Rogers, that every time a new journal comes out, we read an old one! PHILIP EIBEL, MD, FRC5[C] Ste. 370, 5845 Cote des Heiges Montreal, PQ

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