many believe that it has lessened the cowboy mentality of the wards, with its attendant disasters. It is difficult to know which system is best for patient care, for there can be no controlled trial. But at some point in the day or the week or the call cycle, residents must go home, and care must be handed over to someone else. This is a biologic and logistic imperative. We willcontinue to try different scheduling contortions to deal with the inflexible nature of the 24hour clock; all will have drawbacks, and some will have advantages. We should be constructive — and vocal — in our critique, but we should also try to resist the subconscious urge to naysay for the sake of reinforcing our own egos. We also need to match our words with actions. If we have concerns about thechanges, then we should work toward improvement, whether by lobbying for more intelligent rules, researching the effects of these regulations, or finding creative ways to ensure good clinical care
Residency Regulations — Resisting Our Reflexes
and a high level of education within the new constraints. And so we dust off our brains and try to keep up with the scheduling roller coaster. If thepre-call resident is off, we can try to work more closely with the interns. If we detect a sliding toward cookbook medicine, we can intensify our efforts to teach critical thinking. If we sense “shift” mentality setting in, we can be glad we are in a position to model the professionalism we deem vital. Our words of complaint will ring hollow unless our footsteps can be heard on the ground. We shouldresist the reflex to say that the way we did it is the way it should be done. Better to use our energy to elevate patient care and medical teaching to the highest level possible, given whatever constraints we happen to face — even on the Fridays before the bad weekends.
From the Department of Medicine, New York University School of Medicine and Bellevue Hospital, New York.
Bacterial Meningitis— A View of the Past 90 Years
Morton N. Swartz, M.D.
Related article, page 1849
The history of community-acquired bacterial meningitis arguably represents the best example of the salutary effect of the introduction of antimicrobial agents. Before the use of specific antiserums, the outlook for patients with bacterial meningitis was dismal (see Figure). In the 1920s, 77 of 78 children atBoston Children’s Hospital who had Haemophilus influenzae meningitis died. The prognosis for untreated pneumococcal meningitis was equally bleak: of 300 patients, all died. In the first decade of the 20th century, untreated meningococcal meningitis was associated with a mortality rate of 75 to 80 percent. In 1913, Simon Flexner was the first to report some success in treating bacterial meningitis withintrathecal equine meningococcal antiserum: among 1300 patients with epidemic meningitis, mortality was reduced to 31 percent.1 Among 169 children with meningococcal meningitis treated with intrathecal antiserum at Bellevue Hospital, New York, between 1928 and 1936, the outcome was even more favorable, with mortality of about 20 percent. Fothergill reported in 1937 that treatment of H. in-fluenzae meningitis with combined intravenous and intrathecal antiserums reduced mortality among 201 children to 85 percent. The prognosis for patients with pneumococcal meningitis remained extremely grave even after the introduction of specific antiserums. There were only anecdotal reports of recovery after treatment with systemic and intrathecal antipneumococcal serum. In the 1930s, with theintroduction of sulfonamides, the mortality associated with meningococcal meningitis decreased to 5 to 15 percent. By 1944, Alexander had reported that treatment with both a sulfonamide and intravenous rabbit antiserum in 87 children with H. influenzae type b meningitis had reduced mortality to 22 percent. In the early 1950s, chloramphenicol treatment (with sulfadiazine) reduced the fatality rate of...