These two enzymes, SGOT and LDH, are measured as indexes of cell destruction. Cells normally contain them; if the cells die, they rupture and release their enzymes to the bloodstream. A rise in enzyme levels is thought to correspond moderately well with the degree of cellular damage, particularly when examined over several days. However, these enzymes are found in many kinds of cells, and thus an enzyme rise does not pinpoint precisely the area of destruction. For example, heart, skeletal muscle, brain, liver, and kidneys all contain SGOT; damage to any of them will produce an SGOT rise. In recent years, there has been a search for enzymes specific to certain tissues. Cre-atinine phosphokinase, or CPK, is usually considered more specific for heart damage.
At 3:30 a.m., Michael Soper, a medical resident, got back the new set of enzyme values. Everything was further increased: SGOT was now 640, LDH 1250, and CPK very high, at 320. He wrote: "I've never seen a CPK this high and don't know where it is coming from. Doubt it is solely of cardiac origin. Electrocardiogram tonight is unchanged."
At 7 a.m., on morning rounds, Mr. O'Connor's abdomen was again without localizing signs pointing to disease on the right side. All cultures were back from the labs; all were negative. It was decided to continue only penicillin and chloramphen-icol, and discontinue all other antibiotics.
Later in the morning, the patient was seen by the infectious-disease consult, which concluded that the agitation and unresponsiveness were almost certainly secondary to gastrointestinal disorders and metabolic problems. The elevated enzymes could be the consequence of insufficient oxygen and shock, present at admission. However, they noted that the elevated alkaline phosphatase and elevated uric acid were unexplained. They suggested the possibility, previously unconsidered, of staphylococcal food poisoning.
Since no information could be obtained directly from the patient, his wife was closely requestioned about symptoms of thyroid disease, or longstanding diarrhea or other GI problems. The paregoric that the patient had taken on the day of admission was brought into the hospital and checked; it was, indeed, paregoric.
During this period the patient was examined by Dr. Alexander Leaf, the chief of medicine, and Dr. Daniel Federman, the assistant chief, as well as by a large number of other physicians, in an informal brainstorming session. Every conceivable diagnosis, including mushroom poisoning and cholera, was considered at this time.
The patient's condition remained unchanged.
Continued problems with oxygenating the patient's bloodstream produced a consultation by the respiratory unit, which advised drying the lungs as much as possible, naso-tracheal suctioning, encouraging coughing, and close monitoring by arterial blood gases. The patient improved somewhat during the day, becoming less wild. That evening, for the first time, he responded to his name.
The patient was more alert. He was seen again by the surgeons, who noted his abdomen was still soft, without any indications for surgery. His dose of Valium, to contain his agitation, was reduced.
He was seen in the morning by the neurological consults, who felt that he was "still quite ob-tunded," confused and disoriented. Nonetheless his progress since admission was striking. He could answer questions. When asked where he was, he said, "the hospital," though he could not specify which one. When asked his name, he said, "John." He could state his age. He was taken off Valium entirely. His temperature continued to fluctuate in the range of 99°-101°F. Dr. Minna wrote: "He is better in all ways."
Lab values, back from the day before, continued to climb. CPK had now gone to 2900, the highest in the history of the hospital. There was still no explanation for these enzyme changes. The patient continued to improve in alertness and responsiveness, though his mental function was far from satisfactory. In answer to questions, he said that one plus one was "one," and two plus two was "five."
He was able to carry out verbal commands such as "Squeeze my hand" and "Open your eyes." However, for the most part he lay in bed with his eyes closed; he initiated little spontaneous activity, and never spoke except in reply to questions.
His Foley catheter was removed. He was able to urinate in the normal manner. He was more active mentally, and remembered his last name, for the first time.
Blood cultures now revealed growth of a gram-negative bacillus, identified as Bacteroides, probably of bowel origin. The patient was sufficiently improved that he could be questioned about toxins, drugs, mushrooms, work exposure, and possible ingestions of heavy metals; there was no evidence for any of these. He was seen again by surgeons, who concluded that his abdomen was soft, with normal bowel sounds.
Barium enema was repeated, looking for diver-ticulitis or other sources of infection. None was seen.
He was seen by the neurological consults, who observed mild proximal muscle weakness and suggested study of the electrical activity of the muscles, by electromyography. He was also noted to have mushy swelling of his extremities.
Electromyography was normal. It was decided to discontinue his chloramphenicol antibiotic and see if he remained without fever.
Chloramphenicol was stopped. The patient did well, taking liquids by mouth.
The patient's mental condition continued to improve. A repeat kidney X ray was read as normal.
On his second day off antibiotics, his temperature fluctuated in the range of 1000-101°F.
There was continued improvement. Enzymes had dropped to near-normal levels. He had no fever.
The patient had an upper gastrointestinal series of X rays, which were normal. On his third day off antibiotics, the temperature began to spike again, to 102°. Tenderness and guarding of the right-upper abdomen reappeared.
The surgeons concluded that the patient had cholecystitis, or infection of the gall bladder, which had probably begun initially as cholangitis, infection of the bile system. They also wondered, however, whether he might have a liver abscess. The patient was put back on antibiotics.
Mr. O'Connor was transferred from the medical service to the surgical service as a pre-operative candidate for exploratory abdominal surgery. His mental state continued to clear slowly.
The neurological consult saw him and agreed his mental status was improving. The surgeons, moreover, found that his abdominal tenderness had disappeared with the antibiotics. X rays of the gall bladder showed no filling of the bladder sac, but the films were of poor quality. Radioactive scans of the liver and spleen were negative.