Clearly, the hospital has undergone an astonishing growth in size and complexity since those days. That growth generally goes unquestioned; it is a peculiarity of the American mentality that the growth of almost anything is applauded. (Consider the mindless jubilation that accompanied the growth of our population to two hundred million.) One may ask whether there are any drawbacks to the size of today's MGH, and to its current emphasis on acute, curative medicine. The question is difficult to answer.
First there is size. For both patient and physician, the sheer size of the hospital can create problems. The patient may find it cold, enormous, impersonal; the doctor whose patients or consultations are widely scattered may find himself walking as much as a quarter of a mile from bed to bed. The intimate, supportive atmosphere that is possible in a smaller hospital cannot be achieved to the same extent here.
On the other hand, a large patient population permits active research on a range of less common diseases; and the hospital serves a genuine function as a place of expert management in such illnesses. Similarly, highly technical procedures, requiring trained personnel and expensive machinery, can be supported in a large hospital, and these procedures can be carried out with a high degree of expertise. Patients who require open-heart surgery or sophisticated radiotherapy find the expensive equipment for such procedures here-and, equally important, staff that carries out such procedures daily.
As for the emphasis on curative measures directed toward established organic illness, two points can be made. First, the hospital's ability to continue to care for the patient once he has left the hospital is not as good as anyone would like. The MGH founded the first social-service department in America, in 1905, to look after such follow-up care in areas not strictly medical. These departments are now standard in most large hospitals. Similarly, the out-patient clinics are designed to provide continuity of medical care to ambulatory patients. But many patients are "lost to follow-up," to use the hospital's expression; they don't answer the social worker's calls, or they don't keep their clinic appointment Nor can they be wholly faulted in this regard, for the hospital's out-patient services are, in general, quite time-consuming for the person who wants to use them. Not only does the patient spend hours in the clinic itself, but he must take the time to travel to and from the hospital on each visit.
Second, by definition the hospital has not done much in the area of preventive medicine. No hospital ever has. Since the aesculapia, hospitals have defined themselves as passive institutions, taking whoever comes to them but seeking no one out. There are some peculiar sidelights to this. For example, a high percentage of patients in the acute psychiatric service give a family history of severe psychiatric disturbance. In the case of the young girl who had tried to kill her child, her father was an alcoholic; her mother and younger brother had committed suicide; her twenty-year-old husband, a shoe salesman, had recently been admitted to a state hospital for an acute psychotic break.
It is possible to think of psychiatric illness as almost infectious, in the sense that these disorders are so frequently self-perpetuating. One is tempted to reflect that true infectious disease is best treated in the community, using direct preventive and therapeutic measures; indeed, the conquest of infectious disease-one of the triumphs of medicine in this century-is something for which the hospital, as an institution, can take no credit at all.
In the same way, it is in the hospital's approach to mental illness that its limitations as a curative institution, treating already established disease, are today most striking. If major inroads are to be made, they will not come from the hospital system as it is presently structured, any more than the old specialized hospitals for tuberculosis, leprosy, and smallpox had any real impact on the decline of those diseases.
Some of the ways the hospital is restructuring itself to meet these limitations will be discussed later. But the hospital is also revising its internal workings, and that is the subject of the next chapter.
John O'Connor. The Cost of Cure
Until his admission, john o'connor, a fifty-year-old railroad dispatcher from Charles-town, was in perfect health. He had never been sick a day in his life.
On the morning of his admission, he awoke early, complaining of vague abdominal pain. He vomited once, bringing up clear material, and had some diarrhea. He went to see his family doctor, who said that he had no fever and his white cell count was normal. He told Mr. O'Connor that it was probably gastroenteritis, and advised him to rest and take paregoric to settle his stomach.
In the afternoon, Mr. O'Connor began to feel warm. He then had two shaking chills. His wife suggested he call his doctor once again, but when Mr. O'Connor went to the phone, he collapsed. At 5 p.m. his wife brought him to the MGH emergency ward, where he was noted to have a temperature of 108°F. and a white count of 37,000 (normal count: 5,000-10,000).
The patient was wildly delirious; it required ten people to hold him down as he thrashed about. He spoke only nonsense words and groans, and did not respond to his name. While in the emergency ward he had massive diarrhea consisting of several quarts of watery fluid.
The patient was seen by the medical resident, John Minna, who instituted immediate therapy consisting of aspirin, alcohol rubs, fans and a refrigerating blanket to bring down his fever, which rapidly fell to 100°. He was in shock with an initial blood pressure of 70/30 and a central venous pressure of zero. Over the next three hours he received three quarts of plasma and two quarts of salt water intravenously, to replace fluids lost from sweating and diarrhea. He was also severely aci-dotic, so he was given twelve ampoules of intravenous sodium bicarbonate as well as potassium chloride to correct an electrolyte imbalance.
The patient could not give a history. His wife, upon questioning, denied any history of malaria, distant travel, food exposure, infectious disease, headache, neck stiffness, cough, sputum, sore throat, swollen glands, arthritis, muscle aches, seizures, skin infection, drug ingestion, or past suicide attempts.
His past history, according to the wife, was unremarkable. He had never been ill or hospitalized. His mother died at age fifty-five of leukemia; his father at age fifty-nine, of pneumonia. The patient had no known allergies, and did not smoke or drink.
Physical examination was normal except for a slightly distended abdomen and a questionably enlarged liver, which could be felt below the rib cage. Neurological examination was normal except for the patient's stuporous, unresponsive mental state.
The patient was cultured "stem to stern," meaning that samples of blood, urine, stool, sputum, and spinal fluid were sent for bacteriologic analysis. He was also given heavy doses of antibiotics, including a gram of chloramphenicol, a gram of oxacillin, two million units of penicillin; later in the evening, kanamycin and colistin were added to the list.
X rays of the chest and abdomen were normal. Electrocardiogram was normal. Hematocrit was normal. The white count was elevated at 37,000 with a preponderance of polymorphonuclear leukocytes, the cells which increase in bacterial infections. Examination of the urine showed a few white cells. Platelet count and prothrombin time were normal. Measurements of blood sugar, serum amylase, serum acetone, bilirubin, and blood urea nitrogen were normal. Lumbar puncture was normal.
An intravenous pyelogram (an X ray of the kidneys to check their function while they excrete an opaque dye) showed that the left kidney was normal, but the right kidney responded sluggishly. The excretory tubing on the right side seemed dilated. A diagnosis of partial obstruction of the right kidney system was suggested.
Because the abdomen was distended, six abdominal taps were performed in different areas by the surgical residents, Drs. Robert Corry and Jay Kaufman, in an attempt to obtain fluid from the abdominal cavity. None was obtained.
Dr. Minna's diagnosis was septicemia, or generalized infection of the bloodstream, from an unknown source. As possibilities he listed the urinary tract, the gastrointestinal tract, the gall bladder, or the lining of the heart. He felt that there was no good evidence for a central nervous system cause for the fever, and no good history of drug inges-tion or thyroid problems to account for the fever.