This was essentially the conclusion of the neurological consultants who saw the patient later in the evening. They felt that Mr. O'Connor had suffered a primary infectious process with sudden outpouring of bacteria into the blood, and consequent fever and prostration. They felt the infection was somewhere in the urinary or gastrointestinal system, or perhaps even in a small area of the lungs. In their opinion, meningitis, encephalitis, subarachnoid hemorrhage, or other central nervous problems were unlikely.
A formal surgical consult, also later in the evening, reported that in the absence of muscle spasm or guarding of the abdomen, and in the presence of six negative taps, an acute abdominal crisis was unlikely.
Genito-urinary consultants examined the patient that same evening and reviewed his kidney X rays. They felt that there was a probable partial obstruction of the right kidney, but they could not determine whether this was a recent or a slowly developing change. They found no evidence of infection of the prostate gland to explain the fever. Mr. O'Connor was placed on the Danger List and transferred to the intensive-care unit of the Bulfinch Building. At the end of his first twelve hours in the hospital, his fever had been reduced, but was still unexplained.
Before continuing with Mr. O'Connor's hospital course, it is worth pausing a moment to consider the patient's initial symptoms, and initial therapy.
Mr. O'Connor was presented with high fever and shock. Classically, the fever of unknown origin is a pediatric problem, and classically it is a problem for the same reasons it was a problem with Mr. O'Connor-the patient cannot tell you how he feels or what hurts. However, a high fever in a child is less worrisome than it is in an adult, for children have a much greater tolerance for fever. In adults, prolonged high fever is more likely to result in permanent brain damage and death.
The most common cause of fever for anyone, child or adult, is infection; the most common cause of fever of unknown origin is also infection. There are some unusual causes occasionally seen, such as malignancies, bleeding in the brain, drug ingestion, and outpouring of thyroid hormone, but, for the most part, unexplained fevers are produced by unidentified infections.
It is now known that one can harbor an infection in a secluded part of the body, and the body will make very little response to it; however, if the infection spreads into the bloodstream, there may be a "shower" of bacteria, and a subsequent rise in temperature. The shower is usually brief, lasting minutes or hours, and often ends before the temperature rises. This makes diagnosis difficult-if one wants to catch bacteria in the blood, one must draw a sample before the temperature spike, and not during it or after it.
It was thought that Mr. O'Connor was suffering from precisely this sort of situation: a sequestered infection producing episodic bursts of bacteria into the blood, with episodic fever. However, his fever was threateningly high. And thus a classic conflict in therapy as old as Hippocrates.
"For extreme diseases, extreme remedies," Hippocrates wrote. But he also said: "For grave diseases, the most exact therapy is best." But, obviously, an exact therapy depends upon a precise diagnosis, and here lies the conflict.
What is a diagnosis? The question is not as simple-minded as it first appears, for the notion of what constitutes an acceptable diagnosis has radically changed through the years.
A diagnosis is drawn up on the basis of two kinds of knowledge: the physician's concept of disease processes, and his available therapies. Ideally, a diagnosis contains some sense of etiology- the cause of the disease-but for most of medical history etiology was either ignored or wrongly ascribed (as in "fever from excess of black bile").
In a modern sense, precise diagnosis is required because precise therapies are available. Yet the need for precise diagnosis is older; in Hippocratic time, this need was based on a prognostic, not a therapeutic, concern. Physicians were unskilled at curing disease and therefore served mostly to predict the course of an illness which they could not influence. Robert Platt notes that "until quite recently… it did not matter whether your diagnosis was right or wrong… Prognosis mattered rather more, especially to the doctor's reputation."
Hippocrates was deeply concerned with the prestige of the physician as related to prognostic acumen; much Hippocratic writing shows this preoccupation with prognosis: "Sleep following upon delirium is a good sign." "Those who swoon frequently without apparent cause are liable to die suddenly." "Labored sleep in any disease is a bad sign." "Spasm supervening upon a wound is dangerous." "Hardening of the liver in jaundice is bad." "If a convalescent eats heartily, yet does not take on flesh, it is a bad sign."
These observations are still valid today. But we demand something further from diagnosis, as the range of therapies has increased. If a person swoons, for example, it is important to know whether he has aortic stenosis-and is likely to die suddenly-or whether he is hysterical, or diabetic, or has some other reason for fainting. In short, we want more precise diagnoses because we have more precise therapies.
Throughout medical history, physicians have felt that they had precise, specific remedies, but few of these are still acceptable. As medical writer Berton Roueche notes, only three eighteenth-century drugs are still acceptable today: quinine for malaria, colchicine for gout, and foxglove (digitalis) for heart failure. All the other "specifics," as well as what Holmes termed the "peremptory drastics," have disappeared.
Even as recently as 1910, L. J. Henderson commented that "if the average patient visited the average physician, he would have a fifty-fifty chance of benefiting from the encounter." Much has happened since then-in fact, nearly every diagnostic test and therapeutic procedure performed on Mr. O'Connor during those first twelve hours has been developed since 1910. For clinically, diagnosis and therapy go hand in hand; increasing sophistication in either one demands increased sophistication in the other.
The proliferation of tests and techniques in this century is staggering. Consider the following list of tests performed on Mr. O'Connor, and the dates those tests were first described in clinically practical terms:
X ray: chest and abdomen (1905-15)
White cell count (about 1895)
Serum acetone (1928)
Amylase (1948)
Calcium (1931)
Phosphorus (1925)
SCOT (1955)
LDH (1956)
CPK (1961)
John O'Connor 45
Aldolase (1949)
Lipase (1934)
CSF protein (1931)
CSF sugar (1932)
Blood sugar (1932)
Bilirubin (1937)
Serum albumin/globulin (1923-38)
Electrolytes (1941-6)
Electrocardiogram (about 1915)
Prothrombin time (1940)
Blood pH (1924-57)
Blood gases (1957)
Protein-bound iodine (1948)
Alkaline phosphatase (1933)
Watson-Schwartz (1941)
Creatinine (1933)
Uric acid (1933)
If one were to graph these tests, and others commonly used, against the total time course of medical history, one would see a flat line for more than two thousand years, followed by a slight rise beginning about 1850, and then an ever-sharper rise to the present time.
That is the meaning of technological innovation. It has struck medicine like a thunderbolt: far more advances have occurred in medicine in the last hundred years than occurred in the previous two thousand. There is no mystery why this should be so. Most research scientists in history are alive today; therefore most of the discoveries in history are being made today. But the consequences of this vast outpouring of information and technology have yet to be grasped. Major questions are raised in such widely diverse subjects as medical education and euthanasia.
What makes the case of Mr. O'Connor so interesting is the way it illustrates the vast web of technological advances that make diagnostic techniques and treatment today so radically different from what they were only thirty years ago.
Presumably, Mr. O'Connor had an infection. The treatment of infectious disease is considered one of the triumphs of modern medicine, crowned by the introduction of antibiotics. But as the bacteriologist Rene Dubos has pointed out. "The decrease in mortality caused by infection began nearly a century ago and has continued ever since at a fairly constant rate irrespective of the use of any specific therapy." He says, further, that "these triumphs of modern chemotherapy have transformed the practice of medicine and are changing the very pattern of disease in the western world, but there is no reason to believe that they spell the conquest of microbial diseases."