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remained without fever.
DAY 15
Chloramphenicol was stopped. The patient did well, taking liquids by mouth.
DAY II
The patient's mental condition continued to im-prove. A repeat kidney X ray was read as normal.
day 16
On his second day off antibiotics, his tempera-ture fluctuated in the range of 1000-101°F.
day 12
There was continued improvement. Enzymes had dropped to near-normal levels. He had no fe-ver.
day 17
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.
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FIVE PATIENTS
John O'Connor
57
DAY 18
The surgeons concluded that the patient had cho-lecystitis, 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.
day 19
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.
day 20
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.
day 21
The scheduled operation was canceled in order to allow time for further pre-operative studies. A
repeated gall bladder X ray definitely showed no filling, although this time the films were of good quality. A
celiac angiogram was scheduled.
DAY 22 AND DAY 23
The weekend. Specialized procedures such as celiac angiography could not be done, and further work on
the patient was postponed until Monday.
DAY 24
Celiac angiography was performed. Under local anesthetic, a thin, flexible catheter was passed up the
femoral artery in the leg, to the aorta, and fi-nally to the celiac axis, a network of arteries com-ing off the
aorta to supply blood to all the upper-abdominal organs. A dye opaque to X rays was injected, and the
vessels studied. No space-occupying lesion (tumor) was found and the ves-sels were normal in
appearance. The patient made a good recovery from the procedure.
day 25
The abdomen was soft and non-tender. The pa-tient felt well. He was still on chloramphenicol. Enzymes
were, by now, fully normal.
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FIVE PATIENTS
John O'Connor
59
DAY 26
The patient had no fever and felt well. The sur-gical staff decided to stop antibiotics and see if the fever
and symptoms recurred.
was now clear that he was not an operative candi-date. Plans were made for his discharge the fol-lowing
day.
DAY 27
He was taken off antibiotics. Temperature and white cell count remained normal. The patient himself
was in good spirits.
day 28
There was no demonstrable worsening of the patient's condition on his second day off antibiot-ics. His
wife expressed the opinion that his mental state was entirely normal once more.
day 29
His condition remained stable on the third day. He said he felt well. He had no fever and no ele-vation
in white count.
day 30
His condition was still good; his abdomen was soft without tenderness. He said he felt well. It
day 31
Discharged. His discharge diagnosis was fever of unknown origin with bacteroides septicemia. The
opinion of the house staff remained that this patient had probably had a bile-collecting-system infection.
Five days after discharge, he was seen in the surgical clinic by Dr. Jack Monchik, who sched-uled
another set of gall bladder X rays for the fu-ture, and noted that if the patient had further trouble with
infection, it would probably be neces-sary to remove the gall bladder. For the moment, however, the
patient was fully well.
"To do nothing," said Hippocrates, "is some-times a good remedy."
On the surface, Mr. O'Connor's hospital course seems proof of this ancient dictum of "watchful
waiting." But this is not really so: had Mr. O'Connor received no treatment, he would almost certainly
have died within twenty-four hours. He received vital symptomatic therapy (lowering his fever) as well as
acute support of vital functions (assisted respiration). He was closely monitored by teams of physicians
who were prepared to inter-
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FIVE PATIENTS
cede in his behalf, supplying more assistance should his body require it.
He also received a vigorous diagnostic work-up, which did not produce as much information as one
might like. His therapy was successful, but no physician at the hospital could claim, at discharge, that they
really knew what was going on in his case. A diagnosis of cholangitis and cholecystitis was likely, but
never demonstrated.
His hospital bill for a month of care was $6,172.55. This is just a few dollars less than Mr. O'Connor's
annual salary. But he did not have to worry about it; unlike most patients with some form of health
insurance, Mr. O'Connor had cover-age that was essentially complete. His personal bill amounted to
$357.00.
In this, as in many other things, Mr. O'Connor was a very lucky man.
The single most important problem facing mod-ern hospitals is cost. This cost can be analyzed in a
variety of ways, most of them confusing and un-helpful. But the following points are clear:
First, the cost of hospitalization has skyrock-eted. The average MGH patient today pays per hour what
the average patient paid per day in 1925. Even as recently as 1940, a private patient could have his room
for $10.25 per day; by 1964, it cost $50.10 per day; by 1969, $72.00-$ 110.00 per day. This staggering
increase is continuing at the rate of 6 to 8 per cent per year. Each year
John O'Connor 61
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195*60 13510 D
One portion of Mr. O'Connor's 17-fooMong bflfc
for the past three, the MGH has had to raise its charges. Nor is the teaching hospital unique in its financial
squeeze. All American hospitals are rais-ing their charges at this same rate.
Second, hospitalization cost has increased much more rapidly than other goods and services in the
economy. Medical care is the fastest-rising item in the consumer price index in recent years, and per-
62 FIVE PATIENTS
day hospital cost accounts for the largest propor-tion of this increase.*
Third, the individual contemplating hospitaliza-tion no longer worries much, in a direct way, about cost.
Third-party payment has led to public apathy about hospital costs, and this is unwise if for no other
reason than the fact that most people have only one fourth to one third of their costs paid by insurance, a
fact they discover late in the game.
Fourth, the often overlapping coverage of health insurance permits some patients to make money from
their hospitalization, while welfare reim-bursements are always less than the true costs of care. In this
situation, the hospital makes ends meet by overcharging private patients and their in-surance companies to
cover the welfare deficit in the case of the MGH, roughly $10 a day over-charge.
Fifth, no single hospital stands alone in its fi-nancing problems, but rather is influenced by the activity or
decline of other hospitals in the area. The decay of the Boston City Hospital, and its re-duction in size to
nearly half its earlier patient ca-pacity, has created great pressure upon other Boston hospitals to take up
the slack by accept-ing precisely those patients on whom the hospital loses money, namely, patients
covered by welfare.
*Physicians' fees have also been rising faster than other items in the consumer price index. However, hospital costs
have been nearly doubled in the past decade, while physi-cians' fees have increased 30 per cent.
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John O'Connor
The decline of Boston's municipal, tax-supported hospital is similar to the decline of other such in-stitutions
in other American cities. In each case, the reasons behind the decline are political and fi-nancial, but the
consequences are always the same to pass on costs to insured patients, and make them
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