A Memorable Patient

The few of us who examined 2 years of correspondence before Mr. J.'s arrival at Massachusetts General Hospital were even more interested in meeting the man than in validating the exotic diagnosis we had made from his letters.

Herman J., a native of Rumney, New Hampshire, announced himself to us in March 1958, using a lined sheet of paper, green ink, and handwriting from an earlier century. His request triggered a series of remarkable exchanges with Dr. Charles Clay, our hospital's assistant director at the time. Charlie Clay had grown up in rural New Hampshire within a few miles of Mr. J. Their extensive correspondence occupies a thick section of a hospital record that is still in my hands. The following excerpts depict its contents, as well as the improbable relationship that built between the two men.

“Gentlemen,” began Mr. J.'s first letter, “I would be pleased to have a little information. What would the cost be for a Appendix Operation if it becomes neccessary? I asked them at Laconia Hospital here in N.H. an I find that nobody can afford to play around with them. I don't have their kind of money at all. Maybe a poor man is supposed to die.

Enclosed find a stamp for reply.

Yours sincerely,

Herman J”

Within a day, Charlie Clay crafted a reply. (He also penned a brief inquiry to a friend in the region who soon informed him that Mr. J. was a loner who tinkered with guns, sold newspapers, took on odd jobs, and paid his bills on time.)

“Dear Mr. J.,

Our regular ward rate is $28.00 for the first day, $26 for the second, $24 for the third, and $21 a day thereafter, with operating rooms, anesthesia, x-ray and other special services added.” After reminding Mr. J. of several other hospitals to try in New Hampshire, he closes by writing, “It is customary for one's own doctor to arrange for admission to a hospital, anyway, as doctors know more about hospitals and their ways than other people do.

Yours truly,

Charles L. Clay, M.D.”

It was Mr. J.'s response that gave us our first intimation of both who and what we were dealing with.

“Charles L. Clay, M.D.

Dear Mr. Clay,

Your letter of March 19 read and contents noted … . I want to say that if doctors don't know any more about hospitals and their ways than you appear to know about yours, they don't know 1/4 part as much as those other people you tell about. You only gave price of ward 4 days, nothing else. For Pete's sake, how long is a man supposed to be cooped up for an appendix operation—all summer? As for x-rays, I don't see wherein that is needed. You know where to find it, don't you? … I don't have any doctor as I have not needed one much. I always figured they were a darned good thing to keep away from. There isn't one in a dozen that knows B from bull's foot. It can be truthfully said that a lot of them don't know enough to pound sand straight in a rat hole … . I have not got any need of a Doctor telling me what the trouble is, I am more than satisfied I know. If I am wrong, I will make a wager. I will suck a dozen woodpecker eggs … . Now my symptoms are the following, not that it will mean anything to you. Go to sleep reading without any warning. Have spells I am slightly dizzy … . Skin on my face feels quite warm and turns red, also the hide on my hands turns red. This leaves in a minute or so, and my face will be white and pinched up for a few minutes … . Right side, very low down is quite sore to the touch. At time it will be sore up above … . I have got more relief from standing on my head than any other one thing. I figure this trick turns the appendix sac bottom side up an lets the poisons drain off into the intestines. Wish I had got onto this trick earlier. This letter may be frank but you show me where in it isn't 100% right. I thank you for the little information I got which sure was not much. I will guess as to price of the Ether Artist an operating Doctor.

Yours Sincerely.

Herman J.”

Thereupon, Charlie Clay committed an act unthinkable for a hospital administrator, even at that time. He prepared a four-page, single-spaced, typewritten response to this belligerent eccentric with a bizarre problem. From its first sentence, the letter carries a tone of humility:

“Please accept my sincere apologies for the likely delay between my receipt of your letter and your receipt of this answer. I felt that your problem merited my personal attention and offer of assistance. As you see, it required a rather lengthy letter, and I have been under such pressure of work during the past three weeks that I could not get to it before.”

Dr. Clay then goes into great detail about hospital rates, options for financial assistance, the value of good medical care, and respect for self-reliance. Above all, the letter reads as a friend's heartfelt plea for Mr. J. to seek sound medical attention. It gently instructs Mr. J. to start looking around for woodpecker eggs.

The response:

“Your long letter of April 10th read an contents carefully noted. I have had 2 or 3 Chiropractic adjustments for Appendix since I wrote you last. Those adjustments coupled with standing on my head to get rid of the poison has already cleared up 85% of my trouble. So I shall not have to look around for the woodpecker eggs. I knew it was a case of appendix trouble and told you so … .” Six pages of harangue about doctors and medical care follow.

As the months progressed, letters kept exchanging. Dr. Clay described being out of action with an illness of his own. Mr. J. reported continued deterioration and a desire to come to Massachusetts General Hospital:

“I'm not looking for anything fancy or style. If a surgeon is needed, I of course, would want a good one, naturally. After the job is done you can put me out in the barn in the hay mow if it is warm and comfortable an I can get a little attention now and then … .”

At long last, an admission was arranged but never occurred:

“Well in your letter of a while ago you said come down any Monday an I took you at your word. I came down on the 22nd Washington's birthday. I found everything at a standstill. They wouldn't as much as look at me … .”

Dr. Clay wrote a note of deep apology.

A subsequent letter from Mr. J. recounts unrelenting symptoms, despite an appendectomy performed by a local surgeon. He describes worsening of an “evil reddish purple color,” a swollen face in the morning, leg swelling during the day that subsides at night, loss of appetite, and a melting of his flesh. He reports a visit to a chiropractor who placed him on a diagnostic machine. Its readout was that he had poisons in his liver.

“Dear Mr. J.,

I don't know anything about repairing gun actions and you don't know anything about the practice of medicine. The result of our infringing on each other's territory could be disastrous … . Now for heaven's sake, don't start arguing with me about chiropractors and their machines but get yourself down here as fast as you can and let us begin working with you … .

Yours cordially,

Charles L. Clay, M.D.”

On 18 July 1960, some 28 months after his first letter, Mr. J. was finally admitted to Massachusetts General Hospital by Mart Mannik and initially bedded in the overnight ward so that we could have the thrill of presenting him to our chief resident. As a member of the team, I observed a craggy-faced, subdued gentleman whose skin colors were on constant display. A panorama of red, orange, and purple shades interchanged from moment to moment, occasionally vanishing into unexpected pallor. His face had permanent telangiectasia, a huge liver could be easily felt, and a systolic heart murmur was audible. No diagnostic machine was needed to diagnose florid carcinoid syndrome. But in a peculiar way, realizing how little we could do for Mr. J., I didn't feel as though we were saying much more than what he had already been told—that there were poisons in his liver. The positive results for urinary 5-hydroxyindoleacetic acid we obtained were hardly a surprise, nor was the report we received from a New Hampshire hospital of extensive carcinomatosis found during the appendectomy in March. Mr. J. endured 3 weeks of observation and useless treatment at Massachusetts General Hospital before returning to New Hampshire to die.

This all unfolded during my first month of internship. To this day, Mr. J. is easily the most memorable patient I have ever encountered, with a personality as colorful as his disease. Having hauled out his chart once more to reread 40 pages of letters, another thought struck me: Charlie Clay was no slouch as a memorable character either.

• Copyright ©2004 by the American College of Physicians