Dear Louie,

In the beginning, there was Thursday, and for the next forty years, there were Thursdays. Always Thursdays were important and many times different; quiet and hectic; worry-free and troublesome, but always promising and so close to the weekend.

That first Thursday, in mid-July 1954, changed my whole life in a subtle but definite manner. That first Thursday, the first day alone in practice, changed my attitude, habits, and outlook. I had taken over the established practice of the busiest practitioner in Hartford. He had gone to the Navy for a two-year hitch on the day before. I had completed a one-year internship on June 1.

The day began with rounds at the small local hospital, followed by a delivery at ten a.m., followed by office visits; twelve in number, and all new to me, and then a call to the second floor to attend an emergency admission.

The admission was a middle-aged woman, a long-time patient of my partner, the newly appointed naval officer. As mentioned above I had completed a rotating internship of twelve months and had returned to Hartford, my hometown. The day had gone reasonably well until this admission at two in the afternoon. However, the admission of this middle-aged woman was a tragedy to her husband, daughter, and friends and would change their life completely. Suddenly, one hour before admission she had collapsed in the kitchen, become unconscious and developed posturing and rigidity of brain stem involvement.

She was posturing for death.

Exam revealed extensor spasms of the arms and legs, irregular breathing, unresponsiveness to all stimuli; a deep, deep coma. A large mass, hard, firm, indurated extended from the left breast into the left armpit, and the arm was swollen to the fingers. The family stated she had been short of breath, complaining of headaches, and had been clumsy, and forgetful for the past few weeks. She had been withdrawn, had slept a lot, and had fallen on more than one occasion. When the question was posed to the husband, “Did she see her physician during the past few weeks?” it was met with silence, and tension. It soon became evident that the family had ceased to function for quite some time. She had slept alone, smoked most of the day, become slovenly and withdrawn. She and her teenage daughter had drifted apart; the daughter did not come home each night.

The more I questioned, the more obvious it became that life at home wasn’t much for some time. The husband was defensive in his ignorance of his wife’s condition. He had spent many nights away, “at work.” The daughter volunteered that the father was not at work, but was with his girlfriend, ”where he has lived for the past three months.” The daughter feared the father, he had been mean and mostly drunk. Soon transference took place and the blame was placed on the new physician. “If my doctor was here, Mother would be treated instead of all these questions.”

“Don’t ask any more questions, let her die peacefully.”

She died within the hour.

A postmortem revealed a cancer of the breast with metastases to the brain and a massive brain stem hemorrhage. This patient died an unattended death; unattended for months before, and unattended in spirit in the hospital.

My life and attitude were changed almost immediately. No longer was I protected by the attending physician, I now was the attending. I must know the intricacies of the families, the hidden secrets. Stop, look, and listen would be important. I learned that transference of guilt is a game played throughout life and is illogical and self-serving. Knowledge gained by observation and questioning is not only important but protective to the physician.

That same afternoon, the day of my baptism into the real world of family practice continued to be traumatic. Before leaving the hospital an elderly man was admitted to the emergency room. I had known him for years. He suffered a stroke and died within two hours. Two for two, it could only improve!

I went home that night and tried to assure myself that all days would not be as bad as this Thursday; later I learned that some were worse. But, I got up the next day, went to the hospital and office, and continued to learn of the science and art of the practice of medicine and the vagaries of small-town family practice. I matured, my wife and family adjusted, and Thursday’s became the anticipated midweek day of relaxation, oh how I so often wished.

Jim