Bryson City Tales

by Walt Larimore, MD

  I smiled. Indeed, this new dog had a lot to learn from this old dog. In many ways Mitch reminded me of Fred Moody. Both not only knew their profession, but they also knew the people and they knew the community’s ways. I found myself wanting to have their skill and their insight—neither of which was learned in their schooling but was forged on the anvil of time.

  Mitch would often tell me, “Son, good judgment comes from experience, and experience comes from bad judgment.” I didn’t enjoy the mistakes I was making—the deficits in my knowledge base that were continually being revealed—but I was learning that the local doctors’ “backward ways” were often more helpful and fruitful than my book knowledge, which I had thought would be much more valuable than it was turning out to be. I was especially learning to trust Dr. Mitchell’s gut instincts and his vast experience. More important than that, I decided, I was willing to learn—no matter how difficult or humbling Mitch might make that process for me. I was discovering that, in the practice of medicine, the learning never stops. And, like it or not, I had a long, long way to go—and to grow.

  chapter fourteen

  LESSONS IN DAILY PRACTICE

  It was Hal Fergusson’s third visit to the office in less than a month. For a local, that was tantamount to a medical emergency. I was beginning to learn that diseases in these parts usually presented late and well developed. Family physicians in more affluent areas had the opposite dilemma, where running to the physician at the first sniffle or hint of discomfort was nearly a national obsession—almost as rampant as the universal demand for a prescription for maladies that would heal just with the passing of time.

  Hal was a handyman, as had been his dad. Hal was known as a no-nonsense kind of guy who could perform any sort of home repair. Honest and straight shooting. Ray had treated him after a couple of accidents and had indicated that Hal’s pain threshold was fairly high. He had suffered a mean second-degree burn on the top of his hand when a propane torch he was using to solder some copper pipes together slipped. He only came to the office when the pain from a secondary bacterial infection was overwhelming. The delay in treatment cost him a few days in the hospital for intravenous antibiotics and surgery on the burn site to debride the eschar. “He could have lost that hand,” Ray told me.

  So here was Hal in the office for the third time. Something was up, and it wasn’t good. The previous two visits had been for rectal pain and bright-red bleeding with each bowel movement. The diagnosis had been simple and straightforward—an anal fissure, which is a small tear through the thin and delicate skin overlying the anus and the lower rectum. These tears can be slow to heal—especially if the victim is as chronically constipated as Hal, who refused to eat anything with fiber in it and was habitually dehydrated. “Doc, can’t be drinkin’ water all day. Elsewise I’d be peein’ all day. In my work, bathrooms are always available but not always functional. That’s why I’m in ’em.”

  During my first visit with Hal, he shared one of his favorite stories about Dr. Mitchell. “I was called over here to the office on an ‘emergency.’ One of the toilets in the office was leakin’ at the floor and makin’ a mess. I came over and found the problem pretty quick. All I needed to do was tighten a couple of nuts where the toilet was attached to the floor. My bill for this urgent call was $25. Mitch nearly went through the roof. ‘That’s more than three times what I charge,’ he yelled at me. Then he hollered, ‘And I’m a doctor!’

  “I tell ya, Doc, he was red in the face. So I just looked him straight in the eye and told him, ‘Yeah, I didn’t make this much money when I was a doctor either.’ Well, Helen started a’snickerin’—which I hear got her in hot water for several days. But then Doc started laughin’. He paid the bill. We been friends ever since.”

  During Hal’s first visit I simply prescribed a stool softener—which he refused to take—and petroleum jelly to be applied before and after each bowel movement. Unfortunately for Hal, his eliminations were too infrequent to allow the utilization of enough jelly for positive effect. The wound dried and cracked, and the pain and bleeding began again.

  At his second visit I insisted that he try a tablet form of stool softener and a prescription antibacterial ointment. He was very compliant with both orders. We doctors know that pain increases a patient’s motivation to follow the doctor’s recommendations. Unfortunately, even though Hal’s elimination frequency increased, so did his pain.

  On exam today, the fissure looked wider and longer. The area of indurated (hard) tissue around it was larger than at the previous two visits—although there was no sign of abscess. The rule of thumb at Duke had been that if the anal fissure didn’t heal, a surgical operation should be considered to cut out the offending tissue and allow the fresh, uninfected tissue to heal more quickly. Being in the office with two surgeons made such consultations easy and relatively painless.

  While Hal was dressing after the exam, I stepped into the hallway to wait for one of my colleagues to emerge from an exam room. Fortunately for me and for Hal, Mitch was the first one out—as Ray and I would have gladly, but unknowingly and unnecessarily, taken Hal to the operating room for this malady.

  “Son,” Mitch said, “he’s only had this three weeks. Can take months to heal. I don’t hardly ever take them to the OR before the fissure’s been there three months—less’n there’s an abscess. But come to think of it, bet I haven’t had one in OR in a dozen years since Dr. Bacon taught me the ol’ nitroglycerin trick.”

  The ol’ nitroglycerin trick? My mind was racing through mental medical file after medical file but coming up empty. Fortunately, Dr. Mitchell didn’t ask me to reveal my ignorance. This was to be yet another case where my first professors in the world of real-life medicine would teach me something that wouldn’t be published in the medical literature for another dozen years or more.

  “It’s really simple,” Mitch explained. “The older docs have been using this technique forever. It used to be more difficult to formulate, because Doc John had to keep the nitroglycerin in a cool, dark corner of the pharmacy. But when they came out with the premixed nitroglycerin ointment a few years back, it sure made things easier.”

  “How in the world does it work? Does it work?”

  “Like I said, son, I haven’t taken a chronic anal fissure to the OR since I started using the stuff. I suspect the nitroglycerin increases the blood flow to the area, same way it increases blood flow to the heart during an attack of angina. That helps the healing. But it also seems to have a pain-relieving effect. Not rightly sure how it does that, but folks claim it works. It’s sure cheaper and easier than surgery.”

  “So how do you prescribe it?”

  “Simple, son, simple. Just prescribe anal nitroglycerin, and Doc John’ll mix it up for ya. He’ll fill a four-ounce tub with the stuff, and then instruct the patient to apply a pea-sized dab to the sore area four times a day and after each bowel movement. When Hal’s feeling better, he can decrease to three times a day, and, when better yet, he can decrease to twice a day. Let him know it can take up to eight weeks for the fissure to heal completely. Now if it’s not healed in eight weeks, then we can consider operating.”

  “Anal nitroglycerin!” I mused. “Why, I never . . .”

  “Yep.” Mitch got that glint in his eye and the wry smile that preceded some sort of quip or joke. “I call this condition ‘anal angina.’”

  Great name! I thought, as he went chuckling into an exam room to see his next patient.

  Hal was delighted with the suggestion. “Actually, Doc,” he asserted, “done heard of that from ol’ Calvin Johnson when I was up fixin’ some pipes at his place. Said it worked like a charm for him. Don’t know why we didn’t think of that before.”

  Then he leaned toward me a bit, almost whispering, “Calvin said he’d get the prescription and use it for his manly duties.”

  “Manly duties?” I must have looked confused.

  “You know, Doc,” his voice lowered, “it helped his potency.”

/>   “His potency?”

  “Yep,” nodded Mr. Fergusson, continuing to whisper. “He said he’d take a small dab of that nitroglycerin ointment the doctor prescribed and rub it on the end of his thing.”

  “His thing?”

  “Doc, you kidding me? You know, his . . . uh, . . .” He seemed to be searching for just the right word.

  “You mean he put the nitroglycerin on his . . . ?”

  “That’s what he said. Sure as shooting. So, Doc, I’d be wondering . . . ,” he paused and looked at the floor for a moment, then continued, “if you might consider either doubling the prescription size or maybe making it refillable.”

  I decided to comply with the request, but warned, “Hal, topical nitroglycerin can cause a headache or a flushed feeling if you use too much.”

  Hal smiled—looking almost frisky. “Side effects would sure be worth it, Doc!”

  We both chuckled.

  I saw Hal in town a few weeks later. “How is everything?” I inquired.

  “Haven’t seen me back, have you?” He smiled. “Anyway, the prescription you gave me worked on both the north and south end of me.”

  I’m sure everyone within hearing distance of our guffaws wondered what Mr. Fergusson and the new doctor found so exceedingly funny.

  My next patient that day was Leonard, a ninety-eight-year-old man who came to the office for, of all things, a premarital exam. Too embarrassed to tell the staff that it was a premarital exam—for reasons that became fabulously famous during the subsequent months—he simply scheduled a routine heart exam.

  In those days doctors were still doing premarital exams and the state required a blood test for syphilis. (We had only four or five sexually transmitted diseases to be concerned about then; these days it’s approaching fifty.) Anyway, Leonard’s previous three wives had all succumbed to cancer. His impotence problems with wife number three had been “healed” by Mitch’s prescription of topical nitroglycerin.

  During his exam, this brittle elder, who suffered from labile congestive heart failure secondary to several heart attacks, as well as very unpredictable chest pain secondary to a severe case of coronary artery disease, confided to me that he was marrying a young barmaid.

  “Why?” I queried.

  “Because,” he replied, smiling, “I wanted to marry someone who would outlive me!”

  “Are you gonna consummate this thing?” I asked.

  “Of course!” he exclaimed. “But not until we’re married!”

  “But,” I protested, “you must be very, very careful. Too strenuous of a honeymoon could mean a heart attack or even death!”

  He looked me straight in the eye and said, “Well, Doc, if she dies, she dies!”

  I think I must have looked, for a moment, utterly bewildered. Then he smiled and began to laugh. I realized I’d been snookered. He confessed that he was actually marrying a “proper” woman, although she was twenty years his junior. I began to chuckle, both at myself and then with him. We both began to laugh and laugh until we had tears running down our faces. Helen barged in to shush us up. We continued to do some shushed-up giggling.

  One of the many truisms of medicine is that the doctor-patient relationship is foundational to the healing process. I have found that this involves each party learning how to teach the other. Many of the pearls of wisdom and the practical tips I’ve gleaned over two decades were discovered by my patients and taught to me. Some have subsequently been evaluated scientifically—while others remain anecdotal observations only.

  Delores Smith was one of those patients who taught me. This elderly woman suffered from recurrent nosebleeds that occasionally required a trip to the office for an anterior nasal pack or a cauterization. I had tried all of our standard treatments, but topical steroids, nasal saline, topical petroleum jelly, topical Neosporin, and room humidification didn’t help at all. I was befuddled. Finally I decided to try a new trick that I had picked up at a medical conference.

  “Delores, here’s a prescription for an antibiotic ointment. You just take a dab and rub it on the inside of each nostril—once in the morning and once in the evening. Then you kind of give your nose a pinch to spread the ointment a bit. If you use this every day, and keep using a humidifier, I think this’ll do the trick.”

  I didn’t see her for many months, and I was sure my therapy was the distinct reason she wasn’t coming in with any more nosebleeds. She next appeared in the office for her annual exam that spring. During the exam I commented, “Delores, I see from your chart that you’ve not been in for any more nosebleeds. I guess the ointment I prescribed must have worked for you.”

  “Well . . . ,” she started, then blushed, looking away. “A prescription ointment did do the trick.”

  There was an uncomfortable pause in the conversation. “Was it the ointment I prescribed?” I asked.

  Another pause—her eyes still turned away from mine. She shook her head no.

  “Whose then?” I asked.

  “Well, Doctor, it was a prescription from Canada.”

  Trying not to act too defensive, I inquired, “What type of prescription?” Actually, I was a bit curious. A family doctor can never have too many tools in his black bag. Maybe I would learn about a new one today.

  “Fortunately for me, Dr. Larimore, my sister Dianna, who lives in Nova Scotia, inherited the same family predisposition to these types of nosebleeds. Her general practitioner, an ancient man, explained to her that the rosiness of her ruddy Irish cheeks had just migrated into her nostrils. He explained that this seemed to happen in only the most sensitive and exquisite of the grand dames. My sister found this medical assessment charming—especially when this gentleman explained that even Queen Victoria herself suffered this malady.”

  What a cunning old codger, I thought to myself of my Canadian colleague. Amaster of the bedside technique!

  She continued, “He explained to her that as a woman matures . . .”

  Matures! What a great expression! My interest in and admiration for this fellow was increasing by the moment.

  “. . . the skin can thin a bit—become a tad more fragile, dainty, and delicate. This can be true inside the nostril as well as among other parts.”

  “So what did he recommend?” I wasn’t even remotely prepared for the answer.

  “Premarin cream,” Delores stated matter-of-factly.

  I couldn’t contain my surprise. “Premarin vaginal cream?” This common preparation of topical estrogen was often prescribed to women after menopause to thicken the walls of the vagina if vaginal dryness or pain during intercourse was a problem.

  Delores looked at me as though I was daft. “But of course! He said that the lining of a woman’s private parts and the lining of her nostrils contained the same type of skin. Didn’t you know that?”

  “Well,” I stammered, “of course I knew that. I’ve just never heard of using this cream in the nose.”

  “He told my sister that most doctors had never bothered to think this through, but that since the skin of both areas is the same, then the same treatment could be used for both. He told her he had been prescribing it for years.”

  “Well, quite frankly, Delores, it makes a bit of sense, I must admit. How did he say to use it?”

  Her smile radiated as she became the professor, I the pupil. She was fairly gloating in the experience. “This is what he told my sister to do, and it’s what I did too. I applied a BB-sized drop of the Premarin cream to the inside of each nostril with a Q-tip—twice a day for thirty days, then daily for thirty days, then three times a week for another month, and then one or two times per week until the weather began to get a bit warmer.”

  “How long did it take to work?”

  “I had no more nosebleeds after using the cream for just a few weeks.”

  “Mind if I take a look?”

  “Of course not.”

  The inside of her nostrils looked nice and pink. None of the unsightly little spider veins I had seen last fall.


  “Delores, your nasal mucosae look almost as beautiful as you do.”

  She blushed. I can pick up a thing or two, I thought—even across international borders!

  “Thanks for the teaching,” I said.

  She looked at me, cocking her head as though in disbelief. I could almost read her mind: A doctor—thanking me for teaching him?

  “Thank you,” Delores answered, “for being such an attentive pupil.” She smiled. So did I.

  The office calls during my first year in practice continually gave me a chance both to teach and to be taught. Ray approached me in the hall one afternoon about a patient with a skin problem—chronic urticaria, which is doctor-talk for hives. Ray had done the extensive laboratory tests recommended by an Asheville dermatologist he had called—and the lab tests were entirely normal. The medications he’d prescribed had either caused side effects or had had no effect. He and the patient were frustrated, and he was considering sending the fellow off for further treatment. But before doing so, he asked for a second opinion.

  I wasn’t sure I had a single thing to offer, but I did see the patient and spent some time taking an elaborate history—just like a detective looking for the perpetrator. But none was found. For some reason, toward the end of the interview, I remembered Terry Kane, M.D., my chief while I was in training at Duke University, who used to say, “You can take all the history you want, but when all is said and done, you gotta take their clothes off and look!”

  Although the young man was already clad in his briefs, and although his skin, hair, and nails appeared normal, I had him pull down first his briefs and then his socks. And there, underneath the socks that had never been removed before, at least in our office, was a rip-roaring case of tinea pedis and onychomycosis—doctor-talk for athlete’s foot and athlete’s toenails. Ray and I exchanged knowing glances. We both realized, instantly, that this was a likely cause for the hives, since a fungal infection of the skin can result in recurrent hives in a susceptible person.