Bryson City Tales — Lessons in Daily Practice (Part 1) — Anal Angina

This is from the fourteenth chapter from my best-selling book, Bryson City Tales. I hope that you’ll enjoy going back to Bryson City with me each week, and that if you do, you’ll be sure to invite your friends and family to join us.

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LESSONS IN DAILY PRACTICE (PART 1)

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 pre- sented 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 obses- sion—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 habitu- ally 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 doc- tor prescribed and rub it on the end of his thang.”

“His thang?”

“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.

UPDATE: Although this event happened about 35 years ago, look what Up To Date says today about anal fissures: 

For patients with a typical anal fissure (ie, a single posterior or anterior fissure without evidence of Crohn disease), we recommend initial therapy with a combination of supportive measures (fiber, stool softener, sitz bath, topical analgesic) and one of the topical vasodilators (i.e., nitroglycerin) for one month, rather than surgery. 

(TO BE CONTINUED NEXT FRIDAY)

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© Copyright Walter L. Larimore, M.D. 2016. This blog provides a wide variety of general health information only and is not intended to be a substitute for professional medical advice, diagnosis, or treatment from your regular physician. If you are concerned about your health, take what you learn from this blog and meet with your personal doctor to discuss your concerns.