by JULIAN EARL
A most unexpected patient was a tarantula with a broken leg which, being extremely out of the ordinary, did prove a challenge, for various reasons. Apart from the squeamishness that some people have about spiders, especially large hairy ones, they are usually a welcome and interesting patient and on the whole are harmless.
As a side note, skin diseases are very common in dogs and cats, forming approximately twenty per cent of all cases seen by vets. Dogs, unlike tarantulas and boa constrictors, are unable to shed an old diseased skin, more’s the pity. A lot of stress and difficulty would be avoided if a dog with recurrent and lifelong allergic skin disease could just grow a healthy new one. It sometimes takes considerable patience for an owner of a dog with persistent allergic skin disease to accept that, just like hay fever, it is not curable, merely manageable.
Similarly, a badly broken leg of a dog or a cat cannot be removed in order to wait for a replacement to grow, as with a spider. I would suggest that not many spiders receive a metal pin or a cast to fix a damaged leg.
Tortoises were only mentioned briefly in my degree course. They are impossible to examine in the same way as a larger mammal species, simply because of the shell. One cannot feel anything internally, in contrast to a cat or dog, where a precise diagnosis can sometimes be given on the basis of what can be palpated (felt) inside the abdomen using one’s fingers. Weight loss can be a sign of serious illness in a tortoise, and one method of examining them internally is via X-rays. Tortoises are easy to X-ray because, being tortoises, they don’t make sudden movements just when we need them to stay still for the picture. In contrast to dogs and cats that can move at the critical moment, or jump off the table, so necessitating sedation or anaesthesia, with tortoises you just place them on the X-ray film, hope they don’t move, press the button and, hey presto, the job is easily done.
Tortoises have their problems, apart from falling off walls. Having been presented with a forty-year-old tortoise who was losing weight, an X-ray revealed her to have five eggs stuck inside her. The eggs were clearly visible on the X-ray and had probably been there for four or five months. Therefore this case, like that of the boa mentioned previously, was another unexpected pregnancy and the tortoise was ‘egg-bound’. As we were relatively inexperienced with tortoises, a colleague in the practice telephoned a reptile expert who instructed us on what to do. ‘Anaesthetise the tortoise, lie her on her back, cut open the shell on the underneath (called the plastron) in the shape of three sides of a square, fold the flap back, remove the eggs and her ovaries and womb, replace the cut plastron and superglue it back into place. It will take about one year to heal together.’
We immediately looked at each other, blinked in shock, and both stated: ‘No way!’ Absolutely no way. We were not brave enough, nor perhaps foolish enough, to venture into new surgery like this. Luckily I suddenly remembered the boa from many years previously, and we gave the same standard medication that I’d used on the boa, oxytocin, the hormone involved in births. We administered this, at the appropriate dose rate, and without any exaggeration, within five minutes of putting her back in the basket the tortoise had passed all five eggs. She gave birth to these as easily as if we were shelling peas. If only all births were as quick and simple. The kind owner was so grateful; he gave me some of the eggs to keep as a memento. I still have them next to me as I write, in fact. We all decided that a couple of injections were a lot less stressful for everybody, especially for the tortoise, and certainly less traumatic than surgery. Several egg-bound tortoises later, this treatment has always worked and I fully intend never to operate on a tortoise as was originally recommended.
Chapter 8
Common things are common
Uncommon things may also occur
The phrase ‘common things are common’ is often quoted to us as students and inexperienced new graduates, when we worry about being presented with some unusual disease that we are not familiar with. We are told to consider the commonest possible diagnoses first and not start by looking for some obscure, exotic disease when the most likely diagnosis is something that is not unusual at all. Similarly, if you haven’t made a diagnosis yet, it is most likely not the case that you don’t actually know – you simply just haven’t looked hard enough. The clues are there, if you look more closely, to present you with the correct diagnosis. It has been useful to remember this in order to save wasting time, effort and expense looking for something that is highly unlikely to be the cause of a problem. You don’t take a dozen skin biopsies to diagnose a frustrating skin condition without first checking all pets in the household, the unseen cat as well as the dog in front of you, for example, for fleas. Fleas are common; unusual skin diseases are more – well – unusual.
However, there are, in addition, a lot of conditions that have surprised me over the years in terms of how frequently they are identified in a general veterinary practice. For example, once upon a time, diabetes in a cat was so rare that the vet could justifiably report a case in the veterinary press, but now diabetes is commonly identified in both cats and dogs. Although it is less frequent in cats than dogs, it can be described justifiably as an epidemic, as it is in humans nowadays. The reasons are probably similar: diet, exercise and obesity being contributory factors for people and animals alike. Fortunately, control and treatment are better understood now, and many owners have had to learn how to inject their pet with the appropriate dose of insulin needed, in most cases twice daily.
I had also once thought that the hormonal condition named Cushing’s disease would be a rarity in dogs. In fact it has proved remarkably common. One becomes adept at spotting the warning signs for the condition: drinking excessively, loss of muscle mass, skin thinning, hair loss; and it is luckily controlled well by new treatments. Cushing’s disease is caused by an overproduction of natural steroids as a result of a tumour in either the pituitary gland under the brain or in the adrenal gland by the kidneys.
So, while common conditions are indeed common, ‘uncommon’ conditions can be at least significantly more common than one expects. A good example would the brave vet who stopped the abattoir production line on the basis that he suspected he was seeing foot and mouth in 2001. I would expect that he first thought, ‘No it cannot be foot and mouth, surely?’ A brave decision indeed, was made to stop the abattoir working on suspicion alone and of course we now know he did exactly the correct thing. If I wore a hat, I would take it off to him. ‘Chapeau!’ as one might say.
Then, there are other conditions that appear to be completely new, but one quickly realises with hindsight that they might not be new at all, just unrecognised. The most obvious example for me is the common condition seen in older cats, called hyperthyroidism (over-activity of the thyroid gland). It is usually a result of a benign tumour of the thyroid gland in the neck. This is seen when the thyroid gland tumour produces excessive amounts of hormone. Thyroid hormones control the speed of the body’s metabolism, and excessive hormones increase the metabolic rate. It is similar to a stationary car being revved excessively – all noise and fuel consumption, but no action. The cats are abnormally hungry but lose much weight as they burn up the food. They are sometimes hyperactive, groom excessively and are restless, and eventually can develop heart disease as their heart bounds along trying to cope with the increased metabolic rate. This condition was identified in the late 1980s in the USA, I believe. Previously, old cats losing weight were often thought to be suffering from the all-too-common kidney failure seen in older cats (about one in three old cats develop kidney disease). And ‘common things are common’ so kidney disease is always the first line of investigation. Then we suddenly realised (and when I say ‘we’ I mean me, of course), that many of these older cats that we’d been seeing for years, still had good appetites. Some of these almost certainly were hyperthyroid cats before the condition had been identified. Now it is known to be common, often occurring together with kidney disease in older cats. Treatment is more or less straightforward, either by daily table
ts or by a fairly simple operation. It is usually a very rewarding condition to deal with because, in two to three weeks after starting treatment, the cats often start returning to good health.
If only all conditions were like that. At the moment the reasons for hyperthyroidism and why it is so common are currently unknown. In any case, this was not a condition mentioned at university because no one had identified that it existed. This condition falls into the category of new knowledge that is available, and we were told that this doubles every ten years, making it somewhat difficult to keep up to date in every subject. It is no wonder that specialisation in the profession is an attractive option, allowing one to concentrate on one’s chosen interests.
Back a few years ago, when I was a student – with apologies to my lecturer – I’m afraid to say nutrition was not very interesting, quite tedious to be honest. But then, by working on farms, I quickly realised just how crucial feeding is to health, welfare and production in livestock. It was only by working on farms and trying to get to grips with herd- or flock-wide problems that I made a determined effort to study nutrition, the way I should have done as a student many years previously. When attending a conference on sheep health and production I heard a memorable phrase from a speaker, the late and wonderful sheep-vet Andrew M. We had many different speakers come to that society’s conferences, but Andrew was the most eloquent, the wittiest and most informative and a key member of the Society. I have always remembered his comment: ‘There are three secrets to successful sheep farming: nutrition, nutrition and nutrition!’
Very true.
So it seems obvious now, but I have learnt since qualifying that nutrition is not a dull subject after all. Indeed, with poorly pets, many conditions can be treated quite successfully by feeding the appropriate diet – chronic kidney disease being the most obvious example. Those many elderly cats with kidney disease can have their life extended and quality improved by eating the correct prescription diet for kidney disease. No medication can make as much difference as diet for cats with kidney disease. Approximately one-third of all elderly cats develop kidney disease, and having effective dietary treatment is a huge advance for them, and far, far more effective than any tablets we can dispense.
Probably the most important and significant advance in the way we now treat animals has been the much greater use of pain relief. Many years ago, if an animal had for example, a broken leg, pain relief was perceived as risky and probably counterproductive by encouraging the patient to use the affected limb before healing was complete. Likewise, pain relief after routine surgery was thought to enhance activity before wounds were sufficiently healed. Apart from the moral questions raised by this attitude, scientifically it was unjustified as well. Pain can delay healing, can prevent animals from eating properly, and no matter how pain is described or defined (a subjective unpleasant sensation that is aversive), pain is painful and undesirable by any standards. A significant change is that routine pain relief is now standard across the profession for our patients. I have argued that while antibiotics are sometimes essential, pain relief is very frequently required; injuries and wounds are painful; operations are painful; infections cause fever and probably pain as well. We do not know if animals suffer headaches or migraines, but severely dehydrated people comment that they feel that have the ‘hangover from hell’ which apparently includes severe headaches and head pain. It is only reasonable to assume that the very many dehydrated animals that we deal with feel the same so, in my humble opinion, as well as fluids, such dehydrated animals should also probably receive pain relief. Pain relief is now approaching standard treatment, and the widespread use of pain relief is a huge boost for animal welfare. I readily admit to prescribing pain relief for many, many cases that I see, regardless of whether trauma has been involved or not.
I once encountered a dog regularly demonstrating aggressive behaviour towards the owner, and physical examination was somewhat difficult. However, prescribing pain medication improved the dog’s behaviour overnight, much to the relief of the owner and presumably the dog as well. The remaining question was to identify the source of pain, preferably without giving or receiving pain. It was a useful lesson for me that behaviour might have a physical cause and not simply just be ‘one of those things’, a phrase I hate.
In fact, one common issue with which we are presented is the broad classification of behavioural problems. This was barely mentioned when I was at university, but one piece of advice that I regularly heard a vet give to owners that has stayed with me is this: The most important word you can teach a dog is ‘no’. This does not mean bullying the dog, but while having a well-behaved dog that will sit, stay, wait or fetch is very commendable it is more important that a dog learns not to chase children, bicycles nor chew the postman’s delivery and so on. ‘Stop’ or ‘leave’ are essential commands.
Other advances have included the tendency to encourage owners to brush the teeth of dogs and cats. Whilst it is much easier to start them when still puppies or kittens, most dogs and cats show signs of gum disease by their middle age, and extractions are common. Bearing in mind that the roots of carnivores’ teeth are generally much bigger than the portion of the tooth that you can see in the open mouth, extractions often require prolonged, difficult and delicate surgery, so dental hygiene has great benefits for our pets’ well-being. Fortunately our herbivorous farm patients do not need this brushing!
I was extremely surprised in my first eighteen months after qualification to see twelve cases of a surgical problem that I had expected to be unusual, even rare. I was really thrown in the deep end in diagnosing and treating this condition. It is called an intussusception, most easily described as when a length of intestine telescopes inside itself, and is both caused by, and a cause of, vomiting and diarrhoea. The affected intestine is completely blocked as a result and surgery is the only treatment option. The first case I saw was in a kitten aged six months, probably born about the same time that I qualified. Fortunately, the feel of this intussusception inside the abdomen was distinctive even for a new graduate and perfectly matched the description we had been given in lectures. The condition requires surgery; the simplest examples just involve untelescoping, and that is it. A number need the affected portion of intestine removing, which is very, very scary and tricky for an inexperienced surgeon. I subsequently saw cases in several dogs, usually puppies, some repaired as simply as the kitten, some needing major surgery for removal of the affected portion of the intestines. One dog had the intussusception as a consequence of eating the owner’s socks, so needed those removing as well. Despite all the experience achieved by dealing with these cases, I still dread this diagnosis because the worst intussusceptions are technically very fiddly and difficult to repair.
There have been many technological advances, most of which have become available through developments in the human medical field. More specifically, for example, the availability of MRI scanning is wonderful, albeit very expensive, and supplies diagnostic information we would otherwise never obtain short of a post-mortem. More readily available has been ultrasound diagnosis, now performed routinely in many general practices. Whilst it does take considerable skill and experience to understand fully the black and white pictures of internal organs, I wait with eager anticipation for smarter computer programmes to create coloured pictures that will resemble the real organ being studied.
Blood tests are a routine method of investigation of course, but small portable palm-held machines that can produce dozens of results within minutes are now available, which are far more convenient than more expensive machines the size of a suitcase. On farms, these small machines can be very helpful. Eventually, similar machinery may be able to produce diagnostic results from milk produced by dairy cows, giving early warnings to farmers of a cow becoming sick before clinical signs of illness have had time to appear. If I am correct, this information could be sent automatically to a vet for decisions to be made very early in a disease regarding treatment. Howev
er, I do hope that I am wrong, because if I am correct, a vet won’t always be required to physically examine the animal and all we would be left to do are the laborious and the dirty manual jobs, such as difficult births, repairing wounds, removing smelly afterbirths and so on. The challenges to one’s brain are generally a lot more satisfying than physical challenges at work.
Chapter 9
Bloodstains and trauma
Nasty shocks
I’ve been chased and attacked now and again, which is unpleasant, but on one occasion I nearly gave a total stranger a heart attack. I had been to a farm to de-horn some adult cows. This is a job done to prevent cows from injuring either other cattle or people working with them (such as vets who might receive black eyes). De-horning is an extremely strenuous and sometimes bloody job, because the horn stumps can occasionally bleed profusely. The usual method of removal is by cutting through the base of the horn with abrasive wire. The wire saws through the anaesthetised horn and the friction of the wire should generate enough heat to cauterise the blood vessels as it cuts. It doesn’t always work perfectly however, and then the stumps of the horns can bleed a lot and the blood can spray in all directions.
The ten de-hornings I had to perform on this particular day had been like that. Blood had sprayed in my eyes and face, up my nose, and all over my overalls. Unfortunately, there had been no opportunity to wash before driving back to the surgery. I was heading back in my VW Golf, along the road across the Pennine hills, travelling at a legal but fairly rapid 60 mph. I travelled along the undulating moorland road, down one dip, up the following rise, down and up and so on, and suddenly as I crested one rise, I saw another VW Golf coming quickly in the opposite direction and, to my horror, it was about a metre over the white line on my side. To this day I don’t know how we managed to avoid a major collision but we did, and reacted quickly enough to pull to our respective sides just in time. But with both cars being the same model, the door mirrors were perfectly level and the extremely loud bang as they hit each other was followed by my door mirror flying off my car to land in the heather at the side of the road, where it probably still lies to this day! Suitably shocked, we both stopped, and slowly got out of our cars.
