Suffering in silence

I actually thought about writing this story down in my blog a couple years ago.  The topic is pretty emotional for me and sometimes it's hard for me to sit down and write about those kinds of topics.  My office manager came to me the beginning of June and wanted me to write a blog post for cat month.  Since this story is about a cat and since it illustrates a problem a lot of cat owners don't know about, I thought now would be the time to tackle writing this.  
This is Archie's story.

The story actually begins several years before Archie came into my life.  I had a client who had two barn cats.  Actually he had quite a few cats.  There were maybe three or four that lived full time in his house and like most of us who a.) love cats and b.) live in the country, there were a collection of stray cats that lived outside in the barn.  The barn cats were well cared for and loved.  They were spayed and neutered and vaccinated.  One day he brought in two of the barn cats because he noticed they were drooling and having trouble eating.  Both cats had severe dental and mouth disease.  You could smell the rottenness in their mouths.  When I would try and open their mouths to look inside, the cats would cry and wince in pain.   The disease is called stomatitis and unfortunately, no one really knows what causes this.  As in this case, it is not uncommon for me to see this in multiple cats in a household (or barnhold (?) as in this case) and often the cats are related to each other.  It is thought there is a combination of viral and genetic factors that trigger stomatitis.  Or at least that is what I think is going on.   The only treatment that seems to work is extracting all the teeth in the mouth.  Steroids and antibiotics will calm down the inflammation, but does not cure it and the swelling and pain come back when the medicine is stopped.  Although full mouth tooth extractions will cure some cats of this painful disease, it does not cure them all.  If it works, it works well.  If it doesn't work, then the cat is still in pain.  There is a lot of expense and time involved in trying to treat this disease.   I started the cats on antibiotics and discussed treatment and cost with the client.  He took the cats home to think about what he wanted to do.

This is a picture of a cat with inflamed gums caused by ordinary dental disease.  Multiply the redness and inflammation by at least 100 fold and that is stomatitis.

The following week he called me with his decision.  These were stray cats that just showed up at his barn.  And while he truly cared for these cats, he had many other cats to care for and he was retired with limited finances.  But this man had such empathy for the plight of these two cats.  He could not justify spending the money to treat these two stray cats when treatment was far from guaranteed at being successful and he had many more mouths to feed.  He could not see them living their lives in pain either.  So in the end, he asked me to euthanize the cats.  He truly loved all his cats and was holding back tears the day he brought them to the clinic.  The decision was not easy.  To this day, I think he is one of the bravest people I have ever met.   I have such great respect for him for not letting these cats live out their lives in excruciating pain.  Little did I know at the time how I would be faced with a similar decision in my own life.

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I live on a farm and like most of my rural neighbors, I too have a collection of barn cats.  Years ago, I had a three legged house cat, but for reasons I won't get into here, I haven't had a house cat since then.  I do like cats though and because there are so many unwanted cats out there, I am OK with a few of them living in my barn and working to keep the rat and mouse population in check in my chicken coop.  They all get fed, spayed or neutered and vaccinated and get month flea prevention.  I make sure they get treated regularly for worms and that each of them gets a little attention and scratch under the chin every day.

One winter day a few years back, a new cat showed up at the feeding station in the barn.  This is not all that unusual.  This cat was particularly scared and would run anytime I would enter the barn.  It took 6 months, but by summer I was able to approach him at the feeding station and stand next to him while he ate.  I knew that he was an intact tom cat.  As with all feral or semi-feral cats that show up on my farm, I am always concocting plans as to how I will catch them.  Some are live trapped, but if I can get near them, I prefer to just pick them up.  And so it was with this cat.  One day I got my cat carrier ready.  I fed the cats and when this latest stray was happily eating, I very gracefully slid my hand to the back of his neck to hold his scruff and in one motion  my other hand reached underneath him to pick him up and put him in the carrier.  Smooth as silk.  I'm good at this.  Unfortunately I'm not perfect.  It did not go as gracefully on the other end.

Off to the clinic I went with my new cat and the usual plan.  He would be tested for Feline Leukemia Virus and Feline Immunodeficiency Virus and if negative would be neutered, vaccinated, dewormed, treated for fleas and then re-released back at my barn.  I carefully got him out of the carrier, but somewhere along the way I slipped up and lost my grip.  This terrified barn cat went on a mad dash around the treatment room at the clinic knocking things off shelves and walls.  Somewhere along the way I got bit trying to catch him.  One of my technicians astutely went and retrieved a large fishing net we keep in the closet and on one of the cat's laps around the room, she expertly caught him in the net.  She is good at this too.  

Everything after this was easy.  I cleaned up my blood that was laying around the clinic.  The cat was sedated and tested negative for FeLV and FIV.  He then got neutered and put in a cage to recover.   While it doesn't happen 100% of the time, I am always amazed at how these scared nearly feral stray cats can turn into a happy friendly cat the next day after being snatched up and neutered.  It happens a lot.  And so it was with this cat.  The day after neutering I opened the cage and ran my hand down his back.  He arched up his back as cats often do when they are being stroked and petted.  His back arching was quite pronounced and so I named him Archie.  After a few days of recovery, I took Archie back home to my barn.  He got along well with my other cats and although he was always a little more skittish than the others, if I was quiet and calm, I could always get him to come to me to be petted if only just for a bit.  One of his trademarks was that before he would come to me to be petted, he would rub his face on anything and everything that was nearby: the posts in the barn, a table leg, the leg of a saw horse, etc.

One day in the second year he lived in my barn, I noticed a little drool coming from the side his mouth.  You can see it in the picture above.  When I went to look in his mouth, he resisted quite a bit.  Although it was not full blown yet, I knew immediately he was developing stomatitis.  He acted fine.  He ate fine.  Except for that very subtle spot of drool that I had seen one time, you would never know by looking at him from the outside what horrible disease was brewing in his mouth.  But I knew because I had looked inside his mouth.  I spent the next couple months in denial because even though I knew what was happening, I am human.  One day Archie came up to me to be petted and would not even rub his face on anything along the way.  I could ignore his disease no longer.  Although I could run my hand down his back, he would run if I put my hand anywhere near his face.  I had a hard time being as brave as my client with two barn cats from a few years earlier.  I thought about putting forth the effort to extract all his teeth.  It might work.  It might not.  I thought about how many healthy cats there out there looking for a home.  I thought about how much pain Archie was living with every day.  It thought about a lot of things.  It took me longer than it should have to summon the courage for a decision.  There were many reasons involved in my decision, but I knew I could not bear to watch this cat be in pain.  I chose to euthanize him.

The disease that Archie had in his mouth was extreme.  My main reason for telling his story is to illustrate how much cats can hide pain.  Archie's disease did not suddenly appear overnight.  It was a process that took place over many many months.  In the early months, the signs of his pain were extremely subtle.  And while extreme cases like Archie's occur only occasionally, every day at the clinic I see cats coming in with all sorts of broken teeth, rotten teeth, gum disease, etc and almost across the board none of them are outwardly showing any symptoms.  One thing I can say for sure though is that all of these cats are in pain.  You may ask, if they are not showing any outward symptoms, how am I so sure they are in pain?  I am sure because 99 times out of 100, when I cure a cat of its mouth disease by pulling a bad tooth or other treatment I will get a follow up report from the owner that goes something like this:  "My cat hasn't played with his toy like this in years."  or "Well he was sleeping a lot, but I just thought that was what normal cats do.  Now he is up running around the house like a kitten again."

I want to emphasize again that lots of cats have some sort of dental disease, but very few are as severe as what Archie had.  Most are much more simple to treat and to cure.  But don't think that because your cat is seemingly acting normal that it does not have dental disease or dental pain.  They hide it so well.  They truly do suffer in silence.  This is why annual exams in cats are so important.  We are care takers of our animals and it is our duty to make sure they live as pain-free a life as possible.

Lumps and bumps part 2: lump-be-gone

In part one I talked mostly about benign lumps such as lipomas, fatty tumors, that can often be left alone unless they are causing a specific problem.  This blog is dedicated to lumps that should not be left alone.  As a veterinarian, it makes me sad when I see a pet brought into the clinic with a tumor that has grown too large to be removed.  Usually the history given to me is that the growth showed up about a year ago and didn't look too bad.  Then it suddenly started to grow over the last week or two and by the time the pet is brought in for an exam it is either too late to do anything or if surgery is possible it would be so extensive that a referral to a board certified surgeon is necessary.  This is especially true of lumps and bumps on legs.  Remember that when a surgeon cuts a lump off an animal almost always they will have to remove the skin over the lump as well.  On legs especially, there is just not enough loose skin available to cover the surgical wound at least without using some special techniques. It is so much easier to just remove a leg lump when it is small.

As I mentioned in Part 1, I think part of the hesitation about bringing a pet in for an exam to have a lump checked is that we as humans are all afraid of getting a bad diagnosis.  But the good thing about lumps on the outside of the body where they can be seen is that we can do something about them early and that can lead to a good outcome.  Within the past year, I said goodbye to two of patients that will always remind me of what is possible by taking care of cancerous lumps earlier rather than later.  Both patients were diagnosed with cancer.  Buddy had a fairly aggressive mast cell tumor diagnosed in 2008.  Buddy actually had two surgeries to remove his cancer.  Daisy Mae had mammary gland (breast) cancer in 2007 and had a partial mastectomy.  Buddy and Daisy Mae both lived to around 16 years of age which is a fine lifetime for a dog.  I have no doubt that both their lives would have been considerably shorter if they had not had surgery early on to remove their cancerous tumors.

Buddy at age 16  

Gosh I love old dogs.

Unfortunately I don't have a picture of Daisy Mae, but I do want to discuss mammary cancer in dogs for just a bit.  There are many things unknown in our lives, but one thing that has been proven is that if you get a dog spayed before she is two years old, you can really decrease the risk of mammary cancer later in life.  Because of a dog's anatomy, a female dog has on average 10 mammary glands or a chain of 5 on each side, plus or minus.  Sometimes dogs will develop mammary cancer in multiple glands and when that happens, a complete mastectomy is done.  First one side and then the other if appropriate.  A female dog's mammary chain runs from the "armpit" area under the front leg all the back to the groin under the rear leg.  That means to get all the cancer, a surgeon has to make a VERY long incision.  It looks like this.

This little dog was 8 years old, not spayed and never used for breeding.  All this pain and suffering, and nearly always preventable by spaying while young.  Fortunately for this dog, she had an owner that was willing to treat her disease before it became inoperable.  If she makes it one year, she has a very good chance of her mammary cancer being gone for good.

The moral of Part 1 and Part 2 of the lumps and bumps blog?  If your pet  has a lump and you don't know what it is, please have it checked out sooner rather than later.  Time is ticking.

Lumps and bumps part 1: Do you want to see a one pound lipoma?

I have learned a couple of things from blogging.  Number one, the first picture contained in a blog post is often the thumbnail that is used by other web sites when a linked back to the blog.  Number two is that some people don't enjoy looking at gross pictures of tumors and body parts.  I can't quite figure out why someone wouldn't want to look at something as fascinating as a one pound lipoma, but I accept that some people really do feel that way whenever I show someone a recently removed tumor and they turn white as a ghost and leave the room.  Oh well.  I guess the fact that I am fascinated by how things look underneath that covering of skin makes me well suited to being a surgeon.  And so to kick off this blog about tumors and lumps and bumps, I give you a picture of my dog Buddy.  He is lot cuter than a one pound lipoma anyway.

Onward to the blog about lumps.  I decided to write this blog because I have seen a few tumors lately where owners ignored a lump on their dog until the lump was so big or so aggressive that nothing could be done to save the dog's life.  I don't know quite why people wait so long, but it is not uncommon.  Sometimes it is money, but many times it is not.  Maybe it's that we all get busy with other things in our lives or there is some underlying fear that the lump may be something bad, but it is a common human reaction to put things off until they jump up and bite us.  So I thought I would share some examples of when lumps can be ignored and when they can't and how some lumps can be prevented and how some cancers in our pets can truly be cured.  Part 1 will be dedicated to benign lumps that can sometimes be left alone except when they are in bad locations or get really large.

Lumps and bumps are really common especially in dogs.  Lumps can be caused by infections (e.g. abscesses) or irritations (e.g. lick granulomas - that's a good one to type into a Google Image search) or lumps can be caused by abnormal growth of cells (tumors).  Tumors can be either benign or cancerous.

The case of the one pound lipoma

definition of lipoma = a benign tumor made of fatty tissue

Lipomas are one of the most common tumors we see in dogs.  They are benign although there is a cancerous counterpart called a liposarcoma, but those are relatively rare.  Most lipomas occur along the side or the lower part of the chest or the belly, but I have seen them on legs or the head on occasion.  One time I removed a lipoma from the side of a Labrador Retriever's head that was literally as big as the lab's head.  It looked like the dog had two heads.  This dog had been adopted from the local shelter with this growth and his new owners were kind enough to have this monstrous growth removed.  I just want to give people a big hug when they take on a senior dog from a shelter with a problem.

Some dogs get so many lipomas during their middle age to senior years that it would be impossible to remove them all.  Retrievers are especially noted for getting lots of lots of these growths as they get older. These growths are not painful, but if they grow in a bad spot, they can cause difficulty walking or moving.  Because lipomas are common growths that don't bother dogs very much, they are one type of tumor that is often left alone.  They can however get quite large.  My personal record was an 11 pound lipoma that I removed off the side of the flank of a dog.  The dog weighed (after surgery) 17 pounds.  That tumor was nearly 2/3rds of the dog's post-surgery weight.  Holy lipoma batman!

Some lipomas are soft and others have a more firm feel to them.  Some of them are quite easy to determine where they stop and where normal tissue starts.  Others "infiltrate" into normal surrounding body fat.  Through experience, most veterinarians can tell you whether they think a lump is a lipoma or not and most of the time they will be right.  But the truth is that none of us can truly know what kind of lump your pet may have without a biopsy (taking a sample of the cells from a growth and looking at them under a microscope).  And the other truth is that there are some cancerous growths that can feel identical to lipomas.  Hemangiopericytomas and mast cell tumors are two examples and those two growths can be very difficult to deal with especially if you let them get big.  I will say that I don't necessarily recommend a biopsy of every single "lipoma-like" lump, but there are times when I think it is a very good idea.

Teddy was a retriever that came to see me because his owners noticed a swelling in his upper thigh on the inside.  By feeling it I could tell it was a mass of some sort so the next step was to do a needle biopsy.  A needle biopsy (fine needle aspirate) is done by sticking a small needle into the lump and sucking out some of the cells with a syringe.  The cells can then be put on a slide and looked at under a microscope.  Needle biopsies are not nearly as accurate as taking a whole slice out of  a lump, but the nice thing is that most dogs don't need any sedation to get a needle biopsy sample.   Some tumors are really hard to diagnose with a needle biopsy but lipomas are pretty easy most of the time.  I did a needle biopsy on Teddy's lump and the report came back it was a lipoma. We decided to leave it alone for several reasons.  It was in kind of a bad spot to remove, it wasn't causing him any symptoms and because I knew it was a lipoma, I also knew that if it got a little bigger it would not be much harder to remove than it already was.

Teddy did just fine, but about 10 months later, his owners noticed that the lipoma was getting bigger and it was starting to affect how Teddy was using his rear leg.  We decided to remove the lipoma.  I was happy that this lipoma was one of the non-invasive kind and even though it was in a really bad location, it came out relatively easily.  As is typical of growths that are a little larger than average, I like to get them weighed and photographed.  And so here is a one pound lipoma hanging out next to a regular sized Sharpie for size comparison.

Even though lipomas are abnormal growths of fat cells, they are fat cells none the less. If you are carrying a little extra weight, just think about 10, 20, 30 or more of these little buggers hiding out under your skin.  I know I think about it every time I have that extra slice (or two or three) of pizza on a Saturday night.  Certainly gives me some motivation to get out and ride my bike.

Enough about lipomas.  Next blog is part 2 about lumps that should not be left alone.