Authors Posts by Michelle Gerhard Jasny V.M.D.

Michelle Gerhard Jasny V.M.D.

Michelle Gerhard Jasny V.M.D.
Michelle Gerhard Jasny, V.M.D. has been practicing veterinary medicine on the Vineyard since 1982 and writing the Visiting Vet column for more than 25 years. She lives and works in West Tisbury.

Xylitol, a common sugar substitute found in some medications, may prove fatal to dogs.

Tidbit is a tiny toy poodle, weighing only 5 pounds. OK, I don’t really have a patient named Tidbit, but let’s imagine I do. Little dogs pose unique challenges for veterinarians. It can be easier to wrestle an uncooperative Labrador than to safely handle an annoyed Chihuahua.

What tiny dogs lack in size, they frequently make up for with attitude. But we love their big spirits, and do our best to provide them optimum care. So my imaginary patient Tidbit has had a bad back for years, but now the pain medications we had been using were no longer doing the trick. Tidbit needed something to give her relief.

“Maybe we should try gabapentin,” I suggested. This drug is used in humans to treat epilepsy, restless leg syndrome, and as a pain medication for conditions like diabetic neuropathy. It is also used “off-label” for problems like anxiety, insomnia, and bipolar disorder. In recent years, veterinarians have begun trying gabapentin for pets. In dogs, it seems to be helpful treating chronic nerve-related pain, such as Tidbit was experiencing with her intervertebral disc disease.

The veterinary pharmaceutical industry produces many medications that are formulated and approved specifically for use in animals. Because these companies know our patients can range in size from 2 pounds to 2,000 pounds, they typically market a wide variety of strengths to accommodate this. But veterinarians also utilize pharmaceuticals manufactured only for people. Gabapentin is such a medication. If I wanted Tidbit to try it, I would need to prescribe the human product from a local pharmacy. “Let me figure out her dose,” I said, grabbing my calculator. But for the teeny dose needed for this teeny dog, the tablets made for people were way too big, even if we broke them into quarters.

In such situations, veterinarians may use compounding pharmacies to prepare appropriately downsized doses for little patients. Other times, we may find that certain medications are already available commercially in liquid form, designed for children or people who have difficulty swallowing pills. These liquid formulations make accurate delivery of very small doses easier.

“Oh, look!” I exclaimed as I read through my drug formulary. “Gabapentin comes in a liquid. We could use that for Tidbit … oh … wait … no, we can’t.” Why not? Because the liquid product for people is sweetened with xylitol, and even in small doses, xylitol can be lethal to little dogs.

Xylitol is a naturally occurring substance found in plants such as berries, lettuce, and mushrooms. During World War II, a shortage of regular sugar led to the commercial production of xylitol, which could be manufactured from xylan, extracted from wood. A white crystalline substance, xylitol looks and tastes like sugar. Its use as a sweetener has become increasingly popular in recent years, not just because it has less calories than regular sugar, but because of its reputed beneficial properties. Chewing xylitol gum avoids sugar-related tooth decay, and also has antibacterial action that actually reduces periodontal disease, and may prevent ear and throat infections in children. There are even claims xylitol may reduce the risk of osteoporosis, endometriosis, uterine fibroids, and breast cancer. An occasional sensitive individual may get mild diarrhea from xylitol, but in general it appears to be safe for people. It is now found in all kinds of products, including sugar-free gum and mints, toothpaste, mouthwash, and even cakes and candy.

So why is xylitol dangerous for Tidbit? When people consume xylitol, the sweetener is absorbed very slowly into the body without inducing a significant release of insulin. But Tidbit’s body reacts differently. It absorbs the xylitol extremely quickly, and confuses her tiny canine pancreas. “Here comes a huge sugar rush,” her pancreas thinks. “I better pump out a big blast of insulin fast!” But her body doesn’t really need that big insulin surge. Xylitol is not real sugar. The insulin surge makes Tidbit’s blood sugar plummet. This profound drop in blood sugar is life-threatening. The first sign is usually vomiting, followed by lethargy, weakness, collapse, seizures, and sometimes, death. Onset of symptoms is rapid — as little as half an hour after ingestion — but occasionally may be delayed as long as 12 hours. Effects may persist for a day or more. In a small dog, ingestion of just two pieces of gum can be fatal.

Not every sugar-free product uses xylitol. Aspartame, saccharin, sucralose, and stevia are other common artificial sweeteners, and these do not cause hypoglycemia in dogs. But more and more products are now using xylitol. Some of the common xylitol-containing products you might have in your house include Trident gum, Icebreaker mints, Tom’s of Maine Toothpaste, and TicTacs. Some over-the-counter medications that used to be safe to use in dogs have been reformulated to be sweetened with xylitol. Even a kind of peanut butter spread sold by GNC, called Nuts ‘n More, contains xylitol.

So what should you do if Tidbit eats the Trident? As with any poisoning, first grab the package, as that will help your veterinarian determine the degree of exposure. Then call your veterinarian, pronto. If ingestion was recent, we can try to get it out of her system by inducing vomiting. If, however, the xylitol has already reached the bloodstream, it is too late for making her throw up. Instead, we must monitor her blood sugar levels. If they are too low, it may be necessary to give intravenous fluids containing dextrose for 24 hours, or even longer. Once treatment is instituted, the prognosis is excellent, though in certain cases dogs may develop liver failure up to a week later. Symptoms of liver failure include vomiting, lethargy, bruising, and gastrointestinal hemorrhage, and it is often fatal.

The take-home message is simple. Read labels. Carefully. If xylitol is in the ingredient list, don’t give it to your pet. For my imaginary patient Tidbit, I’m calling the imaginary compounding pharmacy and having it mix up a batch of imaginary liver-flavored gabapentin, sans xylitol, which I hope will relieve her imaginary back pain.


Violet’s mysterious malaise.

Violet is a bichon frisé. No, that’s not a kind of lettuce. It’s a canine breed the AKC describes as a “small, sturdy, white powder puff of a dog” with a “merry temperament.” Bichons generally range in size from 11 to 22 pounds, but Violet is one of the smaller ones, weighing in at a mere 13 pounds. Now a senior, she had been having a series of troubles lately. She had inadequate tear production in one eye, causing a gooey crusting all around the eyelids, but she strenuously resisted efforts to clean and medicate the eye and surrounding area. Her mother recently reported occasional discharge from one nostril, but Violet was becoming steadily more irascible when we tried to examine her head closely. We couldn’t check her teeth at all. Small dogs are notoriously prone to serious dental disease, and since clearly something around her muzzle was hurting, we suggested anesthetizing her for a thorough assessment and dental cleaning. “I bet she has loose or infected teeth,” I said, thinking there might be even more extensive dental problems.

Maybe she had a tooth root abscess. This can start as a result of injury, like a broken tooth, or from bacterial invasion in or around the tooth. In dogs, the big upper fourth premolar, called the carnassial tooth, is particularly susceptible. When this chomper gets infected, a tract often forms extending upward, causing a swelling just below the eye which sometimes opens and drains pus. Affected dogs may drool excessively, rub their faces, and often stop eating because of the pain. Oral antibiotics may be sufficient treatment, but extraction of the offending tooth is often necessary to prevent recurrence. Untreated infected tooth roots can progress to infection in the actual bone of the jaw, called osteomyelitis. Another dental issue that impacts more than just the mouth is oronasal fistula. This typically involves the big upper canine tooth, which has an exceedingly long root that extends upward almost all the way to the nasal passage. When this fang gets infected, an open tract can develop, going from the mouth along the tooth root into the nasal passage. Affected dogs may sneeze and have chronic nasal discharge.

Before proceeding with our plan to explore Violet’s mouth, we ran blood tests — SOP before anesthesia, especially for older pets. Wouldn’t you know it? The results indicated potentially serious liver problems. We needed to delay the anesthesia while we gave her medication to support liver function and antibiotics to cover for oral infections. Over time, her condition improved, until she finally seemed well enough, and we proceeded with the anesthesia and dental cleaning.

Violet felt better for a while, but soon her malaise recurred. “I’d like you to see a specialist,” I advised. “Actually, several specialists.” An ideal workup might include consults with a veterinary dentist (for dental x-rays and evaluation of her teeth), an internal medicine specialist (for ultrasound-guided biopsy of her liver), and an ophthalmologist (to check that crusty eye.) Her owner was amenable, but the referral was delayed several times. First the dentist was having problems with his x-ray machine. Then the referral coordinator didn’t call the owner back. Finally things were arranged, but before Violet could see the dentist or ophthalmologist, bad news from the internal medicine specialist put a stop to any further consultation. The specialist suspected that Violet had a tumor growing deep inside her nasal passage that was the source of all her troubles.

Tumors inside the nasal passages occur most commonly in middle-aged or elderly dogs. The vast majority are malignant. Although they don’t tend to metastasize, i.e., spread to other parts of the body, they are usually highly destructive right where they are, often leading to euthanasia as a pet’s quality of life rapidly declines. Clinical signs can include sneezing; nasal discharge, sometimes bloody, from one or both nostrils; ocular discharge; and facial distortion. If both nasal passages are involved, the pet may exhibit trouble breathing or excessively noisy breathing. Occasionally such tumors eat through the bones separating the nasal passages from the brain. When this happens, signs can include seizures, behavioral changes, dull mental status, blindness, circling, and abnormal gait.

These tumors are not visible from the outside, at least not until they are so advanced that the cancer causes facial distortion. Diagnosis relies on radiographs, MRI, or optimally CT scan, to reveal the presence of a mass. These can also show if there is destruction of the bones surrounding the nasal cavity, a finding highly suggestive of cancer, but not definitive. Definitive diagnosis requires biopsy, usually obtained by rhinoscopy, in other words, looking up the nose with a fiberoptic scope and taking a tissue sample to be evaluated by a pathologist.

Long-nosed dogs have a higher risk, and breeds reported to be particularly prone include Airedale, basset hound, Old English sheepdog, Scottish terrier, collie, Shetland sheepdog, German shorthaired pointer, golden retriever, and Labrador retriever. Secondary bacterial infections occur frequently, often fooling veterinarians, just as we were fooled initially, into thinking the problem stems from infected tooth roots. Radiation therapy is the treatment of choice, but the prognosis is guarded at best, and recurrence is common.

Now, don’t panic if your dog gets a nasal discharge. There are many other things that might cause that. Some cases actually are caused by dental disease, or bacterial or fungal infections, even allergies. Foreign bodies like blades of grass or plant awns can get caught up inside the nose. Benign nasal polyps or even little critters called nasal mites are sometimes the culprits.

Violet was not so lucky. Her CT scan revealed advanced cancer, extending into both nasal passages, behind her eye, and into her sinuses. We will try to keep her comfortable with pain medications as long as she shows her “merry temperament” at home … but when this sweet little flower begins to fade, when her quality of life is failing, we will know it’s time to say goodbye.



Vets are often still on the ‘Little House on the Prairie’ model

If you’ve been reading my column faithfully, you already know I broke my big toe a few weeks ago. (I like to remind people I did it falling off my bike, an admirably active undertaking.) It happened on the weekend, so I went to the emergency room after the accident, where they diagnosed the fracture. Then I went home, put my feet up, and waited for the swelling to subside. But day after day my whole foot remained swollen and painful. Now, I’m not particularly stoic, but I figured it was probably a sprain, so I stuck it out for two weeks. Finally I called my doctor. “He’s just going to refer you to the orthopedists,” the receptionist said. “Why not go straight to them? Here’s the number.” So that’s what I did. Straight to the specialists. Do not pass Go. Do not collect $200.

When I was a kid, we had a “family doctor.” Think Dr. Baker on Little House on the Prairie. Our doc made house calls when we were sick … that’s how old I am. Nowadays doctors specializing in family medicine, general pediatrics, or general internal medicine provide people with what is called “primary care.” This is defined by the American Academy of Family Physicians as care provided by physicians specifically trained for and skilled in “comprehensive first contact and continuing care for persons with any undiagnosed sign, symptom, or health concern not limited by problem origin (biological, behavioral, or social), organ system, or diagnosis.” Your primary care doctor knows an amazing amount of stuff, but when you break your toe, he still may send you to the orthopedist.

Veterinarians, well, we’re still on Little House on the Prairie much of the time. On the other hand, just as the practice of human medicine has become exponentially more sophisticated, moving more and more toward specialization, so has veterinary medicine. The dilemma is this. Few people question when their primary care physician sends them to a cardiologist when they are having chest pain (even when it means a trip off-Island.) If you have cancer, you go to an oncologist. If you have glaucoma, you go to an ophthalmologist. But if you have a dog or a cat, you just go to your veterinarian, and expect optimum care. Today we have the ability to refer Rover and Fluffy to veterinary dentists, surgeons, ophthalmologists, dermatologists, oncologists, cardiologists, and so on. In fact, we are ethically obligated to at least offer such referrals whenever a pet’s problems go beyond the basics, but most pet owners hesitate when we suggest taking an animal on such a journey.

For normal people (i.e., those living on the mainland), consulting a veterinary specialist is less daunting than for Islanders. For us, such an appointment likely means a whole day of lost work, a hard-to-get ferry reservation, maybe even an overnight stay in Falmouth. It is a stress on a sick animal as well as on the owners. “I don’t think Fluffy can handle the car ride,” I often hear from the owners of seriously ill or elderly pets. Sometimes it’s the humans who can’t manage the traveling. There are a surprising number of Vineyard folk who don’t feel comfortable driving off-Island, especially if it involves a foray into the city. That often leaves us in a bit of a conundrum. We can’t force a client to go to a specialist, but when they don’t go, we are often faced with having to treat a patient without a definitive diagnosis, without optimum equipment, facilities, or staff, and without the focused training, expertise, or experience to provide state-of-the-art care.

In some ways, this need for figuring out creative solutions is often what has drawn an individual to go into veterinary medicine in the first place. We tend to be a pretty independent bunch, and the challenge of figuring out how to wing it in such circumstances is just part of what we do. But times are changing, and so are the expectations of pet owners. Every veterinarian has his or her own approach to handling referrals. Some eschew sending clients to specialists, focusing on providing the most comprehensive services they can right at their practice. This makes life easier for clients in many ways, but can also do them a disservice if they end up missing out on receiving state-of-the-art care. Other veterinarians refer very frequently, insuring access to optimum care, but then not always being able or willing to provide well for those clients who choose not to go to a specialist. Most of us live somewhere in the middle, offering referral, but doing our best to be that old-time doc and make do when needed.

Which brings us to the crux of the matter. The decision about whether or not to seek the care of a specialist is really up to you, the pet owner. You have to weigh the pros and cons. Face the medical facts, have realistic expectations, then take responsibility for the decision. Please try not to blame your “primary care” veterinarian for not being an ophthalmologist, surgeon, oncologist, dermatologist, and cardiologist, all rolled into one. We know it can be expensive, time-consuming, and emotionally draining when your pet has a serious illness. We can’t change the cost of a specialist, or the ferry schedule. We can’t change that a pet has cardiomyopathy, lymphoma, or a broken leg. What we can do is try our best to help you navigate your options.

The orthopedist said I needed a CT scan. That took several days to arrange, and several days more to get the results, but I didn’t mind. I was just grateful we don’t have to go off-Island for these anymore, that I could get it done right here at our hospital. While I waited for results, I pondered all the limping dogs I have seen these past 30 years. And the fact that none of them ever had a CT scan of a paw.


Counting your pet’s appendages.


I fell off my bike last week and, being old enough that I no longer bounce well, I broke my toe. My big toe. Which got me thinking about toes. “Maybe I should write about broken toes in dogs,” I thought. “Dogs don’t have big toes … and they don’t all have the same number of toes,” I thought, my mind tumbling down the rabbit hole of free association. Human doctors have it easy. Most of their patients have the traditional five fingers per hand, five toes per foot. Counting them is standard. Start at the inside and count outward. One, two, three, four, five. If you want to get fancy, name your fingers. Thumb, index, middle, ring, pinky. Want to get really fancy? Use medical terminology. The big toe is the hallux; the thumb, the pollux. Bear with me and indulge my love of etymology. Hallux is derived from the Latin allus, meaning “great toe,” which is in turn derived from a Greek word meaning “to spring or leap,” evidently referring to the big toe in action. The definitive etymology of pollux is more elusive. Some sources suggest it stems from a Latin word meaning “to project,” I assume because thumbs stick out away from the rest of our fingers. I prefer the explanation that pollux comes from the Latin polus, meaning “a pole on which the heavens turn” (like the star Polaris) … and thus might refer to our wonderful opposable thumbs.

To talk about paws, we have to clarify a few terms. Imagine your pet’s paws as analogous to human hands and feet. The hand bones that go from our wrists to our knuckles are called metacarpals. Same for front paws on Castor the cat and Pollux the poodle. Our metacarpals are numbered one through five, starting with the one connecting to the thumb, and we have five fingers per hand, called digits, numbered the same way. Same for Castor and Pollux, starting with the shorter first digit on the inside of the front foot often called the dewclaw. More about dewclaws in a moment. Stay tuned.

Now, for hind feet. The bones that go from our ankles to the base of our toes are called metatarsals. Same for hind paws on Castor and Pollux. Human metatarsals are numbered one thru five, starting at the big toe. Here’s where it gets tricky. The majority of dogs and cats only have four metatarsals, and four hind toes. But some have five — a dewclaw on the hind foot. It may be fully developed, complete with a joint articulation, or it may be rudimentary — nothing more than a toenail dangling from a bit of skin. Some dogs even have two or more of these rudimentary dewclaws per foot. So how do we standardize numbering the bones of the hind feet, taking into account all these variables? Since there may or may not be dewclaws, and since embryologically the hind dewclaw is analogous to the human big toe, we always count the hind dewclaw as No. 1 … whether it exists or not! Thus for your typical four-toed pet, the existing hind toes and associated metatarsals are numbered two, three, four, and five. No No. 1.

What about “double-pawed” cats? The technical term is “polydactyl,” meaning “many toes.” Sometimes those extra toes are fully developed, complete with articulated joints. Others are just extra-large, or additional, rudimentary dewclaws. Even among veterinarians there is confusion about how to officially describe all these tootsies. I usually resort to drawing pictures on the medical records. Who cares about counting toes, anyway? Why does it matter? Medical clarity. If we are removing a tumor from between two toes, we want to all agree on exactly where that growth was. If it grows back, is it in the same place, or a new location? We need a standardized system.

Why else does anyone care about dewclaws? In dogs, if you want to show Pollux, different breeds have different standards. For example, the official American Kennel Club standard for the Great Pyrenees includes double dewclaws behind and single dewclaws in front. On the other hand, the standards for poodles, and many other breeds, specify that any dewclaws should be removed. Pollux doesn’t care, but dog-show judges do. Then there are folks who use their dogs for hunting or as guard dogs. Many such dogs traditionally have their dewclaws removed, on the theory that these extra protuberances can affect job performance by being vulnerable to trauma, such as getting caught in brush when running through fields. In some areas, dogs wear “hunting boots” to protect their paws from harsh environments, and hind dewclaws can rub on the boots and cause sores. Veterinarians have varying opinions. Some think dewclaws have no use and, having seen enough dogs injure themselves, favor routine removal of all hind dewclaws except for show dogs that are “required” to keep them. Others think we should leave dewclaws alone unless an actual injury occurs.

Traditionally, purebred dogs requiring dewclaw removal would have the procedure done within the first two to three days after birth. Veterinarians were taught to just snip them off. No anesthesia. Tail docking was often done at the same time, also without anesthesia. Nowadays there is more thought given to pain control, with some practitioners using epidural or local anesthesia, or even on occasion gas anesthesia, but then one has to balance the humane concerns with the anesthetic risks. For animals that are not going to be used for show or breeding, another option is to remove dangling dewclaws when the pet is anesthetized for neutering. Double-pawed cats may also benefit from surgical intervention in cases where the claw of an extra toe curls inward, and repeatedly grows into the flesh of the paw.

I’m out of time now, so I’m gonna go put my feet up and give my broken toe a break. This little piggie went to market, this little piggie went to town, this little piggie ….


The famed New York dog show began when a group of sportsmen decided to show off their dogs. This year the beagle is top dog.

This year’s Best in Show at the Westminster Kennel Club (WKC) Dog Show was a beagle named “Ch. Tashtins Lookin For Trouble,” affectionately known as “Miss P.” This is only the second time since 1907, when Westminster began awarding the Best in Show title, that a beagle has taken the trophy.

The show itself dates back to 1877, when a group of wealthy men who owned hunting dogs decided Manhattan needed a venue where their dogs could compete other than in the field. I always assumed the name was somehow connected to England. You know, Westminster Abbey, Westminster Cathedral — men with muttonchops and British accents dressed in hunt colors ready for the chase. But the truth is that the world’s most prestigious dog show was named after a hotel. The WKC web site cites Maxwell Riddle in a newspaper story by William Stifel titled “The Dog Show, 125 Years of Westminster”: “Westminster gets its name from a long-gone hotel in Manhattan. There, sporting gentlemen used to meet in the bar to drink and lie about their shooting accomplishments. Eventually they formed a club and bought a training area and kennel. They kept their dogs there, and hired a trainer. They couldn’t agree on the name for their new club. But finally someone suggested that they name it after their favorite bar. The idea was unanimously selected, we imagine, with the hoisting of a dozen drinking arms.”

The first show was held in Gilmore’s Garden, an open-air arena used for everything from temperance meetings to illegal boxing matches, which was renamed Madison Square Garden in 1879. Madison Square Garden has had multiple incarnations at different sites since then, with the dog show following along to its current location.

The show has weathered everything from the Great Depression to two World Wars, and is reportedly the second longest continuously-held sporting event in the United States. (The Kentucky Derby is first, by one year.) The first show had 1,201 entries, including a “cross between a St. Bernard and a Russian Setter” and a dog named Nellie, “born with two legs only.”

It has always attracted the rich, famous, and powerful. Past entries have included deerhounds bred by the queen of England, a Siberian Wolfhound from the czar of Russia, J.P. Morgan’s collies, a Russian wolfhound belonging to the emperor of Germany, a Maltese belonging to famous American journalist Nellie Bly, and even two staghounds listed as originating from the late Gen. George Custer’s pack. Miss P has had some lofty historical company.

Which brings me to beagles. I’m a big fan. That said, having lived with several during my life, I’m aware it takes a special breed of human to share their home with a hound. Beagles are scenthounds, dogs who find their quarry with their nose, as opposed to sighthounds, who rely on vision. The American Kennel Club gives the following advice about these cheerful, doe-eyed dogs: “Outside in open, unconfined spaces, keep your beagle on a lead, as they are liable to run anywhere, because their instinct tells them to follow their nose, no matter where you’d rather have them go. Beagles will make you laugh, but they are a challenge to train … [they] are at best temporarily obedient, due to their independent nature.” That about sums it up. I love the circumspect phrasing “temporarily obedient.” Miss P’s owners were more forthright, putting “Lookin For Trouble” right in her official name.

The definitive origin of the breed is unknown, but packs of hounds have been used for hunting in England since before the Romans. By the era of Queen Elizabeth I in the late 1500s, these were divided into large dogs for hunting deer called “buck hounds” and smaller ones for hunting hare called “beagles.” Some sources say the word “beagle” may be derived from the Old French beer or bayer, meaning “wide open,” and guele, meaning “mouth” or “throat.” Hence the word beeguele, or “open-mouthed.” That makes sense. No dog can top a hound for open-throated howling. Other sources suggest the word may come from the Gaelic beag, meaning “small,” but I prefer the first theory.

For show judging, beagles are divided into two varieties, those under 13 inches in height (measured at the shoulder), and those over 13 but not exceeding 15 inches. There are also several different kinds of field trials in which beagles may compete, either individually or as packs.

In the American Kennel Club’s 2014 list of most popular breeds in the United States, beagles came in fifth, outranked only by Labrador retrievers, German shepherds, golden retrievers, and bulldogs. Some of this popularity may be credited to “Ch. K-Run’s Park Me In First,” known by the call name “Uno,” who in 2008, became the first beagle to ever win Best in Show at Westminster. This led to a great deal of media exposure for the breed, as Uno attended events ranging from a visit to the White House to riding a float in the Macy’s Thanksgiving Day Parade. But Uno wasn’t the first beagle at the White House. President Lyndon Johnson had a pair named Him and Her while in office. According to the L.B.J. library staff, Her died after swallowing a stone, and Him was killed by a car while chasing a squirrel across the White House lawn, after which FBI Director J. Edgar Hoover gave the President another beagle. L.B.J. named him Edgar, and the pup retired to the L.B.J. ranch along with his owner at the end of his term.

Here on the Vineyard many people still keep beagles for rabbit hunting, but even these are often as much pets as they are working dogs. Because they have been bred to function in packs, beagles tend to be good with other dogs, but they do like to have a job. So if you decide to own one, be prepared. They need plenty of exercise, tend to roam, and are a vocal and mischievous breed.

Angus the Boston terrier stayed warm in this past week's frigid temperatures. – Photo by Jamie Stringfellow

When Mother Nature first graced us with two feet of snow, we diligently kept our animals inside through the actual storm, but afterward, nature called in a different way. My husband gallantly shoveled the back porch, and my daughter cleared a trail for our dog to make her way to the woods. The cats we confined inside with a litter box until there were pathways they could safely negotiate without drowning in drifts. By the second big snow, the animals were a bit wiser about how to manage, as were we, but we must remain vigilant to keep our pets safe through this unusually harsh winter. Now we are facing not only snow but exceptionally frigid temperatures. Let’s talk about hypothermia.

For those of you who have dogs or cats who essentially live outside, let’s skip the discussions about whether that is right or wrong, ecologically and philosophically, and stick to the medical. As long as a pet is acclimated gradually to cold, provided with adequate shelter from wind, rain, and snow, and is of appropriate age, breed, and robustness, outdoor living is usually fine — admittedly not the middle-class suburban vision of the life for a family dog, but nonetheless an acceptable option, embraced by working dogs and barn cats for centuries. But even for such rugged animals, spells of extraordinary weather can be life-threatening.

What happens when Chilly the chow gets cold? First, she alters her behavior to conserve heat, by seeking shelter or curling up. Her fur puffs up (called piloerection), trapping a layer of air close to the skin that serves as an insulator. She will shiver, the tiny muscular contractions generating internal heat. Her body protects core functions by constricting peripheral blood vessels, focusing circulation of her warming blood to the command centers of heart and brain. If all these mechanisms fail to maintain normal core body temperature, hypothermia results.

Any condition that impairs heat production or conservation predisposes Chilly to hypothermia. Smaller animals are more susceptible because of the larger skin surface in proportion to body mass. Short coats provide less insulation than heavy ones. In the very young and very old, thermoregulatory mechanisms may simply not function effectively. Thin animals have less heat-conserving body fat, and also reduced muscle reserves needed to generate heat. Dogs with arthritis or any disability, injury, or illness that impairs mobility, move around less, and as anyone who does outdoor winter activities knows, physical activity keeps you warm. Cardiac disease and endocrine abnormalities such as hypothyroidism also increase risk. A scrawny, elderly Chihuahua invalid who never leaves mother’s lap will quickly become a pupsicle in this weather. Chilly, the fat, fluffy, healthy, young chow with a sturdy insulated doghouse, who has lived outside all fall, may not even notice the cold, but unless he’s a sled dog acclimated to arctic conditions, even Chilly should come inside when the wind-chill factor is in the negative numbers.

Hypothermia often occurs because a pet is injured or lost: the dog who falls through the ice on a pond, the stray cat stuck in a snowdrift. But it doesn’t even have to be winter. Consider Gramps, the old terrier. Thin, arthritic, partially blind, he was sunning himself on the deck while his owner raked leaves on a crisp fall day. Busy doing yard work, no one noticed until dusk that Gramps had wandered off. Calling him was fruitless — Gramps was completely deaf. The neighbors and the animal control officer all joined the frantic search, but it wasn’t until mid-morning next day that he was found half a mile away. He had waded across a little creek, then stumbled into a ditch, injuring his leg. Wet and confused, unable to extricate himself, his night outside had led to significant hypothermia.

Early signs of hypothermia include mental depression, stiff gait, and lethargy. Shivering may be present, but ceases as hypothermia worsens. Pupillary responses become sluggish. Breathing is shallow and irregular. Heart arrhythmias may develop, as well as a profoundly slow heart rate. Blood pressure plummets. Eventually reflexes disappear, pupils are fixed and dilated, and the individual becomes stuporous or comatose. Severe cases may actually be mistaken for death. In human medicine they say about hypothermia cases, “You’re not dead until you are warm and dead.”

Moderate to severe hypothermia is life-threatening, but treatment must be handled appropriately to avoid worsening the situation. Too much movement may precipitate lethal heart problems, so patients must be transported slowly and carefully. Then rewarming can begin. In mild cases, “passive rewarming” may be sufficient, simply wrapping the patient in blankets and letting the body’s natural heat-producing abilities correct the problem. “Active external rewarming” adds heat sources like hot-water bottles or heating pads. These should not be applied directly to the skin, and should be concentrated around the chest, focusing on restoring core temperature first, not extremities. “Core rewarming” involves using things like warm intravenous fluids to increase body temperature from the inside. The complicated interplay of circulation, fluid balance, and heat transfer involved can occasionally result in sudden death called “rewarming shock.”

Large animals are also susceptible. Back when I still worked on horses, I treated a gelding that had fallen at the top of a steep hill in a blizzard. By the time I arrived, he was stiff and stuporous, his extremities icy cold. The wind was so fierce the intravenous fluid line kept freezing. We managed to warm and rouse him sufficiently that, after several hours and multiple attempts, we got him to his feet, but after several stumbling steps down the snowy incline, he cast himself again. Ultimately the owners opted to euthanize him as both his condition and the storm worsened. Gramps, too, did not survive. Although we restored him to normal body temperature, the leg injury was severe. This, his age, and other disabilities, led to the decision for euthanasia. So keep your pets close to home and toasty warm during this bitter weather. And take heart. Mud season is just around the corner.

And how do we get rid of it?

Yoga class. I haven’t done this in a while. When did my toes get so far away? I mindfully follow the teacher’s instructions, but my hiatal hernia objects to the pose. Burping discreetly, I shift to a more comfortable position. A hernia is defined as the protrusion of an organ, or other bodily part, through a wall that normally contains it. In my case, I have a fairly common condition affecting older, heavier people in which a small portion of the junction of my esophagus and stomach protrudes through the diaphragm into my chest. In a small number of human cases, surgical repair is warranted, but most hiatal hernias are small, like mine, causing few if any symptoms, and easily managed medically.

Hernias in pets come in many sizes and locations. The most common and least serious is the congenital umbilical hernia. When puppies and kittens are in utero, each one is attached to a separate placenta via an umbilical cord, which enters their tummies through an opening in the belly wall — the umbilicus. Normally at birth, the cord is broken and the opening in the belly wall closes spontaneously. But occasionally it stays open, allowing a little abdominal fat or membrane to poke out, creating a bulging “outie” belly button. These can range from tiny to fairly large protrusions, but rarely cause serious problems, and are easily diagnosed by location and feel. Often the contents can be “reduced”; in other words, the stuff sliding out can be slid back in by gentle massage. This confirms the diagnosis but doesn’t cure the hernia, as the defect in the abdominal wall persists, and things just slip out again later.

The main concerns with umbilical hernias are that an intestinal loop can get caught and “strangulated,” or the bowel may become obstructed. In these rare cases, the swelling will become warm and painful. The pet may vomit, experience loss of appetite or depression, or be straining to defecate. This is a surgical emergency. Radiographs or ultrasound can be useful in determining the contents of the hernia, but are rarely indicated if it is small and nonpainful. The cause of congenital umbilical hernia is not known, but it is generally thought to be an inherited condition, so affected animals should not be bred. More common in puppies than kittens, it can be easily repaired when the pet is neutered, though there is a high rate of post-surgical recurrence.

Other types of hernias include inguinal, diaphragmatic, abdominal, scrotal, and perineal. Anywhere things are supposed to be contained in one place but somehow poke into another place, you’ve got a hernia. Last year I saw a cat, Wolfy. Missing for three days, he had returned home, weak and in pain, with a swelling on the lower right side of his tummy. He had eaten moderately well, but was uncomfortable walking. His owner reported he had a penchant for climbing on the roof, so perhaps he had taken a tumble off the house. Despite cats’ amazing ability to land on their feet, it doesn’t always work out that way. In fact, it has been suggested that shorter falls may result in more serious trauma for cats, as they have less time coming down to right themselves. In any case, Wolfy had clearly had some kind of accident. Radiographs revealed loops of intestines protruding through the belly wall — an abdominal hernia.

Now in case you are picturing guts falling out on the exam table, back up a minute. There are multiple layers that hold Wolfy’s belly together. The outside layers that constitute the skin were intact. Just the inner abdominal muscles had ruptured, allowing intestines to slide out of the belly, but they were still enclosed within the skin. Traumatic abdominal hernias can vary widely in location, severity, and prognosis. I knew one elderly cat, Hope, who sustained a similar though much smaller injury. Because of her advanced age, her owners opted not to pursue surgical repair, and Hope lived a good long time after, with no complications. But Wolfy’s hernia was big and, although no spring chicken, Wolfy was considerably younger than Hope had been. Surgical repair of abdominal hernias can often be accomplished by simply sewing the damaged muscle layers back together. Sometimes, however, the defect is too large, the damage too extensive. Then the hole needs to be closed using a synthetic mesh implant. There was also the possibility that when Wolfy hit the ground, the blow caused other internal injuries, like a diaphragmatic hernia.

The diaphragm is the muscle that separates the chest and the abdominal cavities. Blunt force trauma, like being hit by a car, or falling off the roof, can cause a sudden increase in intra-abdominal pressure, altering the pressure gradient between chest and belly, resulting in a tear in the diaphragm. Maybe it’s a small tear, with nothing displaced from tummy to chest. Or maybe it’s bigger, with organs ranging from liver to stomach to intestines protruding into the thorax and putting pressure on the lungs and/or heart. In the latter situation, the patient will likely be in shock, with labored, rapid breathing. The gums may be pale or even blue if lung function is sufficiently compromised. Although surgery is necessary, first the patient must be stabilized. Surgical repair of diaphragmatic hernias is difficult. Once the surgeon opens the abdomen, the animal can no longer breathe independently, and a mechanical ventilator or trained assistant must “breathe for” the patient during surgery. Occasionally animals with diaphragmatic hernias show no symptoms at all, and can live for years without treatment, but the majority require surgery.

We referred Wolfy to a larger hospital here, with more veterinarians and fancier equipment. They did a wonderful job repairing a three-inch tear in his abdominal wall, replacing multiple loops of bowel in their rightful place. Happily, there was no damage to his diaphragm. I hope he will stay off the roof now. I am still trying to go to yoga, but taking it easy on those Downward Dogs.

Walter the beleaguered beagle.

Walter was a beagle-springer cross, so I was not surprised that he had an ear infection. Those breeds are both prone to otitis externa, the technical term for an ear infection. You know — when the canal gets all red and oozes that smelly, gooey discharge. Otitis may be caused by yeast or bacteria — sometimes both — and often is initiated by underlying issues such as allergies, frequent swimming, or problems with the anatomical conformation of the ear canals. We treated Walter with a standard ointment, a combination of antifungal, antibiotic, and anti-inflammatory medications. The otitis resolved but then quickly recurred.

“Let’s see what organisms are in there,” I suggested, smearing the green goop I had extracted from Walter’s ear onto a slide, which my assistant heat-fixed and stained. “Lots of cocci bacteria,” I concluded, examining the slide on the microscope. A pretty routine staph infection. Walter also happened to be diabetic, making him more susceptible to infections in general. We dispensed a second ear medication. The otitis got better . . .  then recurred . . .   again. This time as I tried to clean it, the canal began to bleed, and Walter was too tender to let me look down with my otoscope.

When faced with a stubborn case of otitis, there are several things we can try. We could take a culture and see exactly what organisms were growing in Walter’s ear. The laboratory could then run an antibiotic-sensitivity panel to determine the most effective drugs. But some specialists say that culturing an ear is like culturing the inside of a garbage can. You’re going to grow a lot of stuff, but not all the information you get will be useful. Instead, we decided to try a special brew many veterinarians mix up for such situations.

We start with a liquid called trizEDTA, which breaks down bacterial cell walls, allowing antibiotics to then penetrate into the organisms and fight the infection more effectively.  Adding liquid antibiotic to a big bottle of trizEDTA, I instructed Walter’s mom to fill his ears liberally with the fluid twice daily for two weeks. “This should fix him up,” I said confidently. Then, almost as an afterthought, I suggested a recheck in a few weeks. Six weeks later, Walter was back. Once again, the infection had responded, only to rapidly recur when the owner stopped the medication. “OK, let’s see what’s going on,” I sighed, thinking it was time to take a culture, and wheeling over my bright exam light to get a good look. I pulled up Walter’s ear and gazed carefully into the canal. Oh, my. I hadn’t seen that before. A small, red, cauliflower-like mass deep in his ear. “He’s got a growth in there,” I said. At past visits a combination of tenderness, blood, and discharge had made it difficult for me to see what was probably a small growth back then, which had now grown and was easily visible. (Or maybe I just hadn’t looked hard enough.)

Ear tumors are relatively uncommon in dogs, occurring primarily in middle-aged or senior pets. They can affect the flap, canal, or middle or inner ear, and can grow out of the skin, connective tissue, or various glands. They can be benign or malignant. Often there are no obvious clinical signs, depending on where the tumor is, what kind it is, and how fast it grows. If the tumor occurs in the middle or inner ear, neurological and balance problems may occur, resulting in walking problems, facial-nerve paralysis or head tilt. As they did with Walter, ear tumors may lead to secondary infection as they occlude the canal, hindering air flow and trapping debris and wax.

“A lot of times with ear tumors, it’s impossible to remove the whole cancer without removing large portions of the ear canal,” I told his mom. But we needed to start somewhere, so we scheduled surgery to remove as much as we could without being too invasive, and sent out a biopsy.  My hope was that it would be benign and thus not a big problem, even if we had to leave a little behind.

No such luck. Walter’s biopsy came back as ceruminous adenocarcinoma, a malignant cancer originating in the wax glands lining the ear canal. Although in dogs these tumors have only about a 10 percent chance of metastasis (i.e., spreading to other places such as lungs or lymph nodes), they tend to be locally invasive and aggressive. After consulting with a veterinary oncologist, Walter’s mom and I discussed the bad news.  “If you decide to pursue treatment, we start by taking chest x-rays and a lymph-node aspirate to make sure it hasn’t metastasized,” I said. “Then a CT scan gets done off-Island at the specialists’ to determine how far it has spread inside the ear.”  Then, more surgery. Although benign tumors can be removed with less extensive procedures, for this malignant cancer the oncologists advise total ear-canal ablation (TECA), which essentially removes all the ear structures while leaving the flap intact. In about one-quarter of cases, such cancers extend into the tympanic bulla on the skull, in which case the surgeon would also open this area and remove any abnormal tissue in a procedure called a bulla osteotomy. Postoperative complications might include facial-nerve paralysis, healing difficulties, and, of course, deafness on one side.

Walter is not a young dog, and his diabetes increases the potential for poor healing. There are only limited studies tracking the prognosis for dogs in Walter’s situation. Expected survival time for dogs with ceruminous adenocarcinoma who have the TECA surgery is reported to range from one to three years, but these statistics are based on very small numbers of cases. Without treatment, the oncologist says, Walter may develop trouble with his balance as the tumor spreads, and become severely uncomfortable within one year. His mom is considering their options, weighing all these factors . . . and I am taking a good long look down the ears of every dog who comes in with recurrent otitis.

“She’s in the spare bedroom, hiding under the bed,” the owner said when we arrived on our house call.  A recently adopted rescue from down South, this 40-pound bundle of terrified canine is a Louisiana Catahoula Leopard Dog. I had to look that one up. The breed is purportedly descended from crosses of wolves, Native American dogs, and the dogs of  Spanish conquistadors. Some say Catahoula is derived from Choctaw, a regional tribe. As for “leopard,” some have spotted markings, though they actually come with many coat colors and patterns. The Catahoula is the official state dog of Louisiana, and has been widely used to hunt game — everything from bobcats to wild hogs to bears. Knowing timorous Rachel, it’s hard to imagine her hunting bobcat. Today our mission was to give a Lyme booster and trim her toenails without totally freaking her out. “Can we just lift the mattress and work with her on the floor where she is?” her mom suggested.  “We can try,” I said dubiously.

When your pets needs to see their doctor, whether at a clinic, mobile facility, or at home on a house call, let’s face it. Some animals get nervous. Others get downright terrified.  Let’s talk about ways to lessen the stress on Fraidy Cat and Panicky Pup. If you think Panicky will do better at home, ask your veterinarian about house-call options, but most folks travel to the vet’s office, so let’s start there. Be sure Pan has a comfortable, well-fitted collar that he can’t slip out of. Harnesses and head collars are ideal. Occasionally dogs trot up to our door, then put the brakes on and back right out of their collars when they realize where they are. Happily, most run right back to their cars, but occasionally we end up with the dangerous situation of a frightened runaway dog.

For cats, use carriers. Period. I know. Fraidy hates the carrier. You can fix that.  It’s called desensitization and counterconditioning. Choose a well-ventilated carrier with enough room for Fraidy to stand up and turn around. Take the carrier out. Now. Not the day of your appointment. Now. Leave it on the floor with the door open. Let Fraidy explore. Feed her nearby. Gradually move the food bowl closer and closer to the carrier.  Put special treats and toys in or near the carrier. Eventually see if she will eat inside, with the door open. It may take months, but once she is adjusted, leave the carrier out and continue feeding occasional meals or treats inside. You have now turned the carrier from a terrifying instrument of torture to just another fun place to hang out.

So you arrive at the clinic. Now what? In cool weather, anxious pets may do better left in the car until the doctor is ready for you. Check with the receptionist. Larger practices may have separate waiting rooms for dogs and cats. Boy, would I love that. The best we can do at my place is good traffic control, keeping cats and dogs apart as much as possible. If needed, we bring certain pets in through the back door.  It kills me when a client exclaims “Oh, my dog loves cats!” as their Rottweiler sniffs Fraidy’s box in the waiting room. Well, the feeling ain’t mutual. Keep your animal away from others at the vets, please.

In the exam room, we try to greet pets quietly and help them acclimate. Treats. Pats. Soft, soothing tones. A slow approach.  You can help by also staying calm. Owners often use the right words but the wrong tone.”You’re OK, Pan!” they shout repeatedly in a loud, anxious voice. That doesn’t help.  Relax. If there is a chair provided, sit. Some behaviorists think that seeing you or the doctor seated tells Pan that he, too, can relax. Feeding treats throughout the visit helps too.  Of course, most dogs are not used to standing on tables, so the exam table can be daunting. This brings up the question of when to work on the floor versus the table. Usually the advantages of having Pan on the table outweigh the disadvantages. The assistant can use proper restraint techniques that are safe and gentle. The doctor has optimum lighting and easy access for a thorough exam. On the other hand, certain dogs do so much better on the floor, it’s worth the logistical challenges. Discuss it with your veterinarian. (And help me up off the floor. )

For cats, once they’re in the office, we need to help them out of the carriers thoughtfully. For most, it’s fine to simply reach in and take them out gently, but if Fraidy is hissing and cowering in the back of the box, she’s not bad. She’s scared.  Having a carrier that can open from the top or otherwise disassemble easily is helpful. If we take the top off and let Fraidy stay in the bottom half, often that makes her feel safe enough we can proceed.  Because of liability issues, and because we don’t want anyone hurt, it’s generally not smart to have owners restrain their own pets while we work, but sometimes it’s good to let cats and small dogs acclimate first for a while by sitting in their owners’ laps.

If Fraidy or Panicky are still basket cases, talk to your veterinarian about antianxiety drugs or sedatives to give at home prior to future appointments. It can take a while to find the right medication and the right dose, but our goal is always to have your pet have the most positive experience possible. As for Rachel, it was immediately apparent we couldn’t hold her safely on the floor. Instead, we stayed in that bedroom, where she felt a little safer, and her mom scooped Rachel up in her arms. We added a soft muzzle, so the people would be safe too.  While my assistant gently held her head and her mom patted her and made quiet, soothing sounds, I did my vet thing.

I still think we’re often flying by the seat of our pants when it comes to diagnosis, treatment, and long-term implications of tick-borne diseases.

Michelle-JasnyMichelle Gerhard Jasny, V.M.D. has been practicing veterinary medicine on the Vineyard since 1982 and writing the Visiting Vet column for more than 25 years. She lives and works in West Tisbury. She can be reached at:

Yaretzi, a handsome eight-year-old golden retriever, had a pretty typical history for an Island dog when it comes to tick-borne diseases. Lyme-vaccinated as a puppy, he still got infected as a young dog, but we caught it early and treated him. At five, he once again tested positive for Lyme and also for another tick-borne disease, Anaplasmosis. Additional tests indicated he had been exposed, and made antibodies, but was probably not actively infected with organisms.

“We don’t really know what we’re talking about when it comes to these diseases,” I admitted to his owner. Maybe I exaggerate our ignorance. There’s plenty of erudite information published in veterinary journals and textbooks, but I still think we’re often flying by the seat of our pants when it comes to diagnosis, treatment, and long-term implications of tick-borne diseases.

The important thing was by eight years old, Yaretzi was testing negative again and feeling great. Except for one thing. “He drinks an awful lot of water,” his mom said.

Excessive drinking is technically called polydipsia. Excessive urination is polyuria. The two often go together. Medical folks just say “PU/PD.” When owners report polydipsia, the first thing we do is document it, by having them measure their pet’s water for 24 hours. A normal dog drinks between 20 and 70 milliliters per kilogram body weight per day. For a 30-kilo dog like Yaretzi, that’s roughly three to nine cups. Water consumption varies with exercise, salty foods, and hot weather. We don’t consider it true PD until a dog consistently drinks more than 100 milliliters per kilo daily. For Yaretzi, that’s almost 13 cups. Measuring total daily urine output, well, that’s harder to get owners to do. With true polyuria, urine is usually abnormally dilute.

Yaretzi’s daily water consumption measured borderline high. His urine, unusually dilute. His owner, exceptionally dedicated.

The list of possible causes for PU/PD is enormous. We began running tests. We ruled out diabetes and kidney failure. Endocrine tests ruled out underactive thyroid and the adrenal gland disorder called Cushing’s disease. His liver function proved normal with a bile acids test. Urine cultures ruled out bacterial infection. His white blood cell count was consistently low but we found no explanation for this. Yaretzi went to a specialist who repeated some tests, and added others. Ultrasound showed a few small nodules on his spleen, but the specialist thought these benign and unrelated to his PU/PD. More samples were collected to determine serum sodium level and osmolality, urine sodium fractional excretion and osmolality, and a urine protein: creatinine ratio.

Huh? What? Wait! Don’t turn the page! No more big words, I promise. Okay, maybe just a few. Protein-losing nephropathy (PLN) and diabetes insipidus (DI.)  You need classes in pathophysiology and endocrinology to fully understand, but since you probably want to get to the beach, here’s the short version.

Kidneys are made up of thousands of tiny units called nephrons that filter the blood. The parts that do the filtering are called the glomeruli. These work like strainers, letting little molecules like electrolytes pass through, while keeping cells, and bigger molecules like proteins, in the blood. Other portions of the nephron then balance electrolytes and pH. When the glomeruli get injured, the holes in the strainer get too big. Stuff that is supposed to stay in the blood, like protein, leaks out into the urine. A little protein in the urine can be normal, which is why special tests beyond standard urinalysis are needed. Yaretzi had an elevated urine protein: creatinine ratio, confirming abnormal protein loss via the kidneys, i.e., PLN. Over time, dogs with PLN become protein-depleted. Usually this is evident on basic blood tests, but Yaretzi’s was apparently in the very early stages, and his blood protein levels still normal.

What causes PLN? Most cases are thought to be the result of chronic inflammation or infection. Here’s your short course in immunology. The immune system makes antibodies against foreign proteins (called antigens.) Antibodies stick to antigens. These antibody-antigen complexes get trapped in the glomerular membranes. The immune system attacks those trapped complexes, inadvertently damaging the glomeruli. This inflammatory condition is called glomerulonephritis (Oops, another big word). Underlying diseases that produce the antigens can be anything from chronic dental disease, to Lyme, to cancer. Another disease that can also damage glomeruli and lead to PLN is called amyloidosis.  Definitive diagnosis of the cause of a case of PLN requires kidney biopsy, but we rarely recommend going to these lengths. Instead we treat any underlying problems identified and then just treat the symptoms.

“It sounds counterintuitive,” I said, “but he needs a low protein diet. I’m prescribing a medication that reduces protein loss through the kidneys, and low-dose aspirin to minimize risk of blood clots. Omega-3 fatty acids are also helpful. They’re already in the recommended prescription diet.”

Our last question was whether Yaretzi also had diabetes insipidus (DI), a rare disorder that occurs when the pituitary gland doesn’t make enough antidiuretic hormone (ADH)  or when the kidneys themselves are unable to respond properly to ADH. Dogs with diabetes insipidus pass huge quantities of very dilute urine, then drink excessively to compensate. Once the specialist has all the final laboratory results back, we will test for DI by giving Yaretzi a small dose of synthetic ADH. If his kidneys are able to respond, his urine should become more concentrated, and he should drink and pee less, confirming the problem to be inadequate pituitary ADH production. We suspect, however, that the problem is in his kidneys, that whatever is causing his PLN also interferes with his kidneys responding properly to ADH.

A complicated case. We don’t have all the answers yet. Are those past episodes of tick-borne disease exposure implicated? Golden retrievers have a high incidence of cancer. Is there a tumor hiding somewhere? Maybe he has some unidentified genetic abnormality? It’s a puzzle we hope to solve. In the meantime, his mother just keeps filling his bowl with water, and his days with love.