D. E. Larsen, DVM

Today was a late spring day with mostly blue sky but some heavy dark clouds. Walt was waiting when Ruth and I pulled into his barnyard. Ruth was short with dark hair. She had worked for me for a couple of years and although not a farm girl she really enjoyed the farms we visited. Walt’s farm had offered a variety we didn’t often see with Draft horses along with the cattle.

Walt greeted us with his beaming smile and an outstretched hand. His handshake was firm and sincere. I knew these men judged the men they met by their handshake, something I didn’t learn in school, but I had learned long ago growing up around men who earned their living working with their hands.

The little steer calf was standing in the loafing shed twitching his tail and stomping his hind feet. When I moved a little closer, he pressed against his mother’s hind leg. Mamma shook her head at me and moved into the corner of the loafing shed. 

“He is pretty uncomfortable,” I said to Walt. “How did you recognize him out in the pasture?”

Walt was a tall, thin man with a broad smile on his face most of the time. Lean does not mean that he was not strong. Slim, wiry, and tough as nails, Walt could work most men into the ground. Walt had a team of draft horses, Belgiums, that he used to put up his hay in the field that was next to the highway. I am sure that many people would observe him and fail to realize how rare the spectacle was today. I always enjoyed watching the horses work and would often take the back road so I could stop and watch for a time.

“The little guy was not moving around at all,” Walt said, showing his obvious concern with a fading smile. “I notice him and his mamma standing over in the corner of the pasture, all by themselves. With all this stomping and tail twitching, I figured something must be wrong.”

“He is pretty young for a urinary stone, but this is what they act like early on in the course of things,” I said. “We don’t see this much around here, but it was common in Colorado where I went to school.”

Urinary stones in beef cattle in the Willamette Valley were uncommon, meaning that I would see a case once or maybe twice a year at the most. Often going several years between patients. 

It was surprising that Walt would recognize the stomping and tail twitching as enough of an issue to call me early. It demonstrated how some of these old farmers were so in touch with their animals that they knew when there was a significant problem.

“It is early yet, and he is uncomfortable because of his distended bladder. In a little while, one of two things will happen, either his bladder breaks or his urethra breaks. When that happens, the pain goes away, but the problem becomes much more difficult to fix. It is a good thing that you called early.”

The calf was easy to catch, and we tied his head and then ran the mamma cow outside. I was sure of my diagnosis but completed a quick exam. His temperature was normal, and his chest was normal. 

On the rectal exam, I laid my fingertip on his pelvic urethra. It was continually pulsating. This guy had a stone blocking his urethra for sure. 

I took a second rope and tied a loop in the middle of the bite of the rope. I slipped this loop over his neck with the knot lying between his front legs. The rope ends crossed in the middle of his back, ran down his sides, and came out between his hind legs. This was called a “flying W” and is a standard method to throw a cow. It was generally not used on a small calf, but we would have to tie him down for surgery.

I grabbed the two ends of the rope and pulled. The calf stiffened and fell on his side. We rolled him up on his back, flexed his hind legs, and tied each leg with the ropes in a manner that when he kicked, it would put more pressure on his back and add more restraint.

Once restrained, with me on my knees, I could palpate the length of his penis. Stones generally lodge at the point of the attachment of the retractor penis muscle in the sigmoid flexure of the penis. I grasped this portion of the penis with my left hand to stabilize it. With my right hand, I could easily palpate the stone.

“This is going to be easy,” I said to Walt. He was watching closely. Most of these guys had not watched a calf thrown so easily before.

“So far, you make it look easy,” Walt said.

We clipped and prepped the surgery site, and Ruth opened the surgery pack while I put on gloves. This was barnyard surgery at its best. There was fresh straw down, but the ground’s softness under my knees told me we were on top of a foot or more of straw and manure.

The surgery was brief, as I had promised. I injected the area with Lidocaine for local anesthesia, grasped the penis to stabilize it, palpated the stone, and made about a two-inch incision over the stone. I bluntly divided the tissues with a pair of forceps to expose the urethra with the bulge where the stone was located. 

Once this was exposed, I elevated the penis. I drove a scissors under the penis and out the other side to maintain the exposure and stable urethra and free up my left hand. I palpated the stone again, then carefully incised the urethra, feeling the stone’s grit as the scalpel pulled across it. I grabbed the stone and pulled it out of the urethra with forceps. I placed it on the surgery pack. I took a urinary catheter and ran it up the urethra toward the bladder. It was just long enough to reach the bladder. We relaxed as urine drained out of the catheter. 

I could imagine that the calf was feeling some relief at this point. When the urine stopped, I removed the catheter. I then ran it the other direction to ensure the rest of the urethra was open.

Now we had a decision to make, to close or not to close the incisions. I had the option of leaving the incisions open. I sort of favored this option because there may be more stones in the bladder, and they would have the chance of passing out the incision if it is left open. 

Barnyard surgery is not the best in the world, and closing the incision always gave the possibility of infection. And closing the urethra on such a small calf could lead to a narrow spot that could cause problems later. The only problem with leaving the incisions open was that urine would flow out of the incision for a week or so until there was enough healing to allow normal flow.

I was getting ready to discuss all this with Walt when the calf kicked. He got one hind leg free from the restraint. He kicked again, and the surgery pack went flying. The decision was made by the calf. I grabbed the scissors, releasing the penis to return to its normal position. Ruth started gathering instruments that were scattered through the straw. 

Walt was crawling across the straw on his hands and knees, concentrating on one spot. He ran his hand across the straw a couple of times. Then with a beaming smile raised his hand, he had found the stone.

“This is going on my mantle,” he said, still smiling. 

We let the calf up, sprayed for flies, and explained the urine flow issue to Walt. Things turned out okay, and I will never know how Walt could keep track of that stone in all the commotion.

Photo by Matt Seymour on Unsplash

D. E. Larsen, DVM

Raymond came through the door with little Sophie cradled in the crook of his arm. Sophie was a really small Chihuahua, and Raymond, her owner, was a large man. It was one of the things that I always found a little odd. Some of the largest men were attached to these tiny dogs.

After he stretched a towel out on the exam table, Raymond placed Sophie in the middle of the towel. Sophie, at four and a half pounds, was overweight. Her spindly legs looked undersized for her round body.

“She has blood in her urine, Doc,” Raymond said. “And she pees a little puddle every 5 or 10 minutes. The wife is getting upset with all the cleaning up after her.”

I looked at Sophie, her gray muzzle told she was past middle age. She should probably weigh two and a half pounds, not four and a half. Her membranes were normal, with normal capillary refill time. Heavy tartar on her teeth and some chronic periodontal disease suggested that she was a good candidate for a heart murmur. That was confirmed when I placed the stethoscope on her chest.

Chronic periodontal disease leaks bacteria into the bloodstream. These circulating bacteria take up residence on the heart valves, in the kidneys, and the liver. Poor dental hygiene, most common in small dogs on pampered diets, leads to all sorts of significant health complications.

She was heavy enough that it was difficult to palpate her abdomen accurately. But when my fingers reached the posterior abdomen, I bumped a hard firm bladder. Sophie immediately squatted and peed a small puddle of bloody urine onto the towel.

“Raymond, we are going to have to pick up the towel so I can get some urine off the tabletop,” I said as I lifted Sophie up so Raymond could remove the towel.

I sat Sophie down and felt her bladder again, more carefully this time. There was a large stone in the bladder. I could feel some movement in the stone, probably a couple of stones. They were large, making the bladder feel full, but there was little room for urine. Sophie squatted again, depositing a small puddle of bloody urine on the exam table.

I drew the urine into a syringe and placed a small drop on a microscope slide. A quick look at the slide under the microscope showed the blood but also many bacteria and struvite crystals.

Struvite stones were the most common type of bladder stones in the dog at that time. Struvite stones in the dog are caused by a urinary tract infection that leads to acidity changes in the urine, crystal formation, and then the development of stones. These stones grow with time. In male dogs, they often cause urinary tract obstruction as the small stones try to pass down the urethra. That seldom happens in the female.

Today there are diets that can dissolve struvite stones in the bladder. That was not the case in the 1970s and 80s. Stones as large as Sophie’s, are best removed by surgery, even today.

“Raymond, Sophie has a large stone, or more likely 2 or 3 large stones in her bladder,” I said. “These are caused by an infection in the urinary tract. She has a lot of bacteria in her urine. We need to do several things. We need to do a culture on her urine, and while we are waiting for the culture results, we will get her started on a good broad-spectrum antibiotic. We need to get an x-ray, so we can see how many stones we are dealing with, if there are stones in the kidneys, or a bunch of little stones also. We need to do some blood work to make sure Sophie’s kidney function is normal. These stones are going to have to be removed with surgery.”

“Doc, you sound like you are talking about a lot of money,” Raymond said. “I don’t have a lot of money. Are there some short cuts we can take.”

“We can shortcut some of the things if that is what you want to do,” I said. “You need to understand, shortcuts are great if everything works out fine. But if things don’t go just right, we end up spending more money than we would have doing things right in the first place.”

“What kind of things are you talking about, Doc?” Raymond asked.

“Looking at her urine, her kidney function is probably okay,” I said. But if it isn’t, and a random urine sample is not the best indicator of kidney function, we might be delayed in finding that out, and we could lose her. If she happens to have an infection that requires a particular antibiotic, we might not know that without a culture. If we have a bunch of little stones along with the big ones I can feel, we could leave a stone behind and have to do a second surgery.”

“She is sort of long in the tooth, Doc,” Raymond said. “Let’s put her on some antibiotics and do the surgery. If things don’t work out, at least we tried.”

“That is fine, just as long as you remember this conversation,” I said as I shook Raymond’s hand.

“Will I be able to take her home tonight?” Raymond asked.

“We are early enough that she should be able to go home tonight,” I said. “We will have her on c/d diet for a time. That will be important, nothing else.”

“You are going to ruin her life and make mine miserable,” Raymond said.

“You know, you are killing her slowly with kindness, don’t you,” I said.

“What do you mean, Doc?” Raymond asked.

“Look at her, Raymond,” I said. “She weighs twice what she should, her teeth are a mess. She should have those cleaned, and there will be many teeth that are not savable. The infection in that mouth could have been what started this bladder thing, and her heart valves are leaking a little. She needs to be eating dog food, period. But we can work on those things after we get this bladder thing fixed.”

I gave Sophie an injection of Amoxicillin and Gentocin. I planned to send her home on Clavamox. We gave her 80 ccs of fluids by subcutaneous injection and placed her in a kennel while we got the surgery room ready. Sophie was unhappy in the kennel, how dare we treat her like a dog.

After anesthesia was induced and the abdomen was prepped for the last time, I draped the incision site, first with towels and then a surgery drape. I made a short incision over the bulge in the posterior abdomen caused by the large stones in the bladder. I was able to squeeze the bladder out of the incision. It was the size of a full bladder but hard as a rock. 

I placed a couple of stay sutures to hold the bladder in position when I incised it and removed the stones. Then I made an incision into the bladder. The bladder wall was thickened from the chronic infection and the mechanical damage from the stones.

I popped the first stone out, then the next. Amazingly large stones for such a small dog. The bladder lining was burgundy red and almost bubbly from the chronic inflammation. I flushed the urethra in both directions and carefully explored the bladder to make sure no small stones were hiding.

Then I closed the bladder in two layers with Maxon and returned it to normal position. I was careful to remove a couple of drops of urine from the incision and flushed the area liberally. Then the abdomen was closed with a standard 3 layer closure.

Sophie recovered quickly and was probably more comfortable than she had been in months. Raymond was pleased with how lively she was when he picked her up.

“I want to see her in a couple of days, just to check the incision and feel her bladder,” I said. “If you get a chance, try to get a look at her urine in the morning. Mainly to see is the blood is cleared up. And Raymond, you have to be strong, c/d diet only for 3 weeks. No bacon off the breakfast table. You understand, we have come this far, don’t ruin it by being weak when she begs.”

“I will do my very best, Doc,” Raymond said.

“I can guarantee you, Doc,” Sue, Raymond’s wife, said. “He has spent our summer trip to the coast, and he will finish the job if he knows what is good for him.”

Photo Credit: D. E, Larsen, DVM

Prologue: First published January 11, 2021. coupled with last week’s story, this gives a good illustration of a veterinarian’s variety of work and skills.

D. E. Larsen, DVM

I pushed my left arm deeper into the birth canal of the young heifer, sweeping my hand left to right, trying to decide what was wrong here. 

Then I encountered intestines, this was not good. They were too large to be from the calf. This uterus was ruptured. I shoved my arm up to my shoulder. Finally, there was the calf. The calf was in a breech position. I stuck my finger into its rectum. A contraction, this calf was still alive.

I pulled my arm out and washed. “Sue, someone must have tried to pull this calf,” I said.

“Yes, my son Joe was here a bit ago, and he tried to work on it but said that he couldn’t get anywhere.”

“This heifer has a ruptured uterus. The calf is still alive. If we do a C-section, I can save the calf. I don’t know if I can fix the uterus or not.”

“Okay, do what you can,” Sue said. “This is Sam’s favorite heifer. She is kind of small, but he treats her like a pet. I hope you can save her also.”

The heifer was lying on her left side. This was probably good. A right flank incision might give me the best access to repair the uterus.

For me, c-sections on cows were a chore. But most of the work was closing things up. This one would depend on what kind of damage had been done to this uterus.

We clipped and prepped the right flank, and I did an inverted L block with Lidocaine. It did not take long, and we had the calf out, and she was shaking her head as she looked around at her surroundings in this small barn.

The uterus was mostly torn off the cervix. It was held by a narrow strip of tissue. There was no way to repair this.

“Sue, this uterus is almost completely amputated from the cervix. I don’t think that I can repair it,” I said.

“You spay dogs and cats all the time. Can you just remove it,” Sue asked?

The question stunned me for a moment. I looked at the torn mass of uterus and pondered the situation. 

The largest dog has a uterus with a diameter less than my index finger. By comparison, this was a massive uterus. But it was worth a try. Otherwise, we shoot the heifer. If the surgery doesn’t work, at least we tried before shooting the heifer.

“I hadn’t given that any thought, Sue,” I said. “I guess it is worth a try.”

I had difficulty reaching the left ovary. With that problem solved, I placed a transfixed ligature on each ovarian pedicle. After severing the pedicles above the ovaries, I hung the uterus out of the incision. Severing the remaining attachment at the cervix was no problem. I placed a couple of stay sutures in the cervix to keep it close to the incision when I removed the uterus.

With a good twenty pounds of uterus laying in the straw, now all I needed was to close the cervix and ligate a couple of bleeding vessels. Then it was a standard closure of the external incisions. This probably all took less time than a typical c-section.

After giving the heifer some antibiotics and a Dexamethasone dose, I let her up to tend the calf.

“What do you think,” Sue asked?

“Ask me in the morning,” I said. “If she survives the night, I would guess we are good to go. But don’t expect her to have a calf next year.”

“Is she going to be able to raise this calf,” Sue asked?

“That should be no problem. The uterus and the ovaries are not necessary for milk production.”

“Mom and calf were doing well,” Sue said when she called the following morning. 

When I was out to take the sutures out of the heifer, the incision had healed well. The calf was bouncing around, happy to be in this land of the living. 

“When you sell her, make sure you are honest,” I said. “Some poor guy will go nuts trying to get her pregnant.”

“My guess is Sam will make a pet out of her. She will probably never leave the farm.”

It was not long after this event when Pat called. Pat was the elementary teacher with a bunch of classroom pets. It had not been too long ago that I had repaired a fracture on a hamster’s leg for one of her pets.

“It’s Sally, Doc,” Pat said. “She has to be days overdue for delivering babies. And now she is not feeling well. The kids think she has a problem.”

“Tell me more about Sally,” I said.

“Sally is a mouse. They have a gestation for something like 20 days,” Pat said. “We have been watching for babies for over a week now. I am certain that she has to be 4 – 5 days overdue. I can get away for a few minutes shortly, can a drop her off for you to look over?”

“Does she bite,” I asked?

“Sally is the sweetest little mouse,” Pat said. “She loves to be petted and handled, and all the kids love her. That is why everyone is so upset.”

Sally was just as Pat described, sweet as could be. I rolled her onto her back and rubbed her belly in a manner that became palpation. Sure enough, Sally was pregnant with what felt like 8 babies. They were hard as marbles with no feeling of fluid in the uterus. These babies were dead.

I called and talked with Pat. 

“Pat, her babies are dead, and there is a bunch of them,” I said.

“What can we do,” Pat asked?

“If we don’t get them out of there, Sally is going to die,” I said. “She is already dehydrated. I think I should try to do a spay on her. If, by chance, there are any live babies, we could save them. But I don’t think there is anything alive in her uterus.”

“You do what you think is best. The kids and I trust your skills,” Pat said.

We gave Sally a dose of Ketamine for anesthesia and some subcutaneous fluids for her dehydration. I used a razor to shave her belly, and with a surgical prep completed, she was ready for surgery.

With her fur gone from her belly, you could see the lumps in the uterus through the belly wall. 

“I think I am going to need some magnification,” I said as I put on my loupes. “Things are going to be pretty small in there.”

I opened the abdomen and externalized the uterus, two horns of the uterus, one on each side, with 4 hard nodules in each horn, each about the peanut size. The babies were long dead, and all the fluid had been resorbed from the uterus.

The anatomy was the same as a dog or cat, just a lot smaller. I Iigated the ovarian vessels and the uterine body and removed the uterus with the dead babies.  

Closing the abdomen required only a couple of sutures. Sally recovered slowly from the Ketamine, but she was up and eating when I checked her in the morning.

Pat and her class were happy with the results, and we were paid with twenty-some pages of hand-drawn pictures with thank you notes. 

The entire class brought Sally in for suture removal. Typical of classrooms that visited the clinic, some students struggled to be as close to the action as possible. Then some sought the comfort of the reception area.

Sally enjoyed the attention. And she managed to live a year or two longer than a mouse in the wild.

Photo by Colin Davis on Unsplash