Mountain of Love
I watched with interest as Mr. Johnston escorted his bullmastiff into the waiting room. This would have been an effort at any time because of the sheer bulk of the patient. But progress was made all the more difficult by the massive growth encasing the beast's upper thigh, rendering the right hind leg nearly useless. As the dog made her way through the door and down the hall, awkwardly swinging her leg wide and hunching her back in order to lift the leg and advance the foot just a few inches forward, the knee remained fixed and rigid, forcing the toes to scrape the ground as slow progress was made. Traversing the length of the twenty-foot hallway consumed nearly two minutes. Finally, with the help of the technician and the encouragement of the owner, she made her way onto the scale. The digits on the digital display danced for a bit before settling at 165 pounds.
In the examination room, I surveyed both the patient and her owner. Mr. Johnston was unique. Only about five feet six inches or so, he must have weighed more than three hundred pounds. In order to fit all that mass into such a small frame, his contour sported bulges around his center, making him seem almost as round as he was tall. His strawlike yellow hair was long, billowing, and wild, as if the trip over the pass from Fort Valley had been made with his head out the open window. He kept sweeping this hair up and back over his head with his hand as clutches of the stuff broke free and fell like coils of baling twine across his forehead, obscuring his eyes. His cheeks and nose were puffy and red and streaked like a city map with a network of prominent veins. His lower eyelids drooped sadly, Basset-like, a puff of pillowed and pale skin hanging loosely like dusty drapes below each of them. His upper lids seemed a bit too heavy to keep fully open, forcing him to tilt his head back slightly to turn his eyes up to my face.
He was dressed in dark sweatpants, the waist of which was cinched tightly around his middle, the drawstring dimpling his tummy at that spot, with adipose tissue bulging several inches above and below the knot. I hoped the drawstring was strong. I was sure that if it broke free, the pants would soon be around his ankles. I did not indulge the mental image. At the end of his legs, the pants failed to reach the white high-topped tennis shoes he wore, this probably owing to the degree to which he'd had to hitch the front of the pants up to cover his girth. Above his waistline, he wore a buttoned-up dress shirt, the bottom of which just swept the top of the sweatpants. It accommodated his girth only by his having left the last buttons undone. The effect was to make both the shirt and the pants seem ridiculously incongruous.
"Hello, Mr. Johnston. How are you this morning?"
"I'm fine. It's Dahmun I'm worried about." He got right to the point.
"What's her name?" I had never encountered one quite like it.
"It's Dahmun!" He offered no further explanation, but after a short pause, he spelled it as if for a dim-witted schoolboy. "D-A-H-M-U-N." He shook his head and clucked his tongue in annoyance.
"Where did you get that name?"
Mr. Johnston exhaled an impatient sigh, as if my question was delaying some more important engagement.
"Well, among other things, I'm a linguist." He paused in order to let the significance of that sink in. "The name is a patented syllylogy."
I stared at him blankly. I had never encountered a syllylogy before, patented or otherwise, and my mind immediately veered dangerously into wondering with which government agency one would patent a syllylogy—or why.
"I have invented a language in which each syllable represents a discreet meaning. Words are then assembled which convey specific meaning by their very construction."
"So what does Dahmun mean, then?" I asked.
"Well, the syllables represent … I mean ‘dah' is a … uh … a large landmass, especially one with lots of altitude. Combine that with the syllable ‘mun,' which signifies deep affection and fondness. See?"
He looked at me, apparently to watch the light of meaning dawn in my foggy eyes. The fog persisted.
"No, I don't quite get your drift."
He clicked his tongue again, clearly impatient with the obvious dullness of the pupil before him.
"Dah-mun. Dah-mun. Get it? It literally means ‘Mountain of Love.'"
"Oh, I see now." And I really did begin at that moment to understand Mr. Johnston.
"Tell me what's been going on with Dahmun. Start at the very beginning, please."
"About four or five months ago, we were hiking on my property in the Fort."
Fort Valley is a blind valley with an open mouth on the north end. It is contained by two ridges that run along the east and west flanks of its fifteen- or twenty-mile length. The floor of the valley is no more than two or three miles at its widest and is choked off as the ridges squeeze together and finally join at the southern end. It's said that George Washington had scouted out this "fort valley" as a place to hide had the Revolutionary War gone badly. The valley would probably be missed if scouted either from the east or the west, and the mouth could be easily defended against intruders from the north. Over time, Fort Valley became the accepted name of the valley. It also became a place where lots of people settled who liked to hide their homes from prying eyes. It is occupied today by folks for whom Woodstock is too populated and occupied by weekenders escaping from the rush of the nation's capital. Locals call it simply "the Fort."
"Dahmun loves to go hiking with me. That day, we were going up a rather steep hill with loose gravel. She slipped and fell down on her poobus. I—"
"Excuse me." I interrupted him. I was carefully writing down the history in the record and was sure I had been concentrating too hard on this task to have heard him correctly. "What was it that she hit when she fell?"
"Her poobus!" He waited for me to catch up. My face was apparently broadcasting that I was helplessly clawing for clarity.
"Poobus. Poo-bus," he said again for me, more slowly this time and louder. I suspected another patented syllylogy, until he clapped his hand over the lower reaches of his right fanny and repeated again, "Poobus."
"Got it. Go on," I said, finally recognizing that he had just badly mangled the anatomical term pubis.
"So after she fell, she displayed some dysmobility for a few days. It might have lasted as long as a couple of weeks. Then it seemed to improve again. I wasn't too worried at that point. I just assumed she had pulled a muscular infraction or something. But then I noticed that the muscles in the right rear were beginning to atrophatize."
The linguistic license Mr. Johnston displayed began to tickle me. It seemed important to him that I recognize the mastery he possessed over nearly correct medical terminology. The oddities of the syntax and the reinvention of the words were so strange that I knew I would never remember them or be believed when I related them again. So I discreetly slid the record over and began to jot down on a sheet of paper towel the words he was inventing—dysmobility, atrophatize. This was good!
"Please go on, Mr. Johnston."
"About that time, I noticed that a lump was beginning to form at the top of the leg. It didn't really seem painful at the time. But over a period of several months, it's gotten bigger and bigger, until I thought I ought to have it checked out. It has also begun to cause her some pain. I'm sure it's just an abcleft. How much will you charge to have it lanceted?"
"I think it's a little early to talk about treatment," I responded. "I haven't even examined her yet. Let's take a look."
Dahmun was much too large to place on the examination table, so I began my exam by getting down on the floor with her. I started at the head and examined her eyes, ears, and nose. I then opened her cavernous mouth and inspected her bear-size teeth, tonsils, and tongue. My hands traced the lines of her neck, carefully outlining the lymph nodes, salivary glands, and trachea. All looked and felt normal. I heard an audible sigh again and looked up at Mr. Johnston.
"Doctor, the problem is not up there. The problem is back in the hind leg, see?" He rolled his eyes, as if I was too simple to recognize his unmistakable disdain.
"Yes, I noticed that when you came in the door. But you don't want me to miss something else important because I focused in too quickly on what was blatantly obvious, do you?"
He didn't answer. Apparently, he didn't care what I might miss. I continued my examination by listening intently to the dog's heart and the lungs. Then carefully, using both hands on her prodigious belly, I palpated the urinary bladder, the intestines, the kidneys, the spleen, and a bit of the liver poking beyond the arches of the last ribs. All seemed fine.
I then turned my attention to the leg. As Dahmun stood patiently, the toes on her right foot turned under and her leg was stocked in a taut straight line. The skin over her knees and toes bulged with swelling. At the top of her leg, by the hip, a huge mass, larger than a cantaloupe and as firm, encased the bone. The slightest pressure on this mass caused Dahmun to whine and squeal in pain. A little more pressure induced her to turn and nip at my hand apologetically.
I shook my head absently. This wasn't good. I turned and began to write my findings in the record, using this time to organize my thoughts around how I was going to discuss the problem with Mr. Johnston. Apparently, I was taking too long for him.
"So, now that you've had a chance to examine her, how much will you charge to lancet the abcleft?"
"I'm afraid lancing an abscess is not what we need to do here, Mr. Johnston." I sighed. I dislike being the bearer of bad news. But in this case, there was no other option. "The lump is not an abscess. Dahmun has a tumor in her leg. It entirely encases the femur just below the hip. It also apparently has the sciatic nerve entrapped within it, too. That's why she can't bend her leg, and why she knuckles over on her toes like that."
Mr. Johnston processed this for a moment. It was clear that he did not want to believe me.
"What is the causality of this problem?"
"I wish I could answer that question, Mr. Johnston. If we had the answer to why cancer occurs, we would be far along the road to its cure. But for most cancer types, we really haven't identified any specific cause-and-effect relationships. It's just one of those things that happen."
"Could it be the initial injury? Or is it unexpectable for an injury like that to cause tumors?"
"No. I suspect the injury was a result of the cancer, not the other way around. The tumor in its early stages may have made her unstable and led to the fall."
"And the swelling? Is that just the phlebum that can't reticulate back up the leg?"
"Exactly," I agreed. "Because of the poor lymphatic return, extracellular fluid accumulates and causes that type of swelling. It's called ‘pitting edema,' and it's a common consequence of such an invasive growth."
"I m sure you're a good vet and all, Doctor. But I'm still not convinced this isn't just an abcleft. Can't you do some tests or something to find out?"
"Of course, Mr. Johnston. I'll do an aspiration cytology. I'll stick a needle into the tumor and draw some cells out that I can look at under the microscope. If this is just an abscess, what we'll get is pus. X-rays will also be very helpful in this case. But…" I shook my head to underscore my pessimism. "I'd love to be wrong here, Mr. Johnston. But I really don't think it's reasonable to expect that."
"You'll forgive me for this, but I'm eternally optometric."
I plunged a needle deep into the mass and could feel grating against the tip of the needle as I did so. The tumor had begun to incorporate calcium deposits into its structure—not a good sign. I then sprayed the contents of the needle onto a glass slide and took it to the laboratory. While the technicians took Dahmun to get X-rays of the swollen leg, I placed the slide under the microscope's lens. Peering through the eyepieces, I examined the cells I had collected. They were grossly abnormal.
Soon I was called into the radiology room to evaluate the X-rays. The films were classic for bone cancer. Feeling defeated, I trailed back into the exam room.
I came right to the point. "I'm afraid there is really no question about it." "The cells that I collected show all the telltale signs of cancer. And judging by the cellular characteristics, it looks to be quite an aggressive tumor at that. When we combine that with the textbook pattern I see on the X-rays, I'd say I'm more than ninety-five percent sure it's bone cancer. I'm so sorry. A definitive diagnosis can only be made by a pathologist examining a tissue section, but a biopsy confirmation wouldn't change our treatments much."
Mr. Johnston was quiet for a moment, absorbing the impact of my findings.
"It's my own fault. I should have brought her in earlier. I shouldn't have been so delaysive in getting her some help. What do we do now?"
"Well, I'm afraid there aren't many options at this point. These types of tumors don't respond very well to chemotherapy alone. In order to give her any chance at all, we would need to amputate the leg first, then follow with chemotherapy. This treatment has resulted in the best outcomes. One of the problems with that, though, is her size. She may not get around well at one hundred and sixty-five pounds with only three legs. It is also very likely that it has already spread to other areas."
"You think this has already metatheclized?" Mr. Johnston gasped.
"I don't know for sure. But it's very likely. The odds are very much against us. In order to know, we'd need to x-ray the chest and the abdomen and consider ultrasounding the belly." Sometimes you are beaten even before you begin the fight. And this was likely one of those cases.
"Perhaps the best thing for us to do is control her pain with medications for as long as we can. There are a number of ways we can do that."
Mr. Johnston sadly took his big Mountain of Love home. Prescription pain medications kept Dahmun's discomfort at bay for a few more weeks. But eventually, even those were inadequate to allay her constant suffering. As the bulbous growth enlarged ever more quickly, her ability to get up and move around declined precipitously. Soon there was nothing for us to do but ease her suffering in the most permanent of ways.
Mr. Johnston's loss was a difficult one, and I felt bad for him. But the episode apparently bolstered his confidence in me. Though he continues to exhibit the same disgusted frustration with me that he did when I first met Dahmun, he has presented several of his animals to me since then. I've learned some things about dealing with him. First, I never ask for explanations of the names he gives his pets. Second, I'll never go into the exam room again without a slip of paper under the record to write down the lingering linguistic lapses.
Copyright © 2012 by Bruce R. Coston
