by John Hicks
From early childhood I had been encouraged to map read and, in the fading light, I hazarded a guess about our location and plotted a likely escape route for my little beetle and me down some narrow-looking country lanes. Road atlases have their deficiencies, one of them being that they don’t show every minor road. The large truck started up as soon as I took off. We hadn’t travelled very far before I was following my nose. Perhaps the truck driver was lost, too? I became more convinced as he stuck on my tail down one improbable turn after another. Unless by some remarkable coincidence Truckie also had plans to go to the middle of the same nowhere as me, on a gloomy Sunday evening, I was not alone in my predicament. It was becoming increasingly obvious that I was leading him astray. Surely he would be starting to feel a bit suspicious, perhaps even a tad annoyed? It seemed wiser to carry on with confidence rather than risk stopping again.
The narrow lane I finally chanced on was a distinct gamble. It looked suspiciously like a farm track and soon, just as I feared, it ended up in a farmyard. It wasn’t easy with Truckie on my tail, but I managed a quick three point turn and shot back past him in the direction we’d just come. Straight away, I was confronted by what his looming presence and the deep-hedged lanes had been concealing – an army of followers. Even with my little Morris Minor it was a tight squeeze getting past the long queue on that narrow farm track for, scattered among the family saloons, was a fairly representative sample of the heavy vehicles which keep the wheels of industry turning: a concrete mixer, two car transporters, assorted removal vans and some earth-moving equipment. I didn’t stop. It was starting to get dark and besides, imagine what would have happened to me when they found out that I wasn’t the farmer departing his farm for a jolly evening out at the local pub, but the idiot who had led them there! With luck, that accolade would fall on the driver of the truck who had so foolishly assumed that I knew where I was going.
When I got back to Liverpool later that night and watched the late night news, I was not in the least surprised to learn that there was a major traffic jam in the Midlands which, it was anticipated, would take the authorities several more hours to clear. I wondered why they weren’t talking days. I still wonder how they managed to extract those behemoths of industry, many of them articulated and difficult to reverse, from such a tight spot, so quickly.
~
For two more years our courtship played out across those congested miles. At the end of my third year we were married and living in happy penury. Two more years of hard work lay ahead of me before I could earn my first salary as a qualified vet – always assuming I passed all my exams. During my final year I was a kept man while Viv held down a job she detested, behind the counter of a Building Society.
Watling Street had been a lifeline, so I have a certain fondness for it and an admiration for the Romans who built it. I wonder what Alfred, that inspired Saxon king, would have thought of the choking, polluted highway that once formed the boundary of his nation. Where were the pure streams and the deep forests full of game? What spreading cancer of bricks, concrete and asphalt now laid waste to his realm? Would he now feel that he could endorse Shakespeare: this scepter’d isle… This precious stone set in the silver sea…?
I had my doubts and, in due course, they played a part in our decision to emigrate to New Zealand. We never guessed that New Zealand would be where we were to spend the greater part of our working lives and bring up our family. But, much as we love New Zealand, the scepter’d isle is buried in our psyches. Our roots go too deep. I can’t shake off that past and neither can Viv. We have given up trying, for in coming to New Zealand we have become doubly enriched, and now lay claim two spiritual homes: the ancient land of our birth and the beautiful land of our adoption.
Chapter Seven
Krebs and Quills
Thousands of years ago, cats were worshipped as gods. They have never forgotten this. – Anon
Despite my boyhood indiscretions, in my professional life I have ministered to cats with all due care and attention. I overcame my ingrained prejudices and for a few years Viv and I even owned a cat – in so far as anyone can ever lay claim to owning one. Moon was a much-loved pet, but definitely of the common, moggy variety. But my volte-face only went so far. I could never describe myself a cat fancier. Before a chocolate point Siamese or apricot Persian ever reached my examination room table, I made every effort to know precisely which breed was being presented to me and how his or her colour was to be described: silver or blue, never grey; red – so much more exotic than brown. My receptionists were trained to ask these questions and write them on the pet’s card so that I did not suffer the ignominy of failing to recognise a detail that was likely to be of utmost importance to the owner.
I was so much ahead of my colleague Daryl in this regard. His house was crawling with cats. He loved them. Yet he could never be bothered with these details. All cat fanciers are cat lovers, but Daryl is proof that the reverse doesn’t necessarily hold true. He wouldn’t have recognised a Rex from a Ragdoll and filled in the “breed” section of the patient card with one word: “Alley”. Understandably, this did not endear him to genuine Cat Fancy people even though he never dealt with their exotic “alley cats” with anything less than due care. As for me, I must redeem the catapulting sins of my childhood with the tale of Max, a Persian – a “proper” cat.
Some people would, quite correctly, dismiss Persians as long-haired genetic freaks to whom cat fanciers have given an exotic and misleading appellation. They have imposed breed standards that specify the deformity of brachycephaly (squashed-in faces) to give an appealing wide-eyed, rounded-face look. As a direct result Persians are predisposed to tooth problems, corneal injuries and infections, and facial eczemas. Their dim wittedness, gentle natures and a propensity to other medical problems (of which bladder stones are but one example), make them a vets’ delight.
They are the very opposite of the typical cogger’s moggy. Max, like most other Persian cats, would have been totally incapable of supporting himself in the wild, under which designation I include Liverpool. His long, matted coat would have snagged in the broken bottles that many people cemented onto the top of the brick walls – a common strategy in Liverpool to deter vandals and burglars – whereas “pure bred” alley cats floated over them with ease.
During the long course of Max’s treatment Viv and I became great friends with his owners and, I must concede, Max was a bit of a character. When we left to go overseas we were extremely fortunate that Moon, our low born alley cat, was eagerly adopted into their cat-loving family and accepted by her new brother without prejudice, even though he must have known that she wasn’t a “proper” cat.
Max suffered from a complaint that has afflicted man and beast for centuries: bladder stones.
An eternal cycle of complex chemical interactions rages within the tissues of our bodies. As a student I was always aghast to see the wall-poster mapping out all the biochemical reactions known to be involved in “Krebs’ cycle”, the process by which we derive energy from food. It was as colourful as a London Underground map but infinitely more complicated. Arrows marked the transformation of one multi-syllabic molecule into another. Enzymes italicised this busy scene, with curved arrow interferences. I have always had a morbid fear of flow charts, so I preferred to regard it as a work of art than something I would need to understand in detail. Indeed it was, and still is, a work in progress. If that 1970’s map would have occupied the top of a decently sized kitchen table, the modern version, plumped up with the biochemical advances of the last thirty-five years, has expanded to occupy an the area the size of a barn door.
Something, somewhere on Max’s map had gone wrong and Max could no longer urinate freely. Stones were blocking his urinary tract: perhaps triggered by an infection which had altered the acidity of his urine, or a mineral imbalance in his diet of cat biscuits, or even a reluctance to drink enough to keep his urine diluted sufficiently. The pathology of urinary stone formation is complex; b
ut the crystals precipitating out in Max’s bladder had formed a gritty, sandy obstruction in his urethra – the fine and delicate tube draining the bladder to the outside.
The problem for any male cat suffering from this quite common condition, is that grit accumulates near the tip of the penis which, in cats, is the narrowest part of the urethra. Max went around straining to pass urine, but his only reward was a few blood-tinged drips on his owners’ favourite candlewick bedspread. It really is a very fiddly job to grasp a cat’s penis, let alone insert a fine catheter into the minute orifice and flush the sand away. Even if the vet manages to restore the full bore candlewick spraying service, and makes changes to his patient’s diet and lifestyle to try and modify the faulty Krebs’ factors – the condition tends to recur.
There is a surgical treatment: perineal urethrostomy. The name, admittedly, is a mouthful, but sometimes it is advisable to disguise acts of surgical barbarism with euphemistic Latinisms. What owner is going to appreciate your recommendation to “chop the penis off” a beloved pet? Whichever way it is described, amputation of the tip of the penis removes the bottleneck. After consultation with Max’s owners, this delicate operation was duly performed. The wider bore urethra behind the penis was anchored, with fine silk stitches, to his perineal skin leaving a larger opening through which those gritty stones could pass. Max was already castrated, so it is doubtful that he missed what had become a superfluous and bothersome piece of his anatomy.
Max was fine for a while, but he did have some trouble with skin at the site of the operation overgrowing his new orifice – a process known as epithelialisation. This can be managed with periodic re-catheterisation and stretching. In Max’s case my timing was immaculate because we left the district soon after his operation, and while Max was in full working order. As the successful surgeon it fell on me to savour the adulation of his doting owners. Some other poor unfortunate vet was left with his tricky aftercare and the fiddly re-catheterisations periodically required to keep him in full flow.
~
The seraglios of the Levant provide an interesting historical aside to this very problem. It is common knowledge that through the ages the harems of Eastern gentlemen were guarded by eunuchs. In most cases these were castrated men. However, there was also a class of eunuchs who suffered the supreme indignity of having their penises amputated. In this case, it seems, they were, literally, “chopped off”. The losses to such primitive surgery from blood loss and infection were staggering, but those who survived had the same problem with stricture as Max. Without polyethylene catheters how did they manage? The answer, apparently, was goose quills – far more acceptable to those who prefer biodegradable alternatives. Armed with this knowledge you would now know, were you to enter a time warp and come across a mediaeval Arab with a goose quill tucked in his turban, not to make the mistake of assuming he was a scribe.
So much for the distal urethra: anatomists love to sprinkle their descriptions of body parts with Latin or Greek locators: rostral, caudal, palmar, plantar, lateral, medial, distal, proximal. The distal urethra is the part furthest from the body. The next part of our journey plunges proximally along this delicate and sensitive organ, to an area rich in historical associations.
Chapter Eight
Intolerable Urethral Intrusions
March 26th 1667 “…I have cause to be joyful this day, as being my usual feast-day for my being cut of the stone this day nine years; and through God’s blessing am at this day and have long been in as good condition of health as ever I was in my life…” The Diary of Samuel Pepys
There is little time during the busy five year veterinary curriculum at university to reflect on the history of medicine. Many years passed before I realised that my little foray into urinary tract surgery was not without historical precedents, but Thomas Hollier’s name will live longer than mine, even though his surgery was performed more than 300 years earlier. His patient, the famous Samuel Pepys, has ensured that.
The unbalanced diets and lifestyles of the seventeenth century English frequently led to gout and “stone”. However, like Max, Samuel Pepys’ stone almost certainly involved some personal defect in one of Krebs’ (yet to be discovered) biochemical pathways. We can deduce this because both Pepys’ mother and aunt suffered from “stone”, so in his case there was almost certainly some inherited predilection, even if it was exacerbated by his less than restrained lifestyle.
On March 26th 1658 Pepys, a young man of twenty-five who had yet to begin his famous diary, underwent surgery to remove a stone from his bladder. Apparently there were several barber surgeons offering this service, so it was a reasonably common procedure. Some patients lived, some died. Pepys was lucky that Thomas Hollier, his father’s neighbour, was a skilled surgeon attached to St Thomas’s Hospital. Hollier’s record was better than most. He did thirty similar operations in the same year as he operated on Pepys with no subsequent loss of life; yet in another year his first four patients died – almost certainly from post-operative infections. In the days before there was any appreciation of the need for surgical cleanliness, still less sterility, this was the greatest risk. There was no concept of asepsis, and neither patient nor surgeon were too concerned if the instruments they used were dirty and the surgeon’s apron was stiff with dried pus (as, on occasions, they reportedly were). It has been suggested that by having the operation performed in a private house, Pepys was spared some of the risk.
The prospect of being knifed and probed in such a delicate area of his anatomy, without the benefit of an anaesthetic (still two hundred years from discovery), would have been quite terrifying. But Pepys had no choice: the pain and spasms associated with not being able to urinate properly are unendurable.
For analgesia Pepys was prescribed a soothing draught of liquorice, marsh mallow, cinnamon milk, rose water and white of eggs. And that, apart from mopping his brow as the scalpel sliced, is as far as it went.
The technique involved inserting a silver probe, or itinerarium (an unusual traveller), through the penis, along the urethra and into the bladder. The stone would be located when the probe was felt to grate against it. The surgeon could now make his incision, midway between the scrotum and anus, and cut down onto the tip of the probe in the neck of the bladder. A reasonably lengthy incision was required. Samuel Pepys’ stone, by his description, was the size of a “tennis ball”. Even allowing for the fact that it was “real tennis” that was played in those days, for which the ball was marginally smaller than that used in the modern game, an incision about three inches long was required. The stone was grasped with forceps and removed in less than a minute. The wound was not stitched, but left to drain and heal itself.
A similar method is used for the extraction of smaller stones in dogs, to this day, and some veterinary surgeons still recommend leaving the wound unstitched and open to drain. That is the way I was taught, and as a demonstration of the healing powers of that portion of the anatomy, a veterinary surgeon’s faith in leaving it so is usually well rewarded. However, in Pepys’s case it is thought that the wound never entirely healed and that his infertility could have been a consequence of this – not, as he well recorded, that it had any effect on his potency.
Here any parallels between Pepys and Max must be dispelled, for Max, being castrated, was a perfect gentleman. Pepys, on the other hand, behaved like a tom cat. Indeed, it is the disarming honesty with which he reveals his human frailties, and his associated guilt in indulging them, that make his diaries such a delight to read.
So Pepys was lucky, his operation was a success and he celebrated the anniversary of his operation each year and made frequent grateful references in his diaries to his deliverance from his agonising complaint. He duly had his stone mounted in a case and, because he was meticulous about his monetary affairs, we know that this cost him twenty-four shillings.
Pepys’ curiosity knew no bounds and he had many influential contacts. In 1662 he records visiting the Hall of the Barber-Surgeons’ Compan
y and attending the dissection of a seaman who had been hanged for robbery:
I did touch the dead body with my bare hand; it felt cold, but methought it was a very unpleasant sight. But all the Doctors at table conclude that there is no pain at all in hanging, for that it doth stop the circulacion of the blood and so stops all sense and motion in an instant. Thence we went into a private room, where I perceive they prepare the bodies, and there was the Kidnys, Ureters, yard, [Remember? Pepys was not talking about his garden.] stones and semenery vessels upon which he read today. And Dr. Scarborough upon my desire and the company’s did show very clearly the manner of the disease of the stone and the cutting and all other Questions that I could think of.
Dr William Harvey, in 1628, had demonstrated the way in which the blood circulated and the heart’s action as a pump; but the role of nerves and the spinal cord in the transmission of pain to our conscious brain were unknown until an Anglican clergyman, Stephen Hales, started poking them around in decapitated frogs – sometime in the next century – experiments which even then provoked anti-vivisection protests. So Pepy’s learned friends’ conclusions about the pain of hanging were, if correct, correct for the wrong reasons: a common failing of medical experts throughout the history of medicine.
