The Sunday Leader

Remembering A Surgeon Who Was A Cut Above

Excerpts from the inaugural Milroy Aserappa Paul Memorial Oration by Vidya Jyothi Dr. K. Yoheswaran F.R.C.S. Edinburgh, F. R. C.& England Mr. President thank you very much for your kind words of introduction.
At the turn of the Twentieth Century, Colombo was a peaceful and tranquil city. The roads were lined with large Acacia and Flanboyant trees, and lit by gas lamps. Dr. Samuel Chelliah Paul was a medical Officer at the Colombo General Hospital and was soon to leave for England to study for a career in surgery. Dr. S.C. Paul had married Dora Eleanor Aserappa, the only daughter of Dr. Simon de Mellho Aserappa the previous year, and on the 20th of January 1900, she gave birth to her eldest child, a son, Milroy Aserappa Paul, at their residence in Ward Place, then a new suburb known as Cinnamon Gardens. It was aptly named, being a sandy land full of cinnamon bushes, where only a few years previously, officers of the British Garrison from the Fort would of an afternoon, ride out for their sport of shooting hare.

His lineage was a strongly medical one. His paternal grandfather Dr. William Paul had qualified at the Jaffna Medical School in1864. He was a pupil of Dr. Samuel Greene, a medical missionary from Boston U.S.A who had qualified at the Massachusetts General Hospital and came out to the American Mission in Jaffna in the early 1830s. He founded the Jaffna Medical School in 1840. Dr. Green’s aim was to produce medical graduates who would stay in the north of Ceylon to serve the people of that area where the language in use was primarily Tamil. For this purpose he encouraged the use of Tamil in teaching. Dr. William Paul, in addition to his clinical work, translated the surgical texts into Tamil and spent the rest of his life in the practice of surgery in Jaffna. Milroyi’s maternal grandfather was Dr. Simon diMellho Aserappa, who was to become the Chief Medical Officer of the Colombo Municipality.

Milroy was a studious child, soon to have as playmate and brother, Reginald, a year younger. When he was four or five years old, an English governess was engaged to look after the two boys and to teach them, Reading, Writing and Arithmetic. Both lads, particularly Milroy, developed a life long skill in these fundamentals. His parent’s home in Ward Place had a cultured environment with books in profusion. Their liberal education which had a bearing in their later life was a reflection of this. In addition to his own leading role as Senior Surgeon of the Colombo General Hospital, Dr. S. C. Paul had a wide range of interests. He together with Mr. Justin Kotelawala founded the Ceylon Insurance Company and with the De Vos family from Nuwara Eliya the Colonial Motors. Young Milroy and his brothers, including A. T. S. Paul, the first Cardio-Thoracic Surgeon of Sri Lanka, grew up in a home of considerable affluence where learning was prized above all.

His Primary and Secondary education were at the Training College, and in the course of time at Royal College, both at Race Course Avenue. Ball games at school were not his forte. He was more serious minded and carried away many prizes at Royal College. His name still appears on many of the long boards in the main hall as a heritage for the boys of future generations.

When he was nineteen, Milroy Paul was selected for admission to the Ceylon Medical College, just a short distance from his home in Ward Place. Within a year, he was also granted admission at King’s College and King’s College Hospital in London. Cecil Wakely who was on the Consultant staff at Kings, took an interest in the studious young man from Ceylon and they developed a life long friendship involving regular correspondence over the years. Milroy continued to display his academic prowess by enjoying great success at examinations. He qualified with both the Conjoint Diploma and the University degree in 1925.

Being at a loose end between qualifying and assuming duties as a house surgeon in mid 1925, he enrolled in Papworth’s private classes for Membership of the Royal College of Physicians (MRCP) of London. With his usual penchant for examinations, he passed the Membership at the first attempt, and was now a qualified physician just assuming duties as a house surgeon. He was admitted as a Fellow of the Royal College of Surgeons (FRCS) of England in 1926, and shortly after returned to Ceylon, looking forward to a surgical career. Prior to this, only Dr. Vrasapillai Gabriel in 1920 had achieved both postgraduate qualifications. Soon after returning from England, Milroy married his cousin Ponmany Hannah Winifred in 1926, and they had one son Wakely, so named after his mentor at Kingis. She suffered from Mitral Stenosis, which was so incapacitating that in her later years, she had to be carried upstairs. She died in 1944 of cardiac failure due to rheumatic mitral stenosis.

In 1945, he married for the second time, Irma Maheswari Tampoe Phillips, who was a niece of his senior colleague Dr. A. S. Rajasingham. They had four children, three of whom chose medicine as a career. All four of them now live abroad in Australia and the United States of America, and have achieved success in their chosen careers. Shivantha is a practicing Psychiatrist in Jacksonville, Florida. Their only daughter, Shikanthini, was appointed as a Consultant Geriatrician in Australia. Amajit became a dentist, and his services are much sought after in Melbourne. Their youngest son Avinder is an accountant in Sydney. Irma Paul who is here with us today with two of her sons, was a tower of strength to Milroy. They enjoyed ballroom dancing, playing tennis and of course entertaining. They were great ambassadors for our country. Irma took care of Professor Paul in his retirement and they enjoyed visiting wild life parks and their children overseas. She was mainly instrumental in relentlessly pursuing the setting up of this oration to commemorate the great man.

At the time of his return in 1926, Milroy found that the post of Fifth Surgeon at the Colombo General Hospital was vacant. When he applied for the post he was told by Dr. Bridges, Head of the Health Services, that he was too young and lacked experience, and was appointed as Lecturer in Anatomy instead. Two years later, the post remained unfilled, and when Milroy again applied for it he was told that experience was necessary, and was appointed as Surgical Tutor without any defined duties. He made whatever duties there might be for a surgical tutor. One of them was to teach on patients scheduled for surgery the next day. He would anxiously await the surgical findings. This was exciting, as his training had taught him deductive reasoning, whereas the collective reasoning in Colombo was intuitive and based on experience. This work initiated him into a long and successful career as an outstanding teacher.

The following year, Milroy again sought the post of Fifth Surgeon, but to no avail. Dr. Briercliffe who had succeeded Dr Bridges recommended he go back to England to obtain the Mastership in Surgery. He was overjoyed at this advice and returned to King’s College, his alma mater, and that of his father. He soon returned to Ceylon with the added qualification under his belt and was posted as surgeon to the Civil Hospital in Jaffna from 1930 to 1933, only the third surgically qualified man to hold that post. The first surgeon to hold this post was Dr. Kuneratnam followed by Dr. A.H.T. De Silva.

Milroy Paul held the post of Fifth Surgeon at the Colombo General Hospital after he completed his stint in Jaffna, and in 1937 was appointed as the first Professor of Surgery at the Ceylon Medical College. He held this post concurrently with his wards at the Colombo General Hospital and the Lady Ridgeway Hospital for Children. This was also the time when it had been determined that medical education in Ceylon should be guided by professional staff and the initial appointments were made in 1937 with Dr. P. B. Fernando to the chair in Medicine, Dr. G. A. W. Wickremasuriya who had recently been awarded the Kathleen Bishop Herman Prize of the British.

His attitude to patient care was always what was best for the patient. The risks of surgery were never the determining factor, only a consideration to be evaluated. He never denied any patient the opportunity to undergo surgery just because there was a high risk.

There was another side to the man. When called for an emergency operation, he would arrive within ten minutes, don his Black Wellingtons and race along the corridors to the theatre often passing his students ambling along, who he would later refer to as a herd of buffaloes in a sea of treacle. His prudent house officer would ensure the patient and theatre were ready before he arrived and that the anaesthetist and blood bank were informed. On arrival, he would take a head count to ensure that all his students were present. Many were the tricks of impersonations by his students to make sure that the count was correct. He would then go through the history and physical signs with the house officer and examine the patient. The house officer may have called him for a perforated peptic ulcer whereas the professor, after examination, may have disagreed with this. He would address his students and say, “Here we have a problem”. “The history and findings are as follows. My house officer says it is a perforated peptic ulcer; I say it is pancreatitis. Let us find out now”.

The excited students dare not cross the artificial aseptic white line drawn by Lewis his theatre attendant for many years. He knew his quirks and peculiarities, and in return was accorded the privilege of placing the patient on the table and adjusting the light appropriately. Professor Paul would commence the operation talking all the while. On this particular occasion, as he opened the peritoneal cavity, there was the tell tale hiss of escaping gas. He turned to his students and said “My houseman has it. A perforated peptic ulcer it is ! Of course he knew it all along but this was his way of encouraging his students and making the theatre a stimulating environment. For him, all that mattered was the process of deductive reasoning and independent thinking.

Not having the benefit of modern haematological, histo, pathological and immuno his to chemical tests, imaging and other facilities, his research was mainly based on his observations of his surgical patients. A story he often repeated at his lectures on head trauma was regarding extra dural haemorrhage. He had two reasons to challenge conventional belief that extra dural haemorrhage following trauma to the head was from the artery and not the vein. One was that subdural haemorrhage was most often venous in origin. The second reason he had found was the ease with which the bleeder could be stopped. Based on his findings he delivered a Hunterian Oration on i Haemorrhages From Head Injuries” in 1955.

Professor Milroy Paul had a running battle with the physicians whenever there was an entity called Amoebic Hepatitis. His contention was that early stages of amoebic liver disease was the result of several small abscesses which later coalesced into a big one. He felt that the treatment of these small abscesses with Emetine was curative. Today, with the benefit of ultra sound and CT scans this is exactly what we see. Professor Paul has been quoted on this topic in Bailey and Love’s ‘Short Practise of Surgery’ a text book used by under graduates and post graduates in most parts of the world, in page 798 14th edition. His innovative way of treating non-healing leg ulcers with strapping and cast still remains the gold standard.

Professor Paul started contributing to prestigious medical journals published in England. Cecil Wakely who was then on the editorial board wrote back suggesting that Milroy’s submissions were mainly on diseases prevalent in the West, and perhaps might have been increasingly seen in Ceylon, but suffered in comparison with those of his peers in England, on account of lesser investigative facilities. He suggested instead that the latter should turn his attention to tropical diseases, of which an English readership knew next to nothing. Good advice, and gratefully accepted. Then followed a spate of papers, which at the end of his career in 1965 numbered eighty. One has to remember that his period of writing lasted 35 years beginning in 1930 at a time when there was no online search facilities. One had to refer to the Index Medicus with its 6 point print and rely on reprints sent by authors from abroad on request. He contributed to journals in England, Australia, New Zealand, India and USA. There was no field of surgery to which he failed to make an original contribution. His range of interest covered such diverse subjects as Elephantiasis, amoebiasis, typhoid, urological problems and head injuries all of which presented as surgical problems. The writing was not merely descriptive, but evoked an intellectual curiosity as to causation. Almost invariably, they were also provocative. He didnit merely describe tropical diseases, he dissected them until he understood causation, and frequently postulated as such in his presentations.
It is this aspect of the man that was so highly regarded in the Surgical world. Here was one of those rare breed of men n a Surgical thinker. Great Surgeons have abounded over the years. Surgeons, who were also good teachersi were not so common, but they existed in every country. But Surgical Thinkers, who were also great teachers were exceptional. Posterity regards him as one of the great surgical thinkers of this world, and the names of Lord Lister, Louis Pasteur, Ambrose Pare, Bigelow and Mustard come to my mind. To have apprenticed under such a great surgical thinker must be the highest accolade for an aspiring surgeon. To have understood his mental versatility was the ultimate prize!

In the course of his career he delivered the prestigious Hunterian Lecture at the Royal College of Surgeons on three occasions. A very unusual occurrence and to the best of my knowledge one that has not been repeated. The three lectures were entitled, The Surgical Anatomy of the Spermatic Cord in 1950, Congenital Abnormalities of the midline Abdominal Wall in 1953, and Haemorrhages from Head Injuries in 1955. He was unaffected by these achievements and remained a simple man. The story goes that when he went to deliver his third Hunterian oration in 1955, when the doorman apparently mistook him for a post graduate student and asked him whether he had come to register for the post graduate course. Milroy replied i No, I have completed that”. “Ohi , said the doorman, “then you have come to register for the primary?” No, I have finished that tooi responded Milroy. i Perhaps you have come to register for the FRCS examinationi ?. “ No, sir, I have finished that too”. Ah, said the doorman, “you have come to listen to the Hunterian lecture?”. “No siri said professor Paul politely, “I have come to deliver iti !

By now, Milroy Paul’s reputation had spread among the medical communities in most of the English speaking countries, in particular England. Young doctors from Ceylon who went to England for training in surgery were amazed at the popularity and esteem he enjoyed. When they applied for a post, they were frequently asked i Do you know Professor
Milroy Paul? If the reply was “I was his house surgeon, sir,” the next question to the delight of the candidate was “When can you start”. Long after Milroy’s retirement, a surgeon on sabbatical leave from Ceylon was appointed as a Locum consultant in a hospital in London. On his first day, he was faced with an operating list in which there was a patient with Obstructive Jaundice. The pre-operative diagnosis was stones in the Common Bile Duct. Though he disagreed with this, he proceeded with the surgery and found the cause of jaundice was due to a carcinoma of the Ampulla of Vater. The operation continued with a partial pancreatectomy. Unknown to the surgeon, this incident had been the subject of conversation in the Consultantsi Room. Three days later in the hospital corridor, a gentleman stopped him and asked i Are you the surgeon from Ceylon who performed the whipples? The reply was in the affirmative. The gentleman introduced himself as a retired consultant of the hospital and went on to ask “do you know Professor Milroy Paul? “I was his house surgeon siri said the Locum. “I knew it! I told them you must be one of Paul’s trainees” said the retired surgeon. He went on to say that Professor Paul was a popular visitor to their hospital and that they often hosted him to dinner mainly to hear his delightful after dinner speeches. As you may have guessed by now, both were my personal experiences.

Surgeons travelling between England and Australia on the Orient Lines which regularly stopped in Colombo, took the opportunity to break journey to visit Professor Paul. They would attend ward rounds and operating sessions of the professor, and sometimes would be asked to demonstrate operations of their own preference. I recall Sir Cecil Wakely and Sir John Nicholson as two such visiting surgeons. It was not unusual for these surgeons to be hosted to dinner by Irma and Milroy at Rao Mahal.

While known far and wide for his publications and skills and innovation in the field of surgery, it was his teaching that truly defined the legacy of Milroy Paul. He challenged current thinking and theories in those early days. He brought in a breath of fresh air and originality into the thinking process on both medical and non-medical topics which inspired us, his students, to think outside the box. Teaching was his forte and his classroom his stage. It was a performance we wouldn’t miss for anything. He was a brilliant teacher who never repeated what was in textbooks but rather, had his own theories on the causation, management and natural history of a disease, sometimes to the astonishment of some of the students who had memorized the text books. Didactic teaching and learning by rote had no place in his classroom. Whatever it was, his lecture halls were always crowded and his teaching sessions in the ward were always overflowing with students. Latecomers often found they were crowded out. Which of his students would forget his Saturday morning ward teaching sessions for final year students? Students would cling onto the window sills and hang by the windows reminiscent of the overcrowded buses we see today, to get a glimpse of the professor and hear pearls of surgical wisdom from his lips. ‘Look at this chappiei , I get moving man! ^1 or “You are fired” were some of his favourite expressions which were followed by cutting remarks on a student’s performance, thereafter followed by laughter from the student’s peers. These words were never meant to hurt but rather to encourage. In fact, most students considered it to be an honour to be insulted by the great professor so much so that they would boast about it at the faculty canteen over a cup of tea.

Apart from his own group of final year medical students, it was open house for any student to attend the Clinical Demonstrations on a Saturday morning. The usual custom was for one his surgical students to present a hitherto undiagnosed patient giving both history and physical signs. From then on, the professor would proceed by a process of deductive reasoning to arrive at a diagnosis. Carlo Fonseka, now a retired Professor of Physiology, but then just a medical student, thought this performance was highly theatrical and decided to present the same patient over a course of two weeks, confident that the professor would not remember. To his absolute delight, the professor arrived at a different diagnosis on the second occasion. Putting on his grandest manner, young Carlo then said, “Sir, this same patient was presented last week and you then arrived at a different diagnosis. How do you explain that Siri ? Unabashed, Milroy promptly replied to the delight of his students, “Science marches on man. Carlo, you are left standing where we were last week”. Witticisms such as this were common place on Saturday mornings. It would not be an exaggeration to say that these sessions were probably the high light of a student’s week.

Though a strict disciplinarian with a stern exterior, Professor Paul was fair when examining final year students. Dr. M. H. de Zoysa one of his former registras tells the story of a candidate having mis-diagnosed a patient from Badulla, as having Haemorrhoids (piles) when the diagnosis was cancer of the rectum. Professor Paul had given him the minimum pass mark. After the examination Dr. Zoysa asked the professor why he gave the candidate a pass mark. The reply had been “I say Zoysa, when I asked him what he would do with the patient, he said he would refer him to the local surgeon. Now, the surgeon in Badulla is Dr. Sivagnanam, one of the finest in this country. Surely, he is not going to miss the diagnosis” ? If the student had suggested a treatment, he most certainly would have failed. For 32 years Professor Paul continued to teach successive generations of medical students, and I think I speak for every one of them, when I say they all enjoyed his classes.

Professor Paul belonged to many medical societies both at home and abroad. He never talked about it, and few knew of it, but he had membership at a few elite surgical clubs and societies in England, which were exclusive to those who had made significant contributions in the field of surgery. The Moynihan Club in Leeds and the prestigious James the Fourth surgical club come to mind. The latter has only twenty-five members and a next prospective appointee has to await the demise of one of its members. Professor Paul was conferred membership in this esteemed society for his prolific contributions to surgical literature. In the mid nineteen sixties, an Arthur Sims Travelling Professor referred to him as the best known surgeon in the British Commonwealth. He was conferred an honorary fellowship of the Association of Surgeons of Great Britain and Ireland and was a founder fellow of the international college of surgeons.

At home, he founded the Association of Surgeons of Sri Lanka in the Nineteen Sixties which in the course of time gave way to the College of Surgeons of Sri Lanka. Today we honour Professor Milroy Paul by giving this Inaugural Lecture under the auspices of the College of Surgeons of Sri Lanka. He also founded the Sri Lanka Association for the Advancement of Science and held the chair of the Sri Lanka Medical Association and was President of the Sri Lanka National Academy of Sciences. He was honoured by every university in the country with an honorary doctorate in science, and the College of Surgeons of Sri Lanka admitted him to its roll of honorary fellows. Professor Paul was appointed as the Registrar of the Ceylon Medical Council in 1942 and remained in the post until 1982. He attended to the onerous task of registering doctors and para medical personnel, ensuring they always complied with the highest medical ethical standards.

In 1937, he was one of the founders of the Medico-Legal Society of Ceylon, together with Sir Sydney Abraham, Chief Justice, Lalitha Rajapakse, lawyer, Dr. Sinnadurai, Judicial Medical Officer, Drs. Wijerama and Nicholas Attygale. The Society remains active and its members continue to present numerous papers at the affiliated body, the Asia Pacific Medico-Legal Society. He also joined the Volunteer Regiment of the Ceylon Medical Corp. rising to the rank of Major. He served the Army during the Second World War, and resigned his commission shortly after due to the pressure of work.

One of his most endearing features was his interest in young surgeons, what they were doing and most importantly, were they writing? Of his more recent assistants, (and forgive me if some names are omitted), were Doctors Henry Nanayakkara, later Professor, Ananda Soysa, Norman Fernando, Rajayah, Malinga Fernando, M. H. de Zoysa, Douglas Wickremesinghe, Michael Abeyratne and Ranjit de Silva many of whom kept in touch with him even after his retirement. He was particularly pleased when any one of them followed in his footsteps and became surgeons. After his retirement, he continued to visit the Medical Library regularly. Even after blindness overcame him, his continued interest in matters medical would see him attend many of the lectures of the Sri Lanka Medical Association, often supported by either M. H. de Zoysa or Douglas Wickremesinghe.

Generations of Colombo medical students had the privilege of learning from him and I was one of them. I was more fortunate than most, for I was his House Surgeon as were some of you in the audience today. I learnt an enormous amount from him, all of which has stood me in good stead in my career. If I were to summarize the qualities this great surgeon subconsciously passed on to me, they would be humility, honour, integrity, compassion and the ability to indulge in deductive reasoning.

I would like once again to thank the President and the Council of the College of Surgeons of Sri Lanka for affording me this opportunity to deliver the First Milroy Paul Lecture. It has indeed been a singular honour for me, for he was a very unusual chief who was blessed with inborn brilliance and was an inspiration to all of us.

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