Terence Millin: pioneer of the retropubic space

Authors


David M. Bouchier-Hayes, Royal Melbourne Hospital, Urology, Melbourne, Victoria, Australia.
e-mail davidbouchierhayes@yahoo.co.uk

Terence Millin was, without doubt, Ireland's most famous urologist and was responsible for markedly changing the approach to the surgery of the prostate gland. He was truly a man for all seasons, a gifted student, an athlete at the highest levels, a fine surgeon, a gregarious host and a loving family man and friend. His name lives on in the country in which he grew up, and his name has left an indelible mark on Irish surgery and world urology.

He was born to Northern Irish Protestant stock on 9 January 1903 in the picturesque town of Helen's Bay, Co. Down, in what is today the province of Northern Ireland, and had a comfortable upbringing, due to the benefits of his father's practice as a barrister. He was initially schooled in Tipperary, in the south of the island of Ireland, but finished his secondary schooling in St. Andrew's College in Dublin, which still exists today. There he demonstrated not only his intelligence, but also his sporting prowess, playing on the side that won the prestigious Leinster Schools Senior Cup in rugby union in 1921, one of the last times that this small rugby-playing school did so. He achieved numerous academic glories and was awarded a First in Mathematics and a scholarship to the most prestigious Dublin university of that time, Trinity College, bastion of Protestant higher-level education in the early part of the 1900s. Here his remarkable career continued and after a period in Arts and Mathematics, he enrolled as a medical student, and found his true calling.

However, his studies did not temper his sporting achievements, and he was captain of the Trinity Firsts rugby union team, during which time they went unbeaten for an unprecedented three seasons, a remarkable event for any era. The team was characterized by playing a ‘seven-eights’ formation where through the strength of their forward pack, Trinity were able to play with seven forwards as opposed to the usual eight, and thus one extra back to cause havoc with the opposition, a style which is occasionally still used in New Zealand rugby. These displays led to his recognition by the International selectors, and he was capped in the centre in 1925, against Wales (Fig. 1). Against this venerable rugby nation, Ireland scored one of her best wins of the era, by 19 points to 3. Contemporary news reports cite Millin as being the ‘best’ of an excellent group of free-scoring backs and a try-scorer himself. Needless to say, after such a sterling display of rugby football, in true Irish style he was dropped by the selectors and never played for his country again, a shoulder injury limiting his further rugby playing.

Figure 1.

Millin (back row, far right, hands in pockets) capped for Ireland.

As an undergraduate student he won numerous honours and was the recipient of at least one named honour per year. After a stellar undergraduate career, he undertook a house-surgeon post at Sir Patrick Dun's Hospital in Dublin, and from there travelled to London to continue his surgical career. After various posts undertaken to increase his experience and knowledge, he undertook the examination for the Fellowship of the Royal College of Surgeons of England, and passed it on the first attempt, an unusual achievement in its own right. He then took up a position in All Saint's Hospital, where he came under the tutelage of Canny Ryall, the famous Irish-born, Trinity-educated urologist, and it was at this 11-bed purely urological hospital that he developed his interests in matters of the genitourinary tract. He had numerous other appointments but the one where he made his biggest mark was as a private urologist in his clinic in Queen's Gate in London, near to where the Iranian embassy siege was ended so dramatically by the SAS many years later. Here, under the roof of three large conjoined townhouses, he embarked on his career and the operation that made him famous.

At that time, surgery of the obstructing prostate gland was by either an open procedure (usually a Freyer transvesical prostatectomy, named after another Irishman, Sir Peter Freyer of Galway) or an endoscopic procedure, either by the ‘cold punch’ technique, or by the use of a transurethral diathermy loop, as developed by McCarthy of New York. At the time the merits and drawbacks of these two separate approaches were debated frequently, and often heatedly. Having been an avid proponent of the diathermy loop TURP, Millin realized that it had many drawbacks because of the poor optics and excessively large instruments of the time. Incontinence was not uncommon and urethral stricture was extremely prevalent, not unsurprising given that the resectoscopes of the time were often a centimetre or more in diameter. He practised transurethral resection on up to 40% of his obstructed patients, performing the Freyer transvesical operation on the others. However, the years of the Second World War, during which he remained in London, allowed him time for contemplation and thought, and it was this time, combined with the experience of operating on a patient with a fractured pelvis and ruptured urethra, which gave him the idea to approach the prostate retropubically. On 1 December 1946, he published details of his first 20 patients in The Lancet, in his landmark paper [1]. He invented a special self-retaining retractor to aid in exposure and after attempting the judicious use of clamps, finally settled on the use of rapid, water-tight suturing to control bleeding from the capsule. Capsular closure was undertaken in < 5 min, with use of a specially designed ‘boomerang’ needle (Fig. 2), with the eye of the needle near the point, in keeping with the principles of the sewing-machine needle. This rapid period of capsular closure in the midst of significant bleeding was often quite taxing on both surgeon and assistant! An anonymous editorial, entitled ‘Eureka’, the author of which was probably the master general surgeon Sir Heneage Ogilve, compared Millin's achievements to those of Archimedes, Lister, Stanley and Livingstone, and Bilroth, and set the stage for a remarkable expansion of what until then was an approach under-used in the surgery of the prostate gland. In the editorial comment it is noted that: ‘80 years after the birth of surgical craftsmanship, and in the surgery of the prostate, a branch of operative technique, commoner, more important, more closely studied, and more widely pursued than most, T.J. Millin has discovered a method that is not only quite new, but also simpler, safer, and better than those in use’[2], an accolade which would gladly be heard by anyone involved in researching and applying alternative techniques to TURP today! It is this operation that, in the opinion of Prof. Patrick Walsh of Johns Hopkins, has laid the foundation for the anatomical radical retropubic prostatectomy that is used today.

Figure 2.

The famous self-invented ‘Boomerang’ needle.

Millin's practice became enormously successful and he became world famous (Fig. 3), a combination of his surgical prowess and congenial charm making him in high demand not only in London, but also overseas, where he was a frequent invited guest to continental Europe, the USA and Australia, operating on such notables as the then Turkish President, Celal Bayar, in 1953. His concise book ‘Retropubic Urinary Surgery’ describes his initial 345 prostatectomies by the retropubic route, as well as describing one of the first series of radical retropubic prostatectomies performed specifically for organ-confined cancer, and an extremely novel pubovaginal sling from in-situ strips of rectus sheath [3]. This book allowed him to gain a strong (although mixed!) reputation in the USA, and worldwide the impact of his approach was immense. The mortality associated with open prostatectomy was reduced by about 10-fold, and allowed the technique to be used by a more generalist community, as urology in many parts of the world was a nascent speciality, often (and still) practised by general surgeons. His contribution to male health was recognized in 1955 with the receipt of the prestigious Francis Amory Prize, awarded by the American Academy of Arts and Sciences. The previous recipients had included Papanicolau for his smear test for cervical cancer, and Charles Huggins for his Nobel Prize-winning work on hormonal manipulation of prostate cancer (Fig. 4). On the occasion of receipt of this most prestigious of awards, his speech, entitled ‘Man, Beast and Field’ outlined not only contributions of fellow award recipients of that year, but also his theories on animal husbandry, and his extensive use of organic-farming techniques and disapproval of phosphate-based fertilisers, pre-dating present trends and fashions by decades [4]. Further honours included the Saint Peter's Medal, the BAUS’ highest award in 1951, and becoming that society's first Irish President in 1954, which saw a rousing annual meeting in Millin's true home town of Dublin. He was also made an honorary fellow of the Australasian College of Surgeons in 1968, and was appointed as honorary member of the American College of Surgeons.

Figure 3.

Terence Millin at the height of his world renown

Figure 4.

Honoured alongside Charles Huggins, Nobel Prize Winner.

However, Millin had another great love, and that was farming. He essentially retired from operative practice at the age of 57, a relatively young man with a large personal income being penalised heavily by severe British tax laws, returned to Ireland and took up on the first of three farms that he owned subsequently. It was during this time in the 1960s that he also became heavily involved in the running of the Royal College of Surgeons in Ireland (RCSI) and was elected President for an unprecedented two terms from 1963 to 1966; he was instrumental in rejuvenating the undergraduate part of the college, which is now the only surviving undergraduate Royal College of Surgeons in the world, and one of the world's largest multinational medical schools, with students and graduates from over 40 countries. It was during this period that he sat for his Presidential portrait, which features him seated, appearing as an extremely robust, handsome man, with the ubiquitous cigarette in hand that he insisted on having in the portrait!

Unfortunately, the cigarettes of which he was so fond were to cause his demise, and he died in 1980 in a modest labourer's cottage in County Wicklow, from laryngeal cancer, having lost much of his savings in the economic upheavals of the 1970s. Notices of his death were publicised not only in the medical press, but also in the London Times and other contemporary broadsheets, indicating the level of his fame. Ironically, the clergyman who officiated at his funeral underwent a Millin's prostatectomy himself a few years after the funeral, under Mr Michael Butler of the Meath Hospital in Dublin, whom Millin had observed performing his eponymous operation whilst he was a registrar, and had commented by letter on his proficiency at the procedure. His passing was a great loss to all those who knew him, especially his wife of over 40 years, Molly, and two daughters, Deirdre and Zoë. However, his legacy in Irish surgery remains strong, and as well as student accommodation in the RCSI being named after him, the highlight of the college's academic year is the delivery of the Millin lecture. This is given by a young surgeon and was first delivered in 1979 by Mr James Smith, a then young (and now retired) urologist. It has only been given by a urologist on one other occasion, that being by this journal's editor, Prof. John Fitzpatrick. Due to Millin's ill-health, the lecture was given twice that first year, on the second occasion by my father, David. On that occasion Millin penned a letter apologising for his inability to attend because of illness, and remarking of his pride at seeing that the presenter of that lecture was the son of his old friend and classmate, which was my grandfather.

That personal note appears to sum up the life and career of Terence Millin. He was a man who is remembered primarily for his surgical expertise and athletic achievements, but was much more multifaceted than that, a possessor of great charm and wit and an essential humanistic quality (Fig. 5). He was the greatest of Irish urologists and has left a tremendous legacy. To paraphrase Millin's biographer, Prof. Barry O’Donnell, the wider surgical community know an approach to the pelvis and prostatectomy that is called retropubic. In Ireland it will always be called Millin.

Figure 5.

Terence Millin in repose in later life.

CONFLICT OF INTEREST

None declared.

SUGGESTED READING

Terence Millin: A Remarkable Irish Surgeon. Dublin: A&A Farmar, 2002. Available from the Royal College of Surgeons in Ireland, 123 St Stephen's Green, Dublin 2

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