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Biographical entry Balasegaram, Manickavasager (1929 - 2014)

MB BS King Edward VII College 1955; FRCS 1960; FRCS Edin 1960; FRACS 1968; FICS 1968; FACS 1969; Hon FPCS 1975; FIAP 1977; FCICD 1978.

Born
15 April 1929
Kuala Lumpur, Malaysia
Died
5 May 2014
Occupation
General surgeon and Liver surgeon

Details

Manickavasagar Balasegaram was a pioneering surgeon in Malaysia, who gained prominence for his anatomical studies of the liver and for his development of the 'Balasegaram clamp'. 'Bala' or 'Prof', as he was known, was renowned for taking on complex surgeries that few others did in the region. He was also highly respected as a teacher and mentor.

He was born on 15 April 1929 in colonial Malaya, the son of poor Ceylonese migrants. He had an unsettled childhood, living in boarding houses in order to go to school. At 15, after his father's arrest by the occupying Japanese Army, he had to take responsibility for his large family. He resolved early on to become a doctor. It was astonishing ambition: he had little money, influence or decent schooling (at one point he even taught himself), and in colonial Malaya Asian doctors were very rare. Yet he battled every barrier with dogged determination, won a state scholarship to study medicine at Singapore's King Edward VII College and qualified MB BS in 1955.

His surgical career began at Kuala Lumpur's General Hospital under Thomas Thornton, a towering, powerful Scotsman who was a fine craftsman in surgery. After training at the Royal Infirmary of Edinburgh, in 1960 he gained the FRCS from both the English and Edinburgh Royal Colleges.

As a young surgeon, he worked extremely hard. His drive and energy seemed limitless, and he had an insatiable hunger to operate. At one point, covering for a colleague away on training, he spent months sleeping a few hours a night in a hospital rest room. He would later tell his forgiving and supportive wife Jeyaletchimy: 'I have a mistress - her name is surgery and she is very demanding.' He became a consultant surgeon at the General Hospital, Kuala Lumpur, and subsequently head of the department of surgery.

He had confronted the challenge of the liver in the late 1960s in Seremban Hospital after seeing many road trauma cases die from liver injuries. Without seatbelts, drivers often suffered liver trauma when they hit their steering wheels. At that time, the anatomy of the liver was poorly understood, diagnostic procedures were limited and operating on this 'vascular sponge' risked uncontrollable bleeding. To study the liver's blood network, Bala injected coloured rubber latex into cadaveric livers: red latex revealed the intricate arterial system, blue the venous system and green the biliary network. He began liver resection, a procedure probably never done before in the country. It proved to be a marked improvement over the then standard procedure of packing gauze around the injury.

At that time, there were few instruments for the liver; he designed a clamp to control bleeding, manufactured by Down Brothers in London. He also designed other instruments, but never sought royalties.

Bala also took on oesophageal surgery, then rarely done. He had a unique method for resection of the oesophagus in cases of cancer or necrosis; he used the stomach or large intestine as a substitute, reconstructing the stomach as a conduit for food. This was often done on young Indian women from plantations who had ingested caustic agents in suicide attempts, then a common occurrence.

Bala also saw a need for better post-operative care, but he could not get government funds. Ever resourceful, he persuaded the Rotary Club to help fund an intensive care unit (ICU), the local public works department to build it and Siemens to donate instruments. The Rotary Club declared the ICU the 'first of its kind in south-east Asia'. The new unit also helped bring down tetanus mortality from 80% to 18%.

In 1967, Bala travelled around the United States, visiting surgeons to learn and share research. Many surgeons knew of his published papers and his clamp, but few knew of Malaysia. They were stunned to discover his research was done in a small-town hospital in a country that they could not place on a map. On his trip, he visited Thomas Starzl, a leading transplant surgeon. Bala was all set to do transplant surgery, but ran into legal and cultural obstacles in Malaysia.

In 1969, Bala set up the hepato-biliary centre in Kuala Lumpur Hospital: it was to become a referral centre not just for the country, but for the entire region. In the same year, race riots erupted in the country. On 13 May, an injured man rushed into Bala's operating theatre, clutching his bloodied intestines and screaming that he had been attacked. Soon, dozens of injured patients arrived. Bala quickly began triage, recalling what he had seen in a military hospital in Vietnam. When his team ran out of gloves and gowns, he operated with his bare hands. Amazingly, no patient suffered infection later. His unique experience led to many published papers. He later wrote an editorial on emergency procedures in the Journal of Trauma ('Editorial: Management of the critically injured following large-scale civil disturbances in major cities' J Trauma. 1974 Jul;14[7]:628-30).

As the head surgeon of Kuala Lumpur's General Hospital, he ran a tight ship. His training was excellent, but not for the fainthearted. He was a 'field commander' who demanded perfect discipline, rigour and order. At 8am sharp ward rounds began, starting with the third class ward for the poor. Cases awaiting surgery were rare; his junior surgeons usually finished all cases the previous night, no matter how late.

For his loyal troops, he offered much support. He arranged for senior surgeons to visit Malaysia to give coaching. Bala himself was an examiner for FRCS Edinburgh from 1972 to 2004 and for the Royal Australasian College for many years.

Bala was respected not only for his skill, but his daring in surgery. He took on complex operations (such as the Whipple procedure and other pancreatic surgeries) that probably only himself and G B Ong in Hong Kong were doing in the region. He was known for accepting 'salvage cases' that no-one else would touch. Remarkably, he had little to bank on in terms of facilities, tools, machines and resources; what he had was courage and conviction, and excellent clinical acumen.

In 1970, Bala won the Jacksonian prize from the Royal College of Surgeons, and in the same year was awarded the Hunterian professorship. In 1971 he gave the Chiene lecture at the Royal College of Surgeons of Edinburgh on 'modern concepts in surgery of liver trauma', and in 1974 he delivered the Abraham Colles memorial lecture at the Royal College of Surgeons in Ireland. He was an honorary fellow of the Philippine College of Surgeons (PCS), and a fellow of the American College of Surgeons (ACS), the International College of Surgeons (ICS), the International Academy of Proctology (IAP) and of the Collegium Internationale Chirurgiae Digestivae (CICD).

He published many peer-reviewed articles in journals, served on the editorial board of 15 international journals and travelled to more than 40 countries as an invited guest lecturer. He was a visiting professor for many universities. At home, he was given the honorary title 'Dato'. He also won the Rotary Club's gold medal for most outstanding research in 1987.

He retired from government service in 1983. Liberal use of painkillers for constant headaches led to kidney failure. By 1989, he needed regular haemodialysis. He refused to be defeated: he became probably the longest-surviving dialysis patient in the country, with a 25-year run. His nephrologist described him as an 'exemplary patient' who saw dialysis as 'an adjustment to lifestyle'.

At home, he pushed for excellence from his five daughters (Thiruchelvi, Mangai, Uthayasoori, Sauntheri and Gowri) and one son (Manica Vasagar). Two are doctors, one a public health specialist and one a biochemist; another has a PhD in education and one is an art historian. His son, a physician and tropical diseases specialist, is a director with Médecins Sans Frontières, and his eldest granddaughter, Anusha, is a medical student at University College, London.

Bala loved military history and admired the US General George Patton. He also loved ancient history and travel, combining both when he visited ruins in Mexico and Peru. His own history was described in his biography, written by his daughter From small town boy to world-class surgeon (Marshall Cavendish Editions, 2007).

On his 85th birthday party on 15 April 2014, Bala gave an emotional speech to his family, saying he had achieved every one of his goals, the last being to live to 85. It had seemed impossible in the early days of dialysis, but as he'd say, 'When there's a will, there's a way'. A few weeks later, on 5 May, he died peacefully in his sleep at home. He was survived by his wife, six children and 11 grandchildren. After his death, the Academy of Medicine of Malaysia established an annual memorial lecture in his honour.

Mangai Balasegaram

Sources used to compile this entry: [From small-town boy to world-class surgeon Mangai Balasegaram (Marshall Cavendish Editions, 2007); personal communication with family and former trainee surgeons; The Star 23 May 2014 www.thestar.com.my/Lifestyle/People/2014/05/23/A-tribute-to-my-father-Datuk-Dr-Manickavasagar-Balasegaram/ - accessed 15 September 2014; The Malay Mail 31 May 2014 http://manage.mmail.com.my/story/dr-bala-%E2%80%94-surgeon-par-excellence-80448 - accessed 15 September 2014].

The Royal College of Surgeons of England