Remembering the Classics: Helen Taussig, Vivien Thomas & Alfred Blalock- Surgical Palliation of Blue Babies
Alan Jay Schwartz, MD, MSEd Mark A Rockoff, MD
“You can observe a lot by watching.” Yogi Berra
pathophysiology of cyanotic congenital heart disease. In Yogi Berra-esque style, Taussig subscribed to the truism that “You can observe a lot by watching.” She was an astute observer as she watched her babies and observed their cardiovascular pathophysiology.
“Dr. Taussig frequently saw babies who looked blue during and right after the delivery. After every sip at their mother’s breast, they had to gasp for air. They had a congenital malformation, most frequently a tetralogy of Fallot. Because of a narrow pulmonary artery, too little blood can flow to the lungs, where it is normally abundantly provided with oxygen. But why was it, she wondered, that some of these “blue babies” died soon after birth, while others survived for months or even years? Was there a pattern here, a system? A special vessel caught her attention: the ductus arteriosus…Helen [watched and] made…[an] important discovery. The blue babies whose ductus arteriosus stayed patent after birth, did remarkably better than those whose ductus closed spontaneously. They looked less blue and survived for longer. So it must be important, she reasoned, to keep that shunt patent…1.
Taussig, intent on the clinical application of her observation, approached surgeon Robert Edward Gross (1905-1988) with the idea to construct an artificial ductus arteriosus, a systemic arterial to pulmonary artery connection to augment pulmonary blood flow. Gross, who worked at Boston Children’s Hospital and was well known for performing the first successful closure of a patent ductus arteriosus in 1938 in a 7-year-old girl with congestive heart failure2, “…had his doubts…[stating] ‘I have enough trouble closing a patent ductus, without creating one!’ – a remark he would later on come to regret and consider the most idiotic thing he had ever said.”1
Taussig turned to Alfred Blalock (1899-1964), the Surgeon-in-Chief at Johns Hopkins Hospital. She had been a student there at a time when few other medical schools accepted women, and she remained at Hopkins for training in pediatrics and cardiology before establishing a section devoted to pediatric cardiology. Blalock’s laboratory had experience fashioning systemic arterial to pulmonary artery connections in animal studies of pulmonary hypertension. Much of this surgery was performed by Vivien Thomas (1910-1985)3, a Black laboratory technician who worked with Blalock for many years while they were both at Vanderbilt before Blalock brought Thomas to Hopkins with him. Thomas supervised the surgical laboratory, performed dozens of successful shunt procedures in animals, and created some of the surgical instruments used by Blalock when the first successful human systemic to pulmonary artery shunt was performed. Thomas can even be seen in a photograph of one of these early procedures3 standing immediately behind Blalock since Blalock insisted Thomas be available to provide advice during the operation. Yet Thomas was poorly paid and generally viewed more as a menial worker. He earned extra money for his family as a bartender at evening parties hosted by Blalock, serving many of the same individuals he supervised during the day in the surgical laboratory. This was at a time when Johns Hopkins Hospital, located in Baltimore, still had segregated wards, separate dining areas and water fountains for Whites and Blacks, and no Black physicians or nurses on the staff.
“At the age of 15 months…Eileen Saxon weighed only 5 kg…Helen Taussig diagnosed a Tetralogy of Fallot…On the 9th of November, 1944…[Eileen] was brought to theatre and anesthetized…Dr. Blalock cut the artery going to the arm, and grafted it sideways on the pulmonary artery…After the surgery, Eileen changed colour immediately, from a sickly blue to a blushing pink complexion. Without having to gasp for air, she could drink milk again and quickly gained a few kilograms.”1
After successfully performing this new shunt procedure three times, Blalock and Taussig published their clinical surgical approach to palliate blue babies.4 In this article, the authors acknowledged the help of many individuals including anesthesiologists for these cases who were pioneers of our specialty, Merel Harmel5 and Austin Lamont6. However, Thomas was never mentioned. Thereafter, these procedures became known as Blalock-Taussig shunts.
In her own words, Taussig explicitly described the effectiveness of this shunt procedure:
“The operation developed by Dr. Alfred Blalock is designed to increase the circulation to the lungs. This is accomplished by the anastomosis of the proximal end of one of the systemic arteries to the side, or distal end, of the right or left pulmonary artery. In order that the blood should flow from a systemic artery to a pulmonary artery the pressure in the systemic circulation must be higher than that in the pulmonary circulation. This is true in all cases of pulmonary stenosis or atresia. In such malformations a Blalock-Taussig operation virtually restores the condition to that existing before the closure of the ductus arteriosus.”7
I (MAR) was very fortunate to have had a chance to work directly with Vivien Thomas when, as a third-year medical student at Hopkins on my surgery rotation, I and my colleagues were taught how to administer anesthesia and perform several different surgical procedures on dogs. Thomas supervised these laboratory sessions. He was very calm, reserved and humble, and a wonderful mentor to all of us novices. Even then, the syllabus for this course (that I still have) does not mention his name. Instead, two surgeons who were less involved were noted.
Belatedly, Thomas began to receive acknowledgement for his seminal contributions to the development of surgery and especially for this “blue baby” operation. As reported in the Washingtonian by Katie McCabe in the 2020 article titled, The Remarkable Story of Vivien Thomas, the Black Man Who Helped Invent Heart Surgery, “In 1971 Vivien Thomas stood at center stage for the first time when his portrait was hung in the lobby of Johns Hopkins’s Blalock Building, opposite the portrait of his friend and partner, Alfred Blalock. Five years later, formal recognition of Thomas’s achievements was complete when he was awarded an honorary doctorate and an appointment to the medical-school faculty.”8 as an Instructor in Surgery. “Thomas never went to medical school, but he had a genius, a stunning dexterity. He might have been a great surgeon. Instead, he became a legend.”8 Though all this took way too long, the palliative shunt procedure conceived by Helen Taussig, developed by Vivien Thomas, and performed by Alfred Blalock has recently been most appropriately re-christened the Blalock-Thomas-Taussig shunt.9
Those interested in learning more about this remarkable man, Vivien Thomas, should view the 2004 film, “Something the Lord Made”10.
References
1. Van Robays J. Helen B. Taussig (1898-1986). Facts Views Vis Obgyn. 2016; 8(3): 183-187
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5172576/ (accessed 06/30/2023)
2. Murray L, Hendren WH, Mayer JE, Rockoff MA. “A Thrill of Extreme Magnety”: Robert E. Gross and the Beginnings of Cardiac Surgery. J Ped Surg 2013, 48: 1822-1825
3. https://exhibits.library.jhu.edu/exhibits/show/the-blue-baby-operation/vivien-thomas (accessed 06/30/2023)
4. Blalock A, Taussig HB. The Surgical Treatment of Malformations of the Heart in Which There is Pulmonary Stenosis or Pulmonary Atresia. JAMA 1945; 128(3): 189-202
5. Reves JG, Newman MF. Merel Harmel: Portrait of an Anesthesiology Pioneer. Anesth Analg 2-16; 122(2): 539-541
6. Muravchick S, Rosenberg H. Austin Lamont and the Evolution of Modern Academic American Anesthesiology. Anesthesiology 1996; 84: 436-441
7. Taussig HB. The Surgery of Congenital Heart Disease-Malformations of the Heart Amenable to the Blalock-Taussig Operation. Br Heart J 1948 Apr; 10(2): 65-79.
8. https://www.washingtonian.com/2020/06/19/the-remarkable-story-of-vivien-thomas-the-black-man-who-helped-invent-heart-surgery/#:~:text=In%201971%20Vivien%20Thomas%20stood,friend%20and%20partner%2C%20Alfred%20Blalock. (accessed 07/11/2023)
9. Blake K, Yancy CW. Change the Name of the Blalock-Taussig Shunt to Blalock-Thomas-Taussig Shunt. JAMA Surg 2022; 157: 287-288
10. https://en.wikipedia.org/wiki/Something_the_Lord_Made (accessed 07/09/2023)