by Jim Murphy
Thomas’s first attempts to control the blood oxygen level were very simple, even crude. He took a piece of sterile linen cord and tied off the artery leading from the lung to the heart. He performed this procedure on a number of animals, tying the cord a little tighter on each one to restrict the flow of oxygenated blood to just the right level. These attempts all failed because the cord very quickly began to cut into the delicate artery.
Over the following weeks and months, Thomas experimented with a series of other materials—rubber tubing, surgical tape, a silver clamp, even a strip of ox tissue—to see if they would restrict oxygen without damaging the artery. Nothing worked.
As Thomas was developing the blue baby procedure by operating on dogs, he was envisioning what it would be like to perform it on a human patient and trying to anticipate potential problems. This detailed medical drawing shows the small opening and very crowded space inside the chest of a child, where Blalock would have to do delicate cutting and suturing.
After this, with Blalock’s advice, Thomas tried other increasingly complex ways to reduce oxygen levels. He rerouted unoxygenated blood from the right side of a dog’s heart to the left side, which meant the blood never went to the lungs. He did this by connecting the pulmonary artery and vein on the right side of the heart. The procedure produced lower oxygenation, but the animals died when fluid backed up in their lungs.
Next, he removed sections of the lung and rerouted the pulmonary artery and vein. None of these attempts succeeded. Blalock and Thomas had to devise other surgical ways to produce lower oxygen levels.
While this line of research went on, Thomas was also working on other practical aspects of the operation. A baby’s arteries and veins are so tiny—often no bigger than a thin wire—that Thomas had to practice making precise, even sutures. Because the blood vessels of a medium-sized dog’s heart are so tiny, they proved to be very good for this sort of training.
Everyone who ever worked with Thomas praised his skills as a surgeon. Thomas was so demanding of himself, so insistent that nothing short of perfection was acceptable, that his ability as a surgeon went beyond good or even very good. His skills were nothing short of miraculous. Once Thomas was finishing up an experimental procedure when Blalock came in. Blalock looked at the artery that had been reattached and could see only one tiny piece of thread as evidence that anything had happened. Thomas had sewn the artery on the inside so that absolutely nothing could be seen on the outside besides where the silk had been tied off. Amazed, Blalock shook his head and mumbled that Thomas’s work was so close to perfect that it might have been “something the Lord had made.”
Besides perfecting his skills, Thomas also had to design new or improved surgical equipment. Few commercial manufacturers of surgical tools existed at the time. The giant pharmaceutical company Johnson & Johnson had been in business since 1886, but a surgical products unit was not set up until 1941, and it offered only a limited line of items. This forced Thomas to study all the surgical tools that would be needed for the operation and come up with ways to adapt and improve them. When the clamps Thomas was using to close off an artery began to slip, Dr. Longmire (who had assisted at the first surgery) and Thomas created one that screwed closed to provide just the right amount of pressure. Because Blalock was always considered the lead researcher on the blue baby project, the clamp came to be known as the Blalock clamp. Johnson & Johnson sold suturing needles with silk already through the eye. But the needles were too long for the intricate sewing Thomas was doing. So Thomas had to cut them down to the size he needed and sharpen the points himself.
Adding to the pressure on Thomas was the knowledge that more and more severely ill children were being admitted to the hospital. Taussig could worry about them and try her best to help them; Blalock could tell her that progress was being made on devising a surgical procedure, even if slowly. But Thomas knew that the responsibility of developing a workable procedure was his.
After clamps came loose during a procedure, Thomas and Longmire created what was later called the Blalock clamp.
Almost a year into the blue baby research, Thomas had carried out over one hundred experiments and was logging fourteen- to fifteen-hour days, often seven days a week—one failed attempt to create a low oxygen level after another. Yet each failure brought him a step closer to the results he was searching for. Along the way, Thomas began experimenting with a surgical solution to increase oxygen level in the blood.
Here is where the collective knowledge and skill of Blalock and Thomas made a decisive difference. In 1938, while they were still at Vanderbilt, they had tried to create high blood pressure in an animal by attaching an artery leaving the heart to an artery leading to the lungs. They wanted to see if adding so much more oxygen to the blood would create this condition. The procedure did elevate oxygen levels in the blood but didn’t increase blood pressure. This failure didn’t mean the experiment was useless, however. As Professor Robert B. Pond, an authority on scientific creativity, has observed, “It is completely possible to invent something and never know what the need is, never know what problem you had solved.”
Thomas began reworking and refining the failed high blood pressure procedure, hoping to send more oxygenated blood to the heart. This phase of the research went relatively quickly because Thomas had performed the operation many times at Vanderbilt. But it still required numerous repetitions over several months, mainly because Blalock insisted that all results (such as measuring oxygen levels before and after the procedure) be checked multiple times for accuracy.
Besides, there were still many unanswered questions. Some of the animal subjects had suffered temporary paralysis following the operation. Would the same happen to a human subject? Would a blue baby tolerate anesthesia? Would clamping shut the artery carrying oxygenated blood cause brain damage? What other problems might arise? Despite these lingering concerns, toward the end of summer 1944, Thomas was able to say with satisfaction, “As Dr. Taussig had hoped, we, like plumbers, had ‘changed the pipes’ around to get more blood to the lungs. We had found what pipes to put where.”
Now it was time for Vivien Thomas to teach Alfred Blalock how to rearrange the pipes.
CHAPTER SIX
“All the World Is Against It”
ALFRED Blalock was a stickler when it came to being thoroughly prepared for every aspect of his work. Now that Thomas had worked out the blue baby procedure (with, as Thomas himself admitted, the necessary assistance of Blalock’s “brain power in this as in all the other projects”), Blalock wanted the chance to practice it on a number of animals before actually performing surgery on a human. He considered this the only way to avoid a fatal mistake.
The world-famous heart surgeon Denton A. Cooley worked closely with the Professor during that period and understood why he felt a need to practice a procedure so many times. “He was insecure as a technical surgeon,” Cooley observed years later, “and he wasn’t really adept and sure of himself all the time.” Dr. J. Alex Haller Jr. joined Johns Hopkins in the late 1940s and worked side by side with Blalock in the operating room for many years. He concurred with Cooley’s appraisal. Blalock “was very meticulous in the operating room, a good technician, but not a brilliant technician.”
Dr. J. Alex Haller worked very closely with Blalock for many years.
There was more occupying Blalock’s mind than most people suspected at the time. Blalock had grown up in a well-to-do family, gone to private schools, and done really well despite not being an avid scholar. Even when in college studying to be a doctor, according to his best friend and roommate, Tinsley Harrison, Blalock was much more interested in competitive sports and going to parties with pretty girls than in preparing for exams. But Blalock graduated, and he and Harrison went on to Johns Hopkins to complete their medical education.
What changed Blalock from a playboy into a dedicated scientist? He never explained this in his writings, but we can piece together a plausible explanation. When he finished his studi
es, he applied to Johns Hopkins for a surgical residency, a position that would let him work side by side with the best surgeons in the country. He was promptly rejected, in large part because of his reputation for partying.
He was given a residency at Vanderbilt and after a year was also put in charge of the research laboratory. He was making real progress with his research on shock when he developed tuberculosis and was forced to rest and get treatment for months at a time. Other researchers kept his experiments moving at Vanderbilt, but Blalock felt he was a failure—both for not getting a residency at Johns Hopkins and because his illness limited his ability to work—and he feared he was being left behind as a researcher.
When his TB went into remission, Blalock returned to work, but he knew that the disease could come roaring back in a month or a year and incapacitate or even kill him. He became determined to make his mark as a serious researcher as quickly as possible. When he was made head of surgery and research at Johns Hopkins, he felt that his heightened focus on advancing medicine had been justified. Still, his desire to push research projects forward—before his own time ran out—was always tempered by his fear that a miscalculation or lack of preparation might result in failure and dismissal.
Thomas began preparing a dog for a test operation in which he, Thomas, would be the lead surgeon and Blalock would assist. This meant that Thomas would actually perform the operation while Blalock stood next to him to observe what happened, help Thomas when needed, and ask any questions he might have. After this, Blalock would be the lead surgeon on at least two additional research operations with Thomas assisting and advising.
The procedure in which Blalock assisted went exactly as they had hoped. Then Eileen Saxon arrived at Johns Hopkins on Monday, November 27, and Blalock’s careful preparation plan was derailed.
Eileen had an extremely advanced case of blue baby syndrome. At eighteen months, she was twelve pounds underweight and very tiny, with her lips, fingernails, and skin a dark, sickly blue. Worse, she was gasping for air and seemed to be on the verge of heart failure.
All Dr. Taussig could do to help the child was put her in an oxygen tent and hope her condition stabilized and improved. But it was clear that Eileen was still in distress, and Taussig worried that the girl’s oxygen-deprived heart would give out in a day or two, if not sooner. Blalock had informed Taussig that Thomas had succeeded in developing a workable procedure to help her blue babies, and now she contacted Blalock and told him his first human patient had arrived.
Denton A. Cooley checks the condition of a patient.
Blalock was unwilling to operate. He wasn’t prepared, he insisted. He needed time—possibly several weeks—to master the innovative procedure. But Taussig wasn’t about to take no for an answer, not when there was the slightest chance of saving her patient. So, reluctantly, Blalock agreed to schedule the surgery.
Once Blalock agreed to the operation, he and everyone else involved knew that the clock was ticking.
He asked Thomas to set up the operating room with all of the necessary implements and equipment and began assembling his surgical team. Blalock requested that Drs. Longmire and Cooley participate, and also a scrub nurse, Charlotte Mitchell. She would be beside Blalock during the operation to hand him instruments and wipe away blood. Taussig, too, would be in the operating room to watch over her patient. Finally, Blalock asked the head of Johns Hopkins anesthesiology, Dr. Austin Lamont, to administer the anesthesia that would keep Eileen from feeling pain during the procedure.
When Dr. Lamont examined Eileen Saxon, he balked at the idea of operating on her. He was convinced that the tiny patient wouldn’t survive being anesthetized and, if she somehow miraculously did, wouldn’t live through the actual operation.
Lamont may have been concerned that killing such a young patient might damage his professional reputation. At best this was a chancy operation, and many of his colleagues might have questioned the wisdom of attempting it in the first place. But Lamont was known as an especially caring doctor, and he was probably eager to spare Eileen any unnecessary pain. Like most other doctors, Lamont wouldn’t consider necessary an experimental operation that had little chance of succeeding, under any circumstances. As Lamont would say later, “When suffering becomes unbearable, nature often lifts the burden.” That is, sometimes a patient should be allowed to die, and in his opinion Eileen was such a patient.
This was a reasonable position back in 1944. Nowadays, it is common practice not just to operate on human hearts, but to remove a diseased and damaged heart and replace it with either a mechanical device or a donated human heart. Back then, however, the heart was considered untouchable.
This idea had a very long history. For centuries, the common belief was that to merely touch a beating human heart could cause it to stop working. To cut into one was generally viewed as reckless and possibly even criminal. Even after a fellow surgeon successfully sewed up a stab wound to the heart in 1896, Dr. Stephen Paget was not convinced that operating on a beating heart was possible. “Surgery of the heart,” Paget wrote, “has probably reached the limit set by nature to all such surgery. No new method and no new discovery can overcome the natural difficulties that attend a wound of the heart.” In the early 1940s one historian summed up the prevailing attitude: “The heart was considered too critical, too vital, too complex and delicate to permit surgery or other invasive techniques.”
Blalock was responsible for running the Johns Hopkins research facility, a job that involved a great deal of administrative work, such as drawing up budgets and hiring staff. His passions, however, were research, caring for patients, and teaching medical students.
Blalock respected Lamont’s opinion and did not press him to be a part of his surgical team. Instead, he turned to Merel Harmel, a highly skilled anesthesiologist just a year out of medical school. The young doctor thought the operation was risky, but he also felt that any intelligent attempt to save a patient’s life was acceptable. Once Harmel was on board, the operation was rescheduled for the next day.
As head of surgery, Blalock had the authority to okay the operation without seeking approval from anyone else. He did, however, advise the director of Johns Hopkins Hospital that he planned to go forward with the surgery and that Taussig supported his decision.
Thomas and the hospital operating room supervisor, Elizabeth Sherwood, continued to ready room 706 and assemble the necessary instruments. Additional lighting had to be brought in, as well as tanks of oxygen, sheets for the operating table, gauze, and everything else that might be needed. Thomas had cut six 1 1/8-inch-long needles down to 1/2 inch. Then he threaded the eye of each with silk thread and, using a spring-type clothespin to hold the needle, he sharpened each by hand on an emery board. Very little about the operating room or instruments would be considered innovative or even safe today.
Taussig met with Blalock early that evening to discuss Eileen’s condition. It hadn’t improved, she told him, and the baby seemed to be in somewhat greater distress than earlier in the day. Taussig urged the Professor to go home and get some rest. She stayed at the hospital all night to monitor Eileen and comfort her parents.
Dr. William Longmire assisted Blalock during the first blue baby operation even though he feared that the tiny patient might not tolerate anesthesia.
Blalock felt he wasn’t as prepared for this operation as he would have liked. He also knew that every phase of the procedure—from the diagnosis, to the operating conditions, to the postoperative care—was primitive at best. Others agreed with him in hindsight. Dr. William Stoney, a medical historian, noted, “This was an operation that was done before most of the technology to make it easier and safer was available.” Dr. Cooley was even more direct: “Many of us thought this operation was going to be a big disaster.”
Blalock knew that once he had agreed to perform the operation he had no choice but to move forward. Eileen was slowly dying, and the procedure was her only chance at survival. While his reasoning was accurate, it didn
’t make him less anxious. He never recorded his thoughts, but another cardiac surgical researcher, Dr. Charles Bailey, may have captured something of Blalock’s emotional state: “You know that almost all the world is against it; you know that you have a great personal stake and might even lose your medical license if you persist. In fact, the thought crosses your mind that maybe you really are crazy. And yet you feel that it has to be done and it must be right.”
CHAPTER SEVEN
“Vivien, You’d Better Come Down Here”
THE next day, Wednesday, November 29, Blalock was so anxious that he felt he couldn’t drive himself to the hospital and asked his wife to take him. He entered the great domed building, crossed the rotunda, and (following Johns Hopkins tradition) rubbed the toe of the statue of Christ for good luck. Then he went to see how Eileen was doing.
Thomas had arrived earlier to make sure the operating room and surgical supplies were ready. Then he retreated to the laboratory. When a colleague asked if he would observe the operation from the viewing area, Thomas replied that Blalock “had said nothing about my being there” and added jokingly that he “might make Dr. Blalock nervous or even worse, he might make me nervous.”
Just moments before Eileen was to be wheeled into the operating room, Blalock entered room 706 and glanced around. Then he looked up into the viewing area and spotted one of his assistants, Clara Belle Puryear. “Miss Puryear,” Blalock said, “I guess you better go call Vivien.”