Blalock and Taussig Perform the First "Blue Baby" Surgery

Date November 29, 1944

Alfred Blalock and Helen Taussig developed the first surgical method of correcting cyanosis, or “blue baby” syndrome, which is caused by congenital abnormalities in the heart.

Also known as Blalock-Taussig Shunt

Locale Baltimore, Maryland

Key Figures

• Alfred Blalock (1899-1964), American surgeon and physiologist who pioneered the surgical treatment of congenital heart disease
• Helen Brooke Taussig (1898-1986), American physician, recognized as the founder of pediatric cardiology, who studied and corrected heart disease in children
• Sanford Edgar Levy (Sanford Edgar Leeds; b. 1909), American physician who collaborated with Blalock to develop the surgical bypass procedure later used to treat “blue babies”
• Vivien Thomas (1910-1985), surgical laboratory technician who worked closely with Blalock to develop surgical procedures

Summary of Event

The “blue baby” syndrome, or cyanosis, is most often caused by congenital malformations of the heart and associated vessels such that circulation to the lungs and other parts of the body is less than normal. One such condition, known as tetralogy of Fallot, is characterized by four major abnormalities: the pulmonary artery is stenosed (narrowed), a channel exists between the right and left ventricles (ventricular septal defect), the aorta is misplaced so that blood from both the right and left ventricles flows into it, and the right ventricle is enlarged.

These abnormalities result in poor oxygenation of blood (anoxemia), which is manifested by various symptoms, including blue lips and fingertips, episodes of shortness of breath that cause the child to squat, occasional loss of consciousness, stunting of growth, eruptions on the skin, and drumstick or clubbing deformities in the fingers and toes. Before the advent of modern cardiovascular surgery in the 1940’s, children born with these deformities either died at an early age or lived very limited lives with extensive pain and suffering. The incidence of congenital heart disease is about seven in one thousand live births.

Alfred Blalock was a skillful surgeon with a keen interest in the physiology of the circulatory system. His research on hemorrhagic shock led to the development of volume replacement therapy, which saved numerous lives during World War II. His outstanding contributions to the fields of circulatory physiology and surgery at Johns Hopkins University Hospital led to his election to the National Academy of Sciences in 1945, his presidency of the American College of Surgeons in 1954, and his receiving the Passano Award jointly with Helen Brooke Taussig in 1948, the American Medical Association Distinguished Service Award in 1953, and the Albert Lasker Medical Research Award in 1954.

While at Vanderbilt University, Blalock, his laboratory assistantVivien Thomas, and Sanford Edgar Levy (who later changed his last name to Leeds) conducted experiments on dogs to determine the effects of high blood pressure on the lungs. To increase pressure in the lungs experimentally, they linked (anastomosed) the left subclavian artery, a major tributary of the aorta, to the left pulmonary artery. This was the first time that the course of the large artery was diverted to change its function. They found that the blood pressure in the lungs was not increased appreciably by this operation and that the diversion did no harm to the dogs. This operation would be the prototype of the one Blalock would perform five years later to correct “blue baby” disease.

Blalock continued vascular surgery experiments on dogs at Johns Hopkins, bypassing an artificial gap in the aorta by connection to the left subclavian artery. Although this operation, designed to treat coarctation (blockage or constriction) of the aorta, was successful, Blalock was hesitant to attempt it on humans, because clamping the vessels during the operation would cut off circulation to the brain and other organs of the body for too long. His fears were somewhat allayed when the Swedish surgeon Clarence Crafoord reported in 1942 that clamping the aorta for twenty-eight minutes during a patent ductus operation resulted in no ill effects. Unfortunately, the application of his work to this problem was conceived by another physician.

During a pediatric conference at Johns Hopkins, Taussig, head of the Children’s Heart Clinic, reviewed Blalock’s report on blood vessel bypasses for correction of coarctation and inquired if a surgical procedure could be developed to improve pulmonary circulation in children with congenital heart abnormalities. She had spent several years studying cardiac abnormalities in children and was a pioneer in the use of X-ray techniques to diagnose and describe these abnormalities. She developed the theory that narrowing of the pulmonary valve and artery in children suffering from tetralogy of Fallot resulted in poor pulmonary circulation and consequent oxygen deprivation. When Blalock agreed to consider the problem, Taussig began working with him to devise a method for joining the left subclavian artery to the pulmonary artery in children to increase the flow of blood to the lungs. With the help of Thomas, they conducted numerous experiments on dogs to prove Taussig’s theory and to perfect the corrective procedure.

On November 29, 1944, Blalock performed the first “blue baby” operation on a fifteen-month-old girl suffering from tetralogy of Fallot. Blalock was assisted by resident surgeon William P. Longmire, anesthesiologist Merel Harmel, Taussig, and Thomas. During the three-hour operation, Blalock clamped the left subclavian artery, cut through it several centimeters away from where it emerged from the aorta, and tied off the useless upper end. He then pulled the lower end down toward the left pulmonary artery, which had also been clamped. He attached the free end of the subclavian to an opening he had made in the wall of the pulmonary artery and stitched it into place. On releasing the clamps, blood flowed out of the aorta through the left subclavian and into the left pulmonary artery. The net result was increased blood flow to the lungs. The child’s condition improved greatly after she surmounted a few postoperative complications, but she died nine months later. Within nine weeks, Blalock and Taussig performed two more operations and reported their results in the May 19, 1945, issue of the Journal of the American Medical Association.

By December, 1945, Blalock had performed sixty-five such operations with an 80 percent success rate. During this time, he was acclaimed as a hero in the press with many reports about how he had saved the children brought to him from all over the country by hopeful parents. Physicians, too, came from all around the world to learn how to perform the new surgery. In the years following, Blalock traveled to London, Paris, and Stockholm to teach others how to perform the operation.

Significance

The Blalock-Taussig Shunt, as the operation is now called, has saved thousands of lives and allowed numerous children to lead normal lives. That the operation is still in use is testimony to its impact on medical science. Marc R. de Lavel states in the book Surgery for Congenital Heart Defects (1983) that “the Blalock-Taussig operation continues to be the shunt of choice.” Although open heart procedures are now commonly used to correct tetralogy of Fallot and other heart deformities, the Blalock-Taussig Shunt continues to be used as a palliative measure in small children as an initial step in a series of corrective operations.

The only operation performed to correct a congenital cardiovascular disorder prior to the Blalock-Taussig Shunt was closure of a persistent (patent) ductus arteriosus by Robert Gross of Boston in 1939. The ductus arteriosus, a short vessel between the aorta and the pulmonary artery in the fetus, normally closes soon after birth. If it fails to close, the result is an overworked heart, ultimately leading to cardiac failure and early death.

The Blalock-Taussig Shunt remains widely used because it can be performed on very young children, too small for open-heart surgery. It provides a bridge of life for these patients until they are old enough to receive intracardiac repair. Until 1952, repair of internal heart abnormalities had to be done blindly because there was no way to stop the heart and oxygenate the blood during the operation. Among the methods used to try to overcome this problem was body cooling (hypothermia).

These events ushered in the modern era of open-heart surgery and the possibility of correcting most congenital heart abnormalities. Blalock and Taussig played a pivotal role in this attack on congenital heart disease because they had the vision and courage to attempt a radical treatment for a disease affecting young children. Blalock’s brilliant yet practical experiments and Taussig’s keen insight and devoted concern for ailing children led to a fortuitous relationship that ultimately triumphed over a pitiful disease that had long plagued humankind.

Bibliography

Baldry, Peter E. The Battle Against Heart Disease. New York: Cambridge University Press, 1971. A dated but useful history of heart medicine designed for general readers. Chapter 17 describes the various types of congenital heart abnormalities and gives an excellent historical account of how each was discovered. Chapter 18 describes the evolution of surgical treatment of heart disease. This chapter does an excellent job of relating the events leading up to and following the work of Blalock and Taussig.

Blalock, Alfred. The Papers of Alfred Blalock, edited by Mark M. Ravitch. 2 vols. Baltimore: Johns Hopkins University Press, 1966. A comprehensive compilation of Blalock’s published works divided into three phases. Ravitch’s biography of Blalock is complete and includes many photographs and personal anecdotes.

Blalock, Alfred, and Helen B. Taussig. “The Surgical Treatment of Malformations of the Heart in Which There Is Pulmonary Stenosis or Pulmonary Atresia.” Journal of the American Medical Association 128 (May, 1945): 189-202. The original article where Blalock and Taussig discuss their operation and describe three case histories. The article is technical in nature but is filled with interesting details about the surgeries and attendant complications and outcomes. Illustrations, bibliography of related medical reports.

Meade, Richard. An Introduction to the History of General Surgery. Philadelphia: W. B. Saunders, 1968. An easy-to-read college text that provides an organized and comprehensive history of all types of surgery. Chapter 14, “Thoracic Surgery,” discusses the history of heart surgery up to and including Blalock’s operation but lacks information on events that follow. Illustrations, bibliography.

Richardson, Robert G. The Story of Surgery: An Historical Commentary. 1958. Rev. and expanded ed. Shrewsbury, England: Quiller, 2004. A popular history of surgery originally published as The Surgeon’s Tale in 1958. Chapter 16 describes cardiovascular surgery from the early nineteenth century to the first heart transplant by Christiaan Barnard in 1967.