Operation: November 29, 1944

The "Blue Baby" Operation and Heart Surgery

Surgical notes

By: Alfred Blaylock

Date: November 29, 1944

Source: Alan Mason Chesney Medical Archives of the Johns Hopkins Medical Institutions. The operative note by Alfred Blalock was first published in 1966 before enactment of the Health Insurance Portability and Accountability Act (HIPAA) and has been republished in various publications over the years. The citation for the original publication is as follows: Ravitch, Mark M., editor. The Papers of Alfred Blalock. 2 vols. Baltimore: Johns Hopkins Press, 1966. Vol. 1:xli,xliii.

About the Author: Alfred Blalock (1899–1964) was born in Culloden, Georgia, and earned his medical degree from Johns Hopkins University in 1922. Afterwards, he became the first surgical resident of the new Vanderbilt University Hospital in Nashville, Tennessee. There, Blaylock did pioneering work on reversing hemorrhagic and traumatic shock. In 1941, he returned to Johns Hopkins as surgeon-in-chief and director of the department of surgery in the medical school. He remained in these posts until his retirement in 1964.

INTRODUCTION

Blalock demonstated that shock (inability of the body to supply enough oxygen to meet tissue requirements) could be brought on by loss of blood and that transfusion of plasma or whole blood could be an effective treatment. This approach saved the lives of thousands of casualties during World War II (1938–1945). Blalock and his surgical technician, Vivian Thomas, carried out work on dogs while researching shock. Though Thomas had little formal education, his skill in the operating theater was legendary and the two men developed a formidable partnership that was to last over thirty years. In 1938, they performed an anastomosis (surgical joining) between the left subclavian artery (which supplies blood to the neck and arms) and the left pulmonary artery in one animal. The experiment was intended to produce pulmonary hypertension, a condition where there is raised blood pressure in the blood vessels supplying the lungs. The experiment failed in this respect, but the surgical procedure was to prove vital in later research.

On his return to Johns Hopkins, accompanied by Thomas, Blalock turned his attention to heart surgery. Here he met Helen Brooke Taussig (1898–1986), the head of the children's heart clinic. Taussig had an interest in congenital heart defects, including a condition called Tetralogy of Fallot. As the name suggests, this condition involves four different defects—narrowing of the pulmonary artery that serves the lungs, a hole in the wall between the two ventricles (the lower chambers of the heart), enlargement of the right ventricle, and defective positioning of the aorta, the main artery to the body. Tetralogy of Fallot results in severely impeded blood flow to the lungs. The blood cannot be properly oxygenated and children born with Tetralogy of Fallot are very weak, with a bluish tinge to their skin, known as cyanosis, which is due to insufficient oxygen in their blood. Thus, these children often were described as "blue babies."

Blalock and Taussig considered that the anastomosis procedure described above might offer a cure for Tetralogy of Fallot by allowing the blood a chance to oxygenate and bypassing the malformations. Their first patient was fifteen-month-old Eileen Saxon and the course of the operation is described in Blalock's notes reproduced below. The surgical team was very much reliant on their manual dexterity and their determination, since there was little in the way of high-tech equipment available. The role played by Vivian Thomas was especially praised by eyewitnesses to the operation, which was pronounced a success when the child gradually became less and less blue during the days following the surgery. Her mother later recalled "When I saw Eileen for the first time, it was like a miracle … I was beside myself with happiness."

PRIMARY SOURCE

OPERATION: Nov. 29, 1944
Dr. Alfred Blaylock
Ether-Oxygen-Dr. Harmel

ANASTAMOSIS OF LEFT PULMONARY ARTERY TO LEFT SUBCLAVIAN ARTERY

This patient was an undernourished child who had cyanosis on frequent occasions. The diagnosis was pulmonary stenosis.

Under ether and oxygen, administered by the open method, an incision was made in the left chest extending from the edge of the sternum to the axillary line in the third interspace. The second and third costal cartilages were divided. The pleural cavity was entered. The left lung looked normal. No thrill was felt in palpating the heart and pulmonary artery. The left pulmonary artery was identified and was dissected free of the neighboring tissues. The left pulmonary artery seemed to be of normal size. The superior pulmonary vein, on the other hand, seemed considerably smaller than normal to me. I had hoped that the artery to the left upper lobe might be sufficiently long to allow an anastamosis, but this did not appear to be the case. The left subclavian artery was then identified and was dissected free of the neighboring tissues. The vertebral artery and the branches of the thyrocervical axis were doubly ligated and divided. The subclavian was so short that there would not have been sufficient length for our purpose, had this not been done. The subclavian artery as then ligated distal to the thyrocervical trunk. A bulldog clip was placed on the subclavian artery at a point just distal to its origin from the aorta. The subclavian artery was then divided just proximal to the ligature. Two bulldog clips were then placed on the left pulmonary artery, the first clip being placed at the origin of the left pulmonary artery, and the second clip being placed just proximal to the point where the artery entered the lung. There was ample space between these two clips for our purpose. A small transverse incision was then made in the wall of the pulmonary artery. By the use of china beaded silk on fine needles, an anastamosis was then performed between the end of the left subclavian artery and the side of the left pulmonary artery. A posterior row of sutures was placed first. There was practically no bleeding following the removal of the bulldog clips.

The anastamosis seemed to be a satisfactory one, and the main point of worry comes from the small size of the left subclavian artery. I was disturbed because I could not feel a thrill in the pulmonary artery after the clips were removed. I do not believe that this was due to any clot in the subclavian artery, because it seemed to pulsate vigorously. It is possible that it was due to a low pressure in the systemic circulation. I do not actually know what the systemic pressure was. Another possibility was that it might have been due to spasm of the subclavian artery. My only regret was that the subclavian artery was not bigger. It is possible that the increased red cell count in this patient may have predisposed to thrombosis.

Sulfanilamide was placed in the left pleural cavity. This was followed by closure of the incision in the chest wall. The third and fourth ribs were approximated by two encircling sutures of braided silk. The soft tissues of the wall were closed in layers with silk sutures.

The patient stood the procedure better than I had anticipated. It is interesting that the cyanosis did not appear to increase very greatly from the temporary occlusion of the left pulmonary artery. It is also of interest that the circulation in the nail beds of the left hand appeared to be fairly good at the completion of the operation.

I did not attempt to visualize the left common carotid artery. It is possible thatthis would have been bigger than the left subclavian. This child was very small and I am confident that the subclavian artery would be more easily dealt with in a larger child.

                                               (Dr. Blaylock)
ms

PRIMARY SOURCE

OPERATION: NOVEMBER 29, 1944

See primary source image.

SIGNIFICANCE

Blalock and Taussig's "blue baby" operation marks the beginning of modern cardiac surgery and of pediatric cardiology in particular. Prior to this time, there often was little hope for babies born with a congenital heart defect. In 1944, Blalock also pioneered a bypass procedure for another congenital abnormality called coarctation of the aorta. In 1948, he launched an operation to correct transposition of the great blood vessels, a further congenital defect in which the pulmonary artery and the aorta are incorrectly connected.

Meanwhile, the "blue baby" operations continued. The third case, a cyanotic six-year-old boy who could no longer walk, was particularly memorable. Even as the final sutures were put in place, the small patient was acquiring what Taussig described as "lovely normal pink lips." He went on to become an active boy.

At the same time in both theaters of World War II, surgeons were faced with large numbers of casualties with traumatic injuries to the heart (bullets or shrapnel fragments lodged in heart tissues). One U.S. Army surgeon, Dwight Harken, devised a technique for cutting into the wall of a beating heart, locating the shrapnel, and removing it with a finger. In 1952, Walton Lillehei and John Lewis, two surgeons at the University of Minnesota, corrected the heart defect of a five-year-old girl after cooling her body to 81°F (27.2°C), a technique that allowed the body to survive without a pumping heart for ten minutes. True open-heart surgery was perfected after the 1958 invention of the heart bypass machine, which takes over the function of both the heart and lungs during surgery. Shortly thereafter, a drug was invented to stop the heart during surgery, allowing surgeons to correct structural defects and perform complex operations, such as bypass grafts and valve replacements, on an unbeating heart.

In the years that followed the blue baby operation, thousands of "blue babies" were cured by the technique. In 1952, Taussig reported results on the first 1,000 patients. Doctors from all over the world traveled to Johns Hopkins to learn the operation from Blalock and Taussig. Both physicians were honored nationally and internationally as word of their ground-breaking work spread through the medical community.

FURTHER RESOURCES

Books

Acierno, Louis J. The History of Cardiology. London: Parthenon Publishing, 1994.

Westaby, Stephen. Landmarks in Cardiac Surgery. Oxford: Isis Medical Media, 1997.

Web sites

Alan Mason Chesney Medical Archives of the Johns Hopkins Medical Institutions. "The Blue Baby Operation." 〈http://www.medicalarchives.jhmi.edu〉 (accessed November 1, 2005).