Have you heard of a Blalock-Thomas-Taussig shunt for rerouting subclavian arterial blood to the lungs as palliation for cyanotic congenital heart disease (CHD)?
Most clinicians know this technique as the Blalock-Taussig (BT) shunt, named for two of its inventors: Alfred Blalock, a surgeon who began performing the procedure in the 1940s, and Helen Brooke Taussig, who came up with the general idea for the shunt and is remembered as the founder of pediatric cardiology.
But the BT shunt would never have seen the inside of an operating room as early as it did if not for Vivien Theodore Thomas.
Over the course of a career recounted in the 2004 television movie Something the Lord Made, Thomas developed detailed surgical procedures and helped train generations of surgical residents. Yet his name was not attached to the BT shunt, because he lacked formal medical training and for another reason: He was African American.
Born August 29, 1910, in Louisiana, Thomas and his family moved to Nashville, Tennessee, where he grew up hoping to be a physician. Talented with his hands, he started working as a carpenter to earn money for college after graduating from high school in 1929.
The Great Depression thwarted his plans, but he landed a job in a surgical laboratory at Vanderbilt University in 1930. There he met Blalock, a graduate of Johns Hopkins Medical School, who was directing the lab.
Lacking a college degree, Thomas was classified at Vanderbilt as a janitor. But his exceptional manual dexterity and enthusiasm soon had him working effectively at the level of a postdoctoral researcher increasingly vital to Blalock's work.
One of these projects was an effort by Blalock to develop a canine model to study pulmonary hypertension. Blalock and Thomas devised a procedure to connect the right subclavian artery to the right pulmonary artery. This connection provided extra blood to the pulmonary vasculature. The feat, while not particularly helpful to the research at the time, would become paramount a few years later when Blalock returned to Hopkins, bringing Thomas along as his assistant.
Baltimore was not in the Deep South, but Thomas was still subject to racial discrimination, so again he was classified as a janitor. Moonlighting to make ends meet, he would occasionally bartend at Blalock's parties, serving drinks to the surgical residents he'd been teaching during the day.
Eventually, the famed neurosurgeon Walter Dandy donated money to get Thomas a raise. Later, Thomas' demonstrated surgical skill with the laboratory animals prompted local veterinarians to send cases to him. Eventually, he had so many referrals, that effectively he was operating a veterinary surgical clinic in his spare time.
Helen Taussig entered the picture soon after Blalock and Thomas arrived at Hopkins. Caring for "blue babies," children with cyanotic CHD, Taussig had made some pathophysiological observations, especially among children with tetralogy of Fallot. Importantly, Taussig noticed that these children had milder disease if they happened to have another abnormality: a patent ductus arteriosus (PDA).
For babies born with cyanotic shunting, a PDA provides an advantage, Taussig realized, giving oxygen-deficient blood entering the aorta from the left ventricle a second chance to go through the lungs. Today, neonates diagnosed with cyanotic CHD in utero or immediately at birth receive prostaglandin E1 (PGE1) to keep the ductus arteriosus patent on purpose.
In the 1940s, Taussig didn't know about PGE1, nor did she have fetal ultrasonography at her disposal to identify cyanotic CHD prior to birth. But she could auscultate with a stethoscope to determine whether the ductus arteriosus in a child was patent or closed. Most audible around the upper left sternal border, a PDA causes a telltale continuous murmur called a machine murmur, because it revs up during systole and down (but still audible) during diastole, a bit like an annoying leaf-blower. The murmur disappears if and when the ductus arteriosus closes.
Taussig proposed that surgeons create an artificial shunt that would be physiologically similar to a PDA but would remain open reliably. She compared it to a plumber "changing around the pipes."
Hearing this, Blalock and Thomas remembered their experiments in dogs with pulmonary hypertension. Connecting the right subclavian artery to the right pulmonary artery, or the left subclavian to the left pulmonary artery, they could produce a left-to-right shunt to compensate for the cyanotic shunting children with tetralogy of Fallot were experiencing. To get it right in a human patient, the procedure had to be tweaked carefully in the lab.
The two men went to work on the dogs, but whenever something was not quite right, Thomas would tweak the procedure in the lab. Thomas would then guide Blalock through the modified technique.
In 1944, Blalock opted to move forward with a human patient. Although this move was criticized as being too risky, it forced Thomas to improvise much of the equipment based on his lab experience. Eileen Saxon, a 15-month-old child with tetralogy of Fallot, was selected as the first candidate. Being a lab assistant, Thomas assumed that he was supposed to stay out of the operating room. But after scrubbing in to operate, Blalock decided that he needed Thomas in the room to guide him. Standing on a stool behind Blalock, Thomas led Blalock through certain steps of the operation. When everything was anastomosed as needed for the shunt, Blalock loosened the hemostats that had been keeping the subclavian and pulmonary circulation separate, and immediately Eileen went from cyanotic to pink.
Although the operation prolonged Eileen's life by only a few months, the team learned new things that allowed other blue babies to live longer, including that they could later perform a second shunt on the opposite side. Hopkins became a center for operations on blue babies from around the world and, over the decades, technology and a multitude of procedures would enable surgeons to correct tetralogy of Fallot and other cyanotic CHD extensively. The BT shunt is still used today, in a slightly different form, as part of initial palliation, buying time prior to stepwise repair with optimal timing.
In 1964, as Blalock approached the end of his life, he remarked that his biggest regret was having not sent Thomas to medical school. Meanwhile, Thomas kept working in the Johns Hopkins surgical department long after Blalock's retirement and death, and in 1976 the university awarded him an honorary doctorate. It was a doctorate of laws, not medicine, but it meant Thomas' students could finally call him "Doctor" — and also "Professor," as he was also added to the medical school faculty, where he remained until his death in 1985.
Among the many surgeons Thomas trained, possibly the most famous was Denton Cooley, a pioneering cardiac surgeon of the middle to late 20th century. Present as an intern in the now famous Operating Room 706 during the procedure on Eileen in 1944, Cooley reflected on Thomas' surgical talent decades later.
"Even if you'd never seen surgery before, you could do it because Vivien made it look so simple," Cooley noted in 1989, without hesitating to compare Thomas' skill to that of Blalock himself. "Dr. Blalock was a great scientist, a great thinker, a leader, but by no stretch of the imagination could he be considered a great cutting surgeon. Vivien was."
David M. Warmflash, MD, is a freelance health and science writer living in Portland, Oregon. His recent book, Moon: An Illustrated History: From Ancient Myths to the Colonies of Tomorrow, tells the story of the Moon's role in a plethora of historical events, from the origin of life to early calendar systems, the emergence of science and technology, and the dawn of the Space Age.
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Cite this: Vivien Thomas: Teacher and Surgical Pioneer - Medscape - Feb 06, 2023.
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