Breakthrough!

On the morning of November 29, 1944, surgeon Dr. Alfred Blalock prepared to operate on 18-month-old Eileen Saxon in operating room 706 at Johns Hopkins Hospital in Baltimore. Eileen weighed only 8.8 pounds and had a severe congenital heart defect that starved her blood of oxygen, turning her skin a dark blue. The procedure had never been performed on a human being. Blalock's assisting surgeon, Dr. William Longmire, feared the child would die after the first incision, and the chief of anesthesia, Dr. Austin Lamont, refused to participate, believing anesthesia alone could kill her. Blalock had slept poorly the night before and asked his wife to drive him to the hospital. The observation gallery was packed with staff, and a movie camera stood ready to capture what might be a historic moment. Standing behind Blalock on a wooden step stool was his research assistant, Vivien Thomas, the only person who had performed this procedure successfully, though only on dogs. Most people at the hospital assumed Thomas was a janitor.

The book traces how three people converged to make this operation possible. Their story began years earlier, when Thomas followed Blalock from Vanderbilt Medical School in Nashville, Tennessee, to Johns Hopkins in 1941. Thomas and his wife, Clara, were African American, and Baltimore enforced strict racial segregation. Every bathroom at Johns Hopkins was marked WHITE or COLORED, and the couple was forced into a cramped, substandard inner-city apartment after being turned away from white suburbs.

Thomas found the Hunterian Laboratory, where he and Blalock would conduct research, filthy and foul-smelling. Blalock asked Thomas to clean and paint the space, a task beneath the skill level Thomas had developed over 11 years as Blalock's research partner. When the laboratory director, Dr. Edgar Poth, refused Thomas's equipment requests, Blalock intervened with an angry written order. Poth retaliated by orchestrating the lab housekeeper's refusal to clean their workspace, and Blalock confronted him directly. Blalock was no civil rights advocate; he and Thomas shared whiskey privately in the lab but never drank together in public. Yet his willingness to defend Thomas sent a clear message: Nothing would obstruct his research.

The book reveals how Thomas came to work with Blalock. In 1930, 19-year-old Thomas applied for a laboratory job at Vanderbilt after the stock market crash and the Great Depression destroyed his savings and his dream of attending medical school. The son of a master carpenter and a skilled seamstress in Nashville, Thomas had been raised with a fierce commitment to precision and hard work. Blalock hired him at $12 a week, the pay rate for a janitor, telling Thomas he wanted someone he could train to do everything he himself could do. Over the next 15 years, Blalock immersed Thomas in training equivalent to postgraduate medical education. Together they proved that shock, a life-threatening condition whose cause was then unknown, resulted not from a mysterious toxin but from rapid blood and fluid loss. They demonstrated that infusing whole blood or plasma could prevent it. Their findings, validated during World War II, saved hundreds of thousands of lives.

The third member of the team, Dr. Helen Taussig, headed the Children's Cardiac Clinic at Johns Hopkins from 1930 to 1963. Born in 1898 in Cambridge, Massachusetts, Taussig had dyslexia and lost her mother to tuberculosis at age 11. When she pursued medical school in 1921, women made up only 5 percent of practicing physicians. Harvard admitted her but restricted her coursework and refused to grant credit toward a degree. She eventually earned her medical degree at Johns Hopkins and was appointed to run the new pediatric cardiac clinic at 32. Soon after, she began losing her hearing and adapted by reading lips, using an amplified stethoscope, and developing a technique of feeling a child's heartbeat through her fingertips.

Taussig's greatest frustration was tetralogy of Fallot, commonly known as blue baby syndrome, a condition involving four serious heart malformations that deprive the blood of oxygen. Twenty-five percent of affected children died before their first birthday, and 70 percent died by age 10. In 1938, Harvard surgeon Dr. Robert Gross successfully repaired a different defect by tying off an abnormal vessel connecting two major arteries. Taussig reasoned that if Gross could close such a connection, it should be possible to build one surgically to increase blood flow in blue babies. She proposed the idea to Gross, but he dismissed it. When she learned Blalock was coming to Johns Hopkins, she saw a new opportunity.

In 1943, Taussig met with Blalock and Thomas, comparing the concept to a plumber rearranging pipes. Blalock instructed Thomas to pursue the blue baby problem independently. Thomas spent nearly two years on painstaking experimental work. Rather than replicating all four defects in a dog, he focused on reducing oxygenated blood flow to match the dangerously low levels found in blue babies. Early attempts failed repeatedly as various materials and surgical techniques proved inadequate. Thomas simultaneously practiced making precise sutures on tiny blood vessels and designed specialized tools, including an adjustable clamp later known as the Blalock clamp and hand-cut suturing needles. His surgical skill was extraordinary; Blalock once examined an artery Thomas had reattached so perfectly that almost nothing was visible on the outside.

The breakthrough came from revisiting a failed 1938 experiment in which Blalock and Thomas had tried to create high blood pressure by connecting an artery leaving the heart to one leading to the lungs. That procedure had raised oxygen levels without producing hypertension, an apparent failure that inadvertently solved the blue baby problem. By summer 1944, Thomas had refined a procedure that reliably increased oxygenated blood flow and was ready to teach Blalock how to perform it.

Blalock insisted on practicing on animals, but the plan was interrupted when Eileen Saxon arrived at Johns Hopkins on November 27, 1944, desperately ill and on the verge of heart failure. Taussig pressed Blalock to operate immediately. After Lamont refused to administer anesthesia, Blalock recruited Dr. Merel Harmel, a young anesthesiologist just a year out of medical school.

During surgery, Blalock discovered Eileen's arteries were less than half the size of those in the experimental dogs. Thomas stood directly behind him, watching every suture and quietly correcting Blalock when he began a stitch in the wrong direction. After more than 90 minutes, the suturing was complete, but Blalock could not feel blood pulsing through the pulmonary artery. The room fell silent. Then Harmel announced that Eileen's color was improving. The surgical team saw that her ashen, blue-lipped face had changed to a healthy pink. The operation was a success.

Eileen improved over two weeks and was discharged after almost two months with near-normal skin color. However, her symptoms returned, and she died after a second operation, just before her third birthday. Blalock performed additional operations in early 1945, and he and Taussig published a landmark article that triggered worldwide interest. By 1950, 1,000 blue baby operations had been performed at Johns Hopkins alone. The procedure transformed the hospital into the premier surgical training program of the era and sparked the rapid expansion of cardiac surgery worldwide.

Taussig earned wide recognition, receiving 20 honorary degrees, more than 30 major medical awards, and the Presidential Medal of Freedom in 1964. Thomas, by contrast, returned quietly to the laboratory. He was not mentioned in the published article, lectures, or media coverage. He watched as young surgeons he had trained received more public recognition than he did. Even a research dog named Anna, the first animal to survive the experimental procedure, had her portrait painted and hung at Johns Hopkins. The author examines whether Thomas's invisibility stemmed from racial discrimination, the general tendency to overlook research assistants, or both, and places primary responsibility on Blalock, who knew what Thomas had contributed but chose not to disrupt the status quo. Recognition eventually came: Thomas received an honorary doctorate from Johns Hopkins and was named head of the surgical laboratory, where he taught techniques he had perfected to new generations of surgeons, including Denton Cooley, who became the first surgeon to implant a completely artificial heart. In 1971, former students commissioned a portrait of Thomas. At the unveiling, the hospital president announced that the painting would hang in the Blalock Building alongside portraits of internationally famous surgeons. The audience, including surgeons, students, nurses, and janitors, rose to give Thomas a standing ovation. In 1975, Thomas deflected personal glory, writing that he preferred to let others speak to his place in medical history, saying he simply tried to be himself.