Centennial Presidential Perspective: Dr. Alfred Blalock

Abstract

Great men are not a common occurrence. Indeed, they are a rare find. Though respected and lauded in their time, it is only in retrospect that their true contributions can be adequately measured as a surgeon, an educator and a scientist. Such is the case of Dr. Alfred Blalock. Many have considered him the father of modern cardiac surgery. All consider his “blue baby” operation to be one of the landmarks of cardiac surgery and, as the chief of surgery at Johns Hopkins, he trained many who would become the leaders of our discipline. His continual reach for excellence helped him to not only affect, but revolutionize the paradigm of surgical research, an understanding of the physiology of shock and the surgical management of pulmonic stenosis/atresia. Dr. Blalock was the 30^th president of the American Association for Thoracic Surgery and his presidential address was given in 1951.

Early Life

Alfred Blalock was born on April 5, 1899 in the small town of Culloden, Georgia. Located in Monroe County in central Georgia, the town is approximately 0.8 square miles in size and, according to the United States Census of 1900, had a population of 334 citizens. Blalock was the eldest of five children born to George Z. Blalock and Martha (Davis) Blalock. George Blalock was a merchant and owner of a cotton plantation. Often referenced as a firm disciplinarian[1, 2], he placed a significant value on education. It was obvious that Blalock admired his father and as such, strove for the best in his studies. In fact, according to his sister, he would “…rather mother use the hairbrush on him than father look at him hard.”[3] As a youth his family moved to nearby Jonesboro due to his father’s fading health. There, he excelled in academics and athletics. At 14 years of age, Alfred was granted admission to the senior class at the Georgia Military College of Milledgeville, known as a preparatory school for the University of Georgia. Shortly thereafter, in 1915, he was admitted to the University of Georgia as a sophomore, skipping his freshman year. Blalock continued to do well, though he admitted to not being excessively diligent in his studies. While his grades were acceptable, ranging from the 80-90’s, Blalock was able to succeed in other areas. He played tennis, was a member of many organizations and societies and was both the secretary and treasurer of his senior class. In his senior year he became enamored with the field of medicine. With the help of an endorsement from his zoology professor, Dr. John Campbell, Blalock applied and was accepted to the Johns Hopkins University School of Medicine after receiving his Bachelor of Arts degree in 1918.[1]

Upon arrival to medical school, Blalock continued to engage in extra-curricular activities. These often detracted from his academic performance. According to Dr. Tinsley Harrison (one of Blalock’s closest friends and his medical school roommate), Blalock was employed at the student bookstore; devoted to tennis and golf; and very much a ladies’ man, often spending significant time at nearby Goucher college. Due to these outside interests, Alfred did not have excellent grades and Harrison surmised that he was likely in the middle of his class.[3] Despite his average academic standing overall, Blalock excelled in his surgical courses and quickly determined that surgery, particularly experimental surgery, would be his future.

Training and Early Career

As a senior medical student in December of 1921, Blalock wrote Dr. William Halsted expressing his wishes to join the famous Halsted surgical residency.[2] Despite a personal response from the famed physician, Blalock’s lack of academic excellence failed to impress Halsted and he was denied a surgical appointment. Dr. Blalock was able to gain an appointment as a urology intern and performed admirably, despite developing hydronephrosis and undergoing a nephrectomy during the course of the year.[4] His actions that year earned him a general surgery assistant residency appointment for the following year. However, his appointment was not renewed as, in his words, “competition became too keen and I sought position elsewhere without success.”[2]

In 1924, after losing his re-appointment, Blalock began work as an extern in the field of otolaryngology under the guidance of Dr. Samuel Crowe. Recognizing Blalock’s desire to become a surgeon and witnessing his tireless work ethic, Dr. Crowe put in a call to Dr. Harvey Cushing, a former Hopkins’ surgeon who was currently the chairman of surgery at the Peter Bent Brigham Hospital in Boston.[2, 4] Dr. Cushing agreed to interview Blalock and subsequently invited him to continue training in Boston. Blalock accepted and prepared to move to Boston, excited to continue his training. During this time, Blalock’s medical school roommate, Dr. Tinsley Harrison, had accepted the position of chief resident in internal medicine at Vanderbilt Hospital in Nashville. Shortly after arriving in Nashville, Dr. Harrison successfully lobbied Dr. Barney Brooks, the newly appointed chair of surgery at Nashville, to offer a position to Blalock. Dr. Brooks agreed to extend to Dr. Blalock the invitation to become the surgical chief resident at Vanderbilt. As Dr. Blalock arrived in Boston on the train, he found a telegram from Harrison awaiting him. He graciously declined Dr. Cushing’s offer and accepted Dr. Brooks’ position, leaving for Vanderbilt in July of 1925 after only 3 days in Boston.[1, 4]

Blalock completed his chief year at Vanderbilt and stayed on to become faculty. However, in 1927 he was afflicted with pulmonary tuberculosis and was forced to spend nearly two years in Trudeau Sanatorium on Saranac Lake in the Adirondack Mountains. Prior to his return to Vanderbilt, he briefly traveled in Europe where he met Dr. Sauerbruch in Berlin as well as worked in Adrian’s Laboratory in the Department of Physiology at Cambridge under G.V. Anrep and Sir Joseph Barcroft.[1, 2] In 1928, he returned to Vanderbilt. Despite ongoing pneumothorax treatments for the following two years, Blalock rarely missed a day and was very active in the lab.[2] Even at this stage he was an adept educator, frequently accepting students into his lab and allowing his young collaborators co-authorship on their findings.[1]

In January of 1930, Dr. Blalock hired Vivien Thomas to assist him in the laboratory full-time as his clinical responsibilities were increasing. Unbeknownst to him, this relationship would grow to become one of the most fruitful of his career. Thomas was a bright man and an expert experimental surgeon. These men developed a lifelong collaboration in the laboratory and in the training of surgical residents. His contributions to the “blue baby operation” are legendary.[1]

Chief of Surgery

Much of Blalock’s fame derived from his tenure as the chief of Surgery at Johns Hopkins. However, he was not the first choice to replace Dr. Dean Lewis when he stepped down in 1938. Dr. Mont Reid, a former Halsted resident, was the first choice. He declined in order to stay at the University of Cincinnati. Dr. Evarts A. Graham of Washington University in St Louis also declined the position, but offered a strong recommendation of Dr. Blalock to Johns Hopkins President, Isaiah Bowman. In 1941, at the age of 41, 19 years after graduating from the Johns Hopkins School of Medicine, Dr. Blalock was chief of the Department of Surgery at the Johns Hopkins Hospital. [Figure 1]

Figure 1.

Dr. Blalock in full academic regalia. (Reproduced with permission from the American College of Surgeons)

Dr. Blalock’s tenure as chief began remarkably well. He was quick to establish himself in the operating room, performing various operations daily. He brought his Vanderbilt research team with him and continued his basic laboratory research. He also concerned himself with the training of medical students and residents, resurrecting the tradition of Friday noon clinics (educational venues in which students would present a patient to Blalock and outline a therapeutic course based on the latest evidence) which had initially been established by Dr. Halsted. These clinics were well attended by residents and faculty alike.

In 1943, Dr. Blalock was approached by Dr. Edwards Park, professor of pediatrics, regarding a possible surgical alternative for children suffering from coarctation of the aorta. Turning to his resident, Blalock asked, “I wonder how that could be approached in the laboratory?”[3] This challenge prompted a series of experiments which ultimately resulted in an anastomosis of the subclavian artery to the distal aorta. However as this procedure required clamping the aorta, many experimental animals became paraplegic during the process. Unfortunately, the same outcome occurred during Blalock’s first attempt in a human subject.[1] At a conference discussing the outcomes of his coarctation work, Blalock met Dr. Helen Brooke Taussig, head of the pediatric cardiology division. While this encounter changed Dr. Blalock’s career, and pediatric cardiac surgery, forever, it was his well-chronicled pragmatic application of the paradigm of surgical research that was the true hero of the day. [2]

On November 29, 1944, Dr. Blalock operated on a severely cyanotic infant with Tetralogy of Fallot. [1] According to William P. Longmire, Blalock’s resident and assistant for this procedure, “It was quite amazing to see the professor gently but blindly insert a right angle clamp into the mediastinum and after dissecting over his index finger pull out the innominate artery.”[3] With the assistance of Dr. Longmire and Vivien Thomas, who stood behind Blalock in the first operation and offered a number of helpful technical suggestions, the case proceeded smoothly and the patient obtained an excellent response. Subsequent operations returned similar successes and the modern era of cardiac surgery was born. [Figure 2] Dr. Blalock was vaulted into international fame, with referrals and invitations to share his technique coming from all corners of the world.

Figure 2.

Dr. Blalock and colleagues performing “Blue Baby” operation on closed circuit television in 1947. He was assisted by Drs. William Longmire and Denton Cooley with Mr. Vivian Thomas standing behind him. (Reproduced with permission from the Johns Hopkins Medical Archives)

With the success of his operation and the international fame that resulted from it, Dr. Blalock spent many of his later years as surgeon-in chief traveling and lecturing as well as hosting various surgeons eager to learn his techniques. During this time, he continued to operate, perform research, publish and teach. He maintained an interest in the education of medical students and devoted his energies to the development of a children’s surgical unit at the Johns Hopkins Hospital. Because of his contributions, the name of the clinical science building was changed to “The Blalock Building”.

Personal Life

Dr. Blalock married Mary Chambers O’Bryan in Nashville, Tennessee on October 25, 1930. Miss O’Bryan was a true southern belle known for her charm and beauty. The two met during Dr. Blalock’s years at Vanderbilt and their wedding was reported in the local newspapers as a grand event.[2] Their union produced three children: William Rice Blalock, Mary Elizabeth Blalock and Alfred Dandy Blalock. Following the death of Mary in 1958, Dr. Blalock was remarried to Alice Waters in 1959. She provided him much love and support and remained with him until his death on September 15, 1964 from cancer.[1, 2, 7]

Dr. Blalock maintained affection for sports and the great outdoors. He was an avid tennis player. In fact, he and Dr. Harrison were Nashville doubles tennis champions in the late 1920’s. He also found time for golfing, fishing and boating, hobbies which served him well on Maryland’s Chesapeake Bay. Though not a natural athlete, Blalock pursued excellence in sports just as he pursued excellence in medicine.[7]

Academic Career

Dr. Alfred Blalock began his academic career in 1924. Just two years out of medical school, he drafted his first publication in JAMA regarding the clinical course of 735 patients suffering from biliary tract disease.[2] From these origins sprang the prolific career of an excellent scientist. He pushed the boundaries of known science with probing endeavors into circulation and respiration as a young Vanderbilt faculty member. These experiments required innovation and exacting methods from the academician as current technology, such as pH monitors, did not exist and these values had to be calculated by the scientist. His contributions to the understanding of shock were monumental and radically changed the understanding of traumatic shock. [8] Moreover, he demonstrated that with adequate resuscitation, the effects of shock could be reversed.[5] An interesting side note is the fact that Blalock himself was unable to write this landmark paper as he was suffering from tuberculosis at the time. His good friend, Dr. Harrison, “ghost wrote” the paper in his stead and it appeared in the Archives of Surgery in 1930.[4] For his part, Dr. Harrison recalls, “I had nothing to do with the conception or planning of the work on shock…I did take his data and wrote the paper for him without a true realization on my own part of the importance of the work.”[3]

Dr. Blalock continued to pursue academic medicine with a vengeance, amassing 40 publications from June of 1930 to June of 1934.[4] These publications were primarily in the field of shock but also included studies in endocrine surgery (particularly the adrenal gland), myasthenia gravis, the development of vascular suture techniques and an attempt to create a model of pulmonary hypertension by systemic-pulmonary shunting. He also authored the book Principles of Surgical Care: Shock and Other Problems.[9] Dr. Blalock reached the academic rank of Professor of Surgery at Vanderbilt in 1938.

At Johns Hopkins, Blalock continued his academic success. He continued to investigate myasthenia and its relationship with the thymus. He also investigated cardiac and vascular abnormalities such as coarctation and tetralogy of Fallot.[1] Ample publications were written about his revolutionary technique including his 1945 JAMA article co-authored by Dr. Taussig. At the time of his death, Blalock had accumulated more than 135 peer-reviewed articles, a Ruthian feat at the time.

Surgical Educator

As in all things, Blalock excelled in teaching. His passion for education and his lasting effect on academic surgery mirrors the contributions of Halsted in its amazing reach. During his time as surgeon-in-chief at Johns Hopkins, he trained 38 chief residents.[1] Of these chiefs, six went into private practice. From the remaining chiefs, Blalock trained 9 chairman of departments (such as Drs. Sabiston, Longmire, Muller and Greenfield), 10 division chiefs (such as Dr.’s Cooley, Haller, Jude and Kay) and many others with academic appointments at various institutions.[2] [Figure 3] In reference to Dr. Blalock’s amazing ability to bring out the best in his students, Dr. Harrison wrote, ”A teacher is an individual who has the capacity to influence the horizons of his pupils. Al has had that capacity all of his life…”[2].

Figure 3.

Dr. Blalock with his residents in 1945. (Reproduced with permission from the Johns Hopkins Medical Archives)

Surgical Organizations and Honors

Dr. Blalock received many prestigious honors and awards during his life. He was the recipient of 9 honorary degrees from various American universities. In 1955 he was elected as Chairman of the Medical Board of The Johns Hopkins Hospital and at his retirement in July of 1964, he was named both a Professor Emeritus of Surgery and a Surgeon-in-Chief Emeritus for the Johns Hopkins School of Medicine and The Johns Hopkins Hospital respectively.[1]

In addition to these honors, Dr. Blalock was a member of 45 national and international professional and honorary societies. These included the American Philosophical Society[2], the National Academy of Sciences and Royal Society of Medicine. He was also a member of various committees such as the Subcommittee on Shock, the National Society for Medical Research and the Board of Scientific Counselors. He was also an editor for 7 journals including Surgery, Archives of Surgery and The American Surgeon. Finally, Dr. Blalock received 18 national and international awards for his contributions to medicine. Some of the most notable include the Matas Award, the Rene Leriche Award, the National Order of Merit from the government of Cuba, the Modern Medicine Award for Distinguished Achievement and the posthumous Henry Jacob Bigelow Medal in February of 1965.[1]

Memorial

On September 15, 1964, Dr. Alfred Blalock succumbed to metastatic cancer. As the curtain began to fall on the life of this great man, he was visited by many of his surgical residents and friends. These final meetings were quite endearing, best described in the words of Dr. David Sabiston. “These last visits made deep impressions upon us for, despite his illness and pain, he continued to maintain his gracious attitude, his appreciation, and his loyalty to all of us. As the candle grew dim, and when on September 15 the final day came, all knew that his life had been fully complete, touching a vast number of grateful patients, many admiring students, a group of loyal residents, and a host of warm friends everywhere.”[2] Truly, Dr. Alfred Blalock was a great man and his legacy will continue for generations to come.