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Ann Thorac Surg 1997;63:1193-1199
© 1997 The Society of Thoracic Surgeons

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Our Surgical Heritage

Charles Drew and the Origins of Deep Hypothermic Circulatory Arrest

Department of Surgery, McGill University, Montreal, Quebec, Canada, and The Glenfield Hospital, Leicester, England

	Abstract

Top Footnotes Abstract Introduction Background The Drew Technique The Man Postscript Acknowledgments References

 
Convinced that the high risk of operation using the early heart-lung machines was due to a toxic effect of the oxygenators in use in the 1950s, Charles Drew of Westminster Hospital in London devised a circulatory support system in which the patient's own lungs functioned as the oxygenator. With this support, body temperature was reduced to the point where circulatory arrest could be tolerated for the time required to carry out the intracardiac operation. He used only this technique for the rest of his surgical career, a period of 22 years. We have attempted to record how this came to pass and to describe the qualities of this man that led him to be original and creative.

	Introduction

Top Footnotes Abstract Introduction Background The Drew Technique The Man Postscript Acknowledgments References

 
In the early years of intracardiac surgery, which is to say, after 1955, when successful series of patients were first operated upon, most surgeons concentrated on using support systems that reproduced normal physiology as far as possible [1]. The heart-lung machines of the time varied greatly, particularly with regard to the principle of oxygenation used, and there were screen oxygenators, disc oxygenators, rolling-cylinder oxygenators, and primitive bubble oxygenators, none of which were perfectly satisfactory despite the fact that many successful operations were accomplished with their help.

Many surgeons agreed that there was some component of the extracorporeal systems that accounted for the very high mortality in experimental series and in the early clinical experience. The problem seemed to be in the oxygenators, with their direct blood–gas interface. Over time things got better. Diagnosis, medical management, and support systems all improved and surgeons achieved a higher level of expertise. Improvement of the extracorporeal circuits was a continuous feature, with an understanding of the need for disposable oxygenators driving the commercial world to develop better and better devices. Later myocardial protection arose as first a concept, then a reality, and the risk of being attached to a heart-lung machine diminished to the point where it was accepted. The search for an alternative technique was only considered by a few.

But there was an alternative and one man perfected it and used it alone for intracardiac surgery from 1959 until his retirement 22 years later. This article will give some background on the development of the technique and the man for whom it was named.

	Background

Top Footnotes Abstract Introduction Background The Drew Technique The Man Postscript Acknowledgments References

 
Following Bigelow's demonstration that moderate hypothermia (30°C) would permit circulatory arrest for close to 10 minutes [2], surgeons investigated the possibility of extending hypothermia downward in the belief that this would allow longer periods of circulatory arrest. It was quickly realized that the heartbeat became ineffective as body temperature approached 20°C; most of the time the heart fibrillated, sometimes it simply slowed to a stop, but the end result was that the circulation became arrested prematurely and hypoxia occured in the warmer organs. Experimental observations made on these preparations showed that ventricular fibrillation could be prevented with quinidine [3] or by adding carbon dioxide to the inspired air [4]. But this did not solve the basic circulatory problem with deeper levels of hypothermia. Another major problem was that rewarming was extremely difficult without effective circulation. Without a circulatory support system it was a precarious business, although such a system was successfully applied some years later [5].

During the 1950s surgeons concerned with the damage thought to be caused by oxygenators saw the combination of a pump-oxygenator and hypothermia as a possible solution. The pump would support the circulation during cooling and rewarming while hypothermia would permit lower flows through the oxygenator and thus lessen the damage done to the blood by the oxygenator.

The early work was done in physiologic laboratories, and the most imaginative investigator was Frank Gollan, who had developed a small glass bubble oxygenator while at Antioch College in 1951. Subsequently he continued his work at Nashville, from where he reported bloodstream cooling down to 4°C and even 0°C when the experiments were done in a cold room [6]. He was way ahead of his time. He primed with Ringer's solution to produce hemodilution and corrected the low hematocrit by transfusing donor blood as the thoracotomy was being closed. Surprisingly, some animals survived these severe degrees of hypothermia.

Gollan gave a presentation to The American Association for Thoracic Surgery in April 1955 describing experimental left atriotomies in animals supported on his miniature gas dispersion oxygenator and cooled to about 13°C [7]. He described the ideal operating conditions in the arrested empty heart compared with the situation prevailing in operating rooms at this time when surgeons were operating at normothermia with a beating heart and often in a field flooded by coronary venous flow. Of course Gollan, as a physiologist, did not have much clout in a roomful of surgeons, and this remarkable work was largely ignored despite the impressive survival rate.

Investigations were simultaneously underway in Sweden. Juvenelle and his associates [8] focused on the physiologic changes produced by cooling with a small pump-oxygenator and showed that animals could survive the procedure of cooling to 12°C if the perfusion time was less than 2 hours, but there were few long-term survivors. Still these were prescient experiments for 1951 and important observations were made. Nor were the surgical possibilities ignored, because they performed intracardiac operations while the hearts fibrillated for 45 minutes and commented on the advantages of such a system with regard to the operative field, blood damage, and the safety of extracorporeal perfusion. They estimated that a pump-oxygenator need only have a capacity of from 10% to 20% of normal flow when the patient had been cooled.

Ake Senning, who had earlier worked with Juvenelle, subsequently reported experiments with a better extracorporeal system [9]. Animals underwent bloodstream cooling to 20°C and perfusions of 2 to 5 hours with almost 50% survival despite being in ventricular fibrillation for more than an hour. At the time survival after prolonged ventricular fibrillation was unknown. One animal survived 52 minutes of aortic cross-clamping to produce anoxic arrest, probably the first time this maneuver was tried. Senning concluded that the demand on the extracorporeal circuit was less if hypothermia was used and reflected that the combination might enable complex operations to be carried out. Experiments such as these provided important information with regard to later clinical work. The pieces were coming together.

Walton Lillehei and John Kirklin established intracardiac surgery with the pump-oxygenator in 1955, and surgeons everywhere sought to duplicate their techniques and their results in patients. There was a tremendous surge in research and clinical innovations and annual meetings of the American Association were breath-taking with the early revelations of the potential of open heart surgery. The early pump-oxygenators often lacked heat exchangers and body temperature tended to drift downward even when normothermic bypass was intended. Later when heat-exchangers were developed it became possible to control body temperature more precisely and to return patients toward normothermia after modest cooling. Surgeons then began to deviate from the principle of reproducing normal physiology with the extracorporeal circuits. Perhaps temperature, flow, and blood pressure could all be reduced with benefit. The leader in developing this concept was Will Sealy [10] with his associates at Duke University Medical Center, who published several articles in the late 1950s on the combination of hypothermia and extracorporeal circulation.

In 1959 they presented preliminary evidence of the possible advantages of more profound hypothermia [11]. They had had a heat-exchanger developed by the radiator division of General Motors, and their protocol called for maintaining esophageal temperature between 28° and 32°C but they included the description of a 5-year-old child with severe tetralogy of Fallot whose temperature was rapidly reduced to less than 10°C. Flooding of collateral blood flow into the heart obscured the operative field during closure of the defect, and the circulation was arrested on three occasions for periods up to 2 minutes, an early documentation of circulatory arrest under profound hypothermia, albeit for brief periods.

	The Drew Technique

Top Footnotes Abstract Introduction Background The Drew Technique The Man Postscript Acknowledgments References

 
In 1957 Charles Drew and his associates at Westminster Hospital in London were prepared to embark on a series of intracardiac operations using extracorporeal circulation. Drew had visited Minneapolis and Rochester, Minnesota, the two trailblazing centers. He had decided to use the disposable DeWall oxygenator, and he initiated a series of animal experiments to perfect the technique and to train his team for the repair of cardiac malformations in children. Drew, incidentally, was antipathetic to the presumption that normal physiology should be maintained to achieve operating conditions. In this he was much influenced by the minimal blood flow concept propounded in Britain at the Royal College of Surgeons by Andreasen [12]. The report of Drew's experimental work [13] with the DeWall oxygenator referred obliquely to the patients operated upon subsequent to the animal experiments without providing any details or case reports. Almost certainly the results were disappointing, because the technique was soon abandoned, and in 1959 Drew was able to report clinical experience with an entirely different technique in which the patient's own lungs functioned as the oxygenator.

Drew was convinced that oxygenators were dangerous and wondered if operations on the left ventricle and aortic root could be done with left ventricular bypass alone while pulmonary circulation was maintained by the right ventricle. The investigators wondered what would be the effect of cardiac arrest under these circumstances: would venous blood flow passively through the lungs and find its way to the cannula in the left atrium? To test this situation they decided to cool the blood being pumped around the left ventricle, knowing that this would eventually cause asystole. They found that when the right ventricular function became depressed, the flow into the left sometimes stopped completely and at any rate the drainage was always erratic, requiring a high right atrial pressure. Rather than abandon the concept Drew decided that he would need a pump for each side of the heart. The right ventricle, too, would have to be bypassed and replaced mechanically.

Although this complicated the setup it led to the concept of biventricular substitution with extracorporeal cooling. It would allow cooling to be continued after the heart had stopped and body temperatures in the low teens to be reached, temperatures at which the circulation could be arrested for a period of time adequate to carry out intracardiac repairs. This was without the need for a damaging oxygenator.

The experiments were done by Drew, Gerald Keen, who at the time was a surgical research assistant, and David Benazon, registrar in anesthesia. The work was carried out in a converted billiard room on the sixth floor of Westminster Hospital in London. Drainage from the atria was into open reservoirs and was instituted by inserting a thin-walled metal cannula into the left atrial appendage and pumping this effluent through a heat exchanger into the femoral artery. Surgeons generally used the femoral artery as the cannulation site at this time, but Drew continued to use it after techniques for aortic cannulation had been worked out. His argument was that left ventricular ejection continued as cooling was being induced and the warmer blood in the ascending aorta would lead to a more gradual cooling of the brain and the heart. The heat exchanger was simply a long coil of plastic tubing immersed in a 2° to 4°C bath to which ice could be added. As the right ventricular function deteriorated from the cooling, a cannula was inserted into the right atrium and blood was pumped into the pulmonary artery through a cannula introduced through the pulmonary valve from the outflow tract of the right ventricle.

Once the protocol was established, 12 experiments were performed. In 10 the animals were rewarmed as soon as a pharyngeal temperature of about 10°C was reached, and in the remaining two the circulation was arrested for 30 minutes before the blood was rewarmed. As the body temperature rose the heart was defibrillated with a single shock of an alternating-current defibrillator and shortly thereafter right ventricular bypass was discontinued. Many interesting and pertinent physiologic data were recorded. The bottom line, however, was that 2 animals died during the experiments and all but 2 died in the next 24 hours. Still they had shown that it was possible to cool a dog to less than 10°C and rewarm it, and there were encouraging features of this series of experiments in that the cannulations became routine and there were no lung complications in contrast to earlier experiments with cardiopulmonary bypass. The heart rhythm was always returned to normal.

The heat exchanger was clearly inefficient and imposed a high resistance to blood flow. A stainless steel one was constructed with four -inch stainless steel tubes in parallel in a 5-foot trough through which flowed the cooling or warming fluid. In the cooling phase the coolant was kept at 2°C. The two pumps were also upgraded to the roller type from the noisy sigmamotor ones used up to this time.

Four animal experiments were done with cooling down to 15°C and complete circulatory arrest from 20 to 45 minutes before rewarming. Two of them survived without any complications. One died of a postoperative hemorrhage after recovering consciousness, and the last animal, which was not healthy preoperatively, did not recover.

The terse summary and conclusions of all these experiments merits quotation in full. It read as follows:

A small number of experiments was sufficient to show that, using simple apparatus, it is possible to induce profound hypothermia in a dog, followed by complete circulatory arrest for 30 minutes, and then to rewarm it with recovery.

Thus was the Drew technique announced [14], accepted as viable by its originator, and ushered into the operating room of Westminster Hospital. Two major concepts were involved: to support the circulation without an artificial oxygenator and to repair the heart under conditions of circulatory arrest. The hypothesis was that the benefits of the former would outweigh the risks of the latter. Of course the possible advantages of eliminating the oxygenator remained to be seen, and although there might be many unknown risks in cooling and circulatory arrest, the primary one was clearly ischemic brain damage, which would be expected to be directly related to the duration of arrest. Conventional cardiopulmonary bypass was pretty well established at the time, albeit a wide range of oxygenator designs were in clinical use and there was a continuous demand for their improvement. This is perhaps a euphemistic way of stating that unexpected mortality and morbidity were often blamed on the oxygenator and many surgeons at that time would have accepted Drew's hypotheses. Conventional bypass sought to reproduce normal physiology in maintaining gas transfer during the cardiac operation. The Drew technique produced a death-like state of suspended animation. It was an enormous time-dependent aberration, and readers can imagine the pressures existing when it was first applied in patients. Further on we shall indicate Drew's character and background that made him an ideal man for the job.

The first three applications of the technique were reported by Drew and Anderson in the same issue of The Lancet as the experimental work [15].

The first patient was a sickly 1-year-old child with Down's syndrome in failure with an endocardial cushion defect. The "cleft" in the mitral valve was closed with sutures of silk as was the atrial component of the defect during 46 minutes of circulatory arrest at 15°C. Two hours into an apparently satisfactory recovery, the child suddenly had development of complete heart block and died despite open massage.

The second and third children had closure of ventricular septal defects with silk sutures during circulatory arrest periods of 45 and 25 minutes without complications. An addendum to the article listed four more operations with a second failure in an 8-pound infant again apparently due to heart block. One of the successful operations was in a 42-year-old patient arrested for 42 minutes at 15°C. Thus began Drew's clinical series. Already it contained infants and adults, and Drew from the first was impressed with the lack of respiratory complications so common in patients operated upon with oxygenators in the system.

In 1961 he received the great honor of an invitation to present a Hunterian Lecture at the Royal College of Surgeons. His title was Profound Hypothermia in Cardiac Surgery, and having referred to Hunter's interest in the subject and the experimental work of Bill Bigelow and Frank Gollan, he went on to describe the limitations of surface-induced hypothermia. Then he described in detail his own technique culminating in circulatory arrest, exsanguination into the apparatus, and cardiac repair in an ideal operative field. He drew attention to the fallacy of the term "body temperature" under these conditions, having noted the temperature gradients between different organs. At his target temperature of 15°C (nasopharyngeal), the esophageal temperature was usually about 10°C and the muscle temperature between 20° and 25°C. He showed how the thermal gradients tended to equilibrate during the arrest period.

He noted that at about 18° to 20°C (esophageal) the venous drainage diminished, which he attributed to the loss of vascular tone and the expansion of the vascular bed, observing that the electroencephalogram became isoelectric at the same time. He went on to analyze his results in 110 patients, adults and children. Only patients with a very poor prognosis were accepted at first, and those who could be repaired with surface cooling to 30°C were excluded. Thirty-five patients died and the causes were analyzed in detail. Then the postoperative complications were presented. The first 60 patients were cooled with an inefficient heat exchanger and the arrest period varied from 25 minutes to more than 50 minutes without evidence of cerebral damage attributable to the technique. When the more efficient annular exchanger was used, 3 of the early patients had signs of brain stem damage; the protocol was changed to slow down the cooling and rewarming, and this serious problem did not recur in the remaining patients.

It seemed to Drew that the efficient heat exchanger presented a danger. He noted in his lecture that Viking Björk, who encountered the same complication [16], had a powerful heat exchanger, whereas others [17] with relatively inefficient tubular heat exchangers had not. The exact mechanism and whether the damage occurred in the cooling or warming phase was not discussed, although Drew often pointed out to his associates that the short, high-flow basilar artery could produce a dangerously high temperature gradient across the pons with its short pontine arteries. The classic syndrome of these injuries was typical basal ganglion chorea.

Remarkably, few lung complications occurred postoperatively and there were no incidents of pulmonary edema.

Drew summarized that there was no anatomic contraindication to the application of the technique. He thought that 1 hour of safe circulatory arrest could be routinely tolerated. The mortality he blamed on his own failings and the extremely poor condition of many of the patients, some of whom were clearly inoperable. He indicated that the technique would facilitate the repair of infants' hearts and stressed that this was the age in which the operations should be carried out. Remember, he spoke these words 36 years ago.

He emphasized the myocardial protection achieved by cold and the ideal operating conditions in a completely still, dry field. Finally, he paid tribute to his colleages at Westminster and St. George's Hospitals whose collective efforts, he said, had made it possible for him to deliver the Hunterian lecture.

We cannot comment on the reception of the presentation, but it was remarkable for its honesty and its emphasis on the mistakes that were made. It was the address of a still-young surgeon on the threshold of worldwide acclaim.

Some years later John Bailey prepared an article describing the modifications in technique as Drew and his team approached their one thousandth operation. It was never published because Drew was never satisfied with the manuscript, a regular feature of reports from his group including the presentation made to The American Association for Thoracic Surgery in 1971 [18]. Bailey's manuscript pointed out some of the difficulties in applying the technique to adults with valvular heart disease and increased pulmonary vascular resistance and how the circuit had been modified to overcome them. Donor blood had also been virtually eliminated in straightforward procedures. One hundred consecutive operations were analyzed after these modifications were made in late 1968. Sixty-four were congenital procedures and there was one death in this group, but 12 of the 36 patients with acquired disease died. Many of these were in terrible shape when they were operated upon, 11 being emergencies. The great majority were patients with end-stage valvular heart disease, and pulmonary hypertension was often present. Multiple valve replacements took 2 hours of arrest time separated by a period of perfusion, and there was a successful triple-valve replacement in the series. Nevertheless it was clear that Charles Drew was losing ground in the field of acquired heart surgery.

His adult referrals dwindled about this time. Perhaps to some degree this suited him. He loved the uniqueness of each congenital malformation and disliked the more set-piece valvular procedures. He never really got into the field of direct coronary surgery. He continued with profound hypothermia and circulatory arrest until his retirement in 1981 and never returned to the pump-oxygenator.

	The Man

Top Footnotes Abstract Introduction Background The Drew Technique The Man Postscript Acknowledgments References

 
Charles Drew (Figs 1–3) was a big man, a physically impressive human being with the ruddy complexion of a farmer. He smoked a pipe and, like so many, seemed to run through more matches than tobacco.

View larger version (164K): [in this window] [in a new window]   Fig 1. . Charles Edwin Drew at the height of his professional career.

View larger version (175K): [in this window] [in a new window]   Fig 3. . Caricature of Charles Drew drawn on the occasion of the thirtieth annual Westminster Hospital Shrove Tuesday dinner in 1970 at which he was the guest of honour.

He warned John Bailey as a junior against excess pride in success or disappointment in failure and clearly strove to practice what he preached.

In the operating room he was concentrated and deft. He assumed that juniors could learn by observation without the need for formal teaching. He allowed trainees to develop their own technique and only interfered if he saw dangerous potential. He was rough with his assistants if they obstructed him, and being head-butted by him if you got your head in his line of sight ensured you only did it once!

He was a stubborn man: stubborn in persisting with complex valve operations under circulatory arrest without an oxygenator, stubborn in insisting that all coarctations could be repaired without a graft, and stubborn in having no respect for diaries, clocks, or calendars (Joan Smith, unpublished recollections). He was a great admirer of Charles de Gaulle who, of course, would never bend or give an inch. Drew's pet was an English bulldog.

Of Welsh descent, Charles Drew had a long attachment to Westminster Hospital in the center of London. David Evans noted in his address at the Service of Thanksgiving for the Life and Work of Charles Drew held in the Westminster Hospital Chapel, July 29, 1987: "Charles spent half a century here as student, houseman, registrar, chief assistant and consultant."

He was a good athlete excelling in many sports, one of which was water polo. This helped him during his years as a naval surgeon, for he was below decks when his ship was sunk by the earliest of radio-controlled missiles in the Mediterranean and he was forced to swim out a porthole.

After the war he acquired the FRCS in 1946 and became surgical registrar at Westminster and chief assistant to Clement Price Thomas at the Brompton Hospital. In 1950 he was appointed Consultant at Westminster, joining his former chief and lifelong friend, Price Thomas, then one of the dominant figures in thoracic surgery in England. Drew was 34 when he became a consultant and had spent 4 years in the navy. This was rapid advancement considering the large number of experienced surgeons returning from the armed forces. Soon he was appointed Consultant at St. George's Hospital as well, and later he operated 2 days a week at each hospital.

Drew was a marvellous technical surgeon, and as a registrar he did the first coarctation repair in England assisted by Clarence Crafoord. (He never made this claim in public because Price Thomas was the nominal surgeon.) Over a few years he accumulated the largest series of coarctation repairs in England but he never published on the subject. He decided early that all coarctations could be repaired by end-to-end anastomosis, much to the regret of his assistants who had to pull the clamped ends together.

In 1951 Drew and a team from Westminster Hospital moved in to Buckingham Palace to assist Price Thomas as George VI underwent a left pneumonectomy for lung cancer. Charles lived in the palace for 2 weeks after the operation, alternating with his fellow Welshman and registrar, Peter Jones. (Years later, Jones, another Welshman, joined Charles Drew on the staff at Westminster.) They ate with the two princesses and had tea with Mary the Queen Mother. Some time later Price Thomas selected Drew to be his own surgeon when he required a lobectomy for the same disease, and the surgeon-patient enjoyed good health for 11 more years.

Price Thomas wanted Drew to develop cardiac surgery and push toward intracardiac surgery, and Drew journeyed to the United States, visiting Charles Bailey in Philadelphia and Alfred Blalock at Johns Hopkins among others. Later he journeyed to Minnesota and the two world leaders of intracardiac surgery. This led to his experimental work with the bubble oxygenator published in 1957 and his brief clinical work before he abandoned the technique, returned to the laboratory, and developed hypothermic circulatory arrest.

Charles Drew's associates termed him a workaholic. It was not because he was lazy that he did not publish many papers; nor was it because he had nothing to report, because his experience would have been instructive for many surgeons. His associates say that he was never satisfied that an article in preparation was ever ready for submission. His secretary, Joan Smith, the only secretary he ever had, wrote that he was still making changes in his Hunterian Lecture on his way to the lecture hall. So the papers were never finished. The lecture was a typewritten finished product, but he still refused to publish it. There were other factors. He was a kind, thoughtful man but not a great communicator. He had security as a consultant in institutions he loved. He had soon forfeited the role of being the leading cardiac surgeon of his nation. By 1965 he was already considered to be well out of step, which did not bother him at all. He was independent, private, and self-secure and did not rely at all on the plaudits of his peers. There was little urge to publish.

Nor did he in any sense look for recognition in the media. He refused to allow his name to be published when news of some of his exploits was reported. David Shore, who designed the series of heat exchangers and remained a close friend for 25 years, remembers when Drew was approached by the British Broadcasting Company to participate in a program entitled "Your Life in Their Hands." He refused, stating that he was not an entertainer.

When Mr Drew retired in 1981 the occasion was marked by a dinner attended by more than a hundred friends, colleagues, and former trainees. Many of these last, unable to attend, sent letters, and the theme of several concerned the man's creativity. A few selected quotes from these letters will suffice to illustrate the point: "...my most stimulating memory will be of your ability to devise a completely original approach to any problem, frequently defying all attempts to predict, and prepare for, your response" (Dennis Gladstone). "...it was the way you took any surgical problem to be a personal challenge that so impressed. The gauntlet was immediately taken up and from that stemmed many original ideas and the whole subject became exciting" (David Cade).

Charles Drew was a warm human being with a fine sense of humor. He was kind to his juniors, although he could be a tyrant in the operating room, and he helped when he could in establishing their careers. Gerald Keen, who assisted in his first 60 operations as well as in the laboratory, wrote recently that "...his was a remarkable career and he was very fulfilled, although all who knew him hoped for more. It was not to be but those who really knew him, perhaps only four or five people, remember him as a giant and a very warm man" (Gerald Keen, personal communication).

	Postscript

Top Footnotes Abstract Introduction Background The Drew Technique The Man Postscript Acknowledgments References

 
Charles Drew originated the concept of performing prolonged intracardiac operations under circulatory arrest. He suggested that the ideal operating conditions thus achieved would permit the precise repair of complex conditions, particularly in infants. This we all know has proved to be true as surgical pioneers applied the principle of deep hypothermia and circulatory arrest not only to complex congenital heart disease but to complicated aneurysms and reoperations as well. It is now a standard part of the armamentarium of the complete cardiac surgeon. Fortunately Drew's persistent distrust of mechanical oxygenators has proved not to be valid, and present-day surgeons work with a safety net that he denied himself.

View larger version (132K): [in this window] [in a new window]   Fig 2. . Drew was the first recipient of the Price Thomas Medal. In this photograph he is receiving it from Sir Arthur Porritt, President of the Royal College of Surgeons of England.

	Acknowledgments

Top Footnotes Abstract Introduction Background The Drew Technique The Man Postscript Acknowledgments References

	Footnotes

Top Footnotes Abstract Introduction Background The Drew Technique The Man Postscript Acknowledgments References

 
Address reprint requests to Dr Dobell, Royal Victoria Hospital, Room S-830, 687 Pine Ave W, Montreal, PQ, Canada H3A 1A1.

* This is a good example of Drew's attitude to statistics. He once told John Bailey "even a child finds that putting a hand in the fire hurts. He doesn't need to repeat it n times for the statistician."

* In his "Tudor Edwards Memorial Lecture" in 1981 he reported on 83 patients who survived 60 to 90 minutes of circulatory arrest.

* Charles Drew was the third surgical generation in this respect and gained much pleasure from this fact. He himself was born above the milk shop of his maternal grandmother. His mentor, Sir Clement Price-Thomas, was son of a grocer and draper in Abercorn in Wales and his mentor, in turn, was Tudor Edwards, son of a draper in Swansea, also in Wales. All three were appointed in their time as general surgeons to Westminster Hospital, subsequently and under each other's influence taking up the challenge of thoracic surgery.

	References

Top Footnotes Abstract Introduction Background The Drew Technique The Man Postscript Acknowledgments References

 

1. Kirklin JW. Open-Heart surgery at the Mayo Clinic. The 25th anniversary. Mayo Clin Proc 1980;55:339–41.[Medline]
2. Bigelow WG, Lindsay WK, Greenwood WF. Hypothermia-its possible role in cardiac surgery: an investigation of factors governing survival in dogs at low body temperatures. Ann Surg 1950;132:849–66.[Medline]
3. Gollan F, Phillips R Jr, Grace JT, Jones RM. Open left heart surgery in dogs during hypothermic asystole with and without extracorporeal circulation. J Thorac Cardiovasc Surg 1955;30:626–30.
4. Niazi SA, Lewis FJ. Profound hypothermia in the dog. Surg Gynecol Obstet 1956;102:98–106.[Medline]
5. Dillard DH, Mohri H, Merendino KA. Correction of heart disease in infancy utilizing deep hypothermia and total circulatory arrest. J Thorac Cardiovasc Surg 1971;61:64–9.[Medline]
6. Gollan F. Cardiac arrest of one hour duration in dogs during hypothermia of 0°C followed by survival. Fed Proc 1954;13:57.
7. Gollan F, Phillips R Jr, Grace JT, Jones RM. Open left heart surgery in dogs during hypothermic asystole with and without extracorporeal circulation. J Thorac Surg 1955;30:626–30.
8. Juvenelle A, Lind J, Wegelius C. Quelques possibilites offertes par l'hypothermie generale profonde provoquee. Une etude experimentale chez le chien. Presse Med 1952;60:973–8.
9. Senning A. Extracorporeal circulation combined with hypothermia. Acta Chir Scand 1954;107:516–24.[Medline]
10. Sealy WC, Brown IW Jr, Young WG Jr, Stephen CR, Harris JS, Merrit D. Hypothermia, low flow extracorporeal circulation and controlled cardiac arrest for open heart surgery. Surg Gynecol Obstet 1957;104:491–50.[Medline]
11. Young WG Jr, Sealy WC, Brown IW Jr, Smith WW, Callaway HA Jr, Harris JS. Metabolic and physiologic observations on patients undergoing extracorporeal circulation in conjunction with hypothermia. Surgery 1959;46:175–81.[Medline]
12. Andreasen AT, Watson F. Experimental cardiovascular surgery. Br J Surg 1952;39:548–51.
13. Drew CE, Cliffe P, Scurr CF, et al. Experimental approach to visual intracardiac surgery, using an extracorporeal circulation. Br Med J 1957;2:1323–9.
14. Drew CE, Keen G, Benazon DB. Profound hypothermia. Lancet 1959;1:745–7.
15. Drew CE, Anderson IM. Profound hypothermia in cardiac surgery. Report of three cases. Lancet 1959;1:748–50.
16. Björk VO, Hultqvist G. Brain damage in children after deep hypothermia for open heart surgery. Thorax 1960;15:284–91.[Free Full Text]
17. Gordon AS, Meyer BW, Jones JC. Open-heart surgery using deep hypothermia without an oxygenator. J Thorac Cardiovasc Surg 1960;40:787–99.[Medline]
18. Bailey JS, Drew CE, Cullum PA, Lea R, Sabapathy M, Patchett D. Open-heart surgery using deep hypothermia: the development and current method using a no blood, no oxygenator technique for open-heart surgery. Presented at The American Association for Thoracic Surgery Meeting in Atlanta, April 28, 1971, and published by title in the program.

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