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"Any possible restoration of function could not occur": Harvey Cushing and the early description of brain death.
World Neurosurg. 2012 Feb; 77(2):394-7
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29 Jun 2012
Good for Teaching
DOI: 10.3410/f.717547812.792952819
Brain death is a fascinating topic. For instance, national differences in diagnostic criteria mean that a patient dead by neurological criteria in one country might become 'undead' upon being flown to another (parallels to Schrödinger’s cat come to mind!). Those individuals interested in the history of brain death will appreciate Pendleton et al.'s description of a neurosurgical case performed in 1908 by Harvey Cushing (1869-1939). The authors make the case that this was the first instance of documented brain death, even though the concept itself did not formally evolve until about six decades later, with the publication of the 'Harvard criteria' for brain death in 1968.
The case Pendleton et al. describe was an apparent intraoperative uncal herniation following a spinal tap Cushing carried out in order to reduce intracranial pressure. The consequence was a loss of brainstem function and eventual cessation of respiration. In those days, surgical patients breathed spontaneously under ether anesthesia. Although the patient was then ventilated artificially by a bellows apparatus via a tracheotomy (tracheal intubation was not yet commonplace), it soon became clear to Cushing that "any possible restoration of function could not occur" and that the patient’s heart "was running simple as an isolated organ."
Readers of this fascinating account will come to understand the special challenges Cushing and his colleagues had to deal with over 100 years ago: there were no blood banks, electrocardiography was nonexistent, and modern artificial respirators had not been invented. Equally interesting, in documenting the loss of a palpable pulse later in the case, Cushing wrote, "Crile's pneumatic suit was applied, and this brought about a sufficient rise in pressure to enable pulse to be readily palpated." Finally, the article documents Cushing’s ethical struggle concerning the maintenance of artificial measures despite overwhelming brain damage.
Disclosures
None declared
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Doyle D: F1000Prime Recommendation of [Pendleton C et al., World Neurosurg 2012, 77(2):394-7]. In F1000Prime, 29 Jun 2012; DOI: 10.3410/f.717547812.792952819. F1000Prime.com/717547812#eval792952819
F1000Prime Recommendations, Dissents and Comments for [Pendleton C et al., World Neurosurg 2012, 77(2):394-7]. In F1000Prime, 18 Jun 2013; F1000Prime.com/717547812
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OBJECTIVES: To describe a case from 1908 of apparent brain death after operative intervention by Harvey Cushing at the Johns Hopkins Hospital.
METHODS: After institutional review board approval, which waived the requirement of informed consent from patients, and through the courtesy of the Alan Mason Chesney Archives, we reviewed the Johns Hopkins Hospital surgical files from 1896 to 1912.
RESULTS: We selected a single adult patient operated upon by Cushing, whose respirations ceased in the operating room and who was maintained by the use of artificial respiration via a tracheostomy during a 36-hour period, whereas further surgical interventions were performed in an attempt to improve his condition. The patient's condition remained unimproved; artificial respirations were discontinued and the "cessation of all cardiac activity" was observed.
CONCLUSIONS: Brain death is a concept that presents unique challenges to the practicing physician. Although recent advances have allowed for better diagnosis of brain death, the topic remains fraught with controversy. The case described here documents Harvey Cushing's struggles with the ethics of maintaining vital organ function with artificial respiration, despite clear evidence of irreversible ischemic brain damage. This case predates the earliest descriptions of brain death by more than 50 years and illustrates the dilemmas facing clinicians at the turn of the twentieth century.
Copyright © 2012 Elsevier Inc. All rights reserved.
DOI: 10.1016/j.wneu.2011.04.016
PMID: 22120395
