Journal of Critical Care 29 (2014) 867
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Journal of Critical Care journal homepage: www.jccjournal.org
Historical evolution of the brain death concept: Additional remarks☆ De Georgia [1] presented a review, tracing the evolution of the brain death (BD) concept. I will comment and add some remarks to this review [2]. 1. Early accounts of BD This author describes the importance of developing mechanical ventilation for recognizing BD [1]. Nonetheless, earliest accounts, at the end of the 19th century, described states resembling what would today be recognized as BD: during an increment of intracranial pressure, respiration suddenly stopped, whereas the heart remained beating [2]. Jalland [3], reported a case with a brain abscess, in whom respiration returned after having ceased for some time, when the pus was evacuated. Horsley affirmed that patients “die of respiratory and not of cardiac failure.” Duckworth [4] also commented about cases in whom respiration completely stopped for some hours before circulation.” Lastly, Cushing [5] stated that, “in death of a fatal increase in intracranial tension, the arrest of respiration precedes that of the heart … prompt surgical relief, with a wide opening of the calvarium, may save life even in desperate cases with pronounced medullary involvement.” Although these articles provide early descriptions of the BD syndrome, their authors still considered cessation of respiration and/or heartbeat to be the signs of death [1,3-5]. 2. Guy Alexandre at the Company for Chemical Industry Basel (CIBA) symposium De Georgia [1] also commented about Guy Alexandre at the CIBA symposium on transplantation. To investigate this milestone event, I reviewed the little known proceedings of a Company for Chemical Industry Basel (CIBA) symposium held in London, on March 9 to 11, 1966. I also corresponded with Alexandre, Jean-Paul Squifflet (acting chair of the Service of Kidney and Pancreatic Transplants and Surgery of Endocrine Glands of Louvain University), and Sir Roy Calne [6]. Alexandre proposed 5 conditions for BD diagnosis: (1) complete bilateral mydriasis; (2) complete absence of reflexes, both natural and irresponsive to profound pain; (3) complete absence of spontaneous respiration, 5 minutes after mechanical respiration has been stopped; (4) falling blood pressure, necessitating increasing amounts of
☆ Author reports no conflicts of interest. 0883-9441/© 2014 Elsevier Inc. All rights reserved.
vasopressive drugs; and (5) a flat electroencephalogram. He emphasized that these conditions must be met, before the kidney removal can be considered.” Hence, Alexandre proposed one precondition (severe craniocerebral injury) and 5 criteria for BD diagnosis. I could find that, in 1963, Dr Guy Alexandre had not only adopted closely similar diagnostic criteria for BD regarding the Harvard’s report but also applied those criteria in performing the first organ transplant from a brain-dead donor. When Alexandre and his team performed the transplant, they did not discontinue mechanical ventilation and wait for the donor’s heart to stop beating. Therefore, I concluded in that publication, recognized by the American Academy of Neurology with the Lawrence McHenry Award in 2005 [6], that although it is commonly believed that the first set of criteria for BD originated in 1968 [7], actually, 5 years before the Harvard criteria appeared, Guy Alexandre, a Belgian surgeon at the Catholic University of Louvain, introduced a set of BD criteria, and, on June 3, 1963, he and his team performed the first organ transplant from a brain-dead donor [1,6]. Calixto Machado MD, PhD, FAAN Institute of Neurology and Neurosurgery Department of Clinical Neurophysiology, Havana, Cuba Corresponding author. Institute of Neurology and Neurosurgery, 29 y D Vedado, La Habana 10400, Cuba E-mail address: [email protected] http://dx.doi.org/10.1016/j.jcrc.2014.07.002 References [1] De Georgia MA. History of brain death as death: 1968 to the present. J Crit Care 2014;29(4):673–8. [2] Machado C. Brain death: a reappraisal. New York: Springer; 2007 1–126. [3] Jalland. Cerebral abscess secondary to ear disease; trephining; death. Lancet 1892;139(3575):527. [4] Duckworth D. Some cases of cerebral disease in which the function of respiration entirely ceases for some hours before that of the circulation. Edinb Med J 1898;3:145–52. [5] Cushing H. Some experimental and clinical observations concerning states of increased intracranial tension. Am J Med Sci 1902;124:375–400. [6] Machado C. The first organ transplant using a brain-dead donor. Neurology 2005;64:1938–42. [7] A definition of irreversible coma. Report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death. JAMA 1968;205:337–40.
Contents lists available at ScienceDirect
Journal of Critical Care journal homepage: www.jccjournal.org
Historical evolution of the brain death concept: Additional remarks☆ De Georgia [1] presented a review, tracing the evolution of the brain death (BD) concept. I will comment and add some remarks to this review [2]. 1. Early accounts of BD This author describes the importance of developing mechanical ventilation for recognizing BD [1]. Nonetheless, earliest accounts, at the end of the 19th century, described states resembling what would today be recognized as BD: during an increment of intracranial pressure, respiration suddenly stopped, whereas the heart remained beating [2]. Jalland [3], reported a case with a brain abscess, in whom respiration returned after having ceased for some time, when the pus was evacuated. Horsley affirmed that patients “die of respiratory and not of cardiac failure.” Duckworth [4] also commented about cases in whom respiration completely stopped for some hours before circulation.” Lastly, Cushing [5] stated that, “in death of a fatal increase in intracranial tension, the arrest of respiration precedes that of the heart … prompt surgical relief, with a wide opening of the calvarium, may save life even in desperate cases with pronounced medullary involvement.” Although these articles provide early descriptions of the BD syndrome, their authors still considered cessation of respiration and/or heartbeat to be the signs of death [1,3-5]. 2. Guy Alexandre at the Company for Chemical Industry Basel (CIBA) symposium De Georgia [1] also commented about Guy Alexandre at the CIBA symposium on transplantation. To investigate this milestone event, I reviewed the little known proceedings of a Company for Chemical Industry Basel (CIBA) symposium held in London, on March 9 to 11, 1966. I also corresponded with Alexandre, Jean-Paul Squifflet (acting chair of the Service of Kidney and Pancreatic Transplants and Surgery of Endocrine Glands of Louvain University), and Sir Roy Calne [6]. Alexandre proposed 5 conditions for BD diagnosis: (1) complete bilateral mydriasis; (2) complete absence of reflexes, both natural and irresponsive to profound pain; (3) complete absence of spontaneous respiration, 5 minutes after mechanical respiration has been stopped; (4) falling blood pressure, necessitating increasing amounts of
☆ Author reports no conflicts of interest. 0883-9441/© 2014 Elsevier Inc. All rights reserved.
vasopressive drugs; and (5) a flat electroencephalogram. He emphasized that these conditions must be met, before the kidney removal can be considered.” Hence, Alexandre proposed one precondition (severe craniocerebral injury) and 5 criteria for BD diagnosis. I could find that, in 1963, Dr Guy Alexandre had not only adopted closely similar diagnostic criteria for BD regarding the Harvard’s report but also applied those criteria in performing the first organ transplant from a brain-dead donor. When Alexandre and his team performed the transplant, they did not discontinue mechanical ventilation and wait for the donor’s heart to stop beating. Therefore, I concluded in that publication, recognized by the American Academy of Neurology with the Lawrence McHenry Award in 2005 [6], that although it is commonly believed that the first set of criteria for BD originated in 1968 [7], actually, 5 years before the Harvard criteria appeared, Guy Alexandre, a Belgian surgeon at the Catholic University of Louvain, introduced a set of BD criteria, and, on June 3, 1963, he and his team performed the first organ transplant from a brain-dead donor [1,6]. Calixto Machado MD, PhD, FAAN Institute of Neurology and Neurosurgery Department of Clinical Neurophysiology, Havana, Cuba Corresponding author. Institute of Neurology and Neurosurgery, 29 y D Vedado, La Habana 10400, Cuba E-mail address: [email protected] http://dx.doi.org/10.1016/j.jcrc.2014.07.002 References [1] De Georgia MA. History of brain death as death: 1968 to the present. J Crit Care 2014;29(4):673–8. [2] Machado C. Brain death: a reappraisal. New York: Springer; 2007 1–126. [3] Jalland. Cerebral abscess secondary to ear disease; trephining; death. Lancet 1892;139(3575):527. [4] Duckworth D. Some cases of cerebral disease in which the function of respiration entirely ceases for some hours before that of the circulation. Edinb Med J 1898;3:145–52. [5] Cushing H. Some experimental and clinical observations concerning states of increased intracranial tension. Am J Med Sci 1902;124:375–400. [6] Machado C. The first organ transplant using a brain-dead donor. Neurology 2005;64:1938–42. [7] A definition of irreversible coma. Report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death. JAMA 1968;205:337–40.
