Neurology -- Correspondence for Machado, 64 (11) 1938-1942

Correspondence published:

The first organ transplant from a brain-dead donor: Eelco F.M. Wijdicks (19 July 2005)

Reply to Wijdicks: Calixto Machado (19 July 2005)

The first organ transplant from a brain-dead donor 19 July 2005

Eelco F.M. Wijdicks,
Division of Critical Care Neurology, Department of Neurology, Mayo Clinic College of Medicine
200 First Street SW, Rochester, MN 55905
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Re: The first organ transplant from a brain-dead donor

wijde{at}mayo.edu Eelco F.M. Wijdicks

I read with interest the article by Machado. [1] The author asserts that my article on the Harvard criteria failed to discuss the CIBA document and Wertheimer’s paper. [2] It is true that the study concentrated on the committee’s workings and the role of the neurologists.
A comprehensive history of the development of brain death criteria is in a book chapter with earlier descriptions of brain death, including Wertheimer and an even earlier document by Lofstedt and Von Reis.[3] It includes the disclosures of Alexandre presented anew in Machado’s paper. [3] The far less detailed criteria of surgeon Alexandre were actually modified from the criteria of the neurologists Mollaret and Goulon. “Alexandre’s” criteria, the generally negative reception by the attendees and virtual unanimous disinterest to use them, have also been discussed.[4]
Machado also doubts the originality of the Harvard Criteria of brain death. Some committee members attended an earlier CIBA symposium that discussed brain death criteria by Alexandre and Machado speculates they could have been perused. I found no evidence of that in Beecher’s papers. [2] Murray, who authored the proceedings of this CIBA symposium and who was a member of the Harvard committee, also did not mention Alexandre’s criteria in his autobiography.[5]
However, Machado believes the kidney retrieval in the Belgian donors is a “milestone event” and a first. I do not make much of it, but all history is subjective interpretation. I am also not yet persuaded these patients were brain dead. Even a flat EEG in those days could be low amplitude. Without actual documentation of a comprehensive neurologic examination and exclusion of confounders, we cannot say with certainty these patients were brain dead. That came with the Harvard Criteria among other landmarks.
My conclusions in Machado’s paper have been incompletely cited and could be misunderstood. I found no evidence that the field of transplantation drove the development of the Harvard Criteria. [2] However, the potential for conflict of interest and tensions between physicians who declared a patient brain dead and a transplant surgeon may have existed. A recent account is telling. Not being a neurologist and unguided by criteria, Hoffenburg postponed the declaration of death by neurologic criteria when he still could ”elicit neurological reflexes.” A surgeon (not Barnard, for the record), “waiting in the wings and clearly dismayed at my verdict” said, “God, Bill, What sort of heart are you going to give us?” That night he could not sleep and wondered whether he was “unnecessarily obstructive.”[6]
Disclosure: The author reports no conflicts of interest.
References
1. Machado C. The first organ transplant from a brain-dead donor. Neurology 2005;64:1938-1942.
2. Wijdicks EFM. The neurologist and Harvard criteria for brain death. Neurology 2003; 61:970-976.
3. Diringer MN, Wijdicks EFM. Brain death in historical perspective. In: Brain Death. Wijdicks EFM (Ed). Lippincott, Williams, and Wilkins 2001, pp. 5 – 27.
4. Jonsen AR. The Birth of Bioethics. Oxford University Press New York, Oxford, 1998.
5. Murray JE. Surgery of the soul: reflections of a curious career. Canton, MA: Science History Publications, 2001.
6. Hoffenberg R. Christiaan Barnard: his first transplants and their impact on concepts of death. BMJ 2001;323:1478-80.

Reply to Wijdicks 19 July 2005

Calixto Machado,
Institute of Neurology and Neurosurgery
Apartado Postal 4268, La Habana 10400, Cuba
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Re: Reply to Wijdicks

braind{at}infomed.sld.cu Calixto Machado

I am grateful for Dr. Wijdicks' comments and did not intend to criticize him. I only stated that Wertheimer [7] had been quoted less often than Mollaret and Goulon. [8] I agree with Wijdicks' [3] reference to Mollaret and Goulon’s article [8] as the “the landmark”. However, Wertheimer’s paper [7] was published earlier and was a breakthrough considering the neurophysiologic and clinical aspects of brain death (BD) syndrome.
Dr. Wijdicks cites several of his own valuable history reviews emphasizing the impact of the Harvard Committee, which was undeniably of great importance. [2,3] The 1966 Ciba Symposium was a "little-known" meeting and I only first learned about this in 1990. [10] Although others (including Wijdicks) have quoted the 1966 Ciba meeting, [3,4] it had not been reviewed in detail. In my essay, I stated that Alexandre had introduced a set of BD criteria based on the description of coma dépassé as early as in 1963. At the Ciba symposium, he defended these criteria against critics.
Wijdicks is skeptical about the importance of Alexandre’s role, noting that neither Beecher nor Murray mentioned Alexandre's criteria. [2,5] This is consistent with my statement that the Ciba Symposium has been rarely quoted. Wijdicks doubts that Alexandre’s patients were brain-dead. Alexandre worked with Jean Morelle, a neurosurgeon. Morelle authorized the application of BD criteria in those first cases. Clinically, the Harvard criteria and Alexandre’s are similar. The use of EEG has been controversial.
In 1969, Beecher stated that the Committee “was unanimous in its belief that an electroencephalogram was not essential to a diagnosis of irreversible coma.” [10] Moreover, criteria from Commonwealth countries do not include EEG. In 1969, The American Electroencephalographic Society only provided the technical guidelines for recording the absence of bioelectrical activity in BD. [11] Although misdiagnosis was possible in those early years, considering the discussions led by Alexandre at the Ciba Symposium and my correspondence with him, I believe that Alexandre and his team had enough information to make a correct diagnosis of BD. The term “milestone event” is reasonable if Alexandre and his team performed the first-ever known organ transplant using a heart-beating brain-dead donor.
I appreciate the comments by Dr. Wijdicks and also thank him for his contributions as a leading expert in the field of BD.
Disclosure: The author reports no conflicts of interest.
References
7. Wertheimer P, Jouvet M, Descotes J. [Diagnosis of death of the nervous system in comas with respiratory arrest treated by artificial respiration]. Presse Med 1959;67:87–88.
8. Mollaret P, Goulon M. Coma dépassé (preliminary memoir). Rev Neurol (Paris) 1959;101:3–15.
9. Pallis C. Brainstem death. In: Braakman R, ed. Handbook of Clinical Neurology: Head Injury. Amsterdam:Elsevier Science Publisher BV, 1990: 13 (57): 441-496.
10. Beecher HK After the “Definition of Irreversible Coma.” N Engl J Medicine 1969;281:1070-1071.
11. Silverman D, Saunders MG, Schwab RS, Masland RL. Cerebral death and the electroencephalogram. Report of the ad hoc committee of the American Electroencephalographic Society on EEG Criteria for determination of cerebral death. JAMA. 1969;209:1505-1510.