"Any possible restoration of function could not occur": Harvey cushing and the early description of brain death

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.