Life-Prolonging Measures

Medical efforts to prolong the lives of individuals afflicted with serious disease or injury began with primitive medicine, perhaps in the Neolithic Period (8000-3000 B.C.), when we discerned from paleontologic evidence a tendency for primitive men and women to care for the sick and wounded in the shelters provided by the deep caves of Europe.

It was because of the medical (magical) expertise in prolonging (and sometimes saving) the life of the wounded hunter or sick mother, using herbs, rituals, magic, or by invoking friendly spirits, that the healer, the medicine man or Shaman, obtained recognition in primitive societies.

Traditional Medical Ethics and Practice

With the advent of ancient Greece and the advances in science and medicine, and the teachings of Hippocrates (460-370 B.C.), the Father of Medicine, the etiology of illness was ascribed to natural causes rather than magic, and the role of the physician became supportive, using medical knowledge to assist nature in healing the body.

The Oath of Hippocrates specifically held, “I will follow that method of treatment which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous. I will give no deadly medicine to anyone if asked, nor suggest any such counsel.” Thus, the Oath forbade the practice of euthanasia (from the Greek , eu — “good” and thanatos — “death,” for mercy killing ) by Graeco-Roman physicians, followers of Hippocrates and the teachings of his school on the Island of Cos. Doctors who subscribed to the ethics of Hippocrates forswore to “first, do no harm.” It followed naturally that physicians would do their utmost to sustain life while avoiding doing harm to their patients or taking any steps to advance their deaths. From the sixth century B.C., to the Renaissance, the ethical and clinical teachings of the Greek physicians, Hippocrates and Galen (AD 130-200), were paramount.

In the seventeenth century, frantic, and herculean efforts to save the life of the great Stuart monarch, Charles II (1630-1685) were undertaken. The king most likely had suffered a cerebral embolism (stroke), which may not have been fatal. Instead, the desperate measures not only caused him agony, but likely brought about his demise. Among the treatments applied to him were repeated purgings, enemas, cupping, bleeding, and the administration of remedies used by the well-intentioned court physicians possessed only with the very scanty medical knowledge of that era.

Likewise, in the eighteenth century, George Washington (1732-1799), the Father of the United States, succumbed to his illness, most likely streptococcal pharyngitis (“strept throat”) complicated by upper respiratory obstruction — as well as to the excessive bleeding undertaken by his physicians in extraordinary attempts to cure the disease and prevent his death.

Heroic efforts at prolonging life then and now were undertaken because of the assumed ethical obligation on the part of the physician, and because, even with the advances of modern medicine, it was (and still is) sometimes very difficult to ascertain and predict, among the critically ill, who will live and who will die.

The implementation of life-prolonging measures has become a subject of debate because many persons do not die suddenly from acute illness or trauma but, instead, are afflicted with chronic illnesses that cause untold pain and suffering before the patient finally succumbs. These patients may become debilitated, lapse into coma, and become subject to prolonged medical and sometimes “futile” care. After an acute central nervous system (CNS) insult (e.g., a serious brain injury causing a traumatic mass lesion in the brain, like a blood clot, or even following complications from chronic metabolic disorders), patients may undergo alterations in the level of consciousness (LOC), lapse into stupor and coma, deteriorate into deeper stages of coma referred to as rostro-caudal deterioration. This pathophysiologic process of brain dysfunction occurs, stepwise, as if the cerebrum, “from the top,” followed by the midbrain, and finally the brainstem, “at the bottom,” were being serially sliced and their CNS functions progressively turned off. This phenomenon occurs from swelling (edema), vascular congestion and infarction (i.e., decreased circulation with vascular damage), and brain shifts (herniations) that eventually result in death from cardiopulmonary arrest.

At some point, though, this process may be interrupted either by medical therapeutic intervention, or spontaneously, with the brain adjusting to the increased intracranial pressure, and the patient survives, although in a chronic or persistent vegetative state. Generally, life-prolonging measures are instituted when physicians think recovery is possible. Some patients will go on to die despite intensive care efforts, while others languish in a persistent (or chronic) vegetative state (PVS) or remain in a deeply comatose condition.

It is at this stage that physicians must perform serial neurological examinations not only to follow the clinical course but also decide if the patient has still any chance of recovery. Evidence of significant residual brain function means possible recovery and a good prognosis. Severe, irreversible injury means no chance of full recovery and a grave prognosis. Further worsening means that brain death is imminent. It is important to note here that the patient may continue to have a heartbeat and maintain his blood pressure and circulation, despite the development of brain death because of the artificial means of medical support, such as mechanical ventilation (via respirator), which had been instituted earlier by the physician and nursing staff on an emergency basis.

This is a very difficult time for the patient’s family, and the physician must be prepared to provide support and, if necessary, spiritual and psychological counseling using ancillary personnel such as consultation with the family minister or priest, hospital chaplain, or psychological counselor. In patients whose terminal illness is cancer, hospice care may have already been instituted. This provides additional family support.

Until the nineteenth century, all that could be done for patients with chronic, debilitating illnesses was supportive nursing care or, in the case of brain injury, risky decompressive surgery with lamentable but usually rapid, predictable clinical results. With the advent of the twentieth century, intravenous (IV) therapy, providing fluids, nutrition, medication and circulatory support through a catheter placed in a vein, became commonplace. Nasogastric tubes (i.e., a flexible feeding tube inserted through the nose and ending in the stomach) to provide foods and medications become (and remain) standard medical care for the chronically ill unable to take oral nutrition.

Endotracheal intubation, tracheostomies, and mechanical ventilation via respirators, likewise, became available to maintain the patient’s breathing and to provide oxygen to the body. Respiratory therapists to assist patients on mechanical ventilation became commonplace in the modern intensive care unit (ICU). To maintain circulation and adequate blood pressure, medications such as dopamine and other vaso-constrictor agents and cardiac drugs became available and are still being used widely in the ICU setting.

With this therapeutic armamentarium, patients are maintained in the ICU while the vital functions of various organs of the body are supported. This is of utmost importance for the preservation of cerebral function, if the patient is to survive without significant brain damage. To sustain (or replace) renal function and to remove toxic chemicals produced by the body’s metabolic processes, renal dialysis became available. With different methods, such as renal and peritoneal dialysis, harmful toxic substances can be removed from the body when the kidneys no longer function properly.

Unfortunately, prolonging life does not necessarily equate to survival, nor does it assure a return to normal life, if the patient lives. As alluded to earlier, there is no assurance the patient’s life will be saved. Even if a patient’s life is temporarily sustained via cardiopulmonary resuscitation (CPR), which is used to restore breathing and/or heart beat when these functions fail, there is no assurance that the patient will survive intact or that he will not have serious neurological deficits.

Although IV therapy, feeding tubes, respirators, etc., have largely applied to the severely ill patient in the ICU, intensive medical and nursing care and life-prolonging measures can also be administered to the ambulatory patients in the hospital or home setting. Renal dialysis, for example, is routinely performed on an outpatient basis in ambulatory patients who are independent in performing activities of daily living (ADL).

It’s not surprising that chronic illness may cause patients to become depressed and sometimes feel that their lives are no longer worth living. In these cases, family, medical, and nursing support and counseling may be imperative. Counseling goes along with full, informed consent. The patient should be fully informed about the natural history of the disease, treatment options available, advantages of therapy over potential risks, and the prognosis (chances of recovery) discussed. Permission should always be obtained before treatment is instituted. The competent adult patient has a right to refuse medical care.

Most hospitals today provide information about Advance Medical Directives. Advance directives are explained by hospital or nursing personnel and may be signed by patients in anticipation of hospitalization and treatment before unpredictable medical complications or unforeseen medical conditions, such as irreversible brain damage or coma can take place. Progression of the terminal illness may occur, so that the patient later may be unable to communicate with the medical staff. Advance directives therefore can limit the therapeutic interventions that can be ordered and instituted by physicians and nursing staff before the patient worsens and is no longer able to do so.

There are two types of Advance Medical Directives: Living Wills and Durable Power of Attorney. Living Wills consist of expressly written instructions that a patient wishes to have in effect regarding his medical care in advance should his condition worsen. Likewise, with a Durable Power of Attorney the patient authorizes another person to make decisions for him when he becomes medically unable to do so.

In short, advance directives provide guidelines for a patient’s medical care when he is incapacitated and does not wish to have his life prolonged with life-supporting measures when there is little chance of recovery.

Euthanasia — The Debate

As alluded to earlier, sometimes it is difficult to predict who will live and who will die, despite appropriate medical treatment, and it becomes difficult for the physician to advise the family about discontinuing futile treatment. “Do not resuscitate” (DNR) orders are instructions written by the physician so that heroic measures are not instituted in the event that the patient has a cardiopulmonary arrest in the hospital ward or ICU. This means that the nursing staff will not intervene with resuscitative measures, such as endotracheal intubation (insertion of a breathing tube), application of mechanical ventilation, cardiac massage, or electrical defibrillation of the heart. Living Wills and advance directives assist the physician in making life and death determinations (e.g., DNR orders) with the help of the patient’s family.

However, not all physicians agree that advance directives are necessarily desirable. Dr. Jane Orient, Executive Director of the Association of American Physicians and Surgeons (AAPS) writing in her book, Your Doctor Is Not In — Healthy Skepticism About National Healthcare, questions, “ Why do we need a new elaborate, legalistic procedure? Why can’t people simply exercise their right to reject medical care, once they decide that it isn’t worth it? The fact is that they can — I think we are just afraid not enough of them will, unless we encourage that choice.” (Orient 1994, p. 166) In other words, the serious concern is that the advance directive movement is part and parcel of the “right to die” and “duty to die” movements discussed in the article Bioethics — The Life and Death Issue posted on this website — another subtle attempt at promoting utilitarian ethics and the “rational allocation of scarce and finite health care resources” for the good of society, at the expense of the chronically ill and the most vulnerable in our society.

In his book Forced Exit — The Slippery Slope From Assisted Suicide to Legalized Murder, euthanasia opponent and attorney Wesley J. Smith, points out that in 1986 the American Medical Association (AMA) paved the way to legitimize euthanasia by the withholding of water from unconscious, non-terminally ill patients when the AMA Council on Ethical and Judicial Affairs stated that “although a physician ‘should never intentionally cause death,’ it was ethical to terminate life-support treatment, even if ‘death is not imminent but a patient’s coma is beyond doubt irreversible and there are adequate safeguards to confirm the accuracy of the diagnosis and with the concurrence of those who have responsibility for the care of the patient.’ ”  The Council went on to affirm that “ life-prolonging medical treatment includes medication and artificially or technologically supplied respiration, nutrition and hydration.” Smith adds, “There it was. For the first time, food and fluids provided by a feeding tube were ‘officially’ deemed a medical treatment that could be withdrawn ethically, the same as turning off a respirator or stopping kidney dialysis.” (Smith 1997, p. 45)

The famous case of Nancy Cruzan of 1987 was perhaps the most significant in establishing the “consensus” that death by dehydration was “ethical” and lawful. In this case, the courts established that the family of Nancy Cruzan — an unfortunate vegetative survivor of a 1983 automobile accident (in which she was the driver) — had the right to withdraw foods and fluids from the patient. After a series of legal battles, this was finally done and she died twelve days later in December 1990. Even Dr. Jack Kevorkian, the zealot physician assisted-suicide proponent, has been quoted as denouncing death by dehydration as inhumane.

In 1994, the AMA Council on Ethical and Judicial Affairs made another revision down the slippery slope of establishing and approving euthanasia as ethical medical practice. Smith writes, “Where once the patient had to be ‘beyond doubt’ permanently unconscious to permit withdrawing food and fluids, now even if the patient is not terminally ill or permanently unconscious, ‘it is not unethical to discontinue all means of life-sustaining medical treatment [including food and fluids] in accordance with a proper substituted judgment or best interest analysis.’ ” (JAMA 1994, p. 49-50) 

Dr. Edward Annis, past president of the American Medical Association (AMA), states in his book Code Blue — Healthcare in Crisis that a physician has no right to terminate the life of a patient. Nevertheless, he asserts that withdrawing life support machinery is very different from administering euthanasia. He argues that “the current system is so geared to continuing treatment of the terminally ill — even those languishing in a persistent vegetative state — that families of patients sometimes find that they are powerless to stop the treatment.” (Annis 1993, p. 181)

That ethical attitude, though, has been evolving, and with the advent of the twenty-first century, it is no longer prevalent. As early as the 1970s and 1980s, the attitude of physicians was changing from enlightened paternalism to gatekeepers primarily concerned with over-utilization of medical services. Calls were then heard both for patient autonomy and for implementation of means to control health care costs. About this time, proponents of bioethics asserted that some patients' lives were not worth living (i.e., "quality of life" ethic) and that patients and their families had the right to terminate care — not only in cases of terminal disease and persistent vegetative states (PVS; i.e., where the patient is cognitively impaired), but even in non-terminal, chronic debilitating conditions.

No sooner had patient autonomy (i.e., respect of patient's wishes as to resuscitating measures) become an article of faith in bioethics than "ethical" conditions were then redefined. Since the 1990s the utilitarian ethic began to reign supreme, and currently in the early twenty-first century, the futile care theory prevails at least in academic circles. This theory in its essence holds that physicians and hospitals have the right to withhold treatment that they consider futile and to limit life-sustaining measures without patient consent. Futility, though, is not a medical definition but a subjective value judgment made by bioethicists in theory and by physicians in practice, practitioners inclined to the new utilitarian ethics of cost containment, and willing to render judgments about "quality of life" issues and the "proper allocation of finite resources." So much for the cherished principle of informed consent and patient autonomy!

Cerebral Death

Sooner or later, though, life ends, and an individual is pronounced dead because irreversible cessation of brain function occurs. The concept of brain death is presently accepted and utilized by the medical profession, and the legality and constitutionality of cerebral death as representing the death of an individual has been upheld in U.S. courts. Nevertheless, the establishment of cerebral (brain) death is a clinical diagnosis, the determination of which remains the responsibility of the attending physician.

Although traditionally cessation of the heartbeat and respiratory functions have been the necessary conditions for death, the availability of the aforementioned modern, life-support systems, as we have seen, has made this determination more complex and less clear cut. Nevertheless, the determination of brain death must be made in the modern setting, wherein the patient’s respiration and heartbeat have been mechanically maintained.

Brain death is diagnosed by neurological criteria, and once these criteria have been met, the patient is pronounced clinically dead. As of yet, no case of a patient properly diagnosed with cerebral death has been reported to survive despite continuation of life support measures. Brain death indeed means the death of the patient. Brain death should not be confused with patients who have sustained short (i.e., usually less than three to five minutes) episodes of “clinical death” associated with subjective “near-death” experiences. Near-death experiences, like survival, have never been documented in patients diagnosed with brain death. This subject is discussed elsewhere in this encyclopedia under the heading of “Chronic Illness.”

In establishing the diagnosis of cerebral death the following criteria should be met:

1. Total unresponsiveness to external stimuli.

2. No spontaneous respiration.

3. No brainstem reflexes elicitable so that the pupils remain fixed and unresponsive to light and oculocephalic movements are unobtainable.

4. No encephalographic (EEG) activity of brain function. Although an EEG is not usually required for the diagnosis of brain death, it is only of confirmatory value in establishing the diagnosis. An EEG, nevertheless, should be obtained in cases of potential organ donation. Electrocerebral silence is documented when there is no brain activity and a flat line is recorded in the EEG tracings.

5. Repeat assessment. Two clinical assessments should be made no sooner than six hours apart. Some states require that two licensed physicians make the determination independently. One physician makes the diagnosis and the second physician confirms it, no sooner than six hours later. Again, this may be important in patients where organ donation is being considered, and no member of the organ transplantation team should participate in establishing the diagnosis of brain death. Also to make sure that the tradition of Hippocrates of "doing no harm" is preserved in organ transplantation, physicians have adhered to the concept of the dead donor rule, that is the organs are harvested from patients who are clinically dead.

Additionally, the diagnosis of brain death should not be made in the presence of hypothermia (i.e., body temperature below 32.2 degrees centigrade); or when CNS depression has occurred in the presence of barbiturates, iatrogenically induced (i.e., as in medical treatment) or as in cases of drug overdose.

And, the diagnosis of brain death in infants and young children is more difficult and requires longer periods of observations.

References

1. American Medical Association Council on Ethical and Judicial Affairs, “Opinion 2.15,” 1986; See also American Medical Association Council on Scientific Affairs and Council on Ethical and Judicial Affairs. Council report: Persistent vegetative state and the decision to withdraw or withhold life support. JAMA 1990;263(3):426-430.

2. American Medical Association Council on Ethical and Judicial Affairs. Council report: Decisions near the end of life. JAMA 1992;267(16):2229-2233; See also American Medical Association Council on Ethical and Judicial Affairs, “Opinion 2.20,” 1994.

3. Annis, Edward R. Code Blue—Healthcare in Crisis. Washington, DC, Regnery Publishing, 1993, pp. 179-184.

4. Arnett, Jerome C. Jr., and Faria, Miguel A. Jr. The ‘Tavistock principles’ of medical ethics — symposium. Medical Sentinel 2001;6(2):63-64.

5. Byock, Ira. Dying Well: The Prospect for Growth at the End of Life. New York, NY, Riverhead Books, 1997.

6. Carton, Robert W. The road to euthanasia. JAMA 1990;263(16):2221.

7. Cruzan v. Harmon and Lampkins, Case No. CV384-9p, Circuit Court of Jasper County, Missouri, transcript for March 9, 1988;  Nancy Beth Cruzan v. Robert Harmon et al., 760 SW 2nd 408, Nov. 1988; Cruzan v. Director, Missouri Department of Health, 110 Supreme Court, 2841, 1990.

8. Faria, Miguel A. Jr. Vandals at the Gates of Medicine: Historic Perspectives on the Battle Over Health Care Reform. Macon, GA, Hacienda Publishing, Inc., 1995, pp. 3-7, 169-176, 255-263.

9. Faria, Miguel A. Jr. Slouching towards a duty to die. Medical Sentinel 1999;4(6):208-210.

10. Gaylin, Willard, Kass, Leon R., Pellegrino, Edmund D., Siegler, Mark. Doctors must not kill. JAMA1988;259(14):2139-2140.

11. Hendin, Herbert. Seduced by Death: Doctors, Patients and the Dutch Cure. New York, NY, W.W. Norton, 1997.

12. Humphry, Derek. Final Exit: The Practicalities of Self-Deliverance and Assisted Suicide for the Dying. Eugene, OR, The Hemlock Society, 1991.

13. Lipton, Robert L. The Nazi Doctors: Medical Killing and the Psychology of Genocide. New York, NY, Basic Books, 1986.

14. Neuhaus, Richard J. The return of eugenics. Commentary, April 1988, p. 19.

15. Orient, Jane M. Your Doctor Is Not In — Healthy Skepticism About National Healthcare. Macon, GA, Hacienda Publishing, Inc., 1994, pp. 161-172.

16. Payne, Franklin E. Jr. Biblical Healing for Modern Medicine — Choosing Life and Health or … Disease and Death. Augusta, GA, Covenant Books, 1993.

17. Plum, Fred and Posner, Jerome B. Diagnosis of Stupor and Coma. 2nd edition. Philadelphia, PA, F. A. Davis Company, 1975.

18. Smith, Wesley J. Forced Exit — The Slippery Slope From Assisted Suicide to Legalized Murder. New York, NY, Random House, 1997.

19. Smith, Wesley J. Culture of Death — The Assault on Medical Ethics in America. San Francisco, CA, Encounter Books, 2000.

20. Walker, A. Earl. Cerebral Death. 3rd edition. Baltimore, MD, Urban and Schwarzenberg, 1985.

Resources

1. For information “that supports the efforts to effectively communicate a Christian perspective on bioethical issues to today’s pluralistic world”:

The Center for Bioethics and Human Dignity, 2065 Half Day Road, Bannockburn, IL 60015, (847) 317-8180, http://www.cbhd.org

2. For information about euthanasia from an opposing standpoint:

International Anti-Euthanasia Task Force, 328 N 5th St, Steubenville, OH 43952, (740) 282-3810

United States Conference of Catholic Bishops, 3211 Fourth Street N.E., Washington, DC 20017, 202-541-3000, http://usccb.org

Not Dead Yet, 497 State Street, Rochester, NY 14608, (585) 697-1640, http://www.notdeadyet.org

Written by Dr. Miguel A. Faria

This article was written in 2002 but was edited and published exclusively for HaciendaPublishing.com on October 29, 2012. The article can be cited as: Faria MA. Life-prolonging measures. HaciendaPublishing.com, October 29, 2012. Available from: http://www.haciendapub.com/randomnotes/life-prolonging-measures

 Copyright ©2002 Miguel A. Faria, Jr., M.D.

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Comments on this post

Pyramidal Section!

That's funny, because now I remember that it was a paper by Dr. Bucy I had read many years ago that led me to write that. I did not have any reference in front of me. His studies on pyramidal section in monkeys are also noted in an early 1980's edition of Raymond Adams Principles of Neurology. where I had also seen them briefly mentioned.

At the moment, I don't have those materials, so I can only trust my memory to recall that even though the monkeys regained power of movement, it was slow and clumsy. I don't believe there was ever a full return of function. This leads me to speculate that much like the amount of time it takes spinal shock to pass off following complete cord section is a rough indicator of a species comparative neural phylogeny, so it might be true for how much finer motor function is regained following pyramidal section. THAT is the objection I have to the HEAVEN project. If the monkeys were left with some degree of gross motor impairment, and yet the rat without a pyramidal tract did not seem to miss it, then do we really know if in humans, the role of the pyramidal system might be much more crucial to the exquisite degree of voluntary control we have over our hands (for instance)? I consider this one of the most fundamental and unanswered questions in neuroscience today, but is someone going to have to pay dearly for it to be answered? Then what do we do with them if they do have to pay? Tell them what a great contribution they have made to science?

I would like to return later with some commentary on the spinal central pattern generator and also, hypothermia of the spinal cord and brain. ---ARB

Basis for human head transplantation

Dear Miguel, I plan to write a comment on Dr. Sergio Canavero's head transplant project discussed in Surgical Neurology International (SNI) and the popular press. Ignoring (for the moment) many reasonable objections that he dealt with, the keys seem to be in the erroneous assumption that the mammalian pyramidal system is essential for movement, and the central pattern generator in the grey matter of the spinal cord. I had mentioned the latter before, but I have been aware for some time now that the classic "syndrome of the upper motor neuron" has been suspected to occur only when the pyramidal tract is damaged along with some other unknown closely lying descending white matter since the early 1940's. If the pyramidal tract is damaged solely, paralysis and pathological supraspinal release phenomena are not seen. However, while we have been able to "do as we wish" with the pyramidal system in many mammalian species, we can only suppose that the results will be similar in man, because it is not ethical to play around with a human pyramidal system, and lesions involving it are invariably too large for us to say they only involve it. So while he does present some interesting animal and human case material, I am still wary of comparing a human spinal cord to a lower primate's. The arrangement is likely not the same, because the brain has assumed such a larger role in humans. That's why spinal shock passes off so much faster in monkeys, and like lightening in rats. Nonetheless, it seems he simply does not have to have all of the axons "line up." Far from it. Best Regards— Adam.

Adam Bogart, Phd, is a Behavioral Neuroscientist at the Sanders Brown Center for Aging University of Kentucky, Lexington, KY. Behavioral Neuroscience Kent State University Kent, OH. Post doctoral fellow at the Albert Einstein College of Medicine, Gruss Magnetic Resonance Research Center Bronx, NY. MS Immunology conjointly Adelphi University/Mount Sinai Medical Center New York City, NY.
—————
Dear Adam, You have done some good research and I will await your comment. For now let me share some background material. Dr Paul Bucy the founding editor of Surgical Neurology, a great independent neurosurgical journal — one of its offspring is our own Surgical Neurology International, now run by our very own Dr. James Ausman— was the investigator who did much of the work on sectioning the pyramidal tracts in the cerebral peduncles of monkeys and noting the result in the 1940s and 50s. (I mentioned the trailblazing Dr. Bucy in my Psychosurgery series regarding his work, in particular the Klüver-Bucy syndrome. I was very fortunate to meet and hear Dr. Bucy lecture as Visiting Professor at Emory University when I was a resident). Dr. Bucy's editorial associate was none other than Dr. Robert White, who presently is Dr. Sergio Canavero's inspiration. Dr. White performed the first and only successful head transplant in living monkeys, a feat which I commented on under one of Dr Canavero's papers in SNI. I hope all of this material serve as an introduction to the various topics mentioned.— MAF. P/S. This topic was also discussed under my Brief History of Psychosurgery, Part 3. Or a new discussion could be continued under the subject: Random Notes, Bioethics and Thanatology, Life-Prolonging Measures, as I have begun here. --- MAF

Miguel A. Faria, MD, is an Associate Editor in Chief and World Affairs Editor of Surgical Neurology International (SNI). He is a retired Clinical Professor of Surgery (Neurosurgery) and Adjunct Professor of Medical History, Mercer University School of Medicine. Former member of the Injury Research Grant Review Committee of the Centers for Disease Control and Prevention (CDC; 2002-05). Realclearhistory contributor (2012-present). He is President of Haciendapublishing.com

Thinking about Corticospinal Tracts...

I had been doing a bit of research on central pattern generators this evening, but it occurred to me that we might have cases of pure pyramidal section in humans, or something very similar.

I had previously indicated it was Victor Horsely who developed the first modern techniques for surgical relief of intractable focal seizures. Operating in the early 20th century, he did not have any more precise means of locating the focus in the motor area than electrical stimulation, which is not perfect as it may stimulate adjacent areas to the focus, or sometime fail to reproduce the seizure. So, he would remove large portions of the motor cortex to ensure that no hyper-excitable Pyramidal cells would remain. To me, this is closely equivalent to pyramidal section at a lower level. Perhaps you would say if this assumption is incorrect?

He reports on an operation in March 1908 for relief of focal seizures of the left upper extremity, for which he excised a large portion of the precentral gyrus.

JULY I7,1909.
THE LINACRE LECTURE.
THE BRITISH MEDICAL JOURNAL

THE FUNCTION OF THE SO-CALLED MOTOR AREA-OF THE BRAIN.
DELIVERED TO THE MASTER AND FELLOWS OF ST.JOHN'S COLLEGE, CAMBRIDGE, MAY 6TH, 1909,
By
SIR VICTOR HORSLEY,F.R.S., F.R.C.S
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2319388/pdf/brmedj07918-000...

It is not necessary to read it, but the point is that there was no voluntary power of movement in the arm for some time after surgery, but one year later there is partial recovery of voluntary motion in the arm. He did succeed in removing the clonic and "athetoid" spasm of the arm. Because he uses the word athetoid, and because the seizures seem almost continuous, I wonder if this was not epilepsy, but athetosis. It wouldn't matter, because that is how symptoms of basal ganglia disease were dealt with often in this era as well.

We do not know if there was any further recovery, but the removal of the motor area for the arm seems to give results in the human consistent with those found in monkeys with section of the pyramidal tract in the cerebral peduncles of monkeys.

Whether a person undergoing HEAVEN surgery would ever have full voluntary control over his or her new body is unclear, but perhaps they would have a great deal of it after an indeterminate period of time elapsed.

I also wondered if the amount of pyramidal fibers that decussate in the donor and the recipient might matter, because although it seems to be on average 80% in the lateral corticospinal tract, there is a great deal of variation in that, and there have been cases reported where none of them do.---ARB
----
Reply: Interesting musings but I'm not convinced that damage to the pyramidal cells in the cortex is equivalent to sectioning the pyramidal tracts at the level of the cerebral peduncles. Playing devil's advocate: One would be making some valid as well as invalid assumptions. Among such possibly invalid assumptions are ignoring the multiple inputs and neural interconnections upon the corticospinal tracts as they descend in the brainstem before decussation in the pyramids of the medulla oblongata, variability in the composition of the fibers at the different sites, and the fact that the ventral corticospinal tract would be damaged in the upper cortical ablation but not necessarily in the latter pontine section. It would be imperative for you to find and read the results of Dr. Bucy's work as I've mentioned. --- MAF

Dr. Bucy Should be Read!

You read my mind, because at lunch today I was thinking of just that. I believe you are right that the assumption is incorrect. I did read Bucy's work on pyramid section quite some time ago, but I think it is worth revisiting.

The interesting thing is that it has also been shown in monkeys (sorry, I don't have the reference here right now) that after a suitable length of time, total ablation of the occipital cortex will result in pallor of the nerveheads. That indicates to me that if the cell body in the cortex is destroyed, there must be degeneration of the entire axon in time. YET, NOT ALL OF THEM. If it's only some pallor, it can't be. Of course the animals were irreversibly blind immediately with reactive pupils, but that's expected.

I will have to find the reference on this as well, but I believe severe damage to the sensory or motor cortex will result in degeneration of their axonal tracts as far down as the spinal cord. HOWEVER, AGAIN, NOT ALL OF THEM.

If that's true, then I am tempted to say motor cortex ablation might just be the same as ablation in the peduncles, but you are still right...I need to reread his papers.

Somehow, this got deeper than I thought (my initial view was too simplistic) so perhaps I will investigate this more before turning to central pattern generators.
--ARB

CNS Hypothermia

I noticed that a fair amount of the first of the HEAVEN series went into some degree about what way was best to cool the patient's or monkey's CNS, as this would be important to help slow metabolism while surgery is in progress and blood flow is not yet completely restored.

I think we call all agree that this is the correct method to employ to be sure that neurons don't die of starvation while the surgery is underway.

I have experience with hypothermia in animals, because my original specialization as a PhD candidate was in the neurobiology of memory, although I have drifted from that since I graduated.

The laboratory I worked in had been using electroconvulsive shock with the electrodes placed on the rat's eyeballs to induce a profound retrograde amnesia after passive avoidance training. The animals had learned what part of the box to avoid so they would not get shocked, but they would forget it after application of ECT.

However, there are better methods that will also easily pass the IRB review as they are quite non invasive. One is to inject a strong protein synthesis inhibitor IP after training, and test to show the animals have again forgotten the shock. The inhibitor is usually a strong enough antibiotic that it cannot be used clinically (such as Anisomycin or Cycloheximide). However, if it inhibits translation of mRNA into proteins to destroy the bacterial cell wall, it is also going to do that in the normal mammalian brain. Short term memory is thought by some to be held in a feedback loop using LTP in the hippocampus that is eventually translated into proteins and replaced with an "indexing system" (also in the hippocampus). This index indicates which parts of the cortical association areas contain which parts of the memory encoded by the newly formed proteins. At this point it is now long term and stable.

But in our laboratory in 1968 it was discovered that hypothermia for 15 minutes at 4 degrees Fahrenheit applied to any mammal (but we used small to medium sized rodents) would also cause the animal to forget the passive avoidance training. I was reminded of this because I read in Canavero's paper that they needed to suppress bursting activity on the EEG, and that is what we found would happen to the rats. In fact, the convulsions were so strong, that many times the animal broke its own back and was immediately paraplegic. I wanted to verify that by necropsy, but I had already gotten into trouble for necropsy on animals in the operating room, as they were worried about post op infection.

Later search of the literature showed that when this treatment was applied to a rat, EEG first showed sporadic bursts before subsiding into high voltage slow waves. The speculation here is that as the animal is immersed in coolant up to its neck, the cooling CSF and blood in the body eventually reach the brain and cool the hippocampus and cortex, and probably the brain in general. Synthesis of new proteins might be brought almost to a halt.

The interesting problem we had was that if anesthetic was given to minimize distress of the animal in the coolant, hypothermia didn't work. Testing showed the animals to remember the passive avoidance training perfectly. This is something the IRB did not like, because it is reasonable to assume the treatments must have been very painful, yet we couldn't do any experiments on amnesia if we anesthetized them. This observation still has no adequate explanation, but it is as if the processing of short to long term memory is suspended when an animal is under almost all of the common anesthetics. When the animal awakes, further translation of the short term memory held in an LTP feedback loop into proteins is restarted.

This is a situation where classic behaviorism can supply a reasonable explanation that neuroscience has yet not.

"State dependency" is the consideration that a memory is encoded with its context. In other words, all other sensory cues in the immediate environment (or internally) are essential for the brain to know, and not just the place the rat receives the footshock. It has been shown that students who take a mild amount of alcohol when studying for an exam do better if they take the same amount before writing the exam. The mildly pleasant feeling the student has after one or two drinks is the internal contextual cue. So, it could be that if hypothermia is applied under anesthesia, the pain will not be encoded as the context, and retesting without prior application of hypothermia is also free of pain, so the contexts match, and the animal remembers the training.

Cyclohexamide, Anisomycin, and other strong eukaroytic antibiotics induce very unpleasant nausea. The question then becomes whether they are acting as protein synthesis inhibitors or merely inducing nausea to be encoded as the cue along with the passive avoidance training.

It would seem, because hypothermia or cyclohexamide given a day before testing to an animal which has just been exposed to the area of the chamber where it received the shock recover the memory. So, the state of nausea or pain is present at both training and recuing.

I am fanatically against behaviorism, but here it provides the better explanation. However, it still does not give the neurological basis behind state dependency. Ultimately, behaviorism fails again, because it provides a useful working explanation, but not the underlying biological mechanisms. What it does suggest is that in disorders of memory loss in humans, it may be that the memories are still in the brain, but just encoded improperly because of mesial temporal disease, particularly areas CA1, CA3, and the dentate gyrus of the hippocampus. If enough mass of brain tissue is destroyed then, yes, the memory might be gone forever. But in milder cases, state dependency, if the neurological mechanisms were determined, might be exploited to improve memory in those with early to mild dementia.

My next commentary will be on the spinal central pattern generator and how it relates to Dr. Canavero's work. This was a bit of a diversion, because I had so much experience with hypothermia of the murine CNS in grad school that I thought of it immediately when I read the first HEAVEN surgery paper.
--ARB

Spinal apposition, the old fashioned way

A CASE OF SUTURE OF THE SPINAL CORD FOLLOWING A GUNSHOT INJURY INVOLVING COMPLETE SEVERANCE OF THE STRUCTURE
BY
GEORGE RYERSON FOWLER,M.D.
Annals of Surgery,1905 Oct; 42(4): 507–513

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1426030/pdf/annsurg00987-00...

I will comment on the last two issues I raised later. For now, medical historians here might be interested in what seems to be the first attempt to treat a total spinal section.

I don't know what drove this surgeon to attempt this, but I think if Drs. Canavero and White had explained their method and lent him some equipment he did not have in 1905, traumatic spinal injury would no longer be so horrifying, and 2- The debate on HEAVEN surgery would have been long ago concluded.
--ARB

What then?

What, then, are our obligations as patients, or potential patients, as to the conservation of life? What are the relating obligations of specialists and other wellbeing experts? Answers to these inquiries are frequently expressed regarding a difference between what are called "customary" and "phenomenal" means or measures of drawing out life. It ought to be noticed that the expressions "standard" and "uncommon" can be utilized as a part of various ways. As utilized by specialists, "conventional" and "uncommon" will regularly signify "standard" or 'non-standard'. As utilized by ethicists, the expression "conventional" is frequently used to portray those method for drawing out life which are ethically required in perspective of the obligation (of the specialist and/or patient) to protect life and wellbeing.

Gun free zones, Assisted suicide...

From the Macon Telegraph

Gun free zones

Emory Lane (Georgia Southern University): "On October 9, the Crime Prevention Research Center (CPRC) released a revised report showing that 92% of mass public shootings between January 2009 and July 2014 took place in gun-free zones."
http://www.breitbart.com/.../report-92-percent-of-mass.../

Assisted suicide

“California this week became the fifth and largest U.S. state to legalize physician-assisted suicide -- or “aid in dying,” as supporters call it…”

An opponent of physician assisted suicide, Ben Boychuk, associate editor of the Manhattan Institute’s City Journal, writes:

“State-sanctioned, physician-assisted suicide changes the dynamic between doctor and patient, patient and family and family and doctor. California’s law may most likely change everybody’s relationship with his or her insurance company, too.

“If you think it’s difficult getting an insurer’s approval for an expensive cancer treatment now, just wait until the adjusters and actuaries begin weighing the high costs of uncertain therapies against the relatively low-cost of a cocktail of suicide drugs. Even merciful palliative care is pricey compared with a handful of pills.

“We could labor over the particulars of what’s wrong with California’s law, such as how it includes language protecting doctors from legal liability in case the procedure goes wrong -- or goes right for the wrong reason. But the law’s moral and social implications are far more significant.

“Legally sanctioned physician-assisted suicide tends to make suicide more acceptable generally. By all means, let’s look at Oregon’s experience. The Beaver State has the second-highest suicide rate in the United States -- excluding doctor-assisted suicides. The Centers for Disease Control and Prevention in 2013 reported Oregon experienced a 49.3 percent increase in suicides among men and women between the ages of 35 and 64 from 1999-2010, compared to 28 percent nationally. Oregon passed its law in 1997.
“And look at what’s happened in Belgium, which passed its assisted suicide law in 2002. There, euthanasia for depressives -- not just the terminally ill -- is becoming routine.
“We’re assured that could never happen here…

Read more here: http://www.macon.com/opinion/readers-opinion/article38286144.html#storyl...

Ben Damron, American patriot and friend, RIP.

Ben Damron, American patriot, and friend, RIP.

Our dear friend Ben Damron died at 3:00 AM this morning in his home after a relatively brief illness surrounded by his wife Diane and his loving children, grandchildren and family in Warner Robins, Georgia. We extend our most sincere and heartfelt condolences to Dianne and family in this hour of grief. He will be sorely missed, a great loss to his family, friends, and community. Ben was an American patriot who served as Commander of his Veteran chapter and a great debater, a conservative defender of family, country, veteran affairs, and the military.

As an 18 years-old Ben left his family in Kentucky and enlisted in the Air Force serving for 26 years. As a young man, he served in Okinawa and Thailand. He moved to Warner Robins in 1987, and met his devoted wife Dianne a few years after that. He retired in 1988, and they continued to live in Warner Robins.

Despite his humble origins, Ben picked up his conservative Republican politics from his father, “from the time I could walk and follow him.” Reminiscing about his father, Ben told us, “people came to the store bought a coke and began to discuss politics, local and world affairs, and I was right there with him listening to every word. I can also remember him making statements like he was a Republican and there wasn’t another now within 20 miles of him.”

We came to know and meet Ben from the Macon Telegraph Viewpoints forum in 2011, subsequently met his lovely wife Dianne, and we became fast friend along with Elaine and Larry Jones, with whom we discussed politics and world events. About my own mother, whom he heard me talk about or read about in my book, Ben said, “ Tell her I would like to meet her; she is a great lady, and glad she is still around in Florida to be able to vote Republican!”

Ben will be sorely missed along with his informative emails, his Viewpoints political debating, and his (and Dianne’s) Christmas cards scripted with his beautiful calligraphy handwriting! Ben, we will miss you and RIP.

Dr. Miguel and Helen Faria

Already missing him.

I never had the pleasure of meeting Ben face to face, but had many phone conversations and much correspondence with him. We never did have that beer Ben. I regret that. It was all my loss.

RIP my dear friend. You fought a great fight both personally and publicly. My life and memories have been enriched for knowing you. Thank you for that and your service to our nation.

Good bye, Ben

Sad to hear this, but am glad to know that he was with family. Ben and I also met on Viewpoints, and often 'talked' through emails, as well. We never did meet in person, although that wasn't Ben's fault...opportunity was given on several occasions, yet, for various reasons, I was unable to take advantage of it. He was an interesting man, and I will miss him dearly. His voice filled a void, and through it, I have met others of like minds. Praying for his family and friends.

Here's to you, my bud...will have a few in your memory!

Wolf

Well said VC and Uneed!

Well said VC and Uneed,
Ben was great friend and American patriot indeed. Though I'd never met him in person, I enjoyed many years of his commentary and emails. While he will be missed greatly, let us be thankful for knowing him and the friendships he brought together.

Sincerely yours and to all of Ben's friends
Greg Williams

Thank you so much Dr. Miguel

Thank you so much Dr. Miguel and Helen for such a sweet and accurate account of a beautiful friendship. Friends are precious in our lives. Ben surely was precious to all of us because he thought a lot of those he called 'friends'. And that was what Made Ben so special . If he called you friend; that was a deep meaning to him and we are so honored he thought so much of all of us.

He's already missed.

Your Friends
Larry and Elaine Jones