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Redefining brain death

SiR-Madl and colleagues (April 3, p 855) discuss the value ofcortical evoked potentials in predicting neurological outcomeafter cardiac arrest. They showed that long-latency evokedpotentials were a sensitive measure of cortical function andwere useful in predicting favourable as well as unfavourableoutcomes. These results await verification in larger series.

Unfortunately, there were no neuropathological correlations,so that the anatomical significance of their critical cutoff valueof 118 ms, which distinguished between outcomes, is unclear.Although not specifically addressed in their article, their datain figure 2 confirm those of previous studies that the Glasgowcoma scale, which relies on brain-stem function, is not anaccurate guide to prognosis. This fact is not surprising becausethe adult cerebral cortex is selectively vulnerable to the effectsof anoxia; therefore some patients will never awaken despitepreserved brain-stem function, as a result of irreversibledestruction of the cerebral cortex.The real difficulty remains in identifying, early after onset of

cardiac arrest, those comatose patients with a hopeless outlookirrespective of how well they are managed. Accurate predictionof outlook would allow physicians to allocate resources to thosewho would benefit, allow counselling of family members withrealistic expectations, and hasten identification of potentialorgan donors. Madl et al found a uniformly unfavourableoutcome in patients with absent short latency corticol I

potentials-ie, loss of the N20 peak-which represents theconnecting pathway between the cervicomedullary junctionand sensory cortex. This result is consistent with those of manyprevious reports that established that the absence of shortlatency cortical potentials predicts death without awakening.2-4Neuropathological study in these reports disclosed widespreadcortical necrosis.There is ample scientific evidence to review the definition of

brain death, which requires a dead brainstem. Patients who arecortically dead after cerebral anoxia, as proven by the absenceof short-latency cortical evoked potentials, will never regainthe basic qualities of thought and awareness that are necessaryfor a decent life and meaningful existence, and should beregarded as brain dead. Such a redefinition of brain death couldavoid costly and dehumanising medical care that is ultimatelyto no avail.

Ted L Rothstein

1560 N115th Street, (Suite 204), Seattle, Washington 98133, USA

1 Mullie A, Verstringe P, Buylaert W, et al. Predictive value of Glasgowcoma score for awakening after out-of-hospital cardiac arrest. Lancet1988; i: 137-40.

2 Rothstein TL, Thomas EM, Sumi SM. Predicting outcome inhypoxic-ischemic coma. A prospective clinical and electrophysiologicstudy. Electroencephalography Clin Neurophysiol 1991; 79: 101-07.

3 Brierly JB, Graham DI, Adams JH, et al. Neocortical death aftercardiac arrest: a clinical, neurophysiological and neuropathologicalreport of 2 cases. Lancet 1971; ii: 560-65.

4 Walser H, Mattle H, Keller HM, et al. Early cortical median nervesomatosensory evoked potentials: prognostic value in anoxic coma.Arch Neurol 1986; 42: 32-38.

5 Guidelines for the determination of death. Report of the medicalconsultants on the diagnosis of death to the president’s commission forthe study of ethical problems in medicine and biomedical and behaviorresearch. Neurology 1982; 32: 395-99.

Surrogacy in California

SiR-In your June 5 Medicine and the Law Oxman decries therecent Johnson versus Calvert decision by the CaliforniaSupreme Court, in which the court found that there can only beone mother, and that the original contract signed by theparticipants defines the future parental relationship. He states

that science should dictate this matter, on the basis of

"biological realities, not the intentions of people who may bemotivated by selfish or even perverted desires". He furtherposits a "right to know and be with the mother who created itslife", and concludes that "no reason in law, social policy, orlogic exists which should allow one person to use the artificialinstrument of a contract to decide that matter in that person’sfavour".On the contrary, there are very many legal precedents and

social policies that firmly establish the importance of contractsin the affairs of people; the effect of the court’s ruling is to insistthat none of the freely consenting parties tries to change therules in the middle of the process. Scientific findings, unlikecontracts, are constantly changing and provide no firm basis todecide a matter of this magnitude, as the abortion debate hasalso made abundantly clear (a hydatidiform mole is diploid andconceived by man and woman; does it have a soul?). Othersurrogate mothers have stuck to their agreements as written,and have provided an important service to infertile couples andthe child. The selfish and perverted desires shown in this caseseem to apply clearly to the party who wished to violate acontract freely entered into, and who also was reported to haveslandered the other parties to her friends and co-workers.The matter of rights is even more fraught with peril if we try

to let science decide the matter. Do sperm donors have a right toseek out and meet their children?’Obviously, they should beexpected to honour the original contract of anonymity.Contracts are no more artificial than much of the fruits of

science, including surrogacy itself. The first, and most

important right of children is to the calmest, least stressed, leastambivalent, least traumatic parental relationship that can beachieved. In firmly and unambivalently resolving this ques-tion, the court has done this child (and the whole issue ofsurrogacy) a great service.

Stephen G HayesDepartment of Psychiatry and Behavioral Sciences, University of Southern CaliforniaSchool of Medicine, Los Angeles, California 90089, USA.

SIR—Oxman correctly states that the rights of the child shouldbe our main concern, not the rights of the parents. He then goeson to make the amazing statement that "a child has a right toknow and be with the mother who created its life", which seemsto bias any decision in favour of the surrogate mother over the

genetic parents.The fact that the surrogate mother was the carrier of the baby

should not give her (and her partner) any rights if it is not in thebest interest of the child. Oxman seems not to appreciate that,at least in the USA, the "real" mother, surrogate or otherwise,is often someone who needs money and would not make a goodparent. The best interest of the child, (by preventing the kind ofchild rearing which leads to delinquency or neglect) wouldoften be to be raised by someone other than the surrogatemother.

Russell Eisenman

Department of Psychology, McNeese State University, Lake Charles,Louisiana 70609, USA

1 Eisenman R. From crime to creativity: psychological and social factorsin deviance. Dubuque, IA: Kendall/Hunt, 1991.

Toxic effects of herbal medicines and food

supplements

SiR-Following your recent correspondence on herbal medi-cines (Sept 12,1992, p 673; March 6, p 637; June 19, p 1595)wereport the results of a pilot study of the frequency and severity

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of adverse and toxic effects related to the use of traditional

medicines and food supplements reported to the NationalPoisons Unit.

Emergency-case inquiries to the unit, surveyed retro-

spectively during 1983-1988 and prospectively in 1991, showedthat traditional medicines and food supplements were impli-cated in a total of 5563 inquiries. Of these, 657 (12%) patientshad symptoms at the time of the initial inquiry. The possibilityof association between exposure and effect was judged withreference to previous scientific reports and confidentialNational Poisons Unit case files.

Links between exposure and the clinical effects were foundin 49 cases. Most of these were well recognised, such as heavymetal poisoning associated with exposure to Asian medicines,drowsiness and liver damage from herbal tranquillisers,thyrotoxicosis from exposure to kelp, and effects from over-dosing with vitamins. Associations first identified through thisstudy include permanent skin discolouration after the use of atanning preparation, oesophagitis from digestive enzymes,bronchospasm from royal jelly, and death due to liver damagefrom Chinese herbal preparation.1Although these data represent an unknown proportion of all

cases, they nevertheless provide valuable information on thenature of toxicity. Particular areas of concern have been

highlighted. First, some products have been adulterated withheavy metals, which identified the need for appropriateproduct quality control, with correct labelling of ingredients,and instructions for use of the product. Second, medicalprofessionals have not recognised the potential toxicity of theseproducts, which has led to delayed diagnoses in some cases anda probable under-reporting of incidents. Patients need to beasked specifically about their use of alternative therapies.The effects identified by this survey were serious enough to

cause concern, and indicate the need for continuing surveill-ance of large numbers of exposures. Such monitoring wouldenable appropriate risk assessment of traditional medicines andfood supplements to be carried out, to detect, and, wherepossible, limit harm.To achieve this aim, and for information and advice on

diagnosis and management, medical professionals are re-

quested to continue to notify the National Poisons Unit,London, of any suspected case of adverse effects from the use oftraditional medicine or food supplements.

The surveillance is continuing during 1992-93 and is being supported bythe Ministry of Agriculture, Fisheries and Food.

Lucija Perharic, Debbie Shaw, Virginia MurrayNational Poisons Unit, Guy’s and St Thomas’ Hospital Trust, London SE14 5ER, UK

1 Perharic-Walton L, Murray V. Toxicity of Chinese herbal remedies.Lancet 1992; 340: 674.

Canadian MRC’s partnership with the drugindustrySiR-Kondro (May 29, p 1402) considers the possible out-comes of recent Canadian legislation extending patent protec-tion for brand-name drugs to 20 years (Bill C-91), and rightlyexpresses surprise at the Canadian Medical Research Council’s(MRC) naivite in relying on the promise of the drug makers togreatly expand their funding of basic research in academiccentres. Neither his report nor previous reports1,2 really conveythe flavour of the debate in Canada.An article entitled "Science supports the case for brand-

name drugs" in Canada’s leading newspaper (Globe & Mail,Dec 29, 1992), gave the false impression that the entire sciencecommunity was supportive of the legislation. A major lobbywas launched by the multinational drug companies, who hailed

the dawn of a new era for basic research and sponsoredfull-page advertisements bearing the names of a medical schooldean and other members of the medical establishment. In

pointing out the large investment needed before a drug couldbe brought to market, it was argued that there should be aperiod of patent protection before the "generic" drug manu-facturers could compete and force down prices.However, the worst nightmare of the head of a large

brand-name drug company is that there would be a majorresearch advance so that a drug in which the company hadheavily invested became redundant. It is in the interest of thedrug companies to maintain the status quo. Increasing theperiod of patent protection increases this commitment to thestatus quo. Thus, it would be very naive indeed to suppose thatthe drug companies would provide more funds for basic

research, the very process that would disrupt the status quo.Any funds that were made available for research would be verycarefully directed. Investigators willing to engage in clinicaltrials and applied research to increase the effectiveness ofexisting drugs, would receive a generous bounty. The un-spoken aim would be to draw scarce resources (research space,skilled personnel) away from those engaged in basic research.Another argument of the brand-name multinationals was

that increasing the period of patent protection would bringCanadian practices into line with those of its major tradingpartners, especially the USA. Canadian health care consumershad been having a free-ride, whereas consumers in the USAwere having to pay more for their drugs because of the longerperiod of patent protection. The irony of this discrepancy at atime when the Clinton administration was seeking to reducemedical expenses was not lost to California Democrat PeteStark who publically expressed astonishment that the Cana-dians had not been smart enough to demand a renegotiation ofthis provision on the North American Free Trade Agreement:"we should not reward this industry with$400 to$800 millionin windfall profits in Canada unless they [the multinationaldrug companies] promise to lower the cost of their products toAmerican consumers", Stark told the House of Representa-tives trade subcommittee.

Donald R ForsdykeDepartment of Biochemistry, Queen’s University, Kingston, Ontario, Canada K7L 3N6

1 Kondro W. Canada: broadening the scope of the MRC. Lancet 1992;339:1596.

2 Kondro W. Canada: controversy over drug patent-protection bill.Lancet 1992; 340: 902-03.

Development of Dupuytren’s contractureduring growth hormone therapy

SiR-Dupuytren’s contracture is rare during childhood andadolescence. Thickening of the palmar fascia causing flexiondeformity of the fingers, usually affecting the ring and littlefingers, occurs in Addison’s disease, hypothyroidism, diabetesmellitus, and acromegaly. We report a 14-year-old girl whogradually developed Dupuytren’s contracture during re-

placement therapy for hypothalamic panhypopituitarism.At age 8 years, a dysgerminoma producing beta human

chorionogonadotropin (P-HCG) in the suprasellar-epiphysealregion was diagnosed by computed tomography and stereotac-tic biopsy. The girl was treated with radiation therapy (45 and30 Gy to the head and spinal canal). After irradiation, centraldiabetes insipidus, tertiary hypothyroidism, and hypocortiso-lism developed. She was treated with desmopressin acetate,L-thyroxine, and hydrocortisone. At age 10, growth failure wasnoted. No clinical or biochemical evidence for thyroid oradrenal insufficiency, overtreatment, or water balance disturb-