We Have Lost One of Our Friends

FigureAfter the Sixth International Symposium on Cerebral Blood Flow in June 1973 in Philadelphia, a meeting was organized to develop plans for the organization of a Society with regard to the subspecialty of Neurosurgical Anesthesiology. The meeting was hosted by Harry Wollman, MD, Professor, Department of Anesthesiology and Thomas Langfitt, MD, Professor and Chairman, Department of Neurosurgery, both from the University of Pennsylvania School of Medicine. This organizational meeting was attended by 36 anesthesiologists and 4 neurosurgeons, one of whom was Robert J. White, MD. Thus, these 40 signees became the charter members of the Neurosurgical Anesthesia Society, the granddaddy, and early predecessor of Society of Neuroscience in Anesthesiology and Critical Care.1 Bob White graduated from the Harvard Medical School and interned at the Peter Bent Brigham Hospital, where he came under the influence of the famed Francis Moore, MD, who revolutionized intraoperative and postoperative support in the care of surgical and burn patients. White did his neurosurgical residency and fellowship at the Mayo Clinic, where I first met him while I was finishing my residency training and getting ready to start a Fellowship in Neuroanesthesia. Dr. White was a deceptive individual in the sense that underneath his truly cheerful, kind, and jovial visage lay an extraordinary erudite person graced with consummate surgical skill, a near eidetic memory, a great sense of humor, and innate kindness. He had a disdain for the pettiness of a bureaucracy, was a religious individual, and manifested a cherubic appearance. From the time I first met him he was most interested in all aspects of anesthesia, always inquiring about the mechanisms involved relating to its effects on the brain and spinal cord already stressed by pathology and the potential stress of the surgical procedure. From the personal aspect, Dr. White helped me choose to look at central nervous system vulnerability to low levels of hypothermia (to 0°C) for my Master of Science research and dissertation, as the Mayo Clinic had a history of familiarity with the use of surface and vascular cooling for cardiothoracic procedures. When I was first introduced to him, Dr. White was a junior member of the Mayo Clinic staff and I worked assisting him on one of his favorite subjects, microneurovascular surgery, by looking at the consequences of basilar artery ligation in a high-order subhuman primate.2 This necessitated my learning and becoming adept at anesthetizing and ventilating these very large and often very uncooperative subjects. Dr. White was the most patient teacher as I had to learn quite a few surgical techniques to carry out spine and spinal cord surgeries for my work on spinal cord hypothermia. Bob White left the Mayo Clinic in 1961 for one of the 2 main teaching hospitals at Case Western Reserve University in Cleveland, Ohio, and I joined him there a short time later as a member of the Anesthesiology Department at Cleveland Metro General Hospital where he was the Chief of Neurosurgery. The clinical work at that epoch included an illusionary “half-a-day” schedule on Saturday; thus, he and I decided to start our research efforts late Saturday afternoon, usually continuing all day Sunday. We fixated on 2 research efforts, attempting to totally isolate the mammalian brain (dog and monkey), which was Dr. White's project, and develop a standardized model of spinal cord injury in the dog and monkey, which was a continuation of my work on spinal cord hypothermia. Bob White had no “philosophy” about anesthesia and he felt that a surgical procedure was a cooperative venture involving 2 well-trained professionals who knew what they were doing. I made preoperative and postoperative rounds with him on a near daily basis and he always gave weight to my suggestions. He had an acute interest in postoperative surgical care and a global interest in medicine in general. When I mentioned the importance of blood gas analysis for intraoperative and postoperative care and that there was a vendor in Cleveland that had the US marketing rights to the Astrup blood-gas apparatus, he made it a priority to continually badger the hospital administration and miraculously this unit made its appearance on my anesthesia doorstep shortly thereafter—as did a flame photometer and an AO Oximeter for rapid SVO2 determination. Thus, in a very short time, I had a well-equipped blood-gas laboratory and somehow Bob also obtained a technician who I trained to use this equipment and work on our experiments. After about 2 years of making postoperative rounds on different floors and services, I thought it was time to start a neurosurgical intensive care unit (ICU) and within 6 months after making this suggestion to Dr. White, we had a 4 bed neurosurgical ICU (NSICU), probably among the first anywhere. As the neurosurgical service had a very large trauma load at our Cleveland Metropolitan General Hospital, this NSICU was important for our work in the area of hypothermia. We cherry picked the most competent nurses for the NSICU and they were all indeed a devoted crew, often staying past their shift time because of the great interest in patient care. Our weekly Grand Rounds was carried out in Oslerian-Francis Moore tradition with a host of attending physicians, residents, medical students, and nursing staff being present. We frequently had a visiting professor during Grand Rounds, usually a neurosurgeon, but on occasion a neurologist, internist, anesthesiologist, or general surgeon would also be there. Dr. White made it clear that I should present some of the cases in the NSICU and the visiting “fireman” would give his comments, often “raising his eyebrows” when the anesthesiologist would present the case. On one occasion, a most distinguished neurosurgeon visiting professor lost his cool after hearing so many references to acid-base balance, pH, PO2, PCO2, cerebral blood flow and metabolism, and the intracranial compliance curve, which he pointedly exclaimed to Dr. White, “You know Bob, we don't have time to bother with all this blood-gas silliness since our main job is to teach these residents how to operate!” Yet, I know that this type of a new neurosurgical milieu championed by Bob White had a positive effect on many of the neurosurgical residents, as a considerable number of them went into academics and became chairmen of neurological surgery in the US, Canada, and Mexico, and also became well known in head trauma and on subjects tangential to the use of blood gas analysis, intracranial hypertension, and cerebral ischemia. After 3 years at Case Western Reserve University, Dr. White founded the Brain Research Laboratories and he was fortunate to obtain National Institutes of Health funding and other grants in aid for the isolated brain experiments. This experimental work came to fruition in 1963 with the publication in Science on the isolation of the mammalian brain in both the canine and subhuman primate, with the brain being perfused either by the circulation of a large donor animal or through a miniaturized pump-disc oxygenator system.3 This was followed shortly by another article in Science in 1965 in which the canine brain was isolated and then vascularly connected to and transplanted into the neck of a recipient canine with evidence of viability in the transplanted brain as noted by the electroencephalogram and substantial A-VO2 and A-VCO2 differences.4 An important study next appeared in Nature in 1966 showing the feasibility of storing the isolated brain in a super-cooled state using dimethyl sulfoxide for ≥12 hours after which it was rewarmed in an extracorporeal mechanical circulation, again showing evidence of reasonable electroencephalogram activity and A-V O2 and CO2 differences.5 These studies on the isolated, transplanted, and stored mammalian brains were rewarded in 2004 and 2010 when Robert J. White, Maurice S. Albin, and Javier Verdura were nominated by a Nobel Laureate for the Nobel Prize in Medicine and Physiology. By 1964, the Brain Research Laboratories were a very busy location, occupying about a third of a floor at the Cleveland Metropolitan General Hospital, with animal prep rooms, 3 fully equipped animal laboratories, a special monitoring room, and a chemistry laboratory. Numerous experiments were carried out in a number of different areas, including my own work on localized spinal cord hypothermia for acute traumatic spinal cord injury. Dr. White felt that hypothermia was an important tool in the prevention and treatment of cerebral ischemia, and he developed different techniques for isolated cerebral hypothermia. Surface cooling was used in the NSICU for head trauma including acute epidural and subdural hematomas. The application of these vascular isolation techniques in the human was described in a 1967 publication reporting differential extracorporeal hypothermic perfusion and circulatory arrest to the brain in a patient with a large meningioma who recently had a myocardial infarction. In this patient, using the techniques learned from the animal experiments, the brain temperature was reduced to below 12.5°C and circulation to the brain stopped while the tumor was excised with body temperature never falling below 35°C.6 The activities of the Brain Research Laboratories attracted scientists from around the globe and it was also utilized by neurosurgical residents for research projects. There were very few areas of clinical neurosurgery that Robert White did not touch on and this was especially true of his great experience in the area of congenital anomalies, in particular those resulting in hydrocephalus in the pediatric age group. A look through his amazing curriculum vitae of nearly 1000 publications reveals extensive work in experimental hemispherectomy, which was the subject of his PhD thesis, and on head injuries, extracorporeal circulation, neurovascular surgery for intracranial aneurysms and AVMs, intracranial pressure, and brain death resuscitation. Besides his experimental and clinical contributions to medicine, Bob White was an iconic cultural figure in Cleveland, where he contributed almost weekly to the local press, in Russia where he was a welcome guest many, many times even during the Cold War era because of his work on the isolated brain transplantation to which Russian Medicine had a historical connection, and in Italy because of his connection to the Vatican as a member of the Pontifical Academy of Sciences. Bob White had no hesitation at all in engaging the antivivisectionists who used every opportunity to try to sully his name, especially after his superb article defending proper animal research appeared in the Reader's Digest in 1988, which provoked a hailstorm of protest from those opposing vivisection.7 In my perspective, Dr. White was important in terms of his appreciation of the role of the anesthesiologist as a critical ingredient in the successful outcome of a neurosurgical procedure. He practiced this ‘doctrine’ during the decade I had the privilege to work with him, be it in the emergency room, operating room, NSICU, or in the laboratory. It was also specifically directed to the residents, fellows, and medical students on his service and was evident in his daily patient rounds. During Grand Rounds, I commented on any problems related to anesthetic care and very often I would lead the general discussion on the postoperative status of the patient being discussed. There was never any irrational finger-pointing when a complication developed. Instead, a rational discussion would ensue to delineate the factors involved. Robert White was an exceptional man, a great physician, a wondrous human being, and a neurosurgeon who respected and enjoyed working with neuroanesthesiologists. After a prolonged illness, Bob White left us on September 16, 2010.

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