C. Miller Fisher

1983, Chicago, IL

The remarkable accomplishments of C. Miller Fisher, astute observer and describer of clinical phenomena, pathologist, investigator, dedicated physician, and teacher have been summarized in two publications commemorating C. Miller Fisher Day, which was held on September 7, 1980, at the Massachusetts General Hospital (1, 2). It is appropriate on this occasion to review the life of this outstanding physician.

C. Miller Fisher (CMF) was born in the small town of Waterloo, Ontario, Canada, on December 5, 1913. By the time he reached age 10 it was assumed by his family that he would become a doctor, and no thought was ever given to any other career. Following graduation from high school he entered Victoria College in the University of Toronto, where he enrolled in a special 7-year course which combined a science B.A. and M.D. program. While accomplishing an outstanding academic record, he was a member of the University swimming and water polo teams.

Following graduation from medical school in 1938, he won a highly competitive internship at the Henry Ford Hospital and then in 1939 went to the Royal Victoria Hospital in Montreal as a medical resident. World War II was looming, and in April of 1940 he entered the Navy but in a somewhat unusual fashion. A naval surgeon on the staff of the Royal Victoria Hospital applied for transfer but could only do it if he could find another physician to replace him in the Navy. CMF volunteered and divided his time between the residency and examining recruits. After France fell, the call came for volunteer surgeonlieutenants to go to England, and Dr. Fisher went on loan to the royal Navy in September 1940. His assignment was as a general medical officer at the Portsmouth Naval Base on the south coast of England, with his time being divided among medical care, training for defense against a possible invasion of England, and running to air raid shelters.

After a few months he was placed as a medical officer on a cruiser patrolling the North Atlantic Ocean near northern Scotland, Iceland, and Greenland. After spending several dark winter months in this area, his ship docked at Halifax, Canada, for a planned rest period. Hardly had he come ashore when the doctor on another cruiser that was about to leave became ill. CMF took his place, leaving Halifax almost immediately and headed for the South Atlantic. Early in the morning of April 4, 1941, while steaming toward Africa, his cruiser was engaged in surface action by a German raider and sunk. Nine hours were spent in the water before he was picked up by the German vessel. He was transferred to a prison ship and was eventually taken to a prison camp in northern Germany, where he stayed for 3'/2 years.

In this camp he served as a medical officer for prisoners. Two events during this period probably influenced his career. He learned to read German, which enabled him in later years to study the very important original German literature on cerebrovascular disease. He also was able to read widely on many subjects--history, English literature, mathematics, navigation, etc. which not only occupied his time but, he believes in retrospect, satisfied the yen that all of us have to enjoy a great intellectual feast as adults rather than as fledgling students. Thus, he was able to devote his time to medicine without feeling that all else had passed him by.

In September 1944, he was sent back to Canada during the repatriation of prisoners and was assigned to the naval hospital in Halifax. At about this time it was realized that CMF had not had the benefit of a period of specialized training which the Canadian government had been giving medical officers serving in the Forces. Under this program he returned to the Royal Victoria Hospital to continue his training in medicine, with a special interest in endocrinology and diabetes. During this time he had a 2-month rotation on neurology at the Montreal Neurological Institute (MNI), and it was here that one clinical case and one man, Dr. Wilder Penfield, changed the direction of his career. A United States Army general entered the MNI with a seizure disorder, which included the history of hearing the beat of tom-toms, followed by loss of consciousness. CMF recounts that he knew nothing about this clinical problem, so he decided to get out the books. Elementary sleuthing suggested a tumor localized in Heschl's gyrus. Apparently Dr. Penfield was impressed and asked if CMF had considered neurology as a career. A position as actingregistrar of the MNI was offered and accepted. During the next 2 years at MNI he developed an interest in hypertensive encephalopathy and conducted a careful follow-up study on 103 patients who had had a lumbodorsal sympathectomy for hypertension. At the end of this 2-year period, Dr. Penfield proposed that he go abroad for further training in cerebrovascular disease. Dr. Roy Swank felt strongly that there was only one person with whom to train, Dr. Raymond D. Adams at Boston City Hospital. CMF went to Boston on January 1, 1949, spending the next year in neuropathology and enjoying the teaching of both Dr. Adams and Dr. Denny-Brown.

This was his first experience with morbid anatomy, and his interest became centered in cerebrovascular pathology. One of his first observations was that while most of the clinical diagnoses of stroke patients from the general medical services were "middle cerebral artery thrombosis," this was rarely the finding when the brain was examined. Often he had to examine five or six brains per day, sometimes more. One afternoon he was to cut 10 brains. The first had a hemorrhagic infarction, but dissection of the vessels revealed no occlusion. Brain five had another hemorrhagic infarction and, again, no vessel occlusion was found. Late in the afternoon, a third brain had the same findings. At that time relatively little was known about the dynamics of cerebral embolism, and such findings were said to be due to vasospasm. When he looked at the clinical records on all three of these patients, it was found they were atrial fibrillators. When he inspected the distal arterial branches, small emboli particles were found. In this one afternoon the whole idea of the migration, lysis, and disappearance of emboli was formulated, and the relationship of embolism to hemorrhagic infarction was demonstrated. It is of interest that when this finding was first written up, it was not accepted for publication by any pathology journal. It was this study that started him reading the German literature, which emphasized to him how little was known about the vascular pathology in cerebrovascular disease.

CMF returned to the Montreal General Hospital in 1950, where he was to spend the next 41/2years. Three individuals were important to him during this time. He was under the tutelage of Dr. Francis MacNaughton, who was the prime mover in starting a clinical stroke program. At that time, hospital admission of stroke patients was discouraged, but Dr. MacNaughton overcame this problem. Dr. Harold Elliott, the neurosurgeon, was extremely cooperative and encouraged the venture in every way. Last but not least, Dr. Lyman Duff, dean and professor of pathology at McGill, gave strong support to the development of cerebrovascular neuropathology.

Shortly after returning to Canada, CMF had occasion to examine a patient with a stroke at the Veterans Hospital. This is when the concept of transient ischemic attacks (TIA) got started. The patient said, "It is remarkable, before I became paralyzed I would go blind in one eye off and on for just a short time, but when I got paralyzed it was on the wrong side." Within 2 weeks another patient came with the same story. CMF, on looking up the literature, found that a persistent blindness in one eye and permanent paralysis on the opposite side meant carotid occlusion. The idea that hemiplegia and transient monocular blindness might be due to carotid stenosis was born. Several months later the first TIA patient died from metastatic carcinoma when CMF was out of town. When he returned to find that no autopsy had been done, he learned that the family was willing, and with their permission, arrangements were made for it to be done in the funeral home at 11 p.m. the night before the funeral. For the first time, the clinicopathologic correlation of carotid occlusion and TIA was established. During the next 2 years he interviewed many stroke patients at a chronic hospital and one after another told of prodromal symptoms; he examined 1100 pairs of carotid and vertebral arteries for clinicopathologic correlations; and he developed the idea of using anticoagulant therapy to prevent stroke in patients with TIA.

Dr. Raymond Adams, who had by now been appointed chief of neurology at the Massachusetts General Hospital (MGH) and Bullard Professor of Neuropathology at Harvard Medical School, invited CMF to return to Boston to develop a stroke service and continue his cerebrovascular pathological studies. During his 3 decades at the MGH, CMF has continued to describe clinical phenomena, make clinicopathologic observations, teach, publish, and be a compassionate physician. Dr. Fisher's list of accomplishments is long. More than 90 of his publications relate directly to cerebrovascular disease, and many of the others relate to observations and ideas gained from examining stroke patients. Already mentioned are the clinicopathologic correlations in cerebral embolism and carotid artery atherosclerosis and the definition of TIA. Original observations have been made on the examination of the comatose patient, the distribution of atherosclerotic lesions in cervical and intracranial arteries, anatomic variations in the circle of Willis, the fundus oculi during an amblyopic attack, clinical and pathological study of lateral medullary infarction, pathology and clinical syndromes of brain hemorrhage, early diagnosis of all types of stroke patients, the clinical syndrome of small thalamic hemorrhage, the diagnosis of cerebellar hemorrhage, anatomical vascular lesions causing the lacunar state, lacunar syndromes, inflammatory vascular disease, facial pulses in carotid occlusion, carotid bruits, vasospasm in association with ruptured saccular aneurysm, dissection of the internal carotid artery, late life migraine, capsular infarcts, ocular bobbing, transient global amnesia, normal pressure hydrocephalus, and a number of other clinical and pathological problems. His description of Creutzfeldt-Jakob disease made possible the diagnosis in life.

He originated many descriptive terms, some of which are part of our everyday vocabulary. These include TIA, transient monocular blindness (TMB), subclavian steal, symptomatic normal pressure hydrocephalus, the "string" sign, transient global amnesia, lipohyalinosis, transient migraine accompaniments (TMA), pure motor hemiplegia, pure sensory stroke, ataxic hemiparesis, dysarthria-clumsy hand syndrome, ocular bobbing, and the one-and-a-half syndrome.

What are the factors that allowed almost 3 decades of an exceptionally productive career? First one must emphasize his long association at MGH with Dr. Adams, who gave him free rein in pursuing whatever activity CMF thought was fruitful. There are the 25 years of generous uninterrupted support from the National Institutes of Health, without which many of the contributions would not have been possible. An important factor for Dr. Fisher is his congenial working relationship with the neurosurgeons at MGH. His stroke fellows, however, were really the main instruments by which everything or anything was accomplished, as they took him in tow to see hundreds, indeed thousands, of stroke patients, always prodding with questions at CMF and not infrequently raising a skeptical brow. Day in, day out, there was the excitement of finding something new or puzzling on every patient. CMFs first fellow was Herbert Karp and then followed: Carl Bridges, Irving Zeiper, Ernest Picard, John Barlow, Alfred Weiss, Mercy Sodka, Alfred Polak, Jean Angelo, Monro Cole, Jean-Pierre Berger, Proful Dalal, Hiram Curry, Jay Mohr, Louis Caplan, Otto Appenzeller, and Laurent Des Carries. Rounds with his fellows would often last until midnight. CMF felt that clinical evaluation must be unhurried, and only in the evening was there time to spend with patients in a leisurely fashion.

Of great importance to CMF's career has been the support of his lovely wife, Doris, to whom he has been married for 44 years. She has helped him in every way possible, has not complained about his long hours, and has allowed him to devote full efforts to the unsolved problems of neurology. She says it is a team effort.

Anyone fortunate enough to work with this dedicated physician will be aware of his unique approach to clinical neurology. Every discussion of a patient's problem is a learning experience, for each case will be reviewed in relationship to his vast background. His ability to organize clinical observations into wellordered patterns has led to a method and style that has been a constant inspiration. Dr. Lou Caplan has summarized into "Fisher's Rules" the basic principles CMF has followed in his approach to medicine (2):
1. The bedside can be your laboratory. Study the patient seriously.
2. Settle an issue as it arises at the bedside.
3. Make a hypothesis and then try as hard as you can to disprove it or
find the exception before accepting it as valid.
4. Always be working on one or more projects; it will make the daily
routine more meaningful.
5. In arriving at a clinical diagnosis, think of the five most common
findings (historical, physical, or laboratory) found in a given disorder.
6. Describe quantitatively and precisely.
7. The details of the case are important; their analysis distinguishes the
expert from the journeyman.
8. Collect and categorize phenomena; their mechanism and meaning may
become clearer later if enough cases are gathered.
9. Fully accept what you have heard or read only when you have verified
it yourself.
10. Learn from your own past experience and that of others (literature
and experienced colleagues).
11. Didactic talks benefit most the lecturer. We teach others best by listening,
questioning, and demonstrating.
12. Write often and carefully. Let others gain from your work and ideas.
13. Pay particular attention to the specifics of the patient with a known
diagnosis; it will be helpful later when similar phenomena occur in
an unknown case.
14. Be a good listener; even from the mouths ofbeginners may come wisdom.
15. Resist the temptation to prematurely place a case or disorder into a
diagnostic cubbyhole that fits poorly.
16. The patient is always doing the best he can.
17. Maintain a lively interest in patients and people.
Even though CMF has reached "retirement age," Dr. Joseph Martin, chief
of neurology, has provided him an office to continue his clinical and pathological
studies. He can still be found pondering a patient's clinical problem, reading
in the library, or looking at slides late into the evening hours. As a member
of the MGH neurosurgery service, I feel very fortunate to be working with this
"neurosurgeon's neurologist."

REFERENCE
1. Adams, R. D., and Richardson, E. P. Salute to C. Miller Fisher. Arch. Neurol., 38: 137-139, 1981.
2. Caplan, L. R. Fisher's rules. Arch. Neurol., 39: 389-390, 1982.