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When Charles Miller Fisher, MD, died on April 14, 2012, the field of neurology lost one of its 20th century giants. Fisher was born one of 9 children in 1913 in Waterloo, Ontario, Canada. In 1938, he graduated from the University of Toronto Medical School, soon after marrying his life's love, Doris. In 1940, as war engulfed Europe, he volunteered for the Canadian Navy but was transferred on loan to the British Royal Navy in response to the United Kingdom's urgent call for more naval medical officers. In 1941, he was the ship doctor on an armed merchant cruiser called the Voltaire when it was attacked and crippled by a German vessel in the South Atlantic. As the Voltaire listed to 45°, the captain surrendered and all hands were ordered to abandon ship. Lifeboats could not be launched because of the angle of the list, so the survivors had to jump or slide into the (fortunately) warm waters, being plucked out of the ocean by the enemy 6 or more hours later. Fisher spent the next 3½ years as a physician in a German prisoner of war camp, where he taught himself German, principally to read whatever German medical literature his captors made available. Fisher was repatriated in September 1944 as one of the supervising doctors involved in an exchange of wounded prisoners of war.
Charles Miller Fisher, MD
When he resumed his medical career in Canada, his intention was to focus on diabetes and metabolic diseases. However, as part of a medical refresher course, he had a rotation at the Montreal Neurological Institute, where on morning bedside rounds he came to the attention of Wilder Penfield, MD, Montreal Neurological Institute's legendary chief. Penfield quickly recognized Fisher's inquiring mind and became his mentor. He arranged an acting-registrar (residency) position for Fisher at the institute (1948-1950) and subsequently encouraged Fisher to do a neuropathology fellowship with Raymond D. Adams, MD, at Boston City Hospital (1949-1950). At age 36 years, Fisher returned to Montreal to become the neuropathologist at the Montreal General Hospital. It was there that he made the observations that resulted in his groundbreaking report in 1951 that extracranial carotid disease was a fruitful source of cerebral stroke and that the ictus could be preceded by brief warning signs, which he named transient ischemic attacks. Furthermore, he anticipated that carotid-related stroke could be prevented with newly introduced anticoagulation and surgical therapies. This work was facilitated by 2 dedicated pathology assistants (dieners) who, under Fisher's guidance, broke tradition and actually removed the carotid arteries at autopsy, often retrieving them intact from the aorta to their intracranial bifurcation. Inspired by Fisher, these 2 dieners returned to high school and then went on to medical school. One became a university professor of surgery and president of the Royal College of Surgeons, the other a general practitioner. They could be considered the harbingers of the many fellows whom Fisher would later mentor.
In 1954, Adams was asked to develop a Neuromedical Service (the official name for almost 3 decades) at the Massachusetts General Hospital (MGH). He invited Fisher to return to Boston to join him. This began an intensive collaboration that ultimately impacted the construct and culture of neurology, including the recognition of stroke disease as primarily a neurologic rather than internal medicine discipline. Fisher spent the next half century at MGH and Harvard University, where he created and led the first formal Stroke Service. Many of his Stroke Service trainees (fellows) became leaders in the stroke field throughout the world.
Fisher's teaching, care, and contributions were pan-neurological. When Adams formed the MGH Pediatric Neurology Service and became its chief, Fisher became the head of the MGH Adult Neurology Service. However, he is best known for his many seminal contributions to stroke, for example, the discovery not just of carotid stenosis but also of carotid dissection as a cause of stroke; the demonstration that atrial fibrillation was a frequent stroke substrate and that initial strokes owing to atrial fibrillation were often catastrophic; recognition of the clinical and pathologic features of thalamic and cerebellar hemorrhage; description of the major clinical and pathologic syndromes of lacunar infarction (pure motor hemiparesis, pure sensory stroke, ataxic hemiparesis, and dysarthria-clumsy hand); reporting that migrainous accompaniments were important causes of stroke-like events in the elderly; and formulation of the Fisher score for the severity (hence, risk for vasospasm) of aneurysmal subarachnoid hemorrhage based on computed tomographic evidence of the volume distribution of blood in the subarachnoid spaces.
He made numerous innovative contributions to general neurology as well, including description of the following syndromes and phenomena: Miller Fisher syndrome (descending Guillain-Barre); normal pressure hydrocephalus; transient global amnesia; one-and-a-half syndrome (ocular-pontine deficit); wrong-way eyes (thalamic hemorrhage); pontine ptosis; oval pupils; and rostral-caudal (brain) deterioration (in the comatose patient). Frequent collaborators in his stroke and general neurology contributions included Adams, Maurice Victor, E. P. (Peirson) Richardson, and Robert Ojemann. Salomon Hakim, a Colombian neurosurgeon, collaborated in the description of normal pressure hydrocephalus.
Even as he approached the age of 96 years, Fisher still published journal articles. He has received many honors and awards, the most singular of which are his induction into the Canadian Medical Hall of Fame; the creation of the annual C. Miller Fisher Award for excellence in stroke care/research by the New England Branch of the American Heart and Stroke Association; and at MGH, the establishment of the C. Miller Fisher Chair of Neurology, the creation of the CMF Annual Stroke Lecture, and the renaming of the Vascular Neurology Service as the CMF Service. In the weeks before his death, the 3-decade-old Greater Boston Stroke Society was renamed the C. Miller Fisher Society.
Fisher was a very large and imposing man and one easy to caricature. His rounds were very long, slow, and thorough, aimed at extracting every kernel of interest from every patient. His focus included attention to small but often critically relevant details of the clinical history or examination. He noted that meaningful retrieval of such details separates the expert from the novice. He was a collector of unusual patient signs and symptoms that were organized into folders titled, for example, “patients who wrote off the paper,” “mumblers,” “irascible patients,” “topplers,” and “pure sensory stroke.” When sufficient instances of any one finding would begin to correlate with pathoanatomic, pathophysiologic, and/or epidemiologic substrates, he would prepare them for publication, for example, his report on 200 cases of pure sensory stroke.
Fisher was a dedicated teacher and mentor. He spent 5 or more hours each day with his stroke fellows. His method of teaching was Socratic. The fellows would see the stroke cases in depth, then meet with Fisher at dinner, after which, from 6 PM to 11 PM or later virtually daily, they would see the patients together. Fisher continually questioned each fellow about his observations and ideas. He would analyze each neurologic finding—a visual field defect, an arterial retinal embolus, an ataxic arm, or a gait abnormality—often for hours, studying and teaching how the nervous system worked. He was a dedicated reader and could often be found in the Harvard library studying and digesting original English and German reports. He emphasized that “we could not afford to redo the history of neurology every 20 years.” That is, continually rediscovering what had been known but forgotten. He was always available for discussions, characteristically long and detailed, in which he and we would explore a topic. As a very effective role model, his forte was showing how to learn and explore a symptom, sign, phenomenon, or behavior by careful bedside and laboratory analysis and by thorough reading of the literature. His method is captured in a presentation given at his formal retirement titled “Fisher's rules,” which was published in the Archives of Neurology (Figure1A, Figure1B). For the undersigned, he continued to be our mentor and oracle for the duration of his life. He was always available, if only by phone, which became all too frequent in the past few years. He submitted articles for publication until 1996. Until his very last days, he was cognitively intact, and he retained his knack of always knowing what question to ask that would clarify a clinical conundrum.
Figure 1A. “Fisher’s rules” article.
Figure 1B. “Fisher’s rules” article (continued).
Most of all, Fisher considered himself a doctor. He never failed to ask how the patient could be helped. He strived for practical solutions. His efforts at clarification of neurologic signs and symptoms and the mechanisms and causes of stroke were always aimed at improving the condition of patients.
His patients, students, residents and fellows, colleagues, and all physicians and neurologists are richer because of his life's palpable clinical and scientific productivity. He fulfilled the Horatian boast, “Exegi monumentun aere perennius” (“I have built a monument more lasting than bronze”).
Correspondence: Dr Caplan, Beth Israel Deaconess Medical Center, Department of Neurology, 330 Brookline Ave, Palmer 127 West Campus, Boston, MA 02215 (firstname.lastname@example.org).
Financial Disclosure: None reported.
Caplan LR, Mohr JP, Ackerman RH. In Memoriam: Charles Miller Fisher, MD (1913-2012). Arch Neurol. 2012;69(9):1208–1209. doi:10.1001/archneurol.2012.1743
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