Article In Brief
Neurologist Louis Caplan, MD, FAAN discusses his mentor C. Miller Fisher, MD, and his legacy to the field of neurology and stroke.
There were many firsts for C. Miller Fisher, MD, a neurologist who entered the field before the CT scan, before antibiotics, and certainly before the field of medicine knew much or cared much about stroke. His keen insights from talking to patients, from watching patients—from studying the world around him—were gained in large part by his persistence, precision, and what he described as “motion forward.”
“It all starts with the facts of the patient,” he told neurologist Louis Caplan, MD, FAAN, in the later years of his life. “I always thought that if we worked on something thoroughly, it will be new.”
In 1969, Dr. Caplan spent a year of his neurology training working with Dr. Fisher, and the lessons learned at his side remained with him and guided him throughout his esteemed career as a stroke specialist. Now, he gives back to his mentor by penning a beautiful biography–C. Miller Fisher, Stroke in the 20th Century—on this extraordinary journey of a small town Canadian boy, husband, father, prisoner-of-war, clinician, neuropathologist, explorer and teacher. The book was published by Oxford University Press.
Dr. Caplan, whose own path in neurology has been as celebrated for all he has brought to understanding and treating stroke, spoke with Neurology Today about C. Miller Fisher's legacy to the field of neurology and stroke.
What moved you to write a book about Dr. Fisher?
For quite a while, I wanted to write a book about Miller Fisher, to paint a picture of what life was like when he entered the field and took on a disease that few of his colleagues cared about. From the start, it was obvious that he would see things that others did not see. He understood the importance of listening to the patient's story and collecting data at the bedside. He studied with some of the greatest minds of his time, including Canadian neurosurgeon Wilder Penfield, Raymond Adams, and Derek Denny-Brown. Miller Fisher's story is the story of stroke in the 20th century.
I was a history major in college and have always appreciated the importance of knowing the history of something before setting out on one's own journey of discovery. His memoirs filled eight books but the small publishing house in Vermont was closed a long time ago, and few people have actually read them. I did, and it drove me to pick from his memoirs and set out on road trips to interview family and colleagues.
What did you learn about Dr. Fisher's early years?
Born in 1913 and raised in Waterloo, Ontario, Miller Fisher never gave homework a second thought. When he was 11, his mother died in childbirth—she had already brought four boys and four girls into the world—and for some unknown reason, everyone in Miller's life began referring to him as the doctor.
“At 15, I turned up the burners and became a serious student,” he said. In fact, his intellect caught the attention of school administrators and he won a scholarship to medical school at the University of Toronto. It was an eight-year program where he would walk out with a bachelor of arts and a medical degree.
What about his years training in medicine?
In those days, “there was no pressure and no encouragement to do anything” in medical school, he would later write in his own memoirs. There were no full time professors. One time the chief of medicine saw him in the lab on a Saturday—he was listening to heart and breath sounds through his stethoscope—and said to the medical student: What are you doing working in here on such a nice day. Get outside and enjoy yourself. If someone failed a course, there was always next year. “The idea of working hard to achieve a top grade never occurred to me,” he said. He was heading into internal medicine. He said that he'd never heard the word ‘neurology’ mentioned in medical school.
Dr. Fisher graduated in 1938 and went to Henry Ford Hospital in Detroit for an internship. He returned to Canada a year later and got a job at the Royal Victoria Hospital in Montreal.
Tell us about his service in the military.
He'd been in the reserve since high school, and the military came calling six months into his new job. A senior surgeon at the Royal Vic was called to serve in the Navy but there wasn't much a surgeon could do on a ship and the Navy said if he could find someone to take his spot he was welcome to apply to serve in the Army.
Dr. Fisher agreed to take his spot. When France fell in 1940, the young doctor was called to England and then put on a ship to patrol the seas near Iceland. A British physician on another ship heading to West Africa was sick, and the Navy asked Dr. Fisher to take his place. On route, a German cruiser took down his ship and he (and others) floated in the sea for eight hours and was finally rescued by Germans. He spent three years as a naval prisoner in a Prisoner of War (POW) camp in Germany.
What did Fisher tell you about those years as a POW?
To understand this man is to read his memoirs about those years. They were filled with good memories. He continued to doctor during his time spent in the camp, and he used every free moment to study English literature, German, history, mathematics, navigation, physics, and the arts. He also became a master bridge player.
How did he get into neurology?
By the time he returned to solid Canadian ground, he was far behind in medicine. He was sent to the Royal Vic for a six-month refresher course and that is when he met neurosurgeon Wilder Penfield who founded the Montreal Neurological Institute, called The Neuro, in 1934. Dr. Penfield called Miller Fisher to his office. “Ever thought of neurology?” he asked the young doctor. “I am looking for a registrar and fellow in neurology. The job is yours if you want it.”
A few days later, an Army officer was admitted to the hospital with seizures. Miller stood at his bedside and listened as the patient described hearing a drumming sound of tom-toms before the seizure. Miller spent the night in the medical library looking up what was known about different brain regions that could explain a seizure being triggered on the heels of hearing sounds. He found a study published a few years earlier in Brain on musicogenic epilepsy and a discussion about an area called Heschl's gyrus in the temporal lobe. This region is important in hearing. He took what he had learned to Penfield, who was impressed. The rest, as they say, is history.
But he made his mark later in Boston. Tell us how he got there.
Miller was 35-years old and was already married with children when he applied for a fellowship at Boston City Hospital in neuropathology. Ray Adams was already a well-known neuropathologist and this fellowship would prove to be a changing point in his life. Within weeks, the two men, and a chief resident, were cutting ten brains a day—the hospital would do 900 autopsies a year—and in the heady days before brain scans, pathology was the only way to link brain regions to various symptoms their patients had experienced in life.
After two months slicing and fixing brain tissue in the autopsy room, the chief resident developed a dermatitis from the chemicals they were using and one day he was late, or never even showed up. Miller was cutting into the brain and he eyed a hemorrhagic infarct. He looked through the surrounding vessels and saw nothing of consequence that could have led to the bleed. The third brain that day had the same hemorrhagic infarct and again he could not find any blockage of the blood vessels leading to the area of infarction. Brain number nine, the same thing. And in one afternoon, Miller had identified something that no one had ever described before. All the patients had had atrial fibrillation during life. That day, Miller later wrote in his memoirs, he became a bona fide neuropathologist and stroke specialist.
He returned to Montreal to do more neuropathology research?
Yes, after his fellowship in Boston, he returned to Montreal and set up a neuropathology laboratory at the Montreal General Hospital. He saw patients at Veteran's hospitals in Montreal. Listening to patients was key to all of his discoveries. His encounter with a patient who had had a stroke two years earlier but remembered that he went blind in one eye just prior to the stroke was the beginning of a new research adventure.
Two weeks later, another patient came in with the same story. ...He was able to get hold of the brain from the first patient and an autopsy showed carotid artery occlusion.
The idea of stroke patients having prior transient blindness, or other events, led to the identification of transient ischemic attacks or TIAs, and the possibility that something could be done to stop a stroke if these pre-stroke symptoms could be identified. You and Dr. Miller shared some history, as well. You both were trained in medicine at a time when the field of neurology was just coming of age.
Yes, by the time I showed up in 1969, Miller Fisher had already changed the landscape around stroke. He was the first to see many things. His was a steady stream of insights. In 1958, he reported a variant of Guillain-Barré syndrome, which is now called Miller Fisher syndrome. He also studied dementia and hydrocephalus and developed a cerebrospinal fluid test to diagnose normal pressure hydrocephalus. When I was a medical resident at the Boston City Hospital, I rotated through the neurology service and it was this experience that made me sure that I wanted to be a neurologist.
An incoming neurology resident had become ill and could not begin his residency. Dr. Denny Brown contacted me and asked if I wanted to become one of his neurology residents and of course I did. But I had already obligated myself to serve in the army for two years. When I returned to Boston in 1964, I completed a three-year residency under Dr. Denny-Brown in the Harvard neurological unit at Boston City Hospital. After the residency I spent a year as Miller Fisher's only stroke fellow. That experience stimulated me to concentrate my career on stroke and cerebrovascular disease.
What was it about C. Miller Fisher that impressed you most?
The first thing is the importance of being a learner. He took each patient as an opportunity to learn, whether it was about their symptoms or their hobbies. One of his patients lifted cars for fun and Miller was intrigued to know everything about that.
One time, he and I were walking over to look in on a patient who was morbidly overweight and had a hospital plate stacked with meat, butter, bread and cheese. He'd come into the emergency room with a bad ankle sprain.
“Have you ever had a serious medical problem,” Miller asked the elderly man, who was in his 70s and tipping the scale at 300 pounds. “Nope,” he said. Miller went on to ask about family history. He was fascinated that this man who gobbled down cholesterol and fat-rich foods had not had serious heart and vascular problems. That was his way. Collecting cases was his hobby. He would listen and take notes and put his thoughts on paper and place the loose papers into manila folders stacked everywhere in his office.
He continued to learn at the bedside. (When his wife developed Alzheimer's later in life he chronicled her symptoms and behaviors, just as he did when he started having vision issues and other health problems in his 90s. In his final years of life, he was too frail to live on his own and even in his nursing home he spent time writing down symptoms and stories from the other residents. “Don't leave the bedside until you are settled on a diagnosis,” he often said.
He taught fellows and residents and neurologists not by lecturing but asking questions about what they thought was going on with a particular patient. He was a great role model and I approached my patients with the same compassion and intrigue. Everyone who trained with him did. Those were the days when you figured out what was wrong with your patients without the benefit of a brain scan. Still, when CT and MRI came along, Miller was the first to admit that imaging technology significantly sped up discoveries and our understanding of brain and vascular diseases.
Miller Fisher spent his whole life soaking in the world around him. I went to see him a few months before he died. He was 98. I talked about some paper I was working on. He listened, and then said: “We need more pathology.” He believed in the importance of pathology and anatomy to show what was really going on. Imaging devices just don't show all the detail you need, he said. At death, he left exact instructions for his own autopsy. He wanted to understand the events in his eyes that changed his ability to see things in the world and requested that neuropathologists study the tissues and blood vessels in his eyes.
In every way, he lived by the wisdom he learned early on: persistence, precision and motion forward.