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The Investigation of Events that followed the death of Cyril Mark Isaacs
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| This chapter describes the purposes of brain retention, the different categories of brain collections and the origins of the arrangements by which brains were transferred from Prestwich mortuary to the Cambridge brain bank. | |
Sources of information |
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| The information was provided from a number of neuropathology centres and from documents in the Cambridge brain bank. | |
The Chief Medical Officer's Census |
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| The Report of the Census of Retained Organs, published by the Chief Medical Officer in January 2001, showed that brains accounted for 44% of all retained organs for the years 1970-1999. The Census included returns from all NHS Trusts in England. The definition of a retained organ used for the Census was that the organ had been retained after diagnostic examination had been completed. | |
| Why is it necessary to examine the brain in the first place? | |
| For many years it was routine practice for the brain to be removed and a naked eye examination made in almost all post mortem examinations, Chapters 40 and 42. | |
| Prior to 1985, removing the brain during post mortem enabled access to the pituitary gland in the years that these were being collected as part of a national programme for therapeutic purposes, Chapter 5. | |
| At the end of the post mortem it was usual for the brain to be returned to the body with the other organs that had been removed during the examination. | |
| Why is it necessary to retain the brain at the end of the post mortem? | |
| During a post mortem it is not always possible to identify the cause of death from the naked eye appearance of the internal organs. In such cases it is important to take tissue samples to study the microscopic structure to detect disease processes that cannot be seen with the naked eye. | |
| When this is necessary small pieces of tissue, usually referred to as 'blocks', are taken as part of a post mortem examination. The rest of the organ is then returned to the body. The tissue blocks are stabilised in a process called 'fixation' after which very thin slices of tissue are cut and placed on glass slides for study under the | |
| microscope. This process is referred to as 'histological examination'. As brain tissue is very soft, fixation is essential before microscopic examination can begin. | |
| It takes between four and six weeks for the brain to be properly fixed. This delay means that it is not possible to return the brain to the body at the end of the post mortem. If the brain is to be returned to the body, the funeral or cremation will necessarily be delayed. The delay will be longer if the blocks and slides are also to be returned to the body. | |
| What happens to the brain after the diagnostic examination is finished? | |
| Once the histological examination is complete and the pathologist is satisfied that no further diagnostic review will be needed, the brain is usually set aside. Disposal by incineration as clinical waste takes place when a sufficient number of brains have accumulated. (The method of disposal of retained organs, including brains, is an important subject that the Retained Organs Commission has under consideration.)(1) | |
Brain accumulations, brain collections and brain banks |
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| The returns submitted by NHS Trusts in 2000 for the Chief Medical Officer's Census and the discussions during the course of this investigation show that brain collections, including parts of brains, fall into three general categories, depending on their origins and purpose. The categories are: | |
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Brain accumulations |
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| Some hospital pathology departments hold large numbers of brains that were retained for diagnostic reasons and histological examination. There was, however, no plan for further use of these brains for research or teaching. | |
| The number of brains in this category has increased as no instructions have been given or received about disposal. Collections of this type may include brains from Coroners' cases. The overall result has been that the number held has increased over time. These brains awaiting a decision on disposal can be regarded as accumulations. | |
| A decision is needed about the disposal of identified brains about which NHS Trusts have received no enquiries from relatives. This is a matter that is also under consideration by the Retained Organs Commission. | |
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Brain collections |
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| The brains in this category are held in diagnostic pathology departments. The collections have similarities to accumulations in that the brains were retained initially for diagnosis. However, after the diagnostic process has been completed the brains have been intentionally retained for: | |
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| Brain banks or archives |
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| Some brain banks are linked to clinical pathology departments while others are located in University departments and research centres; the brains have been intentionally obtained for research or teaching use. | |
| Brains taken to banks may have come either directly from mortuaries or from diagnostic pathology departments after the diagnostic process has ended. A histology report will usually have been made before a brain is referred to the bank from a diagnostic department (or a decision may have been made that no diagnostic examination is necessary). | |
| Where brains are referred direct to a brain bank, some routinely carry out histology and send a report to the doctor responsible for the medical care of the deceased. Others banks do not undertake histology or send any report to the deceased's doctor. | |
| Some brain banks are highly specialised and these are of national importance. For example, when the first cases of variant CJD were reported in 1996, brain banks and archives were checked to see if there had ever been a case with similar findings. If brain banks and archives had not existed, it would have been impossible to know if variant CJD was a new condition or the re-appearance of one that had been seen before(2). | |
The origin of brain collections |
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| In England, the deliberate retention of brains for research after diagnostic investigations began at Runwell Hospital, Chapter 33. As brains accumulated, the potential of brain collections in the investigation of specific neuropsychiatric conditions was recognised. Brain banking, as it is now known, had begun. | |
| Between the 1950s and 1980s, many brain banks for research had been set up in other countries. By 1987, when Mr Isaacs' brain was retained, brain collections for research and teaching were active in several universities and centres of neuropsychiatric research in this country. | |
| The Corsellis (or Runwell Hospital) collection | |
| The first large collection of brains in England was started in 1950 by Dr Corsellis, who was then Consultant to the Pathology Department of Runwell Hospital. This collection is now held at the West London Mental Health NHS Trust. The Corsellis collection is discussed in Chapter 33, and a further description is at Appendix 16. | |
From diagnostic collection to research archive |
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| The Runwell or Corsellis collection started as an accumulation of brains retained after diagnosis, but over the next four decades became an invaluable research archive. | |
| Two features must be emphasised: |
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| The significance and importance of the Corsellis and other brain collections is referred to in Chapter 46. | |
Other brain collections and banks |
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| Other collections followed the pattern pioneered by Professor Corsellis. Some were condition specific. Others collected brains of patients with many different neuropsychiatric diseases and 'control' brains from those who had died without any such disorders. Some banks acted as repositories from which research teams could request brain samples of the conditions they were investigating. | |
| Chapters 26, 28, 30 and 32 report on the collections visited during this investigation. | |
Collections for teaching |
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| Most retained brains were held for research use, but a smaller number were retained for undergraduate and postgraduate teaching, Chapter 36. This is an important objective of some collections. | |
The Cambridge brain bank |
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| Between 1972 and 1985, brains were regularly referred from mortuaries in the Manchester area, including the Prestwich mortuary, to the Cambridge brain bank. Chapter 26 describes my investigations at Cambridge. | |
| Huntington's disease brains sent to the MRC Neurochemical Pharmacology Unit | |
| In the 1970s, the Medical Research Council provided support for the Neurochemical Pharmacology Unit (NCPU) which, as its name implies, was established to undertake research into the chemistry of the brain. The Head of the Unit was then Dr, now Professor, Leslie Iverson. | |
| Dr E D Bird | |
| Dr Ted Bird, a medically qualified American citizen, was a member of the scientific staff of the unit. In the early 1970s, Dr Bird became interested in neurochemical factors in Huntington's disease. When this research was first mooted, there were doubts about the feasibility of finding enough willing patients and relatives for a meaningful investigation. | |
| Dr
Bird
was
undeterred.
He
explained
his
research
to
relatives,
psychiatrists
and
pathologists
and
began
to
collect
the
brains
of
patients
who
died
from
this
progressive
and incurable condition. His research attracted the enthusiastic support of many relatives. Some became very active in identifying patients with early symptoms of Huntington's disease. As a result, Dr Bird received referrals from many parts of the country(3). |
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| Referrals of brains from Prestwich mortuary to Cambridge | |
| Dr Rockley, a Consultant Psychiatrist at Prestwich Hospital, on hearing of Dr Bird's research, wrote to him on 26 October 1972: | |
| 'We are, of course, agreeable to co-operating in your proposed research, and I suggest that you write to our Consultant Pathologist - Dr. R. Pell-Ilderton - at Crumpsall Hospital'. | |
| In 1972 the pathology services at Prestwich Hospital were provided from Crumpsall (North Manchester General Hospital). | |
| While there is no record of a letter of reply from Dr Bird to Dr Pell-Inderton, further communication must have followed as in April 1973 Dr de Kretser, one of Dr Pell-Ilderton's colleagues, sent Dr Bird the brain of a patient who had died from Huntington's Disease. Dr Bird later wrote requesting the patient's case notes which were sent on 9 July 1973(4). | |
| This referral was the first of at least 28 brain referrals from Prestwich and other mortuaries in North Manchester to Dr Bird and other researchers at the Cambridge brain bank. The records at the Cambridge brain bank show that most of these referrals were made by Dr Farrand after he started working at Prestwich mortuary in 1975. He continued to refer to Cambridge the brains of patients who had died with a diagnosis of Huntington's disease and, at a later date, schizophrenia. | |
| The last referral from Prestwich mortuary to the Cambridge brain bank took place on 11 November 1985(5). This death had been referred to the Coroner, and the telephone number of the Coroner's office in Rochdale and the name 'Joyce Langan' are found in the records at Cambridge. This brain was referred by the pathologist and there is no evidence that the Coroner's office staff were involved in the referral. | |
| Publication on Huntington's disease |
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| In 1974 Dr Bird and Dr Iverson published the first results of their research on Huntington's chorea( 3). The methods section of this report records: | |
| 'Several consultant psychiatrists and pathologists throughout the United Kingdom provided invaluable assistance by seeking permission for post-mortem examinations of the brains of patients with Huntington's chorea and in the initial handling of the brain material. | |
| Controls consisted of coroners' cases and hospital cases of various ages, on which necropsies had been performed in the University Pathology Department at Addenbrooke's Hospital, Cambridge. Cause of death was widely variable…' | |
| This article resulted in more brains being referred for study in the Neurochemical Pharmacology Unit at Cambridge. | |
| Later, the Cambridge brain bank diversified its programme and by 1979 was requesting referrals not only of the brains of patients who had died from Huntington's disease but from cases of Parkinson's disease, schizophrenia, dyskinesias and related disorders(5). | |
| Summary | |
| The brain is the organ most frequently retained at post mortem. | |
| Most brains are retained only for diagnosis. | |
| The brain has to be 'fixed' before it can be examined under the microscope. | |
| The fixation process takes 4-6 weeks. |
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| After the diagnostic process is complete most brains are disposed of as clinical waste. | |
| Brains for research use are obtained either after the diagnostic process is finished or specifically retained for research. | |
| Brains can be retained for teaching. |
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| The first brain collection for research in England was started in 1950 by Professor Corsellis in the Pathology Department of Runwell Hospital, a long-stay mental hospital. | |
| Other brain banks were later set up and brain banks or archives evolved to become an important research resource. | |
| The brain bank at Cambridge began as an investigation into Huntington's disease initiated by Dr E D Bird. | |
| The referral of a brain taken from a patient who had died from Huntington's disease started the link between Prestwich mortuary and the Cambridge brain bank. | |
| Where brain accumulations are now held, a decision on their disposal will be needed after the Retained Organs Commission has given advice on disposal arrangements for both identifiable and unidentified organs. | |
References |
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