MacDonald Critchley: The citadel of the senses and other essays
Author : MacDonald Critchley
Book : The citadel of the senses and other essays
Publishers : New York: Raven Press. 1986
Year of publication : 1986
Type : Hardcover
Number of Pages : 277
Reprinted with kind permission from the article: Martinez AM, Moro A, Munhoz RP, Teive HAG. MacDonald Critchley. Arq. Neuro-Psiquiatr 2013; 71: http://dx.doi.org/10.1590/S0004-282X2013000100013. (Creative Commons Attribution License).
The author, Dr. Critchley, is a striking example of a neurologist in the classic clinical tradition. Endowed with a brilliant mind, highly erudite, always impeccably and elegantly dressed, charismatic in spite of his shyness, Critchley was a gifted lecturer with a sense of humor. He was also a captivating writer [Figure 1] and [Figure 2].
Critchley was born on January 2nd, 1900, in Bristol, England. Son of a gas collector, from an early age, he displayed intellectual ability and an interest in languages including German, Russian, French, Greek and Latin.
During his 74 years at the National Hospital for Neurology and Neurosurgery, Queen Square, London, his scientific publications included more than 300 papers.
Among the books that he published are The Divine Banquet of the Brain, The Citadel of the Senses, The Ventricle of Memory, Music and the brain and, most famous of all, The Parietal Lobes, which was considered his masterpiece. The title The Ventricle of Memory inevitably reminds us of the Galenic period when spirits were believed to circulate through the body and those pertaining to memory were thought to be stored in the most posterior of three ventricles in the cerebrum.
Critchley wrote biographies of Sir William Gowers (1949) and on Hughlings Jackson (1998).
In the obituary of MacDonald Critchley, published in the Arquivos de Neuro-Psiquiatria in 1998, Professor Lees comments on the discrepancy between MacDonald Critchley's international renown and the relatively few honors awarded to him in his own country. (He was made Commander of the British Empire, but his contemporaries at Queen Square, such as Walshe and Symonds, became knights and Russell Brain was made a Lord). When asked about this, Critchley is reported to have replied, with characteristic facetiousness, that it was because he had once driven the wrong way up a one-way street in Portugal.
The book is dedicated to his wife, Eileen.
Born in Somersetshire at Weston-Super-Mare, Critchley (1900-1997) spent most of his working life in London. He graduated in medicine in Bristol. In London, he worked at King's College Hospital before joining the National Hospital for Paralysis and Epilepsy (as it was known then) at Queen Square. On retirement from practice, he returned to the West Country, settling down at Nether Stowey in Somerset. His home was called Hughlings House after ‘the sage of Manchester Square’. (See his essay on Jackson in this volume on pages 15-22).
His interest in headaches resulted in the formation of the British Migraine Trust as well as his paper ‘From Cappadocia to Queen Square’. This paper traced the development of knowledge on the subject from the time Araetus of Cappadocia wrote on it in the second century to his own work in Queen Square. (This essay is not included in this book).
Four papers in the volume under discussion are on migraine, with the one entitled ‘Records of some famous migraineurs’ (pages 130-146) being especially interesting.
Here, we learn of the grievous head pains that troubled such individuals as the Countess Anne of Conway, Blaise Pascal and Professor Max Müller.
Countess Anne was a respected philosopher and a pupil of the Cambridge Platonist, Henry More. He wrote of her that he had: ‘scarce ever met with any Person, Man or Woman, of better Natural parts than Lady Conway’ and that ‘in the knowledge of things as well Natural and Divine, you have not only out-gone all of your own Sex, but even of that other also.'
She was referred to Dr. William Harvey – a relative by marriage – for the treatment of her headache. The distinguished author of Exercitatio Anatomica de Motu Cordis et Sanguinis in Animalibus asked her to go to France and subject herself to trepanation. Wisely, she decided against it. Critchley quotes John Aubrey (famed for his book Brief lives): ‘…'twas believed by the vulgar that he (William Harvey) was crack brain'd…’ The Countess was then referred to Sir Kenelm Digby. Critchley does not deal gently with him either. ‘What Sir Kenelm prescribed we do not know but we suspect it might have been the volatile salt of vipers, which was one of his most favoured remedies.'
The Countess also sought the advice of Dr. Thomas Willis, best known for his description of the principal arteries at the base of the brain. His narrative of her illness is fascinating: ‘Although the Distemper most grievously afflicted this noble Lady, above twenty years, when I saw her, having pitched its tents near the confines of the Brain, had so long besieged its regal tower, yet it had not taken it: for the sick Lady, being free from a Vertigo, swimming in the Head, Convulsive Distempers, and any Soporiferous symptoms, found the chief faculties of the soul sound enough.’ Her treatment at the hand of her doctors even included opening of a jugular vein!
Her end at the age of 48 years was accompanied by nosebleeds, weakness of the arms and oedema of the lower limbs, the pains having long ago spread beyond the confined of the head. In the section, entitled ‘Discussion’, Dr. Critchley analyses her illness. I will not ruin your enjoyment of the book by disclosing his conclusions.
Critchley provides details on the ills that plagued the philosopher, Blaise Pascal (1623-1662), the French child prodigy who matured into a renowned mathematician, physicist, inventor, writer and theologian. Headaches set in at the age of 18 years. Mild facial asymmetry was noted. Sudden, severe paraparesis set in when he was 24 years old. Critchley hints at ‘psychogenesis’. Pascal described a feeling of a chasm on one side, usually the left. Later, intense headaches, episodes of fainting and colic followed. At the age of 39, he was seriously ill with agonizing headache and convulsions. He died on 10 August 1662. At autopsy, the liver and stomach were shrunken and a length of bowel was gangrenous. There was no trace of any of the cranial sutures. A localized bony overgrowth was seen at the site of the anterior fontanelle. Critchley postulated ophthalmic migraine. A recent paper by Bo Laestadius (http://hekint.org/2017/01/29/pascals-disease/) suggests Lhermitte-Duclos variety of cerebellar hypertrophy as the cause of his symptoms.
I shall skip the detailed description given by Critchley of the symptoms experienced by Carolus Piso (1563-1633), physician to Henry II, King of France and author of the book Hemicrania based on his own symptoms but commend it to you.
Instead, I turn to Professor Max Müller as he is of considerable interest to all of us in India. Critchley quotes William Gowers, who, in 1888, wrote in his Manual of Diseases of the Nervous System ‘… [migraine] is often associated with high intellectual ability…’ Critchley applies this description to ‘that mastermind’, Professor Max Müller, holder of the Chair of Comparative Philology at Oxford. We know the Professor through his expertise on Sanskrit, translation of the Rig Veda and the series Sacred Books of the East. Equally interesting, he lived as an Oxford don at 7 Norham Gardens, later to be occupied by Sir William and Lady Grace Osler. Dr. Critchley, an obvious admirer of the professor, quotes from Müller's autobiography: ‘As far back as I remember I was a martyr to headache. No doctor could help me, no one seemed to know the cause…’ His description of his symptoms are vivid and Critchley's narrative of the various forms of treatment used on him thought provoking.
The inscrutability of pain (pages 180-188)
To start with, let me quote Critchley on the importance of diagnosis. ‘Diagnosis must not only be shrewd but be seen by the patient to be shrewd and penetrating. The platitudinous term diagnosis, let us remember, does not entail merely the act of attaching a label to someone's symptoms. By definition, the Greek expression to diagnose is to attain knowledge permeating right through the patient and his problem and of necessity implies the understanding not only of the nature of the trouble but also its essence, cause, probable outcome and means for its alleviation.'
The essay deals with migraine but also describes pain in other parts of the body. Critchley's disagreement with philosophers who advise us to look upon pain as possessing ‘stimulating powers of immense therapeutic value’ will find many supporters. It is difficult, however, to accept his criticism of Sir Charles Bell who described pain as the guardian of life. The problems faced by those with congenital insensitivity to pain argue in favour of Dr. Bell.
Discussing migraine against a background of pain in general, Critchley asks whether it may be a warning against excessive stress – emotional, mental or physical. ‘An attack of migraine might intervene and bring a temporary halt to such a potentially nocuous influence?’ He had often suggested studies within communities on a negative correlation between migraine and disease such as peptic ulcer, coronary artery disease, rheumatoid arthritis – all regarded as stress disorders. ‘I have often thrown out this suggestion,’ he noted with regret, ‘but so far no one has taken it up.’ Would one of our readers be interested in pursuing this?
I wonder if experts on migraine would like to comment on his observation that this illness is, at times, associated with drooping of the eyelids and sensitivity of the temporal artery to touch. Is there a correlation between migraine and temporal arteritis?
Critchley's description of akinesia algera – the motionless head of the migraineur, is masterly as is his use of this feature to rule out the headache of subarachnoid haemorrhage and acute meningitis, where intense restlessness is prominent.
In this chapter, Critchley, clinicien extraordinaire, describes the difficulty for the clinician in determining the severity of pain when faced with a patient who complains of excruciating pain but goes about his routine effortlessly. He also discusses the verbal taboos that surround the concept of pain in some sections of society, which necessitate a roundabout method of interrogation. He describes individuals who have ‘never known what it is to have a headache’. Severe blows to the head and even painful illnesses such as dengue in such individuals cause dizziness or syncope but not pain. We learn that Drs. Hughlings Jackson, Kinnier Wilson and C. P. Snow fell into this headache-free class. Here, too, he sighs, ‘Although I have repeatedly called attention to this anomalous condition and urged that the subject be seriously investigated, we remain in the dark.'
There is much more to ponder.
He quotes Dr. F. M. Walshe on the patient who, despite, psychogenic pains: ‘…may continue for months as fat as a partridge, as rosy as an apple and in an apparent state of beatific calm.'
Critchley also addresses here the ‘states of ecstasy when pain may be swamped or even replaced by a pleasurable experience as evidenced by the martyrology of religion or the self-immolation of fakirs… Pain suffered for a cause glorifies it and provides gratification.'
Whilst there is much more, I must end this section with Critchley's quotation from René Leriche: ‘Physical pain is not a simple affair of an impulse traveling at a fixed rate along a nerve. It is the resultant of a conflict between a stimulus and a whole individual.'
'The citadel of the senses: The nose as its sentinel'
The opening chapter deals with the first cranial nerve, which, Critchley reminds us, ‘does not merit its relative neglect by scientists.’ He goes on to explain why he makes this statement and in doing so, involves us in smells, perfumes, odours, whiffs and sniffs, aromas, bouquets, fragrances, effluvia, reeks, foetors, stenches and stinks.
His question ‘How does one define smell?’ is followed by facts such as the recognition of odoriferous substances by fishes through sensors on large areas of their skin over the flanks and underbelly. Virginia Woolf's description of the olfactory perceptions of Elizabeth Barrett Browning's spaniel, Flush, is fascinating. The section on the role of smell in medical diagnosis will dwell long in your memory. You may also find the paragraph and accompanying illustrations on how W. Septimus Pisse (1820-1882) associated smells with musical notes of interest.
Though I learnt all this and much more, I am afraid I did not find a reference in this essay to Cyrano de Bergerac, whose tale also introduced the word panache into the English language.
Dr. Hughlings Jackson
We are introduced to the sage of Manchester Square in the next essay. Critchley calls him ‘the Plato of neurology’. He paints a poignant picture of his later years. As he put it in the preface to this volume, he wrote this tribute with ‘something like reverence’.
Dr. Jackson's wife – who was also his cousin – died when he was just 31 years old. ‘By one of the cruel tricks that Destiny so often plays, it happened that his wife's terminal illness was characterized by countless epileptiform seizures of a focal character, the significance of which was all too evident to her husband… Jackson never remarried and not being gregarious… became more and more of a recluse… At the dinner table, a place was always laid for his long lost wife. His cronies were few in number, though he was widely acclaimed, respected and held in awe by his colleagues.'
When his marble bust was unveiled at the National Hospital, William Gowers, ‘that difficult and unapproachable neurologist’, was invited to perform the ceremonial unveiling. Confronting the rest of the staff, Gowers flung back the covering sheet with the words: ‘Behold, the master!’ In a footnote, Critchley records his dismay at the fact that 60 years after he had first seen this bust at the threshold of Queen Square, ‘some dastardly sneak thief had filched the bust.'
This essay tells us as much of Jackson, the person, as it does of Jackson the clinical neurologist, the philosopher and the author. I shall leave you to read this perceptive and sympathetic account of a man who ‘was indeed a legend in his lifetime.'
Among those featured in other essays are Critchley's first chief, Dr. Newman Neild; Josef François Babinski; John Addington Symonds, primus and secundus; Oscar Wilde; and, Dr. Samuel Johnson.
I cannot resist reproducing some statements from the tribute to Babinski. ‘I suspect that the name Babinski is familiar to every medical man throughout the world, whatever his special interest, and probably to every fourth-year student as well. Can such a statement be applied to any other eponym in medicine?'
'He could not tolerate confused, obscure or imprecise writings, the products of what he called chieurs d'encre, which may be translated as ink shits.'
In this chapter, you will also learn of how Babinski made Count Thierry De Martel (1876-1940), one of his assistants, travel to London and learn neurosurgery from Dr. Victor Horsley. De Martel went on to devise two neurosurgical instruments that continue to remain in use. The first was a motor driven trephine with a gear that automatically disengaged the cutting edge from the motor as soon as the inner table was breached. When he presented this instrument, other surgeons derided him. To convince them, he placed an inflated balloon within a dried skull so that its wall lined the inner table. The holes he drilled through the full thickness of the skull left the balloon intact. He could not help announcing at the end of this demonstration, ‘As you can see, this trephine can be operated even by an imbecile.’ He also made a guide to prevent the Gigli's saw from injuring the dura. Among his other inventions was a chair on which the patient undergoing an operation on the posterior fossa could be seated.
A great patriot, De Martel was deeply distressed by the entry of German troops into Paris on 14th June 1940. He committed suicide the same day by absorbing strychnine. In a note to his friend, he wrote: ‘I promised you not to leave Paris. Did not tell you if I will stay dead or alive… Farewell. Martel.'
As you might expect from someone who spent a large part of his professional career on aphasiology, five essays in this book pertain to disorders of speech. The paragraph on words and language on page 89 is fascinating. Critchley's quotation from Du Maurier will make you chuckle.
The chapters entitled ‘Why do we laugh?’, ‘The land of smiles’, ‘The secret world of the singer’ and ‘Mythical maladies of the nervous system’ will also enthuse many.
The section on Posthumous papers of the Hexagon Club describes the select, private club known only to its six members: Dr. C. P. Symonds, Dr. Russell Brain, Dr. Hugh Cairns, Dr. Derek Denny-Brown, Dr. George Riddoch and Dr. Critchley. The portraits of these members can be found on pages 110-112. It was their custom to invite eminent neurologists and neurosurgeons from abroad visiting London to their meetings. In 1931, Dr. Otfrid Foerster was the guest at a special meeting convened for him. ‘The occasion was unforgettable… Gradually the conversation turned to that famous patient of his, Lenin’. During the last two years of his life, Lenin had suffered from severe and progressive cerebral arteriopathy. Eventually, Lenin had ‘double hemiparesis and a severe aphasia in which a recurring expletive constituted his only utterance… During his last days, he was afflicted by a vast number of focal seizures.’ As in the other chapters, there is much more of interest.
I recall Critchley's visit to an annual meeting of the Neurological Society of India when he sought and obtained information on the manner in which classical Indian dance forms conveyed so much without the use of words. This augmented his already broad understanding of silent language. In Chapter XVII of his book, The language of gestures, published in 1939, he referred to Indian natya. ‘In ancient India, a language of signs was in common currency, as it is today, though the services of an adept were often required for the interpretation of the more obscure symbols.
As I end this long review, I draw the young reader's attention to the invaluable advice provided by this literary pundit to ‘pioneering writers’ on pages 87-88. Here is a tantalizing glimpse of what is in store for you: ‘Before rushing into print with news of a novel idea in clinical neurology, consult carefully the Manual of Nervous Diseases by William Gowers. The chances of your discovery being at least briefly anticipated, perhaps in a footnote, are 50-50. This two-volume masterpiece is still the Bible of neurology.'
Unfortunately, Dr. Critchley's book lacks an index.
[Figure 1], [Figure 2]