JMS Pearce
Hull, England

Figure 1: Gordon Holmes

“Beneath the exterior of a martinet
there was an Irish heart of gold”

Wilder Penfield

Gordon Holmes (1876-1965) was born in Castlebellingham, Ireland. He was named after his father, a landowner, descended from a Yorkshire family that had settled in King’s County (County Offaly) in the mid-seventeenth century. In a golden era of neurologists, Gordon Holmes was outstanding in his refinements of the clinical examination of the nervous system, which led to his original investigations of its functions. His work illuminated and clarified many areas of uncertain functions in the cerebellum, the sensory, and visual pathways of the brain. His rigorous though trenchant approach and reasoning were widely admired and adopted by contemporary physicians.

 

Early career

A solitary child whose mother died young, he qualified at Trinity College, Dublin in 1899.¹ He was awarded the Dublin University Travelling Prize in Medicine and the Stewart Scholarship that financed a visit to Frankfurt. There he studied neuroanatomy, neurophysiology, and comparative anatomy with Karl Weigert (1845-1904) and Ludwig Edinger (1855-1918)—a baptism of fire—that founded much of his subsequent work. When he returned to England in 1902, he became Resident Medical Officer to Hughlings Jackson (1835 1911) at the National Hospital, Queen Square, founded in 1859. Jackson’s method, as Holmes described it, “was simple owing nothing to apparatus or instrumental techniques; it may be summed up as that of the unresting contemplation of facts of observation, scrupulously and untiringly acquired.”² This emphasis on anatomy (including pathology) and physiology reinforced the teachings of Edinger.³

He obtained the M.D. in 1903, the Membership of the Royal College of Physicians, London (M.R.C.P.) in 1908, and was elected FRCP six years later. He quickly mastered the clinical examination and developed it “to a state of well-nigh scientific perfection.” In 1909 he became honorary physician to the National Hospital and was appointed physician to the Royal London Ophthalmic (Moorfields) and to Charing Cross Hospitals. Holmes was one of a long line of famous physicians and surgeons at Queen Square, which included: Hughlings Jackson, Brown-Séquard, David Ferrier, William Gowers, Charles Bastian, and Victor Horsley—all Fellows of the Royal Society. They served hospital patients without remuneration.

With Sir Henry Head (1861-1940) he wrote a classic paper in Brain in 1911 on sensory disturbances from brain lesions. In it, they first described systematically the functions of the thalamus and how it affected the aspects of sensory perception related to the cortex.⁴ They showed the thalamus was the seat of crude sensations of touch, heat, and cold, while the cortex related more to discriminative sensation. He therefore refined the sensory clinical examination, which soon was widely accepted. So energetic and industrious was Holmes that by the outbreak of war in 1914 he had published 55 papers, 17 of them in the prestigious journal, Brain.

In World War I, his work (with neurosurgeon Percy Sargent) at a Red Cross hospital just behind the front line in France persuaded the War Office to renegotiate his disqualification owing to short-sightedness.⁵ Lieutenant-Colonel Holmes became a consulting neurologist to the British Expeditionary Force in France. Patients with war injuries of the spinal cord and brain, in terrible conditions of dirt, cold, and exhaustion provided the opportunity to study these injuries. He had to treat up to 300 wounded men daily and performed all the neurological post-mortems. This resulted in 18 published wartime papers, many written at the front. Spinal injury was the subject of his Goulstonian Lecture to the Royal College of Physicians in 1915. He was twice mentioned in dispatches and was awarded the C.M.G. in 1917 and C.B.E. in 1919.

After the war, Holmes continued in busy neurological practice and research. He was thorough and precise in collecting clinical signs, though notoriously impatient with less gifted colleagues. In teaching:

He had the great gift of making clear to his students the thread of his thoughts and the grounds on which he reached his conclusions. He never posed as an oracle or a maker of slick diagnoses, . . . to be trained by him was a severe but most salutary discipline.^{6 _}(FMR. Walshe)

In his Introduction to Clinical Neurology (Fig 2.) he lucidly described the foundations of the modern neurological examination.⁷ We get an insight into his scientific integrity in his foreword: “the hypothesis that seems most probable . . . though to-morrow may disprove some of them, they are put forward in the belief that ‘truth comes more readily from error than from confusion.’” From 1922 to 1937 as editor of Brain he was a figurehead of the neurological literature. His own writings covered many nervous diseases and were regarded as authoritative.⁸

In the Goulstonian Lecture in 1915, he dealt with spinal injuries of warfare. His Croonian Lecture in 1922 was on cerebellar disease. He was examiner, councilor, and censor for the College. His pre-eminence was recognized by his election as a Fellow of the Royal Society in May 1933, and many honorary degrees.

Critchley summed up his clinical prowess:

Gordon Holmes developed the foundations of modern neurological examination. “He could coax physical signs out of a patient like a Paganini on the violin,”  . . . every neurologist alive today—wherever he works—is unconsciously utilizing the routine clinical examination propagated, perfected, and perpetuated by Gordon Holmes. It was a sheer delight to watch him evoking one physical sign after another . . . ⁹

 

Figure 2: Introduction to Clinical Neurology

The Cerebellum

Amongst many contributions¹⁰ he challenged the accepted theories of the functions of the cerebellum. After exhaustive physiological and clinic-pathological studies¹¹ he characterized cerebellar disturbances by: asthenia, ataxia, rebound, and adiadochokinesia.¹² With Grainger Stewart he described the rebound phenomenon (Stewart-Holmes symptom). His notions of cerebellar function were largely original and of major physiological importance.¹³ He stated that it assures the regularity and maintenance of muscular contractions and the immediate and effective response of mechanisms to cerebral impulses, and it also exerts a regulating and coordinating influence on the motor centers that effect voluntary movements and by this means assures their harmony, precision, and correct range [of movement].

 

Visual Disorders

He worked with Henry Head, a man of great vision and originality, on the visual and sensory pathways of the optic thalamus.^{4, 14} The results were published in 1911, and reprinted in Head’s Studies in Neurology (1920). Two further problems puzzled him. First, the representation of the macula (fovea) in the visual cortex was not known. Secondly, there was little understanding of those strange defects of appreciation of size, shape, and texture of objects (agnosia) that often resulted from disease or injury to the parieto-occipital lobes.^{15, 16} In the first Montgomery Lecture in ophthalmology at Trinity College Dublin in June 1919 he solved this issue:

. . . Superficial injuries of both occipital lobes—that is wounds that injure the posterior parts of the [occipital] striate areas. In all such cases we find peripheral vision intact and central vision abolished. They are consequently evidence that central or macular vision is represented in the most posterior parts of the visual areas, and that this region is not concerned with peripheral sight. . . .

The second lecture dealt with visuospatial perception, localization, and impaired topographical memory of familiar places. This aided both clinical diagnosis in injuries and other brain pathologies, and also the understanding of how and where the visual pathways were located.¹⁷

With Leslie Paton, Holmes reported 60 brain tumor patients and by histological examinations explored theories of the mechanism of papilloedema.^{17, 18} They proved it was caused by raised intracranial pressure and not, as then sometimes thought, an inflammatory process.

After WJ Adie he established the benign condition of the myotonic (Holmes-Adie) pupil.¹⁹ 

 

Spinal injuries

During World War I, at the front in Boulogne in terrible conditions, he made handwritten notes of over 300 spinal cord and brain injuries. He described signs of injury to the cord and sympathetic chain, hypothermia, and the unusual occurrence of shingles (herpes zoster) in the upper margin of the sensory loss. Of great importance he systematically related the neuropathological and clinical consequences of spinal injury, including the phenomenon of spinal “concussion”, the transient paralysis and impaired sensation in the legs (often wrongly thought to be nervous or hysterical).

 

Holmes the man and neurologist

He was examiner, councilor, and censor for the Royal College of Physicians. His pre-eminent research was recognized by his election to the Royal Society (FRS) in May 1933. He received honorary doctorate degrees from Universities of Dublin, Durham, and Edinburgh. He retired in 1941, and was knighted belatedly in 1951.

After enduring the Second World War blitz, he moved to a country house in Farnham, Surrey, where his passions were his garden and golf, which he played with his devoted wife Rosalie.

Holmes had strong likes and dislikes and was not renowned for wit, diplomacy, or compromise. He was an irascible martinet devoted to detailed observation and collection of data. His notorious feud with Kinnier Wilson, a brilliant clinician and teacher at Queen Square, was related by his house physician Macdonald Critchley:

Wilson was a vain and touchy man, jealous of Holmes, and he would ostracise anyone who stayed in the other camp. Holmes for his part could not care less, and simply ignored his colleague.⁹

An apocryphal story (probably started by Macdonald Critchley) told of the “perfect case at Queen Square in the 1930s”:

The history should be taken by Charles Symonds; the physical examination carried out by Gordon Holmes; the differential diagnosis discussed by Kinnier Wilson; and William Adie was to speak to the relatives.

Despite his acerbic manner he nevertheless inspired affection²⁰ and he warmly entertained many loyal and distinguished medical friends. Wilder Penfield, the Canadian neurosurgical pioneer, in 1971 noted his gentler side, remarking that Holmes was one of the finest teachers he had known; beneath the exterior of a martinet there was an Irish heart of gold.²¹ Walshe too described his great gift of lucid exposition, devoid of rhetorical ornaments.⁶ And Sir Charles Symonds described him as warm and impulsive.

Although vain and exacting at times, he was modest to a fault: he could not bear to hear his achievements or reputation discussed in public; on occasion he was so embarrassed that he would leave the room. Whenever possible he eschewed committee meetings and social engagements.

Hughlings Jackson was his first teacher at Queen Square, but contemporaries thought that Holmes resembled Sir William Gowers more than Jackson, showing the same patient, meticulous methods of collecting physical signs and then correlating them with anatomy and pathology. Critchley commented:

. . . Many neurologists treasured the memories of their apprenticeship to one of the giants of neurology, and to a staunch, fundamentally warm-hearted counsellor and guide. In his profession, as in his garden, Holmes planted seeds for the profit and wonderment of generations to come.⁸

In his leisure time he returned to his native Ireland for his summer holidays, often working on his father’s farm and garden. We can see his spirit of adventure and courage when before appointment to Queen Square he met Captain Robert Scott and tried to join his Antarctic expedition. But an Achilles tendon injury forced Holmes reluctantly to withdraw: he was able only to wave farewell at the quayside in 1910. None of Scott’s ill-fated party returned.

In 1918 he married Dr. Rosalie Jobson, M.R.C.S., L.R.C.P. With their three daughters, she was of invaluable support in his work and close family life at 9 Wimpole Street. Their home was one of great hospitality for Holmes’s colleagues and his old pupils. She predeceased him in 1963. In his seventies he wrote the authoritative history, The National Hospital Queen Square 1860–1948, (1954) of which he had been the leading figure for decades. His Selected Papers (1956) were edited by Sir Francis Walshe in a volume dedicated for his eightieth birthday, and again by CG Phillips in 1979.¹⁰ Aged 89, he died in his sleep on 29 December 1965.

The physical signs exposed and elaborated by Holmes are but shadows of something deeper. They are a mask for the underlying natural laws of neural function: its excitation, its depression, and its dysfunction when diseased. The luminary that was Gordon Holmes left a unique and disciplined legacy to all those who treat diseases of the nervous system.

 

References

1. Lyons JB. Sir Gordon Holmes-A Centenary Tribute. Irish Med J 1974;69:300-2.
2. Holmes GM. The National Hospital Queen Square 1860–1948, Edinburgh and London E&S Livingstone, 1954
3. McDonald I. Gordon Holmes lecture: Gordon Holmes and the neurological heritage, Brain 2007;130:288–298, https://doi.org/10.1093/brain/awl335
4. Head H, Holmes GM. Sensory disturbances from cerebral lesions. Brain 1911;34:102-254. (Reprinted in: Head H. Studies in Neurology. Volume I. London, OUP, 1920.)
5. Parsons-Smith BG. Rose FC, Bynum WF. Sir Gordon Holmes, Historical Aspects Of The Neurosciences. A festschrift for Macdonald Critchley. New York Raven Press. 1982. pp. 357-70.
6. Walshe FMR. Gordon Morgan Holmes 1876-1965. In: Biographical Memoirs of Fellows of the Royal Society. London, The Royal Society, 1966;12:311-9. https://royalsocietypublishing.org/doi/pdf/10.1098/rsbm.1966.0014
7. Holmes GM. Introduction to Clinical Neurology. Edinburgh, Livingstone, 1946.
8. Obituary notice. Sir Gordon Holmes. Br Med J 1966; 1:111-2. [contributions from M. Critchley and FMR Walshe]
9. Critchley M. Gordon Holmes, the man and the neurologist. In: The Divine Banquet of the Brain. New York, Raven Press, 1979.pp.228-35.
10. Holmes GM. Selected Papers. Edited by CG Phillips. Oxford, OUP, 1979. [an extensive collection with a near-complete bibliography]
11. Holmes G. ‘A form of familial degeneration of the cerebellum’, Brain 1907, 30: 466-489.
12. Holmes GM. On the clinical symptoms of cerebellar disease. Croonian Lectures. Lancet 1922;I:1177-82,1231-7;II:59-65,111-5.
13. Pearce JMS. Sir Gordon Holmes (1876-1965) Journal of Neurology Neurosurgery and Psychiatry 2004;75:1502-1503
14. Head H, Holmes GM. A case of lesion of the optic thalamus with autopsy. Brain 1911; 34:255-271. (Reprinted in: Head H. Studies in Neurology. Volume I. London, OUP, 1920.)
15. Holmes G. ‘Disturbances of vision by cerebral lesions’, Brain, 1918; 40: 461-535.
16. Pearce JMS. Sir Gordon Morgan Holmes. In: Koertge, Noretta, ed.  New Dictionary of Scientific Biography.  Detroit: Charles Scribner’s Sons, 2008.pp344-8.
17. Holmes G. ‘The Montgomery Lecture in Ophthalmology. I. The cortical localization of vision’, Br. Med. J., 1919, 2: 193-199. ‘II. Disturbances of visual space perception’, ibid., 230-233
18. Paton L, Holmes G. The pathology of papilloedema: a histological study of sixty eyes. Brain 1911;33:389–432.
19. Holmes G. Partial iridoplegia associated with symptoms of other diseases of the nervous system. Trans ophthalmic Soc. UK. 1931; 51 : 209-28).
20. Parsons-Smith BG. Sir Gordon Holmes. In: Clifford Rose F, Bynum WF. Historical Aspects of the Neurosciences. New York, Raven Press, 1982
21. Penfield W. Sir Gordon Morgan Holmes (1876-1965). Obituary. J Neurol Sci 1967; 5:185-90.

 

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JMS PEARCE, MD, FRCP, is emeritus consultant neurologist in the Department of Neurology at the Hull Royal Infirmary, England.

 

Fall 2019  |  Sections  |  Neurology