Lives of the fellows

Hans van Crevel

b.2 September 1933 d.23 June 2002
DM Leiden(1958) FRCP(1998)

Hans van Crevel was reader in neurology in Rotterdam from 1971 to 1980 and professor and chairman at the University of Amsterdam from 1980 to 1992.

In the title of his farewell lecture in 1992 van Crevel summarised his odyssey through neurology as "brein, brei en beleid" (a literal translation might read "brain, broth and beacon"). The three terms represent the different kinds of knowledge on which neurology is based. "Brain" refers to the structure and function of the nervous system, "broth" to the biochemical and genetic aspects, and "beacon" to the guidelines for clinical practice. Knowledge in the last-mentioned field does not automatically follow from the two other domains, but should evolve from research into clinical practice itself, of diagnosis, prognosis and treatment. It was especially this type of research that he eventually encouraged neurologists and future neurologists to undertake.

Hans van Crevel grew up in The Hague, the only son of a musicologist. He studied in Leiden; initially he chose mathematics and physics, with boxing as a sport, but after one year he switched to medicine and rowing. To earn some extra money he worked in the neuro-anatomy laboratory, led by Verhaart. Soon Hans was persuaded to start doing research himself. By performing selective lesions in cats and by looking at the subsequent patterns of degeneration, he showed that the origin of the pyramidal tract was largely located in the precentral gyrus, with very little contributions from other brain areas, a finding that went against current thinking at that time. His thesis is still a classic. In a copy one of us managed to find in an antiquarian bookshop, he had written the dedication, with characteristic irony: "can also be used as a hypnotic".

After having obtained his doctorate 'cum laude' he decided to finish his medical studies, despite warnings that clinical rotationships "would make him permanently unsuitable for research". Subsequently he started training as a neurologist in the (then) municipal hospital in Rotterdam, under ter Braak, for whom he would foster a lifelong admiration. After certification as a neurologist he spent six months as clinical clerk in the National Hospital for Nervous Diseases (as it was called at the time). He always spoke highly of the professional standards in this institution. Van Crevel had also impressed his British colleagues; in 1986 he would be honoured by the invitation to act for several months as a visiting professor to 'Queen Square'. During his initial stay in London he established contacts with the neurosurgical group at Atkinson Morley's Hospital, which stimulated his interest in the treatment of patients with subarachnoid haemorrhage.

Back in Rotterdam and again under ter Braak's influence, van Crevel embarked on clinical research, the more so after the foundation of the Erasmus University in 1966. He developed a special interest in the circulation of cerebrospinal fluid (CSF). Cisternographic studies with radio-active tracer substances in patients with brain tumours showed that displacement of brain tissue does not necessarily lead to increased CSF pressure and papilloedema, but that this occurs only when vital passages in the CSF circulation are blocked. The introduction of CT scanning prompted him and his growing number of collaborators to perform serial investigations in patients with aneurysmal subarachnoid haemorrhage, at fixed intervals and again after episodes of secondary deterioration. This approach provided important insights about the differential diagnosis of complications after aneurysm rupture and about the advantages and limitations of serial CSF sampling; it also led to a revival of the notion of 'cerebral salt washing'.

After his appointment in Amsterdam in 1980 his interests further developed in the direction of practical patient care. He maintained that health care is always a primary task for every physician, and that good teaching and good research can only follow from this: "two cheers for research" was one of his favourite expressions - a paraphrase of E M Forster's lukewarm endorsement of democracy. He initiated clinical research in the field of dementia and established a memory clinic as early as in 1987. Systematic studies resulted in validated guidelines about the use of anciliary investigations and in practical measures for assessing severity of disease and the needs of carers. In the Netherlands he was a pioneer in stimulating the measurement of outcome in a valid and reliable way, a field for which he adopted Feinstein's term 'clinimetrics'. He was convinced that a truly competent physician should be able to interpret and, if necessary, to criticise the results of clinical research. For this purpose he started a 'journal club' in his department, where clinical studies were critically analysed by staff members and residents. He was well aware of the limitations of this approach to medicine, which would gradually be known as 'evidence-based medicine'. A question that occupied him in his last years was how to apply the results of clinical research and meta-analyses to single patients in the consulting room, the problem of 'individuation', as he called it.

With his critical approach and sharp wit Hans van Crevel could appear stern. But among students his lectures were very popular. He had outspoken views about medical education and was highly critical of the method (fashionable in some circles) of letting teachers discuss clinical problems in areas outside their own specialty. His collaborators could invariably count on his full involvement, spiced with irony. After his retirement he continued to be interested in his former colleagues as well as in newly recruited research fellows. His last two years were sadly marred by Parkinson's disease. He will be greatly missed and remembered, not only for his intellectual heritage, but also for his open-minded and unselfish approach to colleagues. Shortly before his death, on of his English colleagues aptly portrayed Hans van Crevel as "one of the truly great gentlemen in neurology".

J van Gijn
M Vermeulen
A Hijdra

(Volume XI, page 591)

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