Courseware The New England Journal of Medicine March 20, 1952 J.C. Boston Medical Intelligence Living without a balancing mechanism One morning, now about four years ago, I arranged in my pajama pocket toothpaste, toothbrush, razor and shaving soap, mounted my crutches and, with towel and facecloth in steaming hot water, spread it over my hands and then held it to my face. Thus blindfolded, I suddenly lost my balance and fell sprawling on the floor. Unhurt but surprised, I picked myself up and looked around to see if someone had jostled me. There was no one in the room. In an effort to recreate this unexpected accident, I braced myself with both hands on the edge of the sink and tried closing my eyes. Instantly I had a feeling of dizziness and nausea. After that there was no further question in my mind about the diagnosis. Streptomycin treatment had been started nearly two and a half months earlier because it was thought that the acute arthritis in my right knee might be tuberculous. At that time relatively little information about the indications for, dosage and toxicity of this new drug had reached the medical officers in the European army of occupation. Few of us had had any opportunity to use it. The reports we were receiving, however, suggested that streptomycin was as dramatically effective in tuberculosis as penicillin in pneumococcal pneumonia. Penicillin having proved ineffective in my case, it was decided to use streptomycin. The initial dose prescribed was 6 gm. Daily, intramuscularly, with 250 mg. Injected locally into the knee joint. Improvement seemed to follow, and in a week or two the dose was reduced to 4 gm. daily and the painful instillations into the joint were discontinued. Immediately prior to my return to the United States, six weeks after I became ill, the dose was reduced to 3 gm. daily. It was on the seventy-sixth day of continuous streptomycin treatment that the first symptoms of eighth-nerve involvement became evident. I returned to my bed discouraged and frightened. At ward rounds I reported the episode in the lavatory to the medical officer in charge. His response was noncommittal, as always. During that first day symptoms increased rapidly. Every movement in bed now caused vertigo and nausea, even when I kept my eyes open. If I shut my eyes the symptoms were intensified. At first, I found that by lying on my back and steadying myself by gripping the bars at the head of the bed I could be reasonably comfortable. Later, even in this position the pulse beat in my head became a perceptible motion, disturbing my equilibrium. Most of us have experimented with motion pictures at home. This experience can be used to illustrate the sensations of the patient with damage to the vestibular apparatus. Imagine the results of a sequence taken by pointing the camera straight ahead, holding it against the chest and walking at a normal pace down a city street. In a sequence thus taken and viewed on the screen, the street seems to careen crazily in all directions, faces of approaching persons become blurred and unrecognizable and the viewer may even experience a feeling of dizziness or nausea. Our vestibular apparatus normally acts like the tripod and the smoothly moving carriage on which the professionalps motion-picture camera is mounted. Without these steadying influences, the moving picture is joggled and blurred. Similarly, when the vestibular influence is removed from the biologic cinema system, the projection on the visual cortex becomes unsteady. From the beginning of my illness I had resolved to try to be a patient and not the combination doctor-and-patient hybrid who often makes the care of one physician by another so difficult. Hence, at rounds that morning I had reported only my symptoms to the ward medical officer and had restrained myself from asking him to discontinue streptomycin. As I lay in bed during the rest of that day I tried to rationalize the continuing, regular visits by the nurse, who was armed with syringe and needle. Perhaps by now cultures of the joint fluid had grown tubercle bacilli. Perhaps loss of vestibular functions was to be preferred to the consequences of tuberculous arthritis. From time to time I put my wristwatch to my ear to see if I could still hear its ticking and assure myself that cochlear function remained intact. Streptomycin injections were finally discontinued two long days later. At that point my courage began to return, and there began the slow process of learning to live with a handicap. The subsequent period was one of consuming interest to me. In it I saw demonstrated how effectively the loss of one of the sensory systems of the body can be compensated for by the other systems. My first efforts were devoted to overcoming my difficulty in reading. I found that by bracing my head between two metal bars at the head of the bed I could minimize the effect of the pulse beat, which made the letters on the page jump and blur. I gradually learned to keep my place by using a finger or pencil on the page. Once I was again able to read, time began to pass more and more quickly. I soon persuaded myself, nevertheless, that I must try to walk. Already I had discovered, as I lay in bed, that if I turned my head from side to side while looking forward I had the sensation that the room turned around me, rather than that I was turning around in the room. This was less disturbing, however, if I focused on a distant object rather than on one but a few feet from my eyes. I had also learned that less vertigo was associated with moving about or turning over in bed if I kept my eyes closed. This maneuver had its drawback, however, in that with my eyes closed I had the giddy feeling that the bed was no longer horizontal but had been tipped up on end or on its side. On my first attempt at walking, I found that it helped to close my eyes and steady myself with both hands on the bed. Thus oriented by tactile sense, I groped my way around the bed, telling myself, despite sensations indicating the contrary, that both the floor and the surface of the bed were stationary and in a horizontal plane. Later, I learned to open my eyes, fix on a distant object to add visual to tactile orientation and move around the bed. Progress was greatly accelerated when, at last, I was permitted to dispense with the cumbersome plaster shell that had immobilized my right leg from sole to hip. Ten days of physiotherapy restored the strength in the limb so that it no longer collapsed under me when weight was put on it. I began to take excursions around the ward, and later along the endless corridors of the hospital. In these corridors I had the peculiar sensation of being inside a flexible tube, fixed at the end nearest me but swaying free at the far end. In various places the corridors led up or down gentle inclines. On these ramps I had to learn to appreciate that I was going downhill through the sensation of strain on the extensors of my legs or that I was climbing a grade through the strain on the flexor muscles. Of course, if there was a window nearby I could corroborate the proprioceptor signals by comparing the plane of the floor with that of the horizon outside. I learned not to do certain things. One of these was not to look at a newspaper or letter in my hand while walking. In those early days proprioceptive orientation was insufficiently developed to permit even momentary withdrawal of visual orientation. When I was allowed to go outside, I quickly found that it was imperative to restrain the impulse to look up when an airplane passed overhead until I could brace myself against a railing or tree. I discovered, when beginning to walk in open places without a nearby wall available for hasty support, that it was a mistake to slow down or stop. It was as if I were riding a bicycle; the faster I walked, the more easily could I keep a stable upright position. Indeed, I soon noticed that unconsciously I had begun to walk the same type of course that is steered by a shipps gyroscopic compass, veering first slightly to the left and then overcompensating and veering equally to the right. During a walk I found too much motion in my visual picture of the surroundings to permit recognition of fine detail. I learned that I must stand still in order to read the lettering on a sign. These early excursions taught me a habit foreign to one of my New England Background-that of greeting anyone who happened to pass in the opposite direction. Since I was unable to distinguish the familiar from the unfamiliar faces when walking, the obvious solution was to pretend to recognize everyone. Learning to get about at night or in the darkness has been the most difficult part of convalescence. Even after considerable practice in daytime walking, I still find myself almost helpless in the dark-so helpless, in fact, that at night I have sometimes had to resort to achieving my destination on hands and knees. We rarely find ourselves totally without light, however. Thus, for example, in leaving a friendps house in the evening, a short pause outside the door usually permits accommodation so that one can see sufficiently well to maintain orientation from doorstep to automobile. My difficulties in navigation under such circumstances are still noticeable, but they can usually be passed off as due to the final highball of a convivial evening! My life at present is little if at all affected by my disability. Since I am almost wholly engaged in research medicine and teaching, if my gait is wobbly in the evening I am not criticized as I might be if I were a practitioner making house calls. With a little extra caution I can successfully transfer a tray of glassware from one bench to another in the laboratory. I was once told that Ipd have to forget some of my weekend and vacation activities. Nevertheless, I now enjoy tennis doubles as much as I once enjoyed a fast-running game of singles. On the water I am spared the sensation of seasickness and hence am a useful hand in the hot galley when the seas are choppy. For a time I was hesitant about swimming, as a well known neurologist had told me that many patients with central-nervous-system syphilis and vestibular dysfunction had drowned because they lost their orientation in the water and swam down when they thought they were coming up for air. Temptation has been too great, however. Some cautious experiments have reassured me that I can find the surface if I keep my head. To date I havenpt been foolish enough to try swimming at night. When I recall how completely disabled I was by the initial impact of loss of vestibular function, I am amazed that I am so little troubled at present, even though tests show no sign of recovery of that particular sensory system. Is there any man-made machine designed like the human apparatus-with so many alternate systems to accomplish its end?