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 Balance Function
Assessment and Management
Third Edition
Editor-in-Chief for Audiology
Brad A. Stach, PhD
 Balance Function
Assessment and Management
Third Edition

Gary P. Jacobson, PhD

Neil T. Shepard, PhD
Kamran Barin, PhD
Robert F. Burkard, PhD
Kristen Janky, AuD, PhD
Devin L. McCaslin, PhD
5521 Ruffin Road
San Diego, CA 92123

e-mail: information@pluralpublishing.com
Website: https://www.pluralpublishing.com

Copyright © 2021 by Plural Publishing, Inc.

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Library of Congress Cataloging-in-Publication Data

Names: Jacobson, Gary P., editor. | Shepard, Neil T., editor. | Barin,
Kamran, editor. | Burkard, Robert F., 1953- editor. | Janky, Kristen,
editor. | McCaslin, Devin L. (Devin Lochlan), editor.
Title: Balance function assessment and management / [edited by] Gary P.
Jacobson, Neil T. Shepard, Kamran Barin, Robert F. Burkard, Kristen
Janky, Devin L. McCaslin.
Description: Third edition. | San Diego, CA: Plural Publishing, [2021] |
Includes bibliographical references and index.
Identifiers: LCCN 2019035307 | ISBN 9781635501889 (hardcover) | ISBN
1635501881 (hardcover) | ISBN 9781635501995 (ebook)
Subjects: MESH: Vestibular Diseases — diagnosis | Vestibular
Diseases — therapy | Vestibular Function Tests — methods | Vertigo |
Dizziness
Classification: LCC RF260 | NLM WV 255 | DDC 617.8/82 — dc23
LC record available at https://lccn.loc.gov/2019035307
 Contents

Preface ix
About the Editors xi
Contributors xiii

1 An Historical Perspective of the Perception of Vertigo, Dizziness, and 1

Vestibular Medicine
Christopher K. Zalewski

2 Ontogeny of the Vestibular System and Balance 15

Timothy A. Jones and Sherri M. Jones

3 Practical Anatomy and Physiology of the Ocular Motor System 43

Scott D. Z. Eggers

4 Practical Anatomy and Physiology of the Vestibular System 69

Jamie M. Bogle and Robert F. Burkard

5 Practical Biomechanics and Physiology of Balance 87

Lewis M. Nashner

6 Clinical Neurophysiology of Vestibular Compensation 105

Kamran Barin

7 The Vertigo Case History 125

Jay A. Gantz, Belinda C. Sinks, and Joel A. Goebel

8 Assessing Dizziness-Related Quality of Life 143

Erin G. Piker, Gary P. Jacobson, and Craig W. Newman

9 Bedside Assessment of the Vestibular System 167

Carrie W. Hoppes, Karen H. Lambert, and Devin L. McCaslin

10 Eye Movement Recording and Ocular Motility Testing 189

Neil T. Shepard, Michael C. Schubert, and Scott D. Z. Eggers

11 Positional Testing and Treatment 225

Richard A. Clendaniel

12 Caloric Testing 257

Kamran Barin

v
vi Balance Function Assessment and Management

13 Rotational Vestibular Assessment 283

Christopher K. Zalewski

14 The Video Head Impulse Test (vHIT) 333

Ian S. Curthoys, Hamish G. MacDougall, Leigh A. McGarvie, Konrad P. Weber,
David Szmulewicz, Leonardo Manzari, Ann M. Burgess, and G. Michael Halmagyi

15 Computerized Dynamic Posturography: Methodology and Interpretations 365

Lewis M. Nashner and Neil T. Shepard

16 Vestibular-Evoked Myogenic Potentials (VEMPs) 399

Devin L. McCaslin and Gary P. Jacobson

17 Electrocochleography (ECochG) 439

Paul R. Kileny and Devin L. McCaslin

18 Pediatric Vestibular Testing 457

Kristen Janky and Neil T. Shepard

19 Vestibular Balance Therapy for Children 479

Jennifer B. Christy

20 Medical Management of Vertigo That Is Otologic in Origin 489

Brian Neff and R. Mark Wiet

21 Surgical Management of Vertigo That Is Otologic in Origin 501

R. Mark Wiet

22 Neurologic Origins of Dizziness and Vertigo 519

Joseph M. Furman and Susan L. Whitney

23 Behavioral Factors in Dizziness and Vertigo 529

Jeffrey P. Staab

24 Vestibular Rehabilitation 549

Susan L. Whitney and Joseph M. Furman

25 The Aging Vestibular System: Implications for Rehabilitation 577

Dara Meldrum and Courtney D. Hall

26 Topographical Localization of Vestibular System Impairment 597

Gary P. Jacobson, Erin G. Piker, Richard A. Roberts,
Devin L. McCaslin, and Nabih M. Ramadan

27 Challenging Cases 617

Neil T. Shepard

Appendix I Pathophysiology Signs and Symptoms of Dizziness 629

Neil T. Shepard
 Contents vii

Appendix II Coding and Billing 645

Robert F. Burkard, Neil T. Shepard, and Stuart Trembath

Appendix III Interprofessional Education and Practice 653

Neil T. Shepard and Robert F. Burkard

Appendix IV Specialty Rotational Vestibular Assessments 659

Christopher K. Zalewski

Index 689
 Preface
On behalf of the editors and authors, we would like
to welcome you to the third edition of Balance Func-
tion Assessment and Management. Notable updates to
this edition include the first chapter that reviews “An
Historical Perspective of the Perception of Vertigo
and Dizziness and Vestibular Medicine.” We have
also included new chapters on the topics of “Vestibu-
lar Balance Therapy for Children” (Chapter 19) and
“The Aging Vestibular System: Implications for Reha-
bilitation” (Chapter 25). Further, this edition includes
a chapter on “Challenging Cases” (Chapter 27) and
we end this textbook with four appendices covering
“Pathophysiological Signs and Symptoms of Dizzi-
ness,” “Coding and Billing,” “Interprofessional Educa-
tion and Practice,” and “Specialty Rotational Vestibular
Assessments.” In response to the comments from read-
ix
ers of the second edition, we have reduced the length
of the textbook by making it more concise.
Finally, the reader will note that this third edition
has been edited by six nationally and internationally
known clinical scientists in the area of dizziness, ver-
tigo, and chronic unsteadiness. . These editors include
Kamran Barin, PhD, Robert F. Burkard, PhD, Kristen
Janky, AuD, PhD, and Devin L. McCaslin, PhD. We are
grateful for the participation of these talented individ-
uals in the planning, development, and realization of
this third edition. It has been our objective from the first
edition of Balance Function Assessment and Management
to produce a textbook for both the student and the prac-
titioner that treats comprehensively the assessment and
management of dizziness. To the extent that we have
achieved this goal, you, the reader, will be the judge.
Gary P. Jacobson, PhD Neil T. Shepard, PhD
 About the Editors
Gary P. Jacobson, PhD, is Professor in the Depart-
ment of Hearing and Speech Sciences and Director
of the Divisions of Audiology and Vestibular Sciences
at the Vanderbilt University Medical Center. Prior to
that he served as the Director, Division of Audiology
for the Henry Ford Health System. He completed his
undergraduate studies at California State University
at Fullerton. He received his MS in Communicative
Disorders (Audiology) at the University of Wiscon-
sin–Stevens Point and received his PhD from Kent
State University. He is a past-editor of the American
Journal of Audiology (ASHA) and is the current Edi-
tor-in-Chief of the Journal of the American Academy
of Audiology (AAA). Dr. Jacobson has authored or
co-authored 120 peer-reviewed publications and has
co-edited four textbooks in the area of vestibular sys-
tem function. Dr. Jacobson is a Fellow of ASHA and
recipient of ASHA’s highest honor, the Honors of
the Association. Dr. Jacobson received the Lifetime
Achievement Award from the American Balance
Society. Lastly, he received both the Distinguished
Achievement Award and the Jerger Career Award for
Research in Audiology from the American Academy
of Audiology.
Neil T. Shepard, PhD, is former Chair of the Division
of Audiology and Director of the Dizziness and Balance
Disorders Program at the Mayo Clinic in Rochester,
Minnesota. As Professor of Audiology, Mayo Clinical
School of Medicine — Emeritus, Dr. Shepard continues
with a clinical private practice in Missoula, Montana
for the assessment and recommendations for treatment
of patients reporting dizziness and balance disorder
symptoms. He is also involved with research through
the Mayo Clinic and clinical evaluations in the Neural
Injury Center at the University of Montana. He received
his undergraduate and masters training in Electrical
and Biomedical Engineering from the University of
Kentucky and Massachusetts Institute of Technology.
He completed his PhD in auditory electrophysiology
and clinical audiology from the University of Iowa in
1979. He has specialized in clinical electrophysiology
for both the auditory and vestibular systems. His activ-
ity over the past 40 years has concentrated on the clini-
xi
cal assessment and rehabilitation of balance disorder
patients and clinical research endeavors related to both
assessment and rehabilitation.
Kamran Barin, PhD, is Assistant Professor Emeritus,
Department of Otolaryngology–Head and Neck Sur-
gery and Department of Speech and Hearing Science,
The Ohio State University. He established and served
as the Director of Balance Disorders Clinic at the Ohio
State University Medical Center for over 25 years until
his retirement in June 2011. Dr. Barin received his Mas-
ter’s and Doctorate degrees in Electrical/Biomedical
Engineering from The Ohio State University. He has
published over 80 articles and book chapters and has
taught national and international courses and seminars
in different areas of vestibular assessment and rehabili-
tation. Dr. Barin has served on the Board of Directors
of the Vestibular Disorders Association (VeDA) since
2017 and is currently a consultant to Interacoustics and
Bertec Corporation. He previously served as a consul-
tant to Otometrics.
Robert F. Burkard, PhD, is a Professor in the Depart-
ment of Rehabilitation Science, University at Buffalo.
His research interests include calibration, auditory
electrophysiology (in particular, auditory evoked
potentials), vestibular/balance function/dysfunction,
functional imaging, and aging. His professional inter-
ests include health care economics and interprofes-
sional education/practice.
Kristen Janky, AuD, PhD, is the Clinical Coordina-
tor of Vestibular Clinical Services and Director of the
Vestibular and Balance Research Laboratory at Boys
Town National Research Hospital. She received her
PhD from the University of Nebraska and completed
a post-doctoral fellowship at Johns Hopkins Univer-
sity. Her research focus is on the clinical assessment of
dizziness and balance disorders in patients of all ages,
with a particular emphasis on vestibular assessment
and management in the pediatric population. She cur-
rently serves on the Editorial Board for the American
Journal of Audiology and is President-Elect of the Ameri-
can Balance Society.
xii Balance Function Assessment and Management
Devin L. McCaslin, PhD, received a Master’s degree
in Audiology from Wayne State University and a PhD
in Hearing Science from The Ohio State University.
He currently serves as the Director of the Vestibular
and Balance Laboratory at the Mayo Clinic in Roch-
ester and is an Associate Professor in the Mayo Clinic
College of Medicine. He has authored and coauthored
publications that cover the areas of tinnitus, dizziness,
auditory function, and outcome measures develop-
ment. Dr. McCaslin’s major academic, clinical, and
research interests relate to clinical electrophysiology,
vestibular assessment, and the application of artificial
intelligence to manage and treat dizzy patients. He also
serves as the Deputy Editor-in-Chief of the Journal of the
American Academy of Audiology and is the Past President
of the American Balance Society.
 Contributors

Kamran Barin, PhD Ian S. Curthoys, PhD

Assistant Professor Emeritus Emeritus Professor of Vestibular Function
Department of Otolaryngology–Head and Neck School of Psychology
Surgery University of Sydney
Department of Speech and Hearing Science Sydney, Australia
The Ohio State University Chapter 14
Columbus, Ohio
Chapter 6 and Chapter 12 Scott D. Z. Eggers, MD
Associate Professor of Neurology
Jamie M. Bogle, AuD, PhD College of Medicine and Science
Chair, Division of Audiology Mayo Clinic
Mayo Clinic Arizona Rochester, Minnesota
Assistant Professor of Audiology Chapter 3 and Chapter 10
Mayo Clinic College of Medicine and Science
Chapter 4 Joseph M. Furman, MD, PhD, FAAN
Professor
Ann M. Burgess, PhD Department of Otolaryngology, Neurology,
Postdoctoral Research Fellow Physical Therapy, and Bioengineering
School of Psychology University of Pittsburgh
University of Sydney Pittsburgh, Pennsylvania
Sydney, Australia Chapter 22 and Chapter 24
Chapter 14
Jay A. Gantz, MD, PhD
Robert F. Burkard, PhD Otolaryngology Resident
Professor Department of Otolaryngology–Head and Neck Surgery
Department of Rehabilitation Science Washington University School of Medicine
University at Buffalo St. Louis, Missouri
Buffalo, New York Chapter 7
Chapter 4, Appendix II, and Appendix III
Joel A. Goebel, MD, FACS, FRCS
Jennifer B. Christy, PT, PhD Professor and Director
Associate Professor Dizziness and Balance Centre
Program Director, Doctor of Physical Therapy Department of Otolaryngology–Head and Neck Surgery
Program Washington University School of Medicine
Department of Physical Therapy St. Louis, Missouri
University of Birmingham Chapter 7
Birmingham, Alabama
Chapter 19 Courtney D. Hall, PT, PhD
Research Health Science Specialist
Richard A. Clendaniel, PT, PhD James H. Quillen VA Medical Center,
Duke University School of Medicine Professor
Doctor of Physical Therapy Division East Tennessee State University
Durham, North Carolina Johnson City, Tennessee
Chapter 11 Chapter 25

xiii
xiv Balance Function Assessment and Management

G. Michael Halmagyi, MD Karen H. Lambert PT, DPT, NCS

Neurology Department Physical Therapist
Royal Prince Alfred Hospital Bodies in Balance Physical Therapy
University of Sydney Chapter 9
Sydney, Australia
Chapter 14 Hamish G. MacDougall, PhD
GPRWMF Research Fellow
Faculty of Science, School of Psychology
Carrie W. Hoppes, PT, PhD, NCS, CCS
University of Sydney
Deputy Director
Sydney, Australia
Army–Baylor University Doctoral Program in
Chapter 14
Physical Therapy
Chapter 9
Leonardo Manzari, MD
MSA ENT Academy Center
Gary P. Jacobson, PhD Cassino (FR)
Professor Italy
Director of the Division of Audiology Chapter 14
Vanderbilt Bill Wilkerson Center
Vanderbilt University Medical Center Devin L. McCaslin, PhD
Nashville, Tennessee Director
Chapter 8, Chapter 16, and Chapter 26 Vestibular and Balance Laboratory
Associate Professor
Mayo Clinic College of Medicine
Kristen Janky, PhD
Rochester, Minnesota
Director
Chapter 9, Chapter 16, Chapter 17, and Chapter 26
Vestibular and Balance Research Laboratory
Boys Town National Research Hospital
Leigh A. McGarvie
Omaha, Nebraska
Biomedical Engineer
Chapter 18
Royal Prince Albert Hospital
Sydney, Australia
Sherri M. Jones, PhD Chapter 14
Dean, College of Education and Human Sciences
University of Nebraska–Lincoln Dara Meldrum, BSc, MSc, PhD
Lincoln, Nebraska Research Fellow
Chapter 2 School of Medicine
Trinity College Dublin
Dublin, Ireland
Timothy A. Jones, PhD
Chapter 25
Professor Emeritus
Department of Special Education and
Lewis M. Nashner, ScD
Communication Disorders
Partner
College of Education and Human Sciences
NPGMedical, LLC
University of Nebraska–Lincoln
Consultant
Lincoln, Nebraska
Bertec Corp.
Chapter 2
Intelligent Automation, Inc.
Chapter 5 and Chapter 15
Paul R. Kileny, PhD, FAAA, F-ASHA, BCS-IOM
Professor Brian Neff, MD
Academic Program Director Associate Professor of Otolaryngology
Audiology and Electrophysiology Mayo Clinic College of Medicine and Science
University of Michigan Health System Mayo Clinic
Ann Arbor, Michigan Rochester, Minnesota
Chapter 17 Chapter 20
 Contributors xv

Craig W. Newman, PhD Jeffrey P. Staab, MD, MS

Section Head, Allied Hearing Professor of Psychiatry
Speech and Balance Services (Retired) Consultant, Department of Psychiatry and
Head and Neck Institute Psychology
Cleveland Clinic Department of Otorhinolaryngology–Head and Neck
Cleveland, Ohio Surgery
Chapter 8 Mayo Clinic
Rochester, Minnesota
Erin G. Piker, AuD, PhD Chapter 23
Assistant Professor
James Madison University David Szmulewicz, MB, BS (HONS), PhD, FRACP
Harrisonburg, Virginia Neurologist and Neuro-Otologist
Chapter 8 and Chapter 26 Royal Victorian Eye and Ear Hospital Australia
Department of Neurology
Nabih M. Ramadan, MD, MBA, FAAN, FAHS Alfred Hospital
Director of Neuro-Hospitalist Program Victoria, Australia
Carle Foundation Hospital Chapter 14
Urbana, Illinois
Chapter 26 Stuart Trembath MA, CCC-A
Audiologist
Richard A. Roberts, PhD
Hearing Associates, P.C.
Vice Chair of Clinical Operations
Mason City, Iowa
Assistant Professor
Appendix II
Deptartment of Hearing and Speech Sciences
Division of Vestibular Sciences
Konrad P. Weber, MD
Vanderbilt University Medical Center
Senior Physician
Nashville, Tennessee
Interdisciplinary Center for Vertigo and Neurological
Chapter 26
Visual Disorders
Michael C. Schubert, PT, PhD Departments of Neurology and Ophthalmology
Associate Professor University Hospital Zürich
Department of Otolaryngology–Head and Neck University of Zürich
Surgery Zürich, Switzerland
Department of Physical Medicine and Rehabilitation Chapter 14
Johns Hopkins University School of Medicine
Baltimore, Maryland Susan L. Whitney, DPT, PhD, NCS, ATC, FAPA
Chapter 10 Professor in Physical Therapy and Otolaryngology
School of Health and Rehabilitation
Neil T. Shepard, PhD University of Pittsburgh
Professor Emeritus Pittsburgh, Pennsylvania
Former Chair of Division of Audiology and Director Chapter 22 and Chapter 24
of Dizziness and Balance Disorders Program
Mayo Clinic R. Mark Wiet, MD, FACS
Rochester, Minnesota Section Head of Otology, Neurotology, and Lateral
Chapter 10, Chapter 15, Chapter 18, Chapter 27, Skull Base Surgery
Appendix I, Appendix II, and Appendix III Director Acoustic Neuroma Program
Director Auditory Implant Program
Belinda C. Sinks, AuD, CCC-A Assistant Professor
Dizziness and Balance Center Departments of Otorhinolaryngology–Head and
Department of Otolaryngology–Head and Neck Neck Surgery, Neurosurgery, and Communication
Surgery Disorders and Science
Washington University School of Medicine Rush University Medical Center
St. Louis, Missouri Chicago, Illinois
Chapter 7 Chapter 20 and Chapter 21
xvi Balance Function Assessment and Management

Christopher K. Zalewski, PhD

National Institutes of Health–NIDCD
Otolaryngology Branch, Audiology
Bethesda, Maryland
Chapter 1, Chapter 13, and Appendix IV
 1
An Historical Perspective of the
Perception of Vertigo, Dizziness,
and Vestibular Medicine
Christopher K. Zalewski
Historical Beginnings and
Commonplace Misdirection
Most medical histories can, at some point in time,
always be brought back to Aristotle. Along with
Hippocrates of Kos (c. 460–370 bc; Figure 1–1), Plato
(c. 428/7 or 424/3–348/7 bc; Figure 1–2), and Socrates
(c. 470–399 bc; Figure 1–3), Aristotle (c. 384–322 bc; Fig-
ure 1–4) was arguably one of the greatest philosophers
and early scientists in history. He was not only the
first to introduce the scientific study of all the human
senses, he also provided the first written account of
vertigo in 330 bc (Ross, 1927).
Why is it that to those who are very drunk every-
thing seems to revolve in a circle, and as soon as
the wine takes a hold of them they cannot see
objects at a distance? . . . [O]bjects near at hand
are not seen in their proper places, but appear to
revolve in a circle. (p. 892a)
And although the philosophical pondering of alcohol-
induced dizziness does have its medical and vestibu-
lar merit, the actual attribution for the discovery of the
physiologic link between the vestibular system and
1
vertigo would not occur for almost another two centu-
ries. The historical recount of this elusive discovery is,
in many ways, similar to other medical discoveries. It is
one that is shrouded with misdirection and debate, as
well as highlighted with triumph and tragedy.
For some historical discoveries, storied misdirec-
tion is not uncommon during a time period when writ-
ten accounts were sparse and interpretation of science
was more philosophical than fact. One of the most poi-
gnant misdirections is that of Charles Darwin’s legacy.
Although Charles Robert Darwin (c. 1809–1882) is uni-
versally recognized as the Father of Evolution and Nat-
ural Selection, largely due to his published work On the
Origin of Species in 1859, public acknowledgment is sel-
dom given to Alfred Russel Wallace (c. 1823–1913), who
was instrumental in the independent conceptualiza-
tion and propagation of the original framework for the
theory of natural selection in his papers “On the Law
which has Regulated the Introduction of New Species”
(1855) and “On the Tendencies of Varieties to Depart
Indefinitely From the Original Type” (1858), the latter
paper being directly sent to Darwin by Wallace himself.
Interestingly, the overshadowing of Alfred Russel Wal-
lace by Charles Darwin was not the first time contro-
versy surrounded the crediting of the Darwin namesake
for introducing and revolutionizing a groundbreaking
2 Balance Function Assessment and Management
Figure 1–1. Hippocrates of Kos (460– Figure 1–2. Plato (428/7 or 424/3–
370 bc). 348/7 bc).
Figure 1–4. Aristotle (384–322 bc).
scientific theory. Charles’s grandfather, Erasmus Dar-
win, is often given credit for the earliest work on the
origins of vertigo and nystagmus, rather than a young
scientist by the name of William Charles Wells.
Figure 1–3. Socrates (470–399 bc).
William Charles Wells and
Erasmus Darwin: The Dueling
“Vestibular Philosophers”
William Charles Wells was a scientist for whom the
story surrounding the discovery of the vestibular sixth
sense begins. Some 65 years before Charles Darwin
published On the Origin of Species, Charles Darwin’s
grandfather, Erasmus Darwin (c. 1731–1802; Figure
1–5), in collaboration with Robert Waring Darwin (c.
1766–1848), the father of Charles Darwin, published a
section entitled “Of Vertigo” in Zoonomia; or, The Laws
of Organic Life (Vol I) in 1794. This work nearly erased
Charles Wells’s sentinel work on the discovery of the
relationship between vertigo and nystagmus. As such,
Zoonomia’s account of life, medicine, and early theories
of evolution, including rudimentary ideas of vertigo
and dizziness, is the reason that initial descriptions of
vertigo are often attributed to Erasmus Darwin. It is
Erasmus Darwin’s contributions to medicine, nature,
and life that are highly acknowledged as one of the
pinnacles of human physiology and thought. His four
editions of the two volumes of Zoonomia have been
recognized as among the most comprehensive and
foundational works from which theories of modern
medicine and philosophy have originated. As such,
Darwin’s recognition for theories on dizziness and
 1. An Historical Perspective of the Perception of Vertigo, Dizziness, and Vestibular Medicine 3

Figure 1–6. Thomas Willis (1621–1675).

Figure 1–5. Erasmus Darwin (1731–1802).

vertigo in Zoonomia all but dismissed the literary work

published a mere two years earlier by Charles Wells,
an essay that (correctly) refuted the current belief sur-
rounding the sensation of vertigo at the time.

From Visual Vertigo to Visual After-Images:

The Emergence of the Sixth Sense
At the turn of the eighteenth century, Darwin’s pub-
lished views on vertigo and dizziness continued to
propagate the well-accepted notion at the time, that
vertigo and dizziness were a disturbance of “visual
processing.” The idea of “visual vertigo” was first
offered by Thomas Willis (c. 1621–1675; Figure 1–6) in
1661 in his publication De Anima Brutorum quae Hominis
Figure 1–7. Julien Offray de la Mettrie (1709–1751).
Vitals ac Sentitiva Exercitationes Duae [The Beasts and
the Man’s Life: 2 Exercises]. Here, Willis suggested that
vertigo occurred solely from a disturbance of vision
due to animal spirits in the central nervous system. rather occurred due to aberrant visual neural process-
Later in 1737, Julien Offray de la Mettrie (c. 1709–1751; ing of images. This concept of “phantom” neural visual
Figure 1–7) supported this notion in his work Traité processing was similar to phantom leg syndrome, a
du Vertige [Treaty of Vertigo], but stated that vertigo concept that was familiar to Porterfield, whose leg was
was physiological rather than a consequence of animal amputated in his youth.
or humorous spirits. This idea of “visual vertigo” was The suspected origin of “visual vertigo” was held
further supported and refined by William Porterfield for another 65 to 70 years. It was not until 1792 that
(c. 1696–1771) in the same year (1737). However, Por- Charles Wells suggested that the sensation of vertigo
terfield affirmed that visual vertigo was specifically not was actually due to eye movement that could eas-
associated with eye movements (i.e., nystagmus), but ily be elicited following head (body) rotation. In his
4 Balance Function Assessment and Management
Essays upon Single Vision with Two Eyes: Together with
Experiments and Observations on Several Other Subjects
in Optics, Wells published what is now known to be
the first account detailing the association between ver-
tigo and eye movement (i.e., nystagmus of vestibular
origin). In this report, Wells was the first to describe
both the fast and the slow phase of eye movement dur-
ing nystagmus. Although Charles Wells did not specify
what internal organs were responsible for the produc-
tion of this “nystagmus,” with the use of after-images,
Wells was the first to provide irrefutable evidence sys-
tematically linking the pattern of eye movements to
the direction of perceived vertigo (Wade, 2003). Most
notably, Charles Wells published this essay in 1792,
which was two years prior to the publication of Eras-
mus Darwin’s first edition of Zoonomia; or, The Laws
of Organic Life (Vol. I). However, in their publication,
Erasmus and Robert Darwin detailed the characteris-
tics of vertigo and continued to support Porterfield’s
earlier, and erroneous, notion that “visual vertigo”
was specifically not associated with eye movements.
Unfortunately, Wells’s association with eye movement
and post-rotational vertigo as a landmark discovery in
vestibular science went largely unnoticed — so much so
that Charles Wells himself would essentially drift into
historical oblivion for this discovery.1
The Erasmus Wells Debate
One hundred and thirty-one years after Thomas Willis
first introduced the concept of “visual vertigo,” and a
little more than two centuries since Aristotle first intro-
duced the five senses, the notion that there could be a
sixth sense, one of motion perception, was brought to
scientific light. But who was rightfully due the scien-
tific discovery? Although Charles Wells’s sophisticated
experiments on post-rotational vertigo and nystagmus
were seemingly irrefutable, they were also essentially
unknown, and ostensibly almost deliberately unrec-
ognized. This was likely due to the fact that Erasmus
Darwin’s world-renowned publication of Zoonomia
was essentially medical and philosophical law at the
time. Additionally, since the majority of scientific writ-
ings were in the German language, Erasmus Darwin
clearly had the advantage, as Zoonomia was translated
into German, while Charles Wells’s Essays upon Single
Vision with Two Eyes was only published in English
(Wade, 2003). Moreover, his essay appeared in vision
1
 he phrase “drift into historical oblivion” is a play on words, respectfully evoking the title of Nicholas Wade’s book Destined for Distinguished
T
Oblivion (see the Epilogue).
literature, a far cry from that of neurology, or “ves-
tibular” research (if such a medical classification had
existed then). It was also unclear whether Wells’s
work was poorly represented in the German transla-
tion of Zoonomia or Erasmus Darwin himself did not
fully understand Wells’s work, or both. Or perhaps it
was because the word “vertigo” was not even in the
title of Wells’s essay. The topic of vertigo was, in fact,
one of the “Several Other Subjects in Optics” that was
addressed in the title of Wells’s 144-page essay, buried
between pages 85 and 105.
Several sources have suggested that Charles Wells
also struggled against his own exasperation. Despite his
kindness and warmth of heart he was easily offended
(Wade & Tatler, 2005). As such, Wells was at times
irascible, even describing himself as “naturally irrita-
ble” in his own memoir (Wade, 2003). Whether or not
these traits projected Wells as an obstinate and indig-
nant person, it is clear that such qualities would have
undoubtedly affected his reputation within the scien-
tific community. In this regard, one could easily detect
such indignation in two rejoinders Wells published in
The Gentleman’s Magazine in September and October of
1794, only three or four months after the first volume of
Zoonomia was published. Wells’s quick dispute of Dar-
win’s comments on visual vertigo was, if nothing else,
highly detailed and concise. In each letter, Wells pro-
vided a rather pointed rebuttal that articulated a clear
and concise scientific counter argument to each of Dar-
win’s apparent logical statements supporting “visual
vertigo.” Among Wells’s points was the notion that
vertigo could occur in complete darkness, that is, in
the absence of any visual processing (Wade, 2003). How-
ever, it was Wells’s use of optical after-images that pro-
vided the indisputable scientific evidence supporting
a physiologic link between eye movements and vertigo,
thus finally putting to rest the notion of “visual vertigo.”
Though Wells did not provide a theory as to the origin
of the production of these eye movements (i.e., “vestib-
ular” nystagmus), his work did lay the scientific foun-
dation for others to begin considering this question.
The Gentleman’s Magazine Refutes
Wells’s two responses to Darwin’s theory of visual ver-
tigo in Zoonomia were highly publicized at the time,
as The Gentleman’s Magazine was well regarded. How-
ever, the magazine was not widely read by scientists
outside of Britain (Wade & Tatler, 2005). Regardless of
 1. An Historical Perspective of the Perception of Vertigo, Dizziness, and Vestibular Medicine 5

the magazine’s limited readership, Wells’s rejoinders have been the primary reason for the eventual credit-
in The Gentleman’s Magazine had gained both scientific ing of Charles Wells’s work on vertigo and nystagmus.
attention and popularity. As such, Erasmus Darwin The detailed responses by Wells allowed for the public
briefly acknowledged Wells’s alternative theories on expansion of his theories and the devolution of “visual
vertigo and nystagmus in his third edition of Zoono- vertigo.”
mia, which was published in 1801 (i.e., almost 10 years
following the initial publication of Wells’s Essays upon
Single Vision with Two Eyes. Unfortunately, Darwin’s Bridging the Gap:
position on visual vertigo changed little in the third The Physiologic Link Between the
edition. It was not until Darwin’s final fourth edition Vestibular System and Vertigo
of Zoonomia that Erasmus and Robert Darwin would
finally acknowledge, although begrudgingly, Charles The notion of linking head rotation to nystagmus (and
Wells’s scientific contributions linking eye movements vertigo) was a novel finding at the time, and suggest-
(nystagmus) to the perception of vertigo (Wade, 2003). ing that the semicircular canals were the origin for this
Amazingly, however, they continued to support the nystagmus might have been the most logical step in
theory of visual vertigo, thus continuing to dismiss the scientific process. However at the turn of the eigh-
Wells’s conclusions. teenth century, an erroneous notion still persisted.
Most notably, it was Wells’s second letter to The There was a continued belief by many that the “Cre-
Gentleman’s Magazine, detailing the post-rotation nys- tan Labyrinthos,” as Aelius Galen (c. 129–200/216 ad;
tagmus response that possibly offered the best evi- Figure 1–8) had elegantly named the vestibular laby-
dence to suggest his work was the first foundational rinth, was responsible for auditory localization. After
work on vestibular research.2 Specifically, it was Wells’s all, the anatomy of the labyrinth easily supported the
succinct description of the involuntary post-rotational contention that the semicircular canals were aligned
nystagmus in his second retort, which detailed the for optimal sound localization (and amplification as
apparent motion of the environment after cessation Du Verney had suggested in 1683; Figure 1–9). Unfor-
of rotation (Wade, 2003). The apparent rotation of the tunately, at the time of Wells and Darwin, the scientific
environment was dependent not only on the direction bridge between the vestibular labyrinth, head rota-
of subject rotation, but also on the direction of invol- tion, nystagmus, and vertigo had yet to be made, and
untary eye movement. Furthermore, the direction of
the rotation of the environment switched directions
in accordance with the change in the direction of head
rotation (Wade, 2003). Finally, Wells also detailed the
suppression of nystagmus with concentrated vision
(i.e., vestibulo-ocular reflex [VOR] suppression), as
well as the perception of vertigo and documentation
of after-image eye movement in darkness. Collectively,
Wells’s observations on vertigo and nystagmus are the
first and foremost definitions of what we now know
today to be the properties of clinical vestibular nys-
tagmus. However, despite Wells’s scientific evidence
supporting the association between vertigo and eye
movements, the use of rotation for the diagnosis of
vertigo and investigation of vestibular function would
continue to remain absent in neurology clinics for over
a century. In fact, it would take another 100 years until
Róbert Bárány (c. 1876–1936) applied these “rotational”
properties clinically.
It is interesting that the published feud between
Wells and Darwin in The Gentleman’s Magazine may Figure 1–8. Aelius Galen (129–200/216).

2
 espite Wells’s work in vestibular research, it is often Jan Evangelista Purkyně (c. 1787–1869) and Jean Pierre Flourens (c. 1794–1867) who
D
are frequently credited with and subsequently often referred to as the “Fathers of Vestibular Science”— but more to come on this later.
6 Balance Function Assessment and Management

Figure 1–9. Joseph Guichard Du Verney (1648–1730).

because of this, it was unclear whether even Wells’s Figure 1–10. Jan Evangelista Purkyně (1787–1869).
work actually had any direct impact on the work of
two well-known vestibular scientists (Purkyně and
Flourens), who made these final connections.

Purkyně and Flourens

Jan Evangelista Purkyně (Figure 1–10) and Jean Pierre

Flourens (Figure 1–11) were two world-renowned phy-
sician scientists, both performing work in vertigo and
motion perception. Purkyně in particular was highly
regarded and extremely well known, as one merely
had to address a letter to “Purkyně, Europe” and it
would be delivered successfully (Baloh, 2002). Along
with other scientists at the time, such as Ernst Josef
Mach (c. 1838–1916), Josef Breuer (c. 1842–1925), and
Alexander Crum-Brown (c. 1838–1922), the discovery
of the link between the vestibular system, vertigo, and
eye movements advanced quickly. Unfortunately for
Wells, neither Purkyně nor Flourens spoke fluent Eng-
lish (Wade, 2003). As such, neither one ever referenced Figure 1–11. Jean Pierre Flourens (1794–1867).
Wells’s work on vertigo and nystagmus. Most of the
vestibular research at the turn of the century came from
either Germany or France, with German often being
the language of choice. Darwin’s Zoonomia was widely they both often cited Zoonomia) (Wade & Tatler, 2005).
cited and available in German, which was familiar to Both scientists continued to disregard Wells’s evi-
both Purkyně and Flourens (evidenced by the fact that dence on post-rotational vertigo and nystagmus, and
 1. An Historical Perspective of the Perception of Vertigo, Dizziness, and Vestibular Medicine 7
continued to promote their own beliefs.3 For example,
Purkyně continued to promote the idea that vertigo
occurred in response to the independent rotation of
the cerebellum. Moreover, it was likely Erasmus Dar-
win’s work on rotation (not Wells’s work) that may
have swayed Purkyně to abandon this idea and move
toward accepting a link between the vestibular system
and vertigo. In fact, on more than one occasion Purkyně
assigned sole credit to Darwin for his investigation of
vertigo and the physiologic background of this phe-
nomenon (Wade, 2003). This notion further supported
Purkyně’s apparent unfamiliarity with Wells’s work on
vertigo and nystagmus. This was reinforced by the fact
that Purkyně himself is often credited with being the
first to make the association between eye movements
and rotation (Wade, 2003). In fact, most of the work
related to vertigo and its physiologic and subjective
bases often begins with citing Purkyně and Flourens’s
work, which is clearly evident in Coleman Griffith’s
highly regarded, well-known, and often-cited histori-
cal perspective An Historical Survey of Vestibular Equili-
bration, published in 1922. Griffith begins his historical
survey with Purkyně and Flourens’ work on vestibu-
lar physiology, which may explain why most literature
often cites Purkyně and Flourens as the “Fathers of Ves-
tibular Science.”
. . . And Then There Were Six
The characterization of the original Aristotelian five
senses went unchallenged for nearly two thousand
years. It was Charles Wells’s 1792 treatise that provided
the first indisputable evidence that supported the link
between the patterns of eye movements in relation
to the direction of post-rotary vertigo. However, two
decades would linger on this evidential theory, until
scientific discovery would take another giant leap for-
ward. Scientific evidence would soon be provided by
Purkyně and Flourens in the early nineteenth century
that would significantly propel forward Wells’s evi-
dence. Interestingly, Purkyně and Flourens would pro-
vide this evidence independently from one another, as
both were actually unknown to one another during this
time (Bárány 1916, Laureate Lecture).
At the turn of the nineteenth century, both physician-
scientists independently published their reports on
3
While neither Purkyně nor Flourens ever referenced Wells’s work on vertigo and nystagmus, it remains curious that both scientists continued
to neglect Wells’s contributions to vertigo and nystagmus, even after he was briefly acknowledged by Erasmus Darwin in the third edition
of Zoonomia in 1801 (Wade & Tatler, 2005), which was 23 years prior to their landmark manuscript identifying the physiologic link between
vertigo, nystagmus, and the vestibular system.
vertigo and rotation, as well as semicircular canal
function. Purkyně’s early publication in 1820, Beiträge
zur näheren Kenntniß des Schwindels aus heautognost-
ischen Daten, continued to expand on the symptomatic
link between the vertiginous behavior of objects in
the visual field and rotation (Griffith, 1922). However,
it was Flourens’ landmark work published in 1824,
Recherches expérimentales sur les propriétés et les fonctions
du système nerveux dans les animaux vertébrés, that linked
definitively discrete physiologic disturbances in the
visual system when the semicircular canals of pigeons
were stimulated. Flourens would publish three more
landmark articles from 1824 through 1842 on the physi-
ologic link between the visual system and the semicir-
cular canals: (1) Experiences sur les canaux semicirculaires
de l’oreille dans les oiseaux (1830), (2) Experiences sur les
canaux semicirculaires de l’oreille dans les mammifères
(1830), and (3) Recherches expérimentales sur les proprié-
tés et les fonctions du système nerveux dans les animaux
vertébrés (1842) (this 1842 report having the same title
as his initial publication in 1824) (Griffith, 1922). It was
Purkyně’s and Flourens’ experiments and writings
from 1820 through 1842 that provided the scientific
evidence that confirmed the physiologic link between
the vestibular system and vertigo.
In particular, Flourens’ work in 1824 all but single-
handedly transformed the long-held belief, that the
vestibular system was responsible for sound localiza-
tion, into the more scientifically accepted belief that the
vestibular system was actually responsible for motion
perception (and vertigo, when aberrantly stimulated).
It was Flourens’ research involving the extirpation of
semicircular canals in pigeons which provided the ir-
refutable evidence for the vestibular system’s role in the
perception of motion, thus heralding the elusive sixth
sense. In the words of Róbert Bárány during his Nobel
Prize acceptance speech (Bárány, 1916, Laureate Lecture):
Flourens thought that it would be possible to
get an insight into the function of the semi-cir-
cular canal apparatus by destroying it. In fact,
these experiments which were undertaken with
pigeons, rabbits and other animals produced
quite remarkable, constant and previously
unknown disturbances. For instance, if the hori-
zontal semi-circular canal was destroyed in a
pigeon, it went on turning horizontally in a circle.
8 Balance Function Assessment and Management
If a vertical semi-circular canal was destroyed,
the pigeon turned somersaults. Flourens has
described the phenomena extremely well. But he
did not give an explanation. In particular, he did
not have the faintest idea that the animals were
suffering from vertigo. You can see from this how
easily one can pass by within an inch of the truth.
The concept of a sixth sense struggled for nearly
two thousand years after Aristotle first described the
five principle human senses. Therefore, it was not sur-
prising that the concept was not accepted universally
by scientists at the time. This skepticism included Jan
Evangelista Purkyně, who continued to remain some-
what hesitant in acknowledging all the available scien-
tific evidence at the time (Wade, 2003), largely because
his work continued to focus on the symptomatology
of the vertiginous response, rather than the neural
physiology.
Rotation in the Early Nineteenth
Century and Discoveries of
Vestibular Physiology . . . and Never
the Two Disciplines Shall Meet
A majority of the work investigating vertigo and rota-
tion in the first quarter of the nineteenth century was,
interestingly, not focused on that of scientific explora-
tion of dizziness but rather the clinical treatment for
the mentally insane. Despite the growing interest in the
use of rotation and the written accounts supporting
the “new” theory physiologically linking eye move-
ments and vertigo, the use of rotation in the early
nineteenth century was most commonly found in psy-
chiatric asylums.
Secondary to Erasmus Darwin’s publication of
Zoonomia, the application of rotation quickly became
a prominent therapeutic technique during the early
nineteenth century for psychiatric disorders. In 1801,
Erasmus Darwin introduced his “rotating couch”
(Wade, 2003) as a means of inducing intentionally pro-
voked vertigo and subsequent slumber in psychiatric
patients. The idea of “medicinal slumber” was well
accepted at the time and motivated many in the field of
mental health care to prescribe such medically induced
slumber for the treatment of psychiatric disorders in
the early 1800s (Cohen & Raphan, 2004). Well-known
psychiatrists Joseph Mason Cox, of Fishponds Private
Lunatic Asylum, and William Saunders Hallaran (c.
1765–1825), a physician superintendent at the County
and City of Cork Lunatic Asylum, even developed their
own “circulating swings,” for which they are probably
best remembered. The success of “Hallaran’s Circulat-
ing Swing” in 1818 (Breathnach, 2010) was adopted by
many at the time and, in particular, by Anton Ludwig
Ernst Horn (c. 1774–1848), of the Charité-Hospital in
Berlin, Germany. Horn eventually developed his own,
ceiling-suspended, 13-foot rotating bed, which was
capable of spinning 120 revolutions per minute (Belof-
sky, 2013) and producing up to four or five times the
force of gravity (Harsch, 2006). Horn’s “psychiatric
centrifuge” was also well accepted and widely used
between 1814 and 1818 for the treatment of mental
disorders. He reported success for the use of his “psy-
chiatric centrifuge” in patients with hysteria (Harsch,
2006). Medicinal slumber continued through the late
nineteenth century, including use of a human centri-
fuge in 1898 by Dr. F. R. von Wenusch to investigate
the therapeutic potential of acceleration (White, 1964).
However, the transition of using rotation for the treat-
ment of psychiatric disease to the diagnosis of vertigo
and dizziness would not occur until the vestibular sys-
tem’s role was firmly redefined, both physiologically
and clinically, from that of audition to one of motion
perception.
From Rotation of the Mentally Ill to
Vestibular Physiology Discoveries
Despite the absence in the use of rotation for the clini-
cal diagnosis and treatment of vertigo and dizziness
throughout the 1800s, there were significant research
advancements being made in the scientific understand-
ing of vestibular physiology in the later quarter of the
nineteenth century. Most notably, Ernst Josef Mach
(Figure 1–12), Alexander Crum-Brown (Figure 1–13),
and Josef Breuer (Figure 1–14) proposed the “hydrody-
namic theory of semicircular canal function” between
1874 and 1875. Ernst Josef Mach published Grundli-
nien der Lehre von den Bewegungsempfindungen in 1875,
Crum-Brown published On the Sense of Rotation and the
Anatomy and Physiology of the Semicircular Canals of the
Internal Ear in 1874, and most noteworthy, Josef Breuer
published “Über die Funktion der Bogengänge des
Ohrlabyrinthes” in 1874 and “Beiträge zur Lehre vom
statischen Sinne” in 1875. Although all were instrumen-
tal in the development of the hydrodynamic theory,
Josef Breuer’s role was particularly significant in its
development (Baloh, 2017). In fact, Josef Breuer would
be one of the most prolific vestibular physiologists in
the latter quarter of the nineteenth century, publishing
 1. An Historical Perspective of the Perception of Vertigo, Dizziness, and Vestibular Medicine 9

Figure 1–12. Ernst Josef Mach (1838–1916). Figure 1–13. Alexander Crum Brown (1838–1922).

more than 200 articles on the topic of vestibular physi-

ology in his lifetime (Baloh, 2017).
The introduction of the hydrodynamic theory of
semicircular canal function was staggering at the time.
It was a great leap forward in the understanding of ves-
tibular physiology, and the theory still remains promi-
nent to this day. It is interesting that Mach, Breuer, and
Crum-Brown independently arrived at similar conclu-
sions but from different perspectives. The independent
research from each scientist was truly brilliant, and elo-
quently recounted by Róbert Bárány during his 1914
Nobel Prize acceptance speech.
It is also worth noting that, during the time of
these discoveries, Alexander Crum-Brown also devised
methods for measuring thresholds for detecting body
movements on a rotating stool. He determined that the
thresholds were lowest when the head was positioned
so that one of the semicircular canals was in the plane
of rotation, a precursor to Ewald’s laws of semicircular
Figure 1–14. Josef Breuer (1842–1925).
canal function.
During this time period, Ernst Josef Mach also
published scientific reports investigating the nature of
otolith responses as well as the first reports indicating tilting of telegraph poles when rounding an inappro-
that the semicircular canals responded to acceleration, priately banked curve on a train (Cohen & Raphan,
not velocity (Cohen & Raphan, 2004). Between 1874 2004). For his work on subjective visual vertical, some
and 1875, Ernst Mach constructed a rotational chair consider Ernst Mach the “Father of Otolith Function
that was mounted in a rotatable frame and examined Testing.” Despite this otological notoriety, Ernst Josef
the perception of the visual vertical during static tilt as Mach, being an Austrian physicist and philosopher, is
well as the visual aftereffects of body rotation. Mach probably better known for Mach’s principle, which was
performed such studies after observing the vertical a precursor to Einstein’s Theory of General Relativity.
10 Balance Function Assessment and Management
Róbert Bárány and the
Early Twentieth Century
Toward the later part of the nineteenth century and the
early part of the twentieth century, the use of Horn’s
“psychiatric centrifuge” for medicinal treatment finally
gave way to more scientific evidence supporting the
use of rotation as a clinical method for investigating
vestibular function and dizziness. Nearly a century
after the well-accepted and routine use of patient rota-
tion for the treatment of psychiatric disorders, Róbert
Bárány (Figure 1–15) introduced the application of
patient rotation in 1907 as a means for the clinical assess-
ment of the vestibular system. Bárány developed the
first vestibular rotational chair that was universally
adopted in otolaryngology clinics at the time. For this
reason, modern-day rotational chairs are sometimes
referred to as “Bárány chairs.”
Despite the introduction of the Bárány chair into
many neurology clinics, the use of rotation in the clini-
cal diagnosis and treatment of vestibular and balance
disorders was slow. In fact, in the beginning of the
twentieth century, there was almost no advancement
of rotational research. This was likely due to one of
the most significant discoveries in clinical vestibular
physiology. In 1906, Róbert Bárány published his most
renowned paper, “Untersuchungen ueber den vom
Vestibularapparat des Ohres reflektorisch ausgelösten
rhythmischen Nystagmus und seine Begleiterschei-
nungen” [Investigations of Rhythmic Nystagmus and
Figure 1–15. Róbert Bárány (1876–1936).
Its Accompanying Manifestations Arising from the
Vestibular Apparatus of the Ear] (Nylen, 1965). In this
manuscript, Bárány would describe the alternating
nystagmus response that occurred following adminis-
tration of sterile water to the external ear canal. Earlier
Bárány and others (e.g., Gustav Alexander, Heinrich
Neumann von Héthárs) had observed such a nystag-
mus response consequent to ether being used as a ster-
ile wash over the labyrinths during otologic surgery.
Although this response was regularly observed dur-
ing labyrinthine surgical procedures, Bárány made the
crucial “bench-to-bedside” link that forever changed
the clinical assessment of vestibular function. In short,
Bárány had taken a “simple” surgical observation and
conceived the caloric test, a simple bedside measure
that could be used to evaluate each vestibular system
independently. For this landmark work, Bárány would
be awarded the Nobel Prize in Physiology and Med-
icine in 1914. In fact, no other Nobel Prize has been
awarded in the field of vestibular medicine (noting that
George von Békésy received the Nobel Prize in Physiol-
ogy and Medicine in 1961 for his work in the field of
hearing science on the cochlear traveling wave).
Unfortunately, the life of Róbert Bárány and his
receiving the Nobel Prize were not necessarily a cause
for celebration.
Nobel Laureate Róbert Bárány
in a Time of Controversy
Upon the announcement of Bárány’s Nobel Prize,
Róbert Bárány was a few thousand miles away being
held as a prisoner of war in a Russian camp. Bárány’s
notoriety as a world-renowned otologist followed him
as a prisoner of war, such that he found himself not
only treating otologic and neurotologic disease among
his fellow POWs, but also treating the Russian com-
manders and their immediate family members. News
of Bárány winning the Nobel Prize would eventu-
ally make its way across the Russian Steppe to where
Bárány had been serving his time as a POW. Bárány’s
controversial release from the Russian POW camp
was negotiated by Prince Carl of Sweden, after which
Bárány traveled to Sweden and received his Nobel
Prize in 1916. Upon Bárány’s arrival in Stockholm,
Sweden, he was lauded as any other Nobel Laureate.
There, he delivered his Laureate lecture “Some New
Methods for Functional Testing of the Vestibular Appa-
ratus and the Cerebellum” to much pomp and circum-
stance. However, Bárány’s praise would be short-lived.
After receiving his Nobel, Bárány returned to Vienna
and was greeted with disdain and controversy by those
 1. An Historical Perspective of the Perception of Vertigo, Dizziness, and Vestibular Medicine 11
with whom he had practiced and refined his neurotol-
ogy and surgical skills. These individuals included
Heinrich Neumann von Héthárs, Alexander Spitzer,
and Ádám Politzer (who many consider to be one of
the fathers of modern otology4). Bárány even received
a significant amount of criticism from his close friend
Gustav Alexander, as well as from Ernst Mach, Josef
Breuer, and Julius Eduard Hetzig (Baloh, 2017).
There seemed to remain a persistent and pestering
question that lingered in Vienna regarding the “misdi-
rected” awarding of the Nobel to Bárány. Specifically
questions remained as to whether or not Bárány com-
menced his Nobel Laureate work on the bedside caloric
stimulation of the labyrinth after he had witnessed
Alexander Spitzer, Julius Hetzig, and Josef Breuer’s
demonstration of labyrinthine nystagmus in experi-
mental animals, and after he had previously observed
the labyrinthine nystagmus response while ether was
washed over the labyrinth during neurotologic sur-
gery with Heinrich Neumann. Subsequently, formal
“charges” were brought to the Vienna Medical Faculty
Academic Senate claiming that (1) Bárány did not dis-
cover the caloric reaction, but rather this credit should
go to Alexander Spitzer, Julius Hetzig, and Josef Breuer,
(2) Bárány omitted the fact that he obtained the idea
for the change in nystagmus direction with cold and
warm water from Heinrich Neumann, and (3) Bárány
did not give proper credit to earlier investigators in his
writings, specifically failing to cite Alexander’s previ-
ous work outlining otologic surgery at the time (some
of which were even coauthored with Bárány; Baloh
2017). To these charges, the Academic Senate responded
by stating:
Dr. Bárány did not act scientifically correct,
which was his duty as a faculty member, scientist
and writer. His behavior demonstrates eminent
carelessness in terms of the intellectual property
of others. . . . His failure cannot be attributed to
a lack of skill or training; in contrast, it is evident
that Dr. Bárány represents a person of outstand-
ing capabilities, diligence, and training. The
errors, failures, and one-sided descriptions in his
articles and lectures can only be explained by his
addiction to enlarge his own merit at the expense
of others. (Baloh, 2002)
Expectedly, Bárány was bitterly disappointed
by his reception in Vienna and took the opportunity
to accept a position to develop a new otolaryngology
4
Not to slight Guichard Joseph Du Verney, who was perhaps the very first otologist (Traynor, 2015).
clinic in Uppsala, Sweden. During this period, the same
accusations were brought against Bárány to the Medi-
cal Faculty of the Karolinska Institute in Stockholm,
Sweden, the institute responsible for awarding the
Nobel Prize. The Karolinska Institute concluded that
Dr. Bárány did act scientifically correct. Hitzig
and Breuer’s work was purely experimental and
. . . Bárány should be given priority for discov-
ery of the caloric reaction. Regarding Neumann’s
suggestion to Bárány during an operation to test
the effect of cold and warm water on the caloric
reaction, the Faculty concluded that Bárány had
already reported on his findings regarding the
change in direction of the caloric reaction several
months earlier in an article at an Academy meet-
ing. (Baloh, 2002)
Letters in support of Bárány were sent to the Kar-
olinska Institute, most notably by Bárány’s longtime
good friend, Rafeal Lorente de Nó (who would later
be recognized for detailing the VOR pathway in his
1933 landmark paper “Vestibulo-Ocular Reflex Arc”).
Although he was pleased with the outcome, Bárány’s
life was never the same. In spite of being a Nobel Laure-
ate, Bárány lived a very quiet, almost lonely, existence
(Baloh, 2017). He enjoyed music and playing the piano.
Bárány’s life in his last few years would be marred by a
series of strokes from malignant hypertension, leaving
him with partial paralysis (Baloh, 2017). Bárány died
on April 8, 1936, two weeks before an international
meeting to celebrate his sixtieth birthday. He would
later be commemorated numerous times over, culmi-
nating in the establishment of the International Bárány
Society (founded in 1960 by Charles Skinner Hallpike
and Carl O. Nylen), through which the Bárány Medal
is awarded to an individual whose distinguished con-
tributions to neurotology and vestibular medicine are
preeminent in the field.
Moving Forward in the
Wake of History
With the exception of the more nascent vestibular
sensory-evoked potentials (VSEPs) and vestibular
evoked myogenic potentials (VEMPs), vestibular tests
of today have largely rested on the principle founda-
tions of the vestibular ocular reflex arc, head rotation,
12 Balance Function Assessment and Management
and caloric stimulation. These are, in fact, the very same
principles that had their humble beginnings in the late
1700s. Although some may debate how much has really
changed, there is no doubt that significant advance-
ments have been made in vestibular assessment.
The current state of vestibular science is poised to
enter a new renaissance of clinical discovery. There is
evidence for future testing protocols that could favor-
ably expand and even redefine vestibular outcome
measures, from vestibular threshold perception pro-
tocols to neurological vestibular evoked potentials,
to unprecedented complex stimuli delivery systems.
Together with a vast array of physiological and genetic
understanding, new research using highly advanced
devices, methods, and stimuli will undoubtedly
expand our understanding of vestibular function and
dysfunction.
Throughout the entire historical perspective of
vestibular medicine, since the days of Charles Wells,
Jean Pierre Flourens, Ernst Mach, Josef Breuer, and
Robert Bárány, one thing has remained a fundamental
truth: A thorough understanding of vestibular anatomy
and physiology is essential to the understanding and
advancement of vestibular science. We must remember
that it was not complex and ultra-sophisticated devices
that gave us Ewald’s laws and the “hydrodynamic the-
ory of semicircular canal function,” but rather it was the
result of an excellent marriage of thought between the
understanding of stimuli and physiologic outcomes.
No one knows for certain what the future of vestibu-
lar research may bring; however, one thing has always
remained certain since the time of the great Greek poet
Homer (c. 750 bc): “I know not what the future holds,
but I know who holds the future.”
Epilogue
The summation of historical events is, if nothing else,
very labor intensive. Piecing together historical facts
and moments in time can be tricky. Thankfully, there
are bodies of work from individuals that have signifi-
cantly contributed to ease this challenge. Although
many sources have contributed to the events portrayed
in this chapter, there are some bodies of work that have
proven extremely helpful, which I would like to high-
light and acknowledge here.
This chapter could not have been possible without
the literary works from Nicholas Wade and Benjamin
Tatler, specifically for their publications of “Destined
for Distinguished Oblivion: The Scientific Writings of
William Charles Wells” (Wade, 2003) and “The Moving
Tablet of the Eye: The Origins of Modern Eye Move-
ment Research” (Wade & Tatler, 2005). I especially
wanted to highlight these two works, for much of the
synopsis of Charles Wells and Erasmus Darwin relied
on these authors’ tireless research of the historical events
that surrounded Wells’s and Darwin’s scientific lives.
In addition to these two sources, the historical
events of Róbert Bárány were exceptionally summa-
rized by Dr. Robert Baloh in two articles as well as a
text published in 2017, Vertigo: Five Physician Scientists
and the Quest for a Cure.
Credit and praise for these sources are immea-
surably acknowledged here, and all of these sources
would certainly have my strong recommendation for
anyone looking for an excellent read.
Figure 1–16 provides a historical timeline of senti-
nel vestibular events.
Another random document with
no related content on Scribd:
 About nine o’clock we passed Gomba, inhabited by Fulahs, and
the capital of the district. Our guide Amadu evidently thought we
should stop there to see the chief, and showed great surprise at our
pressing on without a halt. To his discreet suggestions I turned a
deaf ear, and our interpreter seemed suddenly to have forgotten all
the Fulah language he knew. In the end our guide resigned himself
to the inevitable.
We had to make haste, for, reflecting on the causes of the check
we had received at Ilo, I was led to think that the English might have
had something to do with it, or, at least, that people who had been
amongst them—for the English themselves have no political
influence in these parts—had had intelligence enough to understand
and look after their interests. In the suite of the chief there was a
native of Bidda, who asked me to let him accompany me back to his
native place, but he too disappeared. In any case, however, as
Amadu told me, the news of our stay at Say had not yet reached
Gomba, still less Bussa, we might still, by pushing on rapidly,
circumvent the plans of those who were anxious to make mischief.
Forward then as rapidly as possible!
 OUR GUIDE AMADU.

We soon passed the mouth of the Ngubi-Sokoto, of anything but

imposing appearance, but, as we were told, navigable at high water
for canoes until nearly up to the village from which it takes its name.
In the evening we had made more than 32 miles, the longest
distance achieved yet by the expedition in one day. We anchored a
little beyond Lanfaku.
Here we were visited by two parties of fishermen, who came to us
in canoes from the villages, such as are scattered about near all
important Fulah centres of population. The young men had their
heads shaved, but for a kind of tuft of hair left on the middle of the
upper part of the head, which was really not at all unbecoming.
Amadu told me that the Grunner expedition had been attacked on its
return from Gando at the village of Gesero, which was at war with
Gando. The inhabitants had tried to stop the guides of the Germans
by firing at them. Grunner had therefore burnt their village.
 At ten o’clock we were overtaken by a tornado. We were back
again in the winter in fact, and every night there was a storm, or at
least a downpour of rain.
On the 29th we continued our forced march, passing several fine
villages surrounded by tatas. Kundji seemed a very big, strong place.
At about eleven o’clock we passed three rocks which probably
form part of a bar across the river when the water is low, marking the
beginning of the difficult and broken course below. At four o’clock we
anchored opposite Tchakatchi, on an island at the foot of a group of
magnificent baobabs. At the end of this island is a great mass of flint,
and the banks were strewn with the big rocks of polished granite we
knew so well. We were back again amongst the rapids, and had
once more to encounter difficulties such as we had conquered at
Ayoru and Kendadji. The whole village turned out to see us, and the
chief himself offered to act as pilot. I accepted his suggestion, for our
old Amadu had rather exaggerated his hydrographical knowledge.
The only garment of most of the men of the village was a little leather
apron worn behind, but some few wore drawers made of blue
Haussa cotton. The faces of the women were scarred in the same
way as those of their sisters of Kebbi, and they wore as ornaments in
the lobes of the ear, little pieces of white stick about a quarter of an
inch in diameter by seven inches long.
At seven o’clock the next day we started, preceded by the chief of
Tchakatchi, who steered a tiny little canoe with a paddle curiously
shaped and carved. The river was very much what we had expected
it would be the evening before, the rocks forming a regular
archipelago of islets, whilst rapids were also numerous. Fortunately
this state of things did not last long, and presently we came to an
almost calm reach, which brought us to Gilua, the capital of Yauri,
where we noted one very large hut, the residence of the chief of the
village.
I was in despair at having to travel like a bale of goods, without
being able to have any intercourse with the people whose country
we were passing through. But what could we do? Since we left Say
we had had no power to treat with the natives, our interpreters were
scarcely any good, whilst before us we had two great obstacles,
Bussa and the English.
According to the most recent information collected, it was at Gilua
and not at Bussa that Mungo Park died. Here then we had reached
the limit of the path he trod one hundred years ago, and I
remembered what Davoust had said to me: “Mungo Park has
become immortal through merely having tried to do what we shall
now endeavour to accomplish.”
I confess in all humility that since my return to France I have had
to change my opinion on that point.
On the left and right of the river there were two mountains
remarkable for their shape and their relative dimensions. I tried to
find out their names, but was told that they had none in particular. To
do honour to our comrades who had died under such melancholy
circumstances, I baptized them Mount Davoust and Mount
Delagarde, the latter having been the name of a naval officer who
died without reaching the Niger.
I trust that these names will be considered of good omen by
geographical critics in France, and that it will be admitted that I had
every right to choose them. Have not the English named all the
peaks of the chain on the banks of the river below Bussa after their
great men? Mount Davoust will look quite as well in our atlases as
Mount Wellington does in theirs.
We pushed on on the right between the villages of Ikum and
Rupia, and after passing a little rapid we anchored opposite a big
tree, beneath which a market was being held—an important one I
was told by the people of Rupia. The chief of Tchakatchi had told us
that we should meet his brother there, who would pilot us further, but
he had left that same morning. As usual the people began to shilly-
shally with us, and some men from Igga, whom we identified by their
white turbans embroidered with green, sold to them by the Royal
Niger Company, interposed in the conversation, but not in our favour.
“Off again!” was the word; we would push on and still push on,
alone and without a pilot or help of any kind, but we would not be
trifled with.
The people of Rupia are many of them Kambaris, a tribe alluded
to by Richard Lander. Their women when young go about quite
naked, and have the head shaved, but for a narrow tuft of hair left on
the top. They have the peculiar custom of dyeing their legs up to
above the knee with rocou, or red dye, which gives them the
appearance at a distance of wearing nothing but light red stockings.
This was the first occasion on which I had seen people in a state
of nudity in the Sudan, and this is the more remarkable as there are
plenty of stuffs to be had cheap at Rupia.

DJIDJIMA.

Noticing my astonishment, one of the beauties of the place made

the following naïve remark to me, which I thought was really rather
sensible: “Why should we wear clothes? Are we so badly made that
we need hide ourselves? All in good time, when we are old like our
mothers, we will make up for the loss of our physical advantages by
well-made clothes, but not till then.”
 Many are the women on this earth of ours who could not say as
much!
A little mollified by what my young friend said, I still felt perfectly
furious at the sullen hostility and evident prejudice against us we
now constantly met with, which delayed our journey in a manner so
dangerous. Rightly or wrongly, I saw the hand of the English or of
their agents in it all. Fortunately, however, the river is easy of
navigation as far as Djidjima, a village picturesquely situated on an
island, opposite to which we anchored at four o’clock.
In the evening we went to the village, and I asked for a guide for
the next day, without much hope of getting one. I tried to win the
people over to my side by distributing a great many little presents.
We were invited to be present at a tam-tam, at which three dancers
performed, wearing leggings from which were suspended little bits of
iron resembling castanets, that made a deafening noise as they
struck against each other. The dancers, moreover, were very clumsy
in their attitudes.
No guide the next morning, but more men from Igga to stare at us.
The accounts that Amadu gives us of the difficulties of navigation
before us are heartrending, and as a matter of fact a little further
down, the river began to divide again into a great many arms. We
therefore anchored, and Digui went on in a canoe to reconnoitre.
Whilst he was away exploring we saw some eighty or a hundred
canoes going up an arm on our right, the tam-tam beating
ceaselessly. On inquiry we were told that it was only a water convoy
on the way to Rupia, where a very big market was about to be held.
All the way along the canoes stop to take up traders and their goods,
very much as the small steamers do on the Seine, or the omnibuses
in the streets of Paris. A canoe presently separated from the rest and
came towards us, its occupants saying very amiably that seeing we
had stopped, they had come to ascertain whether we were in any
difficulty, and to offer to guide us.
There is no doubt there is a good God for honest folk, I very
nearly added, and against the English. Be it remarked, for the reader
to draw his own moral, that everywhere the inhabitants of the little
villages, in a word the poor, helped us. The perpetual difficulties we
had to contend with in this part of our journey only arose in the big
centres.

THE NIGER BELOW RUPIA.

Delighted at this chance of going on, we started, our guides being

anything but de trop, passing several dangerous rapids and arriving
safely at Fogué, where the river became once more calm.
On October 2 we had a hard day, but it was the best before we
got to Bussa. Near Waro we had twice to go on in single file. The
force of the current was now immense, seven miles an hour at least.
Once more we felt as if we were dashing over cataracts, a painful
sensation we were all too familiar with. Our guide had met a friend,
who also to the best of his lights helped us to steer a right course. At
half-past five we reached Bussa, and anchored opposite the landing-
stage of the village. The river here divides into several arms, the
town being on that farthest to the right, about a mile from the bank. A
little village occupied by fishermen and traders was situated close to
our camp. The water, which is of a black colour, seems very deep
here, and the islands are covered with beautiful vegetation. The
natives approached us without fear, and we at once began to barter
with them in the usual manner, exchanging cloth, bracelets, rings
and beads for provisions.
I sent Amadu to greet the chief of the village, promising him a
good present if he succeeded in making that chief behave well to us.
I waited his return with impatience. There we were face to face
with our last but perhaps the greatest difficulty of our voyage. A very
considerable fuss is made about the cataracts or rather the rapids of
Bussa. Providence had so far befriended us, and enabled us to
reach this point without having lost one of our boats. Not a single
man, white or black, belonging to the expedition had lost his life
through what a year ago had been called our temerity. We had
managed everywhere with greater or less difficulty to pass on in
peace, leaving behind us none who had cause to hate us or to vow
vengeance on us. Yet one last effort, and our aim would be achieved
just as I had hoped to achieve it, exactly in accordance with our
instructions, in spite of all the difficulties thrown in our way, not only
by inanimate nature but by man. Just because this was to be our last
struggle we dreaded it more than we had done any other. I was
therefore immensely relieved when I saw Amadu coming back
accompanied by an emissary from the chief. According to him all
would go well, all was arranged; the chief of Bussa would supply us
with all we needed, and, greatly to the delight of our men, give us all
the help required for passing the rapids safely. A good supply of the
fruit called kus accompanied these cheering words. The chief would
receive us the next day.
Whilst I was chatting with our guide and the natives who
accompanied him, some girls were singing our praises and those of
their master. According to their songs the people of Bussa are
descended from the Persians, and they do in fact claim that they are
the children of Kisira, who fought with Mahomet, and were driven
away by him. Reference to history will show us that Kisira is only
another name for Chosroes the Great, who was, as a matter of fact,
the unfortunate adversary of the founder of Islam.
I state the fact for what it is worth, for the benefit of ethnologists.

A PALAVER.
THE SO-CALLED NIGRITIAN, THE OLD PONTOON OF YOLA.
 CHAPTER X

FROM BUSSA TO THE SEA; CONCLUSION OF OUR

VOYAGE

The whole of the morning of the 3rd was occupied in receiving

visits from people more or less nearly related to the chief, and in the
afternoon I was informed that his Majesty himself would receive me.
We crossed a marsh between the village and the bank, and duly
arrived at Bussa.
There is nothing very imposing about the town, and it has been
recently much damaged by fire. We stopped at the door of a big
round hut, some thirty-five to forty-five feet in diameter, which was
really very well built. After a brief delay we were admitted.
The chief of Bussa was squatting on a bench of hardened earth,
some twenty inches high, and wore a bubu of doubtful cleanliness,
and a cap such as that worn by the eunuch in Molière’s play to which
I alluded in speaking of Dendi. The bench was covered with just
such a red carpet, with a lion rampant as I had seen at Tenda. The
chief’s spear was stuck in the ground beside him, and his sceptre
consisted of a cane ornamented with copper and silver. A horribly
ugly wife, with a face covered with scars, shared the royal bench,
whilst the courtiers remained squatted on the sand during the
interview. On entering the hut every one was expected to kneel, and
on reaching the chief the visitor had again to prostrate himself and
cast sand upon his own head.
 VIEW OF BUSSA.

A wooden bench was assigned to us to sit on, and I spread out

the handsomest present I had brought with me.
Salutations were now exchanged. Thanks were given in the name
of the Sultan of the French for the help given to Captain Toutée the
year before by the Bussa canoes. I then slipped in a word about the
facilities of transport I hoped for for myself.
The reply was evasive, and moreover the expression of the chief’s
face was anything but intelligent. We returned on board.
The next day our visitors became more and more numerous.
Having shown off the phonograph to various persons, the rumour of
that wonderful instrument reached the ears of the chief himself, and
he sent word to me that he too would like to hear it.
 NATIVES OF BUSSA.

He was, however, unwilling to put himself to any inconvenience

for the sake of it, and wished me to take it to him. Anywhere else but
at Bussa I would have said he might go to the devil, for it would be a
very delicate operation to take the phonograph to him, especially
across the marsh. But I was determined to do all in my power to
conciliate the chief, so as to have his aid when I crossed the rapids.
Four of my strongest coolies were therefore told off to carry the
instrument, which fortunately arrived without sustaining any damage.
The scene when I showed off the powers of the phonograph was
interesting, for while the attendants of the chief could not conceal
their surprise, he himself maintained his dignity, and his set features
expressed nothing but stupidity. He offered us a sheep, because he
said, “Now that we have been well amused, we must eat well.”
Trying to turn his good humour to account, I reverted to the question
I had at heart—the passage of the rapids. It appeared that my
question on the subject had not been understood the evening before,
at least so I was now given to understand. I repeated my request,
taking care this time to make my meaning perfectly clear. I wanted
Bussa canoes to take everything we had on board down below the
rapids to the village of Auru, as they do the merchandise of the
village. We ourselves could then pass down quite easily in our
lightened crafts with the guides I also asked for. I got a promise at
last that all my wishes should be met.

CANOES AT BUSSA.

On the 5th, however, there were still no canoes, but at four o’clock
the chief sent for me and told me that the whole thing was arranged
and settled. In fact, I heard him give the orders to two negroes, who
were, I was told, the chief canoe men. We agreed that I should pay
two hundred thousand cowries. Thinking that everything was really
settled this time, I gave the chief my own fowling-piece and a little
pocket revolver.
 WOMEN OF BUSSA.

During the day more big canoes, from about twenty-seven to

thirty-three feet long, came alongside of our boats loaded with rice
and the native produce called karité. The English at Seba I was told
give two bags of salt for one of rice, and the karité which comes from
Rupia fetches a good price in the factories.
I must note here, en passant, how little we French know how to
make the most of what we have in our colonies. This karité, for
instance, which is a greasy substance extracted from the fruit of the
Bassia parkii, is to be obtained in immense quantities in the French
Sudan. It has been analyzed, and there has been a great deal of talk
about it in periodical literature, but not a pound of it has been
exported.
 WOMEN OF BUSSA.

I had mentally fixed the 7th as the date for our departure from
Bussa, at whatever cost. We had now been there three days, and
the English must have heard of our arrival. How would they behave
towards us? I know that the Royal Niger Company is not particularly
scrupulous as to the means it employs, and of this there are plenty of
well-known instances: such as the torture of Mizon by Flint at
Akassa, after being wounded in a fight with the Patanis, who were
perhaps incited against him; or in the case of the foundering of the
Ardent, when her crew, deprived of fresh provisions, died off, the
Company showing not a scrap of compassion for them, or at least
not sending them any help.
 TRUMPETERS OF BUSSA.

From the English point of view, it would be a fairer way of making

war to rouse the people of Bussa against us; but never mind, we
have cannon, rifles, and thirty thousand cartridges, so that although
the natives do own a certain number of quick-firing weapons, we
should be the ones to get the best of it in a fight.
What I really dread more than the open hostility of the Company is
a sham friendliness on their part. If they came to our aid, offering to
help us, even in spite of ourselves, it would only be a bit of clever
diplomacy on their part, really quite against our interests.
I knew that the English had a post at Leba, about forty-four miles
down-stream, and if there happened to be men enough there, they
might send a detachment up to us, to conquer difficulties they had
themselves perhaps created, when they would loudly declare that
they had saved our lives.
 Should this take place, I feel pretty sure there are many in France
who would be simple enough to be taken in; such a thing has
happened before now, and I bet you anything you like, the English
will be warmly thanked. Remaining behind after we are gone too,
they will reap all the moral effect of our arrival from the Upper Niger;
the natives distinguish very little between the different white nations,
and it would be only too easy for the English to represent that we are
fellow-countrymen of theirs who have established themselves higher
up-stream.
If, therefore, we meant to succeed, and not to have our expedition
fail at the very entrance of the long-hoped-for haven, we must push
on as soon as possible, with or without the help of the natives. This
was the resolution come to by us five in a little council of war we held
together.
At four o’clock in the afternoon there was still no sign of a canoe.
The moment of decision had come. We had quantities of things in
our holds of little use or value, so I determined to lighten the boats as
much as possible, partly to lessen their draught, and partly to make it
easier to get at their bottoms to plug up any leak which should occur.
To begin with, there was all our ammunition, for except for a few,
used to practise shooting and to kill crocodiles, our store of thirty
thousand cartridges was intact. I decided to sacrifice twenty-two
thousand, and Digui, having found a place where the river was deep
enough not to dry up in the summer, our canoe went backwards and
forwards, and our men threw the cases into the river one by one.
The natives of Bussa ran to the banks and looked on in stupefied
astonishment; the copper cases gleaming in the sunshine excited
their cupidity.
Next we drowned many of our other stores. Into the water with our
bottles of oil and pots of pomade! Then into the fire with our celluloid
bracelets, necklaces, and rings! The despair of the natives on the
bank became deeper and deeper, reaching its height when, just to
wind up with éclat and to increase their regrets rather than from
necessity, we flung two or three dozen many-coloured umbrellas on
to the blazing pile. This produced positive desolation amongst the
spectators. All the better, it would teach them to behave properly to
foreigners.
A Fulah, sent I was told by the Sultan of Gando, flung himself at
my feet and entreated me to stop the destruction, assuring me that
the chief of Bussa would do all we wished. I reminded him of a
proverb current in his native place: “It is no good to put the fish back
in the water after it is cooked.” I had often been to that monarch’s
court, I added, and I had no time to begin all over again, probably in
vain, the palavers of yesterday and the day before that. I had had
enough of it now.
The river was falling too; we had noticed a decrease of some four
inches in the depth of the water during the last twenty-four hours,
and although all the natives agreed in declaring that it was only
temporary, I was not going to run the risk of finding our passage
blocked.
Amongst the crowd I noticed a diavandu from Igga, who was
trying to incite the natives against us. There were several of his
fellow-countrymen there too, easily identified by their bubus with the
green embroideries already referred to as sold by the Niger
Company.
I was now assured that the chief had had his canoe men put in
irons for disappointing us, but unfortunately a minute afterwards I
recognized them in the crowd.
I copy the following sentence from my journal written on the spur
of the moment—
 WOMEN OF BUSSA.

“It is very evident that the English have not lost time since last
year; they have not, it is true, as I feared they would, pushed their
effective occupation up-stream, but have merely, so to speak, set
going the cavalry of Saint George. Their plan is simply to delay us;
yes, to delay us till it is impossible for our boats to pass the rapids.
We should then be obliged to go by land through Burgu, which they
know to be dangerous, and where they have no doubt sown
obstacles for us—one well-aimed shot, one well-planted poisoned
arrow, and there would be an end of our expedition and its results.
Otherwise there would be nothing left for us to do but to go down to
Leba and ask the English to co-operate with us.
“This was the policy described by Agoult, but Inch Allah! our rivals
will not have the latter satisfaction. Let us pass the rapids somehow
or other, and I promise myself that I will describe the odiousness of
such conduct even to, indeed especially to, the honest portion of the
English nation. The first thing to be done is to pass the rapids.”