Keywords: Margaret R. Dix - Charles S. Hallpike - vestibulolithiasis
Palavras-chave: Margaret R. Dix - Charles S. Hallpike - litíase vestibular
In 1945, at the end of the Second World War, Dr. Margaret Dix joined the staff of
the Otological Research Unit at the National Hospital, Queen Square, London, UK. Seven
years later, Dr. Dix, together with the head of service, Dr. Charles S. Hallpike described
the clinical bedside test, aimed to provide an immediate diagnosis of the presence
of solid particles in the endolymph of the posterior vestibular semicircular canal.
We describe the experiences of these two researchers who have enshrined their names
in the history of modern neuro-otology.
MARGARET DIX
Margaret Ruth Dix ([Figure 1 ]), the daughter of a Clerk in Holy Orders (a Shropshire rector), was born in 1902
and grew up with parsonage discipline of kindly good manners and a sense of responsibility.
Little is known about her early school years. She studied medicine in London, at the
Royal Free Hospital, School of Medicine for Women. When asked why she chose a medical
career, she would reply: “Because a woman cannot be a clergyman”[1 ].
Figure 1 Margaret Ruth Dix.Queen Square Archives authorized.
Before the war, Margaret was outstandingly beautiful, with a lovely complexion and
eyes that could truly be described as sparkling—a young woman whose enjoyment of life
was evidenced by her whole bearing.
In 1937, she qualified and was appointed as House Surgeon to Sir Douglas McLaggan
(among others), who recognized her competence and allowed her to perform tonsillectomy
surgeries, which appeared deceptively simple in her hands. During the war in 1940,
in a German air-raid “Blitzkrieg”, a tragic accident changed the course of her life
when she was hit by a window and her face was unrecognizably mutilated by multiple
deep lacerations. One eye was badly damaged and an eardrum torn. Although treated
by the eminent pioneer in plastic surgery, Sir Archibald McIndoe, the scars remained
for the rest of her life. Fragments of glass lodged in her eyes, preventing her from
continuing her career as a surgeon[1 ]. Reconstruction of her face and rehabilitation were prolonged and a painful process,
and pieces of glass were extruded from time to time.
Her own experience and that of her severely deaf mother made her sensitive to the
needs of patients. In 1945, she joined the staff of the Medical Research Council Otological
Research Unit at the National Hospital under the direction of Dr. C.S. Hallpike, carrying
out research on deafness in ex-servicemen. This led her on to a career in neuro-otology,
investigating diseases of the inner ear and its central nervous pathways, and pioneering
what was initially a new branch of medicine at that time.
She published over 100 articles on a wide range of auditory, vestibular, and neurological
conditions, and received international recognition and numerous prizes for her work[2 ].
Margaret Dix was appointed Honorary Consultant to the National Hospital in 1965 and
worked there until her retirement in 1976 as a locum consultant until the age 70.
In her spare time, she was an accomplished painter, and enjoyed writing poetry[2 ]. She died on December 9, 1991, at the aged of 89.
CHARLES HALLPIKE
Charles Skinner Hallpike ([Figure 2 ]), was born in Murree, India on July 19, 1900. At three years of age, his family
came to London, and he was educated at St Paul's School, graduating in 1919[3 ].
Figure 2 Charles Skinner Hallpike (in 1956).Queen Square Archives authorized.
The young Charles was an excellent athlete, but when he has 12 years old, his life
was changed due to an aseptic necrosis of the femoral head (Legg-Calve-Perthes disease)
after a minor trauma. This condition forced him to walk with a crutch due an increasingly
painful osteoarthritis of the hip[4 ].
Hallpike became interested in studying temporal bone pathology while he was a research
fellow at the Ferens Institute of Otology in London in the early 1930s[4 ],[5 ].
He published 241 papers. The most important were on Ménière's disease, vestibular
function, optokinetics, caloric nystagmus, and inner ear degeneration[5 ].
In July 1935, he married Barbara Lee Anderson[5 ] and had two sons and one daughter. The elder son, Jeremy, who was born in 1936,
also studied medicine, and became a consultant neurologist in Australia. The younger
son, Timothy, became an officer in the Royal Navy, and the daughter, Janet, took an
honors degree in English and Theology in Cambridge, but died in 1966[3 ].
In 1942, Hallpike joined the scientific staff of the Medical Research Council at the
National Hospital, Queen Square, London, where his power of organization and administration
resulted in his appointment as Aural Physician and Director of a newly-established
Otological Research Unit at the hospital[6 ].
He began his career in neuro-otology thoroughly reading the works of the Austrian
Nobel Prize winner, Robert Bárány. He was well grounded in the German literature and
frequently quoted Bárány in his publications. Interestingly, there were remarkable
parallels in the careers and lives of Hallpike and Bárány. Both had physical disabilities
in their legs from childhood that limited their physical activity throughout life.
Both had dramatic early successes that propelled their academic career—Bárány with
the caloric test and Hallpike with the pathology of Ménière's disease. They were clinicians
first, researchers second, and much of their work was directed toward developing reliable
clinical diagnostic tests. Both were extreme perfectionists and had a fascination
with the central nervous system. Both (mistakenly) believed that the cause of positional
nystagmus was an otolithic disease. Unfortunately, both had multiple strokes at the
end of their lives[4 ].
According to Margaret Dix, Hallpike was quick to recognize and appreciate good work,
intolerant of fools but unfailing in giving due credit to his co-workers. His special
interest was in the relationship of experimental observation to clinical problems[6 ].
In his 70s, Hallpike suffered several transient ischemic attacks and had to give up
driving in 1976, after having had some minor accidents.
After his retirement, he enjoyed gardening and won prizes locally for his roses. He
died in Southampton on the September 26, 1979, at the age of 79.
THE ‘LAGERUNGS’ MANOEUVRE
THE ‘LAGERUNGS’ MANOEUVRE
Margaret Dix and Charles Hallpike produced vast coauthored otology and neuro-otological
literature[7 ],[8 ]. In 1952, they published a 13-page manuscript: The Pathology, Symptomatology and Diagnosis of Certain Common Disorders of the Vestibular
System
[9 ], which became a landmark in contemporary neuro-otology. They carried out an excellent
study of symptoms and natural history of the three most common peripheral vertigo
diseases: Ménière's disease, vestibular neuritis, and benign paroxysmal positional
nystagmus. For the latter, 100 patients were studied, and the authors described the
‘Lagerungs’ manoeuvre[10 ] in detail ([Figure 3 ]).
Figure 3 The critical head position for positional nystagmus of the benign paroxysmal type.
The ‘Lagerungs manoeuvre[9 ],[10 ]. Queen Square Archives authorized.
Hallpike's final comments on positional nystagmus were presented at a meeting of the
Bárány Society in London, when he was 77 years old[4 ]. Since Dix and Hallpike's description, this has become the most-used test in the
diagnosis of posterior semicircular canal lithiasis, with the sensitivity and specificity
estimated at 79% and 75%, respectively.
