By: Atlanta DUI Attorney Bubba Head
German neurologist Moritz Heinrich Romberg, the 19th Century Jewish doctor from eastern Germany, published a medical book on topics relating to discoveries he had made in his first two decades at the Berlin charity hospital. Charity hospitals were the teaching hospitals of that era, and handled charity patients.
Having thousands of patients needing free medical advice and treatment, Dr. Romberg kept data on the many people with neurological problems. He utilized the information he collected from sick patients to learn how to use a neurological test targeting the vestibular region of the brain, that now bears his name.
Over 175 years later, doctors worldwide STILL use these basic balancing tests to perform two very simple proprioception maneuvers to screen patients for symptoms of a few types of specific neurological conditions. In the mid-1800s, these were called the “standing Romberg tests.” You will see why below.
The book by Doctor Romberg was released in 1840 and later revised in 1846, describing his method of using his “test” to determine if the loss of balance being experienced by the patient was being created by a cerebellar cause, or from a vestibular cause.
Surgery in the mid-19th Century was highly risky and procedures were unrefined, so this procedure to screen for normal proprioception save tens of thousands of lives, from botched surgery or infections that followed surgery.
How the Results of Romberg Tests for Normal Proprioception Excluded Patients with Minor Inner Ear Problems
If a person has a vestibular (inner ear) balance issue while standing or walking, then a doctor can try to correct the imbalance by clearing up a blockage caused by small crystals becoming dislodged from the utricle (a place within your inner ear).
These particles float in the liquid within the semicircular canals and can block and interfere with the free flow of fluids within the three fluid-filled semicircular canals.
We can only assume that the portrait of Dr. Romberg above, shows him holding one of the copies of his medical book.
Correcting this vestibular problem in the mid-1850s (and even today) is done by manipulating a patient in the prone position (laying down) to shift and rotate the patient’s head area by inversion (turning the person’s head and body upside down and sideways) and with rotation movements to try to change the fluid movement within the semicircular canals, where tiny cilia (hairs) exist that may help push the crystal out of the blocked canal. The same manipulation method is used by chiropractors and neurologists and ENT (ear-nose-throat) doctors today.
People with a vestibular problem could typically perform the first step of Doctor Romberg’s test, which is done with their eyes open. Once this ability of sensory systems, for the patients to balance, was shown, the second “eyes closed” segment of the Romberg tests began. The closing of the patient’s eyes was the benchmark for signaling likely serious neurologic disease or trauma to the cerebellar area of the central nervous system.
Step two (closing the person’s eyes) caused the imbalance in many patients, which helped signal that the underlying cause was coming from the cerebellum. This was accomplished by having the patient stand in the same position as before, with both feet together, side by side and touching each other, with arms to their side. When the eyes close, some people lose the ability to remain standing, and start to fall.
Inability to Perform Romberg Tests With Eyes Open Signals Trouble
Some patients of Doctor Romberg could not do the Romberg test either with eyes open or closed. This deficit, when coming from the cerebellum region of the brain near the base of the skull where the spinal cord exits, pointed to a more serious, and possibly incurable disease, or a prior serious trauma that has damaged the dorsal columns (posterior columns) of the spinal cord.
Unfortunately for many of Romberg’s destitute patients, many had tabes dorsalis (neurosyphilis). This is the well-known sexually-transmitted disease syphilis, which (if untreated) eventually leads to infection in the brain and/or spinal cord. When the disease starts affecting the diseased person’s balance, the patient has had chronic, untreated syphilis for about 10 to 20 years after being first infected.
Throughout Medieval Europe, syphilis was known as “the great Pox,” and had afflicted citizens at all levels of society for centuries. Crude, dangerous remedies were tried, but the treatment often led to death.
Romberg’s Test Was for Syphilis, Not Being Drugged or Drunk
When syphilis was the cause of the loss of ability to walk (or even stand normally), a slow, progressive degeneration of the spinal cord called demyelination started years after the person contracted syphilis. The three stages of the syphilitic myelopathy were first signaled by “gait unsteadiness” (awkward, clumsy walking). After that, sufferers next would develop sharp, shooting pains down the spine and legs (and sometimes even the arms) such as those associated with ruptured or herniated spinal disks.
The third and last stage was urinary incontinence (uncontrolled urination), as the wasting away of the spinal cord progressed toward an ugly death.
A person’s loss of sensation in various regions of the body (feet, hands, chest cavity, and torso) was often caused by the damaged or diseased nerves decomposing from advanced-stage syphilis within the person’s body.
This unsteadiness condition also could, in less common situations, be caused by systemic diseases such as diabetes, multiple sclerosis, spinal cord compression from tumor, exposure to toxins such as lead, mercury and arsenic, and a number of other sicknesses.
How Does a Trained Physician Properly Administer a Romberg Test?
Understanding the protocol of a trained physician (usually a neurologist) using the evaluation to check proprioception and obtain a positive Romberg test interpretation is important to know. The first step is to gauge the person’s ability to stand with eyes open for about 60 seconds, looking straight ahead, and arms at his or her sides.
Step two is to then have the same person, in the same position, simply close his or her eyes, and try to remain still and upright for another 60 seconds (or until the person can no longer maintain the stance).
Using the simple physical task of standing upright, with both feet together and hands down by the person’s side, is common to both steps. The closed eyes is the only variable that is changed, to eliminate vision as a means of a person being able to remain standing, without falling or significantly losing balance.
The Safety of a Doctor’s Office Prevents Falling Over While Balancing
As stated earlier, if the person being tested cannot even stand upright with eyes fully open, he or she is in a more advanced stage of illness or is showing symptoms of spinal trauma. If he or she does not have normal balance at this stage, the source of the neuropathy is cerebellar.
These evaluations, for anyone having symptoms, should be done in a doctor’s office, and have medical personnel located next to the subject just in case he or she starts to fall. Since patients come in all sizes, more than one person may be needed to “catch” the person if he or she starts falling. Below, a medical doctor checks a diminutive female patient while her eyes are closed, during Romberg tests.
Simply stated, a person with this condition has lost the ability to gauge his or her body’s position, in relation to the ground. Through trial and error, he created the simple test described in this article, called “Romberg’s test” or the “Romberg test.”
Romberg used the method (sometimes called a “sign,” in medicine) to measure a person’s neurological function, as an effort to isolate whether or not the person possibly had a tumor pushing against a specific section of the spinal cord.
Romberg discovered this correlation, after years of examining scores of patients who noticed they were having imbalance issues. Three most likely answers (in the 1840s) to the onset of loss of balance were: (1) prior serious head or spinal cord trauma, or even a stroke that caused lesions in the brain; (2) disease causing neuropathy, inflammation and swelling around the dorsal columns of the upper spine; (3) tumors that were growing larger and pressing on the person’s spine at the location of the dorsal columns.
In the days of Dr. Romberg, surgery had to be the very last resort, since survival rates for any surgery were poor. Moreover, doctors could test for syphilis, and (if found to be the likely source of imbalance), would not operate at all. So, eliminating other possible causes for imbalance was imperative, before surgery would be risked, in searching for an unlikely spinal tumor.
The doctor’s empirical data from hundreds (if not thousands) of patients pointed to using this methodology to determine the presence of this condition. However, Doctor Romberg would first have to eliminate any chance that the person being tested had not suffered a significant skull fracture or back injury through a serious fall of some type, or by way of a blunt force skull fracture, perhaps from an explosion or a in combat situation.
He would ask about symptoms of stroke. He would examine their skin along the spinal cord, looking for redness, swelling, or fever in that area, to eliminate the cause of loss of balance being from disease or onset of inflammation.
Many of Dr. Romberg’s patients reported that when they arose from bed in the dark, they could not maintain their balance, and many reported falling down. Remember, that electric lighting had not been invented, nor had indoor toilets with plumbing. (Historic footnote: British plumber Thomas Crapper invented the toilet in 1861).
So, when a person in the mid-1800s needed to relieve himself or herself, a person would try to get out of bed and to a chamber pot, to “do their business.” Lighting a lantern or candle before getting out of bed usually was not needed under normal conditions.
The onset of the imbalance condition with his new patients, which occurred almost always in the dark, had started occurring fairly recently with Romberg’s patients, and most reported no prior problems getting up in the dark and walking a short distance.
For many, a fall and some injury from that fall would be what made them come see a physician. It was already known, even in Romberg’s day that unexplained loss of balance had just a few likely medical explanations.
The Romberg test enabled other medical doctors to now help identify those people with sensory ataxia, a symptom or sign of by loss of the normal ability of the person’s nervous system to process the patient’s control of movement and balance, and to properly react to their normal sensory input.
A human being gets this sense of balance and spatial orientation from three sources: (1) proprioception (simply the innate ability to know your body’s upright position, in relation to your feet), (2) inner ear function from the vestibular system, and (3) use of vision as a means of seeing your position in relation to your surroundings and adjust as need to stay upright.
In Romberg’s test, by removing the sense of sight, he evoked imbalance, in those patients with a medical problem.
The Romberg test now provided an additional layer of precision in pointing to one cause over the other. Once the new test became known, other physicians knew how and when to look at vestibular causes, and eliminate these benign problems before looking for a more sinister cause of cerebellar malfunctioning.
Doctors today are trained on the Romberg stand, and the simple but valuable information that comes for two minutes of evaluation and observation.
By altering one seemingly simple variable – closing the person’s eye – a medical doctor looks for significant inability to maintain the previous ability to balance. In the mid-1800s, Dr. Romberg’s test was very advanced. Unlike instantaneous information dispersal today, news of his discovery took years to reach other countries. By the late 1800s, anyone being trained as a physician, and especially neurologists, were trained on and relied upon Dr. Romberg’s simple and useful screening test.[Special note: Dr. Romberg’s last name has been misspelled for over 200 years, as “Rhomberg.” Even the Georgia Court of Appeals misspelled it in a recent criminal case opinion, Kar v. State, 318 Ga.App. 379, 733 S.E.2d 387 (2012). This error likely was picked up from a 2006 unreported Texas appeal, Riddle v. State, 2006 WL 1668764 (2006).
So, if doing research on the Romberg test, it is a good idea to search using alternative spellings of the German doctor’s surname, because even high-level sources like state appellate courts have carelessly carried forward the repeated misspelling as Rhomberg or Rohmberg for two centuries.
On June 26, 2017, the Georgia Supreme Court pointed out the LACK of scientific proof of a reliable correlation of Romberg tests to “signs of drug impairment.” This short synopsis shows that some courts are holding the line on bogus science being used to create a false aura of medical correlations that simply do not exist.
A recent decision by the Georgia Supreme Court, Mitchell v. State, ____ Ga. ____ [2017 WL 2729573; decided June 26, 2017]. From a Fayette County, GA DUI-drugs case, the high court in Georgia reversed the Court of Appeals of Georgia decision, allowing the modified “Rhomberg” test as evidence, “Because the trial court failed to require the proper foundation for the Romberg field sobriety test under Harper v. State, 249 Ga. 519, 524-526 (1), 292 S.E.2d 389 (1982), we reverse on that ground.”
Multiple Misspellings of Doctor Romberg’s Name by American Courts
With the Internet on every computer, historic questions like these should not be missed in important tribunals or documents. In the recent Georgia Supreme Court case of Mitchell v. State, cited above, footnote 5 deals with the constant misspelling of Dr. Romberg’s last name:
Courts of the various states which have considered the numerous variations of the Romberg test do not agree on its name, its elements, its significance, its methodology, or even whether it is a recognized field sobriety test.
See, e.g., Gradford v. Huntsville, 557 So.2d 1330, 1331 (Ala. Crim. App. 1989) (appellant failed “Romberg alphabet test”); People v. Carlson, 677 P.2d 310, 316 n.6 (Colo. 1984) (“The Rhomberg” [sic] requires the subject to stand with hands at sides, feet together, eyes closed and head tilted back, for twenty seconds; “[p]ersons under the influence will sway from side to side or front to rear. Persons not under the influence will move in a circular-type motion.”); Commonwealth v. Jones, 88 Mass. App. 1120 n.1, 43 N.E.3d 349 (2016) (unpublished opinion) (trooper testified that “defendant exhibited pronounced swaying and eyelid tremors indicative of marijuana that is psychoactive in the system” while performing “modified Romberg balance test”); State v. Klawitter, 518 N.W.2d 577, 579 (Minn. 1994) (“Romberg test” used in drug recognition protocol but not in field sobriety testing); Commonwealth v. Keppel, 2016 WL 5266617, 2016 Pa. Super. Unpub. LEXIS 2600 (2016) (trooper testified, “The Romberg Balance Test is a test designed to see if the defendant is under the influence of any drugs”); Buchanan v. State, 1990 WL 51098, 1990 Tex. App. LEXIS 991 (1990) (officer testified that Romberg test required subject to “sit in an erect position with the head tilted back and eyes closed. The officer looks for swaying.”); Johnson v. State, 2009 WL 1563579, 2009 Tex. App. LEXIS 3871 n. 1 (2009) (police officer testified that “the Romberg balance test was not a standardized field sobriety test, but was nonetheless ‘a test that I give everyone.’ ”).]
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