ON THE 
BEST MODE OF TESTING 
TIIE 
HEARING OF SCHOOL CHILDREN, 
-- • 
AND OF 
PROVIDING FOR THE INSTRUCTION OF PARTIALLY 
DEAF CHILDREN. 
BY 
CLARENCE J. BLAKE, M.D., 
INSTRUCTOR IN OTOLOGY IN HARVARD UNIVERSITY. 
Extracted from the Transactions of the 
INTERNATIONAL MEDICAL CONGRESS, 
Philadelphia, September, 1876. 
PHILADELPHIA: 
1877. ON THE 
BEST MODE OF TESTING 
THE 
HEARING OF SCHOOL CHILDREN, 
AND OF 
PROVIDING FOR THE INSTRUCTION OF PARTIALLY 
DEAF CHILDREN. 
BY 
CLARENCE J. BLAKE, M.D., 
INSTRUCTOR IN OTOLOGY IN HARVARD UNIVERSITY. 
Extracted from the Transactions of the 
INTERNATIONAL MEDICAL CONGRESS, 
Philadelphia, September, 1876. 
PHILADELPHIA: 
1877. PHILADELPHIA: 
COLLINS, PRINTER, 
705 Jayne Street. ON THE BEST MODE OF TESTING THE HEARING OF SCHOOL 
CHILDREN, AND OF PROVIDING FOR THE INSTRUCTION 
OF PARTIALLY DEAF CHILDREN. 
One of the strongest arguments in evidence of the importance of the 
subject expressed in the title of this paper, is the fact that, except in 
individual cases, or where the loss of hearing is so great as to result in 
deaf-mutism, no provision is made in our present school system for the 
special instruction of those children whose infirmity, in this respect, 
gives them, if anything, a larger claim upon the efforts of those to whom 
is entrusted the laying of the foundation of that mental development 
which is the basis of the prosperity of a people. To the attainment of 
that proper degree of mental development which raises the man above 
the animal, the sound mind in the sound body is necessary; and when 
one of the channels for communication from without, is either wholly 
or partially closed, there devolves upon those who have the furtherance 
of this development in charge, the duty of compensating in one way or 
another for the loss. How this may be best accomplished in the case in 
question, is for us to consider. 
In a work on the physical and mental education of deaf children, pub- 
lished with the sanction and under the advice of Prof. Von Troltsch, the 
author says d The generally received opinion that diminution of hearing 
in children, in consequence of disease of the ear, is rare, is a mistaken 
one; indeed, in some localities, the cases of disease of the ear exceed in 
number the cases of disease of the eye, and moreover they are apparently 
on the increase; the steadily increasing demands upon the mental capacity,, 
accompanying the advances of the times, bring the defects of hearing more- 
and more prominently forward, because they show themselves to be a 
decided hindrance to the better education of the child. The results, on 
its later mental development, of the loss or diminution of hearing in a 
child,are decided and permanent--affecting the understanding, the char- 
acter, the self-confidence, and, at a later period, the ability of self-support: 
mental tools the possession of which is invaluable, and the want of which 
can never adequately be supplied. In this view, it is a matter of concern 
that more attention has not been directed to the educational develop- 
ment of partially deaf children. 
An examination of a number of cases of partial deafness, occurring in 
children under sixteen years of age, shows that, with the exception of a 
majority of those cases in which the disease of the ear has been of a 
character, or of a degree of intensity, sufficient to so far impair the 
hearing as to be followed by deaf-mutism, the diseases of the ear in 
1 Franciska Schaeling. Beitrage zu einer richtigen, leibliclien, und geistigen Erziehung 
gehbrkranker Kinder. Thorn, 1872. 4 
BLAKE, 
children are amenable to treatment, with more or less improvement in 
hearing, and that the impairment of hearing varies considerably in dif- 
ferent cases, and is moreover subject, in any one case, to variation during 
the progress of the disease. In considering the subject of partial deaf- 
ness, therefore, we have to deal at the outset with a factor in our problem 
representing an unknown quantity ; each individual case of partial deaf- 
ness must be, as it were, a law to itself, as far as the compensatory advan- 
tages to be accorded to it are concerned. To facilitate investigation, 
however, two general divisions of the subject may be allowed. The first 
will include those cases of partial deafness in which the loss of hearing 
is so great as to interfere with the acquirement of articulation, though 
not sufficient to permit the classification of the case under the head of 
deaf-mutism. This division will include those cases in which the dimi- 
nution of hearing is so decided as to interfere with the independent 
acquirement of information through the medium of the hearing, and will 
imply the necessity for special instruction. The second division will 
include a much wider range of cases, from those in which the hearing is 
so slightly impaired as to permit of ordinary intercourse, downward 
through varying degrees of impairment of hearing until the degree 
belonging to the first division is reached. 
Those whose cases come under the first division, form fortunately but a 
small percentage of all the subjects of partial deafness among children; 
and a consideration of their needs may be deferred, as secondary to the 
subject immediately under consideration, and because moreover no pro- 
vision has been very generally made for their instruction. For the in- 
struction of those whose cases come under the second division, there is, as 
far as I am aware, no provision made in our public schools, beyond the 
individual and independent efforts of the teachers. The children who are 
subjects of partial deafness are, however, sufficiently numerous to warrant 
some special attention to the subject, with the view of determining the 
best means for giving them equal educational advantages with their 
more fortunate companions. To do this will require an examination into 
the nature of the cause of their disability, and the establishment of rules 
according to which the degree of impairment of hearing may be deter- 
mined, that the character of the instruction may be varied accordingly. 
An examination into the etiology of partial deafness, shows that the 
diseases of the middle ear are its most frequent cause in children, and 
furthermore that a great many eases of partial deafness are due'either to 
the subacute or chronic catarrhal inflammation of the middle ear, or to 
the purulent inflammation accompanied by perforation of the membrana 
tympani, which follows the simple acute inflammation, or occurs as one 
of the sequelae of the exanthematous diseases of childhood. This general 
rule is subject to certain differences, in differing classes of society; 
among the wealthier classes, for instance, who perhaps merit our atten- 
tion less in this connection, because their children are educated more 
frequently in private than in public schools, the diseases of the ear 
accompanied by partial deafness and more or less amenable to treatment, 
in children under sixteen years of age, amount to but 7.8 per cent, of the 
whole number of cases of ear disease in children and adults taken 
together. Of this number, making the 7.8 per cent, of the whole, 76 per 
cent, are traceable to the exanthematous diseases of childhood, especially 
scarlet fever, and in 56 per cent, there is found an existing purulent 
inflammation of the middle ear, requiring treatment, and causing a suf- HEARING OF SCHOOL CHILDREN. 
5 
ficient degree of deafness to interfere with the patient's participation in 
the ordinary school exercises, on equal terms with other children. 
Among the middle and poorer classes, the proportion of diseases of 
the ear in children is largely increased, and it is these classes which we 
have particularly to consider, since they more generally avail themselves 
of the advantages offered by public instruction. Out of 8715 cases of 
disease of the ear, examined in patients of this category,1 2175, or 24.95 
per cent., occurred in children under fourteen years of age. Of this 
number, 2175 cases of disease of the ear accompanied by partial deafness, 
1085, or 49.8 per cent., are recorded as examples of purulent inflamma- 
tion of the middle ear; 113, or 10.5 per cent, of the cases of purulent 
inflammation, being due to scarlet fever. As many as 514 cases, or 23.6 
per cent, of the cases of disease of the ear in children, are recorded as 
examples of either acute or chronic catarrhal inflammation of the middle 
ear. This brief analysis is sufficient to show the much greater preva- 
lence of such diseases of the ear as are liable to induce partial deafness, 
in the children belonging to those classes in society which depend for 
their instruction on the advantages offered by our public schools. A 
more minute analysis of the material offered, which would hardly be in 
place here, affords interesting information as to the general causes and 
the average course and results of diseases of the ear in children. It may 
be remarked, however, that, in the analysis given, only those cases are 
included in which the deafness was not so decided as to interfere with 
the acquirement of articulation, or even with the use of the ear as a 
medium for instruction. The number of cases of positive deaf-mutism, 
and of cases in which, while there was a certain degree of hearing, it was 
so slight as to render instruction in articulation necessary, was 107, or, 
of all the cases in children examined, 4.9 per cent. The average age of 
all the children examined was about nine years. 
We see, therefore, that in a large majority of the cases of disease of 
the ear occurring in children at an age when they should be profiting 
by school instruction, the disease is accompanied by partial deafness, and 
is moreover of a character to lead us to expect considerable variation in 
the hearing during the progress of the disease, or during the ordinary 
term of school life. This point is one which should be especially con- 
sidered in coming to a conclusion as to the character of the instruction 
to be provided in these cases; we have to deal not only with a different 
factor, in the different degrees in which the hearing is diminished by 
disease in different cases, but also with a possibly variable factor in any 
individual case. 
Admitting the necessity for making some provision for the wants of 
children-of this class in our public schools, and excluding, for the present, 
those cases in which the deafness is of so high a grade that special 
instruction is absolutely necessary, we have to consider the advisability 
(1) of establishing separate classes in our schools for the instruction of 
partially deaf children ; or (2) of instituting such a system of inspection 
as shall lead to a determination of the wants of individual cases, and 
such a consideration thereof, on the part of the teacher, in addition to 
the ordinary course of instruction, as' will permit of education in mixed 
classes, compensatory advantages being accorded in cases of partial deaf- 
ness. 
1 Aural Clinic, Massachusetts Charitable Eye and Ear Infirmary; Statistical Report, 
Service of C. J. Blake. 
* 6 
BLAKE, 
The objections to the former course would seem to be- 
(1) The encumbering of our school system with an additional depart- 
ment for which especial provision would have to be made. Against this 
objection it may be urged that initiatory steps have already been taken 
toward the establishment of separate public schools for the education of 
deaf-mutes, and the so-called semi-mutes, and that children suffering 
from partial deafness could be transferred to such schools, thus making 
use of a department already in process of establishment, and avoiding 
the creation of another additional department for instruction of only 
partially deaf children. While the instruction of semi-mutes in the 
same school with deaf-mutes proper, has certain advantages which have 
been successfully illustrated in the public schools established for that 
purpose in Boston, and of which I shall speak hereafter, there are certain 
aguments against this disposal of the question, and in favor of a different 
provision for the needs of those partially deaf children who do not at 
present, and, from what we know of the nature of the diseases which 
caused their deafness, are but little likely to, in the future, deserve classi- 
fication among semi-mutes. These arguments are included in the fur- 
ther objections to the establishment of separate classes for instruction, 
which are- 
(2) The moral effect upon partially deaf children of making them, and 
recognizing them as, a class by themselves, and the exaggerated sense of 
their infirmity resulting from their being so set apart. The object of 
the public-school education is to fit the children for the best use of their 
mental powers in adult life, and to enable them to associate in the world 
under circumstances which shall make their acquired knowledge best 
available for their own and the general good ; and this object would be 
in a measure defeated by the encouragement, in partially deaf children, of 
those feelings with regard to their infirmity which are one of the chief 
misfortunes of the deaf-mute. To set them apart in the manner referred 
to, would be to permit an underestimate of their own powers, which, 
though every effort to counteract it should be made, would necessarily 
carry its impress into adult life. 
(3) The loss of the beneficial association with hearing children, and of 
a proper spirit of emulation; for since these children are to go out into 
the world, where they will be judged by the general standard of effort 
and success, it is best that they should associate in the beginning with 
those who are to be their companions or their opponents in the struggle 
for existence, and that they should be urged rather themselves to com- 
pensate for their defect than to expect compensation at the hands of 
others. More precisely, the association with hearing children helps 
toward the overcoming of certain faults which are common in children 
who are partially deaf. Partially deaf children are very apt to become 
heedless and inattentive ; from not hearing occasionally, they get into 
the habit of not expecting to hear, and make less mental effort to com- 
bine such sounds of the voice, for instance, as they do hear, or to supply 
the deficiency of those which escape them. The ultimate effect of this 
habit, if uncorrected, on the mental development, is very decided ; for, 
in these cases of partial deafness, nature does not seem to have made that 
effort at compensation which is so strikingly illustrated in the quickened 
perceptive powers of the deaf-mute. Again, many partially deaf children 
are almost morbidly sensitive on the subject of their infirmity, and 
of their implied inferiority: a feeling which, if permitted or encour- 
aged, has a very unfortunate effect upon the child's efforts in its studies, HEARING OF SCHOOL CHILDREN. 
7 
and subsequently upon its efforts at the self-instruction and self-control 
of adult life. The association with hearing children, and that degree of 
participation in class exercises which is possible under certain favoring 
conditions, tend to overcome the self-consciousness which is always more 
or less of a barrier in the way of advancement. 
(4) The final argument against consigning partially deaf children to a 
special class or school, lies in the fact, already mentioned, that the imper- 
fection of hearing is not a fixed factor in the problem. In the majority 
of the cases included in the analysis given, the hearing was susceptible 
of improvement, and in all of them was subject to temporary variations 
during the progress of the disease or course of treatment. 
The best fulfilment of the second course under consideration, education 
in mixed classes, necessarily entails a determination of the degree of 
physical disability of the pupil, for which compensation is to be made. 
This may be accomplished in two ways, of which the best is by means of 
a competent professional examination of each case of supposed or evident 
deafness occurring in the pupils of, or those presented for admission to, 
a public school. This course offers the advantage of determining with 
accuracy, not only the degree of hearing, but also the character of the 
disease which causes the deafness,, the amenability of the case to treat- 
ment, the probable course and duration of the disease, and its probable, 
ultimate effect upon the hearing; in very many cases, as may be judged 
from the statistics given, the need of treatment would be detected where 
otherwise it might have passed unnoticed. The establishment of the 
office of medical supervisor of public schools, the position to be filled by 
a qualified medical man who should devote his time to the duties of his 
office, would cover this in addition to many more important needs in 
connection with the hygiene of our public schools. 
In default of this more thorough method of examination, the object, 
as far as a determination of the degree of hearing is concerned, may be 
accomplished by the teacher, to whom may be committed the task of 
classification according to certain simple rules for testing the hearing, 
applicable to all cases. The ordinary tests for the hearing, by means of 
the watch and tuning-fork, or the use of other musical tones, are each of 
precise value only when taken in connection with a competent examina- 
tion into the condition of the diseased organ, and'a careful consideration 
of points of which only a professional observer is competent to judge. 
Careful tests of the hearing by means of the voice, however, in connection 
with one or other of the tests mentioned, would enable a competent 
teacher to determine whether a subject of partial deafness could be left 
to participate in the ordinary school-room exercises, in common with 
other children, or whether it would be necessary to give the child spe- 
cial attention. 
Following, for instance, the suggestions to be drawn from the obser- 
vations of Oscar Wolf on the musical value of the vowel and consonant 
sounds, and the effect which diseased conditions of the ear have upon 
the perception of consonant and vowel sounds in combination, it is pos- 
sible to arrange a series of test-words which may be used by teachers as 
a standard test in schools. 
Each teacher may be provided with a form for tabulation of cases, 
which is to be preserved as a record of the degree of hearing power, ac- 
companied by instructions as to the method of conducting the examina- 
tion. These instructions should include a clear definition of the precau- 8 
BLAKE, 
tions to be taken in order to arrive at a correct estimate of the hearing, 
the personal opinion of the teacher being required only in remarks upon 
any other symptoms of disease of the ear, such as otorrboea for instance, 
which would seem to indicate the advisability of immediate treatment. 
The watch and the tuning-fork, or the tones of a musical instrument, may 
be employed as subsidiary tests, but the main reliance should be placed 
on tests with the voice, for not only does the human voice, considered as 
a musical instrument, fulfil certain conditions as a test not otherwise 
attainable, but it is the voice of the teacher especially which the child 
is required to hear, and for the accurate hearing of which it is necessary 
that the child should be placed in such a position in the school-room as 
shall serve to compensate for its diminished hearing. As a rule, there- 
fore, the tests indicated should be repeated on the transference of a pupil 
from one room, or one teacher, to another, for every human voice has its 
peculiarities of pitch and quality, which give it, estimated as a test, a 
hearing value of its own. These tests also may be repeated at intervals, 
without proving a great addition to the labors of the teacher, for the 
purpose of determining the average degree of hearing. 
The hearing distance for the voice having been determined, the point 
in the school-room at which all the test-words are distinctly heard, should 
determine the position of the seat to be assigned to the pupil, such prox- 
imity to the teacher as shall enable the particularly deaf pupil to hear 
the teacher's voice as readily as a pupil with perfect hearing at the ex- 
treme limit of the room, being one of the compensatory advantages which 
his diminished hearing demands. Furthermore, the attention of the 
teacher should be directed to the necessity for giving such cases special 
attention, in such manner as to supply the loss of parts in class exercises 
which the pupil may have but imperfectly appreciated. A lack of 
knowledge on the part of teachers of the great obstacle which partial 
loss of hearing may present to a proper appreciation of school exercises, 
and the establishment of a fixed standard of instruction to which all the 
pupils in a class are required to conform, results in added labor on the 
part of the partially deaf pupil, without the consideration which his 
imperfect ability in this respect should command. 
Passing from the consideration of those cases of partial deafness which 
may be provided for in the manner above proposed, we have to consider 
the needs of that more unfortunate class whose hearing is so far impaired 
as to render special instruction absolutely necessary. The objections 
which were made to the separate instruction of the majority of partially 
deaf children, do not apply here. One of the earliest and most unfortu- 
nate consequences of extreme deafness, in children, is the impairment of 
speech ; with the loss of hearing is lost the medium through which the 
knowledge of speech is acquired, and the child gradually lapses into 
the use of gestures (to proclaim its wants) and the production of inar- 
ticulate sounds. To retain or to educate the power of speech, is, how- 
ever, but one of the objects to be attained by special instruction ; some 
means must be supplied which will compensate as far as possible for the 
loss of hearing, and prove another medium through which the child 
may receive the same education as that afforded hearing children in the 
common school. The sense of sight may, in these cases, be called in aid, 
and the child may be taught to hear, as it were, with the eyes. 
Various systems for instruction in this so-called, visible speech, are in 
operation, and their results, as far as I have been able to observe them, HEARING OF SCHOOL CHILDREN. 
9 
are not merely encouraging, but eminently successful. Furthermore, as 
every possible means of imparting instruction should be made available, 
in addition to education in lip-reading and articulation, such hearing 
as the child may possess should be utilized by the employment of arti- 
ficial means, if necessary, for the readier conveyance of sound to the ear. 
As a result of practical experience, and not merely upon theoretical 
grounds, the use of the hearing-trumpet, of one kind or another accord- 
ing to the requirements of the case, may be advised during school exer- 
cises ; indeed, in many cases, the use of such an instrument tends to 
improve the hearing not merely during the time of its use, but generally, 
the subjection of the ear to sound waves of larger amplitude either in- 
creasing the vibratory power of the sound-conducting apparatus of the 
middle ear, or acting as a stimulus to the auditory nerve. The proper 
application of these auxiliaries to instruction, necessitates therefore the 
formation of a separate class, for the benefit of which, as has been said, 
the public deaf-mute school, which now forms an important part of the 
Boston school system, and which must in time be engrafted upon the 
public school system of other large centres, may be made available. 
In the Boston school, the children are divided into two general classes, 
those who are total deaf-mutes, and those who are semi-mutes. Children 
in the latter class are instructed in articulation, for the purpose of over- 
coming faults which always exist where the hearing is imperfect, and in 
lip-reading, that they may learn to understand conversation from sight 
as a substitute for hearing. Such hearing as remains to them is also 
made useful in conveying ideas as to the formation of vocal compounds,, 
by means of an ear-trumpet, if necessary, or by speaking directly into 
the ear. As the total deaf-mutes improve in articulation and lip-reading, 
they are advanced to the class consisting of semi-mutes, partly because 
the grade of instruction has become the same, and partly that they may 
profit by the example of those more fortunate companions who have had 
the advantage of having a little speech or a little hearing to start with. 
On this plan, the Boston school has now been in operation for five years, 
with increasing success and increasing evidence of its great value ; it 
now provides for about sixty pupils, all whom are instructed in lip- 
reading and articulation, the method employed being the system of 
visible speech introduced in this country by A. Graham Bell. 
The conclusions drawn from a study of the subject of this paper, may 
be summed up as follows:-■ 
I. The frequency of partial deafness in children, during the period of 
school life, renders it advisable to make some definite provision in our 
public school system for compensatory instruction. 
II. Since partial deafness is a comparative term, some provision should 
be made for a proper determination of the degree of disability. 
III. This may be best accomplished either by establishing a series of 
speech-tests, to be used by the teachers, or by instituting competent me- 
dical examination at the hands of a medical supervisor of schools; and 
the creation of such an office in connection with our public school system 
is strongly urged. 
IV. Partially deaf children, whose hearing is not so defective as to 
require special instruction in articulation and lip-reading, are better 
taught in mixed classes with those who hear well, compensatory advan- 
tages being allowed them according to their degree of disability. 10 
BLAKE,HEARING OF SCHOOL CHILDREN. 
V. Partially deaf children, whose hearing is so defective as to interfere 
with the natural acquirement of articulation, and to render the ear of 
little or no value as a medium for hearing, should be accorded the ad- 
vantages of special instruction, of which education in articulation and 
lip-reading should form a part.