EXAMINATION OF THE AUDITORY ORGAN 
OF SCHOOL-CHILDREN 
[concluded from page 209] 
BY 
Dr. FRIEDRICH BEZOLD 
MUNICH 
Translated by Isidor Furst, New York 
[Reprinted from the Archives of Otology, Vol. xiv., No. 4, 1885.] EXAMINATIONS OF THE AUDITORY ORGAN 
OF SCHOOL-CHILDREN * 
By Dr. FRIEDRICH BEZOLD, MunicW. 
Translated by Isidor Furst, New York. 
( With four plates of curves and. three ■wood-cuts.') 
RESULTS OF THE EXAMINATION OF THE EXTER- 
NAL AUDITORY CANAL AND THE DRUM 
MEMBRANE. 
ACCUMULATIONS OF CERUMEN.1 
a.-Hindering Examination and Partly Occluding the Lumen. 
Hearing distance. 
Absolute numbers. 
Percentages. 
Above 
16 
Met. 
16-8 
Met. 
8-4 
Met. 
4-0 
Met. 
Total. 
I Above 
16 
Met. 
16-8 
Met. 
8-4 
Met. 
4-0 
Met. 
Total. 
Number examined in 
the twopublic 
schools 
1659 
1189 
470 
296 
3614 
IOO 
IOO 
IOO 
IOO 
IOO 
Common school . 
79 
60 
18 
IO 
167 
7-1 
8.4 
6.1 
4.2 
7-2 
Protestant school. 
73 
67 
15 
13 
168 
13-4 
14.2 
8-5 
14.6 
13-1 
Holland's Institute 
(10) 
(3) 
(13) 
(5 
2) 
(10.0) 
(5-9) 
Boys 
73 
58 
12 
II 
154 
9.0 
11.4 
6.0 
8-5 
9-4 
Girls 
79 
69 
21 
12 
181 
9-3 
10.1 
7-7 
7-2 
9-2 
Boys and girls . 
152 
127 
33 
23 
335 
9.16 
10.68 
7.02 
7-77 
9-27 
* Concluded from page 209. 
1 I have here recorded all those accumulations which obstructed the view of a 
part of the drum membrane, especially the region of the short process or the 
light spot, but allowed a portion of the drumhead to be inspected. The 
slightly larger figures in the Protestant school are probably due to the fact that 
they were more accurately recorded. But as there were found in this school 
nearly double the number of occluding plugs present in the common school, we 
might suspect some connection with the season. The common school was 
examined in summer, the Protestant school in winter. 
Reprinted from the Archives of Otology, Vol. xiv., No. 4, 1885. 243 
Examinations of the Auditory Organ of School-Children. 
Here we find on comparing the four columns, aside from 
Holland's Institute where the number examined was too 
small, that there is no increase in the percentages among 
persons with defective hearing, but rather on an average a 
slight decrease. A slight increment, and that in all the 
series, is shown only in the second column of those hearing 
at 16-8 metres; and possibly we may conclude therefrom 
that when conjoined with other slight disturbances present, 
non-occluding accumulations may contribute in some degree 
to impair the hearing. That alone they are unable to cause 
impairment is shown by the results of apparently occluding 
accumulations. • 
b.-Accumulations Apparently Occluding the Entire Lumen. 
Hearing distance. 
Absolute numbers. 
Percentages. 
Above 
16 
Met. 
16-8 
Met. 
8-4 
Met. 
4-o 
Met. 
Total. 
Above 
16 
Met. 
16-8 
Met. 
8-4 
Met. 
4-0 
Met. 
Total. 
Number examined in 
the two public 
schools . 
1659 
1189 
470 
296 
3614 
100 
IOO 
IOO 
IOO 
IOO 
Common school . 
8 
17 
7 
14 
46 
0-7 
2-4 
2.4 
6.8 
2.0 
Protestant school . 
9 
12 
9 
18 
48 
1.7 
2-5 
5-1 
20.2 
3-8 
Holland's Institute 
(2) 
(2) 
(4) 
(1.0) 
(6-7) 
(1-8) 
Boys 
5 
15 
2 
21 
43 
0.6 
2-9 
1.0 
16.2 
2.6 
Girls 
12 
14 
14 
II 
5i 
1.4 
2.1 
5-2 
6.6 
2.6 
Boys and girls . 
17 
29 
l6 
32 
94 
1.02 
2-44 
3-40 
10.81 
2.61 
The results of the first column should be first empha- 
sized: 17 auditory organs, the inspection of which showed 
a plug apparently completely occluding the osseous meatus, 
heard whispered speech above 16 metres and hence had to 
be considered normal in their function. It is very probable 
that in all these cases a narrow chink was present between 
the accumulation and the wall, though it escaped observa- 
tion ; but they prove how small a lumen suffices for normal 
hearing, and on the other hand, in connection with the 
result of non-occludingaccumulations,how unimportant is the 
shape of the ear canal in reference to the function of the ear. Friedrich Bezold. 
244 
The percentages increase pretty regularly with greater 
hardness of hearing, and they do so both in the total num- 
ber and in the several schools and sexes, with the exception 
of a single number among the boys ; they rise rapidly in the 
last column of those hearing at from 4-0 metres to 10.81 
per cent., while we find among the normal hearing only 
1.02 per cent., and among all the pupils, including those 
with impaired hearing, 2.61 per cent. This gives us an 
instance how a symptom which undoubtedly is connected 
with hardness of hearing finds expression in our tables, and 
in what way we have to expect this prominence in the 
percentages also with the other symptoms which are of 
more or less importance for the diagnosis. 
a.- Triangular Reflex or Point in or near the Umbo. 
NORMAL DRUMHEAD REFLEXES. 
Hearing distance. 
Absolute numbers. 
Percentages. 
Above 
16 
Met. 
16-8 
Met. 
8-4 
Met. 
4-0 
Met. 
Total. 
Above 
16 
Met. 
16-8 
Met. 
8-4 
Met. 
4-0 
Met. 
Total. 
Number examinedin 
the two public 
schools 
1659 
1189 
470 
296 
3614 
too 
IOO 
IOO 
IOO 
IOO 
Common school . 
968 
584 
196 
83 
1831 
86.9 
81.3 
66.9 
40 1 
78.5 
Protestant school . 
466 
360 
128 
30 
984 
85.5 
76.4 
72.3 
33-7 
76.8 
Holland's Institute 
(185) 
(I 
9) 
(204) 
(96.4) 
(63-3) 
(9I-9) 
Boys 
699 
388 
133 
48 
1268 
86.5 
76.2 
66.8 
36.9 
77-0 
Girls 
735 
556 
191 
65 
1547 
85-2 
81.8 
70.5 
39-2 
78.6 
Boys and girls . . 
1434 
944 
324 
113 
2815 
86.44 
79-39 
68.94 
38.18 
77.89 
In my original notes I have stated everywhere whether 
the normal reflex appeared triangular, sharp or diffuse, 
interrupted transversely or longitudinally, or as a simple 
diffuse spot or point in the umbo. However, all these 
various forms of the normal reflex are so irrelevant for 
the function, as I was able to convince myself, that I have 
abstained from complicating the tables by their special 
enumeration. All these different forms are summarized 
under a. One characteristic, howrever, the reflex had to 245 
Examinations of the Auditory Organ of School-Children. 
possess in order to be called normal: its point, even if dif- 
fuse, had to reach the umbo entirely or nearly ; in other 
words, the funnel shape of the drumhead had to be present 
in its purity, or somewhat flattened at the point by the 
widening of the end of the manubrium mallei. 
If we make the limits of the normal reflex thus broad, it 
is found among no less than 84.44 per cent, of all persons 
with normal hearing. Among those having successively 
worse hearing we demonstrate a regular decrease in its fre- 
quency, which is uniformly repeated in every single series 
of numbers of the above collection. These numerical rela- 
tions must not be considered as a clear expression of the in- 
fluence of form alterations of the drumhead on the function, 
-for the numbers among the persons with defective hearing 
are, of course, depressed besides by the greater number of 
occluding plugs of cerumen, of otorrhoeas, and of perfora- 
tions in the region of the reflex, which likewise fall in the 
column of defective hearing-but still this does not fully 
explain the great sinking of the numbers among the latter, 
and not a small part of the cases of absent reflex at the nor- 
mal place is due to alterations of form of the drumhead in 
general or in the region of the normal reflex. We shall ob- 
tain a more exact expression than in the above tabulation 
among the divisions " absence of the normal reflex," dis- 
placed normal reflex," " atrophy," and " cicatrix." 
b.- The Region of the Sulcus Reflex Covered by the Anterior Lower 
Wall of the Ear Canal. 
Hearing distance. 
Absolute numbers. 
Percentages. 
Above. 
16. 
Met. 
16-8 
Met. 
8-4 
Met. 
4-o 
Met. 
Total. 
Above. 
16 
Met. 
16-8 
Met. 
8-4 
Met. 
4-0 
Met. 
Total. 
Number examined in 
the two public 
schools 
1659 
1189 
470 
296 
3614 
IOO 
IOO 
IOO 
IOO 
IOO 
Common school . 
402 
251 
i®6 
49 
808 
36.1 
35-0 
36.2 
23-7 
34-6 
Protestant school . 
135 
114 
39 
11 
299 
24.8 
24.2 
22.0 
12.4 
23.3 
Holland's Institute 
(140) 
(1 
7) 
(157) 
(72.9) 
(56.7) 
(70.7) 
Boys 
237 
134 
55 
17 
443 
28.1 
26.3 
27.6 
I3-I 
26.9 
Girls 
300 
231 
90 
43 
664 
35-3 
340 
33-2 
25-9 
33-7 
Boys and girls . 
537 
365 
145 
60 
1107 
32.37 
30.70 
30.85 
20.27 
30.63 Friedrich Bezold. 
246 
It was some special reason which caused me to devote 
more particular attention to this reflex streak at the ante- 
rior lower periphery among the other above-enumerated 
normal reflexes of the drumhead. The punctiform reflex 
on the short process, and the stripe-like or punctiform re- 
flex at the anterior upper border of Shrapnell's membrane, 
were also noted wherever they were present ; but as no fur- 
ther interest attaches to the frequency of their occurrence, 
I have abstained from giving a r^ume of them in the tables. 
The sulcus reflex arises in the above-described manner as 
a linear streak encompassing the anterior lower periphery of 
the drumhead. As it is produced in the curve formed by 
the periphery of the drumhead with the external lip of the 
sulcus, we may be assured, when it is completely visible, 
that the drumhead can be inspected by us in its entire ex- 
tent, provided no pathological anomalies of form, such as 
exostoses in the auditory canal or accumulations, prevent 
us otherwise. For the anterior lower periphery of the 
drumhead is the only place which is frequently hidden 
by a more curved course of the osseous canal and a cor- 
responding projection of the lower anterior wall of the audi- 
tory canal. If we are able to inspect this portion likewise, 
the drumhead in its entire extent lies before us, and I have 
thought it not to be without interest to ascertain how often 
this is really the case. The number of auditory canals in 
which we can make the sulcus reflex visible is, as appeared 
in the course of these examinations, greater than that in 
which it is more or less completely invisible. Therefore, 
subsequently the latter only were counted, among which are 
included all those cases in which this reflex was wholly or 
largely covered by the anterior lower wall of the auditory 
canal; other hindrances to the inspection of this region 
were left out of consideration. 
It is not quite easy, in all the cases where there is still 
some possibility of seeing the reflex, to bring it to view. 
This is proved by the different figures I have obtained in 
the three schools, and which are to be explained evidently 
by some defect in my early technique. In Holland's Insti- 
tute, which I examined first, I could not bring it to view in 247 
Examinations of the Auditory Organ of School-Children. 
70.7 per cent. ; in the common school, which was next in 
order, in 36.6 per cent.; and in the Protestant school, ex- 
amined last, only in 23.3 per cent. In order to see it as fre- 
quently as the anatomical relations will permit, the auditory 
canal must be energetically straightened both by traction on 
the auricle and by co-operative pressure against the poste- 
rior wall with the speculum, and the line of sight must run 
through the ear canal from behind above to in front below. 
Where the canal is wide and nearly straight, it can indeed 
often be inspected without the aid of a speculum. Rarely 
only is a reflex streak entirely absent at this spot, although 
the periphery is accessible to our eye. Hence by its fre- 
quency alone it deserves the title of a normal reflex, and we 
learn from this tabulation that the anatomical relations, at 
least in children, in more than two thirds of the cases per- 
mit us to inspect the drumhead directly in its entire extent. 
The sulcus reflex suffers a pathological alteration only in 
so far as it may appear somewhat widened in depressions 
which implicate the anterior lower periphery of the drum- 
head. Even in other intense alterations of the drumhead, 
older perforations, etc., its presence may still be demon- 
strated ; for this reason, in the above tabulation, we find 
a slighter decrease in its frequency in defective hearing 
than can be demonstrated with the triangular reflex. 
We now come to the- 
PATHOLOGICAL STATE OF THE DRUMHEAD REFLEXES. 
a.-Absence of the Normal Reflex. 
Hearing distance. 
Absolute numbers. 
Percentages. 
Above 
16 
Met. 
16-8 
Met. 
8-4 
Met. 
4-0 
Met. 
Total. 
Above 
16 
Met. 
16-8 
Met. 
8-4 
Met. 
4-o 
Met. 
Total. 
Number examined in 
the two public 
schools 
1659 
1189 
470 
296 
3614 
TOO 
IOO 
100 
100 
IOO 
Common school . 
20 
37 
20 
21 
98 
1.8 
5-2 
6.8 
10.1 
4-2 
Protestant school 
15 
20 
8 
6 
49 
2.8 
4.2 
4-5 
6.7 
3-8 
Holland's Institute 
(- 
-) 
(3) 
(3) 
(- 
(10.0) 
(i-4) 
Boys 
27 
33 
18 
14 
92 
3-3 
6-5 
9.0 
10.8 
5-6 
Girls 
8 
24 
10 
13 
55 
0.9 
3-5 
3-7 
7-8 
2.8 
Boys and girls . 
35 
57 
28 
27 
147 
2.11 
4-79 
5-96 
9.12 
4-07 Friedrich Bezold. 
248 
Into the tables were entered only those cases in which, 
excepting the sulcus reflex just discussed, there was no re- 
flex present over the whole extent of the lower anterior 
quadrant of the drumhead, and in which the surface as a 
whole had not lost its lustre by maceration of the epidermis 
in consequence of inflammatory processes or secretion. 
Frequently in these cases the reflecting power of the 
external surface of the drumhead was positively proved by 
the presence of other reflexes, especially of the sulcus reflex 
or that on the short process and its surroundings. Audi- 
tory canals in which the free inspection of the anterior 
lower quadrant was interfered with were, of course, left 
out of consideration in the above tabulation. 
As the region of the normal triangular reflex is the only 
one which is struck vertically by sound-waves impinging 
directly, we may assume that it receives the strongest im- 
pulses from these ; and I think, therefore, that I can claim 
the presence of the normal reflex in the umbo as a postulate 
for a completely normal function of the sound-conducting 
apparatus 1 ; Trautmann,' too, on the strength of two 
hundred examinations of the drumhead of children and 
soldiers, thinks " the function to be always reduced with 
alterations of the light reflexes due to anomalies of the 
curvature." I have shown above, on the figure of the 
drumhead section, in what manner a slight concave depres- 
sion of the membrane as a whole may cause a complete 
disappearance of the normal reflex. The tabulation here 
given shows us that a complete absence of the triangular re- 
flex is found not only with reduced function, but also with 
2.11 per cent, of persons with normal hearing. Therefore, 
when this slight alteration of form of the drumhead, alone 
without other accompanying pathological alterations, es- 
pecially without permanent occlusion of the tubes, influences 
the hearing distance at all, its reduction is so slight that it 
is altogether impossible to demonstrate it with our usual 
methods of examination. 
If we consider the frequency of its absence among per- 
1 " Die Corrosionsanatomie des Ohres." Munich (Theodor Riedel), 1882, p. 24. 
' Die Lichtreflexe des Trommelfelles. Arch. f. Ohrenheilk,, Bd. x., p. 91. 249 
Examinations of the Auditory Organ of School-Children. 
sons with defective hearing, we find both in the several 
schools and in the two sexes a regular increase with rising 
impairment of function, so that among those having the 
greatest hardness of hearing it is absent on the average four 
times as often as among the normal hearing. Symptomati- 
cally, therefore, the absence of the normal reflex cannot be 
called worthless. 
-Normal Reflex Far Removed from the Umbo toward the Periphery. 
Hearing distance. 
Absolute numbers. 
Percentages. 
Above 
16 
Met. 
16-8 
Met. 
8-4 
Met. 
4-0 
Met. 
Total. 
Above 
16 
Met. 
16-8 
Met. 
8-4 
Met. 
4-0 
Met. 
Total. 
Number examined in 
the two public 
schools . 
1659 
1189 
470 
296 
3614 
IOO 
IOO 
IOO 
IOO 
IOO 
Common school . 
22 
26 
34 
3b 
Il8 
2.0 
3-6 
11.6 
17.4 
5-1 
Protestant school . 
IO 
22 
15 
15 
62 
1.8 
4-7 
8-5 
16.9 
4.8 
Holland's Institute 
(I) 
(6) 
(7) 
(o-5) 
(20.0) 
(3-2) 
Boys 
18 
17 
20 
15 
70 
2.2 
3-3 
10.1 
U-5 
4-3 
Girls 
14 
31 
29 
36 
no 
1.6 
4.6 
10.7 
21.1 
5-6 
Boys and girls 
32 
48 
49 
5i 
180 
i-93 
4.04 
10.43 
17.23 
4-98 
Under this head were enumerated all those cases in which 
the normal triangular reflex had lost its point and appeared 
changed into a simple or divided, roundish, square, or ir- 
regular spot, whose position corresponded to the basis of 
the normal reflex, or usually was still farther removed 
toward the lower anterior periphery. In many cases this 
spot shows a remarkably bright lustre. That it should be 
accorded a separate position beside the other reflexes oc- 
curring in the anterior lower quadrant is evident by the fact 
alone that not rarely it can be observed simultaneously by 
the side of the latter. For instance, sometimes we can in- 
spect all the three reflexes here under consideration at the 
same time on one drumhead: distant about the length 
of the absent triangular reflex from the umbo lies our 
roundish glossy reflex ; still farther toward the periphery 
lies the glossy streak, which is due to the fact that the 
peripheral zone of the drumhead takes part but little, if at 
all, in the depression, and which Politzer explains as a phe- Friedrich Bezold. 
250 
nomenon of flexion, figured in his text-book1 ; and quite at 
the periphery we find, third, the above-described sulcus re- 
flex. In these cases the three reflexes lie in such a way 
that they are cut in half by the line which divides the tri- 
angular reflex in two. The origin of the displaced normal 
reflex has been traced above to the formation of a greater 
pan-like depression of the drumhead, and it has been shown 
on the section of the drumhead that it must be considered 
as a true picture of a concave mirror. 
Like the absence of the normal reflex, the occurrence of 
this alteration may be observed where the hearing distance 
is perfectly normal, although relative to its frequency gen- 
erally it is somewhat rarer (in 1.93 per cent.). 
If we trace its frequency in the successive degrees of 
hardness of hearing, we find throughout a uniform and 
much greater increase in it than in the simple absence of 
the normal reflex, so that it occurs on an average among 
those hearing at 4-0 metres in not less than 17.23 per cent., 
or nearly nine times as frequently as among the normal 
hearing. In accordance therewith is the pathognomonic 
value of this alteration of the reflex; in the frequency of 
its occurrence, as well as in its rapidly rising presence in the 
higher degrees of hardness of hearing, it follows directly on 
the "posterior fold," undoubtedly the most frequent symp- 
tom of depression. 
It should be emphasized as a remarkable fact, that it is 
to be observed more frequently among the girls, both abso- 
lutely, and especially in the last column, containing the 
worst hearing ; in the latter nearly twice as frequently as 
among the boys, although we shall see further on, in Table 
XXL, that the boys, on the whole, exhibit larger percentages 
of tubal affections than the girls. 
Under c were included all those cases in which a reflex 
was present on Shrapnell's membrane which indicated con- 
cavity of the latter. It has been stated above that a stripe- 
like or punctiform reflex at its anterior and upper border, if 
present, is to be considered normal. Reflexes of convexity 
are to be rarely observed spontaneously in this region, and 
1 Bd. i., p. 306. 251 
Examinations of the Auditory Organ of School-Children. 
in that case it is not difficult to distinguish them from the 
reflexes of concavity, mostly by the simultaneous presence 
of the sickle-shaped reflex of convexity at the posterior 
upper periphery. 
Under d were included all reflexes behind the short 
process, from a simple point or glossy streak on the pos- 
terior fold to the uniform lustre of the entire portion of 
the drumhead lying above this fold, of course excluding 
the occasional reflexes of convexity occurring shortly after 
blowing the nose. 
c.-Macular Reflex ABOVE the Short Process. 
Hearing distance. 
Absolute numbers. 
Percentages. 
Above 
16 
Met. 
16-8 
Met. 
8-4 
Met. 
4-o 
Met. 
Total. 
Above 
16 
Met. 
16-8 
Met. 
8-4 
Met. 
4-o 
Met. 
Total. 
Number examined in 
the twopublic 
schools 
1659 
1189 
470 
296 
3614 
IOO 
IOO 
IOO 
IOO 
IOO 
Common school . 
8 
8 
4 
3 
23 
0-7 
1.1 
1-4 
1-4 
1.0 
Protestant school . 
3 
4 
1 
2 
10 
0.6 
0.8 
0.6 
2.2 
0.8 
Holland's Institute 
(6) 
(- 
-) 
(6) 
(3-1) 
(- 
-) 
(2.7) 
Boys 
7 
8 
2 
2 
19 
1 0.9 
1.6 
1.0 
i-5 
1.1 
Girls 
4 
4 
3 
3 
14 
0-5 
0.6 
1.1 
1.8 
0.7 
Boys and girls 
11 
12 
5 
5 
33 
0.66 
1.01 
1.06 
1.69 
0.91 
d.-Punctiform, Linear, or More Expanded Reflex behind the Short 
Process. 
Hearing distance. 
Absolute numbers. 
Percentages. 
Above 
16 
Met. 
16-8 
Met. 
8-4 
Met. 
4-0 
Met. 
Total. 
Above 
t6 
Met. 
16-8 
Met. 
8-4 
Met. 
4-0 
Met. 
Total. 
Number examined in 
j 
the twopublic 
schools 
1659 
1189 
470 
296 
3614 
IOO 
IOO 
IOO 
IOO 
IOO 
Common school . 
18 
26 
17 
12 
73 
1.6 
3-6 
5.8 
5.8 
3-1 
Protestant school . 
15 
22 
7 
7 
5i 
2.8 
4-7 
4.0 
7.8 
4.0 
Holland's Institute 
(4 
) 
(I) 
(5) 
(2.1) 
(3-3) 
(2-3) 
Boys 
II 
24 
11 
9 
55 
l 1,4 
4-7 
5-5 
6.9 
3-3 
Girls 
22 
24 
13 
IO 
69 
2.6 
3-5 
4.8 
6.0 
3-5 
Boys and girls 
33 
48 
24 
19 
124 
1.99 
4-04 
5-II 
6.42 
3-43 Friedrich Bezold. 
252 
It appears from the above tables that although the forms 
c and d are to be considered pathological, inasmuch as their 
frequency grows almost throughout with increasing hard- 
ness of hearing, they have been met with on the one hand 
more rarely generally, especially the macular reflex above 
the short process, and on the other hand they do not in- 
crease in progression as they approach the zero point of 
the hearing distance, as we have seen to be the case with 
the normal reflex displaced towards the periphery. 
A part, though small, of the reflexes of concavity in 
Shrapnell's membrane is to be traced, as I have learned 
from the clinical history of several cases, to a former per- 
foration at this place and its closure by a cicatrix. 
All these reflexes, like the displaced normal reflex, come 
under observation also with normal hearing distance ; that 
above the short process in 0.66 per cent., and that behind the 
latter in 1.99 per cent, among those with normal hearing. 
COLOR ANOMALIES OF THE DRUMHEAD. 
Acute and subacute inflammatory alterations on the 
drumhead, which were entered under two heads, (a) diffuse 
reddening and extravasation of blood, serum perceptible in 
the drum cavity, were but rarely present ; injection and ex- 
travasation of blood on the whole in 0.42 per cent., and 
perceptible serum in 0.21 per cent. 
Neither alteration causes necessarily a reduction of the 
hearing distance, which, despite their presence, in some 
cases amounts to over 16 metres for whispered speech. 
Although the common school was examined in summer, 
and the Protestant school in winter, the figures of both in 
these columns offer but slight differences. Their special 
tabulation can be of little use to us here on account of the 
small numbers. 
The records of "diffuse opacities," comprising the cases 
in which the opacity was spread more or less uniformly over 
the drumhead, are to some extent arbitrary, because the 
limit between normal and pathological admixture of white 
to the color of the drumhead cannot be sharply drawn, and 
also because the varying illumination can easily lead to 253 
Examinations of the Auditory Organ of School-Children. 
deception in the estimation. In the table only the more 
pronounced opacities were taken note of. That they should 
not be passed over appears from the fact alone that of the 
alterations enumerated under from a to d they give rela- 
tively the most certain landmark of the presence of a 
disturbance of function, as becomes evident from an in- 
spection of the four tables. 
PATHOLOGICAL OPACITIES AND DEPOSITIONS IN THE SUBSTANCE 
OF THE DRUMHEAD. 
a.-Diffuse Opacities. 
Hearing distance. 
Absolute numbers. 
Percentages. 
Above 
16 
Met. 
16-8 
Met. 
8-4 
Met. 
4-o 
Met. 
Total. 
Above 
16 
Met. 
16-8 
Met. 
8-4 
Met. 
4-o 
Met. 
Total. 
Number examined in 
the two public 
schools . 
1659 
1189 
470 
296 
3614 
100 
100 
TOO 
IOO 
IOO 
Common school . 
15 
14 
14 
12 
55 
1-3 
2.0 
4-8 
5-8 
2.4 
Protestant school . 
4 
13 
6 
- 
23 
0.8 
2.8 
3-4 
1.8 
Holland's Institute 
0 
5) 
(5) 
(13) 
(4-2) 
(16.7) 
(5-9) 
Boys 
IO 
12 
IO 
2 
34 | 
1.2 
2.4 
5-0 
X-5 
2.1 
Girls 
9 
r5 
IO 
IO 
44 
1.0 
2.2 
3-7 
6.0 
2.2 
Boys and girls . 
19 
27 
20 
12 
78 
1,15 
2.27 
4.26 
4-05 
2.10 
b.-Circu inscribed Opacities. 
Hearing distance. 
Absolute numbers. 
Total. 
Percentages. 
Above 
16 
Met. 
16-8 
Met. 
8-4 
Met. 
4-0 
Met. 
Above 
16 
Met. 
16-8 
Met. 
8-4 
Met. 
4-0 
Met. 
Total. 
Number examined in 
the two public 
schools . 
1659 
1189 
470 
296 
3614 
too 
IOO 
IOO 
IOO 
100 
Common school . 
114 
104 
49 
20 
287 
10.2 
14-5 
16.7 
9-7 
12.4 
Protestant school . 
59 
68 
30 
13 
170 
10.8 
14-4 
16.9 
14.6 
13-3 
Holland's Institute 
(29) 
(3) 
(32) 
(15 
•i) 
(10.0) 
(14-5) 
Boys 
80 
65 
30 
15 
190 
9-9 
12.8 
151 
11.5 
11.5 
Girls 
93 
107 
49 
18 
267 
10.9 
15-7 
18.1 
10.8 
13.6 
Boys and girls . . 
173 
172 
79 
33 
457 
10.43 
14-47 
16.81 
11.15 
12.65 Friedrich Bezold. 
254 
c.-Calcifications. 
Hearing distance. 
Above 
16 
Met. 
Absolute numbers. 
Percentages. 
16-8 
Met. 
8-4 
Met. 
4-0 
Met. 
Total. 
Above 
16 
Met. 
16-8 
Met. 
8-4 
Met. 
4-0 
Met. 
Total. 
Number examined in 
the two public 
school 
1659 
IT89 
470 
296 
3614 
IOO 
IOO 
IOO 
IOO 
IOO 
Common school . 
14 
6 
8 
7 
35 
1-3 
0.8 
2.7 
3-4 
1-5 
Protestant school . 
8 
6 
3 
3 
20 
i-5 
i-3 
i-7 
3-4 
1.6 
Holland's Institute 
(2) 
(" 
-) 
(2) 
(1.0) 
(0.9) 
Boys 
9 
3 
6 
4 
22 
1.1 
0.6 
3-o 
3-i 
i-3 
Girls 
13 
9 
5 
6 
33 
i-5 
1-3 
1.8 
3-6 
1-7 
Boys and girls . 
22 
12 
11 
IO 
55 
1-33 
2-34 
3-38 
1.52 
d.-Posterior Streak of Opacity. 
Hearing distance. 
Absolute numbers. 
Percentages. 
Above 
16 
Met. 
16-8 
Met. 
8-4 
Met. 
4-0 
Met. 
Total. 
Above 
16 
Met. 
16-8 
Met. 
8-4 
Met. 
4-0 
Met. 
Total. 
Number examined in 
the two public 
schools 
1659 
1189 
470 
296 
3614 
IOO 
100 
IOO 
IOO 
IOO 
Common school . 
56 
42 
21 
II 
130 
5-0 
5-9 
7-2 
5-3 
5-6 
Protestant school . 
6 
12 
9 
3 
30 
1.1 
2.5 
5-i 
3-4 
2-3 
Holland's Institute 
(8 
) 
(3) 
(") 
(4.2) 
(10 
•0) 
(5-o) 
Boys 
48 
28 
14 
5 
95 
5-9 
5-5 
7-0 
3-8 
5-8 
Girls 
14 
26 
16 
9 
65 
3.8 
5-9 
5-4 
3-3 
Boys and girls 
62 
54 
30 
14 
160 
3-74 
4-54 
6.38 
4-73 
443 
Diffuse opacity of the entire drumhead likewise comes 
under observation in a number of persons with normal hear- 
ing (1.15 per cent). Its frequency rises pretty regularly with 
increase in the hardness of hearing in the various schools 
and sexes, but decreases again, in early age, on an average 
among the highest degrees of reduction of function. 
There are special points or predilection for the " circum- 
scribed opacities," for instance, the whole or a part of the 
intermediary of the peripheral zone ; the latter is mostly 
affected in the anterior lower quadrant. Relatively fre- 255 
Examinations of the Auditory Organ of School-Children. 
quently, the anterior upper quadrant likewise shows a 
whitish opacity over a greater extent or only in its upper 
angle. Dendritic opacities, which possibly owe their origin 
in part to the dendritic fibrous structure described by 
Gruber, are more frequently found in the posterior half. 
All these various forms of opacity and thickening of the 
substance of the drumhead have been grouped together 
under the common head of " circumscribed opacities." 
They could be demonstrated with great frequency, alto- 
gether in 12.65 Per cent., although slight indications were 
disregarded. How little their presence per se disturbs the 
auditory function appears from the fact that they exist in 
not less than 10.43 Per cent, of the normal hearing. In the 
slighter degrees of hardness of hearing we observe a mod- 
erate increase in their frequency which, however, proves 
much smaller than in the case of the diffuse opacities. 
The highest grades again show a diminished number, as do 
the diffuse opacities. 
Of " calcifications," which were most frequently found in 
the posterior or anterior intermediary zone, at times by the 
side of still persisting perforations or cicatrices of the drum- 
head, it has been repeatedly shown in the literature that 
their presence does not necessarily form a hindrance to the 
normal function ; they exist in our examinations in 1.33 per 
cent, of the normal hearing. As opposed to the simple 
diffuse and circumscribed opacities, their frequency grows 
most considerably among the highest degrees of hardness of 
hearing-a fact which perhaps should be explained by their 
frequent connection with former purulent processes. 
Finally a separate entry was made of the " posterior streak 
of opacity," because in at least a part of the cases it is dis- 
tinguished from the other opacities by its mode of origin. 
By this short term I understand the streak of opacity which 
frequently extends from the short process backwards and 
downwards, beginning as a more or less sharp line and 
either (1) ending at the posterior border of the drumhead ; 
or (2) gradually disappearing farther downward in the pos- 
terior half; or (3) merging in a further zonular opacity. It 
is probable, at least in conditions 1 and 2, that is has de- Friedrich Bezold. 
256 
veloped at the place of a former posterior fold, and thus 
points to preceding tubal processes, all the more because we 
often enough find streaks of opacity and the formation of 
folds at one and the same time. However, not always is 
the long existing flexion at this point to be considered as 
the most probable cause of the posterior streak of opacity. 
Not rarely we see the streak merely as the clearly-marked 
commencement of an opacity which occupies the entire in- 
termediary or the whole or a part of the peripheral zone. 
In these cases it is possible that inflammatory processes, 
which were localized exclusively in the membrana tympani 
and the drum cavity, may have led to deposits at this point 
in particular, because by its greatest tension it gives rise 
with special facility to disturbances of circulation. Opacity 
of the whole intermediary zone, too, which is of frequent 
occurrence, may possibly be traceable in a part of the cases to 
a persistent flexion due to greater depression of the central 
funnel of the drumhead. 
We encounter the posterior streak of opacity likewise with 
comparative frequency (in 3.74 per cent.) in normal relations 
of hearing. We meet it somewhat more frequently in hard- 
ness of hearing of various grades, but the frequency decreases 
again in the highest degrees. This latter circumstance, which 
we have seen to recur in all the various forms of opacity with 
the exception of calcification, might be interpreted thus : 
That by themselves, even if extensive and thickly deposited 
in the substance of the drumhead, they cause only a mod- 
erate degree of hardness of hearing, or occur, as a rule, at 
least in jnvenile age, merely by the side of the slighter 
similar pathological alterations in the sound-conducting 
apparatus. Possibly, in view of the slight rise of the figures 
which is presented by all the opacities, this small decrease of 
the frequency in high degrees of hardness of hearing finds a 
simpler explanation in the fact that this column includes 
also most cases of occluding plugs and otorrhoeas which 
rendered inspection of the drumhead impossible, and, of 
course, enlarge the total of this column in proportion to the 
numbers here to be considered. 
As to the pathognostic significance of the various forms of 257 
Examinations of the Auditory Organ in School-Children. 
opacity in general, the numbers found show that they possess 
on the whole but a slight diagnostic value. The last place in 
this respect is occupied by the frequent circumscribed opaci- 
ties ; some greater weight attaches to the posterior streak of 
opacity, to diffuse opacity of the entire drumhead, and, 
especially for the higher degrees of hardness of hearing, to 
calcifications. 
FORM ANOMALIES OF THE DRUMHEAD. 
a.-Posterior Fold. 
Hearing distance. 
Absolute numbers. 
Percentages. 
Above 
16 
Met. 
16-8 
Met. 
8-4 
Met, 
4-0 
Met. 
Total. 
Above 
16 
Met. 
16-8 
Met. 
8-4 
Met. 
4-o 
Met. 
Total. 
Number examined in 
the two public 
schools 
1659 
1189 
470 
296 
3614 
IOO 
IOO 
IOO 
IOO 
IOO 
Common school . 
50 
58 
48 
50 
206 
4-5 
8.1 
16.4 
24.2 
8.8 
Protestant school . 
IO 
23 
19 
II 
63 
1.8 
4-9 
10.7 
12.4 
4-9 
Holland's Institute 
(1 
4) 
(9 
) 
(23) 
(7.3) 
(30.0) 
(10.4) 
Boys 
37 
49 
33 
30 
149 
4.6 
9.6 
16.5 
23.1 
9-1 
Girls 
23 
32 
34 
31 
120 
2-7 
4-7 
12.5 
18.7 
6.1 
Boys and girls . 
60 
81 
67 
61 
269 
3.62 
6.81 
14.26 
20.61 
7-42 
b.-Manubrium Mallei Widened or Short Process Projecting. 
Hearing distance. 
Absolute numbers. 
Percentages. 
Above 
16 
Met. 
16-8 
Met. 
8-4 
Met. 
4-o 
Met. 
Total. 
Above 
16 
Met. 
16-8 
Met. 
8-4 
Met. 
4-10 
Met. 
Total. 
Number examined in 
the two public 
schools . . . 
1659 
1189 
470 
296 
3614 
too 
IOO 
IOO 
IOO 
IOO 
Common school . 
9 
17 
12 
7 
45 
0.8 
2-4 
4-1 
3-4 
1.9 
Protestant school . 
6 
15 
8 
8 
37 
1.1 
3-2 
4-5 
9.0 
2-9 
Holland's Institute 
(5) 
(2 
) 
(7) 
(2.6) 
(6-7) 
(3-2) 
Boys 
6 
18 
IO 
6 
40 
0.7 
3-5 
5-0 
4.6 
2.4 
Girls 
9 
14 
10 
9 
42 
1.0 
2.1 
3-7 
5-4 
2.1 
Boys and girls . 
15 
32 
20 
15 
82 
0.90 
2.69 
4.26 
507 
2 27 Friedrich Bezold. 
258 
The formation of a bend, which is changed into a more 
or less pronounced fold by the convexity here normally 
present, and which extends from the short process in the 
posterior half of the membrane backward and downward or 
ends at the posterior upper periphery, is generally regarded 
as an obvious pathognomonic symptom of depression of the 
drumhead. Its diagnostic significance is clearly marked in 
the above tabular statement. The posterior fold likewise 
comes under observation in not a small percentage of 
persons with normal hearing (3.62 per cent.), but its fre- 
quency rises uniformly with increasing hardness of hearing 
both in all the three schools and in the two sexes, and so 
largely that in the last column it amounts on the average 
to 20.61 per cent., or more than the fifth part of the children 
with the greatest impairment of hearing. 
A greater stereoscopic prominence of the short process 
and the manubrium mallei is likewise included, and justly 
so, among the characteristic symptoms of depression of the 
drumhead. In accordance therewith are also the numerical 
relations in table b, which in general show a great increase 
toward the last column. But a comparison of the above 
two tables shows that the latter symptom, which indeed 
was only noted where it was present in a pronounced form, 
stands in frequency far behind the posterior fold, propor- 
tionately. 
There has been left out of consideration in the tabulation 
another symptom which, when very pronounced, is charac- 
teristic of depression, viz., the more horizontal position of 
the manubrium mallei, which manifests itself in a greater 
foreshortening, and which authors place in the foreground 
among the characteristic symptoms. As we are dealing 
here only with differences in degree, and as it is quite im- 
possible to draw the limit sharply between the normal and 
the pathological condition, I had to abstain from the start 
from following this symptom statistically [which is much to 
be regretted.-H. K.]. 
The condition of the reflexes was considered especially 
indicative for the diagnosis of local atrophic depression or 
of a collapse affecting the entire drumhead ; and the term 259 
Examinations of the Auditory Organ of School-Children. 
atrophy was applied to all those cases in which there ap- 
peared, for instance, reflexes of concavity in the posterior 
half, and furthermore a more or less complete circle of 
reflexes round about in the intermediary zone, or still 
farther towards the periphery. Inasmuch as circumscribed 
atrophies and cicatrices cannot always be strictly differen- 
tiated from each other, it is possible that many a case has 
been included under d which, perhaps, had better been con- 
sidered as a simple local atrophy. 
c.-Atrophy of the Drumhead. 
Hearing distance. 
Absolute numbers. 
Percentages. 
Above 
16 
Met. 
16-8 
Met. 
8-4 
Met. 
4-0 
Met. 
Total. 
Above 
16 
Met. 
16-8 
Met. 
8-4 
Met. 
4-o 
Met. 
Total. 
Number examined in 
the two public 
schools 
1669 
1189 
470 
296 
3614 
100 
IOO 
IOO 
IOO 
IOO 
Common school . 
7 
8 
8 
5 
28 
0.6 
1.1 
2-7 
2.4 
1.2 
Protestant school . 
4 
9 
4 
4 
21 
0.8 
1-9 
2-3 
4-5 
1.6 
Holland's Institute 
(- 
-) 
(1) 
(I) 
(- 
(3-3) 
(0-5) 
Boys 
2 
6 
6 
3 
17 
0.2 
1.2 
3-0 
2-3 
1.0 
Girls 
9 
11 
6 
6 
32 
1.0 
1.6 
2.2 
3-6 
1.6 
Boys and girls . 
11 
17 
I2 
49 
0.66 
i-43 
2-55 
3-04 
1.36 
Hearing distance. 
Absolute numbers. 
Percentages. 
Above 
16 
Met. 
16-8 
Met. 
8-4 
Met. 
4-0 
Met. 
Total. 
Above 
16 
Met. 
16-8 
Met. 
8-4 
Met. 
4-0 
Met. 
Total. 
Number examined in 
the two public 
schools 
Common school . 
Protestant school . 
Holland's Institute 
Boys 
Girls 
1659 
IO 
1 
( 
7 
4 
H89 
16 
9 
2) 
* 
470 
14 
5 
( 
7 
12 
296 
IO 
5 
0 
4 
11 
3614 
50 
20 
(3) 
27 
43 
IOO IOO 
0.9 2.2 
0.2 1.9 
(1.0) 
0.9 1.8 
0.5 1 2.4 
IOO 
4.8 
2.8 
(3 
3-5 
4.4 
IOO 
4.8 
5-6 
3) 
3-i 
6.6 
IOO 
2.2 
1.6 
(1-4) 
1.6 
2.2 
Boys and girls . 
11 
IS 
19 
15 
70 
1 
j 0.66 
2.10 
4-04 
507 
1-94 
d.-Cicatrix in the Drumhead. FriedricJi Bezold. 
260 
PERFORATION OF THE DRUMHEAD 
a.- With Otorrhoea. 
Hearing distance. 
Absolute numbers. 
Percentages. 
Above 
16 
Met. 
16-8 
Met. 
8-4 
Met. 
4-0 
Met. 
Total. 
Above 
16 
Met. 
16-8 
Met. 
8-4 
Met. 
4-o 
Met. 
Total. 
Number examined in 
the two public 
schools 
1659 
1189 
470 
296 
3614 
too 
too 
too 
too 
too 
Common school . 
- 
- 
2 
25 
27 
- 
- 
0-7 
12.1 
1.2 
Protestant school . 
- 
I 
I 
6 
8 
- 
0.2 
0.6 
6.7 
0.6 
Holland's Institute 
- 1 
Boys 
- 
- 
I 
14 
15 
- 
- 
0-5 
10.8 
0-9 
Girls 
- 
I 
2 
17 
20 ' 
- 
0.2 
0.7 
10.2 
1.0 
Boys and girls . 
- 
I 
3 
31 
35 
- 
0.08 
0.64 
10.37 
0.97 
- 
- 
- 
- 
- 
The term cicatrix was applied to those darker spots which 
were surrounded by an at least in part sharp, more pro- 
nouncedly opacified, or even calcified border, or which were 
found sharply circumscribed in a drumhead exhibiting in- 
tense opacities over larger surfaces, and partly also were 
clearly depressed. 
Atrophies and cicatrices, in proportion to their frequency 
generally, could also be pretty often demonstrated in per- 
sons with normal hearing, both in nearly the same percent- 
age of 0.66. Both show a nearly equal gradual increase in 
the numbers in successively greater degrees of hardness of 
hearing; only we find the cicatrices more frequent (in 
5.07 per cent.) in the highest degrees of hardness of hearing 
than atrophy (in 3.04 per cent.). They exhibit, therefore, a 
similar relation as the calcifications compared with the sim- 
ple opacities, although this relation is not as clearly marked 
as in the latter case. 
Perforation of the drumhead with still persisting otorrhoea 
is the first division in which normal hearing is no longer 
found at all, and in which, besides, the greatest increase can 
be demonstrated in the numbers towards the zero point of 
the hearing distance. Both circumstances, as compared 261 
Examinations of the Auditory Organ of School-Children. 
b.- Without Otorrhoea. 
Hearing distance. 
Absolute numbers. 
Percentages. 
Above 
16 
Met. 
16-8 
Met. 
8-4 
Met. 
4-0 
Met. 
Total. 
Above 
16 
Met. 
16-8 
Met. 
8-4 
Met. 
4-0 
Met. 
Total. 
Number examined in 
the two public 
schools 
Common school . 
Protestant school . 
Holland's Institute 
Boys 
Girls 
1659 
5 
(- 
3 
2 
1189 
6 
I 
-) 
4 
3 
470 
7 
2 
( 
6 
3 
296 
11 
3 
1) 
7 
7 
3614 
29 
6 
(1) 
20 
15 
IOO 
0-4 
(- 
0-4 
0.2 
IOO 
0.8 
0.2 
-) 
0.8 
0.4 
IOO 
2.4 
1.1 
(3- 
3-o 
1.1 
IOO 
5-3 
3-4 
3) 
5-4 
4.2 
IOO 
1.2 
0-5 
(0-5) 
1-3 
0.8 
Boys and girls . 
5 
7 
9 
14 
35 
0.30 
0-59 
1.91 
4-73 
0-97 
with the other anomalies of the drumhead discussed thus 
far, find their explanation in the fact that, where purulent 
otitis media is still active, a whole series of factors concur 
in curtailing the function ; among these the chief part is 
played probably by thickening of the mucosa at the sound- 
conducting apparatus, infiltration, and inflammatory loosen- 
ing of the articulations and the membranes of the fenes- 
trae ; on the other hand, in older processes, by condensations 
of the mucosa on points important for the conduction, cal- 
cifications, abnormal fixations, and solutions of continuity, 
aside from partial or total filling of the drum cavity and the 
auditory canal with secretion. 
A smaller rise, though still greater than in all preceding 
anomalies, is found in otorrhoeas that have run their course, 
with persisting perforation, at least if we take cognizance of 
the highest degree of hardness of hearing. But even in 
this division there are five auditory organs which could fully 
understand whispered speech at more than sixteen^metres 
in spite of the perforation present. 
In all the anomalies of the drumhead hitherto discussed, 
I have purposely in every case specially emphasized the 
number of auditory organs with normal hearing despite the 
visible alterations, although this fact is well known to every Friedrich Bezold. 
262 
observer. I have done so, in the first place, because I had 
at my disposal unusually large rooms for testing with whis- 
pered speech ; secondly, because these observations are of 
importance not only for our clinical estimation and our 
therapeutical manipulations in anomalies of the drumhead, 
but are also capable of giving us physiologically valuable 
information about the mechanism of the sound-conducting 
apparatus. 
In reference to the first point, we learn in connection with 
the manifold alterations of the reflex anomalies of form 
which are characteristic of depression of the drumhead, that 
by themselves they prove of little importance even when 
the entire drumhead has become atrophic. That they never- 
theless possess a high value for our estimation of the single 
case is evident from the fact that even in auditory organs 
with normal function which presented symptoms of that 
nature, there were frequently reported former hardness of 
hearing, earache, tinnitus, or discharge, or else on examina- 
tion there was found on the other side impaired hearing or 
otorrhcea still present. Depressions of the drumhead gain 
importance for the hearing distance only when they occur as 
symptoms of a persistent occlusion of the tubes, that is, an 
existing difference of air pressure between the cavities of 
the middle ear and the auditory canal ; in other words, 
when, through excess of pressure, though minimal, of the 
external atmosphere on the outer surface of the drumhead, 
there is a disturbance of the exceedingly unstable equili- 
brium of the conducting apparatus. This equilibrium is an 
a priori postulate for its normal function, and is necessary 
for a normal conduction. 
The greatest reduction of the hearing distance which 
may be caused through simple, persistent occlusion of the 
tube without secondary, functionally important alterations, 
and which may be at once changed into normal-hearing dis- 
tance by simple equalization of air pressure, is by my 
clinical experience shown to be the hearing distance of 
io cm. for whispered speech-a disfence which is found 
with uncommon frequency, especially in the first examina- 
tion of the patients in question, that is to say, a reduction 263 
Examinations of the Auditory Organ of School-Children. 
to about the two hundredth part of the normal hearing dis- 
tance. Where the latter is sunk still lower in tubal occlu- 
sion, normal hearing is as a rule no longer regained, or at 
least the hearing rises but slowly. 
The slight weighting of the drumhead and thickening of 
its substance which it undergoes by deposits of lime and 
other elements does not demonstrably impair the hearing, 
particularly not-probably-when the periphery of the 
drumhead and immediate surroundings of the manubrium 
mallei are exempt, as is the rule especially with calcifications. 
With reference to our therapeutics, these observations 
teach that no reliable prospect of material increase of func- 
tion is furnished on the one hand by artificial destruction 
of atrophic portions in order to obtain more resistant tissue 
in their place, and on the other hand by excision of inter- 
mediary calcifications. This fact has been pointed out 
before by Schwartze 1 in connection with a case belonging 
under this head. 
I know no better way for the physiological study of the 
sound-conducting apparatus in the living than the succes- 
sive exclusion of all those parts of it about the functional 
importance of which we seek information. The statements 
given above show us, in this respect at least, how perfectly 
the apparatus is able to functionate despite the weighting 
of the drumhead with deposits, and despite the interruption 
of a large portion by radial and circular fibres such as are 
demonstrated with atrophies, cicatrices, and perforations. 
With reference to the spontaneous loss and the operative 
removal of other single links of the chain of conduction, a 
large series of clinical observations is to be found in the 
literature. It would be a meritorious task to collect and 
sift them. 
A more detailed report might here be subjoined of the 
five cases of dry perforation with approximately normal 
hearing distance. 
Case i.-Girl, aged ten years. Hearing distance right and 
left 18 metres for whis^?red speech. Right, for the watch 45 cm. 
The right drumhead shows in the umbo a round perforation the 
1 Arch. f. Ohrcnheilk., Bd. i., p. 142. Friedrich Fezold. 
264 
size of a lentil, which is bordered toward the front by the normal 
reflex framing the anterior margin of the perforation. Politzer's 
experiment makes a dry sound of perforation. Left, examination 
interfered with by cerumen ; sound of perforation cannot be 
produced. 
Case 2.-Boy, aged ten years. Hearing distance on both sides 
17 metres for whispered speech. Right, normal reflex punctiform ; 
sulcus reflex present. Opacity of the anterior periphery ; in the 
anterior upper quadrant a streak of opacity running from the ma- 
nubrium mallei vertically downward. Left, normal reflex absent; 
sulcus reflex present ; calcification as the continuation of a pos- 
terior fold. Perforation in the anterior lower quadrant. Dry 
sound of perforation during Politzer's experiment. 
Case 3.-Boy, aged ten years. Hearing distance for whispered 
speech, right 17, left 15 metres. Right, dry perforation, occupying 
one fourth in the anterior half. Older and more recent extravasa- 
tions of blood in the drumhead. Left, dry perforation, the same 
size as on the right, in the anterior half. Politzer's experiment 
fails on account of awkwardness. 
Case 4.-Boy, aged nine years. Hearing distance for whis- 
pered speech right 17, left 18 metres. Right, sulcus reflex present; 
calcification in the anterior upper quadrant ; large perforation in 
the anterior lower quadrant. Dry sound of perforation. Left, 
normal reflex absent ; sulcus reflex present. 
Case 5.-Boy, aged seven years. Hearing distance for whis- 
pered speech, right 18, left 17 metres. Right, normal reflex trian- 
gular ; sulcus reflex present ; indication of posterior streak of 
opacity. Left, examination partly hindered by cerumen. Con- 
siderable defect of the drumhead. Politzer's experiment makes a 
dry sound of perforation. 
The following case of extensive calcification and cicatriza- 
tion deserves special mention on account of its good hearing 
distance. 
Boy, aged eleven years. Hearing distance for whispered speech : 
right, twenty ; left, nineteen metres. Right, the triangular reflex 
quite diffuse ; the posterior upper portion of the drumhead forms 
a triangle reflecting in toto. Left, normal reflex absent. In the 
region of the umbo, a round, transparent cicatrix the size of a pea. 
The whole anterior half, with the exception of a narrow border in 
the periphery and along the anterior limit of the manubrium 265 
Examinations of the Auditory Organ of School-Children^ 
mallei, is calcified ; the anterior half of the former perforation is 
limited by the calcification. A second calcification, corresponding 
to the transverse section of a lentil, is found in the posterior upper 
quadrant. Sulcus reflex present on both sides. 
In one instance, in a girl aged nine years, a cicatrix was found 
in the posterior upper quadrant, through which the incudo- 
stapedial joint appeared in relief ; nevertheless, the hearing dis- 
tance for whispered speech was eighteen metres. 
Some malformations, likewise, came under observation. 
In a boy aged nine years, left congenital defect of the external 
meatus and rudimentary auricle, of which only a projection the 
thickness of the little finger was present. Right, the hearing dis- 
tance for whispered speech was eight metres. The tuning-fork is 
heard through the air with uncertainty, probably not at all on the 
left side ; from the vertex it sounds into the right ear. 
Once I observed in a girl aged seven years a congenital fistula 
of the ear on the left side. 
In two instances, boys respectively seven and eight years old, 
once on the right, once on the left side, I noted a remarkable 
malformation of the auricle which I have otherwise seen several 
times. In place of the regular concavity of the concha there is a 
very prominent vertical ridge completely filling the concavity, so 
that the concha here has lost its significance as sound-collector. 
Still the hearing distance of both organs was twenty metres for 
whispered speech. 
In three cases, congenital clefts of the palate were discov- 
ered as causes of the ear affection. 
The first case, a boy aged seven years, in whom the fissure ex- 
tended to a large part of the hard palate, showed characteristically 
depressed atrophic drumheads. The hearing distance for whis- 
pered speech was : right, ten ; left, thirty centimetres. 
The second case, a boy aged eight years, showed on examina- 
tion symptoms of depression of the drumhead only on the left 
side. The hearing distance was: right, fifteen ; left, twelve 
metres. The boy had been repeatedly under my treatment for 
tubal catarrhs. 
The third case, a Latin scholar aged fifteen years, who some 
years ago had had bilateral otorrhoea after scarlatina, shows on 
both sides symptoms of depression and calcification ; on the left, Friedrich Bezold. 
266 
adhesion of the incudo-stapedial joint to a cicatrix. Hearing 
distance: right, fifteen ; left, five metres. In the last-mentioned 
two boys the fissure affected only the soft palate. 
One affection of the auditory canal deserves brief mention 
on account of its total absence, apparently, in childhood, 
viz., true exostoses and hyperostoses of the osseous meatus. 
In the three years comprised in my last clinical report, 
special entry was made of all exostoses and hyperostoses 
which came under observation; I could demonstrate their 
occurrence in twenty-one persons, ten times bilaterally and 
eleven times unilaterally. Two of the unilateral patients 
had suffered for years from chronic suppuration of the 
middle ear, with total destruction of the drumhead; in one 
case there were, besides, proliferations in the drum-cavity. 
In both cases the exostosis showed an uneven surface, with 
irregular epidermal covering. One occurred in an adult 
aged thirty, the other in a boy aged fourteen years. This 
form, which represents merely an ossification of the granu- 
lation tissue, and which has been described by others and 
myself, should not be confounded with true exostoses, 
which are distinguished by their smooth, spherical surface, 
their generally uniform, pale, thin covering of cutis, and 
their frequently symmetrical position on both sides. 
The latter form I have seen exclusively in adults, and 
rather more frequently than previous authorities, if we 
exclude artificially deformed skulls, viz., in 0.5 per cent, of 
all patients and in 0.6 per cent, of adults. It was inter- 
esting to me to be able to demonstrate that among the 
1918 school-children examined they were not once present. 
The reports on exostoses in the literature refer likewise 
exclusively to adults, as far as I am able to judge. 
Finally it should be stated that foreign bodies were four 
times present in the auditory canal; twice the Blatta 
orientalis, once a fly, and once a flea adhering to the drum- 
head. The hearing distance in the four cases was within 
the normal limits. 
The following table gives us information about the twenty- 
seven children in whom nasal speech was present and records 
the hearing distance of their fifty-four auditory organs. 267 
Examinations of the Auditory Organ of School-Children. 
NASAL SPEECH. 
Hearing distance. 
Absolute numbers. 
Percentages. 
Above 
16 
Met. 
16-8 
Met. 
8-4 
Met. 
4-0 
Met. 
Total. 
Above 
16 
Met. 
16-8 
Met. 
8-4 
Met. 
4-0 
Met. 
Total. 
Number examined in 
the two public 
schools . . 
1659 
1189 
470 
296 
3614 
IOO 
IOO 
IOO 
IOO 
IOO 
Common school . 
- 
6 
9 
13 
28 
- 
0.8 
3-1 
6-3 
1.2 
Protestant school . 
3 
2 
8 
13 
26 
0.6 
0.4 
4-5 
14.6 
2.0 
Holland's Institute 
(1) 
(5) 
(6) 
(0.5) 
(i-67) 
(2-7) 
Boys 
1 
4 
11 
12 
28 
0.1 
0.8 
5-5 
9.2 
1-7 
Girls 
2 
4 
6 
14 
26 
0.2 
0.6 
2.2 
8.4 
i-3 
Boys and girls . . 
3 
8 
17 
26 
54 
0.18 
0.67 
3.62 
8.78 
i-49 
Wilhelm Meyer, in his paper on adenoid vegetations in 
the naso-pharyngeal cavity,1 which illuminates the subject in 
all directions, has also reported on extensive investigations 
in schools, made with a view to ascertain their frequency. 
Among 2,000 school-children in Copenhagen, 20, or 1 per 
cent., had the " dead pronunciation " so sharply character- 
ized by him, and in a London school, of 700 children, 13, or 
1.8 per cent. Digital examination proved that this was 
based throughout on adenoid vegetations in the naso- 
pharyngeal space. The close causal connection of ear 
affections with these proliferations has likewise been statis- 
tically ascertained by Meyer, he having found, among the 
175 observations of adenoid vegetations then reported, 130 
cases of ear disease. 
In the above table only those cases were recorded in 
which the occlusion of the nose was permanent. In some of 
the children examined, who were proper subjects of poli- 
clinical treatment, the adenoid vegetations could be demon- 
strated rhinoscopically and removed by operation. 
As regards the frequency of permanent nasal speech, the 
table shows that our interior country is no way behind the 
coast lands, it having been present in my examinations 
1 Arch. f. Ohrenheilk., Bd. viii., p. 241. Friedrich Bezold. 
268 
altogether in 1.49 per cent. Although adenoid vegetations 
were not present in all these cases, but here and there per- 
haps chronic catarrhal intumescences, especially hypertrophy 
of the posterior end of the inferior turbinated bone as the 
basis of the obstruction; still we are justified, according to 
our clinical experience, in ascribing, at least in the great 
majority of cases, the presence of dead pronunciation and 
the characteristic mimic expression to vegetations in the 
naso-pharyngeal space. Besides, these different causes are 
at any rate of nearly equally unfavorable effect for the 
function of the ear. Their injurious influence on the ear 
expresses itself most sharply in the percentages of the 
above table. Normal hearing distance among children with 
permanent occlusion of the nose does not form the rule, but 
rather a rare exception; for of the fifty-four auditory organs 
here to be considered, only three heard normally, all the 
rest more or less poorly, and the increase of the numbers in 
the higher degrees of hardness of hearing is here much 
greater than we have found with the various symptoms of 
depression of the drumhead. Not less than 8.78 per cent, 
of all hearing below 4 metres had at the same time nasal 
speech; even among those hearing at 4-8 metres the 
number is still pretty large (3.62 per cent.). These high fig- 
ures permit, perhaps, of the simple explanation that occlu- 
sion of the tubes, which can be demonstrated in the great 
majority of these cases, besides isolated suppuration of the 
middle ear and its residues, is here much more persistent 
than in the cases not complicated with complete impermea- 
bility of the naso-pharyngeal space, in which latter there 
remains frequently only the depression of the drumhead as 
the residuary symptom, while the tube has regained its 
patulousness some shorter or longer time previous. 
FORMER EAR AFFECTIONS. 
The following tables rest on the historical data furnished 
by the parents and guardians, which, of course, we must not 
expect to be complete, but be satisfied with what is attain- 
able, giving us, as they do, valuable information. 269 
Examinations of the Auditory Organ of School-Children. 
Former Discharge. 
Hearing distance. 
Absolute numbers. 
Percentages. 
Above 
16 
Met. 
16-8 
Met. 
8-4 
Met. 
4-0 
Met. 
Total. 
Above 
16 
Met. 
16-8 
Met. 
8-4 
Met. 
4-o 
Met. 
Total. 
Number examined in 
the two public 
schools . . . 
1659 
1189 
470 
296 
3614 
100 
TOO 
IOO 
100 
IOO 
Common school . 
55 
58 
50 
64 
227 
4-9 
8.1 
17.I 
30.9 
9-7 
Protestant school . 
9 
25 
25 
32 
91 
1-7 
5-3 
14.1 
36.0 
7.1 
Holland's Institute 
(' 
0 
( 
&) 
(13) 
(3 
6) 
(2O.O) 
(5.9) 
Boys 
38 
34 
34 
42 
148 
4-7 
6-7 
17.I 
32.3 
9.0 
Girls 
26 
49 
4i 
54 
170 
3-1 
7-2 
I5-I 
32.5 
8.6 
Boys and girls . . 
64 
83 
75 
96 
318 
3-86 
6.98 
15.96 
32.43 
8.80 
The statements as to preceding suppurations are pre- 
eminently apt to awaken our fullest attention ; in the first 
place, because at this age they are more reliable than in the 
case of adults, in whom the lapse of time for accurate recol- 
lection is far too great, and the relatives, who usually have 
a better memory for past diseases of their wards than the 
latter themselves, are often no longer among the living ; in 
the second place, because of the remarkable statistical re- 
sults yielded by the following table. 
The regularity with which the percentages rise, in the 
several schools as well as in the two sexes, with increasing 
impairment of hearing, was, to me, a very notable and quite 
unexpected fact. It is just this last table which gives us 
the best proof of the suitability of the classification accord- 
ing to hearing-quotas chosen. 
Weil (I. c.) likewise states in regard to his examination of 
schools that a large number of children in Stuttgart had 
suffered, according to the history, from otorrhoea in the 
past: "Thus, for instance, in the Eberhard school, of the 
1,105 children, besides the 26 affected with suppuration, 
60 stated that they had formerly had otorrhcea. . . . 
The szippuration, therefore, had ceased spontaneously in by 
far the majority of cases!" What influence the preceding Friedrich Bezold. 
270 
suppurative processes had exercised on the function of the 
ear escaped Weil's observation, because, in his tables, he did 
not bring the existing and antecedent disturbances into re- 
lation with the grade of the hearing distance. 
The importance of former suppurative processes for the 
subsequent hearing power becomes most clearly marked 
when we represent the series of percentages, gained from 
the total number of children in the above table, graphically, 
as has been done in the adjoining curve (Fig. 3), in which the 
Fig- 3- 
ordinals are formed from the numbers of persons with normal 
and defective hearing of various degrees, who had been for- 
merly affected with suppuration. It shows clearly enough 
how rapidly the figures here rise towards the zero point of 
the hearing distance. While among those with normal 
acuteness of hearing there are only 3.86 per cent, with 
former otorrhcea, the latter is stated to have been present 
in 32.43 per cent, among those hearing between 4-0 metres, 
or nearly in one third among those having the highest degree 
of impairment of hearing. 271 
Examinations of the Auditory Organ of School-Children. 
In a large number of the children absolutely nothing 
could be demonstrated on the drumhead of the antecedent 
perforation, and merely the functional disturbance had re- 
mained as the residue of the long-past purulent inflammation. 
The patho-anatomical alterations which have remained in 
these cases might very probably be considered as analogous 
to those which we suppose in the so-called processes of 
sclerosis, and the temptation is great to conclude from the 
above statistical results that, in a large number of cases 
exhibiting little or no alterations on the drumhead, but 
being well characterized as affections of the middle ear by 
the test for osteo-tympanic conduction, especially by the 
aid of Weber's and Rinne's experiments, would fall at least 
etiologically more correctly under the diagnosis of residues 
of otitis media purulenta with closed perforation than under 
the diagnosis of otitis media catarrhalis. 
Of the other antecedent ear diseases-former defective 
hearing, tinnitus, and earache-of which tabular statements 
were made, the latter two are of some interest. 
As regards the presence of subjective noises, not much is 
learned on the whole from the children directly, and in the 
tables certainly only the higher degrees are recorded, about 
which the children had spontaneously spoken to their rela- 
tives. They are reported : 
Among those hearing above 16 metres in 2.2 per cent. 
" " " at 16-8 " " 2.6 " 
" «« " •• 8-4 " " 5.8 " 
" * 4-o " " 5-8 " 
" all the children "3.1 " 
Accordingly they seem to be more frequent in childhood 
than is usually assumed from clinical experience. 
The former earache reported may give us an approximate 
idea in how many children acute inflammatory processes 
had been present in the ear. Here, of course, we cannot 
exclude pure otalgia, which is not so rare in children in 
connection with dental caries. Earache was reported: 
Among those hearing above 16 metres in 4.3 per cent. 
" " " at 16-8 " " 8.3 " 
" " " " 8-4 " " 8.9 " 
" " " " 4-0 " " 11.6 " 
And in the total number of children " 6.7 " Friedrich Bezold. 
272 
Finally, the statements in reference to antecedent defective 
hearing give us at least an approximate standard how great 
a power of observation we should presuppose in the gener- 
ality of the relatives to whom the questions were directed. 
I have omitted to make inquiry about antecedent symp- 
toms of vertigo, because, in the absence of more detailed 
explanation, the relatives would have reported too many 
things not belonging under this head-a fact with which we 
become sufficiently familiar in daily practice. 
GENERAL DISEASES OF ETIOLOGICAL IMPORTANCE. 
Greater interest again attaches to the acute infectious dis- 
eases, in connection with which we frequently meet with 
complications involving the auditory organ. Weil, too, in 
a school with 1,105 children, has devoted attention to this 
causal connection. Among the children who had had scar- 
latina, measles, diphtheria, or several of these diseases at 
the same time, there were 4.1 per cent, with posterior fold 
and 2.5 per cent, with suppuration ; among the children who 
had remained free from the infectious diseases, 2.2 per cent, 
with posterior fold, and 2 per cent, with suppuration. The 
former, therefore, presented 1.1 per cent, less tubal affections 
and 0.5 per cent, more suppuration. Of the 626 who had had 
infantile diseases, 30.5 per cent, had defective hearing dis- 
tance; of the 479 free from infantile diseases, 33.8 per cent. 
-in other words, a preponderance of 3.3 per cent, of defec- 
tive hearing among those who had not suffered from infec- 
tious diseases-a result which causes Weil himself to doubt 
its availability. 
My statistical results respecting the influence of the acute 
infectious diseases on the hearing power appear from the 
accompanying tables. 
In these tables we obtain, in the first place, as I believe, 
not unimportant information as to the relative frequency in 
general of the acute infectious diseases here considered. 
As the figures in this respect, gained incidentally in my 
investigations, are also of a more general epidemiological 
interest, I place them here again in juxtaposition. 273 
Examinations of the Auditory Organ of School-Children. 
a.-Scarlatina.1 
Hearing distance. 
Absolute numbers. 
Percentages. 
Above 
16 
Met. 
16-8 
Met. 
8-4 
Met. 
4-0 
Met. 
Total. 
Above 
16 
Met. 
16-8 
Met. 
8-4 
Met. 
4-0 
Met. 
Total. 
Number examined in 
the two public 
schools 
1659 
1189 
470 
296 
3614 
100 
IOO 
IOO 
IOO 
IOO 
Common school . 
240 
159 
67 
58 
524 
21-5 
20.2 
22.9 
28.0 
22.5 
Protestant school . 
120 
134 
50 
30 
334 
22.0 
28.4 
28.2 
33-7 
26.1 
Holland's Institute 
(64) 
(* 
) 
(72) 
(33-3) 
(26.7) 
(32.4) 
Boys 
166 
126 
43 
37 
372 
20.5 
24.8 
21.6 
28.5 
22.6 
Girls 
194 
167 
74 
51 
486 
22.8 
24.6 
27-3 
30.7 
24-7 
Boys and girls 
360 
293 
117 
88 
858 
21.70 
24.64 
24.89 
29-73 
23-74 
b.-Morbilli. 
Absolute numbers. 
- 
Percentages. 
Hearing distance. 
Above 
16 
Met. 
16-8 
Met. 
8-4 
Met. 
4-0 
Met. 
Total. 
Above 
16 
Met. 
16-8 
Met. 
8-4 
Met. 
4-o 
Met. 
Total. 
Number examined in 
the two public 
schools 
Common school . 
Protestant school . 
Holland's Institute 
Boys ..... 
Girls 
1659 
555 
308 
(ic 
401 
462 
1189 
375 
253 
8) 
262 
366 
470 
165 
91 
(2 
93 
163 
296 
105 
45 
2) 
61 
89 
3614 
I2OO 
697 
(130) 
817 
1080 
IOO 
49-8 
54-7 
(5t 
49-6 
54-3 
IOO 
49-7 
53-7 
•3) 
5i-5 
53-8 
IOO 
56.3 
51-4 
(7: 
46.7 
60.0 
IOO 
50.7 
50.6 
•3) 
46.9 
53-6 
IOO 
5i-5 
54-4 
(58.6) 
49-6 
54-9 
Boys and girls 
863 
628 
256 
150 
1897 
51.02 
52.82 
54-74 
50.68 
52.49 
c.-Rubeola. 
Hearing distance. 
Absolute numbers. 
Percentages. 
Above 
16 
Met. 
16-8 
Met. 
8-4 
Met. 
4-0 
Met. 
Total. 
Above 
16 
Met. 
16-8 
Met. 
8-4 
Met. 
4-0 
Met. 
Total. 
Number examined in 
the two public 
schools 
1659 
1189 
470 
296 
3614 
100 
too 
IOO 
100 
too 
Common school . 
254 
177 
56 
39 
526 
22.8 
24-7 
19.I 
18.8 
22.6 
Protestant school . 
86 
78 
30 
28 
222 
15.8 
16.6 
16.9 
31-5 
17-3 
Holland's Institute 
(4i) 
(3) 
(44) 
(21.4) 
(10.0) 
(19-8) 
Boys 
T47 
103 
34 
26 
310 
18.1 
20.2 
17.1 
20.0 
18.8 
Girls 
193 
152 
52 
41 
438 
22.7 
22.4 
19.2 
24.7 
22.3 
Boys and girls 
340 
255 
86 
67 
748 
20.49 
21-45 
18.30 
22.64 
20.70 
1 The entry in this and the following tables was likewise made according to the single auditory organs 
which had to be columnized with reference to their normal or reduced hearing distance, and not accord- 
ing to the individuals. The absolute numbers, therefore, give double the numbers of those affected with 
scarlatina, etc.; the percentages, however, give the correct proportions, Friedrich Bezold. 
274 
d.-Diphtheria. 
Hearing distance. 
Absolute numbers. 
Percentages. 
Above 
16 
Met. 
16-8 
Met. 
8-4 
Met. 
4-0 
Met. 
Total. 
Above 
16 
Met. 
16-8 
Met. 
8-4 
Met. 
4-0 
Met. 
Total. 
Number examined in 
the two public 
schools 
1659 
1189 
470 
296 
3614 
IOO 
IOO 
IOO 
IOO 
IOO 
Common school . 
235 
166 
65 
62 
528 
21.0 
23-1 
22.2 
30.0 
22.6 
Protestant school . 
131 
no 
31 
20 
292 
24.O 
23-4 
17-5 
22.5 
22.8 
Holland's Institute 
(53) 
(5) 
(58 
(27.6) 
(16.7) 
(26.1) 
Boys 
167 
119 
31 
41 
358 
20.7 
23-4 
15-6 
31-5 
21.8 
Girls 
199 
157 
65 
4i 
462 
23-4 
23.1 
24.0 
24-7 
23.5 
Boys and girls 
366 
276 
96 
82 
820 
22.06 
23.21 
20.42 
27.70 
22.69 
e.-Meningitis. 
Hearing distance. 
Absolute numbers. 
Percentages. 
Above 
16 
Met. 
16-8 
Met. 
8-4 
Met. 
4-0 
Met. 
Total. 
Above 
16 
Met. 
16-8 
Met. 
8-4 
' Met. 
4-0 
Met. 
Total. 
Number examined in 
the two public 
schools . . 
1659 
1189 
470 
296 
36*4 
IOO 
1OO 
IOO 
IOO 
IOO 
Common school . 
23 
17 
5 
3 
48 
2.1 
2-4 
1-7 
1-4 
2.1 
Protestant school . 
7 
6 
1 
- 
14 
1-3 
1-3 
0.6 
1.1 
Holland's Institute 
(5) 
(1) 
(6) 
(2.6) 
(3-3) 
(2-7) 
Boys 
24 
14 
- 
- 
38 
3-o 
2.8 
- 
- 
2-3 
Girls 
6 
9 
6 
3 
24 
0.7 
i-3 
2.2 
r.8 
1.2 
Boys and girls 
30 
23 
6 
3 
62 
1.81 
i-93 
1.28 
1.01 
1.72 
Among 1,807 children-823 boys and 984 girls-of from 6 
to 13 years old (Holland's Institute was left out of considera- 
tion in the summary), the acute infectious diseases of child- 
hood were represented by the following percentages: 
Scarlatina, 23.74 % of the total number, viz., boys 22.6 %, girls 24.7 % 
Morbilli, 52.49% " " " " " 49-6% " 54.9% 
Rubeola, 20.70% " " " " " 18.8% " 22.3# 
Diphtheria, 22.69 % " " " " " 21.8% " 23.5% 
Meningitis, 1.72 < " " 2.4 % " 1.2% 275 
Examinations of the Auditory Organ of School-Children. 
The numbers in Holland's Institute were usually some- 
what larger, possibly because the relatives of the pupils 
mostly belonged to the better classes, and therefore sup- 
plied more accurate statements. The rather greater fre- 
quency of scarlatina is probably traceable to a recently 
preceding local epidemic, which had attacked several of the 
pupils. 
Our illustrious medical statistician, the Royal Councillor, 
Dr. Friedrich Majer, who for twenty-five years has published 
the general reports of the Health Board in the kingdom of 
Bavaria, shortly before his death in the midst of his restless 
activity, expressed himself thus, by letter, in reply to my 
inquiry as to the relative morbidity of the acute infectious 
diseases in infantile age: " As regards the average per- 
centage of children to the thirteenth year of life who are 
attacked by scarlatina, measles, diphtheria, and meningitis, 
I must state that for such a calculation we lack, in the first 
place, all reliable data, because the number of patients in 
general, and the number of those attacked by special dis- 
eases in particular, is entirely unknown ; if for no other 
reason, because only a certain part of all diseases comes 
under medical treatment. We must restrict ourselves, 
therefore, to the number of deaths, etc." 
We may, therefore, at all events, attach a certain im- 
portance to the above percentages of morbidity, although 
they are based only on the statements of the relatives and 
on a comparatively small material, as bearing some relation 
to the true figures of morbidity. With the figures of 
mortality given in the statistics, however, they can be com- 
pared at most with reference to age and sex. The relative 
frequency of attacks of scarlatina, measles, rubeola, and 
diphtheria admits of no comparison with the figures of 
mortality, because the fatality of these different diseases is 
very variable. In regard to the age at which the several 
diseases occurred, the statements of the relatives were in 
the main inexact or entirely absent, so that the sex alone is 
left to us for comparison. 
According to Majer's statistical tables, there have died 
since 1876: Friedrich Bezold. 
276 
Of 100,000 inhabitants. 
Of 1,000 deaths from all 
causes. 
1876-80 
i88r 
1882 
1876-80 
1881 
1882 
Of scarlatina . • 
Boys . 
35 
56 
55 
10 
17-5 
17.4 
Girls . 
30 
48 
52 
10 
17 
18.7 
Of measles . . • 
Boys . 
Girls . 
22 
22 
17 
16 
28 
28 
6.7 
7.5 
5-4 
5-8 
8.9 
10.2 
Of croup and 
Boys . 
117 
145 
131 
35 
45 
42 
diphtheria. 
Girls . 
106 
135 
119 
37 
48 
43 
In the time above stated, which chiefly concerns us for 
the children examined, there have died of the three infec- 
tious diseases among every 100,000 inhabitants rather less 
girls than boys, although the number affected, according to 
my above results, is throughout a few per cent, higher among 
the girls than among the boys. We obtain a better harmony 
between the above mortality figures with my morbidity 
figures, if the former are calculated on the basis of the total 
mortality figures in the years in question, as has been done 
in Majer's second series. 
With reference to cerebro-spinal meningitis, Majer wrote 
me that in 1883 the whole number of deaths from this dis- 
ease was 495-viz., 328 male and 167 female. The relative 
morbidity found by me for this disease in the two sexes, 
though based on too small figures, agrees well with the 
latter numbers. 
As regards the demonstration of a causal connection of 
ear affections with the various infectious diseases here con- 
sidered, Weil could not arrive at a positive result, because he 
did not put his questions separately for the several general 
diseases, which is absolutely necessary in view of their 
different influence on the ear. Thus, for instance, in my 
last triennial report,1 among 3,787 ear patients, I could trace 
185 affections of auditory organs in 121 individuals to scar- 
latina, but only 15 to faucial diphtheria, and 18 to measles. 
Therefore, the latter two infectious diseases together had 
not implicated the fifth part the number of auditory organs 
that scarlatina had done. Burckhardt-Merian,2 among 1,950 
1 L. c. 
2 Ueber den Scharlach in seinen Beziehungen zum Gehbrorgan. Sammlung 
klin. Votrdge von Volkmann, No. 182. 277 
Examinations of the Auditory Organ of School-Children. 
ear patients, found 85 (4.35 per cent.) cases which had 
occurred in the course of scarlatina. Biirkner 1 and a 
number of authors enumerated by him obtained still greater 
percentages, up to seven per cent. 
Possibly the influence of the infectious diseases on the 
auditory organ, in the mode of investigation followed both 
by Weil and by myself, is hidden in part by the fact that 
the less resistant children have succumbed to the funda- 
mental disease. It could readily be imagined that this fate 
would befall mainly such children as have previously suf- 
fered from affections of the naso-pharyngeal space and con- 
secutively of the ear, and accordingly were specially disposed 
to an extension of the diphtheritic process to these spaces- 
a fact particularly emphasized by Guye at the last Inter- 
national Otological Congress at Basle. In a part of the 
cases it is even the grave implication of the ear which, 
sooner or later after the general disease has run its course, 
leads to a fatal termination, whereby, of course, the number 
of those who become hard of hearing after acute infectious 
diseases must be greatly curtailed. 
In spite of all this, in the historical results of school in- 
vestigations, the influence of a part of the acute infectious 
diseases on the number of ear affections finds a pretty clear 
expression if we employ the representation by hearing-quotas 
chosen above. 
As could be expected, this becomes most manifest in the 
table of scarlatinal diseases. We find, at least in the total 
number of children, a regular rise of the percentages with 
increasing impairment of hearing-a fact which suffers but 
few exception in the various schools and sexes. Of those 
with normal hearing, on the whole only 21.70 per cent, had 
had scarlatina, but among those hearing at 4-0 metres, 
29.73 per cent. 
Also among the children formerly affected with diphtheria, 
some influence on the ear, though not with the same dis- 
tinctness, is recognizable, at least as regards the successive 
increase. Among those with normal hearing, we find 22.06 
per cent. ; among those with the worst hearing, 27.70 per 
* L. c. Friedrich Bezold. 
278 
Cent., who had been formerly affected with diphtheria. To 
be sure, in utilizing the latter number, we must not over- 
look that in this instance the statements of the relatives 
were somewhat lacking in accuracy, many a case perhaps 
having been counted as true diphtheria which was merely a 
complication of scarlatina. 
The results obtained with measles I hold to be uncertain, 
for though we find an increase in moderate degrees of 
hardness of hearing, there is again a slight decrease, even 
as compared with the normal, among the higher degrees of 
defective hearing. 
The results obtained with rubeola I hold to be worthless, 
in the first place on account of the small differences in num- 
bers, and in the second place because this infectious disease 
can be differentiated with the greatest difficulty from the 
others. Thus I was struck by the fact that in some dis- 
tricts and at some time it was diagnosticated with extra- 
ordinary frequency, while otherwise it was reported much 
more rarely. 
It was to be expected that not many ear diseases would 
be found among those formerly affected with meningitis; 
for the cases in which this disease is complicated with affec- 
tion of the ear are to be sought, as a rule, not in the schools, 
but in deaf-mute institutions. 
TRAUMA AND HEREDITY. 
Trauma was given as the cause of auditory disturbances 
altogether only in seven organs of hearing. 
Of special interest, finally, are the statistical results as to 
the part played by heredity in ear diseases, whose relative 
frequency, as shown by Biirkner, has been found so different 
by various authors-by Moos in not less than thirty-seven 
per cent., by Biirkner himself only in six per cent. My own 
statistical investigations, made in the general report on the 
ear patients treated in 1881-83, have furnished me pretty 
large numbers, viz., for otitis media simplex chronica, with- 
out symptoms of depression on the drumhead, 27.3 per 
cent.; for forms of defective hearing that could not be 
accurately localized, 36.4 per cent.; for nervous hardness of 279 
Examinations of the Auditory Organ of School-Children. 
hearing and deaf-mutism, each 22.2 per cent.; aside from 
other forms of disease with smaller percentages. 
Let us see, in view of these figures, what is the relation of 
normally hearing persons, in whose families members with 
defective hearing are found. As in my above-mentioned re- 
port, the consideration included only the direct ascendants 
as far as the grandparents, and brothers and sisters. De- 
fective hearing, due to purulent processes among the 
relatives, was excluded from the enumeration. Still I 
would not omit to state that otorrhcea among the relatives 
was reported comparatively often by persons with defective 
hearing. In my practice, too, I have been struck by the 
fact how often a larger series of brothers and sisters is 
suffering from purulent otitis media, or the same affection 
was formerly present in the parents. 
The school-children showed the following proportions of 
heredity: 
HEREDITY. 
Hearing distance. 
Absolute numbers. 
Percentages. 
Above 
16 
Met. 
16-8 
Met. 
8-4 
Met. 
4-0 
Met. 
Total. 
Above 
16 
Met. 
16-8 
Met. 
8-4 
Met. 
4-0 
Met. 
Total. 
Number examined in 
the two public 
schools 
1659 
1189 
470 
296 
3614 
IOO 
IOO 
IOO 
IOO 
IOO 
Common school . 
IOO 
62 
27 
31 
220 
9.0 
8.6 
9.2 
15-0 
9-4 
Protestant school . 
66 
49 
29 
14 
158 
12.1 
10.4 
16.4 
15-7 
12.3 
Holland's Institute. 
(38) 
(10) 
(48) 
(19-8) 
(33-3) 
(21.6) 
Boys 
83 
58 
25 
19 
185 
IO.3 
11.4 
12.6 
14.6 
II.2 
Girls 
83 
53 
31 
26 
.193 
9.8 
7-8 
11.4 
15-7 
9.8 
Boys and girls. 
166 
in 
56 
45 
378 
10.00 
9-34 
11.91 
15-20 
IO.46 
The table teaches, in the first place, that even among the 
persons with normal hearing a pretty large number, on the 
average ten per cent., shows hereditary affections ; this 
number probably is too small rather than too large, as 
appears also from the statements in Holland's Institute 
with 21.6 per cent., which may be looked upon as on the 
whole more accurate. Friedrich Bezold. 
280 
The increase of heredity with augmenting hardness of 
hearing is not very conspicuous, at least as regards the 
regular rise of the figures with growing hardness of hearing. 
However, in the highest degrees of hardness of hearing at 
least, the percentages are more than one and a half times as 
great as among the normal hearing, and therefore some in- 
fluence of hereditary factors is unmistakable. Perhaps here 
too, as in the exanthematic affections, the number examined 
is too small to furnish positive information. Besides, it 
should be emphasized that the diseases which my clinico- 
statistical results show to be chiefly influenced by heredity 
are comparatively rare in childhood and develop usually at 
a more advanced age. 
FREQUENCY OF THE SEVERAL FORMS OF DISEASE, COL- 
LATED ACCORDING TO AGE AND SEX, AND 
THEIR CURABILITY. 
So far as the forms of the fundamental disease could be 
ascertained from the state of the drumhead, which was alone 
recorded, they are given in tables XX. and XXI. (pp. 281,282). 
Of the several classified ages, the number examined is too 
small to justify its representation in percentages. Also as to 
the frequency of unilateral and bilateral occurrence of the 
several forms of disease, we obtain much more accurate in- 
formation from more extensive series of clinical observa- 
tions, such as are found in otological reports. Therefore, in 
this place the percentages of the several diseases relative to 
each other and those of the two sexes are alone calculated. 
If we collate the percentages of the diseases with reference 
to their curability, we find : 
A.-Forms Completely and Partially Amenable to Treatment. 
I. 
Plugs of cerumen probably occluding the ear canal 
4.3 per cent. 
2. 
Tubal catarrh ........ 
. 27.8 " 
3- 
Tubal catarrh with atrophic drumhead 
. 2.2 " 
4. 
Acute and subacute catarrh of the middle ear 
2.2 " 
5. 
Acute and chronic suppuration of the middle ear 
. 5-2 
Total 
. 41.7 per cent. 281 
Examinations of the Auditory Organ of School-Chzldren. 
7 years . 
8 " . 
9 " • 
IO " 
ii " . 
T2 " 
13 " • 
14 
15 " • 
16 " . 
17 " . 
18 " 
Total . 
Age. 
8 12 
M M M tO tO CH 
Unilateral. 
Bilateral. 
Cerumen closing the ear 
canal. 
co 
O 
14 18 
8 20 
6 9 
8 1 17 
4 3 
7 5 
5 
1 1 
: 2 
Unilateral. 
Bilateral. 
Symptoms of tubal catarrh 
on the drumhead. 
to 
HI 
Unilateral. 
Atrophy of the drumhead. 
co 
'h h to 4* 
Bilateral. 
to 
cn. 
M to to M CO OCR CH 
Unilateral. 
Opacity or calcification of 
the drumhead without 
depression. 
Ln 
CO 
M O OO M M \O 00 
Bilateral. 
HI 
HI 
Unilateral. 
Otitis med. catarrh, acuta 
and subacuta, injection, 
extravasation of blood, 
serum. 
o 
HI to 4^- 10 
Bilateral. 
Ln 
h co cn to to to 
Unilateral. 
Otitis media purulenta 
acuta and chronica. 
O 
H 4^ M to 
Bilateral. 
6 12 
H to H HI HI 
HI U W M 4* 
Unilateral. 
Bilateral. 
Residues of otitis media 
purulenta, with persist- 
ing perforation. 
9 20 
HI HI tO CO H H 
m hi to 4* Ln Ln to 
Unilateral. 
Bilateral. 
Residues of otitis media 
purulenta, with cica- 
trix. 
o 
O' 
hi HtcncnOcncncnO 
Unilateral. 
Negative state of the 
drumhead. 
4^ CO CO O' CD^ CO 
Bilateral. 
to M to to 
Unilateral. 
Cerumen hindering the 
examination. 
O 
HI to H 4- to 
Bilateral. 
HI 
M 
Unilateral. 
Congenital occlusion of the 
ear canal and rudimentary 
• concha. 
M 
co 
N »0 W M 0 
Sick and not examined. 
495 
100 
100 
81 
88 
44 
52 
21 
4 
3 
2 
Total persons with defective hearing. 
The unilateral and bilateral diseases of the ear, found in the three schools examined, collated according to the age of the 
persons affected. 
TABLE XX. Friedrich Bezold. 
282 
( Common School II. A . 
-< Protestant School II. . 
M ( Holland's Institute 
£ Common School II. A. 
g Protestant School II. . 
Total boys .... 
Total girls .... 
Total boys in percentages' . 
Total girls in percentages . 
Total boys and girls in per- 
centages .... 
W cn ** M M 
Unilateral. 
Cerumen closing the ear 
canal. 
UO O' LP 
tn to to m to 
Bilateral. 
13 
IO 
I 
17 
7 
24 
24 
31- 
24. 
27. 
Unilateral. 
Symptoms of tubal catarrh 
on the drumhead. 
26 
11 
5 
3i 
7 
42 
38 
6# 
7# 
8$ 
Bilateral. 
to to m M W M 
Unilateral. 
Atrophy of the drumhead. 
to co 4^ 
cn to to co to h 
Bilateral. 
M tO « U (0 U 0 U 4- tn 
CO M CO 
Unilateral. 
Opacity or calcification of 
the drumhead without 
depression. 
O cn cO 
M CO 
M -J 4- - O Cl 
Bilateral. 
to to to M 
Unilateral. 
Acute and subacute catarrh 
of the middle ear, injec-| 
tion, extravasation of 
blood, serum. 
to bi 
tn tO tO h to tO 
Bilateral. 
to 0 H w 
tn O' Co 
Unilateral. 
Acute and chronic suppura- 
tion of the middle ear. 
to i co 
cn m 
Bilateral. 
Co to cn M 4 h m 
Unilateral. 
a. With persisting per- 
foration of the drum- 
head. 
Residues of middle- 
ear suppuration. 
\D CO CO 
CO M to to 
Bilateral. 
0 kJ Cn -4»> cn M CO >-< M CO 
Unilateral. 
b. With cicatrix on the 
drumhead. 
co to co 
M M 
4* 0 co M CH M 
Bilateral. 
II 
17 
4 
26 
8 
32 
34 
30. 
29. 
29- 
Unilateral. 
Negative state of the 
drumhead. 
15 
15 
2 
25 
14 
32 
39 
6# 
8^ 
Bilateral. 
P P 
to cn 
Unilateral. 
Congenital occlusion of the 
ear canal and rudimentary 
concha. 
4^ co to to CO 
Unilateral. 
Cerumen hindering the 
examination. 
CO to to OS MM 
Bilateral. 
cn co to co <r O' 
Sick and not examined. 
III 
96 
20 
I98 
70 
227 
268 
IOO% 
IOO % 
IOO% 
Total persons with defective hearing. 
1 Pupils with defective hearing who were not examined otoscopically on account of disease, etc., and those in whom the examination was hindered by accumulated 
cerumen, though the ear canal was not completely occluded, were left out in calculating the percentages. 
The unilateral and bilateral diseases of the ear, found in the three schools, collated according to the sex of the persons affected. 
TABLE XXL 283 
Examinations of the Auditory Organ of School-Children. 
B.-Forms not at all or but Slightly Amenable to Treatment. 
I. 
Opacity of calcification of the drumhead without depression, 
18.0 per cent. 
2. 
Residues of middle-ear suppuration with persisting perforation, 
3-9 
3- 
Residues of middle-ear suppuration with closed perforation, 
6-3 
4- 
Negative state of the drumhead 
29.8 " 
5- 
Congenital occlusion of the ear canal and rudimentary 
concha .......... 
0.2 " 
Total ...... 
58.2 per cent. 
Therefore, of the children found in the schools with ear 
disease, according to the state of the drumhead disclosed, 41.7 
per cent, offered a certain prospect of more or less complete cure 
if subjected to appropriate treatment. 
HYGIENIC REMARKS. 
In regard to suppuration of the middle ear, which we find 
represented by 5.2 per cent, among the several diseases, I 
should like to emphasize here especially, that it would be 
not alone to the interest of the patients if their attention 
were called, perhaps by the school authorities, to the im- 
portance of this affection for the function of the ear, and 
furthermore for health and life in general, but also that such 
course would be desirable with reference to the other 
children attending school. 
Among the total number of auditory organs examined, we 
have found 0.97 per cent, of active suppuration of the mid- 
dle ear, and another 0.97 per cent, of temporarily quiescent 
suppuration with persistent perforation, which latter tend to 
fresh relapses of the suppuration with every additional in- 
jurious influence. Besides, it is not improbable that, in a 
part of the cases which were inaccessible to examination 
from the presence of accumulated masses in the depth of the 
ear canal, the obstruction was due, not to cerumen, but to 
crusts of inspissated pus. In the schools of Stuttgart, Weil 
demonstrated a still larger number of otorrhoeas, namely, 
boys, 1.9 per cent, and girls 2.3 per cent. 
Therefore, according to the results of Weil's and my own 
examinations, we shall not err if we assume that about in 
every class in schools there is at least one pupil suffering 
from suppuration of the middle ear, and, if left to itself, from 
temporary or permanent fetid otorrhoea. Such a continual Friedrich Bezold. 
284 
source of, at best, disgusting products of decomposition 
should not leave us indifferent in a place of which we are 
justified in making the highest hygienic demands. 
I would like to show, by but a single instance, of what im- 
portance a day-by-day freshly secreting purulent and sanious 
patch of one person, such as is formed by a chronic purulent 
otitis media left untreated, may become to the rest of the 
pupils. My former assistant, Dr. Nathan, reports a case of 
otitis media purulenta chronica with polypoid proliferations, 
out of my practice,1 which occurred in a boy aged nine years. 
The otorrhoea had existed for five years, and of late had be- 
come very abundant, so that, according to the mother's 
statement, the purulent, very offensive secretion usually 
flowed down to the shoulder during the school hours, 
although cleaned three times a day. (How unbearable 
sleeping-rooms can be rendered by the odor of otorrhoics 
is sufficiently proved by the complaints of the relatives.) 
In this last case, however, repeated microscopic examina- 
tion showed that the secretion almost constantly contained 
Koch's tubercle bacilli, although the lung yielded nothing to 
physical examination. 
I therefore consider it one of the objects of school 
hygiene to ex chide persons affected with otorrhoea from school 
so long until a rational antiseptic treatment has at least re- 
moved all fetor and, if at all possible, the discharge itself. 
INFLUENCE OF THE HEARING POWER ON THE MENTAL 
DEVELOPMENT. 
A part of the mental pabulum which on an average be- 
comes the property of children with senses unimpaired, 
must, of course, be lost to a greater or less extent to per- 
sons with defective hearing of various degrees. However, 
in this instance a completely normal hearing power forms 
only one among a great many factors which in their totality 
form the sum of the mental potency of the individual. For it 
is indubitable that in many cases the absence of stimulus 
caused by a moderate degree of defective hearing may be 
1 Deutsches Archiv f. klin. Medicin, Bd. xxxv., Heft v., p. 491, and 
" Arbeiten aus dem medicinisch-klinischen Institute v. Ziemssen u. Bauer," 
Bd. i., 2 Halfte, p. 593. 285 
Examinations of the Auditory Organ of School-Children. 
compensated and even overbalanced by assiduous care of the 
relatives and teachers with such children, by appropriate 
literature, frequent intercourse with older children, etc., 
apart from the varying original capacity. Still we are a 
priori justified in assuming that, if not in the individual, 
yet in the examination of a large number of children, a but 
partial defect of this special sense, which is of importance 
at least in ordinary instruction, will find expression some- 
how in the mental development of the affected children, 
provided we can apply a uniform measure to them all. 
Such a measure, though but incidental, is furnished in 
schools by the rate of progress noted by the teachers in 
all the subjects of instruction. As I finished my examina- 
tions in Common School II. A in the month of August 
when the pupils were rated at the school, I placed in the 
following table (p. 287) the general rates of progress in re- 
lation to the grade of their hearing distance. 
Among the 1,289 rated pupils of the common school, 
there had been found 296 who on either one or both sides 
heard whispered speech only at 8 metres and less; among 
these were 60 who heard it on both sides at 4 metres and 
less, and, finally, 33 who heard it on both sides at 2 metres 
and less. Now every single class was calculated separately 
in the following manner: Of each of the last-mentioned 
groups of hearing power, all the rates of progress were 
added, and from the sum was calculated the mean average 
place belonging to the single group of pupils with defective 
hearing. This average place was compared with the aver- 
age place of the total number of pupils in the class in ques- 
tion, which is simply expressed by halving the latter num- 
ber. In order to make all the classes comparable with each 
other, it was necessary, too, to render the number of class 
pupils equal to each other, which was taken at 100, so that 
the mean average place for the whole school is expressed 
by the number 50. With reference to this number, the 
average places were calculated which belonged to the above 
three groups with defective hearing. 
In this way I obtained the following results of the rate of 
progression for the three groups with diminished hearing. 
The average rate of progress was: Friedrich Bezold. 
286 
Among those hearing on one or both sides at 8 metres and 
less .......... 54.09 instead of 50 
Among those hearing on both sides at 4 metres and less . 64.36 " " 50 
And among those hearing on both sides at 2 metres and 
less 67.70 " " 50 
These numbers, though gained from a comparatively 
small amount of material, prove distinctly that there was 
not alone some influence on the rate of progress, but that a 
successive* increase of this influence can be demonstrated, 
corresponding to the degree of the hearing defect present. 
In order to appreciate the importance of these figures 
fully, we must bear in mind that the degree of the hearing 
defect ascertained should not, in the majority of the chil- 
dren examined, be looked upon as a permanent and alto- 
gether unalterable condition, but that it is subject to great 
variation, and that, therefore, the limitation in following 
the instruction is not continuous, because, especially, a large 
number of pupils suffering from tubal catarrh, accumulated 
cerumen, etc., now and then will be enabled to hear again 
almost or perfectly normally. This intermittence and re- 
mittence of defective hearing is the main reason why rela- 
tives and teachers do not believe the children to be hard of 
hearing, but merely inattentive ; therefore, the teachers par- 
ticularly cannot be too often impressed with this condition. 
Despite the change in the hearing distance, the influence 
of the hearing expresses itself in the table even in the 
first group with defective hearing, the greater part of whom 
showed only so slight a defect as to hardly be taken into 
consideration in ordinary intercourse, and to remain un- 
known to the majority of the patients and their relatives. 
Hence, I believe that in the accompanying table is furnished 
the first statistical demonstration that also the mental devel- 
opment of the individual suffers a limitation corresponding to 
the degree that his hearing power is diminished. 287 
Examinations of the Auditory Organ of School-Children. 
TABLE XXII. 
Influence of the Hearing Power on the Rate of Progress. 
Common School II. A. 
Sum and average place of the 
various groups with defective 
hearing, calculated per 100 
pupils, respectively, in the 
several classes . . . 
Boys' class la . 
" " lb . 
" Ic . 
Girls' " la . 
" " lb . 
Boys' " Ila .... 
" " lib . 
Girls' " Ila .... 
" " lib . 
" " lie . 
Boys' " Illa 
" " Illb 
Girls' " Illa 
" " Illb 
Boys' " IVa 
" " IVb ... 
Girls' "IVa 
" " IVb ... 
" " V . 
" " Via ... 
" " VIb ... 
Boys' "VII 
Girls' "VII 
V 
1289 
58 
63 
62 
61 
57 
63 
63 
57 
61 
56 
59 
58 
55 
56 
61 
62 
5i 
61 
55 
5i 
49 
33 
37 
Total number of rated pupils. 
29 
3i-5 
3i 
30.5 
28.5 
3i-5 
3i-5 
28.5 
30.5 
28 
29-5 
29 
27-5 
28 
30.5 
3i 
25-5 
30.5 
27-5 
25-5 
24-5 
16.5 
18.5 
Mean average rate of progress ap- 
pertaining to the number of pupils. 
296 
IO 
18 
5 
17 
9 
8 
12 
M 
15 
16 
11 
14 
17 
16 
11 
11 
16 
12 
20 
15 
14 
6 
9 
Number. 
a. Pupils hearing on 
one or both sides 
at less than 8 
metres. 
36.1 
42.8 
22 8 
30.6 
3i-3 
41.8 
35-5 
23.2 
23.8 
30 0 
28.4 
37-9 
32.6 
31.7 
36.5 
38.2 
27.8 
35-8 
30.5 
18.4 
27.8 
14-5 
23.1 
Mean rate of 
progress. 
0 
0 
in HU O'W u JO "U 4- H4- H U4in h O'4- 
Number. 
b. Pupils hearing on 
both sides at less 
than 4 metres. 
c. Pupils hearing on 
both sides at less 
than 2 metres. 
Go ~ 
32.0 2 
49-5 4 
30.0 1 
37-o 2 
33-8 1 
42.7 3 
50 0 1 
40.5 2 
47-0 
49-3 3 
25.0 1 
48.0 1 
4i-5 2 
22.3 2 
3i-7 2 
36.7 3 
27 
34 
29-4 3 
Mean rate of 
progress. 
Number. 
1 
29-5 
5i-3 
30.0 
40.5 
52.0 
42.7 
50.0 
35-0 
55-3 
50.0 
48.0 
4i-5 
9.0 
22.3 
38.7 
32.0 
Mean rate of 
progress. 
5' 
& 
54-09 
Cb4» Ui u in Ln in ChLn Ln Ln 0 4- in W A in O'Ln Ln W O' O' 
IjU O' O'Ln Co 4- H- O O"O Ln COLO O 0'0'4^ O O' 'J (0 
4- 42 ^4 Hin Mln O co OU U m o>4^ -4 61--P iO S5 00 Ln to 
a. Hearing on one 
or both sides 
below 8 metres. 
Among ioo pupils in 
o> 
P 
s, 
64.36 
55-6 
78.6 
48.4 
60.7 
59-3 
67.8 
82 
72.3 
79-7 
85.0 
45-5 
85.7 
68.0 
36.0 
62.2 
60.2 
49-1 
66.7 
60.0 
b. Hearing on 
both sides be- 
low 4 metres. 
each class, those 
with defective 
hearing would oc- 
cupy the following 
average places. 
o 
0 
- 0 
50.9 
81.4 
48.4 
66.4 
91.2 
67.8 
82 
62.5 
95-3 
90-9 
85-7 
68.0 
14-5 
47-6 
63-4 
65-3 
c. Hearing on 
both sides be- 
low a metres. g. p. putnam's sons, printers 
NEW YORK