AMERICAN ASSOCIATION TO PROMOTE THE TEACHING 
OF SPEECH TO THE DEAF. 
Fourth Summer Meeting, 
CHAUTAUQUA, N. Y., JULY, 1894. 
[Proceedings issued in sections.1 
ABNORMALITIES OF THE UPPER RESPIRATORY TRACT 
AND EAR, FOUND COMMONLY AMONG 
DEAF-MUTES 
BY 
ARTHUR AMES BUSS, A. M., M. D. 
ROCHESTER: 
Western New York Institution for Deaf-Mutes. 
1894. ABNORMALITIES OE THE UPPER RESPIRATORY 
TRACT AND EAR, FOUND COMMONLY 
AMONG DEAF-MUTES. 
BY 
ARTHUR AMES BLISS, A. M., M. D., 
LARYNGOLOGIST TO THE GERMAN HOSPITAL, PHILADELPHIA; LARYNG 
OLOGIST AND AURIST TO THE PENNSYLVANIA INSTITUTION 
FOR THE DEAF AND DUMB; FELLOW OF THE 
AMERICAN LARYNGOLOGICAL 
ASSOCIATION, Etc., 
PHILADELPHIA, PENNSYLVANIA. ABNORMALITIES OF THE UPPER RESPIRATORY 
TRACT AND EAR FOUND COMMONLY 
AMONG DEAF-MUTES. 
LECTURE I. 
At the annual meetings of this Association, one of which 
was held in the summer of 1891, and again in 1892, you 
have had the privilege of hearing lectures by Dr. Hewson and Dr. 
Harrison Allen which have described most thoroughly the anat- 
omy of the organs of speech and hearing, as well as the physi- 
ology of these parts. There has been brought to your attention, 
also, some of the abnormal conditions found in the organs of 
speech. So fully and ably have the anatomy and physiology of* the 
respiratory trad and of the ear been presented for your consid- 
eration, that it would be quite unnecessary for me to review 
these subjeds, although 1 feel far from certain, that many of my 
hearers can recall but a small part of what Dr. Hewson so 
clearly laid before you. Doubtless, however, enough remains in 
your memories, to which your own study and investigation have 
added greatly, to enable us to avoid these important, yet time- 
consuming subjeds. 
It is most important that these medical addresses should, 
however, bear certain relations to one another, and thus form 
parts of a continuous course. For this reason, 1 have chosen to 
attempt a presentation of certain abnormalities of the Upper Res- 
piratory TraCt, which are found very frequently among deaf-mutes, 
and it is my hope, that, imperfeCtlv as 1 fear this subjeCt will 
be handled by me, there may still be brought to your attention 
some fads which may be of service to you in your noble work 
as teachers of the oral system. Before taking up my subjed in 
detail, 1 feel that, for a proper understanding of terms and of 
conditions of disease more or less new to many who will hear 
them, it is proper to clear the way by a very general reference 
to certain anatomical pointsU 
Anatomic al 
Notes on the Lar- 
ynx and Lungs. 4 
in few words then, I would recall to your attention the 
fad, that the membranous bands within the larynx—called vocal 
cords—form the instrument which produces the human voice. 
We say “cords," and 1 fancy that we are apt to think of these 
bands as very mechanical contrivances—violin strings or pipe- 
reeds—and to forget that they are living tissue, controlled by a 
fine adjustment of muscle, nerve, and blood-supply, and hav- 
ing, in their own substance, muscular fibres which vary their 
tension and change-the pitch of tone. The air which sets these 
self-adjusting vocal bands in vibration passes through the lower 
part of the larynx, the trachea, and the entire length of those 
many tubes of varying size which constitute the bronchial sys- 
tem. The source of power is embodied in the chest and lungs, 
which are forcibly diminished in size by the expiratory muscles. 
Again we are apt to resort to comparisons, and to think of 
these complex strudures as organ-bellows, drawing in air and 
pumping it out. But we are dealing with living, growing tis- 
sues, changing in their molecular elements every moment, chang- 
ing in their gross strudure as a result of every influence that 
tenas to force them to perform their fundions under abnormal 
conditions. It must be borne in mind, that the inflation of the 
chest is an effort made against a heavy weight of atmosphere: 
that, if this expansion is imperfed, and continues so during any 
prolonged period, the lungs, beneath, so change in strudure, as 
*o lose portions of their air-containing vesicles, like a sponge 
cramped into a space too small for its full expansion. This is 
especially liable to occur during childhood, while the walls of 
the chest are still undeveloped. The cause is, mainly, imper- 
fed inspiration through the abnormally contraded passages of 
the nose and pharynx. 
Above the vocal bands, lie cavities which constitute “res- 
onators.” These consist of the upper part of the larynx, the 
entire pharynx, and the cavities of the nose and mouth, arranged, 
as Landois remarks, in stories, as it were, the one over the other, 
each capable of being closed alternately. Again, we are not 
dealing with a sounding-box of wood, bone, or metal, but of 
living tissue, changing in shape with the development of the 
growing child, and subjed to alterations by disease or abnormal 
use. 
Resonat ng 
Cavities. 5 
Briefly referring to the size of these resonating chambers, 1 
would remind you how much of the skull they involve, a 
matter we are apt to forget in thinking only of the external 
nose. 
Size of the Na- 
sal Chambers. 
Roof, Floor, and Outer Wall of Nasal Fossa. 
Fig. i. 
The dark line indicates plane of triangle bise&ing the nasal chambers. The dotted 
line indicates base line of this triangle. 
The nasal chambers include spaces within the skull, whose 
anterior walls form about one-third of the face, exclusive of the 
lower jaw. These spaces might be included within the lines of 
a triangle whose much-rounded apex would cover the inner 
third of the superciliary ridges and inter-orbital space—the space 
just above the “root of the nose.” Its lateral arms would ex- 
tend downwards, inwards, and backwards, and would join the 
extremities of the base-line, which would itself run through the 
junction of the hard and soft palate, and terminate immediately 
behind the third molar teeth. Posterior to the base-line, extends 
that important annex to these chambers, the post-nasal space. 
Above and behind the plane of this triangle, lie the posterior- 
superior half of the nasal air-passages, the sphenoidal sinus, and 6 
two ethmoidal sinuses. The triangle would biseCt the superior 
maxillary sinuses — those large, air-containing cavities beneath 
the face, opening into the nares. Its apex would biseCt, also, 
the frontal sinuses, between and above the eyes. Below and 
in front of this imaginary triangle, lies the larger part of the an- 
terior nares. Measured on the skull, the antero-posterior depth 
of this area is about three, three and a half, to four inches; ex- 
tending from the external openings of the nares, back to the 
centre of the anterior arch of the first cervical vertebra. With 
the exception of the inferior maxillary and malar bones, every 
bone of the face, together with the basilar process of the occipital 
bone, enters into the formation of these tortuous and extensive 
areas. 
Here, again, we are dealing with cavities not cut out from 
a common standard pattern, but differing, even within striCtly 
normal limits, in each individual; and differing greatly, as a re- 
sult of disease. The walls of thin bone are overlaid with 
mucous membrane, in whose substance lie myriads of glands, 
fine net-works of arteries and veins, and sensory branches of 
the great Fifth nerve which go in bewildering windings to unite 
with ganglia of the sympathetic nerve system. Such union of 
sensory and sympathetic nerves, leads to many series of reflex 
manifestations in regions of the respiratory traCt, and upon the 
heart and blood-vessel system, often far remote from the lim- 
ited area where irritation exists. We should wander far from 
our subject if we entered upon a description of such reflexes or 
upon the subject of the pathology of the upper respiratory traCt, 
in general. This is not intended to be a medical address, yet, 
in presenting certain facts for your attention, I may be forced 
occasionally to give you suggestions of the hospital leCture hall. 
Avoiding, then, any unnecessary attention to the normal or 
morbid anatomy of these parts, I would simply call your atten- 
tion to some of the alterations which are found within the nares, 
post-nasal space, and pharynx. Later in my remarks, you will 
see that the conditions I am about to describe are very commonly 
found among the pupils who seek instruction in your schools. 
Let me assure you, that I shall limit myself striCtly to these le- 
sions and not bore you with others that are less commonly ob- 
served. 
You have learned that the nares is divided into two cham- 
bers by a septum — bridge of the nose—extending through the 
General Struft- 
ure of the Nares; 
Soft Tissues. 
Conditions 
causing Occlu- 
sion of Resonat- 
ing Chambers. 7 
middle line of the skull for a distance of about two inches; 
that this structure is composed of bone and cartilage; that, in 
the outer walls of both nasal air-passages are found thin cush- 
ion-like, rounded masses, placed one above the other, and hav- 
ing a scroll-like, bony structure as their frame-work. The scroll- 
form has caused them to be named, turbinated bodies. Their soft 
structure consists of numerous mucous glands and blood-ves- 
sels in a bed of fibrous tissue. The blood-vessels communicate 
with certain enlargements similar in structure to the vessels 
themselves, vascular pouches or sacks, which can be filled quickly 
with blood, and from which, by contraction of their muscular and 
elastic walls, the blood can be, as quickly, driven back into the 
veins. Thus, by flushings and depletions of these vascular spaces, 
the outer walls of the nares swell and contract frequently dur- 
ing the day and night, coming sometimes in contact with the 
septum and thus partially or completely closing the air-passages. 
BodieSrbinated 
Fig. 2. 
Section through the nasal chambers, showing the nasal septum. 
b, c, d, the lower, middle, and superior turbinated bodies: a, the nasal septum ; e, 
the superior maxillary sinuses; f the ethmoid sinuses. The septum is shown to be lack- 
ing in lateral support, being attached at base of skull and along floor of nose. [From 
Zuckerkandl.] 
Like other parts of the respiratory passages, these turbinated 
bodies are covered with mucous membrane, and their glands se- 
crete an enormous quantity of mucus which constantly moistens 8 
the walls of the nasal chambers. As the air is inspired, 
it absorbs moisture from this mucous cavity, and thus goes 
down to the lungs charged with a certain amount of watery 
vapor, while, at the same time, it is heated to a temperature in 
keeping with the conditions necessary for that normal interchange 
of gases which occurs within the vesicular structure of the lungs. 
Vertical section of head, slightly diagrammatic. 
F'g- 3- 
i. Superior turbinated bone. 2. Middle turbinated bone. 3. Lower turbinated 
bone. 4. Floor of nasal cavity. 5. Vestibule. 6. Se&ion of hyoid bone. 7. Ven- 
tricular band. 8. Vocal cord. 9 and 33. Section of thyroid cartilage. 10 and 24. 
Section of cricoid cartilage. 11. Section of first tracheal ring. 12. Frontal sinus. 13. 
Sphenoidal cells. 14. Pharyngeal opening of eustathian tube. 15. Rosenmiiller’s 
groove. 16. Velum palati. 17. Tonsil. 18. Epiglottis. 19. Adipose tissue behind 
tongue. 20. Artyenoid cartilage. 21. Tubercle of epiglottis. 22. Section of arytenoid 
muscle. [From “ Diseases of the Throat,” Dr. Carl Sethr.] 9 
Deprived of the moisture and heat, the atmospheric air be- 
comes a source of irritation to the lungs, and aids in the 
development of pulmonary diseases. It is for this reason, that 
persistent occlusion of the nares, and, as a consequence, per- 
sistent mouth-breathing, is a grave source of danger to the 
health of the individual. Yet, again, must I avoid this impor- 
tant subject, and confine myself to occlusion of the nares as it 
affects voice-training. 
As a result of prolonged inflammation, the turbinated bodies 
become permanently enlarged. Instead of shrinking down, so as 
to free the air-passage of the nose, they remain swollen and in 
contact with the septum on one or both sides. Such individuals 
appear to have a constant “cold in the head.” Again, as a 
result of inflammation, they may become permanently shrunken, 
their glandular structure, in large degree, destroyed, and their 
mucous membrane covering changed to a harsh, dry, parch- 
ment-like envelope. Great variations in degree exist between 
these two extremes of overgrowth (hypertrophy) and of wast- 
ing (atrophy). Yet both tend to occlude the nose, the former 
by a fixed and swollen mass of tissue, the later, by dried and 
hardened masses of secretion. 
Another source of occlusion to the resonating chambers of 
the nose is found in displacements of the nasal septum. Such 
displacements are exceedingly common, but their consideration 
becomes of importance, only, when the bend of the bridge is 
so extensive as to impinge against one of the lateral walls of 
the nares, causing partial or complete occlusion. The septum 
of the nose is a thin partition wall dividing the nares into two 
equal parts. It is placed vertically to the floor of the nose, and 
extends from the tip of the nose back to the posterior border 
of the hard palate. It is composed of three elements, the 
vomer, a distinct bone, the vertical plate of the ethmoid bone, 
uniting with the vomer at about the central point of the lat- 
ter’s upper border, where the two long plates form a notch with 
wide acute angle, the “triangular notch.” A somewhat trian- 
gular-shaped space is thus left which is filled in, so as to com- 
plete the full extent of the septum, by a large fibro-cartilagi- 
nous plate, called the “triangular cartilage.” This cartilage ex- 
tends beyond the plane of the face, and forms the partition-wall 
of the two nostrils. The relatively large, flat, thin surface of the 
septum, thus composed of three distinft parts, has no lateral sup- 
port (see Fig. 2), but is fixed above, along the base of the skull, 
Results of In- 
flammation on 
the Turbinated 
Bodies. 
D i s p lacement 
of Nasal Septum 
as a source of 
Occlusion. 
Description of 
Nasal Septum. 10 
sep- 
opm”t°f Devel‘ 
and below, along the floor of the nose. Its development begins 
very early in embryonic life—about the fourth week—but the 
complete union of all its parts does not occur until about the 
twelfth year of life. During these twelve years, the skull is 
undergoing constant change. The rates of development at the 
base of the skull and about the upper jaw may not be in pro- 
portion to each other; and, thus, the bridge, still incomplete, 
may be subje&ed to varying degrees of stress and pressure from 
above or below, without having any lateral support. As a result, 
it may be sprung to one side, in accordance with the direction 
of this stress and the lines of least resistance. Thus, it may as- 
sume a curve whose degree may be so decided, as to produce 
one large open naris, while the other one is small or quite 
occluded. 
Elements of Nasal Septum. 
Fig- 4- 
i. Triangular cartilage. 2. Vertical plate of ethmoid bone, 3. Vomer, 4. Open- 
ng of right eustachian tube. 5. Posterior nares. 
A more common cause for serious deflections of the septum, 
however, results from the frequent injuries inflicted upon this 
prominent feature during the years of childhood. Without re- 
gard to sex or social condition; whether the child is a studious, 
sedentary, little recluse, or a boxer, base-ball player, and de- 
stroyer of his anxious mother’s peace of mind, the poor nose is 
bound to suffer, and to come into more or less violent contact 
with the hard, unsympathetic world. So, fraCtures of the carti- 
laginous portion, or partial displacements of the same from its 
bony partners in this septal compaCt, are not uncommon. Such 11 
injury may cause immediate deformity, or may modify the 
normal growth of the parts, so that the crookedness increases 
with the child's growth, and occlusion of one or both sides 
gradually develops. We must remember, too, that this com- 
paratively mechanical defeat results in more serious conditions 
when associated—as it so frequently is—with that enlargement 
of the turbinated bodies to which I have already called your 
attention. Another cause of occlusion to the nasal chambers is 
the presence of an overgrown glandular mass in the posterior 
nares. This mass has much resemblance in structure to the 
faucial tonsils, and is technically called, an overgrowth of the 
normal adenoid tissue of the naso-pharynx, or, for short, an 
“adenoid” Dr. Harrison Allen, in his lecture in 1892, went 
so fully and ably into the description of this overgrowth, describ- 
ing its evil effects upon the physical and mental development 
of the child, that it will be quite unnecessary for me to dwell 
upon these subjetfts. I would simply warn you not to regard 
mass as in any way a tumor, or new formation, but, simply, 
as an overgrowth of tissue in itself quite normal to this space; an 
overgrowth similar to that which the tonsils may at times as- 
sume. Like the tonsils, however, when thus enlarged beyond 
natural limits, it becomes a grave source of danger to the health 
of the child. Here, again, our field broadens out, far away from 
the limits of my subject, and 1 must keep to the narrow road 
we have chosen to follow. In passing, however, let me simply 
remind you that the lower openings of the eustachian tubes 
are in the lateral walls of this posterior nasal space (see Fig. 
3); that these tubes must be free to allow passage of air up 
into the middle ear; that the common cause of the most com- 
mon form of ear trouble, which has produced the deafness of 
your pupils, is closure of these tubes, or the ingress of inflam- 
mation through them into the middle ear. Such occlusion 
results most frequently from the pressure of overgrown adenoid 
masses, from the permanent enlargement of turbinated bodies, 
or from permanent contaft of turbinated bodies with the nasal 
septum. Let me remind you, too, that the lining membranes of 
these eustachian tubes, of the middle ear itself, and of the nasal 
chambers, and the pharynx, is continuous and common in its 
stru&ure, and, that catarrhal disease of these chambers readily 
extends along these passages into the middle ear. Inflamma- 
tion of the middle ear has, in by far the majority of instances, 
P o s t-n a s a 1 
“ Adenoids ” as a 
source of Occlu- 
sion, etc. 
Relation of 
Post-nasal “Ade- 
noids ” to Pro- 
duction of Aural 
Diseases; also 
of Nasal Deform- 
ities and of Catar- 
rhal Inflamma-" 
tion, in relation 
to Aural Diseases. 12 
been preceded by inflammation within the t rafts which we have 
so briefly, and, I fear, imperfectly reviewed. While speaking 
of enlargement or overgrowth of the adenoid tissue of the naso- 
pharynx, I referred to the resemblance of this tissue to that form- 
ing the tonsils. I would now direft your attention to the 
tonsils themselves, as being another of the agents which may 
cause partial occlusion of the upper respiratory traft, and imper- 
fect phonation. 
The normal tonsils are small, glandular structures, placed 
one on either side of the pharynx, between the anterior and 
posterior pillars of the fauces. These “pillars of the fauces,” so 
called, you probably remember, are not columns to hold up the 
soft palate, as their names would imply. In reality, the pillars of 
the fauces are two sets of fibrous bands, one on either side of 
the pharynx, extending from the soft palate downwards and out- 
wards; the forward one being attached, at its lower end, to the 
sides of the tongue, near the base of this member, the back one 
uniting with the tissues in the lateral wall of the pharynx. 
They are muscular structures, the forward one being named the 
palato-glossal muscle, the posterior one being called, the palato- 
pharyngeal muscle. Their situation, in relation to one another, 
produces a triangular space with the apex upward, at the 
junction of the uvula and soft palate. Within these triangular 
spaces, one on either side of the fauces, lie the tonsils, and, 
normally, the upper margins of these latter bodies should not 
extend above a line carried at right angles across the upper sur- 
face of the tongue, where it lies below the soft palate. They 
should not extend beyond the free margins of the faucial pil- 
lars, and should not, in normal conditions, be attached to these 
bands, both of which, during movements of the palate, should 
glide smoothly over them. In short, the tonsils should not press 
upwards against the soft palate or outwards against the sides 
of the tongue. Within the limits I have stated, there is much 
freedom allowed for variations in size quite within the normal. 
A healthy tonsil which is simply large, but which does not in- 
terfere with the movements of the palate or of the tongue, need 
not be considered. If it does produce this interference, it has, 
also, become large enough to cause partial occlusion of the 
faucial space, and interferes, also, with normal respiration and 
deglutition. A tonsil enlarged to this extent is rarely normal 
The Faucial 
Tonsils as being 
Causes of Occlu- 
sion. 13 
in structure, and as a rule, readily undergoes inflammation, as 
shown by attacks of Quinsy, Pharyngitis, or, fortunately rarely, 
Diphtheria. 
The tonsils have no function in phonation. Their physiology 
is obscure, the more recent theories being, that they are blood- 
forming glands. They have been classified among the producers 
of Leucocytes, or the peculiar white-cell, found in the blood and 
in the lymphatic system, which afterwards changes into the red 
blood-corpuscle. Quoting from an article by G. G. Lovell, on 
the function of the tonsils, we learn, that “the newly formed 
leucocytes remain partly in the lymph vessels, thus remaining 
partly in the tonsils, as stationary cells, or, in part, emigrate 
upon the surface, passing through the epithelium.” Thus, a 
protective wall of leucocytes is formed, that stands upon the 
battlements of these two fortresses, one on either side of that 
narrow strait which guards the passages to the digestive and 
respiratory traCts. These little cells, thus, it is claimed, aCt as 
warriors, to attack the invading armies of microbes entering 
with the food or air. Many are slain in this constant warfare, 
but others, born within the fortress, viz, within the lymph- 
spaces of the tonsils, rush to fill up the broken ranks, and fight 
on where the banners hang upon the outer walls. It is an at- 
tractive theory and possesses a strongly dramatic interest. Al- 
though not striCtly proven, it cannot be denied. Much in the 
study of that minute life within and around us tends to suggest, 
that such warfare may be in constant progress between these 
little, individual cells, each with a life-history of its own, which, 
in time, go to form elements' in the blood, muscle, bone, or 
nerve of their human bearer, and that great, varied mass of 
micro-organisms which are foreign to the body but which are 
around us and within us during all our lives, and among which 
are the carriers of deadly diseases, whose ingress and lodgment 
within our bodies mean sickness and even death. Again we 
are attracted to wide fields of discussion, but must return to— 
our tonsils. Whatever may be the function of these structures, 
their presence, when abnormal in size or when actively diseased, 
becomes injurious to the general health of the individual thus 
afflided, and interferes seriously with the aCtion of the tongue 
and soft palate. Together with the enlargements of the post- 
nasal adenoid tissue, both of which conditions commonly exist 
together, they narrow the air-passages, force the subjeCt to 14 
breathe through the mouth instead of through the nose, and thus 
tend to produce those deformities of the chest and imperfect 
development of the child, which Dr. Harrison Allen so fully 
described to you two years ago. 
We are fast coming to the practical application of these dry 
fads which, I fear, have bored you all terribly, but to which 
you have listened with a remarkable degree of patience. Before 
touching upon the subject of what has been been found by 
others and by myself among deaf-mute pupils, as a result of ex- 
aminations of the nose and throat and ear, let me guard you 
against placing undue importance to all lesions. To understand 
the deformities about to be described, you must have some in- 
telligent conception of the parts involved, and of certain gross 
changes which they undergo as a result of disease. This has 
been my excuse for taking you on a dreary pilgrimage over the 
desert of pathological anatomy. I place confidence in the pluck, 
endurance, and long-suffering of my audience; and, as yet, you 
have not risen up against me with the cry, “Hold! Enough! 
Away with him!” 
Lest my words should have a tendency to place the deaf- 
mute child before you too much in the light of a wretched sub- 
ject of disease, let me hasten to prune down any exaggerated 
ideas that may have formed in your minds. I must, also, ask 
you to recall this explanation while I am reviewing the lesions 
which have been found commonly among deaf-mutes. And, 
first, in regard to abnormal conditions within the nares. En- 
largement of the turbinated bodies is a very common condition. 
To a certain degree, it is found in many individuals who are 
totally ignorant -of its existence, as they are not conscious of 
any interference with the normal activity of the parts. It is of 
importance when the overgrowth causes occlusion to the pas- 
sages, or has increased to such a degree as to press against 
the septum. Shrinkage of the turbinated tissue, to a certain 
extent, is also a very common condition, but becomes of im- 
portance, when, as a result of this sclerosing or hardening pro- 
cess, the glandular element of the mucous membrane is greatly 
destroyed and its epithelial covering so altered, that the mem- 
brane itself loses its true character and is converted, more or 
less, into a dry, skin-like covering. 
Twists and bends and even fra&ure of the bridge, as we 
have noted already, are exceedingly common. They deserve 
Care must be 
observed in con- 
sidering condi- 
tions not strictly 
normal, lest we 
exaggerate the 
import a n c e of 
conditions not in 
themselves seri- 
ous. 
Distin&ions in 
regard to Abnor- 
malities within 
the Nares—Tur- 
binated Bodies. 
Septal Deform- 
ities— when im- 
portant. 15 
attention only when causing occlusion to one or both nares or 
contact and pressure at points between the septum and the 
outer nasal walls. 
The presence of a certain amount of adenoid tissue in the 
vault of the pharynx is entirely normal. Its overgrowth, caus- 
ing pressure on the floor of the soft palate, pressure against the 
eustachian openings, excess of secretion, and nasal occlusion, 
are conditions which demand attention. Tonsils that are simply 
large, but whose structure is entirely normal, and which in no 
way interfere with the action of neighboring tissues, need not 
be looked at twice. However, when you examine a pharynx 
and see two large, rounded, India-rubber-like balls, that pro- 
jed far out from the sides of the throat—perhaps almost touch- 
ing in the median line—which press on the sides and base of 
tongue, and which press upwards against the palate, what is 
the use of trying to make the deaf-mute thus accoutered, talk ? 
It seems to me, that you might as well make the attempt on 
one whose tongue has been gagged and whose mouth you have 
stuffed with putty. Such a condition of hypertrophy is most fre- 
quently made worse by the existence, also, of enlarged “aden- 
oids ” in the vault of the pharynx. 
The subject of overgrowth of lymphoid tissue in the throat 
and posterior nares is a large one, and we cannot enter upon it. 
There is much similarity in structure and in development, and, 
probably also, in function, between the different elements that 
go to form that ring of lymphoid tissue which surrounds the 
entrance of the respiratory and digestive tracts. Starting at the 
base of the tongue, where it lies between that organ and the 
epiglottis, its lateral parts are formed by the feudal tonsils, its 
upper arch by the adenoid mass of the posterior nasal space. 
Owing to causes which seem to influence the entire growth of 
the individual, these lymphoid strudures outgrow their nat- 
ural size, and, as a result, soon take on conditions of disease. 
We say such individuals are strumous, scrofulous, etc. They 
are apt to be pale, with flabby tissues, poor digestion, generally 
weak physique, and with certain defeds in the skeleton, which 
modify the shape of the bones and joints and of the frame-work 
of the chest. 
Dr. Allen has referred fully to the relation which occlusion 
to the respiratory trad, by reason of these lymphoid enlarge- 
ments, bears to the development of the mental and physical states 
11 Adenoids 
normal and the 
reverse. 
Tonsils which 
demand atten- 
tion. 
Lymphoid tis- 
sue of the Upper 
Res piratory 
Traft. 16 
of children of this type. 1 refer, only, to the interference which 
these enlargements must have in your work as teachers of the 
oral system. It is not my place, here, nor would it be regarded 
by my medical brethren as in any way proper, that I should 
now go into the details of treatment, and lecture to you of instru- 
ments and drugs and their uses. This, I shall not do; yet, 1 can- 
not leave this subject of hypertrophied tonsils and enlarged pos- 
terior nasal “adenoids,” without asking you to keep your minds 
free from old-time prejudices regarding the removal of these oc- 
cluding masses. Whatever the funftion of these parts may be 
when normal, their removal, in states of overgrowth and dis- 
ease, has too often resulted in improvement of the child's speech— 
I say nothing of the marked improvement in the general health— 
to persuade us that they, should be retained for the sake of any 
good they may accomplish. The danger attending removal has 
been greatly exaggerated. The operation is done, now, so com- 
monly, that its proper technique is well understood. Instances 
of dangerous hemorrhage have occurred in cases, only, where 
total extirpation of the tonsils has been attempted. This is un- 
necessary. The same fact is true of the post-nasal adenoids. 
When properly operated upon, I cannot see how a fatal or even 
alarming hemorrhage can possibly attend their removal. These 
masses do not “recur,” or reappear, and the good results fol- 
lowing their removal are most marked—in regard to the pa- 
tient’s general health, in that normal respiration is effected; in 
regard to vocalization, by causing the release of tongue and pal- 
ate from pressure. As you may know, the presence of enlarged 
tonsils and post-nasal adenoids causes the voice to be dull, 
dead in tone, utterly without resonance, the voice of an individ- 
ual suffering, at once, from “cold in the head” and sore throat. 
In the formation of vocal sounds, the parts attempt to perform 
their function, in spite of the disadvantages under which they 
labor. The ordinary child has the aid of its sense of hearing 
and can approximate the normal tones. Nature always does her 
best, even with imperfect machinery, and by many modifications 
of movement, the various organs of speech in such individuals 
perform their functions. But, in the deaf-mute, thus burdened, 
the chances for gaining speech are greatly lessened. The jaws, 
themselves, are altered. The face of such a child resembles, in 
a degree, that of a fish out of water. The mouth is depressed 
at the angles and is open. The upper lip and cheek, falling heavily 
Importance of 
removal of dis- 
eased and Occlud- 
ing Tonsils and 
“ Adenoids,” es- 
pecially in the 
case of Oral-pu- 
pils. 
Malformations ] 
of the Mouth and 
laws resulting \ 
from Mouth- 
breathing caused 
b y presence o f 
Enlarged Tonsils . 
and “Adenoids.” * 17 
against the sides of the upper jaw, press these parts together, 
so that the hard palate is narrowed, being compressed into the 
form of a high Gothic arch. By reason of this lateral pressure, 
also, the front teeth are crowded together; the upper incisors, 
forced together into a projecting angle, instead of the usual half 
arch, tend, also, to face with their cutting-edges outwards; the 
lower incisors fail to touch them, or, if contad occurs, their 
edges touch the inner surfaces of the upper incisors far behind 
the latter’s cutting-edges. Thus the upper jaw is narrowed and 
lengthened while the palate is narrowed, and changed from 
a low dome-shape to the high angular arch. The child is con- 
stantly gulping, as though swallowing air, especially in attempt- 
ing to speak. In reality it is freeing the pharynx and post-nasal 
space from the excessive secretion of mucus, with which such 
cases are burdened. You know the various shapes which the 
oral-cavity assumes, in forming the vocal sounds. How can a 
mouth, so deformed, arrange itself into the proper position, es- 
pecially when the pupil’s eye, alone, can be the guide, or at; 
most, his sense of touch ? With great difficulty can a mouth, 
so deformed, widen its horizontal and vertical diameters, or vary 
its depth, as must be done in forming the various vowel 
sounds. Much less easily can the consonants be produced, de- 
manding free play of tongue, at its base and tip, and of palate. 
But, you will say, “this sad, melancholy, and fish-faced 
mute, which you have so heartlessly described, is an extreme 
case ; we seldom meet with him in the class-room!” But 1 have 
met him in the examining-room, after he has passed from the 
oral class down to the manual school, branded as an “ oral 
failure.” 
1 do not wonder at the failure! I wonder at the hopeful- 
, ness of the teachers who attempted to teach him vocalization 
with vocal organs thus shackled. My case is not an extreme 
one. It reappears again and again, varying not so greatly in 
degree. The tonsils may be slightly swollen, the nasal cham- 
bers somewhat freer, than in the individual we have pidured, 
but the results of training will be very similar, or but a few de- 
grees better. Among your pupils whom you count as successes, 
are very many whose articulation would be far better, if the 
mechanical obstrudions, caused by the conditions which I have 
mentioned, had been removed before oral training had been com- 
menced. Perhaps benefit might follow removal of such obstruding 
Di ffi c u 11 for 
such children to 
Articulate prop- 
erly. 18 
masses even at a later period; yet, pupils learn certain tricks 
in articulation, often forced upon them by the existence of de- 
formities, which remain after these latter have been corrected. 
Treatment for such conditions should be resorted to, early, for 
another reason. That is, because the malformations of the upper 
jaw, involving the alveolar process and palate, are formed in 
early childhood, before the bones of the face have entirely com- 
pleted their development. Mouth-breathing should be overcome 
during the early stages of this period. So much for this part of 
our subject. 
In regard to certain defeats of the mucous membrane, 
which I shall mention, namely, Sclerosis, Hypertrophy, Engorge- 
ment, or passive congestion, let me say, that these various con- 
ditions are exceedingly common among all classes of people in 
this country. The laity classify them all into one variety of 
disease, to which they give the general name, “Catarrh.” 
Of course, such generalization means nothing, yet you will 
recognize this one mysterious and awe-inspiring word, as as- 
sociating itself in your minds with many wood-cuts of ladies 
and gentlemen, which have adorned the advertisement columns 
of your secular and, even, religious newspaper; while, beneath 
the portrait, will be described, in harrowing detail, the dreadful 
sufferings of the original from “Catarrh;” and yet, how a help- 
less and healthless existence has been changed to a paradise of 
perfect health by the use of Dr. So and So’s “Catarrh Remedy.” 
Now, you will find in my report of cases, that inflammatory 
conditions of the membranes lining the pharynx, naso-pharynx, 
and nares, are quite common among deaf-mutes. But 1 must 
warn you, that, in this country, very few individuals, otherwise 
in perfeft health, are entirely free from the less serious forms of 
nasal or pharyngeal catarrh. Comparatively few, however, are 
sufficiently inconvenienced by symptoms, to require medical treat- 
ment. So you will perceive, that, in examinations of the noses, 
throats, and ears of deaf-mutes, we must bear in mind, that di- 
vergences from the normal are common to large classes of individ- 
uals, and it has been my aim to take note of such lesions, only, 
as they interfere decidedly with the functions of the parts they 
involve. 
Defefts of the 
Mucous Mem- 
branes of N a r es 
and Pharynx — 
when important. 19 
LECTURE II. 
In his able lecture of two years ago, Dr. Harrison Allen called 
attention to some examinations upon the noses, throats, and ears 
of pupils in the Pennsylvania Institution for the Deaf and Dumb. 
Since Dr. Allen referred to those cases, the report of this ex- 
amination has been published and some of my hearers may have 
read it. I regret, that a carefully tabulated and detailed report 
of the work, which was sent to the Volta Bureau, has never 
been printed. The mere enumeration of lesions is of consider- 
able interest, but a matter of still more interest and importance 
is the record of the associated conditions in each case. The 
reader becomes, thus, the examiner for himself. The detailed 
report placed each case in this point of view. 
1 desire, now that we have reviewed in a very general way, 
the common forms of deflexion from the normal, which may 
influence vocalization, by mechanical obstruction, closure of res- 
onating cavities, and interference with normal respiration, to take 
up these examinations conducted at the Pennsylvania Institution, 
and to add to its list of cases others that have been collected 
from similar observations in other schools. As my hearers prob- 
ably know, the pupils of the Pennsylvania Institution are taught 
by oral and manual methods. Formerly, it was left to the judg- 
ment of the teachers or guardians of the children, by which 
system the pupil should be trained. It is the rule now, to place 
every new pupil in the oral department, where he or she is 
given a thorough trial. Since the oral school was started, sev- 
eral years ago, there have been frequent instances where the 
teachers have been unable to accomplish satisfactory results, and 
pupils thus failing to acquire vocalization, have been sent to the 
manual department, their oral training being considered a failure. 
Thus there has been developed a class of pupils whom we may 
call oral failures. It is to this class that I desire to direCt your 
attention most especially. The most common serious affeCtions 
of the upper respiratory traCt found among these pupils were lo- 
cated in the post-nasal space and pharynx. Next in importance, 
were occlusions of the nares by contaCt between hypertrophied 
turbinated bodies and septa, or by exostoses from the latter, in 
contaCt with enlarged, or occasionally, with atrophied turbinates. 
The almost constant condition of the vocal cords was weak- 
ness of the crico-thyroid and thyro-arytenoid muscles. The ad- 
duction and abduCtion movements of respiration were normal, 
The Exami- 
nat i o n s at the 
Pennsylvania In- 
stitution, in r'e- 
ga r d to N a r e s, 
Post-nares, 
Throat and Ears; 
415 pupils. 20 
but the vocal cords were thin, grayish in color, relaxed, and 
manifested a weak degree of tension. Such was the case among 
the 303 pupils of this school, who had been instructed in the sign- 
language, only. There were 91 pupils who were receiving train- 
ing in the oral department. Among these were found conditions 
of the nares and pharynx which corresponded in character and 
in ratio of frequency with those observed in the sign-language 
pupils. The vocal cords, however, approached more nearly the 
normal condition, especially among the older oral pupils. The 
most interesting and important observations, however, were found 
among a group of 21 pupils who had failed to acquire the oral 
method of speech, and had been sent to the sign-language de- 
partment as oral failures. Among these 21 pupils the abnor- 
malities in the parts found so commonly diseased in the cases 
of the entire 415 pupils, were in greater ratio than in the other 
two groups. Thus; deformities, consisting of deviated septa, ex- 
ostoses, hypertrophied turbinates, causing partial or complete 
occlusion of one or both nares, were found— 
among 303 “signers” in 65 pupils. 
“ 91 “orals” “ 14 “ 
“ 21 oral-failures “ 5 “ 
Posterior hypertrophies of the turbinates were found— 
among “signers” in 21 pupils. 
“ 91 “orals” “ 1 “ 
“ 21 oral-failures “ 2 “ 
Adenoid tissue in the vault of the pharynx, causing partial occlu- 
sion of this space or pressure upon the eustachian opening, was 
found— among 303 “signers” in 57 pupils. 
“ 91 “orals” “ 14 “ 
“ 21 oral-failures “ 7" “ 
Large tonsils, which filled the space between the faucial pillars 
of their own sides of the throat, or were greatly hypertro- 
phied and diseased, causing pressure on palate or tongue and 
greatly.occluding the faucial space, were found— 
among 303 “signers” in 50 pupils. 
“ 91 “orals” “ 21 “ 
“ 21 oral-failures “ 5 “ 
Adhesions between tonsils and faucial pillars, the tonsils being 
encapsulated, were found—among 303 “signers” in 30 pupils. 
“ 91 “orals” “ 6 “ 
“ 21 oral-failures “ 5 “ 21 
Abnormal states of the pharyngeal mucous membrane, consisting 
of simple follicular hypertrophy, sclerosis with follicular hyper- 
trophy, simple sclerosis, atrophy, or venous engorgement, were 
found— among 303 “signers” in 117 pupils. 
“ 91 “orals” “ 32 “ 
“ 21 oral-failures “ 9 “ 
The vocal bands were, apparently, normal in color and ordinary 
movement,— among 303 “signers” in 83 pupils. 
“ 91 “orals ” “63 “ 
“ 21 oral-failures “ 12 “ 
Thus, it will be seen, that the 21 pupils who failed to ac- 
quire the oral method, labored under the disadvantages of ab- 
normal vocal organs, in by far greater percentage than existed 
among the successful oral pupils. But these latter, also, show 
numerous instances of abnormal conditions. The question of 
what influence the lesions, which have been enumerated, have 
upon the general health and mental development of children, 
is now well understood. It is merely necessary to suggest, 
that, in ; many instances, treatment for the relief of these con- 
ditions among the 303 sign-language pupils was demanded on 
such general grounds. But, with the oral pupils, the matter is 
of even more vital importance; for the occluded nares, stuffed 
post-nasal spaces, fauces narrowed by enlarged tonsils, pressing, 
also, upon palate and tongue, must offer great, at times, almost 
insurmountable difficulties, in the successful training of the oral 
pupil. The oral method is destined to be employed more and 
more completely in the schools of this country, as it has been, 
for a long time, in the deaf-mute institutions of Europe. Such 
being the case, the importance of a thorough examination of 
the upper respiratory trad, in all pupjls about to undertake this 
training, is quite manifest. The removal of these mechanical dif- 
ficulties will save many pupils from complete failure, while the 
stuffy, impeded phonation, heard so frequently among “Orals’’ 
counted as successful, will be less common than at present. 
Since the examination of the 415 pupils, forming my first 
series of cases, two classes have been admitted to the Penn- 
sylvania Institution. All new pupils are, now, received in the 
oral department, so that a fair opportunity is given to every 
pupil to acquire vocalization. I would refer very briefly to the 
results of my examinations upon the members of these new 
E x a m i nation 
of 106 additional 
Pupils, atthe 
Pennsylvania In- 
stitution, making 
521 pupils in both 
series of exami- 
nations. 22 
classes. The pupils numbered, in all, 106. The conditions found 
within the upper respiratory trad correspond with those already 
recorded. The division into “signers,” “orals,” and “oral- 
failures,” fortunately, no longer holds. These pupils are all 
“orals,” and I understand that their teachers do not propose to 
have any “failures.” The findings from the examination of these 
106 pupils is as follows:— 
1. Pupils whose respiratory trails appear to be quite normal, 26 
2. Deflections of the nasal septum, causing partial or complete occlusion,... 10 
3. Hypertrophied turbinates, 6 
4. Exostoses from the septum, with defleCtion, 1 
5 Atrophic catarrh of nares, 4 
6. Synechial bands, causing adhesion between the septum and turbinates,... 1 
7. Hypertrophied adenoid tissue in the post-nasal space, 17 
8. Large tonsils, 12 
9. Encapsulated tonsils, 2 
10. Hypertrophied tonsils showing evidence of an inflammatory process, 10 
EARS. 
1. Foreign bodies, 2 
2. Varying degrees of adhesion and sclerosis, classified under the general term, 
Plastic Otitis, 34 
3. Chronic purulent inflammation of the middle ear, 8 
4. Perforations of the drum-head which-have undergone cicatrization, 2 
5. Impaded cerumen, ii 
I wish to call your attention to the interesting report of 
Dr. James Kerr Love, aurist of the Glasgow Institution for the 
Education of the Deaf. 175 pupils were examined and the le- 
sions in nares, posterior nares, pharynx and the ears, recorded. 
The findings correspond quite fully with my own 512 cases. 
This fad is of interest, as these series of examinations were 
made in two separate institutions, one in Scotland, the other in 
Pennsylvania. Dr. Love is, apparently, quite ignorant of my own 
work, so cannot have been an imitator of my methods. My first 
series of cases were reported before he had commenced, or com- 
pleted, his own report. It is the more interesting, therefore, that 
we should have, both of us, found the lesions within the res- 
piratory trad of deaf-mutes, to be much the same in two coun- 
tries which differ so decidedly in climate as do Scotland and 
our eastern Middle States. 
In order to illustrate more fully the importance of these 
abnormalities, I have copied the notes of the 21 oral failures 
from my note-book. The great amount of time and space re- 
quired, will prevent me from detailing cases from the other two 
Examination 
by Dr. James Kerr 
Love at the Glas- 
gow Institution 
for the Education 
of the Deaf; 175 
pupils. 23 
groups of pupils. In making these notes, I have.stated simply the 
appearances observed, without any attempt to exaggerate the im- 
portance of lesions. Conditions stated as normal, might in some 
instances, be counted the reverse. But it must be considered, 
that, in this country, we can seldom find instances of perfect 
normality in nares, post-nasal space, or pharynx. In drawing dis- 
tinctions between the normal and the abnormal, I have placed 
in the latter category such conditions as appeared to interfere 
more or less with the functions of the parts involved. 
case 1. 
L. K. Aged 21 years; male. 
Deaf. Since 2 years old. 
Cause. Spotted fever. 
Family. Parents not related; no deaf-mute relatives. 
Anterior nares. FraCture of septum, separating the triangular 
cartilage from the vomer, and deflecting it to the right, 
so as to occlude the right nares. Mucous membrane is 
much sclerosed. 
Posterior nares. End of left lower turbinate is greatly hyper- 
throphied, and almost occludes the left choana. 
Tongue. Normal. 
Palate. High, rounded. 
Pharynx. Mucous membrane is sclerotic. The tonsils ad- 
here by bands to the pillars of the fauces. 
Larynx. Vocal cords hyperaemic; tension not very good. 
Voice “nasal” but fairly clear. 
Ears. The drumheads are retraCted; feebly movable. 
CASE II. 
J. G. Aged 19 years; male. 
Deaf. Since birth. 
Cause. Unknown. 
Family. Parents are not related; no deaf-mute relatives. 
Anterior nares. Mucous membrane is dry; the middle tur- 
binates are covered with dried secretion. 
Posterior nares. An injeCted vessel is seen in the anterior 
lip of each eustachian opening. The adenoid tissue in 
vault is enlarged, but does not appear to cause occlusion. 
Tongue. Normal. 
Palate. High, and narrow. 
Pharynx. Normal. 
Larynx. Vocal cords hyperaemic; voice is fairly clear. 
Detailed re- 
port of the Exam- 
1 n a t i o n a t the 
Pennsylvania In- 
stitution, on 21 
Pupils who had 
failed to acquire 
vocalization and 
had been sent to 
the Manual De- 
partment, as be- 
ing, “Oral-fail- 
ures.” 24 
Ears. Left. Drumhead is retracted; is movable, except the 
manubrium, which is adherent. There is a 
cicatrix in center of drumhead, posterior half. 
Right. Drumhead retracted, movable; scar in centre. 
Hearing. Trace of hearing by bone-condudion. 
case m. 
G. D. Aged 16 years; male. 
Deaf. Since 4 years old. 
Cause. Scarlet fever. 
Family. Parents not related; no deaf-mute relatives. 
Anterior nares. Normal. 
Posterior nares. A large mass of enlarged adenoid tissue in 
centre of vault; not occluding. 
longue. Normal. 
Palate. Normal. 
Pharynx. Normal. 
Larynx. Normal. 
Ears. Left. Canal closed by impadion of cerumen. 
Right. Canal filled with cheesy, foul-smelling pus. 
CASE IV. 
H. R. Aged 15 years; male. 
Deaf. Since birth. 
Cause. Unknown. 
Family. Parents not related; two brothers, and many other 
relatives are deaf-mutes. 
Anterior nares. The right lower turbinate is enlarged and 
is in contad with the septum. The floor of nares, on 
either side of the anterior nasal spine of superior max- 
illa is abnormally high. 
Posterior nares. Mucous membrane is sclerotic. 
Tongue. Normal. 
Palate. Normal. 
Pharynx. The right tonsil is much enlarged, filling space 
between its faucial pillars, and projeding into the fauces. 
Larynx. Vocal cords show a fair degree of tension. 
Ears. Left. Large scar at end of manubrium; drumhead 
much retraded. 
Right. Drumhead is thickened; feebly movable. 
Hearing. Trace of hearing by bone-condudion. 25 
CASE V. 
L. E. Aged 16 years; female. 
Deaf. Since birth. 
Cause. Unknown. 
Family. Parents not related; no deaf-mute relatives. 
Anterior nares. Normal. 
Posterior nares. Vault is nodular and irregular by reason 
of adenoid masses; not occluding. 
Tongue. Normal. 
Palate. Normal. 
Pharynx. Very irregular, lumpy posterior wall, the mu- 
cous follicles being much enlarged; mucous membrane 
of soft palate shows much venous engorgement. 
Larynx. Vocal cords hypersemic; fairly good tension. 
Ears. Drumheads are large, thin, retracted, movable. 
Hearing. Trace of hearing by bone-conduction. 
CASE VI. 
H. Z. Aged 15 years; female. 
Deaf. Since birth. 
Cause. Unknown. 
Family. Parents are deaf-mutes (congenital); one brother, 
two sisters and many relatives are deaf-mutes. Mother 
has one sister and four brothers who are deaf-mutes; 
father has one sister, a deaf-mute. 
Anterior nares. Normal. 
Posterior nares. Normal. 
Tongue. Normal. 
Palate. Normal. 
Pharynx. Tonsils are nodular and fill spaces between their 
faucial pillars; do not occlude the faucial space. 
Larynx. Vocal cords; gray, thin, apparently good tension. 
Ears. Left. Drumhead slightly retracted. 
Right. Drumhead has good lustre, is retraced; very 
feebly movable. 
Hearing. Trace of hearing by bone-condu&ion. 
CASE VII. 
E. F. Aged 15 years; female. 
Deaf. Since birth. 
Cause. Unknown. 
Family. Parents not related; has one brother who is a 
deaf-mute. 26 
Anterior nares. Spur from vomer, centre, not in contad 
with septum. 
Posterior nares. Normal. 
Tongue. Normal. 
Palate. Normal. 
Pharynx. Normal. 
Larynx. Normal. 
Ears. Drumheads greatly retraded, immovable. 
Hearing. Trace of hearing by bone-condudion. 
CASE VIII. 
E. L. Aged 14 years; female. 
Deaf. Since 4 years old. 
Cause. Scarlet fever. 
Family. Parents not related; no deaf-mute relatives. 
Anterior nares. Large lower turbinates, not in contad with 
septum. 
Posterior nares. Mass of enlarged adenoids in centre of 
vault. 
Tongue. Normal. 
Palate. Normal. 
Pharynx. Normal. 
Larynx. Normal. 
Ears. Drumheads both destroyed; otorrhoea from both ears. 
CASE IX. 
J. S. Aged 16 years; male. 
Deaf. Since one year old. 
Cause. Scarlet fever. 
Family. One brother and one sister are deaf-mutes. The 
parents are not related; father has several deaf-mute 
relatives. 
Anterior nares. Mucous membrane is sclerotic. 
Posterior nares. Contains much thick mucus. 
Tongue. Normal. 
Palate. Normal. 
Pharynx. Venous engorgement. 
Larynx. An unusually dependent epiglottis, greatly rounded, 
with pointed end. Vocal cords could not be seen. 
Ears. Large drumheads, good lustre, movable. 
Hearing. Trace of hearing by bone-condudion. 27 
CASE X. 
H. T. Aged 16 years; male. 
Deaf. Since two and a half years old. 
Cause. Scarlet fever. 
Family. Parents not related; no deaf-mutes. 
Anterior nares. Normal. 
Posterior nares. Normal. 
Tongue. Normal. 
Palate. Normal. 
Pharynx. Mucous membrane is sclerotic; tonsils are en- 
capsulated. 
Larynx. Normal. 
Ears. Perforations in drumheads. 
CASE XI. 
J. F. Aged 14 years; male. 
Deaf. Since birth. 
Cause. Unknown. 
Family. Parents not related; one sister is a deaf-mute. 
Anterior nares. Normal. 
Posterior nares. Normal. 
Tongue. Normal. 
Pharynx. Mucous membrane of posterior wall is atrophic. 
Larynx. Vocal cords slightly hypersemic. 
Ears. Drumheads are retraded, feebly movable. 
Hearing. Trace of hearing by bone-condudion. 
CASE XII. 
J. K. Aged 12 years; male. 
Deaf. Since one and a half years old. 
Cause. Measles. 
Family. Parents are not related; no deaf-mute relatives. 
Anterior nares. Mucous membrane is sclerotic. 
Posterior nares. Normal. 
Tongue. Normal. 
Palate. Left half-arch is slightly higher than the right one. 
Pharynx. Normal. 
Larynx. Normal. 
Ears. Destrudion of both drumheads; otorrhoea. 
Hearing. Trace of hearing by bone-condudion. 
CASE XIII. 
J. McE. Aged 17 years; male. 
Deaf. Since seven vears old (?). 28 
Cause. Sickness (?). 
Family. Parents not related (?), no deaf-mute relatives. 
Anterior nares. Septum is deflected to left, not occluding. 
Posterior nares. Normal. 
Tongue. Normal. 
Palate. Normal. 
Pharynx. Tonsils fill the spaces between their faucial pillars, 
are encapsulated and adhere to faucial pillars, thus greatly 
narrowing the fauces, which is still more obstruded by 
the very large uvula. 
Larynx. Normal. 
Ears. Drumheads are normal in appearance; feebly mov- 
able. 
CASE XIV. 
M. F. Aged 17 years; female. 
Deaf. Since 2 years old. 
Cause. Sickness (?). 
Family. Parents not related. Three other children in this 
family are deaf-mutes. 
Anterior nares. Normal. 
4Posterior nares. Normal. 
Tongue. Normal. 
‘Palate. Normal. 
Pharynx. Venous engorgement of mucous membrane. 
Larynx. Vocal cords hypersemic. 
Ears. ImpadTed cerumen in both auditory canals. 
Flearing. Trace of hearing by air and bone-conduftion. 
case xv. 
L. W. Aged 11 years; female. 
Deaf. Since birth. 
Cause. Unknown. 
Family. Parents not related; no deaf-mute relatives. 
Anterior nares. Normal. 
Posterior nares. Considerable adenoid tissue in vault. 
Tongue. Normal. 
Palate. Normal. 
Pharynx. Posterior wall rendered very irregular and lumpy 
by masses of enlarged mucous follicles. Tonsils are large, 
but soft, and do not occlude the fauces. 
Larynx. Vocal cords are relaxed; poor tension. 29 
Ears. Drumheads are much retraded. 
CASE XVI. 
A. S. Aged 12 years; male. 
Deaf. Since birth. 
Cause. Unknown. 
Family. Parents are cousins; no deaf-mute relatives. 
Anterior nares. Mucous membrane is sclerotic and is cov- 
ered with much thick mucus. , 
Posterior nares Large amount of adenoid tissue. 
Tongue. Normal. 
Palate. Normal. 
Pharynx. Enormously enlarged tonsils, filling the faucial 
space, almost in contad with one another; encapsulated 
and nodular. 
Larynx. Vocal cords show a poor degree of tension. 
Ears. Drumheads are much retraded; dull in color. 
CASE XVII. 
J. Z. Aged 17 years; female. 
Deaf. Since birth. 
Cause. Unknown. 
Family. Parents are not related; are both deaf-mutes; 2 sis- 
ters, 1 brother, aunts, uncles and cousins are deaf-mutes. 
Anterior nares. Hypertrophy of left lower turbinate. 
Posterior nares. Normal. 
Tongue. Normal. 
Palate. Normal. 
Pharynx. Normal. 
Larynx. Vocal cords relaxed; poor degree of tension. 
Ears. Drumheads are normal in appearance, but feebly 
movable. 
CASE XVIII. 
S. K. Aged 17 years; female. 
Deaf. Since 9 years old. 
Cause. Typhoid fever. 
Family. Parents are not related; no deaf-mute relatives. 
Anterior nares. Slight hypertrophy of left lower turbinate. 
Posterior nares. Normal. The vomer appears to be split— 
as though doubled—through the center of its posterior 
edge. 
Tongue. Normal. 30 
Palate. Normal. 
‘Pharynx. Mucous membrane is sclerotic. The left half-arch 
of fauces is lower than the right one. 
Larynx. Normal; voice clear and distind. 
Ears. Drumheads retraded; feebly movable. 
Hearing. Slight degree of hearing by air-condudion in right 
ear. 
CASE XIX. 
• 
E. B. Aged 18 years; female. 
Deaf. Since 7 years old (?). 
Cause. Scarlet fever. 
Family. Parents not related; no deaf-mute relatives. 
Anterior nares. Normal. 
‘Posterior nares. Normal. 
Tongue. Short, thick frenum. 
Palate. Normal. 
‘Pharynx. Normal. 
Larynx. Normal. 
Ears. Drumheads move feebly; retraded. 
Hearing. Trace of hearing by bone-condudion in right ear. 
case xx. 
W. McC. Aged 12 years; male. 
Deaf. Since 3 years old. 
Cause. Spotted fever. 
Family. Parents not related; no deaf-mute relatives. 
Anterior nares. Septum is badly defleded to the left. The 
triangular cartilage is in close contad with the left lower 
turbinate, and much muco-purulent discharge oozes from 
between these surfaces. 
Posterior nares. Masses of enlarged adenoid tissue. 
Tongue. Normal. 
Palate. Normal. 
Pharynx. Tonsils are large, filling spaces between their fau- 
cial pillars. The fauces has the general shape of an in- 
verted V, and is narrow. 
Larynx. Vocal cords are slightly hypersemic; show a fair 
degree of tension. 
Ears. Left. Drumhead is thick, granular, and retraded. 
Right. Impaded cerumen, closing the canal. 
Hearing. Trace of hearing by bone-condudion, right side. 31 
CASE XXI. 
J. F. Aged 12 years; male. 
Deaf. Since birth. 
Cause. Unknown. 
Family. Parents not related; no deaf-mute relatives. 
Anterior nares. Slight hypertrophy of both lower turbi- 
nates. 
‘Posterior nares. Enormous enlargement of both lower tur- 
binates, so that they extend beyond the posterior end 
of the vomer, swelling around, obscuring its lower half, 
and coming in contact with each other. 
Tongue. Normal. 
Falate. Narrow and high. 
Fharynx. Tonsils encapsulated; mucous membrane of phar- 
ynx is sclerotic. 
Larynx. Vocal cords show good tension; the arytenoids 
“interfere” with one another, the left tending to over- 
lap the right. 
Ears. Drumheads are greatly retraded and dull-white in 
color. 
Of this list, it might be said, that nine cases present fairly 
normal vocal organs, viz., cases 6, 7, 9, 10, 11, 12, 14, 18, 19, 
while twelve cases, viz., 1, 2, 3, 4, 5, 8, 13, 15, 16, 17, 20, 21, are 
burdened with conditions of these parts, which must, to a 
greater or less degree, interfere with phonation, or with the 
training by which the deaf-mute is enabled to acquire speech. 
To what extent these twelve children would have been bene- 
fited by the removal of adenoids, enlarged tonsils, and the cor- 
redion of nasal deformities, it is now impossible to judge, as 
they have been placed in the sign-language department and their 
oral training abandoned for so long a time that, pradically, such 
training would have to begin de novo. In one case only, No. 
XVI. of the detailed list, has oral training been continued, the 
pupil, however, making no advance whatever. A little over one 
year ago, at the request of this child’s mother and teacher, 1 
performed an operation for the removal of the tonsils and post- 
nasal adenoid. The tonsils were of enormous size, extending 
from the top of the faucial arches, where they pressed upon the 
soft palate, to the upper edge of the epiglottis, and projeding so 
far into the throat as almost to be in contad with each other. 
They were covered by fibrous capsules. 
General Re- 
marks on this se- 
ries of cases. 32 
The boy recovered promptly, and his teacher has lately re- 
ported to me as follows: “1 have noticed much improvement 
in Albert's articulation since the operation was performed. He 
has been entirely freed from the choking or tilling up of the 
throat that attended nearly every attempt at vocalization.” 
As a result of my examinations and the operative work al- 
ready done, I believe that the oral pupils should be treated—when 
treatment is necessary—before any prolonged attempts are made 
towards vocal training. Children with imperfeCt vocal organs are 
apt to acquire habits of phonation based on the presence of ab- 
normalities, which will be more or less permanent even after 
the parts are rendered free from obstruction. Following this 
idea, 1 have operated, for the removal of such obstructions, upon 
four children in the last year’s class, and improvement in the pre- 
liminary instruction is already reported by their teachers. The 
mere faCt that tonsils are large, that the septum is deflected, that 
a small amount of adenoid tissue is seen in the naso-pharynx, is 
not, in itself, of sufficient importance to render operative pro- 
cedures necessary. The faCts to be considered are, whether the 
tonsils press upon the palate or sides of the tongue and inter- 
fere with their movements; whether the septum is in contaCt 
with turbinates or is retaining secretion in concavities of its sur- 
faces; whether the post-nasal “adenoids” are obstructing this 
space, pressing on the eustachian openings, or causing mouth- 
breathing. In the reduction of hypertrophied or enlarged tur- 
binates, it is, of course, first to be determined, whether such 
swellings may not depend upon vaso-motor paresis, and do not 
improve under sedative, cleansing, local treatment, combined 
with proper hygiene, diet, exercise, dress, and the general medi- 
cation indicated. 
The careful work of Holger Mygind, of Copenhagen, has 
demonstrated the central lesions existing, so often, in deaf-mutes, 
and the changes found within the labyrinth. Doubtless, there 
are many deaf-mutes who cannot acquire the oral-method, but 
1 believe that failures will be less numerous, if, before the oral- 
training has advanced beyond the preliminary work, the pupil’s 
organs of phonation, when abnormalities exist, are rendered as 
nearly normal as is possible. 
I have said nothing in regard to the benefit such procedure 
has upon the health of the individual, as my motive was to deal 
mianly with the effects on phonation. It is no longer necessary 33 
to prove the now well-established fad, that improvement in gen- 
eral health is an almost constant sequence to the removal of 
those obstruding masses which cause “mouth-breathing,” or 
exert pressure upon the vascular trads lying near the base of the 
brain. 
It remains for me to give you a brief description of the con- 
ditions of the ear, which are most common to deaf-mutes. 
I have already spoken to you, in passing, of the evil results 
following closure of the openings of the eustachian tubes, and 
I have mentioned, that such closure may result from the pres- 
sure against these openings and against the cartilaginous portion 
of the tubes, by hypertrophy of the post-nasal adenoid tissue, by 
hypertrophy of the lower and middle turbinates, and by thicken- 
ing of the mucous and sub-mucous tissue resulting from long- 
existing catarrhal inflamation. By far the greater number of your 
pupils have lost their hearing as a result of these conditions. 
LECTURE III. 
The Ears of 
Deaf-mutes. 
Vertical Section of the External Auditory Canal, Membrana Tympani, and 
Tympanic Cavity, viewed from in front. (Politzer.)—a. Upper osseous wall of the 
canal, n. Lower osseous wall of the same. b. Tegmen tympani. c. Osseous floor of 
the tympanic cavity, d. Tympanic cavity, e. Mambrane tympani. f Head of the 
malleus, g. Lower end of the handle of the malleus, o. Short process of the malleus. 
h. Body of the incus, i. Stapes in the oval window, k. Fallopian canal. 1. Jugu- 
lar fossa, m. Glandular orifices in the skin of the cartilaginous canal. [From Burnett. 
Fig. 5 A. 34 
Fig. 5 B 
Vertical Section of the Right Eustachian Tube, Tympanic Cavity, and Mastchd 
Cells, with Inner Surface of the Squama above viewed from within.—a. Membrana 
tympani. b. Head of malleus, c. End of the manubrium mallei, d. Incus, e. Short 
process of incus, f. Tensor tympani muscle, g. Faucial opening of the eustachian 
tube. h. Isthmus tubae. i. Tympanic mouth of eustachian tube. [From Burnett.] 
Brief Anatomi- 
cal notes on the 
Ear. 
A section made through the head at right angles to the 
median line, so as to bisect the external auditory canal, middle 
ear, and eustachian tube, shows the relation of these parts. It 
will be seen, that the drumhead stands at an angle of about 
160 degrees in relation to the walls of the external auditory 
canal. Back of the drumhead, lies the middle ear cavity, con- 
taining the chain of three ossicles. The third, or most inner 
ossicle, the stapes, is set by its foot-plate into the “oval win- 
dove." This oval window is one of the means of communication 
between the middle ear and inner ear. The most external os- 
sicle, the malleus, is set into the body of the drumhead. Vibra- 
tions started in the drumhead are transmitted along the chain 
of ossicles to the foot-plate of the stapes, set into the oval win- 
dow. The plunger adion of this foot-plate transmits the vibra- 
tions to the fluid filling the complicated twists and turns of the 
inner ear, and into which extend the terminal filaments of the 35 
auditory nerve. Ankylosis, or stiffening of the joints of the os- 
sicular chain, adhesion between the posterior side of the drum- 
head and the posterior wall of the narrow tympanic cavity, or, 
simplv, adhesion alone of the foot-plate in the margins of the 
oval window, will weaken the force of vibrations reaching the 
inner ear or may prevent their passage entirely. Such adhesion 
may follow, simply, from persistent closure of the eustachian 
tubes. As a result of this closure, there ceases to be any air 
within the middle ear cavity to counteract the atmospheric pres- 
sure pressing inwards through the external auditory canal. Such 
pressure without resistance, forces the drumhead inwards, forces 
the joints of the ossicles together, and forces inwards the stapes' 
foot-plate. 
This abnormal state of things interferes very soon with the 
blood circulation of the parts, inflammation results, and perma- 
nent adhesions are formed, which anchor these movable struc- 
tures and convert the sound-conduCting apparatus into a sound- 
obstrutting apparatus. Again, as a result oi aCtive inflammation 
within the posterior nares or pharynx, we may find, that this 
inflammatory condition extends upwards along the tubes, involv- 
ing the lining membrane of the middle ear. Such inflammation 
commonly exists during severe “colds in the head,” Influenza, 
Measles, Scarlatina, Typhoid fever, Diphtheria, and a large variety 
of other general diseases which are accompanied with inflam- 
mation of the nose and throat. Resulting from such processes, 
we may have a variety of lesions, ranging from a simple thicken- 
ing of the drumhead and the mucous coat of the middle ear 
cavity, to complete destruction of the entire sound-conduCting 
apparatus by suppurative process, or by a process of stiffening 
technically called Sclerosis. 
One or other of these conditions described has been the ex- 
citing cause of that early deafness which has prevented your 
pupils from acquiring speech. There are, however, instances in 
which the inner ear has been the seat of destructive processes. 
These have found their way inwards into the sound-perceiving 
department of the ear by means of the oval or round windows, 
or by destruction of the posterior wall of the middle ear cavity. 
They may, however, have started primarily within the inner ear 
and have caused wide-spread destruction, while the middle ear 
has been left almost, if not quite, intaCt. These changes within the 
inner ear may be classified under the general term of Sclerosing 
Pathology o f 
Sclerosing P r o- 
cesses within the 
Middle Ear. 
S c 1 e r o't i c 
changes in ’ the 
Inner Ear. 36 
processes, a conversion of that delicate and highly specialized 
arrangement of nerve cells, laid within an area, which, although 
small in extent, affords, by reason of its many coils, a wide 
stretch of surface, into a bony or fibrous mass. Still deeper 
may be found the lesions fatal to hearing, for the post-mortem ta- 
ble, where we have learned the changes within the inner ears ot 
deaf-mutes, has revealed, also, certain destructive processes which 
are found occasionally within the brain, itself, which have ruined 
the cerebral centre for hearing or have spread destruction along 
those traCts leading through the brain, from this centre to the 
sound-perceiving apparatus of the inner ear. Let me close this 
dry review of this subjeCt, by a reference to the conditions re- 
vealed by the examinations at the Pennsylvania Institution and 
the Glasgow school. 
In my examination of the 415 pupils in the Pennsylvania 
Institution for the Deaf and Dumb, I found conditions within the 
ear, as follows: — 
Destruflion of 
the Auditory 
Centre. 
Examination of 
the Ears of 415 
pupils at the 
Pennsylvania In- 
stitution for the 
Deaf and Dumb. 
Sign-language 
pupils. 
Oral 
pupils. 
“Oral 
failures.” 
Total. 
Individuals having drumheads which 
were quite normal in appearance, 
54 
24 
3 
81 
Individuals having the objective symp- 
toms of Plastic Otitis Media, 
216 
56 
'4 
286 
Individuals suffering from suppurative 
Otitis Media 
16 
11 
3 
30 
Drumheads showing perforations which 
had healed, 
45 
11 
2 
58 
Cases of occlusion of the external auditory 
canals by impacted cerumen, 
24 
10 
1 
35 
Foreign bodies found in the external audi- 
tory canal, 
5 
0 
0 
5 
Deformed auricle, with imperforate audi- 
tory canal 
2 
0 
0 
2 
Individuals having decided trace of hear- 
•ng, 
62 
28 
10 
100 
Exostosis in bony part of auditory canal, 
1 
0 
0 
1 
Second series, 
of Examinations, 
106 Pupils at the 
Pennsylvania In- 
stitution. 
From the second series of examinations made upon 106 
pupils the following is recorded:— 
Plastic Otitis Media, 34 
Chronic suppurative Otitis Media,.* 8 
Perforations of the drumhead which have undergone cicatrization,... 2 
Impa&ed cerumen, •1 
Foreign bodies, 2 37 
It will be seen from these lists how frequent are the in- 
stances in which the appearance of the ears indicated a sclero- 
sing process, either at an end or still active, within the middle 
ear. Another fact of some interest is the relatively large number 
of individuals whose auditory canals were closed by plugs of 
cerumen, as well as by substance totally foreign to the body. 
Such substances consisted of pieces of tin. sticks of wood, dead 
tly, and rolls of paper. 
In some instances, the appearance of the occluding mass and 
of the skin lining the auditory canal indicated, that the foreign 
matter had remained for long periods within the canal. 
Such fa£ts lead me to believe, that the ears of deaf-mutes 
should be examined carefully and all such substances removed, 
as their presence, in many instances, may lead to cerebral or 
nerve irritation, and interfere with the health of the pupil. I 
have seen cases where a persistent cough, treated for many 
months by medicine internally, and by application of medicated 
pigments to the throat, under the impression that the individuals 
suffered from pulmonary and laryngeal disease, have been cured 
promptly and completely by clearing the auditory canals of 
foreign bodies or impactions of cerumen.* These nervous mani- 
festations result from the intimate nerve connection of the ex- 
ternal auditory canal, with the great Pneumogastric nerve, the 
Glosso-Pharyngeal nerve, and by the Otic ganglion, with the 
Sympathetic nerve system. 
Another reason why the ears of deaf-mute pupils should be 
examined, is, that we may discover and properly treat all cases 
of Otorrhoea. Such suppurative process, if negleCted, leads to 
serious interference with the victim’s general health, by reason 
of the constant absorption of the purulent and offensive dis- 
charge, thus maintaining, in such subjects, a low degree of blood- 
poisoning. These individuals are, in addition, exposed con- 
stantly to the danger of extension of the suppurative process into 
the mastoid cells, the inner ear, and the cerebral membranes. 
By far the most frequent cause of cerebral abscess is to be 
found as a result of the negleit of such suppurative cases. The 
deaf-mute appears to be much less complaining, in regard to 
such conditions, then would be the case with ordinary individ- 
uals. Finding it difficult to attraCt the attention of his care- 
takers to his occluded or discharging ear, he may, in time, 
General Re- 
marks on these 
two series of Ex- 
aminations at the 
Pennsylvania In- 
stitution. 
Frequency ot 
Sclerosis of Mid- 
dle Ear. 
Frequency o f 
t he Presence of 
masses impafled 
C e r umen, or of 
Foreign Bodies in 
the External Au- 
ditory Canal. 
Important that 
the Ears of Deaf- 
m u te Pu p i I s 
should be care- 
fully examined. 
* These patients had not been treated by physicians, but by unskilled members 
of their own families. 38 
become accustomed to the pain or discomfort, especially as no 
interference is caused with his power of hearing, which is al- 
ready lost. 
It will be noted, also, how large is the number of pupils 
showing decided trace of hearing. In my own series of exam- 
nations, this question was not developed with as much care as 
Dr. Kerr Love has devoted to it. 
I find that the hearing-power, when present, except in an 
exceedingly limited number of cases, is so imperfect, that it 
would be quite useless to attempt any treatment for improve- 
ment in this regard. Dr. Kerr Love, of the Glasgow Institution 
for the Deaf and Dumb, has recorded the results of his exam- 
ination upon the ears of 17s pupils. Taken as a class, he finds 
that “congenital deaf-mutes are deafer than acquired deaf- 
mutes.” Among the acquired deaf-mutes, he finds the most 
frequent cause of deafness to have been “ Brain Fever.” He 
finds:— 
Many pupils 
show a decided 
trace of hearing. 
Dr.J. K. Love s 
Examination o f 
the Ears of Pu- 
pils, 175, at the 
Glasgow Institu- 
tion for the Edu- 
cation of the 
Deaf. 
Acquired 
deaf-mutes. 
Congenital 
deaf-mutes. 
Doubtful. 
Total. 
The drumheads normal in 
28 
20 
7 
61 
Suppurative otitis media active or extind 
18 
11 
3 
32 
Charges indicating non - suppurative 
catarrh 
34 
33 
11 
78 
Unexamined cases 
1 
1 
2 
Meatus too narrow for examination. . . 
2 
2 
About seventy per cent, of these pupils showed distinct 
‘thickening of the tonsils, pharynx, or of both these structures.” 
In thirty-three per cent., the tonsils were enlarged. 
I think that these findings of Dr. Kerr Love tend to emphasize 
what I have already remarked in commenting upon the results of 
my own examinations. 
As a means of comparing the aural conditions of the pupils 
of deaf-mute schools with pupils of ordinary educational institu- 
tions, I would call attention to a paper by Dr. Thomas Barr, of 
Glasgow, in the British Medical Journal, for September 28, 
1889. The article is termed, “An Investigation as to the hear- 
ng of School-children.” Dr. Barr, at first, refers to the great 
liability of children to aural disease. Among 3,436 persons, 
treated in the Glasgow Ear Hospital, 1169 or 35 per cent, con- 
sisted of children under fifteen years of age, “the time of life 
Dr. Thomas 
Barr's Examina- 
tion concerning 
the Hearing 
power of School 
Children. 39 
when speech and education are usually acquired.” Dr. Barr’s ex- 
aminations were conduced upon six hundred children varying 
in age from seven to fourteen years. They were about equally 
divided as to sex, and were selected from two schools of quite 
opposite social grade. One hundred and sixty-six pupils or 27.66 
per cent, were found defective in one or both ears. For the sake 
of comparison, he quotes the findings of other observers, from 
similar examinations, thus—Sexton, of New York, found the 
percentage of partially deaf pupils to be 13 per cent.; Weil, of 
Stuttgart, 33.37 per cent.; Moure, of Bordeaux, 17.0 per cent.; 
Bezold, of Munich, 22 per cent. Dr. Barr found that the imper- 
fect hearing among the pupils whom he examined was associated 
frequently with nasal disease and with a certain abnormal ten- 
dency to “take cold in the head.” 
I would refer, also, to a paper by Dr. S. S. Bishop, “ A Statis- 
tical Report of 5,700 cases of ear disease, classified by age, sex, 
occupation, and disease”; Transactions of9th International Medical 
Congress, 1887. This paper is of especial interest, as it gives us 
a comparison between the frequency of aural diseases found 
among the pupils of two deaf-mute institutions, and of those 
found among a large number of patients from aural diseases, for 
which they are undergoing treatment. Of the entire 5,700 cases— 
5.1 per cent, had acute catarrhal inflammation. 
5.3 per cent. “ “ suppurative “ 
53 per cent. “ “ non-suppurative “ 
The external ear was affeCted in 8 per cent. 
The internal “ “ “ “ 2 “ “ 
Deaf-mutes constituted 6 per cent, of the 5,700 cases. The two 
sexes, were affeCted in about equal proportions. Children under 
fifteen years of age constituted about 28 per cent, of the whole 
number of cases. 
In closing this series of lectures upon the gross patholog- 
ical changes which have been observed within the ears and upper 
respiratory tracts of deaf-mutes, we may find it of advantage, 
that the main points of our study should be condensed into the 
conventional series of “conclusions,” a sort of moral to the 
tale. 
Following this plan, therefore, I would present the following 
review of our discourse, to which are added impressions of my 
own based on experiences which the limit of our time has not 
allowed me to place before vou in full explanation: — 
Other Examin- 
ations regarding 
the Hearing- 
powers of School 
Children. 
Dr. S. S. Bish- 
op's Examination 
of 5,700 cases ot 
Aural Disease. 40 
Frequency of 
Abnormalities of 
Nares, Post- 
nares, and Phar- 
ynx. 
ist. We have evidence, that abnormalities of the nares, na- 
so-pharynx, and pharynx are found very commonly among deaf- 
mutes, and, that such lesions tend to interfere, in varying degree, 
with the successful training of the deaf pupil in vocalization. 
2nd. Although in no way claiming that such mechanical 
causes are the only grounds for failure in acquiring speech, it is 
reasonable to believe, that, in many instances, the presence of hyper- 
trophied tonsils, masses of overgrown adenoid tissue in the naso- 
pharynx, deformities of the nasal septum, and hypertrophy of the 
turbinated bodies cause such obstruction to respiration and such 
interference with the movements of parts concerned in articula- 
tion, that the oral-pupil becomes an “oral-failure.” In addition, 
it may be stated, that where such an extremely unsatisfactory 
result is not produced, the voice formed in spite of these ob- 
structions is far from being as pure and distinCt as would have 
been the case had the parts been rendered more nearly normal. 
3d. Before beginning the oral training, the pupil should 
undergo inspection by the Laryngologist of the school, in regard 
to the conditions of his nares, posterior nares, pharynx, and ears, 
and all diseased conditions should be noted. When the exam- 
iner finds, that occlusion to parts of the upper respiratory traCts 
are so pronounced as to cause persistent mouth-breathing or 
pressure against the tongue or the soft palate, the parts should 
be rendered as nearly normal as possible, before education of 
the pupil is commenced. When, however, such conditions are 
less marked, the child should be placed in the hands of the 
teachers, to be by them referred back to the surgeon, if, after 
a fair trial, it is found, that such a pupil fails to progress in 
vocalization. In short, operative work must be resorted to when 
necessary. It can be limited to a relatively small number of in- 
dividuals; yet, it is to be resorted to in all cases, where experi- 
ence proves, that such procedure is required. 
4th. It seems evident, that by far the majority of deaf-mute 
pupils have lost hearing as a result of diseases subsequent to 
birth; i. e., are acquired deaf-mutes. 
5th. The most common lesions which appear to have 
caused loss of hearing are to be classified under the term, scler- 
osing processes of the middle ear. In a certain proportion of 
cases—the exa£t percentage I cannot give—this process within 
the middle ear is associated with a similar condition, which has 
CONCLUSIONS. 
The cause of 
many Failures 
among Oral pu- 
pils. 
S uggestions 
rega r d i n g the 
Manageme n t o t 
Pupils having se- 
rious Deformities 
within Nares. 
P o s t - n ares or 
Pharynx. 
Frequency of 
Acquired Deaf- 
muteism. 
Sclerosing Pro- 
cesses, the most 
common Cause of 
Deafness in Deaf- 
mutes. 41 
attacked and altered the elements of the sound-perceiving appa- 
ratus, i. e. the Labyrinth. Congenital deafness is a most uncertain 
diagnosis, and can be positively elucidated only on the post- 
mortem table — a location as unsatisfactory for the pupil and his 
friends, as it is interesting to the scientific investigator. 
1 believe it to be a far from common condition, and that it is 
found mainly among the offspring of persons suffering from Alco- 
holism, Syphilis, Epilepsy, or whose cerebral development is im- 
peded, such as cretins and idiots. 
6th. The common cause for the middle ear diseases associated 
with loss of hearing are the exanthemata, the negled of proper 
hygiene during childhood, injudicious treatment during attacks of 
acute inflammation of the nares, pharynx, and middle ear, and the 
existence of abnormalities of the upper respiratory trad, which 
cause occlusion of the air-passages, pressure on the lower por- 
tions of the eustachian tubes, and chronic inflammation of the 
entire trad. 
7th. 1 believe, that attempts to restore hearing to a child al- 
most totally deaf and who is, also, mute or semi-mute will result, 
usually, ini failure, and that, as early as possible, such children 
should be placed in institutions for oral training. When the at- 
tempt at medical treatment appears to be rational, it should not 
be continued for a term of months after its hopelessness has been 
made manifest. A few months, at most, should decide this mat- 
ter, and the child should, then, be referred to the proper school 
for its oral training. 
1 have taken you over wide fields, at a rather breathless 
rate of speed; not the flowery meadows of the world of litera- 
ture, where poets sing to you of the beauties of the life within, 
and of that without, the soul; where the grave philosopher tells 
you of the things which go to make our joy and sorrow; where 
the jester laughs away the hours, and bids you laugh, if you 
would kill Dull Care. Our way has led through those shadeless 
levels of dry fads which belong to what we call the world of 
science. 1 must thank you for your company, and for that 
friendly spirit which has not grumbled at my cuts across lots, 
turnings, and counter-marches, but, which, like Charity itself, has 
endured all things and endured to the end. In thanking you for 
this rare patience, 1 would, also, express the hope, that you 
have gathered a few handfuls of sand in our desert-walk, and, 
that, among them, something of worth may remain to you after 
the useless part has been cast away. 
Causes of Mid- 
dle Ear disease. 
Importance of 
p 1 a c i n g Deaf- 
mute ch i 1 d r e n 
early in Oral 
Schools.