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Chapter V

Contents

CHAPTER V

Otolaryngology

Leslie E. Morrissett, M.D.

ESTABLISHMENT OF OTOLARYNGOLOGY BRANCH

    Until the middle. of 1944, the specialty of otolaryngology had 110 official representation in the Office of the Surgeon General. Individual chiefs had the responsibility for the conduct of their otolaryngologic sections, which were usually organized under the surgical services, in hospitals throughout. the Zone of Interior. If problems in this field reached the Professional Service, Office of the Surgeon General, the usual policy was to refer them to the chief of the ear, nose, and throat service at Walter Reed General Hospital. Three civilian consultants in otolaryngologv had been appointed early in the war and were available for consultation. They were Dr. Albert C. Furstenberg, Ann Arbor, Mich., Dr. Dean McAllister Lierle, Iowa City, Iowa, and Dr. John Mackenzie Brown, Los Angeles, Calif.

    The program for aural rehabilitation of the deafened and hard of hearing, which eventually became the most. important consideration of otolaryngology in World War II, was set up under the direction of the Reconditioning Division, Professional Service, Office of the Surgeon General. The impetus for the creation on 15 June 1944 of the Otolaryngology Branch, Surgical Consultants Division, Office of the Surgeon General, was the need for a reorganization of this program. As a matter of fact, when the consultant in otolaryngology was finally appointed, the magnitude of the rehabilitation program made it necessary for him to give almost his entire time to it and left him little time for other duties in the specialty of otolaryngology.

    Although there had been a realization of the potent importance of the problem of the deafened soldier as early as May 1943 (p.112) and the realization had been implemented by the establishment of three specialized centers for the treatment of defective hearing, the initial program was under the direction not of an otologist but of a psychiatrist. In June 1944, Brig. Gen. Fred W. Rankin, Chief Consultant in Surgery to The Surgeon General, following a visit of inspection to two of the three hearing centers, reported to The Surgeon General that the chief defect of the current program was the total lack of uniformity in the operation of these centers. He recommended that, to overcome this defect and to improve the program in other ways, an otologist be placed on duty in the Office of the Surgeon General to devote his full time to the program for the deaf. This recommendation had been discussed informally by per-


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FIGURE 19 - Maj. Leslie E. Morrissett, MC. Chief, Otolaryngology Branch, Office of the Surgeon General.

sonnel concerned with the program since it had first been instituted and had been a matter of particular concern to the late Dr. Walter Hughson, Otological Research Laboratory, Abington Memorial Hospital, Abington, Pa., then serving as a civilian consultant in otology.

    General Rankin's recommendation was implemented on 13 July 1944 with the activation of the Otolaryngology Branch and the appointment of Maj. (later Lt. Col.) Leslie E. Morrissett., MC, as Branch chief (fig. 19). Major Morrissett had been chief of the eye, ear, nose, and throat service at Borden General Hospital, Chickasha, Okla., where his duties had included the direction of the Rehabilitation Center for the Deafened and Hard of Hearing.

CLINICAL POLICIES

    Clinical policies did not require a great deal of Major Morrissett's attention. These policies were fairly well established by the time of his appointment and, in general, followed the policies then in effect. in civilian practice.


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    Elective surgery of the nose, throat, and ears was prohibited except on very clear-cut indications. Since, however, nasal and pharyngeal defects were not usually regarded as causes for rejection, many men inducted into the Army required otolaryngologic. treatment, and the volume of this work was sometimes quite large.

    Tonsillitis was the most frequent otolaryngologic diagnosis in Zone of Interior hospitals, but tonsillectomy was permitted only when it was regarded as absolutely essential for the maintenance of the health and military effectiveness of the individual soldier. Rigorous enforcement of this rule produced no deleterious results. Acute tonsillitis was treated by routine measures, including the use of penicillin after it had become available.

    Pharyngitis and nasopharyngitis occurred in much the same frequency as in civilian life except for the epidemics which often followed the arrival of increments of new troops in camps. Treatment was by the methods ordinarily used in civilian life. Surgery was not permitted for deviations of the nasal septums except when the deflection was marked and was attended with obstructive symptoms, headaches, and complaints referable to the ears.

    Elective surgery on the larynx was limited to the removal of polyps and papillomas. The incidence of carcinoma of the larynx was surprisingly high. in view of the youth of the Army group. Laryngectomy was usually performed, but an occasional patient was treated by the irradiation technique of Cutler.

    Otitis externa, while chiefly a problem in the Pacific, was sometimes observed in Zone of Interior hospitals, particularly in the South. A variety of antiseptic and chemotherapeutic methods were employed in its management, but there was no doubt that the essential phase of treatment was strict cleanliness of the external auditory canal.

    Otitis media furnished the same constant problems that it does in civilian life. Although the chronic condition was not regarded as a cause of rejection for service, it was often necessary to arrange for certificate of disability discharges for men suffering from it. Management of both acute and chronic Otitis media was by the practices then prevalent in civilian life. The sulfonamide drugs were used until penicillin became available and was added to the armamentarium. The fact that there were only a few cases of mastoiditis was considered by some observers to be attributable to the rise of these agents. However, the general impression was that, while these agents might have been helpful in some cases of acute otitis media, they were of doubtful value in acute exacerbations of the chronic disease and were of no value at all in chronic cases. Insufflations of sulfanilamide powder, which at one time were very popular, later were universally believed to be both ineffective and harmful. It was unfortunate that the masking effects of chemotherapy and antibiotic therapy were not more generally realized. Inexperienced physicians did


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not always appreciate the fact that relief of symptoms was not necessarily synchronous with the resolution of infection.

    The volume of cases of chronic sinusitis was very large. Like otitis media, this disease was not regarded as a cause for rejection of draftees, and a considerable number of men later had to be given certificate of disability discharges for this reason. Sinusitis was sometimes a complication of the epidemics of nasopharyngitis which followed the arrival at camps of increments of troops fresh from civilian life. Therapy followed the usual civilian practices, and elective surgery was discouraged. The systemic use of the sulfonamides and penicillin was sometimes valuable in acute cases in which the micro-organisms were sensitive to these agents, but, as in otitis media, they were of no value in chronic cases and their masking effects were often harmful.

    Bronchoscopy and laryngoscopy were used for both diagnostic and therapeutic purposes upon the proper indications. The fenestration operation was not permitted. Rhinoplastic surgery for cosmetic or other reasons was permitted in a few special cases, but for other reasons - for example, physiological reasons - it was permitted in indicated cases. In these instances, it was done by otolaryngologists with special training and with the express permission of the hospital commanding officer.

    Anesthesia was a. matter of the individual surgeon's preference. Endotracheal anesthesia. gradually became popular for radical operations on the antrum and mastoid, which, as just indicated, were not numerous. Tonsillectomy was performed under some form of general or local anesthesia.

    After the activation of the Otolaryngology Branch in the Office of the Surgeon General, special cases which formally would have been referred to the chief of the ear, nose, and throat service at Walter Reed General Hospital now reached the consultant in otolaryngology through channels. Most of the cases which reached the consultant through the physical evaluation review board in the Office of the Surgeon General concerned the disposition of patients. Cases which concerned West Point cadets had to do with whether otolaryngologic conditions such as perforated eardrums would warrant continuation at the Academy or would require dismissal on the basis of physical disability. Army regulations governed decisions on these cases.

    The recommendations made by the consultant in otolaryngology in the Office of the Surgeon General were, of course, not directive in force. In one particular case, which had occupied much time and thought and for which the recommendations were made jointly by several consultants, the commanding officer of the hospital declined to accept the recommendations and continued to refuse to accept them even after active intervention by General Rankin. This was not an unusual situation, of course, but one which did occasionally occur and for which no immediate remedy was obvious.


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ROUTINE ADMINISTRATIVE PROCEDURES

Hospital Organization and Personnel

    Policies on hospital organization were already well established when the Otolaryngology Branch was activated in the Surgical Consultants Division, Office of the Surgeon General, in July 1944. As a rule, sections of otolaryngology were a part of the surgical service. In a few hospitals, otolaryngology was a separate service. In most, sections on otolaryngology and ophthalmology were conducted conjointly by a single officer' trained in one branch or the other or, very occasionally, in both. This was obviously an undesirable state of affairs. In small station hospitals, where there was, perhaps, no other solution to the problem, patients who needed specialized care in the field in which the section chief was not trained were transferred to general hospitals. The larger hospitals, the policy of combined services was unfortunate. There were shortages of specialized personnel, it was true, but the popular explanation of the situation was that the tables of organization which provided for the joint management of two widely dissimilar specialties were the result either of the operation of the Office of the Surgeon General under the Army Service Forces or of the failure to provide for a consultant in otolaryngology on the proper level to advise upon such matters.

    By July 1944, most hospitals, both those in the Zone of Interior and those designated for oversea service, were fully manned, but otolaryngologic personnel were now in short supply. Later, in a number of instances, recommendations for changes in assignment were made and were based on personal observation of competence or were regarded as valid for other reasons. However, for one reason or another, none of these recommendations was implemented.

    The Army Air Forces, which were then part of the Army, had a surplus of well-trained otolaryngologic personnel who were not very busy. Recommendations for transfer of some of these officers to make up for shortages in Army hospitals in the Zone of Interior and overseas were made informally but were not acted upon.

Equipment and Supplies

    Consultations with the proper authorities concerning equipment and supplies for otolaryngology were, as a rule, very disappointing, probably because, again, the Otolaryngology Branch, Office of the Surgeon General, was activated at such a late date. The errors were those which might have been expected in lists of equipment made up, as a rule, by medical officers with no special training in otolaryngology.

    As a rule, however, serious deficiencies were not numerous. Improvisations were sometimes necessary, but no patients really suffered because of lack of equipment. There were numerous complaints, but most of them could be explained by the rather general desire of surgeons in all fields to want more


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than they have. On the other hand, much of the equipment was far too elaborate. It was a good deal more than most otolalyngologists were used to in civilian practice and was entirely unnecessary in view of the limited amount of surgery permitted in many installations. Hospitals which needed more equipment either improvised it or secured it on loan from general surgery services.

    There were, however, a number of deficiencies in the equipment for the hearing centers. Audiometers were in limited supply for a long time. These were delicate instruments frequently in need of checking and repair, and their maintenance was slow and difficult. In many instances, insufficient space had been provided for proper testing (20-foot lanes), and the areas were not sound conditioned or correctly located. In at least one hospital, the room for audiometric testing was adjacent to the motor pool. These deficiencies were partly due to failure to appoint a consultant in otolaryngology until late in the war and were partly a reflection of the status of audiology before the war.

OTHER DUTIES

    Hospital construction. - The professional duties of the consultant included the making of recommendations concerning construction and equipment in new hospitals and alterations in existing hospitals. These duties required consultation with appropriate sections of the Office of the Surgeon General and were chiefly concerned with the hearing centers. Professional advice in regard to these centers was usually readily accepted.

    Special centers. - In addition to the centers for the treatment of hearing impairments, special centers were established for the treatment of laryngeal and esophageal cases and for speech defects. The speech defects were principally from head injuries, and the centers, which were never very active, were operated in conjunction with neurosurgical and neurologic personnel. The principal center for the treatment of laryngeal injuries which injuries proved far more numerous than had been expected, was at Walter Reed General Hospital.

    Field trips. - Each of the hearing centers was visited several times when necessary, but travel by the consultant in otolaryngology was otherwise strictly limited. He was not included in any of the so-called "Flying Circus" trips, in which groups of officers in the Office of the Surgeon General traveled by air to various hospitals in the Zone of Interior to study the administrative organization, the functioning of the various services, and the care of patients. Other consultants, however, were included in these "Flying Circus" trips from time to time.

    The personal observation, which would have been possible had the policy on travel been less restrictive, would have obviated the difficulties which arose from correspondence regarding personnel. In numerous instances, letters were received from otolaryngologists concerning assignments, equipment,


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therapeutic methods, and other matters which were not always easy to evaluate at long distance. Some of these letters could, of course, be discounted upon the first reading. In other instances, however, though the complaints seemed justified, it was almost impossible to recommend action without personal observation. In only one instance was such personal observation permitted. On that occasion, it was recommended that the officer in question be transferred to another installation in which his duties would not provide the opportunities for the surgery he was attempting.

    Liberal use of the log distance telephone compensated to some degree for the restraints upon travel by the consultant in otolaryngology.

    Liaison. - Liaison with various otolaryngologic organizations and with lay and other organizations concerned with this field was one of the duties of the consultant in otolaryngology.

    After his appointment to this position, this consultant served on the Sub-committee on Otolaryngology, Division of Medical Sciences, National Research Council, and replaced the medical and administrative officers who had served previously on the Subcommittee. He was also appointed alternate liaison officer and, later, liaison officer on the Committee on Sensory Devices, Office of Scientific Research and Development.

    Liaison officers were invited to all section meetings of Office of Scientific Research and Development committees, at which their special projects were discussed. Direct and official contact was permitted with National Defense Research Committee contractors without violation of rules concerning communication through official channels. No substantial change in research projects was permitted without the approval of the responsible supervising division of the Office of Scientific Research and Development, but this arrangement. Provided frequent and helpful contacts with persons concerned in these projects. Many of the practical results of the research carried out by the special committees of that office were applied at the hearing centers as preliminary data became available, but the war ended before these projects were completed.

    Other groups with which liaison was maintained included the American Academy of Ophthalmology and Otolaryngology; the American Otological Society; the American Laryngological Society; the Section on Laryngology, Otology and Rhinology of the American Medical Association; the American Broncho-Esophagological Association; the Triological Society (the American Laryngological, Rhinological and Otological Society) the American College of Surgeons; and the American Board of Otolaryngology. For the most part, liaison was effected informally, frequently by telephone or by personal contact. These contacts, however, were extremely profitable in that specialists in the field could be kept informed of Army problems and progress and that the consultant in otolaryngology, in his turn, could keep abreast. of therapeutic and other advances.


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    Close liaison was maintained also with the American Hearing Society through its central office in Washington; the Volta Bureau of the Alexander Graham Bell Association for the Deaf; and other lay organizations. These contacts frequently brought to the attention of the consultant in otolaryngology both general problems and special cases.

    The consultant in otolaryngology served as a member of the Subcommittee on Audiometers and Hearing Aids of the American Standards Association and attended several meetings. At a conference on underwater sound at the U.S. Submarine Base, New London, Conn., a paper was presented as part of a symposium on this subject.

    The consultant attended meetings of specialized societies and presented talks on the occasion of special meetings, such as the silver anniversary meeting of the New York League for the Hard of Hearing when it met with the Otolaryngology Section of the New York Academy of Medicine, New York, N.Y., in 1944.

    Close liaison was maintained with the Veterans' Administration, chiefly through informal conferences. The relationship was invariably cordial and cooperative, and it was believed that a good groundwork had been laid for the assumption by the Veterans' Administration of the care of deafened veterans after the war.

    Public relations. - A large part of the consultant's duties had to do with a field that might be termed public relations. This included correspondence on special cases with members of Congress who forwarded letters from their constituents. These letters usually dealt with physical disabilities which, it was believed by the soldier's parents, would be jeopardized by continuation of service, by continued service in the present assignment, or, in particular, by oversea service. The most usual reasons listed were sinus trouble, hearing defects, headaches, and a former history of mastoid disease. Each of the cases was, of course, investigated, but only very occasionally was the request regarded as justified from the standpoint of the soldier's well-being.

AURAL-REHABILITATION PROGRAM FOR THE DEAFENED AND HARD OF HEARING

Background and General Considerations

    The impetus to the appointment of a consultant in otolaryngology in the Office of the Surgeon General in July 1944 was, as already mentioned, the need for changes in the Army aural-rehabilitation program. The description of this consultant's functions, in fact, began with a statement of his responsibility for the establishment of policies and procedures in the care of the deaf in the Army.

    Specialized centers for the treatment of Army personnel with defective hearing sufficient to preclude their return to duty had been set up in May 1943 at Borden General Hospital (fig. 20) Hoff General Hospital, Santa


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FIGURE 20 - Aural rehabilitation at Borden General Hospital, Chickasha, Oklahoma A Audiometric assessment of hearing loss. B. A group learning lipreading with the aid of motion pictures. C. Practice class in lipreading.


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Barbara, Calif.; and Walter Reed General Hospital, Washington, D.C. The center at Walter Reed General Hospital was transferred to Deshon General Hospital, Butler, Pa., in September 1943 (fig. 21). The first phase of the program was under the direction of a trained psychiatrist, Maj. (later Lt. Col.) Walter E. Barton, MC, Assistant Director, Reconditioning Division, Office of the Surgeon General.

    By January 1944, the increase in the patient load at the specialized centers had resulted in so many problems that a conference on the whole subject of rehabilitation of the deafened was authorized by The Surgeon General and was held at Hoff General Hospital, 2-4 February 1944. The mere perusal of the recommendations made by this conference made it evident that the three specialized centers for rehabilitation of the deafened were operating, for all practical purposes, its individual units, and this lack of coordination was one of the chief reasons for the establishment of an Otolaryngology Branch.

    The reorganized program is described in detail in the volume in this series concerned with otolaryngology, but certain of the essential facts require repeating here.

    The problem with which the Army found itself confronted in the rehabilitation of the deafened and hard-of-hearing soldier had no parallel in civil life, either in the number of patients to be dealt with or, in some cases, in the circumstances of their deafness. At the beginning of the aural-rehabilitation program, the following three special difficulties had presented themselves

    1. The material used in the teaching of the hard of hearing in civilian life was almost entirely directed toward children.
    2. The Army at this time had neither the trained personnel to conduct such a program nor the technical personnel to build, install, and maintain the essential electroacoustic equipment.
    3. Highly specialized and difficult-to-obtain equipment was required.

Development of the Program

    The first duty of the newly appointed chief of the Otolaryngology Branch was to survey the situation at the three hearing centers. An analysis of the data secured made it clear that deafened and hard-of-hearing patients had, on the whole, received excellent care and that the chief deficiencies of the program at this time had to do with lack of equipment, shortages of personnel, and lack of uniformity and procedure. True, corrective action was being taken to overcome these deficiencies, but the added impetus provided by the appointment of the consultant in otolaryngology to coordinate and integrate activities undoubtedly accelerated development, of the full-fledged program which eventually evolved. The following developments were particularly noteworthy

    Equipment. - A list, of basic equipment was drawn up with the assistance of Dr. Richard K. Silverman, director of the Central Institute for the Deaf, affiliated with Washington University, St. Louis, Mo., and Mr. C. E. Harri-


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FIGURE 21 - Aural rehabilitation at Deshon General Hospital, Butler, Pa. A. Speech interview and evaluation. B. Administration of the Larsen discrimination test. C. Psychological evaluation of mental abilities and aptitudes for rehabilitation counseling.


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son, who had had many years of experience in electronics at this institution. In July 1944, all three centers were still without sound-level meters, magnetic tape recorders, some units of electroacoustic equipment, and other equally basic items. However, by 1 November 1944, most of the essential equipment had been procured and installed in all three centers. At the same time, utilization and disposition of the equipment, which previously had varied widely, were standardized and made uniform.

    Personnel. - The staffs already at work in the hearing centers in July 1944 were augmented as rapidly as possible to meet expected patient loads. Qualified personnel already in service were identified from a search of personnel records in The Adjutant General's Office and assigned to the center's. All organizations working in the field, both lay and professional, governmental and private, were solicited for assistance. Eventually, an adequate number of both military and civilian personnel were secured for the positions open in the hearing centers.

    When, on early visits to the centers, it was found that otologists specially trained for the program were being assigned to other duties and that their specialized skills were not being fully utilized, the importance of retaining intact the organization which had been set up was explained to responsible officer's in the service commands, and the time, effort., and monies expended in the training of personnel were emphasized. Later, a War Department memorandum stressed the importance of retaining in their specialized capacities critically needed specialists, among whom were listed psychiatric social worker's, lipreading specialists, speech correctionists, and acoustic technicians.

    Organization. - Under the plan of reorganization put into effect by the consultant in otolaryngology, an otologist directed the aural-rehabilitation program at each center. Medical officers became responsible to the otologist for the diagnostic and therapeutic management of the patients, whereas, formerly, the program had operated as a group of separate services.

    Although compliance with the basic plan of organization was insisted upon, each center was given latitude for the expression of individual initiative in its program. Facilities for the transmission of information from center to center insured the rapid utilization for all patients of any policy or procedure which had proved of value in a single center.

    Selection of patients. - The standards of hearing acuity under which men were inducted into service obviously permitted the entrance of many wit markedly defective hearing. Moreover, the tests by which acuity was determined were admittedly inaccurate. Originally, a hearing loss of 60 decibels was required for admission to the centers, Later, the hearing loss requirement was reduced to 30 decibels, which experienced otologists regarded as much fairer, even though it would immaterially increase the load on the special centers.

    Expansion. - The original plan was that each aural-rehabilitation center should maintain a maximum load of 250 patients. As the patient load increased, problems of additional expansion continued to arise. Early in 1944,


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various estimates brought the maximum number of casualties who might require treatment for deafness within the year to more than 13,000. Available facilities would not permit the handling of more than 4,000 per year, even if the turnover continued as expected. Additional facilities were therefore planned for between 4,500 and 9,000 patients per year, which would require, on the basis of a 10-week hospital residence, an additional bed capacity of between 900 and 1,750 beds.

    Later, it was found more practical to manage patients admitted to the center for aural rehabilitation as convalescents, and, under this plan of management, the proposed additional hospital facilities were considered unnecessary. The plan of transferring patients in the hearing centers to convalescent barracks was originally undertaken experimentally, but it proved both feasible and practical in addition to releasing hospital beds for other, more urgent purposes, it removed the patient from a hospital atmosphere, improved his morale during the period of rehabilitation, and permitted a desirable program of activities outside of actual aural rehabilitation which could better be carried out away from the regimentation and discipline necessary in hospital wards.

    Hearing aids. - War Department Circular No. 81, issued on 23 February 1944, limited the prescription and fitting of hearing aids to the special hearing centers, except for patients in general hospitals under treatment for conditions which precluded their transfer to special centers (fig. 22). The original policy was to supply aids only to men whose impairment had been suffered in line of duty. Later, on 23 February 1944, this policy was altered and aids were furnished to all deafened men in service, regardless of when or how the impairment had originated.

    The situation in respect to hearing aids was altered in the reorganized program in several ways. Scientific tests were devised to determine the special aid suited to the needs of the individual patient. Patients themselves were completely separated from commercial contacts. Savings in both time and money were effected by having the individual Lucite tips for the patients made by trained technicians in Army dental laboratories and by letting indefinite quantity contracts for the purchase of aids most frequently used, as determined by survey.

    Narcosynthesis. - One of the outstanding developments of the aural-rehabilitation program was the management of cases of psychogenic deafness by narcosynthesis. The results in the first cases in which this method was applied were so good that its use was extended, and, in all, 102 patients were thus treated at the Hoff Center, with the cooperation of the otologist, the psychiatrist, and the psychologist. Although this technique was highly successful in military circumstances, it was doubted that it would be as effective in civilian life.

    Civilian consultants. - Valuable suggestions concerning the aural-rehabilitation program were made by the late Dr. Walter Hughson, before the


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FIGURE 22 - Prescription and fitting of hearing aids A. Various types of hearing aids being tested for the reception of normal speech. B. Demonstration of the wearing and use of a particular type of hearing aid.


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establishment of the Otolaryngology Branch in the Surgeon General's Office. Mention has already been made of the assistance rendered by Dr. Richard K. Silverman and Mr. C. E. Harrison in the planning and procurement of special equipment. The latter two individuals made a number of trips to the centers in connection with the designing and installation of this equipment, and Dr. Silverman made valuable suggest ions for the lipreading and speech-correction programs. Dr Gordon Berry, then President of the American Otological Society, gave generously of his time and supplied valuable advice when the program was in its earliest stages as well as after the Otolaryngology Branch had been established. Dr. Hallowell Davis and others of the psychoacoustic laboratory of Harvard University gave valuable help in various aspects of the program for the treatment of the deafened soldier.

    Early in the program, Dr. Douglas Ross was assigned to Deshon General Hospital in connection with the otologic studies of the National Defense Research Committee. His association with the staff there proved of so much benefit that at the suggestion of the consultant in otolaryngology he also visited the other centers, where he held numerous conferences with the staffs and was able to iron out many difficulties on the basis of his experience in similar situations at the Deshon Center.

    Maj. Victor O. Skyberg, SnC, who had had a wide experience in civilian life as both teacher and administrator at the New York School for the Deaf, White Plains, N.Y., at Gallaudet College, Washington, D.C., and at the Minnesota School for the Deaf, Faribault, Minn., visited Borden and Hoff Centers late in 1944 and would have visited the Deshon Center except for his untimely death just as his tour of duty at the Hoff Center was concluded. Major Skyberg's constructive criticisms resulted in further standardization of methods at all centers and in other improvements.

    Followup. - Unfortunately, no adequate follow-up studies were made within the Army on patients discharged from the hearing centers. The Deshon center, however, investigated, by means of questionnaires, 468 of its patients who had been discharged with hearing aids. The personal impressions of workers in the program were that a large proportion of the patients returned to civil life had made highly satisfactory adjustments. In many instances, it was stated that the standards of living, as the direct result of aural rehabilitation, were actually higher than they had been previously. This was especially true of those whose hearing had been impaired before their induction.

Conclusions

    Although nothing new was revealed during the war about the problems of patients who were deafened or who had suffered severe damage to their acoustic mechanism, the mass of military casualties permitted a study of the whole field of deafness which would have been impossible in civilian life. Much of the accumulated data merely confirmed previous impressions, and much of it was inconclusive. Nonetheless, it would be fair to say that, as a result. of


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the wartime experience, the treatment of deafness was advanced by at least two decades.

    The integration of the aural-rehabilitation program was perhaps its most significant aspect. For the first time, there were placed under a single roof, a large-scale collaboration, the otolaryngologist who specializes in otology, the acoustic engineer, the psychologist, the social worker, and the teacher of the hard of hearing. Each specialized center was provided with the best possible equipment. Every member of the staff was a specialist in his field. Some teachers were themselves as handicapped as their pupils and were vital illustrations of what handicapped persons can accomplish. Every phase of the program was carefully planned, with the objective of making it as intensive and, at the same time, as streamlined as possible. Eventually, as would have been desirable from the beginning, an otologist was put in overall charge of the program, since auditory impairment, regardless of its social and emotional complications, was primarily a medical problem.

    In all, some 9,500 deafened and hard-of-hearing soldiers were treated in the three aural-rehabilitation centers.

RECOMMENDATIONS

    In retrospect, the prime achievement of the Otolaryngology Branch, Surgical Consultants Division, Office of the Surgeon General, was the operation of the specialized centers for the treatment of deafened and hard-of-hearing soldiers. It was unfortunate that the uniform program finally put into operation at all of the centers was not instituted as soon as the centers were established. It was equally unfortunate that the program did not develop originally under otologists, the specialists primarily responsible for the management of hearing impairments.

    For these and other reasons, it is indicated that in the event of another war an otolaryngology branch should be created at once as one of the specialty branches in the Office of the Surgeon General, if such a branch should not exist at the time, and regardless of the form the organization of this office may take in the future. It would be fair to say, without unduly magnifying the importance of the specialty, that many of the problems which arose during the early years of the war concerning personnel, equipment, therapy, and other considerations would not have arisen had an otolaryngologic consultant been available for advice and guidance.

    It should be pointed out also that the rank of the consultant in these fields should at least approximate the ranks of other consultants in the various specialties. An officer in the rank of major was handicapped in his dealings with officers of rank higher than his own, even though their duties were comparable.

    Finally, the record would suggest that the restrictions on travel for the consultant in otolaryngology which prevailed in World War II should not prevail in the event of another war.