Contents

CHAPTER VII

IN HOSPITALS CARING FOR DEFECTS OF HEARING AND SPEECH

Reconstruction plans for patients suffering from defects of hearing and speech were assigned at first to the section of the division of special hospitals and physical reconstruction which provided for the blind. This section was divided in March, 1918, its two component parts thereafter functioning separately.¹

Some work had been done in connection with plans for the reconstruction of patients suffering from defects of hearing and speech during the fall of 1917 and the following winter.^{2  This} work had been one of the duties of a medical officer assigned to the section of head surgery and he had called upon a civilian committee to assist him. The outline of a tentative plan of action formulated in consequence in September, 1917, is as follows:² (1) Consideration of the methods of physical treatment of defects of hearing and speech at the front. (2) The reeducation of the deaf and the correction of speech defects, at the front, immediately after the injury or disease; transportation to the interior district where the reeducation would be begun, or transportation to the United States where the reeducation could be carried on under better circumstances and to better advantage. (3) To employ only one method-that of speech reading- in the reeducation of the near deaf or the completely deaf, except in the few cases in which the manual method might be necessary. (4) Necessity for a school to train teachers, the available supply being too limited to meet the expected demands. (5) Provisions for any plastic operations preceding the teaching of speech correction could be instituted. (6) Consideration of the question of rehabilitation, especially with reference to those suffering from defects of hearing.

This plan was approved by the Surgeon General as a basis for future work.³ Subsequently, however, additional details included:³ (1) A canvass to be made of teachers of lip reading and of corrective speech in the United States, with a view to employment. (2) The physical treatment to be done abroad, the correction of deafness, so far as practicable, through local treatment, rest, and removal from the din of battle. Through this means the temporarily deaf and the moderate defects in speech were to be separated from the permanently deaf and the apparently incurable defects in speech. (3) It was not feasible to start reeducation abroad because of the difficulty in selection and segregation; unfavorable environment for the teaching; difficulty in maintaining proper supervision of reeducational work of this type. (4) Though the work could be done in a reconstruction hospital, it was desirable that an institution devoted exclusively to this purpose be used. There were to be one supervisor and six teachers for each section of 50 beds. (5) The personnel of each teaching center was to comprise one head teacher in lip reading; one teacher in corrective speech, who was to give one lecture per week for four months; one volunteer otolaryngologist to lecture on anatomy and physiology of the ear, nose, and throat. (6) Cadet teachers were to be selected for the training classes through

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the cooperation of the women's committee of the National Defense Council or a similar committee of the American Red Cross; to be at least 25 years of age. Each cadet teacher was to have the equivalent of a normal-school education; to receive no compensation while in training, and $60 per month, with lodging and board, after employment. (7) Training schools were to be established in 10 large centers, independent of established schools, each school to give two courses--total expense, $1,400. Ten additional teachers were to be employed in order to give an intensive individual course. (8) This reeducation service was to be placed under a qualified man, preferably medical, who was to be responsible for the development of the details of the training classes. The courses were to be standardized, and were to include a thorough training in the proper formation of the elements of speech, gymnastics of the tongue, proper breathing and calisthenics necessary in the development of the breath and voice, lectures on musical vibrations, special work in the development of hearing with music, and voice placing. (9) Curative workshops were to be established at each reconstruction institution where these classes of patients were received for such occupations as carpentry, painting, mechanical drawing, printing, iron- work, wood turning, metal work on lathes, bootmaking, bookbinding, broom making, mattress making, rubber working, and gardening. The advice of civilians suffering from similar defects was to be obtained as to occupations which it would be best for these men to follow. Public employment agencies and indus- trial organizations were to be convinced that the deaf were not abnormal people in that they had substituted another sense for one in which they were handicapped.

No further preparatory action on this subject was undertaken until March, 1918, when a detailed plan was formulated in the reconstruction division. This plan was so complete that it made provisions for contingencies which never arose.³ In brief, it was an elaboration of preceding plans, with two exceptions: Though foreign statistics, known to be incomplete, indicated that 2 percent of all casualties would constitute those of hearing and speech, it was concluded that the proportion in our Army might be as low as one-half per cent, as our men were subject to a more rigid examination at the time of induction into the service; the proposal to establish training courses had been found to be unnecessary,²and in lieu of them commissioned personnel for this work at three general hospitals--No. 11, Cape May, N. J.; No. 2, Fort McHenry , Md. ; and No. 9, Lakewood , N. Y., was provided for. This latest plan was approved by the chief of the division, but the work was eventually established in only one general hospital--General Hospital No. 11.¹

INAUGURATION OF THE RECONSTRUCTION SERVICE

Much difficulty was encountered in finding a suitable location for establishing a special hospital for the purpose. With one exception, the rental demanded was inordinately high, and the exception was a building of frame construction, with too great a fire risk.¹ It was therefore decided to establish the work as a separate service in General Hospital No. 11, Cape May, N. J.¹ The teachers were employed as head reconstruction aides and the service was formally inaugurated July 24, 1918, with 17 patients.¹ With the exception of a few,

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these first patients were reluctant to take up the work. This was to be expected; these young men had been assigned to hospital, and they saw in the new line of treatment to be inaugurated nothing further than a prolonged stay in hospital and in the Military Establishment. They feared that nothing further could be done for them, and they were anxious to be discharged and to be permitted to go home. Several patients were extremely reluctant, and two of these had to be disciplined in order to bring them to the proper appreciation of the necessities for the treatment. After the work and the treatment had been in progress long enough, so that some of the earlier students began to read with proficiency, the views of all in the hospital were changed. The recalcitrant patients became anxious to follow in the steps of the proficient ones, and new patients inducted into this line of treatment were anxious to take up this work as they saw the benefit which had been obtained by those who preceded them.¹

NUMBER OF CASES EXPECTED AT GENERAL HOSPITAL NO. 11

Throughout the whole work in connection with this section it had been attempted time and again to obtain statistics as to the probable ratio of the number of the near deaf and deaf to the total number of casualties in the various allied armies, so as to make, if possible, advance preparation for the patients to be received.² Usually these efforts were without results. The best received were the statistics furnished by the British Pension Bureau, viz:² That out of the total number pensioned for disability from the beginning of the war to May 31, 1916 , 2.9 per cent were on account of deafness, while from the beginning of the war to May 31, 1918 , the percentage was 1.98. A further report stated that from the outbreak of the war to August 31, 1918 , the total number pensioned for disability is 421,877; of these, 7,731 are invalided on account of deafness, a percentage of 1.83.

These figures indicated that the United States, under the same conditions, would have the same ratio of deaf in connection with the total disabilities. As stated above, a smaller ratio was expected, for two reasons. First, our men, as registrants, were more carefully examined, and those with defects in the auditory organs were rejected. Some few of those who were accepted and taken into the service, on reexamination were excluded from overseas duty and retained for domestic service. In the second examination of recruits all cases of suppurative otitis media were excluded, as well as those showing any catarrh in the middle ear. Those with any degree of impairment of hearing were accepted only for limited service. Second, a large number of the defects in hearing which occurred in the service of the Allies in the war were attributed to trench warfare. Trench warfare practically closed with the entrance of the American Army into the conflict, and, therefore, a large percentage of ear afflictions which were due to trench warfare were eliminated from our service. These two factors were thoroughly considered in the preparation at General Hospital No. 11, and those concerned were not disappointed.²

PROCEDURE ON ADMISSION

All patients were examined in the otolaryngological section of the hospital.² They were all tested out and their conditions noted. The complete deaf, of whatever character, were immediately assigned for speech reading. The near

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deaf and those having deafness in both ears under 5/20, in which the condition of the ears indicated that the hearing would become progressively, although gradually, worse, were also assigned to the speech-reading department. Most of the cases found had some degree of impairment of hearing before entering the service.

It is noteworthy that from the period of December 31, 1918, there was not seen what could accurately be designated the so-called shell-shock deafness.² There were two cases which bore very close resemblance to shock concussion-- that type of cochlea injury which is attendant upon exposure to hours of intensive gunfire in which high-explosive shells predominate.

METHODS EMPLOYED IN TEACHING

The course which was adopted in speech reading was of the individual instructive type.² Each patient was given one-half hour instruction twice daily at the beginning. Two study periods a day proved sufficient for most men. They were given mirrors with which to study their own lip movements, and they were very assiduous in their efforts toward improvement, anxious to gain all the advantages that could accrue from intensive work. All white patients were fairly bright men who had recently become intensely deaf; not possessing any other type of injury, they were more than anxious to remove this one handicap so as to be restored to normal. Contrary to the expectation of some of the teachers of the deaf, no case required manual teaching. Even cases of the most unpromising character, seemingly of the lowest type of mentality, acquired the speech-reading art with unusual facility.

Appreciating the fact that, in all probability, a certain number of cases would enter the hospital whocould be improved and whose hearing could be restored through resorting to the auricular method of training, this subject was given a most thorough consideration.² After examining the various methods which had been adopted by the Allies in connection with this work, it was decided that the auricular method, in which the human voice was employed, seemed the most logical and most promising of results.² This was the method which was reported to be used most extensively in the various French hospitals and institutions to which the deaf were assigned. A full system of carrying out the auricular method to be used by the staff at General Hospital No. 11 was prepared. It was intended to adopt individual methods of training and, if necessary, multiplication of this through phonographic attachment. The staff at this hospital, fortunately, found this employment indicated only in one or two cases.

In the French service it was expected that the average soldier would require about three months for a course in speech reading.² In the British Army it. was expected that the same results would be obtained in four months.² It had not been expected, nor was it intended to make any effort to excel either the French or the British in this type of work.² The effort was simply to give the American soldier the best treatment possible. The method was an intensive one, giving the patient a couple of periods a day, or three, if such could be maintained without causing mental fatigue. It was expected, also, to find that some patients would not be able to grasp the method and to continue the course.

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This proved to be untrue; all of the patients showed energy in the work and keeness in desire, which gave a result far beyond expectations.² Not only were the patients able to read, but also before they were discharged they were able to read well the speech of all people with whom they came in contact.

SPECIAL INSTRUCTION FOR ILLITERATES

Illiteracy proved a serious impediment to speech-reading work, particularly among the naturalized foreign born and most of the native negroes. Since there was not enough work for the aides in speech correction, it was decided to give the illiterates an opportunity to remove their handicap. It was astonishing with what rapidity the aides, not only in the defects of hearing, but also in corrected speech work, removed this impediment. Men who could neither read, write, nor figure would acquire the elements of speech reading within a week or 10 days, and then the instructors would begin with the primary education.

CLASSIFICATION OF PATIENTS

DEFECTS OF HEARING

Defects of hearing were of two main classes, etiologically:⁴ (1) Those due to ordinary diseases common in civil life-acute and chronic mastoiditis, acute and chronic catarrh of the middle ear. (2) Those due to warfare: (a) Shock concussion, most frequently due to the action of a single high-explosive shell in the immediate vicinity of the affected; many of these cases recovered com- pletely. (b) Concussion deafness, due to continuous action of high-explosive shells, shrapnel, or machine-gun fire; these cases probably presented organic changes in the internal ear and were most frequently permanent. (c) The slowly progressive type of concussion deafness so common among artillerymen. (d) Traumatic, due to injury about the auditory apparatus or head.

DEFECTS OF SPEECH

Defects of speech were either congenital, neurotic, or traumatic.⁴ Mutism most frequently of shock origin. Stammering and stuttering, either old cases reestablished or new cases produced during the nervous stress of combat. Atphonias, either neurotic or due to overstrain of the vocal organs, or to nerve and muscle casualties. Affection of voice, due to wounds of the face and upper air tract. The prognosis was fairly good in the majority of cases.

The following classification of cases from a somewhat larger series gives the types of defects encountered at General Hospital No.11: ⁵

By Type

Defects of Speech 

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DEFECTS OF HEARING

Of the 22 suppurative ears there were discharged:
 

The labyrinth tests were not routinely done in all cases. Of 6 tests noted, there were sluggish reactions in 3, no reactions or dead labyrinths in 3.

These labyrinths tests were done in the otitis interna cases. The "dead" labyrinths were in the otitis interna cases following meningitis.

So-called "shell-shock" cases.-There were two cases of otitis interna from shell explosion. The otitis interna had cleared or nearly cleared when they arrived here. The deafness continued from hysteria. Under suggestion and with rest, the hysterical condition cleared and the hearing became normal in each case. In one case only one ear returned to normal because the other ear had been deaf for years, a chronic condition. These two were cases which earlier would have been considered "shell-shock" cases. Two cases died from meningitis, consequent on a chronic brain abscess, secondary to a chronic otitis media, suppurative.

CLASSIFICATION OF PATIENTS FOR DISCHARGE FROM HOSPITAL

On September 20, 1918, the following definitions were made as regards the disposition of patients reaching the stage when they would be ready for classification for either discharge or retention in limited service:²

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All patients who are nearly deaf-that is, below the normal register for acceptance into the service previously as recruits-and who have become proficient in lip reading should be placed in class " C," limited service, for employment in motionless activities only.

Men whose hearing is reduced below 25 per cent of normal, with deafness acquired in line of duty, who have become proficient in lip reading but still hear very loud sounds, should be put in class " D," without limitation as to motion or motionless activities.

Patients who have more or less marked impairment of hearing, near or complete deafness, who still have a disease of the car in the form of suppuration, or dry ears which will suppurate from time to time, however proficient in lip reading they may have become, should be discharged from the service.

Patients who, from want of concentration or from intellectual inability, can not acquire proficiency or near proficiency in lip reading and who have to depend upon other methods of communication after due effort has been made on our part, should be placed in class " D."

TEACHING PERSONNEL

In the speech-reading section, prior to January 1, 1919, there were enrolled as candidates for aides 100 teachers who had signified their desire to become candidates for head aides in the section of defects of hearing and speech, division of physical reconstruction.² In the speech-corrective work there were 51 candidates for corrective-speech aides, under the same qualification, for full military service.² There were a number enrolled as candidates for the position of teachers of speech reading who were not able to give full-time service. ²

RESULTS

The work reached its maximum during the first week of November, 1918; after that date there was a gradual decline in the number of patients received, while the discharges were greater than the increase in patients during November and December.⁵ There were therefore at the end of the year 1918 nearly the same number of patients as when the work was started in July.

Fifty-eight patients were enrolled as having defects of hearing; of these, 34 were discharged as well-qualified speech readers, and 3 discontinued treatment--2 because the deafness existed prior to entry into the service, and 1 who was so improved by the auricular method that further treatment was unnecessary.² These individuals had no difficulty other than what was common to most proficient speech readers. Ordinarily it was not necessary for them to request a repetition of what was stated. Eleven patients were enrolled in the training for defects of speech--4 were discharged cured, 2 transferred to other hospitals, and 5 remained.

In order to insure that none of these patients might lapse or deteriorate in their ability to read, but rather be improved, it was decided that all the patients discharged from United States Army General Hospital No.11 should have the privilege of carrying on practice work at schools or with individual teachers in their home town or near their home town; therefore arrangements were made with a number of schools and teachers throughout the country to give the benefit of their work and effort to our discharged patients, and a similar arrangement was made with the Federal Board for Vocational Education.² They were to furnish practice and instruction to the patients after they had

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been discharged from the Army. As each patient was discharged from the hospital he was given a duplicate copy of the name of the teacher or school to which he must apply, also a note or card of introduction to the school or the teacher. The names and home addresses of the patients were also given to the Federal Board for Vocational Education, which prepared to follow up these men and see that they continued the work and maintained the efficiency which they possessed when they were discharged from the hospital.

RECONSTRUCTION SERVICE TRANSFERRED TO GENERAL HOSPITAL NO. 41

The school for the correction of defects of hearing and speech was transferred to General Hospital No. 41, Staten Island , N. Y., on July 7, 1919 , upon the closing of General Hospital No. 11.⁶ Twenty cases were than transferred, the majority of whom completed the course on or before September 1, 1919 .

A few cases in which physical restoration had not yet been completed were received from time to time, but on November 1 there were remaining only 7 patients with defects of hearing and 14 with defects of speech, and it was expected that these would complete the course before the end of the year.⁷

REFERENCES

(1) Report on the section of defects of hearing and speech, division of physical reconstruction, by the director, Col. Charles W. Richardson, M. C., undated. On file, Historical Division, S. G. O
(2) Richardson, C. W.: Organization of Section of Defects of Hearing and Speech, Division ofPhysical Reconstruction, Surgeon General's Office. Annals of Otology, Rhinology, and Laryngology, St. Louis, 1919, xxvii, 421-451.
(3) Memorandum from Maj. Charles W. Richardson, M. R. C., for Maj. Casey Wood, April 5, 1918 (and attached documents). On file, Record Room, S. G. O., 201 (Wood, Casey A.).
(4) Memorandum on hearing defects, May 14, 1918, by Col. Charles W. Richardson, M. C. On file, Record Room, S. G. O., 356 (General, S. G. O.).
(5) Report on the organization of section defects of hearing and speech, division of physical reconstruction, Surgeon General's Office, with an account of General Hospital No. 11, Cape May, N. J., undated, prepared in the division of physical. resonstruction. On file, Historical Division, S. G. O.
(6) Letter from the chief of the otolaryngological service, United States Army, General Hospital No. 41, to the Surgeon General, July 24, 1919. Subject: Future of the school of defects of hearing and speech. On file, Record Room, S. G. O., 353.91-1 (General Hospital No. 41), K.
(7) Letter from Maj. Gordon Berry, M. C., assistant chief of otolaryngolgical service, United States Army General Hospital No. 41, to the Surgeon General, November 4, 1919. Subject: Future policy of the school for defects of hearing and speech. On file, Record Room S. G. O., 353.91-1 (General Hospital No. 41), K.