higher order are practically closed to them or at least the field is exceedingly limited. From a purely economical standpoint, therefore, deafness must be considered a very important and distressing calamity. Hays has estimated that about 20 per cent of all ear cases belong to the class of chronic catarrhal otitis media. They are all affected by varying degrees of deafness. The financial loss to the community is expressed by him as follows. "In one year (1911) at two of our dispensaries there were approximately 5000 cases of catarrhal deafness treated. Conservatively we may estimate that this is one-half the number being treated in the city (New York). About one-half the cases are females, but 75 per cent. belong to the wage earning class. Let us say that the average earning capacity is $10 per week. As the hearing becomes progressively worse, these patients are thrown out of employment, or obtain some less lucrative employment. Let us say their earning capacity is reduced one-half and reckon it on a money basis. Five thousand people lose $25,000 a week, $100,000 a month, or over $1,000,000 a year. Many of these appeal to the public charities, many have to live on the wages of others." While the figures given in the estimate of Hays may be excessive, we can not question the accuracy of his deductions, and they at least open our eyes to a problem that has been accorded scant attention by the rank and file of our specialty and by the general practitioner.

What can we hope to accomplish in the amelioration of this most important condition?

It matters not, so far as its influence on social and economic conditions is concerned, whether the deafness is congenital or acquired. Whether the pathology is resident in the internal or middle ear, and its nature likewise is unimportant.

On the other hand in our efforts to save what we can of the social and economic waste, consequent upon deafness it is all important, to determine, 1st: the primary cause, 2nd, as accurately as possible the prognosis of each individual case, and 3rd, to give such advice, and apply such treatment as our present knowledge dictates.

Congenital deaf-mutism has been shown to occur in families: that it is likely to result from the intermarriages of deaf mutes and from consanguinity of healthy parents has been definitely recorded. That there occur numerous exceptions to this statement is equally true. Several instances have come to my personal knowledge of deaf-mute children born to parents in good health, and with perfect family histories. Yearsley in a study of 1076 children in three of the schools for the deaf in England found 484 were born deaf,

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and 597 had acquired their defect. sides deafmutism in the direct line or collateral branches of the family and consanguinity of parents, he determined as possible etiologic factors, illegitimacy, insanity and chronic alcoholism. The researches of observers indicate that a certain number of congenitally deaf cases may be due to syphilis. The part that syphilis plays in acquired deafness is well known to us all.

The oft-discussed question of oto-sclerosis has yet to be solved. In spite of the fact that so high an authority as Sir Albert Gray has in a complete and convincing manner given us tables, in which he in numerous instances traces oto-sclerosis from generation to generation, many insist that it is secondary to chronic catarrhal otitis media. The management of these cases constitutes one of the real worries of the otologist. As man is normally endowed with keener hearing power, than is necessary for every day needs, progressive diminution in hearing escapes the notice of most persons so affected, until a considerable degree of deafness has been established. By this time the disease has made inroads in a pathological sense to the extent that return to a normal condition is impossible. Indeed we are fortunate if we succeed in checking the further advancement of the disease.

For the protection of future generations against deaf-mutism and oto-sclerosis, the application of eugenics may furnish a solution.

To quote Yearsley: "It is not possible completely to eradicate congenital deafness, for a certain number of deaf births will happen, like other sporadic cases of defect. I am of the opinion, however, that their number could be materially reduced by the application of eugenic principles. If marriages of the deaf born and of blood relations and the union of alcoholics, syphilitics and those with a family taint of insanity could be prohibited these restrictions alone would be of great assistance. At present we can only try to educate public opinion and this is where our profession should help. The doctor has many grave responsibilities on his shoulders, and not the least of these is his duty to the state. In matters like this he has a great potentiality for good."

Of acquired deafness, the most frequent causes are meningitis. typhoid fever and the exanthemata, particularly measles and scarlet fever. The milder degrees of acquired deafness, can almost invariably be attributed to diseases of the nose and throat. In children, by far the most frequent are adenoids and tonsils. Acute middle ear suppuration, contrary to the belief of the laity, is least often the cause of permanent deafness. Even many cases of chronic middle ear abscess may recover with useful if not perfect hearing. Our

prognosis in the acquired forms, then, is dependent on the early recognition of progressive deafness and prompt removal of its

cause.

We are too prone I think to take a hopeless view of all cases of chronic deafness. Where a labyrinthine deafness has been present for sometime we are really helpless. But on the other hand middle ear affections may unexpectedly yield to treatment. I do not consider the diagnosis of oto-sclerosis always easy, nor do I believe we should invariaibly give a hopeless prognosis when we can definitely determine, an oto-sclerosis in its early stage.

Treatment should be advised and the results carefully noted over a sufficient period of time before we relegate the patient to the great unfortunate class of incurables. The prognosis in many cases depends on the effects of treatment. If only the disease can be held in obeyance, or its progress rendered slower we are rendering a distinct service:

In children, the advent of deafness constitutes an urgent appeal for attention to the naso-pharynx and pharynx. The removal of adenoids and in most cases the tonsils is imperative. In adults the nasal fossae as well as the naso-pharynx demand primary inspection and the correction of any deviation from the normal,

It is our duty to impress on the public, each in our sphere of influence, the importance of ear symptoms. The significance of ear ache is better appreciated than formerly and our efforts should be directed to further impress those, whom we can, with the importance of nipping in the bud any incipient ear disease, be it catarrhal or purulent.

Yearsley agains says, "The prevention of acquired deafmutism embraces a number of factors. It means for one thing better care of children generally, better hygiene, better feeding, better clothing, better surroundings. It means the resolute fighting of many superstitions such as the danger of "stopping a discharge," and the policy embodied in "growing out of" a disease when more frequently it is the disease that out-grows the child. It means better care of the ears during the exanthemata. Until the infectious fevers are shorn of their potency by preventive medicine, there must be ceaseless watch kept for the aural complications by the attendant physician. The practitioner must be educated to watch for deafness or ear pain and to interfere promptly himself or urge the necessity of immediate expert advice. He must also

know how to deal with the nose and throat complications, which lead to this development."

There are certain occupations which are known to predispose, or actually bring about deafness. Bryant has enumerated no less

than sixty (60) trades, at whose door may be laid the blame for many cases of impaired hearing. Any occupation that demands working constantly in a loud noise, such as boiler makers, cooper, riveters, machinists, engineers and many others, cause deafness at an early age. It is a characteristic form of defect, and has been known as boilermaker's deafness.

Another class of occupational disease of the ear is due to rapid and constant variations in barometric pressure, variations of temperature, and humidity. An example of this class is found in caisson workers.

The inhalation of dust and of poisonous gases, by irritation of the naso-pharyngeal mucous membrane. may secondarily be the cause of chronic middle ear disease. In many instances more than one of these factors play a part. The victims of these occupations are sufficient in number to claim consideration, when we are dealing with the economic side of deafness. By training they may be efficient in their individual trade, but are unfitted for any other occupation. So they must submit to the inevitable and remain in their narrow sphere of usefulness. Their deafness is incurable. In the general uplifti movement of the present times, do we not owe them some effort at improving the industrial conditions under which they must earn a livelihood? Suggestions have been made that resort be had to legislation to enforce the necessary reforms in these industries. These suggestions have not received encouragement, and they really seem too drastic.

Is it not possible that in time employers might be induced for humanitarian as well as economic reasons to contrive some means of lessening the dangers incident to their particular trades?

In a number of cases of middle ear deafness, there remains a remnant of hearing power but not sufficient for practical purposes. Many of these can be benefitted by mechanical appliances which have been devised as aids to defective hearing.

That there is value in a few of these devices applied in suitable cases is without doubt. There is also no question that their use in some cases is harmful. This has proven a fertile field for unprincipled tradesmen who by extensive adveritsing have found a ready response from a gullible public. Therefore, no one should resort to the use of these aids except at the advice of a physician who is familiar with the condition of the ear, and the principle involved in the various appliances.

One of the various forms of artificial ear drums, may be useful where the membrana tympani is partially or wholly defective. Tympanic ballast replaces the ossicles when they have been destroyed by suppuration. It reuires judgment to determine the indications.

and contra-indications, the safety or danger of these measures. It cannot and should not be left to the patient.

In catarrhal cases with the drum membrane intact, instruments designed to gather and amplify the sound waves may really perform a good service. The ear trumpet and the fan are examples and have been used for decades. In recent years electrical devices, such as the electrophone have found a ready market.

But these appliances are at best unsightly while the selling price of some places them beyond the reach of the poor. Their bulk and mechanical imperfection are a marked disadvantage and their sphere of usefulness is limited. The natural reluctance of most persons to appear in public with an instrument applied to the ear, which attracts attention, is a serious drawback to their more universal use.

Again, how many employers are willing to overlook this manifest evidence of an infirmity?

In the past decade the education of the incurably deaf child has evoked the earnest efforts of competent and enthusiastic workers, to the end that its present status can truly be said to constitute one of the most important triumphs of modern thought. The history of its evolution from a modest beginning more than a century ago is a very interesting chapter, the recital of which would unduly lengthen this paper.

To our credit be it said that according to Kerr Love of Glasgow the situation in this country is most competently handled. Some of our large cities have splendid institutions. and private schools devoted to this purpose. Many publications, notably the valuable contributions of Makuen and others, both professional and lay workers, have given us knowledge of what is being accomplished. The De l'Epee system of sign language has been practically relegated to the past, except in special instances as an adjunct to the accomplishment of lip reading.

Home training by an intelligent and patient mother under the supervision of an expert or the employment of a private instructor is usually successful. The character of attention suitable to each child depends upon its mental attainments. Those possessing normal mental power very readily are taught the art of lip reading. Those of inferior aptitude for training are taught the combination of lip reading, and sign language. It is claimed by teachers engaged in this most valuable branch of education that the child of superior mind is very quickly and readily made proficient. The average child requires a little more time and patience, but the end is certainly accomplished. Only the mentally defective have difficulty in mastering the oral method and this class require a long period of institu

tional training. Many of these institutions aim to teach more than the ability to hear and speak. They, in addition prepare the student for some practical work in life by giving very thorough courses in manual training. In this manner they go far in solving the economical problem. problem. The most unfortunate of all are those who in addition to deafness are afflicted with blindness, partial or complete. But even the lot of these, hopeless as it may seem, is rendered bearable, by the developmnt of the tactile sense. It is considered most essential that the child possessing even moderate attainments should be taught at home and should attend public school in specially arranged classes according to the degree of deafness and mental capacity. They should associate with those possessing good hearing rather than with their kind.

Someone has said that the time to cure deafness is before it begins.. Certainly the time to begin the education of the deaf child is as soon as the defect is discovered. As Kerr Love states, the untaught deaf child of seven begins his school education with no more intellectual development than the child of two. The most important period of a child's life is before the school age. It is during this time that speech is acquired and if his education for the development of speech is postponed, it will be increasingly difficult in direct proportion to his age.

Above all we must realize that intellectual development of the deaf child is not the only, though it may be the prime consideration. He is not merely an animal because he is deaf and dumb. He has capacity for moral, and social culture. He possesses emotions and is amenable to psychic influences just as well as the normal child. To shun him or to ignore him is a serious mistake. He is on the contrary entitled to special personal attention. He is to be taken to our bosom, made to feel that he is one of us, and that our world is his world. Only in this manner can we make of him a useful citizen and a valued friend.

In conclusion: We are well aware of the many burdens the modern propaganda for the welfare of the public have placed upon the shoulders of the general practitioner. We, specialists, have no desire to add to them. Yet, we may write and preach to our heart's content, but who will carry our message to the homes of the people? It is the family doctor who is awaited with mingled feelings of fear and hope in times of trouble and it is he to whom the anxious mother comes for advice, when the welfare of her children is concerned. He can teach her that half the deafness in the world can be prevented, by a proper recognition of the etiology and prompt attention to the initial symptoms of ear disease. And if deafness has become an established

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J. A. Stucky, Lexington: I think there is very little to add to the practical paper that Dr. Lederman has read to us. I do not think this paper is intended so much for the otologist and specialist as it is for the general practitioner, and I want to emphasize the last clause in the paper that it is up to the general practitioner, after all he is the man behind the gun. He is the most important man to-day in the field of medicine. He is the man that is closest to the mother and the child, closest to the home, and one of the danger signals in the child is when that child begins to listen with its eyes, so to speak, and I mean by that watching the lip movement, he begins to cease to try to hear, and that results naturally in an under development or arrested development of the hearing center. I believe the special centers, like the tactile center of the blind, can be developed. by use. The blind man sees by his fingers, his sense of touch. His sense of touch is much more accurate than yours or mine, and it becomes so by development of that sense of touch. In these cases of ankylosis of the ossiclies, when patients cannot hear in a room in which speaking is going on, they cease to listen because they lose a great deal, and I agree with the essayist that many of these cases can be arrested and many of them improved. I venture to say and I believe, as I advanced at the New York Academy of Medicine two years ago, that oto-sclerosis can be arrested in many cases, and it can be arrested by two people, the physiological chemist and the dietician. We become deaf from a local cause or causes, such as diseases of the naso-pharynx, or we become deaf from constitutional or systemic causes, and the cause of the condition is either from within or from without the body, and the unsolved problems in the metabolism are to be solved with the aid of the physiological chemist and the dietician. That is a point I want to emphasize.

I have now five cases to add to those that I refered to two years age in a paper read at the New York Academy of Medicine. I would call the special attention of the general practitioner to the paper that Dr. Lederman referred to, where the author emphasized and tabulated the economic value of the deaf and his conclusions

are now being used by insurance companies generally. I believe that eugenists will help us a great deal. I think the pendulum is swinging from one extreme to the other and is about to settle. We are not the extremists about eugenics that we were a few years ago, but the medical profession must take an active and decided stand. To those of you general practitioners who have to treat these cases at home of beginning deafness, I want to mention one thing Dr. Lederman referred to but did not emphasize, and that is there is danger in overtreatment locally. I have seen many a case of patent Eustachian tube and relaxed tympanic membrane the result of too freuent and too forcible use of the Politzer bag.

As to hearing devices, it is so easy for the general practitoner to say to a patient, "get you a little horn; get you one of these electric hearing apparatus." I believe there is danger in resorting to these too early. Our patients should be taught to listen. If a child is deaf from organic disease of the auditory nerve, or the child is born deaf, for the sake of the child and its future let some one teach it early, how to talk and read lip movement.

John Wesley Murphy, Cincinnati: I enjoyed Dr. Lederman's paper very much, and those of us who are connected with institutional work realize the importance of this more than others, as we have to come in contact with so frequently these unfortunates who are not able to make a living and are really dependents upon the community, and the amount of economic loss resulting from this disease is greater than any of us realize except when it is brought home to us in such statistics as Dr. Lederman has brought to us this afternoon.

I am satisfied that too frequently the average physician is prone to give an unfavorable prognosis in many cases of beginning deafness or early deafness in children and say "well, the child will outgrow it. Let it alone and we think it will get better." Such advice works great harm. As the essayist has well said, the time to begin treatment of these cases is in the early recognition of the trouble, and that can only be ascertained by careful investigation of each case to find the cause and remove it, and the effect will disappear. The capability of many of these children to pick up even when there is a permanent injury to the hearing, by early education and treatment of the child, can be made to wonderfully improve.

I had the pleasure two years ago of sitting within a few feet of that most remarkable of all cases of deafness and blindness, Helen Keller, and hearing her give the experiences of her life, which were most wonderful. She sat there and listened to the addresses the same as any one here with her teacher sitting by her side, and with her hand in hers, by means of touching her fingers she could follow the papers and remarks, and you would see her laugh when any jokes were

told the same as any one else. What education can do for these cases is most remarkable. Professor Neumann, of Vienna, was with me, and after the address (Neumann, who is the celebrated ear man of Vienna,) said, "I would like to meet Miss Keller." So I took him up and introduced him, and simply by putting his finger on her lips she was able to carry on a conversation with him both in German as well as in English and seemed to get every word he said. That, of course, is unusual.

Of the artificial devices that are used, many of them are abused. Not long ago I had a patient come to the office with a purulent free discharge from both ears. The patient was a woman, thirtyfive years of age, and in washing them out I extracted a couple of artificial drums. They were placed there some months before. These cases must be seen early, and I think many of them that we are apt to consider hopeless can be benefited very materially by early recognition and proper treatment such as the essayist has so clearly brought before us.

W. B. McClure, Lexington: It has been said. that falsehoods, in the order of their enormity, may be classified as lies, d-n lies, and statistics, and this is peculiarly true as regards deafness.

There is a picturesqueness about the available statistics that suggests that they should be taken with a large pinch of salt. You may have heard of the census enumerator in an Irish district who returned such a staggering number of cases of dumbness that an investigation followed and it was discovered that he had listed all the babies as dumb, since they could not talk.

Records at the Kentucky School at Danville show that the principal causes of adventitious deafness in this state are as given in the paper under discussion. It is also shown that consanguinity of parents is a fruitful cause of congenital deafness.

Dr. Edward Allan Fay, of Washington, in an exhaustive work on the marriages of the deaf in which over 4500 such unions are recorded, shows that in marriages between congenitally deaf persons there is a marked tendency to produce deaf offspring. This tendency is lessened where one partner is adventitiously deaf, and practically disappears where both partners are adventitiously deaf, or one is a hearing person.

I have never yet found any statistics that could afford any definite clue to the pre-natal causes of deafness. It is as apt to appear in the palace of the king as in the hovel of the peasant; in the home of the churchman of puritan ancestry as in that of the roue. It is a cruel wrong to approach their cases in the spirit of the Pharisee, who questioned "Master, who did sin, this man or his parents, that he was born blind."

I count a number of intelligent, educated deaf people among my friends, and from what I have seen and heard of the deaf as a class I certainly would not include them among the eugenically

unfit. I know of many happy marriages among them, and am informed from trustworthy sources that, as a rule, the offspring are sound and make intelligent and useful members of the body politic. Only a short time ago one of the historic colleges of the State confirmed the degree of L. L. D. up on the son of a deaf couple, graduate of the Danville School, and a little later two other students, offspring of deaf parents, delivered the valedictories for their classes at other colleges. As for Brown, the grandson of another graduate of the Kentucky School at Danville, led the Middies on Franklin Field-their contest with the Army football squad last fall.

As the speaker has pointed out, deafness usually cuts off those thus afflicted from the better paid occupations and also tends to increase the difficulty of securing employment. Employers, as a rule, know but little of the deaf and are doubtful of their ability. The new Employers' Liability Law has increased this difficulty. I personally know of a number of cases where deaf men who were rendering efficient and satisfactory services, have been dismissed by blanket orders from headuarters that all employees with defective hearing should be dropped. An efficient system of informal training at the various state schools, however, has proved so efficacious that the per cent. of the deaf who are self-supporting is but little less than the hearing. Success has been achieved in many fields, in some of which it would appear that deafness is an insurmountable bar. There is a deaf patent lawyer in Chicago, whose income is said to reach many thousands per year; a chemist and metallurgist in the same city stands at the head of his profession. North Carolina had for years a deaf State botanist. Douglas Tilden, the sculptor, has had his work win the coveted honorable" in the Paris salon, and has been instructor in Hopkins Art Institute, San Francisco. Humphrey Moore's Spanish and Oriental paintings have delighted thousands, there are college professors, doctors, dentists, ministers among the deaf, showing that the opportunity for service in high places is not altogether closed to them.

My experience has been that the commonly received opinions that the deaf are morose and suspicious is far from the truth. If they wear that aspect at all it is as a mask for the purpose of discouraging idle curiosity. Their affliction develops in them a philanthropy and humor that enables them to endure with resignation the inconveniences and deprivations that it imposes. Those who were deaf at birth suffer less though their deprivation is the greater; for having never heard the sweet concord of sound they cannot be said to have lost what they never possessed. It is those who became deaf after they had come to depend on the ear for a large share of the enjoyment who deserve our pity most, for it is of such that the words, "A sorrow's crown of sor