in addition to education in lip-reading and articulation, such hearing as the child may possess should be utilized by the employment of artificial means, if necessary, for the readier conveyance of sound to the ear. As a result of practical experience, and not merely upon theoretical grounds, the use of the hearing-trumpet, of one kind or another according to the requirements of the case, may be advised during school exercises; indeed, in many cases, the use of such an instrument tends to improve the hearing not merely during the time of its use, but generally, the subjection of the ear to sound waves of larger amplitude either increasing the vibratory power of the sound-conducting apparatus of the middle ear, or acting as a stimulus to the auditory nerve. The proper application of these auxiliaries to instruction, necessitates therefore the formation of a separate class, for the benefit of which, as has been said, the public deaf-mute school, which now forms an important part of the Boston school system, and which must in time be engrafted upon the public school system of other large centres, may be made available.

In the Boston school, the children are divided into two general classes, those who are total deaf-mutes, and those who are semi-mutes. Children in the latter class are instructed in articulation, for the purpose of overcoming faults which always exist where the hearing is imperfect, and in lip-reading, that they may learn to understand conversation from sight as a substitute for hearing. Such hearing as remains to them is also made useful in conveying ideas as to the formation of vocal compounds, by means of an ear-trumpet, if necessary, or by speaking directly into the ear. As the total deaf-mutes improve in articulation and lip-reading, they are advanced to the class consisting of semi-mutes, partly because the grade of instruction has become the same, and partly that they may profit by the example of those more fortunate companions who have had the advantage of having a little speech or a little hearing to start with. On this plan, the Boston school has now been in operation for five years, with increasing success and increasing evidence of its great value; it now provides for about sixty pupils, all of whom are instructed in lip reading and articulation, the method employed being the system of visible speech introduced in this country by A. Graham Bell.

The conclusions drawn from a study of the subject of this paper, may be summed up as follows:

I. The frequency of partial deafness in children, during the period of school life, renders it advisable to make some definite provision in our public school system for compensatory instruction.

II. Since partial deafness is a comparative term, some provision should be made for a proper determination of the degree of disability.

III. This may be best accomplished either by establishing a series of speech-tests, to be used by the teachers, or by instituting competent medical examination at the hands of a medical supervisor of schools; and the creation of such an office in connection with our public school system is strongly urged.

IV. Partially deaf children, whose hearing is not so defective as to require special instruction in articulation and lip-reading, are better taught in mixed classes with those who hear well, compensatory advan tages being allowed them according to their degree of disability.

V. Partially deaf children, whose hearing is so defective as to interfere with the natural acquirement of articulation, and to render the ear of little or no value as a medium for hearing, should be accorded the ad

vantages of special instruction, of which education in articulation and lip-reading should form a part.

DISCUSSION ON DR. BLAKE'S PAPER.

After the reading of the preceding paper, Dr. CHARLES H. BURNETT, of Philadelphia, said:-I would ask Dr. Blake if he has noticed, in the schools. visited by him, whether adult mutes have been taught to talk?

Dr. BLAKE said:-I have noticed, especially in the Northampton schools, that pupils who have reached the age of sixteen years, for instance, are taught to talk with very great difficulty. A deaf-mute taught in the sign language, learns to think in a language different from ours. One sign may convey two or three meanings, and its signification often depends upon the context. The deaf-mute's arrangement of words in sentences resembles more closely that of the French, than that of the English, language. The success of deaf-mutes in the acquirement of articulation is sometimes very astonishing. The sound of the voice is at first harsh, and articulation is imperfect. But modulation of the voice is attained, in default of hearing, by the pupils learning to observe the sensations produced by speaking in the throat, by which means they soon learn to appreciate the difference between the rising and the falling inflection. There have been instances in which English deaf-mutes have been taught with such success that they have learned to speak French and German fluently, and to sing harmoniously.

ON AURAL VERTIGO WITH VARIABLE HEARING.

BY

CHARLES H. BURNETT, M.D.,

AURAL SURGEON TO THE PRESBYTERIAN HOSPITAL, PHILADELPHIA.

VERTIGO from disease of the semicircular canals has been fully recognized ever since the publication of Ménière's papers on the subject. Guided by the description of his case, and, more recently, by the investigations of Flourens and others respecting the physiology of the semicircular canals, the tendency among medical men has been to ascribe all cases of acute aural vertigo, not directly traceable to some irritation in the external auditory canal, to disease in the labyrinth, preference being given to the semicircular canals as the seat of the direct lesion.

Without entering into a discussion respecting the precise location of the lesion in labyrinthine vertigo, it can be comprehended why the deafness which is so marked a symptom of this disease, may be permanent. In fact, if the direct lesion be in the labyrinth, as it undoubtedly is, in true Ménière's disease, one cannot understand how the deafness can fail to be permanent. In the affection known as Ménière's disease, called also labyrinthine vertigo (Hinton), the chief symptoms are sudden tinnitus aurium, vertigo, reeling, falling without loss of consciousness, nausea, vomiting, and sudden, total, and permanent deafness in the affected ear. The other symptoms may occur in paroxysms for longer or shorter periods. But there are on record a few cases, and doubtless many others have occurred which have been recognized though not recorded in literature, in which all the above-named symptoms have existed, excepting the permanence of the deafness. Mr. Hinton records such cases, with the statement that the recovery of the hearing was perfect, and then raises the question "were they not caused by muscular spasm?"

Especially noteworthy is that form of acute aural vertigo in which the hearing diminishes during the paroxysm, improves during the interval, and finally is restored when the paroxysms of tinnitus, vertigo, etc., cease to recur. In such cases, it is manifest that the direct lesion cannot be in the labyrinth, and the question might be asked, "Are not such cases due to a spasmodic affection of the muscles of the tympanic cavity?" Future investigations may show that such cases are caused by undue inward pressure of the stapes, which is brought about either by a tonic contraction of the tensor tympani, so powerful as to overcome the equilibrium normally existing between the latter and the stapedius, or by a relaxation of the latter muscle, which permits the normal tensor tympani to act without the antagonistic counterbalance of the stapedius. As tending to answer in the affirmative the question which I have proposed, I would cite the following case:

Mr. X., aged 41, single, a stock broker, was brought to my door in a carriage on May 8, 1875, apparently in collapse; upon approaching him, however, I found him conscious, but very pale and weak, and his surface cold and

1 Questions of Aural Surgery, pp. 261–262.

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clammy. I was asked to accompany him immediately to his home, and while doing so learned from him that he had been suddenly attacked about an hour before, while attending a meeting of the Board of Brokers, with sudden and intense tinnitus aurium and vertigo, with entire inability to stand, and that he had finally vomited, but that, during all the time of this most disagreeable attack, his mind had been perfectly clear. I found his pulse about 75, but very weak, and he stated that there was still some vertigo, but that the buzzing in the ear had given place to a "stunned feeling" in the head, attended with a boring sensation which seemed to start behind the auricle, and to extend inward to the centre of the head. There was no complaint of altered hearing at this time, but I found that the hearing of the watch was reduced to in. in the affected ear. The patient was put to bed, and, as his surface was very cold, a little warm brandy and water were given, and warmth was applied to his feet. In about an hour, the vertigo became much less, the head was more comfortable, and the face lost its intense pallor; pulse 80. The patient then stated that, four or five weeks before, he had noticed occasional attacks of slight tinnitus in the left ear; this was brought on or increased by cold air blowing on the ear. A week or two afterwards, he observed some dizziness with the noises in the ear, and also some confusion in hearing, especially during the playing of the organ and the singing in church. The patient had had a good musical education, and he stated that he heard all notes sharpened (heightened) in pitch, in the left ear, which, of course, produced subjective discord with what he heard in the other ear. This was also true for the tuning-fork, small "A," which seemed to him higher in pitch in the left or affected ear. As the tinnitus passed off, however, notes appeared once more to have their true pitch.

With the cessation of the tinnitus, and with the return of the ability to hear notes in their true pitch, in the affected ear, the hearing also improved for the watch, rising from in., during the attacks, to 8 in. as the paroxysms ceased. This variation in the ability to hear the watch occurred not only once, but repeatedly; and it was also observed that a mantel-clock, easily heard by the patient across the room in the affected ear, when unattacked by the paroxysms, was not heard during the latter. The left membrana tympani was more retracted than the right. The Eustachian tubes were easily inflatable; the fauces normal. There was a history of some stuffiness in the now affected ear, once after sleeping all night upon the ground, when in the army during the war. But beyond this, the patient knew of nothing out of the way in the ears.

The patient remained in bed four days: On the first day, it was found that rest in a reclining posture relieved the tinnitus and vertigo, but on the second day, a severe attack came on in bed, and lasted several hours. On the third day, an attempt to rise brought back all the symptoms, which were finally relieved by vomiting. On the fourth day, another severe and long attack occurred. On the fifth day, the patient observed that the "stunned feeling" in the left side of the head, alternated with the tinnitus; the latter invariably preceded the attacks of vertigo, beginning as a low and distant singing or ringing, and increasing to a loud roaring, which culminated in the vertigo and nausea. On the sixth day, there was no attack. On the seventh, he felt very much better until 11 A. M., when a severe paroxysm occurred; as a rule the attacks occurred in the afternoon or evening. On the eighth day, there was no attack, but on the ninth there was a light one. Again, on the tenth day, there was no attack, but at midnight of the eleventh, there was a very severe paroxysm of tinnitus and vertigo, which woke the patient up. Closing his eyes had always aggravated the vertigo, and he now found that the darkness of his room greatly increased the dizziness. Being entirely alone, and unable to help himself, he was obliged to call for a light in order to gain some relief from the terrible discomfort brought about by the vertigo. He felt as if his whole body were being borne through space. Usually the apparent motion of surrounding objects, during the attacks, was around the patient from the right, over his

head, to the left, under him and up again-that is, in a circle, the plane of which correspended pretty closely with that of the superior semicircular canal, and about at right angles with the antero-posterior diameter of the head.

The severe attack of vertigo on the eleventh day, extended into the twelfth day, but there was no vomiting. On the thirteenth day, there were two attacks, but no vomiting. On the fourteenth day, there were again two attacks, bat they were light, and there was no vomiting. On the fifteenth day, there was no attack, but on the sixteenth day there was one very light and short paroxysm of tinnitus aurium and vertigo. On the seventeenth day, there was no attack, but on the eighteenth there was a very light one, which was the last the patient had. The hearing now became normal.

Before these seizures came on, the patient had been under intense mental excitement, and his general health had failed from the time of the financial panic of 1873 to the date of his first attack of vertigo. He had also been, in this weakened and nervous condition, obliged by his business to endure the intense and peculiar noise of the stock-brokers' board, and also to strain his ears to hear, and his vocal organs to perform his share of, the bidding which goes on in such places.

The treatment consisted in general support, with the administration of good food and some alcohol, together with large doses of bromide of potassium during the persistence of the paroxysms. As the latter diminished in severity, iron and quinine were given. On the sixth day of the disease, twenty grains of bromide of potassium were given every hour, and this was continued until the tenth day, when the patient took but ten grains every two hours. On the sixteenth day, the bromide was taken every three hours, and kept up in this way until the paroxysms had evidently ceased.

The patient went to Europe, made a short tour, and returned to business in the autumn, about six months after his first attack of vertigo. There has been no severe return; this spring, when he was under considerable excitement once more, he had a slight return of the tinnitus, and a slight tendency to vertigo, but no sickness of stomach. A few days of rest, and from six to eight grains of quinine daily, dissipated all these unpleasant warnings, and the patient has been able to continue his attention to business.

This case of aural vertigo is especially interesting on account of the variable hearing which was so prominent a symptom during the disease, and also on account of the recovery of hearing which ensued when the paroxysms of tinnitus, vertigo, nausea, etc., ceased to recur. In fact, these features of the disease would tend to place it either in the list of those of infrequent occurrence, or among those the true nature of which is not often recognized, and hence undescribed. It is well known that the prominent symptoms of aural vertigo, viz., sudden tinnitus, intense dizziness, alteration in the hearing, nausea, vomiting, and falling, without loss of consciousness, may be caused by the irritation set up by the presence of a foreign body in the external auditory canal. But here the cause is easily recognized and removed, and upon its removal the recovery is complete. The same general symptoms are notoriously characteristic of labyrinthine vertigo (Ménière's disease), but there the deafness is sudden, total, and permanent, though the paroxysms of vertigo may cease

to recur.

I have lately seen two cases of tumor in the brain (the one proven post mortem, the other diagnosed as such, but the patient still living), in which the new growths produced symptoms very, much like those usually attending labyrinthine vertigo. Still, there were points of differential diagnosis in these cases.

The subject of the first, a woman, suffered for many years with most of the distressing symptoms of Ménière's disease, with the exception that she became