[frontispiece] LEARNING TO HEAR EDITH WHETNALL M.S. (Lond.), F.R.C.S. (Eng.) Late Founder and first Director of Nuffield Hearing and Speech Centre, formerly Audiology Unit, Royal National Throat, Nose and Ear Hospital; Late Consultant Aural Surgeon, School Medical Service, London County Council AND D. B. FRY Ph.D. (Lond.) Professor of Experimental Phonetics in the University of London; Consultant in Phonetics, Nuffield Hearing and Speech Centre, Royal National Throat, Nose and Ear Hospital Edited by R. B. NIVEN, M.A., B.M., B.Ch. (Oxon), M.A. (Cape Town), F.R.C.P. (London) WILLIAM HEINEMANN · MEDICAL BOOKS · LIMITED LONDON First Published 1970 © R. B. Niven and D. B. Fry, 1970 S.B.N. 433 23250 Made in Great Britain at the Pitman Press, Bath EDITOR'S PREFACE A child is utterly dependent on the adults near to him, most of all on his mother and father. This is true for every child but most of all for the child with a handicap. The special help needed by the handi capped child cannot start until the disability has been detected. Edith Whetnall was sure that the best means of early detection of deafness was a well-informed public whose suspicions would be aroused by deviations from the normal in a child's development of hearing and speech. With Professor D. B. Fry she had produced a Medical Monograph The Deaf Child which epitomised for professional readers their experience at the Audiology Unit (now the Nuffield Hearing and Speech Centre) of the Royal National Throat, Nose and Ear Hospital. When she died in 1965 she was busy on a book, also with Professor Fry, directed to the intelligent layman and designed to make avail able the fundamental facts about hearing and the way it develops both in the normal and in the deaf or hard-of-hearing child. It was not designed as a manual for the parents of deaf children but it was hoped that the principles set out in it would help them to understand the nature of the handicap and their vital part in overcoming it. As her husband I had found Edith's work with deaf children fascinating to an extent far beyond the natural interest that anyone would take in his wife's profession. I was very keen that her death should not prevent the publication of the projected book and almost immediately started discussions about its completion. In the end I agreed to undertake this myself. Although not professionally involved I had read everything that Edith had written on the subject and had heard her speak about it, both in private and on public platforms. In The Deaf Child Edith Whetnall and Dennis Fry did not indicate which chapters had been contributed by each, although it must be pretty clear to anyone who knows the particular angles from which they approached their common objective. The same anonymity has been followed in this book. Dennis Fry's chapters represent the up-to-date views of an expert in his own field. In the chapters begun by Edith Whetnall and completed by me, I have retained her actual words wherever possible. Where it has been necessary to fill in gaps and provide continuity I have endeavoured to write what I think she would have written herself. The result represents, as nearly as I can make it, the views she held in 1965 after some twenty years of professional, and more than thirty years of personal, experience of deafness in children. No one knows better than I that the chapters vii Vili LEARNING TO HEAR are not what she would have written in 1969. Her mind was never static and her opinions and her mode of presenting them were constantly reviewed in the light of further experience. There is one exception to the anonymity of the chapters. Chapter I is based on Edith's writings and sayings, but it is my own personal account of her work and ideas as I saw them develop. Dennis Fry has kindly read the chapters that I have completed to eliminate any obvious nonsense that I had introduced. I am however entirely responsible for these chapters and crave the reader's indul gence for the degree to which the text falls short of what Edith Whetnall would have produced if she had lived to complete it. We do not apologise for any overlap and repetitions. The theme of the book is a simple one—the necessity for both the normal and the deaf child to learn to use his hearing—to 'learn to hear'. This central theme is looked at from a number of angles and some repetition is inevitable if each chapter is to make sense without too much cross-reference to other chapters. Our gratitude to the authors and publishers who have permitted reproduction of illustrations is acknowledged under the figures. The audiograms were all recorded by staff of the Nuffield Centre or the Audiology Unit. As in The Deaf Child all the photographs were taken by Mr. D. Connolly of the Department of Clinical Photography, Institute of Laryngology and Otology and we are grateful for his patience and skill. Figures IX, 3 (ò), (e) and (d) were specially taken for Learning to Hear and we are grateful to parents and children and also to Miss Pamela Colyer, Administrative Assistant, Nuffield Hearing and Speech Centre, who made all the arrangements for these photographs. It is a pleasure to acknowledge the helpfulness of the publishers and particularly of Dr. Raymond Greene, who encouraged me to undertake a task which I have found enthralling, as well as difficult. I could not have completed it without the active help and encourage ment of my present wife, Anne, who knows how grateful I am to her. ROBERT NIVEN CHAPTER I HOW IT BEGAN The Editor Janette was a normal looking baby. She appeared to develop normally. She sat up at the usual age, crawled at the usual age, started to walk at the usual age. But she did not talk. At first no one worried. After all, one of her brothers had talked late but there was nothing wrong with his speech or hearing now. As the months lengthened into years the family's attempts to reassure itself became less convincing and a dreadful doubt began to grow. Eventually the doubt became so strong that they felt they must settle it. Janette was about three by this time and her mother and aunt took her out for a picnic tea on a heath near their home. The adults sat on the grass and Janette played about. Gradually she wandered off a little way. Then the test began. Her mother and her aunt called out to her, louder and louder, but she took no notice. The only way to attract her attention was to go right up to her. The suspicions had become near certainty and she was taken off to the woman doctor who looked after the family's health. Nothing was said about the suspicion in the minds of the family. The doctor took a long time examining her and then she looked up and asked, "Has it ever occurred to you that Janette might be deaf?" The word had been spoken. The diagnosis had been made and now began the agonising search for treatment. This all happened about 40 years ago when the orthodox method of training the deaf-born was by lip-reading. It was thought that many deaf-born children were totally deaf, 'stone-deaf, with no hearing at all. It was realised that some had a little hearing but if a child did not have enough hearing to learn speech 'spontaneously' it was assumed that the little bit of hearing present was of no use. As a result, any hearing the child had {residual hearing) was ignored in his training. There was a controversy between the advocates of sign language and finger-spelling (the manual method) and the advocates of lip-reading (the oral method). Lip-reading was the orthodox method in this country although signs were also used to a varying extent, sometimes officially and deliberately, sometimes unofficially. Any use of residual hearing was discouraged as likely to distract from the all- important gazing at the lips. Training was almost entirely in the hands of teachers of the deaf. Doctors did little more than make the diagnosis, after which they passed the children on to the teachers. l 2 LEARNING TO HEAR Lip-reading is a laborious method of communication. The child is taught to watch the face of the person talking and to associate the shape of the lips with the meaning of the words. At the same time, he is taught to put his own lips into the right shape to express sounds and words—and not only his lips, the whole complicated apparatus of speech employing tongue, teeth, palate, vocal cords and muscles of respiration. Progress is slow and the final result is often an adult who can communicate only with other deaf people and with a limited number of hearing people. Janette's mother became adept at communicating with her and conversation in the home circle would be interrupted while Mother mouthed messages so that Janette should not feel left out. Janette's first teacher was a retired, but very active, headmistress of a school for the deaf, Miss Blanche Neville. Then she went to various schools for the deaf. Her progress was disappointing and after some years Miss Neville took over again. After this progress was more satisfactory but when I first met her at the age of eleven or twelve, I found it impossible to communicate with her. She could not understand me and I could not understand her. All this time Janette's aunt had been watching from the sidelines, interested in her niece's progress, doing what she could to help from time to time. She was just between schoolgirl and student at the time when Janette's deafness was diagnosed. Soon afterwards, she entered medical school where very early she showed a preference for surgery. Even before she qualified she had decided that she wanted to be an Ear, Nose and Throat surgeon. Undoubtedly, her niece's deafness had something to do with this decision. She had met Janette's teacher, the retired headmistress, who had spoken of the need for more medical interest in the deaf child. First, she must complete her surgical apprenticeship. There was no special examination for Ear, Nose and Throat surgeons in those days. She did a job as House Surgeon to a general surgical firm in the hospital where she had trained and took the Fellowship of the Royal College of Surgeons by an examination in General Surgery. Then she began to specialise in Ear, Nose and Throat surgery, first as Registrar and finally as a Consultant Surgeon. By this time, the war had come and passed and Edith herself had been involved in a bad car accident, for Janette's aunt was the late Edith Whetnall, the originator of this book which is being completed by me, her husband, and by Dennis Fry, collaborator in her pioneer work for deaf children. Had Edith lived to complete the book this chapter could not have been written—medical etiquette and Edith's own reticence would have forbidden it. While she was convalescing from the accident Edith was not idle. I was with her one day when the late Sir Terence Cawthorne came HOW IT BEGAN 3 to visit her in her hospital ward. She was still a Registrar and Cawthorne was one of her chiefs. He was also Consultant Aural Surgeon to the London County Council and its School Medical Service. Edith asked if she might attend his clinics for deaf children at County Hall and this was the first work she did when she became well enough. Children suspected of deafness were referred to these clinics for 'ascertainment', that is, to establish whether or not they were deaf. When deafness was diagnosed a recommendation about education was made. Except for the few families who could afford a private tutor there was in those days only one possible recom mendation—education at a deaf school. Changes, however, had begun and when Edith first began attending Terence Cawthorne's clinics he was busy on the creation of Partially Deaf Units. These were small groups of deaf children under a trained teacher of the deaf but in a school for normally hearing children. The deaf children mixed with the normally hearing children for activities like games and physical education. The aim of the Units was to integrate the deaf children as far as possible with the normally hearing children. Whenever possible the deaf children passed on from the Partially Deaf Units to full membership of the ordinary classes for normally hearing children. As in so may other fields of human endeavour, the results depended largely on the calibre of the staff involved— especially on the teacher of the deaf in the Unit and the head teacher of the hearing school. The end of the war saw many new developments in all sorts of fields. There had been advances in electronics during the war and better hearing aids were being developed. The Royal National Throat, Nose and Ear Hospital decided to start a clinic specially devoted to deaf patients. It was perhaps typical of the mental attitude of those days that it was called the 'Deafness Aid Clinic'. Edith had become an Assistant Surgeon to the Hospital in 1946, and in 1947 she was appointed first Director of the Deafness Aid Clinic. The clinic began in a basement room in the Golden Square branch of the Hospital not far from Regent Street and the underground line between Oxford Circus and Piccadilly. Edith Whetnall did a few sessions a week along with her surgical work and there was one full-time technician. At times the basement flooded and they had to retreat until the floods subsided. A major part of the work of the Deafness Aid Clinic was the fitting of hearing aids to deaf adults and teaching them how to get the most benefit from their aids—'auditory training' or 'auditory rehabilitation'. From the start, however, Edith Whetnall was determined to do something for the deaf person with the most grievous handicap—the deaf-born child. She had now succeeded 4 LEARNING TO HEAR Terence Cawthorne at County Hall as Consultant Aural Surgeon to the School Medical Service. There she had met John Blount, Head master of Rayners School for children who had some other handicap as well as deafness. He was also Inspector of Schools for the Deaf for the L.C.C, and Edith Whetnall had been impressed by the advantages of having his educational point of view on the problems that came up in the ascertainment clinic. She therefore pressed for the appointment of a teacher of the deaf to the Deafness Aid Clinic. She was a persuasive advocate and she had two allies in John Young, House Governor of the Hospital, and Frank Ormerod, Chairman of the Medical Committee and later Professor in the newly formed Institute of Laryngology and Otology. Together they laid the founda tions of what was eventually to become the Nuffield Hearing and Speech Centre. All the hearing aids issued in those days were commercial aids. A year after the start of the Deafness Aid Clinic came the National Health Service and the Government 'Medresco' aid. The clinic was swamped with a rush of applicants for the new 'free' aids and Edith used to look back with thankfulness to the first year of comparative peace when she had a chance to learn from the children she saw. There were fifty-seven the first year. The approach at first was based on the usual assumptions of the time—the severely deaf child could not learn to talk through hearing and any child who had not learnt to talk by the age of two or three would never learn to talk through his hearing. He must be taught through lip-reading. This meant that the diagnosis of deafness was automatically followed by a recom mendation for admission to a school for the deaf as soon as the child reached the appropriate age. It all seemed simple and straightforward. The process of educa tion would be lengthy and complicated and would demand all the dedication and skill possessed by the teachers of the deaf but the decision the otologist had to make about the child's education appeared simple. Then along came some children whose condition challenged the assumptions underlying the decisions. These children had severe hearing losses. Measurements of hearing with an audiometer showed losses as great as those of children in schools for the deaf. The surprising thing was that these children could talk and could understand the speech of others. They were attending schools for normally hearing children and managing to hold their own. It all seemed wrong and the natural response was to think that it could not last. The education of the children might suffer if they stayed on in hearing schools. Was it not the otologist's duty to advise transfer to a school for the deaf? Well, before doing this, one had better make sure how the children were doing in their present hearing environment. The parents might be HOW IT BEGAN 5 biased. What did the teachers think? Reports on educational progress were requested from the schools and were found to be satisfactory. These children—or their parents—had done something that the experts thought was impossible. I have a vivid recollection of Edith coming home with stories of these children and of how interested and excited she was. By this time she had secured the collaboration of Dennis Fry, then Reader, and now Professor of Experimental Phonetics in the University of London. They puzzled over these children together. "Well anyhow," he said, "whether we can explain it or not, we have to accept the fact that it has happened." Sir Geoffrey Jefferson, the brain surgeon, once gave the inaugural address at the beginning of the academic year at the Institute of Laryngology and Otology. He said that people could be divided into two groups by their reaction to a new fact which appeared to contradict all their accepted ideas. The reaction could be "Hell!" or "Well?". The first group were angry at the challenge to their com fortably held ideas. They were no use as research workers ; they would indeed obstruct the research of others. The second group immediately began to think about the meaning of the new fact, how to test if it really was a fact, how to revise the established ideas to fit in with the new fact. Fortunately for the deaf child, Edith Whetnall belonged to the second group and so did Dennis Fry. What could be the explanation of these children who had succeeded without professional help where other children had failed in spite of professional help ? One of the first of these children was G.M. He was five years old when he attended the clinic. He had meningitis when he was twelve months old. One of the complications of meningitis is deafness and G.M. became deaf. At the age of two years he had been given a hearing aid. His audiogram is shown in Figure 1.1. Audiograms will be discussed in more detail in a later chapter but it does not require specialised knowledge to see that G.M.'s audiogram shows a considerable degree of deafness. In spite of this he had good speech and good comprehension of speech. He was at an ordinary school. So ingrained was the idea that deaf children should be in deaf schools that he had been referred to the clinic for advice about continuing in an ordinary school. There was no hesitation in recommending that he should do so but perhaps he was an isolated case ; perhaps the reason why he had done so well was that he had had normal hearing for the first year of life and that his first year's listening to speech had been the basis of his surprising success. Further experience showed that he was not an isolated case. Along came other children with similar stories. Some of these had undoubtedly been born deaf and had not had G.M.'s advantage of a