Otology & Neurotology

39:S30–S42 ß 2018, Otology & Neurotology, Inc.

Assessment of Hearing During the Early Years of

the American Otological Society
Matthew B. Fitzgerald and Robert K. Jackler
Department of Otolaryngology—Head and Neck Surgery, Stanford Ear Institute, Stanford University, Palo Alto, California

Objective: To describe the manner in which hearing was with the distance a watch tick could be heard over the
evaluated in American Otological Practice during the late distance of a normal hearing individual. A variety of devices,
19th and early 20th centuries before introduction of the such as Politzer’s Acoumeter, attempted to deliver sound in
electric audiometer. a calibrated manner, thus enhancing the accuracy and
Methods: Primary sources were the Transactions of the reproducibility of test results.
American Otological Society and American textbooks, espe- Conclusion: The early years of the American Otological
cially those authored by Presidents of the Society. Society were marked by a number of ingenious efforts to
Results: In the era before electric audiometry multiple standardize hearing assessment despite the technical limita-
methods were used for evaluating the thresholds of different tions. These efforts facilitated the development of the
frequencies. Tuning forks were important for lower frequen- audiometer, and continue to influence clinical practice even
cies, whisper, and speech for mid-frequencies, and Galton’s today. Key Words: American Otological Society—
whistle and Konig’s rod evaluated high frequencies. Hearing Hearing assessment—History of otology.
threshold was often recorded as in terms of duration of a
sound, or distance from the source, rather than intensity.
Hearing ability was often recorded a fraction, for example, Otol Neurotol 39:S30–S42, 2018.

The diagnosis and management of hearing disorders of the AOS, however, obtaining an accurate measure of
has a long history, predating the onset of the American hearing was a challenging endeavor, and virtually impos-
Otological Society (AOS) by centuries. For example, sible in many respects. For example, in 1877, Charles
Hippocrates (460–337 BC) is widely regarded as Burnett (AOS President 1884–1885) wrote that ‘‘No
‘‘The Father of Medicine,’’ due to his introduction of precise standard of normal hearing has ever been defined.
key concepts such as the power of observation, the The normal ear hears all sounds that fall on it; but it
importance of the case history, and for developing the cannot be said, a priori, where good hearing patients and
ethical code that underlies many facets of medicine even defective hearing begins, for in many senses these are
today (e.g., the Hippocratic Oath). Less known, however, relative terms (4).’’ Similarly, J. S. Prout (AOS President
was that he was among the first to investigate hearing 1886–1889) noted that accuracy of hearing assessment
disorders (1–3). While his belief that hearing loss was would remain challenging until ‘‘an instrument can be
related to the direction of winds or weather changes have made which shall always produce uniform tones.’’ Until
not held up to modern scrutiny, his reports that hearing the advent of the audiometer, Prout’s comment proved
loss is often associated with tinnitus or skull-based largely prescient. Nonetheless, several methods were
trauma reverberate into today’s medical practice as part used to estimate hearing with remarkable degrees of
of our modern case history. ingenuity; the principles of some of these approaches
Over 2000 years later, the AOS was created, and has underlie clinical practice even today. The purpose of this
played a significant role in the diagnosis and manage- manuscript is to highlight techniques used to assess
ment of hearing disorders over the last 150 years. In hearing before the advent of the audiometer, which
modern otological practice, assessment of hearing is a irrevocably changed hearing assessment for the better
routine and crucial part of patient care. In the early days shortly after entering into widespread use.

Address correspondence and reprint requests to Matthew B.

METHODS
Fitzgerald, Ph.D., Department of Otolaryngology—Head and Neck
Surgery, Stanford Ear Institute, Stanford University, 2452 Watson The primary resource for determining hearing testing in
Court, Suite 1700, Palo Alto, CA 94303; E-mail: [email protected] American Otological Practice during the early years of the
The authors disclose no conflicts of interest. AOS was the Transactions of the AOS over its initial decades
DOI: 10.1097/MAO.0000000000001759 (5). Additional sources include the otology textbooks and paper

S30

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 HEARING TESTING DURING THE EARLY YEARS OF THE AOS S31

authored by the founder generation of the AOS including those the early studies of acoustic phonetics, which began in earnest
of Roosa (5), Blake (6), Buck (7), and Burnett (8) as well as during a similar time frame as to the beginning of the AOS, and
publications by others describing hearing test methods in the were later reiterated by Politzer (13).
late 19th and early 20th century America. Because it was widely understood that the voice can vary
tremendously between different individuals, some physicians
The Voice Test attempted to standardize presentation of speech of these early
In 1887, An AOS Committee on ‘‘The examination of the attempts, the phonograph was perhaps the most widely used. In
power of hearing’’ chaired by H. Knapp concluded that: ‘‘The 1904, Bentley proposed, ‘‘Instead of employing directly the
human voice is generally acknowledged to be the most impor- voice of the investigator, and instead of relying upon acoustic
tant test of hearing (9).’’ This statement is consistent with the and organic conditions which vary from experimenter to exper-
idea that perhaps the most common measurement of hearing imenter and from place to place, it proposes to use permanent
used in the first 25 years of the AOS was the ‘‘voice test’’ or the phonographic records, which can be copied an indefinite num-
‘‘whisper test,’’ in which the human voice is used to infer the ber of times and can be reproduced independently of local
hearing status of the patient. Variants of this test are used in conditions (14).’’ Similarly, in 1890 Fiske noted, ‘‘to sum up
current audiologic practice with measurement of the speech briefly we need a method of testing the hearing which shall 1,
reception threshold, which is widely used to cross-check pure- make use of human speech; 2, which shall be accurate and
tone thresholds. Remarkably, the implementation of ‘‘the voice independent of the examiner; 3, which shall make a record
test’’ changed little during the early years of the AOS. In 1869, capable of interpretation and use by other aurists (15).’’ Fiske
Anton von Troltsch recommended, ‘‘. . .you must make a closer proposed using the ‘‘phonometer’’ developed by Lucae which
examination, by testing the power of hearing the voice and would enable a recording of the assessment; this would allow
conversation. While one ear is being examined to this, the other for a record of each appointment, which could then be shared
should be closed by the finger of the patient, and you should with other physicians as needed. Ultimately, however, the cost
speak slowly and distinctly, at first in a whisper. . . You must of the device, and difficulties with reliability meant that wide-
guard against deception, by seeing that the patient does not spread use of the phonometer never occurred. The principles of
practice the habit of watching the mouth of the speaker... thus standardized speech materials, presentation levels, and record-
you will often be informed by a patient. . . that he hears much ing of the responses, however, reverberate through audiologic
worse by twilight and at night in bed, than when it is light practice even today.
around him (10).’’ In 1882, Winslow recommended, ‘‘It is best
to stand a few feet away from the patient upon the side of the ear The Watch Test
to be tested, so that he cannot see the lips move, then ask him In addition to the voice test, one of the most widely used
questions in a low voice. If he cannot hear, address him in a measures of hearing assessment during the early years of the AOS
medium tone, and if he is still unable to hear what is said, raise was the ‘‘watch test’’ (Fig. 1 (16)). Indeed, it was often stated that,
the voice to even a shout if necessary. There are varying degrees ‘‘Thus far, the ticking of the watch has been found to afford the
of hearing for each tone, but low, medium, and high will be
sufficiently exact for all practical purposes (11).’’ Thirty years
later, Barr provided a similar set of instructions, ‘‘The patient
and physician stand at opposite ends of the room, the ear to be
examined turned towards the physician. The opposite ear is
closed firmly by a finger to the meatus. Standing thus sideways
to the physician, the patient cannot see his lips, and the element
of lip-reading is eliminated. The physician now repeats the
words or numbers which he chooses to employ, the patient
having been instructed to repeat after him. If the patient cannot
hear, or hesitates, or calls the word out incorrectly, the physician
at once moves nearer and repeats the experiment, but using
different words, but those having as nearly as possible the same
sound values. The distance between patient and physician is
thus reduced until one is reached at which the words are
repeated promptly and correctly (12).’’ The same author noted
that differences in pitch, timbre, volume, etc., of different
voices make it impossible to determine an exact level of
hearing, but reported consensus that conversational speech
can be heard at 60 to 70 feet.
Also noteworthy during this time was the awareness that
some speech sounds may be audible, while others are inaudible.
This point was illustrated in 1877 by Burnett, who articulated,
‘‘The distance at which separate vowels can be heard has not yet
been established, but they are endowed with the greatest
strength of tone, being heard and understood at a distance at
which all the consonants are inaudible (4).’’ In his manual,
Burnett subsequently provided distances at which various con-
sonants could be heard, noting that ‘‘H is the weakest of all FIG. 1. A specialized watch for use in hearing testing from Bing
consonants when not followed by a vowel. It is lost at a distance 1890 (16). Hearing ability was recorded as the distance at which
of a few paces. . .. Next in strength is B, Ba being heard further the watch tick could be heard. Note the attached tape measure
than Ha (4),’’ and so on. Such comments are similar in spirit to used for this purpose.

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S32 M. B. FITZGERALD AND R. K. JACKLER

FIG. 2. Table of hearing ability from Roosa 1885 (18) for watch tick compared with spoken voice both expressed in terms of distance from
the sound source. The fraction 4/40 refers to perception of the watch tick in inches from the ear (4) over the distance with which a tick was
heard for a normal ear (40).

best practical means of testing the capacity of the ear for dis- During the early years of the AOS, several recommendations
tinguishing delicate sounds (7).’’ The basic premise of this were given to physicians to increase the accuracy of their
approach was to determine whether a patient could detect the measures or the diagnostic power of the watch test. For example,
ticking of a watch, and if so, then to determine the distance at it was generally accepted that ‘‘the distance at which the watch
which the patient could no longer hear the watch. A detailed and used is heard by the normal ear should be known by the examiner
widely cited utilization of this approach was described in 1872 by (11).’’ Internal consistency in the testing approach was also
Prout (17) (Fig. 2 (18)). In his report, he recommended the use of reported to be a key step, as ‘‘it makes considerable difference
distance to estimate hearing acuity in much the same manner as whether one hangs the watch by the finger, or holds it in the palm
the Snellen chart is used in the visual system. In his system, of the hand with the whole hand as a resonator (11).’’ The watch
hearing acuity was recorded as a fraction. ‘‘The numerator of was also used to assess hearing via bone conduction, ‘‘The watch
which is the distance at which the particular sound is heard, the may be placed on the vertex or the forehead to determine roughly
denominator the distance at which it should be heard by an ear of the condition of the middle ear and auditory nerve. . . If the watch
good average hearing power. This denominator must vary is not heard when applied thus, it is pretty sure evidence that there
according to the sonofactor used, and should generally be is disease of the labyrinth or nerve (11).’’ Finally, use of a
expressed in inches (17).’’ Thus, 12/36 would indicate that the stopwatch was widely recommended as well; the rationale behind
ticking of a watch was heard at 12 inches, when it should have this recommendation was that with a stopwatch, the ticking can
been heard at 36 inches. According to Prout, one advantage of be stopped or started, and in this way false positives (e.g.,
using fractional distances was its potential applicability to any reporting hearing the watch when no ticking is present). In other
signal, whether a watch or a whispered voice. In retrospect, it is words, use of the stop watch was a ‘‘means of finding out whether
interesting to consider the use of distance to assess hearing acuity the patient really hears the sound of the watch, or whether he
given that the American Otological Society initially began as an thinks he does because he knows a watch is being held before his
offshoot of the American Ophthalmological Society (see Jackler ear.’’ This approach was reported to be particularly useful with
et al., elsewhere in this issue), and visual acuity as a function of children who ‘‘as a rule, give erroneous statements as to their
distance is a key aspect of the testing of vision. ability to hear a watch (11).’’

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 HEARING TESTING DURING THE EARLY YEARS OF THE AOS S33

While the watch was widely used, its limitations were

evident from the beginning. First and foremost, watches regu-
larly differed with regard to the intensity and pitch of the
ticking; for obvious reasons, this meant that the replicability
of hearing tests across institutions was virtually nonexistent.
Such concerns were articulated effectively by Albert Buck
(AOS President 1879–80) in 1880. ‘‘If measurements of the
hearing distance could be universally made with some standard
source of fixed intensity, the necessity for recording our meas-
urements in fractions (Prout’s method) would be done away
with; it would be sufficient to merely state the actual distance
measured, and every physician who was familiar with such tests
would appreciate at once the degree of impairment of the
hearing reported (7).’’ Another significant limitation was the
relationship between hearing a watch and the ability of the
patient to communicate with others. Such concerns were noted
as early as 1853, ‘‘The degree of hearing with a watch is
sometimes deceptive; some patients who cannot hear a watch, FIG. 3. Politzer’s Acoumeter from Love 1904 (22). Sound was
or even a clock, will hear the voice even in a low tone (19).’’ generated by a small mallet struck by a metal rod with calibrated
Such concerns were repeatedly articulated in different text- force not as readily obtained with tuning forks. An attached metal
disk was used for bone conduction.
books of Otology, ‘‘The watch alone does not afford a sufficient
means of determining the amount of hearing examined, because
the distance at which it can be heard does not always stand in
proper proportion to the power of understanding conversation beginning stages of the AOS (Figs. 3 and 4) (11,22). One
(11).’’ Nonetheless, use of the watch to assess hearing status key advancement of Politzer’s acoumeter was that it was
continued until widespread adoption of the audiometer too hand-held between the middle finger and the thumb.
place. For example, more than 50 years later, general guidelines
were provided to physicians as to its use, ‘‘Naturally, this sound
When the middle finger was depressed, it would raise
(the watch tick) varies considerably in intensity with the size, a small mallet; when released, the mallet would fall to
form, thickness of covers, etc. of different watches. Taking, strike a small iron cylinder. The primary advantage of
however, a man’s watch of average size, its tick will be heard by this approach was that the mallet was always dropped at a
the normal ear of a young adult. . . at a distance of 40 to 50 constant height, unlike the aforementioned devices in
inches. . . As age advances, the hearing distance for the watch is which the height was generally estimated. Hearing was
gradually diminished. . . (20).’’ then measured at known distances at which individuals
with normal hearing could detect the sound of the mallet.
POLITZER’S ACOUMETER This provided for a more consistent measure of hearing
assessment than the widely used ‘‘watch test.’’ A key
As noted by Buck and many others, there was an advantage of Politzer’s acoumeter was that, by attaching
understanding that accurate assessment of hearing would a small metal disk to the acoumeter, bone-conduction
require a signal of a given intensity which could be hearing could also be measured using this device.
reliably delivered. Early attempts in this regard were
often classified as ‘‘Mechanical Acuity Meters.’’ Among
the earliest of such devices was reported by Wolke in
1802. His device was comprised of a pendulum-like
hammer that could be dropped onto a wooden board
approximately 1.5 m high. The height of the pendulum
swing could be varied, and by doing so, different inten-
sities of sound could be produced. This sort of device was
improved upon approximately 20 years later by Itard with
the development of the ‘‘accumeter (21).’’ In this device,
a ring of copper was used as the sound source; the ring
was suspended by a string, and struck by a ball at the end
of a pendulum. The strength of the strike, and thus the
intensity of the signal, depended on the height from
which the ball was dropped. This instrument was widely
used in the early half of the 1800s, as Itard was the
Director of the Paris Institute for the Deaf. [See Feld-
man’s History of Audiology for a more detailed summary
of these early mechanical acuity meters (1)].
The most well known and widely used of these devices
was the acoumeter developed by the legendary otolaryn- FIG. 4. Illustration of Politzer’s Acoumeter in use for bone con-
gologist Adam Politzer of Vienna in 1877 during the duction from Winslow 1882 (11).

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S34 M. B. FITZGERALD AND R. K. JACKLER

While Politzer’s acoumeter resolved some of the tick; this will take the place of the Politzer acoumeter,
concerns surrounding hearing testing at the time, it also which can be discarded (12).’’
presented with a number of limitations. For example, as
with the watch test, the relationship between hearing TUNING FORKS
acuity measured with the acoumeter and the ability to
understand speech was poorly understood at best. More The use of tuning forks to evaluate hearing began early
problematic for some physicians was the fact that early in the 19th century (23–25) They were originally devel-
acoumeters were ‘‘being nothing more than loud watches oped to assist in tuning musical instruments. By the late
(1),’’ and Politzer’s acoumeter was plagued by a similar 19th century, they their use had become routine, but not
issue. Politzer himself noted that ‘‘The acuteness of necessarily universal. In an 1887 position statement in
hearing for the acoumeter, or for the watch, frequently the AOS Transactions titled ‘‘The examination of the
shows marked differences. . .’’ with an average normal power of hearing, and how to record its results’’ opined
hearing distance for Politzer’s acoumeter being 15 m that tuning forks should be part of the standard hearing
(13). Ultimately though, the factors that may have hin- evaluation: ‘‘They should, in every case of impairment of
dered greater acceptance of Politzer’s acoumeter were hearing, be used as regularly as the watch and voice tests.
described succinctly by Buck in 1880, ‘‘Politzer’s idea in (9)’’ By contrast, in his 1880 textbook, Buck in his
producing the ‘‘acoumeter’’ undoubtedly was to furnish chapter on ‘‘Test of the Hearing-Power’’ did not even
a standard test of hearing. Unfortunately, in its present mention tuning forks, emphasizing instead perception of
shape this instrument costs too much, is likely to get out the spoken voice and watch ticking (7).
of order too easily, and cannot be manipulated with There was a wide diversity of tuning fork design
comfort (7).’’ Others held similar views, which persisted (Fig. 5 (22)). Typically, forks were available in C-tones
for over 30 years, ‘‘Use the stop watch with a fairly sharp one octave apart: 64, 128, 265, 1024, and 2048 Hertz. To

FIG. 5. A collection of tuning forks and whistles used in clinical otology from Love 1904 (22).

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 HEARING TESTING DURING THE EARLY YEARS OF THE AOS S35

FIG. 7. Tuning fork with resonating chamber from Gruber 1890 to

enhance audibility for those with severe hearing losses (26).

1881, DB St. John Roosa (AOS President 1874–76)

FIG. 6. Modified tuning forks from Burnett 1877 (4). The Blake
modified tuning fork had an attached hammer in an effort to explained the use of the Rinne test: ‘‘If the vibrating
calibrate the strike force. The adjustable weights at the end of tuning-fork be heard better on the mastoid than when
the tuning fork served two purposes: dampening overtones and placed in front of the meatus, there is disease predomi-
adjusting the pitch of the fork’s ring. nantly of the middle ear (28).’’ Roosa also explained the
Weber test: ‘‘If one ear be normal as to the hearing
power, and the other abnormal, and a vibrating tuning-
mitigate the potential for excessive strike force to gener- fork ‘‘C’’ be placed upon the vertex or the teeth, if its
ate overtones, some had small attached hammers to help sound be intensified in the ear whose hearing power is
calibrate the amount of force to the tine. Burnett in 1877 diminished, there is disease of the external or middle ear,
lauded: ‘‘A very beautiful instrument is the tuning fork but no lesion of the labyrinth or nerve (28).’’
devised by Dr. C. J. Blake, in which the force setting in Other tuning fork tests were developed to discriminate
vibration is obtained by means of a steel hammer padded sensory from conductive losses. In the Bing test, a tuning
with rubber. The handle of the hammer is adjustable at fork is placed on the mastoid and when it is no longer
any point along its length, but which means the blow can
be weakened or strengthened s desired (4)’’ (Fig. 6 (4)).
Charles H. Burnett was AOS President 1884–5 while
Blake served in this role 1877–78. Other tuning fork
designs had clamps attached to dampen overtones, but
these tended to shorten the vibration period. Forks with
an attached weight which could be slid along the tine
allowed tests multiple frequencies without the need to
carry a large supply of individual frequency forks. Others
had resonating chambers to enhance the sound
for patients with severe losses (Fig. 7 (26)). Tuning
forks with a rubber tube attached were facilitated com-
parison of the physician’s hearing with that of the patient
(Fig. 8 (27)).
Today only two tests introduced in the mid-19th
century, Weber (1845) and Rinne (1855), remain in
widespread use. Over 20 different tests were in use during
the late 19th and early 20th centuries before the intro-
duction of the electric audiometer. In 1887, Knapp and
his co-authors emphasized the central importance of the FIG. 8. Tuning fork with a listening tube by Hovell 1894 allowing
Rinne test: ‘‘Rinne’s method, gentlemen, is the most comparison of the examiner’s perception with the patient’s during
expeditious and practically the most important (9).’’ In bone conduction testing (27).

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S36 M. B. FITZGERALD AND R. K. JACKLER

heard the patient’s meatus is occluded with a finger. In whether the patient hears the fork or feels the jar transmit-
sensory losses, perception of the tone returned whereas in ted to the head. Some patients can differentiate between
conductive losses it did not. The Gelle Test was intended the two sensations, while others admit that they cannot be
to evaluate severe hearing loss for stapes fixation. With sure whether they feel the vibrations or hear the sound
the fork on the mastoid compressed air was delivered to (31).’’ In 1887, Theobold noted regarding the Weber test:
the ear canal via a Politzer bag. If the stapes was mobile, ‘‘It is by no means an uncommon experience with me,
it was compressed inward thus diminishing hearing. If when testing with the tuning-fork, that when I place it on
fixed, the added pressure did not alter hearing. the vertex it is heard louder, we will say, in the right ear.
While tuning forks are now used principally to discern Then I will strike it again and place it on the forehead, and it
sensory from conductive loss, in the 19th century they will be heard louder in the left ear. This observation has
were also a primary means of assessing hearing ability at given me less confidence in the tuning-fork as a differen-
different frequencies. Use of the tuning fork for threshold tial test between middle ear and labyrinthine troubles than I
testing is somewhat of a lost art today. For threshold before had (9).’’ Regarding the Rinne test, the nomencla-
testing, tuning forks were especially important for the ture that designates a negative test to be abnormal and a
lower frequencies, speech for the mid-frequencies, while positive test normal has been a source of confusion since
Galton’s whistle and Konig’s rod evaluated the high the test was first described. Many contemporary otologists
frequencies (6). In Schwabach’s Test the duration by use the terms AC > BC (air conduction > bone conduc-
which the tuning fork is heard when applied to the cranial tion) or BC > AC to avoid confusion. In his 1902 contri-
bones and compared with the duration of a patient of bution titled ‘‘Sources of error in functional tests of
similar age with normal hearing. Measuring the duration hearing’’ A.H. Andrews descried: ‘‘In the Schwabach test
of hearing with a variety of tuning forks, struck in a there are two objections to forks which can be heard longer
consistent manner, could provide an estimate of threshold that the time mentioned: 1. In making repeated tests in
not dissimilar to an audiogram (Fig. 9 (29)). Criticism of order to secure accuracy, much valuable time is lost
the Schwabach test was that it was laborious and time waiting for the fork to run down. 2. Repeated tests with
consuming and required repetition at each frequency to forks which vibrate along time are apt to wear out the
enhance accuracy. An early form of audiometer consisted patient’s attention, so that after a few trials his replies are
of a rotating turret of tuning forks of various frequencies found to be uncertain (31).’’
struck in a calibrated manner with a hammer connected to In the 21st century, tuning forks are hardly a quaint
a stop watch (30). The tuning fork audiometer charted the anachronism and remain relevant in contemporary onto-
number of seconds perceived at each frequency. logical practice. Their use is both art and science, with
An awareness that the diagnostic reliability of tuning results varying, and the clinician needs to exercise judge-
forks is imperfect was recognized in the 19th century. ment in interpreting results. In today’s practice, tuning
Striking the fork with an excessive force results in over- forks are an important check of the audiogram in cases of
tones at higher frequencies that intended (31). The diffi- apparent conductive losses. Insufficient masking can
culty in assessing one conduction at low frequencies due to make a deaf ear appear to have a conductive hearing
vibrotactile perception was understood: ‘‘In testing bone loss, with the potential for misdiagnosis leading to
conduction for lower tones, it is difficult to determine improper therapeutic intervention. Use of the Rinné
and Weber tests can clarify this situation. James Sheehy
(1926–2006) of the House Group routinely inquired of
his neurotology fellows about whether or not they com-
pleted the ‘‘DFTF test.’’ New fellows soon became
initiated in his meaning: ‘‘don’t forget tuning forks.’’

OTHER METHODS FOR ASSESSING TONAL

HEARING: THE GALTON WHISTLE, KONIG
RODS, AND SCHULZ’S MONOCHORD

One widely known limitation of hearing assessment in

the 19th century was the inability to reliably test hearing
for higher frequencies. The importance of the use of high-
frequency tonal stimuli was articulated clearly by Blake in
1879, when he wrote ‘‘that the upper limit of audibility of
high musical tones by the normal ear being taken as the
standard, any considerable deviation from this standard,
within certain limits, may be taken as evidence of an
abnormal condition – a. of the sound-transmitting appa-
FIG. 9. An ‘‘audiogram’’ from Bezold 1908 created by charting
ratus of the middle ear; b. of the sound-transmitting
the duration which the patient heard a tuning fork as its vibrations structures of the labyrinth; c. of the auditory nerve and
abated (29). the ultimate organ of perception (6).’’ To address the

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 HEARING TESTING DURING THE EARLY YEARS OF THE AOS S37

FIG. 11. Koning’s rod used in testing high frequencies from

Burnett 1877 (4). Intensity was determined by the height to which
the ball bearing was lifted before release.

frequency hearing sensitivity (Fig. 11 (4)). The Konig

FIG. 10. Galton whistle from Bruhl 1906 produced a variety of
high pitched sounds by varying its aperture. rods consisted of steel cylinders suspended by cords that
produced high-frequency tones when struck by a small
hammer. While similar in their use to Galton’s whistle,
limitation of tools for assessing high-frequency hearing, they differed in some key respects. For example, ‘‘the
Sir Frances Galton (1822–1911) invented the ‘‘Galton intensity of the tone of a Konig’s rod diminishes regularly
Whistle’’ in 1876 (Fig. 10). This device consists of a small from the moment that it is set in vibration, while the
whistle, which has an obturator controlled by a slider. By intensity of the tone of the whistle evidently can be
varying the aperture, the frequency produced by the maintained. The auditory impression produced by the
whistle can be varied. Some variants of the Galton Whistle latter is therefore proportionately greater, and of two
produced sounds ranging from 5 to 42 kHz. Galton suc- tones of the same pitch, sounded at the same distance, by
cessfully used this device to estimate the hearing acuity in Konig’s rod and a whistle, the latter will be more
both humans and animals; much of this work is described distinctly heard (6).’’ While Blake favored the use of
in his 1883 book, ‘‘Inquiries into Human Faculty and Its the Konig rods, they ultimately fell out of favor because
Development.’’ Most notably, through the use of this of the factors described above, leading some to conclude
device, Galton estimated that the upper limit of normal that they ‘‘provide notes of constant pitch, but with
human hearing was approximately 18 kHz, and that the variable intensity. They are inconvenient, and not of
ability to hear high frequencies deteriorated with age. general utility (32).’’
Thus, Galton’s research provided some of the earliest Schulz’ monochord was another tool developed to
characterization of presbycusis in humans. After the audi- deliver high-frequency tonal stimuli to the patient, and
ometer entered widespread use in the 20th century, Gal- to determine the highest frequency that could be heard by
ton’s whistle continued to be used to assess hearing in a given individual. This consisted of a metal wire akin to
animals. Notably, use of this device continues even today, those used in string instruments. When vibrated, the
but is widely referred to as the ‘‘dog whistle.’’ string would elicit a high-frequency tone, and the patient
Konig’s rods were similar in principle to tuning forks, would indicate whether the tone was heard. The mono-
and like the Galton whistle, were used to assess high- chord was not as widely adopted, but its adherents noted

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S38 M. B. FITZGERALD AND R. K. JACKLER

physicians noted limitations of this device, ‘‘In my

experience this apparatus has proved useful, but it has
seemed sometimes to so confuse the individual as to
prevent an accurate test of the ear under examination, the
ear hearing both the noise machine and the fork or voice,
as the case may be, but both with less accuracy (12).’’
Such comments are interesting as they reflect the expe-
riences of many modern-day audiologists, either with
regard to over-masking, or with ‘‘central masking’’ (e.g.,
decrease in ipsilateral hearing threshold when the noise is
presented to the contralateral ear, presumably due to a
central mechanism).

TESTING OF CHILDREN

With the limited (by today’s standards) tools for

hearing assessment, it is perhaps no surprise that even
fewer options were available for ‘‘hard-to-test’’ popula-
tions such as children. For example, the limited reports on
FIG. 12. Barany noise apparatus also known as Barany noise hearing assessment in children generally noted that chil-
Box from Gorham Bacon (AOS President 1891–4) 1918 (33). The dren are often unreliable in their responses, and that
device, still in use today in many centers, is used to mask the better
ear in unilateral or asymmetrical hearing loss. caution should be taken when assessing hearing in this
population. Representative comments are found in the
chapter from Barr, who stated that, ‘‘we contend with two
some advantages over the Galton Whistle or Konig’s principal difficulties: the unwillingness or the inability of
Rods. Notably, ‘‘the limits (of high-frequency hearing) the child to answer correctly... The little patients tire
when tested by the whistle is lower. . . a finding which easily. . . Prolonged examinations of children under
may be due to the whistle giving less intensity of sound at 10 years are apt to be unsatisfactory. . . Many children
these high pitches (32).’’ cannot be accurately tested until the third or fourth year in
school. . . (12).’’
EARLY ATTEMPTS AT MASKING: THE One unique report during the early years of the AOS,
BARANY NOISE BOX however, came from Harold Walker in 1907 (34). He
reported data on 289 children who were tested in their
Another widely known constraint on hearing assess- school in a quiet room. The session began with examin-
ment in the early years of the AOS was the inability to ing the eardrum, nose and throat. Then, ‘‘the hearing was
reliably test hearing in one ear without the contralateral tested by a whispered voice which could be heard by the
ear contributing in some capacity. Most attempts average normal ear at a distance of twenty-five feet, and a
involved closure of the contralateral ear canal by some spoken voice with thirty-five feet as the normal limit.
means; basic forms of plugging the ear were widely used Numbers from one to one hundred, words, and short
in the various voice tests. However, it was clear that such sentences were used, and the distance at which the child
approaches were likely insufficient to achieve their could repeat what was heard was recorded (34).’’ Prout’s
desired goal, particularly when trying to identify or rule ratio approach was then used to determine the hearing
out unilateral deafness. Thus, in 1908, Barany introduced ratio, and these results were compared with the presence
his ‘‘noise box’’ or ‘‘noise apparatus,’’ as it became of adenoids, abnormal otoscopic results, and ‘‘the gen-
widely known (Fig. 12 (33)). To use this device, it would eral facial expression.’’ Using this technique, 2/3 of
first be wound up similar to that of a watch. It was then children were reported to have normal hearing, with
inserted into the ear to be masked, and when turned on, 23% having ‘‘hypertrophied turbinates,’’ 21% showing
would create a loud buzzing sound while the examiner ‘‘chronic supparation of the middle ear,’’ and so on.
speaks or shouts into the contralateral ear. If the patient Finally, he reported what may be perhaps the first
failed to respond, the ear was considered ‘‘Barany deaf.’’ relationship between hearing acuity and academic per-
Around this time, other approaches were developed with formance, as ‘‘of the pupils marked with the grade of
the intent of achieving the same goal as described in ‘excellent’ 17% showed diminished hearing. Of those
Feldman’s History of Audiology (1). For example, Voss marked ‘good’, 20% showed diminished hearing. Of
blew compressed air into the ear to be masked (1908– those marked ‘fair’ 30% showed diminished hearing.
1909), while Luc advocated caloric irrigation (1910). Of those marked ‘poor’ 42% showed diminished
Lucae (1908) and Davidson (1910) both attempted to hearing. . . (34).’’ Such work was prescient in many
mask one ear through use of an electrical vibrator. regards, as the relationship between untreated hearing
Nonetheless, the Barany noise box was likely the most loss and decreased academic outcomes has been repli-
widely used of these approaches, although some cated on numerous occasions.

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 HEARING TESTING DURING THE EARLY YEARS OF THE AOS S39

TESTS TO DETECT MALINGERERS 1914. This audiometer was the Western Electric 1A,
which was limited by its size and prohibitive price.
Malingering was well known and tests were devised to However, it was followed closely by the Western Electric
reveal it. According to Kerrison in 1922: ‘‘Pretended 2A in 1923, which was considerably smaller and
deafness is said to be comparatively common in countries designed for clinical use. This device rapidly gained
where army service is compulsory (20).’’ He went on to acceptance by many otologists. The history of these
remark that: ‘‘In America it is met with chiefly in the case audiometers, and their predecessors were described in
of imposters seeking indemnity on account of pretended great detail by CC Bunch in 1941 (38), and by Feldmann
injury to one or both ears (20).’’ Regarding the identifi- in 1970 (1), and will not be discussed in greater
cation of malingerers, several approaches were used, detail here.
some of which continue to be used today in various Of historical interest are the thoughts of some AOS
forms. Among the first tests, and one that continues to members during the advent of the audiometer. For exam-
be widely used is the Stenger test. This test is based on the ple, in 1930, Keeler stated, ‘‘The greatest value of the
Stenger principle, which stipulates that when a signal of audiometer is the possibility of a uniform standard of
two intensities is presented to two ears of similar hearing, measuring hearing loss which it presents. At present,
the patient will only report hearing in the ear that receives every otologist has his own method of testing, and of
the more intense signal. This test can be performed with estimating the loss of hearing in the subjects of aural
two tuning forks held at the same distance from each ear. impairment whom he examines. There is no uniform
In the case of feigned unilateral deafness, as one tuning standard, and the examiner in California whose patient
fork is brought closer to the ‘‘impaired’’ ear, the malin- travels to New York cannot send his records to his
gerer will report hearing nothing. However, given that the colleague on the Atlantic coast into whose hands the
other tuning fork has not moved, and remains audible, the patient goes, with any certainty that they will coincide
physician can then determine that the patient is malin- with the records and standards of the New York otologist
gering. Feigned bilateral deafness was reported to be (39).’’ Similarly, when describing the existing test bat-
more challenging to identify however, with sample tery (e.g., voice, watch, and tuning forks), Clarke noted
approaches being ‘‘to wake the patient from his sleep that ‘‘these tests form the backbone of our functional
by a moderately loud call (13)’’ or ‘‘by making dispar- diagnosis, and I believe that the lack of otological
aging remarks about him in the presence of a third party, progress in the last thirty years is largely due to their
one may be able to determine by changes in his facial inherent inaccuracy (32).’’ Ultimately, the development
expression his ability to hear the conversational voice. and widespread adoption of the audiometer led to a
Usually, however, the pretense of complete bilateral significant change in hearing assessment, and virtually
deafness is too difficult to maintain. . . (35).’’ obviated the previous forms of hearing assessment other
than tuning forks.
THE ADVENT OF THE AUDIOMETER
EARLY ATTEMPTS TO PLOT HEARING—AND
Perhaps the most significant development in the WHY IS THE AUDIOGRAM UPSIDE DOWN?
assessment of hearing was the audiometer. This device
not only revolutionized hearing assessment, but the In modern otology practice, the audiogram is virtually
practice of Otology, and paved the way for the birth ubiquitous. However, in the early years of the AOS,
of Audiology to come in subsequent years. Shortly after attempts to plot hearing ability varied tremendously
Alexander Graham Bell invented the telephone in 1876, depending on the approach utilized. For example, in
the electric audiometer began to be developed, and these 1885, Dr. Hartmann created the ‘‘Auditory Chart’’ to
efforts were led by A. Hartmann and D.E. Hughes. In record results from tuning-fork testing. This chart indi-
1878, Hartmann developed an instrument for hearing cated the length of time that a given tuning fork could be
assessment in which electric current was used to vibrate heard; seven tuning forks ranging from 64 to 4096 Hz
a tuning fork, and the resulting signal was then passed were included in this graph. To facilitate interpretation,
through a telephone receiver (36). In 1879, Hughes Hartmann even provided ‘‘norms’’ for the duration that
developed what he termed an ‘‘electric sonometer,’’ each tuning fork could be heard via air and bone con-
which also used electric current to vibrate a tuning fork. duction (1). Similar tables existed to report hearing for
In his device, the electric current could be increased or the voice, or the watch tick. Hartmann’s normative data
decreased by sliding a movable induction coil, and by this for tuning forks were eventually called into question.
process hearing acuity could be assessed (37). Both Nonetheless, the desire to have true normative data for
devices were limited, however, by several factors, includ- hearing persisted, and eventually led to the creation of
ing that ‘‘Different fundamental tones can be secured the audiogram.
only by installing forks of different pitch. This tends to While the history of the audiogram itself extends far
make the apparatus complicated, unstable, cumbersome, beyond the first sesquicentennial of the AOS, it may be of
and difficult to standardize (38).’’ These attempts were interest for the AOS members to know why the audio-
followed by several others until the first commercially gram is plotted ‘‘upside down,’’ with regard to hearing
available audiometer was patented in the United States in thresholds. A more detailed accounting of how this came

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S40 M. B. FITZGERALD AND R. K. JACKLER

to pass was provided by Dr. James Jerger in 2013 (40), become accustomed. Eventually, the concept of sensa-
and is well worth reading. An abridged version of his tion units was modified to a decibel notation, which was
article is as follows. later converted to the ‘‘dB HL’’ (Hearing Level in dB)
Dr. Edmund Fowler (AOS President 1930), a legend- that we know today, and the audiogram has since
ary otologist from the first half of the 20th century, came remained unchanged for decades.
to work closely with Dr. Harvey Fletcher and RL Wegel. Dr. Jerger wisely notes that either Fowler’s original
Fletcher was one of the early pioneers in the field of suggestion of ‘‘percentage loss’’ as a function of fre-
speech and hearing sciences, while Wegel was a physicist quency, or Fletcher’s revision which plotted intensity for
who worked predominately with telephones. Fletcher and hearing threshold in a conventional manner (e.g., more
Wegel designed the first commercially available audi- intense signals at the top of the graph) would be prefera-
ometer in the United States, the Western Electric Model ble to the current plotting of the audiogram. First and
1-A; this device was subsequently used in the practice of perhaps most important, both would preserve traditional
Dr. Fowler. The question then became how to represent plotting of data in which larger values are at the top of the
the data obtained from the audiometer. graph, and smaller values at the bottom. Moreover,
In 1922, Wegel (41) published research demonstrating Fowler’s ‘‘percentage loss’’ approach has great counsel-
the range between audibility and the sensation of ‘‘feel- ing utility for the layperson, while the plotting of SPL as a
ing.’’ From data of this sort, Fowler derived that, when function of frequency would align hearing thresholds
intensity was plotted in a logarithmic manner, hearing with procedures for fitting hearing aids. The latter
could be plotted in terms of ‘‘sensation units’’ relative to approach would also have counseling benefits during
normal hearing. In this manner, for each frequency the the fitting process itself, as it would help both audiolo-
number of ‘‘sensation units’’ could be determined. Then, gists and patients avoid the ‘‘mental gymnastics’’ some-
based on the intensity required to obtain the threshold of times necessary to convert from the existing dB HL graph
audibility, one could determine the percentage loss of to a traditional plot of sound pressure as a function of
sensation units. Thus, this approach gave the physician frequency. Given its ubiquity of the audiogram in today’s
and the patient the ‘‘percentage of hearing remaining’’ at practice, it is highly unlikely to ever be changed, but it is
a given frequency. Notably, early attempts to plot this interesting to consider the possibilities had different
graphically had 100% at the top, and 0% at the bottom; in decisions been made by Fowler and Fletcher over
other words, better hearing was depicted at the top, and 80 years ago.
worse hearing at the bottom of the graph, akin to what we
see in today’s audiogram. Fowler favored such an DISCUSSION
approach, as he thought that a percentage of remaining
hearing at a given frequency made for an excellent Mark Twain was a contemporary of many of the early
counseling tool with patients. Based on comments from AOS members, and in a letter to Helen Keller, he wrote,
patients even today who ask questions such as ‘‘What ‘‘. . .all ideas are second-hand. . .’’ In his own autobiog-
percentage of hearing loss do I have?’’, many audiolo- raphy, he expanded on this concept stating, ‘‘There is no
gists and physicians might concur that such an approach such thing as a new idea. It is impossible. We simply take
would be useful! a lot of old ideas and put them in a sort of mental
However, Fletcher was a physicist, and argued that a kaleidoscope. We give them a turn and they make new
more accurate representation of hearing should convey and curious combinations. We keep on turning and
the units of hearing loss (e.g., pressure levels needed to making new combinations indefinitely; but they are
elicit a response) rather than a percentage. His early the same old pieces of colored glass that have been in
presentations on representing hearing levels in this use through all the ages.’’ When one considers how
way plotted these pressure levels in a conventional hearing assessment has evolved since the first 25 years
manner (e.g., more intense signals toward the top of of the AOS, one could readily agree with Twain that
the graph, rather than at the bottom). In today’s clinical ‘‘there are no new ideas.’’ The otologists of that time
practice, many audiologists fitting hearing aids would knew the limitations of their chosen approaches, whether
agree that this would be a logical way to plot hearing the watch, the voice, or the tuning fork. Leaders of the
thresholds, because plotting SPL as a function of fre- founder generation of the AOS including Roosa, Buck,
quency is precisely how hearing aids are fit today! Burnett, and Blake each knew that a reproducible signal
Eventually, Fletcher convinced Fowler to abandon the with true normative data was required to obtain a truly
‘‘percentage of hearing loss’’ approach to plotting hear- accurate measure of hearing, and they strove to create
ing thresholds. Upon doing so, however, he surprisingly those norms using the best available tools at that time.
did not change the scale along the y axis. Rather, he Many of the lessons learned from their efforts are still in
simply shifted the ‘‘percentage loss’’ to ‘‘sensation use today. Ultimately, they were limited by the available
units’’ and left the zero line at the top of the graph, technology, and not by their ideas. Rapid technical
while renumbering the y axis so that increasing amounts advancements in the first half of the 20th century ulti-
of hearing loss were lower. Ultimately, this had the effect mately led to significant changes in how hearing was
of ensuring that the audiogram would forever be ‘‘upside measured. At the same time, however, the goals of those
down,’’ with the inverted y axis to which we have assessments remained unchanged from those of the 19th

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 HEARING TESTING DURING THE EARLY YEARS OF THE AOS S41

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