The Journal of Laryngology and Otology March 1979. Vol. 93. pp. 225-251

Blast injuries to the ear: An historical and literary review By AHMES L. PAHOR (Birmingham) 'But when the blast of war blows in our ears' Shakespeare (HV: III, 1,5) THE fourteenth century witnessed the widespread use of gun-powder and its introduction in wars (Partington, 1960; Hogg, 1968). In time, new explosive mixtures and new weapons were developed and the destructive power of artillery was increased so that its use became more widespread as its effect in fighting became more decisive. The invention of gun-powder, and that of printing, were undoubtedly the most potent factors for the promotion of individualism and the transition of mankind from medieval to modern conditions (Garrison, 1929). Medical books were printed and published and writers, instead of just discussing wounds of the then conventional weapons such as spears, swords and arrows, started to comment on, and devote chapters to, gunshot wounds. The first manual to deal explicitly with gunshot wounds was by Hieronymous Brunschwig in 1497 (Burry, 1950). This paper is an attempt to give an historical review of the progress of knowledge related to blast injuries to the ears up to the Great War. Deafness resulting from other loud noises, including those from natural sources, was referred to by early writers. Thus Antonio Benievieni of Florence (1443-1502) in his book 'The Hidden Causes of Disease', which was first printed in Florence in 1507, wrote under Case XXIII 'Stunned by lightening' that: 'I have seen a father and son so stunned by lightening that they were seized body and mind by a kind of stupor and it seemed as though they were effected by dissolution of the sinews (nerves) which the Greeks call apoplaxia, they actually remained in this wretched state for seven days, almost without food or drink, dumb and senseless.' Whether the deafness was organic or functional is difficult to know from this description; however, a case of functional deafness lasting for nine years after a patient was struck by lightning was presented by Hurst (1920). Pliny (A.D. 77) wrote that the inhabitants of the region of the Cataracts of the Nile became deaf with the noise (Stephens, 1974); though it is possible that because of the background noise, people tended to shout, thus giving the impression to Pliny that they were deaf. War and its various consequences was, and still is, a subject-matter for literary writers expressing their different views and varied feelings. In this paper a selection of literary writings is presented in relation to blast injuries to the ears which show the astute power of observation, shrewd225

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ness and all-round knowledge which characterizes a great many famous literary writers. The effectiveness of the cannons at the start of their employment in wars was due to their noise* and its scaringf effect on the opposite side, a fact which helped Edward III to win Crecy in 1346. Ambroise Pare (v.i.), commenting on the cannons, wrote: 'this kind of engine, was called Bombarda, i.e. a Gun, from that noise it makes which the Greeks and Latines according to the sound call Bombus.' The first medical writer to mention the effect of blast trauma to the ear was the French military surgeon Ambroise Pare (1510-1590), the Father of Modern Surgery (Guthrie, 1945) to whom we owe the famous saying: 'Je le pansay, Dieu le guarit: (I treated him, God cured him)' (Castiglioni, 1947). Pare wrote his Les Oevers which first appeared in 1575 and was translated by Thomas Johnson (d. 1644) in 1634 from a 1579 edition of 'The Works'. Under the heading 'Of Wounds made by Gunshot, other Fierig Engines, and all sorts of weapons' he commented on the tympanic membrane: 'This membrane which is indifferently hardeth grown up from the nerves of the fifth conjugation, which they call the auditory. But they were made thus into crooked windings, lest the sounds rushing in too violently should hurt the sense of hearing. Yet for all this we oft find it troubled and hurt by the noise of thunder, Guns and Bels.' At that period the auditory nerves were considered the 'fifth conjugation of synewesj of the brain, whyche are said to be holow' (Lanfranke, 1565); the nerves were considered 'holow' as they carry the spirit which moves inside them (Johnson, 1684). Gemini (1552) also refers to the fifth pair of nerves, but Vicary (1548) who wrote 'Anatomie', the first in English on the subject of anatomy, refers to them as the seventh nerve: 'The senews that are the Orgayna or Instruments of hearing, spring each from the Brayne, from whence the seven payre of senews do spring; and when they come to the hole of the Eare, of them then be like the head of a worme, or like a little teat, in which is receyved the sounde, and so carried to the common wittes.' As to the nature of the tympanic membrane and its structure, Crooke (1616) says: 'There are almost as manie opinions as there be writes. Some think it ariseth from the braine, some from the Dura Meninx, some from the Periosteum, some from the Pericranium, some from the nerves of the fifth conjugation, some from the Pia mater.' Similar statements were * Aristotle (B.C. 384-322) was the first writer to discuss noise and its nature in his Problems under the heading 'Problems connected with music'. f Homer (c. 900 B.C.) in the Iliad, associated fear with sound: 'terror and consternation at that sound, the mind of Priam felt; erect his hair, bristled his limbs, and with amaze he stood not in loss'. { synewes = tendons or 'nerves'. Shakespeare wrote about the first meaning: 'Stiffen the sinews, summon up the blood' (HV, III, 1, 7). He wrote about the second meaning: 'a second fear through all her sinews spread' (Venus and Adonis, 903).

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made on the structure of the drum by Gibson (1697), Cheselden (1712), Drake (1727), Keill (1731) and Collins (1735). Alberti in 1591 referred to deafness attributed to cannonading (Chadwick, 1971). Fabricius Hildanus (1560-1634) recorded two cases of noise trauma to the ear (Ballance, 1919). The first case: 'In the year 1593 Johan Textor, a neighbour and relative of mine, aged about forty, when encamped at Hilden in the course of some military operations, lay down on the ground and went to sleep. It happened that some of his companions, by way of a joke, fired off a pistol close to his ear in order to wake him up. The sleepy textor, semi-conscious, was so concussed by the report that on account of the great cerebral commotion so produced he rolled over from side to side, and with great pain vomited up crude and undigested food. When called to him I shaved his scalp and rubbed in oil of roses, administered an enema, opened his brachial vein, and administered all remedies which seemed to me necessary. At length, by singular mercy of God, the pain in the head and the other symptoms abated, and he gradually got better, but he had lost the hearing of that ear, and did not regain it until after the lapse of long time.' Thus it is possible that the first recorded case suffering from the 'Tullio phenomenon' was reported by Fabricius Hildanus. The second case of noise deafness reported by Fabricius Hildanus was that of an old priest who rang the bells of his church tower himself, a thing he had not done for many years; he thereupon felt severe pains in his head and complained of tinnitus, and became deaf.* He was purged and cupped; the pain ceased, but the hearing did not return; and Fabricius explains this on account of the age of the priest and of the disruption of the tympanic membrane. Fabricius thus presumed more explicitly the rupture of the tympanic membrane as a result of noise than did Pare, though it is unlikely that the second patient had any such perforation as a sequence of the noise trauma as the injury more likely had been to the cochlea. Crooke (1616) suggested, under the heading of functions of the Eustachian tube, that: 'A fourth use of this canal is that in a vehement and violent noyse such as the shooting of ordenance, thunder and such like is, the membrane of the tympanum or head of the drum might be secured from breaking . . . whereas now the inbred aire (air in the middle ear) having an out-let into which it may retire, it leaveth the membrane scope and room to yeldto the impulsion of the outward ayre.' This function of the Eustachian tube was described as to 'purge the inbred aire' (Bartholinus, 1668). Crooke discussed noise deafness by stating: 'and yet for all this we see often times that the noyse of great Ordenance, or of Bels, if a man be in the steeple, * The noise of the ringing bells was the cause of deafness of Quasimodo, the most famous fictional personality suffering from noise-induced deafness, in The Hunchback of Notre Dame (1831) written by Victor Hugo (1802-1885). Quasimodo was described thus: 'He's lost his hearing with ringing of the bells. He's not dumb'. The effect of the ringing bells was experienced by Wimsey in The Nine Tailors, written by Dorothy L. Sayers: 'His ear-drums were cracking; his senses swam sway. It was infinitely worse than any roar of heavy artillery'.

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yea an intolerable cold ayer doe effect the Eare with paine and dolour; sometimes also breake the Tympane from whence deafnesse followeth.' Crooke also discussed 'Why we hear better indoors than outdoors' and 'Why many men are heard at a longer distance than one man's voice'. Bernardino Ramazzini, the Father and Founder of 'Industrial Medicine' (Arlidge, 1892), wrote his book 'A Treatise of the Disease of Tradesmen' in 1700 and reported deafness in those who hammered copper for a living. He also referred to hysteria among soldiers, though he did not mention hysterical deafness. He wrote: 'Men of no small figure that were overwise very brave, and yet upon the declaration of some intended expedition were so thunder-struck, as to form in their minds all of a sudden an idea of their approaching death' (Ramazzini, 1705). Reference to blast deafness was made by Riolanus (1649), Riverius (1655), Cole and Culpeper (1661), Tanner (1667), Bartholinus (1668), Digby (1669), EttmuUeri (1703), Brookes (1754) and Buchan (1761). It was Archibald Cleland (1741) who was the first to attempt to treat such an ailment. Cleland was a surgeon of General Wade's Regiment (Stevenson and Guthrie, 1949) and was the first to carry out Eustachian catheterization through the nose, using air to inflate the middle ear (Pahor, 1978). As to the cause of noise deafness, he wrote: 'it is possible, that the position of the Membrana Tympani is altered, being forced inwards upon the small bones, and so become concave outwardly.' Tanner (1667) made a similar statement: 'Sometime the Tympane may be relaxed sometimes by excess of moist humors, and sometimes by some violent and sudden noise.' Le Cat (1750) discussed a similar mechanism: 'When the Ear is assaulted by the Impulse of too violent a Sound, this Membrane, whose Center is sunk towards its Sinus, is pushed outwardly by the Spring which terminates in its Center. By this Mechanism this Membrane is relaxed; which Relaxation diminishes so much of the Impetuosity of the sound, as might be capable of hurting the Organ.' For treatment Cleland recommended that the Valsalva manoeuvre be tried first: 'which will, probably push the Membrane back to its natural state.' If this failed he advised the introduction of an ivory tube (Fig. 1) into the meatus and the sucking of air out of the external ear canal to bring the membrane back to its normal position. If the last method failed, he believed the cause may be that: 'the violent shock this membrane has suffered, may have dislocated some of the small bones; in which case there is scaresely any remedy.' Cleland's method was to die out, but to be revived later by Moos and von Troltsch (Politzer, 1902). In the latter part of the eighteenth century, galvanism gained wide popularity as a treatment for many ailments*; nerve deafness was soon * Josiah Wedgwood, FRS (1730-1795) of the Potteries in 1779 used electric current (galvanic) to stimulate the muscles of his daughter who was crippled by poliomyelitis (Meiklejohn, 1950-51), on the instructions of Dr. Erasmus Darwin (1731-1802), the grandfather of Charles Darwin (1809-1882). Luigi Galvani (1737-1798) published his treatise 'On the forces of Electricity in Muscular Movement' in 1791.

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FIG. I Ivory tube used to suck air from the meatus (12), and stopper (11) made of brass. (From: A. Cleland, Philosophical Transactions Royal Society, 1741.)

included (Blizard, 1790; Aldini, 1803, Thomas, 1810; Wright, 1831; Woakes, 1881), and devices were invented for the purpose of delivering such currents to the ear (Fig. 2). Parry (1825) reported blast deafness suffered by Admiral Lord Rodney Smith (Chadwick, 1971) when he wrote under the heading 'Deafness from

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FIG.

2

A device used to deliver galvanic current to the ear in cases of deafness. (From: Galvanism, J. Aldini, 1803.)

Vehement Noise' that: 'I was told by that excellent officer, Lord R., that he was almost entirely deaf for a fortnight after the battle of the 12th of April, 1782, in which his ship, the Formidable, fired eighty broadsides. And another gallant officer, who commanded a ship of war at the attack off Copenhagen (1801), has, I believe, to this day, not recovered his hearing, which in a moment he almost entirely lost by the report of a cannon while he was stooping.' Buchanan of Hull (1828) attributed the cause of deafness of a man married to a deaf wife: 'chiefly his shouting aloud' affecting his auditory nerve. Fosbroke (1831), in discussing noise deafness and explaining its aetiology wrote: 'Other causes of deafness are local and mechanical as in deafness caused by the sudden explosion of cannon, and that by continued noise, as blacksmith's deafness. The former is ascribed to rupture of the membrane of the tympanum by the force of the vibratory impulse, when the ear being taken by surprise the membrane consequently is not regulated and prepared by its muscles to encounter the shock.' Home (1800, 1812) expressed the opinion that the middle layer of the drum head is made of muscular fibres; at the time some authors agreed (Tod, 1832), others disagreed (Bell, 1803; Webster, 1836). Swan (1834) reported a case of a Captain in Portsmouth who became deaf due to blast trauma and: 'that blood only came from the left ear being in a right line towards the percussion, yet the ringing or intense buzzing was

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equal in both ears—sometimes like the chirping of ten thousand sparrows, and at others a monstrous hizzing.' Kramer (1837) mentions under 'nervous deafness' that: 'Complete deafness suceeded to loud explosives of fire-works, artillery, e t c . . . . ' Thus, whereas Pare thought the cause of deafness is a 'hurt' to the drum, Fabricius Hildanus thought it due to rupture of the drum and possible ossicular disruption, and Cleland due to alteration of the position of the drum head, we find Kramer adds sensori-neural deafness as a possible sequel. Kramer recommended the use of 'aethers' introduced to the middle ear via an eustachian catheter as a 'tonic' for the inner ear and he devised two 'vapour' apparatuses for this purpose, a small one (Fig. 3) and a larger one, which are modifications of Itard's apparatus. Kramer (1860) was antagonistic to the use of electricity, purgatives and counter-irritants which were in common use for treating nervous deafness. He recommended blocking the meatus with fine linen or oiled wool as a protection against noise deafness. Pilcher (1838) referred to and illustrated a rupture of the tympanic membrane by a blow which caused a linear posterior perforation in a supero-inferior direction. Wilde of Dublin (1853) reported a case of 'Bell's Palsy' following blast trauma, and a case of bilateral blast deafness with resultant posterior linear scars of the drums. He refers to a letter by Surgeon Thornton of the Royal Artillery who commented on blast deafness by writing: 'The effect of position, with reference to the gun, is peculiar,—those men who stand laearest the muzzle feel the report most, but all who are to leeward suffer jnore than those to windward. Brass ordnance ring louder and make a iharper report than iron guns . . . After some practice the ear becomes accustomed to the shock, and men learn by experience where to stand so as to feel the concussion least.'

FIG. 3 The small vapour apparatus of Kramer. (From: The Nature and Treatment of Diseases of the Ear, W. Kramer, 1835.)

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Nottingham of Liverpool (1858) referred to deafness and/or tinnitus as a result of blast injuries, the deafness being either conductive or perceptive. He mentioned that paralysis of the portio dura (facial nerve) may follow violent sounds. He also remarked on the effect of age on the susceptibility to blast trauma: 'It appears worthy of remark, that these injuries appear to tell much oftener upon adults, and those somewhat advanced in age than they do on children or very young people, whose more yielding and pro gressive organisation seems better adapted, as it were, to bend under, and thus throw off, the effects of this kind of shock'. Kerr and Byrne (1975) in a study of the Abercorn Restaurant explosion in Belfast in 1972, noticed that: 'four children were exposed to the blast and although sitting alongside those who experienced perforations, did not suffer any damage to their tympanic membranes.' Nottingham also mentioned that: 'the rupture of the membrana tympani, really from without, as in the case of violent sound, and its bursting, apparently from within, as in cases of suicidal strangulation or hanging, may be contrasted, until the latter kind of injury be more completely studied and its nature more fully determined.' Politzer (1883) and Burnett (1877) referred to a case of ruptured drum after hanging, described by Ogston. The inability to understand the nature of the last mentioned affliction is a welcomed sacrifice for abolition! Toynbee (1860) noticed deafness and tinnitus as a result of blast injuries and recommended leeches and purgatives as treatment. He mentioned deafness in 'boiler' workers and thought it due to 'ankylosis of the stapes' as a result of the exposure to noise. Toynbee devised 'the artificial membrana tympani' (Fig. 4) for perforated ear drums: a disc made of gutta-percha. He also used a bubble of india-rubber containing air. Yearsley introduced the 'artificial ear drum', a small pellet of moistened

FIG. 4 Toynbee's artificial membrana tympani in the process of insertion. (From: Diseases of the Ear, J. Toynbee, 1860, p. 168.)

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cotton-wool (Fig. 5), about which he and Toynbee had bitter arguments as to who was the first to use such a prosthesis; whereas Dalby (1872) gave the credit to Toynbee, Clarke (1874) claims it for Yearsley. Dalby (1891) referred to the over-use of the artificial tympanic membrane and electricity in Otology in his time, in a paper entitled 'Bubble remedies in Aural Surgery'. Several other devices were used to close the tympanic membrane perforations, with variable degrees of success (Theobold, 1893). Blake (1893) felt that refreshing the edges of the perforation was necessary. Yearsley (1863), commenting on affections of the auditory nerve, says: 'or its functions may be suddenly abolished by loud sounds, as thunder or explosions of artillery, in the same manner as blindness is caused through excessive stimulus of the optic nerve by intense light.' Hinton (1868), Toynbee's student and friend (Reading, 1969), edited Toynbee's book after the latter's death, and added a supplement in which he referred to Politzer's method of treating perforations of the tympanic membrane by using the zinc sulphate irrigation and touching the edges with silver nitrate. Other chemicals were recommended such as copper sulphate (Nottingham, 1858), alum (Hinton, 1871), and trichloracetic acid (Grant, 1900). Green of Boston, U.S.A. (1872) mentioned vertigo as a result of an explosion, that tinnitus may be due to 'the stapes pressing unnaturally on the labyrinth', and inhalation of tincture of iodine via Valsalva's manoeuvre in treating blast injuries to the ear. von Troltsch (1874) reported tympanic membrane perforation resulting from noise trauma and recommended the Valsalva manoeuvre 'immediately before firing as a mode of protection from the effect of such violent atmospheric concussion' and Pritchard (1891) advised the same, von Troltsch

FIG. 5 Yearsley's cotton-wool (upper) and Gruber's membrane (lower). (From: Diseases of the Ear and Nasopharynx, Macnaughton-Jones et al., 1902, p. 160.)

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also discussed the different methods employed to close a tympanic membrane perforation, recommending Toynbee's artificial membrana tympani, and he referred to the first attempt to close a perforation by Marcus Banzer (1640) who 'recommended for this purpose a tube of elk's hoof, closed at one end by a pig's bladder', von Troltsch also mentioned Autenrieth (1815) who used for the same purpose 'the membrane from the air-bladder of a little fish which had been previously stretched when wet, and varnished when dried', and also referred to Moos' practice that: 'in cases in which the stapes is absent, the addition of a stapes taken from the dead subject to Toynbee's artificial membrane is recommended'. Delstanche in 1885 (Jacobson, 1898) introduced his 'rarefacteur' (Fig. 6) which he successfully used in a case of deafness following blast injury

MASSEUR OF CHAS. DELSTANCHE. FIG. 6 Delstanche's 'rarefacteur'. (From: Diseases of the Ear, A. Politzer, 1902, p. 118.)

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(Politzer, 1902). The idea of the 'rarefacteur' was, as was Cleland's, to suck air out of the meatus and thus 'reposition' the drum. Politzer of Vienna (1883), who visited the clinics of Ludwig, von Troltsch, Prosper Meniere and Toynbee (Talbot, 1970), discussed at length the types of perforations resulting from 'a sudden condensation of air in the external meatus', and said that they were usually solitary perforations; but in one case he noticed two such perforations, and referred to Bonnefont who reported a multiple cribriform perforation due to an explosion of gas. Double perforations of the tympanic membrane were referred to by other authors (Hinton, 1866; Macnaughton-Jones, 1902). Politzer recommended no initial treatment as traumatic perforations usually heal, but advised the application of electricity in cases of concussion of the labyrinth. He expressed the idea that rupture of the tympanic membrane protects the labyrinth from the concussive effect of the blast. Thomas Barr of Glasgow, who is noted for his work on boiler-makers' deafness, also discussed blast deafness (1884) and suggested that deafness results from 'sudden and extremely loud noises, such as the report of a cannon or rifle close to the ear, especially if in an enclosed space'. John Swift Walker, who was a Medical Officer of Health for Hanley, Stoke-on-Trent (Warrillow, 1960), devised an attempt to close tympanic membrane perforations. Macnaughton-Jones of Cork (1887) wrote, as a footnote in his introduction to his book: 'Only this day I was interested to learn from himself the successful efforts of Dr. J. Swift Walker of Hanley, Staffordshire, to transplant the egg membrane to close a perforation of the membrana tympani in four patients. The antiseptic solution used to assist transplantation was a solution of 1 to 500 of perchloride of mercury in distilled water and 2 drops of glycerine to the ounce.' Arlidge, (1892), another Victorian doctor from the Potteries, who was a pioneer in hygiene and industrial medicine (Isaacson, 1956; Posner, 1973), worked in Stoke-on-Trent Infirmary, lived in Trentham and practised in Newcastle-under-Lyme, wrote, when referring to the effects of noise: 'And looking at facts, I would throw out the suggestion that sudden, interrupted, and strong vibrations, even when extended for brief periods only, are more hurtful to the ear than almost equally powerful ones in continuous action.' Macnaughton-Jones (1887) recommended the use of 'the sound deadeners' (Fig. 7) of Dr. Ward (1881), or his own 'ear protectors' (Fig. 8) during gun practices. Milligan (1906) referred to protection from blast deafness by 'placing a piece of rubber between the teeth to keep the mouth a little open to allow equalisation of atmospheric pressure on both sides of the tympanum'. Stewart (1902) commented that: 'Very large perforations heal over' and recommended the use of Yearsley's or Gruber's artificial membranes (Fig. 5), favouring the former. Tod (1907) recommended that, in cases of noise deafness: 'If the concussion has been sufficiently severe to produce internal ear deafness, the patients must be kept in bed, strict quietness

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FIG. 7 Dr. Ward's 'sound deadners'. (From: Diseases of the Ear and Nasopharynx, Macnaughton-Jones, 1887, p. 19.)

FIG. 8 Macnaughton-Jones 'aural protectors'. (From: Diseases of the Ear and Nasopharynx, Macnaughton-Jones, 1887, p. 19.)

insisted on, and a blister applied over the mastoid process. After a few days, if deafness still persists, strycknine should be given, beginning with l/6Oth grain three times a day and increasing the dose up to l/3Oth grain. If in addition to the deafness, tinnitus persists, the application of the constant current (galvanism) may be tried.' Milligan and Wingrave (1911) also advised that: 'to relieve tinnitus and to stimulate the auditory nerve in cases accompanied by labyrinthine concussion, the daily employment of the continuous current is useful.' Cheatle (1906) referred to a case of tympanic membrane rupture in a submarine explosion and referred to the Japanese experience during the Russo-Japanese Naval War (1904-5), as communicated by Suzuki (1905),

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who expressed his dissatisfaction with cotton-wool as an ear protector against blast deafness, whereas Lloyd-Thomas (1904) recommended its use.* Lake (1912) suggested, in cases of recent traumatic perforations of the tympanic membrane: 'to pass a small piece of glazed paper, moistened with an antiseptic or collodion, over the perforation. The paper adheres, and the membranes usually heal in a few days.' With the eruption of the Great War, more interest developed in blast deafness: its nature, pathogenesis including experimental studies, and protective aspects (Home, 1914; Bryant, 1917; Wilson, 1917; Fraser, 1917a; McBride and Logan Turner, 1918; Richardson, 1918). Hysterical deafness also attracted more attention (Marriage, 1917; Fraser, 1917b; Hurst, 1922). Hurst (1918) mentioned a rather interesting case: 'A man was admitted for symptoms resulting from the explosion of a high-explosive shell complained when he regained consciousness of constant noises in his head which never ceased and greatly distressed him. His hearing was normal, but I found a thick hair growing in the external meatus close to the drum on each side, it touched the drum on the side in which the noises were loudest and the opposite wall of the meatus on the other side. The removal of the hair was immediately followed by disappearance of the tinnitus.' Hurst (1920) denied the association of anaesthesia of the ear and hysterical deafness as suggested by Briquet in 1859 and favoured by Oppenheim, Politzer and Mackenzie (1895). Bourgeois and Sourdille (1918) discussed injuries of the tympanic membrane in war and stressed that as an immediate treatment: 'complete abstention', and as a later treatment they suggested 'tympanic prosthesis', describing the technique adopted by Bourgeois, namely, the use of very fine india-rubber to close the perforation, with gum-elastic as glue. Ballance (1919) referred to Gruber (1888) of Vienna, who estimated that the normal tympanic membrane is able to withstand a pressure of 140-160 cm of mercury. In the Book of Ecclesiasticus: 38,28 (Book of Sirach), which is a part of the 'Apocrypha't written by Jesu in 180 B.C. (Clarke, 1952), is mentioned the effect of noise on the ears and what seems to be the first mention of temporary tinnitus: 'So it is with the smith, sitting by his anvil, intent on his iron-work. The smoke of the fire shrivels his flesh, as he wrestles in the heat of the furnace. The hammer rings again and again in his ears, and his eyes are on the pattern he is copying.' * For use of ear protectors at that time in the R.N. see also: Lancet (1911) i, 111 and 1242. t The 'Apocrypha' (Greek-hidden) signify books that are 'hidden away' and are fourteen or fifteen in number (Buttrick et al., 1962). They were accepted as biblical by the early Church. The practice of collecting them into a separate unit dates to A.D. 1520. They were included in the first Authorized (King James) Version of 1611.

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The effect of noise on the ear also attracted the attention of literary writers, thus we find a poem on the 'Blacksmiths'* written in the 14/15th century by an anonymous writer (Wright, 1976) which reads: 'Swarte smeked smethes smatered with smokef Drive me to deth with den (noise) of here dintes (blows). Swech (such) nois on nightes ne herd men never: What knovene cryj and clatering of knockes!' Christopher Marlowe (1564-1593) had Faustus (1592) to say, when the seeds for the thought of suicide were laid in his mind: 'But fearful echoes thunders in mine ears.' (Sc. VI, 20). Michel de Montaigne (1533-1592) of Bordeaux, writer, philosopher and politician, was also a medical critic and a keen observer 'that had he lived today he would have been ideally fitted to practice medicine' (Taylor, 1922). Montaigne wrote his Essays (Fig. 9) and had the first two books published in 1580. He wrote Of War Horses in 1572-4 (Frame, 1965) and in this essay he commented on firearms and their effect on hearing, thus reporting noise deafness before Ambroise Pare. Montaigne wrote: 'But as for the pistol, I shall speak of it more amply when I make a comparison of ancient arms with ours; and except for the shock to the ear, with which by now everyone has become familiar, I think it is a weapon of very little effect, and hope that some day we shall abandon the use of it' (Frame, 1958). Francis Bacon (Fig. 10) who wrote Essays (1596), Novum Organum (1620) and Sylva Sylvarum (1627) among others, was praised by Dryden (1631-1700) (Johnston, 1965): 'The world to Bacon does not only owe Its present knowledge but its future too.' The Sylva Sylvarum (Fig. 11) was published after Bacon's death by .his chaplain, Dr. William Rawley, in 1627 (1st Edition). This book comprises 1,000 paragraphs, 190 of which are devoted to sound and music (Stephens, 1974). Bacon (1628) wrote, in paragraph 128 of the Sylva Sylvarum: 'A very great sound, neare hand, hath strucken many deafe; and at the instant they have found, as it were, the breaking of a skin or parchment in their eare: and myself standing neare one that lured loud and shrill, had suddenly an offence as if someone had broken, or beene dislocated in my eare; and immediately after, a loud ringing (not an ordinary singing or hissing, but far louder and differing) so as I feared some deafnesse. But after some halfe quarter of an houre it vanished.' * Longfellow (1807-1882), the American poet, also wrote a poem on The Village Blacksmith. t Grimy blacksmiths smutty with smoke. { Shouting of workmen.

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9

ne. Title page of Florio's translation of the Eraajw wrote by Michel de Montaig

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FIG. 10 10 FIG. FrancisBacon Bacon(1561-1626), (1561-1626),painted paintedby byVan Vander derBauk Baukinin1731. 1731. Francis (Bykind kindpermission permissionofofthe theNational National Portrait Portrait Gallery, Gallery,London.) London.) (By

'i'i

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Written fc ikt rinm JitteSj

FIG. 11 Title page of Sylva Sylvarum wrote by Francis Bacon.

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Shakespeare (1564-1616) who seemingly had been acquainted with Florio's translation of Montaigne's Essais (Ellrodt, 1975), wrote in Henry V: 'But when the blast of war blows in our ears.' (HV, III, 1,5). Whether Shakespeare was influenced by Montaigne to write this, or whether he wrote it through his personal experience,* is impossible to know. And does this passage in Romeo and Juliet refer to tinnitus besides indicating fear and nightmares, when Mercutio was describing Queen Mabf (Fig. 12) and mentioning the soldier's dream: 'Sometimes she drivett 'er a soldier's neck. And then dreams he is cutting foreign throats, Of breaches, ambuscadoes, Spanish blades, Of healths five fathom deep; and then anon, * 'Was Shakespeare ever a Soldier?' by W. J. Thomas, 1865. t Queen Mab, 'the fairies midwife', is first mentioned in literature by Shakespeare and later was adopted as a fairy queen by Jonson (1572-1637) and Drayton (1563-1631).

FIG. 12 Queen Mab: 'Her chariot is an empty hazel-nut' (R&G, I, 4, 73). (Painting by A. E. Chalon and Engraved by W Say. From the Forrest Collection, Shakespeare Library, Birmingham Central Library.)

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Drums in his ears, at which he starts and wakes: And, being this frighted, swears a prayer or two, And sleeps again.' (Romeo and Juliet, I, 4, 83-89). Shakespeare, who referred frequently to physical illness to illustrate his view, had Imogen to say: 'Talk thy tongue weary-speak. I have heard that I am a strumpet, and mine ears, Therein false struck, can take no greater wound, Nor tent to bottom that.' (Cymbeline, III, 4, 115-118). Tents were used for dressing wounds and Pare mentioned them in treating gunshot wounds: 'I observed and saw that all of them (other chirurgions) used that method of dressing which Vigo prescribes; and that they filled as full as they could, the wounds made by gunshot with Tents and Pledgets in the scalding Oyle, at the first dressings; which encouraged me to doe the like to those, who came to be dressed of me' (Pare, 1579). Martin Parker (1600-1656) wrote in The Mounding Soldier (Eberhart and Rodman, 1945): 'Throwing of a hand-granade; Oh! death was very neere, For it took away my eare, And yet, thanke God! ch'am here, ch'am here.' A poem by an anonymous poet entitled The British Grenadiers, first sung in 1780 (Smith, 1926), reads in part: 'Whene 'er we are commanded to storm the palesades, Our leaders march with fuses, and with hand grenades; We throw them from the glacis, about the enemies' ears;' Lord Byron (Fig. 13) wrote in Childe Harolds Pilgrimage: Canto III, XXV (1816), about the psychological effect of war and being 'terror dumb' : 'And swiftly forming in the ranks of war— And the deep thunder peal on peal afar; And near, the beat of the alarming drum Roused up the soldier ere the morning star; Wile thronged the citizens with terror dumb, Or whispering, with white lips—"The foe! they come! they come!".' Charles Dickens (Fig. 14) referred to both permanent and temporary deafness resulting from noise trauma (Yearsley, 1925; Pahor, 1979b). Miss Pross {A Tale of Two Cities, 1859) had her hearing permanently destroyed by the explosion of Madame Defarge's pistol when they were fighting in a room; a 'similar' incident was reported by Dalby

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FIG. 13 Lord Byron (1788-1824), painted by R. Westall in 1813. (By kind permission of the National Portrait Gallery, London.)

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FIG. 14 Charles Dickens (1812-1870), aged 27y. (By kind permission of the Trustees of The Dickens House, London.)

(1873) of a man who 'one day a gun was accidently discharged near to him in a small room when he was sitting. He became not totally deaf to sound, but quite deaf to all conversation.' We also find Mr. Pickwick saying to his friends, as the troops advanced towards them: 'remember that beyond the possibility of being rendered deaf by the noise, there was no immediate danger to be apprehended from the firing' {Pickwick Papers, 1836-37). Leo Tolstoi (1828-1910) was 25 years old when he joined the Crimean War* of 1854-56 and his Sebastopol is a record of the war. In his report of * It is of interest that the Crimean War witnessed the start of fame of two humanists: Leo Tolstoy and Florence Nightingale (1820-1910).

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May, 1855, he shows his disillusionment with the war and reports on the injuries and sufferings of soldiers; some of his writings appertain to noise deafness: 'At that moment, a flame flashed up in front of the company. There was a crash, which deafened them all, stones and splinters flew high in the air.' '. . . and perhaps the roar of the cannonade on the bastion will strike your ear, but your thoughts of a few moments before will not come back again.' 'Suddenly a deafening noise makes you quake from head to foot.' and a moving description of death: 'He stretched himself out, he ceased to see, to hear, or to think, to feel.* He had been killed instantly by a piece of shell striking him full in the breast.' It is of interest to note that Tolstoy mentioned that, in the process of dying, the sense of sight is lost before the loss of the sense of hearing; the same observation was used by Charles Dickens in Bleak House (Pahor, 1979). Henry Newbolt (1862-1938) wrote in the Vitaii Lampada: There's a breathless hush in the close to-night— Ten to make and the match to win— A bumping pitch and a blinding light, An hour to play and the last man in.' Max Plowman (1916) wrote, describing tinnitus as a result of blast injuries, in Going into the Line (Black, 1970): 'There comes a roar nearer and louder till His head is bursting with noise and the earth shakes.' Peter Porter writes about ear protectors in Your Attention Please (Jones, 1968): 'Turn off your radio immediately The Services end. At the same time Secure explosion plugs in the ears Of each member of your family.' Wilfred Owens (Fig. 15) wrote in Dulce et de decorum est, describing how fatigue impairs the senses: 'Bent double, like beggar's under sacks, Men marched asleep. Many had lost their boots. But limped on, blood-shod. All went lame; all blind; * A similar description is exhibited by Oliver (Eberhart and Rodman, 1945), the friend of Roland, when he died in battle (The Song of Roland, CL, c. 1110, in French, by an anonymous author).

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FIG. 15 Wilfred Owens (1893-1918). (By kind permission of the National Portrait Gallery, London.)

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Drunk with fatigue; deaf even to the hoots Of tired, outstripped Five-Nines that dropped behind.'* Robert Nichols (1893-1944) wrote in Battle, The Assault: 'Men, crumpled, going down . . . Go on. Go Deafness. Numbness. The Loudening tornado. Bullets. Mud. Stumbling and skating. My voice's strangled shout. "Steady pace, boys!"' Osbert Sitwell (1892-1969) wrote in The Next War: 'The long war had ended Its miseries had grown faded. Deaf men became difficult to talk to, Heroes became bores.' But still, alas, a more everlasting deafness as a result of 'war' is mentioned by Hamilton Sorley (1895-1915), who died in action in the Great War, in Unfitted: 'When you see millions of mouthless dead Across your dreams in pale battalions go, Say not soft things as other men have said, That you'll remember. For you nead not so, Give them not praise. For, deaf, how should they know.' Acknowledgement

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