9.7 Beethoven's Symphony No 9 in D-minor

It is a well-known story: When his 9th (the Choral) Symphony premiered on May 7, 1824, in the Kärntnertortheater in Vienna, the audience went wild. Ludwig van Beethoven (1770-1827) by then, however, was totally deaf. Contralto soloist, Karoline Unger, had to help turn him around to face the cheering crowd. There were 5 ovations all together, the ultimate respect for a common man (the police stopped further ovations in deference to the royalties who customarily were accorded three). It must have been quite a moving sight.

Beethoven indeed had put all his heart and soul into this symphony. In fact, despite the common belief that the vocal part of the 4th movement, Ode to Joy, was a poem borrowed from Frederich Schiller (1759-1805), Beethoven himself actually wrote portions of it. For example, at the very beginning of the vocal part, i.e., the baritone solo starting on bar 216:

O Freunde, nicht diese Töne!

Sondern laßt uns angenehmere anstimmen,

und freudenvollere.

Freude! Freude!

This symphony is of course remembered forever for its 4th movement. However, IMHO, the 3rd movement beginning with Adagio molto e cantabile is positively celestial that deserves even more attention.

Something about Beethoven's eyes? Ah, yes, we are just coming around to that.

The etiology of Beethoven's deafness has never been clear. Several possibilities have been put forth including otosclerosis, syphilis, noise trauma, Paget’s disease, sarcoidosis, and otitis media. None of them was conclusive, however.

It is known that Beethoven suffered from digestive diseases plus rheumatism, various skin abscesses and recurrent infections, ophthalmia, jaundice, and anemia. Ophthalmia? An old term for inflammation of the membranes/coats of the eye, i.e., iritis/uveitis. This, plus Beethoven's own admission of "constant belly aches, diarrhea and bloody stools" suggests that he might have a bad case of ulcerative colitis or Crohn's disease - both of which are associated episodically with deafness.

So the best guess is then: Beethoven's deafness was an immunopathic manifestation of Inflammatory Bowel Disease (IBD). And iritis/uveitis no doubt flared up from time to time. Unfortunately, after the autopsy, the coroner's report concentrated on the liver and the abdominal fluid, with nothing on the intestines. So we'll never know for sure.

There is a lesson here, though: Patients with IBD need to have their eyes (especially the retina) and ears (at least the hearing) examined regularly - particularly for musicians and composers.

9.6 Diving and retinal breaks

Guo Jingjing is the Gold medalist of Women's 3-m springboard diving of the 2008 Olympics. She took up diving since age 7. And now at age 27, she is the most decorated Olympic female diver ever.

And the price she has paid as far as the eyes? Retinal tears or breaks:
They lead up to the more severe sight-threatening retinal detachment. Which was probably what has happened to Ms Guo. In 2002, a retinal break was discovered in her right eye. After a successful surgical repair, her vision or visual field dropped to 20% of normal anyway. In 2004, right before the Olympics in Athens, the retina apparently has re-detached. She went on to win two gold medals nonetheless. After the 2008 Games, both eyes now require surgery.

Sudden physical impacts or blunt trauma to the eyes in, e.g., boxing, car accidents, baseball or hockey games, can disrupt the retinal (and sometimes choroidal) structure. Even if there is no detectable blow-out detachment when the eyes are examined immediately after the injury, it does not mean that the patient is out of the woods. Unfortunately, the latency for retinal detachment is quite long, often in years. Diving apparently involves repetitive impacts on the top portion of the eye. In other words, when the diver's head enters the pool water, the contact force will have been transmitted to the eyeballs. And the latency of retinal detachment will have been considerably shortened. Even worse if there are other pre-disposing factors, e.g., high myopia and/or family history of retinal detachment.

Athletes in competitive diving should probably have their retinas examined at least once every 6 months.

9.5 You are left-eyed?

No one can spin a better yarn about the eyes as the ancient Egyptians. In the Egyptian mythology, the right eye, aka the Eye of Re (or Ra), symbolizes the Sun. And the left eye, aka the Eye of Horus, is the Moon.

The Eye of Re has a mind of its own and frequently wanders around by itself. On one of the fun-filled outings, it refuses to return, so Re (the father of all gods) sends Shu and Tefnut, two underlings, to retrieve it. The eye stubbornly refuses. And in the ensuing struggle, the eye sheds tears and from which, men emerge.

Another story has it differently, Re actually sends Thoth to fetch it back. And upon returning, the eye discovers that it has been replaced by another eye and becomes quite indignant. To pacify it, Re places the right eye in the shape of the uraeus serpent on his own brow - to show that the eye is now the ruler of the world. This serpent is worn by all Egyptian Pharaohs on their headgears. The right eye later becomes an entity and its association with many goddesses is of course the basis of many other stories.

The story of the left eye, the Moon, is even more complex.

The lunar cycle actually represents the eternal battle between Horus and Seth. They are fighting for the inheritance of Horus's father, Osiris. Seth steals the eye and damages it - cuts it up into six pieces. Thoth, with the help of other gods, puts the eye back together on the 6th lunar day. The healed eye is known as Wadjet. It symbolizes a re-established order after disturbances. The lunar cycle is essentially a description of how the eye is injured and repaired. The latter performed by 14 gods.

For the mere mortals such as you and I, the two eyes also behave somewhat differently - in the form of ocular dominance. About 2/3 of the population sight with the right eye. Ocular dominance seems to correlate with the handedness, i.e., a right-handed person sights with the right eye. However, there are always exceptions; you can be right-handed but sight with the left eye and so on. The reason is simple, each retina is controlled by both hemispheres of the brain, whereas each limb by only one side.

Ocular dominance is actually quite interesting and practical at the same time. It is often why a patient notices a change in vision (i.e., when the dominant eye is seeing less well than the fellow eye) and seeks help. In monovision contact lens fitting, the first attempt is always to fit the dominant eye for distant vision and the fellow eye for reading. Sometimes, this does not work out and the patient actually does better with the dominant eye for reading. In monovision laser vision correction, the dominant eye is also selected for distant vision. You are of course stuck if this arrangement does not work.

Being very capable archers, the ancient Egyptians must have queried their eye doctors why some sighted with one eye vs the other. The mythology of the eyes, on the other hand, is a true testament to their vivid imagination.

Evidence of eye surgery in ancient Egypt? See the lower eyelid of the right eye in this mummy portrait:

An attempt at repairing entropion, it seems.

Exemplary Olympians

In the wheelchair is Su Li-Wen of Chinese-Taipei (Taiwan). She competed with an injured left knee in the women's 57-kg Taekwondo and fought in excruciating pain to the end. In the last round, she fell 11 times yet refused to concede.

Robina Muqimyar of Afghanistan who competed in the 100 meters. She came to Beijing despite the mysterious disappearance of teammate Mehboba Ahadyar (around July 4, while training in Italy), who was to run in the women's 1500- and 3000-m events.

9.4 Valsalva retinopathy

Lu Ying-Chi of Chinese Taipei won a bronze medal of women's 63kg weightlifting

event at Beijing 2008 Olympic Games, Aug 11, 2008.

Chen Xiexia (C) of China, Sibel Ozkan (L) of Turkey and Chen Wei-Ling (R) of Chinese Taipei wave to spectators at the awarding ceremony of the women's 48kg of weightlifting event at Beijing 2008 Olympic Games at the Beijing University of Aeronautics & Astronautics Gymnasium in Beijing, China, Aug 9, 2008. Chen Xiexia, Sibel Ozkan and Chen Wei-Ling won the gold, silver and bronze medals respectively. (From news/xinhuanet.com)

Weight-lifting can injure the eyes. No kidding.

Once a patient came in and complained that his vision in the right eye was suddenly lost when he tried to lift some heavy boxes in his basement. Valsalva retinal hemorrhage immediately comes to mind. However, fundus exam reveals a cellophane membrane over a "wrinkled" macula. A macular pucker, it turned out to be. This is entirely different from the first suspect which occurs when one holds breath performing physically strenuous tasks, e.g., heavy weight-lifting, giving birth, passing stool, etc. The increase in the intrathoracic/abdominal pressure raises the venous pressure which in turn causes rupture of retinal capillaries. The blood accumulates between the retina and the vitreous. And vision changes if the hemorrhages occur within the visual axis. Often the history and a retinal exam confirm the diagnosis:

(Image from Digital Ophthalmology)

The above is an unusually large pre-retinal hemorrhage in a case of Valsalva retinopathy. More common than not, the hemorrhages are much smaller of about 1 disc diameter often found near the disc itself; although they can extend into the macula and obscure vision.

Luckily, most cases of simple Valsalva retinopathy heal quickly, spontaneously, and completely. Some cases, usually those with pre-existing vascular disorders, may require the Nd:YAG laser/surgical intervention.

So who/why/what is "Valsalva"? Well, Mr Antonio Maria Valsalva (1666-1723) was an Italian physician specializing in ear anatomy. He had also described the (original) Valsalva maneuver (i.e., what happens physiologically when you forcibly exhale against a closed glottis). He also coined the term, the Eustachian tube (which connects the middle ear and the pharynx). When you travel by air, when the airplane descends for landing, your ears tend to "pop". The reason is the rapid increase in the atmospheric pressure causes the Eustachian tube to collapse (or become pinched). Gum-chewing works the best in opening this tube and restoring the pressure balance. If you don't have any chewing gums handy, try opening your jaws with the lips closed instead.

08-08-08

9.3 Centrifuges and reading in space

This is a standard desktop centrifuge. Each "hole" accommodates an Eppendorf centrifuge tube. The centrifugal force is about 2,000 x g, strong enough for separating most particulate matters from the solvents. For comparison, 1 x g is what most of us experience on the surface of Earth everyday.

Humans occasionally subject themselves to higher Gs. For example, most rides in amusement/theme parks are actually centrifuges or variations of centrifuges. While most are in the less than 2 x g range (an example is shown below), some in the form of roller-coasters, e.g., the Space Mountain in Disney World, can reach 4 x g.

(An amusement park centrifuge)

Momentary exposure to 4 x g (or even higher) is relatively harmless, unless there is an undiagnosed pre-existing medical condition - then it can end in tragedy. Indeed, heart attacks and brain hemorrhages are known to occur on some high-G rides.

NASA has the ultimate centrifuge for the humans:
This is NASA's 20 x g centrifuge used for testing the physiologic responses of astronauts. And this is where you see the astronauts' faces start to melt, among other things.

Technically, the g-force is calculated thus:

where g = Relative centrifugal force (RCF)
r = rotational radius (centimeters, cm)
N = rotating speed (revolutions per minute, rpm)

Of course, g is also the basic unit of the gravitational force. Without gravity (i.e., zero-g), as that in the outer space, some human reflexes that have worked previously now begin to unravel. And one of them is the simple vestibulo-ocular reflex (VOR).

Now pick one object in your room, stare at it, and then move/rotate your head to left and right, you'll notice the object remains in the same stable position. In other words, the image of the object is stabilized on your retina. This is the VOR at work.

The sensory aspect of VOR is handled in the inner ear by the semicircular canals (which sense angular acceleration to detect head rotation) and the otolith organs (which sense linear acceleration to detect both head translation and the position of the head relative to gravity). The information is processed centrally and the output sent to extraocular muscles.

In zero-G, the semicircular canals do not work well because the fluid contained within no longer convects effectively. So the coordination between head motion and eye movement is now disturbed. If you read too fast, the text lines will appear jerky. Effective reading can be achieved only at voice speed. Whether VOR eventually adapts to long periods of zero-G and normalizes is still yet to be tested. In a long journey to other galaxies, catching up on your reading will become an integral part of mental exercise. Certainly beats looking out of the window into darkness 24/7.

Of course, large centrifuges can be incorporated into space stations and star ships. The centrifugal force will provide simulated gravitation that can make the astronauts' lives easier.

The (presumably) rotating space station shown below is in 3D. You'll need to borrow a pair of red-green glasses from your eye doctor to see the effect.

(From http://farm3.static.flickr.com/2351/2130591814_53d9037897.jpg?v=0)