Is lead a good or bad conductor?

The composer vividly describes the characteristic social isolation of the hearing impaired, the hearing impairment as an illness. With the
Modern medicine could probably have helped him.

As soon as I'm dead . . , so asks him [his doctor Professor J. Adam Schmidt] * on my behalf that he describe my illness,. . . so that at least as much as possible the world may be reconciled with me after my death. . . ”Ludwig van Beethoven wrote this in 1802, just 32 years old, in his Heiligenstadt will.
Beethoven was already hard of hearing at the age of 28. The last years of his life he was deaf - a thorn path for the gifted musician. If you listen to the difficult-sounding piano sonata in D major (op. 10) "largo e mesto", composed in 1798 at the beginning of his hearing impairment, you believe that you will find something of the premonition of this difficult path in music. In 1801, at the age of 31, Beethoven describes his symptoms: hearing loss with loss of treble and speech intelligibility, agonizing noises in the ears [tinnitus], distortions [recruitment] and hypersensitivity to sound [hyperacusis]. In a letter to his friend Dr. Franz Gerhard Wegeler (1765 to 1848) on June 29, Beethoven describes the dissonant cognition of people and their own music:
“The jealous demon has played a bad trick on my health, namely my hearing has been getting weaker and weaker for three years [hearing loss]. . . . only my ears, they rush and roar away day and night [tinnitus]. . . . I spend my life miserably. I've been avoiding all societies for two years because I can't tell people I'm deaf. If I had any other subject, it would have been easier, but in my subject it is in a terrible state. . . . I can't hear the high notes of instruments and voices [loss of treble] when I'm a little far away, nor do the wind instruments in the orchestra. Sometimes I can hear the speaker speaking softly, but not the words [loss of speech intelligibility], and yet, as soon as someone screams, I cannot tolerate it [hyperacusis]. "
It was Kant who remarked that poor vision separates things, whereas hearing loss separates people. Beethoven describes the characteristic, social isolation of the hard of hearing, the hearing loss as an illness that is doubly invisible in the truest sense of the word: You cannot see it and the person affected becomes invisible. Beethoven withdraws from the world of the hearing. Beethoven is inexorably losing a decisive part of his being human.
The sick Beethoven had suicidal thoughts. Only his art saved him. The loss of hearing and bold drafts of compositions - actually a contradiction in terms, and yet they were compatible with Beethoven.
His doctor at the time, Professor J. Adam Schmidt (1759 to 1808) from the Josefinum in Vienna, had recommended the treatment to Beethoven in Heiligenstadt. Beethoven dedicated the piano trio Wo0 38 (an arrangement of Opus 2) to him. He had already written it in 1791, even before he became hard of hearing - a joyful and carefree sounding piece, as if Beethoven wanted to tell his doctor that his hearing and mind should be the same as before. In 1805 the 35-year-old composed the first sketches for the 5th symphony (Op. 67/1, 1807/8). The punch motif is well known. The text reads: “This is how fate knocks on our soul.” Beethoven is not yet deaf - but on the way there.
Beethoven's ear trumpets were made by Johann Melzel, the inventor of the metronome. Illustration: Beethovenhaus Bonn
In order to understand Beethoven's hearing loss and later deafness, one has to know how the ear works. The ear is the most sensitive and fastest human sensory organ. The great sensitivity of the human ear can be assessed if one considers that the sound pressure just perceptible in the inner ear leads to deflections of only about 10-10 m, i.e. about the diameter of a hydrogen atom. More than 1,000 consecutive events per second can be resolved over time. The sound signal is transmitted from the eardrum to the stapes by vibrations of the middle ear bones and from there to the inner ear by inward and outward movements of its footplate. A sound signal causes the stapes to vibrate in the middle ear, creating a wave in the fluid-filled inner ear. This travels through the inner ear (hence its name "traveling wave": it resembles an ocean wave on the beach), eventually stranding and irritating certain hair cells at this point. It is assumed that the traveling wave bends the sensory hairs of the hair cells (graphic) and this shearing of the stereocilia causes the opening of ion channels in the cell membranes at the tip of the cilia. Interestingly, small threads run from the tips of most of the sensory hairs to the wall of the cilia behind. If the stereocilia are bent in the direction of excitation, the tip threads are stretched. One imagines that the pull opens K + -permeable ion channels and that positively charged K + ions flow into the hair cell through these channels. This makes the inside of the hair cell electrically more positive. In this way, the mechanical sound signal is converted into the body's own electrical signal. One speaks of mechano-electrical transduction.
The healthy ear has an astonishingly good ability to distinguish pitches. Without this ability, Beethoven's music would only be sonic mush. Without this ability the patient can hardly understand language either. The inner ear has a sophisticated two-stage mechanism for developing pitch selectivity. Georg von Békésy, who was expelled from Germany in the Third Reich, received the Nobel Prize in 1961 for describing the first stage. The already mentioned traveling wave has two important properties. Depending on the pitch, it is stranded at a specific location along the inner ear: in the case of high notes, it is stranded at the beginning, in the case of medium notes in the middle and in the case of low notes at the end of the inner ear. And then completely different to a sea wave: Immediately before it is stranded, it is suddenly gripped as if by a hand, amplified up to 1,000 times and provided with a very sharp point before it immediately collapses. The tip of the 1,000-fold amplified traveling wave exclusively stimulates the few inner hair cells that are present at this location and responsible for this pitch, which then transmit transmitters to some afferent auditory nerve fibers. So that only the few inner sensory cells are exclusively stimulated at a certain pitch, the traveling wave needs a sharp tip. The outer hair cells are responsible for this tip three times more often than the inner sensory cells.
This is because outer hair cells generate powerful micromechanical vibrations in the sound frequency. In addition, outer hair cells can shorten and lengthen up to 20,000 times per second (20 kHz). As a result, they act like servomotors that grasp the stranded traveling wave and amplify it up to 1,000 times. The additional vibration energy only arises at the narrowly circumscribed location of the inner ear that is characteristic of the respective pitch. The tip of the strong wave generated in this way is sharply localized and delivered to a few inner hair cells. This so-called cochlear amplifier achieves the high frequency selectivity of the healthy ear - a prerequisite for understanding speech and listening to music.
Beethoven's symptoms suggest that, as with many inner ear hearing impaired people, the sharp frequency image in the cochlea was no longer present. As a result, he suffered in particular from the impairment of speech intelligibility that he described. The drastic amplification of the traveling wave, which leads to the sharp point and thus only to frequency selectivity, was apparently missing with him. Today, this fundamental difference can most likely be traced back to the failure of the outer hair cells. If an external auditory cell no longer moves, then the tip of the traveling wave is missing. Then you perceive how Beethoven perceived: “I hear. . . well . . ., but don't understand the words. ”On the basis of Beethoven's descriptions, one can assume that his hearing loss began with the fact that he gradually lost external auditory cells.
Disturbances or loss of function of the motility of outer hair cells are an extremely common cause
the inner ear hearing loss. Clinically they can be recognized by the positive "recruitment" and / or the decrease in amplitude /
-Loss of TEOAE ("transient evoked otoacoustic emission"). At low sound pressure levels, the traveling wave is no longer actively amplified, so that the sound is only heard above the poorer physiological threshold of the outer hair cell, namely from around 50 to 70 dB. So: Inner hair cells hear nothing without outer hair cells at the threshold, but only from 50 to 70 dB. Clinically, there is a threshold increase in the tone audiogram of a maximum of 50 to 70 dB. In addition, the sharp peak of the traveling wave generated by the amplification, which is important for the frequency selectivity, is lost. This can be a
Explain loss of speech discrimination on speech audiogram. Furthermore, recruitment occurs, and the amplitude of transitory evocable otoacoustic emissions decreases or is lost. The TEOAE measure directly the mobility of outer hair cells. In addition, it is to be expected that binaural hearing performance such as lateral spatial hearing and signal recognition will be significantly restricted against background noise.
The treatment of Beethoven's ear problems began in 1800. Almond oil ear drops and horseradish cotton were used, then certain types of tea, but also so-called vesicatoria, which led to blisters on the skin; it was hoped that as the blisters disappeared, the disease would go away. What seems strange today was typical of the time. Finally, he was prescribed lukewarm Danube baths, which are said to have helped him a little with the noise in his ears.
However, there was no question of healing, so Beethoven's doctor hopping was no wonder. But none of the best doctors of his time could help him. And yet Beethoven had completed eight of his nine symphonies in the years up to 1812. It was Johann Melzel, the inventor of the metronome, who gave Beethoven a little help in 1814: an ear tube. Another support was a wooden stick attached to his Erard grand piano, which Beethoven took between his teeth. That way he had a sense of vibration.
(B) Beethoven's live mask by Franz Klein, 1812
But even these small advances were immediately wiped out. From 1814 onwards, Beethoven's hearing impairment worsened. The evidence: 1814 was his last public appearance as a pianist. After that he only played with friends or for himself. The musician Tomaschek described Beethoven as very deaf [“deaf” also meant hard of hearing at the time]. A year later (1815) Neate and Simrock, English pianist one and his publisher the other, said that if there was any residual understanding at all, then only in the left ear. Addressed by his right-hand side, Beethoven no longer understood anything. In 1816, according to Simrock, personal information could only be communicated in writing. Since 1818, conversations with Beethoven have only been in writing. Around 400 so-called conversation books have survived. If one compares Beethoven's portraits from the years 1812, 1815 and 1818, one gets the impression that his face has grown almost 20 years older in these six years. It obviously reflects Beethoven's terrible experience
contrary.
It was to get worse. In 1819 the Swedish poet Atterbom wrote that Beethoven was what they call “pitch-deaf”. Ludwig Spohr observed in 1821 that Beethoven no longer hit the keys on the piano.
On May 7, 1824, Beethoven was announced as the conductor of a concert evening. From the overture “The Consecration of the House” to a partial performance of the Great Mass (Kyrie, Credo, Agnus dei) to the 9th symphony, an extensive program could be heard. Although Beethoven was formally a conductor, the orchestra actually followed Michael Umlauf, the “assistant” conductor. There was frenetic applause after the Kyrie. However, Beethoven did not address the applauding audience. He was taken by the shoulders and gently turned to receive the applause. Obviously Beethoven was deaf. Based on what we know today, one can assume that in 1824 not only Beethoven's external auditory cells but also his internal auditory cells had given up their function.
What did Beethoven compose at the time of his complete deafness? The Missa solemnis with its Kyrie (Op. 123), after which the deafness became evident. But the person affected by social withdrawal also composed: “Be embraced millions” and: “All people become brothers” (9th symphony, op. 125, 1823/24). Perhaps he wanted to say something about himself with his brilliant music that the deaf man could no longer express with language alone.
Even without hearing loss or deafness, Beethoven was a sick man. He'd had measles, but also smallpox. Beethoven's face mask, created by Franz Klein in 1812, shows characteristic pockmarks. Alois Weizenbach, surgery professor in Salzburg, noted typhus before 1798. From 1797 to 1802, his doctor at the time, Professor Schmidt, mentioned rheumatic complaints. It remains unclear whether these correspond to our current medical terms. From 1802 he repeatedly suffered from infections of the nose, from nosebleeds and from bronchial asthma. In 1810 he apparently fell badly on his head. Beethoven was very short-sighted. He wore glasses between 1.5 and four diopters.
In his letters he not only describes his hearing loss, but also abdominal cramps and abdominal diseases. The baths in the Danube that were mentioned served not only to alleviate his ear problems, but also to treat his abdominal ailments. Current findings suggest pancreatitis. In the last years of his life (from 1821) there was jaundice and haemoptosis (from 1825).
“He lay there tired and miserable, sometimes sighing deeply. . . "
The hospital room was very busy during Beethoven's last weeks of life. The patient experienced social affection from which he had excluded himself for more than 15 years. Not only did at least two doctors visit every day, but friends and acquaintances also appeared regularly. The later composer and writer Ferdinand Hiller and his composition teacher, Johann Nepumuk Hummel, spent the last few days with Beethoven. He visited him three times in March 1827, that is, immediately before his death, and on March 8th he was “quite astonished to find the master apparently comfortably sitting at the window”. On his second visit, on March 13th, Beethoven was already bedridden. At times he groaned deeply, but still spoke a lot and lively. And about the visit on March 23, Hiller wrote: “He lay there, miserable and miserable, at times sighing deeply, not a word fell from his lips - the sweat stood on his forehead.” On the same day Beethoven signed his last will - after von Breuning half asleep. In the afternoon of March 24, 1827, a thunderstorm raged over Vienna - and Beethoven died.
(C) Beethoven's death mask Illustrations: Beethovenhaus Bonn
Beethoven's body remained in his bed until the autopsy, which incidentally took place in his house. He was buried on March 29th. By then, souvenir hunters had cut off almost all of his hair. The autopsy was carried out by Dr. Johann Wagner, assistant at the Pathological Museum. His assistant was the later famous Dr. Karl von Rokitansky.
Today one would most likely think that Beethoven suffered from what is known as chronic inner ear hearing loss. Since 1798, Beethoven showed very characteristic signs of this suffering with progressive loss of treble, loss of speech intelligibility, tinnitus and hyperacusis. In this case, the outer hair cells - and with the deafness, also the inner hair cells - would have lost their function and would have died. After the inner hair cells have died down, the auditory nerve can also partially perish. In the autopsy protocol it is stated that the auditory nerve is clearly
was too thin, shriveled and marrowless. Wagner and Rokitansky tried to describe the hearing of the famous man who had suffered from deafness with the means available at the time. The hair cells had not yet been discovered, and there was no microscope. Only the naked eye was available. The description of the too thin auditory nerves is a sign of the greatest possible precision at the time.
The question of why the sensory cells perished is difficult to answer.A syphilis that Beethoven was later ascribed to was obviously not the cause. It is unlikely that a syphilis was solely related to the hearing and otherwise passed by his body without any consequences. Given the frequency of syphilis at that time, the two dissection doctors were certainly looking for signs of syphilis. The skull injury cannot have been the cause of the hearing loss either, because there is no temporal connection. Typhus can also be ruled out as a cause. Here, too, a close temporal connection with deafness will be required: at the time when typhus occurred, deafness should also have occurred. This was not the case. Beethoven was not old enough to have old age deafness. Lead poisoning does not cause hearing loss either: workers in lead mines, for example in South America, suffer from lead poisoning by the thousands. They are not hard of hearing. There is information that Beethoven is said to have suffered from otosclerosis, a bone disease of the ear. The improved hearing with the wooden stick on the piano is taken as an indication. However, otosclerosis extremely rarely makes completely deaf. In 30 years of clinical activity, the author has not yet experienced bilateral deafness due to otosclerosis. In photos of Beethoven's skull, one thinks to see a thickening of the bones, which is typical of Paget's disease. However, the skull known from photos is bed
hovens a plaster cast that was made after Beethoven's exhumation in 1863. At that time, Beethoven's skull had disintegrated into nine parts. After these nine parts had been put together by Alois Wittmann, he made a plaster cast of them. The thickening visible in the plaster cast can also be due to an impression or reconstruction error.
Modern medicine could not have cured Beethoven - but it could have helped him. He would probably have been able to listen to his music with modern hearing aids for many years to come. Later, a modern hearing implant could possibly have been surgically implanted in his middle ear. With micro-vibrations, it stimulates the inner auditory cells when the outer ones are destroyed. After the death of the inner hair cells, Beethoven could have inserted a cochlear implant into the cochlea. A cochlear implant works when the entire inner ear, including the inner auditory cells, stops working, but the auditory nerve is still intact.
Even if - as was the case with Beethoven - the auditory nerves are ultimately also affected, there is help today, namely in the form of a brain stem implant. The implant stimulates the brain directly. The auditory nerve is not needed. However, the cochlear implant and brainstem implant do not work as perfectly as normal hearing. In many cases, however, they enable linguistic communication. It must be said that these implants are expressly not designed to hear music particularly well. Rather, these implants have a highly specialized computer that primarily processes speech and breaks it down into very specific electrical signals. These are picked up by the auditory nerve or the brain and passed on to the language center. Beethoven's music therefore doesn't sound elegant with a cochlear or brainstem implant, but he probably could have heard it.

How this article is cited:
Dtsch Arztebl 2002; 99: A 2762-2766 [issue 42]

The bibliography is available as a reprint from the author and on the Internet (www.aerzteblatt.de).

Author's address:
Prof. Dr. med. Dr. H. c. mult. Hans-Peter Zenner
medical director
University Ear, Nose and Throat Clinic
Elfriede-Aulhorn-Strasse 5
72076 Tuebingen, Germany

* Explanations by the author in square brackets

Acknowledgments: University Music Director Prof. Dr. I am indebted to Sumski, Tübingen, for detailed discussion and help.



In the Heiligenstadt Testament, which Beethoven addressed to his brothers, it says:
“Oh, you people, who consider me hostile, stubborn or misanthropic, or who explain how wrong you are to me, you do not know the secret cause of what seems to you so. . . . (which may take years or even impossible to heal). . . so excuse me if you will see me retreat where I liked to mingle with you, my misfortune hurts me twice by being misunderstood. . . I must live like an exile,. . . what humiliation if someone stood next to me and heard a flute from afar and I heard nothing, or someone heard the shepherds singing and I also heard nothing, such events brought me close to despair, little was missing and I ended my life myself - only she the art, she held me back, alas, it seemed impossible to me to leave the world until I produced everything I felt inclined to do. . . "

Ludwig van Beethoven, Heiglnstadt [Heiligenstadt] on October 6th, 1802.




Autopsy report [excerpts]

About the corpse of (P.T.) Mr. Ludwig van Beethoven, who was pathologically examined in his apartment in the presence of Mr. Med. Doctors and Professor Wawruch, and the following findings were made about this.
The body was very emaciated, especially in the limbs. . .
The auricular cartilage was large and regular in shape, the boat-shaped indentation, but especially its concha, was very spacious and half-deeper than usual; the various corners and turns were considerably raised. The external auditory canal, especially against the covered eardrum, appeared to be covered with shiny skin flakes. The Eustachian ear trumpet was very thickened, its mucous membrane bulged and somewhat narrowed towards the bony part. Scarred pits were noticed in front of the mouth and against the tonsils. The handsome cells of the large mastoid process, which had no incision, were lined with a blood-rich mucous membrane. The entire substance of the petrous bone, pervaded by considerable vascular branches, showed a similar abundance of blood, especially in the region of the snail, the membranous spiral leaf of which appeared slightly reddened.
The facial nerves were of considerable thickness; the auditory nerves, on the other hand, have shrunk and marrowless; the auditory arteries running along the same were stretched out over a raven-feather coil and were cartilaginous. The left, much thinner, auditory nerve arose with three very thin, grayish stripes, the right with a harder, bright white stripe from the substance of the fourth chamber of the brain, which was much more consistent and richer in blood. The convolutions of the otherwise much softer and water-containing brain appeared again so deep and (more spacious) more numerous than usual. The slab vault showed great tightness throughout and a thickness of about half an inch. . .

Doctor Joh. Wagner, assistant at the pathological museum.
27. III. 1827
Baratoux G, Natier M: (1905) A propos de la surdité de Beethoven. Chron. Med. 13 492
Beleites E: (1994) Inaugural Lecture Jena-Univ.-ENT Clinic
Bertein P, Apperece R: (1930) Le cas Beethoven Oto-rhino-laryng. Int 14 113
Biliancioni G: (1921) La sordita di Beethoven. G. Med. Milit. 11 521
Björntorp P: (1998) Vad dog Beethoven av? Läkartidningen 95 No. 20 2364-2367
Bonnier, P., Gernault, P. (1905) La surdité de Beethoven. Chron. Med. 13 521
Boutaric, J.-J. (2000) Une enigma médicale: Ludwig van Beethoven. LA Revue du Praticien 50 125-127
Brunger, E. (1942) Considerations on Beethoven's Disease. Med. Diss., Cologne
Chalat, N.I. (1980) Some psychologic aspects of deafness: Beethoven, Goya, and Oscar Wilde American Journal of Otology 1/4 240-246
Clynes, M. (1995) Microstructural musical linguistics: composers' pulses are liked most by the best musicians. Cognition 55 269-310
Coon, E.H. (1951) The deafness of Beethoven. Wet. Med. News 24 11
Ernest, G. (1927) The Sick Beethoven. Med. World 12 491
Forster, W. (1956) Beethoven's diseases and their assessment. Breitkopf-Härtel
Frimmel, Th. (1880) Beethoven's suffering and end. The press 8-IX
Frimmel, Th. (1912) Beethoven's deafness. In: Beethoven's research 3 82
Hirsch, A. (1886) Hdb. D. Hist. Geographer. Pathol. 2nd ed.
Jacobsohn, L. (1900) L.v. Beethoven's hearing problems and last illness. German med. Wschr. 53 1610
Jacobsohn, L. (1900) L.v. Beethoven's hearing problems. German med. Wschr. 34 1282
Joy, M (1996) Beethoven's final illness. Lancet 347 767
Kenneth, M.S., Hemenway, W.G. (1979) Beethoven's Deafness. Jama 213 434-437
Laskiewicz, A. (1964) Ludwig van Beethoven's tragedy from the audiological point of view Journal of Laryngology, Rhinology, Otology and its Frontier Areas 18 261-270
Ley, St. (1936) Beethoven's last sick bed. Med. World 10 1058
Mallardi, V. (1999) L'Angolo della storia Beethoven, la sorditá di un genio tra vita e mito. Acta Otorhinolaryngol Ital 19, 166-177
Marage, G. (1928) Nature de la surdité des Beethoven. Acad. Sci. (Paris) 186 110
McCabe, B. (1958) Beethoven's deafness. Ann. Otol. (St. Louis) 67 192
McCabe, B.F. (1958) Beethoven's Deafness. Ann. Otol. Rhinol. Laryngol. 67 192-206
Neumann, H. (1927) Beethoven's hearing problems. Medical Weekly 31
Ogrodnick, J. (1996) Bugs, bellows and Beethoven-photographing insects. J. Audiov. Media Med. 19 17-21
Pfuhl, J. (1933) Beethoven's deafness. Ciba Z., Basel 121
Rolland, R. (1929) Beethoven. His great creative epochs. Translated from Th. Mutzenbacher, Frankfurt / M
Rolland, R. (1929) Beethoven's deafness. The island ship 11 38
Schindler, A.F. (1909) Biography of Ludwig van Beethoven. Muenster
Schmidt, F.A. (1928) Once again Beethoven's hearing problems and last illness. German Med. Wschr. 54 284
Schweisheimer, W. (1922) Beethoven's suffering. Munich
Thayer, Alexander Wheelock (1923) Ludwig van Beethoven's life. H. Riemann eds. Vol. III / IV
Wegeler, F.G., Ries, F. (1927) Biographical notes on Ludwig van Beethoven. In: St. Leys Hbg. (Bonn) 13
Zenner, H.P. (2001) Pathophysiology of chronic inner ear hearing loss ENT practice today 21 1-26
Zenner, H.P., Engel, A., Löwenheim, H. (2001) Pharmacology of chronic inner ear hearing loss, research and outlook. ENT practice today 21 27-43
1. Baratoux G, Natier M: (1905) A propos de la surdité de Beethoven. Chron. Med. 13 492
2. Beleites E: (1994) Inaugural Lecture Jena-Univ.-ENT Clinic
3. Bertein P, Apperece R: (1930) Le cas Beethoven Oto-rhino-laryng. Int 14 113
4. Biliancioni G: (1921) La sordita di Beethoven. G. Med. Milit. 11 521
5. Björntorp P: (1998) Vad dog Beethoven av? Läkartidningen 95 No. 20 2364-2367
6. Bonnier, P., Gernault, P. (1905) La surdité de Beethoven. Chron. Med. 13 521
7. Boutaric, J.-J. (2000) Une enigma médicale: Ludwig van Beethoven. LA Revue du Praticien 50 125-127
8. Brunger, E. (1942) Considerations on Beethoven's Disease. Med. Diss., Cologne
9. Chalat, N.I. (1980) Some psychologic aspects of deafness: Beethoven, Goya, and Oscar Wilde American Journal of Otology 1/4 240-246
10. Clynes, M. (1995) Microstructural musical linguistics: composers' pulses are liked most by the best musicians. Cognition 55 269-310
11. Coon, E.H. (1951) The deafness of Beethoven. Wet. Med. News 24 11
12. Ernest, G. (1927) The Sick Beethoven. Med. World 12 491
13. Forster, W. (1956) Beethoven's diseases and their assessment. Breitkopf-Härtel
14. Frimmel, Th. (1880) Beethoven's suffering and end. The press 8-IX
15. Frimmel, Th. (1912) Beethoven's deafness. In: Beethoven's research 3 82
16. Hirsch, A. (1886) Hdb. D. Hist. Geographer. Pathol. 2nd ed.
17. Jacobsohn, L. (1900) L.v. Beethoven's hearing problems and last illness. German med. Wschr. 53 1610
18. Jacobsohn, L. (1900) L.v. Beethoven's hearing problems. German med. Wschr. 34 1282
19. Joy, M (1996) Beethoven's final illness. Lancet 347 767
20. Kenneth, M.S., Hemenway, W.G. (1979) Beethoven's Deafness. Jama 213 434-437
21. Laskiewicz, A. (1964) Ludwig van Beethoven's tragedy from the audiological point of view Journal of Laryngology, Rhinology, Otology and its Frontier Areas 18 261-270
22. Ley, St. (1936) Beethoven's last sick bed. Med. World 10 1058
23. Mallardi, V. (1999) L'Angolo della storia Beethoven, la sorditá di un genio tra vita e mito. Acta Otorhinolaryngol Ital 19, 166-177
24. Marage, G. (1928) Nature de la surdité des Beethoven. Acad. Sci. (Paris) 186 110
25. McCabe, B. (1958) Beethoven's deafness. Ann. Otol. (St. Louis) 67 192
26. McCabe, B.F. (1958) Beethoven's Deafness. Ann. Otol. Rhinol. Laryngol. 67 192-206
27. Neumann, H. (1927) Beethoven's hearing problems. Medical Weekly 31
28. Ogrodnick, J. (1996) Bugs, bellows and Beethoven-photographing insects. J. Audiov. Media Med. 19 17-21
29. Pfuhl, J. (1933) Beethoven's deafness. Ciba Z., Basel 121
30. Rolland, R. (1929) Beethoven. His great creative epochs. Translated from Th. Mutzenbacher, Frankfurt / M
31. Rolland, R. (1929) Beethoven's deafness. The island ship 11 38
32. Schindler, A.F. (1909) Biography of Ludwig van Beethoven. Muenster
33. Schmidt, F.A. (1928) Once again Beethoven's hearing problems and last illness. German Med. Wschr. 54 284
34. Schweisheimer, W. (1922) Beethoven's suffering. Munich
35. Thayer, Alexander Wheelock (1923) Ludwig van Beethoven's life. H. Riemann eds. Vol. III / IV
36. Wegeler, F.G., Ries, F. (1927) Biographical notes on Ludwig van Beethoven. In: St. Leys Hbg. (Bonn) 13
37. Zenner, H.P. (2001) Pathophysiology of chronic inner ear hearing loss ENT practice today 21 1-26
38. Zenner, H.P., Engel, A., Löwenheim, H. (2001) Pharmacology of chronic inner ear hearing loss, research and outlook. ENT practice today 21 27-43
Beethoven's deafness: "I have to live like an exile"

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