Oliver Sacks: People come to me with their experiences and predicaments of music, sometimes of various musical disorders and sometimes of the remarkable powers of music, and both are positive in a negative way. So I am given stories and I am a storyteller. Although my book is subtitled Tales of Music and the Brain, really my field is music and the individual. I thought of giving it a William James-like title and calling it The Varieties of Music Experience.
So I'm a storyteller, but the sort of stories I hear and the stories I tell I then want to bring to my scientific colleagues to try and find out what's actually going on in the brains of these people. The newer science of music pioneered here in Montreal has expanded in an incredible way in the last 15 years. We now have very subtle methods of looking at the brain in real time when people are listening to music, imagining music, hallucinating music, composing music, playing with music, and so forth.
There are many, many different aspects of music. There's not only pitch and tone, there's rhythm, there's the timbre or quality of tones, there's the melodic contour, and there is no one part of the brain which is the music centre. Different aspects of music involve different parts of the brain and their interaction, like an orchestration. And in fact a lot more of the brain is concerned with the perception and imagination and response to music than, for example, with the perception of language.
A great deal of the brain is recruited for music, though in a way which may differ a good deal in different individuals. A delightful, intelligent woman of 70 or so...I used to regard that as old but now being 74 I regard it as just normal...and she described really a life of bewilderment and worse with regard to music. She said that when she'd been a little girl and the other children were asked to sing their names, she couldn't sing her name, she didn't know what was meant by singing. She was puzzled by the contortions and noises which emanated from the others.
When there were classes in music appreciation, she was given five or six tunes, the 'William Tell Overture' and others, she couldn't distinguish them. She said that she comes from a rather musical family and her father decided to get a Victrola, an old gramophone, and train her. But this wasn't really of any help. Her mother was somewhat accusing and said, 'What have you got against music?' But a family friend was able to test her a bit and found that she had great difficulty telling whether one note was higher or lower than another.
And basically this lady, Dolores, 'DL', as I call her in the book, doesn't 'get' tones or semitones. She lacks the building blocks for making a scale, for hearing a melody, and she really can't conceive what melody is, but she has been tantalised and fascinated by the fact that all the other people she has ever met do appreciate music and she herself has been at pains to go to concerts and to let herself be taken to concerts, even though, she says, the experience for her is somewhere between unintelligible and excruciating.
And she said if I wanted to know what her experience of music was like I should go into the kitchen and throw the pots and pans on the floor, and that was what it was like for her. I was really rather shaken when she said that. She said that in 1998 or 1999 she'd seen an article in the New York Times saying that people in Montreal were investigating a condition apparently similar to what she had. Basically she was told three things which were very clarifying to her. First of all she was told that she was not neurotic and 'against music' as her mother used to say, but that she had basically a biological condition, a neurological condition, a brain condition, which she shared with other people with congenital amusia. The most valuable piece of advice she was told; you don't have to go to concerts anymore. And she said she wishes she could have been told that when she was seven and not 70.
So this is amusia. There is a small anatomical abnormality apparently in the right frontal lobe in people with congenital amusia. I've very recently heard of a family in Ireland where there are eight siblings, four of whom are intensely musical and four of whom have amusia. I think work is being done in Ireland and partly here which will start to define some of the biological basis of this.
The group in Montreal but other groups have been comparing the brains of musicians with the brains of non-musicians. In particular a worker called Gottfried Schlaug at Harvard has published over the years a series of fascinating studies, however one is to interpret them, and showing rather striking differences between the brains of musicians and non-musicians. The original study showed that the corpus callosum, the big band of white matter between the cerebral hemispheres, can be enlarged in musicians. Subsequent studies have shown enlargement and thickening of the cortex of the grey matter in many parts of the brain, not only in the auditory parts of the brain but also in some of the visual and special parts of the brain, in the motor parts of the brain, and even down in the cerebellum and various subcortical structures. These changes can be visible really to the naked eye.
Once a musical system...once the networks are set up and established and interconnected, the musical system (if one can put it that way) tends to be very robust, perhaps partly because it calls on so many parts of the brain, and I think an especially striking effect of this is that in something like Alzheimer's disease where there's extensive cortical involvement and where people may become demented and so demented that they lose the use of language and much else, they will virtually always be able to recognise and respond to music they have heard.
A woman, Mary Ellen Geist, wrote me a letter about her father. She said that he's had Alzheimer's for 13 years and now was very damaged. She said he can't remember much of anything about his life. However, he remembers the baritone part to almost every song he has ever sung. He has performed with a 12-man a cappella singing group for almost 40 years. Music is one of the only things that keep him grounded in this world. He has no idea what he did for a living, where he is living now or what he did ten minutes ago. Almost every memory is gone except for the music.
And she described how he was still able to perform at a professional level. The evening he performed he had no idea how to tie a tie (well, I usually stick to t-shirts), he got lost on the way to the stage, but the performance was perfect. A couple of months later I was able to see Woody and his family, at least his wife and a daughter. They came to my office and my little neurological office got filled with song, which was really very, very remarkable to see that this man who was so confused and not there, disorientated, seemed completely there when he sung a song, and not only technically, but he would turn to his wife and his daughter and all the sensibility and intelligence and humour which had gone into the learning of the song originally still seemed to be there.
He was actually a very sweet, easygoing man, and I was reminded here of a story which is told of Emerson. Emerson became quite demented in his 60s but when people would ask him how he was he would say, 'I've lost my mental faculties but I'm perfectly well, thank you.' And at a time when Alzheimer's seems to carry so much stigma and shame and misery and mortification, it's lovely to have that sort of serenity.
So this was a man, then, who like an amnesic had lost the events of his life, in a way had lost his autobiography, but the procedures, the performances, of being able to sing at a wonderful level were completely intact. So something like this shows one different forms of memory. This is common in people with amnesia and Alzheimer's, that you lose explicit memory, the memory of events and facts, but what's called implicit memory, the memory which allows you to perform, is still there and stays with you.
You're too young to worry about this, but at my age one worries about Alzheimer's, but it's nice to know that the powers of performance and skill like this are really almost indelibly recorded and locked away using more primitive parts of the brain, especially the cerebellum and basal ganglia, and even if you get wiped out at the top, these deep parts of the brain still have a great deal. In terms of therapy this means that even people who are much more deeply demented than Woody and even people who are not particularly musical will respond to music.
My first glimpse of the therapeutic power of music came with a different sort of patient. It came in the mid 60s with the deeply Parkinsonian patients whom I later described in Awakenings. These were people who were frozen, transfixed, often unable to initiate any movement or any speech, but music would allow them to move, music would give them its flow, music would let them walk and dance and sing in the most astonishing way.
I took a poet I knew to see one of these therapy sessions, and he immediately quoted an aphorism of Novalis which is 'Every disease is a musical problem, and every cure is a musical solution.' This is sort of too pat, but in a way it does seem to apply to something like Parkinsonism where the person cannot themselves initiate movement, where they don't have any motor flow or motor rhythm.
I think what goes on here is, again, something which has been especially investigated in Montreal which is the very intimate connections between auditory system and motor system. All human beings respond to the beat of music. One keeps time with it; if not physically then mentally one dances. You see children of two or three who start to dance to external music or internal music. You don't see a chimpanzee dancing.
It's true that there's the Thai elephant orchestra, but if you've ever listened to that or seen pictures you will see that although the lead elephant using its trunk can beat a drum with great precision at 72 to 73 beats a minute, the other elephants don't synchronise, and it's the most incredible cacophony or pandemonium. So this sort of synchronisation is an essentially human thing. In the individual it leads one to dance, I think it leads Parkinsonians to move. It may, incidentally, be a reason for supposing that at least some of music, that the rhythmic aspects of music and synchronisation to this have an origin independent from language because this sort of rhythmic pulse in music and keeping time to it has really no analogue in language.
The sort of music which is important for people with Parkinson's, the music has to have rhythm. So the music doesn't have to be familiar, it doesn't have to be liked but it has to have rhythm.
Nietzsche wrote a very angry book about Wagner when he fell out with Wagner, and Nietzsche spoke about the pathological in music, as he called it, and for him this was exemplified by what he called the degeneration of the sense of rhythm in Wagner. Anyhow, Wagner doesn't work if you have Parkinsonism. Separately I might talk about people who have seizures induced by music, but I've read of one patient who had seizures induced by Wagner, and I also understand that very well. Even if one doesn't visibly or externally keep time with music and even if you're just imagining music to yourself, the motor parts of the brain are still involved. So imagining music is not just a purely auditory experience, any more than listening to music. It's an essentially motor experience and it's essentially in time and involves a sort of internal music.
So, given music, a Parkinsonian in a motor sense can perform normally; when the music stops, he stops. With someone with Alzheimer's you are appealing to their emotions and their memories and their identities, and the effect is more complex, but if it works it may also last longer. So people with Alzheimer's may be in much better shape for several hours after a music therapy session.
A special and interesting, a really extraordinary use of music, which has really only been strongly confirmed, robustly confirmed in the last year or two, again, especially by Schlaug at Harvard, is the use of music in people who have lost expressive language, who have aphasia as a result of a stroke, usually in the left frontal part of the brain. People unable to utter a word are usually able to sing, and not only to sing but to sing with words, to get the lyrics. This in itself may amaze them and everyone else because it's thought that they've lost language completely and yet you find that language is still available, even though it may be embedded or locked in the music. The question is then whether one can disembed language from music and get it from its certain bed of rather automatic quality to an independent propositional quality.
This is a matter still of some dispute, but I think with intensive therapy, so-called melodic intonation therapy, it may be possible for people who have shown no natural recovery from an aphasia and very little response to speech therapy, it may be possible for them to regain language and doing so apparently by employing equivalent areas in the right hemisphere of the brain, which are normally rather non-verbal. But if this is fully confirmed it will a most amazing example, really, of cerebral plasticity.
Beside the good powers of music there are some bad powers as well. I think many of us, even if we can't voluntarily summon a tune, tend to have music going through our head. We often discover this, we realise that something has been going through the mind for a long time. I think that the music which goes through the head, which is usually pleasant and companionable, can usually be associated with something one has heard or thought or felt or read. It has some meaning, it is relevant.
A particular form of this is the sort of music I think which may come involuntarily to one with various activities. I know, for example, many cyclists who, if they don't have external iPods, have, as it were, internal iPods and have invigorating music which will make them cycle better. I know for myself as a swimmer, with the sort of 'one two three, one two three' of freestyle, the 'one two three, one two three' suggests a waltz, and a waltz suggests Strauss, and I find myself involuntarily swimming to Strauss. Although the other day, for some reason, it was Tchaikovsky and it was a waltz from Eugene Onegin.
However, that waltz which was appropriate when I was swimming then went through my mind for the rest of the day, in particular a sort of 20-second loop of it kept going round and round, and when this happens then involuntary musical imagery takes on a rather pathological quality. It ceases to be connected to context, it becomes mechanical, fragmentary, it makes no sense, it's uncontrollable, and this is what the music industry in Germany originally called an Ohrwurm, an 'earworm', although I prefer to call it a 'brain worm'.
Let me read you a little bit of description. A friend of mine described to me how he had been fixated on the song 'Love and Marriage', a tune written by James Van Heusen. A single hearing of the song, a Frank Sinatra rendition used as the theme song of the television show Married with Children, was enough to hook him. He got trapped inside the tempo of the song and it ran in his mind almost constantly for ten days. With incessant repetition it soon lost its charm, its lilt, its musicality and its meaning. It interfered with his school work, his thinking, his peace of mind, his sleep. He tried to stop it in a number of ways; 'I jumped up and down. I counted to a hundred. I splashed water on my face. I tried talking loudly to myself,' but none of this worked, and finally it faded away, although of course when he told me the story it came back.
Earworms are universal, and perhaps commoner now for various reasons, not least because of the sort of mischievous research done by the music industry and by advertising and films and television who are concerned to design songs which will hook the mind and will get in and go round and round and can't be stopped. Even if an earworm starts pleasantly, like anything uncontrollable it tends to become unpleasant. Curiously, in an 1870-ish story by Mark Twain there's a lovely description of an earworm, a jingle, as he calls it, which gets into the narrator and he finds his feet involuntarily keeping time to it. It keeps him awake at night. He finally goes to his pastor and confesses this, and the pastor is then infected with the earworm. The pastor mentions it to his congregation and all of them...these things have been called contagious musical viruses.
But I'm not sure that the brain is sensitive to anything else in quite this way. It's true that after horrific scenes or trauma one can have involuntary images and flashbacks of a terrible sort going through the mind, but this needs great trauma or something unusual, whereas I think almost anything can set off an earworm. Whether they are getting commoner now that music is ubiquitous...I don't know how it is in Montreal, but in New York you can't go into a café, a bar or restaurant or swimming pool or mall or anywhere without being bombarded at high volume with music you didn't order and which you don't like and which you find meaningless. But finding it meaningless and not liking it is no protection against an earworm. On the contrary, I think it may make an earworm more likely.
I want to say something about a phenomenon I've been especially interested in and which I think is not uncommon, although there's insufficient awareness of it, and these are musical hallucinations. It's one thing to imagine some music and even to have an earworm, but to have a hallucination is completely different. If you have a hallucination you are suddenly startled, it is physically loud, it is detailed, you wonder if other people hear it, you look around, you want to find the source of the music.
I first heard of this in the 1970s from one of my patients, an old lady who was woken in the middle of the night by hearing Irish songs played with deafening intensity. She was very surprised that someone had turned on the radio at full blast in the middle of the night, and even more surprised when she found that everyone else was asleep, as if bewitched. She couldn't find a radio. She then wondered whether a filling in her tooth could act as a transistor or crystal radio, she'd heard this.
But finally, as songs kept repeating themselves without any commentary, without any words, and only songs she knew, she started to feel this must be a very strange radio station indeed and that it had to be in her head. Mechanical terms are nearly always used by people with such hallucinations. It follows the technology. In the 1890s people would hear a music box. In the 1960s there would be mad neighbour who was putting on a record again and again, and now it's iPods.
I think I'm going to read you again a bit of a letter from another charming and creative woman of 70...I seem to see a great many charming and creative women of 70...and she wrote to me about her...you decide what they were. She said, 'They first started last November when I was visiting my sister and brother-in-law one night. After turning off the TV and preparing to retire, I started hearing 'Amazing Grace.' It was being sung by a choir, over and over and over again. I checked with my sister to see if they had some church service on TV, but they had Monday night football, or some such. So I went onto the deck overlooking the water. The music followed me. I looked down on the quiet coastline and the few houses with lights and realised that the music couldn't possibly be coming from anywhere in that area. It had to be in my head.' And then she went on and described to me what she called her 'play list'.
Usually with such hallucinations you start with a single tune which tends to be...I would say which is invariably something one heard in one's youth, in one's first 20 years. With a lot of the people I see it may be a hymn or a popular song, and then other things are added to it. One of my correspondents wrote to me about what he called his intracranial jukebox and how this had a repertoire of about 20 songs. He couldn't stop it, although he could switch...he learned to switch from one song to another, provided there was a sufficient similarity of rhythm or melody or theme. These things are unstoppable. This lady, her play list included the 'Battle Hymn of the Republic', Beethoven's 'Ode to Joy', the 'Drinking Song' from La Traviata, and what she called a really dreary version of 'We Three Kings of Orient Are'.
'One night', she continued, 'I heard a splendidly solemn rendition of 'Old Macdonald Had a Farm', followed by thunderous applause. At that moment I decided that as I was obviously completely bonkers I'd better get the matter looked into.' So she'd heard from some people that Lyme disease might have musical hallucinations. She'd head that people that take too much aspirin can have musical hallucination; she'd been taking a lot. So she had herself checked out.
In fact about three-quarters or more of the people with musical hallucinations are pretty deaf, and sometimes the hallucinations will come on with a further critical loss of hearing. It's as if when the auditory parts of the brain aren't getting sufficient input, sufficient nourishment, then they start to make an output of their own, and in particular to fish out and regurgitate musical memories.
It's interesting that it's only music that tends to come up here. Despite the thunderous applause there's usually not much in the way of noise and almost nothing in the way of voices. And when people get musical hallucinations they can be very frightened and very bewildered, partly because this is something uncontrollable and intrusive, but partly because the idea of hallucination and hearing things is associated in their mind, in the public mind and the medical mind, with psychosis and schizophrenia. Hearing music has none of the qualities of hearing voices. Voices are accusing, humiliating, seductive, whatever, they're addressed to one, they seem to have a feeling of agency. None of this applies to the musical hallucinations, this is always felt as something mechanical; the jukebox, the iPod or whatever.
The music may be very much at odds with one's tastes. This came up very strongly with one patient I saw who told me rather angrily that his hallucinations were tonal and corny. I thought that was a very odd choice of adjectives. But he said his wife was an eminent composer of atonal music and his own tastes were for Schoenberg and others, and it was a very elitist taste generally. But what he heard first were what he called disgustingly sentimental German lullabies which dated from his early years growing up, he was born in Germany in the 1920s. And then, terrifyingly, he started to heard Nazi marching songs, and as a Jewish boy in Hamburg in the 1930s sort of fearful of being set on by the Hitler Jugend, these were very terrifying for him, although later they changed and after that he started to hear bits of Tchaikovsky's Fifth Symphony. This was not to his taste either, too noisy, emotional, rhapsodic.
You mustn't think that my practice consists entirely of charming and creative ladies of 70. Musical hallucinations can occur at younger ages. I saw one nine-year-old boy who, by his father's account, probably had these from the age of four when sometimes sitting at the back of the car he would block his ears and scream and ask his father to turn off the car radio when it wasn't on.
There is, by the way, an analogy there, something like 10% of people with significant visual impairment or blindness get visual hallucinations of a complex sort, and these, again, can be frightening and misunderstood as something psychotic. They're not. The brain has to keep active, and if it's not getting its right input—musical, auditory or visual—then it will generate one.
Once more, I am basically a storyteller, a listener and a storyteller and an observer, and what I observe and what I hear I want to give to my scientific colleagues so they can explain it and find out what's going on. My book has 29 sections and I've only made reference to about five or six of them. I'd be happy to make reference to the other 22; synaesthesia, absolute pitch, Williams syndrome, music savants, you say it, but I think at this point I shall solicit your questions. Thank you.