by Oliver Sacks
NICK VAN BLOSS, a young English musician, has Tourette’s of considerable severity— he reckons that he has nearly forty thousand tics a day, including his obsessions, imitations, counting compulsions, compulsive touchings, and so on. But when he plays the piano, he shows scarcely a hint of this. I asked him to play some Bach for me (Bach is his favorite composer, and Glenn Gould is his hero), and he did so without interruption. The only tics he displayed, a mild facial grimacing, were far less disturbing, I thought, than Gould’s famous humming. Van Bloss developed his first, rather explosive symptoms when he was seven, attracting savage ridicule and bullying from his schoolmates. There was no intermission in his ticcing until his family got a piano, and this was to transform his life. “Suddenly I had a piano,” he writes in his memoir, Busy Body, “and, as if handed to me on a plate, I found my love…. When I played, my tics almost seemed to disappear. It was like a miracle. I would tic, gyrate, and verbally explode all day at school, get home exhausted from it all and run to the piano and play for as long as I could, not only because I loved the sounds I was making, but primarily because when I played I didn’t tic. I got time off from the ticcy normality that had become me.”
When I discussed this with van Bloss, he spoke of it partly in terms of “energy”— it was not, he felt, that his Tourette’s had disappeared, but that it was now being “harnessed and focused” and, specifically, that his compulsions to touch could now be consummated by touching the keys of the piano. “I was simultaneously feeding and fuelling my Tourette’s by giving it a thing it so craved: touch,” he writes. “The piano appealed to my fingers…provided touch heaven for me— eighty-eight keys all sitting and waiting for my needy little fingers.”
Van Bloss feels that his repertoire of tics was fully developed by the age of sixteen and has changed little in the years since, but he is now far more accepting of them, for he recognizes that his Tourette’s, in a paradoxical way, plays an essential role in his piano playing.
I found it especially fascinating to listen to a conversation between Nick van Bloss and Tobias Picker, the distinguished composer, who also has Tourette’s— to listen to them compare notes on the role that Tourette’s has played in their music making. Picker also has many tics, but when he is composing or playing the piano or conducting, his tics disappear. I have watched him as he sits almost motionless for hours, orchestrating one of his études for piano at his computer. The tics may have vanished, but this does not mean that the Tourette’s itself has gone. Picker feels, on the contrary, that his Tourette’s enters into his creative imagination, contributing to his music but also being shaped and modulated by it. “I live my life controlled by Tourette’s,” he said to me, “but I use music to control it. I have harnessed its energy— I play with it, manipulate it, trick it, mimic it, taunt it, explore it, exploit it, in every possible way.” His newest piano concerto, in some sections, is full of turbulent, agitated whirls and twirls. But Picker writes in every mode— the dreamy and tranquil no less than the violent and stormy— and moves from one mood to another with consummate ease.
Tourette’s brings out in stark form questions of will and determination: who orders what, who pushes whom around. To what extent are people with Tourette’s controlled by a sovereign “I,” a complex, self-aware, intentional self, or by impulses and feelings at lower levels in the brain-mind? Similar questions are brought up by musical hallucinations, and brainworms, and varied forms of quasi-automatic echoing and imitation. Normally we are not aware of what goes on in our brains, of the innumerable agencies and forces inside us that lie outside or below the level of conscious experience— and perhaps this is just as well. Life becomes more complicated, sometimes unbearably so, for people with eruptive tics or obsessions or hallucinations, forced into daily, incessant contact with rebellious and autonomous mechanisms in their own brains. They face a special challenge; but they may also, if the tics or hallucinations are not too overwhelming, achieve a sort of self-knowledge or reconciliation that may significantly enrich them, in their strange fight, the double lives they lead.
19
Keeping Time: Rhythm and Movement
Nineteen seventy-four was an eventful year for me, in several respects, for it was a year in which I had musical hallucinations, twice; attacks of amusia, twice; and the complex musico-motor events I would later describe in A Leg to Stand On. I had had a bad climbing accident on a mountain in Norway, tearing off the quadriceps tendon of my left leg, as well as doing some nerve damage to it. The leg was useless, and I had to find a way to get down the mountain before nightfall. I soon discovered that the best strategy was to “row” myself down, somewhat as paraplegics do in their wheelchairs. At first I found this difficult and awkward, but soon I fell into a rhythm, accompanied by a sort of marching or rowing song (sometimes “The Volga Boatmen’s Song”), with a strong heave on each beat. Before this I had muscled myself along; now, with the beat, I was musicked along. Without this synchronization of music and movement, the auditory with the motor, I could never have made my way down the mountain. And somehow, with this internal rhythm and music, it felt much less like a grim, anxious struggle.
I was rescued halfway down the mountain and taken to a hospital, where my leg was examined, X-rayed, and put into a cast, and then I was flown to England, where, forty-eight hours after the injury, I had surgery to repair the tendon. Nerve and other tissue damage had to await a natural healing, of course, and there was a fourteen-day period, therefore, in which I could not use the leg. Indeed, it seemed to be both numb and paralyzed, and not really even a part of me. On the fifteenth day, when it was judged safe for me to put weight on the leg, I found that I had, strangely, “forgotten” how to walk. There was only a sort of pseudo walking— conscious, cautious, unreal, step-by-step. I would make steps that were too large or too small, and on a couple of occasions managed to cross the left leg in front of the right one, almost tripping on it. The natural, unthinking spontaneity, the automaticity of walking completely evaded me until again, suddenly, music came to my aid.
I had been given a cassette of Mendelssohn’s Violin Concerto in E minor— this was the only music I had, and I had been playing it for two weeks almost nonstop. Now suddenly, as I was standing, the concerto started to play itself with intense vividness in my mind. In this moment, the natural rhythm and melody of walking came back to me, and along with this, the feeling of my leg as alive, as part of me once again. I suddenly “remembered” how to walk.
The neural systems underlying the newly rediscovered skill of walking were still fragile and easily exhausted, and after half a minute or so of fluent walking, the inner music, the vividly imagined violin concerto, stopped suddenly, as if the needle had been lifted from a record— in that instant, walking stopped, too. Then, after I had rested for a while, the music and motion came back to me, again in tandem.
After my accident, I wondered if this sort of experience occurred with others. And barely a month had gone by when I saw a patient at a nursing home— an old lady with an apparently paralyzed and useless left leg. She had suffered a complex hip fracture, followed by surgery and many weeks of immobility in a cast. Surgery had been successful, but her leg remained strangely inert and useless. Though there was no clear anatomical or neurological reason for this, she told me she could not imagine how to move the leg. Had the leg ever been able to move since the injury? I asked her. She thought for a moment and said yes, it had— once: it had kept time at a Christmas concert, “by itself,” when an Irish jig was being played. This was enough; it indicated that whatever was going on, or not going on, in her nervous system, music could act as an activator, a de-inhibitor. We bombarded her with dance tunes, especially Irish jigs, and saw for ourselves how her leg responded. It took several months, for the leg had become very atrophied; nevertheless, with music, she was not only able to delight in her own quasi-automatic motor responses— which soon included walking— but to extract from them an ability to make whatever discrete, voluntary mov
ements she desired. She had reclaimed her leg, and her sensorimotor system, in full.
* * *
HIPPOCRATES, more than two thousand years ago, wrote of people who fell and broke their hips, which in those presurgical days demanded months of bandaging and immobility to let the bones knit. In such cases, he wrote, “the imagination is subdued, and the patient cannot remember how to stand or walk.” With the advent of functional brain imaging, the neural basis of such “subduing” has been clarified.1 There may be inhibition or deactivation not only peripherally, in the nerve elements of the damaged tendons and muscles and perhaps in the spinal cord, but also centrally, in the “body image,” the mapping or representation of the body in the brain. A. R. Luria, in a letter to me, once referred to this as “the central resonances of a peripheral injury.” The affected limb may lose its place in the body image, while the rest of the body’s representation then expands to fill the vacancy. If this happens, the limb is not only rendered functionless, it no longer seems to belong to one at all— moving such a limb feels like moving an inanimate object. Another system must be brought in, and it is clear that music, above all else, can kick-start a damaged or inhibited motor system into action again.
Whether it was the singing of a simple rowing song on the mountain or the vivid imagining of the Mendelssohn Violin Concerto when I stood up in the hospital, the rhythm or beat of the music was crucial for me, as it was for my patient with the fractured hip. Was it just the rhythm or beat of the music, or was the melody, with its movement, its momentum, also important?
Beyond the repetitive motions of walking and dancing, music may allow an ability to organize, to follow intricate sequences, or to hold great volumes of information in mind— this is the narrative or mnemonic power of music. It was very clear with my patient Dr. P., who had lost the ability to recognize or identify even common objects, though he could see perfectly well. (He may have suffered from an early, and primarily visual, form of Alzheimer’s.) He was unable to recognize a glove or a flower when I handed it to him, and he once mistook his own wife for a hat. His condition was almost totally disabling— but he discovered that he could perform the needs and tasks of the day if they were organized in song. His wife explained to me:
I put all his usual clothes out, in all the usual places, and he dresses without difficulty, singing to himself. He does everything singing to himself. But if he is interrupted and loses the thread, he comes to a complete stop, doesn’t know his clothes— or his own body. He sings all the time— eating songs, dressing songs, bathing songs, everything. He can’t do anything unless he makes it a song.
Patients with frontal lobe damage may also lose the ability to carry out a complex chain of actions— to dress, for example. Here, music can be very useful as a mnemonic or a narrative— in effect, a series of commands or promptings in the form of rhyme or a song, as in the childhood song “This Old Man.” It is similar with some autistic people and with severely retarded people, who may be unable to perform fairly simple sequences involving perhaps four or five movements or procedures— but who can often do these tasks perfectly well if they set them to music. Music has the power to embed sequences and to do this when other forms of organization (including verbal forms) fail.
Every culture has songs and rhymes to help children learn the alphabet, numbers, and other lists. Even as adults, we are limited in our ability to memorize series or to hold them in mind unless we use mnemonic devices or patterns— and the most powerful of these devices are rhyme, meter, and song. We may have to sing the “ABC” song internally to remember the alphabet, or imagine Tom Lehrer’s song to remember all the chemical elements. For someone who is gifted musically, a huge amount of information can be retained in this way, consciously or unconsciously. The composer Ernst Toch (his grandson Lawrence Weschler tells me) could readily hold in his mind a very long string of numbers after a single hearing, and he did this by converting the string of numbers into a tune (a melody he shaped “corresponding” to the numbers).
A neurobiology professor recounted to me the story of an extraordinary student, J., whose answers on one exam sounded suspiciously familiar. The professor wrote:
A few sentences later, I thought, “No wonder I like her answers. She’s quoting my lectures word for word!” There was also a question on the exam that she answered with a direct quote from the textbook. The next day, I called J. into my office to have a talk with her about cheating and plagiarism, but something did not add up. J. did not seem like a cheater; she seemed totally lacking in guile. So as she walked into my office, what came into my head and out of my mouth was the question, “J., do you have a photographic memory?” She answered very excitedly, “Yes, sort of like that. I can remember anything as long as I put it to music.” She then sang back to me from memory whole portions of my lectures (and very prettily too). I was flabbergasted.
While this student is, like Toch, extraordinarily gifted, all of us use the power of music in this way, and setting words to music, especially in preliterate cultures, has played a huge role in relation to the oral traditions of poetry, storytelling, liturgy, and prayer. Entire books can be held in memory— The Iliad and The Odyssey, famously, could be recited at length because, like ballads, they had rhythm and rhyme. How much such recitation depends on musical rhythm and how much purely on linguistic rhyming is difficult to tell, but these are surely related— both “rhyme” and “rhythm” derive from the Greek, carrying the conjoined meanings of measure, motion, and stream. An articulate stream, a melody or prosody, is necessary to carry one along, and this is something that unites language and music, and may underlie their perhaps common origins.
The powers of reproduction and recitation may be achieved with very little idea of meaning. One has to wonder how much Martin, my retarded savant patient, understood of the two thousand cantatas and operas he knew by heart or how much Gloria Lenhoff, a woman with Williams syndrome and an IQ under 60, actually comprehends the thousands of arias in thirty-five languages which she can sing from memory.
The embedding of words, skills, or sequences in melody and meter is uniquely human. The usefulness of such an ability to recall large amounts of information, especially in a preliterate culture, is surely one reason why musical abilities have flourished in our species.
* * *
THE RELATIONSHIP BETWEEN motor and auditory systems has been investigated by asking people to tap to a beat or, where commands cannot be given verbally (as with infants or animals), by observing whether there is any spontaneous synchronization of movement with an external musical beat. Aniruddh Patel at the Neurosciences Institute has recently pointed out that “in every culture there is some form of music with a regular beat, a periodic pulse that affords temporal coordination between performers, and elicits synchronized motor response from listeners.” This linking of auditory and motor systems seems universal in humans, and shows itself spontaneously, early in life. But, as Patel wrote in his 2006 paper, “there is not a single report of an animal being trained to tap, peck, or move in synchrony with an auditory beat.”2
The rather mechanical term “entrainment” is sometimes used in regard to the human tendency to keep time, to make motor responses to rhythm. But research has now shown that so-called responses to rhythm actually precede the external beat. We anticipate the beat, we get rhythmic patterns as soon as we hear them, and we establish internal models or templates of them. These internal templates are astonishingly precise and stable; as Daniel Levitin and Perry Cook have shown, humans have very accurate memories for tempo and rhythm.3
Chen, Zatorre, and Penhune in Montreal have studied the ability of human beings to keep time, to follow a beat, and they have used functional brain imaging to visualize how this is reflected in the brain. Not surprisingly, they found activation of the motor cortex and of subcortical systems in the basal ganglia and cerebellum when subjects tapped or made other movements in response to music.
What is more remarkable is their finding that lis
tening to music or imagining it, even without any overt movement or keeping time, activates motor cortex and subcortical motor systems, too. Thus the imagination of music, of rhythm, may be as potent, neurally, as actually listening to it.
Keeping time, physically and mentally, depends, as Chen and her colleagues have found, on interactions between the auditory and the dorsal premotor cortex— and it is only in the human brain that a functional connection between these two cortical areas exists. Crucially, these sensory and motor activations are precisely integrated with each other.
Rhythm in this sense, the integration of sound and movement, can play a great role in coordinating and invigorating basic locomotor movement. I found this when I was “rowing” myself down the mountain to “The Volga Boatmen’s Song,” and when the Mendelssohn enabled me to walk again. Musical rhythm can be valuable, similarly, to athletes, as the physician Malonnie Kinnison, a competitive cyclist and triathlete, observed to me:
I have been a competitive cyclist for a number of years and have always been interested in the individual time trial, an event that pits the rider against the clock only. The effort required to excel at this event is painful. I often listen to music while I am training, and noticed fairly early that some pieces of music were particularly uplifting and inspired a high level of effort. One day, in the early stages of an important time trial event, a few bars of the overture to “Orpheus in the Underworld” by Offenbach started playing in my head. This was wonderful— it stimulated my performance, settled my cadence at just the right tempo, and synchronized my physical efforts with my breathing. Time collapsed. I was truly in the zone, and for the first time in my life, I was sorry to see the finish line. My time was a personal best.