Musicophilia

by Oliver Sacks

  But if music is present, its tempo and speed take precedence over the parkinsonism and allow parkinsonian patients to return, while the music lasts, to their own rate of moving, that which was natural for them before their illness.

  Music, indeed, resists all attempts at hurrying or slowing, and imposes its own tempo.4 I saw this recently at a recital by the eminent (and now parkinsonian) composer and conductor Lukas Foss. He rocketed almost uncontrollably to the piano, but once there, played a Chopin nocturne with exquisite control and timing and grace— only to festinate once again as soon as the music ended.

  This power of music was invaluable with one extraordinary post-encephalitic patient, Ed M., whose movements were too fast on the right side of his body and too slow on the left side. We could not find any good way to medicate him, for whatever improved one side would worsen the other. But he loved music, and he had a small organ in his room. With this— and this only— when he sat down and played, he could bring his two hands, his two sides, together in unison and synchrony.

  A fundamental problem in parkinsonism is the inability to initiate movement spontaneously; parkinsonian patients are always getting “stuck” or “frozen.” Normally there is a virtually instantaneous commensuration between our intentions and the subcortical machinery (the basal ganglia, especially) that allows their automatic enaction. (Gerald Edelman, in The Remembered Present, refers to the basal ganglia, along with the cerebellum and hippocampus, as the “organs of succession.”) But it is the basal ganglia especially which are damaged in parkinsonism. If the damage is very severe, the parkinsonian may be reduced to virtual immobility and silence— not paralyzed but in a sense “locked in,” unable by himself to initiate any movement, and yet perfectly able to respond to certain stimuli.5 The parkinsonian is stuck, so to speak, in a subcortical box, and can only emerge from this (as Luria brings out) with the help of an outside stimulus.6 Thus parkinsonian patients can be called into action, sometimes by something as simple as throwing them a ball (though once they catch the ball or throw it back, they will freeze again). To enjoy any real sense of freedom, a longer release, they need something which can last over time, and the most potent unlocker here is music.

  This was very clear with Rosalie B., a post-encephalitic lady who tended to remain transfixed for hours each day, completely motionless, frozen— usually with one finger “stuck” to her spectacles. If one walked her down the hallway, she would walk in a passive, wooden way, with her finger still stuck to her spectacles. But she was very musical, and loved to play the piano. As soon as she sat down on the piano bench, her stuck hand came down to the keyboard, and she would play with ease and fluency, her face (usually frozen in an inexpressive parkinsonian “mask”) full of expression and feeling. Music liberated her from her parkinsonism for a time— and not only playing music, but imagining it. Rosalie knew all of Chopin by heart, and we had only to say “Opus 49” to see her whole body, posture, and expression change, her parkinsonism vanishing as the F-minor Fantasie played itself in her mind. Her EEG, too, would become normal at such times.7

  When I came to Beth Abraham in 1966, music was chiefly provided by the indefatigable Kitty Stiles, who spent dozens of hours each week at the hospital. Sometimes there was music from a record player or radio, though Kitty herself seemed to have a stimulating power of her own. Recorded music was not portable at this time— battery-powered radios and tape recorders were still large and heavy. Now, of course, everything has changed, and we can have hundreds of tunes on an iPod the size and weight of a matchbook. While the extreme availability of music may have its own dangers (I wonder whether brainworms or musical hallucinations are more common now), this availability is an unmitigated boon for those with parkinsonism. While most of the patients I see are the severely disabled residents of chronic care hospitals and nursing homes, I get letters from many parkinsonian people who are still relatively independent and living at home, perhaps with a little help. Recently Carolina Yahne, a psychologist in Albuquerque, wrote to tell me about her mother, who, because of Parkinson’s disease, had had great difficulty walking. “I made up a goofy little song,” the daughter wrote, “called ‘Walkin’ Mama’ that included a finger-snapping beat. I have a rotten voice, but she liked hearing it. She would play it with the tape recorder hooked on her waistband, and earphones. It really seemed to help her navigate around the house.”

  * * *

  NIETZSCHE WAS intensely interested, throughout his life, in the relationship of art, and especially music, to physiology. He spoke of its “tonic” effect— its power of arousing the nervous system in a general way, especially during states of physiological and psychological depression (he was himself often depressed, physiologically and psychologically, by severe migraines).

  He also spoke of the “dynamic” or propulsive powers of music— its ability to elicit, to drive, and to regulate movement. Rhythm, he felt, could propel and articulate the stream of movement (and the stream of emotion and thought, which he saw as no less dynamic or motoric than the purely muscular). And rhythmic vitality and exuberance, he thought, expressed itself most naturally in the form of dance. He called his own philosophizing “dancing in chains” and thought the strongly rhythmic music of Bizet as ideally suited to this. He would often take his notebook to Bizet concerts; he wrote, “Bizet makes me a better philosopher.”8

  I had read Nietzsche’s notes on physiology and art as a student, many years before, but his concise and brilliant formulations in The Will to Power came alive for me only when I came to Beth Abraham and saw the extraordinary powers of music with our post-encephalitic patients— its power to “awaken” them at every level: to alertness when they were lethargic, to normal movements when they were frozen, and, most uncannily, to vivid emotions and memories, fantasies, whole identities which were, for the most part, unavailable to them. Music did everything that L-dopa, still in the future, was subsequently to do, and more— but only for the brief span while it lasted, and perhaps for a few minutes afterwards. Metaphorically, it was like auditory dopamine— a “prosthesis” for the damaged basal ganglia.

  It is music that the parkinsonian needs, for only music, which is rigorous yet spacious, sinuous and alive, can evoke responses that are equally so. And he needs not only the metrical structure of rhythm and the free movement of melody— its contours and trajectories, its ups and downs, its tensions and relaxations— but the “will” and intentionality of music, to allow him to regain the freedom of his own kinetic melody.

  21

  Phantom Fingers: The Case of the One-Armed Pianist

  Some years ago I received a letter from Erna Otten, a piano student who had once studied with the Viennese pianist Paul Wittgenstein. Wittgenstein, she explained,

  had lost his right arm in World War I— I had many occasions to see how involved his right stump was whenever we went over the fingering for a new composition. He told me many times that I should trust his choice of fingering because he felt every finger of his right hand. At times I had to sit very quietly while he would close his eyes and his stump would move constantly in an agitated manner. This was many years after the loss of his arm.

  As a postscript, she added, “His finger choice was always the best!”

  The varied phenomena of phantom limbs were first explored in detail by the physician Silas Weir Mitchell during the Civil War, when great numbers of veterans came to the many hospitals established to treat their wounds, including what was known as the “stump” hospital in Philadelphia. Weir Mitchell, a novelist as well as a neurologist, was fascinated by the descriptions he received from these soldiers, and he was the first to take the phenomenon of phantom limbs seriously. (Prior to this, they had been regarded as purely “in the mind,” apparitions conjured up by loss and grief, like the apparitions of recently deceased children or parents.) Weir Mitchell showed that the appearance of a phantom limb occurred in every patient who had an amputation, and he surmised that it was a sort of image or memory of the lost limb
, a persistent neural representation of the limb in the brain. He first described the phenomenon in his 1866 short story “The Case of George Dedlow,” published in The Atlantic Monthly. It was only some years later, in his 1872 book Injuries of Nerves and Their Consequences, that he addressed his fellow physicians on the subject:

  [The majority of amputees] are able to will a movement, and apparently to themselves execute it more or less effectively…. The certainty with which these patients describe their [phantom motions], and their confidence as to the place assumed by the parts moved, are truly remarkable…the effect is apt to excite twitching in the stump…. In some cases the muscles which act on the hand are absent altogether; yet in these cases there is fully as clear and definite a consciousness of the movement of the fingers and of their change of positions as in cases [where the muscles to the hand are partially preserved].

  Such phantom memories and images occur to some extent in almost all amputees, and may last for decades. Although the phantoms may be intrusive or even painful (especially if the limb was painful immediately before amputation), they may also be of great service to the amputee, enabling him to learn how to move a prosthetic limb or, in the case of Wittgenstein, determine the fingering of a piano piece.

  Before Weir Mitchell’s account, phantom limbs were regarded as purely psychic hallucinations conjured up by bereavement, mourning, or yearning— comparable to the apparitions of loved ones that mourners may experience for some weeks after their loss. Weir Mitchell was the first to show that these phantom limbs were “real”— neurological constructs dependent on the integrity of the brain, the spinal cord, and the remaining, proximal portions of the sensory and motor nerves to the limb— and that their sensation and “motions” were accompanied by excitation in all of these. (That such an excitation in fact occurred during phantom motion was proved for him by its “overflow” into movements of the stump.)

  Recent neurophysiology has confirmed Weir Mitchell’s hypothesis that the entire sensory-ideational-motor unit is activated in phantom motions. Farsin Hamzei et al. in Germany described in 2001 how there can be striking functional reorganization in the cortex after the amputation of an arm— in particular, “cortical disinhibition and enlargement of the excitable area of the stump.” We know that movement and sensation continue to be represented in the cortex when the limb is physically lost, and Hamzei et al.’s findings suggest that the missing limb’s representation may be conserved and concentrated in the now-enlarged, hyperexcitable stump area of the cortex. This might explain why, as Otten noted, Wittgenstein’s stump moved “in an agitated manner” when he “played” with his phantom arm.1

  The last few decades have seen great advances in neuroscience and biomechanical engineering, advances particularly pertinent to the Wittgenstein phenomenon; and engineers are developing highly sophisticated artificial limbs with delicate “muscles,” amplification of nerve impulses, servomechanisms, and so on, that can be married to the still-intact portion of the limb and allow phantom motions to be turned into real ones. The presence of strong phantom sensations and of willed phantom movements is, indeed, essential to the success of such bionic limbs.

  Thus it seems possible, in the not-so-far-off future, that a one-armed pianist may be fitted with such a limb, and with it be able to play the piano again. One wonders what Paul Wittgenstein or his brother would have thought of such a development.2 Ludwig Wittgenstein’s final book speaks of our first, grounding certainty as being the certainty of our bodies; indeed, his opening proposition is, “If you do know that here is one hand, we’ll grant you all the rest.” Although Wittgenstein’s On Certainty is well known to have been written in response to the ideas of the analytic philosopher G. E. Moore, one must wonder, too, whether the strange matter of his brother’s hand— a phantom, indeed, but real, effectual, and certain— did not also play a part in inciting Wittgenstein’s thinking.

  22

  Athletes of the Small Muscles: Musician’s Dystonia

  In 1997 I received a letter from a young Italian violinist, who related to me how he had started playing the violin when he was six, had gone on to the conservatory, and then embarked on a career as a concert violinist. But then, at the age of twenty-three, he started to experience peculiar difficulties with his left hand— difficulties which, he wrote, “have cut short my career, and my life.

  “Playing pieces of a certain degree of difficulty,” he continued, “I found that the middle finger was not responding to my commands, and imperceptibly tended to shift from the position where I wanted to place it on the string, affecting the pitch.”

  He consulted a physician— one of many he was to consult in the years to come— and was told that the overwork of this hand had caused “an inflammation of the nerves.” He was advised to rest and desist from playing for three months— but this, he found, had no effect. Indeed, when he resumed playing, the problem had become worse, and the strange difficulty in controlling finger movement had spread to the fourth and fifth fingers. Now only the index finger remained unaffected. It was only when he played the violin, he stressed, that his fingers “disobeyed” him; they functioned normally in all other activities.

  He went on to describe an odyssey of eight years in which he had consulted physicians, physiotherapists, psychiatrists, therapists, and healers of every sort, all over Europe. He had been given many diagnoses: strained muscles, inflamed tendons, “trapped” nerves. He had undergone carpal tunnel surgery, faradization of nerves, myelograms, MRIs, and a great deal of intensive physical therapy and psychotherapy— all to no avail. Now, at thirty-one, he felt that he could no longer maintain any hope of resuming his career. He had a deep sense of bewilderment, too. He felt that his condition was organic, that in some way it came from his brain, and that if there were any peripheral factors, such as nerve injuries, these had at most played a subsidiary part.

  He had heard, he wrote, of other performers with similar problems. With almost all of them a seemingly trivial problem had grown steadily more severe, resisted all attempts at treatment, and ended performance careers.

  * * *

  I HAD RECEIVED a number of similar letters over the years and had always referred my correspondents to a neurologist colleague, Frank Wilson, who had written an important early paper in 1989, “Acquisition and Loss of Skilled Movement in Musicians.” As a result, Wilson and I had been corresponding about so-called focal dystonia in musicians for some time.

  The problems my Italian correspondent described were not, indeed, anything new— such problems have been observed for centuries, not only in players of musical instruments, but in a variety of other activities that demanded continuous, rapid movements of the hands (or other parts of the body) over long periods. In 1833, Sir Charles Bell, the famous anatomist, gave a detailed description of the problems that could affect the hands of people who wrote incessantly, such as clerks in government offices. He later called this “scrivener’s palsy,” though it was already well recognized among such writers, who called it “writer’s cramp.” Gowers, in his 1888 Manual (of diseases of the nervous system), devoted twenty close-packed pages to discussing writer’s cramp and other “occupation neuroses,” the generic term he adopted for “a group of maladies in which certain symptoms are excited by the attempt to perform some oft-repeated muscular action, commonly one that is involved in the occupation of the sufferer.”

  “Among clarks who suffer” writer’s cramp, Gowers said, “lawyers’ clarks constitute an undue proportion. This is no doubt due to the cramped style in which they commonly write. On the other hand, writers’ cramp is practically unknown among those who write more, and under higher pressure, than any other class, shorthand writers.” Gowers attributed this freedom to their using “a very free style of writing, generally from the shoulder, which is also adopted by them in long hand writing.”1

  Gowers spoke of the susceptibility of pianists and violinists to their own “occupation neuroses” other provocative occupations included “tho
se of painters, harpists, artificial flower makers, turners, watchmakers, knitters, engravers…masons…compositors, enamellers, cigarette makers, shoemakers, milkers, money counters…and zither players”— a veritable tally of Victorian occupations.

  Gowers did not see these task-specific problems as benign: “The disease, when well developed, is one in which the prognosis is always uncertain, and often unfavourable.” Interestingly, at a time when such symptoms were either ascribed to peripheral problems with muscles, tendons, or nerves or seen as hysterical or “mental,” Gowers did not feel satisfied with either explanation (though he allowed that these factors could play a subsidiary role). He insisted, rather, that these occupational “neuroses” had an origin in the brain.

  One reason for this thought was the fact that, though different parts of the body could be afflicted, all the provocative occupations involved rapid, repetitive movements of small muscles. Another was the conjunction of inhibitory features such as unresponsiveness or “paralysis” with excitatory ones— abnormal movements or spasms, which increased the more one fought against the inhibition. These considerations disposed Gowers to see “occupation neuroses” as disorders of motor control in the brain, disorders he thought might involve the motor cortex (the functions of the basal ganglia were unknown at this time).

  Once “occupation neuroses” developed, there was little chance of continuing in the same occupation or profession. But despite the mysterious nature and crippling consequences of this condition, remarkably little attention was paid to it, medically, for almost a century.

  Though it was well known in the world of performing musicians that this dread condition could lie in wait for anyone— perhaps one in a hundred musicians would be affected, at some point in their career— a natural reserve, even secrecy, prevailed. To acknowledge an occupation-related cramp was close to professional suicide— it would be understood that one would have to give up performing and become a teacher, a conductor, perhaps a composer, instead.2