Musicophilia

by Oliver Sacks

  But by 1995, when “The Last Hippie” was republished in book form (in An Anthropologist on Mars), we had got our answer, and it was resoundingly negative. There was not, and perhaps could never be, any carryover from performance and procedural memory to explicit memory or usable knowledge.

  While, at least in someone as amnesic as Greg or Woody, singing cannot be used as a sort of back door to explicit memory, still the act of singing is important in itself. Finding, remembering anew that he can sing is profoundly reassuring to Woody, as the exercise of any skill or competence must be— and it can stimulate his feelings, his imagination, his sense of humor and creativity, and his sense of identity as nothing else can. It can enliven him, calm him, focus and engage him. It can give him back himself, and not least, it can charm others, arouse their amazement and admiration— reactions more and more necessary to someone who, in his lucid moments, is painfully aware of his tragic disease and sometimes says that he feels “broken inside.”

  The mood engendered by singing can last awhile, sometimes even outlasting the memory that he has sung, which may be lost within a couple of minutes. I could not help thinking of my patient Dr. P., the man who mistook his wife for a hat, and how vital singing was for him, and how my “prescription” for him was a life that consisted entirely of music and singing.

  Perhaps Woody, though he could not have put it into words, knows that this is the case for him, for in the last year or so he has taken to whistling. He whistled “Somewhere over the Rainbow” softly to himself for the entire afternoon we spent together. Whenever he is not actively singing or otherwise engaged, Mary Ellen and Rosemary told me, he now whistles all the while. Not only through his waking hours; he whistles (and sometimes sings) in his sleep— so, at least in this sense, Woody is companioned by music, calls on it, around the clock.

  * * *

  THERE IS, of course, a world of difference between such patients, who (with the help of family, friends, and therapists) are still living a semi-independent life in the outside world, and the patients with very advanced dementias who constitute much of the population of a chronic disease hospital or nursing home. Nevertheless, music may be as important to people with advanced dementia as it is to those in the earlier stages.

  Bessie T., a lady in her eighties, is a former blues singer who used to work at the famous Apollo Club in Harlem. She now lives in a nursing home, though she often thinks she still works in a store (“I work in men’s clothing…the better line”). Her Alzheimer’s has left her with an amnesia so severe that she can hold nothing in mind for more than a minute. But learning that there was to be a talent show at the hospital, she (with her music therapist) practiced her songs assiduously, getting better all the time, though retaining no explicit memory of her practice sessions. When the day came, and she was escorted to the microphone and asked if she would sing for the audience, she said, “Sure, honey— but why didn’t you ask me before?” She then went on to sing beautifully, with great feeling, though a few moments later, she had no memory of having performed.

  Sometimes music therapy is communal, sometimes individual. It is astonishing to see mute, isolated, confused individuals warm to music, recognize it as familiar, and start to sing, start to bond with a therapist. It is even more astonishing to see a dozen deeply demented people— all in worlds or nonworlds of their own, seemingly incapable of any coherent reactions, let alone interactions— and how they respond to the presence of a music therapist who begins to play music in front of them. There is a sudden attention: a dozen pairs of distracted eyes fasten on the player. Torpid patients become alert and aware; agitated ones grow calmer. That it may be possible to gain the attention of such patients and hold it for minutes at a time is itself remarkable. Beyond this, there is often a specific engagement with what is being played (it is usual, in such groups, to play old songs that everyone of a similar age and background will have known).

  Familiar music acts as a sort of Proustian mnemonic, eliciting emotions and associations that had been long forgotten, giving the patient access once again to moods and memories, thoughts and worlds that had seemingly been completely lost. Faces assume expression as the old music is recognized and its emotional power felt. One or two people, perhaps, start to sing along, others join them, and soon the entire group— many of them virtually speechless before— is singing together, as much as they are able.

  “Together” is a crucial term, for a sense of community takes hold, and these patients who seemed incorrigibly isolated by their disease and dementia are able, at least for a while, to recognize and bond with others. I receive many letters about such effects from music therapists and others who play or sing music to the demented. One Australian music therapist, Gretta Sculthorp, after working in nursing homes and hospitals for ten years, expressed this eloquently:

  At first I thought I was providing entertainment, but now I know that what I do is act as a can-opener for people’s memories. I can’t predict what will be the trigger for each person, but there is usually something for everyone, and I have a part of my brain that “watches” in stunned amazement what is happening…. One of the loveliest outcomes of my work is that nursing staff can suddenly see their charges in a whole new light, as people who have had a past, and not only a past but a past with joy and delight in it.

  There are listeners who come and stand beside or in front of me, touching me, for the whole time. There are always people who cry. There are people who dance, and people who join in— for operetta or for Sinatra songs (and Lieder, in German!). There are disturbed people who become calm, and silent people who give voice, frozen people who beat time. There are people who don’t know where they are, but who recognize me immediately, as “the Singing Lady.”

  With a movement disorder like Parkinson’s disease, there is no significant carryover effect with the power of music. The patient can regain a fluent motor flow with music, but once the music stops, so too does the flow. There can, however, be longer-term effects of music for people with dementia— improvements of mood, behavior, even cognitive function— which can persist for hours or days after they have been set off by music. I see this in the clinic almost daily, and constantly receive descriptions of such effects from others. Jan Koltun, who coordinates care giving to the elderly, wrote to me with this story:

  One of our caregivers…went home and made the simple intervention of turning on the classical music channel in front of the couch where her mother-in-law had mostly sat watching TV “shows” for the preceding three years. The mother-in-law, diagnosed with dementia, had kept the house awake at night when the caregivers turned off the TV in order to get some sleep. Daytimes, she would not get off the couch for toileting or family meals.

  After the channel change, she had a profound behavioral change: She asked to come to breakfast the next morning, and did not want to watch her usual TV fare the next day, and asked for her long-neglected embroidery the next afternoon. Over the next six weeks, in addition to communicating with her family and taking more interest in her surroundings, she mostly listened to music (primarily country and western, which she loved). After six weeks, she died peacefully.

  The perception of music and the emotions it can stir is not solely dependent on memory, and music does not have to be familiar to exert its emotional power. I have seen deeply demented patients weep or shiver as they listen to music they have never heard before, and I think that they can experience the entire range of feelings the rest of us can, and that dementia, at least at these times, is no bar to emotional depth. Once one has seen such responses, one knows that there is still a self to be called upon, even if music, and only music, can do the calling.

  There are undoubtedly particular areas of the cortex subserving musical intelligence and sensibility, and there can be forms of amusia with damage to these. But the emotional response to music, it would seem, is widespread and probably not only cortical but subcortical, so that even in a diffuse cortical disease like Alzheimer’s, music can stil
l be perceived, enjoyed, and responded to. One does not need to have any formal knowledge of music— nor, indeed, to be particularly “musical”— to enjoy music and to respond to it at the deepest levels. Music is part of being human, and there is no human culture in which it is not highly developed and esteemed. Its very ubiquity may cause it to be trivialized in daily life: we switch on a radio, switch it off, hum a tune, tap our feet, find the words of an old song going through our minds, and think nothing of it. But to those who are lost in dementia, the situation is different. Music is no luxury to them, but a necessity, and can have a power beyond anything else to restore them to themselves, and to others, at least for a while.

  Acknowledgments

  I dedicate this book to three close friends and colleagues, each of whom has played an essential part in its genesis and evolution. Without our conversations over many years on music and much else, this book would have been impossible.

  Orrin Devinsky of the New York University Medical School (and founder of its Comprehensive Epilepsy Center), my fellow physician and neurologist, has been unstintingly generous over the years in introducing me to patients and sharing his great clinical knowledge and insight with me.

  Ralph M. Siegel, professor of neuroscience at Rutgers University, has been my close associate in various cases— some involving his particular field of vision research, others not— and he has always forced me to consider their underlying physiological basis.

  Connie Tomaino— who came to Beth Abraham Hospital when I was working there with my Awakenings patients, went on to become President of the American Association of Music Therapists, and then founded the Institute for Music and Neurologic Function at Beth Abraham— has been my co-worker and adviser in all matters musical for more than twenty-five years.

  Many other scientists, physicians, therapists, patients, friends, colleagues, and correspondents have generously shared with me their experiences, their thoughts and expertise, and, in some cases, their patients. Among them, I must especially thank Patrick Baron, Ursula Bellugi, Diana Deutsch, Steve Frucht, Daniel Levitin, Bruce Miller, Aniruddh Patel, Virginia Penhune, Isabelle Peretz, and Robert Zatorre. They have each shared their deep knowledge and experience of music and the brain with me, have read and reread drafts of this book, suggested resources, and offered invaluable criticisms, corrections, and additions.

  I had the pleasure of knowing Anthony Storr and corresponding with him over many years. We often talked about music, and when he published Music and the Mind in 1992, I thought it the best book on the subject I had ever read. I still think so, and I have plundered it quite shamelessly in writing my own book. Indeed, I have to borrow from Storr again to quote what he wrote in his own acknowledgments: “Old men forget, and there may be other people whom I have omitted to thank. To them I can only offer apologies.”

  And though I will inevitably omit many others who should be mentioned, I would like to express my special gratitude to D.L., Frank V., G.G., Gordon B., Jacob L., John C., John S., Jon S., Joseph D., June B., Louis F. and his wife, Michael B. and his parents, the patients and staff at the Williams Syndrome Clinic of the Children’s Hospital at Montefiore, Rachael Y., Salimah M., Samuel S., Sheryl C., Silvia N., Solomon R., Steven, Meghan, Christian and Anne, Sue B., Sydney A., Jean Aberlin, Victor Aziz, Andrea Bandel, Simon Baron-Cohen, Sue Barry, Caroline Bearsted, Howard Brandston, Jerome Bruner, David Caldwell, Todd Capp, John Carlson, Sheryl Carter, Melanie Challenger, Elizabeth Chase, Mike Chorost, Tony Cicoria, Jennifer and John Clay, Jonathan Cole, Heidi Comfort, Richard Cytowic, Mark Damashek, Merlin Donald, Gerald Edelman, Patrick Ehlen, Tom Eisner, Glen Estrin, Leon Fleisher, Cornelia and Lucas Foss, Lawrence Freedman, Allen Furbeck, Richard Garrison, Mary Ellen Geist, Rosemary and Woody Geist, Matt Giordano, Harvey and Louise Glatt, John Goberman, Elkhonon Goldberg, Jane Goodall, Temple Grandin, T. D. Griffiths, Mark Hallett, Arlan Harris, John Harrison, Mickey Hart, Roald Hoffmann, Mark Homonoff, Anna and Joe Horovitz, Krista Hyde, John Iversen, Jorgen Jorgensen, Eric Kandel, Malonnie Kinnison, Jan Koltun, Eric Korn, Carol Krumhansl, Jaron Lanier, Margaret Lawrence, Christine Leahy, Gloria Lenhoff, Howard Lenhoff, Wendy Lesser, Rodolfo Llinás, Dwight and Ursula Mamlok, Robert Marion, Eric Markowitz, Gerry Marks, Michael Merzenich, Jonathan Miller, Marvin Minsky, Bill Morgan, Nicholas Naylor-Leland, Adam Ockelford, David Oppenheim, Tom Oppenheim, Erna Otten, Alvaro Pascual-Leone, Charlotte Pharr, Tobias Picker, Emilio Presedo, Maria Ralescu, V. S. Ramachandran, Leo Rangell, Isabelle Rapin, Harold Robinson, Paul Rodriguez, Bob Ruben, Yolanda Rueda, Jonathan Sacks, Gottfried Schlaug, Gretta Sculthorp, Peter Selgin, Leonard Shen-gold, David Shire, Bob Silvers, Allan Snyder, Elizabeth Socolow, Steven Sparr, Larry Squire, Alexander Stein, Daniel Stern, Doug Stern, Dan Sullivan, Michael Sundue, Michael Thaut, Michael Torke, Darold Treffert, Nick van Bloss, Erica vanderLinde Feidner, Indre Viskontas, Nick Warner, Jason Warren, Bob and Claudia Wasserman, Deborah and Clive Wearing, Ed Weinberger, Larry Weiskrantz, Ren Weschler, E. O. Wilson, Frank Wilson, Stephen Wiltshire, Rosalie Winard, Michael Wolff, Caroline Yahne, Nick Younes, and Carol Zitzer-Comfort.

  This book would not have been completed without the financial support of many universities and organizations which have hosted me over the past years, and in particular I am grateful to the Alfred P. Sloan Foundation, and to Doron Weber there, for providing a generous grant to support this project.

  For editorial and publishing support and advice, I am grateful to Dan Frank, Fran Bigman, Lydia Buechler, Bonnie Thompson, and many others at Alfred A. Knopf, and to Sarah Chalfant, Edward Orloff, Andrew Wylie, and all at the Wylie Agency. And above all, I must thank Kate Edgar, who has spent thousands of hours collaborating with me on the research, writing, and editing of this book— and much else.

  Finally, I would like to thank my correspondents, the thousands of people who write to me from all over the world, sharing their lives and especially their neurological experiences with me. I could not hope to see, in my own small practice, a fraction of what I hear about and learn from my correspondents. They often write seeking information; but more often just want to reach a sympathetic ear, or share an interesting view into the human brain and mind. These correspondents form, in effect, a wonderful and exciting extension of my practice, telling me things I would have never encountered otherwise. This present book, especially, is far richer for their contributions.

  Bibliography

  Alajouanine, Théophile. 1948. The aphasie and artistic realisation. Brain 71:229–41.

  Albert, Martin L., R. Sparks, and N. Helm. 1973. Melodic intonation therapy for aphasia. Archives of Neurology 29: 130–31.

  Aldridge, David. 1992. Rhythm man. In Don’t Think About Monkeys, ed. Adam Seligman and John Hilkevich (pp. 173–82). Duarte, CA: Hope Press.

  Allen, D. A., and I. Rapin. 1992. Autistic children are also dysphasic. In Neurobiology of Infantile Autism, ed. H. Naruse and E. M. Ornitz (pp. 157–68). Amster dam: Elsevier.

  Amedi, Amir, Lotfi B. Merabet, Felix Bermpohl, and Alvaro Pascual-Leone. 2005. The occipital cortex in the blind: Lessons about plasticity and vision. Current Directions in Psychological Science 14 (6): 306–11.

  Ayotte, Julia, Isabelle Peretz, and Krista Hyde. 2002. Congenital amusia: A group study of adults afflicted with a music-specific disorder. Brain 125: 238–51.

  Baron-Cohen, Simon, and John Harrison. 1997. Synaesthesia: Classic and Con temporary Readings. Oxford: Blackwell.

  Bauby, Jean-Dominique. 1997. The Diving Bell and the Butterfly. New York: Alfred A. Knopf.

  Bayley, John. 1999. Elegy for Iris. New York: St. Martin’s Press.

  Bear, David. 1979. Temporal-lobe epilepsy: a syndrome of sensory-limbic hyper-connection. Cortex 15: 357–84.

  Beeli, G., M. Esslen, and L. Jäncke. 2005. When coloured sounds taste sweet. Nature 434: 38.

  Belin, P., P. Van Eeckhout, M. Zilbovicius, P. Remy, C. François, S. Guillaume, F. Chain, G. Rancurel, and Y. Samson. 1996. Recovery from nonfluent aphasia after melodic intonation therapy: A PET study. Ne
urology 47 (6): 1504–11.

  Belin, P., R. J. Zatorre, P. Lafaille, P. Ahad, and B. Pike. 2000. Voice-selective areas in human auditory cortex. Nature 403: 309–10.

  Bell, Charles. 1833. The Nervous System of the Human Body. London: Taylor and Francis.

  Bellugi, Ursula, Liz Lichtenberger, Debra Mills, Albert Galaburda, and Julie R. Korenberg. 1999. Bridging cognition, the brain and molecular genetics: evidence from Williams syndrome. Trends in Neuroscience 22: 197–207.

  Berlioz, Hector. 1865/2002. The Memoirs of Hector Berlioz. Translated by David Cairns. New York: Everyman’s Library.

  Berrios, G. E. 1990. Musical hallucinations: A historical and clinical study. British Journal of Psychiatry 156: 188–94.

  — — — . 1991. Musical hallucinations: A statistical analysis of 46 cases. Psy chopathology 24: 356–60.

  Blake, D. T., N. N. Byl, S. Cheung, P. Bedenbaugh, S. Nagarajan, M. Lamb, and M. Merzenich. 2002. Sensory representation abnormalities that parallel focal hand dystonia in a primate model. Somatosensory and Motor Research 19 (4): 347–57.