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For G.G., music does not just provoke a seizure; it seems to constitute an essential part of the seizure, spreading (one imag- ines) from its initial perceptual locus to other temporal lobe sys- tems, and occasionally to the motor cortex , as when he has generalized seizures. It is as if, at such times, the provocative music is itself transformed, becoming first an overwhelming psy. chic experience and then a seizure.
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and snippets of motor patterns amongst and between themselves-_and because of the odd, re-entrant inhibitory connectivity amongst and between these nuclei, they seem to act as a continuous, random, motor pattern noise genera- tor. Here and there, a pattern or portion of a pattern escapes, without its apparent emotional counterpart, into the con- text of the thalamocortical system." And suddenly," Llinás concludes, "you hear a song in your head or out of seemingly nowhere find yourself anxious to play tennis. Things sometimes just come to us."
Anthony Storr, a psychiatrist, writes eloquently in Music and the Mind of his own musical imagery and wonders "what pur- pose is served by music running in the head unsummoned and perhaps unwanted?" He feels that such music generally has a positive effect: "It alleviates boredom, makes ... movements more rhythmical, and reduces fatigue." It buoys the spirits, is intrinsically rewarding. Music drawn from memory, he writes, "has many of the same effects as real music coming from the external world." It has the additional bonus of drawing attention to otherwise overlooked or repressed thoughts, and in this way may serve a function similar to that of dreams. All in all, Storr concludes, spontaneous musical imagery is basically "beneficent" and "biologically adaptive."
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Many people are set off by the theme music of a film or televi- sion show or an advertisement. This is not coincidental, for such music is designed, in the terms of the music industry, to "hook" the listener, to be "catchy" or "sticky," to bore its way, like an carwig, into the ear or mind; hence the term "earworms". though one might be inclined to call them "brainworms" instead. (One newsmagazine, in 1987, defined them, half face- tiously, as "cognitively infectious musical agents."| A friend of mine, Nick Younes, 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 this song--a Frank Sina- tra rendition used as the theme song of the television show Mar- ried. with Children-was enough to hook Nick. 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 inter- fered with his schoolwork, his thinking, his peace of mind, his sleep. He tried to stop it in a number of ways, all to no avail: "I jumped up and down. I counted to a hundred. I splashed water on my face. I tried talking loudly to myself, plugging my ears." Finally it faded away--but as he told me this story, it returned and went on to haunt him again for several hours.?
I. An earlier generation will remember the tune of "Love and Marriage" as the Camp- bell's soup advertisement "Soup and Sandwich." Van Heusen was a master of the catchy tune and wrote dozens of (literally) unforgettable songs-_-including "High Hopes," "Only the Lonely," and "Come Fly with Me"-for Bing Crosby, Frank Sinatra, and others. Many of these have been adapted for television or advertising theme songs.
2. Since the original publication of Musicophilia, many people have written to me about ways of dealing with a brainworm- such as consciously singing or playing it to the end of the song, so that it is no longer a fragment circling round and round, incapable of resolu- tion; or displacing it by singing or listening to another tune (though this may only become another brainworm in turn).
Musical imagery, especially if it is repetitive and intrusive, may have a motor component, a subvocal "humming" or singing of which the person may be unaware, but which
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Though the term "earworm" was first used in the r980s (as a literal translation of the German Ohrwurm), the concept is far from new.3 Nicolas Slonimsky, a composer and musicologist, was deliberately inventing musical forms or phrases that could hook the mind and force it to mimicry and repetition, as early as the 1920s. And in 1876, Mark Twain wrote a short story ("A Lit- erary Nightmare," subsequently retitled "Punch, Brothers, Punch!") in which the narrator is rendered helpless after encoun- tering some "jingling rhymes": They took instant and entire possession of me. All through breakfast they went waltzing through my brain fought hard for an hour, but it was useless. My head kept hum- ming... . I drifted downtown, and presently discovered that my feet were keeping time to that relentless jingle.... I jingled all through the evening, went to bed, rolled, tossed, and jingled all night long.
still may exact a toll. "At the end of a bad music-loop day," wrote one correspondent, "my throat is as uncomfortable as it might have been had I sung all day." David Wise, another correspondent, found that using progressive relaxation techniques to relax the 'muscular correlates to the hearing of music involving the tightening and movement of the speech apparatus.. associated with auditory thinking" was efficacious in stopping annoying brainworms. While some of these methods seem to work for some people, most others have found, like Nick Younes, no cure.
3. Jeremy Scratcher, a scholarly musician who has studied the folk genres of Northum- berland and Scotland, informs me that
Examination of early folk music manuscripts reveals many examples of various tunes to which have been attributed the title "The piper's maggot." These were perceived to be tunes which got into the musician's head to irritate and gnaw at the sufferer--like a maggot in a decaying apple. There is one such tune in the [1888] Northumbrian Minstrelsy. The earliest collection of pipe music was penned in 1733 by another Northumbrian, William Dixon, and this along with other Scottish collections suggests that the "maggot" most probably appeared in the early I8th century. Interesting that despite the disparity of time the metaphor has remained much the same!
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Tourette's syndrome whom I described in An Anthropologist on Mars, "One cannot always find sense in these words," he said "Often it is just the sound that attracts me. Any odd sound, any odd name, may start repeating itself, get me going. I get hung up with a word for two or three months. Then, one morning, it's gone, and there's another one in its place." But while the involuntary repetition of movements, sounds, or words tends to occur in people with Tourette's or OCD or damage to the frontal lobes of the brain, the automatic or compulsive internal repetition of musi- cal phrases is almost universal--the clearest sign of the over- whelming, and at times helpless, sensitivity of our brains to music.
There may be a continuum here between the pathological and the normal, for while brainworms may appear suddenly, full- blown, taking instant and entire possession of one, they may also develop by a sort of contraction, from previously normal musical imagery. I have lately been enjoying mental replays of Beethoven's Third and Fourth Piano Concertos, as recorded by Leon Fleisher in the I96os. These "replays" tend to last ten or fifteen minutes and to consist of entire movements. They come, unbidden but always welcome, two or three times a day. But on one very tense and insomniac night, they changed character, so that I heard only a single rapid run on the piano (near the beginning of the Third Piano Concerto), lasting ten or fifteen seconds and repeated hundreds of times. It was as if the music was now trapped in a sort of loop, a tight neural circuit from which it could not escape. Towards morning, mercifully, the looping ceased and I was able to enjoy entire movements once again.+
4. The duration of such loops is generally about fifteen to twenty seconds, and this is similar to the duration of the visual loops or cycles which occur in a rare condition called palinopsia, where a short scene—a person walking across a room, for example, seen a few seconds before—may be repeated before the inner eye again and again. That a similar periodicity of cycling occurs in both visual and auditory realms suggests that some physiological constant, perhaps related to working memory, may underlie both.
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Brainworms are usually stereotyped and invariant in charac- ter. They tend to have a certain life expectancy, going full blast for hours or days and then dying away, apart from occasional afterspurts. But even when they have apparently faded, they tend to lie in wait; a heightened sensitivity remains, so that a noise, an association, a reference to them is apt to set them off again, sometimes years later. And they are nearly always fragmentary. These are all qualities that epileptologists might find familiar, for they are strongly reminiscent of the behavior of a small, sudden-onset seizure foeus, erupting and convulsing, then sub- siding, but always ready to reignite.
Certain drugs seem to exacerbate earworms. One composer and music teacher wrote to me that when she was put on lamot- rigine for a mild bipolar disorder, she developed a severe, at times intolerable increase in earworms. After she discovered an article (by David Kemp et al.) about the increase of intrusive, repetitive musical phrases (as well as verbal phrases or numerical repeti- tions) associated with lamotrigine, she stopped the medication (under her physician's supervision). Her earworms subsided somewhat but have remained at a much higher level than before. She does not know whether they will ever return to their origi- nal, moderate level: "I worry," she wrote, "that somehow these pathways in my brain have become so potentiated that I will be having these earworms for the rest of my life."
Some of my correspondents compare brainworms to visual afterimages, and as someone who is prone to both, I feel their similarity, too. (We are using "afterimage" in a special sense here, to denote a much more prolonged effect than the fleeting afterimages we all have for a few seconds following, for instance, exposure to a bright light.) After reading EEGs intently for several hours, I may have to stop because I start to see EEG squiggles all over the walls and ceiling. After driving all day, I may see
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fields and hedgerows and trees moving past me in a steady stream, keeping me awake at night. After a day on a boat, I feel the rocking for hours atter I am back on dry land. And astro. nauts, returning from a week spent in the near-zero-gravity con. ditions of space, need several days to regain their "earth legs" once again. All of these are simple sensory effects, persistent activations in low-level sensory systems, due to sensory over. stimulation. Brainworms, by contrast, are perceptual construc. tions, created at a much higher level in the brain. And yet both reflect the fact that certain stimuli, from EEG lines to music to obsessive thoughts, can set off persistent activities in the brain.
There are attributes of musical imagery and musical memory that have no equivalents in the visual sphere, and this may cast light on the fundamentally different way in which the brain treats music and vision.S This peculiarity of music may arise in part because we have to construct a visual world for ourselves, and a selective and personal character therefore infuses our visual memories from the start—whereas we are given pieces of music already constructed. A visual or social scene can be constructed or reconstructed in a hundred different ways, but the
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recall of a musical piece has to be close to the original. We do, of course, listen selectively, with differing interpretations and emotions, but the basic musical characteristics of a piece—its tempo, its rhythm, its melodic contours, even its timbre and pitch— tend to be preserved with remarkable accuracy.
It is this fidelity-this almost defenseless engraving of music on the brain--which plays a crucial part in predisposing us to cer- tain excesses, or pathologies, of musical imagery and memory, excesses that may even occur in relatively unmusical people. There are, of course, inherent tendencies to repetition in music itself. Our poetry, our ballads, our songs are full of repetition. Every piece of classical music has its repeat marks or variations on a theme, and our greatest composers are masters of repetition; nursery rhymes and the little chants and songs we use to teach young children have choruses and refrains. We are attracted to rep- etition, even as adults; we want the stimulus and the reward again and again, and in music we get it. Perhaps, therefore, we should not be surprised, should not complain if the balance sometimes shifts too far and our musical sensitivity becomes a vulnerability. Is it possible that earworms are, to some extent, a modern phe- nomenon, at least a phenomenon not only more clearly recog- nized, but vastly more common now than ever before? Although earworms have no doubt existed since our forebears first blew tunes on bone flutes or beat tattoos on fallen logs, it is significant that the term has come into common use only in the past few decades.6 When Mark Twain was writing in the 1870s, there was 6. It may be that brainworms, even if maladaptive in our own music-saturated modern culture, stem from an adaptation that was crucial in earlier hunter-gatherer days: replay- ing the sounds of animals moving or other significant sounds again and again, until their recognition was assured--as one correspondent, Alan Geist, has suggested to me: I discovered, by accident, that after five or six continuous days in the woods with- out hearing any music of any kind, I spontaneously start replaying the sounds that
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cinations could occur until 1967, when Jerzy Konorski, a Polish neurophysiologist, devoted several pages of his Integrative Activ. ity of the Brain to the "physiological basis of hallucinations." Konorski inverted the question "Why do hallucinations occur?" to "Why do hallucinations not occur all the time? What constrains them?" He conceived a dynamic system which, he wrote, "can generate perceptions, images, and hallucinations... the mechanism producing hallucinations is built into our brains, but it can be thrown into operation only in some exceptional conditions." Konorski brought together evidence—weak in the 196Os, but overwhelming now—that there are not only afferent connections going from the sense organs to the brain, but "retro" connections going in the other direction. Such retro connections may be sparse compared to the afferent connections, and may not be activated under normal circumstances. But they provide, Konorski felt, the essential anatomical and physiological means by which hallucinations can be generated. What, then, normally prevents this from happening? The crucial factor, Konorski suggested, is the sensory input from eyes, ears, and other sense organs, which normally inhibits any backflow of activity from the highest parts of the cortex to the periphery. But if there is a critical deficiency of input from the sense organs, this will facilitate a backflow, producing hallucinations physiologically and subjectively indistinguishable from perceptions. (There is normally no such reduction of input in conditions of silence or darkness, because "off-units" fire up and produce continuous activity.)
Konorski's theory provided a simple and beautiful explanation for what soon came to be called "release" hallucinations associ- ated with "de-afferentation." Such an explanation now seems obvious, almost tautological-_but it required originality and audacity to propose it in the I960s.
There is now good evidence from brain-imaging studies to
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support Konorski's idea. In 2000, Timothy Griffiths published a detailed and pioneering report on the neural basis of musical hallucinations; he was able to show, using PET scans, that musical hallucinations were associated with a widespread activation of the same neural networks that are normally activated during the perception of actual music.
IN 1995 I received a vivid letter from June B., a charming and I'creative woman o/seventy, telling me of her musical halluci. nations: This first started last November when I was visiting my sis- ter 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 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 realized that the music couldn't possibly be coming from anywhere in that area. It had to be in my head. Mrs. B. enclosed her "play list," which included "Amazing Grace," "The Battle Hymn of the Republic," Beethoven's "Ode to Joy," the drinking song from La Traviata, "A-Tisket, A-Tasket," and "a really dreary version" of "We Three Kings of Orient Are." "One night," Mrs. B. wrote, "I heard a splendidly solemn ren- dition of 'Old Macdonald Had a Farm,' followed by thunderous applause. At that moment I decided that, as I was obviously com- pletely bonkers, I'd better have the matter looked into." Mrs. B. described how she had tests for Lyme disease (she had
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With the development of brain imaging in the r9gos, it became possible to actually visualize the brains of musicians and to compare them with those of nonmusicians. Using MRI mor. phometry, Gottfried Schlaug at Harvard and his colleagues made careful comparisons of the sizes of various brain structures. In 1995, they published a paper showing that the corpus callosum, the great commissure that connects the two hemispheres of the brain, is enlarged in professional musicians and that a part of the auditory cortex, the planum temporale, has an asymmetric enlargement in musicians with absolute pitch. Schlaug et al. went on to show increased volumes of gray matter in motor, auditory, and visuospatial areas of the cortex, as well as in the cerebellum.? Anatomists today would be hard put to identify the brain of a visual artist, a writer, or a mathematician—but they could recognize the brain of a professional musician without a moment's hesitation.3
How much, Schlaug wondered, are these differences a reflec- tion of innate predisposition and how much an effect of early musical training? One does not, of course, know what distin- guishes the brains of musically gifted four-year-olds before they start musical training, but the effects of such training, Schlaug and his colleagues showed, are very great: the anatomical
2. See, for example, Gaser and Schlaug's 2003 paper and Hutchinson, Lee, Gaab, and Schlaug, 2003. 3. Nina Kraus and her colleagues (see Musacchia et al.), struck by these changes in the auditory, visual, motor, and cerebellar regions of musicians' brains, wondered whether basic sensory mechanisms at the brain-stem level might also be enhanced in musicians. They found that there was indeed a difference: "Musicians had earlier and larger brain- stem responses than non-musician controls to both speech and music stimuli… evident as early as ten milliseconds after acoustic onset." This enhancement, they found, is "strongly correlated with length of musical practice." Such functional changes in the brain stem of musicians may not seem as spectacular as the grossly visible enlargements of corpus callosum and cortex and cerebellum, but they are no less remarkable, for one would scarcely have thought that experience and training could affect so basic a sensory mechanism.
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changes they observed with musicians' brains were strongly cor- related with the age at which musical training began and with the intensity of practice and rehearsal.
Alvaro Pascual-Leone at Harvard has shown how rapidly the brain responds to musical training. Using five-finger piano exer- cises as a training test, he has demonstrated that the motor cortex can show changes within minutes of practicing such sequences. Measurements of regional blood flow in different parts of the brain, moreover, have shown increased activity in the basal ganglia and the cerebellum, as well as various areas of the cerebral cortex--not only with physical practice, but with mental practice alone.
There is clearly a wide range of musical talent, but there is much to suggest there is an innate musicality in virtually every- one. This has been shown most clearly by the use of the Suzuki method to train young children, entirely by ear and by imitation, to play the violin. Virtually all hearing children respond to such training.+
Can even a brief exposure to classical music stimulate or enhance mathematical, verbal, and visuospatial abilities in chil- dren? In the early r990s Frances Rauscher and her colleagues at the University of California at Irvine designed a series of studies to see whether listening to music could modify nonmusical cog- nitive powers. They published several careful articles, in which they reported that listening to Mozart (compared to listening to "relaxation" music or silence) did temporarily enhance abstract spatial reasoning. The Mozart effect, as this was dubbed, not only aroused scientific controversy but excited intense journalistic attention and, perhaps unavoidably, exaggerated claims beyond anything intimated in the researchers' original modest reports.
4. Even profoundly deaf people may have innate musicality. Deaf people often love music and are very responsive to rhythm, which they feel as vibration, not as sound. The acclaimed percussionist Evelyn Glennie has been profoundly deaf since the age of twelve.
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The validity of such a Mozart effect has been disputed by Schellenberg and others, but what is beyond dispute is the effect of intensive early musical training on the young, plastic brain. Takako Fujioka and her colleagues, using magnetoencephalography to examine auditory evoked potentials in the brain, have recorded striking changes in the left hemisphere of children who have had only a single year of violin training, compared to children with no training.S
The implication of all this for early education is clear. Although a teaspoon of Mozart may not make a child a better mathematician, there is little doubt that regular exposure to music, and especially active participation in music, may stimu- late development of many different areas of the brain--areas which have to work together to listen to or pertorm music. For the vast majority of students, music can be every bit as impor- tant educationally as reading or writing.
Can musical competence be seen as a universal human potential in the same way as linguistic competence? There is exposure to language in every household, and virtually all children develop lin guistic competence (in a Chomskian sense) by the age of four or five. This may not be the case with regard to music, since some households may be almost devoid of music, and musical potential, like other potentials, needs stimulation to develop fully. In the
S. It is not always easy or possible for children to receive musical training, especially in the United States, where music instruction is being eliminated from many public schools. Tod Machover, a composer and leading designer of new technology for music, seeks to address this problem by "democratizing" music, making it accessible to anyone. Machover and his colleagues at MIT's Media Lab have developed not only the Brain Opera, the Toy Symphony, and the popular video game Guitar Hero, but Hyperinstru- ments, Hyperscore, and other interactive systems used by professional musicians from Joshua Bell, Yo-Yo Ma, and Peter Gabriel to the Ying Quartet and the London Sinfonietta. 6. There are very few exceptions here- some children with autism and some with con- genital aphasia. But for the most part, even children with marked neurological or develop- mental problems acquire functional language.
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relationship between the pitch to be named and another pitch whose name they already know When I hear a musical note and identify its pitch, much more happens than simply placing its pitch on a point (or in a region) along a continuum. Suppose I hear an F-sharp sounded on the piano. I obtain a strong sense of familiarity for "F-sharpness"--like the sense one gets when one recognizes a familiar face. The pitch is bundled in with other attributes of the note-_its tim- bre (very importantly), its loudness, and so on. I believe that, at least for some people with absolute pitch, notes are per- ceived and remembered in a way that is far more concrete than for those who do not possess this faculty.Absolute pitch is of special interest because it exemplifies a whole other realm of perception, of qualia, something which most of us cannot even begin to imagine; because it is an isolated ability with little inherent connection to musicality or anything else; and because it shows how genes and experience can interact in its pro- duction.
It has long been clear anecdotally that absolute pitch is commoner in musicians than in the general public, and this has been confirmed by large-scale studies. Among musicians, ab- solute pitch is commoner in those who have had musical train- ing from an early age. But the correlation does not always hold: many gifted musicians fail to develop absolute pitch, despite intensive early training. It is commoner in certain families--but is this because of a genetic component or because some families provide a richer musical environment? There is a striking association of absolute pitch with early blindness (some studies estimate that about 50 percent of children born blind or blinded in infancy have absolute pitch).
One of the most intriguing correlations occurs between
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absolute pitch and linguistic background. For the past few years, Diana Deutsch and her colleagues have studied such correlations in greater detail, and they observed in a 2006 paper that "native speakers of Vietnamese and Mandarin show very precise absolute pitch in reading lists of words"; most of these subjects showed variation of a quarter tone or less. Deutsch et al. have also showed very dramatic differences in the incidence of ab. solute pitch in two populations of first-year music students: one at the Eastman School of Music in Rochester, New York, and the other at the Central Conservatory of Music in Beijing. "For stu- dents who had begun musical training between ages 4 and s," they wrote, "approximately 60% of the Chinese students met the criterion for absolute pitch, while only about I4% of the US nontone language speakers met the criterion." For those who had begun musical training at age six or seven, the numbers in both groups were correspondingly lower, about 55 percent and 6 per- cent. And for students who had begun musical training later still, at age eight or nine, "roughly 42% of the Chinese students met the criterion while none of the US nontone language speakers did so." There were no differences between genders in either group.
This striking discrepancy led Deutsch et al. to conjecture that "if given the opportunity, infants can acquire AP as a feature of speech, which can then carry over to music." For speakers of a nontonal language such as English, they felt, "the acquisition of AP during music training is analogous to learning the tones of a second language." They observed that there was a critical period for the development of absolute pitch, before the age of eight or so roughly the same age at which children And it much more difficult to learn the phonemes of another language (and thus to speak a second language with a native accent). Deutsch et al. suggested, therefore, that all infants might have the potential for acquiring absolute pitch, which could perhaps be "realized
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by enabling infants to associate pitches with verbal labels dur- ing the critical period" for language acquisition. (They did not exclude the possibility, nonetheless, that genetic differences might be important, too.)
The neural correlates of absolute pitch have been illuminated by comparing the brains of musicians with and without absolute pitch using a refined form of structural brain imaging (MRI mor- phometry), and by functional imaging of the brain as subjects identify musical tones and intervals. A 1995 paper by Gottfried Schlaug and his colleagues showed that in musicians with absolute pitch (but not musicians without), there was an exag- gerated asymmetry between the volumes of the right and left planum temporale, structures in the brain that are important for the perception of speech and music. Similar asymmetries in the size and activity of the planum temporale have been shown in other people with absolute pitch.+
Absolute pitch is not just a matter of pitch perception. People with absolute pitch must be able not only to perceive precise pitch differences, but to label them, to line them up with the notes or names of a musical scale. It is this ability which Frank V. lost with the frontal lobe damage caused by the rupture of his cerebral aneurysm. The additional cerebral mechanisms required to correlate pitch and label are in the frontal lobes, and this, too, can be seen in functional MRI studies; thus, if someone with absolute pitch is asked to name tones or intervals, MRIs will show focal activation in certain associative areas of the frontal cortex. In those with relative pitch, this region is activated only when naming intervals.
4. Such asymmetries are not seen, interestingly, in blind subjects with absolute pitch, where there may be radical reorganizations of the brain, with parts of the visual cortex being recruited for the detection of pitch, as well as a variety of other auditory and tactile perceptions.
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birth, at least in the first five years of life, if the left hemisphere is damaged. (Geschwind's interest in this phenomenon was ignited in part by the remarkable fact that a left hemispherectomy--a drastic procedure sometimes performed for intractable epilepsy, in which the entire left hemisphere is removed- -does not render a young child permanently languageless but is followed by the development of language functions in the right hemisphere.) It seems quite possible that something like this happened with the three-year-old Martin, following his meningitis. Such hemi- spheric shifts may also occur, though to a lesser degree, in adults who have predominantly left-sided damage to the brain.
Savantlike talents may sometimes emerge in later life. There are several anecdotal descriptions of such an emergence following brain injuries, strokes, tumors, and frontotemporal dementia, especially if the damage is confined initially to the left temporal lobe. Clive Wearing, described in chapter I5, had a herpes en- cephalitis infection affecting especially his left frontal and temporal regions and, in addition to his devastating amnesia, developed a savantlike speed of calculation and punning.
The rapidity with which savant talents may emerge in such circumstances suggests a disinhibition or release of right-hemisphere functions from an inhibition or suppression normally exerted by the left temporal lobe.
In 1999, Allan Snyder and D. J. Mitchell inverted the usual ques- tion of why savant talents are so rare and asked instead: why don't we all have savant talents? They suggested that the mechanism for such skills might reside in all of us in early life but that as the brain matures, they are inhibited, at least trom conscious awareness.
is unexceptional in any area." (Miller goes on to consider other factors--obsessional tendencies, special opportunities, right-hemisphere dominance, genetic predisposition, etc.-but concludes that no single factor is adequate to explain or predict the appearance of savant skills.)
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They theorized that savants might have "privileged access to lower levels of information not available through introspection." Subse- quently they started to test this theory experimentally using trans- cranial magnetic stimulation (TMS), which now allows a brief and virtually instantaneous way of inhibiting physiological functions in different parts of the brain. Using normal volunteers, they applied IMS to the left temporal lobe for a few minutes, in a stimu- lation designed to inhibit the abstract and conceptual thought gov- erned by this area of the brain and, they hoped, to allow a transient release of perceptual functions in the right hemisphere. These experiments have produced modest but suggestive results, seem- ingly improving skills like drawing, calculating, and proofreading for a few minutes. (Bossomaier and Snyder are also investigating whether absolute pitch can be released by TMS.)7
Similar techniques have been used by Robyn Young and her colleagues, who found in one study that they could duplicate the release effect but only in five out of seventeen subjects. They concluded that "these mechanisms are not available to everyone and individuals may differ in either their ability to access these mechanisms or even whether they possess such a mechanism." Whether or not this is the case, it certainly seems that a sizeable minority, perhaps thirty percent, of "normal" adults may
7. Something perhaps analogous happened to me in 1965, when, like a certain number of medical students and residents at the time, I was taking massive doses of amphetamines For a period of two weeks, I found myself in possession of a number of extraordinary skills normally lacked. (I published an account of this, "The Dog Beneath the Skin," which tocused on the heightening of smell, in The Man Who Mistook His Wife for a Hat.) I could not only recognize everyone I knew by smell, but could hold very accurate and stable visual images in my mind and trace them on paper, as with a camera lucida. My Powers of musical memory and transcription were greatly increased, and I could replay complex melodies on my piano after a single hearing. My enjoyment of these newfound powers and the world of greatly heightened sensation that went with them was mitigared, however, by Anding that my abstract thinking was extremely compromised. When, decades latér, I read of Bruce Miller's patients and of Allan Snyder's experiments, I won. dered whether the ampheramines mipht have caused a transient temporal lobe disinhibi- tion and a release of "savant" powers.
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have latent or suppressed savant potentials which may be released to some degree by techniques such as TMS. This is not entirely surprising, given that various pathological conditions—frontotemporal dementia, dominant-hemisphere strokes, certain head injuries and infections -may lead on occasion to the appearance of savantlike abilities.
One must infer that there are, in many individuals, at least, very concrete eidetic and mnemonic powers which are normally hidden, but which may surface or be released under exceptional conditions. The existence of such potentials is only intelligible in evolutionary and developmental terms, as early forms of per- ception and cognition which once had adaptive value but are now suppressed and superseded by other forms.8
Darold Treffert, who has studied dozens of people with savant powers, both congenital and acquired, emphasizes that there are no "instant" savants, no easy path to savantism. Special mechanisms, whether they are universal or not, may be necessary but not suffi- cient for savantism. All savants spend years developing and honing their skills, sometimes obsessively and sometimes drawn on by the pleasure of exercising a special skill--a pleasure perhaps height- ened by its contrast with their own overall intellectual impair- ments, or by the recognition and rewards their powers may bring. Being a savant is a way of lite, a whole organization of personality, even though it may be built on a single mechanism or skill.
8. Ongoing work by Tetsuro Matsuzawa and his colleagues in Kyoto on the numerical memory span of chimpanzees may provide an example of such a "primitive" ability. In a paper with Nobuyuki Kawai, Matsuzawa showed that Ai, a young chimpanzee, could remember a sequence of at least five numbers, more than a preschool child; and at a recent symposium in Chicago on "The Mind of the Chimpanzee," he showed how Ai, with further training, had developed powers of working memory beyond that of most adult humans. He suggested that "our common ancestors might have had immediate memory, but in the course of evolution, they lost this and acquired languagelike skills." (See Kawai and Matsuzawa, 2000, and a news report on the symposium in Science, by Jon Cohen.
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was his life, I was his lifeline. Every time he saw me, he would run to me, fall on me, sobbing, clinging.How, why, when he recognized no one else with any consis- tency, did Clive recognize Deborah? There are clearly many sorts of memory, and emotional memory is one of the deepest and least understood.
Neal J. Cohen has written about the famous experiment of Édouard Claparède, a Swiss physician, in I9II:
Upon shaking hands with a patient with Korsakoff syn- drome (the condition which caused my patient Jimmie's severe amnesia), Claparède pricked her finger with a pin hid- den in his hand. Subsequently, whenever he again attempted to shake the patient's hand, she promptly withdrew it. When he questioned her about this behavior, she replied, "Isn't it allowed to withdraw one's hand?" and "Perhaps there is a pin hidden in your hand," and finally, "Sometimes pins are hidden in hands." Thus the patient learned the appro- priate response based on previous experience, but she never seemed to attribute her behavior to the personal memory of some previously experienced event.For Claparède's patient, some sort of memory of the pain, an implicit and emotional memory, persisted. It seems certain, likewise, that in the first two years of life, even though one retains no explicit memories (Freud called this infantile amne- sia), deep emotional memories or associations are nevertheless being made in the limbic system and other regions of the brain where emotions are represented—and these emotional memories may determine one's behavior for a lifetime. And a recent
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events depended on these structures.) Yet H.M., though he lost many memories of his former life, had not lost any of the skills he had acquired, and indeed he could learn and perfect new skills with training and practice, even though he would retain no memory of the practice sessions.
Larry Squire, a neuroscientist who has spent a lifetime explor- ing mechanisms of memory and amnesia, emphasizes that no two cases of amnesia are the same. He wrote to me,
If the damage is limited to the medial temporal lobe, then one expects an impairment such as H.M. had. With somewhat more extensive medial temporal lobe damage, one can expect something more severe, as in E.P. (this is a patient whom Squire and his colleagues have investigated intensively]. With the addition of frontal damage, perhaps one begins to understand Clive's impairment. Or perhaps one needs lateral temporal damage as well, or basal forebrain damage. Clive's case is unique, and not like H.M. or like Claparède's patient, because a particular pattern of anatomical damage occurred. We cannot write about amnesia as if it were a single entity like mumps or measles.Yet H.M.'s case made it clear that two very different sorts of memory could exist: a conscious memory of events (episodic memory) and an unconscious memory for procedures and that such procedural memory is unimpaired in amnesia.
This is dramatically clear with Clive, too, for he can shave, shower, look after his grooming, and dress elegantly, with taste and style; he moves confidently and is fond of dancing. He talks fluently and abundantly, using a large vocabulary; he can read and write in several languages. He is good at calculation. He can make phone calls, and he can find the coffee things and find his
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way about the home. If he is asked how to do these things, he cannot say, but he does them. Whatever involves a sequence or pattern of action, he does fluently, unhesitatingly,?
But can Clive's beautiful playing and singing, his masterly conducting, his powers of improvisation be adequately charac- terized as "skills" or "procedure"? For his playing is infused
7. An extraordinary but not uncommon condition, first recognized in the 1960s, is tran- sient global amnesia, or TGA-an amnesia that lasts only a few hours but may be very severe. It has never been clear what causes TGAs, but they are more common in middle. aged and elderly patients and sometimes occur in the course of a migraine; there is often only a single attack in a lifetime. Such a transient amnesia may come on at any time, with effects that can be comic or alarming. My niece Caroline Bearsted, a physician in England, told me of a patient of hers, an ardent fisherman, who had longed for years to catch a giant trout in a nearby stream. By a bizarre coincidence, he had an attack of TGA while he was fishing one day. It did not impair his skills in the least, and he caught the trout-_but catching it, the absolute peak of his fishing life, left no trace in his mind, and no memory of it was ever retrieved. When shown photographs of himself cradling the prize fish in his arms, he did not know whether to laugh or cry.
A more alarming story was related to me by the neurologist Harold Klawans, about a colleague of his, a general surgeon, who became amnesic towards the end of a gallbladder operation. He became uncertain, confused, repetitive: "Did I remove the gallbladder?" he asked repeatedly. "What am I doing? Where am I?" The nurse who was assisting him won- dered if he had had a stroke but, seeing that his surgical skill was unimpaired despite a profound memory impairment, kept him going by handing him the sutures one by one- and so, with her help, he closed the abdomen successfully. While he was himself again in a few hours, he never recovered any memory of the operation he had performed. Klawans subsequently published a description of this incident, and of his own careful examination of the surgeon while still amnesic.
The commonest cause of a brief global amnesia is a "blackout," as may occur if one has drunk too heavily. It is typical here, as in attacks of TGA, that one may--like the fish- erman or the surgeon--function at quite a high level; event memory may be knocked out, but procedural memory can carry one along. A correspondent, Matthew H., related the following story:
I used to play keyboards in a rock band for many years, and for my twenty-second birthday we were playing in a small town at a small bar (luckily with not too many patrons). Being young and irresponsible, I drank a few too many alcoholic bever- ages in between sets. Then I seem to have blacked out, and "came to" on stage while playing a Rolling Stones song. I was so inebriated that I remember being amazed that my fingers could play the song, and I was completely disassociated from it, just watching them move and play the right notes and chords with the rest of the band. When I tried to interject and "play along" with the music, I literally could not remember how to play a single thing, and I completely interrupted the flow of my playing. Luckily I seem to have blacked out again after that, because that was all I remembered. Oddly enough, when I quizzed my band mates the next day, they said that I played along with every song just fine (aside from the brief interlude during the Stones song), and they had not known I was so drunk.[222]
with intelligence and feeling, with a sensitive attunement to the musical structure, the composer's style and mind. Can any artistic or creative performance of this caliber be adequately explained by "procedural memory"? Episodic or explicit mem- ory, we know, develops relatively late in childhood and is depen- dent on a complex brain system involving the hippocampi and temporal lobe structures, the system that is compromised in severe amnesiacs and all but obliterated in Clive. The basis of pro- cedural or implicit memory is less easy to define, but it certainly involves larger and more primitive parts of the brain--subcortical structures like the basal ganglia and cerebellum and their many connections to each other and to the cerebral cortex. The size and variety of these systems guarantees the robustness of procedural memory and the fact that, unlike episodic memory, procedural memory can remain largely intact even in the face of extensive damage to the hippocampi and medial temporal lobe structures.
Episodic memory depends on the perception of particular and often unique events, and one's memories of such events, like one's original perception of them, are not only highly individual (colored by one's interests, concerns, and values), but prone to be revised or recategorized every time they are recalled. This is in fundamental contrast to procedural memory, where it is all- important that the remembering be literal, exact, and reproduc- ible. Repetition and rehearsal, timing and sequence are of the essence here. Rodolfo Llinás, the neurophysiologist, uses the term "fixed action patterns" (FAPs) for such procedural memories. Some of these may be present even before birth (fetal horses, for example, may gallop in the womb). Much of the early motor development of the child depends on learning and refining such procedures, through play, imitation, trial and error, and incessant rehearsal. All of these start to develop long before the child can call on any explicit or episodic memories.
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Is the concept of fixed action patterns any more illuminating than that of procedural memories in relation to the enormously complex, creative performances of a professional musician? In his book I of the Vortex, Llinás writes:
When a soloist such as (Jascha] Heifetz plays with a sym- phony orchestra accompanying him, by convention the con- certo is played purely from memory. Such playing implies that this highly specific motor pattern is stored somewhere and subsequently released at the time the curtain goes up.But for a performer, Llinás writes, it is not sufficient to have implicit memory only; one must have explicit memory as well:8
Without intact explicit memory, Jascha Heifetz would not remember from day to day which piece he had chosen to work on previously, or that he had ever worked on that piece before. Nor would he recall what he had accomplished the day before or by analysis of past experience what particular problems in execution should be a focus of today's practice session. In fact, it would not occur to him to have a practice session at all; without close direction from someone else he would be effectively incapable of undertaking the process of learning any new piece, irrespective of his considerable tech- nical skills.
8. There is no one way to memorize a piece of music-_different musicians use different ways, or combinations of ways: auditory, kinesthetic, visual, along with higher-order perceptions of the music's rules, grammar, feeling, and intentionality. We know this not only from personal accounts of musical memory and experimental studies of it, but from the many brain regions which (with fMRI) are visibly activated in the learning of a new piece.
But once a piece is learned, analyzed, studied, pondered, practiced, and incorporated into one's repertoire--one's procedural memory-then it can be played or will "play itself" automatically, without effort of deliberation or conscious thought.
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This, too, is very much the case with Clive, who, for all his musi- cal powers, needs "close direction" from others. He needs some- one to put the music before him, to get him into action, and to make sure that he learns and practices new pieces.
What is the relationship of action patterns and procedural memories, which are associated with relatively primitive portions of the nervous system, to consciousness and sensibility, which depend on the cerebral cortex? Practice involves con- scious application, monitoring what one is doing, bringing all one's intelligence and sensibility and values to bear-even though what is so painfully and consciously acquired may then become automatic, coded in motor patterns at a subcortical level. Each time Clive sings or plays the piano or conducts a choir, automatism comes to his aid. But what comes out in an artistic or creative performance, though it depends on automa- tisms, is anything but automatic. The actual performance reani- mates him, engages him as a creative person; it becomes fresh and alive, and perhaps contains new improvisations or innova- tions.? Once Clive starts playing, his "momentum," as Deborah writes, will keep him, and keep the piece, going. Deborah, herself a musician, expresses this very precisely:
The momentum of the music carried Clive from bar to bar. Within the structure of the piece, he was held, as if the
9. The ability to retain and enlarge artistic repertoire, even in the presence of amnesia, was also startlingly evident in an eminent actor who developed amnesia after open-heart surgery. Despite the loss of event memory, his enormous repertoire, from Marlowe to Beckett, and his superb acting skills were never affected, and he remains able to perform at the highest professional level. His ability to learn new parts is also quite intact-_for learning a part, entering into it, taking it into oneself, is very different from acquiring new "information" and is essentially procedural in character. Lacking any explicit memory of his past performances, he feels, may even be an advantage, for it enables him to confront every night on stage as something new and unique, to which he will respond in rich and unexpected ways.
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guage out until he could sing all the words of "Ol' Man River, then leading him on to sing a whole range of old songs, then, by the right sort of questions, drawing him into short responsive phrases. Whether there is a chance of going beyond this, of restoring fluent narrative or propositional speech to patients with long-standing aphasia, remains an open question. Saying "Had a great time" or "Saw the kids" may be as far as Samuel S. can go. It might be said that such verbal responses are modest, limited, and formulaic--but they do represent a radical advance from purely automatic speech, and they can have an enormous effect on the daily reality of an aphasic person's life, allowing a formerly mute and isolated person to renter a verbal world, a world he had seemingly lost forever.
In 1973 Martin Albert and his colleagues in Boston described a form of music therapy they called "melodic intonation therapy." Patients were taught to sing or intone short phrases--for example, "How are you today?" Then the musical elements of this were removed slowly until (in some cases) the patient regained the power to speak a little without the aid of intonation. One sixty. seven-year-old man, aphasic for eighteen months--he could only produce meaningless grunts, and had received three months of speech therapy without effect- started to produce words two days after beginning melodic intonation therapy; in two weeks, he had an effective vocabulary of a hundred words, and at six weeks, he could carry on "short, meaningful conversations."
What is happening in the brain when melodic intonation, or any type of music therapy, "works"? Albert et al. originally thought that it served to activate areas in the right hemisphere, areas homologous to Broca's area. Albert's close colleague, Nor- man Geschwind, had been fascinated by the way in which chil- dren could recover speech and language even after the removal of the entire left hemisphere of the brain (this was sometimes done
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in children with uncontrollable seizures). Such a recovery or reacquisition of language suggested to Geschwind that, though linguistic ability was generally associated with the left hemi- sphere, the right hemisphere also had linguistic potential and could take over language functions almost completely, at least in children. Albert and his colleagues thus felt, without clear evi- dence, that this might be the case, at least to some degree, even in aphasic adults, and that melodic intonation therapy, calling as it did upon right-hemisphere musical skills, could help to develop this potential.
Detailed imaging of patients undergoing MIT was not possible during the 1970s, and a 1996 PET scan study by Pascal Belin et al. seemed to show that there was no activation in the right hemi sphere of such patients. They reported, moreover, that there was not only an inhibition of Broca's area in aphasic patients, but hyperactivity of a homologous area in the right hemisphere (we may call it, for convenience, the "right Broca's area"). This sustained hyperactivity on the right side exerts an active inhibiting action on the "good" Broca's area, which, in its weakened state, is powerless to resist. The challenge, then, is not only to stimulate the normal, left Broca's area, but to find a way to damp down the "right Broca's area," with its malignant hyperactivity. Singing and melodic intonation seem to do exactly this: by engaging the right-hemisphere circuits in normal activity, they disengage them from pathological activity. This process has a certain self-sustaining momentum of its own, for as the left Broca's area is released from inhibition, it can exert a suppressant action on the "right Broca's area." A vicious circle, in short, is replaced by a therapeutic one.6
6. There is some preliminary evidence that the same effect may be accomplished by using repetitive bursts of transcranial magnetic stimulation applied to the "right Broca's area" to suppress its hyperactivity. Paula Martin and her colleagues have recently tried this
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conjoined meanings of measure, motion, and stream. An articu- late 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 thou- sand 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 lan- gages 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 flour- ished in our species.
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where commands cannot be given verbally (as with infants or ani- mals), by observing whether there is any spontaneous synchro- nization 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 listen- ers." This linking of auditory and motor systems seems univer- sal in humans, and shows itself spontaneously, early in life.?
2. Humans, it seems, are the only primates with such a tight coupling of motor and auditory systems in the brain—apes do not dance, and though they sometimes drum, they do not anticipate a beat and synchronize to it in the same way that humans do.
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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
The evidence for musical abilities in other species is mixed. In Thailand, some ele- phants have been trained to strike percussion instruments and "play together" on their own. Intrigued by accounts of this Thai Elephant Orchestra, Aniruddh Patel and John Iversen made careful measurements and video recordings of the elephants' performances. They found that an elephant could "play a percussion instrument [a large drum] with a highly stable tempo"-_indeed, a tempo more stable than most humans could achieve. But the other elephants in the "orchestra" struck their instruments (cymbals, gongs, etc.) in seeming disregard of one another, without synchronizing to the auditory beat of the drum elephant.
But some bird species are known for their ability to sing duets or choruses, and some do keep time to human music. Patel, Iversen, and their colleagues have studied Snowball, a sulphur-crested Eleanora cockatoo who had achieved some reknown on You Tube for his dancing to the Backstreet Boys. Patel et al. found evidence of true synchronization to a musical beat by Snowball, who bobs his head and moves his feet in time with music. As they reported in a 2008 paper, "when the tempo of a song is increased or decreased over a limited range, Snowball adjusts his movements accordingly, and stays synchronized with the music."
Many animals, from the Lipizzaner horses of the Spanish Riding School of Vienna to circus elephants, dogs, and bears, have been trained to "dance" to music. It is not always clear whether such animals are responding to subtle visual or tactile cues from the humans around them, but it is hard to resist the impression that such animals are, on some level, enjoying the music and responding to it in a rhythmic way.
Many people report that their pets will respond or attend only to particular songs, or will "sing along" or "dance" to particular music. Such stories go back a long way, and a delightful 1814 book- titled The Power of Music: In which is shown, by a variety of Pleasing and Instructive Anecdotes, the effects it has on Man and Animals--includes accounts of snakes, lizards, spiders, mice, rabbits, bulls, and other animals responding to music in various ways. Ignacy Paderewski, the Polish pianist and composer, gives a very detailed account in his memoirs about a spider which could apparently distinguish thirds from sixths, and would come down from the ceiling to the piano whenever he played Chopin études in thirds, only to decamp ("sometimes, I used to think, quite angrily") when he switched to études in sixths.
As one correspondent wrote to me, "None of (this rises to the level of scientific proof, of course, but having lived with animals for years ... I firmly believe that we underesti- mate the emotional and the analytical capabilities of nonhuman vertebrates, especially mammals and birds." I replied that I agreed with him, and suspected that we underesti- mated the abilities of invertebrates, too.
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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 listening 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 move- ment, 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 physi- cian Malonnie Kinnison, a competitive cyclist and triathlete, observed to me:
3. Galileo famously exemplified this in his experiments timing the descent of objects as they rolled down inclined planes. Having no accurate watches or clocks to go by, he timed each trial by humming tunes to himself, and this allowed him to get results with an accu. racy far beyond that of the timepieces of his era.
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movement and to whip up a collective and perhaps martial excitement. We see this not only with military music and war drums, but also with the slow, solemn rhythm of a funeral march. We see it with work songs of every sort--rhythmic songs that probably arose with the beginnings of agriculture, when till- ing the soil, hoeing, and threshing all required the combined and synchronized efforts of a group of people. Rhythm and its entrainment of movement (and often emotion), its power to "move" people, in both senses of the word, may well have had a crucial cultural and economic function in human evolution, bringing people together, producing a sense of collectivity and community.
This, indeed, is central to the vision of cultural evolution presented by Merlin Donald in his astonishing I99I book Ori- gins of the Modern Mind, and in many subsequent papers. An essential feature of Donald's vision is his concept that human evolution moved from the "episodic" life of apes to a "mimetic" culture-_and that this flourished and lasted for tens, perhaps hundreds of thousands of years before language and conceptual thinking evolved. Donald proposes that mimesis--the power to represent emotions, external events, or stories using only gesture and posture, movement and sound, but not language- is still the bedrock of human culture today. He sees rhythm as having a unique role in relation to mimesis:
Rhythm is an integrative-mimetic skill, related to both vocal and visuomotor mimesis.... Rhythmic ability is supramodal; that is, once a rhythm is established, it may be played out with any motor modality, including the hands, feet, mouth, or the whole body. It is apparently self- reinforcing, in the way that perceptual exploration and motor play are self-reinforcing. Rhythm is, in a sense, the
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Music and Identity:
Dementia and Music Therapy
Of the five hundred or so neurological patients at my hos- pital, about half have dementia of various sorts from multiple strokes, from cerebral hypoxia, from toxic or metabolic abnormalities, from brain injuries or infections, from frontotemporal degeneration, or, most commonly, trom Alzheimer's disease.
Some years ago, Donna Cohen, a colleague of mine, after study- ing our large population of patients with Alzheimer's, coauthored a book called The Loss of Self. For various reasons, I deplored the title (though it is a very good book as a resource for families and caregivers) and set myself to contradicting it, lecturing here and there on "Alzheimer's Disease and the Preservation of Self." And yet, I am not sure that we were in real disagreement.
Certainly someone with Alzheimer's loses many of his powers or faculties as the disease advances (though this process may take many years). The loss of certain forms of memory is often
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an early indicator of Alzheimer's, and this may progress to a profound amnesia. Later there may be impairment of language and, with the involvement of the frontal lobes, loss of subtler and deeper powers, like judgment, foresight, and the ability to plan. Eventually a person with Alzheimer's may lose some fundamen- tal aspects of self-awareness, in particular the awareness of their own incapacities. But does the loss of one's self-awareness, or some aspects of mind, constitute loss of self?
Shakespeare's Jaques, in As You Like It, considering the seven ages of man, sees the final one as " sans everything." Yet though one may be profoundly reduced and impaired, one is never sans everything, never a tabula rasa. Someone with Alzheimer's may undergo a regression to a "second childhood," but aspects of one's essential character, of personality and personhood, of self, survive- -along with certain, almost indestructible forms of memory-even in very advanced dementia. It is as if identity has such a robust, widespread neural basis, as if personal style is so deeply ingrained in the nervous system, that it is never wholly lost, at least while there is still any mental life present at all. (This, indeed, is what one might expect if perceptions and actions, feelings and thoughts, have molded the structure of one's brain from the start.) This is poignantly clear in such mem- oirs as John Bayley's Elegy for Iris.
In particular, the response to music is preserved, even when dementia is very advanced. But the therapeutic role of music in dementia is quite different from what it is in patients with motor or speech disorders. Music that helps patients with parkinsonism, for example, must have a firm rhythmic character, but it need not be familiar or evocative. With aphasics it is crucial to have songs with lyrics or intoned phrases, and interaction with a therapist. The aim of music therapy in people with dementia is far broader than this- it seeks to address the emotions, cognitive powers, thoughts, and
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memories, the surviving "self" of the patient, to stimulate these and bring them to the fore. It aims to enrich and enlarge existence, to give freedom, stability, organization, and focus.
This might seem a very tall order-nearly impossible, one would think, seeing patients with advanced dementia, who may sit in a seemingly mindless, vacant torpor or scream agitat- edly in incommunicable distress. But music therapy with such patients is possible because musical perception, musical sensi- bility, musical emotion, and musical memory can survive long after other forms of memory have disappeared. Music of the right kind can serve to orient and anchor a patient when almost nothing else can.
I see this continually with my patients, and I hear of it con- stantly in the letters I receive. One man wrote to me about his wife:
Although my wife has Alzheimer's-_diagnosed at least seven years ago_-the essential person miraculously remains . She plays piano several hours daily, very well. Her present ambi- tion is to memorize the Schumann A-minor Piano Concerto.And yet this is a woman who is, in most other spheres, grossly forgetful and disabled. (Nietzsche, too, continued to improvise at
I. Elliott Ross and his colleagues in Oklahoma published a case study of their patient S.L. (see Cowles et al., 2003). Although he was demented, probably from Alzheimer's disease, S.. could still remember and skillfully play a large musical repertoire from the past, even though he had "profound disturbance in both recall and recognition on other anterograde memory tests," such as word lists or the sounds of musical instruments. He also showed "'arked impairment on measures of remote memory (famous faces, autobiographical memory)." Even more remarkably, this amnesic and demented man was able to learn a new song on his violin, despite having virtually no episodic memory--a situation remi- niscent of that of Clive Wearing (in chapter I5).
There have been formal studies of the persistence of musical powers in advanced dementia, including those of Caddy and Duffin, 2005; Fornazzari, Castle, et al., 2006; and Crystal, Grober, and Masur, 1989.
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sions, emotions, and postures appropriate to the song, and to singing in a group-_turning to the others, awaiting their cues, and so on. This was so with all the songs they sang-whether they were exuberant, jazzy, lyrical and romantic, funny, or sad.
Mary Ellen had brought along a CD Woody had recorded years before with his a cappella group, the Grunyons, and when we played this, Woody sang along beautifully. His musicality, at least his performing musicality, like his civility and equanimity, was completely intact--but again, I wondered if it could be just a mimesis, just a performance, representing feelings and meanings he no longer had. Certainly Woody looked more "present" when singing than at any other time. I asked Rosemary whether she felt that he, the man she had known and loved for fifty-five years, was totally present in his singing. She said, "I think he probably is." Rosemary looked tired, exhausted, from her almost nonstop caring for her husband, and the inch-by-inch way in which she was being widowed, as he lost more and more of what used to constitute his self. But she was least sad, least widowed, when they all sang together. He seemed so present at such times that his absence a few minutes later, his forgetting that he had sung for could sing), would always come as a shock.
Given her father's powerful musical memory, Mary Ellen asked, "Why can't we use this as an opening... embed shopping lists, information about himself, in his songs?" I said I feared this would not work.
Mary Ellen had, in fact, found this out already for herselt. "Why couldn't we sing him his life story?" she had written in her journal in 2005. "Or the directions from one room to the next? I've tried-it doesn't work." I too had had this thought, in rela- ton to Greg, an intelligent, very musical, very amnesic patient I had seen years before. Writing about him in the New York Review of Books in 1992, I observed:
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It is easy to show that simple information can be embedded in songs; thus we can give Greg the date every day, in the form of a jingle, and he can readily isolate this, and say it when asked--give it, that is, without the jingle. But what does it mean to say, "This is December the I9th, I99I," when one is sunk in the profoundest amnesia, when one has lost one's sense of time and history, when one is existing from moment to moment in a sequenceless limbo? "Know. ing the date" means nothing in these circumstances. Could one, however, through the evocativeness and power of music, perhaps using songs with specially written lyrics- songs which relate something valuable about himself or the current world--accomplish something more lasting, deeper? Give Greg not only "facts," but a sense of time and history, of the relatedness (and not merely the existence) of events, an entire (if synthetic) framework for thinking? This is something which Connie Tomaino and I are trying to do now. We hope to have an answer in a year.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 mem- ory 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, remember- ing anew that he can sing is profoundly reassuring to Woody, as the exercise of any skill or competence must be-_and it can stim- ulate his feelings, his imagination, his sense of humor and cre- ativity, and his sense of identity as nothing else can. It can enliven him, calm him, focus and engage him. It can give him
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a lovely face, my sister and I as children (his darlings), the joys of work, of food, of travel, of family?What did this music touch? Where was this landscape where there is no forgetting? How did it free another kind of memory, a memory of the heart not tethered to time or place or events or even loved ones?
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 de- mented 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 amu- sia with damage to these. But the emotional response to music, it would seem, is widespread and probably not only cortical but sub- cortical, so that even in a diffuse cortical disease like Alzheimer's, music can still 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 lux- Wry 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.