by Oliver Sacks
And there we left it. I wonder whether I will get a call from Mr. S. one day, saying, “I just heard it on the radio! It was a Bach suite for unaccompanied violin,” or whether what he heard was a dreamlike construction or conflation which, for all its “familiarity,” he will never identify.
* * *
HUGHLINGS JACKSON, writing in the 1870s, remarked upon the feeling of familiarity that is so often a feature of the aura which may precede a temporal lobe seizure. He spoke, too, of “dreamy states,” “déjà vu,” and “reminiscence.” Such feelings of reminiscence, Jackson noted, may have no identifiable content whatever. Although some people lose consciousness during a seizure, others may remain perfectly aware of their surroundings yet also enter an odd, superimposed state in which they experience strange moods or feelings or visions or smells— or music. Hughlings Jackson referred to this situation as a “doubling of consciousness.”
Eric Markowitz, a young musician and teacher, developed in his left temporal lobe an astrocytoma, a tumor of relatively low malignancy, which was operated on in 1993. It recurred ten years later, but was then considered inoperable due to its proximity to the speech areas of the temporal lobe. With the regrowth of his tumor, he has had repeated seizures, in which he does not lose consciousness but, as he wrote to me, “music explodes in my head for about two minutes. I love music; I’ve made my career around it, so it seems a bit ironic that music has also become my tormentor.” Eric’s seizures are not triggered by music, he emphasized, but music is invariably a part of them. As with Jon S., Eric’s hallucinatory music seems very real to him, and hauntingly familiar:
While I am unable to state exactly what song or songs I may be hearing during these aural seizures, I know they seem quite familiar to me— so familiar, in fact, that I am sometimes uncertain whether or not these songs are on a nearby stereo or in my brain. Once I become aware of that strange yet familiar confusion and realize it is in fact a seizure, I seem to try not to figure out what the music may be— indeed, if I could study it closely like a poem or piece of music, I would…but perhaps subconsciously I am afraid that if I pay too much attention to it, I may not be able to escape the song— like quicksand, or hypnosis.
Though Eric (unlike Jon S.) is quite musical, with an excellent musical memory and a highly trained ear, and though he has had more than a dozen such seizures, he is (like Mr. S.) completely unable to recognize his aural music.
In the “strange yet familiar confusion” which is an integral part of his seizure experience, Eric finds it difficult to think straight. His wife or friends, if they are present, may notice a “strange look” on his face. If he has a seizure while at work, he is usually able to “wing it” somehow, without his students realizing that anything is amiss.
There is a fundamental difference, Eric brings out, between his normal musical imagery and that of his seizures: “As a songwriter, I’m familiar with how melody and words seem to arrive out of nowhere…this is intentional, though— I sit with my guitar in the attic and work on completion of the song. My seizures, though, are beyond all this.”
He went on to say that his epileptic music— seemingly contextless and meaningless, though hauntingly familiar— seemed to exert a frightening and almost dangerous spell on him, so that he was drawn deeper and deeper into it. And yet, he has also been so creatively stimulated by these musical auras that he has composed music inspired by them, trying to embody, or at least suggest, their mysterious and ineffable strange-but-familiar quality.
3
Fear of Music: Musicogenic Epilepsy
In 1937 Macdonald Critchley, a superb observer of unusual neurological syndromes, described eleven patients he had seen with epileptic seizures induced by music, as well as extending his survey to cases reported by others. He entitled his pioneer article “Musicogenic Epilepsy” (though he indicated that he preferred the shorter and sweeter term “musicolepsia”).
Some of Critchley’s patients were musical, some were not. The type of music that could provoke their seizures varied a good deal from patient to patient. One specified classical music, another “old-time” or “reminiscent” melodies, while a third patient found that “a well-punctuated rhythm was for her the most dangerous feature in music.” One of my own correspondents had seizures only in response to “modern, dissonant music,” never in response to classical or romantic music (her husband, unfortunately, was partial to modern, dissonant music). Critchley observed how some patients responded only to particular instruments or noises. (One such patient reacted only to “deep notes from a brass wind instrument” this man was a radio operator on a large ocean liner but, continually convulsed by the sounds of its orchestra, had to transfer to a smaller ship with no orchestra.) Some patients responded only to particular melodies or songs.
The most striking case of all was that of an eminent nineteenth-century music critic, Nikonov, who had his first seizure at a performance of Meyerbeer’s opera The Prophet. Thereafter, he became more and more sensitive to music, until finally almost any music, however soft, would send him into convulsions. (“The most noxious of all,” remarked Critchley, “was the so-called ‘musical’ background of Wagner, which afforded an unrelieved and inescapable sound-procession.”) Finally Nikonov, though so knowledgeable and passionate about music, had to relinquish his profession and avoid all contact with music. If he heard a brass band in the street, he would stop his ears and rush for the nearest doorway or side street. He developed a veritable phobia, a horror of music, and this he described in a pamphlet he titled Fear of Music.
Critchley had also published papers, a few years earlier, on seizures induced by nonmusical sounds— usually sounds of a monotonous type, such as a kettle on the boil, an airplane in flight, or machinery in a workshop. In some cases of musicogenic epilepsy, he thought, the particular quality of sound was all-important (as with the radio operator who could not tolerate the deep brass); but in others, the emotional impact of the music, and perhaps its associations, seemed more important.1
The types of seizure that might be provoked by music were quite varied, too. Some patients would have major convulsions, fall down unconscious, bite their tongues, be incontinent; others would have minor seizures, brief “absences” their friends might hardly notice. Many patients would have a complex temporal lobe type of seizure, as did one of Critchley’s patients who said, “I have the feeling that I have been through it all before; as if I were going through a scene. It is the same on each occasion. People are there, dancing; I believe I am on a boat. The scene is not connected with any real place or event which I can recall.”
Musicogenic epilepsy is generally considered to be very rare, but Critchley wondered if it might be notably more common than supposed.2 Many people, he thought, might start to get a queer feeling— disturbing, perhaps frightening— when they heard certain music, but then would immediately retreat from the music, turn it off, or block their ears, so that they did not progress to a full-blown seizure. He wondered, therefore, if abortive forms— formes frustes— of musical epilepsy might be relatively common. (This has certainly been my own impression, and I think there may also be similar formes frustes of photic epilepsy, when blinking lights or fluorescent lights may produce a peculiar discomfort without inducing a full-blown seizure.)
Working in an epilepsy clinic, I have seen a number of patients with seizures induced by music, and others who have musical auras associated with seizures— and occasionally both. Both types of patient are prone to temporal lobe seizures, and most have temporal lobe abnormalities identifiable with EEG or brain imaging.
Among the patients I have seen recently is G.G., a young man who was in good health until June of 2005, when he had a severe attack of herpes encephalitis that started with a high fever and generalized seizures; this was followed by a coma and then a severe amnesia. Remarkably, a year later, his amnesic problems had virtually cleared, but he remained highly seizure-prone, with occasional grand mal seizures and, much more commonly, comp
lex partial seizures. Initially all of these were “spontaneous,” but within a few weeks they started to occur almost exclusively in response to sound— “sudden, loud sounds, like ambulance sirens”— and, especially, music. Along with this G.G. developed a remarkable sensitivity to sound, becoming able to detect sounds too soft or distant for others to hear. He enjoyed this, and felt that his auditory world was “more alive, more vivid,” but wondered, too, whether it played any part in his now-epileptic sensitivity to music and sound.
G.G.’s seizures may be provoked by a large range of music, from rock to classical (the first time I saw him, he played a Verdi aria on his cell phone; after about half a minute, this induced a complex partial seizure). He speaks of “romantic” music as being the most provocative, especially Frank Sinatra’s songs (“He touches a chord in me”). He says that the music has to be “full of emotions, associations, nostalgia” it is almost always music he has known from childhood or adolescence. It does not have to be loud to provoke a seizure— soft music may be equally effective— but he is in particular trouble in a noisy, music-permeated environment, so much so that he must wear earplugs most of the time.
His seizures start with or are preceded by a special state of intense, involuntary, almost forced attention or listening. In this already altered state, the music seems to grow more intense, to swell, to take possession of him, and at this point he cannot stop the process, cannot turn off the music or walk away from it. Beyond this point he retains no consciousness or memory, though various epileptic automatisms, like gasping and lip-smacking, ensue.
For G.G., music does not just provoke a seizure; it seems to constitute an essential part of the seizure, spreading (one imagines) from its initial perceptual locus to other temporal lobe systems, 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 psychic experience and then a seizure.
* * *
ANOTHER PATIENT, Silvia N., came to see me towards the end of 2005. Mrs. N. had developed a seizure disorder in her early thirties. Some of her seizures were of grand mal type, with convulsions and a total loss of consciousness. Others were of a more complex type in which there would be some doubling of consciousness. Sometimes her seizures seemed to be spontaneous or a reaction to stress, but most often they occurred in response to music. One day she was found unconscious on the floor, having had a convulsion. Her last memory before this was of listening to a CD of her favorite Neapolitan songs. No significance was ascribed to this at first, but when she had a similar seizure soon afterwards, also during the playing of Neapolitan songs, she started to wonder whether there could be a connection. She tested herself, cautiously, and found that listening to such songs, either live or on a recording, would now infallibly arouse a “peculiar” feeling, followed quickly by a seizure. No other music, though, had this effect.
She had loved the Neapolitan songs, which reminded her of her childhood. (“The old songs,” she said, “they were always in the family; they always put them on.”) She found them “very romantic, emotional…they had a meaning.” But now that they triggered her seizures, she began to dread them. She became particularly apprehensive about weddings, coming as she did from a large Sicilian family, because such songs were always played at celebrations and family gatherings. “If the band started playing,” Mrs. N. said, “I would run out…. I had half a minute or less to get away.”
Though she sometimes had grand mal seizures in response to the songs, Mrs. N. more often experienced just a strange alteration of time and consciousness in which she would have a feeling of reminiscence— specifically, the feeling of being a teenager, or the reliving of scenes (some seemingly memories, others clearly fantasies) in which she was a teenager. She compared these to dreams and said she would “wake” from them as from a dream, but a dream in which she retained some consciousness, though little control. She was able, for instance, to hear what people around her were saying, but unable to respond— that doubling of consciousness which Hughlings Jackson called “mental diplopia.” While most of her complex seizures referred to the past, she told me, on one occasion, “it was the future I saw…. I was up there, going to heaven…. My grandmother opened up the gates of heaven. ‘It’s not time,’ she said— and then I came to.”
Though Mrs. N. could avoid Neapolitan music most of the time, she also began to have seizures without music, and these grew more and more severe, finally becoming intractable. Medications were useless, and she sometimes had many seizures in a single day, so that daily life became virtually impossible. MRIs had shown both anatomical and electrical abnormalities in her left temporal lobe (probably from a head injury she had suffered as a teenager) and a virtually nonstop seizure focus associated with this, so early in 2003 she underwent brain surgery, a partial temporal lobectomy, to treat it.
The surgery eliminated not only the majority of her spontaneous seizures, but her highly specific vulnerability to Neapolitan songs as well, as she discovered almost by chance. “After the surgery, I was still afraid to listen to the type of song I had seizures with,” she said, “but one day I was at a party, and they started to play the songs. I ran out into another room and closed the door. Then someone opened the door…I heard it like far away. It didn’t bother me that much, so I tried to listen to it.” Wondering if she was finally cured of her vulnerability to music, Mrs. N. went home (“it’s safer there, you’re not in front of five hundred people”) and put some Neapolitan songs on her stereo. “I turned it up little by little, until it was really loud, and it didn’t affect me.”
So now Mrs. N. has lost her fear of music and can play her favorite Neapolitan songs without problem. She has also ceased to have her strange, complex, reminiscent seizures; it seems as though her surgery has put an end to both types of seizures— as Macdonald Critchley might have predicted.
Mrs. N. is delighted, of course, by her cure. But she is occasionally nostalgic, too, for some of her epileptic experiences— like the “gates of heaven,” which seemed to take her to a place unlike anything she had ever experienced before.
4
Music on the Brain: Imagery and Imagination
Heard melodies are sweet, but those unheard are sweeter.
— JOHN KEATS, “Ode on a Grecian Urn”
Music forms a significant and, on the whole, pleasant part of life for most of us— not only external music, music we hear with our ears, but internal music, music that plays in our heads. When Galton wrote on “mental imagery” in the 1880s, he concerned himself only with visual imagery and not at all with musical imagery. But a tally of one’s friends will suffice to show that musical imagery has a range no less varied than the visual. There are some people who can scarcely hold a tune in their heads and others who can hear entire symphonies in their minds with a detail and vividness little short of actual perception.
I became aware of this huge variation early in life, for my parents stood at opposite ends of the spectrum. My mother had difficulty voluntarily calling any tune to mind, but my father seemed to have an entire orchestra in his head, ready to do his bidding. He always had two or three miniature orchestral scores stuffed in his pockets, and between seeing patients he might pull out a score and have a little internal concert. He did not need to put a record on the gramophone, for he could play a score almost as vividly in his mind, perhaps with different moods or interpretations, and sometimes improvisations of his own. His favorite bedtime reading was a dictionary of musical themes; he would turn over a few pages, almost at random, savoring this and that— and then, stimulated by the opening line of something, settle down to a favorite symphony or concerto, his own kleine Nachtmusik, as he called it.
My own powers of musical imagery, and of musical perception, are much more limited. I cannot hear an entire orchestra in my head, at least under normal circumstances. What I do have, to some degree, is a pianist’s imagery. With music I know well, such as Chopin
’s mazurkas, which I learned by heart sixty years ago and have continued to love ever since, I have only to glance at a score or think of a particular mazurka (an opus number will set me off) and the mazurka will start to play in my mind. I not only “hear” the music, but I “see” my hands on the keyboard before me, and “feel” them playing the piece— a virtual performance which, once started, seems to unfold or proceed by itself. Indeed, when I was learning the mazurkas, I found that I could practice them in my mind, and I often “heard” particular phrases or themes from the mazurkas playing by themselves. Even if it is involuntary and unconscious, going over passages mentally in this way is a crucial tool for all performers, and the imagination of playing can be almost as efficacious as the physical actuality.
Since the mid-1990s, studies carried out by Robert Zatorre and his colleagues, using increasingly sophisticated brain-imaging techniques, have shown that imagining music can indeed activate the auditory cortex almost as strongly as listening to it. Imagining music also stimulates the motor cortex, and conversely, imagining the action of playing music stimulates the auditory cortex. This, Zatorre and Halpern noted in a 2005 paper, “corresponds to reports from musicians that they can ‘hear’ their instrument during mental practice.”
As Alvaro Pascual-Leone has observed, studies of regional cerebral blood flow
[suggest that] mental simulation of movements activates some of the same central neural structures required for the performance of the actual movements. In so doing, mental practice alone seems to be sufficient to promote the modulation of neural circuits involved in the early stages of motor skill learning. This modulation not only results in marked improvement in performance, but also seems to place the subjects at an advantage for further skill learning with minimal physical practice. The combination of mental and physical practice [he adds] leads to greater performance improvement than does physical practice alone, a phenomenon for which our findings provide a physiological explanation.
