by Oliver Sacks
People often ask Mrs. L. what she hears when music is played, and she answers, “If you were in my kitchen and threw all the pots and pans on the floor, that’s what I hear!” Later, she said that she was “very sensitive to high notes” and that if she went to an opera, “it all sounded like screaming.
“I couldn’t recognize ‘The Star-Spangled Banner,’ ” Mrs. L. said, “I had to wait until others stood up.” She also failed to recognize “Happy Birthday to You,” even though when she became a teacher, she would play a recording of it “at least thirty times a year, when any of my students had a birthday.”
When she was in college, a professor did some hearing tests on all of his students, and told D.L. that she had “impossible results”— he wondered if she could, in fact, perceive music. Around this time, she started going out with boyfriends. “I went to all these musicals,” she told me, including Oklahoma! (“my father managed to cough up enough for a ninety-cent seat”). She would sit through these musicals— they were not too bad, she said, if only one person was singing, as long as it was not too high.
She mentioned that when her mother had a stroke and was admitted to a nursing home, all sorts of activities, but especially music, delighted and calmed her. But Mrs. L. said that if she were in the same position, music would make her worse, drive her mad.
Seven or eight years ago, Mrs. L. saw an article in the New York Times about Isabelle Peretz’s work on amusia, and she said to her husband, “That’s what I have!” Although she had never thought of her problem as “psychological” or “emotional,” as her mother seemed to, she had not explicitly thought of it as “neurological.” Excitedly, she wrote to Peretz, and in her subsequent meeting with Peretz and Krista Hyde, she was reassured that the condition was “real,” not in her mind— and that others had it as well. She got in touch with other amusic people, and feels that now, with a bona fide “condition,” she can excuse herself from going to musical events. (She wishes that a diagnosis of amusia had been made when she was seven rather than seventy— this might have saved her from a lifetime of being bored or excruciated by concerts, to which she went only out of politeness.)
In 2002 Ayotte, Peretz, and Hyde published a paper, “Congenital Amusia: A Group Study of Adults Afflicted with a Music-Specific Disorder,” in the journal Brain, based on their investigation of eleven subjects. Most of them had normal perception of speech and environmental sounds, but the majority were profoundly impaired in recognizing melodies and in pitch discrimination, unable to distinguish between adjacent tones and semitones. Without these basic building blocks, there can be no sense of a tonal center or key, no sense of scale or melody or harmony— any more than, in a spoken language, one can have words without syllables.5
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WHEN MRS. L. compared the sound of music to that of pots and pans being thrown around the kitchen, I was puzzled, for it seemed to me that pitch discrimination alone, however defective, would not produce such an experience. It was as if the whole character, the timbre, of musical notes was being radically undermined.
(Timbre is the particular quality or acoustic richness of a sound produced by an instrument or a voice, independent of its pitch or loudness— it is what distinguishes a middle C played on a piano from the same note played on a saxophone. The timbre of a sound is influenced by all sorts of factors, including the frequencies of harmonics or overtones and the onset, rise, and decay of acoustic waveforms. The ability to maintain a sense of timbre constancy is a multileveled and extremely complex process in the auditory brain that may have some analogies with color constancy— indeed, the language of color is often applied to timbre, which is sometimes referred to as “sound color” or “tone color.”)
I had a similar impression reading Hécaen and Albert’s case history of the man for whom music was transformed into the sound of “a screeching car,” and with my own experience of a Chopin ballade sounding as if it were being banged out on a sheet of steel. And Robert Silvers has written to me of how Joseph Alsop, the journalist, “used to tell me that the music I admired, or indeed any music, for him was something like the sound of a horse-drawn carriage passing over cobbled streets.” These cases, like D.L.’s, differed somewhat from the cases of pure pitch amusia described by Ayotte et al. in 2002.
The term “dystimbria” is beginning to be used to denote such experiences, and to be recognized as a distinct form of amusia that may coexist with defective pitch discrimination or occur on its own. Timothy Griffiths, A. R. Jennings, and Jason Warren recently reported the striking case of a forty-two-year-old man who, after suffering a right-hemisphere stroke, experienced dystimbria without any alteration of pitch perception. Mrs. L., it would seem, has both congenital dystimbria and impairments of pitch perception.
One might think, too, that a gross dystimbria for musical notes would make speech sound very different, and perhaps unintelligible. But this was not the case with Mrs. L. (Indeed, Belin, Zatorre, and their colleagues have found “voice-selective” areas in the auditory cortex that are anatomically separate from the areas involved in the perception of musical timbre.)
I asked Mrs. L. how she felt about her failure to “get” music. Was she ever curious or wistful about what others were feeling? She replied that she had been curious as a child: “If I had a wish, it would be to hear music as others heard it.” But she no longer gives this much thought. She cannot perceive or imagine what others are enjoying so much, but she has many other interests and does not think of herself as “defective” or as missing an essential part of life— she is simply the way she is, and always has been.6
In 1990, Isabelle Peretz and her colleagues in Montreal devised a special battery of tests for evaluating amusia, and they have been able, in many cases, to identify the broad neural correlates of certain types of amusia. They feel that there are two basic categories of musical perception, one involving the recognition of melodies, the other the perception of rhythm or time intervals. Impairments of melody usually go with right-hemisphere lesions, but representation of rhythm is much more widespread and robust and involves not only the left hemisphere, but many subcortical systems in the basal ganglia, the cerebellum, and other areas.7 There are many further distinctions; thus some individuals can appreciate rhythm but not meter, and others have the reverse problem.
There are yet other forms of amusia, all probably with their own specific neural bases. There may be an impairment of the ability to perceive dissonance (the discordant sound produced by a major second, for example), something that is normally recognized and reacted to even by infants. Gosselin, Samson, and others in Peretz’s lab have reported that loss of this ability (and nothing else) may occur with particular types of neurological lesion. They tested a number of subjects in discriminating dissonant from nondissonant music and found that only those with extensive damage to an area involved in emotional judgments, the parahippocampal cortex, were affected. Such subjects were able to judge consonant music to be pleasant, and to judge music as happy or sad, but they did not show the normal response to dissonant music, which they rated as “slightly pleasant.”
(In a quite different category— for it has nothing to do with the cognitive aspects of appreciating music— there can be a partial or total loss of the feeling or emotions normally evoked by music, even though perception of music is unimpaired. This too has its own specific neural basis, and is discussed further in chapter 24, “Seduction and Indifference.”)
In most cases, an inability to hear melodies is the consequence of very poor pitch discrimination and a distorted perception of musical tones. But some people may lose the ability to recognize melodies even though they can hear and discriminate the component tones perfectly. This is a higher-order problem— a “tune deafness” or “amelodia” analogous to the losing of sentence structure or meaning, perhaps, though words themselves are intact. Such a person hears a sequence of notes, but the sequence seems arbitrary, seems to have no logic or purpose, makes no musical sense. “What suc
h amusics seem to be lacking,” wrote Ayotte et al., “is the knowledge and procedures required for mapping pitches and musical scales.”
In a recent letter, my friend Lawrence Weschler wrote:
I have an excellent sense of rhythm, and yet I am almost completely amusical in another sense. The missing element for me is the ability to hear the relations between notes and hence aurally to appreciate their interactions and interweavings. If you were to play two relatively close notes on the piano, say within an octave, I would likely not be able to tell you whether one was higher than the other— whether, say, in any given sequence of notes you had gone up and up and then down and down and then up…or the reverse.
Curiously, I have a relatively good sense of melody, or rather melodic memory, in that I can, tape-recorder-like, hum back a tune or even take to whistling or humming it with relative fidelity, days or weeks after being exposed to it. But I couldn’t even tell you in my own humming if a particular melodic trill were going up or down. I have always been this way.
Some years ago my colleague Steven Sparr told me of a patient of his, Professor B., a greatly gifted musician who had played double bass with the New York Philharmonic under Toscanini, was the author of a major textbook in musical appreciation and a close friend of Arnold Schoenberg’s. “Now, at 91,” Sparr wrote, Professor B., “still articulate, vibrant and very much intellectually alive, had had a stroke that left him suddenly unable to discern a tune as simple as ‘Happy Birthday.’ ” His perception of pitch and rhythm was perfectly intact; it was only their synthesis into melody that was gone.
Yet Professor B. was admitted to the hospital with weakness of the left side, and on the day of admission had hallucinations of a choir singing. He was unable to identify Handel’s Messiah (played to him on the bedside music channel) or “Happy Birthday” (hummed to him by Dr. Sparr). Professor B. did not recognize either piece of music, but he did not acknowledge any problem, maintaining that his difficulties were due to “poor fidelity of the recording equipment” and that Dr. Sparr’s humming was mere “pseudovocalization.”
Professor B. could immediately get a melody by reading its notation. His musical imagery was intact— and he could hum a melody himself quite accurately. His problem was wholly one of auditory processing, an inability to hold an auditory sequence of notes in memory.
While there have been many accounts of such melody deafness coming on after a head injury or stroke, I had not heard of a harmony deafness— until I met Rachael Y.
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RACHAEL Y. WAS a gifted composer and performer in her early forties when she came to see me a few years ago. She had been a passenger in a car that had skidded off the road and into a tree; she suffered severe head and spine injuries and was paralyzed in her legs and right arm. She lay in a coma for some days, followed by a twilight state for several weeks, before finally emerging into consciousness. She then discovered that though her intelligence and powers of language were intact, something extraordinary had happened to her perception of music, and she described this in a letter:
There is “before” the accident and there is “after” the accident. So many things changed, so many things are different. Some changes are easier to take than others. The most difficult one is the enormous change in my musical abilities and in the perception of music.
I cannot remember all my musical abilities, but I do remember the fluency and easiness, the “no effort” feeling in anything I tried to do musically.
Listening to music was a complex process of quick analysis of form, harmony, melody, key, historical period, instrumentation…. Listening was linear and horizontal at the same time…. It was all at the tip of my fingers, at the tip of my ears.
And then came the blow to my head that changed everything. Perfect pitch disappeared. I still hear and differentiate pitches, but am no longer able to recognize them with name and place in the musical space. I do hear, but in a way I hear too much. I absorb everything equally, to a degree that becomes at times a real torture. How does one listen with no filtering system?
Symbolically the first piece I desperately wanted to listen to after I regained enough discernment was Beethoven’s opus 131. A four-voice, complicated string quartet that is very emotional and abstract. It is not an easy piece, either to listen to or to analyze. I have no idea how I even remembered that there was such a piece, at a time when I hardly remembered my name.
When the music arrived, I listened to the first solo phrase of the first violin again and again, not really being able to connect its two parts. When I listened to the rest of the movement, I heard four separate voices, four thin, sharp laser beams, beaming to four different directions.
Today, almost eight years after the accident, I still hear the four laser beams equally…four intense voices. And when I listen to an orchestra I hear twenty intense laser voices. It is extremely difficult to integrate all these different voices into some entity that makes sense.
In his letter referring her to me, Rachael’s physician described her “agonizing experience of hearing all music as discrete, contrapuntal lines, being unable to hold on to the harmonic sense of chordal passages. Thus, where listening was linear, vertical and horizontal at the same time, now it was horizontal only.” Her major complaint, when she first came to see me, was of this dysharmonia, her inability to integrate different voices and instruments.
But she had other problems, too. The injury had rendered her deaf in the right ear; she did not realize this at first, but wondered later whether it played a part in her altered perceptions of music. And though she noted the disappearance of absolute pitch right away, she was even more disabled by the undermining of her sense of relative pitch, her representation of tonal space. Now she had to rely on literal enaction: “I can remember a pitch only because I remember how it feels to sing it. Just start the process of singing, and there it is.”8
Rachael found that if she had a score in front of her, it could at least provide a visual and conceptual representation of harmony, though this could not by itself supply the missing perception, “any more than a menu can provide a meal,” she said. But it served to “frame” a piece, to prevent the music from “spreading all over the place.” Playing the piano, and not just listening, she discovered, would also help to “integrate musical information…demands both a tactile and an intellectual understanding…contributes to the ability of quickly switching attention between the different musical elements, and thereby helped integrate them into a musical piece.” But this “formal integration,” as she called it, was still very limited.
There are many levels in the brain at which perceptions of music are integrated and many levels, therefore, at which integration may fail or be compromised. In addition to her difficulties with musical integration, Rachael experienced a similar problem with other sounds, to some extent. Her auditory environment was split sometimes into discrete and unconnected elements: street sounds, domestic sounds, or the sounds of animals, for example, might suddenly stand out and preempt her attention because they were isolated, not integrated into the normal auditory background or landscape. Neurologists refer to this as simultagnosia, and it is more often visual than auditory.9 For Rachael, this simultagnosia meant that she had to build up a picture of her auditory environment in a much more conscious and deliberate, item-by-item way than the rest of us do. And yet, paradoxically, this had some advantages, as it forced her to experience previously overlooked sounds with a supernormal attention and intensity.
Playing the piano had been impossible in the months following her injury, when her right hand was still almost paralyzed. But she taught herself, in these months, to use her left hand for writing and all else. Remarkably, she also took up painting at this time, using her left hand. “I never painted before the accident,” she told me.
When I was still wheelchair bound and my right hand was in a splint, I taught myself to write with my left hand, to make needlepoint works…. It was not an option to let injury dictate my
life. I was dying to play, make music…. I bought a piano and got the shock of my life. Yet the burning creative urge did not stop and I turned to painting…. I had to open the color tubes with my teeth and left hand, and my very first painting ever, a 24-by-36-inch canvas, was painted only with the left hand.
With time and physical therapy, her right hand became stronger, and Rachael found herself slowly able to play the piano again with both hands. When I visited her a few months after our initial meeting, I found her working on a Beethoven bagatelle, a Mozart sonata, Schumann’s Forest Scenes, a Bach three-part invention, and DvoÅ™ák’s Slavonic Dances for Four Hands (this last she would play with her piano teacher, whom she visited weekly). Rachael told me that she had experienced a distinct improvement in her powers to integrate the “horizontals” of music. She had recently been to a performance of three short Monteverdi operas. At first, she said, she delighted in the music, experiencing it for the first time since her accident as harmony, as integration. After a few minutes, however, it became difficult: “It was a great cognitive effort to hold the strands together.” And then the music burst apart, becoming a chaos of different voices:
At the beginning I enjoyed it very much, but then I was caught up in a fragmented music environment…. It became a challenge, and gradually a torture…. And Monteverdi is a good example, because he is so contrapuntally complicated, but at the same time uses a very small orchestra, with no more than three vocal parts at the same time.
