Musical Ears

Oliver Sacks

The late 19th-century neurologist Hughlings Jackson said that he had never been consulted for ‘reminiscence’ as the sole manifestation of epilepsy. But I have – in particular, for the forced or paroxysmal reminiscence of tunes, and, less commonly, of faces or scenes. Wilder Penfield was able to elicit such recalls – the forced replaying or reminiscence of what he called ‘fossil memories’ – by stimulation of the exposed cerebral cortex. I have had this described to me by my own patients – as a rather rare symptom in migraine and, quite frequently, in post-encephalitic patients ‘awakened’ by L-DOPA. And it may occur, as Hughlings Jackson notes, in the course of some seizures.

Mrs O’C. was somewhat deaf, but otherwise in good health. She lived in an old people’s home. One night, in January 1979, she dreamt vividly, nostalgically, of her childhood in Ireland, and especially of the songs they danced to and sang. When she woke up, the music was still going, very loud and clear. ‘I must still be dreaming,’ she thought, but this was not so. She got up, roused and puzzled. It was the middle of the night. Someone, she assumed, must have left a radio playing. But why was she the only person to be disturbed by it? She checked every radio she could find – they were all turned off. Then she had another idea: she had heard that dental fillings could sometimes act like a crystal radio, picking up stray broadcasts with unusual intensity. ‘That’s it,’ she thought, ‘one of my fillings is playing up. It won’t last long. I’ll get it fixed in the morning.’ She complained to the night nurse, who said her fillings looked fine. At this point another notion occurred to Mrs O’C.: ‘What sort of radio-station,’ she reasoned to herself, ‘would play Irish songs, deafeningly, in the middle of the night? Songs, just songs, without introduction or comment? And only songs that I know. What radio station would play my songs, and nothing else?’ At this point she wondered: ‘Is the radio in my head?’

She was now thoroughly rattled – and the music continued deafening. Her last hope was her ENT man, the otologist she was seeing: he would reassure her, tell her it was just ‘noises in the ear’, something to do with her deafness, nothing to worry about. But when she saw him in the course of the morning, he said: ‘No, Mrs O’C., I don’t think it’s your ears. A simple ringing or buzzing or rumbling, maybe: but a concert of Irish songs – that’s not your ears. Maybe,’ he continued, ‘you should see a psychiatrist.’ Mrs O’C. arranged to see a psychiatrist the same day. ‘No, Mrs O’C.,’ the psychiatrist said, ‘it’s not your mind. You are not mad – and the mad don’t hear music, they only hear “voices”. You must see a neurologist.’ And so Mrs O’C. came to me.

Conversation was far from easy, partly because of Mrs O’C.’s deafness, but more because I was repeatedly drowned out by songs – she could only hear me through the softer ones. She was bright, alert, not delirious or mad, but with a remote, absorbed look, as of someone half in a world of their own. I could find nothing neurologically amiss: nonetheless, I suspected that the music was ‘neurological’.

What could have happened with Mrs O’C. to bring her to such a pass? She was 88 and in excellent general health with no hint of fever. She was not on any medications which might unbalance her mind. And, manifestly, she had been normal the day before.

‘Do you think it’s a stroke, doctor?’ she asked, reading my thoughts.

‘It could be,’ I said, ‘though I’ve never seen a stroke like this. Something has happened, that’s for sure, but I don’t think you’re in danger. Don’t worry and hold on.’

‘It’s not so easy to hold on,’ she said, ‘when you’re going through what I’m going through. I know it’s quiet here, but I am in an ocean of sound.’

I wanted to do an electroencephalogram straightaway, paying special attention to the temporal lobes, the ‘musical’ lobes of the brain, but circumstances conspired to prevent this for a while. In this time, the music grew less – less loud and, above all, less persistent. She was able to sleep after the first three nights and, increasingly, to make and hear conversation between ‘songs’. By the time I came to do an EEG, she heard only occasional brief snatches of music, a dozen times, more or less, in the course of a day. After we had settled her and applied the electrodes to her head, I asked her to lie still, say nothing and not ‘sing to herself’, but to raise her right forefinger slightly – which in itself would not disturb the EEG – if she heard any of her songs as we recorded. In the course of a two-hour recording, she raised her finger on three occasions, and each time she did this the EEG pens clattered, and transcribed spikes and sharp waves in the temporal lobes of the brain. This confirmed that she was indeed having temporal-lobe seizures, which, as Hughlings Jackson guessed and Wilder Penfield proved, are the invariable basis of ‘reminiscence’ and experiential hallucinations. But why should she suddenly develop this strange symptom? I obtained a brainscan, and this showed that she had indeed had a small thrombosis or infarction in part of her right temporal lobe. The sudden onset of Irish songs in the night, the sudden activation of musical memory-traces in the cortex, was, apparently, the consequence of a stroke, and as it resolved, so the songs ‘resolved’ too.

By mid-April the songs had entirely gone, and Mrs O’C. was herself once again. I asked her at this point how she felt about it all, and, in particular, whether she missed the paroxysmal songs she heard. ‘It’s funny you should ask that,’ she said with a smile. ‘Mostly, I would say, it is a great relief. But, yes, I do miss the old songs a little. Now, with lots of them, I can’t even recall them. It was like being given back a forgotten bit of my childhood. And some of the songs were really lovely.’

I had heard similar sentiments from some of my patients on L-DOPA – the term I used was ‘convulsive nostalgia’. And I was reminded of a story of H.G. Wells’s, ‘The Strange Case of Davidson’s Eyes’, and how Davidson, as he recovered, became quite wistful, and missed his visions. I told the story to Mrs O’C. ‘That’s it,’ she said. ‘That’s just how it is. One day you must write up “The Strange Case of Mrs O’C.’s Ears”.’

I did not see a similar case until June last year, when I was asked to see Mrs O’M., who was now a resident at the same home. Mrs O’M. was also a woman in her eighties, also somewhat deaf, also bright and alert. She, too, heard music in the head, and sometimes a ringing or hissing or rumbling; occasionally she heard ‘voices talking’, usually ‘far away’ and ‘several at once’, so that she could never catch what they were saying. She hadn’t mentioned these symptoms to anybody, and had secretly worried, for four years, that she was mad. She was greatly relieved when she heard from the Sister that there had been a similar case in the home some time before.

One day, Mrs O’M. recounted, while she was grating parsnips in the kitchen, a song started playing. It was ‘Easter Parade’, and was followed, in swift succession, by ‘Glory, Glory, Hallelujah’ and ‘Good night, sweet Jesus’. Like Mrs O’C., she assumed that a radio had been left on, but quickly discovered that all the radios were off. This was in 1979: it was now 1983. Mrs O’C. recovered in a few weeks, but Mrs O’M.’s music continued, and got worse and worse.

At first she would hear only these three songs – sometimes spontaneously, out of the blue, but for certain if she chanced to think of any of them. She tried, therefore, to avoid thinking of them, but the avoidance of thinking was as provocative as the thinking.

‘Do you like these particular songs?’ I asked, psychiatrically. ‘Do they have some special meaning for you?’

‘No,’ she answered promptly. ‘I never specially liked them, and I don’t think they had any special meaning for me.’

‘And how did you feel when they kept going on?’

‘I came to hate them,’ she replied with great force. ‘It was like some crazy neighbour continually putting on the same record.’

For a year or more, there was nothing but these songs, in maddening succession. After this – and though it was worse in one way, it was also a relief – the inner music became more complex and various. She would hear countless songs – sometimes several simultaneously; sometimes she would hear an orchestra or choir; and, occasionally, as I’ve said, voices, or a mere hubbub of noises.

When I came to examine Mrs O’M. I found nothing abnormal except in her hearing, and here what I found was of singular interest. She had some inner-ear deafness, of a commonplace sort, but over and above this she had a peculiar difficulty in the perception and discrimination of tones of a sort which neurologists call amusia, and which is especially correlated with impaired function in the auditory (or temporal) lobes of the brain. She herself complained that recently the hymns in the chapel seemed more and more alike so that she could scarcely distinguish them by tone or tune, but had to rely on the words, or the rhythm. And although she had been a fine singer in the past, when I tested her she sang flat and out of key. She mentioned, too, that her inner music was most vivid when she woke up, becoming less so as other sensory impressions crowded in; and that it was least likely to occur when she was occupied. In the hour or so she was with me, she heard music only once – a few bars of ‘Easter Parade’, played so loud, and so suddenly, she could hardly hear me through it.

When we came to do an EEG on Mrs O’M. it showed strikingly high voltage and excitability in both temporal lobes. And whenever she ‘heard’ anything, the high voltage waves became frankly convulsive. It was clear that she had a musical (and, more recently, a gross auditory) epilepsy, associated with disease of the temporal lobes.

The EEG was followed by a brainscan which showed only a little atrophy of the cortex in these lobes, as might be seen with a degeneration of the cortical nerve cells there. Such a focal atrophy of the temporal lobes – causing, first, excitement and, then, impairment of auditory perception, culminating finally in a profound mind-deafness – was described by Pick, and is sometimes called ‘Pick’s disease’. It was thought by the great neurologist, Alajouanine, that Ravel had Pick’s disease: he seems to have suffered – or enjoyed – somewhat chaotic musical stimulation in the autumn of 1932, perhaps evident in the sudden extravagances of his last, unfinished work, Arabian Nights, which he himself called ‘orchestral effects without music’, followed by a total loss of the ability to imagine music, a ‘mind-deafness’, utterly different from Beethoven’s deafness, which, of course, left his musical cortex intact. I suspect that something of the sort will happen, is happening, with Mrs O’M.: that the wild epilepsies of music she has been subject to these last four years will become fainter, and finally pass into their opposite – an absolute inner deafness in which she will lose all idea of sounds and music. She will not miss them because she will cease to remember what they were like.