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The Musical Brain: Myth and Science

Antonio Montinaro

When I listen to music I fear no dangers, I am invulnerable, I see and signals of a primordial rhythm lost to our senses but immanent
no enemies, I am in harmony with the earliest times and with in the sets of genes that govern our lives and all the expressions of
the latest. human existence (42).
Life ends when the music of the heart stops, denying the infinitely
Thoreau, Journal (1857)
fragile cerebral cells their vital supply of nutrient factors (above all
oxygen and glucose) that enable the physicochemical exchange pro-

M usic and the brain: their resemblance is striking. A quick

glance at the stave dense with notes of a Bach fugue will
immediately remind us of the cytoarchitecture of the ce-
rebral cortex, where the ordered distribution of thousands of mil-
lions of neurons responds to needs that could easily be defined as
cesses to take place and regulate the interneuronal relationships and
systems linking the different encephalic regions. In reality, it is the
music of the brain that stops, finally interrupting the link, as vital
and tangible as it is mysterious, with the rhythm of the universe.
If we consider the nervous system as a great orchestra that can
musical (Figures 1 and 2). express a complete range of rhythms and melodies and the most
In fact, it is the equivalent of a musical pathway that transmutes complex harmonic combinations, we will find it easier to under-
thought to action, gesture, language: we have only to think of the stand how any lesion will be translated into an alteration of the
athlete’s body during a high jump, the pianist’s fingers inflaming rhythmic systems that synchronize the brain, so that the neurons
the keyboard with a dizzying progression of chords, the neurosur- can be activated at the wrong time or make wrong connections or not
geon’s hands preparing the neck of an aneurysm to insert the clip be activated at all (13).
and so exclude the damaged part of the vessel from the circulation, Because music spreads to the deepest corners of the brain and body
of the organist’s feet and hands acting in harmony on the keyboard and can bring to the surface things that belong to the subconscious
and pedals—we could multiply the examples to infinity. world, outside music can contribute to restore the tone to inner, neuro-
The origin and precise plan of each movement are seated, as we logic music. Music preserves this magic power because it is indissolubly
well know, in the brain—supplied both with cortical areas that linked to the “bath of primordial sounds of endouterine life” (57) and
generate the movement (centers processing the command and cen- thus “pre-existent to the separation” (57). It is thus a re-evocation of a
ters triggering the motor stimuli) and subcortical centers that mod- mythical symbiosis: objective nostalgia of a world lost to our senses but
ulate the movement and give it its unmistakable, genetically deter- painfully rebuilt in dreams, the impossible dreams of an unrealizable
mined character. return to the foetus, to a deep refuge where the waves protect us from
The melody and harmony of any somatic motor activity—music of the crashing din of violence and passion of the world (42).
the body—are thus a faithful reproduction of the melody and har-
mony of the cerebral staves: the music of the brain (13). But more than
this, like music the brain needs an interpreter to exist, in the same
way as an isolated brain lacking any connections does not exist. To PHYSIOLOGY OF MUSIC PERCEPTION
be in the world, it needs on one hand to relate to the surrounding The perception of music takes place in three stages: the first is an
environment and on the other, to interpret itself. In other words, it elementary perception of the auditory musical stimulus; the second
must be able to read each time with absolute precision the thousands corresponds to the structural analysis of music, at both an elemen-
of staves that mark the rhythms, melodies, and fascinating har- tary (pitch, intensity, rhythm, duration, timbre) and an advanced
monic creations. Who knows where these derive from, these signs level (phrasing, timing, themes); the third stage is identification of

Key words From the Neurosurgical Unit, “V. Fazzi” Hospital, Lecce, Italy
! Amusia
To whom correspondence should be addressed: Antonio Montinaro, M.D.
! Brain
[E-mail: a.montinaro@libero.it].
! Functional magnetic resonance
! Mozart Effect Citation: World Neurosurg. (2010) 73, 5:442-453.
! Music therapy DOI: 10.1016/j.wneu.2010.02.060
Journal homepage: www.WORLDNEUROSURGERY.org
Abbreviations and Acronyms
EEG: Electroencephalogram Available online: www.sciencedirect.com
ERG: Event-related desynchronization 1878-8750/$ - see front matter © 2010 Elsevier Inc. All rights reserved.
fMRI: Functional magnetic resonance imaging
PET: Positron emission tomography

442 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, DOI:10.1016/j.wneu.2010.02.060


Anatomical and physiological research has long since demon-

strated a primary acoustic projection center localized in areas 41 and
42 of the temporal lobes that correspond to the transverse loops of
Heschl. The adjacent area 22 is the secondary auditory projection
center. A tonotopical organization has been shown within these
areas (9, 46). Auditory stimuli are projected by the medial geniculate
bodies to the relative cortical areas through auditory radiations that
cross the internal capsule. The primary and secondary areas are in
turn connected to almost the entire brain, through two-way connec-
tions that create complex circuits of association and feedback (16).
The new neuroimaging techniques (positron emission tomogra-
phy [PET], functional magnetic resonance imaging [fMRI]) enable
visualization of the cerebral areas that are activated in response to
musical stimuli and reveal the way the different cerebral regions
allow the perception of music and evoke emotions (11, 12, 30, 34, 47,
Electroencephalographic (evoked potentials, quantitative electro-
encephalography, event-related desynchronization [ERD]) and
magnetoencephalographic techniques are more limited than PET on
the spatial resolution plane, but on the other hand they offer excel-
lent temporal resolution, which makes them particularly well suited
to studies of auditory perception, with its intrinsically temporal,
sequential characteristics.
Using quantitative electroencephalogram (EEG), Auzou dem-
onstrated that passive listening to musical sounds provokes elec-
trophysiological alterations in the temporal regions, with a prev-
alence on the right side, and that this prevalence is accentuated,
involving the frontal lobe, during the discrimination of pitch and
timbre (6).
Recently, the clinical case of a left-handed epileptic woman with-
out any musical education was described. During epileptic crises,
she would sing a Portuguese folk song, clapping her hands in time
with the music. The epileptogenic zone was localized in the left
hemisphere. She was successfully treated with selective amygdalo-
hippocampectomy, although the zone triggering the crises could
not be lateralized on scalp EEG. This rare case of ictal singing
supports the evidence that cerebral music production seems to re-
quire both hemispheres, in accordance to the concept that brain
specializations for music is associated with a dynamic, well-orches-
trated interaction of music-specific neural networks (10).
Using magnetoencephalography, Pantev demonstrated that the
tonotopic organization of the auditory cortex is modified by musical
experiences, especially at an early age, and that the response to pure
or complex sounds is identical in nonmusicians but clearly differen-
tiated in musicians. Among the latter, the auditory cortex response is
even greater if they possess absolute pitch (46), for example, the
ability to identify or produce the pitch of a sound without any refer-
ence point (68).
PET performed in healthy subjects while they listen to music has
shown that, in inexpert listeners, listening activates the right side of
Figure 1. A, Bach: Incipit of the fugue in C major from Book I of The
Well-Tempered Clavier (Ed. Curci, Milano). B, A drawing of a typical six- the brain, that is, the more intuitive part, whereas in musicians the
layered neopallial cortex (from Crosby, Humphrey, Lauer: Correlative more rational part, the left, is activated. Moreover, areas typically
Anatomy of the Nervous System. Macmillan, 1962.) deputed to different functions are involved: the “creative” right
hemisphere perceives the timbre and melody while the “logical” left
analyzes rhythm and pitch, interacting with the language area, that
the work being played. Different cortical centers come into play for even seems to be able to recognize musical “syntax” (20, 30, 62, 63,
each of these functions (32). 67, 79).

WORLD NEUROSURGERY 73 [5]: 442-453, MAY 2010 www.WORLDNEUROSURGERY.org 443


that specialized neural systems in the right superior temporal cortex

participate in perceptual analysis of melodies; pitch comparisons
are effected via a neural network that includes right prefrontal cor-
tex, but active retention of pitch involves the interaction of right
temporal and frontal cortices (80).
Neuropsychological studies of epileptic patients who have under-
gone therapeutic unilateral temporal cortectomy have contributed a
great deal to our knowledge of the localization of musical functions:
right temporal cortectomy alters the perception of both pauses and
the melody, whereas the same lesion on the left alters only the
analysis of pauses. Current knowledge thus allows us to conclude
that the dominant hemisphere identifies the rhythm, pauses, and
pitch, whereas the perception of timbre is localized in the right
temporoparietal region, as also the emotional and hedonistic re-
sponses to music. Moreover, the data collected by Zatorre, in pa-
tients with unilateral temporal lobe excisions, indicate that lesions
of right auditory cortex anterior to or including portions of primary
auditory cortex disturb localization performance on both spatial
hemifields, whereas similar damage on the left generally results in
little or no disturbance. The findings suggest that a relative func-
tional asymmetry exists in the representation of auditory space,
which arises at early levels of cortical processing, but not exclusively
within primary auditory cortex (59, 79, 81).
There have been attempts to see whether musical training can
alter the organization of the sensory subcortical areas in a similar
manner to language processing. It was found that in musicians, the
electrophysiological responses of the brain stem to auditory stimuli
are more pronounced and have less latency than in nonmusicians.
These responses are also correlated to the number of years of train-
ing and extend to the areas deputed to language processing, giving
musicians a decisive advantage in processing information about
tones and pauses (39). This result does not only imply a common
subcortical role in language and music processing, which is usually
attributed only to the cortex, but also helps to explain the neurophys-
iological reason why musicians show better language-learning abil-
ities (58, 76).
In a recent study, two specific event-related brain potentials com-
ponents, early right anterior negativity and N5, were used to study
cerebral processing of the syntactic structures of music and lan-
guage in children. Because these two functions are believed to be at
least partly overlapping in the brain, the authors expected to find
difficulties in processing musical syntax in children showing diffi-
culties in language processing. The results confirmed their expecta-
tions. In children with language difficulties, neither early right an-
terior negativity nor N5 were evoked by musical stimuli, unlike in the
control group. These findings suggest a close interrelation between
the systems for language and music processing, and open out po-
tential for the use of musical education in children with language
difficulties (27).
Figure 2. A, J. S. Bach: Incipit of the prelude in C major from Book I of Much of the current research has been devoted to those aspects of
The Well-Tempered Clavier (Ed. Curci, Milano). B, Schematic view of the musical function whose anatomophysiological substrate has not yet
cerebellar cortex (from Crosby, Humphrey, Lauer: Correlative Anatomy of
the Nervous System. Macmillan, 1962.) been identified (30). For example, is musical memory or so-called
musical talent in some way connected with hemispheric dominance
or a particular functional development of some cerebral areas? And
how can we explain individual differences in “native” ability? And
The neural correlates of music perception were studied by mea- what effects does training have on brain function and structure?
suring cerebral blood flow changes with PET. This study showed Perhaps special neuronal circuits are more rapidly and easily estab-

444 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, DOI:10.1016/j.wneu.2010.02.060


lished in people with musical talent and training, and the hemi- personal musical experience can mould the individual’s neuronal
spheric dominance itself may change over time as a result of musical plasticity and that adaptation of the auditory neurons extends well
abilities. A clear progress has been made in the specific domain of beyond the acoustic and communication structures (43).
“absolute pitch,” where interactions between genetic and environ- The cerebral areas that process tone and frequency have a funda-
mental factors are beginning to be unraveled. It is now emerging mental role in understanding language, perceiving music, and mak-
that absolute pitch cannot develop without musical training during ing a spatial discrimination of the sources of simultaneous sounds.
childhood. But because not all children given music lessons develop A study attempted to individuate these areas using a test based on
this skill, new evidence suggests that genetics can play a role (77, 78). stimuli with a dissociated tone (periodicity) and frequency. It con-
Learning to play a musical instrument requires complex multimo- cluded that the neural representation of tones seems to be localized
dal skills involving simultaneous perception of several sensory mo- at the lateral margin of the primary auditory cortex in a region that
dalities: auditory, visual, somatosensory, as well as the motor sys- responds to low frequencies, in agreement with findings of recent
tem. Therefore, musical training provides a good and adequate neuroimaging studies, and also extends to the nonprimary auditory
neuroscientific model to study multimodal brain plasticity effects in cortex (18).
humans. The impact of short-term unimodal and multimodal mu- fMRI (associated with Visual Analogue Score) and measurement
sical training on brain plasticity has been investigated. Two groups of the blood oxygenation level– dependent signal contrast have been
of nonmusicians were musically trained over the course of 2 weeks. used to investigate the neural circuits involved in the perception of
One group (sensorimotor–auditory) learned to play a musical se- feelings of joy or sadness while listening to classical music. Accord-
quence on the piano, whereas the other group (auditory) listened to ing to the study findings, the processing of emotions in response to
and made judgments about the music that had been played by par- music occurs, apart from the medial temporal areas traditionally
ticipants of the sensorimotor–auditory group. Training-induced assigned to this function, in a network that integrates the ventral and
cortical plasticity was assessed by recording the musically elicited dorsal striatus, a zone involved in reinforcement and movement,
mismatch negativity from magnetoencephalographic measure- and in the anterior cingulate, a zone that is important when focusing
ments before and after training. Sensorimotor-auditory and audi- attention (41).
tory groups showed significantly different cortical responses after It has not yet been established whether the emotions and percep-
training. Specifically, the sensorimotor-auditory group showed sig- tive contents referred to are processed by different areas or else the
nificant enlargement of mismatch negativity after training com- cerebral regions mediating emotions are also involved in processing
pared with the auditory group, reflecting greater enhancement of the associated contents. fMRI has demonstrated that when music is
musical representations in auditory cortex after sensorimotor–audi- associated with a film showing real actions, there is greater activa-
tory training compared with after mere auditory training. Thus, the tion of the amygdala, the hippocampus, and the lateral prefrontal
authors have experimentally demonstrated that not only are senso- areas, whereas this differential activation does not occur if the emo-
rimotor and auditory systems connected but also that sensorimo- tion is provoked only by music. It can be concluded that the amyg-
tor–auditory training causes plastic reorganizational changes in the dala, the center of human emotions, is more intensely stimulated
auditory cortex over and above changes introduced by auditory train- when emotions referred to the real world are also evoked (17).
ing alone (31). But is musical sensitivity innate? Partly yes: mention of Mozart
A study investigating neural correlation of musical memory has seems natural in this context. But other famous examples of musical
been conducted using event-related fMRI. To prevent bias due to any precocity can be quoted: the Bach family, Handel, Mendelssohn,
previous experience of the participating subjects, a completely new Schubert.
piece of music was used. The findings suggested that musical mem- Moreover, current research supports the hypothesis of a congen-
ory involves the right area of the hippocampus, the temporal regions ital origin of musical abilities and the capacity to modify them in
bilaterally, the inferior left frontal gyrus, and the left precuneus. response to environmental stimuli. And it is known that some peo-
Moreover, the activity of the right hippocampal area is correlated ple can express their emotions more easily by music than words.
with the percentage rate of success in recalling the musical passage, This is possible even without the sensory feedback that is a conditio
demonstrating that this area plays an important role in musical sine qua non of other forms of art. It is difficult to imagine a blind
memory (75). painter, whereas a composer can produce very complex works even
It has been shown that to adapt to a constant sensory stimulus, the after having lost his hearing many years before (Beethoven, Smet-
auditory system neurons are “attuned” to some acoustic character- ana, Fauré). How can we forget the episode, which sounds like an
istics of the stimulus. A recent study investigated whether in musi- anecdote but is actually a true story, of Beethoven who, when assist-
cians this particular programming of the acoustic neurons is af- ing conductor Umlauff in the first execution of the Ninth Symphony,
fected by their personal musical experience. For this purpose, in two translated into gestures the reading of the score without being able
groups of expert musicians, namely violinists and flautists, while to hear anything, or again when he was invited by the young soprano
their cerebral blood flow was being recorded by fMRI they were Unger to turn to the excited Viennese public waving white handker-
subjected to selective recordings of some arrangements by Bach for chiefs so that he, the author, could see the enthusiasm since he couldn’t
the violin and the flute, respectively. The images demonstrated that hear it.
an extensive neuronal network underlies the subjective musical ex- Up to now, musical perception and performance have rarely been
perience, and showed a greater sensitivity to musical syntax, timbre, considered from the genetic standpoint. A recent Finnish paper
and sound–movement interactions (precentral gyrus) when music is published the results of a study of the genetic substrate of musical
played with the expert’s own instrument. These results show that the perception; 234 subjects belonging to 15 Finnish family groups were

WORLD NEUROSURGERY 73 [5]: 442-453, MAY 2010 www.WORLDNEUROSURGERY.org 445


recruited to undergo two specific tests determining their musical the right inferior frontal gyrus and a larger amount of grey matter, as
aptitude, belonging to the Finnish Karma Music test. These assessed compared to the control group. A second, more in-depth research
the subjects’ ability to structure auditory information, the Seashore was then made in the same field, measuring the thickness of the grey
pitch and timing discrimination subtests (SP and ST, respectively), matter in this area. In subjects affected by amusia, the authors found
used internationally to evaluate tone and time discrimination. The a significant thickening of the grey matter in the cortex of the infe-
authors then analyzed the entire genome using 100 markers to verify rior right frontal gyrus, suggesting that the presence of this cortical
whether these traits were inherited. Percentages of 42% for the malformation, possibly attributable to an altered pattern of neural
Karma Music test, 21% for the ST, 58% for the SP and 48% for the migration, might underlie the characteristic deficiency in this type of
combined tests were obtained. Linkage analysis also revealed a pos- amusia, thus affecting normal development of the frontotemporal
sible contribution of many genes to a genetic predisposition to a tract (21).
musical aptitude, including a genome portion previously associated Mandell et al. demonstrated with voxel-based morphometry anal-
with dyslexia, namely DYX6, when a combination of music and text ysis the existence of a left frontotemporal network that appears to be
is played (54). involved in the melodic and rhythmic discrimination skills and hy-
pothesized that these regions were part of a network that enable
subjects to map motor actions to sounds creating a feedback loop
MUSIC PERCEPTION ABNORMALITIES that allows for corrections of the motor actions based on that per-
ceptual feedback. Thus, the amusicians may actually have an impair-
Subjects affected by congenital amusia (also called tone deafness)
ment of the auditory-motor feedback loop and/or auditory-motor
have an altered musical perception and production (28, 48). This
integration (38).
was first reported in 1752 by J. Ph. Rameau, who described the
Recently, Peretz et al. showed near-normal neural processing of
difficulties encountered in teaching singing to a young man who
musical pitch incongruities in congenital amusia and therefore re-
could not recognize unison, the octave, and pitch. The condition is
vealed that the amusic brain is equipped with the essential neural
more frequent than might be imagined, because it is difficult to
circuitry to perceive fine-grained pitch differences. What would dis-
diagnose. Musicians themselves are often unaware of the condition.
tinguish the amusic from the normal brain is the limited awareness
Quantitative studies of amusia were made by the English linguist
Tennis Butler Fry in 1948 and 1980 (the second time with the Czech of this ability and the lack of responsiveness to the semitone changes
geneticist Hans Calmus), who concluded that about 4% of the gen- that violate musical keys (49).
eral population suffer from amusia (28). Familial studies suggest Tillmann et al. investigated congenital amusics’ short-term mem-
the disorder is heritable and associated with structural differences in ory for tones, musical timbres, and words, and their findings
temporal and frontal cortices (28, 66). showed that amusics’ deficits extend to nonverbal sound material
Disturbances of musical reception have often been assimilated to other than pitch, such as timbre, while not affecting memory for
disturbances of the language sphere (aphasia), since they frequently verbal material. This was in line with previous suggestions about the
coexist. But already in 1922, after observing some cases with amusia domain specificity of congenital amusia (71).
but not aphasia and vice versa, Henschen concluded that language Nonexistent music of all types is perceived in the course of musi-
and music must have different cerebral substrates. In fact, amusia cal hallucinations. These have been described above all in elderly
does not necessarily accompany aphasia: the case of Shebalin, Rus- patients with a severe hearing deficit. PET has shown that during
sian composer and director of a Conservatory, who continued to hallucinations, the same cerebral areas are activated as when listen-
compose and supervise the work of his pupils despite a severe lan- ing to music, except for the primary auditory cortex. Thus, in ab-
guage disturbance, is well known (36). His Fifth Symphony, com- sence of a real acoustic stimulus, only the secondary auditory areas
posed after the left brain stroke, was considered by D. Shostakovitch are activated. It is not clear why this occurs. It is probably the result of
“a creation of a great master” (53). In the same way, cases have been self-generated disordered impulses that are interpreted as sounds
reported of pianists, organists, and orchestra conductors who con- and then processed by the associative areas deputed to manage
tinued with their careers even after developing Wernicke aphasia musical memory, yielding familiar melodies with a strong emo-
because of a left ischemic temporal lesion that caused verbal alexia tional impact (19, 67).
but left their musical reading abilities intact. As regards musicogenic epilepsy, the neural correlates have
Hyde and Peretz suggest that congenital tone deafness is best recently been studied in a woman affected by frequent musico-
understood as a developmental disorder that arises from failures genic crises. She underwent fluorodeoxyglucose PET and SPECT
to encode fine-grained pitch with sufficient resolution to allow with MRI co-recorded ictal subtraction (SISCOM). She suffered
acquisition of core knowledge regarding the pitch structure of partial complex comitial crises consisting of palpitations and a
music and that the disorder is not specific to music but rather is feeling of malaise, staring eyes, and dietary automatisms. Ictal
related to a more general, psychoacoustic difficulty in fine pitch EEG showed theta waves originating from the right temporal
resolution. Hence, one may consider congenital amusia as a lobe; SISCOM demonstrated ictal hyperperfusion in the right
mirror image of some developmental disorders of language (22, portion of the insula, amygdala, and at the head of the hippocam-
50, 51, 52). pus and the right temporal lobe. Finally, fluorodeoxyglucose PET
In a study conducted on a group of amusicians with voxel-based revealed interictal hypometabolism in the same cerebral region.
morphometry, which allows whole-brain analysis without requiring The picture featured an anomalous activation of the temporal-
the delineation of predetermined regions of interest (5), it was found limbic structures associated with the emotional response to mu-
that they presented a reduced quantity of white matter at the level of sic (14).

446 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, DOI:10.1016/j.wneu.2010.02.060


MUSIC AS THERAPY: “David took an harp and played with his hand; so Saul was re-
APOLLO, DAVID, ORPHEUS, freshed.” David can thus be considered the first music therapist. The
MOZART—FOR WHAT relationship between Saul and David is clearly that between the
EFFECT? doctor and patient, and music is the drug. The trouble that afflicts
In Ancient Greece, Apollo was the King is the patient’s feeling of being alone, the sense of isolation
the God of both Medicine and that impedes communication. Hence the need to use a tool that can
Music. In his fundamental create communication between Saul and David. The choice of music
work “The Advancement of is not a random one, because music speaks the language of the emo-
Learning,” F. Bacon declared: tions and, as such, can reveal pain and by doing so, assuage it (35).
“The poets were right to unite The use of music for therapeutic purposes can so be seen to date
music and medicine under back to ancient times, despite the fact that even now we lack a
Apollo because the task of scientific description of the mechanisms underlying the effects that
medicine is nothing other music has. In fact the neurosciences have mostly been focused on
than tuning that strange harp the most common form of communication, namely verbal language,
that is the human body and re- even though Pietro Lichtenthal in his “Trattato dell’influenza della
storing its harmony.” musica sul corpo umano” (Dissertation About the Influence of Mu-
In primitive cultures, to ex- sic on the Human Body) (1811) states: “Worthy of the experiment of
Figure 3. Orpheus (A. Canova, 1775, ert a direct influence on nature a physician is in my opinion, research into the impact of music on
Correr Museum, Venice). or the spirits that govern natu- man and, led by philosophical reasoning, use it in the treatment of
ral phenomena, the chanting illnesses. This idea has not yet been honoured to a high enough
witch doctor had to learn to standard. . . . I’m trying to spread a little more light on this sub-
perceive the inner music of ject. . . . I hope that this attempt will not prove unwelcome to gifted
these phenomena and not just the sounds that everyone can hear. In this physicians.”
way, he acted as a “cosmic interpreter,” calling up and awakening the The therapeutic function of music lies in its communicative
God in each individual (57). In fact, each being received from the Gods power, and its ability to open nonverbal communication channels.
an “individual song” or melody that expressed her or his individual In music, a link is formed between our ability to perceive ourselves
rhythm and a fundamental sound that represented the ultimate, per- and to perceive those parts of ourselves of which we are still un-
sonal metaphysical reality of its possessor (64). aware. That is why the world of sound has a therapeutic power, a
Disease should be considered as an error that casts the human relation that undoubtedly originates from the sounds themselves
but that then transcends them (35).
being into the clutches of a spirit whose cracked voice is nourished
Music is able to evoke and stimulate in the individual a series of
by sucking the sound substance from the human body. It flees when
reactions whose purpose and ultimate end is to project us toward the
it hears the chant of its own name or its own voice. The aim of
absolute, to fulfill us and relieve us, even if only for an instant, of our
treatment is therefore to restore the original music. In an analytical
approach, this corresponds to listening to the music of others, the
sounds and rhythm that are their essence, which lies within the
words and beyond them. If we perceive others as music they become
a reality for us, arousing affection and so a moral obligation. Other-
wise they remain an atomic aggregate of signals, each of which can
be interpreted singly but only as a scholastic exercise, lacking in any
harmony or soul. The doctor must play the music the patient lacks
but that is hidden within him (57).
The sound of Orpheus’ lyre, when he descended to Hades to find
his Eurydice, moved the terrible Furies to tears and they restored her
to him (Figure 3). So Orpheus’ lyre anesthetizes evil, puts a brake on
passions, and opens the way along a path that, although tinged with
pain and desperation, will lead to the final union of the couple, albeit
outside the world where time no longer has a value and where the
great peace and harmony of silence reign. “Music unites because it
plays chords among all those elements that can vibrate” (57).
In Mozart’s “The Magic Flute,” Tamino and Pamina, about to face
the terrible initiation rites, exclaim: “Thanks to the power of Music
we will travel joyfully through the dark vales of death.” This is the
illuministic utopia that the Mozart–Tamino–Pamina initiation
aimed to create on Earth, arriving with the aid of music in Sarastro’s
world of peace and light (Figure 4) (42).
In the Book of Samuel, it states: “But the spirit of the Lord de-
Figure 4. The Temple of Sarastro. (Scene by Remigius Geyling, 1930)
parted from Saul and an evil Spirit from the Lord troubled him”;

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extraordinary sense of incompleteness. The great power of music is “language group” listened to reading tapes, whereas the control
exactly that of forging a link between the finite and the infinite (that group did no prescribed listening. All three groups also underwent
same dichotomy that is sometimes defined as mind– body, or na- the standard care program. Tests made at 1 week, 3 months, and 6
ture–nurture), causing them to dance around the historical and psy- months after the stroke indicated that the music group showed more
chic dimension that is life itself (35). significant and faster cognitive recovery (verbal memory and fo-
By bringing about a reconciliation with our lost vital rhythms, the cused attention), and also showed less depression than the other
specific vital rhythms that define each one of us, music can foster a two groups (61).
metamorphosis, a rebirth, a change in our way of seeing ourselves In another study, to test whether listening to certain types of
and others, in our way of facing life (42). music could control blood pressure in hypertense subjects, and if so
It is in music and through music that we find ourselves directly in to what extent, 30 subjects aged between 63 and 93 years were
the presence of the energy of life that is logically and verbally inex- subdivided into two groups; one group carried out selective listening
pressible but perfectly tangible, and that communicates to our to music for 25 minutes per day for 1 month. At the end of the study,
senses, to our reflection that little that we can encompass of the pure a decrease in systolic and diastolic pressure, by 11.8 and 4.7 mmHg,
miracle of life. It is, beyond all liturgical or theological specificity, a respectively, was observed in the study group whereas there was no
sacramental tension. Or, as Leibniz says: “Music is a secret arith- significant difference in the controls. Music therapy could thus be a
metic of the soul that does not know it counts” (exercitium arith- valid support tool in the treatment of hypertension (70).
meticae occultum nescientis se numerari animi) (Epistolae ad Diver- A study was carried out in a mouse model to probe the physiolog-
sos, letter 154 to Goldbuch, 1712) (57). ical mechanisms whereby music exerts a positive effect on states of
The ability of music to decode emotions or of emotions to decode depression and anxiety, investigating whether music can modulate
themselves through sound has much deeper roots. In music there is the production of neurotrophins (nerve growth factor and brain-
something nonmusical, bound to premusic, to man’s spirituality. derived neurotrophic factor) in the hypothalamus, known to be in-
This existential consciousness made possible by music is a manifes- volved in states of anxiety induced by the hypothalamus–pituitary–
tation of the psyche that is revealed to itself through sounds, that adrenal gland axis. A group of adult mice were exposed for 21
were originally a part of it (35). consecutive days to 6 hours of background music daily at a volume of
between 50 and 60 dB. At the end of the treatment, dosage of the
neurotrophins in the animal brains showed significantly increased
CLINICAL STUDIES ON THE EFFECTS OF MUSIC brain-derived neurotrophic factor and reduced nerve growth factor
Ongoing clinical studies on the effects of music have shown beyond in the hypothalamus, suggesting that neurotrophin modulation can
any doubt that music improves the precision of fine movements, explain, at least in part, the positive effects of music on the brain (3).
walking, posture control, as well as the state of affective and behav- But to what extent can music alleviate stress? The effects of recre-
ioral well-being in patients with locomotor system alterations. ational musical activities on some markers of stress was evaluated in
The positive effects of music on the motor parameters in patients a group of Japanese males working for a large company. Volunteers
affected by Parkinson or Alzheimer disease, multiple sclerosis, were subdivided into two groups, one of which did recreational
ataxia, or spasticity have been amply demonstrated. Affected pa- music activities for 1 hour a day, whereas the other group spent the
tients are very happy to take part in motor activities accompanied by same time doing recreational reading. Half way through the study,
music and with other emotionally involving stimuli (dance, rhythm, the groups were inverted. The data were analyzed pre- and posttreat-
games) in which music plays a predominant role (7, 45, 60, 72). ment. The effects on stress of these activities were measured both by
The potential role of music in neurologic rehabilitation has not yet self-assessment tests and by dosing biochemical markers of im-
been systematically studied but recent publications have provided a mune system activation. In this experimental mode, musical activity
considerable contribution to the knowledge in this specific sector was objectively shown to reduce the level of stress from the biochem-
(29, 55, 65). In 20 patients affected by a stroke (10 with paresis of the ical standpoint, reducing inflammation markers and improving the
right arm and 10 of the left), a rehabilitation strategy based on music activation of the immune system natural killer cells (72).
to evoke sensorimotor responses was adopted, in addition to the In another study, 10 patients in critical conditions were enrolled in
traditional therapy. The music therapy consisted of guided training a randomized study to identify what biochemical mechanisms, if
in the use of the keyboard or drums, for 3 weeks, using first the any, underlie the relaxant effect of music. Some slow movements
paralyzed arm and then the contralateral arm. All the patients in from Mozart’s Sonatas were chosen for the test; before and 1 hour
the musical training arm showed a significant improvement in the after listening to these passages, the cerebral activities were moni-
speed, precision, and fluency of their movements as compared to tored as well as the serum levels of stress hormones and cytokines.
the control group, confirming the efficacy of this approach for neu- Finally, the sedative dosage needed to obtain relaxation of the pa-
romotor rehabilitation in stroke patients (4). tient was recorded. The results showed that listening to music can
A recent Finnish report investigated whether systematic daily lis- markedly reduce sedative requirements, and that in the blood sam-
tening to music could facilitate the restoration of cognitive functions ples of patients undergoing music therapy there are higher levels of
and mood tone after cerebral stroke in 60 patients, admitted for an growth hormone and lower levels of interleukin-6 and epinephrine.
ischemic lesion in the acute phase, in the median right or left cere- This reduction in circulating stress hormones is also associated with
bral artery. They were subdivided into three groups: music, lan- a drop in blood pressure and heart rate. Thus, the study suggests that
guage, and control. For the next 2 months, the “music group” lis- the beneficial effects of music are neurohormonal, dependent on the
tened daily to music selected on the basis of personal preference; the hypothalamus–pituitary–adrenal gland axis (15).

448 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, DOI:10.1016/j.wneu.2010.02.060


The effects of major and minor tones on stress reduction were unproven conviction that musical abilities are intact and indeed
studied by optical topography and monitoring the levels of an often more developed in children with tuberous sclerosis than
endocrinological marker of stress, salivary cortisol. The major other abilities (language, cognition, and motor development).
keys significantly reduce the levels of cortisol in the salivary The results also suggested a potential field of action for bringing
glands in the course of mental fatigue. This suggests that music about the rehabilitation of these children by means of music
can induce an emotional response similar to that of pleasure or therapy (40).
happiness. In addition, the authors observed the typical asym- Music by W. A. Mozart has most often been used both in experi-
metrical pattern of response to stress in the superior temporal ments on music– brain relations and in music therapy, and it seems
cortex, and suggested that the processing of the emotions sad- that this music yields the best, most constant results in general, and
ness and happiness could be correlated to music’s ability to in particular on cognitive skills (the so-called Mozart effect) (23, 25,
reduce stress (68). 26, 33). The hypothesis formulated by Gordon Shaw is that apart
A recent research aimed to ascertain whether listening to a pas- from Mozart’s incredible logical, mnestic and musical talents, the
sage from Vivaldi’s “Four Seasons” could affect elderly subjects’ fact that he composed at a young age means that he exploited
ability to carry out memory tests. The study showed a significantly the space–time differentiating powers of the temporal cortex to
improved performance in those subjects who listened to music as the utmost during the developmental phase, in other words when it
compared to the control group exposed just to background sounds. was at the height of its perceptive and creative potential. Instead,
In the discussion section, the authors hypothesized that their results Alfred Tomatis believes that the maximal therapeutic effect of
could indicate an increased vigilance and mood tone in the active Mozart’s music on the human body is due to the fact that it is the best
listening group (37). known and loved, and so it can foster the best organization of the
Other authors studied the effects of Sonata K.448 by Mozart on neuronal circuits and reinforce the creative and cognitive processes
voluntary and involuntary attention in a survey of behavioral data and of the right hemisphere.
evoked visual potentials based on the oddball paradigm. The com- My personal opinion is that it is the incomplete musical knowl-
ponents P3a (related to involuntary attention) and P3b (related to edge of the researchers and the great notoriety and familiarity of
voluntary attention) were assessed. The Mozart effect was revealed
much of the vast production by Mozart, especially after the resound-
in the data on the evoked potentials but not on behavior. Sonata
ing mass media effect of the multiple award–winning film Amadeus
K.448 had an influence on the latency of P3b but no effect on P3a. On
by Forman, have in a certain sense “directed” the experimentation
the contrary, in fact, in conditions of musical stimulation, a reduc-
and led to the identification of a Mozart effect rather than a Haydn
tion in the width of both signals was observed. The authors inter-
effect or Vivaldi effect or Mendelssohn effect. In fact, the very con-
preted these variations as a positive Mozart effect on involuntary
trasting results obtained in the experiments conducted over the past
attention and negative on voluntary attention, but attributed these
10 years verifying whether systematic listening to the music by the
effects to different mechanisms (82). In another study, the same
Salzburg genius can positively and above all stably affect cognitive
Sonata was used to assess its effects on space–time reasoning using
performance support my doubts. It is no coincidence that the ex-
near-infrared spectroscopy. The authors found that listening to
pression “requiem for the Mozart effect” has recently been coined,
Mozart (as compared to silence and to music by Beethoven) induced
to oppose the excessive and above all self-interested use made of this
a greater activation of the dorsolateral prefrontal and occipital cor-
tex, both of which are considered essential for space–time reasoning tool in the United States (42) and that the German government
powers (69). decided to tackle the myth of the “Mozart effect” following the
Can music be used as a tool to improve lower secondary school conclusion of a report analyzing all the scientific literature on music
pupils’ reading abilities, and especially those affected by specific and intelligence, commissioned to a team of nine German neurosci-
reading difficulties? A test conducted in middle school pupils dem- entists, psychologists, educationalists, and philosophers, all music
onstrated that the use of musical training brought about a signifi- experts (1).
cant improvement in the subtests on decoding and vocabulary both However, nobody can deny that Mozart’s music possesses special
in the pupils with specific problems and overall, in the whole sample characteristics that makes it a virtually universal ideal place of re-
examined (56). turn. Mozart himself helped us understand why when he wrote in his
Another study suggests that music therapy can be a valid support letters: “In my work music is for all kinds of listeners, except those
in care programs for children with autism (74) and a major tool with long ears” (December 1780); and on the subject of the Concerts
helping to reduce stress in pediatric oncology wards. This study K413, 414, 415: “They are a compromise between the too difficult
reported the authors’ experience with music used to alleviate dis- and the too easy: they are very brilliant, pleasant to the ear, natural
tress in children undergoing radiotherapy. The use of music therapy without falling into the trap of emptiness, here and there only ex-
in the waiting rooms built a creative communication bridge with perts can gain satisfaction but even non experts will feel pleasure
their families too (44). without knowing why” (December 1782).
A controlled study was conducted to make an objective test of For about the last 30 years, in our own experience our complex,
musical abilities and “sensitivity” in children with tuberous scle- delicate surgical procedures on the central and peripheral nervous
rosis, a dominant autosomal disease that manifests with epi- system have been carried out in presence of background music at
lepsy; skin lesions; hamartoma in the heart, brain, and kidneys; low volume in the operating theatre. The positive effect was gradu-
and above all mental retardation that severely affects their verbal ally noted by most of the staff and the background environmental
skills and social interaction. The study confirmed the previously noise, which severely disturbs the concentration of the surgeon

WORLD NEUROSURGERY 73 [5]: 442-453, MAY 2010 www.WORLDNEUROSURGERY.org 449


It is virtually impossible for anyone acting as ferryman between

Table 1. The Passages Selected in the Operating Theatre two worlds apparently so far apart (Music-Science and Music-
T. Albinoni: Concerti op. 7, op. 9, op. 10 Myth) to remain free from contagion by the worlds they have
experienced. Can we speak of the scientific bases of a myth? Can
J. S. Bach: Violin concertos, Brandeburg concertos, keyboard
we speak of a myth becoming a tool of a science that has not yet
succeeded in revealing its own constitutive elements and hence
A. Corelli: Concerti grossi op. 6 neurologic correlates?
F. Geminiani: Concerti grossi op. 2, op. 3, op. 7 Let’s get back to the Myth, the profound mystery of this Music that
P. A. Locatelli: Concerti grossi op. 1, op. 4 the more it takes us over, the more it takes on indescribable, unat-
tainable connotations, as soon as it ceases to exist and becomes a
G. F. Haendel: Concerti grossi op. 6, op. 3
W. A. Mozart: Violin concertos; Flute, harp and oboe concertos, I have always wondered how far and how the message present in
Divertimenti, serenades, Salzburg symphonies,
the notes (I take it for granted that there is a message) reaches the
Flute and oboe quartets
listener. The powers of reception and emotions are very different
A. Scarlatti: Flute concertos, String concertos from one person to another but assuming that one can enter in
A. Vivaldi: Oboe and flute concertos, concerti op. 3, op. 4, complete tune with the mind—the composer’s soul—would this
op. 10, op. 11, op. 12 reveal, beyond the pure intelligible form, the link that allowed the
melodic fragments and latent rhythms of the universe to be per-
ceived and revealed? And again, is this not perhaps the only possible
way we have been granted to approach the threshold of the Act of
working at the microscope, was reduced as if by magic, as had Creation at the beginning of time?
already been reported by other authors (24). The result cannot but be directly proportional to the listener’s
The passages selected (Table 1) naturally reflect the preferences ability to achieve an empathetic solidarity with the composer (a leap
and culture of the surgeons but also vary according to the type of into infinity?). To gain this threshold, which is truly remote, one
surgical procedure (exclusive use of the microscope, or a particularly needs a strong will and continual practice to refine one’s listening
delicate procedure). Personally, I believe that the music of the Ba- abilities and understanding. In other words, the mind and soul must
roque Age is best suited to very challenging surgery. The three con- be constantly in training—without fail and with no drawing
certs for violin by Bach have been an exceptional and irreplaceable back—to challenge the impossible.
accompaniment to clipping all the aneurysms I have treated up to But it is equally essential to have a profound knowledge of the
now, inspiring me with the necessary calm and enhancing the pre-
composer’s world and history, so as to be able to appreciate the
cision of my movements. I exclude vocal music as well as romantic
meaning hidden beyond and inside the notes and to enter in contact
music, in other words all music full of “passion” and permeated with
with universal elements through specific ones.
extramusical meaning (42).
It is impossible to understand Tchaikovsky’s Symphonie Pathet-
Our experience cannot be described as a scientific experiment
ique, unless one knows what lies behind this extreme musical score
conducted with the necessary rigor, but still it has allowed us to
and what tinged the suffering that exudes from its essence. Nor will
validate the efficacy of the use of music during surgical procedures
it be possible to perceive the signs of the dramatic destiny that
(2, 42). To my great satisfaction, I have seen that over the course of
impregnates Schubert’s wanderer’s path unless we become his
the years, some colleagues and medical staff, previously unexposed
travel companions. Instead, everyone can, with some difficulty, re-
to musical culture, have learned to know and love the passages we
late to the last song in Winterreise, desolate Leiermann, but few can
play most frequently, committing them to memory in appreciation
succeed in relating to and taking on the heavy burden up to its
of their haunting beauty.
According to what Popp suggests: “There are times when we must extreme consequences (42).
set aside our instruments of inquiry and simply enjoy the genius It is difficult to imagine an identical music– brain relationship in
embodied in the music of the masters” (53). everyone: the genetic makeup, specific sensitivity, training, and
above all listening education make the difference.

[Because] listening means putting oneself in a position to

A RETURN TO THE MYTH decode what is obscure, confused or mute, to reveal to the
consciousness what is “beneath” the meaning (what is
Der Leiermann (The Organ Player) experienced, postulated, wantingly hidden). The commu-
nication implicit in this second type of listening is reli-
Wunderlichter Alter, soll ich mit dir geh’n?
gious: it links the listener subject to the occult world of the
Willst zu meinen Liedern deine Leier dreh’n? gods that, as we know, speak a language of which only a
few enigmatic fragments reach human beings whereas—
(Strange old man, should I come with you? cruel situation—it is vital for them to understand it. Listen-
Will you grind your hurdy-gurdy to my songs?) ing is the ultimate evangelical verb: faith is entirely based
on listening to the divine word and it is through listening
F. Schubert, from W. Mueller’s Winterreise (1827) that man is linked to God (8).

450 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, DOI:10.1016/j.wneu.2010.02.060


We prefer to fall back on the words by Wackenroder, who ex- But why do I try, fool that I am, to melt the words into sounds?
pressed what we are trying to say better than anyone else: It is never how I feel. Come, you sounds, draw near and save
me from this painful terrestrial straining towards words, em-
Among the mathematical relations of the single sounds and brace me with your milliform rays in your shining clouds, and
the different fibres of the human heart an unexplainable sym- lift me up, in the ancient embrace of the heavens that love all
pathy is manifest, through which the art of sounds has be- (73)!
come a rich, well handlable mechanism for describing hu-
The drama of the solitude and desperation of Schubert’s wanderer
man sentiments. . . . No other art is able to fuse in such a
reaches beyond words to the desolation of the uninterrupted, un-
mysterious way profundity, sensual force and obscure fantas-
changing sound of the old organ player.
tic meanings. . . . No other art has a raw material like music,
Nothing is left but music. The music of silence: faithful mirror of
that is already in itself rich in the divine spirit (73).
his destiny.
Audaciously, music touches the divine harp, and traces in this
obscure world, but with a precise order, precise, obscure
magical signs, and the chords of our heart resound and we ACKNOWLEDGMENT
understand their resonance. In the mirror of sounds the hu- The author would like to thank Sheila McGarry and Noel Gallagher
man heart recognizes itself (73). for helping with the English translation of the text.

11. Binder JR, Frost JA, Hammeke TA, Cox RW, Rao SM, sia: when less is better than more. J Neurosci
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Zhou C: The influence of Mozart’s sonata K.448 on Citation: World Neurosurg. (2010) 73, 5:442-453. reserved.

WORLD NEUROSURGERY 73 [5]: 442-453, MAY 2010 www.WORLDNEUROSURGERY.org 453