Culture
The Musical Brain: Myth and Science
Antonio Montinaro
When I listen to music I fear no dangers, I am invulnerable, I see
no enemies, I am in harmony with the earliest times and with
the latest.
Thoreau, Journal (1857)
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
musical (Figures 1 and 2).
In fact, it is the equivalent of a musical pathway that transmutes
thought to action, gesture, language: we have only to think of the
athlete’s body during a high jump, the pianist’s fingers inflaming
the keyboard with a dizzying progression of chords, the neurosur-
geon’s hands preparing the neck of an aneurysm to insert the clip
and so exclude the damaged part of the vessel from the circulation,
of the organist’s feet and hands acting in harmony on the keyboard
and pedals—we could multiply the examples to infinity.
The origin and precise plan of each movement are seated, as we
well know, in the brain—supplied both with cortical areas that
generate the movement (centers processing the command and cen-
ters triggering the motor stimuli) and subcortical centers that mod-
ulate the movement and give it its unmistakable, genetically deter-
mined character.
The melody and harmony of any somatic motor activity—music of
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
be in the world, it needs on one hand to relate to the surrounding
environment and on the other, to interpret itself. In other words, it
must be able to read each time with absolute precision the thousands
of staves that mark the rhythms, melodies, and fascinating har-
monic creations. Who knows where these derive from, these signs
Key words
! Amusia
! Brain
! Functional magnetic resonance
! Mozart Effect
! Music therapy
Abbreviations and Acronyms
EEG: Electroencephalogram
ERG: Event-related desynchronization
fMRI: Functional magnetic resonance imaging
PET: Positron emission tomography
442 www.SCIENCEDIRECT.com
and signals of a primordial rhythm lost to our senses but immanent
in the sets of genes that govern our lives and all the expressions of
human existence (42).
Life ends when the music of the heart stops, denying the infinitely
fragile cerebral cells their vital supply of nutrient factors (above all
oxygen and glucose) that enable the physicochemical exchange pro-
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
express a complete range of rhythms and melodies and the most
complex harmonic combinations, we will find it easier to under-
stand how any lesion will be translated into an alteration of the
rhythmic systems that synchronize the brain, so that the neurons
can be activated at the wrong time or make wrong connections or not
be activated at all (13).
Because music spreads to the deepest corners of the brain and body
and can bring to the surface things that belong to the subconscious
world, outside music can contribute to restore the tone to inner, neuro-
logic music. Music preserves this magic power because it is indissolubly
linked to the “bath of primordial sounds of endouterine life” (57) and
thus “pre-existent to the separation” (57). It is thus a re-evocation of a
mythical symbiosis: objective nostalgia of a world lost to our senses but
painfully rebuilt in dreams, the impossible dreams of an unrealizable
return to the foetus, to a deep refuge where the waves protect us from
the crashing din of violence and passion of the world (42).
PHYSIOLOGY OF MUSIC PERCEPTION
The perception of music takes place in three stages: the first is an
elementary perception of the auditory musical stimulus; the second
corresponds to the structural analysis of music, at both an elemen-
tary (pitch, intensity, rhythm, duration, timbre) and an advanced
level (phrasing, timing, themes); the third stage is identification of
From the Neurosurgical Unit, “V. Fazzi” Hospital, Lecce, Italy
To whom correspondence should be addressed: Antonio Montinaro, M.D.
[E-mail: a.montinaro@libero.it].
Citation: World Neurosurg. (2010) 73, 5:442-453.
DOI: 10.1016/j.wneu.2010.02.060
Journal homepage: www.WORLDNEUROSURGERY.org
Available online: www.sciencedirect.com
1878-8750/$ - see front matter © 2010 Elsevier Inc. All rights reserved.
WORLD NEUROSURGERY, DOI:10.1016/j.wneu.2010.02.060

ANTONIO MONTINARO
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-
layered neopallial cortex (from Crosby, Humphrey, Lauer: Correlative
Anatomy of the Nervous System. Macmillan, 1962.)
the work being played. Different cortical centers come into play for
each of these functions (32).
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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,
67).
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
the brain, that is, the more intuitive part, whereas in musicians the
more rational part, the left, is activated. Moreover, areas typically
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
even seems to be able to recognize musical “syntax” (20, 30, 62, 63,
67, 79).
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Figure 2. A, J. S. Bach: Incipit of the prelude in C major from Book I of
The Well-Tempered Clavier (Ed. Curci, Milano). B, Schematic view of the
cerebellar cortex (from Crosby, Humphrey, Lauer: Correlative Anatomy of
the Nervous System. Macmillan, 1962.)
The neural correlates of music perception were studied by mea-
suring cerebral blood flow changes with PET. This study showed
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THE MUSICAL BRAIN
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).
Much of the current research has been devoted to those aspects of
musical function whose anatomophysiological substrate has not yet
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
what effects does training have on brain function and structure?
Perhaps special neuronal circuits are more rapidly and easily estab-
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lished in people with musical talent and training, and the hemi-
spheric dominance itself may change over time as a result of musical
abilities. A clear progress has been made in the specific domain of
“absolute pitch,” where interactions between genetic and environ-
mental factors are beginning to be unraveled. It is now emerging
that absolute pitch cannot develop without musical training during
childhood. But because not all children given music lessons develop
this skill, new evidence suggests that genetics can play a role (77, 78).
Learning to play a musical instrument requires complex multimo-
dal skills involving simultaneous perception of several sensory mo-
dalities: auditory, visual, somatosensory, as well as the motor sys-
tem. Therefore, musical training provides a good and adequate
neuroscientific model to study multimodal brain plasticity effects in
humans. The impact of short-term unimodal and multimodal mu-
sical training on brain plasticity has been investigated. Two groups
of nonmusicians were musically trained over the course of 2 weeks.
One group (sensorimotor–auditory) learned to play a musical se-
quence on the piano, whereas the other group (auditory) listened to
and made judgments about the music that had been played by par-
ticipants of the sensorimotor–auditory group. Training-induced
cortical plasticity was assessed by recording the musically elicited
mismatch negativity from magnetoencephalographic measure-
ments before and after training. Sensorimotor-auditory and audi-
tory groups showed significantly different cortical responses after
training. Specifically, the sensorimotor-auditory group showed sig-
nificant enlargement of mismatch negativity after training com-
pared with the auditory group, reflecting greater enhancement of
musical representations in auditory cortex after sensorimotor–audi-
tory training compared with after mere auditory training. Thus, the
authors have experimentally demonstrated that not only are senso-
rimotor and auditory systems connected but also that sensorimo-
tor–auditory training causes plastic reorganizational changes in the
auditory cortex over and above changes introduced by auditory train-
ing alone (31).
A study investigating neural correlation of musical memory has
been conducted using event-related fMRI. To prevent bias due to any
previous experience of the participating subjects, a completely new
piece of music was used. The findings suggested that musical mem-
ory involves the right area of the hippocampus, the temporal regions
bilaterally, the inferior left frontal gyrus, and the left precuneus.
Moreover, the activity of the right hippocampal area is correlated
with the percentage rate of success in recalling the musical passage,
demonstrating that this area plays an important role in musical
memory (75).
It has been shown that to adapt to a constant sensory stimulus, the
auditory system neurons are “attuned” to some acoustic character-
istics of the stimulus. A recent study investigated whether in musi-
cians this particular programming of the acoustic neurons is af-
fected by their personal musical experience. For this purpose, in two
groups of expert musicians, namely violinists and flautists, while
their cerebral blood flow was being recorded by fMRI they were
subjected to selective recordings of some arrangements by Bach for
the violin and the flute, respectively. The images demonstrated that
an extensive neuronal network underlies the subjective musical ex-
perience, and showed a greater sensitivity to musical syntax, timbre,
and sound–movement interactions (precentral gyrus) when music is
played with the expert’s own instrument. These results show that the
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personal musical experience can mould the individual’s neuronal
plasticity and that adaptation of the auditory neurons extends well
beyond the acoustic and communication structures (43).
The cerebral areas that process tone and frequency have a funda-
mental role in understanding language, perceiving music, and mak-
ing a spatial discrimination of the sources of simultaneous sounds.
A study attempted to individuate these areas using a test based on
stimuli with a dissociated tone (periodicity) and frequency. It con-
cluded that the neural representation of tones seems to be localized
at the lateral margin of the primary auditory cortex in a region that
responds to low frequencies, in agreement with findings of recent
neuroimaging studies, and also extends to the nonprimary auditory
cortex (18).
fMRI (associated with Visual Analogue Score) and measurement
of the blood oxygenation level– dependent signal contrast have been
used to investigate the neural circuits involved in the perception of
feelings of joy or sadness while listening to classical music. Accord-
ing to the study findings, the processing of emotions in response to
music occurs, apart from the medial temporal areas traditionally
assigned to this function, in a network that integrates the ventral and
dorsal striatus, a zone involved in reinforcement and movement,
and in the anterior cingulate, a zone that is important when focusing
attention (41).
It has not yet been established whether the emotions and percep-
tive contents referred to are processed by different areas or else the
cerebral regions mediating emotions are also involved in processing
the associated contents. fMRI has demonstrated that when music is
associated with a film showing real actions, there is greater activa-
tion of the amygdala, the hippocampus, and the lateral prefrontal
areas, whereas this differential activation does not occur if the emo-
tion is provoked only by music. It can be concluded that the amyg-
dala, the center of human emotions, is more intensely stimulated
when emotions referred to the real world are also evoked (17).
But is musical sensitivity innate? Partly yes: mention of Mozart
seems natural in this context. But other famous examples of musical
precocity can be quoted: the Bach family, Handel, Mendelssohn,
Schubert.
Moreover, current research supports the hypothesis of a congen-
ital origin of musical abilities and the capacity to modify them in
response to environmental stimuli. And it is known that some peo-
ple can express their emotions more easily by music than words.
This is possible even without the sensory feedback that is a conditio
sine qua non of other forms of art. It is difficult to imagine a blind
painter, whereas a composer can produce very complex works even
after having lost his hearing many years before (Beethoven, Smet-
ana, Fauré). How can we forget the episode, which sounds like an
anecdote but is actually a true story, of Beethoven who, when assist-
ing conductor Umlauff in the first execution of the Ninth Symphony,
translated into gestures the reading of the score without being able
to hear anything, or again when he was invited by the young soprano
Unger to turn to the excited Viennese public waving white handker-
chiefs so that he, the author, could see the enthusiasm since he couldn’t
hear it.
Up to now, musical perception and performance have rarely been
considered from the genetic standpoint. A recent Finnish paper
published the results of a study of the genetic substrate of musical
perception; 234 subjects belonging to 15 Finnish family groups were
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ANTONIO MONTINARO
recruited to undergo two specific tests determining their musical
aptitude, belonging to the Finnish Karma Music test. These assessed
the subjects’ ability to structure auditory information, the Seashore
pitch and timing discrimination subtests (SP and ST, respectively),
used internationally to evaluate tone and time discrimination. The
authors then analyzed the entire genome using 100 markers to verify
whether these traits were inherited. Percentages of 42% for the
Karma Music test, 21% for the ST, 58% for the SP and 48% for the
combined tests were obtained. Linkage analysis also revealed a pos-
sible contribution of many genes to a genetic predisposition to a
musical aptitude, including a genome portion previously associated
with dyslexia, namely DYX6, when a combination of music and text
is played (54).
MUSIC PERCEPTION ABNORMALITIES
Subjects affected by congenital amusia (also called tone deafness)
have an altered musical perception and production (28, 48). This
was first reported in 1752 by J. Ph. Rameau, who described the
difficulties encountered in teaching singing to a young man who
could not recognize unison, the octave, and pitch. The condition is
more frequent than might be imagined, because it is difficult to
diagnose. Musicians themselves are often unaware of the condition.
Quantitative studies of amusia were made by the English linguist
Tennis Butler Fry in 1948 and 1980 (the second time with the Czech
geneticist Hans Calmus), who concluded that about 4% of the gen-
eral population suffer from amusia (28). Familial studies suggest
the disorder is heritable and associated with structural differences in
temporal and frontal cortices (28, 66).
Disturbances of musical reception have often been assimilated to
disturbances of the language sphere (aphasia), since they frequently
coexist. But already in 1922, after observing some cases with amusia
but not aphasia and vice versa, Henschen concluded that language
and music must have different cerebral substrates. In fact, amusia
does not necessarily accompany aphasia: the case of Shebalin, Rus-
sian composer and director of a Conservatory, who continued to
compose and supervise the work of his pupils despite a severe lan-
guage disturbance, is well known (36). His Fifth Symphony, com-
posed after the left brain stroke, was considered by D. Shostakovitch
“a creation of a great master” (53). In the same way, cases have been
reported of pianists, organists, and orchestra conductors who con-
tinued with their careers even after developing Wernicke aphasia
because of a left ischemic temporal lesion that caused verbal alexia
but left their musical reading abilities intact.
Hyde and Peretz suggest that congenital tone deafness is best
understood as a developmental disorder that arises from failures
to encode fine-grained pitch with sufficient resolution to allow
acquisition of core knowledge regarding the pitch structure of
music and that the disorder is not specific to music but rather is
related to a more general, psychoacoustic difficulty in fine pitch
resolution. Hence, one may consider congenital amusia as a
mirror image of some developmental disorders of language (22,
50, 51, 52).
In a study conducted on a group of amusicians with voxel-based
morphometry, which allows whole-brain analysis without requiring
the delineation of predetermined regions of interest (5), it was found
that they presented a reduced quantity of white matter at the level of
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the right inferior frontal gyrus and a larger amount of grey matter, as
compared to the control group. A second, more in-depth research
was then made in the same field, measuring the thickness of the grey
matter in this area. In subjects affected by amusia, the authors found
a significant thickening of the grey matter in the cortex of the infe-
rior right frontal gyrus, suggesting that the presence of this cortical
malformation, possibly attributable to an altered pattern of neural
migration, might underlie the characteristic deficiency in this type of
amusia, thus affecting normal development of the frontotemporal
tract (21).
Mandell et al. demonstrated with voxel-based morphometry anal-
ysis the existence of a left frontotemporal network that appears to be
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
that allows for corrections of the motor actions based on that per-
ceptual feedback. Thus, the amusicians may actually have an impair-
ment of the auditory-motor feedback loop and/or auditory-motor
integration (38).
Recently, Peretz et al. showed near-normal neural processing of
musical pitch incongruities in congenital amusia and therefore re-
vealed that the amusic brain is equipped with the essential neural
circuitry to perceive fine-grained pitch differences. What would dis-
tinguish the amusic from the normal brain is the limited awareness
of this ability and the lack of responsiveness to the semitone changes
that violate musical keys (49).
Tillmann et al. investigated congenital amusics’ short-term mem-
ory for tones, musical timbres, and words, and their findings
showed that amusics’ deficits extend to nonverbal sound material
other than pitch, such as timbre, while not affecting memory for
verbal material. This was in line with previous suggestions about the
domain specificity of congenital amusia (71).
Nonexistent music of all types is perceived in the course of musi-
cal hallucinations. These have been described above all in elderly
patients with a severe hearing deficit. PET has shown that during
hallucinations, the same cerebral areas are activated as when listen-
ing to music, except for the primary auditory cortex. Thus, in ab-
sence of a real acoustic stimulus, only the secondary auditory areas
are activated. It is not clear why this occurs. It is probably the result of
self-generated disordered impulses that are interpreted as sounds
and then processed by the associative areas deputed to manage
musical memory, yielding familiar melodies with a strong emo-
tional impact (19, 67).
As regards musicogenic epilepsy, the neural correlates have
recently been studied in a woman affected by frequent musico-
genic crises. She underwent fluorodeoxyglucose PET and SPECT
with MRI co-recorded ictal subtraction (SISCOM). She suffered
partial complex comitial crises consisting of palpitations and a
feeling of malaise, staring eyes, and dietary automatisms. Ictal
EEG showed theta waves originating from the right temporal
lobe; SISCOM demonstrated ictal hyperperfusion in the right
portion of the insula, amygdala, and at the head of the hippocam-
pus and the right temporal lobe. Finally, fluorodeoxyglucose PET
revealed interictal hypometabolism in the same cerebral region.
The picture featured an anomalous activation of the temporal-
limbic structures associated with the emotional response to mu-
sic (14).
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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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ANTONIO MONTINARO
extraordinary sense of incompleteness. The great power of music is
exactly that of forging a link between the finite and the infinite (that
same dichotomy that is sometimes defined as mind– body, or na-
ture–nurture), causing them to dance around the historical and psy-
chic dimension that is life itself (35).
By bringing about a reconciliation with our lost vital rhythms, the
specific vital rhythms that define each one of us, music can foster a
metamorphosis, a rebirth, a change in our way of seeing ourselves
and others, in our way of facing life (42).
It is in music and through music that we find ourselves directly in
the presence of the energy of life that is logically and verbally inex-
pressible but perfectly tangible, and that communicates to our
senses, to our reflection that little that we can encompass of the pure
miracle of life. It is, beyond all liturgical or theological specificity, a
sacramental tension. Or, as Leibniz says: “Music is a secret arith-
metic of the soul that does not know it counts” (exercitium arith-
meticae occultum nescientis se numerari animi) (Epistolae ad Diver-
sos, letter 154 to Goldbuch, 1712) (57).
The ability of music to decode emotions or of emotions to decode
themselves through sound has much deeper roots. In music there is
something nonmusical, bound to premusic, to man’s spirituality.
This existential consciousness made possible by music is a manifes-
tation of the psyche that is revealed to itself through sounds, that
were originally a part of it (35).
CLINICAL STUDIES ON THE EFFECTS OF MUSIC
Ongoing clinical studies on the effects of music have shown beyond
any doubt that music improves the precision of fine movements,
walking, posture control, as well as the state of affective and behav-
ioral well-being in patients with locomotor system alterations.
The positive effects of music on the motor parameters in patients
affected by Parkinson or Alzheimer disease, multiple sclerosis,
ataxia, or spasticity have been amply demonstrated. Affected pa-
tients are very happy to take part in motor activities accompanied by
music and with other emotionally involving stimuli (dance, rhythm,
games) in which music plays a predominant role (7, 45, 60, 72).
The potential role of music in neurologic rehabilitation has not yet
been systematically studied but recent publications have provided a
considerable contribution to the knowledge in this specific sector
(29, 55, 65). In 20 patients affected by a stroke (10 with paresis of the
right arm and 10 of the left), a rehabilitation strategy based on music
to evoke sensorimotor responses was adopted, in addition to the
traditional therapy. The music therapy consisted of guided training
in the use of the keyboard or drums, for 3 weeks, using first the
paralyzed arm and then the contralateral arm. All the patients in
the musical training arm showed a significant improvement in the
speed, precision, and fluency of their movements as compared to
the control group, confirming the efficacy of this approach for neu-
romotor rehabilitation in stroke patients (4).
A recent Finnish report investigated whether systematic daily lis-
tening to music could facilitate the restoration of cognitive functions
and mood tone after cerebral stroke in 60 patients, admitted for an
ischemic lesion in the acute phase, in the median right or left cere-
bral artery. They were subdivided into three groups: music, lan-
guage, and control. For the next 2 months, the “music group” lis-
tened daily to music selected on the basis of personal preference; the
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CULTURE
THE MUSICAL BRAIN
“language group” listened to reading tapes, whereas the control
group did no prescribed listening. All three groups also underwent
the standard care program. Tests made at 1 week, 3 months, and 6
months after the stroke indicated that the music group showed more
significant and faster cognitive recovery (verbal memory and fo-
cused attention), and also showed less depression than the other
two groups (61).
In another study, to test whether listening to certain types of
music could control blood pressure in hypertense subjects, and if so
to what extent, 30 subjects aged between 63 and 93 years were
subdivided into two groups; one group carried out selective listening
to music for 25 minutes per day for 1 month. At the end of the study,
a decrease in systolic and diastolic pressure, by 11.8 and 4.7 mmHg,
respectively, was observed in the study group whereas there was no
significant difference in the controls. Music therapy could thus be a
valid support tool in the treatment of hypertension (70).
A study was carried out in a mouse model to probe the physiolog-
ical mechanisms whereby music exerts a positive effect on states of
depression and anxiety, investigating whether music can modulate
the production of neurotrophins (nerve growth factor and brain-
derived neurotrophic factor) in the hypothalamus, known to be in-
volved in states of anxiety induced by the hypothalamus–pituitary–
adrenal gland axis. A group of adult mice were exposed for 21
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
brain-derived neurotrophic factor and reduced nerve growth factor
in the hypothalamus, suggesting that neurotrophin modulation can
explain, at least in part, the positive effects of music on the brain (3).
But to what extent can music alleviate stress? The effects of recre-
ational musical activities on some markers of stress was evaluated in
a group of Japanese males working for a large company. Volunteers
were subdivided into two groups, one of which did recreational
music activities for 1 hour a day, whereas the other group spent the
same time doing recreational reading. Half way through the study,
the groups were inverted. The data were analyzed pre- and posttreat-
ment. The effects on stress of these activities were measured both by
self-assessment tests and by dosing biochemical markers of im-
mune system activation. In this experimental mode, musical activity
was objectively shown to reduce the level of stress from the biochem-
ical standpoint, reducing inflammation markers and improving the
activation of the immune system natural killer cells (72).
In another study, 10 patients in critical conditions were enrolled in
a randomized study to identify what biochemical mechanisms, if
any, underlie the relaxant effect of music. Some slow movements
from Mozart’s Sonatas were chosen for the test; before and 1 hour
after listening to these passages, the cerebral activities were moni-
tored as well as the serum levels of stress hormones and cytokines.
Finally, the sedative dosage needed to obtain relaxation of the pa-
tient was recorded. The results showed that listening to music can
markedly reduce sedative requirements, and that in the blood sam-
ples of patients undergoing music therapy there are higher levels of
growth hormone and lower levels of interleukin-6 and epinephrine.
This reduction in circulating stress hormones is also associated with
a drop in blood pressure and heart rate. Thus, the study suggests that
the beneficial effects of music are neurohormonal, dependent on the
hypothalamus–pituitary–adrenal gland axis (15).
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ANTONIO MONTINARO
The effects of major and minor tones on stress reduction were
studied by optical topography and monitoring the levels of an
endocrinological marker of stress, salivary cortisol. The major
keys significantly reduce the levels of cortisol in the salivary
glands in the course of mental fatigue. This suggests that music
can induce an emotional response similar to that of pleasure or
happiness. In addition, the authors observed the typical asym-
metrical pattern of response to stress in the superior temporal
cortex, and suggested that the processing of the emotions sad-
ness and happiness could be correlated to music’s ability to
reduce stress (68).
A recent research aimed to ascertain whether listening to a pas-
sage from Vivaldi’s “Four Seasons” could affect elderly subjects’
ability to carry out memory tests. The study showed a significantly
improved performance in those subjects who listened to music as
compared to the control group exposed just to background sounds.
In the discussion section, the authors hypothesized that their results
could indicate an increased vigilance and mood tone in the active
listening group (37).
Other authors studied the effects of Sonata K.448 by Mozart on
voluntary and involuntary attention in a survey of behavioral data and
evoked visual potentials based on the oddball paradigm. The com-
ponents P3a (related to involuntary attention) and P3b (related to
voluntary attention) were assessed. The Mozart effect was revealed
in the data on the evoked potentials but not on behavior. Sonata
K.448 had an influence on the latency of P3b but no effect on P3a. On
the contrary, in fact, in conditions of musical stimulation, a reduc-
tion in the width of both signals was observed. The authors inter-
preted these variations as a positive Mozart effect on involuntary
attention and negative on voluntary attention, but attributed these
effects to different mechanisms (82). In another study, the same
Sonata was used to assess its effects on space–time reasoning using
near-infrared spectroscopy. The authors found that listening to
Mozart (as compared to silence and to music by Beethoven) induced
a greater activation of the dorsolateral prefrontal and occipital cor-
tex, both of which are considered essential for space–time reasoning
powers (69).
Can music be used as a tool to improve lower secondary school
pupils’ reading abilities, and especially those affected by specific
reading difficulties? A test conducted in middle school pupils dem-
onstrated that the use of musical training brought about a signifi-
cant improvement in the subtests on decoding and vocabulary both
in the pupils with specific problems and overall, in the whole sample
examined (56).
Another study suggests that music therapy can be a valid support
in care programs for children with autism (74) and a major tool
helping to reduce stress in pediatric oncology wards. This study
reported the authors’ experience with music used to alleviate dis-
tress in children undergoing radiotherapy. The use of music therapy
in the waiting rooms built a creative communication bridge with
their families too (44).
A controlled study was conducted to make an objective test of
musical abilities and “sensitivity” in children with tuberous scle-
rosis, a dominant autosomal disease that manifests with epi-
lepsy; skin lesions; hamartoma in the heart, brain, and kidneys;
and above all mental retardation that severely affects their verbal
skills and social interaction. The study confirmed the previously
WORLD NEUROSURGERY 73 [5]: 442-453, MAY 2010
CULTURE
THE MUSICAL BRAIN
unproven conviction that musical abilities are intact and indeed
often more developed in children with tuberous sclerosis than
other abilities (language, cognition, and motor development).
The results also suggested a potential field of action for bringing
about the rehabilitation of these children by means of music
therapy (40).
Music by W. A. Mozart has most often been used both in experi-
ments on music– brain relations and in music therapy, and it seems
that this music yields the best, most constant results in general, and
in particular on cognitive skills (the so-called Mozart effect) (23, 25,
26, 33). The hypothesis formulated by Gordon Shaw is that apart
from Mozart’s incredible logical, mnestic and musical talents, the
fact that he composed at a young age means that he exploited
the space–time differentiating powers of the temporal cortex to
the utmost during the developmental phase, in other words when it
was at the height of its perceptive and creative potential. Instead,
Alfred Tomatis believes that the maximal therapeutic effect of
Mozart’s music on the human body is due to the fact that it is the best
known and loved, and so it can foster the best organization of the
neuronal circuits and reinforce the creative and cognitive processes
of the right hemisphere.
My personal opinion is that it is the incomplete musical knowl-
edge of the researchers and the great notoriety and familiarity of
much of the vast production by Mozart, especially after the resound-
ing mass media effect of the multiple award–winning film Amadeus
by Forman, have in a certain sense “directed” the experimentation
and led to the identification of a Mozart effect rather than a Haydn
effect or Vivaldi effect or Mendelssohn effect. In fact, the very con-
trasting results obtained in the experiments conducted over the past
10 years verifying whether systematic listening to the music by the
Salzburg genius can positively and above all stably affect cognitive
performance support my doubts. It is no coincidence that the ex-
pression “requiem for the Mozart effect” has recently been coined,
to oppose the excessive and above all self-interested use made of this
tool in the United States (42) and that the German government
decided to tackle the myth of the “Mozart effect” following the
conclusion of a report analyzing all the scientific literature on music
and intelligence, commissioned to a team of nine German neurosci-
entists, psychologists, educationalists, and philosophers, all music
experts (1).
However, nobody can deny that Mozart’s music possesses special
characteristics that makes it a virtually universal ideal place of re-
turn. Mozart himself helped us understand why when he wrote in his
letters: “In my work music is for all kinds of listeners, except those
with long ears” (December 1780); and on the subject of the Concerts
K413, 414, 415: “They are a compromise between the too difficult
and the too easy: they are very brilliant, pleasant to the ear, natural
without falling into the trap of emptiness, here and there only ex-
perts can gain satisfaction but even non experts will feel pleasure
without knowing why” (December 1782).
For about the last 30 years, in our own experience our complex,
delicate surgical procedures on the central and peripheral nervous
system have been carried out in presence of background music at
low volume in the operating theatre. The positive effect was gradu-
ally noted by most of the staff and the background environmental
noise, which severely disturbs the concentration of the surgeon
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ANTONIO MONTINARO
Table 1. The Passages Selected in the Operating Theatre
T. Albinoni: Concerti op. 7, op. 9, op. 10
J. S. Bach: Violin concertos, Brandeburg concertos, keyboard
concertos
A. Corelli: Concerti grossi op. 6
F. Geminiani: Concerti grossi op. 2, op. 3, op. 7
P. A. Locatelli: Concerti grossi op. 1, op. 4
G. F. Haendel: Concerti grossi op. 6, op. 3
W. A. Mozart: Violin concertos; Flute, harp and oboe concertos,
Divertimenti, serenades, Salzburg symphonies,
Flute and oboe quartets
A. Scarlatti: Flute concertos, String concertos
A. Vivaldi: Oboe and flute concertos, concerti op. 3, op. 4,
op. 10, op. 11, op. 12
working at the microscope, was reduced as if by magic, as had
already been reported by other authors (24).
The passages selected (Table 1) naturally reflect the preferences
and culture of the surgeons but also vary according to the type of
surgical procedure (exclusive use of the microscope, or a particularly
delicate procedure). Personally, I believe that the music of the Ba-
roque Age is best suited to very challenging surgery. The three con-
certs for violin by Bach have been an exceptional and irreplaceable
accompaniment to clipping all the aneurysms I have treated up to
now, inspiring me with the necessary calm and enhancing the pre-
cision of my movements. I exclude vocal music as well as romantic
music, in other words all music full of “passion” and permeated with
extramusical meaning (42).
Our experience cannot be described as a scientific experiment
conducted with the necessary rigor, but still it has allowed us to
validate the efficacy of the use of music during surgical procedures
(2, 42). To my great satisfaction, I have seen that over the course of
the years, some colleagues and medical staff, previously unexposed
to musical culture, have learned to know and love the passages we
play most frequently, committing them to memory in appreciation
of their haunting beauty.
According to what Popp suggests: “There are times when we must
set aside our instruments of inquiry and simply enjoy the genius
embodied in the music of the masters” (53).
A RETURN TO THE MYTH
Der Leiermann (The Organ Player)
Wunderlichter Alter, soll ich mit dir geh’n?
Willst zu meinen Liedern deine Leier dreh’n?
(Strange old man, should I come with you?
Will you grind your hurdy-gurdy to my songs?)
F. Schubert, from W. Mueller’s Winterreise (1827)
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It is virtually impossible for anyone acting as ferryman between
two worlds apparently so far apart (Music-Science and Music-
Myth) to remain free from contagion by the worlds they have
experienced. Can we speak of the scientific bases of a myth? Can
we speak of a myth becoming a tool of a science that has not yet
succeeded in revealing its own constitutive elements and hence
neurologic correlates?
Let’s get back to the Myth, the profound mystery of this Music that
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
memory.
I have always wondered how far and how the message present in
the notes (I take it for granted that there is a message) reaches the
listener. The powers of reception and emotions are very different
from one person to another but assuming that one can enter in
complete tune with the mind—the composer’s soul—would this
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
Creation at the beginning of time?
The result cannot but be directly proportional to the listener’s
ability to achieve an empathetic solidarity with the composer (a leap
into infinity?). To gain this threshold, which is truly remote, one
needs a strong will and continual practice to refine one’s listening
abilities and understanding. In other words, the mind and soul must
be constantly in training—without fail and with no drawing
back—to challenge the impossible.
But it is equally essential to have a profound knowledge of the
composer’s world and history, so as to be able to appreciate the
meaning hidden beyond and inside the notes and to enter in contact
with universal elements through specific ones.
It is impossible to understand Tchaikovsky’s Symphonie Pathet-
ique, unless one knows what lies behind this extreme musical score
and what tinged the suffering that exudes from its essence. Nor will
it be possible to perceive the signs of the dramatic destiny that
impregnates Schubert’s wanderer’s path unless we become his
travel companions. Instead, everyone can, with some difficulty, re-
late to the last song in Winterreise, desolate Leiermann, but few can
succeed in relating to and taking on the heavy burden up to its
extreme consequences (42).
It is difficult to imagine an identical music– brain relationship in
everyone: the genetic makeup, specific sensitivity, training, and
above all listening education make the difference.
[Because] listening means putting oneself in a position to
decode what is obscure, confused or mute, to reveal to the
consciousness what is “beneath” the meaning (what is
experienced, postulated, wantingly hidden). The commu-
nication implicit in this second type of listening is reli-
gious: it links the listener subject to the occult world of the
gods that, as we know, speak a language of which only a
few enigmatic fragments reach human beings whereas—
cruel situation—it is vital for them to understand it. Listen-
ing is the ultimate evangelical verb: faith is entirely based
on listening to the divine word and it is through listening
that man is linked to God (8).
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 CULTURE
ANTONIO MONTINARO THE MUSICAL BRAIN

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

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received 30 January 2010; accepted 20 February 2010
Citation: World Neurosurg. (2010) 73, 5:442-453.
DOI: 10.1016/j.wneu.2010.02.060
Journal homepage: www.WORLDNEUROSURGERY.org
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