by Oliver Sacks
When I asked Deborah whether Clive knew about her memoir, she told me that she had shown it to him twice before, but that he had instantly forgotten. I had my own heavily annotated copy with me, and asked Deborah to show it to him again.
“You’ve written a book!” he cried, astonished. “Well done! Congratulations!” He peered at the cover. “All by you? Good heavens!” Excited, he jumped for joy. Deborah showed him the dedication page (“For my Clive”). “Dedicated to me?” He hugged her. This scene was repeated several times within a few minutes, with almost exactly the same astonishment, the same expressions of delight and joy each time.
Clive and Deborah are still very much in love with each other, despite his amnesia (indeed, the subtitle of Deborah’s book is A Memoir of Love and Amnesia). He greeted her several times as if she had just arrived. It must be an extraordinary situation, I thought, both maddening and flattering, to be seen always as new, as a gift, a blessing.
Clive had, in the meantime, addressed me as “Your Highness” and inquired at intervals, “Been at Buckingham Palace?…Are you the prime minister?…Are you from the U.N.?” He laughed when I answered, “Just the U.S.” This joking or jesting was of a somewhat waggish, stereotyped nature and highly repetitive. Clive had no idea who I was, little idea who anyone was, but this bonhomie allowed him to make contact, to keep a conversation going. I suspected he had some damage to his frontal lobes too— such jokiness (neurologists speak here of Witzelsucht, joking disease), like his impulsiveness and his incontinent chattiness, could go with a weakening of the usual, social frontal lobe inhibitions.
He was excited at the notion of going out for lunch, lunch with Deborah. “Isn’t she a wonderful woman?” he kept asking me. “Doesn’t she have marvelous kisses?” I said yes, I was sure she had.
As we drove to the restaurant, Clive, with great speed and fluency, invented words for the letters on the license plates of passing cars: JCK was Japanese Clever Kid; NKR was New King of Russia; and BDH (Deborah’s car) was British Daft Hospital, then Blessed Dutch Hospital. Forever Today, Deborah’s book, immediately became “Three-Ever Today,” “Two-Ever Today,” “One-Ever Today.” This incontinent punning and rhyming and clanging was virtually instantaneous, occurring with a speed no normal person could match. It resembled Tourettic or savantlike speed, the speed of the preconscious, undelayed by reflection.
When we arrived at the restaurant, Clive did all the license plates in the parking lot and then, elaborately, with a bow and a flourish, let Deborah enter: “Ladies first!” He looked at me with some uncertainty as I followed them to the table: “Are you joining us, too?”
When I offered him the wine list, he looked it over and exclaimed: “Good God! Australian wine! New Zealand wine! The colonies are producing something original— how exciting!” This partly indicated his retrograde amnesia— he is still in the 1960s (if he is anywhere), when Australian and New Zealand wines were almost unheard of in England. “The colonies,” however, was part of his compulsive waggery and parody.
At lunch he talked about Cambridge— he had been at Clare College, but had often gone next door to King’s, for their famous choir. He spoke of how after Cambridge, in 1968, he joined the London Sinfonietta, where they played modern music, though he was already attracted to the Renaissance and Lassus. He was the chorus master there, and he reminisced that singers could not talk during coffee breaks; they had to save their voices (“It was often misunderstood by the instrumentalists, seemed standoffish to them”). These all sounded like genuine memories. But they could, equally, have reflected his knowing about these events, rather than actual memories of them— expressions of “semantic” memory rather than “event” or “episodic” memory.
Then he spoke of the Second World War (he was born in 1938) and how they would go to bomb shelters and play chess or cards there. He said that he remembered the doodlebugs: “There were more bombs in Birmingham than in London.” Was it possible that these were genuine memories? He would only have been six or seven, at most. Or was he confabulating or simply, as we all do, repeating stories he had been told as a child?
At one point, he talked about pollution and how dirty petrol engines were. When I told him I had a hybrid with an electric motor as well as a combustion engine, he was astounded, as if something he had read about as a theoretical possibility had, far sooner than he had imagined, become a reality.
In her remarkable book, so tender, yet so tough-minded and realistic, Deborah wrote about the change which had so struck me: that Clive was now “garrulous and outgoing…could talk the hind legs off a donkey.” There were certain themes he tended to stick to, she said, favorite subjects (electricity, the Tube, stars and planets, Queen Victoria, words and etymologies), which would all be brought up again and again:
“Have they found life on Mars yet?”
“No, darling, but they think there might have been water…”
“Really? Isn’t it amazing that the sun goes on burning? Where does it get all that fuel? It doesn’t get any smaller. And it doesn’t move. We move round the sun. How can it keep on burning for millions of years? And the earth stays the same temperature. It’s so finely balanced.”
“They say it’s getting warmer now, love. They call it global warming.”
“No! Why’s that?”
“Because of the pollution. We’ve been emitting gases into the atmosphere. And puncturing the ozone layer.”
“OH NO!! That could be disastrous!”
“People are already getting more cancers.”
“Oh, aren’t people stupid! Do you know the average IQ is only 100? That’s terribly low, isn’t it? One hundred. It’s no wonder the world’s in such a mess.”
“Cleverness isn’t everything…”
“Well, no…”
“It’s better to be good-hearted than clever.”
“Yes, you’ve got a point.”
“And you don’t have to be clever to be wise.”
“No, that’s true.”
Clive’s scripts were repeated with great frequency, sometimes three or four times in one phone call. He stuck to subjects he felt he knew something about, where he would be on safe ground, even if here and there something apocryphal crept in…. These small areas of repartee acted as steppingstones on which he could move through the present. They enabled him to engage with others.
I would put it even more strongly and use a phrase that Deborah used in another connection, when she wrote of Clive being poised upon “a tiny platform…above the abyss.” Clive’s loquacity, his almost compulsive need to talk and keep conversations going, served to maintain a precarious platform, and when he came to a stop, the abyss was there, waiting to engulf him. This, indeed, is what happened when we went to a supermarket and he got separated briefly from Deborah. He suddenly exclaimed, “I’m conscious now…never saw a human being before…for thirty years…it’s like death!” He looked very angry and distressed. Deborah said the staff calls these grim monologues his “deads”— they make a note of how many he has in a day or a week and gauge his state of mind by their number.
Deborah thinks that repetition has slightly dulled the very real pain that goes with this agonized but stereotyped complaint, but when he says such things, she will distract him immediately. Once she has done this, there seems to be no lingering mood— an advantage of his amnesia. And, indeed, once we were back in the car, Clive was off on his license plates again.
* * *
BACK IN HIS ROOM, I spotted the two volumes of Bach’s Forty-eight Preludes and Fugues on top of the piano and asked Clive if he would play one of them. He said that he had never played any of them before, but then he played Prelude 9 in E major and said as he played, “I remember this one.” He remembers almost nothing unless he is actually doing it; then it may come to him. He inserted a tiny, charming improvisation at one point, and did a sort of Chico Marx ending, with a huge downward scale. With his great musicality and his playfulness, he can easily improvise, j
oke, play with any piece of music.
His eye fell on the book about cathedrals, and he talked about cathedral bells— did I know how many combinations there could be with eight bells? “Eight by seven by six by five by four by three by two by one,” he rattled off. “Factorial eight.” And then, without pause: “That’s forty thousand.” (I worked it out laboriously: it is 40,320.)
I asked him about prime ministers. Tony Blair? Never heard of him. John Major? No. Margaret Thatcher? Vaguely familiar. Harold Macmillan, Harold Wilson: ditto. (But earlier in the day, he had seen a car with JMV plates and instantly said, “John Major Vehicle”— showing that he had an implicit memory of Major’s name.) Deborah wrote of how he could not remember her name, “but one day someone asked him to say his full name, and he said, ‘Clive David Deborah Wearing— funny name that. I don’t know why my parents called me that.’ ” He has gained other implicit memories, too, slowly picking up new knowledge, like the layout of his residence. He can go alone now to the bathroom, the dining room, the kitchen— but if he stops and thinks en route, he is lost. Though he could not describe his residence, Deborah tells me that he unclasps his seat belt as they draw near and offers to get out and open the gate. Later, when he makes her coffee, he knows where the cups, the milk, and the sugar are kept. (He cannot say where they are, but he can go to them; he has actions, but few facts, at his disposal.)
I decided to widen the testing and asked Clive to tell me the names of all the composers he knew. He said, “Handel, Bach, Beethoven, Berg, Mozart, Lassus.” That was it. Deborah told me that at first, when asked this question, he would omit Lassus, his favorite composer. This seemed appalling for someone who had been not only a musician but an encyclopedic musicologist. Perhaps it reflected the shortness of his attention and recent immediate memory— perhaps he thought that he had in fact given us dozens of names. So I asked him other questions on a variety of topics that he would have been knowledgeable about in his earlier days. Again, there was a paucity of information in his replies and sometimes something close to a blank. I started to feel that I had been beguiled, in a sense, by Clive’s easy, nonchalant, fluent conversation into thinking that he still had a great deal of general information at his disposal, despite the loss of memory for events. Given his intelligence, ingenuity, and humor, it was easy to think this on meeting him for the first time. But repeated conversations rapidly exposed the limits of his knowledge. As Deborah writes in her book, Clive “stuck to subjects he knew something about” and used these islands of knowledge as “stepping stones” in his conversation. Clearly Clive’s general knowledge, or semantic memory, was greatly affected, too— though not as catastrophically as his episodic memory.4
Yet semantic memory of this sort, even if completely intact, is not of much use in the absence of explicit, episodic memory. Clive is safe enough in the confines of his residence, for instance, but he would be hopelessly lost if he were to go out alone. Lawrence Weiskrantz comments on the need for both sorts of memory in his book Consciousness Lost and Found:
The amnesic patient can think about material in the immediate present…he can also think about items in his semantic memory, his general knowledge…. But thinking for successful everyday adaptation requires not only factual knowledge, but the ability to recall it on the right occasion, to relate it to other occasions, indeed the ability to reminisce.
This uselessness of semantic memory unaccompanied by episodic memory is also brought out by Umberto Eco in his novel The Mysterious Flame of Queen Loana, where the narrator, an antiquarian bookseller and polymath, is a man of Eco-like intelligence and erudition. Though amnesic from a stroke, he retains the poetry he has read, the many languages he knows, his encyclopedic memory of facts; but he is nonetheless helpless and disoriented (and recovers from this only because the effects of his stroke are transient).
It is similar, in a way, with Clive. His semantic memory, while of little help in organizing his life, does have a crucial social role; it allows him to engage in conversation (though it is occasionally more monologue than conversation). Thus, Deborah wrote, “he would string all his subjects together in a row, and the other person simply needed to nod or mumble.” By moving rapidly from one thought to another, Clive managed to secure a sort of continuity, to hold the thread of consciousness and attention intact— albeit precariously, for the thoughts were held together, on the whole, by superficial associations. Clive’s verbosity made him a little odd, a little too much at times, but it was highly adaptive— it enabled him to reenter the world of human discourse.
In the 1986 BBC film Deborah quoted Proust’s description of Swann waking in a strange room, not knowing at first where he was, who he was, what he was. He had only “the most rudimentary sense of existence, such as may lurk and flicker in the depths of an animal’s consciousness” until memory came back to him, “like a rope let down from heaven to draw me up out of the abyss of not-being, from which I could never have escaped by myself”— this gave him back his personal consciousness and identity. No rope from heaven, no autobiographical memory will ever come down in this way to Clive.
* * *
FROM THE START there have been, for Clive, two realities of immense importance. The first of these is Deborah, whose presence and love for him have made life tolerable, at least intermittently, in the twenty or more years since his illness.
Clive’s amnesia not only destroyed his ability to retain new memories, it deleted almost all of his earlier memories, including those of the years when he met and fell in love with Deborah— he told Deborah, when she questioned him, that he had never heard of John Lennon or John F. Kennedy. Though he always recognized his own children, Deborah told me, “he would be surprised at their height and amazed to hear he is a grandfather. He asked his younger son what O-level exams he was doing in 2005, more than twenty years after Edmund left school.” Yet somehow he always recognized Deborah as his wife when she visited and felt moored by her presence, lost without her. He would rush to the door when he heard her voice, and embrace her with passionate, desperate fervor. Having no idea how long she had been away— since anything not in his immediate field of perception and attention would be lost, forgotten, within seconds— he seemed to feel that she, too, had been lost in the abyss of time, and so her “return” from the abyss seemed nothing short of miraculous.
“Clive was constantly surrounded by strangers in a strange place,” Deborah wrote,
with no knowledge of where he was or what had happened to him. To catch sight of me was always a massive relief— to know that he was not alone, that I still cared, that I loved him, that I was there. Clive was terrified all the time. But I was his life, I was his lifeline. Every time he saw me, he would run to me, fall on me, sobbing, clinging.
How, why, when he recognized no one else with any consistency, did Clive recognize Deborah? There are clearly many sorts of memory, and emotional memory is one of the deepest and least understood.
Neal J. Cohen has written about the famous experiment of Édouard Claparède, a Swiss physician, in 1911:
Upon shaking hands with a patient with Korsakoff syndrome [the condition which caused my patient Jimmie’s severe amnesia], Claparède pricked her finger with a pin hidden in his hand. Subsequently, whenever he again attempted to shake the patient’s hand, she promptly withdrew it. When he questioned her about this behavior, she replied, “Isn’t it allowed to withdraw one’s hand?” and “Perhaps there is a pin hidden in your hand,” and finally, “Sometimes pins are hidden in hands.” Thus the patient learned the appropriate response based on previous experience, but she never seemed to attribute her behavior to the personal memory of some previously experienced event.
For Claparède’s patient, some sort of memory of the pain, an implicit and emotional memory, persisted. It seems certain, likewise, that in the first two years of life, even though one retains no explicit memories (Freud called this infantile amnesia), deep emotional memories or associations are nevertheless being made
in the limbic system and other regions of the brain where emotions are represented— and these emotional memories may determine one’s behavior for a lifetime. And a recent paper by Oliver Turnbull et al. has shown that patients with amnesia can form emotional transferences to an analyst, even though they retain no explicit memory of the analyst or their previous meetings. Nevertheless, a strong emotional bond begins to develop. Clive and Deborah were newly married at the time of his encephalitis, and deeply in love for a few years before that. His passionate relationship with Deborah, a relationship that began before his encephalitis, and one that centers in part on their shared love for music, has engraved itself in him— in areas of his brain unaffected by the encephalitis— so deeply that his amnesia, the most severe amnesia ever recorded, cannot eradicate it.
Nonetheless, for many years he failed to recognize Deborah if she chanced to walk past and even now, he cannot say what she looks like unless he is actually looking at her. Her appearance, her voice, her scent, the way they behave with each other, and the intensity of their emotions and interactions— all this confirms her identity, and his own.