Musicophilia

by Oliver Sacks

  The other miracle was the discovery Deborah made early on, while Clive was still in the hospital, desperately confused and disoriented: that his musical powers were totally intact. “I picked up some music,” Deborah wrote,

  and held it open for Clive to see. I started to sing one of the lines. He picked up the tenor lines and sang with me. A bar or so in, I suddenly realized what was happening. He could still read music. He was singing. His talk might be a jumble no one could understand but his brain was still capable of music…. I could hardly wait to get back to the ward and share this news. When he got to the end of the line I hugged him and kissed him all over his face….

  Clive could sit down at the organ and play with both hands on the keyboard, changing stops, and with his feet on the pedals, as if this were easier than riding a bicycle. Suddenly we had a place to be together, where we could create our own world away from the ward. Our friends came in to sing. I left a pile of music by the bed and visitors brought other pieces.

  Miller’s film showed dramatically the virtually perfect preservation of Clive’s musical powers and memory. In these scenes from only a year or so after his illness, his face often appeared tight with torment and bewilderment. But when he was conducting his old choir, he did this with great sensitivity and grace, mouthing the melodies, turning to different singers and sections of the choir, cuing them, encouraging them, to bring out their special parts. It is obvious that Clive not only knew the piece perfectly, how all the parts contributed to the unfolding of the musical thought, but also retained all the special skills of conducting, his professional persona, and his own unique style.

  Clive cannot retain any memory of passing events and experience and, in addition, has lost most of the memories of events and experiences preceding his encephalitis— how, then, does he retain his remarkable knowledge of music, his ability to sight-read, to play the piano and organ, sing, conduct a choir, in the masterly way he did before he became ill?

  H.M., a famous and unfortunate patient described by Scoville and Milner in 1957, was rendered amnesic by the surgical removal of both hippocampi along with adjacent structures of the medial temporal lobes. (This was considered at the time the best treatment for his intractable seizures; it was not yet realized that autobiographic memory and the ability to form new memories of events depended on these structures.) Yet H.M., though he lost many memories of his former life, had not lost any of the skills he had acquired, and indeed he could learn and perfect new skills with training and practice, even though he would retain no memory of the practice sessions.

  Larry Squire, a neuroscientist who has spent a lifetime exploring mechanisms of memory and amnesia, emphasizes that no two cases of amnesia are the same. He wrote to me,

  If the damage is limited to the medial temporal lobe, then one expects an impairment such as H.M. had. With somewhat more extensive medial temporal lobe damage, one can expect something more severe, as in E.P. [this is a patient whom Squire and his colleagues have investigated intensively]. With the addition of frontal damage, perhaps one begins to understand Clive’s impairment. Or perhaps one needs lateral temporal damage as well, or basal forebrain damage. Clive’s case is unique, and not like H.M. or like Claparède’s patient, because a particular pattern of anatomical damage occurred. We cannot write about amnesia as if it were a single entity like mumps or measles.

  Yet H.M.’s case made it clear that two very different sorts of memory could exist: a conscious memory of events (episodic memory) and an unconscious memory for procedures— and that such procedural memory is unimpaired in amnesia.

  This is dramatically clear with Clive, too, for he can shave, shower, look after his toilet, and dress elegantly, with taste and style; he moves confidently and is fond of dancing. He talks fluently and abundantly, using a large vocabulary; he can read and write in several languages. He is good at calculation. He can make phone calls, and he can find the coffee things and find his way about the home. If he is asked how to do these things, he cannot say, but he does them. Whatever involves a sequence or pattern of action, he does fluently, unhesitatingly.5

  But can Clive’s beautiful playing and singing, his masterly conducting, his powers of improvisation be adequately characterized as “skills” or “procedure”? For his playing is infused with intelligence and feeling, with a sensitive attunement to the musical structure, the composer’s style and mind. Can any artistic or creative performance of this caliber be adequately explained by “procedural memory”? Episodic or explicit memory, we know, develops relatively late in childhood and is dependent on a complex brain system involving the hippocampi and temporal lobe structures, the system that is compromised in severe amnesiacs and all but obliterated in Clive. The basis of procedural or implicit memory is less easy to define, but it certainly involves larger and more primitive parts of the brain— subcortical structures like the basal ganglia and cerebellum and their many connections to each other and to the cerebral cortex. The size and variety of these systems guarantees the robustness of procedural memory and the fact that, unlike episodic memory, procedural memory can remain largely intact even in the face of extensive damage to the hippocampi and cerebral cortex.

  Episodic memory depends on the perception of particular and often unique events, and one’s memories of such events, like one’s original perception of them, are not only highly individual (colored by one’s interests, concerns, and values), but prone to be revised or recategorized every time they are recalled. This is in fundamental contrast to procedural memory, where it is all-important that the remembering be literal, exact, and reproducible. Repetition and rehearsal, timing and sequence are of the essence here. Rodolfo Llinás, the neurophysiologist, uses the term “fixed action patterns” (FAPs) for such procedural memories. Some of these may be present even before birth (fetal horses, for example, may gallop in the womb). Much of the early motor development of the child depends on learning and refining such procedures, through play, imitation, trial and error, and incessant rehearsal. All of these start to develop long before the child can call on any explicit or episodic memories.

  Is the concept of fixed action patterns any more illuminating than that of procedural memories in relation to the enormously complex, creative performances of a professional musician? In his book I of the Vortex, Llinás writes:

  When a soloist such as [Jascha] Heifetz plays with a symphony orchestra accompanying him, by convention the concerto is played purely from memory. Such playing implies that this highly specific motor pattern is stored somewhere and subsequently released at the time the curtain goes up.

  But for a performer, Llinás writes, it is not sufficient to have implicit memory only; one must have explicit memory as well:

  Without intact explicit memory, Jascha Heifetz would not remember from day to day which piece he had chosen to work on previously, or that he had ever worked on that piece before. Nor would he recall what he had accomplished the day before or by analysis of past experience what particular problems in execution should be a focus of today’s practice session. In fact, it would not occur to him to have a practice session at all; without close direction from someone else he would be effectively incapable of undertaking the process of learning any new piece, irrespective of his considerable technical skills.

  This, too, is very much the case with Clive, who, for all his musical powers, needs “close direction” from others. He needs someone to put the music before him, to get him into action, and to make sure that he learns and practices new pieces.

  What is the relationship of action patterns and procedural memories, which are associated with relatively primitive portions of the nervous system, to consciousness and sensibility, which depend on the cerebral cortex? Practice involves conscious application, monitoring what one is doing, bringing all one’s intelligence and sensibility and values to bear— even though what is so painfully and consciously acquired may then become automatic, coded in motor patterns at a subcortical level. Each time Clive sings or pl
ays the piano or conducts a choir, automatism comes to his aid. But what comes out in an artistic or creative performance, though it depends on automatisms, is anything but automatic. The actual performance reanimates him, engages him as a creative person; it becomes fresh and alive, and perhaps contains new improvisations or innovations. Once Clive starts playing, his “momentum,” as Deborah writes, will keep him, and keep the piece, going. Deborah, herself a musician, expresses this very precisely:

  The momentum of the music carried Clive from bar to bar. Within the structure of the piece, he was held, as if the staves were tramlines and there was only one way to go. He knew exactly where he was because in every phrase there is context implied, by rhythm, key, melody. It was marvellous to be free. When the music stopped Clive fell through to the lost place. But for those moments he was playing he seemed normal.

  Clive’s performance self seems, to those who know him, just as vivid and complete as it was before his illness. This mode of being, this self, is seemingly untouched by his amnesia, even though his autobiographical self, the self that depends on explicit, episodic memories, is virtually lost. The rope that is let down from heaven for Clive comes not with recalling the past, as for Proust, but with performance— and it holds only as long as the performance lasts. Without performance, the thread is broken, and he is thrown back once again into the abyss.6

  Deborah speaks of the “momentum” of the music in its very structure. A piece of music is not a mere sequence of notes, but a tightly organized organic whole. Every bar, every phrase, arises organically from what preceded it and points to what will follow. Dynamism is built into the nature of melody. And over and above this, there is the intentionality of the composer, the style, the order, and the logic which he has created to express his musical ideas and feelings. These, too, are present in every bar and phrase.7 Marvin Minsky compares a sonata to a teacher or a lesson:

  No one remembers, word for word, all that was said in any lecture, or played in any piece. But if you understood it once, you now own new networks of knowledge, about each theme, and how it changes and relates to others. Thus, no one could remember Beethoven’s Fifth Symphony entire, from a single hearing. But neither could one ever hear again those first four notes as just four notes! Once but a tiny scrap of sound, it is now a Known Thing— a locus in the web of all the other things we know, whose meanings and significances depend on each other.

  A piece of music will draw one in, teach one about its structure and secrets, whether one is listening consciously or not. This is so even if one has never heard a piece of music before. Listening to music is not a passive process but intensely active, involving a stream of inferences, hypotheses, expectations, and anticipations (as David Huron and others have explored). We can grasp a new piece— how it is constructed, where it is going, what will come next— with such accuracy that even after a few bars we may be able to hum or sing along with it.8

  When we “remember” a melody, it plays in our mind; it becomes newly alive.9 There is not a process of recalling, imagining, assembling, recategorizing, re-creating, as when one attempts to reconstruct or remember an event or a scene from the past. We recall one tone at a time and each tone entirely fills our consciousness, yet simultaneously it relates to the whole. It is similar when we walk or run or swim— we do so one step, one stroke at a time, yet each step or stroke is an integral part of the whole, the kinetic melody of running or swimming. Indeed, if we think of each note or step too consciously, we may lose the thread, the motor melody.

  It may be that Clive, incapable of remembering or anticipating events because of his amnesia, is able to sing and play and conduct music because remembering music is not, in the usual sense, remembering at all. Remembering music, listening to it, or playing it, is entirely in the present.

  Victor Zuckerkandl, a philosopher of music, explores this paradox beautifully in his book Sound and Symbol:

  The hearing of a melody is a hearing with the melody…. Itis even a condition of hearing melody that the tone present at the moment should fill consciousness entirely, that nothing should be remembered, nothing except it or beside it be present in consciousness…. Hearing a melody is hearing, having heard, and being about to hear, all at once. Every melody declares to us that the past can be there without being remembered, the future without being foreknown.

  It has been twenty years since Clive’s illness and, for him, nothing has moved on. One might say he is still in 1985 or, given his retrograde amnesia, in 1965. In some ways, he is not anywhere at all; he has dropped out of space and time altogether. He no longer has any inner narrative; he is not leading a life in the sense that the rest of us do. And yet one has only to see him at the keyboard or with Deborah to feel that, at such times, he is himself again and wholly alive. It is not the remembrance of things past, the “once” that Clive yearns for, or can ever achieve. It is the claiming, the filling, of the present, the now, and this is only possible when he is totally immersed in the successive moments of an act. It is the “now” that bridges the abyss.

  As Deborah recently wrote to me, “Clive’s at-homeness in music and in his love for me are where he transcends amnesia and finds continuum— not the linear fusion of moment after moment, nor based on any framework of autobiographical information, but where Clive, and any of us, are finally, where we are who we are.”

  16

  Speech and Song: Aphasia and Music Therapy

  Samuel S. developed severe expressive aphasia following a stroke in his late sixties, and he remained totally speechless, unable to retrieve a single word, despite intensive speech therapy, two years later. The break for him came when Connie Tomaino, the music therapist at our hospital, heard him singing one day outside her clinic— he was singing “Ol’ Man River” very tunefully and with great feeling, but only getting two or three words of the song. Even though speech therapy had been given up with Samuel, who was by then regarded as “hopeless,” Connie felt that music therapy might be helpful. She started to meet with him three times a week for half-hour sessions in which she would sing with him or accompany him on the accordion. Mr. S. was soon able, singing along with Connie, to get all the words of “Ol’ Man River,” and then of many other ballads and songs he had learned growing up in the 1940s— and as he did this, he started to show the beginnings of speech. Within two months, he was making short but appropriate responses to questions. For instance, if one of us asked Mr. S. about his weekends at home, he could reply, “Had a great time,” or “Saw the kids.”

  Neurologists often refer to a “speech area” in the premotor zone of the brain’s dominant (usually left) frontal lobe. Damage to a particular part of this— an area first identified by the French neurologist Paul Broca in 1862— whether from a degenerative disease, a stroke, or a brain injury, may produce expressive aphasia, a loss of spoken language. In 1873 Carl Wernicke had described a different speech area in the left temporal lobe— damage to this area was apt to produce difficulty understanding speech, a “receptive” aphasia. It was also recognized, at much the same time, that brain damage could produce disturbances of musical expression or appreciation— amusias— and that while some patients might suffer from both an aphasia and an amusia, others could have aphasia without amusia.1

  We are a linguistic species— we turn to language to express whatever we are thinking, and it is usually there for us instantly. But for those with aphasia, the inability to communicate verbally may be almost unbearably frustrating and isolating; to make matters worse, they are often treated by others as idiots, almost as nonpersons, because they cannot speak. Much of this can change with the discovery that such patients can sing— sing not only tunes, but the words of operas, hymns, or songs. Suddenly their disability, their cut-offness, seems much less— and though singing is not propositional communication, it is a very basic existential communication. It not only says, “I am alive, I am here,” but may express thoughts and feelings that cannot be expressed, at this point, by speech. Being able to
sing words can be a great reassurance to such patients, showing them that their language capacities are not irretrievably lost, that the words are still “in” them, somewhere, even though it may take music to bring them out.

  Speech itself is not just a succession of words in the proper order— it has inflections, intonations, tempo, rhythm, and “melody.” Language and music both depend on phonatory and articulatory mechanisms that are rudimentary in other primates, and both depend, for their appreciation, on distinctly human brain mechanisms dedicated to the analysis of complex, segmented, rapidly changing streams of sound. And yet there are major differences (and some overlaps) in the processing of speech and song in the brain.2

  Patients with so-called nonfluent aphasia not only have an impairment of vocabulary and grammar, but have “forgotten” or lost the feeling of the rhythms and inflections of speech; hence the broken, unmusical, telegraphic style of their speech, to the extent that they still have any words available. It is such patients who, as a rule, do best with music therapy, and who feel most excited when they are able to sing lyrics— for in doing so, they discover not only that words are still available to them, but that the flow of speech is also accessible (though bound, apparently, to the flow of song).

  This may also be the case with a different form of aphasia, so-called dynamic aphasia, where it is not the structure of sentences that is affected but the initiation of speech. Patients with dynamic aphasia may speak very sparingly, yet produce syntactically correct sentences on the rare occasions when they do speak. Jason Warren et al. described how an elderly man with mild frontal lobe degeneration and extreme dynamic aphasia was nonetheless unimpaired in musical initiative. He played the piano, could read and write music, and took part in a weekly singing group. He was also able to recite, as Warren et al. noted: “He was able to read a passage chosen at random from the Torah using the heightened intonation (distinct from both singing and ordinary reading) reserved for reading aloud.”