Jean-Martin Charcot's Role in the Study of Music Aphasia
Jean-Martin Charcot's Role in the Study of Music Aphasia
Charcot's dramatic teaching lectures attracted junior and senior clinicians from around the world. During the summers of 1883 and 1884, Charcot delivered a series of 14 lectures on aphasia at the Salpêtrière Hospital (Brais, 1993). Nine lectures were delivered during the summer of 1883 and five during the summer of 1884. Various parts of the lectures were transcribed and published by Charcot's students and clinical associates (Goetz et al., 1995). Charles Féré (1852–1907), an assistant physician and personal secretary to Charcot, published the first five lectures in 1883 (Féré, 1883a, b, c, d, e). Pierre Marie (1853–1940), a physician and head of Charcot's clinic in 1883, also wrote a summary of the 1883 lessons in two publications (Marie, 1883, 1888). Two others carried out theses under Charcot's supervision during this period, and each included discussions from the Friday Lessons: Désiré-Antoine-François Bernard's (1853–88) 'De l'aphasie et de ses diverses formes' (Bernard, 1885) and Gilbert Ballet's (1853–1916) 'Le langage intérieur et les diverses formes de l'aphasie' (Ballet, 1886). Gaetano Rummo (1853–1917), an Italian physician attending Charcot's clinic, published in Italian what appears to be the only complete version of the 1883 lectures (Rummo, 1884). Domenico Miliotti (dates unknown), another Italian student-physician, attended the five lectures during the summer of 1884 and later published them in Italian: 'Lezioni cliniche dell'anno scolastico 1883-84 sulle malattie del sistema nervoso' (Miliotti, 1885) (Fig. 1). It was in the context of the Friday Lessons that Charcot discussed his ideas about music and the brain.
(Enlarge Image)
Figure 1.
Reproduction of the book cover of Miliotti (1885).
This paper presents the details of Charcot's lectures that included discussion about music based on these second-hand reports provided by his students and clinical associates. It must be noted that, in such instances, there is always the risk that the accounts of the lectures reflect the interpretations by the students rather than reproducing directly the ideas of their originator. For example, the veracity of transcriptions of Charcot's lectures on tics, published by another Italian student, Guilio Melotti, has been challenged (Kushner et al., 1999). However, Charcot wrote the preface for both the Miliotti and Rummo texts, thereby giving his approval of the translations, and Goetz et al. (1995) noted that Charcot's lectures were presented in a form that was nearly ready for publication. The aim of this paper is to provide one of the first comprehensive reviews of Charcot's ideas about music using the available documents.
During the Friday Lessons, Charcot discussed music abilities of several patients as illustrations of organization of the language faculty. These lectures appear to be a unique instance in which Charcot considered aspects of music abilities and impairments; no mention of this topic appears in his own publications. However, the writings of Féré, Ballet, Bernard and Miliotti document four cases that Charcot discussed with regard to his ideas about music in the 1883–84 lectures. The following sections detail these cases, which are also summarized in Table 1.
The Aphasic who Could Sing 'La Marseillaise'. Féré (1883d) recorded the case of Patient 'H' who could correctly sing the melody of the French national anthem 'La Marseillaise' but only while using a 'guttural sound'. Féré commented that the preserved ability to produce the melody without the song text exemplified the fractionization of music abilities. He stated:
'If time permitted, it would be the case for you to notice that the musical faculty may be, too, as the language faculty, split, somehow, by the disease, in a number of compartments. I could indeed give you several examples where it is musicians who have retained the ability to recognize the song to play the piano, however, had become unable to decipher written music' (Féré, 1883 d, p. 522; original text in Supplementarymaterial).
This dissociation between the melody and song text was the most common report of music in earlier neurology literature (Johnson et al., 2010). Féré also referred to other cases (without citations) in which musicians with brain damage were able to recognize a familiar melody but not read music notation, possibly referring to the those by Finkelnburg (1870) and Fischer (1867) discussed above. Bernard (1885) also mentioned Patient 'H' but provided no additional details.
The Piano Teacher With 'Music Blindness'. Bernard (1885) reported Charcot's case of a 45-year-old piano teacher (a female also called 'H') who had a non-fluent aphasia and complete music blindness ('cécité musicale complète') owing to epilepsy. She suffered aphasia several years earlier, but recovered somewhat before she entered the Salpêtrière on 12 December 1881. Charcot discussed her on Friday, 1 June 1883, making it likely that this case was discussed as a part of that Friday Lesson. Patient H was also known as 'la Dame blanche', as she often sang an aria from the comic opera of this name by Boïeldieu. (It is important to note that 'la Dame blanche' was not Blanche Wittmann, the famous patient depicted on the Lecon à la Salpêtrière painting by Brouillet). Bernard noted that although her speech was impaired, she was able to accurately sing both the melody and text of this song and a few others, but she refused to sing other less familiar songs. Bernard (1885) wrote:
'The lyrics are distinct, the melody exactly repeated. When she sings H … uses her left hand, her fingers beat time on the bed cover. The condition of the patient does not allow us to try placing her in front of a piano, to see how these movements were related. She regularly sings a rude song. It was impossible to get her to sing other familiar melodies. But she hums dance tunes when asked, rhythmically waving her fingers of her left hand. Impossible also to talk with her about famous opera, music of masters (teachers). "I forgot all that, I do not know"' (p. 120; original text in Supplementary material)
Bernard (1885) also noted that she was unable to read music notation:
'The score itself, the musical notation is completely indecipherable for her. Often the experiment was done. No sign on (musical) stave could not be recognized or called by her. She read the header of a piece, line by line, by following it with the finger. On staves, her finger stopped or went astray. In vain we pressed, we varied the questions: 'What have you under your eyes? Where such a key? where such a note?. The uncertain eyes, she answered steadily: 'I do not know, I do not know' … The words and figures arranged between staves, the text of songs and signs showing the movement were read as well as printed words posted' (p. 122; original text in Supplementary material).
Patient H died of pneumonia on 11 May 1884, and an autopsy revealed a large 'yellow plaque' on the surface of the left frontal and parietal lobes that extended to several subcortical structures. Bernard provided a schematic of the lesion (Fig. 2). Such pathological evidence was viewed as key by Charcot and his disciples for theorizing about the localization of brain functions. [However, see Bastian (1898) for an alternative interpretation of the case based on the autopsy findings].
(Enlarge Image)
Figure 2.
Sketch of location of brain damage after autopsy of Bernard's (1885) case with 'music blindness' discussed by Charcot during the Friday Lessons.
The Medical Professor and Musician With 'Music Blindness'. Both Bernard (1885) and Ballet (1886) referred to another of Charcot's aphasic patients with music blindness ('cécité musicale') discussed in the 1883 lectures. Bernard (1885) discussed Charcot's report of this case:
'Charcot reported in one of his lectures in 1883 that in one of his colleagues at the Faculty of Medicine, who died aphasic and hemiplegic on the right, the first symptom of his brain damage was a music blindness. One day he sits at the piano, opens a partition and can not decipher a single note, while he moves his fingers on the keyboard with ease and accuracy. Finkelnburg's patient, struck with the same blindness, could play from memory and play melodies he heard sung or perform. Bouillaud's patient cited above presented verbal and music blindness' (pp. 118–19; original text in Supplementary material).
Ballet (1886) also made a brief reference to this case:
'M. Charcot told us that one of his colleagues, an eminent Faculty of Paris professor and distinguished musician, was unpleasantly surprised when he was at the piano one day and was not able to play as usual. He saw the notes, but did not understand them any more. Musical blindness was, in this particular case, the forerunner of a hemiplegia to which the patient succumbed' (p. 110; original text in Supplementary material).
Both Ballet and Bernard discussed this case in the context of comprehension of symbols, such as numbers and mathematical equations. Because he was interested in documenting isolated deficits and dissociations, Charcot used this case to point out that music alexia could be initially present as an isolated syndrome, with aphasia and hemiplegia evolving later. As noted by Ballet (1886), Charcot was also aware of cases by Finkelnburg (1870) and Bouillaud (1865) who had both music alexia and verbal alexia.
The Trombonist With Music Agraphia and Music Aphasia. The final case relating to music abilities is the most detailed and significant of the four cases presented by Charcot during his 1883–84 Friday Lessons. It includes a description of what Charcot called music aphasia and music agraphia. During the 16 May 1884 lesson at the Salpêtrière hospital, Charcot discussed a professional trombone player who had difficulty playing his instrument and copying music. These music deficits contrasted with his preserved verbal language skills. Charcot further discussed this case during the 13 June, 20 June, and 27 June lessons of the same year, as documented by Miliotti (1885) in Italian. This report by Miliotti has been translated into English for the first time and is summarized below.
In the preamble to the lecture demonstration, Charcot discussed aphasia as an impairment of concept expression in speech and writing. He extended this by analogy to other faculties and means of expression, such as numbers and gestures, and questioned whether music was a similar ability. Prior to his illness, the trombonist played for several years in the well-known 'Republican Guard' military band, which travelled throughout the world. The trombonist is identified as Dherbecourt (last name) by Gasser (1995), and Comettent (1894) lists Dherbecourt as one of the saxhorn players in the Republican Guard military band that visited Boston, Massachusetts for the Peace Jubilee in 1872 (Fig. 3). After a few years in the military band, the trombonist played in orchestras and theatres in Paris and was a professional copyist employed by some of the 'greatest music teachers in Paris', such as Jules Massenet (1842–1912), to produce performance copies of musical scores. Charcot noted that copying music at this level demanded a good knowledge of music, the ability to read music notation quickly and write clearly, as well as to correct mistakes.
(Enlarge Image)
Figure 3.
Photograph of the Republican Guard military band taken during a trip to Boston, Massachusetts in 1872. The photo likely includes Dherbecourt; however, we were unable to locate a list of persons in this photo. The original photo is part of the archive of la Garde Républicaine de Paris and is reproduced with permission from la Garde Républicaine.
The trombone player's past medical history included an unconfirmed report of syphilis as a child. His father was an alcoholic and had a hand tremor; and although the trombonist also had a hand tremor, he did not drink alcohol. Charcot, therefore, deduced that the tremor was a benign familial tremor. Importantly, the tremor did not interfere with the trombonist's ability to copy music or play his instrument prior to his present illness.
At the age of 45, the trombonist was described as having 'sudden dazes' and dizziness that caused him to vomit and fall (without loss of consciousness). Charcot noted some similarities to Ménière's disease (only recently defined by the French physician Prosper Ménière in 1861), but ruled out this diagnosis as several of the auditory symptoms were absent in the trombonist.
In September 1883 after leaving Trouville where he had been working long hours playing in an orchestra, the trombonist returned to his work as a music copyist; however, he found that although he could 'sing the music in his mind', he could not write it. There was no change in his hand movements or written language. Charcot compared the inability to copy music notation, or music agraphia, to verbal agraphia. He also suggested that the dissociation of writing music notation and writing verbal language supported the theory of cerebral localization but required confirmation by autopsy.
Charcot then went on to demonstrate a second impairment, namely a difficulty playing his instrument. The patient was unable to move the trombone slide or produce a meaningful sound (using his lips and tongue to make an embouchure). The interpretation provided for this was as follows:
'As the musical phrase sounded in his brain, awakened by the reading of written music, he should have been able to translate it in sounds through his instrument; but instead he has lost the memory of those movements of lips, tongue, and hand which allowed him to do that' (Miliotti, 1885, p. 141; original text in Supplementary material).
Charcot also acknowledged the need to imagine the melody and then translate this imagined melody into specific motor movements required for playing an instrument, such as the trombone, which has no keys. He attributed the inability to play the imagined melody to a deficit in the memory for movements:
'When he tries to play his instrument, which does not have existing notes like a piano, he needs to evoke in his spirit the tonal image, the note, actually a hallucination of the note; he needs to use his interior hearing; and when the note plays in his ear through this hallucination, he needs to express it, to externalize it through his instrument using his tongue and lips to articulate the note (this is what the patient says) and then his hand too, to extend or contract the instrument following the intonation's need' (Miliotti, 1885, p. 140; original text in Supplementary material).
It is not clear if this account is from Charcot, or the patient himself, or how much of Miliotti's own thinking also shaped this interpretation of the trombone player's difficulties in the complex series of steps from an imagined melody to producing a musical tone. Discrepancies were also described between the sounds made by the trombone and the musical qualities of the imagined sounds:
'The sound that came out of his trombone did not represent the musical thought he had seen written; it was a weird sound which did not have musical qualities. With everything he says, and you can hear him now repeating the statement that he intended to replay perfectly the notes in his brain, he had an interior hearing, he created a concept of the melody he saw in writing, but he could not play it' (Miliotti, 1885, p. 140; original text in Supplementary material).
Thus, Charcot pointed out that the trombonist was able to imagine the melody but was unable to produce sounds that matched the imagined melody. Such discussion of the mental representation of music was relatively new in the field of neurology.
In contrast to his difficulty with music production, the trombonist was able to speak, write and understand verbal language without difficulty. Importantly, there was no change in his tremor or ability to write verbal language. Charcot discussed the trombone player's ability to move his lips and tongue, blow, whistle, suck and grimace, and concluded that he did not have oral apraxia. Charcot also utilized the findings from a comprehensive examination to detect any limb apraxia, noting that the trombonist could make the movements required to play the trombone in the absence of the instrument. This ability to make learned movements was at odds with his difficulty in making similar movements when actually playing his musical instrument.
It is not clear from the case description whether or not Charcot asked the trombone player to attempt to write music notation or perform during the lecture (there is, however, mention of the trombonist playing an aria from the Faust opera after treatment with potassium iodide). The testing of different types of music writing, such as copying music notation from a written source, writing musical notes after hearing them played, or spontaneously writing music without a written or aural source for the notes (music composition), were not documented. These tasks would later be added to the examination of music writing in patients (Knoblauch, 1888).
In the more general neurological examination, the patient's pupils were slow to react to light, but otherwise normal. The patient's evolution of symptoms was also discussed. While his difficulties with playing the trombone showed some gradual improvement, he had begun to show a mild decline in memory and word finding, and his gait showed slight hesitation. He was in a 'sort of intellectual slumber' (Miliotti, 1885, p. 141). Charcot argued that these slight difficulties were independent of his difficulties with music. Charcot thought this reflected 'chronic diffuse peri-encephalopathy' (periencefalite diffusa cronica) (without delirium) of the 'congestive and motor' form (forma congestiva e motoria), which was shown to affect primarily the frontal lobes by his colleague Jules Falret (1853).
Charcot diagnosed the trombone player with music aphasia ('afasia musicale' in Italian and 'aphasie musicale' in French) and music agraphia ('agrafia musical' in Italian and 'agraphie musicale' in French). Thus, Charcot attached the label 'music aphasia' to the inability to perform the correct motor movements needed to produce music on a musical instrument, and 'music agraphia' to the inability to copy music. He concluded that this was the first example of a case of music aphasia and music agraphia without verbal aphasia. Charcot pointed out the dissociation between writing music notation and writing language saying,
'He only suffers from what we call music agraphia, as he is not agraphic with ordinary writing' (Miliotti, 1885, p. 139).
Thus, Charcot made three important observations regarding the trombonist. First, he identified the possibility that the inability to copy music could exist without verbal aphasia or agraphia. Second, he identified an inability to play a musical instrument without oral or limb apraxia. Charcot attributed this to a defect in the 'memory' for the movements needed to play the musical instrument. And third, Charcot also considered the dissociation between creating and imagining a melody (musical thought) and recognizing the musical qualities of a melody.
Ballet (1886) added further discussion of the trombone player:
'… I point out a curious case reported by Mr. Charcot in his Lessons, [in which he writes about] observations of a trombone player who lost the memory of the hand and mouth movements necessary to play the instrument. All the others driving memories were intact except this one. The musician had forgotten the handling of the trombone, as others forgot that of the pen' (p. 134; original text in Supplementary material).
Ballet further developed the idea of auditory images, including images of musical sounds ('les images de sons musicaux'), which were analogous to images of words.
The Friday Lessons on Aphasia
Charcot's dramatic teaching lectures attracted junior and senior clinicians from around the world. During the summers of 1883 and 1884, Charcot delivered a series of 14 lectures on aphasia at the Salpêtrière Hospital (Brais, 1993). Nine lectures were delivered during the summer of 1883 and five during the summer of 1884. Various parts of the lectures were transcribed and published by Charcot's students and clinical associates (Goetz et al., 1995). Charles Féré (1852–1907), an assistant physician and personal secretary to Charcot, published the first five lectures in 1883 (Féré, 1883a, b, c, d, e). Pierre Marie (1853–1940), a physician and head of Charcot's clinic in 1883, also wrote a summary of the 1883 lessons in two publications (Marie, 1883, 1888). Two others carried out theses under Charcot's supervision during this period, and each included discussions from the Friday Lessons: Désiré-Antoine-François Bernard's (1853–88) 'De l'aphasie et de ses diverses formes' (Bernard, 1885) and Gilbert Ballet's (1853–1916) 'Le langage intérieur et les diverses formes de l'aphasie' (Ballet, 1886). Gaetano Rummo (1853–1917), an Italian physician attending Charcot's clinic, published in Italian what appears to be the only complete version of the 1883 lectures (Rummo, 1884). Domenico Miliotti (dates unknown), another Italian student-physician, attended the five lectures during the summer of 1884 and later published them in Italian: 'Lezioni cliniche dell'anno scolastico 1883-84 sulle malattie del sistema nervoso' (Miliotti, 1885) (Fig. 1). It was in the context of the Friday Lessons that Charcot discussed his ideas about music and the brain.
(Enlarge Image)
Figure 1.
Reproduction of the book cover of Miliotti (1885).
This paper presents the details of Charcot's lectures that included discussion about music based on these second-hand reports provided by his students and clinical associates. It must be noted that, in such instances, there is always the risk that the accounts of the lectures reflect the interpretations by the students rather than reproducing directly the ideas of their originator. For example, the veracity of transcriptions of Charcot's lectures on tics, published by another Italian student, Guilio Melotti, has been challenged (Kushner et al., 1999). However, Charcot wrote the preface for both the Miliotti and Rummo texts, thereby giving his approval of the translations, and Goetz et al. (1995) noted that Charcot's lectures were presented in a form that was nearly ready for publication. The aim of this paper is to provide one of the first comprehensive reviews of Charcot's ideas about music using the available documents.
Discussion of Music During the Friday Lessons
During the Friday Lessons, Charcot discussed music abilities of several patients as illustrations of organization of the language faculty. These lectures appear to be a unique instance in which Charcot considered aspects of music abilities and impairments; no mention of this topic appears in his own publications. However, the writings of Féré, Ballet, Bernard and Miliotti document four cases that Charcot discussed with regard to his ideas about music in the 1883–84 lectures. The following sections detail these cases, which are also summarized in Table 1.
The Aphasic who Could Sing 'La Marseillaise'. Féré (1883d) recorded the case of Patient 'H' who could correctly sing the melody of the French national anthem 'La Marseillaise' but only while using a 'guttural sound'. Féré commented that the preserved ability to produce the melody without the song text exemplified the fractionization of music abilities. He stated:
'If time permitted, it would be the case for you to notice that the musical faculty may be, too, as the language faculty, split, somehow, by the disease, in a number of compartments. I could indeed give you several examples where it is musicians who have retained the ability to recognize the song to play the piano, however, had become unable to decipher written music' (Féré, 1883 d, p. 522; original text in Supplementarymaterial).
This dissociation between the melody and song text was the most common report of music in earlier neurology literature (Johnson et al., 2010). Féré also referred to other cases (without citations) in which musicians with brain damage were able to recognize a familiar melody but not read music notation, possibly referring to the those by Finkelnburg (1870) and Fischer (1867) discussed above. Bernard (1885) also mentioned Patient 'H' but provided no additional details.
The Piano Teacher With 'Music Blindness'. Bernard (1885) reported Charcot's case of a 45-year-old piano teacher (a female also called 'H') who had a non-fluent aphasia and complete music blindness ('cécité musicale complète') owing to epilepsy. She suffered aphasia several years earlier, but recovered somewhat before she entered the Salpêtrière on 12 December 1881. Charcot discussed her on Friday, 1 June 1883, making it likely that this case was discussed as a part of that Friday Lesson. Patient H was also known as 'la Dame blanche', as she often sang an aria from the comic opera of this name by Boïeldieu. (It is important to note that 'la Dame blanche' was not Blanche Wittmann, the famous patient depicted on the Lecon à la Salpêtrière painting by Brouillet). Bernard noted that although her speech was impaired, she was able to accurately sing both the melody and text of this song and a few others, but she refused to sing other less familiar songs. Bernard (1885) wrote:
'The lyrics are distinct, the melody exactly repeated. When she sings H … uses her left hand, her fingers beat time on the bed cover. The condition of the patient does not allow us to try placing her in front of a piano, to see how these movements were related. She regularly sings a rude song. It was impossible to get her to sing other familiar melodies. But she hums dance tunes when asked, rhythmically waving her fingers of her left hand. Impossible also to talk with her about famous opera, music of masters (teachers). "I forgot all that, I do not know"' (p. 120; original text in Supplementary material)
Bernard (1885) also noted that she was unable to read music notation:
'The score itself, the musical notation is completely indecipherable for her. Often the experiment was done. No sign on (musical) stave could not be recognized or called by her. She read the header of a piece, line by line, by following it with the finger. On staves, her finger stopped or went astray. In vain we pressed, we varied the questions: 'What have you under your eyes? Where such a key? where such a note?. The uncertain eyes, she answered steadily: 'I do not know, I do not know' … The words and figures arranged between staves, the text of songs and signs showing the movement were read as well as printed words posted' (p. 122; original text in Supplementary material).
Patient H died of pneumonia on 11 May 1884, and an autopsy revealed a large 'yellow plaque' on the surface of the left frontal and parietal lobes that extended to several subcortical structures. Bernard provided a schematic of the lesion (Fig. 2). Such pathological evidence was viewed as key by Charcot and his disciples for theorizing about the localization of brain functions. [However, see Bastian (1898) for an alternative interpretation of the case based on the autopsy findings].
(Enlarge Image)
Figure 2.
Sketch of location of brain damage after autopsy of Bernard's (1885) case with 'music blindness' discussed by Charcot during the Friday Lessons.
The Medical Professor and Musician With 'Music Blindness'. Both Bernard (1885) and Ballet (1886) referred to another of Charcot's aphasic patients with music blindness ('cécité musicale') discussed in the 1883 lectures. Bernard (1885) discussed Charcot's report of this case:
'Charcot reported in one of his lectures in 1883 that in one of his colleagues at the Faculty of Medicine, who died aphasic and hemiplegic on the right, the first symptom of his brain damage was a music blindness. One day he sits at the piano, opens a partition and can not decipher a single note, while he moves his fingers on the keyboard with ease and accuracy. Finkelnburg's patient, struck with the same blindness, could play from memory and play melodies he heard sung or perform. Bouillaud's patient cited above presented verbal and music blindness' (pp. 118–19; original text in Supplementary material).
Ballet (1886) also made a brief reference to this case:
'M. Charcot told us that one of his colleagues, an eminent Faculty of Paris professor and distinguished musician, was unpleasantly surprised when he was at the piano one day and was not able to play as usual. He saw the notes, but did not understand them any more. Musical blindness was, in this particular case, the forerunner of a hemiplegia to which the patient succumbed' (p. 110; original text in Supplementary material).
Both Ballet and Bernard discussed this case in the context of comprehension of symbols, such as numbers and mathematical equations. Because he was interested in documenting isolated deficits and dissociations, Charcot used this case to point out that music alexia could be initially present as an isolated syndrome, with aphasia and hemiplegia evolving later. As noted by Ballet (1886), Charcot was also aware of cases by Finkelnburg (1870) and Bouillaud (1865) who had both music alexia and verbal alexia.
The Trombonist With Music Agraphia and Music Aphasia. The final case relating to music abilities is the most detailed and significant of the four cases presented by Charcot during his 1883–84 Friday Lessons. It includes a description of what Charcot called music aphasia and music agraphia. During the 16 May 1884 lesson at the Salpêtrière hospital, Charcot discussed a professional trombone player who had difficulty playing his instrument and copying music. These music deficits contrasted with his preserved verbal language skills. Charcot further discussed this case during the 13 June, 20 June, and 27 June lessons of the same year, as documented by Miliotti (1885) in Italian. This report by Miliotti has been translated into English for the first time and is summarized below.
In the preamble to the lecture demonstration, Charcot discussed aphasia as an impairment of concept expression in speech and writing. He extended this by analogy to other faculties and means of expression, such as numbers and gestures, and questioned whether music was a similar ability. Prior to his illness, the trombonist played for several years in the well-known 'Republican Guard' military band, which travelled throughout the world. The trombonist is identified as Dherbecourt (last name) by Gasser (1995), and Comettent (1894) lists Dherbecourt as one of the saxhorn players in the Republican Guard military band that visited Boston, Massachusetts for the Peace Jubilee in 1872 (Fig. 3). After a few years in the military band, the trombonist played in orchestras and theatres in Paris and was a professional copyist employed by some of the 'greatest music teachers in Paris', such as Jules Massenet (1842–1912), to produce performance copies of musical scores. Charcot noted that copying music at this level demanded a good knowledge of music, the ability to read music notation quickly and write clearly, as well as to correct mistakes.
(Enlarge Image)
Figure 3.
Photograph of the Republican Guard military band taken during a trip to Boston, Massachusetts in 1872. The photo likely includes Dherbecourt; however, we were unable to locate a list of persons in this photo. The original photo is part of the archive of la Garde Républicaine de Paris and is reproduced with permission from la Garde Républicaine.
The trombone player's past medical history included an unconfirmed report of syphilis as a child. His father was an alcoholic and had a hand tremor; and although the trombonist also had a hand tremor, he did not drink alcohol. Charcot, therefore, deduced that the tremor was a benign familial tremor. Importantly, the tremor did not interfere with the trombonist's ability to copy music or play his instrument prior to his present illness.
At the age of 45, the trombonist was described as having 'sudden dazes' and dizziness that caused him to vomit and fall (without loss of consciousness). Charcot noted some similarities to Ménière's disease (only recently defined by the French physician Prosper Ménière in 1861), but ruled out this diagnosis as several of the auditory symptoms were absent in the trombonist.
In September 1883 after leaving Trouville where he had been working long hours playing in an orchestra, the trombonist returned to his work as a music copyist; however, he found that although he could 'sing the music in his mind', he could not write it. There was no change in his hand movements or written language. Charcot compared the inability to copy music notation, or music agraphia, to verbal agraphia. He also suggested that the dissociation of writing music notation and writing verbal language supported the theory of cerebral localization but required confirmation by autopsy.
Charcot then went on to demonstrate a second impairment, namely a difficulty playing his instrument. The patient was unable to move the trombone slide or produce a meaningful sound (using his lips and tongue to make an embouchure). The interpretation provided for this was as follows:
'As the musical phrase sounded in his brain, awakened by the reading of written music, he should have been able to translate it in sounds through his instrument; but instead he has lost the memory of those movements of lips, tongue, and hand which allowed him to do that' (Miliotti, 1885, p. 141; original text in Supplementary material).
Charcot also acknowledged the need to imagine the melody and then translate this imagined melody into specific motor movements required for playing an instrument, such as the trombone, which has no keys. He attributed the inability to play the imagined melody to a deficit in the memory for movements:
'When he tries to play his instrument, which does not have existing notes like a piano, he needs to evoke in his spirit the tonal image, the note, actually a hallucination of the note; he needs to use his interior hearing; and when the note plays in his ear through this hallucination, he needs to express it, to externalize it through his instrument using his tongue and lips to articulate the note (this is what the patient says) and then his hand too, to extend or contract the instrument following the intonation's need' (Miliotti, 1885, p. 140; original text in Supplementary material).
It is not clear if this account is from Charcot, or the patient himself, or how much of Miliotti's own thinking also shaped this interpretation of the trombone player's difficulties in the complex series of steps from an imagined melody to producing a musical tone. Discrepancies were also described between the sounds made by the trombone and the musical qualities of the imagined sounds:
'The sound that came out of his trombone did not represent the musical thought he had seen written; it was a weird sound which did not have musical qualities. With everything he says, and you can hear him now repeating the statement that he intended to replay perfectly the notes in his brain, he had an interior hearing, he created a concept of the melody he saw in writing, but he could not play it' (Miliotti, 1885, p. 140; original text in Supplementary material).
Thus, Charcot pointed out that the trombonist was able to imagine the melody but was unable to produce sounds that matched the imagined melody. Such discussion of the mental representation of music was relatively new in the field of neurology.
In contrast to his difficulty with music production, the trombonist was able to speak, write and understand verbal language without difficulty. Importantly, there was no change in his tremor or ability to write verbal language. Charcot discussed the trombone player's ability to move his lips and tongue, blow, whistle, suck and grimace, and concluded that he did not have oral apraxia. Charcot also utilized the findings from a comprehensive examination to detect any limb apraxia, noting that the trombonist could make the movements required to play the trombone in the absence of the instrument. This ability to make learned movements was at odds with his difficulty in making similar movements when actually playing his musical instrument.
It is not clear from the case description whether or not Charcot asked the trombone player to attempt to write music notation or perform during the lecture (there is, however, mention of the trombonist playing an aria from the Faust opera after treatment with potassium iodide). The testing of different types of music writing, such as copying music notation from a written source, writing musical notes after hearing them played, or spontaneously writing music without a written or aural source for the notes (music composition), were not documented. These tasks would later be added to the examination of music writing in patients (Knoblauch, 1888).
In the more general neurological examination, the patient's pupils were slow to react to light, but otherwise normal. The patient's evolution of symptoms was also discussed. While his difficulties with playing the trombone showed some gradual improvement, he had begun to show a mild decline in memory and word finding, and his gait showed slight hesitation. He was in a 'sort of intellectual slumber' (Miliotti, 1885, p. 141). Charcot argued that these slight difficulties were independent of his difficulties with music. Charcot thought this reflected 'chronic diffuse peri-encephalopathy' (periencefalite diffusa cronica) (without delirium) of the 'congestive and motor' form (forma congestiva e motoria), which was shown to affect primarily the frontal lobes by his colleague Jules Falret (1853).
Charcot diagnosed the trombone player with music aphasia ('afasia musicale' in Italian and 'aphasie musicale' in French) and music agraphia ('agrafia musical' in Italian and 'agraphie musicale' in French). Thus, Charcot attached the label 'music aphasia' to the inability to perform the correct motor movements needed to produce music on a musical instrument, and 'music agraphia' to the inability to copy music. He concluded that this was the first example of a case of music aphasia and music agraphia without verbal aphasia. Charcot pointed out the dissociation between writing music notation and writing language saying,
'He only suffers from what we call music agraphia, as he is not agraphic with ordinary writing' (Miliotti, 1885, p. 139).
Thus, Charcot made three important observations regarding the trombonist. First, he identified the possibility that the inability to copy music could exist without verbal aphasia or agraphia. Second, he identified an inability to play a musical instrument without oral or limb apraxia. Charcot attributed this to a defect in the 'memory' for the movements needed to play the musical instrument. And third, Charcot also considered the dissociation between creating and imagining a melody (musical thought) and recognizing the musical qualities of a melody.
Ballet (1886) added further discussion of the trombone player:
'… I point out a curious case reported by Mr. Charcot in his Lessons, [in which he writes about] observations of a trombone player who lost the memory of the hand and mouth movements necessary to play the instrument. All the others driving memories were intact except this one. The musician had forgotten the handling of the trombone, as others forgot that of the pen' (p. 134; original text in Supplementary material).
Ballet further developed the idea of auditory images, including images of musical sounds ('les images de sons musicaux'), which were analogous to images of words.
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