by Oliver Sacks
Many aphasic patients can get not only the words of songs, but can learn to repeat sequences or series— days of the week, months of the year, numerals, etc. They may be able to do this as a series, but not to disembed a particular item from the series. So one of my patients, for instance, can recite all the months of the year in order (January, February, March, April, May…); he knows what the current month is, but when I ask him, he cannot respond, simply, “April.” Indeed, aphasics may be able to reproduce much more elaborate familiar sequences— a prayer, or lines from Shakespeare, or an entire poem— but only as automated sequences.3 Such sequences unfold, once they are started, in much the same way as music does.
Hughlings Jackson long ago distinguished “propositional” speech from what he called, variously, “emotional,” “ejaculate,” or “automatic” speech, stressing that the latter could be preserved in aphasia, sometimes to a startling extent, even when the former was grossly impaired. Cursing is often cited as a dramatic form of automatic speech, but singing familiar lyrics can be seen as equally automatic; a person with aphasia may be able to sing or curse or recite a poem but not to utter a propositional phrase.
The question of whether singing has any use in the recovery of speech, then, can be formulated another way: can language embedded in unconscious automatism be “released” for conscious, propositional use?
During the Second World War, A. R. Luria began to investigate the neural basis of speech and language, of different forms of aphasia, and of methods for restoring speech. (His work was published in Russian in a massive monograph, Traumatic Aphasia, in 1947, and in a small, startling book, Restoration of Function After Brain Injury, in 1948— though neither was translated or known in the West until several decades later.) Given an acute injury to the brain such as he saw in the stroke patients or injured soldiers he studied, Luria emphasized, there would always be two levels of disturbance. First, there was a “core” of tissue destruction, which was irreversible; and second, a larger, surrounding area, or “penumbra,” of depressed or inhibited function, which under certain conditions, he felt, might be reversible.
When one first meets a patient immediately after a stroke or head injury, one sees only the total effects of injury: paralysis, aphasia, or other disabilities. It is difficult to distinguish disabilities produced by anatomical damage from those produced by inhibition of the surrounding neural tissue. Time will show the difference in most patients, for inhibition tends to lift spontaneously, usually in a matter of weeks. But in some patients, for reasons that are still unclear, it does not. At this point (if not before), it is crucial to start therapy, to promote what Luria called “de-inhibition.”
Speech therapy may lead to de-inhibition, but it may sometimes fail; if it fails, one may wrongly assume that the patient’s aphasia is due to permanent anatomical damage and is thus irreversible. But music therapy, for some patients, can succeed where conventional speech therapy has failed, as in the case of Samuel S. It may be that cortical areas previously inhibited but not destroyed can be de-inhibited, kick-started into action, by reexperiencing language, even if it is of a wholly automatic sort, language embedded in music.
* * *
A VERY CRUCIAL ASPECT of speech or music therapy for the aphasic patient is the relationship between therapist and patient. Luria emphasized that the origin of speech was social no less than neurological— it required the interaction of mother and child. It is likely that the same is true of song, and in this sense, music therapy for patients with aphasia is profoundly different from music therapy for a movement disorder like parkinsonism. In parkinsonism, it is the motor system which is being activated, almost automatically, by music— and a tape or CD, in this limited sense, can do as much as a therapist. But with speech disorders like aphasia, the therapist and her relationship with the patient— a relationship which involves not only musical and vocal interaction but physical contact, gesture, imitation of movement, and prosody— is an essential part of the therapy. This intimate working together, this working in tandem, depends on mirror neurons throughout the brain, which enable the patient not only to imitate but to incorporate the actions or abilities of others, as Rizzoletti et al. have explored.
The therapist not only provides support and an encouraging presence, but literally leads the patient into more and more complex forms of speech. With Samuel S., this involved drawing language out until he could sing all the words of “Ol’ Man River,” then leading him on to sing a whole range of old songs, then, by the right sort of questions, drawing him into short responsive phrases. Whether there is a chance of going beyond this, of restoring fluent narrative or propositional speech to patients with long-standing aphasia, remains an open question. Saying “Had a great time” or “Saw the kids” may be as far as Samuel S. can go. It might be said that such verbal responses are modest, limited, and formulaic— but they do represent a radical advance from purely automatic speech, and they can have an enormous effect on the daily reality of an aphasic person’s life, allowing a formerly mute and isolated person to reenter a verbal world, a world he had seemingly lost forever.
In 1973 Martin Albert and his colleagues in Boston described a form of music therapy they called “melodic intonation therapy.” Patients were taught to sing or intone short phrases— for example, “How are you today?” Then the musical elements of this were removed slowly until (in some cases) the patient regained the power to speak a little without the aid of intonation. One sixty-seven-year-old man, aphasic for eighteen months— he could only produce meaningless grunts, and had received three months of speech therapy without effect— started to produce words two days after beginning melodic intonation therapy; in two weeks, he had an effective vocabulary of a hundred words, and at six weeks, he could carry on “short, meaningful conversations.”
What is happening in the brain when melodic intonation, or any type of music therapy, “works”? Albert et al. originally thought that it served to activate areas in the right hemisphere, areas homologous to Broca’s area. Albert’s close colleague, Norman Geschwind, had been fascinated by the way in which children could recover speech and language even after the removal of the entire left hemisphere of the brain (this was sometimes done in children with uncontrollable seizures). Such a recovery or reacquisition of language suggested to Geschwind that, though linguistic ability was generally associated with the left hemisphere, the right hemisphere also had linguistic potential and could take over language functions almost completely, at least in children. Albert and his colleagues thus felt, without clear evidence, that this might be the case, at least to some degree, even in aphasic adults, and that melodic intonation therapy, calling as it did upon right-hemisphere musical skills, could help to develop this potential.
Detailed imaging of patients undergoing MIT was not possible during the 1970s, and a 1996 PET scan study by Pascal Belin et al. seemed to show that there was no activation in the right hemisphere of such patients. They reported, moreover, that there was not only an inhibition of Broca’s area in aphasic patients, but hyperactivity of a homologous area in the right hemisphere (we may call it, for convenience, the “right Broca’s area”). This sustained hyperactivity on the right side exerts an active inhibiting action on the “good” Broca’s area, which, in its weakened state, is powerless to resist. The challenge, then, is not only to stimulate the normal, left Broca’s area, but to find a way to damp down the “right Broca’s area,” with its malignant hyperactivity. Singing and melodic intonation seem to do exactly this: by engaging the right-hemisphere circuits in normal activity, they disengage them from pathological activity. This process has a certain self-sustaining momentum of its own, for as the left Broca’s area is released from inhibition, it can exert a suppressant action on the “right Broca’s area.” A vicious circle, in short, is replaced by a therapeutic one.4
For various reasons, little research attention was paid during the 1980s and 1990s to melodic intonation therapy for people with severe, nonfluent B
roca’s aphasia— or to the mechanisms by which it might work. Nonetheless, music therapists continued to observe that, in many cases, such therapy could allow very significant improvement.
Recent work by Gottfried Schlaug and his colleagues carefully documents the brain activity of eight patients undergoing melodic intonation therapy (this involves seventy-five sessions of intensive therapy). All of these patients, Schlaug et al. report, “showed significant changes in speech output measures and in a right-hemispheric fronto-temporal network while repeating simple words/phrases in the MRI scanner.” Schlaug showed me a number of videos of such patients, and the change in their ability to speak was indeed striking. Initially many were incapable even of responding clearly to the question, “What is your address?” Following MIT, they were able to reply much more easily to such questions, even offering additional details beyond those asked for. They had clearly achieved at least a measure of propositional speech. These changes, both behavioral and anatomical, were retained even several months after the course of treatment had ended.
As Schlaug points out, “the neural processes that underlie post-stroke language recovery remain largely unknown and thus, have not been specifically targeted by most aphasia therapies.” But MIT, at least, has been shown to be “ideally suited for facilitating language recovery in non-fluent aphasic patients, particularly in those with large left hemisphere lesions for whom the only route to recovery may be the engagement of right hemispheric language regions.”
We have become accustomed, in the last twenty years or so, to dramatic revelations of cortical plasticity. Auditory cortex, it has been shown, can be reallocated for visual processing in congenitally deaf people, and the visual cortex in blind people may be recruited for auditory and tactile functions. But perhaps even more remarkable is the notion that the right hemisphere, which in normal circumstances has only the most rudimentary linguistic capacities, can be turned into a reasonably efficient linguistic organ with less than three months of training— and that music is the key to this transformation.
17
Accidental Davening: Dyskinesia and Cantillation
Solomon R. was an intelligent middle-aged man with a dyskinesia, an unusual movement disorder which, in him, took the form of rhythmic pulsions of various sorts: forcible expulsions of breath, accompanied by loud phonations (“eughh, eughhh…”), and a synchronous contraction of abdominal and trunk muscles, causing his body to bow or rock with each expiration.
Over the weeks that I saw him, there was a strange elaboration of this picture. The expiratory-phonatory “beat” began to acquire a sort of melody, a repetitive singsong to accompany it, and to this, in turn, was added a half-articulate, murmuring quality, like the prosody of a soft, unintelligible language. With this, and his now-increasing bowing movement, Mr. R. seemed to be cantillating, praying— “davening,” as such murmuring, rhythmically motoric prayer is called by religious Jews. Indeed, a couple of weeks later, I was able to catch a number of Hebrew words, which seemed to confirm my impression. But when I asked Mr. R., he told me that though they were indeed Hebrew words, they made no sense— they were “plucked out of the air,” he said, as if to fill the prosodic and melodic demand of his dyskinesia. Random though the words were, this strange activity gave Mr. R. a deep satisfaction and allowed him to feel he was “doing something,” and not just the victim of a physical automatism.
Wanting to document this extraordinary scene, I went one day to the hospital with my tape recorder. As soon as I entered, I could hear Mr. R. down the hall. Or so I thought, but when I entered the room I found a Sabbath service in progress. The cantillation was coming not from my patient, but from the davening rabbi himself.
With the rabbi, presumably, the rhythmic emphases of prayer had led to a sympathetic rhythmic movement of the body— but with Mr. R., it had happened the other way round. Not originally a man attracted to cantillation or prayer, he had now been drawn to this through the physiological accident of dyskinesia.
18
Come Together: Music and Tourette’s Syndrome
John S., a young man with Tourette’s syndrome, recently wrote to me, describing the effect of music on his tics:
Music is a huge part of my life. It can be both a blessing and a curse when it comes to ticcing. It can send me into a state where I forget all about Tourette’s, or it can bring on a surge of tics that is difficult to control or bear.
He added that his tics were especially brought on by “certain kinds of music heavy with rhythm” and that their frequency and intensity might be determined by music, accelerating or slowing along with the music’s tempo.
Reactions like this are very similar to those of parkinsonian patients, who may find themselves forgetting their parkinsonism, enjoying a delicious motor freedom, with some kinds of music, but being driven or entrained by others. But while Tourette’s may be considered, like parkinsonism, a movement disorder (albeit of an explosive rather than an obstructive kind), it is much more. It has a mind of its own. Tourette’s is impulsive, productive, where parkinsonism is not. Sometimes this productivity is more or less confined to the production of simple tics or repetitive, fixed movements, and this seems to be the case with John S. But for some people, it may assume an elaborate, phantasmagoric form remarkable for its mimicry, antics, playfulness, inventions, and unexpected and sometimes surreal associations. People with this rarer, phantasmagoric form of Tourette’s may show much more complex reactions to music.1
One such man, Sydney A., could have very extravagant reactions to music, as he did one day to a piece of Western music on the radio. He lurched, jerked, lunged, yelped, made faces, and gesticulated exuberantly— and, above all, he mimed and mimicked. The music seemed to trigger a cascade of wild mimetic representations of the tone, the tenor, the landscape of the music, and all the images and emotional reactions these provoked in him as he listened. This was not just an exacerbation of ticcing, but an extraordinary Tourettic representation of the music, a very personal expression of his sensibility and imagination, though dominated by Tourettic exaggeration, parody, and impulsiveness. I was reminded of a description by Henri Meige and E. Feindel in their 1902 book Tics and Their Treatment, of a man with Tourette’s who showed on occasion “a veritable debauch of absurd gesticulations, a wild muscular carnival.” I thought of Sydney sometimes as a mimetic virtuoso, but this was not a mimesis under his control, and for all its brilliance, it always had a certain flavor of the convulsive and the excessive.
And yet on another occasion, when Sydney took up his guitar and sang an old ballad, there was no ticcing at all, but a total immersion in or identification with the song and its mood.
Extraordinary, creative interactions can occur when someone with Tourette’s performs as a musician. Ray G. was a man strongly drawn to jazz who played drums in a band on the weekends. He was noted for his sudden and wild solos, which would often arise from a convulsive drum-hitting tic— but the tic could initiate a cascade of percussive speed and invention and elaboration.2
Jazz or rock, with its heavy beat and its freedom to improvise, may be especially attractive to a musical person with Tourette’s, and I have known a number of brilliant Tourettic musicians who are jazz artists (though I also know other musicians with Tourette’s who are more drawn to the structure and rigor of classical music). David Aldridge, a professional jazz drummer, explored these themes in a memoir entitled “Rhythm Man”:
I’ve been banging on car dashboards since I was six years old, following and flowing with the rhythm until it poured out of my ears…. Rhythm and Tourette syndrome have been intertwined from the first day I found that drumming on a table could mask my jerky hand, leg and neck movements…. This newly found masking actually harnessed my unbounded energy, directing it into an orderly flow…. This “permission to explode” let me tap into vast reservoirs of sounds, and physical sensations, and I realized that my destiny lay clearly before me. I was to become a rhythm man.
Aldridge relied on
music frequently, both to mask his tics and to channel their explosive energy: “I would learn to harness the enormous energy of Tourette syndrome and control it like a high-pressure fire hose.” Harnessing his Tourette’s and expressing himself in creative, unpredictable musical improvisations seemed to be deeply intertwined: “The urge to play and the desire to release the endless tension of Tourette syndrome fed on each other like fuel on fire.” For Aldridge, and perhaps for many with Tourette’s, music was inseparably linked to movement and to sensation of all sorts.
The attractions, the joys, and the therapeutic powers of drumming and drum circles are widely known in the Tourette’s community. In New York City recently, I took part in a drum circle organized by Matt Giordano, a gifted drummer with severe Tourette’s. When he is not focused or engaged, Matt is in constant Tourettic motion— and, indeed, everyone in the room that day seemed to be ticcing, ticcing in their own time. I could see eruptions of tics, contagions of tics, rippling around the thirty-odd Touretters there— but once the drum circle started, with Matt leading them, all the ticcing disappeared within seconds. Suddenly there was synchronization, and they came together as a group, performing “in the moment with the rhythm,” as Matt puts it— their Tourettic energy, motor exuberance, playfulness, and inventiveness all drawn upon creatively and given expression in the music. Music here had a double power: first, to reconfigure brain activity, and bring calm and focus to people who were sometimes distracted or preoccupied by incessant tics and impulses; and second, to promote a musical and social bonding with others, so that what began as a miscellany of isolated, often distressed or self-conscious individuals almost instantly became a cohesive group with a single aim— a veritable drum orchestra under Matt’s baton.