Brain (1980), 103, 367-392.

MUSIC AND LANGUAGE
MUSICAL ALEXIA AND AGRAPHIA
by JOHN C. M. BRUST
(From the Department of Neurology, Harlem Hospital Center and Columbia University College
of Physicians and Surgeons)

INTRODUCTION

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Music, 'the art or science of arranging sounds in notes and rhythms to give a desired
pattern or effect' (Jacobs, 1967), joins language differently in song, recitative, chant,
sprechstimme, poetry, the inflection of everyday speech, and, of course, musical
notation (Critchley, 1972; Henson, 1977a, b). Amusia and aphasia occur alone or
together, and prosody, which includes the musical elements of pitch, rhythm and
stress, and which gives both propositional and emotional meaning to speech, may be
altered in aphasics who retain ability to sing and to appreciate music (MonradKrohn, 1947). There appears to be left hemispheric dominance for identifying words
whose meaning depends upon pitch (Van Laucker and Fromkin, 1973), whereas
identification of the emotional context of speech seems to require the right
hemisphere (Tucker, Watson and Heilman, 1977). Musical stimuli have precipitated
seizures in patients with either right or left hemispheric lesions (Scott, 1977), and
seizures generated from either hemisphere may include musical hallucinations
(Mulder and Daly, 1952). In epileptics (Penfield and Perot, 1963), hallucinated
music or spoken voices followed stimulation of either temporal lobe, and there was
no topographical difference between areas associated with voices and those
associated with music.
Music is usually non-propositional, yet appreciation of music may be more
intellectual than emotional. Although most people enjoy music, some lack the
fundamental skill of either recognizing or reproducing simple melodies or even single
intervals. A majority are musically illiterate, although they may be musically
talented. Few have absolute pitch in the accepted sense of the term. The elements of
music—pitch, timbre, duration, loudness and rhythm—are separable, and recognition of sounds in a chord is horizontally non-linear, in contrast to recognizing
melody. Musical notation includes both verbal and non-verbal elements and
indicates both simultaneous and serial events.

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It is not surprising, therefore, that studies of music and language, and attempts to
localize and to classify amusia, have been conflicting. Henschen (1920, 1925, 1926)
considered amusia, like aphasia, to be either motor (vocal and instrumental amusia
and musical agraphia) or sensory ('music deafness', 'amnestic amusia' and musical
alexia). On the basis of autopsy studies he believed centres for particular musical
functions existed in the language-dominant hemisphere, for example a 'singing
centre' in the pars triangularis of the third frontal convolution, a receptive music
centre at the temporal pole, a note-reading centre near the angular gyrus and an
instrumental centre at the foot of the second frontal convolution (although there
appeared to be a special centre for violinists). Despite this rigidly anatomical
approach, Henschen (1926) observed 'Musical faculty is phylogenetically as well as
ontogenetically older than speech, and its representation is more uniformly
distributed over both hemispheres'. Preserved musical function in the presence of
aphasia he attributed to right hemispheric takeover.
Kleist (1928) divided motor and sensory amusias into those affecting either tone
or melody, and placed the responsible lesions in the left hemisphere. 'Tone
muteness', for example, he attributed to destruction of the lower third of the left
anterior central convolution, between centres for singing and for whistling. On the
basis of a single autopsy case of normal musical function and destroyed temporal
tips, Kleist discounted their importance in musical reception. Feuchtwanger (1930),
more interested in the neuropsychology of music and speech than in anatomical
localization, observed that language and music each had symbolic and nonsymbolic aspects and predicted that bilateral cortical activity was involved in the
production and understanding of each. Although aphasia was present in each of his
34 amusic patients, he acknowledged that phonemic and melodic perception could
be lost independently. Ustvedt (1937), noting the heterogeneity of amusic patients
and the frequent failure of investigators to determine premorbid musical capacity or
to use standardized tests, stressed ' . . . how slight the possibility of localization is in
the majority of cases and how unjustifiable it is to draw conclusions regarding the
normal localization of a given function from the localization of a lesion associated
with a particular defect'. He also criticized the neuropsychological views of
Feuchtwanger as 'theoretical and artificial'.
Hecaen (1962) believed right hemispheric lesions caused difficulty with sound
recognition, whereas left-sided lesions resulted in 'a disorganization of musical
understanding'. Wertheim (1969, 1977) believed receptive amusia was most often
due to lesions of the language-dominant hemisphere, whereas expressive amusia
followed non-dominant hemispheric damage, the second frontal convolution in the
case of instrumental amusia and the pars triangularis with vocal amusia. Damasio
and Damasio (1977) accepted right hemispheric dominance for 'musical execution'
but believed musical perception shifted from the right to the left hemisphere as a
person became increasingly sophisticated musically. Benton (1977) noted that
expressive amusia was associated with anterior lesions and receptive amusia
('defects in the perception and recognition of tones and melodies... with or without

MUSIC AND LANGUAGE

369

concomitant expressive impairment') was caused by temporal lobe disease, but that
either kind of amusia could follow damage to either hemisphere.
The two present cases demonstrate the prematurity of broad generalizations
regarding either music and language or hemispheric specialization for musical
function. Each was a professional musician, able to read and write music, in whom
aphasia was accompanied by disturbed musical function, but of very different kind
and degree, including musical alexia and agraphia.

PATIENTS AND METHODS
To minimize fatigue both patients were examined in short sessions seldom exceeding an hour. For
language testing the manual of Goodglass and Kaplan (1972) was used. For musical testing
Wertheim's (1969) procedure was used, and additional tests of musical alexia and agraphia were added.
These included playing written single notes; playing or singing written intervals; matching written
intervals with what was heard; observing whether a written interval was upward or downward; tapping
out written rhythms; drawing specific notes, clefs and rests; indicating pitch on a score; and writing
heard intervals.

In February 1976 a 22-year-old music student was admitted to hospital for partial complex, right
focal motor, and generalized seizures. Neurological examination was normal, but carotid angjography
revealed a lemon-sized meningioma beneath the left temporal lobe. During attempted total removal,
unexplained massive left temporal swelling developed; emergency right craniotomy and dural incision
failed to reveal hsematoma or swelling on that side. To allow skin closure, left hemicraniectomy and
anterior temporal lobectomy were performed. She left the operating room breathing spontaneously
but with both pupils dilated and unreactive to light.
Within several hours pupillary reactivity returned, and a few days later she was awake, with right
hemiplegia and sensory loss, right homonymous hemianopia and global aphasia. At re-operation the
left cerebral convexity was still swollen and discoloured. No significant himatoma was apparent, and
the dura was closed with a fascia lata graft. Over the next few weeks her strength improved, and speech
gradually became fluent, consisting largely of paraphasic jargon; there was little evidence of language
comprehension. Deterioration attributed to hydrocephalus led to placement of a right ventriculo-atrial
shunt through the right frontal lobe, following which improvement resumed.
In November 1976 computerized tomography revealed a large low density area in the posterior
temporo-parietal area, consistent with infarction, plus an inferior contrast-enhanced lesion which was
believed to represent residual neoplasm (fig. 1). Following uncomplicated total removal of the
meningioma she had several major motor, partial complex, and right sensory seizures, controlled with
phenytoin and carbamazepine. During the next eighteen months, the aphasia gradually unproved, and
strength became normal. Alexia and agraphia remained severe, and her visual field defect and sensory
loss persisted. Resuming her studies, she received a degree of Bachelor of Music in May 1978.
Always right-handed, she had learned how to read music with the guitar in early
adolescence and had begun singing lessons at the age of 14 years and piano lessons at
the age of 15 years. When she was first admitted, during her fourth year of
professional study, she could sigh tread madrigals by voice and Chopin waltzes on the
piano and often wrote out musical parts. She did not have absolute pitch.

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Case 1

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J. C. M. BRUST

Even while severely aphasic she enjoyed listening to music and later said that in
contrast to her language difficulties, musical understanding never seemed impaired.
Similarly, although she had often been aware of paraphasic errors when she spoke,
she believed she had, from her first attempts at singing, sung the notes properly and
with fewer paraphasic errors. Unable to read or write either words or music, she
memorized new songs by listening to recordings. Right hand clumsiness prevented
piano playing, and so she returned to the guitar, using her left hand for finely coordinated chord placement and her right hand for coarse but properly rhythmical
strumming; individual string plucking was too difficult for her.
Language and music testing {July 1977). Despite paraphasic errors, her spontaneous speech was
intelligible. Prosody was normal. Auditory comprehension was especially impaired for body parts,
prepositions, passive subject-object discrimination, possessive relationships, and complex ideational
material. Naming produced verbal paraphasic errors, and she named only six animals in one minute.
Word and phrase repetition led to only occasional literal paraphasias, usually self-corrected, and she
was able to repeat syntactically complex phrases (for example, 'no ifs, ands, or buts'). Reciting the days
of the week and the months, she omitted Saturday and December. Literal and verbal paraphasias
contaminated recitation of nursery rhymes and the words of familiar songs.
Reading single words and sentences aloud produced many literal and verbal paraphasias, for
example, 'sammock' for 'hammock', and 'atomic' for 'explode'. Written language comprehension was
more severely impaired than reading aloud. She mis-identified most written words after hearing them
spoken and mis-named most words spelled orally. Selecting written words to complete written
sentences or to answer questions about written paragraphs revealed severe disability. Word-picture

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FIG. 1. Case 1. CT scan, A, left inferior temporal lobe lucency, consistent with infarction, plus contrast-enhancing
residual meningioma (arrow). B, temporo-parietal lucency. Amputated left anterior temporal lobe is not
demonstrated.

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371

matching, on the other hand, was normal; she pointed to the correct pictured object, geometrical
shape, number, colour, or action for the written word shown, including those she had read
paraphasically or said she could neither read aloud nor understand.
She wrote her name correctly but not her address; 'Fair Hill Road' became 'Fa Ro'. Transcribing
printed sentences into script was done clumsily but correctly. Writing the alphabet and numbers up to
21, she did the first few correctly and then made paragraphic errors, omissions and repetitions. She
correctly wrote most dictated letters and numbers, but could write no more than the first letter of any
dictated word or the name of something seen. Attempting to describe the cookie theft picture, she
wrote, 'she m . . . . ' , and then could write no more.
There was neither left-right confusion nor finger agnosia. Simple calculation, spoken and written,
was poor, even when she understood the number involved. There was no apraxia. Copies of simple
diagrams, including a Necker cube, and spontaneous drawings of a clock and a flower were normal,
and there was no hemi-inattention.

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Summary. She had moderately severe transcortical sensory aphasia. Repetition,
though not normal, was much less impaired than auditory comprehension. Alexia
and agraphia were marked, yet semantic understanding of written words appeared
intact as far as matching them to pictures was concerned.
Non-lexic receptive musical appreciation was normal for tone, melody, and
harmony. She correctly identified the higher or lower of two pitches, including halftones. Single tones played on a piano were correctly sung. She identified a variety of
well-known melodies either sung or played to her, and was aware of intentional
errors. She correctly identified by naming or by imitation musical instruments from
recordings. Identification of serially and simultaneously played intervals was correct
within the limits of anomia. Major and minor chords, the number of notes in a chord
(up to four), and intervals in chords (if arpeggio) were identified. She recognized 3/4
and 4/4 metre and correctly reproduced rhythms tapped, played on a single piano
note, or bound to a melody. Fast vs slow, accelerando vs ritardando, and crescendo
vs diminuendo were also identified.
Non-graphic musical expression was also intact. She correctly sang well-known
melodies, accompanied and unaccompanied, and with upward and downward key
transposition. She could learn new melodies. Ascending and descending scales,
legato and staccato, were correctly imitated, and she could sing crescendo,
decrescendo, accelerando, and ritardando. With her left hand she could play simple
melodies on the piano and make proper chords on the guitar, and she correctly
played named piano notes, guitar chords, and intervals. She believed her left-handed
instrumental ability was as good as it was before her illness and, singing several
current popular songs, correctly accompanied herself on the guitar. When she added
words, there were paraphasic errors to the same degree as when she recited rhymes
or lyrics, but the melody and rhythm remained correct.
She identified by naming or selection from a list all the notes on a piano keyboard.
Naming written single notes was often incorrect, however, and playing written notes
on the piano, especially in the bass clef, led to frequent errors. Written intervals and
chords were played and sung badly, whether or not she played thefirstor lowest note
correctly, and she could not match written intervals with what she heard. She

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J. C. M. BRUST

always recognized, however, whether an interval was upward or downward.
Unsuccessfully attempting to sigh tread simple melodies, she usually heard her errors
and attempted self-correction. She recognized whole, half, quarter and eighth notes,
time signatures, accidentals and dynamic symbols, including letter abbreviations (J,
pp, etc.). Rhythm was read better than pitch, with only occasional errors tapping
simple written patterns, including sixteenth notes, dotted quarters and eighths, and
easy syncopation. She figured out guitar chord fingering with her left hand from
standard tabulature.
Several lines of a four-part score were correctly copied, including clefs, metre
indication, key, measures, rests and notes, and she drew on command whole, half,
quarter and sixteenth notes, a treble and a bass clef, and whole, half and quarter
rests. She could not, however, indicate pitch on a score. Attempting to write
intervals (sung or played), she made frequent errors, but always wrote upward or
downward correctly. Writing well-known melodies (named or played) was done
laboriously and with errors of note placement and rhythm (fig. 2), especially in the
bass clef, and with no improvement when she wrote either element alone.

J UJJ
FIG. 2. Case 1. Attempt to write'Happy Birthday', demonstrating errors of note placement and rhythm. (This and
subsequent musical illustrations have been transcribed by an artist for clarity.)

In April 1978 she gave a singing recital, which included works infivelanguages
('Ah, Spietato', by Handel; 'Zwei Lieder', Op. 91, by Brahms; 'Le Bestaire', by
Poulenc; 'Cancion De Duna Para Dormir A Un Negrito', by Montsalvatge; and
'Four Songs', based on the poetry of Thomas Campion, by Virgil Thomson).
Several of these pieces she had learned since her illness. There were no apparent
errors of either music and words, although she believed that there had been
occasional paraphasias in the foreign languages, especially German.
Several weeks later aphasia was barely apparent on casual conversation. There
were still, however, disturbances in auditory comprehension and naming; repetition
was normal. Reading and writing were only mildly improved. She still made
frequent verbal paralexias, had considerable difficulty naming words spelled aloud,
and missed most of the tests of reading comprehension. Written words were again
correctly matched with pictures even when she could neither read them aloud nor
give other evidence of comprehending them., She wrote her address better than
before ('Fail Hill Rd' for 'Fair Hill Rd'), as well as dictated words and names of

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i J J JJIJ 1 IJJJJ I J J

MUSIC AND LANGUAGE

373

objects; but spontaneous written description of the cookie theft picture was limited
to 'The gil + the bog'.
Except for reading and writing, musical abilities continued to be normal. She still
made errors reading notes, especially in the bass clef, whether using her right or left
hand. Written intervals were often incorrectly played or sung, and she tended to
ignore sharps and flats, but as before, was correct on upward or downward
movement. Although sightreading notes, intervals, and simple melodies was still
very difficult, rhythm was now nearly normal. Single notes written to dictation were
frequently wrong, especially in the bass clef, and dictated or played intervals or wellknown melodies were written nearly as badly as before. Rhythmical elements,
however, were much improved (fig. 3), and when she wrote a tune with all notes of
the same pitch, rhythm was done correctly.
About this time she embarked on a career singing popular songs (in English) in
New York nightclubs. Attending a performance, the author was unable to detect
errors of either words or music.

•0-4

JJ

t) f r J J ii
FIG. 3. Case I. Later attempt to write 'Happy Birthday'. There has been greater improvement with rhythm than with
note placement; in fact, when she wrote the same tune with all notes of the same pitch, rhythm was correct.

Case 2
A 42-year-old hypertensive man was admitted October 3,1978, following a major motor seizure. He
was initially mute and did not appear to comprehend any speech. There was left gaze preference and
right homonymous hemianopia, facial weakness and sensory loss, but he moved his limbs
symmetrically, and reflexes were normal. Cerebrospinal fluid (CSF) was grossly bloody, with 52,000
red blood cells per high power field, xanthochromic supernatant, protein 320 mg/dl, and normal
glucose content. At left carotid angiography there was an avascular mass in the posterior temporal
lobe, plus an aneurysm at an early bifurcation of the middle cerebral artery. Computerized
tomography, three weeks after admission, revealed lucency suggestive of infarction in the left posterior
temporal and inferior parietal lobes (fig. 4). Recurrent seizures during the first week were effectively
treated with phenytoin and phenobarbital, which he took for the remainder of his stay. Improving
steadily, he refused operation or further studies and on November 8 signed out against medical advice.

A professional jazz double-bassist, he could read and write music, more easily in
the bass than the treble clef. He had been able to sing, but had never done so
professionally and did not have absolute pitch. Though not a pianist, he had known
where individual notes were on the keyboard.

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J IJ J 1

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J. C. M.

BRUST

Language andmusic testing {October 16 and 17,1978). He was alert, attentive, and co-operative, and
had no neurological abnormalities other than aphasia, apraxia and amusia. Spontaneous speech was
fluent with normal prosody and infrequent verbal paraphasias, but lacking in substantive content.
Describing the cookie theft picture, he said, 'What I see... I see the woman... beginning to fall... I see
the person . . . pressure... putting places all over the place . . . I see the mess all right.' He comprehended
most spoken single words but had difficulty with more complex spoken material. He recited the days of
the week and the months, but could count no higher than 12, and, reciting the alphabet, skipped several
letters. He could neither recite nursery rhymes and well-known songs nor properly repeat phrases or
more than one-syllable words. Grammatical phrases were no worse than non-grammatical. For
example, he repeated 'The spy fled to Greece' as 'The spy fights flights', and 'One would have been
enough' as 'One were as one'. Naming led to frequent verbal paraphasias.
Reading aloud produced literal and verbal paraphasias, for example, 'tinakeP for 'triangle' and
'How lo go home from worse' for 'I got home from work'. He correctly matched printed and script
writing, but had great difficulty matching written and spoken words; there was neither semantic nor
phonetic preference in his choices. He failed to identify orally most spelled words. Although there were
frequent errors, he selected the correct written word for a picture more often than for a spoken word.
He wrote his name correctly but could write no more than the numerals of his address. He correctly
. wrote dictated letters and numbers. Transcribing a printed sentence into longhand led to several literal
paragraphias, for example, 'bumps' for 'jumps', as did writing words of pictured items, for example,
'squain' for 'square'. He could write no dictated words, saying, 'I forgot my memory'. Shown the
cookie theft picture, he wrote only Tallin'.
Calculation, with the question spoken by the examiner and the answer spoken by the patient, was
done poorly, but simple written calculation (addition of three numbers, subtraction, and multiplication) was nearly normal. There was neitherleft-right confusion nor finger agnosia. Despite his impaired
comprehension, it was apparent that he had ideomotor apraxia for many transitive actions: he was

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FIG. 4. Case 2. CT scan. Left parieto-temporal lucency consistent with infarction.

MUSIC AND LANGUAGE

375

unable to imitate use of an object, but performed normally when given it. He was not apractic,
however, in showing how to play his double-bass. He copied simple diagrams and put numbers
correctly in a clock face, but he could not properly copy a Necker cube.

FIG. 5. Case 2. Attempt to write 'Happy Birthday' (which he recognized as it was played).

He correctly drew a treble and bass clef and quarter, half and eighth notes. On
both treble and bass clef he wrote a C correctly when the name was dictated to him,
but misplaced most other notes. He would occasionally write bass clef notes as if
they were treble. Starting with C in bass or treble clef, he could not correctly write
any intervals heard on the piano. Told to write 'Happy Birthday' (and recognizing it
played), he produced only three half-notes with no resemblance to the initial
intervals (fig. 5). Nor, using a single note, could he write the correct rhythm. Asked
to write a C-sharp and shown it on the piano keyboard, he wrote first a treble clef,

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Summary. He had moderately severe conduction aphasia; repetition was
significantly more impaired than auditory comprehension. Alexia and agraphia
were marked. Although matching written words with pictures was superior to other
reading tasks, he did make errors.
Music did not sound 'right' to him, but he could not elaborate. He was able to tell
which of two tones was of higher pitch and to recognize well-known melodies. He
identified intentional errors in these tunes and recognized instruments by timbre. He
mis-identified most heard intervals, whether trying to name them or to select their
names from a list. Similar difficulty occurred recognizing major and minor chords
and the number of notes or the intervals in a chord. Attempts to imitate, by singing
or whistling, single tones, intervals, or familiar melodies failed, with or without
words and whether or not the examiner sang or played along. He would sometimes
hit a note correctly but then fall off it; asked if he recognized what he was doing, he
replied, 'I can't even hear my voice.' It was thus uncertain to what degree this
difficulty was receptive as well as expressive. He appeared unable to recognize metre
(e.g. 3/4 vs 4/4), and was unable to imitate either dynamic changes or rhythms
tapped, played on a single piano note, or bound to a melody.
With written music he correctly named (or selected the name from a list) clefs,
quarter, half, and whole notes, accidentals, rests, and time signatures, but not eighth
or sixteenth notes or dynamic symbols (including pp,ff, and non-letter symbols for
crescendo and decrescendo). He could neither name, identify, nor play on a piano
keyboard written notes in bass or treble clef. He also had great difficulty, however,
naming the notes of the piano keyboard, at a time when he had only mild difficulty
naming objects, body parts, and colours. He was unable to sing or play simple
written intervals, to match heard intervals with what was written, or to imitate
written rhythm.

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J. C. M. BRUST

then a backward note in the bass clef C position, then a- misplaced sharp (fig. 6).
Asked to copy a simple four-part hymn, he first incorrectly wrote a treble clef,
spanning two staves. Starting again, he correctly copied the clefs, and then made
frequent errors with note location, duration and bar placement.

FIG. 6. Case 2. Attempt to write a C-sharp.

-ZJ-

•V.

-

f

B

-B-

P r—P

FIG. 7. Case 2. A, later attempt to write 'Happy Birthday'. B, attempt to write 'Jingle Bells'.

He wrote simple heard rhythm poorly even when binding it to a single note; it made
no difference whether the rhythm was tapped, played as a single note, or bound to a
melody (fig. 8). Still error-ridden were his sightreading (singing) of two-note
intervals and rhythm, matching of written intervals with what he heard, naming of
written single notes, and identification of dynamic symbols, including letter
abbreviations.

J. M

J'I,J

B

r r rr

FIG. S. Case 2. Attempt to write rhythm. A, rhythm played for patient on single piano note and then tapped.
B, patient's written reproduction of same rhythm.

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On November 6 spontaneous speech, naming and auditory comprehension were
nearly normal; repetition was still moderately impaired. He wrote well to dictation,
and although he wrote few words to describe pictures, what he wrote was correct. He
read well aloud and correctly matched written words with both pictures and spoken
words.
Music now sounded nearly normal to him. He correctly sang single tones,
intervals and well-known tunes, with or without words, after either hearing them or
being told their titles. He continued, however, to imitate rhythm badly. Musical
writing was still poor. Shown where to put the first note of a heard interval, he
misplaced the second most of the time. He could not properly write well-known
tunes after hearing them, choosing them himself, or correctly singing them (fig. 7).

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377

DISCUSSION

Aphasia without Amusia
The first report of aphasia with relatively preserved musical ability was probably
Dalin's (1745). A man with right hemiparesis and speech limited to the word 'yes'
could sing hymns learned before his illness. To get started, however, he had to hear
someone else singing the same song. He could also 'recite certain prayers without
singing, but with a certain rhythm and in a high-pitched shouting tone'. Similar
nineteenth-century reports were summarized by Edgren (1895), who found that
aphasia and normal musical function were as common as aphasia plus amusia.
Jackson (1871) described two children with non-fluent aphasia; one could sing with
words; the other could sing only without them. Henschen (1925), citing 89 cases of
aphasia and preserved musical function, found that appreciation of pitch might be
intact with altered rhythmic sense, or vice versa. Critchley (1953/1966) described a
patient with jargon aphasia, due to left parieto-temporal glioma, who was able to
conduct his own orchestra.
A 47-year-old right-handed man (Smith, 1966), globally aphasic following left
hemispherectomy, gradually recovered considerable auditory comprehension,
although his speech remained severely limited. He was able to sing familiar songs
'with little hesitation and few errors in articulation'. Similarly preserved singing
followed left hemispherectomy (Gott, 1973) in a right-handed 14-year-old whose
spontaneous speech was 'limited as a rule to single words or short phrases'.
A woman who survived carbon monoxide poisoning (Segarra and Quadfasel,
1961; Geschwind, Quadfasel and Segarra, 1968) had spontaneous speech limited to
a few recurrent utterances (e.g. 'Hi, Daddy'), echolalia, palilalia and no apparent
language comprehension. She could sing the words and music of familiar songs and

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These two aphasic patients had musical dysfunction, yet to compare them with
each other and with cases from the literature should discourage one from trying to
predict what kind of amusia, if any, might follow a particular brain lesion. Case 1,
with transcortical sensory aphasia, had entirely normal musical function except for
musical alexia and agraphia, which in turn were greater for pitch than for rhythmic
elements. Case 2, with conduction aphasia, had severe expressive (and probably
mild receptive) amusia, which affected rhythm more than pitch, plus musical alexia
and agraphia in which rhythm and pitch elements were affected with equal severity.
Case l's musical agraphia was less severe than her language agraphia; in Case 2, the
reverse was true.
Previous reports cover a spectrum of aphasia without amusia, aphasia with
amusia, and amusia without aphasia, and within each category the severity and type
of aphasia or amusia varies widely. To appreciate the heterogeneity of each
subgroup, including the presence or absence of musical alexia and agraphia, it is
useful to review in detail some of these cases, none of whom, however, closely
resembles either of the present patients.

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BRUST

Aphasia plus Amusia

A number of nineteenth-century workers reported amusia in aphasics (Edgren,
1895). Although usually neither language nor musical dysfunction were described in
detail, it was apparent that amusia could be expressive, receptive, or mixed, and that
it was sometimes of uncertain type. A left-handed aphasic with a right hemispheric
lesion (Finkelnburg, 1870) could play heard melodies on the violin but not on the
piano.
A patient with mild anomia (Potzl and Uiberall, 1937) heard music as dissonant
and voices, including his own, as too high-pitched; he could neither sing nor
reproduce rhythmic patterns. At autopsy the auditory cortices were bilaterally

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of new material taught to her. Serial speech was adequate for a few digits and
months, and she could say rhymes but not random words in unison with the
examiner. At autopsy there was widespread destruction of frontal, parietal and
temporal lobes (including both temporal tips), but preservation of peri-opercular
regions. The authors considered the case an example of mixed transcortical aphasia
(Goldstein, 1917), due to 'isolation of the speech area', and correlated the pathology
with her ability to repeat rather than with musical function per se.
Yamadori, Osumi, Masuhara and Okubo (1977) found that 21 of 24 Broca's
aphasics sang satisfactorily, six excellently. Two produced poor melody and one was
unable to form a melody at all. Six of the 21 who sang well could not produce words
with the melody and 3 contaminated the words with literal paraphasias. Eight who
could sing required a few notes by the examiner to get started. Ability to sing, with or
without words, did not correlate with severity of aphasia.
Preserved musical function in aphasics has included musical reading and writing.
Jackson (1871) cited a patient of Trousseau's, 'completely aphasic', including alexia
and agraphia, who 'could note down a musical phrase sung in his presence'.
The Russian composer Shebalin, despite severe Wernicke's aphasia, with alexia
and agraphia (Luria, Tsvetkova and Futer, 1965), continued musical composition
'... which other musicians considered to be up to standard', including songs, quartets,
choruses and a symphony. At autopsy there was 'massive red softening of the left
hemisphere of the brain in the temporal and inferior parietal regions'. Luria et al.
concluded that '. . . phonematic and musical (prosodic) organization of acoustic
perception and memory are included in different systems, and have as their basis
different cortical structures.' A similar patient (Blau and Henson, 1977) had severely
impaired comprehension of spoken and written speech, yet could read music and
play the piano properly with his left hand.
A professional pianist (Assal, 1973) with Wernicke's aphasia, including
moderately severe alexia and agraphia, continued to play the piano publicly. Not
only could he play melodies sung to him, whether or not he had heard them before,
reproduce heard chords, and recognize dynamics, instruments and intentional
errors, but he could read a score nearly correctly and could write and compose
music.

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damaged. A professional singer with absolute pitch (Jellineck, 1956) had anomic
aphasia with mild alexia and agraphia. Her major musical disability consisted of
difficulty recognizing melodies she had once sung unless the words were added. A
patient with Wernicke's aphasia (Kleist, 1962) was unable to recognize or play
familiar melodies although he could still appreciate pitches and intervals, tuning his
zither precisely and reproducing chords properly. At autopsy there was infarction of
the left anterior second and posteriorfirsttemporal convolutions, extending into the
supramarginal gyrus. Two aphasic patients (Dorgeuille, 1966) following left
anterior temporal lobe surgery had difficulty discriminating tone and, in one,
timbre. A third patient, with a more posterior left temporal lobe lesion, had difficulty
recognizing tonal sequences.
Receptive amusia has accompanied both auditory agnosia and pure word
deafness. A woman unable to distinguish speech from music following a lesion in the
left superior temporal transverse gyri (Heschl's and adjacent) could, however, sing
songs after reading their titles (Schuster and Taterka, 1926). A man with word
deafness but nearly normal speech (Ziegler, 1952) could not recognize melodies, and
although able to tell which of two or three notes was higher, could not reproduce
intervals. He imitated heard rhythms but not dynamics. A patient who heard speech,
including his own, as an 'undifferentiated mass of sounds without structure or
rhythm' and could not repeat spoken words (Klein and Harper, 1956) could none
the less recognize people's voices and regional accents and identify other sounds and
melodies. He could not, however, reproduce melodies correctly.
After excision of a right frontal glioma, a right-handed man (Botez and
Wertheim, 1959) had left hemiparesis and aphasia consisting of dysarthria and
altered prosody on spontaneous speech and repetition, mildly impaired speech
comprehension, paraphasias on reading aloud and paragraphias. Although lacking
musical training, he had played the accordion and sung in a dance band. A year after
operation language function was nearly normal except for dysprosody and
tachyphemy, yet he still sang 'wrong' and could not play his instrument. On formal
testing he correctly sang notes sung to him, but hearing them played on his
accordion, he sang them a fourth too high or too low. He was aware of his errors but
could not correct them. Imitation of rhythm was poor, improving when it was
'bound' to a melody. He sang well-known tunes poorly with wrong tones, poor
stress, inappropriate staccato and tremulo, and inability to do accelerando vs
ritardando or crescendo vs decrescendo. Attempts to learn new songs failed; rhythm
was especially poor. He could not play his accordion, although he held his hands
correctly. As the authors conceded, cerebral language dominance was uncertain in
this patient. If bihemispheric language representation is likely in dextrals with
'crossed aphasia' (Brown and Hecaen, 1976), the question of'musical dominance' in
such patients becomes even more problematical than in conventional right-handers.
Predominantly motor amusia was described in another dextral with crossed aphasia
by Barraquer-Bordas, Mendilaharsu, Peres-Serra, Acevedo de Mendilaharsu and
Grau-Veciana (1963).

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In cases of aphasia plus amusia, musical reading and writing may be either spared
or affected. Proust (1866) reported an aphasic patient who could recognize, sing,
play and write music, but could not read it. An aphasic music teacher (Fischer, 1867)
recognized melodies and rhythmic patterns and could play tunes on the violin but
could neither read nor write music, nor play or sing tunes sung to him. A woman
(Proust, 1872) with 'a smattering' of musical knowledge had conduction aphasia
with agraphia but normal reading comprehension; she could read notes, play scales,
and recognize tunes, but could not hum them. A 'completely aphasic' musician
(Proust, 1872), unable to speak or write, was also unable to hum, yet she recognized melodies, read music and composed. Dejerine's (1892) patient with pure
alexia also lost the ability to read music; speech, writing and singing were
normal.
A piano teacher (Souques and Baruk, 1926, 1930) sustained infarction of the left
superior posterior temporal lobe, causing jargon aphasia with severely impaired
speech comprehension, reading and writing. She could play, spontaneously, a
simple 'air de danse' on the piano, but no other piece. Scales were played properly
after demonstration by the examiner, and she imitated rhythm well but although she
could play scales in thirds, she could not play them in sixths or ninths. She could not
play, copying the examiner, simple tunes, although she sometimes reproduced the
correct rhythm with wrong notes. She recognized deliberate errors in scales. In
contrast to her inability to play what she heard, she played from score perfectly a
Clementi sonatina. A prelude from Bach's Well-tempered Klavier was performed
slowly, as by a novice. She copied music well, although transposing with difficulty,
and she wrote correctly music she heard.
Each of Ustvedt's (1937) 19 patients with left hemispheric stroke, most of whom
were aphasic, noted less emotional involvement with music afterward. Uniformly
impaired were appreciation of measure and recognition of short melodic-rhythmic
figures; appreciation of pitch, volume, and timbre was intact. Some had difficulty
singing; others sang well, with or without words. In the few who had been able to
read music pre-morbidly, musical alexia paralleled or was worse than language
alexia.
Maurice Ravel had Wernicke's aphasia, alexia, agraphia and ideomotor apraxia
(Alajouanine, 1948); a definite aetiology was never established. 'Memory, judgement, affectivity, (and) aesthetic taste' were said to be intact, as was 'musical
thinking': he recognized melodies and errors of rhythm and pitch, including a badly
tuned piano. He could not, however, play the piano or sing properly, either
spontaneously, by imitation, or from score, nor could he name, play, or sing written
notes. He wrote music poorly, although better than he wrote words; copying music
was 'almost impossible'. Alajouanine did not determine to what degree Ravel's
difficulties with musical expression, reading and writing involved rhythm, pitch,
interval, or melody, but simply observed that, although he could 'still listen to music,
attend a concert, and express criticism on it or describe the musical pleasure he felt',
he never again was able to compose the pieces he heard 'in his head'.

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Amusia without Aphasia
Not surprisingly, cases of amusia without aphasia have been reported infrequently. Edgren (1895) collected 5 cases from the literature, in contrast to 23 with
amusia plus aphasia. There have been several accounts of right hemispheric damage
with inability to sing or to whistle but with preserved language function and melody
recognition; such patients have had either frontal (Mann, 1898) or temporal (Brain,
1941) lobe injury, or even hemispherectomy (Damasio, Lima and Damasio, 1975).
Gordon and Bogen (1974) found, following right carotid amobarbital injection to
right-handed subjects, impaired singing ability; pitch was more affected than
rhythm, but patients had a general tonal sense, tried to correct errors and could
recognize songs sung to them. Speech was rather dysarthric, but had normal
prosody and phonetic stress.

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A singer-guitarist after left frontal lobe surgery (Jellineck, 1956) had mixed
aphasia, including alexia and agraphia, as well as mixed amusia. Singing was wrong
in pitch and rhythm, worsening if words were added, and scales and pure phrases
were more difficult than extended tunes. He did not recognize his errors. He could
immediately repeat melodies, but could not later recognize them and often did not
recognize well-known melodies. Musical alexia was total, and worse than reading
language; he could not even orientate himself on the page, tell if a note was higher or
lower than another, or identify a chord.
A professional violinist with absolute pitch had mild Wernicke's aphasia and
right hemiparesis following a stroke (Wertheim and Botez, 1961). There were
paraphasias on spontaneous speech, naming and repetition, decreased comprehension for complex commands, paralexias on reading aloud and mild agraphia.
Reading comprehension was intact. Amusia was said to be 'receptive' because of
difficulty naming intervals, pitches, and rhythmic patterns and inability to name
familiar melodies played on the piano after correctly identifying them when they
were sung. Some of his other difficulties, however, could have been either receptive
or expressive, for example, failure to imitate heard rhythm or to sing a melody
previously unknown to him, and some were probably expressive, for instance,
singing familiar songs with frequent intonational errors. He copied music correctly,
but writing music both spontaneously and to dictation was poor; rhythm was better
than placement of notes. He named most notes correctly in the treble clef but had
great difficulty with the bass and viola clefs; he could not sing solfeggio simple tunes
written on any clef. A problem with this case is that, in addition to the difficulty in
defining many components of his amusia as either 'expressive' or 'receptive', it is not
clear whether the anomia and decreased speech comprehension distorted the results
of musical testing.
An orchestral conductor and composer (Critchley, 1970) was unable to play the
piano or write music properly while aphasic, although he said'... I have the music in
me'. Following removal of a left parietal meningioma, speech and ability to
compose seemed to improve in parallel.

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The Present Patients
The varieties of amusia, including musical alexia and agraphia, are thus not
predicted by the presence or absence of aphasia, and there is considerable
heterogeneity among those cases of aphasia with normal musical function, including
musical reading and writing (Jackson, 1871; Luria, Tsvetkova and Futer, 1965;
Assal, 1973; Blau and Henson, 1977), aphasia with amusia, including musical alexia
and agraphia (Fischer, 1867; Ustvedt, 1937; Alajouanine, 1948; Jellineck, 1956;
Wertheim and Botez, 1961), and aphasia with amusia but preserved musical reading
and writing (Proust, 1872; Souques and Baruk, 1926, 1930).
The present Case 1, with transcortical sensory aphasia and normal musical
function except for musical alexia and agraphia, appears to have no well-studied

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Difficulty with musical perception has been described. Kohl and Tschabitscher
(1953) and Pittrich (1956) reported inability to recognize musical sounds following
right hemispheric lesions, and Potzl (1939) reported difficulty appreciating rhythm.
Following right temporal lobe surgery, a man (Jellineck, 1956) reported that music
sounded 'out of tune'. He found it easier to imitate melodies sung by male than by
female voices; chords, however, were better recognized when high-pitched. Rhythm
was normally appreciated, but rhythmic changes gave him a sense of tonal change as
well. A woman with a right thalamic tumour (Roeser and Daly, 1974) experienced
'gross distortion of music perception in her left ear'. A man unable to recognize any
non-verbal sounds (Spreen, Benton and Fincham, 1965) was poor at pitch
identification, yet could comprehend speech. At autopsy there was infarction of the
right frontal, parietal and temporal lobes and insula.
Milner (1962) gave the Seashore Test of musical abilities (which measures
discrimination of pitch, loudness, rhythm, duration, timbre and tonal memory) to
27 left speech-dominant patients before and after either right or left temporal
lobectomy. Whereas there was no loss of musical ability after left lobectomy,
deterioration followed right lobectomy, slight for pitch and rhythm, marked for
timbre and tonal memory. There was no difference whether or not Heschl's gyrus
was removed. Shankweiler (1966) found that whereas melody recognition deteriorated after right temporal lobectomy, pure frequency discrimination did not.
Musical reading and writing have seldom been tested in patients with amusia but
not aphasia. A professional trombonist and music copier, seen by Charcot (Souques
and Baruk, 1930), suddenly lost the ability to copy music or to play his trombone
properly, yet he appreciated music and could read it, singing it mentally. There was
no weakness or other apraxia and language function, including reading and writing,
was normal. The site of pathology was not determined. Jossmann's (1927) patient,
following right carotid ligation and left hemiparesis without aphasia, could neither
sing, whistle tunes, nor read music, but recognized pitch and his own errors. A
trumpeter, after head injury (Dorgeuille, 1966), had difficulty writing heard
rhythmic patterns; language and musical function were otherwise normal.

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counterpart in the literature. Proust's (1866) patient, while unable to read music,
could write it. Dejerine's (1892) patient was unable to read music as part of a pure
alexia syndrome. How much Case 2, with conduction aphasia, resembles previously
reported patients is uncertain, as details of both language assessment and musical
reading and writing have usually been absent. Proust's (1872) patient with
conduction aphasia could not hum tunes, but could play scales and read notes; she
apparently had never written music. Jellineck's (1956) patient had mixed aphasia
and more severe musical alexia. Wertheim and Botez's (1961) patient had rather
similar aphasia, although the relative severity of comprehension and repetition is
unclear, and reading comprehension and writing were better preserved than in Case
l's earliest testing. As with Case 2, there were abnormalities of musical function
which could have been either receptive or expressive. In contrast to our case,
Wertheim and Botez's patient copied music well and wrote rhythm better than he
designated pitch. Anomia and expressive (singing) amusia leave the degree of his
musical alexia uncertain, and many components of musical reading and writing
were not tested.
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Musical Reading and Writing
Musical reading and writing involve 'skills commonly believed to be languagespecific' (Henson, 19776). Sloboda (1976), comparing musically literate and illiterate
subjects, found that the musically sophisticated, when analysing written note
sequences, appeared to use neither visual (that is, spatial), naming, nor pitch codes
but rather to code 'relations between the notes rather than the notes themselves'.
Similar processing has been suggested to underlie the reading of language (Kolers,
1972). Musical reading and writing, however, involve more heterogeneous symbols
than ordinary reading and writing of words. There are real words, often
abbreviated (allegro, largo, DC, pp, f, etc.); notes whose pitch is designated by
letters (A, B, C, etc.) but represented spatially, and whose duration is indicated by
appearance (minim, crotchet, quaver, etc.); metre, expressed as numerical fractions
and dependent upon placement of bars; and purely musical symbols for pitch
alteration and key signature (sharps, flats, naturals), pauses (rest), tonal prolongation (fermata), pitch calibration (clef), crescendo or decrescendo, staccato, legato
and repeat. Both simultaneous and sequential events are indicated.
It was therefore of interest to determine whether those aspects of musical notation
closest to verbal language or most dependent upon temporal (sequential) processing
were maximally impaired in our aphasic patients. Such was not the case. In fact, the
first patient suggested an opposite dissociation. Her maximal difficulty with reading
music was with note placement (pitch designation); she could not read single notes,
two note intervals or chords properly, but knew whether the second of two notes
was higher or lower. That this difficulty did not reflect inability to read notes as
letters is suggested by the fact that she named written notes and intervals better than
she sang or played them. She was considerably more adept at reading the kind of
note present, key and time signatures, accidentals, dynamic and agogical symbols,

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BRUST

Singing and Repetition
When Case l's aphasia was still moderately severe, she could sing nearly
flawlessly, infivelanguages, songs learned since her illness. Reports of aphasics who
sing better than they speak have been mostly concerned with Broca's or otherwise
non-fluent speech (Yamadori et ai, 1977; Geschwind etal., 1968) and have included

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word abbreviations and significantly, from the standpoint of sequential processing,
pure rhythm. Writing music led to errors of both pitch and rhythm, whether done
alone or together. Her greater difficulty reading and writing in the bass clef
paralleled reports of others (Wertheim and Botez, 1961) as well as the experience of
beginning musicians. At her second examination reading alexia and musical alexiaagraphia had all improved more than language agraphia, and there was particular
improvement in writing rhythm.
Case 2 showed no dissociation between temporal and non-temporal or verbal and
non-verbal elements in his musical alexia and agraphia (or, for that matter, early in
his expressive and receptive amusia, although later he could imitate pitch and
interval better than rhythm). Like Case 1 he named written notes better than he
sang, played or wrote them. Unlike Case 1, his musical alexia and agraphia
remained severe when his language alexia and agraphia had improved considerably,
and he had more difficulty recognizing musical dynamic abbreviation (p, pp,f,ff)
than in reading letters, words or sentences.
A Japanese patient with transcortical sensory aphasia (Sasanuma and Monei,
1975) could not comprehend written kanji (Chinese ideogrammatic) characters yet
understood kana (phonetic) characters and wrote kanji with more difficulty than
kana. Conversely, preservation of kanji relative to kana reading has been reported in
anomic aphasia (Yamadori, 1975). No such dissociation between kinds of musical
symbol occurred with either Case 1 or Case 2.
Like a patient with better repetition than auditory comprehension (Albert,
Yamadori, Gardner and Howes, 1973), Case 1 had severe disability comprehending
written words or sentences and spelled words, yet successfully matched written
words with appropriate pictures, suggesting preservation of 'semantic understanding' of written words. There was no corresponding ability to match written musical
notes or intervals with what she heard played or what was spoken to her. Non-pitch
musical alexia was too mild for such dissociation to be testable.
As noted, it seems unlikely that letter coding was the main reason for these
patients' difficulty reading and writing pitch; it cannot, however, be dismissed as a
contributing factor. Experienced musicians do not usually name individual notes or
chords as they read them (Henson, 19776), but beginners do. Several reported
patients with aphasia but preserved musical reading and writing were older or more
musically experienced than our patients (Souques and Baruk, 1926; Luria,
Tsvetkova and Futer, 1965; Assal, 1973). On the other hand, so were some with
aphasia, amusia and musical alexia-agraphia (Alajouanine, 1948; Jellineck, 1956;
Wertheim and Botez, 1961).

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Experimental Studies
Attempts, using dichotic or reaction-time techniques, to determine hemispheric
superiority for components of music have yielded conflicting results. Kimura (1964),
playing fragments of different baroque and classical melodies simultaneously into
the ears of normal subjects, found the left ear, and therefore presumably the right
hemisphere, superior in melody recognition. King and Kimura (1972) demonstrated
left ear superiority for non-verbal human voice sounds as well (for example,
laughing, crying, coughing). Schuloff and Goodglass (1969) showed, in normals, left
ear superiority for tonal sequences, right ear superiority for spoken digits, and no

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those who could sing with words (Jackson, 1871; Ustvedt, 1937; Smith, 1966; Gott,
1973; Geschwind et al., 1968; Heilman, Tucker and Valentstein, 1976; Yamadori
et al., 1977) and those who could not (Jackson, 1871; Head, 1926/1963; Jellineck,
1956; Yamadori et al., 1977). The ability to sing words which could not be spoken
has been attributed to the factor of automaticity. Ustvedt (1937) cited the same
phenomenon in parkinsonians and stutterers. Goldstein (1927) suggested that
singing would be preserved in an aphasic to the degree that'... it is an activity closely
connected to the patient's affective life. Under such conditions the song is not
representative speech, but a "series speech" performance expressive of feeling, like a
prayer.' More mechanistically, Bogen (1969) suggested that the addition of words to
song might lead to transcallosal inhibition of the right hemisphere by the left.
Whether Case 1 's ability to sing with words was related to her relatively preserved
repetition, as with the cases of Geschwind et al. (1968) and of Heilman et al. (1976),
and whether Case 2's inability to sing, with or without words, was related to his
particular difficulty with repetition, is conjectural. Case 1 sang well in English and
made infrequent para phasic errors in foreign languages. Henson (1977c) stated
'There is no apparent record of any professional vocalist who was able to perform
acceptably with permanent dysphasia'. This statement would apply to Case 1 as far
as non-English singing is concerned, yet she has been able to pursue a singing career
within the limits of popular songs in her own language.
It is also speculative whether Case 2's particular difficulty in repetition was related
to his disability with written and imitated rhythm. Musical function was not
discussed in a recent review of conduction aphasia (Benson, Sheremata, Bouchard,
Segarra, Price and Geschwind, 1973). It is difficult to relate his repetition deficit to
his greater difficulty, compared to Case 1, with non-pitch written symbols, either
ideogrammatic, numerical or word abbreviations, but it is of interest that whereas
his alexia-agraphia for language became much milder than Case l's, his musical
alexia-agraphia for these types of symbols was much more severe. Unlike Case 1 he
had difficulty in matching written words with pictures; in addition, like her, he could
not match heard intervals with a read score. His musical alexia-agraphia remained
severe when music sounded normal to him and he could sing heard notes, intervals
and songs, yet was still unable to imitate simple rhythms, whether bound to melody
or not.

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difference for simple clicks. For pure tone recognition Kallman and Corballis (1975)
found left ear superiority, Haydon and Spellacy (1973) right ear superiority, and
Nachshon (1973) no difference. Kallman and Corballis (1975) found left ear
superiority for timbre, and Robinson and Solomon (1974) right ear superiority for
rhythm, but Spellacy (1970) detected no difference for either. Gordon (1970) found
left ear superiority for chord recognition but no difference for melodies. Spellacy
(1970) and Spreen, Spellacy and Reid (1970) believed that asymmetry for music
recognition was influenced by duration of the interstimulus interval. Halperin,
Nachshon and Carmon (1973), using dichotic sets of three tones, found that as the
number of frequency or duration transitions increased from zero to two, ear
superiority shifted from left to right.
As noted, musical understanding involves both sequential-analytic and
simultaneous-gestalt processing and so, more than language, might be expected to
require co-operation between the 'propositional' left hemisphere and the 'appositional' right. Speech itself is, of course, not wholly a left hemispheric activity
(Larsen, Skinhej and Lassen, 1978). It is hardly surprising, therefore, that those
studies which have attempted to isolate temporal and non-temporal aspects of
musical ability have not consistently placed them in either the left or right
hemisphere (Wyke, 1977). Moreover, people listen to or perform music differently.
Werner (1948) observed 'Musically experienced listeners have learned to perceive a
melody as an articulated set of relations among components rather than as a whole'.
Consistent with this idea, Bever and Chiarello (1974) found that, whereas musically
naive listeners recognized melodies better with the left ear, sophisticated listeners did
better with the right. The authors noted that Gordon (1970) had used college
students of probably intermediate sophistication, perhaps explaining their nonlateralization of melody recognition. On the other hand, Cook (1973) found left ear
superiority for melody recognition in sophisticated listeners. Oscar-Berman,
Blumstein and DeLuca (1974), using bilateral simultaneous tachistoscopy, demonstrated that musically sophisticated subjects were more likely than those musically
naive to use both hemispheres in the analysis of musical symbols.
If Case l's musical sophistication had led, pre-operatively, to left hemispheric
musical dominance, with post-operative return to right hemispheric musical
processing, such a change was not reflected in her non-lexical musical ability,
subjectively or objectively. Left hemispheric destruction was massive and the
anterior temporal lobe was amputated. Musical sophistication, with prominent left
hemispheric participation in analysing musical symbols, could have contributed to
musical alexia and agraphia, but would be at variance with cases from the literature
of preserved musical reading and writing in aphasic professional musicians and
composers (Souques and Baruk, 1926; Luria et ai, 1965; Assal, 1973; Blau and
Henson, 1977).
Case 2, although a musically literate professional musician, was less sophisticated
than Case 1, and so his musical abilities might be expected to be less dependent upon
the left hemisphere. Moreover, his lesion was far smaller than Case l's and, by

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387

computerized tomography, occupied an area shared by Case l's lesion. Yet, in
contrast to her, he did have expressive and probably receptive amusia, and, whereas
his aphasia was milder than hers, his musical alexia-agraphia was more severe.
Conclusion
These two cases thus do not clarify the question of music's relation to speech,
language and hemispheric function; rather, consistent with previous literature, they
illustrate the complexity of the problem and the prematurity of defining as
propositional or appositional either music, its components, or the kind of
processing employed by each hemisphere. Chomsky (1972), stressing the inadequacy
of present concepts of language and the need to study it in abstract, not physical,
terms, stated 'We can only leave open for the future the question of how these
abstract structures and processes are realized or accounted for in some concrete
terms, conceivably in terms that are not within the range of physical processes as
presently understood—a conclusion that, if correct, should surprise no one.' The
same can be said about music.

Two aphasic right-handed professional musicians with left hemispheric lesions
had disturbed musical function, especially musical alexia and agraphia. In Case 1
aphasia was of transcortical sensory type, with severe agraphia and decreased
comprehension of written words, although she could match them with pictures.
Except for reading and writing, musical ability was normal; she could sing in five
languages. Musical alexia and agraphia affected pitch symbols more than rhythm.
Case 2 had conduction aphasia and severe expressive amusia, especially for rhythm.
Although his language alexia and agraphia were milder than Case l's, his musical
alexia and agraphia were more severe, affecting rhythm as much as pitch. In neither
patient were those aspects of musical notation either closest to verbal language or
most dependent upon temporal (sequential) processing maximally impaired.
These cases are consistent with the literature in suggesting that the presence or
absence of aphasia or of right or left hemispheric damage fails to predict the
presence, type, or severity of amusia, including musical alexia and agraphia. The
popular notion that receptive amusia follows lesions of the language-dominant
temporal lobe, whereas expressive amusia follows non-dominant frontal lobe
damage, is an over-simplification, as is the view that increasing musical sophistication causes a shift of musical processing from the right hemisphere to the left.
ACKNOWLEDGEMENTS
I thank Dr James E. O. Hughes, Dr Lewis P. Rowland and Mr Charles Mee for helpful suggestions.
Reprint requests to Dr John C. M. Brust, Harlem Hospital Center, 506 Lenox Avenue, New York,
NY 10037.

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SUMMARY

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