J. COMMUN. DISORD. 26 (1993). 73-82 COMMON HEMISPHERICITY OF LANGUAGE AND MUSIC IN A MUSICIAN A CASE REPORT S. HOFMAN Department of Neurology, Medicine C. KLEIN Ichilov Medical Center, Tel-Aviv University Sackler School of and A. ARLAZOROFF Department of Neurology. Assaf Harofeh University Sackler School qf Medicine Medical Center, Zerifin. Tel-Aviv Aphasia coupled with amusia is reported in a 73-year-old male musician who was a lawyer by profession. This condition followed an ischemic stroke in the lateral aspect of the parieto-occipital region of the left hemisphere. The patient’s music production exhibits jargon amusia, similar to that in his verbal production. This case supports the thesis that language and music may share a common hemisphere. INTRODUCTION concept of hemisphericity of music has been a subject of controversy and still so remains (Bever and Chiarello, 1974; Brust, 1980; Hachinski, 1989; Henschen, 1926; Kimura, 1964; Mesulam, 1985). Language and music share common cognitive and emotional elements, though in different proportions; the emotional element being more prominent in music (Wertheim, 1969). Some authors consider emotion to be more closely associated with the right hemisphere (Galin, 1974). Also, the number of left-handed and ambidextrous persons is greater in musicians than among the general population (Hachinski, 1989). Therefore, it may be conjectured that the hemisphericity of language does not necessarily correspond to that of music. This study discusses a patient with aphasia and amusia. This case The Address correspondence Harofeh Medical Center, to A. Arlazoroff, M.D., Zerifin 70300, Israel. 01993 by Elsevier Science Publishing Co., Inc. 655 Avenue of the Americas, New York, NY IO010 Department of Neurology, Assaf 73 002 I -9924/93/$6 .OO 74 HOFMAN. KLEIN, and ARL,AZOROFF offers evidence for the association of both syndromes as a consequence of a single lesion, localized in the major (left) hemisphere. CASE REPORT The patient was a 73-year-old right-handed male lawyer and a violinist of advanced training, having played in a symphony orchestra and as a first violinist in a chamber ensemble. The patient had been fluent in German (mother tongue), Rumanian, Hungarian, and Hebrew. He was admitted with aphasia, mainly receptive, and a moderate right hemiparesis following a cerebrovascular accident (CVA). EEG showed runs of low-voltage slow activity over the left temporo-parietal region. Computerized tomography of the brain, performed two weeks after the CVA. revealed a hypodense, nonenhancing lesion which was located subcortically close to the postero-lateral border of the left lateral ventricle, compatible with an ischemic infarction. It also showed a small. subdural hematoma in the left temporo-parietal area. There was no mass effect or displacement of the ventricular system (Figure I). There was no history or of head trauma to explain this last finding. Under local anesthesia a cranial burr-hole was performed and a small, liquefied. subdural hematoma was successfully evacuated. Recovery following this procedure was uneventful, with no changes in the patient’s cognitive status and behavior. The patient was followed over a two-year period, during which time his aphasia was assessed by a variant of the Boston Diagnostic Aphasia Examination (Goodglass and Kaplan, 1972) and for amusia by a battery of tests which contained elements of rhythm. meter, dynamics, agogics. i.e., subtle nuances of rhythm and dynamics (Ape], 1944). timbre-vocal and instrumental, reading, writing, music dictation, copying music, spontaneous musical expression, singing a canon with the examiner (SH). and violin playing. Hebrew and German languages were both studied in terms of spontaneous speech, reciting excerpts of prose. poetry, and biblical items, reading. writing. repetition. and memorizing. It should be noted that his right hemiparesis had disappeared over the two-year period. The patient had a true jargon aphasia, including neologisms, paraphasias, and distorted verbal sounds. He was totally alexic, agraphic (Fig. 2). and acalculic. He was also incapable of copying musical notes (Fig. 3). Drawing was severely distorted (Fig. 4). He was unable to sing a simple unaccompanied tune (Fig. 5). The patient could not name musical items or musical instruments or any of their parts, but could show how they were played. Even on COMMON HEMISPHERICITY OF LANGUAGE AND MUSIC 75 Figure 1. CT study following contrast injection. There is a cortical and subcortical area of low density in the left temporo-occipital region compatible with ischemic infarction, without ventricular displacement and with patchy contrast uptake (A). A narrow hyperdense subdural hematoma is also seen in the same region (B). 76 HOFMAN, KLEIN, and ARLAZOROFF Figure 2. A, the patient’s spontaneous writing in German; B, the patient’s writing of three German sentences dictated to him by the examiner: Lines IO Das Beste hoffen. 11 Tun Sie, wie Sie wollen. 12 Ich moechte wissen. C, the patient’s writing of the same three sentences, translated for him into English: Lines 13 Hope for the best. 14 Do as you please. 15 I should like to know. the violin, his instrument since childhood, he was unable to name the particular strings and parts of the violin body. When shown the picture of the whole violin family, he pointed to the double bass saying “lo anyi” (not me, Hebrew). He could imitate playing the trumpet, flute, and kettle drums, when shown a picture of the specific instrument. When asked to play his violin, the patient could play a simple scale like C major or G major, in a moderate pace, but failed to name the notes he was playing. Neither could he name the fingers as he used them, although he used them correctly. He could not repeat simple, well-known melodies without distortion. He could not recognize melodies he knew previously nor could he continue playing melodies once COMMON HEMISPHERICITY OF LANGUAGE AND MUSIC 77 A B Figure 3. A, the patient’s copy of a musical motif; B, the patient’s copy of a series of rhythmic values. Figure 4. Patient’s designs: A, table; B, chair; C, bank; D, clock; E, house; F, bus; G, cat; H, man; I, ear. 78 HOFMAN, 6 i bE OH BEN YE-W- mu Figure 5. The patient’s distorted KLEIN. and ARLAZOROFF -TWO wn-mcb vocal performance Tuiu-TY FOUR (A) of his address, dressed on a simple tune (B). another person initiated them. He began to sing and simultaneously play Schubert’s “Serenade,” but after the first two words he merely hummed the melody. After a few bars he also stopped playing and changed to some kind of improvisation of a short melodic curve (Fig. 6). He repeated this melody again and again with little variation. When asked to play a passage from the Beethoven Violin Concerto, he acted in a similar way but without singing. He was unable to play any portions of either the Tschaikovsky or Mendelssohn violin concertos, which he played with piano accompaniment prestroke. Musical phrases performed instrumentally on his violin or vocally were often a disorganized sequence of musical motifs and phrases from different musical works, or motifs and phrases of his own invention, a true jargon amusia. At the two-year follow-up the patient was no longer hemiparetic, but his instrumental performance remained distorted due to his music- Lt.1 SC flc _ he,, Figure 6. A, the vocal patient’s improvised mri _ ne Lir _ drr incipit of Schubert’s continuation thereof. durrh dir Staendchen Nachc zu dir; (Serenade); B, the COMMON HEMISPHERICITY OF LANGUAGE AND MUSIC 79 amnestic deficit. This was consistent with his distortion of verbal contents of folk tunes he originally knew well but now failed to produce. DISCUSSION There have been relatively few investigations of amusia. Some authors (Assal, 1973; Benton, 1977; Henshen, 1926; Wertheim, 1969) explored the multiple facets of sensory and motor amusia. Of particular interest are the studies of aphasia correlated with amusia. The split-brain investigations of the last few decades revealed the existence of some language control in the minor hemisphere (Benowitz et al, 1983; Levy, Nebes, and Sperry, 1971; Sperry, Gazzaniza, and Bogen, 1969). Some authors advanced the theory that music processing is subserved, partly or entirely, by the minor hemisphere (Critchley, 1970; Gates and Bredshaw, 1977; McFarland and Fortin, 1982). There are reports of aphasia without amusia (Hofman, 1977; Luria, 1973) as well as aphasia with amusia (Ustved, 1937; Wertheim, 1969). Concerning reading, patients with visual-lexic disturbances may have both text and music reading impairment, but other language and music functions may be preserved (Judd, 1983). There is no widely accepted explanation for the observation (Bever and Chiarello, 1974) that some persons are able to sing words they cannot say. This phenomenon, however, seemed to stimulate the formation of a theory, or hypothesis, of dichotomy of musical perception. Apparently, with increasing musical sophistication, musical memory becomes more dependent on the left hemisphere. There are reported cases of professional musicians who retain their ability to compose music, while becoming aphasic. Such cases support the thesis of dissociation of text and music writing, i.e., separation of language and music (Hachinski, 1989). According to Bever and Chiarello (1974), music perception by trained musicians is subserved by the left hemisphere, whereas in naive musicians, or amateurs, it is subserved by the right hemisphere. These authors also claim that features based on pitch elements such as melody, harmony, and timbre are subserved by the left hemisphere, whereas features based on temporal elements, such as rhythm, meter, and pace are controlled by the right hemisphere. As outlined by Peretz (1990), melodies are first encoded and retrieved in terms of their global features, i.e., contour (pitch detection), a right hemisphere function and then later encoded for local features, such as specific intervals or individual pitches, a left hemisphere function. This suggests that a hierarchical cooperation between the hemispheres is required for the processing of the pitch-dimension melodies. HOFMAN, 80 KLEIN, and ARLAZOROFF Aphasia and amusia in our patient were both caused by a cerebrovascular event with a single intracerebral lesion in the left hemisphere confirmed on CT scan. Thus in our patient the functions of language and music both appear within the left hemisphere. Furthermore, as no cerebral lesion other than the one located in the left parieto-temporal region could be seen on CT scan, it is suggested that in our patient, the functions of language and music may share contiguous areas, if not a common area, located within the left hemisphere. It should be added that in view of this patient’s musical proficiency, many would not consider him an amateur although he was never paid. 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