Aphasia and artistic realization (being the Harveian lecture of the Harveian Society, delivered March 17th 1948) by Th. Alajouanine. Brain 1948: 71; 229–241.
Cambridge
Paraphrasing the context from Sir William Gowers, Dr Alajouanine (Fig. 1) declares his subject as lying within the ‘borderlands of aphasia’—specifically the effects of aphasia on three individuals, known to him professionally, each having considerable pre-morbid artistic ability in writing, music or painting, respectively. He considers whether comparisons of their work before and after the onset of illness might illuminate the psychology of language, the mental state associations of aphasia, or (what we would now call) the ‘neuroscience’ of artistry.
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The successful writer makes his conversational language prosy and tunes his prose to reflect everyday language. He writes as he speaks and vice versa, mimicking Moliere's ‘Would-be gentleman’, M. Jourdain, who was amazed and delighted ‘that his language was prose and that he was thus using prose without being aware of it’. For Charles Baudelaire, ‘perhaps ... the greatest French poet of the 19th century ... [who] suffered from [sudden] right-sided hemiplegia with aphasia ... [being] able to say just one word, a curse: "cré-nom" ... to express quite different states of mind ... the essential features so well expressed by Hughlings Jackson: the preservation of a "leit-motiv word" (a curse as so frequently is the case)’, aphasia closed the door on artistic expression. And like Baudelaire, for whom ‘one fact is sure: any artistic realisation had been since forbidden’, the aphasic writer, musician or painter may become artistically mute.
Dr Alajouanine's contemporary French writer—still living and so anonymous—became acutely aphasic and hemiplegic at the height of his powers as a poet, novelist and literary critic specialising in the English canon. Expressive aphasia with reasonable preservation of comprehension gradually improved through stages of ‘leit-motiv’ in which output was initially confined to the stereotyped utterance of ‘Bonsoir les choses d’ici bas’, and later a state of reasonable vocabulary, phonetics and adequate syntactical construction both in speech and writing. But whereas this author remained able to read and appreciate the nuances of literature in several languages, all creativity was rendered impossible through the loss of synthetic construction—‘at least the one he was used to for he did not employ that conventional agrammatism of some of the young literary schools’. This failure of artistic output cannot be attributed to loss of memory, reasoning, judgement or affect. For example – having indicated his views on James Joyce but finding himself stuck for the name of another English-language author on whom he had also written a critique—the writer easily picks out a book from his shelves written by the un-nameable Englishman (the 19th century poet, Coventry Patmore). The patient can proofread and see through to publication works in press. And he is able judiciously to improve a piece in production that both he and his editor agree is inferior in places by indicating where the problems lie. Nor are his aesthetic sensibilities impaired. The essence of his disability is a ‘disease which converted that delicate artist and subtle grammarian into an agrammatist’.
Turning to his second case, Dr Alajouanine explains how, just as aphasia breaks the ‘poet's calamus’ so, too, it ‘ruins Orpheus's lyre’ and reduces the musician's ability to vary the laws of harmony, instrumental technique and rich orchestral possibility into the language of music. The patient is Maurice Ravel. He had ‘introduced a novel style, an original manner ... expressed in a particular language ... which will endure in the history of his art’. Ravel considered himself to ‘think and feel in sounds .... I am a musical hydrant, music flows from me like water’. Gradually, he develops Wernicke's aphasia with ideomotor apraxia. The cause is a form of cerebral atrophy but not Pick's disease. Memory, judgement, affect and aesthetic sense are unimpaired; spoken language is moderately affected and writing much impaired by apraxia. Musical expression is lost but musical thinking retained. A favoured pupil and a neurologist talented in music have analysed Ravel's difficulties: he can recognise his own and other composers’ tunes and detect errors (when his pupil inserted mistakes of notation or rhythm in a rendering of the ‘Tombeau de Couperin’, started in 1914 and completed in 1917 with each movement dedicated to a friend killed in battle, or ‘La Pavanne de ma Mère l’Oye’); register that Dr Alajouanine's piano needs tuning; and listen to, enjoy and make critical comments upon performances. Conversely, he cannot name or decipher notes or write musical notation. He can play with the right hand but not both together except for a few snatches of pieces known by heart, especially his own—an irony since Ravel had written a piano concerto for the left hand in 1931 (commissioned by Paul Wittgenstein, an Austrian pianist who lost his right arm in the Great War, and considered by Max Harrison [Phillips Classics Productions 1993] to be a work of subversive violence and black magic); and he can also sing familiar pieces. Together, these disabilities explain why Maurice Ravel's composition and creative work have been completely arrested by the cerebral affection.
The aphasic painter is famed for his depictions ‘of the poetry of the Normandy coast, the glowing beauty of flowers or marine life, and the richness of feminine flesh ... he creates a climate where personal sounds vibrate ... one often feels the bitter and sensual poetry of Baudelaire and at times the delicious polyphonic music of Debussy mixing by a kind of sorcery their different languages to form his coloured magic’. He has a complex aphasia with deficits of expression and comprehension in speech and in writing, but no impairments of memory, judgement or aesthetic taste; and his affective response to illness is both appropriate and fully expressed. But other than during a brief period of apraxia, his artistic activity is entirely unimpaired. There are no errors of form, expression or colour interpretation—no technical failure nor disturbance of thought—and his productivity has increased; connoisseurs even consider his work to have improved in the intensity and acuteness of its expression. In him ‘the aphasic and the artist live together on two distinct planes’ and the patient reflects that ‘there are in me two men ... the one who grasps reality ... the other who is lost as regards abstract thinking ... when I am painting I am outside my own life ... I find everything again; I am a whole man ... these are two men, the one who is grasped by the reality to paint, the other one, the fool, who cannot manage words anymore’.
Allowing that details of the aphasia differ between these individuals, and each had varying degrees of apraxia at onset affecting the manual execution of artistic expression, their disabilities allow some general conclusions on the nature of intellectual impairment in aphasia and its consequences in the realization of art. ‘We believe that language is the expression of a complex whole, that goes beyond language itself, and expresses a totality and an individuality’ ... ‘art is the expression of individuality by way of a preferred technique’ ... ‘our three aphasic artists have in common a language trouble that spares their personality, especially its aesthetic components ... [but] they differ in that the writer and ... composer are ... annihilated as to their artistic production, while the painter is not’. Dr Alajouanine wants to understand why aphasia reduces expression in writing or music but not painting. Perhaps it is not so surprising that—for the writer—artistic output through a medium that requires linguistic precision, adaptation of thinking to verbal or graphic expression, grammatical construction and abstraction beyond the material of a schematic tale will inevitably suffer major stumbling-blocks. In all these respects, the aphasic patient, restricted to involuntary use of ready-made sentences unadapted to what he wants to express, cannot engage with the volitional constructions of literary art. To paraphrase Hughlings Jackson, the aphasic writer is as ‘lame in literary writing’ as he is ‘lame in thinking’.
Loss of language in the aphasic musician affects his art since this also is dependent on the use of symbols arranged in an ascending hierarchy of sounds, phrases, intentional description and affective content that are represented graphically. Thus, just as the speechless aphasic inevitably cannot write so, too, the musician is no less constrained than the writer in the inability to express personality through a language-based symbolic medium. For these artists, ‘to conceive is nothing, to express is all ... the failure of both our artists appears to be a technical one. Mechanisms necessary to technical accomplishment of literary or musical works have been destroyed or altered by aphasia’.
But the painter escapes because of the insignificant part played by language in ‘plastic realization’. His expression and the appreciation of that work are dependent on representations of the world based on visual perception, form and colour in which visual sensations are prominent and language only important if we wish to articulate the aesthetic appreciation. The form is not symbol-based and it has no language. ‘The climate of a Rembrandt ... Leonardo da Vinci ... or Turner is immediately recognizable ... [and] in quite a different way than is the language of Byron or Wagner’. Furthermore, appreciation of the plastic arts is immediate whereas the work of the writer or musician flows in phases that must be remembered and synthesised. By the same argument, Dr Alajouanine predicts that, leaving aside the manual inconvenience of apraxia, only agnosia will disrupt the art of the painter. More difficult to assess is the extent to which abstract art might be threatened by aphasia since, in this school, the symbolic elements of language participate in the art-form, now making its execution and appreciation vulnerable to aphasia. ‘We would not, however, go so far as to hope that Picasso becomes aphasic, to show us that he can no longer paint in his present manner, but that he is still able to give us the fine paintings of his blue period’.
‘Artistic creation becomes impossible when aphasia disturbs techniques based on language but preserves techniques based on visual perceptions’. As Hughlings Jackson has stated, aphasia alters only a part and not the whole of intelligence; and creativity cannot be accommodated by an all embracing theory such as the Gestalt of German authors. More useful and accurate is (Sir) Henry Head's concept of the symbolic as the essential deficit of aphasia. The paper we publish on page 39, describing the artistic preoccupation and talent for depictions of ‘Boléro’ in the painting of an individual with corticobasal degeneration, is poignantly reminiscent of the issues raised by Théophile Alajouanine—painting, music, Maurice Ravel, the syndrome of primary progressive aphasia and human creativity.
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