William H. Calvin and George A. Ojemann's CONVERSATIONS WITH NEIL'S BRAIN (chapter 4)
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Conversations with Neil’s Brain
The Neural Nature of Thought & Language
Copyright  1994 by William H. Calvin and George A. Ojemann.

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William H. Calvin, Ph.D., is a neurophysiologist on the faculty of the Department of Psychiatry and Behavioral Sciences, University of Washington.

George A. Ojemann, M.D., is a neurosurgeon and neurophysiologist on the faculty of the Department of Neurological Surgery, University of Washington.

If Language Is Left, What’s Right?

THE “HALF-A-BRAIN” TEST. That’s the name Neil had invented, by the time we next met in the atrium. In the intervening week, he’d experienced one of the major diagnostic tests used on all epilepsy surgery candidates.
      “So I passed,” he smiled, as I sat down and took the first sip of my cappuccino. “I qualified for the epilepsy operation. What’s the test’s proper name, anyway? Wada something?”
      George says that the test is properly known as the intracarotid amobarbital perfusion test. But I’ve never heard it called anything other than by the name of the man who devised it, a Japanese-Canadian neurologist with a conveniently short name, Juhn Wada. The test not only shows which side of the brain contains the major language functions, but it is also used to determine whether each side of the brain is capable of managing recent memory functions on its own, when the other side inactivated.
      Just as in the arterial dye studies, a radiologist threads a long catheter into a leg artery. The tip of this hollow tube is guided up into the internal carotid. If you then inject a short-acting anesthetic like amobarbital into the left carotid, the right brain stays awake and working. But the front two-thirds of the left brain stops working, at least for a few minutes.
      “They had me hold my arms out, and my right arm drifted down even when I tried to keep it up,” Neil said.
      Arm drift is just the way that neurologists tell that the anesthetic has arrived. They were also very interested in whether you could keep talking — to make sure that you are not one of those people with language in the right brain rather than the left. But your language failed, as it should then language is on the left side.
      “They also said that I’d failed to identify some music.”
      That was during the right-sided anesthesia. Identifying simple musical rhythms — not selections of music, per se — seems to be one of the things that the right brain does.
      “But how come nothing very dramatic happens when the right half of the brain isn’t working?”
      Depends on what you mean by dramatic. Woodrow Wilson apparently suffered a right-brain stroke during the Versailles peace conference just after World War I. It didn’t paralyze him, but his fellow statesmen noticed that his personality seemed to change overnight; he became harsh and vindictive, whereas earlier he had been farsighted and conciliatory. But he also became more socially outgoing rather than showing his usual reticence. Then a few weeks later, he had another stroke that paralyzed his left side.
      Despite this perfectly obvious paralysis, he claimed that nothing was wrong with him — and that’s what really distressed the people working around him. He even fired his secretary of state for trying to discuss this puzzling situation with the cabinet. Dramatic enough for you?
      “I guess so! You mean, as in setting the stage for World War II?”
      Exactly. Wilson couldn’t argue effectively for League of Nations membership before Congress and, of course, he’d fired his secretary of state for “usurping power” as part of his denial of illness. So the United States withdrawal effectively crippled the League.
      World War II several decades later had many additional “causes,” but you can certainly imagine a different outcome if Woodrow Wilson had not become so strangely disabled by his right brain stroke.
      Actually, Wilson had suffered a series of strokes, starting at age 39 when he was a history professor at Princeton. After the stroke that left him paralyzed on his left side, President Wilson’s wife and doctors kept quiet about how disabled he had become after Versailles and they essentially ran White House affairs for the next year. They kept Wilson’s illness — and his denial of it — so quiet that Wilson’s lack of insight into his disability never made it into the history books until a half century later, when a neurologist with a historical bent wrote a book about it.
      By far the strangest aspect of right parietal lobe damage is what neurologists now call “denial of illness.” Despite the obvious evidence of paralysis, the patient claims that nothing is wrong. Or that he merely has a head cold. To be fair, the characteristic problems you get with right brain strokes were only beginning to be recognized by neurologists in 1919, when Wilson’s major strokes occurred.
      Usually when a leader fails, subordinates can take up the reins. But there was nothing that the vice president and secretary of state could do: because Wilson’s language was not impaired, he could order them around. He could hold on to office even though so severely disabled as to be unable to lead. Although the 25th Amendment to the U.S. Constitution has since provided procedures for some kinds of presidential disability, Wilson’s type of disability — a lack of insight regarding his illness — could still confound the intent of the amendment and leave the United States with yet another leadership vacuum.
      Or it could leave the United States with a president having an altered personality. In 1974, while still on the Supreme Court, Justice William O. Douglas suffered a right brain stroke. He, too, denied his illness, even issuing a press release that suggested his left arm had been injured in a fall.
      Wilson developed an uncharacteristic obsession with being overheard and with protecting the secrecy of his papers. Douglas also developed some mild paranoia that, in a president, might have had far more serious consequences. Unlike Wilson’s subordinates, Douglas’ fellow justices were eventually able to persuade him to retire; for about a year, however, they had to cope with a Justice Douglas who was not his former self.

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[FIGURE 23 A typical Woodrow-Wilson-type right brain stroke]

WILSON’S STROKES had many of the other features we now associate with right brain damage, such as defective body image. A person may be lying in bed, with the left side of his body paralyzed, and still deny that anything is wrong. If you pick up his left hand, place it on his right chest, and then ask him about it, he may deny that it’s his hand. He may become obsessed with what another person is doing in bed with him.
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[FIGURE 24 How left vision winds up in right brain]

      In less dramatic cases, you can see what neurologists call “neglect.” While the right eye sees both to the left and to the right side of the nose, everything to the left of the midline is sent to the right brain. The right brain winds up with what is seen by both eyes of the left side of the visual world. And vice versa. Some patients with right-brain strokes tend to ignore anything on the left side of their visual world.
      Others pay attention to objects on their left side — but only if there is nothing else on their right side to compete for their attention. When driving a car and approaching an intersection, such a person may be able to see cars approaching from the left just as readily as cars approaching from the right, but only so long as they don’t approach from both directions at once. If they do, the patient may ignore the car on the left and pay attention exclusively to the car on the right.
      For some patients, such as my father after he had a small left parietal lobe stroke, the neglect is temporary; his lasted only a few days. But for others, it persists and becomes a big problem. Such patients must stop driving, but it is difficult to persuade them to do so; as far as they can tell, nothing is wrong with them.
      “That’s hard to believe. They really have no insight into their condition?”
      The very first neurology patient I ever saw, at a Saturday morning conference at Harvard Med, had this kind of problem. He seemed normal in every other way, and he was quite articulate. It was very impressive to see the neurologist stand behind this patient and bring his hands slowly forward around the patient’s head while the patient was looking straight ahead. The patient reported seeing the hand off to his left when it had reached halfway around his head. When the neurologist repeated the test on the right side, the patient saw that hand normally as well. But when the neurologist brought both hands around at the same time, the patient reported only the one on his right — even though the neurologist was waving his fingers on the left, trying to attract the patient’s attention. The patient had stopped driving, at the insistence of doctors and family, but maintained that everything seemed normal from his point of view.
      A self portrait painted by the German artist Anton Räderscheidt after he suffered a right-brain stroke illustrates what neurologists mean by “neglect” and “defective body image.” The portrait fills only the right half of the canvas, and in that right side, only one side of the face is accurately depicted.
      “If you don’t have an internal image of the left half of your body, to say that nothing is wrong with it does have a certain logic,” Neil said.
      Agreed. But the problems caused by this kind of right-brain stroke are anything but trivial. Imagine a president who claims to be normal and still speaks in an authoritative tone of voice. He has no interest in participating in rehabilitation and does not know his own limitations. These are among the most difficult of all the brain-damaged patients to rehabilitate because they have so little insight into their problem.
      “Which raises the question, Where do we get insight?”
      Well, the psychotic patient often lacks insight into the illness. And we suspect that animals lack the mental capacity for such insight.
      “Maybe insight is part of consciousness,” Neil said. “Whatever that is. Something else to add to the consciousness list.”
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[FIGURE 25 “Neglect” of the left side of visual space]

UNUSUALLY GOOD FUNCTION OF THE RIGHT BRAIN is said to characterize those who excel in the visual arts: painters, sculptors, architects, moviemakers. Neurologists suspecting a right-brain stroke often try to test for elementary versions of these abilities.
      Neurologists like to draw a circle and ask the patient to fill in a clock face. The right-brain stroke patient knows that there should be numbers from one to twelve, but he is likely to crowd all of these into his “good side,” the right half of the circle between twelve and six o’clock.
      “The patient just ignores the left half of the clock face?”
      Right. Ask such a patient to draw a cross, and it is likely to be drawn missing the left arm. You can get a house that has only details on its right side, a face with only one eye, a flower with only the half of its petals — all drawings that the patient will claim are complete and normal sketches. The auto mechanic with such a stroke may be able to identify all the parts of an engine, but nonetheless be unable to assemble them. Subtle forms of this “constructional apraxia” are tested in the mental rotation of objects, seen in the multiple-choice questions on standard intelligence tests. These are all examples of “visual-spatial” functions.
      The other deficit often present with a large right-hemisphere stroke is “dressing apraxia”: the patient can’t get his arms into the sleeves, even though not paralyzed. The patient can name sleeves or pant legs and describe their use, but still can’t perform, apparently because his image of his own body is defective. Even if Woodrow Wilson hadn’t been partially paralyzed, it is likely that Mrs. Wilson would have needed to help him get dressed every morning.
      “So does sign language operate out of the right brain?” Neil asked.
      In a word, no. Deaf patients using sign language are just as impaired with left-brain strokes as the rest of us, and their sign language is just as unimpaired by right-brain strokes as ours is.
      People have also wondered if the pictographs of some Asian languages involve the right brain. But a language, no matter how it is implemented, seems to be a language — even for pictographs or hand gestures. And it depends primarily on the left brain, although some emotional aspects of prosody — the way your voice rises at the beginning of a question or falls at the end of a sentence — are affected by right-brain strokes. People with right-brain strokes sometimes talk in more of a monotone than they did before.
      Clearly, right-brain strokes and left-brain strokes have different symptoms. You can see where the popular notions of left brain for language, versus right brain for spatial skills, have gotten their impetus. But the reality of biology is much more complicated. As George likes to say, the popular view is slightly more than half right. For every patient who has bilateral or right-brain language, there are 13 with left-brain language. Yet lateralization of spatial skills to the right brain is not the reverse. Nothing there is as strongly lateralized as even six to one.
      “Lateralized?” Neil asked, raising his eyebrows.
      That’s when functions with no left-right intrinsic aspect are not equally represented in both hemispheres. Functions like judging the distance of an object are not lateralized: both sides of the brain can do it, seemingly equally well. You usually measure lateralization by reviewing numerous patient records to see if right- and left-brain damage is equally likely to disrupt a particular function, such as knowing how to put on a shirt. Maybe five patients have dressing apraxias after right brain strokes, for every one patient with a dressing apraxia after a left-brain stroke. Only two patients show constructional apraxia after right damage, for every one with that symptom after a left-brain stroke. So constructional abilities are “less lateralized” than dressing abilities, but they are both lateralized, compared to depth perception.
      “Estimating distances sounds like one of those survival mechanisms, handy for hunting with spears and such.”
      The ability evolved much earlier than that. Lateralizations were originally thought to be uniquely human, but now they’re thought to go back to the monkeys, probably to a specialization for hanging on to the tree branch with the left hand while using the right hand to move food to the mouth. Monkeys have a minor version of our tendency to use the left brain for listening carefully to rapid sound sequences. So it’s a matter of the extent of lateralization, as well as the emergence of additional specialties such as language. And the corpus callosum can be a real bottleneck, simply because impulses travel rather slowly on that pathway. Coordination has its price.
      Many patients with strongly lateralized language do not necessarily have strongly lateralized visual-spatial functions. Visual-spatial functions are more strongly lateralized in males than in females, probably because they depend on adequate levels of testosterone, the male sex hormone, during brain development, back when you were a fetus in your mother’s womb. The difference between individuals in the degree of lateralization of different functions is just another example of how variable individuals are.
      “So does your degree of lateralization make any difference in your abilities — say, as a painter?”
      That’s still an open question. Certainly some evidence suggests that more lateralization is associated with better function. When both sides of the brain have some language ability, certain types of language disability seem to be more likely. Stuttering, in particular. It’s as if the two language areas can’t coordinate their act properly, with all of those messages being sent back and forth through the corpus callosum.
      “I know. I worked for a company where the higher-ups were split, half on the East Coast, half on the West Coast. They could never make up their collective mind. People said that when we introduced a new product, we stuttered. Now I run a start-up with two other guys. We don’t have that problem.”

COMPARED TO THE LANGUAGE SUBDIVISIONS in the left brain, we know much less about how these visual-spatial abilities are housed in the right brain. For the right brain, we’re not even up to the nineteenth-century Broca-Wernicke level of theoretical summary.
      We find it difficult to even place neglect, denial of illness, and defective body image on a right-brain map — or to be sure that their definitions don’t overlap. The strokes that produce these visual-spatial problems tend to be large, with smaller strokes producing symptoms that are difficult to recognize by present methods. Defects of body image may be more likely with a stroke centered in the lower portions of the parietal lobe. Neglect is more likely with strokes higher in that lobe.
      And that’s consistent with the generalization that’s made about monkeys, about what happens in analyzing the visual world after the information leaves the primary visual cortex. Damage to the underside of the temporal lobe tends to interfere with object recognition, but damage to parietal lobe tends to impair awareness that objects are even there — and, of course, making movements toward them.
      “So temporal lobe takes care of what something is and parietal lobe handles the where?”
      Pretty much, though there is always overlap. For example, we know a lot about the parietal lobe’s Area 7 from the study of single neurons — at least in monkeys, which probably aren’t very lateralized. With a little wiretapping, you can figure out what the neurons in Area 7 are interested in. They respond best to objects moving in the space just beyond your skin. Those neurons are truly egocentric.
      “Just outside — you mean, like when I hold a fork?”
      No, mostly for things you’re not touching — yet. The next time you’re on an airline flight, watch the flight attendants as they serve trays of food in very close quarters. You can watch the elbow of a flight attendant, poised inches away from the head of a person in the row ahead, and marvel at how well she seems to know where that person’s head is, even though no longer looking in that direction. Out of sight, perhaps, but not out of mind.
      I once asked a flight attendant about this. She claimed that she had eyes in the back of her head. Those “eyes” were probably neurons in her parietal lobes, contributing to a mental model of her extrapersonal space. The parietal lobes are probably what keep our visual experiences from looking like an amateur videotape, jerking from here to there. Our eyes do indeed jerk from here to there, even faster than a camera, but we don’t perceive it that way. The seeming stability of our perceived world is porbably because it is, in large part, actually a mental model of our visual world — that we update from all those jerky images we get.

THE RIGHT TEMPORAL LOBE functions are a little better known, compared to those of the right parietal lobe. The right temporal lobe is interested in faces, among other things.
      “The man who mistook his wife for a hat?”
      Not exactly. But the ability to recognize faces can be disrupted by temporal lobe strokes damaging either side of the brain, particularly if they involve the undersurface of the back part of temporal lobes. The famous patients who cannot recognize familiar faces, such as that of a spouse, may have a more general problem. Someone tested such patients on a series of pictures of cars, perhaps just as a control to testing them on portraits of people. The patients who couldn’t pick out the faces of relatives from among the portraits also could not pick out a picture of their own car from among other somewhat similar cars. They can get the general category — cars and faces — but not unique examples. Their problem is with proper nouns, not ordinary nouns.
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[FIGURE 26 Emotional facial expressions and right brain]

      The right temporal lobe is particularly interested in the emotional content of the facial expression. This was discovered by using the fact that the image from the left half of your retinal images goes to the right brain. If half of a face is smiling, and the other half frowning, the side to the observer’s left is likely to be picked.
      Better yet, you get yourself a set of pictures of faces, those of actors trying to portray an emotion — using both sides of the face — such as happiness, sadness, disgust, anger, and so on. George has tried stimulating the right temporal lobe while showing patients such actors’ faces depicting a standard emotion like disgust. Normally, the patients are quite reliable at naming the emotion being acted out. But they make mistakes when stimulated at some sites in the temporal lobe.
      “Do they see happy or angry? I mean, is the right brain a pessimist or an optimist?”
      Sorry, but they make errors in both directions. They just pick the wrong name, from among the possibilities. In the real world, that could lead to some serious misunderstandings.
      “So when another animal approaches you, and you misread its facial expression as one of friendliness rather than hunger, you aren’t likely to leave many offspring behind.”
      Yes and no. Basically, that turns out to be the wrong evolutionary argument. Primates usually don’t eat others of their own species. And you don’t need to check out the expression on his face to know that an approaching tiger presents a threat. But facial expressions are extraordinarily important among the apes, for judging the intentions of other members of the group. That’s how an solicits help in a dispute, judges what the dominant animal will permit without retaliation, or just finds a grooming partner.
      Reading the emotional state of another member of your species is probably more important for sexual selection than for staying alive. Males that misread the body and facial postures of a potential mate get bitten or kicked. That’s the real law of the jungle. Those that are particularly good at judging readiness to mate may wind up with a lot more offspring. Staying alive is the name of the game when you’re a juvenile, which, because of all that juvenile mortality, is when most natural selection occurs. But sexual selection may be more important in adulthood.
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[FIGURE 27 Three-part model of facial recognition]

      In the temporal lobes of monkeys, neurons can be found that are interested in faces — but only faces of the appropriate species, and then only the eyes or the mouth. Nearly two-thirds of the neurons recorded from the human temporal lobe seemed to be interested in faces. In monkeys, there are a number of face-specialist neurons in the first fold below the sylvian fissure. And the monkeys are also lateralized for emotional face features, reacting more appropriately when the emotional clues are in the left half of their field of view.
      We think there is a series of steps in recognizing a face as a familiar person. One of the higher-order visual areas, running along the underside of the temporal lobe, is particularly good at extracting facial features such as eyebrows. The front of the temporal lobe is thought to be involved with storing biographical information and proper names. A third area, in between them, is thought to be an association area that relates facial features to the biographical information. The right brain is far more involved with this job than the left brain.
      “So what about my storehouse of people’s names? Do I lose it with this operation that’s going to shave off the front of my left temporal lobe?”
      No, but patients occasionally complain afterward that they have more trouble with proper names than with memories in general. We like to talk about areas of the brain having specialties, but the information is usually stored redundantly over a wide area. And removing the front end of one temporal lobe still leaves the other temporal tip.
      “So how about adding two and two together? Where do I do that — in the right brain?”
      Either right- or left-brain damage can disturb arithmetic, particularly when it involves the parietal lobe. When you see disturbances in calculation abilities after a left-brain stroke, it’s usually complicated by some links with language abilities. There’s a constellation of symptoms known as Gerstmann’s syndrome in which calculating fails — but also the labeling of body parts, especially fingers. And those patients get confused about labeling things as being right or left.
      “Sounds as if they were counting on their fingers! But what about fancier counting abilities, balancing the checkbook, and so on?”
      There are some stimulation mapping studies on calculating abilities done in the O.R. George has occasionally asked patients undergoing right-brain operations to do some simple problems of addition, subtraction, division and multiplication while he stimulates sites in the right parietal lobe. He identified a number of sites where only one of these four functions was altered, and few sites where more than one was altered.
      But no checkbook-balancing studies. The existing studies do suggest, however, that there are somewhat different neural systems for each type of calculation. With the evidence of difference between sexes in the degree of lateralization of visual-spatial functions — it’s greater in males — and now this evidence of specific right-brain mechanisms in mathematics, you can see how eventually we might answer some of the questions about why males are so overrepresented in the “tail of the distribution” for math abilities. We’re talking here not about the average engineering student sweating his or her way through advanced calculus, but about those extremely gifted in mathematics, regardless of schooling or environmental emphasis, most of whom are male. And more are left-handed, allergic, and dyslexic than you’d normally expect.

MUSIC IS SIMILAR TO LANGUAGE in its neurology, but some differences have been seen. For example, George tells about a patient who was a country and western musician, a quite gifted amateur. After he had the worst headache of his life, his doctors diagnosed a bleed, a hemorrhage from an aneurysm in the left superior temporal gyrus, immediately below the sylvian fissure. For a few days, the patient had some difficulty saying exactly what he wanted to. And some of his words were nonsense, but this all cleared up. When his speech was normal, he tried to sing one of his favorite songs — and discovered that he couldn’t do it. When the neurologists explored this a little further, they found that he couldn’t hum the melody or sing the lyrics to any of his old favorites. But he could speak the words. And it works the other way as well. Patients with Broca’s aphasia can often sing words that they can’t speak.
      Such findings suggest that music depends on both sides of the brain. After the front of the right temporal lobe is removed, there is some reduced musical ability — memory for a set of tones or for rhythms. But that’s only for amateurs. Disturbance of musical abilities in professional musicians usually takes left-brain damage. It’s been suggested that as you gain proficiency in music, it is increasingly organized like a language, dependent on your left brain. But not on exactly the same areas as spoken language.

George has also wiretapped some neurons in the temporal lobe while having the patient listen to music. Short recordings of classical music caused their activity to decrease, sometimes to levels half of that before the music started. Classical music may be soothing, literally.

“I’m going to have to get you to explain the wiretapping business one of these days. But go ahead.”

In music with a pronounced rhythm, activity of some neurons was entrained by the beat, just as if the neurons were clapping in unison. When rock music with a heavy beat was played, the activity of the neurons usually increased, and their firing patterns became even more emphatic. Some observers have commented, half seriously, that these neurons are firing in the “bursting” pattern reminiscent of that seen in recordings from epileptic areas.

As George likes to say in an ominous tone of voice, perhaps everything your grandmother told you about rock ’n roll is true.

LANGUAGE IS NOT SOLELY A FUNCTION of the left hemisphere, but the changes after right-brain strokes are more subtle than the dramatic language changes seen after left-brain strokes. When you hear a sentence, you have to make a mental model for what that string of sounds represents. A full understanding of an utterance may well involve many right-brain functions.

Right-brain stroke patients may not understand all of the connotations of a common word. They may become more “literal-minded,” having trouble appreciating figures of speech. Ask them to paraphrase a short story, and they may repeat it verbatim without making changes. They have trouble with antonyms. The spontaneous speech of such patients is often rambling.

As you might expect from the flat tone of voice used by many right-brain stroke patients, they may also have trouble interpreting the speaker’s tone of voice. Testing them on narratives is particularly revealing. Unlike aging patients who are quick to admit when they are uncertain about a memory, right-brain stroke patients seldom indicate a lack of confidence when making mistakes in recalling test stories. They are particularly bad about retelling a story in the right order, tripling the normal number of errors. This is almost as bad as the patients with left-brain strokes causing aphasia.

“So if they can’t keep the story straight, jokes must be wasted on them. They won’t be surprised at the punch line.”

Yes, subtlties go right past them. Their own attempts at humor are often crude, off-color, or inappropriate. So while the left brain may be more involved with the building blocks of language, the right brain is quite helpful in interpreting it all.

Whereas the left hemisphere might appreciate some of Groucho’s puns, and the right hemisphere might be entertained by the antics of Harpo, only the two hemispheres unified can appreciate an entire Marx Brothers routine.
    Howard Gardner, Hiram H. Brownell, Wendy Wapner, Diane Michelow, 1983

Conversations with Neil's Brain:
The Neural Nature of Thought and Language
(Addison-Wesley, 1994), co-authored with my neurosurgeon colleague, George Ojemann. It's a tour of the human cerebral cortex, conducted from the operating room, and has been on the New Scientist bestseller list of science books. It is suitable for biology and cognitive neuroscience supplementary reading lists. ISBN 0-201-48337-8.
AVAILABILITY widespread (softcover, US$12).
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