Tuesday, November 24, 2009

Brain, coma, vegetative state and misdiagnosis.



This is a truly appalling story about a Belgian man who after a car accident fell (as doctors thought) into a coma and then had been diagnosed as being in a vegetative state. The accident occurred more than 20 years ago, and the man claims that while during the whole time he was fully aware of what was happening around him in the hospital, he could not respond or even cry out, because he was paralysed. It was recommended that the family would let him die. Fortunately, they refused to accept the diagnosis and continued to fight for him all these years. His mother, who was always convinced that he was conscious, took him to the USA five times (!) to perform medical tests. About three years ago, they finally got in touch with Professor Steven Laureys of Belgium's Coma Science Institute. Laureys conducted a specialized PET scan that was not available in the 80th, and the scan determined that the patient was conscious. The neurologist who worked with him said they saw in the scan that his brain was “almost normal”. They attempted to establish some communication with the patient, and finally he managed to move his foot slightly to stir a computer device to indicate yes or no. Then they attached a special touch-screen to his wheelchair and he started to communicate extensively. Since then he had been diagnosed with a “locked-in syndrome”, a condition in which a person cannot move or speak, but is able to think and reason. While mentally, he appears to be absolutely normal, (he has just started writing a book about his experience), doctors think that his physical condition is unlikely to improve. However, his mother refuses to give up. She says, “We continue to search and search. For 26 years already”


I cannot imagine what this unfortunate individual was going through. To be able to feel, think, meditate, hear, see, understand, reflect, but not to move, respond, speak or even cry- for 23 years- this is inconceivable. During that time, the patient’s father had died and he heard the sad news in the hospital, but could not respond or show any emotion. I am not sure that it can be called a “happy ending”, but at least due to the heroic and perhaps superhuman efforts of his mother the man is still alive today. However, reading this report I could not help remembering the heartbreaking case of Terry Schiavo. She was a young and successful Florida woman, who after experiencing cardiac arrest in 1990 resulting in extensive brain damage was diagnosed as being in persistent vegetative state. She spent almost 15 years in a hospital, on life support, unable to speak, reason, feed herself and so on. Several years later, her former husband filed a petition to remove her feeding tube, which her parents surely opposed. That is how their prolonged legal battle started. I lived in the USA at that time, and witnessed the end of this story, when in the beginning of 2005, the final decision was made to remove her feeding tube. While she was dying, it appeared that the entire country was involved in the case, from the ordinary citizens to the Governor of Florida (a brother of President Bush), the United States Congress and the President himself. However, nothing worked, court decision could not be overturned, and Terry was allowed to die. After her death, the autopsy confirmed that her brain was extensively damaged in all regions, and it weighed only 615 g, as a result of the loss of a massive amount of neurons. Nonetheless, I still cannot get rid of the feeling that something was wrong. There was a lot of publicity around this case, and I watched a video of Terry with her mother in the hospital. It appeared that Terry responded to her mother talk with smile, and occasional nods, while her facial expressions were definitely changing. Interestingly, I just reviewed a study published by the same Dr. Laureys who helped the man in this story. The study demonstrated that about 41% of patients in minimally conscious state might be misdiagnosed. The condition of these patients is very often diagnosed as vegetative state, which associated with a much lower chance of recovery. That is what Dr. laureys has to say, "Differentiating the vegetative from the minimally conscious state is often one of the most challenging tasks facing clinicians involved in the care of patients with disorders of consciousness. Misdiagnosis can lead to grave consequences, especially in end-of-life decision-making".

Sunday, November 22, 2009

The origins of music and language.

Book Review

Steven Mithen
“The Singing Neanderthals” 2005, Weidenfeld & Nicolson, London


I have recently (re)read a fascinating book by one of the scientists featured in the video that we watched last week, Steven Mithen. It is called “The Singing Neanderthals: The Origins of Music, Language, Mind and Body”. The author maintains that while some of universal attributes of the human mind such as capacity for language and creative thought have been addressed in the literature, music has been neglected (or underestimated/misunderstood). He is convinced that the evolution of music holds the key to language. In the book, he reviews extensive evidence from anthropology, psychology, neuroscience, and sociology to demonstrate that music predated language, and to explain why music is so important to humans. The book consists of two parts. Part I concerns with character of music and language and their relationship. Here, the author attempts to answer such questions as, how music and language are constituted in the brain; how we communicate with prelinguistic infants; and the relationship between music and emotion. Part II explores the communication system of monkeys, apes, Early Humans, Neanderthals and Homo sapiens. The main questions in this part are: how characteristics of music and language are explained by the evolutionary history; how these characteristics relate to the evolution of the human mind, body and society.


It appears that the book originated as a scientific dialogue or rather polemics with such prominent scientist as Dr. Steven Pinker, Professor of Psychology at Harvard University. It all started when Dr. Pinker in his 1997 book “How the mind works” made his famous statement “music is nothing more than auditory cheesecake”. He maintained that from the evolutionary point of view music could not be compared with such important attributes as language, vision, social reasoning, and physical knowledge. Pinker claimed that music is an evolutionary by-product. In other words, it emerged as a result of the development of other capacities that have direct adaptive value. He attributed the existence of music to the pleasure it provides. In his opinion, “music could vanish from our species and the rest of our lifestyle would be virtually unchanged”. While for us as musicians, this assertion might sound outrageous, interestingly, Dr. Pinker is not alone. Professor Dan Sperber from the French National Center for the scientific research in Paris in his 1997 book “Explaining culture” calls music “an evolutionary parasite”. John Barrow, cosmologist, Professor of Mathematics at the University of Cambridge in England maintains that music “has no role in survival of our species”. These people are among the most influential scientists in the world today, and, perhaps, their opinion counts. Besides, this does make sense. Music does not belong to the list of characteristics that are essential for survival. Additionally, I have a large collection of quotes from renowned individuals (from the celebrated artists to distinguished philosophers and writers) which appear to not only support the view that music is biologically superfluous but also question its moral and aesthetic value. Here are just two examples: “Music is essentially useless, as life is”. (George Santayana 1863-1952, a Spanish philosopher, essayist, poet, and novelist). “My loathings are simple: stupidity, oppression, crime, cruelty, music”. (Vladimir Nabokov, 1899-1977, a Russian-born novelist, one of the greatest English prose stylist). However, if music is worthless and biologically unessential, why we still have it? To answer this question, Mithen examines recent anthropological findings on Neanderthals, which appear to endorse the view that Neanderthals had no language. (Just to update, the latest discovery of the FOXP2 gene (which is called “the speech and language gene) in Neanderthals suggests they may have had language skills). Neanderthals had evolved in Europe about 250.000 years ago, survived the ice ages, and become extinct about 30.000 years ago. In other words, they existed for more than 200.000 years! Amazingly, they survived dramatic environmental changes in ice-age Europe. Obviously, in order to survive they needed intelligent decision-making and extensive social collaboration. So, how did they communicate without language? Mithen maintains that they developed music like, complex communication system, which he calls Hmmmmm: holistic, manipulative, multi-modal, musical, and mimetic. He argues that while there were no words, this system consisted of a combination of gestures, dance, vocal replication and large number of holistic utterances, where each utterance functioned as a complete message in itself. I can imagine a group of Neanderthals communicating in this manner-dancing, using a variety of auxiliary tools, gesticulating, and vocalizing while preparing for such complex social activities as, for instance, hunting. This might sound bizarre, but I have witnessed a similar case with my own eyes. When I was a Music Director of the Youth Jerusalem Orchestra, we had an extremely knowledgeable conductor, with exceptional professional skills and qualities. However, there was a problem. As a recent immigrant, he did not speak Hebrew at all. Yet, he managed to communicate with the kids, and they created a great music together! His system of communication consisted of exact the same things that Mithen described in the book. He gesticulated profusely, sang, jumped, used his stand to produce a variety of different noises, vocalized, imitated the instruments with his voice, and even danced. Somehow, the kids managed to catch the meaning of his messages and the orchestra did quite well. Evidently, the Neanderthals’ communication system did not disappear altogether. Mithen maintains that the remnants of this structure can be observed today in the way that mothers communicate with prelinguistic infants. They vocalize, and employ a great variety of facial expressions and their babies seem to understand them perfectly. Mithen argues that both language and music share the same source of origin. In fact, this idea is not altogether new. It could be traced back to Darwin, and it was recently advanced by a Canadian neurologist Steven Brown, who coined a term “musilanguage” to describe this sort of communication method. I found this idea fascinating.