Language

Introduction

To envisage the clinical examination of language is to consider it as an existing entity, clinically observable. It is not customary at present to insert it into the assessment that the physician is in the habit of carrying out. However, it seems to us well to underline that if language was once the object of studies carried out chiefly by linguists and phonologists, it has for some decades regained an incontestable medical impetus.

The enormous impetus given by BROCA, barely a century ago, the awakening of psychology, the psychoanalytic monologue — all seem to have recalled to the clinician that language had a word to say. Doubtless we have not yet succeeded in detecting with what perspicacious intuition AVICENNA succeeded in placing, in a kind of three-panelled, hierarchically developed unfolding, the word in the first place, the herb in the second and the knife last. We are nevertheless justified in noting therein the primordial place given to the verb — whose therapeutic power cannot escape the practitioner who knows its efficient value.

Language must henceforth allow the clinician, by bringing him multiple and precious indications, to draw conclusions on the use that the subject knows how to make of the possibilities offered to him.

Let us now see what language may be. As a general rule, it is considered as an instrument of communication.

We should prefer, for our part, to consider it as the expression, as the prolongation of a gesture whose aim is to inform. It is like a secretion that exudes from our body. Thus this secretion has analysable characteristics, and what is more, measurable in their totality. Thanks to current techniques, the different elements of the linguistic chain can readily be gathered and identified.

There exist two ways of assuring oneself of the real value of an entity that one wishes to approach in its various components: that which consists on the one hand in relying upon the data that pathology reveals to us, and that which allows on the other hand the inventorying of the elements liable to circumscribe normality. In fact, it seems very difficult, even impossible, to elaborate from the outset any approach to the normal or pathological linguistic structure (under the clinical angle, that is) without referring at once to these two sources of information. Indeed, every plunge into the one or the other domain brings useful materials to each of them.

Language is therefore what comes out of an individual when the latter sets himself to express himself, to externalise himself, to communicate, to inform. This evidently implies that he have something to say, that he know how to express himself, that he wish to externalise himself, that he desire to communicate, that he accept to inform. What conditions raised by such a decision!

When the emitted language delivers us its material, we can, if we judge it appropriate, study its intrinsic value, that is, the development of the discourse, and detect the faults of logical structure within it. It is then much more a question of analysing the unfolding of the elucidated thought than of discovering the linguistic material proper. It is to approach language with a psychiatric experience with the aim of seeing the incoherences of reasoning emerge.

The language as we should like to study it — while taking account of course of this parameter — must deliver us many other elements, in general too neglected. The chief among them constitute a research grid aiming to define intensity, quality, rhythm — so many characteristics that determine the verbal flow. At a higher stage, it will be well to study the manner of using this exceptional acquisition.

In order to be better able to comment on the normal mechanisms of language, we think it useful to refer to the case answering to the most favourable conditions of a well-structured language emitted by a subject master of his elocution and capable of using it to free and verbalise his thought, according to his desire, at will therefore. This subject possesses a right, timbred, modulated language, rich in extra-linguistic, redundant elements.

What is meant by a right, timbred, modulated voice? A right voice is one emitted by a subject lateralised on the right and specially well lateralised. It is indeed necessary, to be a good speaker, to answer to this condition. It is also necessary that there be associated with this quality the possibility of hearing in a certain manner and, better still, of self-listening in a well-defined manner.

Before progressing in our descriptions, it seems necessary to open here a wide experimental parenthesis so as not to place the uninitiated before multiple affirmations that might rebut him. Let us specify therefore that, in vocal emission used for the purpose of information, the emitter — in the present case the speaker — is the pilot of his language (1); thereby, all the problems of piloting are imposed upon him. He becomes the first listener of what he must say, but an attentive listener and corrector of all the parameters involved in linguistic emission.

Thanks to the self-listening of his own language, the speaker effects unawares one of the most ingenious arrangements that cybernetics has brought to light. It will be remembered that this science of monitoring stipulates that any directed, commanded or remote-commanded act requires that there be introduced into its circuit a retroactive complement acting in return to ensure a relation between what the realised act may be and the intention that motivated it. This monitoring return requires a so-called receptor element whose power of apprehension associated with that of analysis plays upon the intentional process. The latter is commonly termed “the input”; the accomplished act will form the object of “the output”. Without plunging into the technical, even philosophical, considerations that such arrangements always provoke, we may estimate, in the present case, that the output is language itself and that the input corresponds to the decision to let thought flow or to verbalise the thing to be said; the ear is the monitoring receptor which reports to consciousness the different parameters proper to the spoken act.

It moreover turns out that the two ears do not have the same function. Indeed, one ensures a shorter return pathway and thereby a more rapid one, therefore more effective. The right has the privilege of being this directional ear (2) which holds language under its rule. The causes that determine this preference are difficult to specify at the present hour, although we are inclined to bring into play the play of the two pneumogastric nerves, so implicated in language and so asymmetrical in their distribution from the emergence of the recurrent nerves, whose differences of path are remembered.

Without wishing to dwell further on the value of the two ears that a choice singularly differentiates for the monitoring of phonation, and while leaving our explanations at the level of a working hypothesis, we must consider the fact in itself. It is there which imposes itself by its existence. The right ear set in function as a receptor allows the elaboration of audio-vocal counter-reactions of a highly specific efficiency, which can in no way be encountered on the opposite side, that is to say on the left ear.

Moreover, the setting in function of this structure of linguistic monitoring rapidly entails a homogeneous right lateralisation. One knows, at present, how to measure the rate of auditory laterality by appreciating in decibels the dominance of audition during the “aiming” of sounds, just as one can do on the plane of vision. In this last case, when a target presents itself to us, and we must take it as the point of aim, one eye eliminates itself, leaving all the monitoring to the other. The latter then plays the role of directing eye — that is to say of receptor eye ensuring the monitoring of our position with respect to the target which, itself, remains fixed, unchanged during our placement. What we are aiming at is ourselves with respect to the object to be reached. The proof is that, if the target were a mirror, we should meet our eye in it. The ear does likewise; it positions us vis-à-vis language, it allows us to meet ourselves during our own discourse which, in its essential form, can only be the reflection, the mirror of what we claim to reach.

How can this particular choice for one of the sides be conceived, and how can such a differentiation be admitted? For reasons that we cannot evoke here, for lack of space, we have been led to admit, some years ago, that language saw its genesis in utero, as though the desire for communication were already conferred upon the embryo (3); everything leads us to think, at present, that there is established in the uterus a law of mother-foetus love whose reciprocal foetus-mother will condition, thereafter, a great part of our analytic fixations. Without dwelling further on what we have been able to verify as to the sonic (and doubtless verbal) transmission from mother to child, we may say that there is installed in utero a bilateral desire for communication, which will only grow after birth.

The newborn child, apparently symmetrical since benefiting from two ears, two eyes, two mouths (the median raphe will be remembered), is in fact asymmetrical at the level of his two hemi-larynges which receive the non-simultaneous attacks of the two recurrent nerves. Thus this asymmetry is sonic and indeed answers essentially to the visceral asymmetry and not to the cortical asymmetry.

The child will soon dialogue with the mother; and from a discourse made for her intention, asymmetrical and redoubled since played on both sides, will spring the words that every infant knows how to emit: mama, papa, pipi, popo, dodo. After this true song to the mother will appear social language, which will take support upon the desire to communicate with the other, with this stranger that is the father, a constellation at once close and distant, crushing and burning. If everything happens comfortably, the monitoring of this language will be made with the help of a rapid, precise and efficient aiming (after a few hesitations, of course) through the shortest circuit, that is, through the right. Thus the language addressed to the father will be monitored on the right side, bringing to light the symbolic triad so commonly encountered of the Verb, the Right, and the Father.

The desire to communicate may not be born, if the mother refuses the child; thereby, language does not manage to be elaborated. If, by contrast, the relation operates normally with the mother, but proves difficult with the father, contact is established with an enormous distance which will solicit the left posture. In these conditions, the left ear, mouth and larynx become the conductors of a circuit introducing considerable latency times. This long and complex pathway certainly permits the distancing of the father’s image, but renders difficult the piloting of the verbal flow. Finally, if the father is impossible to meet for any reason whatsoever, the child cannot lateralise himself — that is to say, no circuit becomes dominant. This non-lateralisation entails ipso facto the impossibility of locating oneself in space, no more than in time. As for language, it remains fixed at the stage of that created for the mother; and from babbling, the first song elaborated for her, is born stammering, the chronic form of this earlier stage of communication.

Thus language is established on the basis of laterality. Moreover, it is directly linked to the characteristics of its auditory monitor, or right acoustic receptor. One conceives therefore that the right ear, becoming an apparatus so delicate, so precise and so important in all the mechanisms of emission, sees its intrinsic qualities highly appreciated since on them — and on them alone — depend the regulations of the different parameters of the emitted sound: intensity, timbre and rate, which are, let us recall, the principal traits that differentiate sounds from one another.

The qualities one can demand of an ear will therefore be those of hearing language. This is no easy thing and corresponds (let one think about it) to a long secondary adaptation.

Indeed, nothing in man has, it seems, been conceived initially to perform the analysis of language, no more than we should know how to discover in him organs specific to the spoken function. However, thanks to the embryological and neuronal internal liaisons which exist, it is remembered, between the bucco-pharyngeal, pneumo-laryngeal and auditory apparatuses, every progress of the ear in the linguistic domain finds a resonance in the pneumo-digestive area, at the level of the pharyngo-laryngeal crossroads. The counter-reactions that are established between the mouth and the ear are notably made in the image of a pantograph following a previously established relation.

The ear must therefore hear and hear well within the limits of language. It must be adapted to the frequencies of the latter to practise its deciphering, its reading in a way. It is commonly said that it is an impedance adapter. This is exact, but what indeed is the role of such an apparatus? It must achieve a junction of the environment, which is the unique material of communication, with the neuronal milieu of the apparatus of Corti, the sensory part which solicits and informs the auditory nerve, or eighth cranial pair.

The surrounding air permits, thanks to its exceptional elasticity, the setting in acoustic wave of our thought. It offers the possibility of achieving an informational bridge addressed to the other one decides to reach. This junction, which is in fact permanent since it concerns the air which surrounds us, can be awakened in the circumstance in its physical properties by the acoustic phenomenon. The ear must therefore decipher all these sonic artefacts which will take on a semantic value only later.

The ear certainly has its limits within which language is inscribed. It does not always use, moreover, the entire band physiologically allotted to it. Thus the French ear confines itself between 1,000 and 2,000 hertz, while the English ear gives itself a band beyond 2,000 hertz, while the Spanish ear is situated around a culminating point towards 250 and 500 hertz. It is to be noted that the Slavic ears know how better than all others to benefit from the great auditory opening offered to them, as do the Portuguese ears.

Finally, let us specify that this listening ear must be of high fidelity to translate with the maximum of exactitude what self-information must concede to it. So a last characteristic appears necessary: that which gives the ear the possibility of hearing with the minimum of distortion and the maximum of analysis.

To return to our language, let us take up one by one the elements which constitute this learned arrangement: we have an air that vibrates and resonates, a bucco-pharyngeal-laryngeal complex helped by the whole body which knows how to play this resonating air, and finally an auditory complex which acoustically regulates this whole — like an admirable conductor capable of giving and imposing the measure on the infinity of instruments solicited to achieve a perfectly elaborated verbal act.

Here then we are in the presence of this ideal personage that we evoked a few moments ago, a good speaker, a good listener and strongly lateralised on the right. Let us now see how we shall proceed before a subject in a poor linguistic posture. What matters, in our various investigations, is to gauge and count the “lacks” relative to this ideal profile. All forms of non-elaboration of this final structure may be encountered. They represent fixations at this or that initial stage, manifesting themselves essentially by signs of immaturation in the global organisation.

Clinical examination

After this long preamble required by the definition of such an object of study, we may more readily approach the clinical examination.

The important thing is to consider the subject presented in consultation as much during his spoken function as outside it.

It is to the child that we most often address ourselves. We observe him throughout the interview conducted before the parents. His attitude, very significant, reveals to us his adherence, his participation in the surrounding world, or his disinterest and the difficulties he encounters in being a listening subject. Then we detail his behaviour as we begin to speak to him, and we judge his listening tension; we already see which ear he offers us and we gather the synkinesias that this simple gesture of attention provokes. Finally, we have him speak.

In the first place, we take account of the quality of the voice. The latter may be intense or weak, modulated or white, vibrant or dull.

In the second place, we observe the vocal gesture associated with the emission, proceeding first to the examination of the face. The latter may be mobilised in its right part or in its left part. This is one of the great signs to seek. From the emission, good speakers are very clearly asymmetrical to the benefit of the right face. The mouth, notably, offers a dominant right motor function which carries the left; it is the dynamic element that assures us of the good functioning of the right ear in its monitoring play.

It is quite otherwise for the patients whom we are led to examine. In most cases, it is on the left that the spoken function is effected; it is the left mouth which appears to dynamise the whole. But, we remember, who says mouth, says ear; who says ear, says cerebral hemisphere. The whole subject, in sum, is implicated in the simple fact of speaking. Sometimes, there is neither right nor left, and language is, in this case, ill or little elaborated.

Beyond facial play, we observe the associated synkinesias. In a great speaker, the right hand alone presents some gestural associations, above all at the level of the thumb-index pincer. In the less favoured on the linguistic plane, all associated synkinesias are encountered, and anything may be imagined at the level of the two hands, the left above all, the shoulders, the neck, the trunk, the lower limbs — so many movements that know how rapidly to exhaust the potential of energy which the cortical act needs to bring to fruition the completion of the spoken act.

Then we ask the subject to show us his ear; the normally lateralised speaker designates with his right hand his right ear, his right eye and his mouth. The dyslateralised will offer one or the other ear with one or the other hand, or without manual participation — likewise for the other designations, eye and mouth. The non-lateralised, such as stammerers, generally respond to our questions, which they moreover find absurd, with another question: “which one?”.

Then we ask the subject to show us our ear, our eye. There too, in contrast with the hyper-right-lateralised who, with his right hand, chooses our right ear, all fantasies are offered. They reveal to us, in fact, the difficulties the subject encounters in positioning himself, in aiming at himself, in grasping himself in the temporo-spatial universe.

We also seek a sign to which we attribute a definite clinical value and which we call “self-information”. We have the subject say his name and address, asking him to place his right hand near his mouth, just as though he were holding a microphone; we help him by holding his hand with our opposite hand, since we are face to face. The voice is normally tonic, timbred with the right hand, while it is not so on the left. The interest is to measure the awakening of this cutaneo-vocal reflex which must always be right-handed. It is also to be noted that when the subject does not wish to recognise his right and thereby the symbolic support that this side represents, one observes a more or less powerful rejection of the hand. It is generally the right that is repelled and that must be firmly held. Moreover, in the utterance of the name and address, one observes most often a scotomisation of the name when the right is refused.

Finally, we study, listening or by carrying onto cathode tube and sonograph, the emission of the voice when the right ear alone is left in circuit by the suppression of the left, and vice versa. It is also the right that dominates the most modulated voice, and there again we may judge the potential already acquired in this phenomenon of self-monitoring.

Pathology

It is precisely that of the non-insertion of the being into the universe of others, and the abnormality observed reveals, without doubt, an immaturation in the process which leads to an ideal structure — the support of the different systems leading to a well-elaborated language.

It is evident, in function of what we have just said, that two aspects of the pathology of language may be observed. We shall essentially keep under our purview the mechanistic side, we shall say, leaving to our psychiatrist colleagues that of the spirit and of reason. In other words, what matters is the way in which the subject knows how to exploit his body to ensure his verbal flow. It is true that in the clinic everything is interwoven, but it is precisely within the domain of our medical science to know how to dissociate such mechanisms in order to better apprehend them separately.

Thus in language, the disorders that may be encountered offer a broad range from the absence of speech to the most elaborate linguistic virtuosity.

The absence of language testifies to the non-structuration of the audio-vocal circuit:

Either the desire to speak does not inhabit the child, and the problem is psychoanalytic. It is encountered in autism, in schizophrenia.
Or the receptor is absent, as is the case in profound deafness. From then on, deaf-mutism installs itself for want of self-monitoring (4).

If language is created with distortions, we have several cases to examine:

Either the ear is deficient and articulatory disorders are the faithful translation of a receptor of poor quality.
Or the ear is good, but the subject has only a weak desire to use it; indeed, caught in the game of wishing to listen, he has rapidly lost the desire for it and thereby the use.

Or else the structure of his laterality is not elaborated, and the disorders engendered render abnormal all the inherent relational rapports — the child fabricating, if his potential allows it, a world made for him alone.

We thus find dysarthrias, stammerings and dyslexias.

The dysarthrias translating the imperfections of the auditory microphones.
The stammerings revealing the difficulty of meeting the paternal totem, through immaturation of laterality.
The dyslexias preventing the normal deciphering of the universe, of language, and consequently of the book, through the impossibility in this last case of translating written language into sonic language (5).

Treatment

This short account of language and of the pathology of expressive disorders leads us quite naturally to speak of the therapies put to work to help the individual assume himself, realise himself within the world that surrounds him.

These therapies derive from the hypotheses, from the theories that we have been led to elaborate in the course of this research work in the domain of audio-psycho-phonology. They call principally upon the auditory phenomenon taken in its broadest sense and aim to give to each, child or adult, the possibility of using his ear as an apparatus capable of listening to the language of the other. They tend essentially to trigger or to retrigger the desire to communicate, hitherto unelaborated or poorly elaborated.

The techniques of re-education of spoken or written language have been largely modified for some fifteen years by the contribution of knowledge made in the field of electronics. The latter has permitted the construction of devices capable of awakening and rapidly causing the integration of the conditionings that are at the origin of a quality language — namely, a good listening on a highly differentiated right laterality.

Thanks to electronic filters and to gating phenomena, we modify at will the circuits and the curves imposed on listening, in order to procure for the subject submitted to re-education the auditory posture of the good listener, of the one who has structured a normal relational network.

While the listening to the “Other” is elaborated and tends to increase the attention of the subject, a second gating engages a self-listening each time the patient must respond or repeat. He is thus unconsciously obliged to hear his voice as a normal subject hears his.

This pathway directs the subject towards an awareness of his monitorings, towards the mastery of his bodily Self, at the same time as his verbal Self is constructed.

The aim sought by the proposed auditory therapy is therefore to re-establish relational structures through a correction of the defective initial conditionings.

Conclusion

What we have aimed at in this exposition is to bring out the idea that an audio-psycho-phonological assessment must be inserted into every clinical investigation. We remain persuaded that the few steps undertaken in this domain are only the outline of a vast study on the relations which exist between the psyche and the body in their numerous interweavings and their psycho-somatic counter-reactions.

“Speak and I shall tell you who you are” is no longer dissociable from “and I shall tell you how you fare”. To be sure, we are not yet in a position, at present, to put systematically into application the techniques of investigation of language, but we think that, in the years to come, the progression in this direction will be such that linguistic trials will be inscribed within the framework of every clinical process.

Language is, moreover, one of the most effective means of penetrating into the problems of the life of relation, of adaptation to the environment, the immanent source of the psychic or somatic disorders that do not fail to manifest themselves. Language, in the circumstance, is a forerunner alarm sign which indicates to the warned ear of the clinician that his vigilance must be kept on the alert before even the premonitory disorder fixes itself.

The reader will forgive us for having delivered so much substance in so few words, but he will surely understand how difficult it is to treat in a few pages a subject whose breadth has not escaped him and whose importance remains considerable.

Clinical Examination - Pathology - Treatment

by A. TOMATIS

Extract from the Société de Médecine de Paris, Revue d’Enseignement Post-universitaire, no. 2, 1970

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A. TOMATIS: “L’oreille directrice”. Bulletin du Centre d’Études et de Recherches Médicales de la S.F.E.C.M.A.S., July 1953.
A. TOMATIS: “L’oreille et le langage”. Éditions du Seuil. Microcosme Collection, “Le rayon de la science” series.
A. TOMATIS: “La surdité”. Éditions de l’Organisation des Centres du Langage.
A. TOMATIS: “La dyslexie”. Éditions de l’Organisation des Centres du Langage.