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Volume 96, Number 1 >
Pp. 23-27
7 Oxgangs Road, Edinburgh EH10 7BG, Scotland, UK
Anthony Babington was 24 and a company commander in the 1st Dorset Regiment when he was wounded by shrapnel in Holland early in the morning of 2 November 1944, in the aftermath of the Arnhem campaign. His story is in his own writings1,2 and in his army medical records3, both quite exceptional in detail and perception.
CASE HISTORY
He was felled by the shell burst and briefly unconscious, and had sustained a left parietal penetrating injury which made him mute and hemiplegic. He was evacuated by stretcher, ambulance and plane. ‘During the flight I felt something stiff and cold on the right side of my chest. I puzzled about it for a while before it dawned on me that it was my right arm, heavy, insensate and quite paralysed... At one point I thought the end had come...’2. On the evening of the same day he reached the Military Hospital for Head Injuries at St Hugh's College, Oxford.
X-rays showed ‘a large MFB [metal foreign body] deep in the left parietal lobe just above the ventricular roof but may impinge on it.’ On 3 November Major C A Calvert4 operated on a semiconscious, globally aphasic man who had a right hemiplegia, hemianaesthesia, and hemianopia (Figure 1):
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‘... wound stank horribly... contamination with hairs and dura down brain track—marked oedema... toothpaste brain and clot... bone chips indrawn about 2 cm, metallic body about 4 cm from cortex, inner end about 6 cm... debrided... many toothpaste pockets extending laterally from track... area of cortex destruction about 4 cm x 4 cm... gush of CSF... ventricle into which MFB had protruded... 5000 U penicillin... dura left open... drain...’3.
After the operation Anthony Babington recalled1,2 gesticulating with his left hand to indicate that he needed treatment for head pain, something to drink, or a urine bottle. When asked to write his home address with his left hand ‘I knew exactly what I intended to write but I was dismayed to find myself drawing a series of short and very crooked lines... when shown a newspaper I could see letters but not understand them... might have been Chinese.
‘I woke one morning feeling slightly better. The night sister said "You are over the worst and out of danger... The doctors think you might get back a little movement in your right side, in the leg at any rate. But I am afraid they think it unlikely that you will ever be able to speak again".’
This forecast also ended a close personal relationship.2
Like Dr Johnson after his stroke5, he was comforted by his ability to say the Lord's Prayer silently.
In the medical records3 Captain G Northcroft wrote on the fourth postoperative day that there was now no hemianopia and that he could indicate yes and no by head movements. On 11 November he could just utter ‘well’, and on the 14th there were a few single words, and ‘speech therapy’ was started by a sympathetic lady who had trained as a singing teacher and by a Norwegian fellow patient1,2.
Early progress
He began to try to read a book: ‘... laborious... words slowly...
wrong lines... Writing even more discouraging... left hand awkward... entirely
lost the art of spelling... even ridiculously simple words. I did not seem
capable of visualising them on
paper’1. Three
months later his speaking, reading and left-handed writing had improved enough
to make feasible his intention to take up law studies, according to
psychometric testing by Major W R
Reynell3. He was
discharged from hospital in May 1945, with the advice to take up market
gardening. But he went to the Middle Temple later in 1945, and in 1948 he
qualified as a barrister, having had the use of an amanuensis for his written
examinations1.
The next 57 years
Ever since, his speech has continued to be slow, with a slight stammer, and
persistent inability to utter some words which he has managed to cover by
circumlocution; there are no wrong words. His reading also has remained slow,
both silent reading and reading aloud, but adequate for public performance. He
achieves a slow sinistral script which looks like his old dextral writing but
with persistent mis-spelling, even of common words
(Figure 2). He has been
rendered moderately dyscalculic by the injury, but considers his powers of
reasoning, and his memory for abstract data, for places and faces, as good as
before. He never experienced difficulty in understanding spoken speech. He had
a successful career as a barrister, at first in chambers, then for 8 years as
metropolitan magistrate, and lastly as circuit judge until beyond the usual
retiring age2.
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He has also written ten books, three of which were republished. Two are autobiographical1,2, the others are on legal and military history. His writings were influential in changing the public attitude to the execution of soldiers in the First World War for desertion and for cowardice, and to ‘shell shock’.
He had bad headaches in the first post-traumatic year, and intermittently later, related to low-grade skull infections until the tantalum skull implant was removed by Mr C Connolly in 1975. In the early years he had a few partial (right hemisensory) seizures, treated with phenobarbitone; he stopped taking this because of retardation, and the attacks have remained in abeyance. The right hemisensory loss has persisted, as has near-total paralysis of the right upper limb. The initial right lower limb paralysis improved sufficiently to allow pleasurable walking of up to five miles, but has worsened in his 70s, and he is now limited to a slow few hundred yards with a walking-stick. He also weathered long spells of inpatient treatment, with a lobectomy in 1951, for pulmonary tuberculosis, and later acute surgery for a duodenal ulcer, and aortic valve surgery. Despite his disabilities he retains his joie de vivre at the age of 82.
COMMENT
Site of lesion and clinical features
Speedy and expert neurosurgery, as well as the newly available penicillin,
were lifesaving. But he was left with a deficit of parietal cortex (‘4
cm across’) extending deeply through the white matter down to the
lateral ventricle. There must also have been damage to the left (frontal)
motor cortex, or to its connections, to cause the right hemiplegia.
The initial aphasia was termed ‘global’3, but he did not seem to lose understanding, even at his worst. Much of this, like the transient right hemianopia, must have been due to cerebral oedema. The penetrating shrapnel and bone chips impinged just in front of, and above, the temporal gyri described in 1874 by Wernicke6 as the site of sensory (i.e. receptive) aphasia, and a little further from Broca's more anterior low frontal site of motor or expressive aphasia (Figure 3). Both Broca and Wernicke made their discoveries from cases of cerebrovascular disease; Broca in particular was severely criticized in 1906 by Pierre Marie7 for anatomical oversimplification, as Broca's extant post-mortem specimen had shown more extensive lesions than just in the left second and third frontal convolutions.
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Accordingly aphasiologists preferred the ‘crisper’ trauma material from the wars of the last two centuries—Larrey8 from the Napoleonic wars, Henry Head9, Pierre Marie10 and Kurt Goldstein11 from the First World War, and A R Luria12 and Ritchie Russell13 from the Second World War. The studies of the last dealt with the 1100 head injuries treated at St Hugh's College, Oxford3 and the other British neurosurgical units.
While confirming the great importance of Broca's frontal and Wernicke's temporoparietal speech areas, both the Russian12 and the British13 compositions agreed on a wider left hemisphere distribution of lesions causing aphasia, but clustering around Broca's and Wernicke's areas, with, conversely, an absence of aphasia after more distant left hemisphere lesions (Figure 4). Right hemisphere lesions were exceptional in causing aphasia, even in left-handers. Freda Newcombe14 conducted a more intensive late assessment in 153 selected patients from the above 1100 military head injuries, noting in particular professional achievers. Anthony Babington is not discernible in her14 or in Russell's13 accounts.
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Recovery
Apart from the spontaneous resolution of brain oedema after C A Calvert's
operation, leading to the improvement recorded in the first few weeks, his
later recovery may be attributed in part to his determination and vocation.
There is also the theoretical concept, in a young man, of reserve brain
potential and
‘plasticity’15,
linked perhaps to the degree of left hemisphere dominance and right hemisphere
speech
functions16.
The notion of left hemisphere dominance goes back to the observations of Dax and Broca in the 19th century, and has an anatomical basis in specially developed areas of cortex on the left side17. While most left-handers, like right-handers, have their speech ‘centres’ on the left side of the brain, as judged by Wada's intracarotid sodium amytal injection testing18, they may still recover better than right-handers after left hemisphere lesions with aphasia12,19. One needs to consider degrees of left-handedness or of ambidexterity, and any family history of left-handedness, or left eye or ear dominance16. While dextrad for everything else, Anthony Babington was a left-handed bowler at cricket and a left-footed footballer as a boy.
Beside the overall better outlook in traumatic than in stroke aphasia20, Babington's high initial intelligence was probably also a good prognostic factor21, as opposed to the adverse prognostic factors of the immediate severity and ‘globality’ of the aphasia10 and of the concomitant hemiplegia.
Did the so-called speech therapy help his recovery? While there has been continuing interest in communication skills after severe brain traumas22, there has been no critical study of the value of speech therapy in aphasia23. The bulk of aphasia cases in peace-time are due to strokes, with inevitably great variability and a worse prognosis than in the mostly younger sufferers of traumatic aphasia—and, indeed, amateurs may do as well as trained speech therapists in stroke aphasia24.
Modern investigations such as positron emission tomography (PET) scanning25 and functional magnetic resonance imaging (fMRI)26 which can demonstrate changes in regional cerebral blood flow during various language tasks have greatly advanced our ideas of the anatomy and physiology of speech, beyond what had been derived from the deficits resulting from brain lesions: it has unfortunately not been possible to study Anthony Babington's communication skills in this way.
That he achieved so much in his two vocations as a lawyer and as a writer may serve as a warning to dismal prognosticians, and as a tribute to his personality.
Acknowledgments
I am most grateful to His Honour Anthony Babington for permission to write about him, and for his help; also to the late Dr Freda Newcombe for giving me access to the medical records at Oxford. I am obliged to David Jellinek and Charles Romanowski, of the neurosciences department, Sheffield, for demonstrating the neuroanatomy of the lesion by MRI superimposition.
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