J. Neurol. Neurosurg. Psychiat., 1952, 15, 184.

DYSPHASIA IN LEFT-HANDED PATIENTSWITH UNILATERAL BRAIN LESIONS

BY

M. E. HUMPHREY and 0. L. ZANGWILL

Fror,n the Department of Neurology, Radcliffe Infirmary, and the Institute of Experimenital Psychology, Oxford

The importance of the left cerebral hemispherefor speech and allied functions in right-handedpersons is an accredited fact, whatever may be itscorrect explanation. In the same way it hascommonly been assumed that in the case of left-handed persons the same importance attaches tothe right hemisphere. Thus unequivocal handed-ness, whether right or left, has been thought toimply a corresponding " dominance " of thehemisphere contralateral to the preferred hand.

Evidence concerning the cerebral organization ofleft-handed people has inevitably been scarce. Oneof the earliest cases on record is that reported byHughlings Jackson (1879), of motor aphasiaassociated with left-sided hemiplegia in a railwaysignalman whose speech was restricted to the singlerecurring utterance, " Come on to me !" ; thepatient was said to be left-handed. Later Head(1926) reported a case of semantic aphasia in a manwho had always been strongly left-handed, " evenusing a chopper with the left hand"; here againthe lesion was right-sided. Exceptional cases havebeen reported from time to time in which aphasiawas associated with a lesion of the hemisphereipsilateral to the individual's preferred hand.Bramwell (1899) suggested that in most of thesecases, which he termed " crossed " aphasia, enquirywill reveal first that the patient's ancestors were allright-handed, and secondly that the patient himselfhas been taught to write with the right hand and/oris ambidextrous. Crossed aphasia as a transitoryphenomenon is not uncommon, and was in Bram-well's view due to the fact that in certain individualscorresponding areas of the minor hemisphere playa definite, if subordinate, part in speech, so thatinjury to such areas gives rise to mild and transientdysphasic symptoms. Persistent crossed aphasia,on the other hand, was in Bramwell's experienceconfined to left-handers, except where there wasreason to suppose that the normal development ofthe speech centres had been interfered with in earlylife. It may be added that the present writers have

searched the literature in vain for a convincing caseof crossed aphasia in an overtly right-handedperson.The problem of ambidexterity and mixed hand

dominance has seldom been considered from thispoint of view. Some writers have suggested thatbilateral cortical representation of speech functionsis to be expected in ambidextrous cases, as also inyoung children before unequivocal hand dominancehas been finally established. Gowers (quoted byMcNaughton-Jones, 1914), in his plea for thecultivation of ambidexterity, put forward the viewthat " as far as can be judged from present facts, bythe use of both hands equally for all manualoccupations, including writing, we should secureimmunity from grave defects of speech" (i.e., ifdisease of either hemisphere were to occur). Sucha view appears to have been founded on somewhatdubious theoretical considerations rather than onclinical and pathological evidence, which at thattime was virtually non-existent. Admittedly Bastian(1898) had reported the case of an ambidextrousmarine engineer who developed complete motoraphasia in association with right-sided hemiplegia.The patient continued to write fluently with hisleft hand, and before his illness had been able touse both hands equally well. Speech recoveredsuddenly 24 days after the onset of the attack.However, while doubtless the early literature ofaphasia contains a few other unusual cases of thistype, it is only comparatively recently that systematicstudy of the laterality of brain lesions causingaphasia in relation to handedness has been attempt-ed. Thus Weisenburg and McBride (1935) foundthat among 92 cases of unequivocal handednessthere were only four exceptions to the rule thataphasia results from a lesion of the dominanthemisphere as indicated by handedness, and fails toresult from a lesion of the minor hemisphere; inother words, the inference from handedness tocerebral dominance was justified in about 95°, oftheir cases. Of their five ambidextrous cases, three

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developed aphasia from a left-sided lesion and onefrom a right-sided lesion.

Chesher (1936) summarized the evidence from166 cases of circumscribed lesion within the speecharea of one or other cerebral hemisphere. Hefound that where a patient was strictly unilateral inhis hand dominance, be it right or left, hemispheredominance followed the normal rule. (There were,however, only three purely left-handed patients inhis series.) Where on the other hand a naturallyleft-handed patient had been taught to write withthe right hand, thus acquiring a measure of ambi-dexterity in some cases and a mixture of handpreferences in others,- aphasia appeared with lesionsof either hemisphere. In all there were nine suchcases; all showed aphasic symptoms, the lesionbeing left-sided in five cases, right-sided in four.In regard to this atypical group Chesher suggestedthat " the tentative conclusion is justified thattheir language mechanism is unlateralized, so thata lesion on either side is capable of producing adisturbance of speech".

Needles (1942) quoted four cases in which thecommon factors were loss of function of the righthand, adoption of function by the left hand, andonset of aphasia at a much later date. The lesiongiving rise to the aphasia was left-sided in two casesand right-sided in the other two. He adoptedChesher's hypothesis of bilateral cortical represen-tation of speech in explanation of these cases,while at the same time suggesting that in naturallyleft-handed persons training of the right hand, forexample, in writing, may result in the left hemi-sphere acquiring dominance for speech. Anaccount by Tilney (1936) of the circumstances ofhis own aphasia is of interest in this connexion.Conrad (1949) studied 47 cases of traumatic brain

lesion in markedly left-handed patients. Of these18 showed some form of speech disturbance, thelesion being left-sided in 10 cases, right-sided inseven, and bilateral in the one remaining case.Severe and lasting dysphasic syndromes wereobserved in five cases of left-sided and the samenumber of right-sided injuries; other left-handedcases showed only slight and transitory dysphasiawhere the nature of the injury was such as wouldhave been expected to cause a more profound lossof speech. Thus left-handedness, in Conrad'sview, differs from right-handedness in that it doesnot imply strict dominance of the contralateralhemisphere, but on the contrary shows all the signsof less advanced specialization.

In view of the limitations and inconclusiveness ofthe evidence produced by previous writers, it wasfelt that any fresh cases bearing on the problem of

cerebral dominance should be placed on record.The authors were fortunate in having access to thedetailed histories of approximately 1,150 cases ofpenetrating brain wounds from the recent worldwar. These were studied from the view-point of psychological functions in general, butespecially with reference to handedness and thedifferent effects of left- and right-sided cerebrallesions. In what follows we shall be concernedprimarily with the various manifestations ofdysphasia, although other symptoms will be notedas and when they are considered relevant.

Selection of CasesDespite the large total of cases surveyed, the

necessary information did not prove to be availablein a sufficient number to enable a statistical studyto be made, as was originally planned. (Left-handedness is, after all, a comparatively rarephenomenon, being confined in its more obviousforms to about 7 to 8% of the population, accordingto conservative estimates (Wile, 1934)). The onlyalternative was to select from the total materialcases showing clear evidence of a marked tendencytowards left-handedness and to report them insome detail. It was hoped that even a very smallnumber of carefully studied cases might provideuseful information concerning the degree of cerebraldominance associated with atypical handedness.The selection of cases was based on the following

criteria. (1) the lesion must be strictly unilateral.(2) The patient must have been tested specificallyfor dysphasia by adequate methods and at varyingintervals. A psychological report based on routinepsychometric tests, while clearly desirable, was notconsidered indispensable. (3) In the absence ofdysphasia the lesion must be such as would beexpected to interfere with speech functions if theaffected hemisphere were the dominant one.(4) Adequate information was required as to thepatient being left-handed; mere indications thatthe patient was not entirely right-handed wereconsidered insufficient. (5) The patient should beof at least average pretraumatic intelligence, in sofar as could be judged from his personal historyand/or psychological tests. (In the event most ofthe patients selected were of above average intelli-gence.) This proviso was made in order to excludecases of so-called " pathological " left-handedness,as described by Russell Brain (1945).

This method of selection yielded a total of nomore than 10 cases, in five of which the lesion wasleft-sided and in five right-sided. All showedsome degree of dysphasia in the early stages ofrecovery, and all were predominantly left-handed.

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It must be emphasized that, with one or two excep-tions, the writers were unable to examine thesecases personally, and were thus obliged to rely onthe written testimony of other observers and, insome cases, of the patients themselves.

Cases of Left Hemisphere InjuryThe severity of the dysphasic symptoms, both

initial and residual, in our selected group of left-handed patients with left hemisphere injuries showsmarked individual variations, as the followingbrief histories reveal. In only one case, however,was the speech loss so severe as to be permanentlydisabling.

Case 1 (No. 14718).-A private, aged 36, normallyleft-handed except for writing, sustained in May, 1944, asevere penetrating wound of the left hemisphere whichcaused gross destruction of the temporal lobe. Noinformation is available as to his condition in the twoyears immediately following his injury, but when re-admitted in July, 1946, his general physical conditionwas good. Neurologically he showed a right upperquadrantic field defect, but remarkably little sensori-motor disability. Post-traumatic amnesia was assessedat between three and four weeks. An electroencephalo-gram showed unusually severe abnormality over a widearea in the left hemisphere. Psychological examinationrevealed a severe disability in the verbal field withmarked impairment of reading and writing and severedyscalculia. Spontaneous speech was sometimes nearlynormal in grammatical form, choice of words, andenunciation, and at other times he managed to convey agood deal of what he wanted to say by drama, or bywriting an odd word or figure. He had great difficultyin naming common objects, but expressive speech,reading, and writing were all more impaired than com-prehension. He showed marked perseveration, andpsychometric tests gave evidence of gross generalintellectual loss.When re-examined in September, 1947, his spon-

taneous speech showed an increase in vocabulary andhe could name 95% of objects presented, but the so-called " telegraphic " style was still in evidence. Writinghad improved but reading remained at the same rudi-mentary level. In addition, a slight receptive difficultywas suggested by his tendency to answer questions ofhis own instead of those put by the examiner.

In April, 1949, the patient's speech therapist reportedthat he was still suffering from a very severe expressivedysphasia, dysgraphia, and dyslexia. There was, how-ever, a considerable improvement in his receptivepowers, and he was continuing to make slow but steadyprogress in both expressive speech and reading. Beforethe war he had been a shipping clerk, but his disabilityprevented him from returning to his former occupation,and he was advised instead to take up some form oflight manual work.As regards handedness, the severity of dysphasia

made it impossible to obtain a full and accurate account,

but it was ascertained that before his injury he had usedthe right hand for writing and drawing (presumablyowing to early training, though this was never estab-lished with certainty), but would throw and play tennisleft-handed. He was left-footed.A lesser but well-marked degree of speech

impairment was shown by the following patient:

Case 2 (No. 9616).-An officer, aged 23, naturallyleft-handed but partially ambidextrous, sustained apenetrating mortar shell wound of the left parieto-occipital region in August, 1944. Operation (Lieut.James) revealed that the dura was torn and the brainlacerated. Pulped brain, clot, and three bone chipswere sucked out and a metallic foreign body removed.The bone defect, which was in the left mid-parietat areain the inter-auricular line, measured 5 x 3 cm. Neuro-logically his main symptom was a right-sided hemi-paresis; there was no hemianopia.

Initially he showed complete motor aphasia, butcould understand the spoken word and obey simplecommands. Three weeks after injury he was able tosay " yes " and " no " and " good morning ", but therest of his speech was slow and laboured and full ofmistakes, which, however, he was quick to recognize.He was thus unable to name objects or read aloud buthe could write down the names of objects correctly withhis left hand and succeeded in writing a letter more orless correctly and without undue difficulty.

Five weeks later (about two months after injury) theword-mutilations had disappeared and he was speakingwith what would pass for an ordinary stammer. Psycho-logical examination at that time revealed little evidenceof intellectual impairment apart from a slight residualdysphasia; memory and abstract thought were almostunimpaired, but there was a tendency, probably dys-phasic, to make slips, e.g., in letter writing. Pre-traumatic intelligence was judged to be well aboveaverage.When re-admitted in December, 1945, his main

physical disabilities were the remnants of his righthemiparesis and some sensory abnormalities in theright hand. Speech still showed a slight hesitation andslowness but on the whole had recovered very well.There was an occasional mild paraphasic error, andspelling was slow and a little uncertain. Reading andwriting were both apparently normal, but there wassome slight impairment in calculation. He had mean-while been attempting a certain amount of difficultreading (e.g., Trevelyan's English Social History) andhad found some difficulty in retaining the knowledge andideas thus acquired. The more complex material hehad to read some six or seven times before being able tomemorize it, though comprehension of the meaning ofindividual sentences was little impaired. Once he hadcommitted something to memory he considered that hispowers of retention were as good as ever. He was alsoaware of a slight impairment of constructive thought,and when writing an essay was apt to lose the thread ofthe argument. In general, however, he had made areasonably good recovery from his injury, and his

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intellectual capacity had suffered only at the higherlevels of conceptual thinking.

This improvement was subsequently maintained andhe was able to manage successfully clerical work of amoderately responsible nature. When interviewed byone of us (M.E.H.) in November, 1950, he could addlittle to the account so far given. He stated that hismemory was now " extraordinarily erratic ", especiallyfor names, yet on tests of immediate memory, bothverbal and visual, he was easily within normal limits.His subjective feelings of memory impairment becamemore readily understandable in the light of his statementthat at school his capacity for rote learning had beenwell above average. Certainly he had made an excellentrecovery from his early dysphasia, the residual signs ofwhich were obvious only under unfavourable conditions,such as fatigue or emotional stress. In view of hissuperior abilities it was perhaps too much to expect thathe would ever regain full command of his intellectualpowers, yet for all practical purposes he was back tonormal.

Handedness was of considerable interest in this case.Though naturally left-handed, attempts had been madeto convert him to right-handed writing over a period ofabout eight months, at the age of 8 or 9. These attemptshe had resolutely resisted and he had in fact continued towrite with his left hand, though acquiring a certainambidexterity, especially for games, such as tennis, inwhich he would transfer the racket from his left to hisright hand in order to avoid back-hand shots. Inmost things, however, he always preferred to use hisleft hand and regarded himself as primarily left-handed.He was also left-footed and left-eyed. He did notknow of any left-handedness in his immediate family.

That dysphasia may involve a selective amnesiafor words without any appreciable degree ofgeneral memory disturbance is commonly acknow-ledged. In the following case, however, where theresidual dysphasic handicap was largely confinedto a difficulty in word-finding, there was also evi-dence of a more widespread disorder in the memorysphere.

Case 3 (No. 2671).-A regular officer, aged 44,naturally left-handed, sustained a severe penetrating gun-shot wound of the left fronto-temporal area in October,1940. The bullet entered the left orbit and the point ofexit was in the posterior part of the left temporal lobe.There was haematoma of the left orbit, and the left eyewas destroyed. Operation (Mr. Summers and Mr.Oliver) was performed on the following day, revealingcomplete laceration of the orbital structures, and theremains of the left eye were removed. A secondoperation (Mr. Oliver) was performed a fortnight later,in which small pieces of necrotic bone were removed.The duration of post-traumatic amnesia was estimatedas approximately six weeks, and retrograde amnesiaas two days.The patient was at first unconscious, and had a right-

sided facial paralysis. Two days after injury he recog-D

nized his surroundings, and was able to ask for a bottle.Four days later he was reported as occasionally talkingrationally, but it was not until three weeks after injurythat he began to show any marked improvement in hismental condition. At this time he was described as" quite intelligent, but still aphasic ". By the end ofNovember, 1940, (seven to eight weeks after injury) theaphasia had practically cleared up, and his memory wassaid to be very good except for the names of people andplaces.When examined in December, 1940, there was some

loss of 2-point discrimination in the right hand but noother abnormal neurological signs, and he was reportedto have made a good recovery from a very severe injury.Owing to post-traumatic amnesia he had no memory ofthe period during which he had been completely aphasic.His main complaint now was of his speech and memory.He had great difficulty in expressing himself and inrecalling the names of objects; though usually able toproduce the correct name eventually, he was occasionallyat a loss, e.g., over a pencil-sharpener, where he wasobliged to resort to pantomine. Except when tired hecould grasp and define the meaning of words, but hisreaction to questions was slow, suggesting that oralcomprehension was probably a little impaired. Writingwas affected to about the same degree as speech; thushe was at first unable to write a cheque to his satisfaction,could not think of the words he wanted, and when hedid attempt to write the result was an illegible scrawl.He also had great difficulty in spelling even simplewords. The following is a specimen of his writing atthis stage: " I have a shoot of 2,500 acres, where gameare very .... (long pause, and then) aborive (for " abun-dant "). No shooting has been done. I have been inPalestine, Iraq and Persia, the journey is best by travellingto Kurdistan. However it will be impossible to useyour car when it is park then use your mule." Readingon the other hand was relatively easier: a little slowbut, except when hurried, fairly accurate. He admittedto some difficulty in concentration and in comprehensionof the total meaning, but was sure that he could identifyand understand individual words. In addition to hisspecific loss of memory for words and for the names ofacquaintances, there was evidence of a more generalmemory deficit, in that he was unable to recall recentevents, even those after the period of post-traumaticamnesia, and would often forget things he wanted to do.On his return to duty in May, 1941, (about seven

months after injury) he was employed in an admini-strative capacity. Subjectively both speech and memorycontinued to improve, but he found himself frequentlyunable to memorize instructions. Thus he would visithis Commanding Officer, be told to do something, andby the time he had got outside the door he had forgottenwhat he had to do. This difficulty he overcame tosome extent by writing down notes of all his orders.Physically he felt " as fit as hell"; his main complaint,in fact, was his memory, and in particular he wasdistressed by his inability to recall the names of race-horses.When next examined in December of the same year,

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he reported considerable further improvement in bothspeech and memory. His difficulties remained of muchthe same character, but he was learning to adjust tothem and felt that he could manage his work moreadequately. On the other hand a report from hisCommanding Officer stated that "his memory cannotbe relied upon, and his general behaviour is that of aman who has not entirely recovered from a seriousinjury ". His difficulty in word-finding was still verymarked in ordinary conversation, especially when hewas searching for some precise expression, for example:" Battleships are no damn good, they're too big, theycan't .... what's the bloody word I want, you can'thide them." Despite this difficulty, or possibly onaccount of it, he showed a remarkable capacity formaking himself understood by circumlocution, gesture,and vocal inflection. His powers of oral comprehensionremained appreciably retarded, and he still complainedof difficulty in following a rapid conversation. Readingand writing were apparently back to normal, but spellingwas still considerably disturbed, e.g., he mis-spelt aboutone out of every three words from the scholastic agelevel of 10 upwards (buisness, discease, promiscuse).His behaviour here suggested that he relied very muchon the auditory word-image for his spelling. Onpsychological examination, his dysphasic handicap didnot prevent him from obtaining a very superior score(38 plus) on the Stanford-Binet vocabulary test, and hewas able to repeat seven digits forwards with an effort.His reproduction of the "cowboy story " was good.On a picture-naming test he scored 32 out of a possible36 successes, his only obstacles being toy truck, dressing-table, comb, and alarum clock. Simple tests of visualmemory revealed no significant impairment. A score of33/60 on the Raven matrices hinted at some degree ofgeneral intellectual deterioration, although it wasdifficult to determine how much of the test result was dueto his impaired efficiency and how much to his tempera-mental response to the test situation. The generalimpression was that " the impairment of learning andconcentration is comparatively little and probablycapable of further improvement; being an extrovertedcharacter and a versatile personality, he copes with hisword-amnesia rather well and will do better still underconditions where his temperament does not carry himaway ".Although he had had a generalized epileptic attack a

few months previously, an electroencephalogram showedno evidence of abnormality, and there were no abnormalneurological signs.

Very little information is available as to his sub-sequent progress. When re-admitted briefly in August,1949 (nearly nine years after injury), he stated that hisgeneral health was still good, and that he had beentravelling all over the world. Subjectively his speechwas almost normal, although he would occasionallybring out a word the exact opposite of what he hadintended.As regards handedness, this was another case of a

naturally left-handed man who had been taught towrite with his right hand at an early age. He did not

lay any special claim to ambidexterity, and did notknow of any left-handedness in his immediate family.

Two further cases of left hemisphere injury inwhich the dysphasic manifestations were lessstriking, may be reported more briefly.

Case 4 (No. 9531).-A private, aged 30, showed earlyglobal dysphasia with mild right-sided hemiparesisfollowing a deep wound of the left frontal lobe pene-trating to the ventricle; there was probably somedegree of intellectual deterioration, but he achieved agood physical recovery and appreciable recovery oflanguage functions within six months, although stillliable to difficulties of word-finding 18 months afterinjury.Case 5 (No. 10213).-A corporal, aged 32, who was

naturally left-handed though partially ambidextrous,also presented a similar picture of early global dysphasia,with associated right hemiplegia, following a penetratingwound of the left parietal lobe. Gradual recoveryfrom the hemiplegia took place over the first fourmonths after injury, with similar improvement inlanguage functions.

Cases of Right Hemisphere InjuryIn the group of left-handed patients with right

hemisphere injuries, variations in the severity ofdysphasia were equally apparent, and in one casethere was virtually no evidence of any disorder ofthis kind. Since we were concerned, among otherthings, to stress the liability of left-handed personsto speech disturbances even when the lesion isstrictly confined to the left hemisphere, most of ouravailable space has been given up to describing suchcases. We shall, however, describe a case of righthemisphere injury in a left-hander sufficiently toindicate that a comparable language disability maybe involved.Case 6 (No. 9501).-A private, aged 21, strongly left-

handed, was wounded by a shell fragment in the rightmid-parietal region in August, 1944. The woundextended to the body of the lateral ventricle, and therewas a large right extradural haematoma arising fromthe torn posterior branch of the middle meningealartery. Operation (Lieut. Guthkelch) was performedwithin 24 hours for removal of a metallic foreign bodyand indriven bone fragments.On examination the principal neurological signs were

left spastic hemiplegia, supranuclear paralysis of theleft side of the face and tongue, and some left-sidedsensory loss. There was no hemianopia. Post-trau-matic amnesia extended over about five days, retrogradeamnesia being only momentary. There was almostcomplete motor aphasia with associated dysgraphia, butoral comprehension appeared fairly good despite sometendency to perseverate in his actions.A fortnight later he still had great difficulty in pro-

ducing a complete sentence, and was frequently at a loss

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for the word he wanted. Objects were for the mostpart named correctly, though there were occasionalfailures. In addition he had considerable dyslexia,reading about 50% of words incorrectly, without anyapparent insight into his errors.A month after injury the dysphasia had improved to

the extent that he now had no difficulty in sentence-construction, word-finding, or object-naming, but onlyin pronunciation. Reading, however, was still muchimpaired, and this defect was still in evidence threemonths later, when he tended to mispronounce somewords and insert others which were not there, thoughwithout appreciably altering the meaning of sentences.Writing could not be tested properly owing to thehemiplegia. (The patient wrote with his left hand.)Calculation was not extensively tested, but he wasdistinctly slow at simple arithmetic, especially sub-traction and multiplication. General memory was alsoaffected, in addition to his specific disability in theverbal field.On psychological examination four months after

injury, he was only slightly dysphasic in ordinary con-versation; reading was slow but fairly accurate. Hisspelling, which he claimed had been above averagepreviously, was now very poor, and this in addition tothe hemiplegia made letter-writing very troublesome.(" Raise" and "rough " correct; "pleasant" =" plesent"; unable to attempt " saucer ", " answer "or" Wednesday ".) In arithmetic he only just succeededwith two out of three average adult problems, and wasvery slow on these; here also he claimed to have beengood before his injury. Verbal memory tests were notvery well done: he repeated seven digits forward andfive backwards, but took five attempts to master theBabcock sentence, and retained only 11 items out of 20from a story of 20 lines. Regarding general intellectualcapacity, vocabulary, general information, and com-prehension (Wechsler) were all above average, but hisscore of only 39/60 on the Raven matrices suggested thepossibility of some degree of intellectual deteriorationat this stage. Moreover, although attention was saidto be well sustained, there was a definite impairment oflearning capacity on non-verbal tests. By the time ofhis discharge from hospital shortly afterwards he wasexpressing himself quite adequately, but complained thathe still had difficulty with the longer words-" mytongue won't do what I want it to ".When re-admitted in August, 1945, a year after

injury, he still showed moderate spasticity of the left legand arm, with some sensory abnormalities. In thepatient's own opinion language functions, memory, andgeneral intellectual capacity seemed to have improvedalmost up to his pre-traumatic level, although he ad-mitted to some difficulty in concentration, e.g., whenplaying chess or writing letters. On examination,however, his speech was still slightly hesitant andcalculation slow.A second operation (Capt. Northcroft) was carried

out to remove an indriven bone fragment. Degeneratedcortex was found adhering to the dura.When re-examined four months later he was able to

read with normal fluency provided he took his time, andhe had learnt to write quite well with his right hand,though he was still apt to make mistakes. On enquiry,he admitted that spontaneous speech still caused him alittle difficulty, but it appeared almost normal exceptunder stress. On an object-naming test he hesitated ononly one out of 12 objects (wrist-watch = " winder ").Owing to the development of post-traumatic epilepsy

he was detained in hospital under observation for thegreater part of the next 18 months. When finallydischarged in May, 1947, he was able to resume hispre-war work (hosiery dyeing) for a short time.

Regarding handedness, there can be no question thatthis patient was strongly left-handed before his injury,and had always written with his left hand. Since hisinjury he has been able to do very little with his lefthand owing to residual hemiplegia.

Case 7 (No. 8846).-On an officer, aged 32, who hadbeen left-handed apart from writing, both the injuryand the ensuing dysphasia were broadly comparable tothe preceding case. Since, however, this case presentedin addition to the dysphasia certain other features,notably impaired visualization and topographicalloss, which were thought to have a special bearing onthe problem of minor hemisphere function, it has beenmade the subject of a separate communication (Hum-phrey and Zangwill, 1952).

In our next case the outstanding feature was apermanent agraphia, other language functions beingonly temporarily impaired.

Case 8 (No. 9982).-A corporal, aged 26, naturallyleft-handed though partially ambidextrous, was woundedby a shell fragment in the right frontal lobe in September,1944, causing extensive destruction of brain tissue in thefronto-parietal region. Operation (Capt. Turner) wasperformed to remove a large, indriven bone fragment,and necrotic brain was sucked out, leaving a shallowlaceration under a large dural defect. Early neuro-logical signs included a left hemiplegia with facialparesis, sensory and Babinski loss, and left homonymoushemianopia.When first examined he was sufficiently conscious to

obey simple commands, but would not attempt tospeak or answer questions. Three weeks later it wasstill difficult to elicit other than monosyllabic answersfrom him: moreover his speech was slurred, thoughsome of his words were quite clearly enunciated. Hehad no apparent difficulty in naming objects. Whenasked to write his name he seemed quite unable to putpencil to paper, merely remarking " it might be signingmy own death warrant ". In attempting to read aloudhe would read several words at a burst, then miss out anumber and pick up a few more later in the paragraph.He showed no sign of understanding simple writtencommands. A month after injury his speech functionshad recovered very well, apart from writing: thus hewas able to carry out complicated oral commands,could express himself well, read normally and give the

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gist of what he had just read, yet he could manage no

more than an indecipherable scrawl with his right hand,though he seemed quite confident that he would be ableto write his name. (It must be borne in mind, however,that the patient had always written with his left hand forpreference before his injury, though he claimed to havebeen able to write with his right hand to a limiteddegree.) He also showed considerable impairment ofcalculation: simple feats of subtraction or multipli-cation were within his grasp but he failed consistentlyin his attempts to add double figures. He furthercomplained of difficulty in recognizing people and infinding his bed in the ward.Psychometric tests in December, 1944, gave evidence

of marked intellectual deterioration: vocabulary,general information, and comprehension (Wechsler)were somewhat above average, corresponding to IQ 110,but he scored under 20 on the progressive matrices, andmemory and learning capacity were noticeably impaired.Spelling was about average. At the time of his dis-charge from hospital in May, 1945, his general conditionwas almost back to normal, but his ability to write withhis right hand had not improved.

In May, 1946, he was re-admitted following persistentattacks of traumatic epilepsy. Meanwhile the left leghad improved immensely, but there was still severe

spasticity of the left arm. There was partial improve-ment in the hemianopia. He stated that his powers ofreading had improved tremendously, and he was now

able to read a book right through. Writing, on theother hand, was very little improved. Thus an examiningneurologist commented: "A very interesting case of a

deep fronto-parietal injury in a left-handed man. Com-plete recovery of speech except for almost completeagraphia, suggesting that the 'writing centre ' is in thiscase entirely right-sided but that the rest of his speechfunctions were bilaterally represented ". There was no

evidence on psychometric tests of any appreciableimprovement in his general intellectual level. Calcu-lation was still definitely impaired, and there was probablysome verbal memory loss; for example, he was unablecompletely to master the Babcock sentence in thecourse of 10 trials. His behaviour in the test situationwas described as very " concrete " in Goldstein's sense.

More recent information indicates that the hemiplegiaand intellectual loss have left him permanently disabled,as might have been expected from the severity of hisinjury.The patient was naturally left-handed, but some

attempt had evidently been made to teach him to writewith his right hand since he claimed that he had previouslybeen able to write with either hand, though normallypreferring his left for this and most other purposes.

The two remaining cases of right hemisphereinjury deserve brief mention.

Case 9 (No. 9054).-A private, aged 31, who was

wounded by a shell fragment high up in the posteriorfrontal region, never gave any definite clinical evidence

of true dysphasia, but about six months after injury anexamining psychologist found, on the evidence ofselected verbal tests, a slight residual impairment oflanguage in both its expressive and receptive aspects.Spelling was also affected. He made a good generalrecovery, yet even as long as two years after injury,when he was admitted for skull repair, an examiningneurologist commented, "I think there is a minimalnominal dysphasia and slight dysarthria ". The patientalso complained of frequent memory lapses. Beforehis injury he had been left-handed for most purposesother than writing, but subsequently he found greatdifficulty in adapting to the change-over that was forcedupon him by the sensory loss in his left hand.

Case 10 (No. 10880).-A lance-corporal, aged 31,naturally left-handed but a right-handed writer, sustaineda severe injury of the right mid-parietal region, causingleft hemiplegia, cortical sensory loss, and slight slurringof motor speech but no true dysphasia. (Indeed, heremembered being able to speak immediately afterinjury.) There was no appreciable intellectual loss.

(A similar case of severe right hemisphere injury pro-ducing no obvious language disability in a patient whowas entirely left-handed has since come to our notice.)

Analysis of Case MaterialSite of Injury.-The anatomical distribution of

left and right hemisphere injuries in terms of areasof the cerebral cortex is shown in Table I.

TABLE ISITE OF WOUNDING IN THE CASES STUDIED

Site of Wound Left Hemisphere Right Hemisphere

Parietal .. .. ..1 2Posterior parietal 1 1Fronto-parietal 1 2Temporal .. .. .. -

Fronto-temporal 1 -

Handedness.-All patients had regarded them-selves as predominantly left-handed before theirinjury. Three patients in either group had beentaught to write with the right hand, while the othertwo had written with the left hand up to the time ofinjury. Further, at least two cases of left hemi-sphere injury and at least one (possibly two) ofright hemisphere injury had shown ambidextroustendencies. One may suggest that the latter werecertainly present to a limited degree in all cases ofleft hemisphere injury, but more doubtfully so inthe right hemisphere group. Residual physicaldisabilities resulting from the injury compelled analmost complete change of handedness in all theright hemisphere cases, although only two patients(Cases 6 and 8) had to change their writing hand.A peculiar difficulty in adapting himself to thechange of handedness was reported by only one

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DYSPHASIA RELATED TO BRAIN LESIONS IN LEFT-HANDED PATIENTS 191

patient (Case 9), although no doubt this wasexperienced to some extent in all cases; onepreviously left-handed writer (Case 6) learntsuccessfully to write with his right hand in the yearfollowing his injury.

Language Disorders.-The distribution of lan-guage disorders in the two groups (left and righthemisphere injuries) is given in Table IL.

TABLE II

DISTRIBUTION OF LANGUAGE DISORDERS IN THE CASESSTUDIED

Left Hemisphere Right HemisphereInjuries Injuries

Case No. 1 2 3 4 5 6 7 8 9 10

Expressionand/or word-finding . . + + ± + + + + ± + -

Comprehension + - + ± + + + ? -Reading ..+ + (+) + + + + + - -Writing ..+ (+) + ? + ? + + -Spelling .. + + ± ? ± + -Calculation . + + + + +Spatial sense. . . . . .+ + - _

Plus sign = impaired; minus sign = no evidence of impairment;(+) = probable slight impairment.

Owing to the varying intervals between successiveexaminations, the fact that the cases were seen bydifferent examiners at different stages, the diffi-culties which, in any case, would be involved intrying to determine at all accurately the degree ofimpairment, and in deciding whether such impair-ment is to be regarded as permanent, no attempthas been made to differentiate in Table IL betweenmild and severe, or transitory and permanent,grades of defect. Broadly speaking, however, itmay be noted that in the left hemisphere grouprecovery of language functions after periodsvarying from six months to two years was prac-tically complete in Case 2, very satisfactory inCases 3 to 5, and extremely limited in Case 1 (avery severe injury, involving gross loss of brainsubstance). Speech therapy was given in Cases 1,2, and 4. In the right hemisphere group, languagerecovery was complete in Case 7 with the help ofspeech therapy, and very satisfactory in Case 6;in Case 8 writing was the only language functionpermanently impaired; in Case 9 the degree oforiginal impairment was relatively slight, while inCase 10 language was never affected apart from amild slurring of motor speech. On the other handcalculation was permanently impaired in all theright hemisphere injuries except Case 10. Distur-bances of spatial sense were confined to two casesin this group. Residual dysphasia in almost all

cases of both groups took the form of a slighthesitancy of speech and difficulty in word-finding.The relative incidence of the various defects is

illustrated numerically in Table HI.

TABLE IIIRELATIVE INCIDENCE OF DEFECTS IN CASES STUDIED

Side of LesionDefect

Left Right

Global dysphasia .. 4 2Expressive and/or nominal dysphasia 5 4Receptive dysphasia .. 4 2Dyslexia .. 5 3Dysgraphia .. 4 2Spelling defects .. 4 2Dyscalculia .. 1 4

Thus if we exclude dyscalculia, which apart fromthe one case of severe and permanent dysphasia,where the lesion was left-sided, was confined to theright-sided cases, the incidence of dysphasic andother symptoms is consistently higher in the lefthemisphere group.

General Intellectual Capacity.-There is goodevidence that Cases 2 and 3 of the left hemisphere,and Case 7 of the right hemisphere, injuries weremen of superior intelligence, as judged by personalhistory and performance on the Wechsler tests ofvocabulary, general information, and comprehen-sion. The remainder were probably all of at leastaverage intelligence and in some cases a little aboveaverage. The balance between the two groups isapproximately even in this respect. Varying degreesof general intellectual deterioration, as measured bytests of sorting and of reasoning by analogy, weredemonstrated in three cases of left hemisphereinjury (Nos. 1, 3, and 4) and in all the right hemi-sphere injuries with the exception of Case 10.This deterioration was severe and caused permanentincapacity in Cases 1 and 8 (both very extensivelesions, left- and right-sided respectively), milderand with less harmful consequences in the remainingcases. A specific memory defect, as distinct fromsevere loss of general intellectual capacity, wasconspicuous in Cases 3 and 9, left- and right-sidedinjuries respectively.

Physical Signs.-Hemiplegia was severe andresidual in Cases 2 and 5 of the left hemisphereinjuries, and in all the right hemisphere injuriesexcept Case 9, where it was mild and transitory.A lesser degree of early hemiplegia was also shownby Cases 1 and 4, but there was none in Case 3(left hemisphere injuries). Varying degrees ofcortical sensory loss were demonstrated in all cases

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M. E. HUMPHREY AND 0. L. ZANGWILLof right hemisphere injury, but only in Case 2 ofthe left hemisphere injuries. Hemianopia waspresent in Cases 1, 7, and 8. Apart from theabove disabilities, a good physical recovery wasachieved in all cases.

DiscussionThe fact which emerges most clearly from this

study of the effects of unilateral brain lesions inleft-handed patients is that some evidence of" language disorder ", this broad term beingintended to cover disturbances of reading, writing,spelling, calculation, and verbal memory or learning,in addition to dysphasia in the narrower sense, wasfound in one form or another in all cases exceptone, irrespective of the laterality of the lesion. Itis true that one of the criteria determining theselection of our cases was that " the lesion must besuch as would be expected to interfere with speechfunctions if the affected hemisphere were thedominant one"; yet if left-handedness werecorrelated with "right-brainedness" to the samedegree as right-handedness with " left-brainedness, "as has commonly been assumed, then dysphasiawould have been expected to occur only in the righthemisphere injuries. Our findings go even furtheragainst the traditional view in that the variousforms of language disorder, with the exception ofdyscalculia, show a higher incidence in the cases ofleft hemisphere injury.

In drawing attention to this apparent anomaly wecannot claim to have made an entirely new dis-covery. In the nine cases reported by Chesher(1936) of persons with mixed handedness, thelesions giving rise to dysphasia were again almostequally divided between the left and right hemi-spheres, while the same lack of uniformity regardingcerebral dominance has been observed by Conrad(1949) and by Penfield and Rasmussen (1950) evenin persons who were not noted for any mixture ofhandedness. It would appear, however, that themere fact of writing with the right hand, in a personwho is strongly left-handed for most other purposes,is regarded by some writers as an example of mixedhandedness. In some of the cases studied by theother authors quoted here handedness may havebeen " mixed " in this sense. Moreover, the sameslight, and not necessarily significant, preponderanceof left hemisphere lesions was observed by Conradin his series of left-handed aphasics. Yet nodetailed account of dysphasic manifestations intheir cases is offered by any of the above-mentionedauthors, and so far as we are aware none of themore elaborate studies of aphasia so far publishedhave been brought into relation with problems

of handedness. On such grounds alone it is hopedthat our own detailed presentation will provejustified.

The fact that only one of our carefully selectedcases was free from dysphasic symptoms lendsfurther support to the hypothesis put forward byprevious writers that cerebral dominance eitherdoes not occur at all in the so-called left-handed, orif it does occur, tends to be less well developed thanin the general run of right-handed persons. It istrue that no detailed study of right-handed aphasicshas been included here; yet in support of ourcontention the following facts may be adduced.Of 492 cases of penetrating brain injuries studiedfrom the point of view of handedness, site of lesionand presence or absence of dysphasia, 436 wereknown to be right-handed; of these 105 were stilldysphasic at the time of their discharge fromhospital, yet the lesion was with one single exceptionconfined to the left hemisphere. Thus it would beimpossible to select from this group of right-handedaphasics 10 cases showing a comparable divisionbetween left- and right-sided lesions, while it isextremely unlikely that, if 10 cases were selected atrandom from the total right-handed group of 436cases, only one would be free from dysphasia.

In regard to individual differences of handednessin our 10 cases, the available information was toolimited for us to apply the method of assessment andclassification put forward by one of us elsewhere(Humphrey, 1951). Broadly speaking, however,our patients were all primarily left-handed, thoughsome were partially ambidextrous. It is thusremarkable that only two cases, left-handed andright-handed writers respectively, showed anappreciable degree of " right-brainedness " so faras spoken language was concerned; in one othercase there was good evidence of left-handed writingbeing predominantly governed by the right hemi-sphere, according to expectation, yet the remainingseven cases showed a marked tendency toward"left-brainedness " in all their speech functions.The fact that only three of our patients were

under 30 at the time of injury, all being left-handed:writers, is of considerable importance in the presentcontext. Of the rest only one had remained aleft-handed writer, the others having been com--pulsorily shifted at an early age; in two of theleft-handed writers also there was some history ofearly interference with writing habits. If we takeinto account the conclusion reached by Humphrey(1951) that the early conversion of a naturally left-handed individual to right-handed writing is liableto influence his later manual habits not only inregard to writing itself, but also secondarily in

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D YSPHASIA RELATED TO BRAIN LESIONS IN LEFT-HANDED PATIENTS 193

promoting a greater tendency toward ambidexterityand a more frequent preference for the right handin situations favouring its use, then it seems reason-

able to assume that a corresponding influence islikely to be exerted on such an individual's ultimatecerebral organization. If this is the case, then we

should also draw attention to the fact that mostof the patients included in the present study were

born at a time when social pressure against left-handedness in general, and left-handed writing inparticular, was still fairly strong. Now that thependulum has swung the other, way, and childrenare in many cases even actively encouraged to writewith the left hand if so inclined, it is theoreticallypossible that " right-brainedness " will gradually gainin both strength and frequency among the naturallyleft-handed.One final point merits brief discussion. It has

already been suggested that cerebral dominancemay be relatively undeveloped in many left-handedpersons. This would in turn imply that cerebralrepresentation of the language functions in suchcases is bilateral, at any rate to a greater degreethan in most right-handed people (Chesher, 1936).From this it would follow that handedness was a

possible or even an important factor in speed ofrecovery from dysphasia, since the other, uninjuredhemisphere would in these circumstances be farmore ready to take over full control of the speechfunctions when called upon to do so. Unfortunatelyour material does not throw any further light on

this question. It is true that our left-handedpatients achieved an excellent recovery of language,except in those two cases where the injury was

exceptionally severe; yet this has no final signifi-cance without a control group of right-handedaphasics with broadly comparable lesions. Whileit would be easy enough to assemble such a groupof cases, the assessment of comparative rates ofrecovery through the study of case histories wouldbe a far more problematic undertaking. Carefulstudy and psychological assessment of aphasicpatients personally and over a long period, coupledwith a full investigation of their handedness andother aspects of laterality (Humphrey, 1951), will benecessary if this tentative conclusion is to be testedas systematically as it deserves; while at the sametime we must realize that the problem of recoveryfrom aphasia cannot be approached from theneurophysiological viewpoint alone, since various

other factors, including above all the personality ofthe patient, are undoubtedly involved. By drawingattention to this apparent peculiarity in the cerebralorganization that is associated with left-handednesswe may hope to stimulate further research alongthese lines, while at the same time stressing theimportance of obtaining accurate information as tohandedness in the course of routine neurologicalexamination of patients with brain injury.

SummaryTen carefully selected cases of unilateral brain

lesion (five left-sided and five right-sided) innaturally left-handed patients of good intelligencewere studied with reference to the cerebral represent-ation of language functions.

Dysphasia was present in all cases of left hemi-sphere lesion and in all but one of the right hemi-sphere cases. On balance the dysphasic symptomswere more severe in the former group, althoughdefects of calculation were more prominent in thelatter.Some theoretical implications in regard to

handedness and cerebral dominance are discussed.

We wish to thank Dr. W. Ritchie Russell for hisgenerous encouragement and kind permission to quoteextracts from the case records of the Head Injury AdviceBureau, and to interview patients under his care.

REFERENCES

Bastian, H. C. (1898). Aphasia and Other SpeechDefects. London.

Brain, W. Russell (1945). Lancet, 2, 837.Bramwell, B. (1899). Ibid., 1, 1473.Chesher, E. C. (1936). Bull. neurol. Inst. N. Y., 4, 556.Conrad, K. (1949). Nervenarzt, 20, 148.Head, H. (1926). Aphasia and Kindred Disorders of

Speech. Cambridge.Humphrey, M. E. (1951). Bril. J. educ. Psychol., 21,214.

, and Zangwill, 0. L. (1952). Brain. To bepublished.

Jackson, J. Hughlings (1879). Brain, 1, 304. Reprintedin Brain, 1915, 38, 107.

Macnaughton-Jones, H. (1914). Ambidexterity andMental Culture. London.

Needles, W. (1942). J. nerv. ment. Dis., 95, 270.Penfield, W., and Rasmussen, T. (1950). The Cerebral

Cortex of Man. New York.Tilney, F. (1936). Arch. Neurol. Psychiat., Chicago,

36, 897.Weisenburg, T., and McBride, K. E. (1935). Aphasia, a

Clinical and Psychological Study. New York.Wile, I. S. (1934). Handedness: Right and Left. Boston.

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