Original Paper Received: April 22, 2002 Accepted: August 5, 2002 Eur Neurol 2003;49:45–52 DOI: 10.1159/000067027 Apraxia of Tool Use: An Autopsy Case of Biparietal Infarction Toshio Fukutake Department of Neurology, Chiba University Graduate School of Medicine, Chiba, and Department of Neurology, Kashima Rosai Hospital, Ibaraki, Japan Abstract Although disorders in the use of single objects have been reported, there have been few detailed analyses. We describe the autopsy case of a 65-year-old, righthanded male patient with severe impairment of actual tool use which was caused by biparietal infarctions. He persistently and stably showed a severely defective use of actual objects, single or multiple, and relatively wellpreserved pantomimes of object use and intransitive gestures. He did not have aphasia or dementia, and his ability for tool naming and function description was completely preserved. The author identified similar patterns of errors about a tool-action(-target) relationship both in single-object use and multiple-object use. Lesion analysis showed cortical infarcts mainly located in the bilateral inferior parietal lobules, extending into the temporal lobe on the right side. Copyright © 2003 S. Karger AG, Basel ABC © 2003 S. Karger AG, Basel 0014–3022/03/0491–0045$19.50/0 Fax + 41 61 306 12 34 E-Mail karger@karger.ch www.karger.com Accessible online at: www.karger.com/ene Introduction In order to manually handle objects as tools, the elementary sensorimotor function of the hands must be maintained, but equally essential are the ability to comprehend the three-dimensional structure of the objects as tools and the spatial and functional relationship among hands, tools and their proper targets, the ability to link the tools with their proper actions correctly and the ability to sequence actions in the correct order. These abilities are required for single-object use as well as multiple-object use. A century ago, Pick [1] gave a detailed report of a patient who had lost these abilities and had shown gross errors with single objects (e.g. he combed his hair with the wrong side of the comb; he held a pistol in the mouth), but he did not discuss this point in detail. Thereafter, impairment of tool use has been described under variable terms such as ideational apraxia (IA) or ideomotor apraxia [2], agnosia of utilization [3], conceptual apraxia or loss of knowledge about the use of tools [4, 5] or semantic amnesia of tool use [6]. Disorders in the sequencing of actions which require the use of multiple objects have been emphasized, but disorders in the use of single objects have also been reported [2, 4, 6–8]. Liepmann [2] reported a case in which the patient imitated striking something with a pistol and mentioned that in exceptional cases IA may Dr. T. Fukutake Department of Neurology, Chiba University Graduate School of Medicine 1-8-1 Inohana, Chuo-ku Chiba 260-8670 (Japan) Tel. +81 43 226 2129, Fax +81 43 226 2160, E-Mail fukutake@med.m.chiba-u.ac.jp Downloaded by: UCONN Storrs 137.99.31.134 - 5/21/2015 9:01:35 PM Key Words Apraxia W Tool use W Ideational apraxia W Ideomotor apraxia W Parietal lobe W Cerebral infarction W Autopsy W Magnetic resonance imaging Case Report Medical History A 65-year-old, right-handed man, a former streetcar conductor, was admitted to our hospital on August 5, 1988, for neurological examination. His parents, brothers, sisters and children were all right-handed. 46 Eur Neurol 2003;49:45–52 In 1982, 6 years before admission, transient symptoms had appeared which seemed to be the concurrence of hemianopia homonyma dextra and quadrantia homonyma sinistra inferior. Six months later, he experienced difficulty in using his right hand and getting dressed. In 1986, he began to have difficulties with each hand or both hands in using tools and could no longer eat meals or use the toilet by himself. On admission he was alert and cooperative. Cranial nerves were normal except for hemianopia homonyma sinistra. He had minimal muscle weakness in the right hand, but his right arm showed elevation in the arms stretching-out test. Bilateral tendon reflexes were active, and extensor plantar responses were elicited bilaterally. Sensations of pinprick, temperature, touch and vibration were normal, but there was tactile extinction in his left hand with very mild impairment of the position sense. In the ward, he sometimes took a walk but spent most of his time lying or sitting on his bed, reading newspapers or chatting with his wife, as he had been at home. He was assisted by his wife in most actions which required handling objects with his hands, including eating, putting clothes on or off, and passing stools. His behavior was quite natural when he greeted or spoke with other patients. The following investigations were made during his 2 months of hospitalization. His condition remained stable during that time and after discharge. On January 8, 1992, he was admitted to a local hospital because of general malaise and 2 weeks later died of pneumonia. An autopsy confined to the brain was permitted. General Neuropsychological Examinations Aphasia Test (Japanese Version of the Western Aphasia Battery) Aphasia testing showed that he was in the normal range for fluency (19.0), comprehension (8.7), naming (8.6) and repetition (10.0) and that he made no mistakes in grammar. He had an aphasia quotient of 92.6. He could read both kanji (Japanese morphograms) and kana (Japanese syllabograms) smoothly, having a score of 7.2, but a slight effect of unilateral spatial neglect was found. His ability to write, however, was impaired with notable apraxia and scrawling (score: 0.15). On the whole, he showed normal communication behavior except for the action of writing. Intelligence and Memory Tests Generally, his level of intelligence was good. In the Hasegawa Dementia Scale test, the most popular examination for senile dementia in Japan, he scored 31.5/32.5, indicative that there was no obvious disturbances of remote, recent and immediate memory. In the Revised Wechsler Adult Intelligence Scale test (Japanese version), he had a verbal intelligence quotient of 109, but his performance intelligence quotient could not be assessed. In the Picture Completion, Picture Arrangement and Object Assembly subsets, he could explain each picture or cartoon but could not complete or arrange them. Miscellaneous Examinations Left unilateral spatial neglect was observed, but there were no topographical disorders, asomatognosia, right-left disorientation, acalculia, finger agnosia, visual agnosia or Balint’s syndrome (optic ataxia). Fukutake Downloaded by: UCONN Storrs 137.99.31.134 - 5/21/2015 9:01:35 PM occur for even relatively simple motions. Morlaas [3] was the first to emphasize that IA patients also fail with single objects. In their systematic investigation, De Renzi et al. [7] reported that left-brain-damaged patients also show impairment in the use of single objects. De Renzi and Lucchelli [6] reported that in 20 left-brain-damaged patients performance in the single-object test was highly correlated with that in the multiple-object test. Recently Yamadori [9] and his colleagues have proposed the descriptive term of ‘apraxia of single-tool use’, based on their encounter with a rare case in which the ability to demonstrate the use of a single tool was disproportionally impaired [10]. Nevertheless, there have been few analyses of single-tool use. De Renzi and Lucchelli [6] classified errors in the object use tests into 6 categories: clumsiness (considered to reflect the presence of ideomotor apraxia), perplexity, omission, mislocation, misuse and sequence error. They stated that sequence errors were rare, omission, mislocation and misuse being by far the most frequent errors. Although they described that their patients also failed in a single-object use test with a significant correlation with the multiple-object use test, there was no detailed analysis on errors in single-object uses. The patient in the report by Motomura and Yamadori [8] achieved only 13 of 24 tasks in the single-object test and completely failed the multiple-object test. They analyzed the multiple-object tests according to De Renzi and Lucchelli [6] but did not analyze the error patterns in the single-object test. The following 4 aspects which were proposed by Hayakawa et al. [10] are the first criteria to analyze errors in single-tool use tests: the part of a tool the patient held, his/her way of holding it, the locus of the target where he/she applied it and his/her way of its manipulation. We report the autopsy case of a patient with severe impairment of actual tool use for both single and multiple objects, which was caused by biparietal infarction but not accompanied by aphasia or dementia. We also report a detailed study as to error analysis on his tool use correspondingly to two above-mentioned classifications [6, 10]. Table 1. Patient’s performance on praxis a Tool use tests Tool use with object Single object Multiple objects Tool pantomimes Pantomime to command Pantomime on imitation Total Correct Impre- Score cise right hand left hand both hands 24 24 6 13 3 (13%) 8 (33%) 0 (0%) 0 (0%) 3 4 1 0 9/48 (0.19) 20/48 (0.42) 1/12 (0.08) 0/26 (0.00) right hand left hand both hands right hand left hand 24 24 6 24 24 24 24 24 11 (46%) 14 (58%) 3 (50%) 12 (50%) 15 (63%) 24 (100%) 24 (100%) 24 (100%) 10 8 2 – – 32/48 (0.67) 36/48 (0.75) 8/12 (0.67) – – 24/24 (1.00) 24/24 (1.00) 24/24 (1.00) 20 20 3 13 13 3 15 (75%) 15 (75%) 1 (33%) 8 (62%) 8 (62%) 1 (33%) 1 1 1 3 2 0 31/40 (0.78) 31/40 (0.78) 3/6 (0.50) 19/26 (0.73) 18/26 (0.69) 2/6 (0.33) 13 13 3 8 8 3 4 4 3 12 6 (46%) 9 (69%) 0 (0%) 4 (50%) 5 (63%) 0 (0%) 4 (100%) 4 (100%) 3 (100%) 12 (100%) 5 1 0 3 1 0 0 0 0 0 17/26 (0.65) 19/26 (0.73) 0/6 (0.00) 11/16 (0.69) 11/16 (0.69) 0/6 (0.00) 8/8 (1.00) 8/8 (1.00) 6/6 (1.00) 24/24 (1.00) Tool naming Tool identification by function Tool function description b Imitation of intransitive gestures Special Examination for Praxis Method The following tests for praxis were recorded by video camera. Tool Use. The same 24 single objects (without any target: 3; with an obscure target: 3; used on the body or toward the body: 9; used on a target away from the body: 9; see Appendix 1a) were used in all the versions of the tests for each hand. The 6 fairly complex objects (see Appendix 1b) were used for both hands. The multiple-object tests used 13 pairs/sets of objects (see Appendix 1c). In order to exclude the possibility that he could not use tools because he had an impairment of general knowledge, we first evaluated his knowledge about tool use such as his ability to name the following objects, to identify them by function and to describe their function. After that, actual use with single or multiple objects, pantomime to verbal command of use with single objects and pantomime on imitation of it were assessed. Pantomime to Command. The pantomime to command test for intransitive gestures consisted of 20 meaningful gestures (13 for pantomime on imitation) and 13 meaningless gestures (8 for pantomime on imitation) for each hand and 3 for both hands (see Appendix 2). For these pantomimes, his abilities for pantomime on verbal command and pantomime on imitation were assessed. Descriptions of the leg, truncal and head-oral tasks are omitted. Scoring. The tasks were scored via video by 2 trained neuropsychologists, blind to the patient. A 3-point system was used: 2 points, if correct; 1 point, if the performance clearly resembled the correct one, but was somewhat imprecise; 0, if the gesture was so wrong or incomplete as to be unrecognizable. Tool pantomime on imitation Apraxia of Tool Use Eur Neurol 2003;49:45–52 47 Downloaded by: UCONN Storrs 137.99.31.134 - 5/21/2015 9:01:35 PM Meaningful (symbolic) gestures Pantomime to command right hand left hand both hands Pantomime on imitation right hand left hand both hands Meaningless (nonsymbolic) gestures Pantomime to command right hand left hand both hands Pantomime on imitation right hand left hand both hands Leg tasks right leg left leg Truncal tasks Head-oral tasks Table 2. Correspondence of error patterns identified in this patient to two proposed classifications De Renzi and Lucchelli [6] Error patterns in this patient types patterns Errors in relation between a hand and a tool Errors in part of a tool held Errors in way of holding Errors in mutual position between a tool and its target Errors in locus of a target for a tool Errors in direction of a tool to its target Errors in way of manipulation Errors in direction of manipulation Errors in linking a tool with its proper action Misuse Errors in temporal sequence Inversion Omission Sequence errors Omission Attitude Perplexity Catastrophic reaction Perplexity Results Tool Use. The patient was fully able to name objects (table 1), identify them by function and describe their functions (score: 1.00). He could pantomime how to use the single objects on verbal command and imitate the examiner’s pantomime (movement) in more than half the cases (score: 0.65–0.75). He was very disordered in his actual use of the objects (score: 0.08–0.42). With relatively simple and frequently used objects (daily necessities), such as a toothbrush and comb, he generally used them correctly (sometimes correctly without any errors), but he made errors which normal persons would never make, e.g. he touched his hair with the spine, not the teeth of the comb. These actions tended to change frequently and could be improved or worsened by advice from the examiner. The patient could not handle complex objects with both hands. For example, he was not able to hold a nail clipper in the correct position, nor could he hold a Japanese teapot in the right position. Furthermore, he could not open an umbrella or unfold a fan to use it. He showed good results in handling objects mainly by the proximal parts of the arms, e.g. throwing a ball or swinging a bat. He moved his right hand rather clumsily, and when both hands were to be used, his right hand was used less frequently than the left. Apraxic errors were made by each hand with right-side predominance. Partial and elementary actions were maintained, but there were various errors in the movements he appeared to perform correctly. In the present study, five types of 10 patterns of errors were identified, based on two classifications by De Renzi and Lucchelli [6] and Hayakawa et al. [10] (table 2). First, he made errors in the relation between a hand and a tool. This type of errors was divided into two patterns. One was about the part of a tool to be held (right hand: 12/24 tasks; left: 10/24; both: 5/6). He often grasped the position close to the object’s ‘action point’ (e.g. the bristle of a toothbrush or bowl of a spoon), and he sometimes grasped the wrong side or end (e.g. a comb or cigarette). The other was about the way of holding a 48 Eur Neurol 2003;49:45–52 (Clumsiness) Errors in part of a tool held Errors in way of holding Mislocation Errors in locus of a target for a tool Errors in way of manipulation tool (right: 13/24 tasks; left: 7/24; both: 6/6). He pinched the hand stock of a pistol with the thumb and forefinger but did/could not grasp it. He grasped the handles of scissors but did/could not insert his fingers. Second, he made errors in the mutual position between a tool and its target. This type of errors was also divided into two patterns. One was about the locus of a target for a tool (mislocation; right: 1/16 assessable tasks; left: 0/16; both: 1/3). He put the eraser onto the wrong part of a paper with his right hand. The other was about the direction to a target (right: 7/17; left: 6/17; both: 3/4). He often touched his hair with the spine, not the teeth, of the comb. He did/ could not put the temples of the eyeglasses onto his ears but directly put the outer side of the front to his eyes. Third, he made errors in the way of manipulation of a tool (misuse). Predominant errors of this type were in the direction of manipulation (right: 5/20; left: 1/20; both: 2/4). Although he placed the tool into the right part of the target with the right direction, he pulled it in the wrong direction (e.g. a nail extractor or a bottle opener). There was another error pattern in linking a tool with its proper action (right: 2; left: 2; both: 1). He did/could not fan himself with the Japanese round fan/uchiwa but repeatedly rotated it horizontally or turned it upside down. However, he never made actions completely unconnected with the intended action such as holding a pistol in the mouth as reported by Pick [1]. Fourth, he showed an abnormal attitude such as ‘perplexity’ [6] (right: 3/24; left: 3/24; both: 2/6) and ‘catastrophic reaction’ (see below; right: 2/24; left: 2/24; both: 0/6). He looked hesitatingly at the objects (comb, pistol, Japanese fan/uchiwa, Japanese folding fan/sensu and umbrella), picked it up, grasped at variable parts of it, turned it over, put it down and rotated it or turned it upside down on the desk. Brief delays in initiating the action were not scored as perplexity. He sometimes showed persistence and excessive correction of his actions. These actions tended to change frequently and could be improved or worsened by advice from the examiner. In about half the cases of perplexity, he failed catastrophically to correct errors. Once when he seemed to behave correctly, immediately after he failed at the same task and did many fruitless attempts until the Fukutake Downloaded by: UCONN Storrs 137.99.31.134 - 5/21/2015 9:01:35 PM could not be analyzed due to the low quality of the videotape. When there was disagreement between the 2 examiners (less than 10%), final scoring or classification was done by joint consultation. Hayakawa et al. [10] ginal gyrus (area 40 of Brodmann) and the most part of the angular gyrus (area 39), extending to the superior parietal lobule (area 7) (fig. 1). On the right side, the infarcts were located in the cortex and white matter of the greater part of the angular gyrus, extending into the occipital lobe (area 19), the upper portion of the middle temporal gyrus (area 37) and superior parietal lobule (area 7). Aside from these main lesions, there were 3 microinfarcts in the right hemisphere, in the border zone between the superior and middle frontal gyri, in the caudate head and in the lower aspect of the temporo-occipital region in each (fig. 1). Discussion Postmortem Findings The brain weighed 1,200 g. The carotid and basilar arteries were severely atherosclerotic, and the latter was almost completely occluded in the top portion. Gross inspection showed diffuse cortical atrophy and bilateral focal atrophy of the inferior parietal lobules, greater on the right side, indicative of necrotic infarcts. Coronal section of the cerebrum showed that on the left side the infarcts involved the cortex and white matter of the posterior portion of the supramar- The patient had a severe apraxia, when showing how to use tools not only during the praxis testings but also in his daily life. There are several interesting features. First, the patient was not demented or aphasic, and could name and describe the functions of tools. Second, he was more apraxic with real tools than when pantomiming the use of these tools. Third, there was the tool use disturbance in his handling even a single object as well as multiple objects. Fourth, his impairment of tool use persisted stably over a long period, showing no improvement or exacerbation. This kind of impairment of single-tool use has been rarely reported, and there have been few autopsy cases. In spite of his highly damaged use of tools, the patient could give complete verbal explanations of the function and use of the tools. He had no aphasia or dementia. These findings suggest that his impairment of tool use cannot be attributed to any disorders of language ability, comprehension of the meaning of objects as tool or understanding of the purpose of using tools. The fact that the patient performed worse with tools than when pantomiming the use of tools is important. Usually, the presence of a tool limits possible hand configurations and movement, making the task easier. In this instance, the presence of the tool seemed to interfere with performance. Its reason is unclear, but there has been only a report of a similar case, which showed a striking dissociation between failure to manipulate objects and preserved ability to pantomime their use [8]. The authors of the report mentioned that it is difficult to explain the tool use disturbance in their case with some previously proposed hypotheses [3, 4, 6] and supposed that the sensory information interfered with the activation of the motor engrams, which could be roused by verbal or visual information when their patient handled a tool. Error analysis showed several characteristics. First, two error patterns about temporal sequence were detected Apraxia of Tool Use Eur Neurol 2003;49:45–52 Lesion Analysis Neuroradiological Examinations X-ray computed tomography (CT) and magnetic resonance imaging (MRI) showed diffuse cortical atrophy and focal lesions in the lateral segments of the bilateral posterior parietal lobes, the right lesion being slightly extended to the occipital lobe. Positron emission tomography gave similar CBF (cerebral blood flow) and CMRO2 (cerebral metabolic rate for oxygen) images, showing somewhat extended lesions compared to those obtained by CT and MRI. 49 Downloaded by: UCONN Storrs 137.99.31.134 - 5/21/2015 9:01:35 PM examiner would stop him (‘catastrophic reaction’). There were no so-called ‘amorphous actions’, all his errors being classified as the type of errors described above. Perseveration was not observed in the actual use test of single objects either. Errors in temporal sequence could not be assessed in tasks of 6 single objects because these tasks had been finished halfway without success in holding or the first step of manipulation (e.g. opening an umbrella before putting it up). This incompleteness may be interpreted as omission of the final action. In the pantomime to command test, the error patterns consisted of errors in the way of holding (6/48 tasks), ones in the direction of manipulation (2) and ‘body-part-as-objects’ (4). Tool pantomime on imitation could not be analyzed due to the low quality of the videotape. He could not handle multiple objects at all (score: 0). Error patterns were similar to those in the actual use test of single objects: errors in the part of a tool held (7/12 tasks), in the way of holding (5), in the locus of a target for tools (7), in the direction to the target (9), in the direction of manipulation (9), in linking tools and actions (6), perplexity (2) and catastrophe (5). Other than these patterns, two error patterns in the temporal sequence were identified. One was omission (3/12 tasks). He seemed to forget to carry out an action necessary for completing the sequence. The other was a pattern of errors in the order of actions (4). He employed an object without having carried out an action that must come before. After he had performed badly, he sometimes said that he could understand neither the relation of the objects and their spatial elements (direction, position, etc.) nor the timing of the actions. Imitation of Intransitive Gestures. In terms of his lower extremities, trunk and head (mouth), he correctly performed all the tasks. For each hand, both the meaningful and meaningless movements to verbal command and on imitation were more correctly performed than was the actual use (score: 0.65–0.78). Both hand tasks were poorly performed as was the actual use. Imprecise movements were mainly caused by clumsiness (insufficient separation of the fingers). The most frequent error pattern was perseveration (6/120 tasks) and other patterns were rare. He responded very similarly when asked to perform tasks with his eyes opened or closed. Fig. 1. Autopsy findings. a Brain coronal section at the angular gyrus level showing discrete necrotic infarcts of the bilateral angular gyri and a microinfarct in the right temporo-occipital region. b Schematic lesion location on Brodmann’s cytoarchitectural fields (modified by Anderson [11]); see text. 50 Eur Neurol 2003;49:45–52 test. This point is also considered to be due to the fact that spatial and temporal elements increase along with the number of objects. In this view, the patient’s words that he could not understand the relationship among ‘spacetime’ elements in both the single- and multiple-object use tests are very important. Although a task involving multiple objects makes impairment easier to be detected, it can be elicited with a single object. Even in single-object use, there is necessarily a tool-action(-target) relationship, for which the patient produced errors similar to those in multiple-object use. Déjérine [12] and Denny-Brown [13] argued that IA is not a discrete symptom but the manifestation of global mental deterioration. Actually many cases of IA have Fukutake Downloaded by: UCONN Storrs 137.99.31.134 - 5/21/2015 9:01:35 PM in the multiple-object use test and not in the single-object use test. This is considered to be due to the fact that temporal elements increase along with the number of objects. It is, however, uncertain whether or not a task of singleobject use produces these errors, because tasks with twostep manipulations such as using a Japanese folding fan or umbrella were not completed due to errors in their first step. Second, the other 8 error patterns out of 10 were found both in the single-object and multiple-object use tests. Third, frequencies of perplexity and 2 error patterns about the relation between a hand and a tool were similar in both tests, while those of catastrophe and error patterns in mutual position and way of manipulation were higher in the multiple-object use test than in the single-object use been reported to concern dementia due to Alzheimer’s disease [14, 15] or diffuse brain damage [8]. This view, however, is negated by our patients with cerebrovascular accidents who showed dissociation of normal intelligence and disorders in the use of objects (see also the report by De Renzi et al. [7]). Judging from the patient’s clinical records, a left inferior parietal lesion that did not extend into the temporal area developed first, followed by a right inferior parietal lesion that extended into the temporal area, immediately after which apraxia of tool use emerged. The localization of lesions producing IA or apraxia of tool use is much more controversial, but it has been reported that the responsible lesion is in the left parieto-occipital area near the angular gyrus [2]. In addition to the present case, there has also been a report of a case of bilateral parieto-occipital vascular lesions [16]. In cases of IA with unilateral left-sided lesions, Foix [17], Morlaas [3] and De Ajuriaguerra et al. [16] stressed the spread of the lesion into the temporal area. They confirmed the rarity of IA in cases with unilateral, circumscribed lesions. Knapp [18] reported that in 9 out of 10 cases, IA is the result of bilateral or extremely diffuse lesions. Therefore, IA or apraxia of tool use may have been produced not only by the left parieto-occipital lesion but by the left temporal or right parietotemporal lesion in addition. It is also likely that the patient’s left lesion is related to deficits in the temporal elements of tool use and the right lesion to deficits in the spatial elements. This is only a speculation but is consistent with the view of Hécaen and Albert [19] that the deficits in IA are linked preferentially to the damaged hemisphere (spatial organization on the right and sequential organization on the left). That the patient’s symptoms were extremely stable may be due to the presence of lesions in both hemispheres. In conclusion, the patient’s apraxia of tool use occurred in an isolated and pure form. There was no essential, qualitative difference between single-object and multiple-object use. These rare manifestations could be caused by the bilateral inferior parietal and right temporal lesions. Appendix (1a) Twenty-four single objects for each hand – Without any target (3): faucet (turning), book (paging), switch (turning-on) – With an obscure target (3): ball (throwing), cigarette lighter (lighting), pistol (pulling the trigger) – Used on the body or toward the body (9): toothbrush, comb, cigarette, Japanese fan/uchiwa, hat, cup, toothpick, brush, electric shaver – Used on a target away from the body (9): spoon, bottle (pouring), nail extractor, eraser, bottle opener, hammer, screwdriver, saw, scissors (1b) Six single, fairly complex objects for both hands Bat, nail clipper, umbrella, eyeglasses, folding fan/sensu, T-shirt (1c) Thirteen pairs/sets of objects for multiple-object use tests Key and lock; bolt and nut; hammer and board with nail; beer bottle and cap opener; telephone base and handset; wide-mouthed bottle and twist-off cap; teapot and teacup; bottle and cup; Japanese sake bottle/tokkuri and cup/sakazuki; straw and milk cup; envelope and letter paper; candle, candlestick and matchbox; stamp, stamppad and paper (2) Intransitive gestures for pantomime tests Meaningful pantomimes for each hand (20): military salute, wave good-bye, oide-oide (come-on), chodai (give me)*, genkotsu (make a threatening fist), OK sign*, V sign*, girl (extend a little finger)*, boss (erect thumb)*, ghost’s hand (flex a hand)*, throw*, hit hard, pat softly, beard stroke, yakuza (cheek cut), stinker (hold nose), chikara-kobu (flex an arm to make the muscle stand out)*, gu (make a fist like a stone)*, choki (raise the second and third fingers like scissors)*, pa (open palm like paper)* (The asterisk indicates tests for movements on imitation) Meaningful pantomimes for both hands (3): hakushu (handclap), gassho (join the hands in prayer), butterfly or bird (flap hands) Meaningless pantomimes for each hand (13): erect thumb*, erect little finger, make a ring with the first and second fingers*, make a ring with the first and fifth fingers*, put the hand on the chin (Luria)*, touch nose with thumb, hide the right/left eye with the palm, grasp the right/left earlobe with the first and second fingers*, touch lips with the second finger, tap opposite elbow with the palm*, place hand on knee* (The asterisk indicates tests for movements on imitation) Meaningless pantomimes for both hands (3): chain of rings made with the fingers, two-handed nose-thumb (meaningless in Japan), grasp arms with both hands Acknowledgements I am very grateful to Prof. Mituru Kawamura, Showa University, Tokyo, for his longtime help and Prof. Atushi Yamadori, Tohoku University, Sendai, for his constructive advice. 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