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HAND MOTOR PATTERNS AFTER THE CORRECTION OF
LEFT-NONDOMINANT-HAND MIRROR WRITING
RECARHDO RoDRic1ur7
Speech Clinic of the National Institute of Neurology and Neurosurgery, SSA Insurgentes Sur No . 3877 .
Dr 14269, Mexico
(Received 22 Sepiemher 1990 ; aeeepied 18 June 19911
Abstract-In a previous report, the author studied a left-nondominan[-hand mirror writer,
postulating that her mirror writing resulted from the failure to reverse the right-hand writing motor
patterns when transmitted front the left to the right cerebral hemisphere . In this study, the patient was
asked w write in normal faslnuu with the left hand ; the result was a utixtmC of handwriting motor
patterns which included normal letters, letters with reversed direction tracings, letters with one or
more than one loop-tracings and illegible letters . The author considers this result to be a further
support for the above-proposed hypothesis_

INTRODUCTION
MIRROR writing has remained a mysterious abnormality for many centuries . One of the most
outstanding cases of mirror writing was that of Leonardo Da Vinci (1452-1519) . This
peculiarity brought him a wicked reputation at a time when such writing modality was
considered to be related to witchchcraft or to a pact with the devil [14] . It was not until the
beginning of the present century when this writing abnormality was subjected to a more
serious and scientific approach .
JAVA, . [5] thought that the normal written expression of the left-handed was a complete
reversal of the normal right-handed writing . SURENI [11] put forward the suggestion that the
innervation of the left hand muscles would give a motion opposite to the one given by the
same innervation applied to the right hand . CRITCHLEY [2] proposed that the natural
movements of the left hand were the mirror movements of the right one, and if they were not
rectified by the visual memory of the correct orientation of written words, mirror writing
would result .
KALtZHNYUK [6] reported that his observations, in 30 children with cerebral palsy and
mirror writing in one or both hands, indicated that the discovered elements of opticospatial
agraphy could be caused by Gerstmann's syndrome .
SUNOHARA et al . [12] and SATO [10] attributed mirror writing in Japanese to an imagery
confusion of Kanji constructions .
HEn .MAN et ell . [4] thought that the reversal of the normal left to right writing pattern with
the availability of mirror motor engrams induced mirror writing . TANKLE and HF7LMAN [13]
expressed the hypothesis that the right cerebral hemisphere contained writing motor
patterns which were the mirror image of the ones harbored in the left one . This hypothesis
was based on the easiness observed in left- and right-handed subjects when writing in mirror
fashion with their left hand as compared with mirror writing with their right one .
1191

1192

R . Rnuaiuurz

There appears to be no report in the medical literature concerning what would happen
with the mirror-writing motor patterns of an adult patient when forced to write normally
with the mirror-writing hand . This will be the subject of discussion it) this paper .

MATERIAL AND METHODS
In a previous report [9], the author studied the case of a 35-year-old right-handed woman, with a sixth-Grade
grammar school education . She sustained a cerebrovascular accident in the territory of the left middle cerebral
artery . 'I here was a suhco rtical cerebral infarction of the left occipitoparietal region with an anterior extension w Inch
involved the striatum and the internal capsule, as shown by the CT scan study (rig . I) . The neurological
examination disclosed a moderate motor and sensory aphasia, a right hen,iparests with hyperactive deep tendon
reflexes, a right Babinski s sign and a right central facial weakness'three months after the onset of her illness, speech examination with the aphasia test used b- the author [7]
showed a deficit of the sensory association processes involving verbal acoustic verbal visual, nonverbal visual and
so mesthetie sensory modalities_ There was also involvement of oral language with severe dysnon' a and Ineral
paraphasias, as well as a writing disturbance with omissions, substitutions and transpositions of letters .
Writing with the left nondominant hand showed complete mirror writing from right to left (Pig . the21e
linguistic
errors already observed in right-hand writing were again noticed . There was a severe deficit of the short-term verbal
acoustic and verbal visual memory modalities, especially the first one, suspected by the aphasia test and
corroborated by the Wechsler memory scale [15] .
The ncurophysiological mechanisms involved in writing were carefully examined us follows :
11) visual functions, assessed with the I .uria Neurop. ychological Diagnostic 'lest I I I, which included visual
discrimination and visuuspatial orientation :
121 visuomotor coordination :
131 body-image integration andidentiiicationofthcleftandtherightsidesofthebody,inthepatient'shodyusedl
as in the examiner's :
141 tipper limb motor performance in right- and left-hand writing with and without visual monitoring,
15) analysis ol'directionality in right-and left-hand writing tracing, in reference to the body midline .
None of the above-mentioned mechanisms showed any important abnormalities except for the last One . II was
found that the motor patterns of the left-nondominant-hand mirror writing had the same directionality, with
reference to the body m idline . a s the motor patterns of the normal right-hand writing (Fig . 3) . In other words . the
muter patterns of the right dominant hand had not been reversed by the left nondominant one so as to produce
normal left-hand writing .
l hercrc fore . ii wag proposed that the reason fur left-nondominant-hand mirror writing, in the reported patient . was
a failure to reverse the left-dominant-cerebral-hemisphere-hand writing motor patterns when transmitted to the
right nondominant One to accomplish normal left-hand writing [3, 5J
'to further probe, whet her the patient was or" as not conscious of her left-hand mirror writing . she had to face all
to samples of her own rigid-mid left-hand writing . First . she recognized both samples as her own : then she was asked
if she noticed any difference between them, she said that her left-hand writing sample 'w as not correct . After further
questioning, she stated that 'it was crooked and out of shape' By the light ofthe foregoing responses and trying to avoid mentioning anything that could give her a lure as to the
mirror writing, tier attention was drawn to the hand" ritingdireetionality . She was asked in which direction she had
written. first with her right and then with her left hand, but she persisted in her previous response than her left-hand
writing sample 'was not correct' . Eventually, she said that her left-hand writing sample was 'backwards' .
Shc was then asked if she had already become aware of her left-hand mirror w rung . a t any time during the various
aphasia testings applied to her in the past 4 years_ She answered that she never noticed it because 'she had never
written with her left hand before her present illness' . It was not possible to obtain more accurate information clue to
her limited understanding and deficient short-term meniory already referred to, which prompted her to repeatedly
ask the examiner 'DO I peak alright, Doctor'?' .
Alter it was certain than the patient was aware of tier left-hand mirror writing, she was asked to try to correct it
when performing the written section of the aphasia test [7] in its four afferent modalities : verbal acoustic (dictation) .
verbal visual Icopyingll
nonverbal visual (writing the name ofiheobjects shown I . and soniesthetie (writing the name
of the objects palpated) .
As soon as the patient began writing, it was apparent that she was producing a mixture of uorrnal and abnormal
letters, many of them written in a reversed direction, so than every precaution was taken to indicate with arrows the
directionality of the different segments of the letters .
To assess the patients performance during con ected left-hand writing, each letter was an alyud scparalely . It was
necessary quite frequently, to use a magnifying glass to examine the tracings and determine their course . The
following perfonnanees were considered as abnormal' . (al all letters and tracings abuse directionality aas the
opposite to the one observed in normal writing : (hl all letters and tracings written in duplicated fashion with

HAND MOTOR PATTERNS

Fig . 1 . C .T . scan showing in (a), (h) and (C), a left subeortical occipitoparietal infarction with a deep
anterior extension involving the internal capsule and the basal ganglia .

1193

1195

HAND MOTOR PATTERNS

l j
I7 f

/ Y J'Y

/ .

{y~

CGirtc.r~~

- \

c

u
Fig . 2 . Samples of right-hand normal writing (left column) and left-hand mirror writing (right
column), the afferent pathway employed was the verbal visual one (copying), with the stimuli
momentarily exposed for 2 or 3 sec .

reversed direction ; Mall letters and tracingsin mirror writing ; (d) the horizontal tracing of letters "A' and `t' written
in a reversed direction, from right to left ; (e) all letters with one or more than one loop-tracings ; and (f) all letters
whose tracings were impossible to follow due to their complexity . These letters were classified as illegible .
The above criteria was applied, in the same fashion, to the Spanish compound letters `ch' and iI' considering each
element separately .

R . RODRIGLL2

1196

BODY
MIDLINE
LEFT HAND MIRROR

RIGHT HAND NORMAL

WRITING

WRITING

Fig . 3 . Levers a . a e. g and p written in normal right-hand writing (right Column) and in left-hand
mirror writing (left column I . The double-headed arrow stands for the body unit line . Each letter has
been divided into 2, 3 or 4 segment, to show the directionality of each segment. As can be seen . the
right-hand writing motor patterns dircctioiialisy, with reference to the body'smidline.have not been
reversed in the left-hand air For writing .

RESULTS
When the patient attempted to write in normal fashion with the left hand a great deal of
difficulty and awkwardness was observed as well as excessive gesticulation, tip and tongue
biting, teeth clenching and some right-hand mirror movements . When the patient was
questioned about this, she replied that her left hand and forearm felt stiff and clumsy . She
stated that it was easier for her to write it) mirror writing than to write in normal fasion with
the left hand .
In all samples of her corrected left-hand writing .. regardless of the afferent pathway used
[7], there were letters with abnormal tracings . This occurred mostly in letters 'a','o','e' .'
and 'p , in the horizontal tracing of letters A' and 't' . in letter'l' at the beginning of words, and
occasionally in letters 'I' and 11' in the middle of words which contained them such as
PIRINOLA (small spinning top) . CEPILLO (brush) and TORNILLO (screw) .
From a total of 237 letters produced, by the patient's corrected left-hand writing . 55 .5%
were normal and 44 .5% were abnormal . The distribution of the abnormal letters by the
different afferent sensory pathways employed, showed that more abnormal letters appeared
when the somesthetic pathway was employed and less when the verbal visual was used

1 19 7

HAND MOTOR PATTERNS

(Table 1) . Perhaps this last finding could be explained by the additional help provided to the
patient by the verbal visual patterns used as stimuli in the verbal visual afferent pathway .

Table I .
Afferent pathway

Normal letters

Abnormal letters

Verbal acoustic
Nonverbal visual
Verbal visual
Somesthetic

35 .5 (14 .9'%%)
37 .0 115 .6%)
42 .5 117,9%)
16 .5 (6 .9%)

23 .5 (9 .9%)
21 .0 (8 .8"/%)
17 .5 (7 .3%)
43 .5 1183%)

Total

131 .5 (55 .5%)

105 .5 144 .5%4I

A more detailed analysis of this 44 .5% of abnormal letters, by the type of abnormality
shown, disclosed that 25 .5% were letters containing one or more than one loop-tracings,
6 .9% were letters with reversed direction tracings, 4 .2% were letters with duplicated tracings
in reversed direction, 1 .8% were mirror writing letters, 4 .6% were horizontal tracings of
letters 'A' and 't' in reversed direction, and 1 .2% were illegible letters (Table 2) .

Table 2 . Detailed analysis of abnormal letters

Letters
with
reversed
direction
16 .5
(6 .9%)

Duplicated
tracings in
reversed
direction
10 .0
(42%)

Mirrorwriting
letters

Reversed
direction
horizontal
tracings of
'A' and 'T

Letters
with one
or more
loops

Illegible
letters

4 .5
11 .8"1)

11 .0
(4 .6%)

60 .5
(25 .5%)

3 .0
11 .2%

It was also observed that there were numerous interruptions in writing (Figs 4 and 5, small
straight arrows) which were not present in the patient's mirror writing (Fig . 2) . These
interruptions appeared in 28 .6% of the letters produced ; 9 .2% occurred after letters with
reversed direction tracings and mirror writing letters, 2 .1 %, after letters with one or more
than one loop-tracings and 173% in the course or after apparently normal letters .
In only two words the patient changed from handwriting to boldface type letters writing,
these were GOMA (eraser) and PEINE (comb) (Fig . 4) . This was done spontaneously
without any specific instructions to the patient and when the afferent pathway employed was
the verbal acoustic one (dictation) ; they represented 3
.7",o of the letters produced .
The omissions, substitutions and transpositions of letters and some perseveration of
writing were present in the corrected left-hand writing as they were in the left-hand mirror
writing . The patient wrote PIENE instead of PEINE, CANATA instead of CANICA .
CUCHURA instead of CUCHARA, TONILLO instead of TORNILLO, PITOLA instead
of PIRINOLA and CIRUGO instead of SEGURO (Fig . 4) . However, these linguistic errors
were not considered in the present analysis of letters and tracings unless they would show any
of the previously-mentioned abnormalities in the direction of the tracings .

1195

It . Ruuaicuei

.''2
q

A '-f'
4-?

C,,.

cfcu= c

,OvE

Gr c/~

~qyy
.

L,cz

in
Fig . 4 . Sample of corrected left-hand writing employing the verbal acoustic afferent path "ay
Idictationl . Small curved arrows indicate directionality of the tracings and small straight arrows
interruptions in writing. The reader is advised to resort to a magnifying glass when examining the
ahnormal letters . I or further explanation, see text .

DISCUSSION
The different motor letter patterns obtained in the corrected left-hand writing appear to be
the result of the interaction of two major brain mechanisms of the patient, the abnormal
motor left-hand writing mechanism and the normal visual monitoring one . These two brain

HAND M01 OR PA IIERNS

1199

mechanisms interact between each other in different combinations and proportions to
produce the diverse letter patterns observed .
The fact that 55 .5% of all the letters produced were well executed when the patient was
instructed to correct her left-nondominant-hand mirror writing indicates a complete control
over the abnormal motor left handwriting mechanism by the visual monitoring one . This
abnormal motor left-hand writing mechanism was perceived by the patient as a left upper
limb stiffness and awkwardness and it was made evident by the great difficulty exhibited in
the corrected left-hand writing, as described previously .
The examination of one loop-tracing letters such as letter 'a' of lapiz (Fig . 5, heavy arrow
d) using the magnifying glass showed that the first segment of the letter,just before the loop,
probably corresponded to the initial tracing of a hypothetical upside-down letter 'a' or
inverted writing letter (Fig . 6(A), heavy arrow d) ; at this point the patient seemingly became
aware of the abnormal directionality of the tracing and tried to reverse it by resorting to the
use of a loop, to form a more acceptable letter pattern .
Letters with two or more loop-tracings like letter 'a' of COMA, written as COMA, (Fig . 5
and 6(B), heavy arrow a) showed that the segment before the first loop, as in the case of the
one loop-tracing letter 'a', corresponds to the first segment of a hypothetical upside-down
letter 'a' . After this, the second loop came, it seemed to be aimed at modifying a tracing
probably corresponding to the first segment of a hypothetical 'mirror writing' letter 'a' .
Finally, the third loop came . It appears to have again the intention of correcting a tracing,
probably corresponding to the first segment of a second hypothetical upside-down letter `a' .
After the third unsuccessful loop-tracing, the patient gave up in her attempt to correct the
tracing and interrupted it to look for another solution to the problem ; she finally added a new
tracing which seems to correspond to the third segment of a normal letter 'a' (Fig . 3) .
Close examination of letters with loop-tracings appears to indicate that the loops
represented an effort to correct the tracings that the continuous visual monitoring of the
patient indicated to her that they were not resulting in the normal direction . In this case there
is only a partial control of the abnormal motor left-hand writing mechanism by the visual
monitoring . It is a partial control because the abnormal motor pattern of the letter had only
been partially expressed by the time the visual monitoring detected it . The use of more than
one loop-tracing in a single letter means more than one attempt at modifying the direction of
a tracing which repeatedly kept going on the wrong way_ This last example represented a
great effort on the part of the patient to correct the abnormal motor left-hand writing
mechanism .
Letters with reversed direction tracings and mirror writing letters suggest the presence of
mirror writing motor patterns in the right cerebral hemisphere of the patient, as proposed by
TANKL .e and HFlLsiAN [13], whose directionality is not corrected by the visual monitoring
and thus represent a complete failure of the visual monitoring to control the abnormal motor
left-hand writing nmechanism . It is considered to he a complete failure because the abnormalhand writing motor patterns were already fully expressed by the time the visual monitoring
indicated to the patient that an abnormal letter had been written . At this point, the patient
gave one of three solutions to the problem : either went around the letter and then came down
on its right side to produce a duplicated tracing in reversed direction (Fig . 4 heavy arrow d) ;
or crossed the upper part of the letter to come out from its right side (Fig . 4 heavy arrow 1), or
interrupted the tracing to start anew the normal left to right writing flow .
Illegible letters probably represent a continuous failure of the visual monitoring mechanism
in correcting the abnormal motor left-hand writing one, since the result is an entangled scribble

1 10

R .RouRiootz

f

I .JlI//10

7

rf

. QrR<=

0

/fr.

G

Pie .5 . Sample of corrected left-hand writing using the verbal visual utTerenl pathuny (copying) . Small
curved arrows indicate directiomdity of the tracings and small straight arrows interruptions in
writing . The reader is advised to resort to a magnifying glass when looking at the abnormal letter, .
Fur further explanation, see text

whose tracings could not be followed even with the help of a magnifying glass (Fig . 4 heavy
arrow m and Fig . 5 heavy arrow t) .
The interruptions in writing probably represent another 'correcting mechanism' which
was employed by the patient when she could no longer cope with the problem, finally

1201

HAND MOTOR PATTERNS

A r-

I
I
I
I
I

I
I
I

Fie . 6 In (A) there is a drawing of the second inset of Fig . 5 . where the first segment of a one
loop-tracing letter a' has been drawn with a heavy line to make it stand o ut
. i t probably corresponds
to the first segment of a hypothetical upside-down letter'a' . In (B) there is a drawing of the first inset of
Pig . 5 which depicts a three-loop-tracing letter 'a', where the segments preceding each one of the loops
have been drawn with a heavy line to make them more apparent they probably represent the first
segments of hypothetical upside-down and mirror writing letters 'a' as explained in the text . The
interrupted line tracings were drawn by the author to complete the image of these hypothetical letters .

deciding to interrupt the tracing . They could represent a partial or a complete failure of the
Casual monitoring in correcting the abnormal motor left-hand tvriting mechanism depending on
whether they took place after one or more than one loop-tracing letters or after reverseddirection tracing letters and mirror-writing letters, respectively . The reason for the
interruptions in writing when they occurred in the course or after apparently normal letters is
not known to the author at the present time .
Finally, the use of the boldface type letters writing might be interpreted as another attempt
to overcome the abnormal motor left-hand writing mechanism, making use of a completely
different motor writing pattern as a last recourse to deal with the problem ; however, even in
this type of writing . reversed-direction tracings appeared, such as happened with GOMA
(eraser) in which the letter 0' was broken into three segments, where segment number ( I ) is a
reversed-direction tracing. Letter'O' is a reversed-direction tracing letter as indicated by the
small curved arrow and the horizontal tracing of letter' A' is also a reversed-direction tracing
(Fig . 4) .
CONCLUSIONS
The correction of left-nondominant-hand mirror writing, of the patient studied, resulted in
the production of a mixture of different motor letter patterns :

1202

R . RooRiacez

(I) in 55 .5% of the letters, there was a complete control of the abnormal left-hand writing
mechanism by the patient's visual monitoring, giving origin to normal letters ;
(2) in 25 .5"/0 of the letters, there was a partial control of the abnormal left-hand writing
mechanism by the patient's visual monitoring, originating one or more than one looptracing letters :
(3) in 17 .5% of the letters, there was a complete failure to control the abnormal left-hand
writing mechanism by the visual monitoring producing mirror writing letters and
reversed-direction tracing letters ; and
(4) in 1 .2% of the letters, there was a repeated complete failure to control the abnormal lefthand writing mechanism by the patient's visual monitoring which produced illegible
letters .
These findings suggest that the patient's right-nondominant-ccrehral hemisphere harbors
mirror handwriting motor patterns ; which show themselves up in the corrected leftnondoniinant-handwriting in the form of mirror writing letters, letters with reversed
direction tracings and letters with one or more than one loop-tracings: and that they forced
their way out despite the patient's efforts to correct them .
The author thinks that these findings give further support to the hypothesis that the
patient's left-nondominant-hand mirror writing, is the result of an abnormal motor left-hand
writing mechanism characterized by great difficulty in reversing the right-hand writing
motor patterns when transmitted from the left to the right cerebral hemisphere .
1 he alternative hypothesis that mirror wrnmgcould he the result of a visual, a visuospatlal
or a somesthetic abnormality, in the patient reported . does not receive support from the
neurological examination and from the extensive neuropsychological testing applied to the
patient [9] .
However, SUNOHARA et ell . [12] and HLILMAN ei al. [4] reported cases which indeed
suggest a visuospatial disorientation as the responsible mechanism for mirror writing with
the left-nondominant and with the left-dominant hand, respectively . In addition, they
showed that mirror writing, in their cases . was a transient phenomenon . It lasted 40 days in
the first case and 9(l days in the second one, contrary to our reported case where the
alteration seems to be a more stable one since it has persisted unchanged through a follow-up
period of 5 years . I he author suspects that this last feature of mirror writing in our case is
probably pointing to a different mechanism of production of the abnormality, as postulated
before .
It is to be hoped that the information reported herein will be of interest and, in some way .
useful to the specialists devoted to the study and treatment of learning disabilities in which
mirror-writing letters are not a rare occurrence .

REFERENCES
I . CHRIS[ tNsFN . A . I . LI Diatpiostfrn .'v'nvupsirotrgiro fit, Luria, S . A . PABLO err Rio (Editor l, pp . 12 19, 1 st cdn
in Spanish . Madrid, 1974 .
2 . C RIT(HLPN . M . The significance of mirror writing . Prnc . R Set, .tiled . . Nfurnlow', 20, 397 . 1937 .
3 . (it] R .R .I : . .Gt1R .R .C .,SLssu,N .N .M .,O'CON'NOR,M .landVey .M .M .Hemisphcriccontrolol'IllcwriIIng
hand : the effect of caIIosotomy in a left-hander . Aeuroloyr 34, 904-908, 1984 .
4 . I IRirs AN . K . Nt . . Howei l ., (i ., Vsi INS I I- IN, F . sod RoJHI . I . . Mirror reading and wa icing m a ssociatiol with
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,w S7rephosrnoholiu, ORTIix, S . 'r. IFditorl, compiled by J . 1 . ORTON The Orton Soc . Inc. PamGCt, CT.
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HAND MOTOR PATTERNS

1203

6 . KALIZHSVUK, E . S . On mirror writing in children with cerebral palsies . Zh Neuropath . Psikhiar . 70, 1566-1571,
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7 . RODRIGUEZ . R . and CAMACIIO, I . A new method for the examination of language in aphasics . Internal and
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Congr. Neural . (Mexico, October 1975) . Neurologia-Neurociruyia-Psiquiatria . 18, 115 125 . 1977 .
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10 . SATO.K .A .Clinicalstudyonaphasicagraphiaofcerebralvasculardiseaseorigin,inreferencetomirrorwriting
and perseveratory paragraphia. Tohoku-iyaku-zasshi 92 (1),26-42, 1979 .
11 . SERENI, E . Re,'. Psicol . 19, 135, 1923 . In Word blindness in School Children and Other Papers on Strephosymholia,
S . T . ORTON (Editor), compiled by J . L . ORTON- The Orton Soc . Inc . Pamfret, CT . Monogr . No . 2 . 1966 .
12 . SUNOHARA, N . . SAKU . S ., KISOSHITA . M . and SATOVOSHi, F . A case of mirror writing due to a focal cerebral
lesion . Rinsho Shinkei .gaku 18, 525-531, 1978 .
L3 . TANKLE,R .S .andHEILMAN,K .M Mirror writing in right-handers and in left-handers . Brain andLanguage .19,
115 123 . 1981 .
t4 . VERDEJO, C . Leonardo da Vinci . Hiblioteca Hispanics llluslrdda . Figuras . Editorial Ramon Sopena, S .A .
Bacelana . 13, 189, 1969 .
15 . WECHSLER, D . The I1''eehsler Memory Scale- Psychological Corporation, New York . 19 72 .