Crossed Aphasia
in a Chinese Bilingual Dextral
Robert S. April, MD, Peter C. Tse, MD

\s=b\ A
persistent nonfluent aphasia following a right cerebral infarction developed
in a 54-year-old right-handed Chinese
man. Computerized axial tomography

localized the lesion in the distribution of
the right middle cerebral artery. The
speech and language dysfunction was
greater for performances in Chinese than
in English, despite the fact that the patient
was born in China, was schooled in
Chinese until age 7, and spoke Chinese at
home and in his business.
It is suggested that early learning of
Chinese, an ideographic language based
on visual spatial percepts, might have
been critical for the establishment and
maintenance of language dominance in
the right hemisphere.
(Arch Neurol 34:766-770, 1977)

the small number of reported
cases of crossed aphasia in dextrals,1 exceptions to a fixed relation¬
ship between aphasia and left hemi¬
sphere lesions have been given the

In

"

following explanations: personal ambilaterality and/or familial sinistrality'"12; possible bilateral hemispheric
dysfunction2-41"-"; and long-standing
brain dysfunction from acquired epi¬
lepsy or infantile brain trauma.2-3·8·12
Two case reports have documented a

Accepted for publication June 7, 1977.
From the Department of Neurology, New York
Medical College.
Reprint requests to Department of Neurology,
New York Medical Center for Chronic Disease,
Roosevelt Island, NY 10044 (Dr April).

single right hemisphere lesion at
autopsy7 " and one other by computer¬
ized axial tomography (CT).S This

report describes another case. It is of
special interest because it is the first

reported example, to our knowledge,
of crossed aphasia in a Chinese and
English-speaking dextral. It has rele¬
vance to the study of aphasia in
nonalphabetical languages, aphasia in
polyglots, as well as to the problem of
atypical cerebral organization for lan¬
guage.

REPORT OF A CASE
The patient was a 54-year-old Chinese
family laundry business in
New York City until the present illness. He
was born near Canton, China, where he
went to elementary school. At age 7 he
came to the United States and finished
both elementary and high school in New
York City. When he was 17, he returned to
China to visit his native village. Before the
trip, he studied the Chinese language in
New York City in daily classes for three
years; when in China, he went to language
classes daily for three months. During that
one-year visit he married, and brought his
wife and her mother to the United States,
where they settled. He established a
laundry shop in New York City, employed
16 Chinese workers, and kept the account
books in Chinese. His mother-in-law
always lived with his family; because she
spoke only Chinese, the family usually
spoke Chinese at home. The patient's seven
American-born children speak both Chi¬
nese and English, but do not read or write
man who ran a

Chinese. The patient's premorbid Chinese
writing demonstrated a fluent usage of the

written language.
In October 1975, he suffered sudden left
hemiparesis and aphasia. The first detailed
examination of his language and speech
was done in another hospital, where hesi¬
tant, partial, nonfluent speech with agrammatism was described. On April 28, 1976,
he was admitted to New York Medical
College Center for Chronic Disease. Re¬
sults of general physical examination were
unremarkable; blood pressure was 130/80
mm

Hg.

Neurologic Examination
The patient was alert, cooperative, and
aphasie. There was left hemiparesis with
hyperreflexia and a left Babinski sign. The
hemiparesis included the lower face and

greatest in the left upper limb.
Confrontation disclosed a left visual field
defect. On gaze movements to the left, the
eyes lagged behind the head. Face-hand
test showed displacement of perceived
stimuli from the left hand to the left face.
One observer noted transient right-left
disorientation.
was

Laboratory Studies
Results of hemogram, urinalysis, and
blood

chemistry

studies

were

normal

except for diabetes mellitus, which was
controlled by diet alone. Chest roentgenogram, electrocardiogram, skull x-ray films,
and radioisotope brain scan were normal.
Pure tone audiogram showed normal
thresholds in either ear. A CT scan showed
a large region of encephalomalacia in the
distribution of the right middle cerebral

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was

slowness, hesitancy, and mild impair¬

ment for simple phrases-such as "yester¬
day" for "a year yesterday"-and complete
inability to repeat even short phrases
correctly. He could not spell words aloud.
Reading comprehension for very simple
sentences was unimpaired. Matching writ¬
ten words to objects or to spoken words, or
matching spoken words to one of a group of

written words, was usually done correctly.
Reading of simple sentences aloud was
slow, hesitant, and erroneous. He skipped
small words, read slowly and made many
omissions, hesitations, and repetitions. He
had much less trouble reading single
words, but still made omission errors—such
as "termine" for "determine"—and some
paraphasias—"potato" for "tomato."
Writing of numbers or letters to dicta¬
tion was minimally impaired. He also had
difficulty with automatic writing, viz, the
numbers 1 to 20. Writing of single words to
dictation was impaired. This contrasted
with his penmanship, which was coordi¬
nated and fluid. His right-hand orientation
during writing was noninverted. Copying
of letters, geometric figures, Greek letters,
and Bender-Gestalt designs showed no
impairment. He drew freely and was able
to complete incomplete figures with ease.
Written arithmetic performance—in¬
cluding written addition, multiplication,
and fractions—was poor. He had no trouble
making correct change in a concrete situa¬
tion involving money.

Chinese Speech and Language

Computerized tomograms, without contrast enhancement, showing extensive encephright cerebral hemisphere in distribution of middle cerebral artery.
Irregular areas of decreased density on left are artifacts that were not confirmed by
density matrix.
alomalacia of

artery, involving the frontal, temporal, and
parietal lobes with secondary dilation of
the body and anterior horn of the right
lateral ventricle. The densities over the
parenchyma of the left hemisphere, the
position of midline structures, and the
shape of the left lateral ventricle were
normal (Figure).

Electroencephalogram
There was diffuse slow activity down to
3 Hz in all right-sided leads. Alpha rhythm
was not observed on the right. Left-sided
alpha rhythm had an average frequency of
8V2 to 9 Hz. No abnormal activity was seen
in left leads. This pattern did not change
over the next eight months.

English Speech and Language
The

original examination revealed

sparse, hesitant spontaneous speech. It was
composed of short, agrammatic, incom-

píete phrases, verbal hesitations, pauses,
and severe word-finding difficulty. The
patient gestured with the right hand to
compensate for his desultory speech.
Verbal comprehension was relatively
preserved—that is, he could follow simple
three-step commands and answer "yes-no"
questions correctly. He had difficulty with
commands containing more than three
steps.

He was able to indicate object pictures,
actions, letters, colors, and body parts
correctly on verbal instruction. Ability to
name colors and objects from pictures was
relatively preserved. Some of his errors
were "spoon" for fork, "brella" for umbrel¬
la, and "shoe" for horseshoe. He was able

particularly those
category,—such as,

to correct his errors,

within

the
uh

same

fork."
no
"spoon
Repetition was fair with no impairment
of single-syllable words. However, there
...

...

...

Schuell's test (Minnesota Test for the
Differential Diagnosis of Aphasia) was
administered in Chinese by one of us
(P.C.T.). English performance in general,
and on Schuell's test in particular, was
better preserved than Chinese.

Spontaneous aphasie utterances were

made in English, not Chinese. When
addressed in Chinese, he first responded in
English and then attempted to speak
Chinese. The responses were usually mix¬
tures of Chinese and English speech.
Chinese utterances were single words or
short phrases, always accompanied by
gestures. He could not say his wife's given
name intelligibly and made errors in
naming objects and body parts. On some
occasions he used a substitute word related
in meaning to the correct one. For exam¬
ple, he said "sky" instead of "sun," "house"
instead of "window," "hand" instead of
"finger," and "car" instead of "ship."
He repeated single Chinese words cor¬
rectly. His sentence repetition was ex¬
tremely impaired. He omitted connecting
words in the sentence. For example, he said
"pass home" for "I'm going home for a
weekend on pass," "today fine" for "today

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Neuropsychologic Test Scores
8/3/76

9/14/76

9/15/76

10/21/76

20

26

11/2/76

11/15/76

WAIS (raw scores)

Digit span
Digit symbol
Picture completion
Block design
Picture arrangement
Object assembly
Performance IQ

11
12
12
74

Raven's Coloured Matrices
Benton's Visual Retention
A

Purdue Pegboard, right
hand, 30 sec

12

Symbol digit modalities
Written
Oral

Pointing
Peabody Picture Vocabulary
Raw

99

Ceiling

113
14

Errors

Design copying

Good
Normal (left

Double simultaneous stimulation

face-right
hand)

Minimally
impaired

Color naming
Color recognition

Good
Good

Singing

melody
Good
Good

Facial recognition
Recognition of nonspeech sounds

is a fine day," and "sit wheelchair" for "I'm
sitting in a wheelchair."
The pitch and rhythm of his Chinese
speech cannot be described in detail
because of its paucity. Moreover, speech
was phonetically inaccurate and hardly
intelligible. His family had difficulty
understanding him in Chinese. Hence,
proverb testing could not be done. He often
laughed in response to humorous Chinese
proverbs but was unable to explain why or
to describe the humor. After humming the
melody of a Chinese nursery rhyme
accurately, he sang the words hesitantly
and nonfluently.
Written Chinese was severely impaired.
Before the present illness he had kept his
account book in neat, well-written Chinese
characters. However, when tested, the
patient made errors in writing his own
name. He wrote only some simple words to
dictation. He made many errors in
sentence copying. The graphic errors
included omission of strokes, erroneous
strokes, mistakes of sequence, and direc¬
tion of strokes.
Word comprehension was tested with a
list of Chinese school words. He read eight

of 33 correctly, but understood 13 others
that he could not read. When a picture
illustrating the general meaning of the
word was shown, he could read 14 words
and understand 25. When the 33 words
were read to him in multiple-choice form,
he chose 27 correctly. In summary, there
was more difficulty in reading aloud than
in comprehending written Chinese. Oral
presentation of the words further in¬
creased comprehension. He made correct
gestural responses to commands and ques¬
tions in Chinese.

Neuropsychologic Testing
The patient was strongly right-handed.
A questionnaire for hand preference was
adapted from that used by Hécaen, which
asks for hand preference on 22 common
tasks. The patient indicated premorbid
right-handed preference for each. The
questionnaire was given to each of his
seven children, aged 23 to 37. All were
exclusively right-handed. There was no
history of left-handedness in the family.
Standard neuropsychologic tests were
administered. The results are summarized
in the Table. The language subtests of the

Wechsler Adult Intelligence Scale (WAIS)
could not be done because of aphasia;
hence, scores are given from the perfor¬
mance subtests alone.
Some performances merit emphasis,
namely, Raven's scores (20 and 26) and
impaired visual retention. The latter could
not be explained by the left visual field
defect alone. In addition to omitting
objects on the left, he made errors in
figures from the right (intact) part of the
visual field. Equally complicated figures
were copied directly without error.
Attempts were made to determine the
patient's preferred ear for perception of
dichotic phonemes. The interpretation of
the results was made difficult by the high
error rate of the performance. This diffi¬
culty in performing the test to criteria
obscures the trend toward left ear prefer¬
ence disclosed in the data. Six of his seven
children were tested and all showed

unequivocal right ear preference.
There was no ideomotor apraxia. Simple
learned movements were done well to
command. Imitation of the examiner's

gestures was performed correctly. Repeti¬

tive oral-buccal movements showed some

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dyspraxia, but articulation was, in general,
normal except for decreased vocal ampli¬
tude. He was able to recognize faces and
showed no spatial disorientation or prob¬
lems in dressing.

Hospital Course
The patient was observed and tested
repeatedly for eight months. He had daily
speech therapy. Improvement was ob¬
served in repetition of phrases and
sentences, oral reading of words and
sentences, automatic speech, conversation¬
al ability, and verbal responses to simple
questions. Sentence length increased and
language became more descriptive. Rightleft orientation was normal. He still had
difficulty with simple numerical problems
and on a qualitative level was agrammatic,
nonfluent, and showed Broca's aphasia
with severe left hemiplegia.
In January 1977, he suddenly went into
coma and showed signs of rostrocaudal
deterioration of brain stem function. A
lumbar puncture demonstrated clear, col¬
orless, acellular fluid with opening pres¬
sure of 115 mm H20. Despite several days
of support of vital functions and treatment
of pneumonitis, the patient died on Feb 22,
1977. Permission for postmortem examina¬
tion was not given.

COMMENT
The patient described in this report
was right-handed and had neither
familial sinistrality nor evidence of
early brain damage or seizure disor¬
der. Therefore, his aphasia could not
be explained as an example of shifted
sinistrality or the influence of familial
ambilaterality.5 7 We conclude that the
aphasia was the result of an unusual
pattern of lateralization of hemi¬
spheric language function.
Can aphasia be the result of the
demonstrated single right hemisphere
lesion alone? This relationship has
been demonstrated unequivocally in
other anatomically confirmed case
reports.71'11 Our patient had neither
clinical, EEG, nor CT evidence of left
cerebral abnormality. These data
would strengthen the hypothesis that
the right hemisphere was his domi¬
nant one for language.
We cannot exclude the possibility of
some bilateral representation of lan¬
guage. However, as Wechsler" has
stated, if language were bilaterally
represented in a patient, one might
expect greater recovery of speech and
language than we observed in the

present case. The nature of recovery

of function after a brain lesion is
poorly understood at this time,14 but
recovery of speech and language is
relatively more complete in aphasie
sinistrals than in dextrals.15"1 It has
been postulated that there is incom¬
plete unilateral dominance for speech
and language in sinistrale.1617
How do the neuropsychologic per¬
formances—especially the low nonlanguage scores—relate to the single
right hemisphere lesion? Do they indi¬
cate some left (nondominant) hemi¬
sphere dysfunction as well? The
Raven's Coloured Progressive Ma¬
trices (RCPM) has been used as a test
of nonverbal intelligence in adult
aphasie patients and others.,K Its
strong spatial component has led to
criticism of its unqualified value as a
test of nonverbal intelligence alone.19
Our patient scored 20 and 26 on this
test on two different occasions. These
scores compare well with those gener¬
ated by Kertesz and McCabe's pa¬
tients.18 It is not clear if the RCPM
scores correlate with the languagespeech abnormality alone or whether
they reflect a spatial disorder due to
the topographic relationship of the
lesion apart from its major disruption
of language function. In this regard,
the relatively low WAIS performance
scores and the low RCPM scores would
support the diagnosis of construc¬
tional apraxia, even though free draw¬
ing and figure copying were intact.
Some investigators relate construc¬
tional apraxia to lesions in the parietal
lobe of the nondominant hemi¬
sphere.20-- Others relate it to bilateral
lesions.23-25Kertesz and McCabe1" did not pre¬
sent independent neurologic data to
exclude the possibility of bilateral
lesions in their typical left-hemi¬
sphere aphasies. Our patient's scores
were in the range of those of their
Broca's aphasies. Thus, our patient's
RCPM and his typical aphasie per¬
formance appeared to be compatible
with a single lesion of the language
zone—in this case, on the right, not the
left.
We do not know why RCPM scores
are low in aphasies. Perhaps aphasies
have a related disturbance in problemsolving functions of the dominant

hemisphere and not specific distur¬

bances in visual-constructional func¬
tion. Milner1" has suggested that more
could be learned if comparisons were
made between RCPM scores of apha¬
sies with constructional apraxia and
nonaphasics with corresponding right
hemisphere lesions with construction¬
al apraxia. Typical (noncrossed) apha¬
sies without severe comprehension de¬
ficits generally perform relatively
well on tests of nonlanguage reason¬
ing.26-'" Case reports of crossed apha¬
sia in dextrals describe varying diffi¬
culty with visual-constructive tasks.
In summary, one might interpret our

patient's nonlanguage performances
as supporting either incomplete right
cerebral dominance for visual-spatial
functions or as a problem-solving
difficulty associated with aphasia.
We conclude that our patient had
one right cerebral lesion responsible
for aphasia and no left hemisphere
lesions. We base this on the aphasie
performance, the mild impairment of
nonlanguage tasks, the normal senso¬
rimotor status of the right hand, the
electroencephalogram, and the CT
scan. His nonfluent aphasia with
minimum comprehension deficit re¬
sembles other cases of crossed aphasia
in dextrals113 and also in left-handed
adult aphasies and children with

acquired aphasia.17

The data also suggest that the

patient was relatively right cerebral
dominant for language. This is the
first example, to our knowledge, of
crossed aphasia in a Chinese and
English-speaking dextral and, like
other cases of crossed aphasia, bears
witness to the independence of lateral
organization of different hemispheric
functions. Although handedness and
language-brainedness usually segre¬
gate together, contralateral to the
dominant side for nonlanguage func¬
tions,3""32 this is not an absolute rela¬
tionship and admits infrequent devia¬

tion from the mode.33 The explanation
for this deviation, exemplified by
reported cases of crossed aphasia, is
now known. Neither is it known why
the aphasie disturbances are so similar
in crossed aphasia.
Wechsler," who described crossed
aphasia in an illiterate dextral, specu¬
lated about the relationship between

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not learning to read and write and

inverted cerebral
development
dominance. Looking for possible de¬
velopmental influences that might
have affected our patient's cerebral
organization, we might speculate that
his original experience in the Chinese
language was a significant factor.
Chinese is an ideographic, nonalphabetical language that presents visualspatial elements to the reader. Recog¬
nition of characters and their rerepresentation for speech might weight
of

more

heavily on geometric spatial

factors than do similar recognition
and rerepresentation of English
words. If true, then it is possible that
right language dominance is related
in part to these influences of the

original language experience. Thus,
we have a right-handed patient with
aphasia from a right cerebral lesion

with greater preservation of English
than Chinese and some deficits in
nonlanguage performance tasks. In
our patient, this might also be related
to sharing of both the semantic and
the spatial linguistic systems in the
dominant right hemisphere. If these
linguistic factors were the major
determinants of inverted cerebral
organization, one would expect to see
many cases of crossed aphasia in
Chinese patients. Unfortunately, the
literature on Chinese aphasies is very
small. To our knowledge, only Alajouanine et al31 described Chinese
aphasie performance in linguistic de¬
tail. The paucity of crossed aphasie
patients of any language origin sug¬
gests that other factors must play
equally important roles.
It has been asserted that aphasia in
polyglots is associated with less severe

dysfunction in the maternal (firstlearned) language.33 There are, how¬
ever,

several

case

reports

to the

contrary.36 We are aware of only one

detailed study of aphasia in a ChineseEnglish polyglot.37 In that case, as in
ours, Chinese was more severely
disturbed even though it had been the
maternal language. That case does not
permit us to generalize about a
possible relationship between the
right-sided lesion in our patient and
his greater deficit in Chinese than
English. Detailed reports on aphasie
performance in Chinese-Americans

are necessary to answer these ques¬
tions in a more solid fashion.

Samuel Anderson, PhD, performed dichotic
listening tests. Ray Brinker, MD, performed CT.

Aaron Smith, PhD, and Jason Brown, MD,
reviewed the manuscript. Marcel Solomon, MD,
referred the patient to us. Anne Polin typed the

manuscript.

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