Brain (1982), 105,29-51

APHASIA IN A PRELINGUALLY
DEAF WOMAN
by CHRISTINE CHIARELLO, ROBERT KNIGHT
and MARK MANDEL 1
(From the Department of Linguistics, University of California, Berkeley, CA 94720,
University of California, Davis, and the Veterans Administration Medical Center Martinez,
California, USA)

INTRODUCTION

,

I N order to understand the neural substrate of linguistic behaviour it is necessary
to consider language in all its various guises. This will include data integration of
non-European spoken and written languages (Sasanuma, 1975; Naeser and Chan,
1980), as well as languages which do not utilize the vocal/auditory modality
(Critchley, 1970). Identification of the similarities and differences in the neural
representations of such diverse language systems may identify those which are
shared by all languages, and those which are related to specific linguistic structures
or particular input/output modalities.
Of the various manual languages of the deaf, American Sign Language (ASL) has
recently become the focus of intense study. It is the primary means of communication used by many deaf persons in the United States, and is a fully developed
language (Klima and Bellugi, 1979), although it is not derived from English or any
other spoken language. Finger-spelling, in contrast, is a system in which words are
spelled manually, with one symbol for each letter of the English alphabet. (Those
unfamiliar with the structure of ASL may wish to consult the Appendix for a brief
synopsis of those properties relevant to this study.)
ASL is of particular neurolinguistic interest because of the simultaneity inherent
in the structure of signs, and its use of space to encode linguistic information. Visual
half-field studies have generally suggested a greater involvement of the right
hemisphere in the processing of ASL by native signers than is expected for a spoken
language (Manning, Goble, Markman and LaBreche, 1977; McKeever, Hoemann,
Florian and Vandeventer, 1976; Poizner, Battison and Lane, 1979; Poizner and
Lane, 1979; but see also Neville and Bellugi, 1978). Only a handful of cases of sign
language aphasia have been recorded (Burr, 1905; Critchley, 1938; Leischner, 1943;
Tureen, Smolik and Tritt, 1951; Douglass and Richardson, 1959; Sarno, Swisher
1

Current affiliation: Department of Psychology, Northeastern University.

30

CHRISTINE CHIARELLO, R. KNIGHT AND M. MANDEL

and Sarno, 1969; Kimura, Battison and Lubert, 1976; Meckler, Mack and Bennett,
1979; Underwood and Paulson, 1981). In all these cases the lesion involved the left
hemisphere, although precise intrahemispheric localization data have been lacking.
It is reasonable to expect a somewhat different intrahemispheric organization for
visual-gestural languages. Isolated disturbances of visual language (alexia with
agraphia) have usually been associated with lesions in the left parietal lobe, in
particular the angular gyms (Dejerine, 1892; Albert, 1979). It would follow that this
region, rather than the classic auditory association areas, would subserve the
decoding of sign language.
Previous studies of sign language aphasia have been inconclusive. In some cases,
the individual was not prelingually deaf (CritchJey, 1938; Kimura et al., 1976;
Meckler et al., 1979). In others, adequate lesion localization data were not available
(Burr, 1905; Douglass and Richardson, 1959; Sarno et al., 1969; Underwood and
Paulson, 1981). Leischner (1943) presented detailed post-mortem findings, but the
existence of multiple lesions involving both hemispheres prevents specific clinicoanatomical correlations. Lastly, investigators have not viewed sign language
aphasia as the disruption of a cohesive linguistic system. Thus, little information on
the quality of the aphasic symptoms in such cases is available for comparison with
data from hearing aphasic patients.
In this paper we report sign language aphasia in a 65-year-old prelingually deaf
woman who was fluent in ASL before suffering a left parietal cerebrovascular
accident. Her language abilities were assessed three times within the first two weeks
following her stroke, and a more extensive investigation was done five to seven
weeks post-onset. Our aims were twofold: (1) to document the patient's linguistic
disorder in sufficient detail to determine whether her symptom complex would
parallel that expected for a hearing person and whether there were any features
unique to the gestural modality; (2) to correlate the site of the lesion as evident on the
CAT scan with the aphasic symptoms in order to provide information on the
neuroanatomical organization of sign language.
CASE REPORT
Background
The patient, L.K., a right-handed woman, was bora in Mexico in 1914. She entered the US the
following year, and was adopted. She became deaf at 6 months of age after an episode of scarlet fever,
and was the only deaf person in her (adoptive) family. Early records state only that L.K. was
'completely deaf in both ears'. Communication with her family was reportedly accomplished via fingerspelling. A childhood (hearing) friend, who had also communicated with L.K. using finger-spelling,
stated that to her knowledge, the patient never lip-read or used speech. At the age of 5 years she was
enrolled in a residential school for the deaf. There she was taught both oral techniques (speech and lipreading) andfinger-spelling.American Sign Language was not used for instruction, but was used
among the students outside of the classroom. The patient stated that she learned ASL from an older
student when she was 7 or 8 years old. She reported that she preferred signing to oral techniques and
always used the former except in the classroom. She began learning to read and write English at
approximately the same time. L.K. was a ' C student, excelling in crafts and other manual arts. She left

APHASIA IN A DEAF WOMAN

31

school at 16 years of age without graduating, and was employed in a number of manufacturing jobs. In
1946 she married a hearing-impaired person, and remained married for seventeen years. An associate
described the patient as quite self-sufficient and capable. Most of the patient's friends were members of
the deaf community.
A sign language interpreter (J.L.), who had interpreted for the patient several times within the year
before her stroke, stated that L.K. wasfluentin ASL and used finger-spelling to a moderate extent. She
was described as being quite voluble, and was known to sign non-stop for extended periods. The
patient also vocalized, but her 'speech' was not understandable, and therefore could not serve as a
medium of communication. This interpreter felt that L.K. did not read lips. L.K.'s reading level was
estimated by a hearing associate to be at least fifth grade at this time. She reportedly read and
understood the newspaper. A sample of her pre-stroke writing (seefig.1) indicates that, while adequate

Sc-

[17?

FIG. I. Sample of L.K.'s writing, approximately three months before her stroke.

32

C H R I S T I N E CHIARELLO, R. K N I G H T AND M. MANDEL

to serve her needs, it was substandard in some respects. The errors in punctuation, spelling, and the
misuse or omission of articles and prepositions are characteristic of the writing of deaf persons who are
not highly educated. However, it is notable that the patient used appropriate English syntax and verb
inflections.
It appears, then, that the patient primarily used ASL, supplemented by finger-spelling, to
communicate prior to her stroke. She could also read and write English sufficiently well to manage her
own affairs. As far as could be determined, L.K. never acquired spoken language. Finger-spelled
English may have been her 'first language', but herfluencyinfinger-spellingprior to the acquisition of
signs could not be ascertained.
We will adopt the following conventions to represent words in the various language systems used by
the patient: WATER represents an ASL sign; I-GIVE-YOU represents a single ASL sign which
requires more than one word to translate: W-A-T-E-R indicates afinger-spelledEnglish word; water
represents printed or written English; 'water' is the translation of an ASL sign, or signs.
Neurological Examination and CAT Scan Findings
On March 27, 1980, L.K. developed right-sided weakness of acute onset and was brought to the
Emergency Room. On admission, her general medical examination was unremarkable. Neurological
examination revealed her to be awake and alert with moderate weakness of the right arm and slight
right central facial and right leg weakness. Pin-prick, touch, vibration and proprioception were
markedly decreased on therightside. Her reflexes were increased on therightside, herrightarm and leg
wereflaccidand she had a right extensor plantar response. No hemi-inattention was noted. Vascular
examination revealed a loud left carotid bruit. The patient was admitted with a diagnosis of embolic
infarction of the left hemisphere. A sign language interpreter (J.L.), who had known L.K. prior to her
stroke, was called for more detailed evaluation of her mental status. The patient was found unable to
follow two-part sign commands. Her output of signs was limited to YES, NO and I-DON'T-KNOW.
She was able to read and perform a bucco-facial command such as open your mouth or an axial
command such as close your eyes but could not perform more complicated written commands. Her
writing was severely impaired and she wrote her first name as response to all sign questions. She
could mimic all letters of thefinger-spellingsystem, but when asked to finger-spell the alphabet
spontaneously, she spelled A-B-C-D-I-D-I-D. She tended to use gestures to express her needs to the
examiners.
Five days after admission the patient remained with a trace of right central facial paresis, worse to
volitional than to emotional movement. She had severe weakness of her right upper extremity with
some increase in tone in her arm, and her leg was moderately weak. Strength and dexterity in her left
arm were normal. She had markedright-sidedsensory decrease to primary somatosensory modalities
with the arm most severely affected. She was able to perform, without difficulty, discrete oral
movements such as puckering, opening her mouth or sticking out her tongue. However, she had
difficulty performing sequential combinations of these movements. She was able to perform isolated
left-hand movements such as open palm, make fist, spread fingers, but her ability to combine these
motor acts in a sequence was impaired. For example, she was unable to perform the sequence 'flat, fist,
edge of palm' with her non-paretic hand although she could perform each individual position well.
Stereognosis was intact in her left hand and absent in her right hand. Optokinetic nystagmus was
present in both directions. No visualfielddefects were detected and no hemi-inattention was observed.
Visual acuity was 20/20, right eye and 20/30, left eye.
Neurological evaluation at six weeks post-onset demonstrated clear improvement. Sensory
examination to primary modalities showed recovery in her right hand. She had return of stereognosis,
although objects still felt 'different' in herrighthand. She was now able to move thefingersof this hand
against gravity. She performed at 100 per cent accuracy on the Ishihara colour plates. Audiograms
performed at this time revealed no response up to 115 dB in both ears.
A CAT scan performed the day after admission revealed a low density lesion in the left anterior
parietal lobe in the region of the supramarginal and angular gyri. The combination of CAT scan

APHASIA IN A DEAF WOMAN

B

findings,rightarm paresis, and severe primary somatosensory loss indicated that the lesion involved or
undercut areas 4, 3,1 and 2 in addition to areas 39 and 40 (Gado, Hanaway and Frank 1979; Gonzales,
Grossman and Palactos, 1976; Mazzocchi and Vignolo, 1978, 1979; Naeser and Hayward, 1978). A
repeat CAT scan done at ten weeks post-stroke {seefig.2) confirmed the left parietal localization and
revealed an anterior slit-like subcortical extension under areas 4, 3, 1 and 2 not seen on the initial CAT
scan. The inferior frontal operculum (areas 44 and 45) and the posterior superior temporal plane (areas
41, 42 and 22) were spared by the lesion.

FIG. 2. CAT scan ten weeks after onset with lateral reconstruction of lesion. There is clear definition of the left
parietal lesion (dots only). Note the slit-like anterior subcortical extension under the pre- and postcentral gyri
(diagonal lines and dots). The lesion is not apparent on cuts immediately above or below.

Initial Language and Neuropsychological Assessment

Aphasia testing five days after admission showed the patient unable to perform
two-part ASL commands accurately. Attempts to provoke spontaneous signing by
questions about her childhood, friends, or pictures of simple scenes mainly
produced a reiteration of the question or I-DON'T-KNOW. She had a severe

34

CHRISTINE CHIARELLO, R. KNIGHT AND M. MANDEL

anomia in both ASL andfinger-spellingfor objects or pictures of objects, and could
only produce the signs for 2 of 11 test items. Her usual response was I-DON'TKNOW, although twice a gesture was given instead of a sign. When shown a picture
of wine, the patient produced an uninterpretable sign (hand in front of mouth,
fingers straight and parallel, pointing to side, palm down, repeatedly bringing
extended fingertips to thumb), which consists of standard ASL formational
parameters in a novel combination. She perseverated on this response frequently
throughout the rest of the test session. L.K. could imitate signs she could not
produce spontaneously, and could sometimes indicate what the test objects were
used for. However, when given a choice of photographs of signs she could not select
the depicted sign which represented the actual object. She could not name colours in
either ASL orfinger-spelling,although when asked in ASL to point to blue, red, or
yellow she did so correctly.
The patient was unable tofinger-spellthe names of any of the test items, but could
finger-spell herfirstname. She could not match an object to the correct printed word
from a list of 3 or 4 words. However, she was able to give the correct sign for a few of
the printed words, or produce a semantic paralexia (DRINK (signed incorrectly
with closed fist) for water, ORANGE for banana) in some cases. The patient could
count to 12 spontaneously. Her digit span, using signed response, was three. During
this session, some vocalizations were noted, but they were not articulate, consisting
mainly of simple phonation.
At two weeks post-onset, the patient's output of sign had noticeably increased,
although it remained severely impaired. Her spontaneous expression still contained
a great deal of gesturing rather than signing, and many signs were misarticulated.
She was unable to recite the days of the week or the Lord's Prayer. She attempted to
shadow the Lord's Prayer, but was unable to keep up with the experimenter,
omitting many signs and mispronouncing others.
On an ASL sentence repetition task, single sign sentences were repeated correctly,
but the patient made several articulatory errors on 2-sign sentences. On 3- and 4sign sentences only 2 signs at best were repeated. Grammatical modulations were
generally preserved in the patient's (often incorrect) responses. For example,
L.K. repeated MAN KEEPS-ASKING-ME-QUESTIONS as MAN KEEPSDRINKING-LIQUOR. The latter has a handshape similar to the stimulus sign and
a simpler movement.
Articulatory errors, occurring both spontaneously and during repetition, often
involved substitution of a hand configuration, place of articulation, or movement
feature. SIN, for example, was mispronounced with a palm-in flat hand (instead of
pointing hand) circling in front of the face (instead of the chest). Such errors appear
to be literal paraphasias.
A marked anomia was still evident for ASL, finger-spelling, and written
responses. The patient could write her first and last names, copy from a written
sample, and write a simple sentence to ASL dictation. However, she was unable to
finger-spell her last name correctly, and could not finger-spell any items in

APHASIA IN A DEAF WOMAN

35

confrontation naming. She couldfinger-spellfrom a written sample, but could not
provide the ASL equivalents for the same printed words. On Marie's Three Papers
Test (ASL), the patient could only perform the first of the three commands.
Repeating the instructions resulted in the same response. Little vocalization, none of
it articulate, occurred during this session.
The patient could demonstrate how 3 of 4 objects shown to her were used.
Sequential movement copying ('flat, fist, edge of palm' sequence) was impaired.
Digit span was 2. Nonverbal visual sequential memory span, as tested by the Knox
Cube Test (Inglis, 1957), was 3. The patient could not add simple sums (written
response), and had difficulty providing signs for written numbers.
L.K. was able to copy shapes (square, circle, Greek cross) and could copy block
designs of up to 8 blocks. She correctly pointed to specific places on an outline map
of the United States.
In summary, the patient's initial aphasia was characterized by a greatly reduced
sign output, severe anomia and the production of literal and verbal paraphasias.
Although ASL comprehension was not systematically assessed, some comprehension impairment was apparent in the patient's difficulty in grasping test instructions
and inability to carry out 2- or 3-part commands. Finger-spelling, except in the
presence of a written English stimulus, was impossible. No articulate vocalizations
were present at this time. At least some reading and writing skills were preserved. In
addition, there was deficient movement copying, reduced verbal and nonverbal
visual memory span, and acalculia.

FURTHER LANGUAGE AND NEUROPSYCHOLOGICAL TESTING

The patient was available for more extensive testing betweenfiveand seven weeks
following her stroke. During this period she was alert, gregarious, and extremely
co-operative. She was aware of her linguistic problems, but was not very frustrated
by them. Signing and writing were still carried out exclusively with the left hand.
Our assessment included tests of each of the patient's language systems (ASL,
finger-spelling, and written English), as well as nonlinguistic gesture and verbal and
nonverbal short-term memory. Testing was always conducted at the same time of
day (a.m.), and with the assistance of a certified sign language interpreter. Sessions
were videotaped for later analysis. All test instructions were given in ASL, and
elaborated with pantomime if necessary.
Language Assessment

The language investigation was modelled after, but not limited to, the Neurosensory Center Comprehensive Examination for Aphasia (Spreen and Benton,
1969). However, since test items were frequently modified to accommodate the
structure of ASL, reference to the standard scoring procedures and norms is not
appropriate.

36

CHRISTINE CHIARELLO, R. KNIGHT AND M. MANDEL

1. American Sign Language
(a) Production-Articulation. Stimuli for this test comprised 86 ASL signs and 10
nonsense signs. The former were selected to represent all the known distinctive
manual elements of ASL. Of the nonsense signs, 5 were composed of standard ASL
parameters and could easily be signs, but in fact are meaningless, like the syllable
'blick' in English (Chomsky and Halle, 1968). The other 5 were constructed so as to
be deviant or impossible as ASL signs (compare 'bnick', which could never be an
English word). The patient was instructed to copy each sign as modelled by the
interpreter. We made no special effort to limit the test to one-handed signs, having
noted L.K.'s means of accommodation to her right hand paresis. Her previously
nondominant hand assumed the active signing role. She used a tabletop or her
paretic right hand as a substitute for the passive base hand in most signs requiring
only one active hand (see Appendix). Two-handed symmetrical signs, in which both
hands normally move, were simply 'halved'.
Overall performance on this test was quite good. Only three errors occurred in the
patient's copying of actual signs: MORON and BIRD were copied with an improper
hand orientation (fingertips pointing sideward, rather than facing toward
(MORON) or away from (BIRD) the signer); OVERSLEEP was reproduced with
an inappropriate contact and place of articulation (forehead), and downward
(rather than upward) movement. All 5 of the possible nonsense signs ('blicks') were
copied without error or hesitation. In contrast, 3 of the 5 impossible signs ('bnicks')
were reproduced incorrectly (one of these was later self-corrected). In these cases,
L.K.'s 'errors' involved changes in the direction of ASL phonology. That is,
impossible signs were reproduced as possible or actual signs (analogous to changing
'bnick' into 'blick' or 'brick'). For example, a nonsense sign which involved a
deviant contact and movement (flat hand, fingers together and palm down, taps
chest with thumb-index edge; wrist and knuckles bend sofingerspoint down, then
tap again) was reproduced with the contact and movement of an actual sign
(TIRED, not in the test). Unimpaired signers show a similar normalizing tendency
when imitating foreign signs (Coulter, 1974).
Visual Naming. Ten objects were presented for naming. Although L.K. was asked
to provide the ASL sign, she often attempted tofinger-spellthe name as well. Six of
the objects (ring,flowers,paper, fork, rope, umbrella) were named correctly in ASL,
the first 4 of these also being correctly finger-spelled. In one case (cup), only the
finger-spelled name could be produced. A thermometer elicited a gesture which
could be interpreted as 'it goes up'. When shown a padlock L.K. finger-spelled
L-O-C-K, but gave the sign TO-LOCK (as a door) which can only be used correctly
as a verb. Finally, a parallel naming error in ASL andfinger-spellingoccurred to the
stimulus object bottle:
L.K.: P'you drink from it'
P-O-P-L-

APHASIA IN A DEAF WOMAN

Interpreter:
L.K.:
Interpreter:
L.K.:

37

'that's wrong' . . . 'I've really forgotten—
I can see it and I know what it is'
L-K-P-A'I can't remember'
'what's the sign?'
SODA-POP
'another sign?'
'drinking, drink, I've forgotten'
SODA-POP

Colour Naming. L.K. succeeded in producing ASL colour names with 100 per cent
accuracy.
Description of Object Use. Ten objects (different from those used for naming) were
presented to the patient, and she was asked to describe their use. She provided
adequate sign descriptions for all objects.
Sentence Construction. The patient was shown 2 or 3 signs and instructed to form
a sentence with them. Her responses were grammatical and appropriate. However, in
2 of the 5 sentences L.K. omitted one of the stimulus signs in her response. Some misarticulations resembling literal paraphasias were also noted. WRITE, for example,
was articulated with improper extension of the fingers (a different ASL handshape).
Sentence Repetition. The stimulus set for this test contained 17 phrases and
sentences of increasing length (1 to 10 signs) and grammatical complexity. The latter
included the addition of dependent clauses and aspectual (habitual or continuous
action) and indexical (subject, object) inflections.
L.K. repeated the first 5 stimuli (those composed of one or two signs) correctly.
Only one of the longer sentences was copied even approximately correctly, with
omission of at least one sign from each such sentence, as well as mispronunciations,
hesitations, uninterpretable gestures, and perseverative errors. For example, she
repeated MANY BLACK CAT ('many black cats') as BLACK (incorrect
handshape) CAT. As the stimuli grew in length and complexity her responses were
more and more garbled, seeming to be rearrangements of some remembered signs,
often fleshed out with signs that had not been in the stimulus, but were semantically
related and enabled the patient to construct a more or less coherent response. For
example, the stimulus
MY FRIEND BRING-ME TWO NEWSPAPER 'My friend brought me two
newspapers' was repeated as
?FRIEND ?MOVE-TO-ME NEWSPAPER ?SUBSCRIBE NEWSPAPER
BRING-ME gesture NEWSPAPER
This response is not interpretable as a sentence. It should be noted that, as in the
earlier test of sign and phrase repetition, grammatical modulations were not lost.
There was also a tendency for information which occurred near the end of the longer
sentences to be preserved in the patient's responses.

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CHRISTINE CHIARELLO, R. K N I G H T AND M. MANDEL

Practised Sequences and Spontaneous Signing. L.K. was now able to recite the
days of the week, with some hesitation. She attempted to sign the Lord's Prayer and
could recall fragments of it, but was unable to recite the entire prayer.
The patient's spontaneous signing, during conversation or in interview, was
described (by J.L.) as fluent, but somewhat vague and circumlocutary. This
interpreter felt that she had to rely more on contextual information to understand
the patient than was the case before her stroke. L.K. used indexical pronouns
inconsistently in her narrative signing. In some cases she neglected to establish (via
spatial placement) the referents for such pronouns. She was still using gestures (as
opposed to signs) to a greater extent than she had pre-stroke, and misarticulated
signs were not uncommon. Her characteristic garrulousness had returned. The
patient frequently vocalized concurrent with signing, and many of the vocalizations
now exhibited syllabic structure. However, as was the case pre-stroke, these were not
interpretable and did not enhance her ability to communicate.
(b) Comprehension-Identification by Name. The patient could recognize the ASL
names of all objects and colours used in the previously described naming test. She
responded, without hesitation, by pointing to the correct object/colour from an
array of items.
Token Test. The Spreen and Benton (1969) version of this test (39 items) was
administered in ASL. Almost no modification of the standard procedure was
necessary; scoring follows the weighted method of Spreen and Benton (1969), which
awards credit for partially correct responses.
The patient's score on each of the subsections is indicated in Table 1 A. It is evident
that performance breaks down on those parts (E and F) which are highest in
mnemonic and grammatical complexity. The total score would place L.K. in the
bottom third of hearing aphasics who were given this version of the Token Test
(Spellacy and Spreen, 1969), and indicates a substantial comprehension deficit.
Verbal Commands. The patient was able to perform two- but not three-part
commands (Boston Diagnostic Aphasia Exam (Goodglass and Kaplan, 1972) and
Marie's Three Papers Test). She had difficulties with left/right commands.
Story Comprehension. Four stories, adapted from a primary school reading test
(Gates, 1958), were presented in ASL. Following each, L.K. was asked a series of
yes-no questions, based on the story. She answered about 75 per cent of these
questions correctly. Performance was unrelated to story length. The patient
sometimes tended to base her answers on real-world knowledge rather than actual
story content.
2. Finger-spelling
L.K. could now finger-spell her first and last names, but only fragments of the
manual alphabet spontaneously (A-B-C-D-E-L-M-N-O-P ...). A series of line
drawings and colours were presented to her tofinger-spell.The former items were
selected to encompass a range of spelling difficulty, the most difficult being spellable

APHASIA IN A DEAF WOMAN

39

by 99 per cent of ninth-graders (Buckingham, no date). Approximately one-third of
her responses contained errors. In many such instances, however, she could provide
the correct sign. Errors were most often misspellings (P-A-N-C-E for fence) or
perseverations. The latter included intra-word repetitions (P-I-N-K-K) and intrusions from earlier items (M-A-N for monkey). In one case the patient appeared
to carry over a handshape from ASL intofinger-spelling.(Some ASL handshapes
also occur as letters in the finger-spelling system. However, there is normally no
relationship between the ASL signs in which such handshapes occur, and the
spelling of the corresponding English words (Klima and Bellugi, 1979).) When
shown a drawing of an Indian, she produced the correct sign (using the 'F'
handshape, index finger and thumb opposed, other fingers extended) several times
and then spelled F-A-I-N. Jargon responses were occasionally given (L-A-L-A-Y
for suitcase). In general, however, L.K. appeared to have at least partial knowledge
of the target's spelling.
When given thefinger-spelledname for the same test items, L.K. always selected
the appropriate drawing or colour. Finger-spelling from a written sample was much
better than confrontation naming, with only occasional perseverative errors
occurring.

TABLE I. ASL

AND READING COMPREHENSION TEST PERFORMANCE

A. Token Test
Score
Part
A
B
C
D
E
F

Sample item
Show me a circle
Show me the yellow square
Show me the small white circle
Take the red circle and the green square
Take the large white circle and the small green
square
Put the red circle on the green square
Total score

ASL commands
(5/5/80)

Written commands
(5/9/80)

7/7
8/8
11/12
14/16

7/7
10/12
12/16

12/24
40/96

16/24
—

92/163

53/67

8/8

•

B. Reading Comprehension Battery for Aphasia (5/5/80)
Subtest
Word Recognition
Visual Confusions
Auditory Confusions
Semantic Confusions
Sentence Comprehension
Short Paragraph Comprehension

No. correct
9/10
9/10
9/10
9/10
5/10

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CHRISTINE CHIARELLO, R. KNIGHT AND M. MANDEL

3. Written English
(a) Writing. L.K. could write herfirstand last names legibly. When asked to write
the alphabet, she omitted several letters.
Written naming was assessed using the same stimuli as in thefinger-spellingtask.
Less than half of the patient's responses can be considered adequate. Perseverative
errors, either of letters, word fragments, or entire 'words', and/or misspellings were
common, sometimes entirely obliterating any relation to the target word. For
example, a drawing of an umbrella elicited ummber, the next stimulus, bicycle, was
written gmber. Many responses were elaborated. These might include the target
word (fig. 3A, stimulus 'house'), an incorrect version of the target (fig. 3B, 'Indian'),
or bear some type of relation to the target (fig. 3c, 'fence'). In some cases the patient
provided the correct sign for stimuli which elicited agraphic responses, and in
general demonstrated an awareness of her errors.

Fio. 3. Written Confrontation Naming, A: house; B: Indian; c: fence.

The sentence construction test which had previously been administered in ASL,
was given with the stimulus words printed on cards and written response required.
For the first three test items, L.K. wrote sentences devoid of paragraphias, but
which seemed to follow ASL rather than English grammar (fig. 4A, stimuli rain,
cold). The final two sentences in the test contained paragraphic errors, and were so
contaminated by words from the earlier sentences, as to be uninterpretable
according to the grammar of either language (fig. 4B, stimuli hair, water, girl).

APHASIA IN A DEAF WOMAN

41

B

FIG. 4. Sentence Construction, A: stimuli rain, cold; B: stimuli hair, water, girl. Morning and drink had
appeared in the previous sentence.

Writing to Dictation. A series of 10 words were dictated in finger-spelling. L.K.
wrote 4 correctly. Errors were predominantly letter substitutions and/or perseverations from previous words. None of the former appeared attributable to fingerspelling confusions.
L.K. was able to write single words to ASL dictation. Sentences of 3 to 5 signs
were also dictated. The only 3-sign sentence (MY SISTER PRETTY) was written in
grammatical English (my sister is pretty). Longer sentences contained misspellings,
word omissions, and what appear to be attempts to partially reconstruct stimulus
information (fig. 5). Words occurring at the end of the signed sentences were more
likely to appear in the patient's responses.

S
FIG. 5. Writing to ASL dictation, A: ME HAVE TWO CHILDREN; B: NOW MORNING ME WATCH TV.

42

CHRISTINE CHIARELLO, R. KNIGHT AND M. MANDEL

(b) Reading. Several subtests of the Reading Comprehension Battery for Aphasia
(La Pointe and Homer, 1979) were administered, testing word, sentence and short
paragraph comprehension. L.K. was 90 per cent correct on the word and sentence
subtests (Table 1B). It should be noted that the sentence subtest items primarily
tested comprehension of a single target word. When the information processing load
increased (short paragraph comprehension), L.K.'s reading comprehension
deteriorated (Table 1B). The most difficult paragraphs in this subtest were at the 4th
grade reading level (La Pointe and Homer, 1979).
The Token Test was readministered using written commands. L.K. read the
command, then the written stimulus was withdrawn, and she made a response. She
was unable to follow this procedure, however, for the final subpart of the test. The
results of the other subsections (Table 1A) indicate a comprehension level
comparable to that in ASL.
Summary of Language Data
At five to seven weeks post-onset, L.K.'s signing was relatively fluent, with
improved articulation, although paraphasias (mainly literal) were evident. Moderate
anomia was present. There was a marked repetition deficit. ASL comprehension was
intact at the single sign level, but broke down as mnemonic and grammatical
complexity increased. Finger-spelling was at least as impaired as signing. A definite
agraphia was present under all test conditions. Reading comprehension paralleled
ASL comprehension, with impairment appearing at higher levels of linguistic
complexity. The patient's vocalizations had returned to the pre-stroke level, at times
being articulate, though uninterpretable.
Nonlinguistic Gesture
Apraxia Testing. A lengthy series of limb and facial movements were demonstrated for the patient to imitate. These included nonrepresentational (for example,
placing hand behind head), intransitive (for example, saluting), and transitive (for
example, hammering) movements (Brown, 1972). L.K.'s reproductions of these
were accurate. We also assessed the patient's manipulation of actual objects (comb,
screwdriver, etc.). In all cases, she demonstrated the object's use appropriately, and
without hesitation. Since many ASL commands to perform an action (BRUSHTEETH) are quite similar to the actual movements themselves (brushing one's
teeth), it was not feasible to test the patient's praxis to verbal command. There was
no evidence for an ideational apraxia (Brown, 1972). L.K. could, for example, fold a
piece of paper, place it in an envelope, seal, and stamp it.
Movement Copying. The finger flexion and manual movement copying tests
described by Kimura (Kimura and Archibald, 1974; Kimura et al, 1976) were
administered. L.K.'s finger flexion was normal. However, a severe impairment of
movement copying was evident for 2 of the 5 sequences. Even with 3 consecutive
attempts at these, L.K.'s copies were deficient. There were errors in hand posture,

APHASIA IN A DEAF WOMAN

43

orientation, place of contact, direction of movement, and number of movements.
Sequencing errors per se (correct movements in incorrect order) were not
noted.
The patient's reproduction of the 'flat, fist, edge of palm' sequence, which by
now had been tested innumerable times, was still impaired. She tended to
perseverate on hand postures and had great difficulty in switching from one posture
to the next in the sequence. L.K. could, however, copy rhythmic hand-tapping
sequences which did not involve changes in hand postures, and easily learned to tap
once whenever the experimenter tapped twice, and vice versa.
Pantomime Comprehension. We devised a test of simple pantomime and gesture
comprehension, similar to that of Gainotti and Lemmo (1976). The interpreter
pantomimed the actions (for example, aiming and firing a pistol) using postural
stances and body movements so as to be maximally distinct from the signs for the
actions. The patient then selected, from a set of three drawings, the one which
was related to the pantomime. One of the distractor drawings was associated
in some way with the correct drawing (knife/pistol), but unrelated to the
gesture or pantomime. L.K. erred on only one of the nine actions, selecting
a drawing of a judge after having seen the interpreter stand at attention and
salute.
Short-term Memory
The patient's digit span, with stimulus and response in ASL, was 3. Performance
did not improve when the signed stimulus was reported by pointing to written
numbers. In fact, under these conditions, she only achieved a digit span of 2.
Although digit spans reported for deaf adults are typically lower than those for the
hearing population (Olsson and Furth, 1966), this patient's performance seems
depressed.
Nonverbal visual sequential memory span was assessed by the Knox Cube Test
(Inglis, 1957). This test requires the subject to reproduce a tapping sequence on four
blocks. Score is the longest sequence correctly copied. L.K.'s span was 4 on one
administration and 3 on retesting two days later. Inglis (1957) reports a mean score
of 4.25 for his elderly control subjects on this test.
Calculation
L.K. could carry out written calculations involving the addition, subtraction, or
multiplication of one-digit numbers. However, she was unable to perform correctly
more complex calculations which involved carrying over digits. We could obtain no
information about her mathematical competence prior to her stroke, other than the
fact that she had maintained her checkbook.

44

CHRISTINE CHIARELLO, R. KNIGHT AND M. MANDEL
DISCUSSION

The aphasic sequelae of a left parietal infarct in a deaf user of American Sign
Language are consistent with what is known about aphasia in hearing populations
and with the structure of ASL. Initially, the patient's nearly global aphasia was
characterized by impoverished signing, severe anomia, literal and verbal paraphasias, impaired comprehension and an almost total loss of finger-spelling. By five
to seven weeks post-onset expressive skills had improved, leaving the patient with a
pattern of symptoms similar to that of hearing aphasics with posterior lesions: fluent
signing with circumlocutions and (predominantly literal) paraphasic errors, anomia
(less severe in ASL than in written English), impaired repetition, comprehension
difficulties (for both ASL and written English), and agraphia. The associated
findings of reduced short-term verbal memory and impaired movement copying are
also frequently present with aphasia for spoken language (Albert, 1976; Heilman,
Scholes and Watson, 1976; Kimura and Archibald, 1974; Mateer and Kimura,
1977).
Before discussing the issues raised by the present case, we will consider whether
L.K.'s impaired signing might be traceable to motor imprecision or an apraxia. It
might be expected that the patient's reliance on her nondominant hand for signing
would entail articulatory difficulties. However, normal signers frequently use their
nondominant hand in the active signing role for grammatical or stylistic reasons
(Frishberg, 1979), and are accustomed to signing one-handed when tired, or when
one hand is occupied with driving, carrying, etc. (Battison, 1974). It seems unlikely,
then, that one-handed signing with the non-dominant hand, in and of itself, would
have engendered many misarticulations. In addition, we observed that the patient's
articulatory errors were no more likely to occur on two-handed than on one-handed
signs. L.K.'s normalfingerflexionand manual dexterity with handling objects in her
left hand also suggest that adequate digital mobility was present.
The types of articulatory errors made by L.K. conform to the formational
structure of ASL signs and resemble the speech errors of oral aphasic patients. It has
been noted that aphasic errors tend to be substitutions of those sounds which are
more frequent and less distributionally restricted, for sounds which are less common
and more restricted in their occurrence (Blumstein, 1973). L.K.'s misarticulated
signs, likewise, often involved the substitution of a common neutral handshape
('B', '5', 'G', 'O'), or were displaced to the mouth/lower face area, which is the most
frequent place of articulation (Battison, 1978). Most of the patient's misarticulated
signs can be analysed as the substitution, perseveration, or anticipation of one or
more ASL formational parameters: handshape, place of articulation, movement,
and orientation. Since they occurred in the midst of fairly fluent signing it seems
reasonable to regard them as literal paraphasias.
Most previous investigators of sign language aphasia have remarked on the
absence of apraxia (Critchley, 1938; Tureen et al., 1951; Douglass and Richardson,
1959; Sarno et al., 1969; Meckler et al., 1979). L.K. was not apraxic as that disorder

APHASIA IN A DEAF WOMAN

45

has traditionally been defined. However, there was a definite impairment in her
ability to copy unfamiliar movement sequences. A similar dissociation was reported
in another aphasic signer (Kimura et al., 1976). As mentioned earlier, L.K.'s
movement copying errors were not attributable to a serial ordering difficulty, but
rather to an inability to carry out smooth transitions between movements or to
achieve a correct target posture when embedded in a complex sequence. Similar
difficulties characterize the oral sequential movement copying of fluent hearing
aphasics (Mateer and Kimura, 1977). Whether L.K.'s aphasia can be reduced to a
sequential motor apraxia is debatable since the language comprehension deficit
would be difficult to account for under this theory. The rule-governed nature of the
patient's articulatory errors and their occurrence in a matrix of generalized linguistic
disruption suggests to us an aphasic rather than an apraxic origin. It is probably
advisable to consider the impaired movement copying as an associatedfindingin the
absence of firm evidence to support its inherent relationship to aphasia (either oral
or manual).
The presence of'gestures' noted during L.K.'s signing requires comment. By this
is meant any manual activity occurring during the patient's signing which was not
interpretable as a sign or even a misarticulated approximation to a sign. Many of
these (particularly those appearing within the first two weeks of her stroke) were
fairly gross gestures lacking the expected internal structure of ASL signs, and
imparting little specific information to the examiner. It is impossible to ascertain
whether they represent attempted signs which were so degraded as to be
unrecognizable, or some extralinguistic attempt to communicate. Occasionally,
L.K.'s 'gestures' seemed to be more mimetic and occurred in contexts in which
standard ASL signs would have been more appropriate. For example, on one
occasion L.K. pantomimed pouring milk into coffee and stirring it, rather than
providing an ASL sentence as requested. In several instances gestures of this type
were replaced by ASL signs as the patient showed recovery. It should be noted that
signers sometimes incorporate pantomimed sequences in their narrative signing.
Such mimetic gestures, however, were more frequent in the patient's signing at five
to seven weeks than they had been before her stroke.
Can any of the 'gestures', be considered instances of neologistic jargon? Since
jargon-like responses were noted in L.K.'s written naming (seefig.3) and to a lesser
extent in finger-spelling, this would seem a likely possibility. We would expect a
neologistic sign to conform to ASL formational structure conditions, but to be
meaningless and unrelated to any sign expected in context (Buckingham and
Kertesz, 1976). With one exception (a pseudo-sign used perseveratively by L.K.
during an early testing session) it was the opinion of fluent signers that L.K.'s
spontaneous signing was devoid of any neologisms. Occasionally when attempting
to recall a sign, the patient would grope for the word, producing intermediate 'signs',
of which some might be uninterpretable and bear no relation to the target sign.
However, these intermediate gestures were never used in her spontaneous signing.
The absence of sign neologisms suggests that their occurrence might be dependent

46

CHRISTINE CHIARELLO, R. KNIGHT AND M. MANDEL

on a disruption of the sequential aspect of word structure not present in ASL.
If we assume, however, a continuum between paraphasia and neologistic jargon
(Kertesz and Benson, 1970; Brown, 1972) the more jargon-like responses for
English (written and finger-spelled) in the present case may only reflect a
quantitatively greater disruption of those systems which were less well-established
premorbidly. In-depth studies of other aphasic signers with varying degrees
of competency in written and/or finger-spelled English are needed to resolve
this issue.
Disturbances of pantomime and gesture comprehension have been shown to
occur with aphasia for spoken language (Gainotti and Lemmo, 1976; Seron,
Van Der Kaa, Remitz and Van Der Linden, 1979). However, our patient performed
rather well on such a test, despite deficits in ASL and reading comprehension. The
greater redundancy of the relatively simple pantomimed sequences probably
contributed to her better performance. L.K.'s sign comprehension was poorer for
low redundancy commands (Token Test) than for connected texts (story comprehension). The relative preservation of pantomime (perception and production) in
this patient may also indicate that these two forms of gestural communication are
neurolinguistically separable.
With respect to behavioural-anatomical correlations, this case supplies further
clinical evidence for a left hemisphere predominance for sign language. It would
appear that the left hemisphere provides an essential substrate for the processing of
a visual/gestural language, despite the equivocal lateralization results obtained from
experiments using normal signers (Manning et al., 1977; McKeever et al., 1976;
Poizner et al., 1979; Poizner and Lane, 1979).
This patient's comprehension deficit was associated with a lesion which spared the
posterior superior temporal plane. Studies correlating CAT findings with aphasia
typically report involvement of the left posterior temporal-parietal region for fluent
aphasias with impairment of spoken language comprehension (Naeser and
Hayward, 1978; Kertesz, Harlock and Coates, 1979; Mazzocchi and Vignolo, 1979).
This patient's lesion location fits better with reported cases of conduction aphasia
(Benson, Sheremata, Bouchard, Segarra, Price and Geschwind 1973; Mazzocchi
and Vignolo, 1979). The patient did have a severe repetition disorder with
spontaneous sentence length being longer than the ability to repeat, but her
comprehension is more impaired than reported cases of conduction aphasia.
Comprehension disorders have been associated with subcortical lesions, particularly
those involving the left putamen and thalamus (Naeser and Hayward, 1979;
Alexander and LoVerme, 1980). However, this patient's subcortical involvement is
rostral to that reported in these cases.
Based on the clinical constellation of left parietal deficits and the CAT scan
findings, we suggest that the left supramarginal and angular gyri comprise the
critical regions needed for linguistic decoding of sign language. Leischner (1943)
made a similar suggestion. However, his patient's lesion also involved the left
posterior superior temporal plane and subcortical structures in the right hemisphere

APHASIA IN A DEAF WOMAN

47

as well as the uncus. The present case more precisely delimits the cortical areas
critical for sign language comprehension to the left parietal region.
In conclusion, we found the most striking behaviouralfindingin this case to be the
fundamental similarity of L.K.'s symptoms to those of oral aphasic patients. While
further studies will undoubtedly uncover some aphasic features unique to the
gestural modality, our results indicate that many important aspects of the neural
mechanisms of language are not modality-dependent, but are related to processes
shared by all human languages.

SUMMARY

A left parietal infarct in a prelingually deaf person resulted in an aphasia for both
American Sign Language (ASL) and written andfinger-spelledEnglish. Originally
the patient had a nearly global aphasia affecting all language systems. Byfiveto
seven weeks post-onset her symptoms resembled those of hearing aphasics with
posterior lesions: fluent but paraphasic signing, anomia, impaired comprehension
and repetition, alexia, and agraphia with elements of neologistic jargon. In addition,
there was a pronounced sequential movement copying disorder, reduced short-term
verbal memory and acalculia. In general, the patient's sign errors showed a
consistent disruption in the structure of ASL signs which parallels the speech errors
of oral aphasic patients. We conclude that most aphasic symptoms are not
modality-dependent, but rather reflect a disruption of linguistic processes common
to all human languages.
This case confirms the importance of the left hemisphere in the processing of sign
language. Furthermore, the results indicate that the left supramarginal and angular
gyri are necessary substrates for the comprehension of visual/gestural languages.

ACKNOWLEDGEMENTS
This study was made possible by the enthusiastic participation of a number of people. We thank: Dr
Jamil Sulieman for referring the patient to us; Jennifer Lane and Bobbe Skiles for their skilful
interpreting; Ursula Bellugi, Ben Bahan, and Jennifer Lane for sharing their ideas and expertise in
American Sign Language with us; Dr Robert Efron and Dr R. Conrad for helpful comments, Dr
Brown and the staff of Fairmont Hospital for facilitating this research; Ann Juell (Educational TV,
UCB) and Vic Harke (Health and Medical Sciences, UCB) for lending technical support and
equipment; Beate Lewis for translation assistance; Bette Laccoarce for preparation and editing of the
manuscript; Meredith Hoffman for help in obtaining funding; andfinally,L.K. for her unflagging good
humour and co-operation throughout the study. This research was partially supported by Biomedical
Sciences Support Grant 1-44212032061.

48

CHRISTINE CHIARELLO, R. KNIGHT AND M. MANDEL

APPENDIX: SOME ASPECTS OF ASL STRUCTURE
Signs in ASL have a conventionalized internal structure (Stokoe, 1978; Stokoc, Casterline and Cronebcrg,
1965/1976; Friedman, 1977a). Only some of the physically possible manual articulations are used to form lexical
items (Friedman, 1977a). Every sign involves the simultaneous expression of a specific handshape, place of
articulation, movement, and orientation (direction of palm and fingers) feature. These formational parameters in
isolation have no meaning; they are actually sets of the articulatory primes which combine in certain restricted ways
(Battison, 1978) to form meaningful units. In this way they are somewhat analogous to phones in a spoken
language, although we must emphasize that they occur in parallel and not in a linear sequence. For example, in the
sign BLACK the index finger is extended from the fist (handshape), with palm facing down and the index finger
pointing to the side (orientation), pulling laterally (movement) across the forehead (place of articulation).
Some signs (approximately 40 per cent, according to the count of Klima and Bellugj, 1979) require the use of only
one hand. Others are two-handed. These can be of two types (Battison, 1974): (1) both hands have identical
handshapes and are active, making the same type of movement (about 35 per cent are of this symmetrical type); (2)
only the signer's dominant hand moves; the other hand acts as a passive base for the articulation of the sign. The
passive base hand either has the same hand configuration as the active hand, or assumes one of six simple
handshapes.
ASL predicates can be inflected to express a variety of aspectual (habitual, repeated, or intense action) and deictic
(source, goal, or place of action) modifications (Klima, Bellugi and Pedersen, 1979; Klima, Bellugi, Newkirk,
Pedersen and Fischer, 1979; Fischer and Gough, 1978). While spoken languages typically inflect words by attaching
a grammatical marker before or after the stem of the word, ASL inflections are generally formed by changing the
movement or some other formational parameter of the stem sign itself. Several such inflections can be applied to a
single sign; they are all present simultaneously when the sign is pronounced. There is no temporal division between
the stem sign and its inflectional markers) (Ellenberger, 1977). Separate function words (such as the, of, is) do not
occur in ASL.
We have only mentioned those structural properties relevant to the data we are presenting. Several studies of ASL
grammar are available (Klima and Bellugi, 1979; Wilbur, 1979; Friedman, 1977i; Siple, 1978).

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