The Telltale Hand

Look at this handwriting sample from a spry and healthy 97-year-old woman. It shows good control, balance, and a disciplined yet flowing style that combines angles and curves. One could quibble about some tightness here and there, and some resting points at the ends of words, such as in the “s” of “was” in line 4, but overall this handwriting represents an ideal to which we all might aspire: a brain that has worked just fine for almost an entire century.

Written language is a further evolution of the highly complex human capability for spoken language that probably goes back at least 250,000 years, to the time when our distant ancestors were just beginning to make tools. Because it is both neurological and psychological, handwriting is a window into the complex interplay of brain and mind.

If the brain is injured by accident or disease, handwriting will be affected in specific ways that scientists are only beginning to delineate. Conversely, studying handwriting may give us important clues to how and where a brain is malfunctioning.

Inventing the Ultimate “Tool”

The Russian neurologist A.R. Luria pointed out that the development of language enabled humans to create symbolic representations of events and physical objects. Through a process of “inner speech,” man, unlike any other animal, was freed from the confines of the present to reflect upon the past, learn from purely verbal instruction, and plan for the future. Luria even suggested that voluntary behavior and consciousness itself evolved because of the development of language, and that thinking in words to organize the world dramatically increased cerebral complexity.¹ Written language breaks the bounds of the present still further by enabling communication between people in distant places and times.

Our modern Latin alphabet traces its descent from exquisitely realistic prehistoric cave drawings and simpler carvings and line drawings dating back about 35,000 years to the advent of petroglyphs, which evolved into hieroglyphics. Some 6,000 years ago, merchants were marking their property with cuneiform signs on soft clay. Papyrus scrolls apparently go back 5,000 years. Chinese and Phoenician (which evolved into Hebrew) alphabets trace their roots back about 4,000 years. A millennium later, the lean Greek and Latin alphabets came into being.

Some written languages create all words out of a relatively small alphabet—for example our 26 letters—while others, like the Chinese, have thousands of abstract symbols. But all written languages involve specialized activities and communication among many areas of the brain.

A Journey Through the Brain

Most humans have their predominant language center in the brain’s left hemisphere, although signatures and other graphic pictograms usually get transferred to, or at least get processed by, the right hemisphere. There must be communication between the hemispheres because the essential picture of the event, or the point being made, is located in the right hemisphere and gets translated into language in the left.

Anatomically, even scrawling a quick note to yourself, “pick up milk,” is a complex voluntary procedure, engaging the cooperation of all lobes of your cerebral cortex with other parts of your brain—including the limbic system, hippocampus, brain stem, and cerebellum—and finally the spinal cord, which sends impulses out to your hands and fingers. Damage to any of these parts will affect your fine motor control and show up as some type of break in the rhythm or control of your handwriting.

The sequence that produces handwriting begins at “control central,” the cingulate cortex in your frontal lobes where the decision to initiate the process is made, although the limbic system also acts at the outset to color the emotional content of the motor sequence. The visual cortex sees the paper to be written on and internally pictures how the writing will look, and a part of the parietal lobe called the left angular gyrus converts the visual perception of letters into the comprehension of words. If needed, Broca’s and Wernicke’s areas kick in to process and comprehend spoken words. The corpus callosum, which connects the cerebral cortex’s left and right hemispheres, combines the pictorial/holistic right-brain procedures with their sequential/linguistic left-brain counterparts. The parietal lobe then coordinates all these signals with the motor cortex, producing the motor signal to the arm, hand, and fingers.²

Once the signal is initiated, it travels along the pyramidal track—which monitors fine movements—to the fingers. Along the way, it passes through the limbic system, where emotion can again affect the signal, through the hippocampus, where memory can have an effect, and through the basal ganglia, which modifies the fine motor control necessary to write. When passing through areas in the brainstem such as the pons and the medulla, the signal can be altered by primitive impulses or unconscious desires. Before the signal exits the brain, the cerebellum plays a critical role by programming the entire process into an automatic habit. This programmed routine combines physical aspects of writing with its psychosocial and emotional counterparts. Like speech, handwriting is learned through interaction with other people and is therefore influenced by social and environmental variables, as well as by our neural architecture.

“Handwriting,” explains Luria, “starts out as a chain of isolated motor movements, but is radically altered with practice, and converted into a ‘kinetic melody’ no longer requiring the memorizing of the visual form of each letter or the motor impulse for making every stroke.”³ Handwriting’s cerebral organization changes, becoming more deeply ingrained and requiring less energy to execute. It is, in effect, a multilayered, dynamic, kinesthetic memory that involves picturing how the letters are formed, how the writing looks, and how it feels to move the pen across the page.

As we write, what is called inner speech also plays a crucial role. You can see an example of it in the note on the previous page written by a 20-year-old community college student with a severe learning disability, a speech impediment, dyslexia, and, most likely, auditory aphasia. It can take her up to two hours to partially complete a 45-minute exam. When she speaks, she leaves off the ends of many words, a tendency reflected when she writes the word “scare.” Because she does not pronounce it as “scared,” she does not hear the “d” and so does not write it. You can also see her dyslexia in the third sentence, where she misplaces the word “I.” One could guess that she has a dysfunction in her frontal lobes and in Wernicke’s area that, in turn, has caused a problem in Broca’s area and also, no doubt, in the left angular gyrus, whose task it is to combine speech with the visual perception of words and their kinesthetic output.

All Writing Is Brain Writing

The first attempts to explore the relationship between handwriting and neurological organization were made by William Preyer, an Englishman by birth and a German university professor, who in 1895 established that handwriting was really “brain writing.” Preyer proved this by demonstrating that the basic pattern of one’s script stays the same whether one writes with the hand, foot, or mouth. Look at the extraordinary sample, above, written with a pen held between her teeth by Joni Earekson, author of Joni: The Unforgettable Story of a Young Woman’s Struggle Against Quadriplegia and Depression. She wrote this 15 years after being injured in a diving accident. Its pleasing aesthetic aspect is similar to the style that Earekson, an artist and equestrian, had developed with her hand before her injury. The automatic aspect of her handwriting, augmented by some mobility of her shoulders, was simply shifted from the nerve fibers that controlled her hand to the ones that control her neck and mouth.

In the 1950s, an Austrian émigré and Holocaust survivor named Alfred Kanfer hypothesized a link between handwriting and the onset of cancer. Working at the Strang Clinic in New York City, where I interviewed him in 1971, Kanfer proposed that cancer would affect the fine motor control apparatus at its most delicate juncture—the minuscule pause at the site of the connecting stroke, where downward contractual muscles change to upward releasing ones. Having his subjects write with a fountain pen, and using a microscope and camera, Kanfer would create slides and then magnify the writing strokes to the thickness of an arm. In this way, he could view them on a large screen and catalog different types of minute spasms, which he attributed to different kinds of cancers. Essentially, Kanfer’s idea was that the brain would be affected by the disease long before it reached a full-blown stage, and the fine motor apparatus was the early warning sign.⁴

Although Kanfer’s work remains controversial, it is clear that many types of illness do leave telltale signs along the writing trail. Brain diseases and traumas have an impact on different parts of the brain and so affect different parts of the process. In general, unnatural breaks between letters, misspellings, and letter substitutions reflect difficulty in the cerebral cortex and the communication between the two hemispheres.

Tremors, breaks within letters, involuntary movements, broken forms, and regressive or childlike styles reflect serious problems in the higher brain centers or subcortical problems stemming from the limbic system, basal ganglia, brain stem, or cerebellum. By working with MRI scans, cataloging the progression of various diseases, and obtaining handwriting samples from patients over a period of time, scientists are beginning to parse the distinctive ways that handwriting reflects both voluntary behavior and the brain’s hardwired functions.

Illnesses of Fine Motor Control

Any illness that disrupts the basal ganglia will adversely affect fine motor control because signals sent via the thalamus to the frontal lobes, motor cortex, and parietal lobe will be tainted. Such illnesses include Parkinson’s disease, with its diminishment of dopamine production in the substantia nigra; Friedreich’s ataxia, with loss of cells in the posterior root of the ganglia; and Huntington’s disease, with effects on the caudate nucleus.⁵ According to Robert Iacono of the Neuroscience Clinic at Loma Linda University, basal ganglia diseases will cause “negative symptoms [including]… akinesia [loss of movement] and loss of postural reflexes …[and] positive symptoms [such as…] tremors, rigidity and involuntary movements.”⁶ Parkinson’s disease causes both. Its signature is tremors and, frequently, a dramatic reduction in the size of handwritten letters and words—a phenomenon called “micrographia” that many clinicians consider a diagnostic sign of the disease.

Other diseases that affect the higher brain centers, particularly the major lobes of the cerebral cortex, will also adversely influence fine motor control. These include stroke, which can restrict blood flow to specific areas of the brain; cerebral palsy, which involves the atrophy of cortical cells; dyslexia, which affects the left angular gyrus; and multiple sclerosis, which can create cerebral lesions. Epilepsy, schizophrenia, brain tumors, and coma also fall in this category.

A Bullet Through the Brain

A dramatic example of how damage to fine motor control affects handwriting can be seen above. At the top are two samples of the handwriting of former presidential press secretary James Brady. The top signature was written shortly after he began his recovery from the gunshot wound to the head that he sustained in 1981, during an assassination attempt on President Ronald Reagan. The second was created about 15 years later for Lorne Adrain’s book The Most Important Thing I Know. Note Brady’s inability to shut off a motor program once it is initiated. This is seen particularly in the earlier sample in the letters “m” and “B.” The inhibiting feedback loop, which signals the brain to stop writing, has been disrupted.

The illustration at the bottom shows the path the bullet took, shattering his forehead, then tearing through the tip of the left frontal lobe and the right frontal lobe, cutting off part of the corpus callosum, and lodging itself near Brady’s right ear. He was paralyzed on his left side and confined to a wheelchair, and his movements became awkward and jerky. Although Brady did not sustain a direct injury to the motor cortex, his motor functions were severely disabled because they are initially controlled by the prefrontal lobes.

According to Brady’s surgeon, Richard Cytowic, M.D., who wrote “The Long Ordeal of James Brady” for the New York Times Magazine (September 27, 1981), “the more frontal the injury, the more severe the spasticity.” Brady survived the gunshot wound because the bullet did not hit the deeper centers of his brain. Clearly, his abstract thinking has been affected, but his well-known wit miraculously survived. Through physical therapy and compensatory techniques, such as printing the “B” instead of writing it in cursive, one can see that Brady’s signature became more fluent over time.

A Storm in Two Hemispheres

A great danger during an epileptic seizure is that the electrical storm in one hemisphere can cross over, via the corpus callosum, and cause mirror damage to the same lobe of the other hemisphere. Psychobiologist Roger Sperry was first to realize that if, in severe cases of epilepsy, the corpus callosum were cut above the optic nerve, the electrical storms would subside without damaging the opposite hemisphere.

On the next page, we see the handwriting of two epileptics who had their corpus callosa surgically severed. The top is from a low-functioning split-brain writer, the bottom from a high-functioning one. In the first case, it is clear that a great deal of brain damage occurred prior to the operation. This writer was never able to make his handwriting truly automatic because of the great trauma that occurred to his brain as he was growing up. His writing shifts between printing and cursive, the spacing and spelling are poor, the style is childlike, there are signs of dyslexia (letters have been substituted for other letters), and many words are unintelligible. The second line probably reads, “Then they gave him a toy.” If this is the case, we see the substitution of an “h” with a “g” and an “m” with an “n.”

Without seeing a presurgery sample of this person’s handwriting, we cannot be sure how the operation affected the output; but, in general, those who have had this operation tend to have arrhythmic “splits,” or unnatural stops and starts, between and within letters. Note the extra dots in the last two words: “the toy” on line 1; and the clear break in the connecting stroke between the “e” and the “n” in the word “hen” on line 2. One would suspect damage not only to all or most of the lobes of the cerebral cortex, but also to deeper centers, including the basal ganglia and the cerebellum.

The second sample is from an educated writer whose handwriting is clear and well formed. Because of the deep-rooted, automatic aspects of writing, she is able to mask the disruption in interhemispheric communication, but careful analysis reveals evidence of the surgery. Note the unnatural breaks between letters, such as between the “r” and the “e” in the word “There” and the “a” and the “s” in “was” (line 1), and the false starts, as seen in the “h” in “happy” and the “l” in “little” (also line 1). There is also patching and misalignment of some letters, such as the “t” of “with” (line 2), where she tacks on an extra vertical loop, and in the “y” in “happy” (line 4), which she has made with two separate movements. Such misalignments are found frequently in the handwriting of split-brain writers.⁷

Script After Stroke

In the illustration above, we see three samples of handwriting from a 41-year-old male stroke victim. The stroke was a single, powerful event that caused a permanent lesion to his speech area, which can be seen as a clouded portion on the left of his MRI. The stroke left him hospitalized and unable to speak for 12 hours. A psychologist with a master’s degree, he monitored himself as he struggled to emit intelligible sounds and realized that he could not even say the alphabet. He was, however, able to watch the show Jeopardy during these first 12 hours, and knew many of the answers, although he could not verbalize them. Over the next few days and weeks, his speech came back, but he noticed he had difficulty spelling. Yet, 45 days later, except for occasional blockages, he was talking fluently and even delivered a public lecture that had been scheduled months earlier. Ten years later, the effects of the stroke are still evident, as he occasionally stumbles on words when he speaks.

He wrote the top check two weeks before the stroke, the middle check two weeks after the stroke, and the bottom check 10 years later. A fluent speaker and dynamic high school teacher, this man is easily able to mask any remnants of his stroke from those with no knowledge of its occurrence. Indeed, at first look, the handwriting seems unaffected. In all cases, it is a rapidly written, slightly chaotic script that makes great use of primary thread—a term in graphology (the study of handwriting) used to describe the simplification of the writing trail achieved by the elimination of lateral strokes. Primary thread can be seen in the top check in the words “Hundred” and “Fifty.” Notice how easily one can read the words, yet a number of letters have been sandwiched together, and parts of letters and whole letters are missing.

Although a bit awkward, the use of primary thread from a neurological viewpoint has created a kinetic melody, a movement phrase, that shows proficient use of the lobes of his brain. This shortcut requires less energy to create letters and words, freeing up the frontal lobes to think on other levels.⁸ The key to this writing is that simplification has not hampered legibility. In the second check, written after the stroke, the well-designed automatism has suffered. The “e” has been put back into the word “hundred,” the “t” has been put back into the word “Fifty,” and the entire word “and” has been put back in as well. Here is evidence that the stroke caused a regression to a slightly less effective and, most likely, earlier rendition of these automatic aspects of his writing trail. Ten years later, the kinetic melody has progressed even further than in the original sample. The writer almost completely eliminated the second “d” in the first word, and completely eliminated the t-bar and the “t” in the second word, yet in the context of this check, there is no doubt as to the meaning of the scribble.

The Effects of MS

Our next example, above, shows the handwriting of a 61-year-old man with multiple sclerosis (MS), which attacks the nervous system by causing a breakdown in the myelin sheath that insulates nerves. His MRIs (next page) reveals extensive lesions in the frontal lobes, corpus callosum, left pons, central and right medulla, and right cerebellum; and he has, in addition, suffered three heart attacks over the last 15 years. But his writing is bold, clear, and rhythmic, suggesting that the frontal lobe lesions may not be as severe as the MRI suggests. MS specialist Ferenc Jolesz, M.D., a neurologist at Harvard Medical School, comments that “Brain swelling is very well seen on MRI, but cannot be easily distinguished from dead brain tissue.”

Even though his MRI is dramatic, the patient still functions well, drives, and has a part-time job. Evidence of the disease and frontal lobe problems can be seen in the spelling mistakes on the first line and in the many hesitations within and between letters: “writting,” line 1; “shot” for “short,” line 1; the “r” in “writings,” line 4; “c” in “pencil,” line 5; and the “t” in “boating,” line 7. The involuntary movements seen in the “i” of “this” (line 8) and the “l” of “help” (line 9) may be associated with the deep brain lesions seen in the MRI in the corpus callosum, pons, medulla, and cerebellum.

Progressive Brain Tumor

All the handwriting samples on the next page were made by a man in his early 70s, called A.J. He had a brain tumor at the front of his right parietal lobe, near the post central gyrus, which left him dizzy and subject to seizures. A.J. wrote the samples at the top five and six days before a major seizure. You can see great differences in fluidity between the June 5 sample and the one written just a day earlier. Clearly, A.J. had suffered a debilitating neurological event on June 4 and recovered the following day. Nevertheless, even in the better sample, you can see arrhythmic disconnections. Note the lack of ability to connect the “d” with the “r” in the name “Andrew.” This kind of arrhythmia indicates a disruption in communication between the brain’s two hemispheres caused by either the seizures or the tumor in the parietal lobe.

Five days later, on June 10, A.J. suffered a seizure that caused him to collapse to the floor and then to walk with awkward movements. The third signature was made on June 15. Note the evidence of what is called akinesia: the handwriting appears flaccid and has weak pressure. Two weeks later, on June 19, A.J. underwent brain surgery to remove the grade 4 glioblastoma. The fourth sample was given one month after the surgery. The ability to integrate simple curved movements had been severely disrupted. Also, the directionality of the writing trail is troubled and the baseline undulates. This increased lack of muscle control (ataxia) suggests an additional problem in the central nervous system.

The last sample, given four months after surgery, shows that A.J. was still severely disabled. At this time, he was paralyzed on his left side, able only to lie in bed. His writing reflects not only the grave disruption of activity in his right parietal lobe and brain damage caused by seizures, but also problems from deeper areas of the brain, perhaps the basal ganglia.

Symbolic Distortions

Sometimes an illness can create symbolic representations in the writing trail. The fragmentation, ataxia, size distortions, and bizarre elaborations in the handwriting of this schizophrenic patient (next page, top) can be correlated psychologically with her emotional outbursts, tension, and strange ideas, and neurophysiologically with disturbances in her cortical/subcortical/cerebellar motor circuit, involving imbalances of such neurotransmitters as serotonin, dopamine, and noradrenaline.⁹

Other oddities can be seen in the other handwriting samples on that page. The one on the lower left is by a 75-year-old poet who had a brain tumor that regrew 10 years after it had been removed. Although her writing is unaffected, suggesting that the tumor had not impacted the motor system, there is an extra loop above the “W” in the word “West.” This miscue could be an ordinary mistake, or it could indicate some type of neurological interference or unconscious manifestation of her natural concern about the tumor. The lower right specimen was written by a 65-year-old engineer who suffered eight mild strokes. The involuntary zigzag stroke in the “J” of the signature most likely reflects his neurological problem, which does not show up in any other area of his writing.

COMA’S CONSEQUENCES

Our final examples, on the next page, were written by a woman in her 40s who had been in a coma for 21 days as a result of a traffic accident. She broke both pubic bones and her left shoulder and had a significant brain injury that included edema (swelling) on the right temporal lobe that was removed shortly after she was admitted to the hospital. After two months, she was transferred to a hospital specializing in brain trauma. For weeks after she recovered from the coma, she was fed by a tube into her stomach because her swallowing reflex had been impaired. Unable to walk upon admittance, and able to communicate only by nodding yes or motioning to a card reading “no,” she undertook three months of physical and speech therapy before leaving the hospital. At that time, she could walk with a walker, which she still uses 14 years later.

She wrote the top sample on a postcard when she was in excellent health, two years before her accident. Her writing combines cursive and print script. Minute, incidental tremors can be seen in the “a” of “area” and the “n” of “fascinating”—possibly attributable to slight nervousness or impatience. In general, however, the writing is clear, mature, legible, and stylistic, with fanciful lower zone letters like the “f,” “g,” and “y.”

The bottom sample is from one of the first letters she was able to write, five months after her accident. At the time, she was still severely incapacitated, mentally confused, simplistic in her responses, and emotionally drained. The writing is slow, unsteady, but deliberate. Note changes in pressure, the rising up of words off the baseline (for example, “took,” line 5; “now,” line 6), and the great variation in size of letters (for example, the “l’s” in “beautiful” and “plant,” line 3). Each word is written separately, with no continuity between them. A dyslexic movement associated with the partial memory of an automatism neurologically linked to the parietal lobe and cerebellum can be seen in the misplacement of the apostrophe in the word “couldn’t” (line 6). Involuntary movements, which may be attributable to problems with the premotor area of the frontal lobes, can be see in the “a” of “Dear” (line 1) and in the word “I” (line 7). The first hesitation is associated with beginning the entire motor sequence, and the second extra motion, on the word for “I,” may be linked to some inhibition or trauma attached to her self-image. Her MRI shows lesions in the right prefrontal lobe. This type of damage may be linked to her motor ataxia and could have affected the overall style and grace of the writing. Her abstract reasoning has also been affected.

The Unique Insights of Scientific Graphology

Handwriting is one of the most advanced human abilities, since it combines all the complexities of language with intricate psychomotor activity. It gives physical form to our thoughts and emotions, and, because of the many parts of the brain that are involved, that form reflects in unique ways the damage caused by brain trauma. When used in conjunction with diagnostic tools such as the MRI, the scientific study of handwriting can aid both the physician and the neuroscientist. Paying attention to a patient’s handwriting can give a physician clues to what parts of the patient’s brain are being affected by a particular disease and, subsequently, to the nature and extent of the healing process. Researchers who call on the techniques and knowledge of scientific graphology have a special and perhaps unique tool for understanding mind/brain interactions, the localization of brain functions, and how mental processes can be converted to physical action. Handwriting can indeed tell a scientifically important tale.

For their guidance, MRIs, and handwriting samples, I would like to thank handwriting experts Kathie Koppenhaver, Thelma Imber Seifer, and Sheila Lowe; also Barry Horwitz, Ph.D., National Institute of Mental Health; Ferenc Jolesc, M.D., Harvard Medical School; Herbert Meltzer, M.D., and David Goode, M.D., Billings Hospital, University of Chicago; Warren TenHouten, Ph.D., UCLA; and two doctors from the Department of Neurology, School of Medicine, Brown University: Syed Risvi, M.D., specialist in multiple sclerosis and neuro-immunology, Rhode Island Hospital, and Lorcan O’Tuama, M.D., chief of neuroradiology, VA Medical Center.