AMERICAN JOURNAL OF OPHTHALMOLOGY Published Monthly by the Ophthalmic Publishing Company EDITORIAL STAFF LAWRENCE T. POST, Editor H. ROMMEL HILDRETH 640 S. Kingshighway, Saint Louis 824 Metropolitan Building, Saint Louis WILLIAM H. CRISP, Consulting Editor PARK LEWIS 530 Metropolitan Building, Denver 454 Franklin Building, Buffalo C. S. O'BRIEN EDWARD JACKSON, Consulting Editor The State University of Iowa, College of Medicine, Iowa City Republic Building, Denver M. URIBE TRONCOSO HANS BARKAN Stanford University Hospital, San Francisco 500 West End Avenue, New York HARRY S. GRADLE JOHN M. WHEELER 58 East Washington Street, Chicago 635 West 165th Street, New York EMMA S. Buss, Manuscript Editor 4907 Maryland Avenue, Saint Louis
Directors: EDWARD JACKSON, President, LAWRENCE T. POST, Vice-President, DR. F. E. WOODRUFF, Secretary and Treasurer, WILLIAM L. BENEDICT, WILLIAM H. CRISP, HARRY S. GRADLE. Address original papers, other scientific communications including correspondence, also books for review and reports of society proceedings to Dr. Lawrence T. Post, 640 S. Kingshighway,
Exchange copies of medical journals should be sent to Dr. William H. Crisp, 530 Metropolitan Building, Denver. Subscriptions, applications for single copies, notices of change of address, and communications with reference to advertising should be addressed to the Manager of Subscriptions and Advertiseing, 640 S. Kinoshichioa», Saint Louis. Copy of advertisements must be sent to the manager by
the fifteenth of the month preceding its appearance. Author's proofs should be corrected and returned within forty-eight hours to the manuscript editor. Twenty-five reprints of each article will be supplied to the author without charge. Additional reprints may be obtained from the printer, the George Banta Publishing Company, 450-458 Ahnaip Street, Menasha, Wisconsin, if ordered at the time proofs are returned. But reprints to contain colored plates must be ordered when the article is accepted.
READING DIFFICULTIES Ophthalmologists have taken a good deal of trouble to impress upon teachers and parents the fact that retardation in school work is often due to visual defects and refractive errors. The general truth of this statement cannot be questioned. But, after careful measurement and fitting of the proper glasses, ophthalmologists and parents alike are often gravely disappointed by lack of improvement in the little patient's school record. There are cases in which the child's general intelligence seems excellent and yet his reading ability is atrociously poor. Such children are apt to be blamed for inattentiveness, restlessness, lack of desire to learn, when as a matter of fact they are afflicted with a natural difficulty in learning to read. The sufferer may substitute one word for another, may substi-
tute one letter for another, may invert the order of letters, may omit letters or whole words. The condition has been referred to as "word blindness." But this term suggests a confusion with the cerebral lesions of later life, due to intracranial pathology or traumatism. The affected children are not word-blind. They see the word on the printed page, but are unable to recall the mental picture of the word which they have just seen. To this defect the psychiatrist Orton has applied the name "strephosymbolia," from Greek roots signifying "twisted symbols," because the afflicted person distorts or "twists" the arrangement of letters which form a word. (Samuel Torrey Orton, "Reading, writing, and speech problems in children.") Ronne uses the expression "dyslexia."
Reading disability may of course be develop in a child who is anxious to sucmerely a part of a general intellectual ceed but lives in constant anticipation of defect. But it must not be regarded as a failure. But in every large school there special disability unless it is contrasted are many cases in which the existence of with normal or special ability in other strephosymbolia cannot be blamed prifields of mental activity. As a striking ex- marily upon any of the factors just menample of such contrast, Orton mentions tioned. Orton is satisfied that the great mathe case of a boy who, after three years in school, was reading almost nothing, jority of these children see the letters and was spelling even less, but who had well enough, but simply fail to rememan intelligence quotient of 145, and in ber vividly and collectively what they every other field except reading, spelling, have momentarily seen. There may be no and writing was ranked as a "near refractive error, and if one exists it may have no important bearing on the probgenius." In the progress of civilization the art lem. The child is often attentive and of reading was a relatively late addition eager when dealing with a subject in to the faculty of speech. In the complete which he does not encounter special diffiprocess of reading, a complex act of vi- culty. He may be an eager listener to the sion must at first be translated into an printed page as read by others in the orderly group of sounds and then into a school or in the home. Conscious of his meaning or idea. At first slow and con- own reading difficulties and eager to overscious, these steps late'!" become automatic COme them, his restlessness may be the and extremely rapid, and recede into what result of a sense of personal insufficiency we are pleased to call the subconscious. and defeat. Every step lost in school makes further Orton tells us that in the Iowa public schools investigation revealed that the progress more difficult. If the situation "sight" or "flash-card" method of teach- is only recognized after several years' deing to read resulted in three times as great lay, then, in spite of special efforts in the a proportion of cases of reading difficulty home or through individual tuition, the as did the "sound" method of teaching. handicap is often little short of insuperFor many years there has 'been an in- able. The evil must be remedied early if creasing emphasis on the advantages of the best possible results are to be hoped silent reading, beginning approximately for. with the third grade. It is possible that, "Obviously," says Orton," "the earlier congenitally or by early environment, special measures are adopted . . . the some school children are much less fitted greater will be the chance of ultimate than others for the silent method. success, and we feel that no child with No entirely satisfactory explanation for average intelligence or better should be the existence of strephosymbolia or dys- allowed to continue into his second year lexia has been put forward. It has been of schooling, if there be tangible evidence variously blamed upon emotional dis- of a reading difficulty, without an analysis turbances, upon a general indifference to- to determine whether or not he be of the ward all forms of school work, upon strephosymbolic group so that special lack of. harmony between teacher and measures may be instituted, when indipupil, and upon defective home training. cated, before he suffers the emotional disIt is probably aggravated in some degree orders and language deficits which are by the sort of fear neurosis which may usua~ly cumulative from this time on."
In Orton's efforts at special training of such cases, the great majority had already been unsuccessfully exposed to the "sight" or "flash-card" method of teaching reading. He came therefore to feel not only that repeated "flash" exposure of the whole word was ineffective, but that in certain children it might even increase the tendency to confusion and failure of recognition. Rather he made use of their normal development in spoken language to teach them the phonetic values of the printed letters and the process of blending such letters in sequences. Some of the children, seen in the first or second year of school, or even later, were made to trace the letters over patterns drawn by the teacher, at the same time giving the phonetic equivalents. The emotional reactions of the child were important for success. Simply teaching the child the sounds for the individual letters and their variations was entirely inadequate. The habit shown by some children, of pointing to the words while reading, has been criticized as retarding the rate of reading. But Orton raises the very important questions whether this habit arises from the fact that the child is a slow reader and whether he is slow because of strephosymbolic confusions and uses the finger to overcome the difficulty. "Our choice," he says, "may not lie between rapid and slow reading but between slow reading or none at all." Orton has therefore actually resorted to use of this trick to encourage the habit of progression toward the right. The possibility of cure will vary with individual cases. Sometimes the only hope will lie with patient, kindly, individual tuition, in some instances to be accomplished by the mother, in others by a hired tutor who grasps the psychologic realities of the case. The writer of the present comment has recently had personal contact with a case in which the
first tutor employed was a complete failure because she persisted in use of the "flash-card" method of repeated attempts at identification of whole words; whereas a second tutor stimulated the pupil's advance by resorting to emphasis upon phonetic values. Such a child cannot be expected at once to read passages normally pertaining to his age. Moreover, all sense of punishment for failure must be carefully avoided. It may frequently be necessary to ask the cordial cooperation of teachers in subjects to which reading is merely incidental. Thus, for example, a child may fail in arithmetic because he cannot read the problems. Although recognizing that refractive errors may help to create reading difficulties, the thoughtful and sympathetic refractionist needs to remember that the history of the case, and the child's behavior in a reading test, may often suggest that a refractive error has little immediate importance. In such cases the ophthalmologist may prove more useful by offering suggestions as to home treatment and as to enlisting the broad understanding of the school teacher; or even by referring the patient for study by a psychiatrist. W. H. Crisp. THE QUACK IN SPECTACLES The quack is perfectly at home in spectacles. For hundreds of years the great uneducated mass of mankind has regarded spectacles as an evidence of wisdom, or at least of experience; and the predisposition has been to listen to the voice of him who assumes this mark of fitness to instruct. In the absence of statistics, we may assume that the quack in general understands this, and resorts to this mask as a first and most important mode of concealing his predatory purpose. It is not surprising that one of the most