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Disabilities in Speaking and Reading
Medical Clinics of North America May, 1938. Boston Number
CLINIC OF DR. EDWIN M. COLE FROM THE NEUROLOGICAL SERVICE, MASSACHUSETTS GENERAL HOSPITAL, AND THE DEPARTMENT OF NEUROLOGY, HARVARD MEDICAL SCHOOL
DISABILITIES IN SPEAKING AND READING
IN a clinic devoted to the problem of disordered function in language a large amount of apparently quite diverse material is met with. The cases are such as are seen by physicians the country over and it may be of interest to consider them here. The realization of certain facts is important to the worker in a language clinic. What are these facts? The first and most obvious is the value amounting to necessity for the in~ dividual nowadays to master language. The second is that language is nothing more nor less than a quantity of symbols, symbols of actions, motions and their results such as feelings. Thus language is a system of symbolic representation. As such, like any code, it must be learned in order to be of use. But it is precisely here that many patients have difficulty. There are great variations between individuals in their ability to learn the code. We are all more or less aware of this. We know that some people talk with ease, others not. Some are rapid, accurate readers, others read laboriously. Some spell well, others with many errors. Some write clearly, others illegibly. Similarly we observe that there are people who can with ease develop great skill and proficiency in music and other arts; in tennis or other athletics, and in the whole gamut of skilled acts that mankind has attempted. Differences in performance are due to diverse individual endowments. Some people are sufficiently gifted in a given line to be successful in that line without apparent effort. Others, without particular talent, still may achieve satisfactory results through deliberate acquisition of the requisite skills. A third group is unable to master the necessary technics, or skills, owing to a complete lack of talent.
608
EDWIN M. COLE
It would seem, then, that many of our achievements are the result of our heredity-as shown by our innate gifts and deficiencies. We are interested here in deficient performance in language. Let us review some of the material seen in a clinic devoted to language problems, for such material, diverse as it is, may have a common denominator which, if appreciated, will throw light upon the handling of such cases .. I need hardly say, that I am not considering language deficiencies due to blindness, deafness, a congenital defect, or . disease affecting the speech apparatus, foreign schooling, parentage, or other similar causes of inadequate exposure to the language of the particular group. We are considering a physiologic dysfunction rather than anatomic variations which are self -explanatory. We see three types of speech case frequently. The first of these, is motor speech delay. This is a particularly trying condition as far as the patient's family is concerned. Parents see a child develop normally. He may feed well, he may De trained readily, he may sit up, stand and walk as expected, he seems to hear and understand but he doesn't talk! What is mild disappointment on the part of parents when a child of eighteen months doesn't talk, becomes annoyance at the silence of two years, apprehension at the silence of three years, and great concern at the silence of four years. This concern is intensified by tales brought by well meaning neighbors or friends who knew of somebody who couldn't talk because he had a shock or brain tumor, or again somebody's child who was mentally retarded and hence unable to speak. These differential diagnoses pass through one's mind but usually they can be ruled out easily. The child in question is neurologically sound. He seems bright and attentive to what goes on about him. He obeys directions well. Yet, his speech is either entirely absent or consists of a confused jumble of sound which we do not recognize as our language. A second type of speech disorder, is a speech replete with infantilisms. This we know as "baby talk." It exists to a varying degree, often being so slight a deviation from normal speech that nothing is done about it. The following case will serve as an illustration.
DISABILITIES IN SPEAKING AND READING
609
Case I.-A boy of four years, three months, was brought in because his speech was so indistinct that he could not be understood by the children in the kindergarten which he attended. In spite of this, he had seemed to be a bright and intelligent child both at home and at school. His birth and early development were uneventful. He had had no serious illnesses. He walked at nineteen months but did not begin to talk until three years, and then only a few indistinct words. Thereafter he learned to talk more fluently, but always in a modified language of his own which was largely ununderstandable to strangers. He had always shown a marked preference for the use of his left hand, and no attempt had been made to interfere with this. The family history is interesting. The paternal grandfather is left-handed. A brother aged seven did not talk until he was four, and now is having a great deal of trouble learning to read. The patient presented a very infantile speech. It was striking that there were no speech sounds which he could not imitate. He was an intelligent youngster, showing no abnormalities other than in his speech. In more severe cases the child's speech is so far from normal that only the mother can understand it, and she must act as an interpreter. At this point it should be said that a great many factors enter into baby talk, once established, which tend to perpetuate it. Baby talk may be thought "cute," and thus rewarded, becomes a source of satisfaction to the child. Or, a tolerant mother allows herself to be a willing slave to the youngster whose speech she must interpret. The child in this situation is overprotected and will with difficulty give up the speech which ensures for him a favored position. Again a child may cling to infantile speech in an attempt to compete with a younger sibling who has displaced him in the comfortable position of baby in the family. There are, of course, many other variations on this theme, which must be taken into account when working with the child and his family. However, in my experience the most important factor in the therapy of both these cases is repeated, routine drills by a skilled teacher who can help the child to develop speech through a kinesthetic as well as auditory approach. VOL. 22-39
610
EDWIN M. COLE
A third type of speech disturbance is stuttering. A great many of these cases present themselves in a language clinic. Case II.-A boy of eight years was brought in because of stuttering, which had been persistent for about six years. Aside from this, there was nothing unusual in his history. His mother had noticed that his speech was at its best when he was rested and at his ease. Sometimes the stuttering seemed to be disappearing only to recur again. Of late it had been associated with blinking of the eyes. The family history is interesting. The maternal grand. father stuttered as a boy and he was right-handed. The patient's mother knew of no left-handedness in her family, and no other instances of speech disturbance. The paternal grand· father was left-handed and stuttered. A paternal aunt is lefthanded, has no speech disturbance. The father is righthanded, and stuttered from early childhood though it is now hardly noticeable. The patient is left-handed, and no attempt has been made to influence his choice of hand. Eyedness tests revealed him to be left-eyed also. The problem that speech becomes for the stutterer, and all the personal implications involved, has been described fully in the mass of literature that has been written on the subject. We shall not attempt to add to it here. It should be said, however, that some workers have stressed the differences between cases. This has not seemed to add to the understanding of the problem. It is true that some people stutter on one group of sounds, others on another, some in one situation, others in another, some with a prolonged repetition of an initial sound, others with a complete block-or silence-at a word. We suppose there are as many individual variations as there are individuals who stutter. Similarly we hear of a great variety of cures of stuttering, each one depending on the particular point of view of the therapist involved. Each is helpful in some cases, none always so. There are, however, observations which we make with surprising regularity in our cases of stuttering. We find in our clinic as elsewhere, that the great majority of cases are males. Secondly, there is a familial feature in the 3 types of speech disturbance already described. Not only do stutterers often show a quite marked amount of
DISABILITIES IN SPEAKING AND READING
6ll
speech delay and infantilisms in their speech development, but their siblings, parents, and other relatives provide instances of the same thing. And finally, more common still, is the association of left-handedness and stuttering in the family history. It is not meant by this that the stutterer is always left-handed, ambidextrous, or one converted to the use of his right hand though indeed such cases are not uncommon. Of course, very many stutterers are purely right-handed, but, where an adequate family history can be obtained, we always find lefthanded ancestors. This, in our experience, is true in the cases of motor speech delay which we have seen, and certainly in a large number of cases of baby talk. We repeat, then, that in addition to the fact that these cases have the feature of disordered speech production in common, they also share certain familiar characteristics. The obvious question-what possible connection can there be between handedness and speech, we shall attempt to answer in another part of this paper. Problems in language development frequently come to one's attention in relation to school work. The parent of the child with a marked motor speech delay or an extremely infantile speech is forced to do something about it when the time for starting school approaches. So, too, stuttering is most often first noticed at the time when the child learns to read and write. But there is another type of language disability which in its development, presents itself solely in the school situation. Parents bring such children to our hospital clinic as they must in other places to their own family physicians, "because the teacher says he can't learn to read."
Case III.-A boy of eleven years, six months, was brought in because he could not learn to read or spell at school. He was the son of a physician and his general health had always been good. Eyesight and hearing were adequate. He had an unusually high intelligence score by a variety of psychometric tests. He had been in both public and private schools, and had had much individual tutoring, yet he had made very little progress in reading. His family history is interesting. The paternal grandfather and greatgrandfather were left-handed. A paternal aunt is left-handed, as is the patient's father. One of the patient's
612
EDWIN M. COLE
3 siblings is left-handed. The patient himself is right-handed. The father says that he himself has always had a tendency to reverse the order of letters and numbers. As we review these cases, the situation shapes itself somewhat as follows: At first at school, the child learns something about routines, and discipline; all of which are required for group work and for the development of skills. He then learns something of reading, writing, spelling and arithmetic-some children more rapidly than others for there is a wide range of abilities among so-called "normal" children. In a year or two, there are some who begin to lag behind others. This may be for a variety of reasons; poor physical equipment, such as poor eyesight, poor hearing, or illnesses necessitating irregular attendance. All these possibilities must be investigated thoroughly. Poor mental equipment also is a cause of inadequate performance. Here, however, I feel that we must be very careful. There is a tendency among teachers to feel that because a child doesn't keep up with the average in being able to absorb what is taught, he is stupid, has a low intelligence. Where the intelligence is the cause of school retardation, this fact should be accurately determined and not left to the haphazard guesses of teachers and parents. The children who interest us here particularly, however, are those with good physical mental equipment but who nevertheless do not progress in school. Such children deserve careful individual investigation. If this is done, we find a group of children who have certain things in common. These have been admirably described by Dr. Samuel T. Orton, who pointed out some striking features of this group which he called specific reading disability cases, or congenital nonreaders. After several years of school experience, a child may do uniformly well or poorly. If, however, a child makes absolutely no progress in one part of the school curriculum, though he does adequately elsewhere, and has a good intelligence, such a discrepancy is worthy of note. Children, in the third, fourth, fifth or even higher grades, who master arithmetic, have a good understanding of material used in general class discussions, adequate vocabularies, but are unable to read or spell, present such a discrepancy. Their letter patterns are
DISABILITIES IN SPEAKING AND READING
613
insecure and confused. rhe printed "b" and "d," "p" and "q," "t" and "f" and other letters are mistaken for each other. When written work is attempted, letters may appear reversed, as their own mirror images, or in reverse order as "dog" for "god." The same can be said for their reading-which is mostly guesswork. Since letter patterns are not secure words cannot be recognized. Sounds are not associated with letters. All this, in spite of the fact that arithmetic goes well, there is no demonstrable physical or mental defect, and emotionally the child seems ready to learn. The point we wish to make is the inconsistency of these cases. Bright children, able to do some of their school work, but failing where written language is concerned. At first, if no corrective measures are taken, such is the picture. Later, if the disability has not been too profound, a certain amount of reading becomes possible. This is always laborious and most inaccurate. Rarely if ever does the boy read for pleasure. His spelling remains primitiveoften 4 or 5 grades behind that of the others in his class. School becomes the place in which the child has been defeated, where he has met with ridicule, as being the boy who could not learn to read and spell. His written examination papers are never completed, and are returned with caustic remarks from well meaning teachers who in this way hoped to spur the boy on to exert himself to spell and write better. Meeting with nothing but failure, the largest boy in the class, yet the slowest and poorest scholar, the only opportunity for achievement is games and pranks. In self-defense such a child is forced to become a behavior problem. There is one feature of these reading cases which we wish to stress. That is the hereditary feature. Nonreaders are usually members of the male sex. They give a family history of left-handedness and careful questioning uncovers a brother, uncle, parent or grandparent who stutters, or who learned to talk very late, or who clung to baby talk or who never could spell and was not much of a scholar. In this, then, reading disabilities have the same familiar characteristics as other disturbances in the language function. We have found an association in families of different types of language problems, and left-handedness. It must be said, however, that left-handedness is stressed only because handedness is a fairly reliable and
EDWIN M. COLE
quite convenient indication of which cerebral hemisphere is dominant in the language function. Thus, in most righthanded individuals the left hemisphere is dominant, while in left-handed persons the right hemisphere is correspondingly so. Speech, we all know, is regulated entirely by one hemisphere-the hemisphere dominant in the language function. Such is usually the same hemisphere which is dominant as indicated by the most skilled hand. Hence we can consider handedness as a convenient indicator of the hemisphere regulating speech. Since this is so, we can more accurately say, that we observe an association between stuttering and a heredity containing a mixture of right and left cerebral dominance. We know, that when there is an impairment in function of certain areas of the brain, talking, the understanding of speech, reading and writing become impossible, or at least are less adequately performed, depending upon the severity of the damage. The striking fact is, that in a given individual, these areas are all in one hemisphere. Lesions inthe same area of the opposite hemisphere have no influence upon the functioning of language. In this respect, language is unlike any other measurable brain function. For instance, damage to the right motor cortex or cortical fibers produces a resultant distortion of movement or paralysis, on the left side of the body while the same area involved in the left side of the brain will show similar signs of dysfunction on the right side of the body. The same can be said of sensation. However, in language, although the two halves of the brain are practically identical as to weight, cellular structure, etc., apparently only one half is important. We can say, then, that the functioning of language is entirely regulated from one side of the brain. As was intimated above, this is the so-called "dominant hemisphere." For speaking, reading, writing, and the understanding of any of these processes, we must have a perfectly functioning neurologic mechanism on one side of the brain, on the dominant side. We repeat this statement so often, because it seems to us that it is of prime importance in order to understand the factors influencing the development of language. We can only speculate, perhaps, upon the effect of the fusion of two heredities of opposite cerebral dominance. We
DISABILITIES IN SPEAKING AND READING
615
are dealing with a skill-Ianguage-phylogenetically very young and consequently relatively insecure. We are dealing with a skill which to exist, depends upon the perfect functioning of a dominant hemisphere. Might it not, then, be possible, that, in fusing two inheritances which are antagonistic as far as cerebral dominance is concerned, we may impair that perfect functioning requisite for speech and reading? Much more than a speculation, is the careful and original work of Orton who first recognized the importance of cerebral dominance in developmentallanguage disturbances. In treating these various language disturbances we are helped by the observations we have made. To acquire facility where there is an absence of natural talent, a great deal of carefully planned, repeated drilling is essential. The drill must consistently point in one direction. It is only by repeatedly doing that for which one has little skill that one can learn to do it more easily. This does not mean that we should overlook arousing the interest and full cooperation of our patient in what we are doing. But it does mean that without exercising the defective skill we will not make it stronger. When working with a child whose speech is either delayed or infantile one repeats simple sounds again and again until the patient can master them. Ears alone should not be relied upon. The child must be shown how the teacher uses his lips, teeth and tongue to make the sounds. In this way his sight and his kinesthetic sense will reenforce his hearing in teaching him to talk, somewhat as they take the place of hearing in teaching the deaf to talk. Since we know that language is controlled by the dominant cerebral hemisphere and since we consider these developmental language disabilities to be the result of a poorly established cerebral dominance in respect to language we should, in our treatment, attempt to strengthen the dominance of the hemisphere. We do this by reenforcing the deficient skill through associating it with a well performed skill. For instance, we observe that many patients who stutter can read aloud with much less stuttering. Reading the words seems to reenforce their speech. We find that writing is of similar assistance. For the stutterer, then, we devise drills that associate speech with reading and writing. There are many different ways of
616
EDWIN M. COLE
doing this and we must adjust the drills to the patient's performance. In cases of reading disability these same principles are carried out. The child displays a varying degree of confusion when letters, and obviously words, are met. By associating the visual letter patterns with sound values, and with forms, as is done in seeing, sounding and writing the letter, the visual pattern finally becomes established and reading is possible. In none of these cases is anything accomplished by sporadic attempts, but only by repeated drilling can the necessary skill be acquired.
CLINIC OF DR. EDWIN M. COLE FROM THE NEUROLOGICAL SERVICE, MASSACHUSETTS GENERAL HOSPITAL, AND THE DEPARTMENT OF NEUROLOGY, HARVARD MEDICAL SCHOOL
DISABILITIES IN SPEAKING AND READING
IN a clinic devoted to the problem of disordered function in language a large amount of apparently quite diverse material is met with. The cases are such as are seen by physicians the country over and it may be of interest to consider them here. The realization of certain facts is important to the worker in a language clinic. What are these facts? The first and most obvious is the value amounting to necessity for the in~ dividual nowadays to master language. The second is that language is nothing more nor less than a quantity of symbols, symbols of actions, motions and their results such as feelings. Thus language is a system of symbolic representation. As such, like any code, it must be learned in order to be of use. But it is precisely here that many patients have difficulty. There are great variations between individuals in their ability to learn the code. We are all more or less aware of this. We know that some people talk with ease, others not. Some are rapid, accurate readers, others read laboriously. Some spell well, others with many errors. Some write clearly, others illegibly. Similarly we observe that there are people who can with ease develop great skill and proficiency in music and other arts; in tennis or other athletics, and in the whole gamut of skilled acts that mankind has attempted. Differences in performance are due to diverse individual endowments. Some people are sufficiently gifted in a given line to be successful in that line without apparent effort. Others, without particular talent, still may achieve satisfactory results through deliberate acquisition of the requisite skills. A third group is unable to master the necessary technics, or skills, owing to a complete lack of talent.
608
EDWIN M. COLE
It would seem, then, that many of our achievements are the result of our heredity-as shown by our innate gifts and deficiencies. We are interested here in deficient performance in language. Let us review some of the material seen in a clinic devoted to language problems, for such material, diverse as it is, may have a common denominator which, if appreciated, will throw light upon the handling of such cases .. I need hardly say, that I am not considering language deficiencies due to blindness, deafness, a congenital defect, or . disease affecting the speech apparatus, foreign schooling, parentage, or other similar causes of inadequate exposure to the language of the particular group. We are considering a physiologic dysfunction rather than anatomic variations which are self -explanatory. We see three types of speech case frequently. The first of these, is motor speech delay. This is a particularly trying condition as far as the patient's family is concerned. Parents see a child develop normally. He may feed well, he may De trained readily, he may sit up, stand and walk as expected, he seems to hear and understand but he doesn't talk! What is mild disappointment on the part of parents when a child of eighteen months doesn't talk, becomes annoyance at the silence of two years, apprehension at the silence of three years, and great concern at the silence of four years. This concern is intensified by tales brought by well meaning neighbors or friends who knew of somebody who couldn't talk because he had a shock or brain tumor, or again somebody's child who was mentally retarded and hence unable to speak. These differential diagnoses pass through one's mind but usually they can be ruled out easily. The child in question is neurologically sound. He seems bright and attentive to what goes on about him. He obeys directions well. Yet, his speech is either entirely absent or consists of a confused jumble of sound which we do not recognize as our language. A second type of speech disorder, is a speech replete with infantilisms. This we know as "baby talk." It exists to a varying degree, often being so slight a deviation from normal speech that nothing is done about it. The following case will serve as an illustration.
DISABILITIES IN SPEAKING AND READING
609
Case I.-A boy of four years, three months, was brought in because his speech was so indistinct that he could not be understood by the children in the kindergarten which he attended. In spite of this, he had seemed to be a bright and intelligent child both at home and at school. His birth and early development were uneventful. He had had no serious illnesses. He walked at nineteen months but did not begin to talk until three years, and then only a few indistinct words. Thereafter he learned to talk more fluently, but always in a modified language of his own which was largely ununderstandable to strangers. He had always shown a marked preference for the use of his left hand, and no attempt had been made to interfere with this. The family history is interesting. The paternal grandfather is left-handed. A brother aged seven did not talk until he was four, and now is having a great deal of trouble learning to read. The patient presented a very infantile speech. It was striking that there were no speech sounds which he could not imitate. He was an intelligent youngster, showing no abnormalities other than in his speech. In more severe cases the child's speech is so far from normal that only the mother can understand it, and she must act as an interpreter. At this point it should be said that a great many factors enter into baby talk, once established, which tend to perpetuate it. Baby talk may be thought "cute," and thus rewarded, becomes a source of satisfaction to the child. Or, a tolerant mother allows herself to be a willing slave to the youngster whose speech she must interpret. The child in this situation is overprotected and will with difficulty give up the speech which ensures for him a favored position. Again a child may cling to infantile speech in an attempt to compete with a younger sibling who has displaced him in the comfortable position of baby in the family. There are, of course, many other variations on this theme, which must be taken into account when working with the child and his family. However, in my experience the most important factor in the therapy of both these cases is repeated, routine drills by a skilled teacher who can help the child to develop speech through a kinesthetic as well as auditory approach. VOL. 22-39
610
EDWIN M. COLE
A third type of speech disturbance is stuttering. A great many of these cases present themselves in a language clinic. Case II.-A boy of eight years was brought in because of stuttering, which had been persistent for about six years. Aside from this, there was nothing unusual in his history. His mother had noticed that his speech was at its best when he was rested and at his ease. Sometimes the stuttering seemed to be disappearing only to recur again. Of late it had been associated with blinking of the eyes. The family history is interesting. The maternal grand. father stuttered as a boy and he was right-handed. The patient's mother knew of no left-handedness in her family, and no other instances of speech disturbance. The paternal grand· father was left-handed and stuttered. A paternal aunt is lefthanded, has no speech disturbance. The father is righthanded, and stuttered from early childhood though it is now hardly noticeable. The patient is left-handed, and no attempt has been made to influence his choice of hand. Eyedness tests revealed him to be left-eyed also. The problem that speech becomes for the stutterer, and all the personal implications involved, has been described fully in the mass of literature that has been written on the subject. We shall not attempt to add to it here. It should be said, however, that some workers have stressed the differences between cases. This has not seemed to add to the understanding of the problem. It is true that some people stutter on one group of sounds, others on another, some in one situation, others in another, some with a prolonged repetition of an initial sound, others with a complete block-or silence-at a word. We suppose there are as many individual variations as there are individuals who stutter. Similarly we hear of a great variety of cures of stuttering, each one depending on the particular point of view of the therapist involved. Each is helpful in some cases, none always so. There are, however, observations which we make with surprising regularity in our cases of stuttering. We find in our clinic as elsewhere, that the great majority of cases are males. Secondly, there is a familial feature in the 3 types of speech disturbance already described. Not only do stutterers often show a quite marked amount of
DISABILITIES IN SPEAKING AND READING
6ll
speech delay and infantilisms in their speech development, but their siblings, parents, and other relatives provide instances of the same thing. And finally, more common still, is the association of left-handedness and stuttering in the family history. It is not meant by this that the stutterer is always left-handed, ambidextrous, or one converted to the use of his right hand though indeed such cases are not uncommon. Of course, very many stutterers are purely right-handed, but, where an adequate family history can be obtained, we always find lefthanded ancestors. This, in our experience, is true in the cases of motor speech delay which we have seen, and certainly in a large number of cases of baby talk. We repeat, then, that in addition to the fact that these cases have the feature of disordered speech production in common, they also share certain familiar characteristics. The obvious question-what possible connection can there be between handedness and speech, we shall attempt to answer in another part of this paper. Problems in language development frequently come to one's attention in relation to school work. The parent of the child with a marked motor speech delay or an extremely infantile speech is forced to do something about it when the time for starting school approaches. So, too, stuttering is most often first noticed at the time when the child learns to read and write. But there is another type of language disability which in its development, presents itself solely in the school situation. Parents bring such children to our hospital clinic as they must in other places to their own family physicians, "because the teacher says he can't learn to read."
Case III.-A boy of eleven years, six months, was brought in because he could not learn to read or spell at school. He was the son of a physician and his general health had always been good. Eyesight and hearing were adequate. He had an unusually high intelligence score by a variety of psychometric tests. He had been in both public and private schools, and had had much individual tutoring, yet he had made very little progress in reading. His family history is interesting. The paternal grandfather and greatgrandfather were left-handed. A paternal aunt is left-handed, as is the patient's father. One of the patient's
612
EDWIN M. COLE
3 siblings is left-handed. The patient himself is right-handed. The father says that he himself has always had a tendency to reverse the order of letters and numbers. As we review these cases, the situation shapes itself somewhat as follows: At first at school, the child learns something about routines, and discipline; all of which are required for group work and for the development of skills. He then learns something of reading, writing, spelling and arithmetic-some children more rapidly than others for there is a wide range of abilities among so-called "normal" children. In a year or two, there are some who begin to lag behind others. This may be for a variety of reasons; poor physical equipment, such as poor eyesight, poor hearing, or illnesses necessitating irregular attendance. All these possibilities must be investigated thoroughly. Poor mental equipment also is a cause of inadequate performance. Here, however, I feel that we must be very careful. There is a tendency among teachers to feel that because a child doesn't keep up with the average in being able to absorb what is taught, he is stupid, has a low intelligence. Where the intelligence is the cause of school retardation, this fact should be accurately determined and not left to the haphazard guesses of teachers and parents. The children who interest us here particularly, however, are those with good physical mental equipment but who nevertheless do not progress in school. Such children deserve careful individual investigation. If this is done, we find a group of children who have certain things in common. These have been admirably described by Dr. Samuel T. Orton, who pointed out some striking features of this group which he called specific reading disability cases, or congenital nonreaders. After several years of school experience, a child may do uniformly well or poorly. If, however, a child makes absolutely no progress in one part of the school curriculum, though he does adequately elsewhere, and has a good intelligence, such a discrepancy is worthy of note. Children, in the third, fourth, fifth or even higher grades, who master arithmetic, have a good understanding of material used in general class discussions, adequate vocabularies, but are unable to read or spell, present such a discrepancy. Their letter patterns are
DISABILITIES IN SPEAKING AND READING
613
insecure and confused. rhe printed "b" and "d," "p" and "q," "t" and "f" and other letters are mistaken for each other. When written work is attempted, letters may appear reversed, as their own mirror images, or in reverse order as "dog" for "god." The same can be said for their reading-which is mostly guesswork. Since letter patterns are not secure words cannot be recognized. Sounds are not associated with letters. All this, in spite of the fact that arithmetic goes well, there is no demonstrable physical or mental defect, and emotionally the child seems ready to learn. The point we wish to make is the inconsistency of these cases. Bright children, able to do some of their school work, but failing where written language is concerned. At first, if no corrective measures are taken, such is the picture. Later, if the disability has not been too profound, a certain amount of reading becomes possible. This is always laborious and most inaccurate. Rarely if ever does the boy read for pleasure. His spelling remains primitiveoften 4 or 5 grades behind that of the others in his class. School becomes the place in which the child has been defeated, where he has met with ridicule, as being the boy who could not learn to read and spell. His written examination papers are never completed, and are returned with caustic remarks from well meaning teachers who in this way hoped to spur the boy on to exert himself to spell and write better. Meeting with nothing but failure, the largest boy in the class, yet the slowest and poorest scholar, the only opportunity for achievement is games and pranks. In self-defense such a child is forced to become a behavior problem. There is one feature of these reading cases which we wish to stress. That is the hereditary feature. Nonreaders are usually members of the male sex. They give a family history of left-handedness and careful questioning uncovers a brother, uncle, parent or grandparent who stutters, or who learned to talk very late, or who clung to baby talk or who never could spell and was not much of a scholar. In this, then, reading disabilities have the same familiar characteristics as other disturbances in the language function. We have found an association in families of different types of language problems, and left-handedness. It must be said, however, that left-handedness is stressed only because handedness is a fairly reliable and
EDWIN M. COLE
quite convenient indication of which cerebral hemisphere is dominant in the language function. Thus, in most righthanded individuals the left hemisphere is dominant, while in left-handed persons the right hemisphere is correspondingly so. Speech, we all know, is regulated entirely by one hemisphere-the hemisphere dominant in the language function. Such is usually the same hemisphere which is dominant as indicated by the most skilled hand. Hence we can consider handedness as a convenient indicator of the hemisphere regulating speech. Since this is so, we can more accurately say, that we observe an association between stuttering and a heredity containing a mixture of right and left cerebral dominance. We know, that when there is an impairment in function of certain areas of the brain, talking, the understanding of speech, reading and writing become impossible, or at least are less adequately performed, depending upon the severity of the damage. The striking fact is, that in a given individual, these areas are all in one hemisphere. Lesions inthe same area of the opposite hemisphere have no influence upon the functioning of language. In this respect, language is unlike any other measurable brain function. For instance, damage to the right motor cortex or cortical fibers produces a resultant distortion of movement or paralysis, on the left side of the body while the same area involved in the left side of the brain will show similar signs of dysfunction on the right side of the body. The same can be said of sensation. However, in language, although the two halves of the brain are practically identical as to weight, cellular structure, etc., apparently only one half is important. We can say, then, that the functioning of language is entirely regulated from one side of the brain. As was intimated above, this is the so-called "dominant hemisphere." For speaking, reading, writing, and the understanding of any of these processes, we must have a perfectly functioning neurologic mechanism on one side of the brain, on the dominant side. We repeat this statement so often, because it seems to us that it is of prime importance in order to understand the factors influencing the development of language. We can only speculate, perhaps, upon the effect of the fusion of two heredities of opposite cerebral dominance. We
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are dealing with a skill-Ianguage-phylogenetically very young and consequently relatively insecure. We are dealing with a skill which to exist, depends upon the perfect functioning of a dominant hemisphere. Might it not, then, be possible, that, in fusing two inheritances which are antagonistic as far as cerebral dominance is concerned, we may impair that perfect functioning requisite for speech and reading? Much more than a speculation, is the careful and original work of Orton who first recognized the importance of cerebral dominance in developmentallanguage disturbances. In treating these various language disturbances we are helped by the observations we have made. To acquire facility where there is an absence of natural talent, a great deal of carefully planned, repeated drilling is essential. The drill must consistently point in one direction. It is only by repeatedly doing that for which one has little skill that one can learn to do it more easily. This does not mean that we should overlook arousing the interest and full cooperation of our patient in what we are doing. But it does mean that without exercising the defective skill we will not make it stronger. When working with a child whose speech is either delayed or infantile one repeats simple sounds again and again until the patient can master them. Ears alone should not be relied upon. The child must be shown how the teacher uses his lips, teeth and tongue to make the sounds. In this way his sight and his kinesthetic sense will reenforce his hearing in teaching him to talk, somewhat as they take the place of hearing in teaching the deaf to talk. Since we know that language is controlled by the dominant cerebral hemisphere and since we consider these developmental language disabilities to be the result of a poorly established cerebral dominance in respect to language we should, in our treatment, attempt to strengthen the dominance of the hemisphere. We do this by reenforcing the deficient skill through associating it with a well performed skill. For instance, we observe that many patients who stutter can read aloud with much less stuttering. Reading the words seems to reenforce their speech. We find that writing is of similar assistance. For the stutterer, then, we devise drills that associate speech with reading and writing. There are many different ways of
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doing this and we must adjust the drills to the patient's performance. In cases of reading disability these same principles are carried out. The child displays a varying degree of confusion when letters, and obviously words, are met. By associating the visual letter patterns with sound values, and with forms, as is done in seeing, sounding and writing the letter, the visual pattern finally becomes established and reading is possible. In none of these cases is anything accomplished by sporadic attempts, but only by repeated drilling can the necessary skill be acquired.