Journal ofNeurology, Neurosurgery, and Psychiatry 1994;57:21 1-216

Spelling dyslexia: a deficit of the visual word-form

Elizabeth K Warrington, Dawn Langdon

AbstractA patient with spelling dyslexia read bothwords and text accurately but slowly andlaboriously letter by letter. Her perfor-mance on a test of lexical decision was

slow. She had great difficulty in detectinga 'rogue' letter attached to the beginningor end of a word-for example, ksong-or in parsing two unspaced words, suchas applepeach. By contrast she was

immune to the effects of interpolatingextraneous coloured letters in a word, a

manipulation that affects normal read-ers. Therefore it is argued that thispatient had damage to an early stage inthe reading process, to the visual wordform itself.

(7NeurolNeurosurg Psychiatry 1994;57:211-216)

The National Hospitalfor Neurology andNeurosurgery,London, UKE K WarringtonD LangdonCorrespondence to:E K Warrington, TheNational Hospital forNeurology andNeurosurgery, QueenSquare, London WC1N3BG, UK.

Received 3 November 1992and in revised form26 April 1993.Accepted 30 April 1993

Dyslexia without dysgraphia, first describedby Dejerine,l can spare the ability to readaloud single letters. Patients whose letternaming is preserved typically adopt a letter byletter reading strategy, spelling the wordaloud, hence the term 'spelling dyslexia' todescribe this syndrome.The very distinctive clinical syndrome,

spelling dyslexia, has been the subject ofnumerous, detailed, single case studies.There is as yet, however, no consensus as towhich subcomponent of the reading process

is impaired, or even whether it represents a

reading specific deficit.2Warrington and Shallice3 published the

first detailed experimental account of spellingdyslexia. They demonstrated that the time ittook their patients to read a word was directlyrelated to the word length. Two manipula-tions that attenuated letter by letter reading,script writing, and brief tachistoscopic pre-sentation, resulted in further disruption toalready laboured reading. Their patientsappeared to have lost the ability to process

letters as whole word recognition units.Warrington and Shallice suggested that theirfindings were consistent with damage to a

presemantic lexical stage of processing, whichthey termed a visual word form system. Thisword form system they placed before bothphonological and semantic analysis of thewritten word. Letter by letter reading was

considered to be dependent on the viability ofthe compensatory strategy of reversedspelling.

Since this formulation there have been a

number of alternative accounts of letter by

letter reading. Most of these have argued fora prelexical locus of the deficit, before theaccess to whole word recognition units. Thebest articulated account of letter by letterreading as a prelexical stage in the readingprocess has been advanced by Patterson andKay.4 They proposed that an intact wordform system could only be accessed serially,the input from letter recognition being lim-ited to one letter at a time. Schacter et aF pro-vided supporting evidence by demonstratingsome positive priming effects in a letter byletter reader. This, they argued, impliedintact word recognition units.

Others have adopted a more radical versionof the prelexical hypothesis by suggesting thatletter by letter reading can be accounted forby visual impairments that are not specific tothe reading process6 7 notwithstanding theobservation that patients with gravelyimpaired visual form perception may be ableto read at a normal speed.8The possibility of a more central deficit has

also been advanced. Shallice and Saffran,9and subsequently Coslett and Saffran,'0demonstrated some partial semantic knowl-edge of words that could not be read. Thiswas held to implicate a post word formdeficit, there being a failure to achieve a fullsemantic or phonological specification of thewritten word.

In this paper we describe a patient, with avery clear cut and selective dyslexic syndromefollowing a left occipitoparietal infarction.She was a letter by letter reader with intactspelling and writing. We describe four teststhat manipulate the orthography of the writ-ten word. We conclude that our findings pro-vide evidence that is consistent with damageto an early stage in the reading process, to thevisual word form system itself.

Patient and methodsCASE REPORTThe patient was a 50-year-old (date of birth23 October 1938) woman, a secretary ofWest Indian extraction. In 1986 a pituitarytumour was diagnosed and successfullytreated surgically at the National Hospital,Maida Vale, London. In August 1988 shewas re-admitted to Maida Vale Hospital, sud-denly having lost the ability to read. Onexamination, there were no neurological signsof note other than a uniocular nasal quan-drantanopia in the left eye. Acuity was nor-mal and there was no visual field loss in theright eye. CT showed an extensive area of

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Figure CT scans showingthe occipitoparietalinfarction.

infarction in the occipitoparietal region of theleft hemisphere (fig). She was treated withwarfarin and she continues to be seen inter-mittently; the tests reported here, however,were all completed by January 1989.

NEUROPSYCHOLOGICAL ASSESSMENTThe patient obtained a Wechsler adult intelli-gence scale verbal IQ of 99 and performanceIQ of 69, prorated from four verbal subtestsand three performance subtest scores. On arecognition memory test for faces, sheobtained an average score (41/50 correct). Onthe verbal version of the task she obtained alow average score (38/50 correct). On a strin-gent naming test, the graded naming test"she scored at an average level (13/30 correct).She had no difficulty on an easier test ofnaming objects from their description (15/15correct). 12

She scored at an average level on a gradeddifficulty test of written spelling (set A 20/30correct)."3 Her ability to recognise words thatwere spelt to her was particularly impressive;she managed to identify correctly 24/30 of theBaxter set B that were spelled aloud to her bythe examiner. Her correct responses included'mechanical', 'buoyant', and 'picnicking'. Ona digit copying task which required her tocopy six rows of 10 digits at speed, herresponse time of 60 seconds was at an aver-age level for her age.'4 This observation indi-rectly demonstrates that she can processindividual visual symbols at speed.

READING SKILLSThe most striking feature of her neuropsycho-logical assessment was that she had no viablereading. She read very slowly, apparently let-ter by letter. For example, she took threeminutes 40 seconds to read aloud a 35-wordsentence (making one error, flow for blow).

She read almost without error the first 10lines of a prose passage'5 but took 8 minutes50 seconds to do so.

LETTER READINGIdentification of letters presented singly wascompletely accurate. Her reading of singleblack letters flanked on either side by red let-ters was very satisfactory (22/23 correct), sim-ilarly she was able to read the centre targetletter, underlined in a row of five (49/50 cor-rect). Matrices of 5 x 5 letters were read with-out error. This task was replicated three timeswith different arrays and on each occasion herletter naming was again error free.

WORD READINGTwenty-four, four-letter, six-letter and eight-letter words were presented singly. Half of thewords of each letter length were of high fre-quency (>A) and half were of lower fre-quency (<A). The time she took to readaloud each word correctly was recorded by astopwatch. This task was repeated at a latertest session. Her performance on this task wasaccurate. Table 1 shows her mean readingtime per word for each word length. It is clearthat she read slowly and that the time to reada word increased with word length.

NON-WORD READINGHer ability to read pronounceable non-words

Table 1 Reading rates in relation to word lengthMean response time(s) *

Word length 4 6 8

Trial 1 5-2 (2 0) 11 0 (8-1) 11-4 (5 9)Trial 2 6-0 (2 8) 7-8 (3 0) 8-9 (4 3)Total 5-6 (2 4) 9-4 (6 3) 10-2 (5 3)

*Mean response time (SD) for each word length in each trial(n per cell = 24).

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Spelling dyslexia: a deficit of the visual word-form

was very satisfactory albeit slow. She readcorrectly 19/20 three-letter non-words-forexample, wib, dep, 18/18 four-letter non-words (nusk, beld), and 4/4 five-letter non-words (dreed, bleam). This establishes that herability to transcode from print to sound isunimpaired.

SCRIPT READINGTwenty printed eight-letter words and 20 dif-ferent eight-letter script words (Letraset no.520, 28 point and no. 279, 36 point) werepresented singly. The time to read each wordwas recorded by a stopwatch. All wordsexcept the script word anecdote were read cor-rectly. The mean reading time for each printword was 11 9 s which is very similar to thetimes recorded in the word reading task. Hermean time to read script words was 24-8 swhich is more than twice as long as forprinted words. For the patient, script wordreading was considerably more difficult thanprint word reading.

TACHISTOSCOPIC READINGTachistoscopic reading forces 'whole' wordreading with exposure durations that are toobrief to permit a letter by letter strategy. Herability to read words presented using briefexposure durations (500 ms) was assessedusing a Cambridge tachistoscope (modelCT2).

For the first task, 24 three-letter words and25 three-letter non-words, such as bev andtas, were presented in random order. She wasfirst asked to categorise the letter strings as aword or non-word and then to report theconstituent letters. She was encouraged toguess if uncertain. Ten words (and 52 of theirconstituent letters) and eight non-words (49of their constituent letters) were reported cor-rectly. She was only able to categorise cor-rectly 14 of the 31 words and non-words thatcould not be read. There is thus no evidenceof a 'real' word gain or lexical effect on thistask.

For the second task, 12 common inani-mate object names and 12 animal namesmatched for word length and frequency werepresented singly in random order. After eachpresentation she was asked, Is it an animal?This categorisation task was replicated threetimes and on each occasion she obtained achance score (12/24, 13/24, and 13/24 cor-rect respectively).

For the third task, 25 boys' names and 25girls' names, which she was required to readand categorise, were presented in randomorder. She failed to read any of the namesand she scored 28/50 correct on the categori-sation task: again a chance score.

Table 2 The detection of 'rogue' letters at the beginnings and ends ofwords

MRTfor beginning ofword(s)* MRTfor end of word(s)*

'Legal' 'Illegal' 'Legal' 'Illegal'

Trial 1 16-2(10-2) 27-9(212) 22-9(24-1) 17 1(9-9)Trial 2 15 0(13 9) 15-2(12-5) 14-9(17-3) 15-9(11 6)

*Mean response time (SD) for each word length in each trial (n per cell = 24).

The findings of these three tasks demon-strate that her ability to categorise words pre-sented tachistoscopically is very impaired andthat she does not even have partial knowledgeof words presented too quickly to be read let-ter by letter.

INVESTIGATION OF READINGLexical decisionThis test manipulated orthographic con-straints in a lexical decision task. The stimuliconsisted of three types of letter strings: 19common three-letter words, such as pen, car,19 pronounceable three-letter non-words (cal,fot) and 19 three-letter non-pronounceableletter strings, (rks, isr). The stimuli weretyped singly on index cards in lower case andpresented in random order for unlimited timeacross the desk. The patient was asked, Is it aword? and her response was timed by a stop-watch. The mean response time for each typeof letter string was 4-8 s (real words), 6-8 s('legal' non-words) and 4-2 s ('illegal' non-words). Her overall error rate was very low(55/57 correct). Her response rate was com-parable to that observed in reading aloud(table 2). There was no difference in lexicaldecision time for words and illegal non-words. She took significantly longer (Mann-Whitney U test, z = 79 5, p < 0.01) to decidethat orthographically legal letter combinationswere non-words. This demonstrates a normalincrease in reaction time for a no response.

WORD DETECTIONIn this test we assessed whether word detec-tion is affected by additional letters. Thestimuli consisted of 60 common nouns towhich an extra 'rogue' letter had been addedeither at the beginning of the word or at theend of the word. An 'illegal' letter combina-tion was used (ywatch, sheepr) for 30 and a'legal' letter combination (truler, threet) for 30of the stimulus words. For each type of lettercombination, 15 were at the beginning and15 at the end of the word. There were anequal number of words of three, four or fiveletters in each of the four conditions. Thestimulus words were typed in lower case onindex cards and presented singly in ran-domised order for unlimited time across thedesk. The patient was asked to cross out the'rogue' letter with a red ballpoint pen asquickly as possible. This test was attemptedon two occasions.

Table 2 gives the mean response times foreach condition on each trial. The overall errorrate was very low indeed but her responsetimes were slow and very variable. Therewere no significant effects of letter position orletter legality. She proceeded by a very labori-ous process of trial and error 'spelling' outdifferent letter combinations until shedetected the stimulus word. This processtook considerably longer than reading aloudwords of comparable length (see table 1).

PARSING WORD STRINGSIt has been demonstrated that a letter stringconsisting of three unspaced words such as

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Wamington, Langdon

orangeredchicken can be parsed and read aloudby a patient with a transcortical sensory apha-sic syndrome, with virtually no capacity tocomprehend either the written or the spokenword. McCarthy and Warrington'6 arguedthat the integrity of the visual word form wasnecessary to parse the letter strings into theirconstituent words and that this provided evi-dence of presemantic lexical processing.The patient attempted a similar task of

parsing three word letter strings by markingthe boundaries between the words. She failedcompletely on this task. After numerousattempts with different letter strings she hadnot produced one correct solution. Indeed,she took up to three minutes to split the firsttwo words. The task was therefore simplifiedby asking her to mark the boundary betweentwo unspaced words.The stimuli consisted of 48 unspaced word

pairs: words of four, five or six letters werepaired, such that the combined length was 10letters-that is 5 + 5, 4 + 6, 6 + 4). Twelvepairs of high frequency words were of thesame category, (such as applepeach), 12 pairswere semantically related (fieldsheep) and 24pairs were unrelated words (grasstrain). Thepatient was required to mark the boundarybetween the two words with a red ballpointpen.

Table 3 shows the mean response times foreach condition. She was able to detect theboundary between the word pairs slowly butaccurately. Her response times were very vari-able but with persistence she was able tocomplete this task. The task apparentlystretched her strategy of letter by letter read-ing to the limit. The patient's reading whichwas at all times laborious was even furtherdisrupted by this task. Additionally there wasno evidence of any semantic facilitation in sofar as she was as slow with the semanticallyrelated pairs as the unrelated pairs.

INTERPOLATED LETTERSIt has been demonstrated that distortion ofthe orthography of the printed word by inter-polating extraneous letters can be very dis-ruptive of whole word reading in normalsubjects (McCarthy, unpublished observa-tions). One patient with transcortical sensoryaphasia, investigated by McCarthy andWarrington, was able to read regular words ata normal speed and to parse word strings (seeabove).'7 Like normal subjects, however, this

Table 3 Parsing unspaced word strings into their constituent words

Stimuli (two words) Same category Semantic association Unrelated

Number of word pairs 12 12 24Errors 0 0 1Mean response time (SD) (s) 16-8 (12-0) 22-3 (15 2) 14-5 (9 2)

Table 4 Reading words with extraneous interpolated letters

Control Interpolated letters Interpolated asterisksn =30 n =30 n =30

Mean response time (SD) to 7-3 (4-9) 7-6 (4-1) 9-6 (4-5)read aloud the stimulus wordin each condition

patient resorted to letter by letter reading andmade multiple errors in attempting to readshort words typed in black that had randomlyselected red letters printed between eachadjacent letters of the word (denotedhere by emboldened type-for example,QrUnIyCeK, DkAbNaCmE).Our patient attempted a similar task.

Fifteen four-letter words and 15 five-letterhigh frequency words were selected. These 30words were (a) typed conventionally in uppercase, (b) with a red asterisk between each let-ter-for example, B*R*A*V*E, and (c) withthe letters of a second word typed in redlower case interspersed (BbRaAkVeE). Eachcondition was tested in blocks of 10 wordsusing a Latin square design. Her error ratewas very low (88/90 correct). Table 4 givesthe mean time to read each word in each con-dition. The times to read aloud the words inthe critical conditions, the control as com-pared with the interpolated letters, were obvi-ously not significantly different; nor didsplitting the word with asterisks have a signifi-cant interference effect (Mann-Whitney Utest, z = 1I6, p > 0.1). Our patient, unlikenormal subjects and the patient previouslydescribed, was very little disrupted by thismanipulation of the orthography of the word.Individual letter processing was sufficientlyefficient to be virtually immune to the effectsof adjacent interfering letters.

DiscussionWe have established that our patient is a clas-sical spelling dyslexic who reads letter-by-let-ter.'7 Her writing and spelling were excellent.Her performance on tests of letter namingwas intact whether they were presented singlyor in arrays. The time she took to read wordswas directly related to their length. She hadgreater difficulty in reading script than print.Her ability to read words that were presentedfor a brief tachistoscopic exposure was excep-tionally bad. We would assume that both ourpatient and other pure examples of this syn-drome have a reading specific deficit. In thiscontext we would emphasise the dissociationbetween the ability to name letters and arraysof letters (which were read quite normally)and the impairment of whole word reading.

In the tachistoscopic tasks there was noevidence of even crude comprehension ofwords that could not be read and there wasno evidence of partial semantic knowledge.She failed to categorise object names as livingor inanimate, and had equal difficulty in cate-gorising boys' and girls' names. These aretypical features of dyslexics whose semanticanalysis of the written word is faulty.28 Moreimportant, it has been established that apatient with virtually no comprehension ofthe written word, but with intact phonology,can read aloud at a normal speed. Our evi-dence indicates that our patient has intactphonology. Like the patient in the McCarthyand Warrington study,'7 who had transcorti-cal sensory aphasia with gravely impairedcomprehension of the written word, our

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patient is able to read aloud non-words com-petently. But she, unlike the previous patient,is unable to read at a normal speed usingphonological procedures. It therefore followsthat her deficit must arise before semanticand phonological analysis.

There remain two plausible candidates:damage to an input stage in the word readingprocess before accessing a visual word form;and damage to the visual word form systemitself. The typical characteristics of the pureletter by letter reading syndrome, wordlength, a script and exposure duration effectare all entirely consistent with the disruptedword form hypothesis. But equally, theseeffects do not differentiate between a degra-dation of the representations in a word formsystem, and the input procedures to that sys-tem. In an attempt to addiess this issue, wehave focused on assessing her orthographicrecognition capacities. If her deficit impli-cated a degradation within the word form sys-tem, one would predict that her performancewould be disproportionately disrupted onreading tasks that demand its integrity. If thiswere not the case, however, then readingtasks that maximise the operation of a wordform system should not present additionaldifficulty.Her performance on the lexical decision

task was slow. Indeed she took as long tomake the lexical decision as to read aloud aword letter by letter. There did not appear tobe a significant gain with the non-pronounce-able letter trials when a no response should bepossible after processing the first two lettersof the trigram.Our patient had great difficulty in detect-

ing a 'rogue' letter placed at the beginning orend of a real word, some of which created'legal' and some 'illegal' letter combinations.Not only was her performance particularlyslow on this task, there was no influence onthe type or the position of the 'rogue' letteron her speed. This is entirely consistent withthe notion that the person with spellingdyslexia bypasses the damaged word formsystem and resorts to an indirect reversespelling strategy. But it is less clear how itcould be accomrnodated by an input position.We would suggest that a 'rogue' letterstretches a reverse spelling strategy to thelimit. Our patient appeared to solve the taskby repeatedly reading the letter string (albeitaccurately) until a real word solution wasdetected.When the 'rogue' letters were clearly sig-

nalled by a colour change, however, a verydifferent result was obtained. The manipula-tion of interpolating extraneous letters in aword has a dramatically disruptive effect onnormal readers. Indeed they become letter byletter readers and show word length effects(McCarthy, unpublished observations). Ourpatient was unaffected by this orthographicmanipulation. In fact her performance couldbe regarded as supranormal. One would pre-dict on the serial input model that interpo-lated letters in a word would have a verysignificant disruptive effect.

Our patient was unable to cope with thetask demands of marking the boundaries of arow of three words printed without the con-ventional spaces. On the much easier task ofmarking the boundary between two wordswithout any requirement to read the wordaloud she was significantly slow. According toa serial input model, one might expect thatthe strategy of reading slowly letter by lettershould be able to complete this task at least asquickly as reading aloud words of the samelength.

Overall we have been impressed by theabsence of any lexical effects together withthe particular difficulty our patient experi-enced in tackling the simple, clinically admin-istered tasks that disrupt letter by letterreading. We would argue that these manipu-lations overload a reverse spelling strategy. Atany rate, our patient was reduced to repetitivetrial and error on these tasks, and her nor-mally slow but accurate reading all but disin-tegrated. At the same time she was immuneto a simple manipulation that reduces thenormal reader to letter by letter reading.These observations -are, we suggest, difficultto reconcile with a deficit of input, to a wordform system, that is, itself intact.

Rather we propose that these findings pro-vide direct evidence that, for our patient,there has been damage to the visual wordform system and that her letter by letter read-ing is a strategy to overcome a lexical loss.Accepting that letter by letter reading is astrategy resorted to when normal reading isno longer possible, one would then predictsome degree of heterogeneity of this type ofacquired dyslexia. Although in this case wewould argue that the locus of deficit is theword form system itself, we would not wish togeneralise this interpretation to all othercases. The core deficit in other cases couldwell be either prelexical or at a later stage inthe reading process.

There have been relatively few casesreported in whom there was both a welllocalised lesion and a relatively pure spellingdyslexia. To our knowledge, however, inevery case, including our patient, a lesion wasdemonstrated in the occipitoparietal region inthe left hemisphere.'91920

We are grateful to ProfessorW I McDonald for permission totest ROC, a patient under his care and to report our findings.We thank Frances Clegg and Jane McNeil for their assistancein testing the patient and Rosaleen McCarthy and Dr PeterRudge for their advice in the preparation of this manuscript.

1 Dejerine J. Contribution a l'etude anatomoclinique etclinique des differentes varietes de cecite verbal. C RSoc Biol (Paris) 1892;4:61-90.

2 Shallice T. From neuropsychology to mental structure. NewYork: Cambridge University Press, 1988.

3 Warrington EK, Shallice T. Word form dyslexia. Brain1980;103:99-112.

4 Patterson K, Kay J. Letter-by-letter reading: Psychologicaldescriptions of a neurological syndrome. QJ Exp PsycholA 1982;34:411-41.

5 Schacter DL, Rapscak SZ, Rubens AB, Tharan M,Laguna J. Priming effects in a letter-by-letter readerdepend upon access to the word form system.Neuropsychologia 1990;28: 1079-94.

6 Friedman RB, Alexander MP. Pictures, images, and purealexia: A case study. Cogn Neuropsychol 1984;1:9-23.

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216Wamngton, Langdon

7 Farah MJ, Wallace MA. Pure alexia as a visual impair-ment: A reconsideration. Cogn Neuropsychol 1991 ;8:313-34.

8 Warrington EK. Visual deficits associated with occipitallobe lesions in man. Exp Brain Res 1986;11 (suppl.)247-61.

9 Shallice T, Saffran EM. Lexical processing in the absenceof explicit word identifications: Evidence from a letter-by-letter reader. Cogn Neuropsychol 1986;3:429-58.

10 Coslett HB, Saffran EM. Evidence for preserved readingin 'Pure Alexia'. Brain 1989;112:327-59.

11 McKenna P, Warrington EK. The graded naming test.Windsor, UK: NFER-Nelson, 1983.

12 Coughlan AK, Warrington EK. Word-comprehension andword-retrieval in patients with localised cerebral lesions.Brain 1978;101:163-85.

13 Baxter-Versi DM. Acquired spelling disorders. Ph D Thesis,

Sir Jonathan Hutchinson (1828-1913) and anearly description of temporal arteritis

The subject ... was an old man ... the father ofa well remembered beadle at the LondonHospital College 30 years ago.... I was asked tosee him because he had "red streaks on his head"which were painful and prevented his wearing hishat. The "red streaks" proved to be his temporalarteries which... were inflamed and swollen.Pulsation could be feebly detected in the affectedvessel, but it finally ceased; the redness then sub-sided, and the vessels were left impervious cords.The old gentleman lived, I believe, several yearsafter this without any other manifestation of arte-rial disease".'Although headache does not figure prominently in

Hutchinson's description, the inflammatory signs areunmistakable. Widespread recognition succeeded the1934 paper of Horton, Magath, and Brown.2Hutchinson was born in Selby and with his friend

Hughlings Jackson, studied at the York School ofMedicine and Surgery, proceeding to St Bartholo-mew's, London, in 1849, qualifying MRCS and LSAin 1850. He was appointed to the London HospitalMedical College in 1862 and became FRS in 1882.His fame earned him honorary degrees from the

University of London, 1987.14 Willison JR, Warrington EK. Cognitive retardation in a

patient with preservation of psychomotor speed. BehavNeurol 1992;5:113-6.

15 Burt C. Handbook of tests for use in schools. London: StaplesPress, 1923.

16 McCarthy RA, Warrington EK. Phonological reading:Phenomena and paradoxes. Cortex 1986;22:359-80.

17 McCarthy RA, Warrington EK. Cognitive neuropsychology.New York: Academic Press, 1990.

18 Warrington EK, Shallice T. Semantic access dyslexia.Brain 1979;102:43-63.

19 Kinsbourne M, Warrington EK. A disorder of simultane-ous form perception. Brain 1962;85:461-86.

20 Kinsboume M, Warrington EK. The localizing signifi-cance of limited simultaneous form perception. Brain1963;85:697-702.

Universities of Glasgow, Cambridge, Edinburgh,Oxford, Dublin, and Leeds. He was knighted in 1908.

Hutchinson was, like his associate ThomasHodgkin (1798-1866), a devout Quaker, who lec-tured on Sunday afternoons at the meeting house nearhis home in Haslemere, Surrey, where he housed alibrary and museum. Few doctors have been so versa-tile; he practised as surgeon, ophthalmologist, neurol-ogist and dermatologist. He wrote the 10 volumeArchives of Surgery (1885-99) a remarkable single-handed labour. But he is most remembered for hisstudies on syphilis based on more than a millionpatients, and for the notched, short, narrow, centralupper incisor permanent teeth of congenital syphili-tics-Hutchinson's teeth3-and for the fixed dilatedpupil of temporal lobe coning-Hutchinson's pupil.

JMS PEARCE304 Beverley Road,

Anlaby, HullHU1O 7BG

1 Hutchinson J. Diseases of the arteries. Arch Surg 1890;1:323-33.

2 Horton BT, Magath TB, Brown GE. Arteritis of thetemporal vessels. Arch Intern Med 1934;53:400-9.

3 Hutchinson J. Clinical lecture on heredito-syphiliticstruma: and on the teeth as a means of diagnosis. BM3r1861;1:515-7.

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