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CLUMSY CHILDREN
1252
Careful trimming of the nail, treatment of infection, and cauterisation of granulation tissue in the nailfold will clear up most cases in six weeks. This may seem long, but the patient need not stop work for a single day, and he can continue to wear ordinary shoes throughout the period. The ancient method of lifting the nail from the nailbed by wedging cottonwool under the nail and into the nailfolds fails sometimes, because either the patient has cut the nail too short or he finds the procedure too painful. This difficulty can be overcome if nail and folds are softened by enclosing the top of the toe in ’ Elastoplast ’ for a few days; indeed, this should be done after each dressing. After the first few weeks this is unnecessary; but, as Lloyd-Davies and Brill point out, the patient must learn to control the symmetrical growth of the nail by using cottonwool wedges intelligently. Patients are sometimes impatient; they may demand operation in the fond hope that this is a speedy end to the trouble. But if they are firmly told that six weeks of elementary care, without pain and without being laid up, will achieve the same purpose, they can usually be persuaded to persevere. CLUMSY CHILDREN
IN the organisation and development of skilled motor activity there are many factors which are still obscure. As everyone knows, individuals vary in physical as in mental constitution. Whereas some are lithe and graceful in their movements, in others the coordination and control of muscular activity is much less efficient: movements often involve excessive expenditure of energy, with inaccurate judgment of the necessary force, tempo, and amplitude. Such people are regarded as constitutionally clumsy. Clumsiness is extremely difficult to define, and many clumsy people are well able to adjust to the demands of normal society: they can be educated in ordinary schools and eventually achieve a reasonable standard of physical, as well as mental, activity. On the other hand, Walton, Ellis, and Courtpoint out that some children have a degree of clumsiness well outside the normal range. They describe five in whom it interfered seriously with education and training, and they suggest that it was due to a form of developmental apraxia and agnosia which has not yet had
adequate attention. All five had been regarded as mentally backward because of failure to progress in school. Nevertheless, all were able to read satisfactorily, and their difficulty lay in carrying out manual tasks such as writing, drawing, and dressing. On the Wechsler intelligence scale for children, their verbal scores revealed that they were of normal or abovenormal intelligence, though their performance scores were extremely low. This discrepancy between the verbal and performance scores seems to be characteristic of this particular syndrome. In four of the cases there was some evidence of ambidexterity or ambilaterality. In three of them the difficulties were mainly on the motor or executive side, and were attributed to developmental apraxia; in one there was a combination of articulatory apraxia with agnosia for tactile sensations; and the fifth child showed a profound tactile agnosia with a severe disorder of the bodyimage and of topographical sense. In none of the five did careful neurological examination show any primary defect in motor or sensory pathways. In other words, clinical examination yielded no indication that any had had focal brain damage at or about the time of birth, or that any of them had a localised acquired brain lesion. The authors 1.
Walton, J. N., Ellis, E., Court, S. D. M. Brain, 1962, 85, 603.
remark that in congenital dyslexia or reading defect 2-4 one finds a similarly circumscribed defect in the acquisition of verbal, rather than motor, skills. There now seems to be ample evidence that this disability arises not from a lesion of the brain but rather from a defect of cerebral organisation in the physiological sense.56 Walton and his colleagues conclude that their clumsy children probably have a similar defect of cerebral organisation; but here the pathways that are poorly organised are those concerned with the organisation of skilled movement or with the recognition of tactile and other sensory stimuli. The finding of ambidexterity or ambilaterality in these children givess some support to this view, since it has been suggested that congenital reading defect is due to failure of the establishment of dominance in either cerebral hemisphere. It seems clear that this syndrome is much commoner than has been generally supposed. Excessive clumsiness of movement, poor topographical orientation, and, in a child who can read fluently, inability to draw, to write easily, or to copy, are features suggestive of a specific apraxic or agnosic defect. The defect can be identified more accurately by psychological tests of motor and sensory function and can be confirmed by estimation of the intelligence quotient on the Wechsler scale for children. The experience of Walton, Ellis, and Court suggests that it is not due simply to a delay in maturation, since in several of their children the difficulties persisted for many months or years. Careful individual teaching and training, given by schoolteachers with particular experience and understanding of children with executive and cognitive defects, pays considerable dividends. The training takes a lot of time and great patience; but it seems to be justified, for in several cases the results achieved have been impressive. LIVINGSTONES OF EDINBURGH
E. & S. Livingstone began in May, 1863, when Edward opened a shop for the sale of new and secondhand books at 57, South Bridge, Edinburgh.’7 Two years later he took as partner a younger brother, Stuart; and this energetic and ingenious combination of E. & S. built up a business that has developed into one of the world’s foremost medical publishers. To celebrate the centenary, the firm gave a dinner last week at the Royal College of Surgeons in Lincoln’s Inn Fields, at which a large gathering of authors and other friends paid tribute to a hundred years of splendid achievement. " Integrity, high quality of bookcraft, and, above all, friends " were the ingredients of this success, said Dr. Hugh Clegg, a famous editor. Sir Francis Walshe, a famous writer, declared that E. & S.L. had a standing unsurpassed in medical publishing and a great reputation for their kindly treatment of authors. And, speaking of the remarkable way in which Livingstone publications had kept up with medical progress, Sir Arthur Porritt attributed much of this feat to the alertness and enterprise of Mr. Charles Macmillan, the present chairman and managing director-" the keystone of this friendly firm ". To these and many other tributes to the names of Livingstone and Macmillan, we add our congratulations and
good wishes.
Morgan, W. P. Brit. med. J. 1896, ii, 1378. Hermann, K. Acta psychiat., Kbh. 1956, suppl. 108, p. 177. Gutelius, M. F., Layman, E. M. Clin. Proc. Child. Hosp., Wash. 1960, 16, 15. 5. McFie, J. J. Neurol. Psychiat. 1952, 15, 194. 6. Zangwill, O. L. Cerebral Dominance and its Relation to Psychological Function. Edinburgh, 1960. 7. Footprints on the Sands of Time: the Story of the House of Livingstone. Edinburgh: E. & S. Livingstone. 1963. Pp. 71. 2. 3. 4.
Careful trimming of the nail, treatment of infection, and cauterisation of granulation tissue in the nailfold will clear up most cases in six weeks. This may seem long, but the patient need not stop work for a single day, and he can continue to wear ordinary shoes throughout the period. The ancient method of lifting the nail from the nailbed by wedging cottonwool under the nail and into the nailfolds fails sometimes, because either the patient has cut the nail too short or he finds the procedure too painful. This difficulty can be overcome if nail and folds are softened by enclosing the top of the toe in ’ Elastoplast ’ for a few days; indeed, this should be done after each dressing. After the first few weeks this is unnecessary; but, as Lloyd-Davies and Brill point out, the patient must learn to control the symmetrical growth of the nail by using cottonwool wedges intelligently. Patients are sometimes impatient; they may demand operation in the fond hope that this is a speedy end to the trouble. But if they are firmly told that six weeks of elementary care, without pain and without being laid up, will achieve the same purpose, they can usually be persuaded to persevere. CLUMSY CHILDREN
IN the organisation and development of skilled motor activity there are many factors which are still obscure. As everyone knows, individuals vary in physical as in mental constitution. Whereas some are lithe and graceful in their movements, in others the coordination and control of muscular activity is much less efficient: movements often involve excessive expenditure of energy, with inaccurate judgment of the necessary force, tempo, and amplitude. Such people are regarded as constitutionally clumsy. Clumsiness is extremely difficult to define, and many clumsy people are well able to adjust to the demands of normal society: they can be educated in ordinary schools and eventually achieve a reasonable standard of physical, as well as mental, activity. On the other hand, Walton, Ellis, and Courtpoint out that some children have a degree of clumsiness well outside the normal range. They describe five in whom it interfered seriously with education and training, and they suggest that it was due to a form of developmental apraxia and agnosia which has not yet had
adequate attention. All five had been regarded as mentally backward because of failure to progress in school. Nevertheless, all were able to read satisfactorily, and their difficulty lay in carrying out manual tasks such as writing, drawing, and dressing. On the Wechsler intelligence scale for children, their verbal scores revealed that they were of normal or abovenormal intelligence, though their performance scores were extremely low. This discrepancy between the verbal and performance scores seems to be characteristic of this particular syndrome. In four of the cases there was some evidence of ambidexterity or ambilaterality. In three of them the difficulties were mainly on the motor or executive side, and were attributed to developmental apraxia; in one there was a combination of articulatory apraxia with agnosia for tactile sensations; and the fifth child showed a profound tactile agnosia with a severe disorder of the bodyimage and of topographical sense. In none of the five did careful neurological examination show any primary defect in motor or sensory pathways. In other words, clinical examination yielded no indication that any had had focal brain damage at or about the time of birth, or that any of them had a localised acquired brain lesion. The authors 1.
Walton, J. N., Ellis, E., Court, S. D. M. Brain, 1962, 85, 603.
remark that in congenital dyslexia or reading defect 2-4 one finds a similarly circumscribed defect in the acquisition of verbal, rather than motor, skills. There now seems to be ample evidence that this disability arises not from a lesion of the brain but rather from a defect of cerebral organisation in the physiological sense.56 Walton and his colleagues conclude that their clumsy children probably have a similar defect of cerebral organisation; but here the pathways that are poorly organised are those concerned with the organisation of skilled movement or with the recognition of tactile and other sensory stimuli. The finding of ambidexterity or ambilaterality in these children givess some support to this view, since it has been suggested that congenital reading defect is due to failure of the establishment of dominance in either cerebral hemisphere. It seems clear that this syndrome is much commoner than has been generally supposed. Excessive clumsiness of movement, poor topographical orientation, and, in a child who can read fluently, inability to draw, to write easily, or to copy, are features suggestive of a specific apraxic or agnosic defect. The defect can be identified more accurately by psychological tests of motor and sensory function and can be confirmed by estimation of the intelligence quotient on the Wechsler scale for children. The experience of Walton, Ellis, and Court suggests that it is not due simply to a delay in maturation, since in several of their children the difficulties persisted for many months or years. Careful individual teaching and training, given by schoolteachers with particular experience and understanding of children with executive and cognitive defects, pays considerable dividends. The training takes a lot of time and great patience; but it seems to be justified, for in several cases the results achieved have been impressive. LIVINGSTONES OF EDINBURGH
E. & S. Livingstone began in May, 1863, when Edward opened a shop for the sale of new and secondhand books at 57, South Bridge, Edinburgh.’7 Two years later he took as partner a younger brother, Stuart; and this energetic and ingenious combination of E. & S. built up a business that has developed into one of the world’s foremost medical publishers. To celebrate the centenary, the firm gave a dinner last week at the Royal College of Surgeons in Lincoln’s Inn Fields, at which a large gathering of authors and other friends paid tribute to a hundred years of splendid achievement. " Integrity, high quality of bookcraft, and, above all, friends " were the ingredients of this success, said Dr. Hugh Clegg, a famous editor. Sir Francis Walshe, a famous writer, declared that E. & S.L. had a standing unsurpassed in medical publishing and a great reputation for their kindly treatment of authors. And, speaking of the remarkable way in which Livingstone publications had kept up with medical progress, Sir Arthur Porritt attributed much of this feat to the alertness and enterprise of Mr. Charles Macmillan, the present chairman and managing director-" the keystone of this friendly firm ". To these and many other tributes to the names of Livingstone and Macmillan, we add our congratulations and
good wishes.
Morgan, W. P. Brit. med. J. 1896, ii, 1378. Hermann, K. Acta psychiat., Kbh. 1956, suppl. 108, p. 177. Gutelius, M. F., Layman, E. M. Clin. Proc. Child. Hosp., Wash. 1960, 16, 15. 5. McFie, J. J. Neurol. Psychiat. 1952, 15, 194. 6. Zangwill, O. L. Cerebral Dominance and its Relation to Psychological Function. Edinburgh, 1960. 7. Footprints on the Sands of Time: the Story of the House of Livingstone. Edinburgh: E. & S. Livingstone. 1963. Pp. 71. 2. 3. 4.