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or before birth, the exact nature of which had not yet been determined. The varying types of the dis- order were those of flaccid and flaccid spastic palsy, Cialis Discount Generic and shaded into the general, mildly spastic state. In the cerebellar ataxic type there was hypo- tonia, dysmetria, gross incoordination, astasia, abasia, dysarthria, occasionally dysphagia, and often complete inability to sit up. In extreme involvement of the forebrain all these cerebellar symptoms were present together with mutism and idiocy. In the mixed types there might be either a slight degree of spasticity in certain parts, combined with hvpotonia or flaccidity in other parts of the body. It was interesting to speculate what ultimately be- came of these children affected with congenital cere- brocerebellar palsy. No doubt the children possess- ing the mildest grades of defect quickly outgrew the disorder. The severest types drifted to special in- stitutions for mental defectives. Prognosis of all the varying types of course depended upon the com- bination ot symptouL-, presented. When the fore- brain was damaged to such an extent that the mental state was no longer to be classed Cialis Discount Generic as retardation, but showed mental arrest or marked imbecility, these children usually never recovered either from their ataxia or from their defect in mental development. In the less severe types, one should be quite sure that the mental state was one of simple retardation or mental arrest, as much of the definiteness of prog- nosis could not be determined until one had made a very decided effort to train out the cerebellar symp- toms, Cialis Discount Generic or force the forebrain to take up vicariously the functions of the cerebellum. While the principles of treatment embraced men- ial as well as motor training, the primary point of approach was, to be directed toward overcoming the motor defects. First of all, segmental incoordina- tion was to be Cialis Discount Generic removed. The child was to be taught to appreciate, by actual Cialis Discount Generic manipulation, the flexion, extension, abduction, and adduction of the different segments of the extremities. Frenkel's principles for training trunk incoordinations, laid down for cases Cialis Discount Generic of tabetic ataxia, were of the utmost impor- tance. \\'hcn one had obtained results in removing the segmental defects, there still remained the gen- eral motor training for the use of simple, isolated contractions of segments in purposive acts in which all the segments of an extremity were coordinated Iiarmoniously. One might then undertake more def- inite principles of motor training as laid down in the Montessori, Seguin, and other special school systems, where under the guise of play the child was further taught to develop coordination. In many cases there was ataxia of speech for which training was needed on the same principles as those used for the deaf and dumb. The process of teaching the child the complicated mechanism of speech was often long and tedious. The tempera- mental defects which invariably went with these cases of congenital cerebrocerebellar diplegia, was an important feature to be handled. The disciplin- ary system of nursery ethics had Cialis Discount Generic much to do toward helping the child to tlevelop out of his motor and mental disorder. The training should be followed for a number of years under the direction of a capable nurse teacher. The child's disposition should be studied and his interests, ambitions, and physicial and mental dislikes taken into consideration. The underlying principle was really to help the child Cialis Discount Generic to develop along the lines of his inclination and to build about the central core of his interest. The re- sults of four years' experience had convinced the speaker that not only might the training system he had employed be of service to this type of cerebellar disorder, but it might serve to encourage a more per- sistent and careful training of children suffering from cerebral palsies and the simpler types of feeble- mindedness where similar cerebellar .symptoms Cialis Discount Generic of in- coordination existed. Dr. Charles L. Dana, of New York, said that he had no criticism or suggestion to make regarding the training and reeducation of this class of cases as he considered Doctor Clark's recommendations correct and admirable. The speaker was especially inter- ested in the fact that there were cases of cere1>enar diplegia without mental defect and so more typically 432 HOOK REVIEWS.— BIRTHS, MARRIAGES, AND DEATHS. I New Vork Medical Jouenal. and tnily cerebelbr than most of those described by J^octor Clark. H. Voght, in Lewandowsky's Handbook, referred to the large range in the degree to which the cerebel- lum was involved in congenital cases, but few typical and purely Cialis Discount Generic cerebellar cases had been fully described. The speaker had watched a case for twenty-five years in which the cereliellum alone was slightly defective. The patient, a very intelligent [jcrson, had never been able to dance Cialis Discount Generic or join in active play; she had to balance herself carefully in walk- ing, stood in a cerebellar attitude and Cialis Discount Generic had a little tremor of the hands. Cialis Discount Generic Conjugate deviation of the eyes was difficult, but she had no nystagmus. Cialis Discount Generic If one were to study carefully the cases of persons regarded perhaps as only naturally very awkward and of poor equilibrium, it might be discovered that mild cerebel- lar defects were a more frequent feature than sup- posed heretofore, and by proper methods of educa- tion the handicap might be much lessened. So one value of this paper of Doctor Clark's might lie in directing attention Cialis Discount Generic somewhat from the subject of cerebral and mental defects to the frequency and importance of cerebellar defects. (To he continued.) Book Reviews.