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Page 51
Many children the subjects of cerebral diplegia are credited with less
intelligence than they really possess, partly because they are
necessarily backward, and partly because of their difficulty in
expressing themselves, the speech-muscles sharing in the disease. These
muscles need to be carefully educated, and this might almost be made the
subject of a treatise by itself. Each case will require study as to the
special difficulties in the way of speech. Some experience most trouble
with the vowel sounds, more find the consonants the worst obstacles.
Patient practice in forming the sounds soon produce some results; the
pupil must be taught, like the deaf mute, to watch and imitate the
movements of the lips and tongue.
S�guin's books and the numerous special works should be consulted by the
physician or parent desiring to pursue these methods to their fullest
development.
When once the control of muscular movement begins to improve, more
elaborate exercises may be set. In speech, if the patients be
intelligent, they will sometimes be amused and profitably trained at the
same time by the effort to learn and repeat long words or nonsensical
combinations of difficult sounds, like the "Peter Piper" nursery rhymes.
B.M., �t. fourteen, an intelligent lad, of Jewish parentage, suffered a
forceps-injury at birth, and had convulsive seizures later. He began to
make futile attempts at walking when five or six years of age, when the
spastic rigidity was first noticed. His speech was better at this time
than later, and a sort of relapse seemed to be precipitated by a fall in
which he struck his head when seven years of age. His mother, finding it
almost impossible to teach him to walk, devoted herself faithfully to
improving his mind, so that at fourteen years of age he read well and
enjoyed books, and was mentally clear, observant, and docile. His speech
was almost incomprehensible,--stuttering, thick, and nasal. He stood,
swaying in every direction, though not apt to fall, with bent knees,
rounded shoulders, every muscle in the extremities rigid, the mouth
half-open, the head projected forward, and, upon attempting to move,
the toes turned in, the legs almost twined around one another, and,
unless supported, he would stumble and twist about, scarcely able to get
forward at all. With a guiding hand he did a little better. His first
lessons were in "setting-up drill," while the feeble, disused muscles
were strengthened by massage, which served at the same time to help his
very irritable and imperfect digestive apparatus, so that it was soon
possible to give him a greater variety and more nourishing kinds of food
than he had before been able to take. He was kept in bed up to three
o'clock in the afternoon, the morning hours occupied with massage and a
half-hour's lesson in erect standing, with slow trunk movements
afterwards. An hour after dinner he was dressed and taken for two hours
in a carriage or street-car. He did his reading and some study on his
return, and had another half-hour's drill, superintended by his mother.
In two or three weeks some improvement began to be observable in his
attitude, and a great change in his color and general expression, but it
was three months before it was thought wise to attempt education in
small co-ordinate movements. At about the same time speech-drill was
commenced.
In all these lessons the greatest care was taken that adequate rest
should intervene between each series of efforts, and it was always found
that fatigue distinctly impaired his co-ordination, as did emotion or
indigestion. When his speech grew clearer he was set tasks of learning
many-syllabled words and also began to practise drawing patterns. Every
new lesson was first given under medical supervision and then continued
by his mother or by the masseur. To shorten the history it will suffice
to say that in six months he was able to go to school, where with
certain allowances made for his thick speech by a kindly master he did
well, and returned to his home in the South able to walk without
attracting attention, to speak comprehensibly, to write a good letter,
and with every prospect fair for a still greater improvement, which I
learn he has since made.
The important things to be recognized in the treatment of these cases
are, first, that rest in proper proportion allows of the patients doing
an amount of exertion which, ungoverned, or performed in wrong ways
would harm them; secondly, that full feeding is of value, because these
disorders are mostly of the character of degenerations and involve
failure of nutrition in various directions; and, lastly, that the
exactness of routine is of the highest moral and mental as well as
physical importance.
Paralysis agitans needs scarcely more than to be mentioned as amenable
to the same methods, with small differences in the application of
details. Body movements to counteract the tendency to rigidity in the
flexor groups of spinal muscles will be especially useful, as the
stiffness of these is one of the causes of displacement forward of the
centre of gravity, a displacement which results in the festination
symptom usually seen in such cases. Prescriptions of special exercises
for the muscle-masses particularly involved in each instance must be
given, remembering that contraction of the affected muscles will to a
certain degree overcome their rigidity even at first, and to a still
greater extent as the patient reacquires voluntary control.
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