First, as to massage:  the operator must direct his efforts primarily to the relaxation of the tense muscles, secondarily to the strengthening of the opponent groups, this last being of special importance where actual contraction has taken place.  He should make frequent attempts by stretching the rigid groups to overcome the spasm, which in large muscle-masses may be done by grasping with both hands, taking care not to pinch, and pulling the hands apart in the line of the muscle’s long axis, thus stretching the muscles.  Pressure will sometimes accomplish the same end, and it will be found in certain cases that by kneading during action,—­that is, while the patient endeavors to produce voluntary contraction,—­the result will be better.  Except in the most spastic states, a certain degree of relaxation is possible by effort, though not without practice, and this has to be constantly inculcated and encouraged.  After a period varying in length according to the case, lessons in co-ordinating movements are begun.  It is best for the patient’s encouragement to start with the least affected muscles, so that, seeing the good results, he may be stimulated to persistent effort.  The lessons differ only in detail from those given in the list under tabes.  Improvement is slower than in ataxia.

In birth-palsy cases not much can be accomplished in the way of education, beyond the attempt by such means as ordinary gymnastics and lessons in drill and walking offer, until the child shall have reached an age when he is able to comprehend what is being attempted.  For the imbecile, idiotic, or backward a training-school is the proper place, where mental and bodily functions may both receive attention and where constant intelligent supervision is available.

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.

Seguin’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.