In the treatment of all cases of weakened muscle or of paralysis the final restoration is not in our hands. It rests with the patient whether recovery is as complete or as rapid as the nature of his injury allows. Our part is to help him, to show him what to do and how to do it; to keep all that remains uninjured as intact as may be, and to make the earliest possible use of all opportunities. Having done this we have done our duty: but we have failed lamentably and sadly in its performance if we have failed to keep intact, to encourage, to re-educate if need be, or even occasionally to repress - the volitional element in our patient. He does not consist of an injured nerve or weakened muscle: he has a mind, and the success or failure of our treatment may depend entirely upon the effect it has on the mentality of the patient.

1 See the Society's Journal, June, 1919.

There is one great danger in muscle re-education, which must be fully appreciated. As voluntary movements only, and not individual muscles, are represented on the cortex, it follows that, if a command is sent from the cortex to the periphery to perform a certain movement, that action will be executed if in any way possible, even though the muscles that usually perform the movement are paralysed. Thus, unless due precaution is taken when training a patient who has a recovering ulnar nerve lesion, we may succeed only in teaching him to abduct his fingers in hyper-extension by his long extensors, and adduct them again in flexion by his long flexors. If there is no chance of recovery this may be a valuable "trick" to teach: it is the worst possible treatment if recovery is to take place. The same applies throughout the whole realm of muscle re-education. It is for this reason that the task of muscle training calls for great care and watchfulness on the part of the masseur, and also for a high degree of technical knowledge and proficiency. The mental strain involved by good muscle training is exacting to a degree, and not the least difficult part of the treatment is to secure the full co-operation of the patient in the form of volitional effort. Even this is not enough; the effort must be purposeful and intelligent.

Prof. Wood-Jones, in his Arris and Gale lecture, concludes by giving a list of the more common forms of "trick" movements that can be developed by patients recovering from paralysis. If recovery is hopeless, by all means let us take advantage of them: while there is any chance of recovery, let us check their development with all the skill we may. The list given is as follows: -

"(a) Complete division of the musculo-cutaneous nerve. The elbow is flexed by the supinator longus.

"(b) Complete division of the musculo-cutaneous and musculo-spiral. The elbow is flexed by the pronator radii teres.

"(c) Complete division of the musculo-spiral. The wrist may be extended by producing flexion of the metacarpophalangeal joints. The two terminal phalanges may be extended by the action of the interossei. The terminal joint of the thumb may be extended by "spring back" from the long extensor tendon, which acts as a ligament when the long flexor is brought into play.

"(d) Complete division of the ulnar. The fingers may be spread apart and brought together again by the action of the long extensors and flexors. The index finger may be adducted to the middle line by the extensor indicis proprius. The two terminal phalanges may be extended by the long extensors if the metacarpo-phalangeal joints remain slightly flexed.

"(e) Complete division of the median. Not uncommonly a fair fist may be made involving some flexion of all finger-joints by the pull of the flexor profundus innervated by the ulnar. This is one of the best examples of a cortical volition overcoming obstacles. The metacarpo-phalangeal joints may be flexed by the interossei. The proximal phalangeal joints may be flexed by the flexor profundus after the terminal joints are bent. The terminal joint of the thumb may often be bent, just as in musculo-spiral paralysis it may be extended, by using the paralysed tendon as a ligament. Opposition is often perfectly carried out by the action of the extensor ossis metacarpi pollicis and the ulnar-supplied adductors. The thumb can be "abducted" by the extensor ossis metacarpi pollicis.

"(f) Complete division of median and ulnar. The wrist may be flexed by the extensor ossis metacarpi pollicis. The fingers may be flexed by producing extension of the wrist.

"(g) Complete division of the internal popliteal. The foot may at times be depressed by the dissociated action of the peronei."

To this list I would add the record of a patient under my care at the Special Military Surgical Hospital. He had complete and permanent paralysis of the deltoid. By flexing his elbow slightly and then extending it suddenly he was taught to swing his arm away from his side sufficiently far to allow the supraspinatus and clavicular part of his pectoralis major to complete, in perfect manner, the movement of abduction of the arm. This affords one of the rare examples in which the teaching of a muscle "trick" rendered great service to the patient.