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THE literature on poliomyelitis contains many references to the value of willing the muscle to make the motion. The first reference that the writer has been able to find on this is by John Hunter and he has been quoted by later authors. He probably had this idea about 1750. There is in my mind no doubt of the value of using the will in training the muscles the point should be insisted upon by those are doing physiotherapy. The patient should devote his entire attention to the hands, excluding all other outside thoughts and all conversation. A few light remarks from time to time rest the will but that should only be indulged in between motions. The best account of training the muscles by use of the will is that given by Mathias Roth, a Hungarian physician, who removed to London. This is to be found in his little book on infantile paralysis published in 1869.

In addition Roth quotes from Ward and from West. All three extracts are given below:

I. "The manner in which stimulants are supposed to act in paralysis is by increasing that energy of the brain which is necessary to the production of muscular action. The stimulus which appears to me the most safe, the most completely under our control, and the best calculated to effect this object, is that of frequent exercise excited by or dependent on volition.

"The power of immediate association between volition and muscular action can be only recognized by repeated attempts; want of attention to these circumstances will explain the general failure of the usual means that have been resorted to for the cure of paralytic affections after the primary disease of the central organs, whatever may have been its nature, has been removed. The intimate connection and dependence which exists between the sensorial and muscular power has not been adverted to, and that most powerful of all muscular stimulants, volition, has been altogether overlooked, or regarded only as a casual or secondary means of cure." (Ward)

II. "Of the efficacy of the will, as a subsidiary means of restoring power to the partially paralyzed limb, I have no doubt whatever. Of course the child, whose will is feeble and liable to be distracted by very trivial causes, this power is far less energetic than in the grown person, but still it is a power well worth cultivating, and the steady perseverance in it exercised from childhood up to adult age will, I am sure, do more towards the recovery of a paralyzed limb than would ever be imagined from its casual employment on one or two occasions." (West)

III."Although all authors agree in recommending exercise for the paralyzed part, there are but few who insist on the necessity of an enduring physical tension on the part of the patient to try to make an effort to move a part, notwithstanding they are conscious that they are unable to move. Although children under the age of four or five years are scarcely supposed to be able to understand how to make the mental effort of directing the will in a given direction, I have several times seen children only three years old trying to assist in moving a paralyzed limb whilst it was, in fact, moved by another person. In older and more intelligent children, as well as in youths and adults, the difficulty and resistance to the mental exertion of energetically willing we must be prepared to overcome in all cases, in the young as well as in the old patient, but if the medical man has sufficient energy, patience, perseverance, and knowledge how to manage the little ones and to make use of their power of imitation, and, I may add, if be has some love for them, he will finally succeed, and his hand will feel, before his eye observes it, that the child tries to will, and this is the first and a very important trace of real improvement. A loving mother and an intelligent painstaking nurse interested in the child s welfare are most desirable assistants. It is very well to recommend elastic bands with handles, all kinds of mechanical and gymnastic contrivances, such as go-carts, baby-jumpers, etc., for cases where partial power of movement exists, but these cannot be used when there is an impossibility of making the slightest movement.

"The following is the manner I have hitherto found best to answer the purpose of rousing the will and of increasing the innervation:

"l. The patient is placed in a comfortable position, lying, half lying or sitting, in which he can remain without any exertion, perfectly passive.

"2. The paralyzed limb is raised and supported by the operator, who moves it in a given position, bends, stretches, turns or rotates it several times, while the patient is requested to see the movement which is done for him.

"3. First only one movement is done. Suppose the extensors acting on the elbow-joint are perfectly paralyzed, and that the patient is able to make the flexion, the operator makes the extension, and after having done so several times, the patient is directed to stretch the arm. The usual answer, 'I cannot,' is not permitted; he is induced to say, 'I will try,' and is encouraged to try; but as the patient knows by experience that he is not able to stretch the arm, and it is probable that for some time he has made no attempt at trying to do it, he finds a difficulty even in making the mental effort of trying. After some persuasion and encouragement he gives way and endeavors to try. At this moment it is important to make for him slowly and gently the extension, which being coincident with his mental process is at the same time seen by the patient; the impression thus conveyed through the eye to the brain convinces him that his effort was not in vain, because the arm is really stretched. The little patient believes that he has some share in it, because he knows he has made some effort, which is itself a new and unaccustomed sensation. These efforts of the will are repeated three or four times, and the corresponding movements are always done for him. I consider this mental dynamical operation the first step towards influencing the conducting or efferent nerves, and indirectly the paralyzed muscles. When flexors and extensors are simultaneously paralyzed, the operator will proceed in a similar way. In this case he is obliged to do alternately and slowly the flexion and extension of the forearm, while the patient endeavors to direct his attention and will to the movements as is suggested in the previous case.

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"When the joint to be moved is rigid, the attempts on the part of the patient's will should begin only after the operator has repeatedly and for some time endeavored by passive movements, manipulations, and other means to ease the joint and undo the rigidity.

"4. The greatest precision is desirable regarding the direction of the movement, its uniformity and duration.

"5. The patient's will is to act simultaneously with the operator's will, or according to his command.

"6. The repetition of the movement depends upon the patient's mental and physical powers.

"7. The sympathetic influence of the will is made use of by inducing the patient to move also the healthy limb, while be tries to influence the corresponding paralyzed part.

"8. The parts adjacent to the perfectly paralyzed part should be moved actively, i.e., by the patient alone, if this can be done, or while assisted by another person if the patient's power is not sufficient to overcome the resistance of the weight of the part to be moved; it happens frequently that the inactivity of a part continues only because the patient is unable to move it with ease, whilst a slight diminution of its weight enables him easily to overcome the difficulty.

"9. The energy of the will is increased in parts under the patient's perfect control, by another person gently resisting the movement he intends to do, or by the patient's gentle resistance to a movement of his body or limbs, while done by another person.

"The following are the successive stages regarding the functions of volition on the part of the patient:

"1. The patient is encouraged by another person to make the first effort to will.

"2. The patient tries, his power of moving is deficient; the movement is done for him.

"3. The patient exerts his will, has but partial power, anoher person assists his movement either by diminishing the weight of the part or by actually doing a part of the movement.

"4. The patient's will and power are sufficient to move the weak part, although not yet with case; his power increases by degrees and the weak part is moved with less difficulty.

"5. The will of the patient is stimulated by another person gently resisting him, while doing an intended movement; or be gently resists the other person doing a movement with any part of his body.

"Great caution is required not to fatigue the patient by the attempts to use his will; if a dull or acute pain in the head is caused by the patient's endeavors to will, these attempts must be stopped, and passive movements only should be used, til at a later period new trials can be made without causing headache." (Roth).