Studies in the Osteopathic Sciences
The Physiology of Consciousness: Volume 3
Louisa Burns, M.S., D.O., D.Sc.O.
    People who are sick in any way are usually sick in many ways. The unity of the body in sickness and in health is one of the things easiest to teach and easiest to forget. Many centuries ago Marcus Aurelius wrote, “What is good for the bee is good for the hive,” and this is as true for the parts of the body physical as it is of the body politic. The evils which afflict one part of the body do not long leave any other part of the body in its best working order. The mentality suffers ultimately in all disorders, and the symptoms should receive the same attention given to other symptoms in the treatment of the patient. This is not saying that sick people are imbecile or insane; it is only saying that the physiological activity of the cortical neurons depends upon the same conditions as does the physiological activity of the other cells of the body. As it is not probable that the glands, or muscles, or the spinal centers act normally in the absence of the good blood, flowing freely, and the nerve impulses normal to them, so the neurons of the cortex are unable to act normally in the absence of good blood flowing freely, and the nerve impulses normal to them. Osteopaths use the condition of the spinal neurons in the diagnosis of disease. The presence of excessive irritability of certain spinal centers is held indicative of certain abnormalities. So, it is possible to see in certain mental peculiarities the indications of certain abnormalities of structure or of function. The cause of the peculiar mental condition of the patient should be studied as other symptoms are studied, and the information thus gained may be used in diagnosis, just as the information gained in the study of other symptoms is used.

    Osteopaths study the condition of the spinal centers constantly in diagnosis, and make use of the various nerve connections to increase or decrease the nerve impulses to different viscera. It is just as rational to study the relative irritability of the cortical centers, when these are acting abnormally, and to increase or decrease their activity according to the needs of the individual patient. The study of the variations in the activities of the cortical centers and the modification of their activities through rational and physiological means, is as essentially osteopathic as is the study of the variations in the activities of the spinal centers, and the modification of their activities by rational and physiological methods.

Causes of Insanity
    The causes of abnormal activities of the cortical neurons may be considered briefly. The gross structural degenerations associated with the insanities need not concern us at this time, sine these are incurable. The functional disturbances associated with the insanities must be studied in insane asylums and sanitariums for a long time before any statements may be made concerning their treatment from the osteopathic standpoint. It is greatly to be desired that some osteopath may be associated with such institutions and study the cases with reference to the osteopathic viewpoint, and thus our knowledge concerning the pathology and treatment of such cases be increased.

    With a few exceptions, our knowledge is limited to the study of the borderland cases, and to the mental characteristics of certain diseases, not to be classed properly as insanities.

    Many patients of the neurotic type are such because of a faulty inheritance. The neurotic inheritance includes hysteria, excessive irritability of temper, migraine, epilepsy, tuberculosis, marasmus, rachitis, alcohol and drug addictions, and, indeed, whatever makes for poor nutrition or nervous instability. It is probably that it is less the actual use of alcohol or drugs which makes the bad inheritance as it is the nervous abnormality which renders the excessive use of such stimulants possible. Individuals whose ancestors include the drunkard, the epileptic, the hysterical, the bad-tempered, and the subject of migraine, as well as of the grosser insanities, are more liable to the neuroses and the psychoses. These persons may live fairly normal lives as long as they are placed under fairly normal conditions; but any overwork, or the use of stimulants, or any of the exhausting diseases, may injure them in much greater degree than is the case with the normal person under the same conditions. Physicians need to recognize these neurotic persons, and to insist with urgency upon their living quiet lives under the most favorable conditions. Children born of neurotic parents must not be subjected to any overwork at school, must live quietly, out of doors, with much work of a normal kind, no excitement, and with only the normal and well-balanced mental and nervous activities permitted them.

    These neurotic individuals usually appear in the physician’s office suffering from “nervous prostration” or some other euphonious disease. Unfortunately, such patients do not respond very well to ordinary methods; the diagnosis is not easy, and too frequently they are simply sent from one doctor to another, with no very careful study of their cases anywhere. Their instability of character is in part responsible for this constant changing from one doctor to another, and from one fad to another, and from fad to philosophy, and from philosophy to fanatic, and from fanatic to physician again. Many of these patients are hopelessly unsane—not insane, but simply without sanity. The condition of such people should be recognized and their relatives informed of it, so that no expense need be incurred in useless attempts at cure. Others, and this includes most of such cases, are capable of being helped to lives of comparative usefulness. Others yet can be persuaded to be treated rationally, and they may recover apparently completely.

    In studying these cases it is necessary to determine what centers of the cortex or basal ganglia have been subjected to overuse, or which have been left undeveloped. The usual methods of examination usually show the unbalanced relationships existing in certain regions. Ordinary conversation along unplanned lines, letting the patient follow his own tendencies, often throws light upon his peculiarities. The omissions should be noted, as well as his statements. The fingers upon the pulse will often note circulatory disturbances when some subject with an emotional bearing is broached. The variations in blood pressure should also be noted.
Questions concerning his past life, and especially of his life of about the time the “nervousness” first appeared, sometimes help in fixing the nature of his mental processes. Questions regarding his view upon governmental and religious affairs, his social and club relationships, show whether he is excessively self-centered or not, and whether any tendency to an abnormal emotional instability exists.
Classes of Neurasthenics
    Most such cases fall into one of four classes:

    The patient who has been overworked in truth, and whose neurons are generally fatigued, has the symptoms called neurasthenic. There are no particular localization symptoms present. No excessive egoism and emotional shock are to be found even upon close questioning. The history includes an amount of overwork in excess of that which the normal individual should endure. The tests for muscular strength, reaction time, etc., are characteristic of the neurasthenic. The spinal column is almost invariably flat, with a lack of the normal mobility either throughout or extending through certain areas. The place of the immobile areas differs according to the habits of the patient. These patients do well under the ordinary method of treatment. They must have their condition explained to them, must have lessened amounts of work, and must be well fed. They usually do best without sharply-marked variations from the usual habits of life, but in certain cases the complete change is needful. Their habits must be studied, drugs omitted, foods easily digestible and nutritious substituted for abnormal foods, and dietetic fads subjected to scrutiny. Such people are often half-starved by their addition to fads, or they are half-poisoned by their use of abnormal and indigestible foods.

    The second class of patients includes those who have suffered some long illness, and have recovered to a certain extent, but not altogether. Such people are often those who have been treated by certain drugs. When the nerve impulses concerned in the consciousness of pain, or weakness, or inability have been frequently initiated, the neuron systems have used some drugs, have suffered from some sexual excesses, and who give accounts of complex symptom groups. The complications of such patients are many, and it is sometimes impossible to make any exact diagnosis.

    In all classes of neurotic patients there is apt to be found an unbalanced egotism, or at least egoism. The peculiar symptoms of each case need to be studied and treated in connection with the special case, and without much reference to classes or pathology.

    In all of these cases the diagnosis must include the complete study of each patient. Many cases of Meniere’s disease, of incipient paresis, of nephritis, of heart lesions, of pernicious anemia, of tuberculosis, begin with symptoms similar to those described. The fact that any person is neurasthenic or hysterical is no reason why there may not be tuberculosis, or a brain tumor, or pelvic abnormality, or hemorrhoids, or any other disease, in fact. The examination of the patient who has been passed around from one doctor to another should be at least as thorough as the examination of the patient who has not that discouraging history.

Treating Neurasthenics
    The physician must consider only the needs of his patient in this matter. It is his duty to place the patient in the best possible condition to do good work; and while he may, as a friend of the patient and as a member of society, use his influence to encourage the brave, and wise, and kindly attitude toward life, he must never permit his endeavors along these lines to interfere with his more urgent duty as a physician, and this is, that he give his patient the very best possible body; for the body is the first and most urgent care of the physician, and in securing the very best possible bodily conditions, the first necessity for the very best possible attitude toward life is secured—the first step toward fine, and wise, and kindly living is made.

    The brain cells which are normal, which are well fed with good, clean blood flowing rapidly through them, under normally high pressure, brain cells which receive from the body and its surroundings a constant stream of the sensory impulses needed for their normal activity, such brain cells as these act normally, which is to say, wisely and happily, causing by their activity the consciousness of work well done, of emergencies well met, of problems of existence well handled. If there is apparent in the attitude of any patient a lack of these qualities, an appearance of inability to meet the daily demands of life, if there seems lack of the joy in living, then it is the duty of the physician to determine the causes of this cerebral inefficiency. It is not for him to make a hasty diagnosis of a deficiency in mentality. He must find the physical abnormality underlying the mental ineptitude. Some efficient factor underlying the conscious ineptitude is always present. It may be found in a faulty education, and in this case the physical nature of the patient may also be affected. But in practically every case in which the more superficial study renders the diagnosis of faulty education as the only etiological factor, a more careful study will display the symptoms of a physical cause underlying the faulty mental activity. It must be held, more and more, that the activity of the normal brain is an activity which is associated with mental stability, with energetic living, and with the activities concerned in happiness and sanity. The lack of sanity and happiness, the presence of ennui, and worry, and dread are not compatible with the functioning of a normal brain, well fed and well drained of its wastes.

    It is the duty of the physician to find this physiological factor in all cases. He must leave no stone unturned in the search for the physical cause of the disease He may not consider himself justified in engaging to care for any patient unless he recognizes some underlying condition which he may hope by his care to alleviate.
True, there may be cases in which the educational factor alone is concerned. These cases are becoming apparently fewer as our knowledge of diagnosis increases.

    Though not a matter of certainty the conclusion is fairly enough drawn that the unbalanced development of the frontal cortex, and the excessive development of the relations between this part of the brain and other areas, must be associated with an unbalanced personality The person of undue egotism, as well as the one of undue lack of self-appreciation, probably suffers from an unbalanced relationship between the frontal areas and other parts of the cortex.
An excess of egoism is the consciousness which is caused by a lowered liminal value of the left frontal intermediate area, so that the activity of other cortical areas initiates the stimulation of these neurons; in other words, the environmental changes and the results of the activities of the association areas are perceived in the light of personal experiences in excessive degree.

    These persons may be intensely egotistical and selfish, but they may merely be egoistical. The condition is not exclusive of marked self-sacrifice. The person who comes often in contact with suffering may constantly be affected by the presence of “such misery, and I can do nothing.” The very endeavor to relieve the suffering brings about a constantly-increasing sense of desire to help and a sense of helplessness. So long as such a person retains good physical health, so long will the wholesome reactions occur in other cortical areas. But when such a person suffers from overwork, or some neurasthenic or hysterical tendency, then the self-centered sense of helplessness is apt to be associated with the unbalanced reactions, and the tendency to help others becomes only a source of self-injury.
The man who supports his family may be anxious to supply them with increasing luxuries. He may constantly dwell upon his desire to make better provision for them, and he may be so persuaded that only his own efforts prevent disaster to those unable to earn a living that he, in time of overwork or indigestion, or an attack of grippe, or some other exhausting condition, may become morbidly egoistic.

    The person who has been long ill, especially with certain diseases, may become self-centered to a morbid degree. Such a one translates every environmental variation into terms of his own physiological processes.

    The only child, the center of the life of the house, in the very nature of things becomes egoistic early in life. Almost all children pass through a stage of genuine egotism at the time when the anterior intermediate areas begin to act more energetically. This occurs at about the age of puberty. The “spoiled child” is not necessarily the one who has the things he wishes, but it is the one whose attention has been too early directed to his own personality. This may be done as easily in the imposition of hardship as in the imposition of ease and luxury. It is not the number of dresses a little girl owns, nor the material of which they are made, that makes her vain; it is the number of times she looks in the glass, and the number of times during which she is compelled to attend to her own personality. Children who grow up in the midst of attention, whether the attention be of admiration or of fault-finding, are apt to be extremely egoistical throughout life, and to suffer from the ills which must be associated with such a temperament.

    When we recognize the structural basis of this unbalanced idea of personality, the cure is already indicated. First, of course, must be considered the securing of the good blood flowing under normal pressure to the cortical neurons. It is not to be expected that any amount of stimulation can make ill-fed and half-poisoned neurons assume normal relationships.

Educational Treatment
    Having provided the conditions needful for normal activity of the neurons, it becomes desirable to send into the cortical centers those impulses which will bring into activity the neurons of the posterior intermediate areas.

    The posterior intermediate area lies between the motor, visual and auditory overflows. The auditory and visual areas are already related thoroughly with the anterior intermediate area. So, unless the auditory and visual stimuli can be so well chosen as to compel their coordination in the posterior area, it is better to use the motor overflow in the process, at first, at any rate. It is not usual for motor impulses to be so very intimately associated with the activity of the anterior association area. Probably this is, in part, because of the lack of any direct association tract between the motor area and the frontal lobes, and in part because in all probability there are many efferent impulses from the frontal lobes which are carried by the fronto-pontal tracts and thus the motor cortical area is not concerned in the reaction to any great extent.

    For these reasons, as well as for others which are apparent, the motor area may be chosen as the starting point of a new series of neuronic associations. No attention need to be paid to the person’s consciousness, or his feelings, or any of those things. If he has enough confidence in the doctor to obey the inst ructions, that is enough to begin on. The chief thing is to get him to use the motor area, and to obey instructions. He must have no choice as to especial movements, but it is important he learn to do as he is told. The personal factor must be eliminated as far as possible. Exercises may be chosen which add to his physical strength, if this seems desirable for the particular patient. He may assume some other person’s duties, if that seems best. He may be encouraged to walk a certain distance, if that seems best. If it is in any way possible, walk or the duties or the exercises should be planned to have an altruistic basis; no self-sacrifice should be imposed, for that makes the matter worse. The thing to do is to send sensory impulses essentially related to other persons or things into the cortical centers, in such a way that the motor impulses will result without bringing into activity any more of the anterior neuron systems than is unavoidable. The motor impulses should be exaggerated. He should be constantly directed to attend to his work or his walk. If he is an eye-minded person, make him write an account of his walk, and read it aloud to some member of his family. If he is earminded, make him hunt for any interesting objects which may be found in the vicinity. Let him bring to you, or to someone who has, or pretends to have, an interest in them, the stones, shells, leaves, bugs, or what not, which he finds. Let him grow radishes, if he can, or chickens, or take photographs, or engage in any wholesome sport. Games are rather apt to inculcate the self-idea; camera shooting, or fishing, or any sport without emulation is better than golf or tennis, though these have their places in the treatment of certain cases. The underlying principle is simply this, to make use of the motor area in answer to sensory impulses which have almost or quite no personal relationship, and to compel the use of the larger muscles of the body.

Use of the Stereognostic Sense
    The stereognostic sense also is practical unrelated to the anterior intermediate areas. This center may be used for beginning the neuronic relations. Let the patient be blindfolded, and then let him handle familiar objects and name them. It is surprising how many mistakes will be made by a person who has not been accustomed to doing this, and especially by those who are egoistic. The association tracts are not well developed between these areas, and the egoistic person finds himself in a manner cut off from his accustomed paths. Fatigue results readily in the use of such tests, so only a few minutes should be employed in this manner. A similar series of exercises consists in putting a limb of the blindfolded person in a certain position, then having him place the opposite limb in the same position. Or he may be told to repeat a series of movements first passively given. Or he may not be blindfolded, and may imitate the movements of some person standing before him.

    At first such methods appear trivial. But if it is worthwhile to spend time trying to loosen tightened ligaments which are doing harm, is it not fully as important to loosen the effects of abnormally irritable neuron groups which are doing harm? If it is worthwhile to work for the sake of strengthening a muscle group, why is it not worthwhile to work for the strengthening of a neuron group? The underlying principles are the same, and when the essential etiological factor lies in the functional relationships between neuron groups, then the only rational treatment is to modify these relationships.

Eye Brained and Ear Brained
    Under normal conditions the association processes which are concerned in the activities called intellectual depend for their original stimulation upon the auditory or the visual impulses. Probably in the complete absence of these stimuli no mentality worthy of the name could be produced. At once such a statement suggests the names of Helen Kellar and Laura Bridgman, who attained such great mental heights in the absence of auditory or visual impulses. But it must be remembered that neither of these persons attained any mental activity worthy of the name until the mental successes or normal people were imposed upon the vacant association areas. Normal brains employed the common sensory and olfactory and gustatory areas of the brains of these deficient persons as a sort of gateway through which language and the associations normally dependent upon audition and vision were carried into their consciousness. In such cases as these, the sensory overflow probably includes large areas of what would, in normal people, be included as auditory and visual overflow.

    Among normal people there is found great difference in the development of the overflow areas and the development of the relationship between the overflow areas and the intermediate areas.

    This difference appears the more conspicuously when the visual and auditory relationships are taken into account, though a similar series of differences exists between each of these and the so-called common sensations or the muscular sensation. People whose auditory coordinations and associations are most efficient are said to be “ear brained”; those whose visual associations are best developed and most efficient are said to be “eye brained.” The terms are old, and have been applied in the sense of these being an underlying mental factor rather than a physiological one at the root of the phenomenon.

    Why it is that the visual coordinations are best developed in one person and the auditory in another it is impossible to say. Probably a number of factors enter into the problem, such as an inherited neuron structure, accidental use of one area rather than the other during the time of most rapid development, circulatory changes, and other physiological or environmental conditions.


    In education the attempt should be made to develop both the auditory and visual overflow neurons to as great a degree as possible. This is done by the use of the familiar methods of encouraging students to express ideas both by spoken and written words, and to give instruction by means of spoken, written and printed words. Other methods of instruction and of expressions, as the use of pictures, the examination of natural objects, gestures, picture-writing, modeling, singing, manual training, and every other method which employs different cortical areas, either in the reception of an idea, in the coordination of the impulses arising from any stimulation, or in the expression of an idea by forms of motor activity, are to be encouraged as a means of developing the association neurons as fully as possible. The more freely the different overflow areas communicate, the more efficiently will the reactions of any individual answer his environmental demands.

    In dealing with neurotic patients, a certain use may be made of these considerations. If the patient is eye minded, then he is more apt to understand to obey written or printed instructions. He is more apt to state the really important points of his symptoms if he writes them. It is a good thing, in dealing with an eye minded neurasthenic, to ask him to write exactly his feelings and symptoms—just once, of course. This takes something of the place of the “catharsis” so often commended in certain lines of therapeutics; the important points are apt to be stated; the physician can use his own discretion as to the amount of his own time that is occupied in the reading of the records; the written record should be kept with the records of the physical examination, laboratory tests, etc., of the case. Many interesting lights upon the cortical processes of such patients are to be secured by means of the written records of those patients whose mentality is suitable. Such records made by the ear-minded patient are of less import, but are very interesting.

    The ear-minded patient should receive his instructions by spoken words, and he should give his symptoms I like manner, at first The development of the visual relationship must be secured later.

    In both classes of patients appeals must be directed in the manner most impressive to the particular person. Figures of speech are most effective if visual images are employed for the eye-minded and auditory images for the ear-minded. If figures of speech and explanations can be made which employ the particular line of work or of pleasure in which the patient is most interested, he attends more actively and obeys more implicitly than if new terms are employed, or unfamiliar illustrations are used. This is not because he chooses so to obey or to attend, but because his association processes are most complete among the centers most used in his previous experience.

    The use of new association processes is often of value. If any person has become neurasthenic or hysterical or subject to any similar functional disturbances, it may be advisable to secure the activity of new neuron groups. This may be accomplished by sending the patient to some other surroundings, but even then he takes with him the same old brain, with the same old circles of association processes with their lowered liminal value. New scenes may be efficient, but they are not always so, and the complete change of habit so often advised in such cases may not be possible for reasons financial or otherwise. In the cases in which the change of scene is inadvisable, or when such measures have failed, it is sometimes possible to bring about the increased activity of new neuron groups, and thus “change the see-er instead of the see-n,” as one patient expressed it.

    This change may be brought about in any one of many ways. If the patient is eye- minded, he may be encouraged to read aloud, to attend lectures and concerts under certain conditions, to try to secure phonographic records of the songs of birds or the sounds which animals make, or of the wind or the waves on the seashore. He may be set to getting photographs of interesting scenes in the vicinity, and these scenes must be planned for some specific purpose. Usually it is very stupid work to take pictures simply for the fun of spoiling films. Anything which makes the eye-minded person use his ears, or use his eyes in a new manner, or which leads him to employ new groups of motor neurons, gives him the same physiological effects as the change of scene, with much less discomfort and expense, provided he can be induced to give enough energy and time to the new pursuits to educate the new neuron groups to increased efficiency.

    It is much easier to plan the change of activity for the ear-minded person. He may be encouraged to copy certain chosen essays or articles. He may be asked to do these things as a favor to some other person, or as a sort of lesson for himself. Such things should be simple, easily understood, and short. The tasks may be graded according to the mental possibilities of the patient. The intelligent person may be asked to give his opinion of certain articles. Others may be encouraged to draw, to study pictures, to study flowers, or bees or moths, or any other thing in which it is any way possible to interest him. Children may be set to hunting four-leaved clovers, or small stones of different colors and shapes, or any other new task which necessitates out-of-door exercise. Any new fad may be encouraged. If other members of the family can be induced to cooperate in encouraging complete change in conversation, habits, etc., it is possible to develop new cortical relationships in a degree sufficient to secure the rest of the old association groups and assist very materially in the process of recovery. It must not be forgotten in dealing with this aspect of any case that the maintenance of a normal circulation through the injured brain cells, the providing of good, clean blood, the correction of whatever structural abnormalities may be present, and the securing of hygienic habits, are all of first importance. These things being secured, however, the use of the new association groups is of a very real value in hastening recovery from the neurasthenic states, and in providing the wider relationships for nerve action which prevent the recurrence of the trouble.

    In treating diseases caused by a lack of use of certain muscle groups, the treatment must include putting those muscle groups into action. If any bodily disease is due to poor circulation, the rational treatment must include the correction of whatever causes the poor circulation. If some factor perpetuates irritation, that factor must be removed.

    In treating cases associated with abnormal mental factors, the treatment must be based upon the same principles. First, the true condition of the patient must be recognized. It would be foolish to spend a great time treating any person whose cortex has been incurably diseased, or which has been deficient from birth. No one thinks of trying to treat a deformed part of the body into a normal structure, or to treat the body so as to make a new arm or leg grow to replace a lost one. So it is of practically no use to assume that in cases of actual structural degeneration, or of deficient development, the patient can be made into a normal person. All that can be done in such cases is to make the best of what capacity the patient does have, and to try to place him where he will be comfortable and as useful as conditions permit.

The Inhibitions

    The place of the inhibitions in normal activities has been discussed elsewhere. It may be remembered that the inhibitions are probably the result of the withholding of the nerve impulses by transmitting them from the cortical cells, the small pyramids, the inverted cells to the cortex, and then by their transmission again through the same or a similar circle, until the impulses from other areas are able to modify the resultant action. Under certain abnormal conditions the impulses from areas concerned in the consciousness and the expression of pain and weakness and of unhygienic habits may have a lowered liminal value, so that the sensations concerned in the consciousness of well-being, or directions concerning hygienic living, are met by such violent inhibitions as to become practically worthless. Such patients do not obey the directions of the physician, though they may intend to do so, and may promise to do so with every appearance of their good intentions. Yet they do not one thing they are told, because the inhibitory impulses from the centers of the lower liminal value are more efficient than the memories of the words of the physician. It is possible to employ methods of instruction which are efficient in spite of these inhibitions.

    The inhibitory impulses are initiated chiefly by the motor and the intermediate areas. When the motor and intermediate areas are less active, then the inhibitory impulses are less active. The motor areas are less active when the person has his muscles most relaxed. The intermediate areas are less active when the person has a slightly lowered blood pressure. If the osteopathic treatment is given first, and, after the necessary corrective movements have been given, the pulse is found to be slightly slower, and the blood pressure lower than before, if the result of the corrective movements has been to secure a feeling of restfulness, and the muscles of the spine and neck especially are well relaxed, then any instructions may be given without arousing antagonism in as marked degree as would be the case before the treatment had been given. The patient, perfectly conscious, and in no way hypnotized, in the ordinary sense of the term, yet listens better and accepts the instructions better, and believes what is said to him more implicitly than under ordinary conditions. Children, especially, are much more obedient under such conditions than they are after they are up and ready to doubt and consider.

Securing Obedience

    By far the larger number of patients seek advice because they want to get well, and obey the instructions they ask for, and usually pay for, because they wish the benefit of the physician’s knowledge and skill. But certain persons, usually neurotics, are so subject to their own inhibitions that with the best of intentions they are unable to obey. In dealing with these use should be made of the manner of instruction suggested The important point is to give the directions and instructions when the muscles are relaxed and the blood pressure is low.

    When any patient persists in any habit which is injuring him, the same methods may be used. It may be that the habit is too strong for him to overcome under ordinary conditions. Even if he knows perfectly well the consequences of that habit, the physician must repeat those consequences to him with every figure of speech and every manner of language possible to add to the effectiveness of what he is saying. If anything can be said which brings disgusting images into relationship with the abnormal habit, that should be said. After this the effects of stopping the habit should be described in even more vigorous language. The good things waiting for the patient upon his recovery should be described most vividly. Whatever he desires most greatly, whatever he admires most, and whatever appeals to him on the highest grounds, should be employed in association with the good thing waiting for him when he has broken that bad habit. No promises should be made, unless the physician is in a position to grant them, but the attempt should be made to associate the activities of the cortical neurons concerned in the consciousness of good things with the activities of the cortical neurons concerned in the performance of certain actions, or the inhibition of other actions.

    Such methods are not open to any criticism, as are the hypnotic methods; they can not be of harm, they lead to no bad after-effects, they are perfectly consistent with the truths of physiology, and are in the same class with the correction of bony or muscular lesions in the relief of bodily diseases.

Right Naming of Fears
    In dealing with patients who are subject to the borderland psychoses, the naming of fears and obsessions may be a step toward their elimination. The trouble here is found in the fact that the real nature of the obsessions is so often unrecognized by the patient. The real nature of the phobia is rarely the fear which the patient thinks it is; it is usually something more or less distantly related to that which he thinks he fears If it is possible to find out the origin of his fear and explain the matter clearly to him, one step toward recovery is taken. If the real origin is in his own perverted metabolism, as in cases associated with auto-intoxication, the matter is easily explained to him. It is not always so easy to make him believe that this is the case, however. Constant repetition of such teaching, bringing the matter up with new lights and under the influences of increased weight, better color, etc., may help him to “name the monster” and thus destroy him.

    At the same time, the ideas associated with sane thinking and wholesome habits must be called by name. The expression of the patient’s plans, his fads, his wishes, his use of his health, and his ideas of his relationship with his fellows, helps him to recognize his returning health. These things do not eliminate his auto-intoxication, do not correct his bony lesions, do not feed or bathe or strengthen him in the least, but they do help him to recognize his own strength, to see his own improvement, to enjoy his own food, and to make use of the neurons which the better blood helps to returning function. Just as every doctor should teach his patients to make use of the muscles whose function is returning, as he would teach them to begin to use the broken leg as it becomes strong, so should he teach them to use the returning powers of cortical function, of better thinking and saner living.

Education of the Emotions
    Work may be performed in a perfunctory manner, as a duty, with no particular coloring or interest, as a perfectly impersonal matter. Such work, if not of the most mechanical character is not usually very well done, and if there is any opportunity for failure the work is not usually successful. On the other hand, work may be done with interest, with a desire to succeed, with faith in the ultimate outcome. Such work may fail, but if there is any chance for success it is not apt to fail. Children in school may work perfunctorily, uninterested, and simply because the work is to be done. They may learn something from such work, but if there is any chance for them to miss the real point of it all, they surely will do it. Patients may obey the instructions of the physician in this perfunctory manner, but if there is any opportunity for them to fail in grasping the point of the matter, they surely will do it.

    Earnestness, and pluck, and enthusiasm, these things make for success in school life and in life’s school, in health seeking and in health giving, in attainment and in transforming apparent failure into real success, and these things result from the normal relationship between the activities of the cortical centers and the ganglionar centers of the cerebrum.

Paths of Emotional Impulses
    The ganglionar centers send impulses into the pontine, medullary and spinal centers, partly by way of the rubro-spinal tract and partly by way of the indirect paths which include the cerebellum. The impulses carried by the rubro-spinal tract, and probably the thalamo-spinal tract, reach both the somatic and the visceral motor centers. Thus the action of the heart, the respiratory movements, the action of the digestive and other viscera, are related to the somatic movements being governed, and the reaction is thus made the stronger and more forcible.

    In the perfunctory, uninterested movements, the descending impulses seem to be carried directly to the somatic centers, and no modification of visceral activities is produced. No changes in the blood pressure or the heart’s action follows, and the efficiency of the reaction is not particularly marked.

    The fronto-pontal and the temporo-pontal tracts carry the impulses concerned in certain reactions, and the collaterals from the descending pyramidal cells of the motor area are sent into the red nucleus and the substantia nigra. From these centers the fibers of the rubro-spinal tract carry the impulses to the lower centers, and the resulting reaction is made efficient and strong by the associated activity of the viscera as well as of the somatic muscles.

    This associated activity of the ganglionar centers and the cortical centers causes the manner of action called interested or enthusiastic or earnest.

    The use of the lower centers in adding to the energy of the cortical impulses is a matter of education. The same methods which result in the development of the ability to use this force also are efficient in lessening the danger of the uncontrolled activity of the ganglionar centers.

Danger of Unbridled Emotions
    Uncontrolled activity of the so-called emotional or passional states is a danger, and a very serious danger under certain circumstances. The uncontrolled emotional states act most destructively n the metabolism of the body. The child which has exhausted itself in a fit of anger is really as badly injured as if it had been sick. The grown person who loses himself in such a way is injured also, but less seriously than is the child with its developing nervous system. There is a certain danger in the fact that men are apt to imitate the emotional storms of others. Anger is contagious. The very fact of seeing another person angry, or afraid, or courageous, or laughing, causes one to begin to imitate the reactions, and soon to feel the emotion. This fact that people imitate one another, and share the expression of emotional and instinctive states, is responsible for the terrors of mob law. Any one of a number of people may be honest and just and kind, but mobs are cruel beyond expression, and corporations are notoriously unjust and mercenary. Apparently, two men are half as honest as one man, and a hundred men are honest not at all under emotional stress.
Mob Psychology
    Mob psychology depends upon the imitation of the expression of any one person, and upon the fact that the inhibitions, as well as the altruistic feelings, are coordinated by neurons of higher development than are the ganglionar centers. Thus, in excitement, under the influence of the expressions of passion by others, the higher neurons are rendered non-functional, and great danger results.
Function of Education
    It is the function of education to lower the liminal value of the cortical neurons, and the neuron systems which relate the ganglionar and the cortical centers, so that under conditions of excitement the cortical centers also may be active.

    It is not desirable that the emotional states should be repressed. The activity of the ganglionar centers is a source of great power, and this power should be employed wisely in the ordinary reactions of life. But it must be controlled by the action of the cortical centers. Self-control is the thing to be desired, and not self-repression.

    There is no difference in the ultimate quality of the emotional reactions. All are equally good, and none are essentially bad. Any emotional state may be productive of evil under certain conditions, and each has its normal place in modifying the history of the individual or the race. The feelings of enthusiasm and interest and determination have their basis in what resembles anger among the lower animals and in young children. Conservatism and hesitancy and modesty and delicacy have their basis in what resembles fear in animals and children.

    The normal relationship is this, that the activity of the cortical centers, especially the anterior intermediate areas, is concerned in certain decisions relating to conduct.

    These decisions, as they are being made, and as they are expressed in words more or less vividly, lower the liminal value of the neuron systems concerned in acting upon those decisions. If any one decides upon a certain course of action, the liminal value of the neuron systems concerned in that course of action is lowered, and any given stimulation is more apt to initiate that course of action than any other. By repeated decisions, and especially if these decisions are expressed in words, in detail and with exactness, the reaction decided upon becomes as probable as if the habit had been formed by repetition of the whole incident.

    In school the ends to be secured are all implied in the lowering of the liminal value of the neurons of the cortical centers, and of the neuron systems which relate the cortical and the ganglionar centers in function. This is done by associating them in function through the action of the memories and associations.

    Teachers, parents and physicians should realize this relationship, and should endeavor by all means to increase the relationship between the cortical activities and those of the lower centers. Always it must be kept in mind that only postponement and not prevention is the aim of the control—that expression itself is not to be prevented, but that the manner of the expression is to be subject to the effects of impulses form all parts of the nervous system, and especially from those cells in which are stored memories of past experiences and instructions.

Educational Methods
    The teacher may lessen the resistance to the passage of nerve impulses between the lower and the higher centers by the use of history and poetry. Let the imagination of the child be used in the endeavor to fancy himself experiencing the emotions he reads of, let him consider how it feels to be angry, and afraid, and jealous, and ambitious. Let him, at the same time, consider the most adequate expression of these emotions, the most wise and sensible thing to be done if one felt as those heroes felt. Thus, let him also see the effects of such reactions as people are apt to make under the influence of such feelings. If there is any appearance of the ludicrous in any of the unguarded reactions, if any occurrences of the playtimes give opportunity for the display of a ludicrous aspect to unguarded display of the emotions, then these may be used. But it is not ever wise to try to show the boy or girl who is under the influence of any emotion the humorous aspect of it. Afterward, possibly, this may be done. But it is the other person’s feelings and passions which are funny. Ridicule is too sharp and cruel a weapon to use in dealing with children.
Development of Choice
    Always, children should be taught to choose, and to decide, and to determine the proper reaction. Almost never should there be merely the prevention of any action, the disapproval of any action of others or the negative stand taken, without associating it immediately and emphatically with some positive and decided action which is admirable. The negative phase of existence is too often the one impressed upon children; there is too much of “don’t” and too little of “do” in the home teachings, if not at school.

    Now it is evident that those reactions are most apt to follow any given stimulation which have most often followed that same stimulation before. It is not really necessary that the reaction should be a concrete reply to concrete environmental conditions—if the nerve impulses concerned in any given reaction be brought vividly to consciousness, and if the chosen reaction be forced vividly into consciousness, the educational effects are practically the same as if the concrete reaction had been experienced. It is true that no determination can altogether replace actual experience in vividness and force, but the more thoroughly any one determines upon any course of action, and the more often he reviews his reasons for that action, and the good which is to result from its performance, the more apt he is to accomplish it when opportunity occurs. But if he decides upon the negative phase, if he constantly determines not to do a certain thing, and keeps this possibility present in consciousness, he is the more apt to do that which he so greatly detests. It is not good to try to conquer a fault, except as it is replaced by some other thing seen as a virtue.

Effects of Story of Cowardice
    Take, for example, the effect of a story of extreme cowardice. Such a story should arouse feelings of abhorrence, and it usually does when it is told among surroundings which are pleasant and safe. Now, if the matter remains at this point, if only the feelings of abhorrence are aroused and the matter is permitted to drop out of consciousness, then at some later time there may be a similar occurrence. The person who was most disgusted at the cowardly action of the story sees his own safety to depend upon a like reaction. The action is inhibited and all of the abhorrence of the story he has heard returns, whether he remembers the details or not. Now, because of the postponement of the reaction, the longer on account of its emotional coloring, the impulses concerned in the more vivid appreciation of his danger are increased; the cowardly way of escape is seen the more vividly also, and his ultimate reaction may become the cowardly one. His fault is the more grievous and his action the more unforgivable because of the very inhibition which should have made the brave act possible.

    In this case the trouble lies in the original telling and discussion of the story. The recognition of the abhorrence of the cowardly act should have been followed by a discussion and a decision concerning the more rational action; the attention of all who heard the story should have been for a time centered upon the manner of reaction which should win the approval and the commendation of all. Then, upon the occurrence of similar circumstances, the inhibition of the first cowardly impulse would be followed by the appreciation of courageous action which had been admired, and in many instances the brave action would be the one chosen.

Self Control
    Because of the tendency toward the development of erratic and inefficient emotional reactions, it is needful that educational methods be directed toward the development of motor ideas together with those associated with inhibition. In securing a postponement of the discharge of motor impulses, pending the receipt in consciousness or by the lower centers of the impulses stored as memories of experiences or of associations, it is needful always to see that some efficient motor reaction be associated with every fancied or actual circumstance; that is, for example, if the student be permitted to fancy himself placed under certain circumstances in which people usually make mistakes, then he should not be permitted merely to see the mistake and determine that the reaction as usually employed is unwise, but he must be compelled to determine also, if it is possible, what other reaction should be substituted for that whose inefficiency is demonstrated. Nor must this determined reaction be held merely to include a vague and theoretical discussion of means of avoiding the contretemps, though the prevention of unfortunate conditions has a place in every discussion of them; but he must say to himself, at any rate, “What would I, thinking as I now do, consider the right, and wise, and proper reaction under such and such conditions?”

    If the student’s attention be directed toward the foolishness of anger with inanimate objects, for example, it is not enough for him to recognize the absurdity of this condition, but he must also be induced to see the proper reaction for conditions in which inanimate objects appear possessed of evil intentions. He should be led to see the origin of such appearances as they usually are—that is, in the weariness or the haste of the person who seems to be subject to the unpleasant combination of circumstances. Thus is he able to correct the evil, whereas if he were merely taught to inhibit the tendency to angry words or deeds, he would have no remedy at all.

Educational Therapeutics
    When people have been a long time sick and in pain, their inhibitions are apt to become erratic. They are apt to hesitate and fail in exertion because of their fears and their memories of suffering. It is needful at times for a physician to take into serious account this tendency on the part of the convalescent.

    In teaching them a better view of life it is not enough to try to get them to endeavor to conquer their feelings of fear and distrust; they must be asked to decide what they will do when they do get well; they must plan for good health, not try to get it; they should attend to the pain and the feelings of unrest just enough to do the things which are needed for the relief of these conditions; then they must consider the discomfort, if they consider it at all, as something which has been attended to. It is not possible to try to forget pain, and it is not wise to force inattention to the symptoms of disease until the message of the pain has been heeded. But the chief thing in the treatment of those abnormal mental conditions which follow the excessive passage of the impulses concerned in suffering through the cells of the cerebral cortex is to cause nerve impulses concerned in altruistic feelings to stimulate the cortical neurons. Thus the liminal value of the cells of other parts of the cortex become lowered and the personality of the patient is improved. There is no easy road to this improvement either for the patient or for his nurse. It is just to take up a new and unselfish life, but in so doing he finds his own in greater abundance.

    Patients who suffer from the states called neurasthenic, or psychasthenic, or melancholy, or hypochondriac, or to whom other adjectives expressive of abnormal activity of the cortical neurons are applied, must be treated partly by educational methods.

    The fears include a great number of the symptoms from which these people suffer. The various phobias are innumerable. These fears include the photophobia, or fear of being afraid; claustrophobia, or the fear of being in close places; agorophobia, or the fear of open spaces; mysophobia, or the fear of contamination, and a hundred others more or less frequently seen. These fears have their basis, apparently, in some experience, but actually in the abnormal conditions of the neuron systems concerned in the consciousness and the expression of that fear.

    The most important thing in dealing with cases of the types just mentioned is the correction of whatever is keeping up the faulty metabolism of the nerve cells. Auto-intoxication, starvation, fatigue, any of the peripheral irritations, and last, but not least, the almost omnipresent malpositions of vertebrae, ribs or occiput. The circulation of good blood, flowing freely with a normal pressure, is first, last and all the time of most importance in the recovery of the borderland states.
The educational treatment must be based in part upon the methods suggested in the education of children, but must be modified to suit individual requirements. The methods described in another chapter of this volume may be found helpful in this connection.