THE PSYCHOLOGY OF A CONSERVATIVE The dictionaries define the word 66 conservative" as "indisposed to change"; "adhering to the existing order of things"; "disinclined to novelty or alteration, as of institutions or methods"; "opposed to change, hence often opposed to progress.'

For the purposes of this paper we shall exclude that large class who are conservative "for revenue only." The laws of economics force us all to play the game of business, or of making a living, whether we like the rules or not. If the cards are marked and the dice loaded it is better for those on the inside; the beneficiaries of unfair methods, nefarious institutions, corrupt systems, or perverted laws, actuated by selfish motives, usually oppose reforms. There are also the rank outsiders who hope to worm their way to the inside. They are like the slave who defends slavery because he hopes to be a slave owner, or at least a driver himself; or like the rural "come-on" who goes up against a "brace game," knowing it to be such, but who believes himself "cute enough to skin de gang."

We shall confine our analysis to the mental equipment and processes of that specimen of arrested intellectual development whose conservatism is a psychological condition and not an attitude. His tribe is numerous; we meet him everywhere.

A man who has but few concepts, a feeble imagination, and a limited ability to reason, must necessarily be a conservative. He can not think for himself, so he must turn to the past to see what others have said and done, unconscious of the fact that his "authority" was but a man who spoke and acted amidst other environments. As he has no initiative, he must be governed by precedents; without them he is as helpless as a mariner drifting at sea without charts or mathematical instruments. To him our institutions, sciences, arts-in short, the existing order of things-long since reached perfection. The last word has been said, the last seal broken; therefore what is new is wrong, and what is wrong is dangerous, and what is dangerous should

As he is a poor

be fought to the bitter end. reasoner, he goes first into a panic, and then into a rage when he sees his borrowed or inherited misconceptions, which he fondly calls his "principles,' endangered by research and discoveries. His instinct is to use brute force, as that is the only method of argument that he can comprehend; so he answers the philosophy of Socrates by forcing the deadly hemlock down his throat, and that of the ill and blind Galileo by compelling him to swear that the earth does not move. spikes one reformer to a cross and burns another at the stake. He is vindictive, not so much through malice as through cowardice.

He

Like most other degenerates, he has the "exalted ego," and when opportunity presents, he writes constitutions that it is impossible to amend, and laws that it is difficult to change. In his egotism he desires to legislate for all time, and often succeeds in fastening his idiotic fallacies on future generations. Ancient Egypt, where most innovations were punished with death, and modern Russia and China, are notorious examples of conservative folly.

The conservative is in a rut without the strength to get out. His eyes are fixed with a stony stare on the past; he worships the setting and not the rising sun. He is cocksure that all he does is right, for he has precedents for everything. You must run him down with an automobile before his dull and stubborn little mind can be convinced that such a machine is possible. And yet we often place this pigmy, this stunted and deformed thing, in important places, over better men, for no other reason than that he will oppose all innovations and is therefore "safe and sane, forgetting that where there is progress there must be advancement and change.

The reasons are apparent why the average man becomes more conservative as he grows old. He has been years building up his systems of theology, politics, business and all the rest. Remove a foundation stone from one of his structures and he sees with helpless horror the whole castle totter. He has not the vitality and time to make repairs or build again. He would have to form

THE RECEPTION ROOM AND OFFICE

We would do well to bear in mind that the visit of the patient to the office, which to the physician is a mere incident in the days work. is to the patient an absorbing and nerve-racking event, upon which his mind is more or less morbidly centered, and in consequence he is in an exceedingly sensitive and impressionable condition of mind. The furnishment of the waiting room, therefore, should be so ordered as not to intensify this morbidness, but as much as possible to counteract it and to restore the patient's normal poise.

Photographs of operating theaters or hospital wards, pictures and prints like Rembrandt's "Lessons in Anatomy," ginning skulls and ghastly skeletons, and such examples of professional art, are scarcely inspiring objects for the contemplation of a sensitive person waiting for even the most trifling operation or awaiting a verdict of life or death. Even such a work of art as Luke Field's "The Doctor" is, in our opinion, out of place. It is a beautiful painting, with a touching significance, but the doctor's reception room is not the place for a patient to be "touched."

Of course, one should not rush to the other extreme, and make the ostentatious gaiety of the room a mockery of the patient's misfortune. A simple cheerfulness is the keynote. A light, cheery room, with no suspicion of "shop" about it; a few dainty touches, such as a woman's hand can give it encourage the attendant to exercise her feminine tact in this direction); some interesting pictures of wholesome, vivacious scenes from nature and the lighter side of life; and above all, if practicable, a nosegay of bright, simple flowers upon the table; these will go a long way towards calming and cheering the waiting patient's perturbed and anxious spirit.

When one comes to the office itself while the same tactful considerations for the patient's sensibilities should prevail, and all that is likely to grate upon his overwrought nerves kept in the background, it is not well to carry the ingenuous idea too far. The patient is there for a serious purpose, and it is both a slight upon his claims

and a reflection upon the doctor's good sense to make any show of dalliance at this point. To be sure, the patient does not wish to be "impressed" with a glittering display of formidable surgical instruments or an imposing array of bottles, .or any such mistaken ostentation as that, but he does expect a certain, quiet, business-like attention and preparation-a clearing of decks for action, so to speak-bespeaking adequate equipment and confident readiness for the work in hand. Any attempt at decoration or artistic effect in the office itself is in bad taste. As intimated, the patient is here for business-like treatment in every way. The more severely and plainly the office is equipped the better, all apparatus and materials being kept out of sight as much as possible, but everything wearing the air of alert attention and adaptation to the patient's immediate needs.

These may seem like trivial matters, but it is the little things that count in dealing with people, especially with persons who are in the peculiarly sensitive and impressionable state of mind. as the ordinary patient. The psychology of the office and reception room is no mean factor in the conduct of a successful practice.

WANING ALLEGIANCE TO THE DOCTOR It seems to be pretty generally conceded that there is at least a sentiment abroad among the laity, if not an actual movement, of lessened fealty to the physician-not exactly an attitude of "no confidence," but something approaching it, so that the doctor no longer occupies the position of trust and devotion and high regard that he did in the "good old times," and a great many attempts are being made to discover the underlying reason for the change.

To be sure, it is more than likely that a good deal of the trouble is fancied, or at least fallacious. The medical man, like the priest and the preacher, held for so many centuries a pedestal of such exaggerated adulation that it is altogether probable that a descent to the sane and rational standards of the twentieth century appears to us in the light of a serious loss of caste and derogation of office. And furthermore, the viewpoint of the twentieth century in such matters is so different from that of centuries agone, the things for which we honor a man and the ways in which we show him honor, that one is quite likely to mistake these differences of viewpoint and treatment for disparagement in real values. So that it is reasonable to assume that a certain percentage of the supposed decrease in the allegiance of the public to the medical man must be discounted to allow for these considerations.

Possible Causes However, when this allowance has all been made—and it is, we think, larger than is usually imagined-still it is idle to deny that the bond of allegiance between the public and the physician is being sensibly weakened, and nobody on either side seems able to tell exactly what the cause or causes of it are. Indeed, the situation is so indefinite and intangible that there does not appear to be any decided agreement, either among the laity or among the medical profession, as to just where the strain in the relations is making itself felt. Some times one is inclined to think that the subtle change in sentiment affects the entire medical profession, as a class; and at other times and in other moods it seems that it represents only a waning of respect for and loyalty to the type of physician whom we know as the "general practitioner" or the "family doctor." Doubtless the real truth is that the whole profession is involved in the process, but that the general and family practitioners, who are in closest contact with the public, feel the brunt of it. The search for possible causes of the defection naturally divides itself into two categories, namely, those assigned by the profession itself, and those assigned by the laity; and since the profession is naturally more vitally interested in working out the problem than the laity, we find it being discussed much more widely and animatedly by the doctors and their journals than in public quarters. Almost all of the reasons suggested by the medical profession, however, can be reduced to three general heads, which are, in order of their ascribed importance: (1) the influence of the specialist; (2) the prevalence of hostile fads and cults, and (3) the over-supply of physicians.

Specialism.

The first of these reasons regards the medical situation as parallel with that of the commercial -tending toward large central co-operative monopolies of specialism, similar to the trusts and department stores, by which the general practitioners, like the small merchants, lose caste and business, and the whole profession comes to be viewed upon a commercial, competitive plane. And there is no doubt a great deal of truth in the plea. But it is not necessarily so deplorable a condition as the medical man lugubriously figures it out. It is simply an illustration of that change of viewpoint and gauge which we have already pointed out is characteristic of the century, and which does not indicate any fundamental lowering of values. It is the fashion of the times to regard every commodity and service as a matter of quid pro quo, a phase of the division of the world's labor (and who shall say it

is a wrong conception?) to which the doctor, by reason of those long centuries of sentimental standards of which we spoke, has not adapted himself. He is, in fact, face to face with the same problem as the small and local merchant. The public demands its money's worth, and if they find that the specialist, like the trust, gives a better money's worth for certain services than the local practitioner, then the latter must, like the local tradesman, find some way in which he can give the people a better relative money's worth than the specialist. It is not a time or a place for false pride and traditional delicacy, but for the true pride that meets and vanquishes new conditions and gives all that is asked.

For one thing the general practitioner will, we believe, admit that he has been too neglectful of his own interests in his relation to specialism. Without any intention of belittling specialism or the specialist, we do not hesitate to rally the general practitioner on having been too ready to surrender to their influence, and to yield up his own prestige and his own business to their demand. He has allowed himself to become a mere feeder for the specialist. There is no moral discredit or dishonor to him that he has done so, for his course has been inspired by the praiseworthy desire to do the best for his patient, and both the specialist and the political leaders of the profession have taken advantage of his position to employ every form of influence available from ethics to economics-to divert this class of practice from him.

A Remedy

One way to counteract the untoward effects of specialism upon the profession is for the general practitioner-especially the country practitioner -to cease playing the role of procurer to the specialist and to develop his own status and work into what Albright calls "the general practitioner as a specialist." Not that the specialist has no place that were absurd. But his proper sphere is as special adviser and aid to the general practitioner, not as his entire supplanter and dictator. There is nothing in specialism, per se, to degrade medicine or to lessen the people's allegiance to it quite the contrary. It is one of the natural and inevitable tendencies of the times. But the utter subjection of the general practitioner to the specialist is both debasing and unwarranted, and tends to discredit practitioner and specialist alike in the eyes of the people. We are bound to repeat our belief that the general practitioner is himself largely to blame for the situation in this respect, for the reasons just set forth, and the remedy is in his hands. A proper reassertion of himself and a sturdy determination to square him

self with the spirit of the times and to give the public what it demands, to "deliver the goods," will go far toward removing this factor in the situation, and in getting a fresh hold upon that popular esteem and confidence which is felt to be slipping away from him.

Fads are Results.

The second general cause assigned by the profession for the waning fealty of the public-the growth of hostile fads and cults, such as Christian Science and the like-may, we think, be dismissed in a very summary fashion, by pointing out that they are not the cause at all, but the result, of whatever sentiment may prevail of dissatisfaction with medicine.

A Crowded Profession.

The third factor-the over-supply of physicians -deserves some serious consideration. It can not be gainsaid that an overcrowded condition of the profession, assuming it to exist, does in a certain sense tend to lessen the esteem in which its members are held, both because, in a general way, the value of any commodity decreases in proportion to its commonness, and also because the individual practitioner, who was formerly "the doctor" of a village or neighborhood, now has to share the distinction with several competitors, and the laity recognize a condition of competition in the field. This is really a more basic consideration than that of specialism, because it is beneficial to both medicine and the pubile-is, indeed, the automatic process by which progress is brought about; for if there were never more than enough men to do a given type of work there would be no incentive to develop other and higher types.

Its operation, however, need not and should not give rise to such wide lines of demarcation as seem to obtain between practitioner and specialist, and ought not to have the effect of lowering the public esteem for the profession. The same law is operating in every line of work, and while there is always a residue of men who lag behind the procession and represent the "submerged tenth," yet the net effect upon the industry is to elevate its plane, for the offshoots of progress, forced by the crowding of the stock, bring down new vitality into the parent stem and invigorate it. We fear that here again the practitioner has not shown quite the adaptibility to adjust himself to new conditions which other departments of work have displayed.

When a business enterprise finds its hold upon the public patronage and allegiance failing, it promptly sets itself to discover the reason from the public's standpoint. We medical men, it is to be feared, are a little too complacent, and prone

to despise the popular viewpoint. Perhaps, indeed, this is the real root of the entire trouble. At all events, unless we come out of our professional shells and take counsel with the public, who are, after all, the ultimate arbiters of our destiny, the bond of sympathy between us is likely to go on weakening until some day it may even vanish altogether.

Next month, therefore, we will consider some of the reasons assigned by the laity for the attitude which we charge them with adopting-we will try, as best we may, to " see oursels as ithers see us, ‚"if perchance we can gather some useful suggestions as to cause and remedy. 惺惺惺

CHRONIC INTESTINAL STASIS

Dr. Gray, in the International Journal of Surgery, advises medical treatment should be tried in all cases, and if not successful, surgical measures should be tried. A large median incision should be made, in order to obtain a large field for orientation. The principal operative indication is the presence of dilatation and hypertrophy, be they localized in the stomach, gallbladder, small intestine or colon. In children in whom often the secondary changes in the intestinal tube have not yet developed, or where the bands are of such character as to lead us to anticipate flexion of the intestine later, Gray advises intervention only if the band has a very narrow base of attachment, in other cases it is best to resort to expectant treatment with special regard to conservation of the intestinal tone.

Operative interference includes fixation of the stomach or intestine, resection of the bands, colectomy, short-circuiting operations (gestroenterostomy, etc.), depending on the anatomical structure affected.

Resection of the bands must be complete; otherwise there will later be a greater tendency to flexions, due to subsequent contraction of the site of attachment. The surface of the wound should then be covered by stretching and suturing in loco the adjacent peritoneum, or by an omental graft, taking care to choose a portion of omentum free from fat on account of the danger of fibrous metamorphosis and subsequent contraction.

Ileosigmoidostomy in intestinal stasis due to bands is contraindicated except as a preliminary operation to colectomy. Whether the anastomosis is made above or below the point of flexion or whether the angulation is removed at the same time through a plastic operation on the mesosigmoidal adhesions, in the majority of cases fecal matter at a certain point will take a backward course from the sigmoid into the colon which is thus transformed into a real cloaca. Although colectomy is an operation technically very diffi

cult, in many instances it alone can exclude the danger of recurrence or unfavorable postoperative results. Colectomy is to be preferred in cases where there exists marked ptosis of the ascending or transverse colon and in cases where the base of attachment of the bands is so wide that complete resection would leave extensive raw surfaces. Only the part of the colon should be removed which is absolutely necessary, that is, the dilated and hypertrophied area. Where possible, short circuiting and colectomy should be done at one sitting.

In many of these cases the sigmoidal loop is long. In order to leave a long portion of the colon in its normal place, Gray after having excised the ascending, transverse and part of the descending colon, frequently incises the peritoneum along the external surface of the remaining portion of the descending colon and the corresponding mesosigmoid, and transfers the portion of colon thus mobilized as much as possible to the place formerly occupied by the transverse colon so that it forms a straight line with the rectum; the proximal extremity of such a portion thus comes to constitute the beginning of the new transverse colon, and the ileum is made to open into it.

It is important to preserve as much omentum as possible since it can be utilized for the plastic purposes above mentioned.

Operative results are extremely satisfactory in many cases, the intestinal functions returning to normal, and even the numerous disturbances in the general condition of the patient disappear completely.

DIAGNOSTIC VALUE OF PAIN Pain is a symptom of vast moment to the sufferer no matter what its origin, says the N. Y. Medical Journal, but to the clinician it is too often of very doubtful importance. The pain from a carious tooth is sometimes more distressing than that from an appendix which is about to rupture, and a sprained sacroiliac joint may be more painful than a malignant growth.

The sense of pain is a very primitive and crude one, but one which in man has been unconsciously made more frequent and important. His development of consciousness heightens the function of pain, his lack of proportion in bodily exercise, and in maintenance of bodily harmony, increases his susceptibility to suffering, and his ways of living have made him more liable to injuries which set up disturbances in these comparatively insensitive receptors of external and internal change. A serious wound received in the thick of a fight may not be noticed until after the battle, and the man or woman with little leisure makes light of bodily disturbances which are all too important to the

concentrated imagination of those who have little else to think about. Not only is pain magnified because of the large cerebral regions which, nowadays, an injury is likely to bring into play, but because undue vasomotor and possibly other peripheral changes come to pass from the concentration of the attention of the sufferer, changes which, in turn, add to the previous centripetal effects.

If pain is often misleading from its abnormal severity it is as often so from its unexpected absence or mildness. In tuberculosis of the lungs there is little local distress, and so in nephritis. Since the loss of a tooth is a real calamity, there should be pain at the beginning of the decay, though it is, at this stage, absent.

Pain, then, is of very uncertain importance to the diagnostician, and in making use of this symptom, as he always should, he must have in mind the mental state of the patient, or what Jean Paul Richter called the "magical condenser of the imagination." The patient's well or ill balanced constitution and his habits must be taken into account, and last, and most important, the physical findings. Also it is to be remembered that the internal organs, like the stomach, heart, and kidneys, are poorly supplied with pain receptors, and that, for this reason, disease of such an organ may go far without such a symptom, while pain on the surface may, on account of the lack of such receptors in the deeper organ, with related innervation, be caused by the disturbance in the latter structure to which no feeling of pain is referred.

If pain is an uncertain sign in diagnosis, it is equally uncertain and troublesome in treatment. Especially is this true in many chronic joint and muscle lesions where pain often delays the use of limbs that ought to be exercised. Here we suspect deeper causes for the pain than are interpretable in terms of anthritis or myositis, and the persistence of pain should be an inciter for probing beyond the physical into the symbolic.

Pain is after all one of the most important of Nature's devices to cause men and communities to perceive that their devices, physical as well as economic, are out of order. It compels attention and is therefore prophylactic. Continuous pain is a challenge to investigation. To relegate it to "imagination" is a confession of bankruptcy of the scientific imagination.

济济济

The one who has a remedy which cures everything is not alone a quack, but also an ignoramus. He knows that he is deceiving and he is not conscious of having a conscience. He possesses the attributes of a quack, the main one of which is to get the money by any means possible.