one's way of looking at a thing has an immense influence on what one does about it. obvious as this principle is in the every-day affairs of life, it becomes still more obvious as one studies a disease and watches the way in which different individuals react to it. the state of mind of a few people infected with a rare condition may not seem a matter of more than passing interest, but in a disease which is a wide-spread and disastrous influence in human life, the sum-total of our states of mind about it determines what we do against it and, to no small degree, what it does to us. syphilis as a medical problem offers comparatively few difficulties at the present day. what blocks our progress now is largely an affair of mental attitudes, of prejudices, of fears, or shame, of ignorance, stupidity, or indifference. mental strain, a powerful influence in many diseases, is a factor in syphilis also, and the state of mind of the patient has often almost as much to do with the success of his treatment as has salvarsan or mercury. for that reason it is worth while to devote a chapter to picturing in a general way the mental side of syphilis.

the public attitude toward syphilis.—first of[pg 142] all, in order to understand the mental state of the patient, consider once more the attitude of the world at large toward the victim of syphilis. a few who are frankly ignorant of the existence of the disease to start with are unprejudiced when approached in the right way. but ninety-eight persons in a hundred who know that there is such a disease as syphilis are alive to the fact that it is considered a disgrace to have it, and to little else. such a feeling naturally chokes all but secret discussion of it. most of us remember the day when newspaper copy containing reference to tuberculosis did not find ready publication. syphilis is just crossing this same threshold into publicity. it is now possible to get the name of the disease into print outside of medical works and to have it referred to in other ways than as "blood poisoning" in quack advertisements. the mention of it in lectures on sex hygiene is an affair of the last twenty years, and the earlier discussions of the disease on such occasions were only too often vague, prejudiced, and inaccurate. there are many who still believe, as did an old librarian whom i met in my effort to reach an important reference work on syphilis in a great public library. "we used to keep them on the shelves," he said, "until the high school boys began to get interested, and then we thought we would reserve the subject for the profession." syphilis has been reserved for the profession for five hundred years and the disease has grown fat on it. the lean times will come when a reasonable curiosity about syphilis can be satisfied without either shame or secrecy[pg 143] by a reasonable presentation of the facts. we need the light on this subject and the light on reserved shelves is notoriously poor. the stigma attaching to syphilis as a disease is one of the most tragic examples of a great wrong done to do a little right. what if there are a few who deserve what they got? we may well ask ourselves how free we are to cast the first stone. and why single out syphilis as the badge of venery? the "itch" is transmitted by sexual relations too. why not make the itch a sign of shame? the power that has done the damage is not the intrinsic viciousness of syphilis, but the survival of the old idea of sexual taboo, the feeling that sex is a secret, shameful thing, essentially unclean. to this age-old myth some one added the idea of punishment, and brutalized our conception of syphilis for centuries. if there were a semblance of crude, stern justice in accepting syphilis as the divinely established punishment for sexual wrong-doing, protest would lose half its meaning. not only does syphilis fail to punish justly, but there is also something savage, akin almost to the mental attitude that makes "frightfulness" possible in war, in the belief that it is necessary to make headway against a sexual enemy by torturing, ruining, and dismembering men, women, and children, putting out the eyes of the boy who made a slip through bad companionship and mutilating the girl who loved "not wisely but too well." only innocence pays the spiritual price of syphilis. the very ones whose punishment it should be are the most indifferent to it, and the least influenced by fear of it in their pursuit[pg 144] of sexual gratification. i always recall with a shock the utterance of a university professor in the days when salvarsan was expected to cure syphilis at a single dose. he rated it as a catastrophe that any such drug should have been discovered, because he felt that it would remove a great barrier to promiscuous relations between men and women—the fear of venereal disease. this is the point of view that perpetuates the disease among us. it is this attitude of mind that maintains an atmosphere of disgrace and secrecy and shame about a great problem in public health and muddles our every attempt to solve it. those who feel syphilis to be an instrument adapted to warfare against sexual mistakes, and are prepared to concede "frightfulness" to be honorable warfare, will, of course, fold their hands and smugly roll their eyes as they repeat the words of the secretary of a london lock hospital, "i don't believe in making it safe."[14]

[14] quoted by flexner in "prostitution in europe."

syphilis as a "disgrace" and a "moral force."—if syphilis really deterred, really acted as an efficient preventive of license, we might have to tolerate this attitude of mind, even though we disagreed with it. i had occasion, during a period of two years, to live in the most intimate association with about 800 people who had syphilis—every kind of person from the top to the bottom of the social scale. it was not a simple matter of ordering pills for them from the pharmacy, or castor oil from the medicine room. i had to sit beside their beds when they heard the truth; i had to see the women crumple up[pg 145] and go limp; i had to tell the blind child's father that he did it, to bolster up the weak girl, to rebuild the wife's broken ideals, to suppress the rowdy and the roysterer, to hear the vows of the boy who was paying for his first mistake, and listen to the stories of the pimp and the seducer. what made syphilis terrible to the many really fine and upright spirits in the mass thus flung together in a common bondage? it was not the fear of paresis, or of any other consequence of the disease. it was the torture of disgrace, unearned shame, burnt into their backs by those who think syphilis a weapon against prostitution and a punishment for sin. it wrecked some of them effectually—left them nothing to live for. it case-hardened others against the world in a way you and i can well pray we may never be case-hardened. it left scars on others, and others laughed it off. hundreds of sexual offenders passed through my hands, and in the closest study of their points of view i was unable to find that in more than rare cases had the risk of syphilis any real power to control the expression of their desires. sexual morality is a complex affair, in which the habit of self-control in many other activities of life plays an important part. the man or woman who best deserves to be called clean and honorable and sexually blameless has not become so through a negative morality and an enlightened selfishness. the man who does not have bred into him from childhood the instinct to say the "everlasting no" to his passions will never learn to say it from the fear of syphilis. sexual self-control is a habit, not a reasoned-out affair, and its[pg 146] foundation must rest on the rock bottom of character and not in the muck of venereal disease.

the broader outlook.—if, then, it avails nothing in the uplifting of our morals to treat syphilis as a disgrace, if the disease is ineffective as a deterrent, and barbarously undiscriminating, inhuman, and unjust as a punishment, let us in all fairness lay aside the attitude of mind which has so hindered and defeated our efforts to deal with it as an arch enemy to human health, happiness, and effectiveness. in the face of all our harsh traditions it takes a good deal of breadth of view to look on the disease impersonally, rather than in the light of one or two contemptible examples of it whom we may happen to know. but, after all, to think in large terms and with a sympathy that can separate the sinner from his sin and the sick man from the folly that got the best of him, is no mean achievement, well worthy of the samaritan in contrast with the levite. to the remaking of the traditional attitude of harsh, unkindly judgment upon those unfortunate enough to have a terrible disease, we must look for our soundest hope of progress.

the mental states of syphilitics.—the mental outlook of the person with syphilis is in its turn as important a factor in our campaign against the disease as is that of the person without it. in order to give some idea of the ways in which this can influence the situation it may be well to sketch what might be called the four types of mind with which one has to deal—the conscientious, the average, the irresponsible, and the morbid. under the morbid type are[pg 147] included those persons who, without having syphilis, are in morbid fear of the disease, or have the fixed belief that they are infected with it, even when they are not.

the conscientious type.—conscientious patients, speaking from the physician's standpoint, are the product of intelligence and character combined. though distinctly in the minority, and usually met in the better grades of private practice, one is often surprised how many there are, considering the treacherous and deceptive features of the disease, which leave so much excuse for laxity and misunderstanding on the part of the laymen. a conscientious patient is one who is not content with any ideal short of that of radical cure. it takes unselfishness and self-control to go without those things which make the patient in the infectious stage dangerous to others. for a time life seems pretty well stripped of its pleasures for the man who may not smoke, must always think beforehand whether any contact which he makes with persons or things about him may subject others to risk of infection, and perhaps must meet the misunderstanding and condemnation of others whom he has to take into his confidence for the same purpose. an element of moral courage and a keen sense of personal responsibility help to make the ideal patient in this disease. to meet a treatment appointment promptly at the same day and hour week after week, to go through the drudgery of rubbing mercurial ointment, for example, to say nothing of the unpleasantness of the method to a cleanly person, night after night for[pg 148] weeks, takes unmistakable grit and a well-developed sense of moral obligation. the man who has been cured of syphilis has passed through a discipline which calls for the best in him, and repays him in terms of better manhood as well as better health.

the physician's co?peration in the development of the necessary sense of responsibility and the requisite character basis for a successful treatment is invaluable. to the large majority of the victims of the disease it is a severe shock to find out what ails them. many of them, without saying much about it, give up all hope for a worth-while life from the moment they learn of their condition. just as in the old days the belief that consumption was incurable cost nearly as many lives as the disease itself, by leading victims to give up the fight when a little persistence would have won it, so among many who acquire syphilis, especially when it is contracted under distressing circumstances, there is a lowering of the victims' fighting strength, a sapping of their courage which makes them an easy prey to the indifference to cure that is so fatal in this disease. the person with syphilis should have the benefit of all the friendly counsel, reassurance, and moral support that his physician can give, and such time and labor on the latter's part are richly repaid.

the average state of mind.—the average mental attitude stops tantalizingly short of the best type of conscientiousness. average patients are good co?perators in the beginning of a course of treatment or while the symptoms are alarming or obvious, but[pg 149] their energy leaves them once they are outwardly cured. the average patient only too often overrules his physician's good judgment on trivial grounds, slight inconveniences, and temporary considerations, forgetting that cure is what he needs more than anything else in the world. the deprivations go hard with this type of patients, and it is difficult, almost impossible, to persuade them to stop smoking or to abstain from sexual relations or other contacts that are apt to subject others to risk. average patients will almost never remain under the care of a physician until cured. a year, or at the most two years, is all that can be expected, and a second or third negative blood test is usually the signal for their disappearance. they are, of course, lost in the great unknown of syphilis, and swell the total of deaths from internal causes of syphilitic origin, such as diseases of the arteries and of the nervous system. a good many have to be treated for relapses, but the amount of infection spread by them, while of course unknown, is probably small considering how many of them there are.

effect of the high cost of treatment.—a factor which is extremely influential in forcing average treatment and ideals on those who, if opportunity were more abundant, would be conscientious about the disease, has already been mentioned as the cost of treatment, which is such that persons with small incomes, who are too proud or sensitive to seek charitable aid, can scarcely be expected to meet. the cost of salvarsan under present conditions is a burden that few can hope to assume to the extent that[pg 150] modern treatment tends to require, and the slower methods of treatment are more of a tax on the patient's courage and determination, and less effective in preventing the danger of infectiousness, although quite as reliable for cure. there is no more serious problem in the public health movement against syphilis than to get for the average man who can pay a moderate but not a large fee the benefits of expensive and elaborate methods of recognizing and treating a disease such as syphilis. some practical methods of doing this will be taken up in the next chapter.

the irresponsible.—the irresponsible attitude of mind about syphilis forms the background of the darkest and most repellent chapter in the story of the disease. yet we ought to confront it if we wish to master the situation. the irresponsible person has either no regard for, or no conception of, the rights of others where a dangerous contagious disease is concerned, and often little conception of, and less interest in, what is to his own ultimate advantage. irresponsible syphilitics lack character first and sense next. many of them, through the gods-defying combination of stupidity and ignorance, cannot be approached through any channel of reason or persuasion. the only argument capable of influencing such minds is compulsion. others are, of course, mental defectives with criminal and perverted tendencies. yet it is both amazing and discouraging to find how many irresponsibles there are in the ordinary and even in the better walks of life. to the wilful type of irresponsible person the transmission[pg 151] of a syphilitic infection is nothing, and cannot weigh a straw against the gratification of his desire or the pursuit of his own interest. the disease cannot teach such people anything, and if it cannot, how can the physician? such people pursue their personal and sexual pleasure, marry, spread disaster around them, and outlive it all, perhaps brazenly to acknowledge the fact. others, suave, attractive, agreeable, seductive, often masquerade as respectability, or constitute the perfumed, the romantic, the elegant carriers of disease. the proportion of ignorant to wilful irresponsibility can scarcely be estimated. but there is little choice between the two except on the score of the hopefulness of the latter. as examples of the mixture of types with which a large hospital is constantly dealing, i might offer the following at random, from my own recollections: a milkman came to a clinic one morning with an eruption all over his body and his mouth full of the most dangerously contagious patches. two of us cornered him and explained to him in full why he should come in if only for twenty-four hours. he promised to be back next morning and disappeared. another, a butcher in the same condition, put his wife, whom he had already infected, into the hospital, and in spite of every argument by all the members of the staff, went home to attend to his business—the selling of meat over the counter. a lunch-room helper, literally oozing germs, was after several days induced to come up for an examination and promised to begin treatment, whereupon he disappeared. a college student reported with an[pg 152] early primary sore. "x——," i said, "if you will pledge me your honor as a gentleman never to take another chance and not to marry until i say you are cured i will use salvarsan on you, which is just about as scarce as gold now, and give you a chance for abortive cure." he pledged himself, and six months later there was every sign that we were going to secure a perfect result. suddenly he failed to appear for a treatment appointment, and i never saw him again. but i did see a letter written to him by the clinic which showed that he had come up for the examination with a newly acquired sore while he knew i was away—in all probability a reinfection. he was not even man enough to face me with his broken word. three or four men with chancres may report in an afternoon and leave, the clinic powerless to detain them or to protect others against the damage they may do. one such, a greek boy, had exposed four different women to infection before we saw him, and only the most strenuous efforts of the entire staff got him into the hospital, because he had neither money nor sense. half-witted tramps, gang laborers, and foreigners who cannot understand a word of any other language than lithuanian or some other of the european dialects for which no interpreter can be secured, pass in a steady stream through the free clinics of large cities. the impossibility of securing even the simplest co?peration from such patients is scarcely realized by any one who is not called upon to deal with them face to face. even with an interpreter, they display the wilfulness of irresponsibility. one[pg 153] italian woman wiped her chancre, which was on her lip, with her fingers at every other shake of the head. she was cooking for two boarders and had two children. she did not like hospitals and was homesick and pettish. would she go over to the dispensary in the next block and find out how to take care of herself? not a bit of it. she was going home, and she went. i saw the children later in the children's ward, both infected with syphilis—a poor start in life. criminal intent in the transmission of syphilis is common enough, and the writer can think off-hand of four or five cases in which men or women "got" their estranged partners later in their careers.

the necessity for legal control.—all these repulsive details have a place in driving home a conception of the cost to society of the immoral and irresponsible syphilitic. syphilis is an infectious disease, dangerous to the individual and to society. if it is rational to quarantine a mouth and throat full of diphtheria germs, it is rational to quarantine a mouth and throat full of syphilitic germs at least until the germs are killed off for the time being. there can be no more excuse for placing society at the mercy of the one than of the other.

the morbid attitude of mind: syphilophobia.—the morbid attitude of mind, whether in persons who have the disease or in those who fear they may have it, is one of the hardest the physician has to deal with. any one who knows anything of the disease naturally has a healthy desire to avoid it, and if he is a victim of it, a considerable belief in its seriousness. but certain types of persons, who are[pg 154] usually predisposed to it by a nervous makeup, or who have a tendency to brood over things, or who perhaps have heard some needlessly dreadful presentation of the facts, become the victims of an actual mental disorder, a temporary unbalancing of their point of view. to the victims of syphilophobia, as this condition is called, syphilis fills the whole horizon. if they have not been too seriously disturbed by the idea, a simple statement of the facts does wonders toward relieving their minds. a few of them cling with the greatest tenacity to the most absurd notions. for those victims of the disease who are the prey of morbid anxiety the assurance that it is one of the most curable of all the serious diseases, and that if they are persistent and determined to get well, they can scarcely help doing so, usually sets their minds at rest. the idea that there is a cloud of disgrace over the whole subject, and the old-fashioned belief that syphilis is incurable and hopeless, inflict needless torture and may do serious damage to the highly organized sensitive spirits which it is to society's best interest to conserve. the overconscientious syphilitic hardly realizes that the real horrors of the disease are usually the rewards of indifference rather than overanxiety. persons who subject themselves to the ordinary risks of infection which have been described in the preceding chapters do well to be on their guard and to maintain even a somewhat exaggerated caution. those who do not expose themselves need not look upon the disease with morbid anxiety or alarm. in the relations of life in which syphilis is likely to be a[pg 155] factor it should, of course, be ferreted out. but there is no occasion for panic. we need a sane consciousness of the disease, a knowledge of its ways and of the means of prevention and cure for the world at large. we do not need hysteria, whether personal or general, and there is nothing in the facts of the situation to warrant the development of such a mental attitude either on the part of the syphilitic or of those by whom he is surrounded. insofar as morbid fear in otherwise normal persons is the product of ignorance it can be dispelled by convincing them of this fact.