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 frankly4 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 tuberculosis5 did not find ready publication. Syphilis is just crossing this same threshold into publicity6. 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 quack7 advertisements. The mention of it in lectures on sex hygiene8 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 inaccurate9. 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 secrecy10[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 stigma11 attaching to syphilis as a disease is one of the most tragic12 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 "itch13" 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 taboo14, the feeling that sex is a secret, shameful15 thing, essentially16 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 semblance17 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 savage18, akin19 almost to the mental attitude that makes "frightfulness20" 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 innocence21 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 utterance22 of a university professor in the days when salvarsan was expected to cure syphilis at a single dose. He rated it as a catastrophe23 that any such drug should have been discovered, because he felt that it would remove a great barrier to promiscuous24 relations between men and women—the fear of venereal disease. This is the point of view that perpetuates25 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 muddles26 our every attempt to solve it. Those who feel syphilis to be an instrument adapted to warfare27 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 deterred28, really acted as an efficient preventive of license29, 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 pharmacy30, 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 crumple31 up[Pg 145] and go limp; I had to tell the blind child's father that he did it, to bolster32 up the weak girl, to rebuild the wife's broken ideals, to suppress the rowdy and the roysterer, to hear the vows33 of the boy who was paying for his first mistake, and listen to the stories of the pimp and the seducer34. What made syphilis terrible to the many really fine and upright spirits in the mass thus flung together in a common bondage35? 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 wrecked36 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 offenders37 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 "everlasting38 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 deterrent40, and barbarously undiscriminating, inhuman41, 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 impersonally42, rather than in the light of one or two contemptible43 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 folly44 that got the best of him, is no mean achievement, well worthy45 of the Samaritan in contrast with the Levite. To the remaking of the traditional attitude of harsh, unkindly judgment46 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 sketch47 what might be called the four types of mind with which one has to deal—the conscientious48, the average, the irresponsible, and the morbid49. Under the morbid type are[Pg 147] included those persons who, without having syphilis, are in morbid fear of the disease, or have the fixed50 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 treacherous51 and deceptive52 features of the disease, which leave so much excuse for laxity and misunderstanding on the part of the laymen53. A conscientious patient is one who is not content with any ideal short of that of radical54 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 condemnation55 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 promptly57 at the same day and hour week after week, to go through the drudgery58 of rubbing mercurial59 ointment56, for example, to say nothing of the unpleasantness of the method to a cleanly person, night after night for[Pg 148] weeks, takes unmistakable grit60 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 requisite61 character basis for a successful treatment is invaluable62. To the large majority of the victims of the disease it is a severe shock to find out what ails39 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 incurable63 cost nearly as many lives as the disease itself, by leading victims to give up the fight when a little persistence64 would have won it, so among many who acquire syphilis, especially when it is contracted under distressing65 circumstances, there is a lowering of the victims' fighting strength, a sapping of their courage which makes them an easy prey66 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, reassurance67, and moral support that his physician can give, and such time and labor68 on the latter's part are richly repaid.
The Average State of Mind.—The average mental attitude stops tantalizingly69 short of the best type of conscientiousness70. 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 deprivations71 go hard with this type of patients, and it is difficult, almost impossible, to persuade them to stop smoking or to abstain72 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 disappearance73. They are, of course, lost in the great unknown of syphilis, and swell74 the total of deaths from internal causes of syphilitic origin, such as diseases of the arteries75 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 influential76 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 contagious77 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 persuasion78. The only argument capable of influencing such minds is compulsion. Others are, of course, mental defectives79 with criminal and perverted80 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 wilful81 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 brazenly82 to acknowledge the fact. Others, suave83, 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 dealing84, I might offer the following at random85, from my own recollections: A milkman came to a clinic one morning with an eruption86 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, literally87 oozing88 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 abortive89 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 strenuous90 efforts of the entire staff got him into the hospital, because he had neither money nor sense. Half-witted tramps, gang laborers91, 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 wilfulness92 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 pettish93. 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 ward3, 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 estranged94 partners later in their careers.
The Necessity for Legal Control.—All these repulsive95 details have a place in driving home a conception of the cost to society of the immoral96 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 makeup97, 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 disorder98, 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 tenacity99 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 persistent100 and determined101 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, inflict102 needless torture and may do serious damage to the highly organized sensitive spirits which it is to society's best interest to conserve103. 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 sane104 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 dispelled105 by convincing them of this fact.
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disastrous
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| adj.灾难性的，造成灾害的；极坏的，很糟的 | |
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indifference
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| n.不感兴趣，不关心，冷淡，不在乎 | |
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ward
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| n.守卫，监护，病房，行政区，由监护人或法院保护的人（尤指儿童）；vt.守护，躲开 | |
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frankly
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| adv.坦白地，直率地；坦率地说 | |
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tuberculosis
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| n.结核病，肺结核 | |
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publicity
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| n.众所周知，闻名；宣传，广告 | |
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quack
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| n.庸医；江湖医生；冒充内行的人；骗子 | |
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hygiene
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| n.健康法，卫生学 （a.hygienic） | |
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inaccurate
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| adj.错误的，不正确的，不准确的 | |
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secrecy
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| n.秘密，保密，隐蔽 | |
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stigma
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| n.耻辱，污名；(花的)柱头 | |
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tragic
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| adj.悲剧的，悲剧性的，悲惨的 | |
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itch
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| n.痒，渴望，疥癣；vi.发痒，渴望 | |
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taboo
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| n.禁忌，禁止接近，禁止使用；adj.禁忌的；v.禁忌，禁制，禁止 | |
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shameful
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| adj.可耻的，不道德的 | |
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essentially
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| adv.本质上，实质上，基本上 | |
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semblance
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| n.外貌，外表 | |
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savage
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| adj.野蛮的；凶恶的，残暴的；n.未开化的人 | |
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akin
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| adj.同族的，类似的 | |
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frightfulness
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| 可怕； 丑恶； 讨厌； 恐怖政策 | |
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innocence
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| n.无罪；天真；无害 | |
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utterance
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| n.用言语表达，话语，言语 | |
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catastrophe
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| n.大灾难，大祸 | |
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promiscuous
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| adj.杂乱的，随便的 | |
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perpetuates
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| n.使永存，使人记住不忘( perpetuate的名词复数 )；使永久化，使持久化，使持续 | |
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muddles
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| v.弄乱，弄糟( muddle的第三人称单数 )；使糊涂；对付，混日子 | |
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warfare
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| n.战争(状态)；斗争；冲突 | |
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deterred
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| v.阻止，制止( deter的过去式和过去分词 ) | |
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license
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| n.执照，许可证，特许；v.许可，特许 | |
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pharmacy
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| n.药房，药剂学，制药业，配药业，一批备用药品 | |
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crumple
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| v.把...弄皱，满是皱痕，压碎，崩溃 | |
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bolster
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| n.枕垫；v.支持，鼓励 | |
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vows
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| 誓言( vow的名词复数 )； 郑重宣布，许愿 | |
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seducer
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| n.诱惑者,骗子,玩弄女性的人 | |
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bondage
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| n.奴役，束缚 | |
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wrecked
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| adj.失事的，遇难的 | |
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offenders
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| n.冒犯者( offender的名词复数 )；犯规者；罪犯；妨害…的人（或事物） | |
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everlasting
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| adj.永恒的，持久的，无止境的 | |
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ails
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| v.生病( ail的第三人称单数 )；感到不舒服；处境困难；境况不佳 | |
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deterrent
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| n.阻碍物，制止物；adj.威慑的，遏制的 | |
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inhuman
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| adj.残忍的，不人道的，无人性的 | |
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impersonally
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| ad.非人称地 | |
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contemptible
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| adj.可鄙的，可轻视的，卑劣的 | |
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folly
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| n.愚笨，愚蠢，蠢事，蠢行，傻话 | |
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45
worthy
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| adj.(of)值得的，配得上的；有价值的 | |
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46
judgment
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| n.审判；判断力，识别力，看法，意见 | |
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47
sketch
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| n.草图；梗概；素描；v.素描；概述 | |
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48
conscientious
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| adj.审慎正直的，认真的，本着良心的 | |
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morbid
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| adj.病的；致病的；病态的；可怕的 | |
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fixed
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| adj.固定的，不变的，准备好的；(计算机)固定的 | |
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51
treacherous
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| adj.不可靠的，有暗藏的危险的；adj.背叛的，背信弃义的 | |
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deceptive
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| adj.骗人的，造成假象的，靠不住的 | |
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53
laymen
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| 门外汉，外行人( layman的名词复数 )； 普通教徒（有别于神职人员） | |
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radical
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| n.激进份子，原子团，根号；adj.根本的，激进的，彻底的 | |
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condemnation
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| n.谴责; 定罪 | |
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ointment
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| n.药膏，油膏，软膏 | |
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promptly
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| adv.及时地，敏捷地 | |
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drudgery
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| n.苦工，重活，单调乏味的工作 | |
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mercurial
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| adj.善变的，活泼的 | |
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grit
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| n.沙粒，决心，勇气；v.下定决心，咬紧牙关 | |
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61
requisite
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| adj.需要的，必不可少的；n.必需品 | |
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invaluable
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| adj.无价的，非常宝贵的，极为贵重的 | |
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incurable
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| adj.不能医治的，不能矫正的，无救的；n.不治的病人，无救的人 | |
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persistence
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| n.坚持，持续，存留 | |
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distressing
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| a.使人痛苦的 | |
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prey
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| n.被掠食者，牺牲者，掠食；v.捕食，掠夺，折磨 | |
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reassurance
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| n.使放心，使消除疑虑 | |
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labor
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| n.劳动，努力，工作，劳工；分娩；vi.劳动，努力，苦干；vt.详细分析；麻烦 | |
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tantalizingly
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| adv.…得令人着急，…到令人着急的程度 | |
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conscientiousness
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| 责任心 | |
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deprivations
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| 剥夺( deprivation的名词复数 )； 被夺去； 缺乏； 匮乏 | |
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abstain
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| v.自制，戒绝，弃权，避免 | |
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disappearance
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| n.消失，消散，失踪 | |
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swell
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| vi.膨胀，肿胀；增长，增强 | |
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arteries
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| n.动脉( artery的名词复数 )；干线，要道 | |
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influential
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| adj.有影响的，有权势的 | |
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contagious
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| adj.传染性的，有感染力的 | |
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persuasion
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| n.劝说；说服；持有某种信仰的宗派 | |
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defectives
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| 次品 | |
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perverted
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| adj.不正当的v.滥用( pervert的过去式和过去分词 )；腐蚀；败坏；使堕落 | |
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wilful
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| adj.任性的，故意的 | |
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brazenly
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| adv.厚颜无耻地；厚脸皮地肆无忌惮地 | |
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suave
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| adj.温和的；柔和的；文雅的 | |
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dealing
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| n.经商方法，待人态度 | |
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random
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| adj.随机的；任意的；n.偶然的(或随便的)行动 | |
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eruption
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| n.火山爆发；（战争等）爆发；（疾病等）发作 | |
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literally
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| adv.照字面意义，逐字地；确实 | |
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oozing
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| v.（浓液等）慢慢地冒出，渗出( ooze的现在分词 )；使（液体）缓缓流出；（浓液）渗出，慢慢流出 | |
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abortive
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| adj.不成功的，发育不全的 | |
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strenuous
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| adj.奋发的，使劲的；紧张的；热烈的，狂热的 | |
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laborers
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| n.体力劳动者，工人( laborer的名词复数 )；（熟练工人的）辅助工 | |
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wilfulness
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| 任性；倔强 | |
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pettish
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| adj.易怒的，使性子的 | |
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estranged
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| adj.疏远的，分离的 | |
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repulsive
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| adj.排斥的，使人反感的 | |
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immoral
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| adj.不道德的，淫荡的，荒淫的，有伤风化的 | |
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makeup
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| n.组织；性格；化装品 | |
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disorder
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| n.紊乱，混乱；骚动，骚乱；疾病，失调 | |
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99
tenacity
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| n.坚韧 | |
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100
persistent
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| adj.坚持不懈的，执意的；持续的 | |
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101
determined
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| adj.坚定的；有决心的 | |
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102
inflict
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| vt.(on)把…强加给，使遭受，使承担 | |
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103
conserve
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| vt.保存，保护，节约，节省，守恒，不灭 | |
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104
sane
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| adj.心智健全的，神志清醒的，明智的，稳健的 | |
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105
dispelled
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| v.驱散，赶跑( dispel的过去式和过去分词 ) | |
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