Mental Attitudes in Their Relation to Syphilis
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 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 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 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 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 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 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
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 coöperation 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 coöperators in the beginning of a course of treatment
or while the symptoms are alarming or obvious, but 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 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 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 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 coöperation 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
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 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 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.