Chapter XII

Means for Controlling Infectiousness.—The usual method of controlling a very contagious disease, such as scarlet fever or measles, is to put the patient off by himself with those who have to care for him and to keep others away—that is, to quarantine them. This works very well for diseases which run a reasonably short course, and in which contagious periods are not apt to recur after the patient has been released. But in diseases such as tuberculosis and syphilis, in which contagiousness may extend over months and years, such a procedure is evidently out of the question. We cannot deprive a patient of his power to earn a living, to say nothing of his liberty, without providing for his support and for that of those who are dependent on him. To do this in so common a disease as syphilis would involve an expenditure of money and an amount of machinery that is unthinkable. Accordingly, as a practical scheme for preventing its spread, the quarantine of syphilis throughout the infectious period is out of the question. We must, therefore, consider the other two means available for diminishing the risk to others. The first of these, and the most important, is to treat the disease efficiently right from the start, so that contagious sores and patches will be as few in number as possible, and will recur as little as possible in the course of the disease. This will be in effect a shortening of the contagious period, and should be recognized as one of the great aims of treatment. The second means will be to teach the syphilitic and the general public those things which one who has the disease can do to make himself as harmless as possible to others. This demands the education of the patient if we hope for his coöperation, and demands also the coöperation of those around him in order that the pressure of public sentiment may oblige him to do his part in case he does not do it of his own free will.

Control of Infectiousness by Treatment—Importance of Salvarsan.—In a disease which yields so exceptionally well to treatment as syphilis, a great deal can be done to shorten the contagious period. Especially is this so when we are able to employ an agent such as salvarsan, which kills off the germs on the surface within twenty-four hours after its injection. When a patient is discovered to be in a contagious state, in a large majority of cases the risk to the community which he represents can be quickly eliminated, at least for the time being. Combining the use of mercury and salvarsan in accordance with the best modern standards, the actively contagious period as a whole can be reduced in average cases from a matter of years to one of a few weeks or months. Certainly, so far as recognizable dangerous sores are concerned, periodic examination, with salvarsan whenever necessary, would seem to dispose of much of the difficulty.

Obstacles to Control by Treatment.—There are, however, obstacles in the way of complete control of infectiousness by treatment. For example, one might ask whether a single negative blood test would not be sufficient assurance that the patient was free from contagious sores. It is, however, a well-recognized fact that a person with syphilis may develop infectious sores about the mouth and the genitals even while the blood test is negative. An examination, moreover, is not invariably sufficient to determine if a patient is in a contagious state. The value of an examination depends, of course, entirely on its thoroughness and on the experience of the physician who makes it. It is only too easy to overlook one of the faint grayish patches in the mouth or a trifling pimple on the genitals. The time and special apparatus for a microscopic examination are not always available. Moreover, contagious lesions come and go. One may appear on the genitals one day and a few days later be gone, without the patient's ever realizing that it was there—yet in this interval a married man might infect his wife by sexual contact. The patient with a concealed syphilis often lacks even the incentive to seek examination by a doctor. It is important also to realize that when mercury has to be the only reliance, the risk of infection cannot be entirely controlled by treatment. Contagious sores may develop even during a course of mercurial injections, especially in early cases. It requires the combination of mercury and salvarsan to secure the highest percentage of good results.

The Five-year Rule.—The truth of the matter is that, as Hoffmann says, no treatment can guarantee the non-infectiousness of a syphilitic in the first five years of his disease. Time is thus an essential element in pronouncing a person non-infectious and hence in deciding his fitness for marriage, for example. The person with active syphilis who has intimate relations with uninfected persons, who will not abandon smoking or take special precautions about articles of personal use which are likely to transmit the disease, is unsafe no matter what is done for him. In spite of this qualifying statement it may be reiterated, however, that good treatment with salvarsan and mercury reduces the risk of infecting others in the ordinary relations of life practically to the vanishing point, and of course reduces, but not entirely eliminates, the dangers of the intimate contacts.

Personal Responsibility of the Patient.—If we are compelled then to fall back to some extent upon the personal sense of responsibility of the patient himself to fill in the gap where treatment does not entirely control the situation, it becomes increasingly important that in the irresponsible and ignorant, when the patient fails to meet his obligation, we should push treatment to the uttermost in our effort to prevent the spread of the disease. To supply this necessary treatment to every syphilitic who cannot afford it for himself, and make it obligatory, if need be, will be a long step forward in the control of the disease. The educational campaign for it is well under way all over the world, and the money and the practical machinery will inevitably follow. We have the precedents of the control of tuberculosis, smallpox, malaria, and yellow fever to guide us, to say nothing of a practical system against sexual disease already in operation in Norway, Sweden, Denmark, and Italy.

Syphilis and Marriage.—The problem of the relation of syphilis to marriage is simply an aspect of the transmission of an infectious disease. The infection of one party to the marriage by the other and the transmission of that infection to children summarizes the social problem. Through the intimate contacts of family life, syphilis attacks the future of the human race.

Estimated Risk of Infecting the Wife.—How serious is the risk of infecting the wife if a man should marry during the contagious period of syphilis? This will depend a good deal on the frequency of relapses after the active secondary stage. On this point Sperk estimated that in 1518 patients, only ten escaped relapses entirely. These were, however, not patients that had been specially well treated. Keyes, quoted by Pusey, estimated, on the basis of his private records, that the chances taken by a syphilitic husband who used no special precautions to prevent infecting his wife were twelve to one the first year in favor of infection, five to two the second year, and one to four the third year, being negligible after the fourth year.

Syphilis in the Father.—Even while we recognize the infection of women and children as the greatest risk in marriage we should not lose sight of the cost to society which syphilis in the father of the family himself may entail. For such a man to be stricken by some of the serious accidents of late syphilis throws his family as well as himself upon society. A syphilitic infection which has not been cured not only makes a man a poor risk to an insurance company, but a poor risk to the family which has to look to him for support and for his share and influence in the bringing up of the children. A sufficient number of men and women in the thirties and forties are crippled, made dependent, or lost to the world entirely, to make the responsibilities of the family when assumed by persons with untreated or poorly treated syphilis a matter of some concern, whether or not they are still able to transmit the disease to others.

The Time-treatment Principle and the Five-year Rule.—In setting a modern standard for the fitness of syphilitics for marriage it may be said at the outset that there is little justification for making the mere fact of a previous syphilitic infection a permanent bar in the majority of cases. The risk of economic disaster to the parent and wage-earner, and the risk of transmission of the disease to the partner and the children, are both controllable by a combination of efficient treatment and time. The man who has conformed to the best practice in both particulars may usually marry and have healthy children. The woman under the same circumstances need not fear that the risk of having offspring injured by her disease is any greater than the risk that they will be injured by any other of the unforeseen risks that surround the bringing of a child into the world. A vast experience underlies what might be called the time-treatment principle on which permission to marry after syphilis should be based. It has recently been ably summarized again, and with commendable conservatism, by Hoffmann in the rule that a syphilitic who has been efficiently treated by modern standards, with mercury and salvarsan, over a period of two to three years, and who has remained free from all symptoms and signs of the disease for two years after all treatment was stopped, including negative blood and spinal fluid tests, may marry in from four to five years from the beginning of his infection. Variations of this rule must be allowed only with great conservatism, since salvarsan, on whose efficiency many pleas for a shortening of probation have been based, is still too recent an addition to our implements of warfare to justify a rash dependence upon it. The abortive cure in relation to marriage is a problem in itself, and the shortening of time allowed in such cases must be individually determined by an expert who has had the case in charge from the beginning, and not, at least as yet, by the average doctor. Such a standard as this for the marriage of persons who have had syphilis steers essentially a middle course between those who condemn syphilitics to an unreasonable and needless deprivation of all the joys of family life, and those who are too ready to take our conquest of syphilis for granted and to cast to the winds centuries of experience with the treachery of the disease.

Even while we concede the value of generations of experience with syphilis in determining the probable risk of infection, it is a duty to investigate thoroughly by the modern methods, such as the Wassermann blood test, the condition of all members of a family in which syphilis has appeared. This means, for example, that even though the husband with syphilis may have married years after the usual period of infectiousness has passed, his wife, though outwardly healthy, should have a Wassermann test, and his children would be none the worse for an examination, even though they seem normal. Syphilis is an insidious disease, a consummate master of deceit, able to strike from what seems a clear sky. The latest means for its recognition have already revolutionized some of our conceptions of its dangers and its transmission. It is only common prudence to take advantage of them in every case, to forestall even the remotest possibility of mistake or oversight.

Where both husband and wife have had syphilis, even though both are past the infectious stage, both should be treated, and a complete cure for the wife is advisable before they undertake to have children. This must mean an added burden of responsibility on both physician and patient, and one extremely difficult to meet under existing conditions. A reliable means of birth control used in such cases would place the problem in women on a par with that in men, and give the physician's insistence on a complete cure for the woman a reasonable prospect of being needed. Where his advice is disregarded and a pregnancy results, the woman should be efficiently treated while she is carrying the child.

Syphilis and Engagements to Marry.—If a five-year rule is to be applied to marriage, a similar rule should cover the engagement of a syphilitic to marry, and it should cover the sexual relations of married people who acquire syphilis. It is not too much to expect that an engaged person who contracts syphilis shall break his engagement, and not renew it or contract another until by the five-year rule he would be able to marry with safety.

Engagements nowadays may well be thought of as equivalent to marriage when the question of syphilis is considered. They not infrequently offer innumerable opportunities for intimacies which may or may not fall short of actual sexual relations. Attention has been called to this situation by social workers among wage-earning girls. It has been a distressingly frequent experience in my special practice to find that the young man, overwrought by the excitement of wooing, has exposed himself elsewhere to infection and unwittingly punished the trustfulness of his fiancée by infecting her with syphilis through a subsequent kiss. The publication of banns before marriage is worth while, and unmistakable testimony as to the character and health of the parties concerned might well be exchanged before a wooing is permitted to assume the character of an engagement. It is of little use to say that a Wassermann and a medical examination should be made before marriage, when the damage may be done long before that point is reached.

Medical Examination for Syphilis before Marriage.—How shall we recognize syphilis in a candidate for marriage? The prevailing idea is to demand a negative Wassermann test. Assuredly this is good as far as it goes, but it is not so reliable as to deserve incorporation into law as sole sufficient evidence of the absence of syphilis, as has been done in one state. From what has been said, it is plain that a single negative Wassermann is no proof of the absence of syphilis. The subject must be approached from other angles, and when syphilis may be suspected, the question should be decided by an expert. A thorough general or physical examination is desirable, and if this reveals suspicious signs, such as scars, enlarged glands, etc., it is then possible to investigate the Wassermann report more thoroughly by repeating the test, sending it to another expert for confirmation. In some cases it may even be necessary to insist that the patient submit to a special test, called the provocative test, in which a small injection of salvarsan is used to bring out a positive blood test if there is a concealed syphilis. These are, of course, measures which are seldom necessary except in patients who have had the disease. Much depends on the attitude of the patient toward the examination and his willingness to coöperate. A resourceful physician can usually settle the question of a person's fitness for marriage, and the result of a reliable examination offers a reasonable assurance of safety.

Laws Crippling Physicians in Such Matters.—What shall the physician do when confronted with positive evidence that a patient who is about to marry has an active syphilis? It is important for laymen to understand that the law relating to professional confidence between physician and patient ties the hands of the physician in such a situation. For the doctor to tell the relatives of the healthy party to such an intended marriage that the other has active syphilis would make him subject to severe penalties in many states for a violation of professional confidence, or to suit for libel. Of course, if the patient has agreed to submit to examination to determine his fitness for marriage, the physician's path is clear, but if the condition is discovered in ordinary professional relations, there is nothing to be done except to try to persuade the patient not to marry—advice he usually rejects. To this blind policy of protecting the guilty at the expense of the innocent an immeasurable amount of human efficiency and happiness has been sacrificed. Fortunately there are signs of an awakening. For example, Ohio has recently amended the law so as to permit a physician to disclose to the parties concerned that a person about to be married has a venereal disease (Amendment to Section 1275, General Code, page 177). This is preventive legislation, as distinguished from the old policy of locking the stable door after the horse was stolen by laws punishing one who infects another with a venereal disease after marriage has been contracted. Recent Supreme Court decisions (Wisconsin) have also taken the ground that a venereal disease existing at the time of marriage and concealed from the other party is ground for annulment of the marriage, provided the uninfected party ceases to have marital relations as soon as the fact is discovered.

The problem of syphilis in its relation to marriage is, of course, a serious one. It is safe to say that it will never be completely met except by a vigorous general public program against syphilis as a sanitary problem. It is by no means so serious, however, that it need lead clean young men and women to remain single for fear they will encounter it. The medical examination of both parties before marriage, efficiently carried out by disinterested experts, each perhaps of the other's appointing, is the best insurance a man and woman can secure at the present day against the risk that syphilis will mar their happiness.[12]

Chapter XIII

Genital and Non-genital Syphilis in Lax Individuals.—The prevalence of syphilis among women who receive promiscuous attentions is enormous. It is practically an axiom that no woman who is lax in her relations with men is safe from the danger of the disease, or can long remain free from it. The type of man who is a Light o' Love does not go far before he meets the partner who has been infected by some one else. Becoming infected himself, he passes on his infection to his next partner. Syphilis is not so often transmitted in prostitution, open or secret, as gonorrhea, but it is sufficiently so to make the odds overwhelmingly against even the knowing ones who hope to indulge and yet escape. The acquiring of syphilis from loose men or women is usually thought of as entirely an affair of genital contacts. Yet it is notable that extra-genital chancres are the not uncommon result of liberties taken with light women which do not go to the extent of sexual relation. Women who accept intimacies of men who, while unwilling to commit an outright breach of decency, will take liberties with a woman who will accept them have only themselves to blame if it suddenly develops that the infection has been transmitted from one to the other by kisses or other supposedly mild offenses against the proprieties.

Syphilis Among Prostitutes.—As to the prevalence of syphilis among both public and clandestine or secret prostitutes, several notable surveys of more or less typical conditions have been made. With the aid of the Wassermann test much heretofore undiscovered syphilis has been revealed. Eighty to 85 per cent of prostitutes at some time in their careers acquire the disease.[13] About half this number are likely to have active evidence of the disease. Thirty per cent of the prostitutes investigated by Papee in Lemberg were in the most dangerous period—the first to the third year of the disease. Three-fourths of these dangerous cases were in women under twenty-five years of age—in the most attractive period of their lives. Averaging a number of large European cities, it was found that not more than 40 per cent of prostitutes were even free of the outward signs of syphilis, to say nothing of what laboratory tests might have revealed. It is more than evident that prostitution is admirably fitted to play the leading rôle in the dissemination of this disease. The young and attractive prostitute, whether in a house of ill-fame, on the street, or in the more secret and private highways and by-ways of illicit sexual life, is the one who attracts the largest number with the most certain prospect of infecting them.

Concealed Syphilis and Medical Examinations of Prostitutes.—A number of delusions center around the relation of open and secret prostitution to disease. From the description of syphilis given in the foregoing pages, it must be apparent how little reliance can be placed, for example, on the ordinary medical examination of prostitutes as practised in segregated districts. The difficulties of efficient examination are enormous, especially in women. Even with the best facilities and a high degree of personal skill, with plenty of time and laboratory help in addition, extremely contagious syphilis can escape observation entirely, and even the negative result of one day's examination may be reversed by the appearance of a contagious sore on the next. Women can transmit syphilis passively by the presence of infected secretions in the genital canal even when they themselves are not in a contagious state. In the same way a woman may find herself infected by a man without any idea that he was in an infectious state. She may in turn develop active syphilis without ever realizing the fact. Medical examination of prostitutes as ordinarily carried out does actual harm by deluding both the women and their partners into a false sense of security. The life which such women lead, with the combination of local irritation, disease, and fast living, makes them especially likely to develop the contagious mucous patches, warts, and other recurrences, and to relapse so often that there can be little assurance that they are not contagious all the time.

Under such circumstances one might almost expect every contact with a prostitute on the part of a non-syphilitic individual to result in a new infection. The factors which interfere to prevent such wholesale disaster are the same which govern infectiousness throughout the disease. Local conditions may be unfavorable, even though the germs are present, or there may be no break in the skin for the germs to enter. If the syphilitic individual is beyond the infectious period, there may be no dangerous lesions. Here, as all through the history of infections with syphilis, there is an element of the unexpected, a favoring combination of circumstances. Sometimes when infection is most to be expected it is escaped, and conversely it seems at times that in the "sure thing," the "safe chance," and the place where infection seems most improbable, it is most certain to occur.

Personal Hygiene in Syphilis

Syphilis is a constitutional disease, affecting in one way or another the whole body. For that reason, measures directed to improving the general health and maintaining the resistance of the patient at the highest point have an important place in the management of the disease. By his habits and mode of life a person with syphilis does much to help or hinder his cure, and to protect or endanger those around him. For that reason a statement of general principles may well be drawn up to indicate what is desirable in these regards.

A Well-balanced Life.—First, for his own sake, a syphilitic should live a well-balanced and simple life so far as possible. In this disease the organs and structures of the body which are subject to greatest strain are the ones most likely to suffer the serious effects of the disease. Worry and anxiety, excessive mental work, long hours without proper rest, strain the nervous system and predispose it to attack. Excessive physical work, fatigue, exhaustion, poor food, bad air, exposure, injure the bodily resistance. Excesses of any kind are as injurious as deprivation. In fact, it is the dissipated, the high livers, who go to the ground with the disease even quicker than those who have to pinch.

Alcohol.—Alcohol in any form, in particular, has been shown by extensive experience, especially since the study of the nervous system in syphilis has been carried to a fine point, to have an especially dangerous effect on the syphilitic. Alcohol damages not only the nervous system, but also the blood vessels, and makes an unrivaled combination in favor of early syphilitic apoplexy, general paresis, and locomotor ataxia. A syphilitic who drinks at all is a bad risk, busily engaged in throwing away his chances of cure. Even mild alcoholic beverages are undesirable and the patient should lose no time in dropping them entirely.

Tobacco.—Tobacco has a special place reserved for it as an unfavorable influence on the course of syphilis. It is dangerous to others for a syphilitic to smoke or chew because, more than any other one thing, it causes the recurrence of contagious patches in the mouth. It is remarkable how selfish many syphilitic men are on this point. In spite of the most positive representations, they will keep on smoking. Not a few of them pay for their selfishness with their lives. These mucous patches in the mouth, often called "smoker's patches," predispose the person who develops them to one of the most dangerous forms of cancer, which is especially likely to develop on tissues, like those of the mouth and tongue, which have been the seat of these sores.

Sexual Relations, Kissing, Etc.—Contagious Sores.—Sexual indulgence, kissing, and other intimate contacts during the active stage of syphilis, as has been indicated, directly expose others to the risk of getting the disease. For that reason they should not be indulged in during the first two years of the average well-treated case receiving salvarsan and mercury by the most modern methods. Exceptions to this rule should be granted only by the physician, and should be preceded by careful and repeated examination in connection with the treatment. Under no circumstances should a patient kiss or have intercourse if there is even the slightest sore or chafe on the parts, regardless of whether or not it is thought to be syphilitic.

Articles of Personal Use.—Persons with a tendency to recurrences in the mouth or elsewhere should report to the physician any sore they may discover and should watch for them. Persons with syphilitic sores in the mouth or elsewhere should have their own dishes, towels, toilet articles, shaving tools, pipes, silverware, and personal articles, and should not exchange or permit others to use them.

Secrecy.—Professional secrecy is something to which the syphilitic is most certainly entitled when it can be had without danger to the public health. So long as a syphilitic in the contagious period carefully observes the principles which ought to govern him in his relations to others, his condition is his own concern. But there is one person within the family who should, as a rule, know of his infection if it is still in the contagious period, since it is almost impossible to secure coöperation otherwise. No matter how painful it may be, a person with syphilis, if advised to do so by his physician, should tell husband or wife the true state of affairs. There is no harder duty, often, and none which, if manfully performed, should inspire more respect. For those who will not follow his advice in this matter the physician cannot assume any responsibility, and is fully justified, and in fact wise, if he decline to undertake the case.

Re-infection.—Since it is a common misconception, it cannot be said too forcibly that no person with syphilis should forget that his having had the disease does not confer any immunity, and that as soon as he is cured he may acquire it again. It is possible, by a single exposure to infection, to undo the whole effect of what has been done, just after a cure is accomplished. There can be only one safe rule for infected as well as uninfected persons—to keep away from the risk of syphilis.

Quacks and Self-treatment.—Hot Springs.—The temptation to take up quack forms of treatment or to treat himself without the advice of a physician besets the path of the syphilitic throughout the course of the disease; an enormous number of fraudulent enterprises thrive on the credulity of its victims. Most of them are of the patent medicine specific type. Others, however, have a tinge of respectability and are dangerous simply because they are insufficient and not carried out under proper direction. Many popular superstitions as to the value of baths in syphilis and of the usefulness of a short course of rubs with bathing, or a "trip to the springs," are of this kind. Enough has been said in the foregoing chapters to make it plain to any one who is open to conviction that syphilis is no affair for the patient himself to attempt to treat. The best judgment of the most skilled physicians is the least that the victim owes himself in his effort to get well.

Patient and Physician.—For the same reasons every person who has or has had syphilis, cured or not, or has been exposed to it, should make it an absolute rule to inform his physician of the fact. The recognition of many obscure conditions in medicine depends on this knowledge. For a patient to falsify the facts or to ignore or conceal them is simply to work against his own interests and to hinder his physician in his efforts to benefit him.

Chapter XIV

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]

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.