The Third Great Plague A Discussion of Syphilis for Everyday People online

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.




Chapter XV

Moral and Personal Prophylaxis


Prophylaxis, of course, means prevention, and it has been a large part
of the purpose of the present study to deal with syphilis from the
standpoint of prevention and cure. The material of this chapter is,
therefore, only a special aspect of the larger problem.

+Repression of Prostitution.+ - By the moral prophylaxis of syphilis is
meant the cultivation of such moral ideals as will contribute to the
control of a disease which is so closely associated with sexual
irregularities. Since public and secret prostitution serve as the
principal agencies for the dissemination of the disease, it follows that
anything tending to decrease the amount of disease in prostitutes, on
the one hand, or to diminish the amount of promiscuous sexual activity,
on the other, will retard the spread of syphilis. Systems based on the
first ideas, aiming rather to control the disease in public women by
inspection of their health and activities than by suppressing
prostitution, have failed because the methods of control ordinarily
practised are worthless for the detection of infectiousness. So-called
regulation has, therefore, given way very largely in progressive
communities to the second ideal of repressing or abolishing the outward
evidences of vice as far as possible. In behalf of sanitary control of
prostitution, leaving out of the question its moral aspect, it must be
admitted that Neisser, probably the greatest authority on the sexual
diseases, believed that, as far as syphilis is concerned, the use of
salvarsan as a means of preventing infection from prostitutes has never
had a satisfactory trial. In behalf of abolition it would seem that
systematic stamping-out of the outward evidences of vice, the making of
immorality less attractive and conspicuous, is, in theory at least, a
valuable means of diminishing the extent and availability of an
important source of infection.

+Educational Influences.+ - To do something positive against an evil is
certainly a more promising mode of attack than to use only the negative
force of repression of temptation. Education of public opinion offers us
just such a positive mode of attack. Men and women and boys and girls
should first be taught sexual self-control even before being made aware
of the risk they run in throwing aside the conventional moral code.
Teach honor first and prudence next. The slogan of education in sexual
self-restraint is the easiest to utter and the most difficult to put
into practice of all the schemes for the control of sexual diseases. A
large part of the difficulty of making education effective arises from
one or two situations which are worth thinking over.

+Economic Forces Opposing Sexual Self-control.+ - In the first place,
while continence, or abstinence from sexual relations, is a valuable
ideal in its place, it cannot be indefinitely extended with benefit
either to the individual or to the race. The instinct to reproduce is as
fundamental as the instinct of self-preservation and the desire for
food. A social order which disregards it or defies it will meet defeat.
To an alarming extent the tendency of the present economic system is to
create unsocial impulses by making the normal gratification of sexual
instinct in marriage and the assumption of the responsibility of a
family more and more difficult. The cost of living is steadily rising
without a corresponding certainty on the part of a large proportion of
young men that they can meet it for themselves, to say nothing of
meeting it for wife and children. The uncertainties of a 'job' are often
serious enough to discourage the rashest of men from depending on a
variable earning power to help him do his share for the advancement of
the race. It will be an impossible task to convince even naturally
clean-minded, healthy young men and women that they should live a life
of hopeless virtue because it is part of the divine order that they
should be so held down by hard times and small earnings as to make
marrying and having children an unattainable luxury. Continence and
clean living as preparations for decent and reasonably early marriage
and the raising of a healthy family are the highest of ideals, and ought
to be preached from every housetop. Continence as a life-long punishment
for the impossible demands of an oppressive social and economic order
gets as little attention as it deserves. First, let us make a clean
sexual life lead with greater certainty to some of the rewards that make
life worth living and we shall then have a more substantial basis for
making continence before marriage other than empty words. If every
father, for example, could say to his sons and daughters that if they
showed themselves clean men and women he would back them in an early
marriage, there would be an appreciable decrease in the amount of young
manhood which is now squandered on indecency. If every employer, or the
state itself, would give a clean marriage a preferred position in the
social and economic scale, and, by helping to meet the cost of it,
recognize in a substantial way the value to the race of a family of
vigorous children, an important factor in youthful sexual laxity would
be robbed of its power. No one will assert that such remedial proposals
are of themselves cure-alls for present evils, but they must have at
least an emphatic place in the future of moral prophylaxis.

+The Teaching of Sexual Self-control.+ - First then, make the social
order such that sexual self-control yields a reward and not a
punishment. Second, teach sexual control itself, since it is one of the
fundamental means of attack on the problem of syphilis. How can such
control be taught? Information about the physical dangers of illicit
sexual indulgence is of course of value, and should be spread broadcast.
But taken by itself, the fear of disease, especially if it enters the
individual's life after the age when he has already experienced the
force of his sexual instincts, is a feeble influence. The person who has
nothing but the knowledge that he is taking great risks between him and
the gratification of his sexual desires will take the risks and take
them once too often. One cannot begin to teach the boy or girl of high
school age that sexual offenses mean physical disaster, and expect to
control syphilis. The time to control the future of the sexual diseases
is in the toddler at the knee, the child whose daily lesson in
self-control will culminate when he says the final 'No' to his passions
as a man. The child who does not learn to respect his body in the act of
brushing his teeth and taking his bath and exercise, and whose thought
and speech and temper are unbridled by any self-restraint, will give
little heed when told not to abuse his manhood by exposing himself to
filth. The prevention of syphilis by sexual self-control goes down to
the foundations of character, and has practical value only in those
whose self-control is the expression of a lifelong habit of
self-discipline bred in the bone from childhood, not merely painted on
the surface at puberty. Those who want their sons and daughters never to
know by personal experience the meaning of syphilis must first build a
foundation in character for them which will make self-control in them
instinctive, almost automatic. Knowledge of sexual matters has power
only in proportion to the strength of the character that wields it, and
on well-rounded character education, rather than mere knowledge of the
facts, the soundest results will be based.

[Illustration: E. ROUX

ÉLIE METCHNIKOFF [1845-1916]

(From McIntosh and Fildes, "Syphilis from the Modern Standpoint,"
New York, Longmans Green & Co., 1911.)]

The moral prophylaxis of syphilis is then briefly summed up in the
repression of as many of the recognized agencies for the spread of the
disease as possible; the making of continence a preparation for a normal
sex life rather than an end in itself; the control and remedying of
those influences which are making normal marriage harder of attainment;
and the development of an instinctive self-control and self-discipline
in every field of life from childhood up as the character basis
necessary to make knowledge about sexual life and sexual disease
effective.

+Personal Preventive Methods. - Continence.+[15] - There remains to be
considered what is often called the personal prophylaxis of syphilis,
meaning thereby the methods by which the individual himself can diminish
or escape the risk of infection. The first and most effective method of
avoiding syphilis is abstinence from sexual relations and intimacies
except in normal marriage with a healthy person. Although it has been
alluded to under the moral prophylaxis of syphilis, it deserves to be
reëmphasized. No consideration as to the justice or desirability of
continence and self-restraint can add anything to the simple fact that
it is _the_ way to avoid disease, and can be unhesitatingly recommended
as the standard for personal prophylaxis. In the experience of
physicians it is an axiom that disillusionment sooner or later overtakes
those who think they are exempt from this rule. Persons who discard
continence in favor of what they believe to be some absolutely safe
indulgence are so almost invariably deceived that the exceptions are not
worth considering. Although infection with syphilis is no necessary
evidence of unclean living, clean living will always remain the best
method of avoiding syphilis.

[15] The American Social Hygiene Association, 105 W. 40th Street,
New York City, can supply pamphlets and lists of authoritative
publications bearing on this and related subjects.

+The Metchnikoff Prophylaxis.+ - The second method of personal
prophylaxis of syphilis was developed as a result of the discovery of
Metchnikoff and Roux in 1906, that a specially prepared ointment
containing a mercurial salt, if rubbed into the place on which the germs
were deposited within a few hours (not exceeding eighteen hours, and the
sooner the better) after exposure to the risk of syphilis, would prevent
the disease by killing the germs before they could gain a foothold. This
method of protection against syphilis has been subjected to rigid tests,
with fairly satisfactory results. It has been adopted by the army and
navy of practically every country in the world, and, as carried out
under the direction of physicians and with military control of the
patient, has apparently reduced the amount of syphilitic infection
acquired in the armies and navies using it to a remarkable degree. The
method, of course, cannot assume to be infallible, but if intelligently
applied, it is one of the important weapons for the extinction of
syphilis in our hands at the present day. It fails to meet expectations
precisely in those circumstances and among those persons in whom
intelligent employment of it cannot be expected. This of course covers a
considerable number of those who acquire syphilis. What disposal an
awakened opinion will make of this knowledge remains to be seen. At the
present time it may well be doubted whether the indiscriminate placing
of it in the hands of anybody and everybody would not work as much harm
as good through ignorant and unintelligent use. This opinion is shared
by European as well as American authorities. Administered under the
direction of a physician, the Metchnikoff prophylaxis of syphilis would
undoubtedly be at its best in the prevention of the disease. For these
reasons, as well as to prevent the spread of the knowledge to those who
would be damaged by it, those interested are referred to their
physicians for a description of the method. Any one having the benefit
of it should be able to convince his medical advisor that there is good
reason why this kind of professional knowledge should be brought to bear
on his case. The ordinary methods of preventing infection by washes and
similar applications used by the "knowing ones" are most of them
worthless or greatly inferior to the Metchnikoff prophylaxis. They are,
moreover, a positive source of danger because of the false sense of
security which they create. If every person who has run the risk of
contracting syphilis should visit his physician _at once_ to receive
prophylactic treatment, the effect on syphilis at large would probably
be as good as in the army and navy. There would still be opportunity on
such occasions to bring moral forces and influence to bear on those who
would respond to them. There can be no object in withholding such
knowledge from those who are confirmed in their irregular sexual habits.
At the same time there could be few better influences thrown across the
path of one just starting on a wrong track than that exerted by a
physician of skill and character, to whom the individual had appealed to
avert the possible disastrous result of an indiscretion.




Chapter XVI

Public Effort Against Syphilis


+The World-wide Movement Against Venereal Disease.+ - This chapter is
intended to give some account of the great movements now begun to
control syphilis and its fellow-diseases throughout the world. A
campaign of publicity was the starting-point of the organized attempt to
control tuberculosis, and in the same way a similar campaign has been at