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

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]

[12] The problem of gonorrhea is not considered in the framing of
this statement.




Chapter XIII

The Transmission and Hygiene of Syphilis (Continued)


SYPHILIS AND PROSTITUTION

In taking up the consideration of the relation of syphilis to illicit
sexual relations, we must again remind ourselves that we are approaching
this subject, not as moralists, important though their point of view may
be, but for the time being as sanitarians, considering it from the
standpoint of a method of transmission of a contagious disease.

+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.

[13] The figures here given are based on those of Papee, Wwednesky,
Raff, Sederholm, and others. The recently published investigations
of the Baltimore Vice Commission showed that 63.7 per cent of 289
prostitutes examined by the Wassermann test had syphilis. Of 266
examined for gonorrhea, 92.1 per cent showed its presence. Nearly
half the girls examined had both diseases and only 3.39 per cent had
neither. (Survey, March 25, 1916, Vol. 35, p. 749.)

+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

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