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[Pg 142] all, in order to understand the mental state of the patient, consider once more the attitude of the world at large toward the victim of syphilis. A few who are 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[Pg 143] by a reasonable presentation of the facts. We need the light on this subject and the light on reserved shelves is notoriously poor. The 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[Pg 144] 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[Pg 145] 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[Pg 146] foundation must rest on the rock bottom of character and not in the muck of venereal disease.

The Broader Outlook.—If, then, it avails nothing in the uplifting of our morals to treat syphilis as a disgrace, if the disease is ineffective as a 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[Pg 147] 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[Pg 148] 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 co?peration in the development of the necessary sense of responsibility and the requisite character basis for a successful treatment is invaluable. To the............