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.