As was emphasized in the preceding chapter, sexual symptoms are usually the subject of so much worry and disturbance of mind and become the center of so much unfavorable suggestion, that the only way to ameliorate the conditions which develop is by securing relaxation of the attention and diversion of mind. Mental influence is much more important than any other remedies that we have at our command in these cases, not only for their relief but for their ultimate cure.

A state of depression of mind similar to that which develops in patients frightened by seminal emissions is often seen in those who have for some time indulged in the habit of self-abuse. Rather frequently a physician, especially if he is known to be interested in nervous diseases, has to listen to the story of a patient who is sure that his health is completely undermined and that his future is the darkest possible, because of this habit in younger days. Usually the patient is a young man who has been reading some of the literature of the advertising "specialists" who distribute reading matter which pictures appalling and almost irretrievable effects from such sexual habits. The consequence is that the patient is in highly nervous condition, has lost his appetite, is not sleeping well, is avoiding society, because he fears that some one may recognize his condition and its cause, and he is really in a pitiable state. Such patients are usually sure that little can be done for them. Sometimes they have already been through the hands of several "specialists," particularly of the mail-order variety, and the literature provided for them and the letters written to them have all helped to make them worse and much more solicitous about themselves.{483}

Unfortunately some of the exaggerated notions with regard to the effect of these habits that are so widely diffused by the exploiters of the young have been adopted by moralists with the idea that they can thus deter youth from certain practices and scare the victims of such habits out of them. It is extremely doubtful, however, whether self abuse of itself, unless practiced in very early years or indulged in to a degree that is possible only in those of unbalanced mind, ever works anything like the serious harm that is claimed. Certainly physicians who are most familiar with its results are not ready to confirm the opinions usually advanced as to the awful harmfulness of the practice. Personally, I have had a number of patients confess to me that they had indulged in the habit to some extent for twenty years and longer and yet had never suffered anything more than passing physical discomfort. It is unfortunate, then, that the exaggerations of the quack should by receiving the approval of the well-intentioned moralists, be emphasized so as to add to the neurotic disturbance of mind which makes these patients so miserable and for a time may seriously interfere with their health. Occasionally even suicides are reported in which the underlying motive seems to have been the dread on the part of a young man that a sexual habit has so undermined his health that cure is impossible and that physical and mental deterioration to a marked degree is inevitable. The opinions of conservative physicians tend to show that there is no good reason for thinking that in normal healthy persons such habits ever have the serious effects thus set forth.

Patients can be assured that whatever evil effects follow the practice will not remain after it has been given up. There are no serious enduring sequelae, with one or two exceptions in very special cases, that perhaps should be noticed. Most men of considerable experience in the matter are now decidedly of the opinion that self-abuse does not produce any more serious consequences than the same amount of ordinary sexual intercourse. It is possible for sexual intercourse indulged in excessively, as it sometimes is in early marital life, to produce the same feelings of exhaustion, lack of control over the vasomotor system and disturbance of the gastro-intestinal tract which are noted in self-abuse. In both cases the symptoms promptly disappear upon proper regulation of life. This is a very different opinion from that which used to be expressed in this matter and it is given only after due deliberation and consultation of many authorities both in writing and orally. Its expression, far from taking away one of the best deterrent motives against the practice, rather forces an appeal to the manliness of the individual. The motive of fear never accomplishes much, while a frank statement of the real condition may be greatly helpful.

While the habit of self-abuse as indulged in by the ordinary individual practically never has the awful consequences that have been sometimes pictured as resulting from it even long after its cessation, there is no doubt that it is productive of many physical symptoms during the time of its indulgence. There is almost sure to be a discouraging lassitude and a tendency to exhaustion after even comparatively small efforts. While this is true for ordinary muscular efforts it is also true for other bodily functions that involve muscular activity. In recent years we have learned that of the stomach functions the motor is more important than the chemical. In the bowels the motor function is extremely important. There are likely to be disturbances, then, in the gastro-intestinal tract as a consequence of the muscular condition that {484} develops in those patients. Probably more important even than the physical, however, are the psychic results of the habit. The patient feels discouraged and cast down at his inability to conquer himself and is likely to avoid such exercise and diversion of mind as would make normal healthy function possible.

Mental Disturbances.—It is the custom to say that mental deterioration almost surely follows the habit. Those familiar with mental cases often see self-abuse practiced with serious results by young folks whose mentality is deteriorated. In these cases the practice was indulged in with great frequency and with direct physical consequences, such as loss of sleep, of appetite and the like. It is not the habit, however, that has caused the mental deterioration. The young patients are going crazy, but not because of self-abuse. Their habit of self-abuse had originated and become exaggerated because they were already mentally unbalanced. Their extreme indulgence in it is especially due to their lack of control over themselves, because they are not possessed of strong will power with regard to any thing. A vicious circle is formed and the insane young man gradually deepens his insanity by hurting his physical condition through over-indulgence in the habit and all this further lessens his self-control; but were it not for the original mental weakness the habit would not have been indulged in to so great an extent.

Effect on Prostate.—There is one phase of the ill effects of self-abuse that it is well to recall as having the confirmation of men of large experience and conservative views. There is a definite impression among specialists in genito-urinary diseases that enlargement of the prostate in some cases is due to the frequently repeated irritation and the prolongation of that irritation of the prostate during the practice of self-abuse. When such men as Bangs and Keyes are agreed on a subject of this kind, then even though in a certain number of cases the changes in the prostate leading to its enlargement are evidently inflammatory, it is well to consider that the functional over-activity of the gland superinduced by the practice may lead at least to an enlargement of the glandular elements with the consequent interference with urination which so frequently comes in old age.

Physical Factors.—Besides mental elements that predispose to the formation of sexual habits there are physical factors that are important in these cases. They must be particularly looked for and treated carefully if found, or there can be little hope of relief for the conditions. The most prominent of these is the existence of a long foreskin, especially if its opening is small, thus leading to the retention of urine, the deposition of urinary salts with the formation of preputial concretions or so-called calculi. These are intensely irritant, cause frequent itching and thus predispose to these sexual habits. Even where the preputial opening is free and allows egress of urine without residue, the accumulation of smegma often causes considerable irritation and if the most scrupulous cleanliness with cleansing at least once a day is not maintained, irritative conditions arise, especially in hot weather, that may give occasions for sex habits.

Under these conditions the habit is sometimes seen in extremely early years. The youngest case I ever saw occurred in a child not quite nineteen months old whose mother said that for several months she had noticed certain curious actions that she could scarcely understand until finally the truth dawned on her. Then she was morbidly sensitive about it, sure that the habit was due {485} to a fault of her own and it was some time before she consulted a physician. This was her fourth child and, strange as it may seem, it was only at the conception of this child that she first knew what sexual pleasure was. She feared that her feeling had been in some way sinful and that as a consequence of her sin this curious habit had developed in such early years in her baby boy. As is usually the case in these instances, I found that the prepuce was very tight indeed, having scarcely more than a pinhole opening in it. During urination this ballooned and there remained in the pouch-like process at the end of the penis a certain amount of residual urine after every urination. From this urinary salts had been precipitated and had formed scaly concretions which remained in the preputial pouch and were extremely irritant. As a consequence of this irritation the baby had been very itchy and it was in the endeavor to relieve the itching by the natural process of scratching that the pleasure of the sensations aroused had been discovered and the sexual habit had been formed.

Not infrequently in young men a condition resembling this to some degree at least is found and then, of course, the question of its removal must be taken up at once. It is surprising how often in youths in their late teens concretions are seen. The constant irritation makes it practically impossible for the patient to keep his hands from the parts, and so circumcision is absolutely necessary. Not infrequently when the preputial condition is not nearly so bad this operation may also be at least advisable if not necessary. The matter of cleanliness must be attended to, preferably after getting up in the morning and not before going to bed at night, for the reaction after cold water may cause congestion of the organ. After a time the frequent use of cold water seems to make the parts much less reactive to irritation of any kind.

Physical Effects.—The super-excitation of nerves consequent upon the more or less general erethism that is induced, lessens resistive vitality. Victims of the habit are more liable to colds, to various infectious diseases, and are subject to fatigue and lassitude, with incapacity to work to their full power. They lose control over their vasomotor system to some extent as a result of this systemic erethism. They blush easily, they perspire easily, there is a tendency in many of them to flash as if of heat and cold, they become pale under excitement or anger more than formerly, they are likely to suffer from cold hands and feet, and the surface of the body is inclined to be cold and as a consequence patients are tremulous. This represents a waste of nervous energy and as a consequence sleep may be disturbed and digestion interfered with.

It is important, therefore, to consider these cases as really needing medical care. For their treatment the most important consideration is prophylaxis, not alone of the habit itself, but of each of the acts. Prophylaxis of the habit is an ethical question that we can scarcely do justice to here. Prophylaxis of the acts requires consideration of the physical and moral factors that predispose to their commission. While the habit may have secured such deep control that the patient almost despairs of relief from it, when care is taken to remove physical and moral predispositions the conquest of the habit becomes comparatively easy. Over and over again I have seen cases that have lasted for years in which the patients were surprised at the ease with which they were able {486} to drop the habit just as soon as they took the measures necessary to prevent predisposing conditions.

Breaking the Habit.—Once physical factors predisposing to it are removed, the habit is not so hard to break as it would seem to be from the suggestions to that effect made in sensational literature. It is neither so deleterious in its physical effects nor so deteriorating as regards character as is usually stated. Anyone with a reasonable amount of firmness can break it off if he really resolves to. Over and over again I have seen patients quite surprised at the ease with which they were able to avoid the practice for weeks once they made up their minds in the matter. Indeed this is one of the unfortunate features in completely conquering the habit. It is comparatively so easy to break it off when the mind is made up that there comes the feeling that now it must be absolutely facile to keep away from it. This is, however, never true. Relapses are extremely easy. If the patient allows himself to read vicious books, or suggestive literature of any kind, or permits himself an indulgence in the reading of several columns of the account of a sex murder trial, or goes to see a sex problem play with its suggestions, or exposes himself to sexually exciting conditions of any kind, he will be almost sure to lapse into the old habit.

Relapses are almost inevitable. But it is easier to break the habit the second time than it was the first and it becomes increasingly easy if the patient keeps up the effort of regulating his life so as to avoid the occasions of the habit. Relapses are quite as sure to occur as with regard to alcoholism if occasions for the taking of liquor are not sedulously avoided. The patient always seems to need a confidant—someone to whom he can go for help and who assures him of the ability that he has to overcome himself if he only will. The practice of confession in the Roman Catholic Church makes it comparatively easy for serious people of that faith to overcome the habit. The physician must be taken into confidence in the same way and for a time, at least once a week, the patient may have to be perfectly frank with regard to his condition in order to have the help afforded by such confidences. The physician can often, particularly at the beginning, make the physical conditions such as to help in the breaking of the habit. Bromides taken to the extent of a dram or more a day are almost a specific for superirritability of the nervous system, and if taken for two or three weeks the patient will usually have little or no difficulty in overcoming the habit. They are not of much avail after this time unless the patient's character has been aroused to determined helpfulness in the matter.

In obstinate cases it may be necessary to have a patient come every day, or at least every second day, for some time and give an account of how he has succeeded in resisting his habit in the interval. At least he must be asked to report whenever there is a lapse. It is surprising how much the anticipation of having to tell someone else of a drop back into the habit means in helping the patient eventually to overcome it. Very slight motives serve to cause relapses, but almost any external personal aid, if pursued with confidence, will avail effectually to break it. I talk from an experience of many cases and know how much can be accomplished even though patients insist that they have tried all the resources of their will power and of prayer without avail. They have really not tried, they have not willed in reality; sometimes they {487} have reached a point where they cannot will without the moral support of another personality. This can be readily supplied to them by a firm, sympathetic physician whom they respect. It will take time to overcome the tendency to relapse whenever the will is relapsed, but the habit itself can be broken without much difficulty in a few days.

Certain times are particularly dangerous for relapses into the habit. These are just before going to sleep at night and before getting out of bed in the morning. At these times the mind must be occupied or else the patient will almost surely find his habit recurring. Often the habit of reading in bed, properly supported by pillows and with abundant light at an angle that makes reading easy, seems to be good for these patients, because they may read until their eyelids get heavy, then pull the chain of their light to extinguish it and turn over to sleep. In the morning prompt rising after waking is important. Bed clothes that are too heavy and too great warmth of clothing predispose to sexual excitation and must be avoided. The room should be cool rather than warm and the mattress rather hard.

The more tired the patient is the less liability will there be to difficulty in these matters. But air is even more important than exercise in giving the tiredness which superinduces deep sleep. A lessening of the normal amount of oxygen seems to relax the inhibitory power of the higher centers over the sexual centers in the cord. People who are drowned, those who are hanged, and those whose supply of oxygen is shut off by the inhalation of the heavier gases are likely to have involuntary seminal emissions. These are probably consequent upon the shutting off of the air.

The important element in the treatment is to make the patient feel that, if he really wants to, he can conquer in this matter. The old motives of fear, and especially fear of physical consequences, were quite unworthy, and inasmuch as they had any effect rather produced a deterioration of character than a strengthening of it. The patient must understand that if he is a man he can overcome it. Religious motives will help much. I do not know that I have ever seen a case where religious motives were not the most important element in the cure, but that may be due to the conditions in which I have been placed. I have seen a number of these cases in men and women because clergymen have sent them to me in order that they might be helped in the work of reform, and while there are many relapses and some had apparently given up the effort in despair of their power to overcome themselves, nine out of every ten of those who have seriously faced the problem have succeeded in overcoming themselves, and as a result have a better knowledge of their own characters and more respect for themselves. They are better men in every way than if their improvement had come about through selfish fear of physical consequences.

After Cure.—After the habit of self-abuse has been conquered the seminal vesicles will have a tendency to evacuate themselves rather more frequently than before and as a consequence they will nag at certain sexual nerve endings. They are used to having their contents emptied and distention is followed by rather ready evacuation. During the course of this evacuation sexual thoughts are awakened in dreams and this may lead to dream states in which there seem to be lapses into the old habit. This constitutes a serious difficulty in getting rid of the habit entirely in young and vigorous men. They may even become disheartened by it. It should be explained to them that they must let {488} contrary habits form gradually and permit nature to accommodate herself to the new state of affairs. The bromides are a useful adjunct for body and mind.

Supposed After-effects.—At times a patient suffering from some exhausting or serious disease, consumption, heart disease or the various forms of Bright's disease, will be discouraged by remembrance of the fact that in earlier years he allowed himself for some time to fall into the habit of self-abuse. If he has read, and very few men have not, some of the literature issued by the advertising "specialists" and has heard the unfortunately exaggerated ideas commonly entertained with regard to the influence on health of this habit, he will become more or less disheartened by the idea that he thus undermined his constitution and that one reason why he is not able to react better against his affection is that he seriously diminished his resistive vitality. This idea must, of course, be overcome or it will act as a constant source of unfavorable suggestion, lessening appetite, tending to disturb sleep, banishing peace of mind to some extent and thus inhibiting the patient from releasing such stores of vital energy for his recovery as would surely be in his power under favorable conditions.

Female Habits.—The habit is more rare in women than in men, but when it occurs is a little harder to break. In men it usually develops in youth, but oftenest in women who are past thirty-five and unmarried. In these cases it is much harder for the patient to regain self-control, because the class of women patients who acquire such a habit have less character, as a rule, than the men who fall into the same condition. In all sex matters, once passion is aroused or habit formed, the woman is likely to lose control of herself more than is the man. Even in women, however, it is not only possible, but under favorable circumstances, quite easy to secure a break in the habit, though relapses are more frequent than in men. Certain occupations seem particularly to favor the development of the habit. These are mainly sedentary occupations that can be followed without the necessity for such attention as to prevent the mind from wandering off into thoughts that may prove provocative of sexual sensation. Dressmakers seem particularly likely to suffer from the affection, and those who run sewing-machines are predisposed by the movements involved in their occupation to the development or, at least, to the persistence of the habit.

For women even more than men religion and the motives it supplies are the most efficient factors for the ultimate cure of the habit. In general, the greater difficulty of overcoming it in them is due in no small degree to the fact that they live indoors much more than men, often have sedentary occupations, and are more frequently alone. These afford opportunities for introspection and for the harboring of thoughts that lead to relapses into the habit. Besides, women are more prone to read novels and stories relating to sex problems and the details of sex murder trials and the like which constitute ever-recurring sources of mental erethism. If their habits can be modified, especially if they can be made to realize the necessity for being out in the air as much as possible, and for keeping their windows open at night, as well as for thorough cleanliness—for every gynecologist notes the necessity for this and how frequently it happens that neglect of it leads to irritability of the external organs that is of itself a serious factor—then it would be no more difficult for women to overcome the habit and get beyond the relapses than it is for men. {489} Sometimes we have to overcome a morbid dread of touching themselves even for cleansing purposes which allows the accumulation of irritant material and predisposes to relapse.

Sexual Perversion.—Sexual perversions are sometimes considered as different from sexual neuroses, but such they really are. They are oftener due to habit than to anything deeper. Much has been said about the unfortunate natural inclination of some people to indulge in sexual perversion, but such talk partakes of the nature of similar remarks with regard to habits of other kinds. The alcohol habit, for instance, is formed by many men as the result of their environment and a weakness of character, with lack of resolution to support themselves in self-denial when they are tempted to drink. In recent years it has been only too often the custom to excuse or to justify many of these cases. There are a few persons in whom, owing to weakness of character, alcoholism is more or less inevitable if occasions for indulgence occur. And in the same way there has been much maudlin sentimentality wasted on sexual perverts, as if most of these men could not avoid the actions that the rest of humanity abominates. There are, perhaps, a few individuals who because of a failure on the part of nature to define sex in them properly—as if she had not quite made up her mind which sex they should belong to—are more to be pitied than held to account for their delinquencies in this matter. Compared to the whole number of sexual perverts, however, these are very few. Under the protection of the pity awakened for these, a large number of others find quasi-justification for their acts.

Anyone who knows much about these patients realizes that their story is, as a rule, very different from what it would be if they were inevitably impelled to the commission of the acts in question. Many of them had the greatest abhorrence for it at the beginning, were attracted to it out of curiosity and morbid sexualism, because they had allowed themselves to think and read and dream about sex matters overmuch. They are usually idle people who do not take life seriously and who have an inordinate curiosity about sex subjects. At the beginning the commission of the perverted sexual act was associated with an intensely deterrent rather than an attractive feeling, but gradually this was overcome and a contrary habit has been formed. It is difficult to break this habit and to get away from the morbid sexual ideas that have been allowed to develop and grow strong in connection with it.

This opinion is somewhat different from that held by many men who are recognized as authorities on this subject and who find many excuses in the nature of their patients for these perversions. If it is recalled, however, that whenever wealth has brought luxury to a people and luxury has brought over-refinement, such sex perversions have been particularly noted, it will be realized that not nature, but the ways of men are responsible for their development. Whenever men pay much attention to their bodies, exercise for the sake of their muscles, bathe not for cleanliness but for luxury, sex perversions become common in history. The story of Greek love is well known. Corresponding conditions developed at Rome under similar circumstances. According to good authorities, the English universities became tainted with it a generation ago. Our athletic clubs in this country have rightly or wrongly fallen under suspicion in this matter, though the tendency to exaggeration with regard to such things, and popular credulity in such matters must be recalled. {490} Some confirmatory evidence undoubtedly there was. Sexual perversions then would seem to be due in most cases to definite conditions and our knowledge suggests readily what should be the prophylaxis.

In the course of some studies with Professor Magnan at L'Asile Ste Anne in Paris I saw a number of these curious cases of sexual divagations, exhibitionism, sex perversions and similar conditions. Some of his cases were clearly curious examples of natural tendency, at least, to mental hermaphroditism. Occasionally men of normal development otherwise have a woman's waist and woman's torso above the waist, and many womanly coquettish ways that point to this curious mixture of sexes. Occasionally women are lacking in all the sex characteristics of the upper portion of the body, have no breasts and have the hirsute characteristics of men on the face and even on the chest. In such cases one may be tempted to let one's pity override one's better judgment and feel that resistance to the temptations to indulge in perverted sexual feelings may be so difficult for these people as to be almost impossible. Even in such cases, however, under Magnan's gentle tutelage, under his faithful care and sympathy, men and women lost most of the tendency to commit unnatural acts and certainly found it easier to live normal lives than before.

For the majority of these sexual perverts, however, it is as with regard to drug addictions, alcoholism, and obesity, just a question of willing not to indulge in certain appetites that serves to help them. There is no doubt that it is a difficult matter to break a habit that has become a second nature, and it is almost impossible that it should be accomplished without a number of relapses. If the patient really wishes to correct the evil habit, however, this is perfectly possible.

The talk of a third sex with homo-sexual inclinations is quite beside the mark. Certain of this class have a weakness of intellect and of will that is at the root of their trouble, but not a few of them pride themselves on their intellect and will power in most other things and must not be permitted to deceive themselves as to their weakness and its significance. It is not nature but self that is at fault and the disease can be completely eradicated.{491}