These symptoms, however, are not effects of the long prepuce, but are results of the neurotic influence of concentration of mind on it. It will often be advisable, in young men particularly, to have circ.u.mcision performed, but in most cases this is unnecessary, and if the patient can be made to understand how the symptoms have developed he will learn a precious lesson in not interfering with his functions by over-attention to them. Of course, there are many surgeons who will continue to hold, as they seem to now, that nature was quite at fault in the production of this organ and that it should be removed in nearly every human being. The majority of men, however, have lived their lives quite well and happily without such intervention and there are certain inconveniences attached to the condition which remains after operation that may in their way be quite as bothersome as the symptoms due to the long foreskin.

Psychic Impotence.--An important s.e.xual neurosis, at least in the eyes of sufferers from it, is what physicians have come to know as psychic impotence. Young married men, because of over-anxiety with regard to themselves for a number of reasons, but without any physical factor to disturb them, find it impossible to complete the s.e.xual act. Naturally this creates a serious disturbance of mind. The patient will either hurry to a physician at some place on his wedding tour, or his wedding tour will be shortened and he will return to consult a friend. He presents a lively picture of despair. He has not been sleeping, his appet.i.te is disturbed, he feels la.s.situde and weakness, and if he has a lively imagination he is inclined to think that the fatal termination of some serious nervous disease of which he has heard, and which is accompanied by the symptom of s.e.xual impotence, is impending over him. His condition is quite pitiable, though largely imaginary.

_Rea.s.surance_.--The treatment of the condition is not so difficult as it might seem if the patient has a reasonable confidence in his physician. If he {476} goes to an advertising "specialist," as occasionally happens, because he concludes that the ordinary physician cannot know all the details of these intricately complex nervous diseases, he is sure to suffer severely in general health before cure is obtained. His morbid ideas will be fostered because he is ready to pay any amount of money in order to stop the progress of the presumed serious disease. An investigation of these "specialists" in New York, made a few years ago by a committee of the New York County Medical Society, showed to what an extent the terrors of these unfortunate patients are exploited for monetary reasons.

A physician of even a little experience in these matters, however, recognizes at once the entirely neurotic character of the case and by rea.s.surance soon enables the young man to dispel many of his worst terrors. His general health can be regulated, his constipation, which so frequently exists, is relieved, and he can be told, what is very true, that the excitement consequent upon the preparations for his wedding and the exhaustion due to the overwork so frequently necessary in order to enable him to take the time off for his wedding journey, have made him so nervously irritable that the ordinary mechanism of the s.e.xual act, which is extremely delicate and requires nice co-ordination for proper function, has been disturbed. Just as soon as this fatigue and the over-excitement of mind consequent upon the unfortunate experience are mitigated his potency will return. This a.s.surance can be given almost at once.

His fears, however, will delay his recovery. His dread of incapacity will become an obsession. Probably the most effective means of treating this is to forbid him to attempt the s.e.xual act for a definite length of time, say two or three weeks. This must be impressed upon him. There is a good reason for insisting that he shall not irritate his already excited s.e.xual system by such attempts.

Usually at the end of a week or ten days he will come back with a smiling look of confidence in himself and his physician, to confess that he has violated the injunction, but that he was not disappointed as before.

_Subconscious Obsession_.--In most of these cases the young men have been victims of s.e.x habits of some kind or of drug addictions, and they have heard that occasionally individuals who have had such experiences may suffer from s.e.xual impotence later in life. This is a strong suggestion to them and in some cases becomes a haunting obsession, and produces the unfavorable effect upon the organism. It is necessary to remove this obsession before a cure can be effected.

The patient's confidence must be obtained and the physician's personality and persuasive powers used to change his point of view.

Occasionally I have seen cases in which the patients themselves seem to be scarcely aware of this strong suggestion or obsession at work in them. It seemed to be more or less subconscious. An idea with regard to the evil effects of the old habit had been implanted and remained in their minds, occasionally making itself felt but more often apparently lying dormant. In these cases it is important that the physician should make this underlying factor clear to the patient. In some of these cases hypnosis is necessary. Usually the hypnoidal condition, with suggestions in the waking state, is all that is necessary and ordinary suggestions will often effect the purpose completely.

Organic Impotence.--Certain forms of s.e.xual impotence are really preliminary signs of serious organic nervous disease. Sometimes it is the first {477} symptom of paresis or of locomotor ataxia. Oftener it is a very early symptom of syphilitic spinal myelitis. In practically all of these cases, however, there is a history of syphilis and the presence of this should always be a warning not to think of functional or psychic impotence until the possible influence of the syphilis itself or of some of the parasyphilitic diseases is thoroughly excluded. Unfortunately, not a few people who have had syphilis are nervous and anxious about themselves and by their very antic.i.p.ation of possible developments may auto-suggest themselves into a state in which these symptoms will develop. It is cases of neurasthenia that develop after secondary syphilis in persons who have been studying syphilis and its possible effects, which present the most difficult problems in diagnosis that come to the nerve specialist. Many simulated symptoms are unconsciously developed and this makes differential diagnosis extremely hard. As a rule, the psychic impotence is merely functional and patients need rea.s.surance more than anything else.

Nocturnal Emissions.--One of the s.e.xual neuroses that gives rise to a high degree of solicitude centers around the question of involuntary seminal emissions. Young men who are living normal healthy lives and who are in robust health with no indulgence of s.e.xuality are likely to experience more or less regular involuntary emissions. If for any reason they become nervous or anxious about their s.e.xual functions, especially at times when they are under much mental strain, these phenomena of emptying the seminal vesicles may occur rather frequently. If they have been reading some of the literature, or hearing some of the exaggerated notions that are often expressed with regard to the evil effects that may come from this, they are likely to suffer much mental anxiety over it. Occasionally they lose sleep, frequently they feel so wearied and worried the day after the occurrence as to be disturbed at their work, sometimes they are sure they are so tired that they are unable to fulfill their ordinary duties, and I suppose every physician has known young men who were even sure that the loss of the seminal fluid was seriously interfering with health, hampering many physical functions and bringing them to an untimely grave. They had no appet.i.te and in consequence of not eating enough they were constipated and then a whole round of physical troubles, headache, la.s.situde, over-fatigue, to which they are almost sure to add loss or disturbance of memory, began to annoy them.

In those cases it is not the physical effect of any loss of seminal fluid that is the disturbing factor of their health, but their worry over the losses. Just as soon as their minds can be taken off the subject, the supposed physical effects begin to disappear. So long as the solicitude continues the emissions themselves increase in number and the condition is made worse. These patients must be taught that in every normal healthy man in whom there is no regular occasion for the emptying of the seminal vesicles, nature provides for an evacuation about every ten days or two weeks. In some it is more frequent than this. In those who are much indoors and in whom oxidation processes are low this emptying takes place more frequently. In those who lead a sedentary life with the consumption of much proteid food the same thing seems to be true. Any anxiety about it is sure to cause frequent repet.i.tion of the evacuation processes. Over-solicitude about the bladder will have just the same effect. If the patient will take his mind off the subject, will eat normally, will get out in the air more than before, tiring himself thoroughly {478} if he is young and vigorous, and will not allow the s.e.xual side of his being to be excited by stories or pictures, plays or voluntary thoughts, his affliction will soon disappear.

_Prophylaxis_.--Certain directions are helpful and by occupying the patient's mind will overcome certain physical factors that underlie the affection. It is important that the bladder should not be allowed to be full, above all, not to be over-distended at night. Some care should be exercised in not taking too much to drink shortly before going to bed and the bladder should be faithfully emptied before retiring. The weight of a large amount of urine in the bladder pressing down upon the seminal vesicles situated below and behind it causes them to contract rather easily. This is particularly true if the patient sleeps on his back and occasionally in certain over-irritable patients for a time at least an arrangement may have to be made by means of small pillows that will prevent him from sleeping on his back. On the other hand, it must not be forgotten that too great abstinence from fluid will cause the urine to be more concentrated and this will irritate the bladder and either wake the patient up at night, which of itself is undesirable, or else will cause congestion in the prostatic region which will irritate the seminal vesicles to the point of evacuation. While five or six gla.s.ses of water a day should be taken besides the ordinary fluid taken at meals, the only regulation necessary is of the amount of fluid taken in the evening after the last meal, that is, if more than three hours intervene before retiring for the night.

Besides the physical conditions in the bladder, an acc.u.mulation of fecal material in the r.e.c.t.u.m may cause irritation of the seminal vesicles. It is important, moreover, to remember that thoroughly free movements of the bowels, by preventing to a great extent the reabsorption of material from the intestines which may prove irritant when excreted through the kidneys and when present in the bladder, is of itself an excellent therapeutic measure in cases of irritability of the genital organs. The setting of the patient's mind to thinking about his r.e.c.t.u.m, his bowels, and his bladder instead of his genital tract is an excellent psychotherapeutic measure that will soon bear fruit.

The consumption of various foods, condiments and drinks enters into the underlying condition which produces frequent emissions. We have already suggested that the use of a large amount of proteid materials, especially in people who live a sedentary life, often predisposes to this condition. An abundance of the carbohydrates, however, by supplying more heat than is necessary may have a like effect. Certain spices seem to predispose to irritability of the s.e.xual system. Red pepper has always seemed to those who saw much of these cases to be particularly at fault. Mustard, curries, peppers generally, however, and even other spices seem to have a corresponding effect. As a rule, young folks suffering from this disturbance or from the tendency to eroticism in other ways should be warned about this irritation of spices. In neurotic individuals tea and especially coffee has the same effect. Probably this is only an indirect influence of tea upon the nerve centers, making them more irritable, but coffee, by raising the blood pressure, seems to have a direct unfavorable effect.

All alcoholic drinks are contraindicated in these cases and must be forbidden. Certain of them seem to be more harmful than others.

According to French tradition warm wine or mulled ale as it is used in England is {479} especially likely to excite s.e.xuality. Warm alcoholic drinks of any kind are absorbed more rapidly than are cool drinks, which is the main reason in modern times for having these liquids cooled so that they will not be absorbed too rapidly and disturb the equilibrium. Champagne also has, by tradition, a special effect, sometimes said to be due to the increased hyperemia of the stomach induced by the carbonic acid gas and the consequent more rapid absorption.

The prohibition of spices and alcoholic drinks has a good effect in itself. It acts constantly as a suggestion to the necessity for care and guard over one's self. Besides the exercise of self-denial necessary to keep away from the use of such substances, especially under present social conditions, is of itself a good training that strengthens the will against certain tendencies to indulgence in s.e.xual thoughts which predispose to the frequent emptying of the seminal vesicles.

_Erotic Dreams_.--Very often these nocturnal seminal emissions are a.s.sociated with erotic dreams. Patients are inclined to attribute the occurrence of these dreams to some fault of their own or to consider that they are at least in some way responsible for them. This thought often becomes a source of serious worry, making their condition worse.

A study of this question has convinced me that in most cases there is practically no responsibility in the matter. Pressure on the seminal vesicles by an over-full bladder, or a distended r.e.c.t.u.m, leads to the production of nervous stimuli around which the erotic dream-ideas gather. A straightforward explanation of this will relieve many patients' minds, and keep them from bothering about the subject in such a way as to make their genital tract even more sensitive than it is because of their concentration of attention on it.

s.e.xual Mental Troubles.--In our generation s.e.x occupies a great deal of attention. s.e.xual tendencies are emphasized by suggestive reading of all kinds and by forced attention to s.e.x matters. Most of the successful novels deal with the so-called s.e.x problem, our plays are to a great extent s.e.x problem plays and our newspapers are full of s.e.x crimes and s.e.xual divagations of many kinds. This acts as a strong incitement to s.e.xuality and represents exactly the opposite of what nature intended in the matter. As a consequence, all the tendencies to over-solicitude with regard to s.e.xual affections and all that instability of mind and over-reaction to all forms of irritation that comes in the midst of s.e.xual excitation are noted. This seriously disturbs the minds of many patients and makes their health as well as their morals worse than they should be. The neurotic conditions seen in those who occupy their leisure with erotic subjects are fostered by this unfortunate over-attention to s.e.xual matters. For general prophylaxis the physician needs to throw all the weight of his influence toward the correction of unfortunate tendencies in our present-day life and healthier subjects of thought should be encouraged.

We often hear it said in our time that the great fact of life is s.e.x.

Indeed, this has been insisted on _ad nauseam_ in recent years. There is no doubt that without the s.e.x element the race would not continue under the present dispensation. If s.e.xual feelings did not mean so much to the generality of men and women it is doubtful whether marriage would be the success that it is, though so much is said nowadays about its failure. The a.n.a.logy with all the beings lower in the scale than man shows how imperative and prominent {480} in life this instinct is and how much it signifies. Those who insist so much, however, on s.e.x as the one great fact of life seem to forget that there are many other natural functions of quite as much importance to the individual at least, if not to the race. Without eating neither the individual nor the race could go on. Neither would the race go on without eliminating waste products. If there is one thing that our consideration of the problems of psychotherapy has made clear it is that whenever any of these animal facts of life is made much of and occupies attention to the exclusion of higher ideas, there is sure to be trouble. It matters not how apparently automatic and completely spontaneous a function may be, if exaggerated attention is given to it, it is sure to be disturbed in its functions and cause serious troubles in the organism.

There is no need further to ill.u.s.trate this with regard to such physiological necessities as feeding and excretion. At present the world is much occupied with s.e.x problems because, unfortunately, its attention has been focused on this subject. Physicians, particularly if they are paying attention to nervous patients, are likely to know many individuals who have food problems, diet problems, digestion problems, bowel problems, and many others of similar nature because they have been focusing their attention on these functions of their being.

The most distinguished psychiatrist of our generation, certainly the man whose works have done most to open up new vistas for us in mental diseases and who has added not only new knowledge but new possibilities of development, visited this country not long since and said, "Oh! here in America you are s.e.x mad." He added, "I knew that we were madly following s.e.x problems in Europe, but I thought that in this country, with so many other things to occupy the minds of men and women, you were not bothered so much with s.e.x problems." What he said represents the impression of nearly every thoughtful foreigner who is surprised to find that wealth and luxury have brought to us this same degenerate interest in things s.e.xual that occupies the so-called upper cla.s.ses and their imitators in Europe.

Livy, the Roman historian, said long ago, "Whenever women become ashamed of the things they should not be ashamed of, it will not be long before they will begin not to be ashamed of the things they should be ashamed of." Whenever in history men and women have occupied themselves, not with the rearing of families, but with the suppression of families to as great an extent as possible, s.e.x problems have always become emphasized. The woman who is a mother, and especially many times a mother, usually has no trouble at all about s.e.x problems and no tendency to have "affinities." With her there is usually no question of s.e.x as the central factor of life nor of any other of the curious nonsense that has been talked about this matter as the result of giving s.e.x a place of importance that it does not deserve. Until there is a reform in this matter we can look for many "neurotic, erotic and tommy-rotic" tendencies, as they have been called, due to over-attention to one set of organs. Any organic system in the body would be disturbed by such attention, but the s.e.xual system is particularly susceptible to suggestion.

The state of affairs thus emphasized is the result of interfering with an animal instinct. It will make itself felt properly and secure the due exercises of function if allowed to pursue the even tenor of its way under reasonable {481} control, but if it is fostered, thought about, discussed, excited in various ways, pampered by indulgence and perversion, it runs away with nature. The gourmet who constantly thinks about food, plans new modes of exciting the appet.i.te, studies savors and odors in order to satisfy a palate that has been artificially stimulated, gets a certain animal enjoyment out of his food that other people do not; but he usually overeats, loses his appet.i.te, and with it any real satisfaction in eating, and suffers from indigestion as a consequence of indulgence, so that the suffering much more than compensates for any slight additional pleasure that he has enjoyed. Besides, man is an essentially intellectual being, and occupation with the things of sense, that will manage themselves very well if let alone, takes up just so much of the precious time that should be devoted to other things to attain that satisfaction that makes life well worth living. s.e.xuality cultivated with the degree of attention that certain people devote to feeding, becomes a pest, ruins intellectual effort, hurts initiative, leads to the most serious disappointments in life and is the most fruitful cause of despondency and suicide that we have besides being the origin of many social evils that still further complicate life.

One great modern nation has debauched its literature to such an extent that probably the major portion of its books treat of s.e.x and s.e.x problems. Practically all of its esthetic expression has been seriously hurt by the same fault. Its painting, its sculpture, its dramatics, its art of all kinds, have all gone the same road. The result is seen in the lowered moral fiber of its people. A recent census report showed that the nation has reduced some 20,000 in numbers and that this was only the beginning of the race suicide. They have been thinking, talking, writing, painting, chiseling, acting s.e.x problems, but in the only phase of life in which s.e.x really counts it has been so pushed into the background or perverted that there it is failing utterly to accomplish its one legitimate purpose. The younger generation as they grow up are given the idea that they are missing the most wonderful thing in life unless they have memorable s.e.x experiences. These experiences must be varied in order to satisfy the artificial appet.i.te that has been created. As a consequence, family life and the real meaning of love and the affection of man for woman rooted in the depths of their nature is spoiled by mere animal pa.s.sion and its pa.s.sing expression.

Nature's own att.i.tude with regard to over-attention to s.e.x matters must not be forgotten. The purely s.e.xual organs have been pushed into the background to as great an extent as possible and are intimately a.s.sociated in both s.e.xes with one of the two ugly excretory functions, urination, and placed in close relationship with the structures which subtend the other--defecation. Evidently nature intended that they should be the subject of as little attention as possible.

Unfortunately, the paying of attention to them to any great extent lessens somewhat of the disgust naturally aroused by the excretory functions with which they are a.s.sociated. Nature has provided as far as possible for deterrence from over-interest. One might expect that cleanliness and the cultivation of the feelings of refinement would serve as auxiliaries in the repression of s.e.x indulgence. The lessons of history are that usually the great bathing nations have been most s.e.xually divagant. Among the Greeks and the Romans the ugliest s.e.x habits and proclivities found a place--among peoples who devoted themselves to the cleanliness of the body. The cla.s.ses {482} who bathe most are often those with the strongest tendency to s.e.xuality.

Refinement instead of lessening the tendency to s.e.xual indulgence rather increases it.

Education and the development of intellectuality, far from being a barrier to s.e.xual divagations, seem to predispose to the exaggeration of the significance of s.e.x in life, unless the individual has a well-balanced character or has been thoroughly grounded in ethical principles. The ugly stories of Greek love at a time when the Greeks were at the climax of culture, as well as what we know about the relations of the freedmen to their masters among the Romans during the cla.s.sical period, is all confirmed by the revelations of corresponding tendencies in recent generations among the intellectual cla.s.ses even at the universities. Development of mind apparently does not neutralize to any extent these s.e.xual tendencies. Evidently the rule of life for health's sake must be to push s.e.xuality as much into the background of the mind as nature has put the s.e.x organs in the human body. Reason does not protect knowledge but increases suggestion. Only absorbing occupation of mind with other subjects that will bring about neglect of these functions, as of all other physiological functions, leaving them to nature, serves to keep them in their proper place and condition.

CHAPTER III

s.e.xUAL HABITS

As was emphasized in the preceding chapter, s.e.xual 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 s.e.xual habits. The consequence is that the patient is in highly nervous condition, has lost his appet.i.te, 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 pa.s.sing 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 s.e.xual 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 a.s.sured 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 s.e.xual intercourse. It is possible for s.e.xual 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 la.s.situde 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 appet.i.te 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 s.e.xual 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 s.e.xual habits. Even where the preputial opening is free and allows egress of urine without residue, the acc.u.mulation of s.m.e.g.m.a 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 s.e.x 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 s.e.xual 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 p.e.n.i.s 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 s.e.xual 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 circ.u.mcision 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 la.s.situde, 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.