MASTURI3ATIOX (ONAYISNI*) It seems justifiable to include masturbation in the group of heredi tary neuropathie phenomena, because it is a pathologic condition only when practised to excess and because this is the case practically ex clusively in psychopathic individuals.
There is a difference of opinion whether masturbation is very com mon among children or not, partly because there is no agreement on the definition of what shall be called masturbation in the child. Accord ing to Lindner, Hirsehsprung and others, it is not rare even among infants and is more frequent in girls than in boys. But according to these two authors any state of voluptuous excitement constitutes masturbation, even when the excitement is brought about not by direct, irritation of the genitalia but by sucking movements with the lips, suck ing the fingers, the arm, the bedclothes or part of the clothing, or by rubbing or pulling at the ears, picking the nose, scratching the scalp or other similar manipulations.
While these vicious habits, which belong among the stereotypias, are no doubt frequently the result of a neuropathic disposition, we shall reserve the diagnosis of masturbation for cases in which there is actual irritation of the genitalia with a resulting orgasm. In eases occurring (luring the first months or years of life, that is, before there is even a suspicion of sexual feeling—be it ever so abnormally premature and indistinct—v(-e must assume the existence of some organic cause in the genitalia. The most frequent sources of irritation probably arc inter triginous processes in the vulva accompanied by itching and, according to a. wide-spread belief, oxyuris vermieularis, the worms being some times found in the vulva, whither they migrate from the anus. The pleasurable relief from itching, which is at first the only; result of scratching and rubbing the vulva and pressing the thighs together, soon engenders a habit that is persisted in on account of the voluptuous sensations which it excites.* This, however, is not the way children usually begin the bad habit of masturbation. As a rule it is not until some years later, when the child goes to school and is old enough to have a vague, indefinite idea of sexual things, that it first discovers, either by accident or through a playmate, that manipulation of the sexual organs is productive of voluptuous sensations. In itself this is neither morbid nor harmful unless masturbation is indulged in to excess. It has already been stated that the latter occurs almost exclusively in otherwise abnormal children; opinions are divided, however, whether masturbation in such individuals possesses merely the significance of a symptom, or whether it plays a more or less important part in the etiology of the neuropathic constitu tion by exhausting the nervous system with the repeated excitations terminating in an orgasm. The point is undoubtedly a difficult one to decide, and the arguments offered on either side appear to be based on theoretical considerations rather than on accurate clinical observation. The case reported by Tobler, for example, of a little girl six years old, a member of a healthy family, who kept up excessive masturbation for years without any bad effect on her general health, shows that one is not justified in attributing pallor, a sickly appearance with dark rings around the eyes, headache, an uncertain and capricious disposition, and all sorts of nervous symptoms in a child to a 11101'C or less proble matical habit of masturbation. We must always assume (in such cases)
that there is a congenital weakness of the central 11CIWOUS system. It cannot of course bc altogether denied that in the presence of such it predisposition repeated, violent sexual excitement may add to the mis chief; it must be remembered, however, that as a matter of experience— recently confirmed by II. Neumann—the effects of excessive masturba tion in small children are comparatively slight. As we are accustomed to regard the nervous system in early childhood as peculiarly sensitive, the fact is worth bearing in mind and should make us scrutinize our cases more critically. Incidentally we may briefly remark that the writers of popular literature on masturbation 1.1letau and others) fairly revel in exaggerated and most harmful descriptions of the consequences of masturbation.
It is evident from what has been said that the diagnosis of mastur bation is quite easy when one has an opportunity of witnessing the act, and in the case of children such opportunities are numb more frequent than in the case of older individuals. Descriptions of the act by the parents, particularly if they have themselves indulged in masturbation, must be accepted with reserve.
The prognosis &Tends on the degree of neuropathic constitution present and on the duration of the disorder; it is most favorable in those cases in which sexual sensations have not yet developed.
The treatment in the case of young children, before sexual feeling has begun, consists in finding and removing the source of irritation and in preventing the act by means of suitable night clothes, bandages, or some s.pecial contrivance such as a pad between the thighs to keep them apart during sleep. In this way the habit is gradually broken up and eradicated.
In older children these mere prohibitive measures are usually insuffi cient, partly because it is, practically impossible to keep the child under constant supervision day and night (in school, in the water-closet, etc.), and partly because even the prevention of the act no longer suffices to eliminate the psychic component (psychic masturbation), which has by that time become more important. In addition to explanation and supervision, dietetic and especially psychic treatment must be instituted with the object not merely of suppressing the perverted imaginative activities, but, by diverting the child's thoughts into other channels and encouraging normal emotions and interests, of gradually di:placing the harmful concepts by healthy mental images. In this respect the treatment of masturbation is the same as that of all other psychopathic phenomena (manifestations).