Quackery: the role of scaremongering and peddling cures

Hare claimed that the masturbation-illness relationship was potentially initiated by quackery. Let us examine this in more detail than he did.

Onania or the Heinous Sin of Self- Pollution was first published by an anonymous author in 1716. The term Onania is a reference to Onan from the Hebrew bible, who was struck dead by God for spilling his seed rather than doing his family duty and impregnating his deceased brother's wife. The title page describes Onania as providing ‘spiritual and physical advice to those who have already injured themselves by this abominable practice.’

Stolberg (Reference Stolberg2000, Reference Stolberg2003) reports that in England a religiously inspired anti-masturbation campaign beginning in the late 1600s sowed the ground for this book but Onania introduced a medical slant into the campaign. A few years prior to Onania's appearance, a surgeon named John Marten published a treatise on venereal disease in which he also discussed the harmful consequences of masturbation. Marten's passages about masturbation were reprinted in Onania. Laqueur (Reference Laqueur2003) argues that John Marten was the anonymous author of Onania.

According to the author of Onania, it is alarming that so many people of both sexes regularly engage in this dangerous practice yet are not aware of the grave risk at which they are putting themselves. Its visible signs were enfeeblement and wasting away – including a pale complexion, loss of strength, and emaciation. Among the frightful consequences that could result from masturbation described in the book were epilepsy, consumption, impotence, imbecility, and death.

In the 4^th edition, first published in 1718, the anonymous author claimed that there are effective medicines for some of the ills consequent to ‘self-pollution’ such as discharges unrelated to venereal diseaseFootnote ^†Footnote ¹ and impotence. The author reported that he had intended to insert the prescriptions into the book but the ingredients were costly and hard to prepare. Rather than compelling users to admit their sin and ask an apothecary to make the medicines – perhaps imperfectly, the author had the medicines made by a trusted and competent physician. The author also asked this physician to distribute the medicines freely and to run some trials with them. After two years the medicines had been proven to work, but the physician was put at considerable expense. As a result, the author conferred to this physician the power to dispose of these medicines as he wished. Readers were informed that the medicines can be purchased in London at one of the bookshops where Onania was sold – and the author confided to the readers that he had forgone any share in the profits that might accrue.

Publishing pamphlets and newspaper advertisements that described ailments and then marketed medicinal cures was a common practice in eighteenth and nineteenth century England (Laqueur, Reference Laqueur2003; Stengers & Van Neck, Reference Stengers and Van Neck2001). Despite its obvious association with quackery, aided by continual advertisements in various publications, thousands of copies of Onania were sold and the term ‘onanism’ became synonymous with masturbation. The book also became the inspiration for imitators peddling their own cures.

These imitators were the main focus of Comfort's (Reference Comfort1969) examination of masturbatory panic in nineteenth century England. According to him, through the volume of their output, the pamphleteers had a greater influence on public opinion than did physicians. Comfort says the sheer volume of noise they generated drowned out less dire perspectives. In addition to charlatans drumming up panic about masturbation and promising a speedy cure – for a price, Comfort noted that some physicians joined the trade to take advantage of the easy profits that could be gained.

The pamphleteers helped both spread and maintain beliefs about the harmful effects of masturbation. Psychologically, if a claim is repeated enough, people assent to it. Even if the claim is unbelievable at first, as repetition leads to increasing consensus, the claim can seem increasingly rational (Hertwig, Gigerenzer, & Hoffrage, Reference Hertwig, Gigerenzer and Hoffrage1997). When what is being repeated is a speculative causal theory, and it is further ‘supported’ by clinical lore and experience, it could even seem self-evident.

Darby (Reference Darby2005) also documents how much of the anxiety regarding masturbation was moral panic focused on protecting children from the harmful consequences of ‘self-abuse’. Indeed Hall (Reference Hall1992) reports that the height of public anxiety about masturbation occurred in the decades prior to and just after 1900.

Many physicians who specialized in the treatment of mental illness and accepted the masturbation hypotheses as rational also condemned the pamphleteers as quacks. For example, Drysdale (Reference Drysdale1861) in criticizing ‘mercenary’ claims for cures, asserted that it is a disgrace to medicine that the disorders related to masturbation have become the trade of unscientific men, and even some physicians. Clouston (Reference Clouston1883) criticized what he labeled ‘shameful quack advertisements’ for fattening the vilest of mankind, aggravating those who suffer only minor effects of the vice, and introducing evil thoughts to those who would otherwise be free of them. Also writing about advertisements that ‘defile our walls and newspapers,’ Yellowlees (Reference Yellowlees and Tuke1892) reported that these imposters ‘trade on the fears of their victims in order to empty their pockets.’ They painted, he claimed, a frightening picture of the dangers of masturbation - including permanent insanity, but promise that a cure is available with the ‘priceless medicine that they alone can supply.’ (p. 784).

Hall (Reference Hall1992) also provides references to letters and editorials in The Lancet The Editors (1870) and The British Medical Journal The Editors (1892) that call attention to the problem of quack advertisements which create panic and then take advantage of readers by selling them cures. Interestingly, by the 1870s, these advertisements had become disreputable in London but continued to have success in rural newspapers. One editorial specifically criticized the newspaper publishers for being willing to print deceptive claims as long as those claims brought in advertising dollars.

Treating disorders not punishing crimes

The bridge between Marten's Onania and general medical practice was a 1760 book by the Swiss physician Samuel Tissot titled L'Onanisme.Footnote ² It was translated into English as Onanism: or, a Treatise upon the Disorders produced by Masturbation. An elite and well-connected physician, Tissot was a respected expert on smallpox and later became a celebrity throughout Europe as the author of the 1761 book Advice to the People About Health.

Tissot (Reference Tissot1760/1766) distanced himself from Onania by presenting his book as a medical, not a clerical tract. He said that his purpose was to write about the disorders occasioned by masturbation and emphasized loss of control over the habit throughout the book.

Tissot brought the danger of masturbation squarely into respectable medical discourse, in part by disputing contrary views that viewed masturbation benignly. Stengers and Van Neck (Reference Stengers and Van Neck2001) report that from the Middle Ages on, moral condemnation of masturbation was common, but there is almost no reference harmful physical consequences until the eighteenth century. In fact, in Galenic medicine, a primary concern was the danger of bodily fluids being corrupted – and the importance of evacuating them. Tissot disputed this view, arguing instead that the ‘seminal liquor’ is an essential humor. When first produced it is responsible for the production of secondary sex characteristics and increased vigor and if it is lost, the body cannot restore itself. The reason Eunuchs do not waste away like masturbators, said Tissot, is that their bodies have never benefited from the positive effects of the seminal fluid and therefore are not impoverished by its loss.

In the early eighteenth century, physicians shifted from viewing the physical basis of mental disorders as humoral to speculations about intestinal fermentations (‘the vapors’ and ‘the spleen’) and nerve vibrations. In the second half of the century, their focus shifted almost entirely to disorders of the nerves. In this vein, Tissot also noted that the continual obsession with masturbation fatigues the brain. He also added that the negative effects of masturbation were not inflicted equally on all, but more so for with those who inherited vulnerable constitutions.

One feature that stands out in the subsequent medical discourse, as emphasized by Hare, is the use of condemnatory language. For instance, Ellis (Reference Ellis1838) referred to masturbation as a vice and a disgusting habit, opining that the resulting wretchedness of those who practice it is the just reward of their own misconduct. Writing from the perspective of degeneration theory, Maudsley (Reference Maudsley1868), stated that physicians should not suggest that a conformed masturbator marry and have children because ‘… if he be not entirely impotent, what an outlook for any child begotten of such a degenerate stock! Has a being so degraded any right to curse a child with the inheritance of such a wretched descent? Far better that the vice and its consequences should die withFootnote ³ him’ (p. 158). Kellogg (Reference Kellogg1887) declared of masturbation: ‘It is worse than beastly…The most loathsome reptile, rolling in the slush and slime of its stagnant pool, would not bemean itself thus…A boy who is thus guilty, ought to be ashamed to look into the eyes of an honest dog’ (p. 339).

On the other hand, a point that Hare did not emphasize is that many physicians saw themselves as medical doctors who had a duty to care for patients. Religious and moral aversion to masturbation manifestly colored people's interpretations. However, whatever their moral qualms, some physicians saw it as their duty to treat the unwell. This tradition begins with Tissot, who, although referring to masturbation as ‘odious,’ ‘filthy,’ and an ‘abomination,’ claimed that he explicitly tried to avoid what he termed entering upon the moral part.

Such an attitude has an interesting parallel with the diagnosis of same-sex sexual attraction as a mental disorder in the mid-twentieth century. Even psychiatrists who were morally opposed to homosexuality, viewed their profession as having played a progressive role in defining it as a disorder rather than a criminal act subject to prosecution (Bayer, Reference Bayer1981). A similar attitude regarding masturbation was stated most explicitly by Tissot who claimed he set out to write about the disorders occasioned by masturbation, not about the crime of masturbation. In doing so, Tissot established the framework for many subsequent thinkers.

For instance, writing about the negative consequences of compulsive masturbation, Drysdale (Reference Drysdale1861) begins by quoting a passage from the French physician Lallemand: ‘Instead of blaming these unfortunates, ought we not rather to pity and still more to relieve them?’ (p. 89) Drysdale then states that that path of the true physician is to reverence and love every human being irrespective of their actions. Physicians, he asserted, should not hate, reproach or despise these individuals, but seek to benefit them to the utmost of their power.

It is also important to not divorce condemnatory language from its context. Certainly, the physicians were condemnatory about excessive masturbation. More in context, consider Ellis's above referenced claim about the wretchedness that results from masturbation being a ‘just reward.’ In the preceding sentence Ellis clearly stated that this what he would like to say to young people if he could take them on his daily rounds in the asylum and show them what awaits them if they continue this practice. It was as much a warning off as a condemnation.

Writing about young people who are vulnerable to developing a habit of hard-to-control masturbation, Clouston (Reference Clouston1883) refers to medical men as teachers of the truths of medico-psychology and physiology who can help them with counsel and knowledge, but unfortunately, he wrote, our help is too seldom called in. If these habits could be reduced among the rising generation, Clouston said, then ‘…life would be elevated in a large degree, self-respect would be increased, social intercourse would be sweetened, and its pleasures intensified, while the sting of self-accusation and remorse would be far fewer…’ (p. 342). Moreover, Clouston emphasized that although many cases do not recover, a majority of cases are treatable.Footnote ⁴

The insanity of masturbation replaced with successor diagnostic concepts

Inspired by the Toulmin's (Reference Toulmin1972) ideas about conceptual diversity and intellectual selection, Mace (Reference Mace and Sadler2002) argues that psychiatry can be identified with a shared pool of diagnostic concepts that have undergone transformation, division, combination, and replacement. In replacement, new conceptual variants are proposed, gain a competitive advantage, and supplant existing concepts. In this section we will suggest that some cases which once would have been diagnosed as masturbatory insanity were instead diagnosed with two new concepts – hebephrenia and neurasthenia.

Kendler and Engstrom (Reference Kendler and Engstrom2017) report that in the middle of the nineteenth century Karl Kahlbaum and Ewald Hecker argued that psychiatric diagnostic concepts represent only symptom clusters, not valid disease forms. In their view, diagnosing mania and melancholia is analogous to diagnosing a cough. Instead, they proposed that physicians should attend to natural history, i.e. the typical course of an illness and its outcome. With this in mind, in 1863 Kahlbaum introduced the concept of ‘hebephrenia’ to refer to a disorder that began in adolescence.

According to Kraam and Phillips (Reference Kraam and Phillips2012), a few years later using his own observations and Kahlbaum's notes, in 1871 Hecker published a detailed monograph including several case studies that provided the first actual description of the natural course of hebephrenia, i.e. mood disturbance, followed by excitement and agitation and progressing rapidly to an incurable dementia (i.e. disorganization) (Hecker and Kraam, Reference Hecker and Kraam2009a, Reference Hecker and Kraam2009b). Some of Hecker's cases featured masturbation as a precipitant. Kraam and Phillips argue that several attempts to deny the existence of hebephrenia over the next 20 or so years were futile as the concept was too compelling. It became institutionalized beginning in 1893 when Kraepelin incorporated it into his evolving notion of dementia praecox (and later as part of Bleuler's broader notion of schizophrenia).

The person who was the most explicit about a specific masturbation-related syndrome was the Superintendent of the Royal Edinburgh Asylum – David Skae (Reference Skae1863). Similar to Kahlbaum and Hecker, Skae was a practitioner, not a university-based psychiatrist. Like them, Skae claimed that diagnosing acute mania or melancholia is analogous to diagnosing a fever. In Skae's view, these are symptoms of disease, not diseases in themselves. The problem, noted Skae, is that we cannot refer mental symptoms to known diseases processes, but nevertheless by attending to precipitants, causes, course, and probable termination we can identify natural groups.

Skae proposed 25 natural groups, one of which was the mania of masturbation. Although, he claimed that masturbation refers only to the cause, Skae said it is associated with a characteristic natural history. It first manifests as imbecility and shy habits in youth, developing over time into suspicion, fear, dread, and suicidality, gradually progressing to fatuity or dementia. Later, Skae (Reference Skae1874) gave a more elaborate description of the insanity of masturbation in his Morosonian lectures, noting that if treatment begins before the mind has become too impaired to exert self-control, recovery is typical. If patients continue to masturbate after dementia begins, he reported that the prognosis is not hopeful.Footnote ⁵

Hare (Reference Hare1962) claimed that Skae's description of masturbatory insanity anticipated what would become hebephrenia. Had Skae not selected as a name the mania of masturbation, Hare said he would be remembered for giving one of the earliest descriptions of hebephrenia. This is plausible. Several of Hecker's studies mentioned excessive masturbation as a precipitant. In addition, the natural histories of hebephrenia and the insanity of masturbation are similar, involving onset in adolescence and potentially terminating in incurable dementia.

Hare said masturbation ceased to be seen as a cause of insanity in the final years of the nineteenth century, which implies the ground was passively ceded to hebephrenia. We would like to argue something slightly different, namely, that as hebephrenia became better known, it replaced the insanity of masturbation as the primary diagnosis whether or not one accepted the masturbation hypothesis.

In some respects, however, hebephrenia and the insanity of masturbation differ. For example, Skae's description of the insanity of masturbation included a gradual not a rapid onset. Skae and Clouston both reported that not all cases progress to an uncurable dementia. Clouston (Reference Clouston1883, Reference Clouston1888) specifically claimed that the insanity of masturbation is a disorder distinct from other early onset dementias. Masturbation-induced dementia, he said, has a specific character, – being solitary, unsocial, and impulsive. The salience of symptoms related to brain exhaustion, he thought, justify the insanity of masturbation being a primary diagnosis.

Masturbation-induced disorders were broad and protean, but there are a few consistencies that appear across the various descriptions, including Skae and Clouston's distinct insanity of masturbation. From Onania onward, the consequence of excessive masturbation included fatigue, loss of vigor, and wasting away. Masturbation practiced to the point of exhaustion was solitary and self-focused. Sufferers were described as physically emaciated and pale. Furthermore, dementia was only a possible outcome. These core features were not readily captured by hebephrenia.

However, another new concept may have created a diagnostic niche into which the some of the less severe cases of the insanity of masturbation could fit, namely, neurasthenia which was defined by Beard (Reference Beard1869) as exhaustion of the nervous system. Beard emphasized the physical nature of the disease, that it can be acute or chronic, and is more likely to occur in those with a hereditary disposition. That same year a similar description of neurasthenia was offered by Van Deusen (Reference Van Deusen1869).

Book length treatments of neurasthenia were published in England by Campbell (Reference Campbell1873) and in the U.S. by Beard (Reference Beard1880, Reference Beard1881) – each describing a cornucopia of possible consequences of nervous exhaustion. These descriptions included features previously attributed to masturbation such as malaise, blank facial expressions, involuntary seminal loss in men, and even death. They also included new features such increased sensitivity to stimuli and alcohol and drug abuse.

Neurasthenia became better known just about the time that Hare claimed that the insanity of masturbation declined while the masturbation hypothesis found new life by being proposed as the cause of neurosis. For example, Beard (Reference Beard1884) wrote a book called Sexual Neurasthenia (published posthumously) that allowed masturbation to be a precipitant in both neurasthenia and insanity.

Beard's view of masturbation's role, however, was not uniformly shared. Indeed, in his initial description of neurasthenia, Van Deusan asserted that masturbation could not even be considered a predisposing cause in any of the cases he reported.

Short of explicit claims on the part of physicians that what they use to diagnose as less severe forms of masturbation-related mental disorder was actually neurasthenia, however, this replacement notion is speculative. The closest thing we found is a report by Kosenko and Steger (Reference Kosenko and Steger2022) showing how as a medical student, in 1883 Anton Chekhov treated a patient who he considered to have a masturbation induced nervous disorder. Because the disorder did not progress to insanity, Chekov diagnosed it as neurasthenia instead.Footnote ⁶

Neurasthenia became a faddish diagnosis in the 1880s, increasingly psychological in nature, which sufferers readily self-applied. Wessely (Reference Wessely, Berrios and Porter1995) reports that people's willingness to pay for treatment helped the concept of neurasthenia to stay in use long past the introduction of its own successor concepts. The concept's popularity would be another possible reason that neurasthenia could have gained a competitive advantage and become a primary diagnosis, even though masturbation remained a possible precipitant according to some.Footnote ⁷

The arc of history?

The decline of diagnosing masturbation-induced mental disorder does not mean that ideas about the negative effects of masturbation were suddenly discarded. Watts (Reference Watts1972) reported that when he was a student in Canterbury in the 1920s, boys his age were given the impression that masturbation could result in many dreadful consequences including syphilis, epilepsy, and death. Furthermore, when Kenneth Kendler was interviewing patients with schizophrenia in the West of Ireland for the Roscommon Family Studies in the 1980s, he was struck at the guilt about masturbation in male patients. He recalls that the level of self-repugnance described by many of these patients was painful to listen to and far beyond the scope of any attempts at reassurance.

Hare adopted a somewhat triumphalist tone when he argued that contemporary psychiatry can see beyond the many fallacies that supported the masturbation hypothesis and would not repeat such mistakes. In our view, it would be difficult for the concept of a specific masturbatory mental disorder to regain a competitive advantage over the categories in the DSM and the ICD or the factor analytic dimensions of the psychologists if for no other reason than that introducing new disorders into the classifications require meeting a high bar of validating evidence (Kendler, Kupfer, Narrow, Phillips, & Fawcett, Reference Kendler, Kupfer, Narrow, Phillips and Fawcett2009).

In other respects, Hare may have been overly confident about being beyond the errors of the past. This article began by briefly describing the views of contemporary advocates for abstaining from masturbation. The similarity between these views and some eighteenth and nineteenth century views would raise doubts about an assertion that the masturbation hypothesis has been so completely disproven that it is gone for good and beyond resurgence. If some could gain benefits from making seemingly implausible claims about disorders, and they are repeated enough, such claims could seem increasingly plausible. Especially if the claims could be further linked with risks to children, we suspect quack treatments would probably not be far behind.