At the same time these medical authors were developing new theories of medicine, concern over onanism was increasing. The concept of onanism is based on the story in Genesis 38:7-10 of Onan, who, following the Levirate custom, was supposed to take over the wife of his deceased brother Er, who had been killed by Jehovah. In addition, Onan was sup posed to impregnate his sister-in-law, which he was ordered to do by his father Judah:

And Onan knew that the seed should not be his;

and it came to pass, when he went in unto his brother's wife, that he spilled it on the ground, lest that he should give seed to his brother. And the thing which he did displeased the Lord; wherefore He slew him also.

Though the story has often been interpreted as a prohibition against masturbation, the act described is coitus interruptus; the punishment seems to have been meted out not so much for Onan's having spilled the seed as for his having refused to obey the Levirate requirement that he take his brother's wife as his own.

Around 1700 an anonymous writer, perhaps in London, wrote a work in English dealing with onania. This had a wide circulation and was translated into several languages. The first U.S. edition was published in Boston in 1724 under the title of Onania; or, the Heinous Sin of Self-Pollution, and all its Frightful Consequences, in both Sexes, Considered. With Spiritual and Physical Advice to those, who have already injur'd themselves by this Abominable Practice. And Seasonable Admonition to the Youth (of both SEXES) and those whose Tuition they are under, whether Parents, Guardians, Masters, or Mistresses. To which is Added, A Letter from a Lady (very curious) Concerning the Use and Abuse of the Marriage-Bed. With the Author's Answer thereto. The author attributed a number of "corruptions of the body" to "self-pollution," including palsies, distempers, consumptions, gleets, fluxes, ulcers, fits, madness, childlessness, and even death itself. Some of these ideas were derived from Boerhaave, but the author went so far as to imply that onanism could affect offspring, who were likely to be born sickly and ailing.

A copy of the book eventually passed into the hands of the distinguished Swiss physician Simon André Tissot, doctor to a pope, a correspondent of François Voltaire and Jean Jacques Rousseau, and a researcher very much interested in the prevention of disease. In Lausanne, Tissot (1758) had printed his own Tentamen de Morbis ex Manusturpatione, which went through many editions and translations. Later editions, including Tissot's own French version, were entitled Onanism. The English translation by A. Hume was published in 1776. There were many printings and editions in most Western languages.

Although he considered the earlier treatise on onania truly chaotic and the author's reflections nothing but theological and moral trivialities, Tissot did adopt some of the concepts it contained (including the association of sexual activity with insanity). More important, he put onanism into the theoretical medical framework of the day. Tissot believed that the physical body suffered from continual wastage, and unless this was periodically restored, death would result. Much could naturally be restored through nutrition, but even with an adequate diet the body could waste away through diarrhea, loss of blood, and, more important for the purposes of this chapter, seminal emission. The importance of semen to the male, Tissot observed, was documented by the effect it had on physiognomy, because semen was what caused the beard to grow and the muscles to thicken. Proof of this influence came from the fact that these physiognomic effects could be eliminated by amputation of the testicles. Though Tissot recognized that semen was lost in the process of "replenishing" the human race, he held that too great a loss (from too great a frequency) was dangerous and hence sexual intercourse had to be limited if health was to be preserved. Tissot asserted that involuntary emissions such as "wet dreams" were also weakening. Most dangerous, however, was the "unnatural loss" of semen through masturbation.

Masturbation (or onanism) comprised a broad category of sexual activities. For men, it included all seminal emissions not intended for procreation, and thus in effect every sexual activity not leading to procreation was not only a cause of illness but an illness in itself. Tissot defined the sequelae of masturbation as the following: (1) cloudiness of ideas and sometimes even madness; (2) decay of bodily powers, resulting in coughs, fevers, and consumption; (3) acute pains in the head, rheumatic pains, and an aching numbness; (4) pimples on the face, suppurating blisters on the nose, breast, and thighs, and painful itching; (5) eventual weakness of the power of generation, as indicated by impotence, premature ejaculation, gonorrhea, priapism, and tumors in the bladder; and (6) disordering of the intestines resulting in constipation, hemorrhoids, and so forth. Though Tissot recognized that not everyone addicted to onanism was so cruelly punished, he felt that most were, and that everyone was afflicted to some degree or another.

Onanism affected women even more than men because in addition to most of the male sequelae, onanism left women subject to hysterical fits, incurable jaundice, violent stomach cramps, pains in the nose, ulceration of the matrix, and uterine tremors that deprived them of decency and reason by lowering them to the level of the most lascivious and vicious brutes. Even worse than simple masturbation in women was mutual clitoral manipulation that caused them to love one another with as much fondness and jealousy as they did men. Onanism was far more pernicious than excesses in simple fornication, although both were dangerous. Onanism was particularly debilitating to those who had not yet attained puberty, because it tended to destroy the mental faculties by putting a great strain on the nervous system.

Tissot's explanation gained a number of followers not only because it fit into some of the general medical theories, but because it was consistent with general superficial observations. It also tied into the general anxiety about sexual activity that was so much a part of the Western Christian tradition.

Many of the sequelae that Tissot associated with onanism we now know derive from sexually transmitted diseases such as syphilis, gonorrhea, genital herpes, and others, all of which at that time were often explained by the concept of onanism. Moreover, it was observed that individuals in some mental institutions frequently masturbated, as did those who were developmentally disabled, and rather than being regarded as a consequence of institutionalization, it was believed to be a cause. The decline in male potency and sexual activities with age were indicative, according to Tissot's theory, of the dangers of having lost semen or vital fluids earlier in life. The neatness of Tissot's explanation was that it not only squared with current medical theory but explained so many previously unexplained illnesses and diseases.

In sum, if a syndrome can be defined as the concurrence or running together of signs and symptoms into a recognizable pattern, then onanism furnished such a pattern. As Tristam Engelhardt (1974) put it, onanism was more than a simple pattern, because a cause was attributed to the syndrome, providing an etiologic framework for a disease entity. If the development of the concept of disease is seen as a progression from a collection of signs and symptoms to their interrelation in a recognized causal mechanism, then the disease of onanism was fairly well evolved.

Once established as a disease entity, onanism had a long and varied life, adapting to new developments in medicine and in society. One of the leading exponents of Tissot's ideas was Benjamin Rush (1794-8), the dominant medical figure in the United States of the late eighteenth and early nineteenth centuries. Rush, after studying in Edinburgh, returned to the United States to introduce a variation of John Brown's medical beliefs whereby all disease was considered to be the result of either a diminution or an increase of nervous energy. Because sexual intercourse was a major cause of excitement, careless indulgence in sex inevitably led to a number of problems, including seminal weakness, impotence, dysuria, tabes dorsalis, pulmonary consumption, dyspepsia, dimness of sight, vertigo, epilepsy, hypochondriasis, loss of memory, manalgia, fatuity, and death. Rush, however, also cautioned against abnormal restraint in sexual matters because it too could produce dangers.

The syndrome of onanism was seized on by a wide variety of popularizers as well, some physicians and some not. In the United States, Sylvester Graham (1838) concluded that excessive sexual desire led to insanity, and insanity itself incited excessive sexual desire. In fact, the influence of sexual desire was so pervasive that it could disturb all the functions of the system, causing a general debility. Claude-François Lallemand, a French surgeon, was concerned with the involuntary loss of male semen, spermatorrhea, which he felt would lead to insanity. This caused his U.S. translator (1839) to report that 55 of the 407 patients in the Massachusetts State Lunatic Hospital at Worcester had become insane from the effects of masturbation.

William Acton (1871), an English physician, had a somewhat different view of the dangers of sexual activity, arguing that God had made women indifferent to sex in order to prevent men's vital energy from being totally depleted. John Harvey Kellogg (1882), another popularizer in the United States, held that the nervous shock accompanying use of the sexual organs was the most profound to which the nervous system was subject, and even those who engaged in procreation would have to place rigid limitations on themselves or else insanity would result.

Because the dangers of sexual activity were so great, one problem with the new syndrome was to explain why the human race had not died out earlier. George M. Beard (1884) believed that it had not been necessary for earlier generations to be so concerned about excessive sexual activity because their lives had been simpler. It was the growing complexity of modern civilization and evolutionary development that put so much stress on men and women. Consequently, a larger and larger number of them were suffering from nervous exhaustion. This exhaustion, he held, was particularly serious among the educated and intelligent workers in society, who represented a higher stage on the evolutionary scale than the lower social classes. In other words, as humanity advanced, it became more and more necessary to save nervous energy.

Those who were unable to control their sexuality not only would suffer physical debilities but would become homosexuals, which was a consequence of youthful masturbation according to such nineteenth-century writers as John Ware (1879), Joseph Howe (1889), James Foster Scott (1899), and Xavier Bourgeois (1873). The alleged correlation of sexual activity with nervous energy, which in turn was associated with intellectual development, led some writers such as Edward Clarke (1874) to argue that, because menstruation was a result of nerve stimulation, women should not engage in mental activity at all. Some even argued that menstruation itself was pathological.

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