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"This work owes its existence to observations of the effects of therapeutic suggestion upon individuals subject to contrary sexuality. The favorable results obtained in "congenital" urnings by psychical treatment in the hypnotic state placed before me the alternative either to assume that suggestion is capable of influencing congenital abnormalities of the mind or to prove that in the idea of homo-sexuality at present prevalent the hereditary factor is overestimated, to the disadvantage of educational influences."--Therapeautic Suggestion in Psychopathia Sexualis (1898) by Albert von Schrenck-Notzing

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Therapeautic Suggestion in Psychopathia Sexualis With Special Reference to Contrary Sexual Instinct (1898) is a book on sexual pathology by Albert von Schrenck-Notzing and Charles Gilbert Chaddock.

Contents 1 Full text 2 I. SEXUAL HYPERESTHESIA. 3 II. SEXUAL IMPOTENCE AND ANESTHESIA. 4 III. SEXUAL PARiESTHESIA. 4.1 CHAPTER VII. 4.2 CHAPTER VIII. 4.3 CHAPTER IX. 4.4 CHAPTER X. 4.5 CHAPTER XI. 5 See also

Full text

PREFACE.

This work owes its existence to observations of the effects of therapeutic suggestion upon individuals subject to contrary sexuahty. The favorable results obtained in " congenital" urn- ings by psychical treatment in the hypnotic state placed before me tlie alternative eitlier to assume that suggestion is capable of influencing congenital abnormalities of the mind or to prove that in the idea of homo-sexuality at present prevalent the hereditary factor is overestimated, to the disadvantage of educa- tional influences. Thus it became necessary to examine more carefully the etiology and patliogenesis of the perverse tenden- cies of the sexual life. Onanism and functional (psychical or relative) impotence, as constant accompaniments of sexual per- versions, likewise demanded more thorough study ; and in this work, in separate sections, they are considered both patliologi- cally and therapeutically, as far as is necessary for an under- standing of paraesthesia sexualis.

But the phenomena of sexual anaesthesia and uranism in the female sex could be given but brief consideration, first, because in medical practice and social life they have attained nothing like the importance of male homo-sexuality ; and, secondly, because, owing to the infrequency of these anomalies, I have had no opi)ortunity for personal observation of tliem.

Thus, the title of the book, strictly speaking, does not correspond exactly with its contents ; for it emphasizes only the therapeutic aspect, and should really be : " Pathological and Suggestive Therapeutic Studies of the Abnormal Manifestations of the Sexual Instinct.^ But the title used was chosen for tlie sake of brevity, and to indicate that the studies of the patho- logical side of the subject became essential only from a thera- peutic stand-])oint ; in other words, that, to a certain extent, they are the foundation for a correct comprehension of the therapeutics of the subject.

Among the most important tasks confronting neuro-

(V)

1 PREFACE.

pathology, and one offering richest returns, is undoubtedly the establishment of precise indications for the employment of psychical therapeutics ; to whicli Wilhelm Erb, witli clearness of view, has lately called attention, botli ^vitll reference to psy- chical treatment in the waking state, as well as to hypnotic suggestion/ Tliough, in spite of the obstinate opposition and continued indifference of prominent cHnicians, all the greater series of exi)eriments of late years agree in demonstrating that with necessary precautions hypnotic suggestion, used for reme- dial purposes, after the methods of " Liebeault, Bernheim, and Forel," is an effective and harmless therapeutic agent ; " and though thus the question concerning the justification of hyp- notic suggestion and its admission among the available' means of our thempeutic armamentarium may at last be regarded as settled, yet the exact determination of the sphere of thera- peutic operation of hypnotic suggestion may be regarded as the second importiint part of the problem to be solved. Experi- mentation in the most heterogeneous domains of disease external and internal, organic and functional has now to establish a place for systematic application of suggestion in functional disturbances of certain kinds, by the side of other remedial measures, with exact valuation and comparison.

' Wilhelm Erb, " Die nacliten Aufgaben der Nervenpathologie," Deutsche Zeitschrift for Nervenheilkunde, Vogel, Leipzig, 1891, p. 3.

' (a) Comp. RlDgier : Erfolge des therapeutlechen Hypnotismus in der Landpraxis (Lehmann, Manchen, 1891). The author reviews 210 cases in his practice, which fulfill all requirements with reference to details of description, numerical grouping, continuance of obserratioD after discharge, etc. He has never seen hypnosis have an injurious influence.

(&) Van Renterghem and von Eeden : Comte rendu des rdsultats obtenus pendant la premiere pi-rlode bisannuclle, 1887-1889 (Brussels, Manceaux). The authors, whose clinic I visited in 1891, likewise testify to the innocuousness of therapeutic hypnosis, and were able to add nearly 1000 cases to the 414 cases of the article cited, which had since been studied.

(c) Wetterstrand, according to his work, " Der Hypnotismus und Seine Anwendung in der praktlschen Medicin " (Urban und Schwarzenberg, Leipzig and Vienna), in the course of the last few years, has^ubjected 3200 persons to hypnotic procedures, and induced hypnosis some 60,000 times, without observing any injurious results.

(d) Von Corval (" Suggestivctheraple," Realencyclopadie der gesammten Heil- kunde, von Eulenburg, Encycloj^d. Jahrbiicher, Bd. i. Urban and Sihwarzoiiborg) gives a complete review of this branch of therapeutics, and, from his own as well as from the experience of others in general, comes to the conclusion that hypnosis, correctly employed, U unaccompanied by any danger.

PREFACE. Vli

If, as Erb justly remarks, this limitation to certain fields dispels many illusions ; still, the results of such investigations are incomparably more valuable to science than the generaliza- tion which looks upon suggestion as a " panacea." Thus it will be necessary next to arrange the suggestive-therapeutic material after the manner as yet used but by two observers, Van Renterghem and Ringier (compare foot-note), which is followed in tliis work.

The duration of the effects of suggestive treatment seems of great importance. Like Ringier, the author gave especial

(e) Miiide, iu bis learned work, " Ueber Hypnotismus " (Diepolder, Muucbeii, 1891), which is supplied with many important proofs taken from literature (p. 62), speaks of the " dangers " of inducing hypnosis. According to him, these result from light-minded play, thoughtless exi)erimentation, and the desire to satisfy curiosity and vanity by public ex- hibitions for amusement, and they are usually to be ascribed to dilettaiitie awkwardness or incorrect methods, or to auto-suggestion in the subjects. Minde also thinks (p. 66) these dangers may all be avoided with proper care. f

(/) Prof, von Krafft-Ebing expresses his views on this point in his last article on hypnotism ("Zur Verwerthung der Suggestionstherapie in Psychosen und Neurosen," Wiener klin. Wochenschrift, 1891, No. 43), iu the following words : "Treatment by hyp- notic suggestion, according to my experience, I must state, is Innocuous when it is scien- tifically employed with due reference to the circumstances of the individual case."

{g) Prej'er (Hypnotismus, " Vorlesungen," Urban and Schwarzenberg, Leipzig and Vienna, 1890, p. 146) also warmly commends the employment of hypnotic suggestion, and thinks that " it can have an injurious effect only when unskillfullj' used."

(K) Li6beault, who during thirty years has hypnotized 10,000 persons (some of them more than 100 times), ascribes his early " petits malheurs " to incorrect procedure; and with proper precaution he has never observed untoward effects to follow hypnosis. Comp. Revue de I'hypnot., i, p. 105 rf teq.

(i) Professor Bernheim, from his observations on several thousand patients, has lately expressed himself as follows : " Stiggedion often cures ; when it docs not cure, it ameli- orates ; and if it does not benefit, it is still harmless." Comp. Hypuotisme, Suggestion, Psy- chotherapie, Doin, Paris, 1891, p. 18.

(jfc) Grossniann used hypnosis in 30 cases of influenza, and found the legend of Its dangers unconfirmed ; on the contrary, he characterizes suggestion as a powerful means of cure. Comp. Grossmann, Die Enfolge der Suggestionstherapie bei Influenza, Brieger, Berlin, 1892, p. 2.

(0 Professor Hirt (Brcslau), from Augu.t, 1889, to the middle of April, 1890, made hypnotic experiments for therapeutic purposes oji 598 persons. More than 4000 sittings have proved to him that hypnosis is never accompanied by harmful effects, even when frequently induced in the same individual. On the other hand, Hirt is greatly opjM)sed to allowing the laity and unqualified persons to practice it ; and he warns against premature and erro- neous judgments of it, which are only too willingly credited by those unqualified to form an opinion. Comp. Wiener med. Wochenschrift, 1890, Nos. 27 and :W.

(m) The evidence mentioned is augmented by the wide experiences of Forel, Moll, and numerous other experimenters, all of which leads Ui the conclusion that, with pro|)er individualization of hypnotism for therapeutic purposes, it is devoid of any disadvantages.

Observations of the author on more than 300 iKTScms, of whom many were hypno- tized more than 100 times and some 200 or 300 times, also speak in favor of the barm- lessuess of therapeutic suggestion.

Vm PREFACE.

attention to the duration of the suggestive-thcmijeutic results after cessation of treatment. Many of the patients were very soon beyond observation, and therefore, with the best of will, it was impossible to obtain late reports of all of them. Never- theless, it has been possible for the author, as it has been for Prof, von KmfFt-Ebin<^, to continue to observe many patients for seveml years after cessation of treatment. In one of the author's cases the time of observation after discharge was two years and seven months, and in several other cases about one year and eight months. Thus the tables here are made to indicate cases of " recovery with later reports," and cases of " recovery without later reports."

Where possible, for the sake of objectivity, I have allowed patients to speak for themselves, and give their letters verbatim. The custom, which is certainly justified, of believing in the reality of disease in many cases only when a pathologico-ana- tomical substratum is appreciable and demonstrable to our senses, even with but slight functional disturbance, has led many physicians to regard, in a one-sided manner, states of subjective disturbance without such substratum in many patients ; and to distrust their testimony concerning subjective symptoms, as well as their statements concerning favorable changes in such symp- toms. Self-deception in the patient, unconscious auto-suggestion on the part of the physician, exaggeration of the results on both sides, and many similar phrases are not infrequently heard instead of well-founded objections. In reply to this it may be stated: The reader may form his own judgment of the conscientiousness and objectivity of the descriptions, from the histories of the cases. On this point I fear that by pedantic communication of details which, perhaps, are interesting only in a negative way, I have made great demand upon the patience of my readers; but I hope that my effort to describe actual facts as exactly as possible will at least receive recognition. As for the second objection, an opponent using such an argument would also be driven to deny the existence of ])ain, for which we have no appreciable objective substratum. But what other evidences of pain are there than the statements and gestures of

PREFACE. IX

the patient, which also hold for the majority of disturbances of the sensory sphere, for psychoses, etc. ^ And though a com- mendable attempt has lately been made to establisli objective signs in certain cases of neurasthenia, still, in his work, Lowen- feld^ designates neurasthenia as that affection for whicli the veiy absence of objective symptoms is characteristic. The untenable- ness of such objections as those mentioned is so evident that more extended discussion of them would be superfluous.

It may be questioned whether it is justifiable to discuss the anomalies of the sexual instinct apart, instead of treating of them in their proper place in psychiatry. As a rule, tljey are certainly only symptoms of a constitutional malady or of a weakened state of the brain, which present themselves in the various forms of sexual perversion.

Moreover, attention has been directed to the baneful influ- ence possibly exerted by such publications as " Psychopathia Sexualis." To be sure, the appearance of seven editions of the book could not be accounted for, were its circulation confined to scientific circles. Therefore, it is not to be denied that a pornographic interest on the part of the public is accountable for a part of its wide circulation. But, in spite of this disad- vantage, the injury done by implanting knowledge of sexual pathology in unqualified individuals is not to be compared with the good accomplished. History shows that uranism was very wide-spread long before the appearance of " Psychopathia Sexualis." The courts have constantly to deal with sexual crimes, in which the responsibility of the accused comes in question. For the physician himself, the sexual anomalies, treated as they are in text-books on psychiatry in a distant manner, are in greater part a ierra incognita. Exact knowledge of the causes and conditions of development of sexual aberra- tions, and of the influence on them of liereditary constitution, education, the impressions of every-day life, and our modem, refined civilization, is the pre-requisite for a rational prophy- laxis of sexual aberrations and a correct sexual education. Without careful study of the circumstances which attend the

' Ldwenfeld : Die obJectiveD Zeicben dcr Neurasthenle, Lehmann, Mtlnchen, 1893.

X PREFACE.

development of sexual anoraalies, we should never be in a po- sition to use effectual therapeutic means. The majority of these unfortunate patients von Krafft-Ebing calls them Nature's step-children are devoid of insight into their malady ; like in- sane patients destitute of understiinding of the ethical develoi)- ment of man, they are happy in their abnormal instinctive tendency. For this reason, in spite of the great prevalence of uranism, very few of its subjects seek medical treatment. Wliile the terminal forms of abnormal sexuality end in asylums for the insane, the doubtful cases, in which incompleteness of development or apparent viciousness renders correct diagnosis difficult, make up the majority. But a thorough knowledge of the aberrations of the sexual instinct is absolutely indispensable to the jurist. The reasons given are thus sufficiently important to prove the need for a hand-book on " psycliopathia sexualis."

But a thorough treatment of the subject seems even more important in the light of the theory of suggestion. Thanks to therapeutic nihilism, which, unfortunately, still finds numerous adherents among physicians, until now such patients have re- mained the life-long victims of tlieir imperative feelings, and not infrequently have finally seen themselves placed before the alternatives of the prison or the asylum ; to say nothing of a consciousness, ever more acutely felt with advancing years, of a useless existence, at least, as far as the foundation of a family is concerned.

By means of suggestion, especially by its application in the hypnotic state, the possibility this much may be said with cer- tainty from the seventy cases detailed in this work is demon- strated to us that aberrations of instinctive life from its proper channel may be corrected.

The manifestations mentioned may be regarded as impera- tive sensations and imperative ideas, which occur either as pure auto-suggestion or have their origin in organic conditions. The ideational stimuli, induced in the brain by suggestion from an- other, are in a measure imperative ideas in statu nascendi, which assisted by the law of the ideomotor and ideodynamic reflex transference, with individually suitable and correct > wording,

PREFACE. XI

and, in case of necessity, with cumulative application in re- peated sittings gradually gain irresistible power over the pa- tients, and thus finally assume auto-suggestive direction of their conduct. According to this we are able to remove by sugges- tion abnormal moods, affects, feelings, instincts, ideas, and even hallucinations and illusions. The suggestive influence, liow- ever, reaches its limits in inherited constitution or ])redis- position of the brain, liuving its root in organic conditions; and likewise in " phenomena having a very deep foundation in the psychical mechanism " (von Krafl't-Ebing).

The proof offered by me in this book, that a much larger proportion of sexual aberrations than has heretofore been pre- sumed is, in pathogenesis, to be referred to external conditions (accidental causes, education), opens to psycho-therapeutics a much wider field in this class of cases, with points of departure essentially much more favorable. In spite of the great difficul- ties which frequently enough attend the treatment of such pa- tients, it will become a hopeful and productive task for the therapeutics of the future.

For the stimulus to the study of this subject, I am espe- cially indebted to the well-known work of Prof von Krafft- Ebing, which has been constantly by my side as a guide in these questions ; ' and if in some points the results of my studies do not accord with those of my highly-honored teacher, my indebtedness is thus increased, since in the cases of his book I found the way indicated which has been followed in this work.

The humane purpose of this work with reference to ther- apeutics, as well as the effort to arrive at an unprejudiced ex- planation and truth, should be sufficient to overcome any scru- ples to which the sexual character of the subject might give rise. This circumstance made it especially obligatory for the author to carefully avoid anything like a popular style of ex- pression, and to preserve as carefully as possible, in spirit and letter, the scientific character of tlie work.

When one considers tlie difficulties which suggestive ther- apeutics has still to encounter in the larger part of the public, and how few psycho-sexual cases apply to the physician, not to

Xll PREFACE.

sj^eak of their asking for treatment, esi)ecially hypnotic treat- ment, then a series of seventy cases, therapeutically considered, forms a basis, in a measure, sufficient for the ibrmation of a judgment concerning the prospect of cure of such patients, especially when the long duration and care of observation in a number of cases is also taken into account.

Of the 70 therapeutic observations detailed in tliis work, 22 have already appeared in various publications, journals, books, etc., viz. : Cases 9, 31, 32, 39, 40, 41, 42, 43, 44, 45, 46, 47, 50, 53, 54, 55, 56, 57, 58, 59, 60, 61.

Twenty-four cases have been placed at my disposal, in manuscript, for use in this work, by recognized specialists in the field of suggestive thera))eutics, viz. : Cases 1, 2, 3, 4, 5, 6, 7, 8, 17, 19, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 48, 49, 51, 52.

In addition, there are 24 cases of my own, of which but one has yet been published (in von Krafft-Ebing's "Psychopathia Sexualis,"), viz.: Cases 10, 11, 12, 13, 14, 15, 16, 18, 20, 33, 34, 35, 36, 37, 38, 62, 63, 64, 65, 66, 67, 68, 69, 70.

As a rule, the authors made use of the Beraheim-Liebeault methods of hypnosis, where nothing particular is stated on this point.

In order to estimate the depth of hypnosis, Liebeault has recommended its division into six degrees. Professor Bernhcim into nine, and Professor Forel into three. The material of this work is arranged in accordance with the division into three degrees, and follows this schema :

I. Sonmolence. The individual but slightly influenced, with the use of all his energy is still able to resist the sugges- tion and open his eyes. Consciousness intact.

II. Hypotaxia. The individual is no longer able to resist suggestions. No amnesia.

III. Somnamhuliam} With the manifestations of the

' In order to give an idea of the susceptibility to hypnosis in general, I give here tbe numerical rcsulta of several authors for comparison with my own, under the foregoing classification. My results, up to November, 1890, among the people of Munich, were as follow :

PREFACE.

XUl

second degree there is also amnesia, or susceptibility to hallu- cination, or botli.

Post-liypnotic phcMiomena occur with somnambulism, and even with the second degree.

Finally, it is my pleasant duty to acknowledge in this place my indebtedness to all those who, by their co-oi)eration in any way, have assisted in the production of this book ; espe- cially to my honored guide and teacher in the domain of sug- gestive therapeutics, Dr. Forel, Professor of Psychiatry in Ziirich, to whom the work is dedicated; and, further, to Dr. R. von Krafft-Ebing, Professor of Psychiatry and Neurology in Vienna, for his repeated encouragement and advice.

Besides those named, I have been assisted in the prepara- tion of this work by means of patients kindly sent to me, by unpublished histories of cases placed at my disposal, and by Ijiterary communications and advice by the following gentle-

Persons. Per Cent.

Refractory, . . . 29 = 12.08

Somnolence, 42 = 17.5

Hypotaxis, 100 = 41.67

Somnambulism, _69 = 28.75

240 100.00

The results at Nancy (Li6beault), Amsterdam (Van Renterghem), and In Switwr- land (Ringier), in comparison, are as follow:

Li^beanlt. 1011 Persons.

Li^beanlt, 7S3 Persons.

Van Renterghem, 178 Persons.

Ringier, 221 Persons.

Sohrenck-

Notsing, 240 Persons.

Refractory .... Somnolence . . . Hypotaxis .... Somnambulism .

Per Cent.

2.67

3.26

78.04

16.02

Per Cent. 7.97 10.09 ft3.21 18.73

Per Cent.

3.93

5.06

79.77

11.24

Per Cent.

5.43

7.24

52.49

34.84

Per Cent. 12.08 17.50 41.67 28.75

iW.W

100.00

100.00

100.00

100.00

According to my preliminary summary, the susceptibility to hypnosis of 8705 per- sons, of various nationalities, is shown by the following figures :

Persons. Per Cent

Refractory, 519 = 6

Somnolence, 2557 = 29

Hypotaxis, 4316 = 49

Somnambulism, 1313 = 15

8705 100

Advanced years, on the whole, diminish Busceptibllity, while the figures for earliest youth do not quite reach those for middle life.

XIV PREFACE.

men: Dr. Hcriiheim, Professor of IntcMual Mediciiu' at Nancy; Dr. Stiimpf, Professor of Pliilosopliy (Municli); Dr. Gussnuui (Stuttjjart); the prival-docenten^ Dr. Kopp (Munich) and Dr. Max Dcssoir (BerUn); Dr. Liebeault (Nancy); Dr. Wetter- strand (Stockhohn) ; Dr. Van llenterghem (Amsterdam); Dr. Rosenberg (Carlsrnhe) ; Dr. von Hosslin (Neuwittelsbach, near Municli) ; Max OfFner (Municli) ; and Mr. X. X., urning.

1 here express my thanks to them all for their friendly and helpful co-operation.

The Author.

MCNICB, October, 1894.

TRANSLATOR'S PREFACE.

The favorable reception given von KrafFt-Ebiiig'sPsyclio- pathia Scxualis " induced me to undertake an Englisli version of tlie work by von Schrenck-Notzing. The views for which the latter contends so ably are in striking contrast witli those held by von Krafft-Ebing, and, for that reason, this work deserves to be placed in English by the side of " Psychopath ia Sexualis." The importance of the question treated in these works cannot be overestimated ; for upon tlie decision concern- ing the influence of congenital and educational factors must rest the theory and art of human culture. In the study of these perversions a wide field is opened to view, disclosing pos- sibilities which therapeutic nihilism looked upon as dreams.

As a contribution to the literature of suggestive thera- peutics this work stands without a rival, in view of the duration of the observation of reported cures.

A growing experience in cases of sexual perversion but tends to confirm me in von Schrenck-Notzing's views, and I hope soon to make an original contribution to the literature of this subject.

The medico-legal question of responsibility in sexual per- versions is one of great importance, and, as here clearly shown, is to be decided not by the fact of perversion, but by the psychical condition as a whole.

Charles Gilbert Chaddock, M.D.

St. I/OUis, Mo..

December, 1894.

(XV)

TABLE OF CONTENTS.

PAGE

Preface, iii-xiv

SECTION I.

Sexual Hyperesthesia, 1-77

CHAPTER I. Pathology, 1-33

A. Onanism, 2

Causes and predisposition, 3 ; forms, 7 ; onanism by means of tactile excitation, 7 ; througli psychical stimuli, 9 ; through combination of both, 12 ; dangers and results of onanism, 15 ; diagnosis, 26 ; prognosis, 27. ,

B. Satyriasis and Nymphomania, 28

Causes and symptoms, 29 ; diagnosis and prognosis, 33.

CHAPTER II.

Therapeutic Suggestion in the Treatment of Abnormal Inten- sification OF Sexual Desire, ' 34-50

Sexual prophylaxis and education, 34 ; other methods of treatment, 42 ; psychical treatment in the waking state, 44 ; suggestive psycho- therapy, 46.

CHAPTER III.

Cases illustrating Suggestive Treatment of Sexual Hypefuss-

thesia, 51-77

Onanism through tactile stimuli, Cases 1 to 16, 51 ; onanism through psychical stimuli. Cases 17 and 18, 64 ; satyriasis and nympho- mania. Cases 19 and 20, 68 ; tabular review, 73 ; conclusions, 74.

SECTION II.

Sexual Impotence and AN.a:sTUESiA, 78-116

CHAPTER IT^*

Pathology, / . . . . 78-91

Physiology, 78; causes and forms of K jpotence, 79; female impo- tence, 84 ; diagnosis, 90 ; prognosis,

(xvii)

Xviii TABLE OF CONTENTS.

CHAPTER V.

PAOB

The RdLE of Suggkstivb Therapeutics in the Treatment of

Functional Sexual Weakness, .... 92-98 Methods of treatment, 92 ; suggestion in the method of Brown- 86quard, 93 ; psychotherupy, 94 ; waking suggestion and hypnotic treatment, 96.

CHAPTER VI.

Cases illustratinq Suooestive Treatment op Some Forms of

Impotence, 99-116

Therapeutic results in psychical, functional, relative, and paralytic impotence. Cases 21 to 88, 99 ; tabular review, 114 ; conclusions, 118.

SECTION III.

Sexual Pakssthesia, 117-305

CHAPTER VII.

The Forms of Sexual Perversion with Reference to the

Theory of von Krafft-Ebing, 117-123

Definitions and classification, 117 ; inversion of sexual feeling, 118 ; perverse activity of the sexual instinct without reference to its object, 120.

CHAPTER VIII.

The History of the Development of Contrary Sexual Feeling

among the Ancients, 123-144

Age and extent of sexual inversion, 123 ; historical conditions of development, 124 ; pederasty as a cause of homo-sexuality and castra- tion, 126 ; eunuchism, 128 ; the historical origin of uranism in Europe, 180 ; Greek boy-love, 180 ; impure male-love in Greece, 185 ; O^Xcta voDcoi, 136 ; spontaneous origin and cultivation of the feminine type in the male, 137 ; views of some ancient writers concerning the pathicus, 189; conclusions, 142.

CHAPTER IX.

Heredity and Education in theie Etiological Relations to Sex- ual Perversions, 145-191

Importance of heredity, 145 ; hereditary predisposition in general, 146; predisposition and pathogenetic excitants, 147; heredity and exciting causes in insanity, 148 ; development of sexual instinct, 150 ; pathological determination of undifferentiated sexual feeling by ex- ternal excitants, 151 ; hereditary lack of resistive power, and patho- logical associiCtion, 154 ; psycho-sexual diseases, moral insanity, and

TABLE OF CONTENTS. xix

weak-mindedness, 155 ; transitional cases and lessened responsibility, 157 ; sexual instinct in imbeciles, 158 ; original disposition in parses- thcsia sexualis, and its proofs, 158; objections, 160; the etiological ' role of educational factors and imagination, 161 ; the exciting causes in histories of urnings and other sexual perverts, 167 ; conclusions, 190.

CHAPTER X. Diagnosis and Prognosis, 192-196

Remarks on perverse activity, original disposition, accessory causes, and neuropathic and psychopathic symptoms, 192 ; dependence of prognosis upon the causes of origin, 195.

CHAPTER XL

Psychical and Suggestive Treatment of Sexual Perversion, 197-209

Consciousness of moral duty as a prophylactic, with remarks on education in morals, from the stand -point of the theory of sugges- tion, 197 ; other means for the prevention of sexual errors, 202 ; should urnings be treated? 203; marriage, 203; onanism and ex- citing causes, 204 ; psycho-therapeutics in cases of perverse instinct, 205 ; regulated sexual intercourse, 206 suggestive treatment in hypnosis, 208.

CHAPTER XII.

Histories illustrating Suggestive Therapeutics in Perversions

OF THE Sexual Instinct, 210-305

Psycho-sexual hermaphroditism, Cases 39 to 45, 210 ; contrary sexual instinct. Cases 46 to 59, 217 ; algolagny. Cases 60 and 61, 230 ; con- trary sexual instinct, Cases 62 to 67, 232 ; algolagny. Cases 68 to 70, 291 ; tabular review, 803 ; conclusions, 302.

Appendix, 307-319

I. SEXUAL HYPERESTHESIA.

CHAPTER I. PATHOLOGY.

The great importance of premature excitation of sexual feelings, with the masturbation usually accompanying it, in the production of psycho -sexual abnormalities, justifies an exami- nation here of its causes and their nature. In his classification of the cerebrally conditioned sexual neuroses, von Krafft-Ebing correctly difterentiates sexual insthict arising in childhood and sexual desire re-awakened in old age (paradoxia) from abnormal intensification of it (hyperaesthesia^). In a study of onanism from a therapeutic stand-point, based upon histories of patients, it is difficult to carry out this principle. According to von Krafi't-Ebing, we have to do with actual paradoxia in a child only when sexual feelings and impulses occur as a result of cerebral processes^ but not, by any means, in the numerous cases where peripheral causes (phimosis, balanitis, oxyuris, etc.) in- duce manipulation of the genitals. This etiological distinction cannot always be made in cases of onanism ; and it cannot be denied that an original peripheral stimulus is capable of in- ducing the same symptoms of psycho-sexual abnormality as those resulting from a purely central cause, and, in a measure, may become the exciting cause of the premature appearance of sexual desire. On the contrary, in almost all cases an ab- normally intense sexual desire is the result of masturbation in childhood ; a desire which is scarcely ever satiated within the limits of that indulgence which is usually sufficient with relatively frequent repetition of intercourse.

The individual, at first suffering with " paradoxia," is soon affected with " hyperaesthesia of the sexual instinct." But, also

' Comp. von Krafft-EbIng, " Psychopathla Sexualls," Chaddock's traiielatloD (F. A. Davis Co., Phila., 1892), pp. 48, 51-55.

(1)

SEXUAL HYPEK.ESTnESIA.

in so m? as ominism in itself presumes an unconquerable im- pulse, and incapability to control it, it may be classified as hyiKjrajsthesia sexualis.

In spite of full recognition of tlie theoretical and clinical importance of von Kraft't-Ebing's classification, practical con- siderations in the main have induced me to unite the cases at my command under the title of " Sexual liyperaesthesia," and, for the sake of clearness, to divide them hito two classes :

1. Onanism (auto-sexual indulgence).

2. Satyriasis and nympliomania (hetero-sexual indulgence). Upon tlie opinions we entertiiin of the nature of tliese

pathological conditions depend the therapeutic measures. Only an exact study of the various forms of manifestation in which hypercesthesia sexualis may appear, as well as a correct ap- preciation of otlier metliods of treatment, can make clear the indications for the application of therapeutic suggestion.

A. Onanism.

The most common method of abnormal satisfaction of sexual desire is onanism (derived from the word Onan ; comp. Genesis, xxxvi, 9). By this term, in its widest sense, are understood all means used by either sex to induce the sexual orgasm outside of the conditions of normal sexual intercourse.^

According to this definition, even those acts which in nowise resemble coitus, but which are practiced by one person on another for the artificial induction of the sexual orgasm, are to be regarded as onanistic, no matter whether the persons be of the same or of opposite sex. Tlierefore, coitus in os, coitus inter mammae, mutual masturbation, etc., may be designated as onanistic acts performed by means of the body of anotlier person.

These perverse manifestations, i.e., those wanting the purpose of procreation, when practiced inordinately or homo- sexually, are, as a rule, to be regarded as symptoms of forms of psycho-sexual disease which we shall consider in later chapters.

• Comp. Christian (Charenton), Extr. da Hist, encyclop. des scienc. ni6dlc. ; aud

Centralb. fftr Nenrenheilk., von Erlenmeyer, 1882,

ONANISM. 3

In a narrower sense, we understand by onanism those acts which an individual carries out on himself in order to induce the sexual orgasm. Only tliis manner of sexual indulgence, which is the most common, will occupy us here.

Catises aiid Predisposition. The occasion for handling the genitals frequently arises in connection with irritation of them in childhood (eczema, pruritus, phimosis with consequent ac- cumulation of smegma). Besides this source of masturbation, which is, to a certain extent, involuntary, there are movements, made for other purposes, which may accidentally lead to mas- turbation, for example, gymnastics, running sewing-machines,^ etc., while wearing too close-fitting clothing. In sucli cases, therefore, the participation of the fancy in the lustful feeling is secondary and concomitant. In fact, excessive auto-mastur- bation may exist for years with perfect purity of the child*s imagination ; indeed, with complete ignorance of the sexual relations. In one of the cases treated by me onanism had been practiced for eight years, and the patient had never had any impure fancy in connection with it ; she could not have had, owing to her absolute ignorance of the sexual relations. It seems to me that, in the numerous publications on this subject, the significance of this point has not received due consideration. And yet the associations which become connected with the onanistic act are of fundamental importance in the etiology and development of the special form of the resulting psycho-sexual abnormality.

More frequently than the accidental influences affecting the genitals that have been mentioned, seduction, bad example, etc., occasion the development of the vice, especially in schools, in boys' and girls' academies, and in prisons and houses of cor- rection. Almost an invariable accompaniment of masturbation thus acquired is the implication of the imagination through pictures having a sexual and obscene content. Often, too, in the family itself the cause lies in nurses, servant-maids, and servants who, either for their own pleasure or to quiet the

• Comp. Fournier, De I'onaniBme. 4th ed. Perls, 1885, p. 07>

4 SEXUAL HTPER^STnESIA.

crying children, manipulate their genitals/ It is also clear that certain subjects taught turn the attention of pupils to sexual matters, and thus give childish fancy an evil direction. It is only necessary to recall certain passages in Greek and Roman classics, and certain chapters in the Bible that are not to be misunderstood.

Gyurkovechky^ is of the opinion that idleness of pupils during play-hours, spicy food, and exciting drinks, as well as early retiring and late rising, are to be regarded as predisposing causes of inordinate onanism. Even though it cannot be denied that any of these circumstances may give an onanist welcome opportunity to indulge excessively in his vice, it is difficult to understand how such influences could lead a pure child to masturbation. Indeed, in all cases it requires some other ex- traneous influence to lead the child to the first indulgence in the pernicious habit.

Too, even in individuals untainted hereditarily, continued onanistic irritation of the central nervous system is capable of inducing a neuropathic constitution, and, in consequence, numerous maladies. Moreover, continued or temporary absti- nence from sexual intercourse, after the occurrence of sexual maturity, predisposes to the development of neurasthenia and sexual hyperexcitability, at least in many untainted individuals, who then resort to auto-masturbation fante de mieux. In the majority of cases which come for medical treatment, however, the individuals are of tainted heredity.

Lombroso^ examined 11 onanists, and found: without physical anomalies, 3 ; with physical anomalies, 8 ; parents normal, 3 ; unknown, 1 ; abnormal, 7.

In cases of neuropathic predisposition onanism frequently becomes the exciting cause of the malady, while, according to von Kraff*t-Ebing's* experience, which is no less extensive, in untainted individuals the limits of an asthenic neuropsychosis

' Comp. Gyurkovechky, PaUi. und Tberapie der Miunl. Impotenz, Urban und Schwarzenberg. Wien, 1889, p. 106. Loc. eU., p. 108.

• Lombroeo, Der Verbrecher, Hamburg, 1887, p. 128.

• YoD Krafll-Ebing, P^chiatrle, S aufl. Stuttgart, p. 208.

ONANISM. 5

are scarcely ever passed as a result of onanistic excesses. To be sure, the addition of some other exciting cause may, on the basis of tlie acquired neuropathic condition, give rise to any form of insanity. But there are also cases in which onanism is to be regarded as an immediate symptom of the neuropathic state or psychosis ; for example, in maniacal states with sexual excitement, as they occur in hysteria and epilepsy, and as the forerunners of mania and paretic dementia.^ In his classification based upon anatomical principles, Magnan classifies a certain form of onanism as belonging to the " spinal " sexual anomalies, and speaks of automatism of the genital reflex centre. He mentions a female idiot, aged 7, who masturbated continuously after her third year, and who could not be kept from it by any means. Magnan believes that tlie girl masturbated as a result of irritation seated in the genito-spinal centre ; for all sensorial cerebral functions were to be regarded as absent.*^ Here it may be advantageous to review the anomalies of the sexrtal instinct in imbeciles and idiots. In relation to the symptoms of par- adoxical expression of the sexual appetite, sexual hyperses- thesia in general, according to the statements of Sollier^ and Bourneville,* onanism is of the greatest importance. The author first named expresses himself as follows :

" In uncleanly and incurable idiots there can be no thought of a real sexual instinct; the onanism which most of them practice cannot be regarded as its expression. In idiots capable of education sexual instinct may make itself noticeable, but it is always weak. Sometimes it is abnormally developed and per- verse, but never normal. On tlie other hand, imbeciles are often prematurely developed, and, at the same time, they mani- fest most of the sexual perversions."

The most frequent and earliest aberration of the sexual instinct is, according to Sollier, onanism. Some masturbate

' Magnan, " Des anomalies, des aberrations, et des perversions sexuelles,". Progris M6dlcal, 18a5.

• Comp. von Krafft-Eblnp, " Ueber Irreseln durch Onanie bel Mannem," Allgetn.

Zeltschiift fiir Psychiatrie, 1874, p. 425.

• Paul Sollier, Der Idiot und der Imbecilles, Leipzig, 1891, p. 75 et teq.

• Bourncville and Sollier, " Des anomalies des organs gdnitaux chez lea idiota et lea

epileptlques," Progrfes Medical, 1887.

6 SEXUAL HYPERit:STHESIA.

automatically ; others know what they do, and seek in the prac- tice sexual gratification. Idiots of two or three years, who masturbate constantly, so to speak, belong to the first category. " With them it is a tic similar to others they present. That sexual desire has nothing to do with it is clear. Ollen there are seen malformations that are in nowise related to the sexual instinct. On the otlier hand, I have previously called attention to the fact that certain idiots experience pleasant sensations with their tics.^

Automatic masturbation occurs at a certain age in idiotic dements. It is also found in very young idiots and imbeciles, as sometimes in normal children. In the latter the habit is abandoned with increasing years, esiDccially with the occurrence of puberty and as a result of education. Even tliough idiotic children find a certain sexual satisfaction in the practice, it is not to be regarded as true sexual pleasure. Usually real sexual pleasure is to be observed only after the genitals have reached their full development at puberty. Iii many in- stances, however, true sexual instinct is developed remarkably early. Sollier saw several idiots of very low intelligence, who, from the fourth or fifth year, found pleasure in touching little girls or women. Many sought to violate their little sisters and touch them indecently ; others approached tlieir mothers by lifting their skirts. " Often in asylums for idiots they are seen to attempt indecent fondling of their nurses, and they like to come in contact with them, thus being thrown into a state of general excitement. These inclinations are observed toward women and girls more frequently than toward children of the same sex. This seems to demonstrate that the inclination is a true sexual instinct. But in normal children sexual excitation occurs more frequently, and that before puberty, than is sus- pected."

In imbeciles onanism is less frequent up to puberty than in idiots; but afler that period the relation is reversed. After puberty onanism occurs under the influence of the sexual in- stinct for sexual gratification. In this respect the girl is like the boy. Sollier reports: "A girl in Bicetre masturbated by

ONANISM. 7

rubbing the thighs together (the most common method), and thus finally induced an erythema of both thighs. In spite of this condition she continued tlie practice so long that the skin became gangrenous, and the surface of the sores could never be entirely healed."

According to tlie later psychiatric investigations (Christian, Kraepelin, Forel, Vogel, Lowenfeld, Uffelmann, von Krafft- Ebing, etc.^) it is put beyond doubt that habitual masturbation is either a concomitant symptom of an existent neuropathic condition, or, as a rule, induces, in connection with inherited or acquired predisposition, pronounced disturbances of the nervous system.

Forms of Onanism. The induction of sexual orgasm in onanists is either by means of peripheral or central irritation, or both simxdtaneoushj. From a practical stand-point, three groups may be distinguished: 1. Onanism by means of tactile excitation, 'z. Onanism by means of psychical excitation. 3. Onanism by n eans of a combination of sensory and ideational excitation.

1. Onanism hy Means of Tactile Excitation {Masturhationy Manustnpratioii). While in the first group the implication of the imagination takes place as a secondary accompaniment, in the second group it is the principal means of gratification. Merely friction of the glans, rubbing of the clitoris, or other tactile irritation of erogenous areas (in women : vagina, cer- vix uteri, nipples, and, under pathological conditions, places in the proximity of the genitals and mammge; in men: the skin of the external genitals, and, according to some authors, under pathological conditions, the anus), according to Hammond's^ opinion, is not sufficient to induce the necessary degree of sensual excifcition ; rather, the peripheral stimulus induces ideas

' Christian, Onnnisme (Extr. du diction, encyclop. des sciences mMlcales) ; reference In Erlenmeyer's Centralbl. fur Nervenhellkundc, 1882, p. 198. Kraepelin, Lelirbuch der Psychiatric, p. 32. Forel, ' Einige Worte iiber die reglementirtc Prostitution in Klew und fiber sexuelle Hygiene," Scparatabdruck ausdeni Corrcspondenzblatt fur Schweirer Aerzte, 1889. Vogel, Lehrbuch fur KInderkrankhcltcn, 5 aufl., p. .387. Uffelmann, Handbuch der dffentl. und privaten Hygiene des Kindcs, 1881, p. 368. Ldwenfeld, Die nervosen Stdr- angeu sexuellen Ursprungs, Wiesbaden, 1891, pp. 64,65.

• Hammond, Sexual Impotence.

8 SEXUAL HYl'EKiESTHESIA.

with whicli pleasurable feelings become associated. The con- tent of these ideas is, in the majority of instances, concerned with sexual relations and situations. The most common method of tactile stimulation of tlie genitals consists of rubbing, press- ing, swinging movements of the thighs, or of fondling and friction with the hands. Females^ make use of the most vari- ous objects for masturbation;^ they insert large and small objects into the vagina, such as hairpins, crochet-hooks, needle-cases, lead-pencils, radishes, spools, and caudles. " Married women," according to Winckel,^ " choose fir-twigs, artiiicial penes made of bacon, and even pomade-jars and drinking-glasses. Tlie most ludicrous combination of this kind that has ever been dis- covered was found by K. Schroder, a pomade-jar and a cricket in the vagina." These objects, whicli easily slip from the hand, often give occasion for operative interference. One of my pa- tients rubbed the clitoris with a sponge. Too, the ideas which accompany the manipulations sometimes concern strange objects. Thus, one of my patients who masturbated thirty years, and lived for the most part in the country, conceived that she was in coitus with a stallion.

Here but brief allusion can be made to the anthropological significance* of masturbation. Among the Klioikhoin (Nama Hottentots), according to Ploss,'* in the youths of the female sex masturbation is so frequent that the practice might be re- garded as a custom. Therefore, no especial secret is made of the matter, and in their tales and folk-lore the people speak of it as of a customary matter (Fritsch").

The vice, even at the time of the arrival of the Spaniards, was wide-spread among the females of the Philippines ; they had invented an artificial penis with which to gratify their insatiable

' Pouillet, De rOnnnisme de la femme. 2d ed. Paris, 1877.

De Giovanni, Di una causa posa valutata nella patogencel di alcune inflrmit& mall- ebrl (Gazz. Med. Lombarda, 1877, No. 1.5, p. 141).

Comp. Winckel, Diseases of Women.

According to Mantepazza (ITygiene dcr Liebe, p. 83), tlie English physician. Cope- land, has stated : " Tlie Jews owe their great power of resisting many epidemic diseases and a certain mental deliberation to the fact that masturbation is unknown among them." That this statement is erroneous is shown by the exiiericnce of Mantcgazza and others.

Floss, Das Weib, Leipzig, 1891, Bd. 1, p. 330.

Fritoch, Die Eingeborcn Sudafrikas, Breslau, 1873, pp. 111,280.

ONANISM. ' 9

desires, and they had other similar means for the satisfaction of their unnatural -lust (Blumcntritt').

Manipulations which cause enlargement of the clitoris and labia minora, it seems, are indulged in either purposelessly (at least, not in conscious action) or for various purposes. Accord- ing to Ploss,^ among many barbarous peoples the indulgence of the youthful females in masturbation, pleasurable titillation, and lustful pinching and pulling of the excitable portions of the genitals, is the cause of their gradual change of foma. Still, perhaps these practices are undertaken with the more or less clearly-conscious purpose, not only of increasing the individual's own lustful pleasure, but also with a view to so change the genitals as to better adapt them for the performance of tri- badism, a vice which has always been very wide-spread in the Orient.

2. Onanism hy Means of Psychical Stimuli {PsycJtical Onanism). Central excitation of the sexual orgasm, as by simple memoiy-pictures, is always a sign of psycho-sexual hypersesthesia, and is to be regarded as occuning, for the most part, as a manifestation of cases falling in group 1 ; for example, in hysterical individuals, those tainted hereditarily, and in states of psychical exaltation. According to von Krafft-Ebing,^ where this means is effectual the fancy is abnormally excitable, and associations are facilitated.

The pollutions which take place in both- sexes as a result of erotic thoughts, both in dreams and the waking state, must be placed in this "class; the sensual excitation is brought about purely by an act of the imagination. Thus, for example, a man concentrates his entire attention in thought upon a female.; " fancies that he approaches her vulva and attempts immissio penis ; then he thinks of the various stages of coitus, until finally he experiences the complete orgasm."*

According to Hammond, there are men who know only

' Blumentritt, " Der Ahnencnitas und die religldscn Augchauungen des Philippinen archipels," Mitth. d. 12, 12 gcog. Gesellsoli. In WIeii, 1885, ixvlil, 3.

PloBs, Das Welb, Leipzig, 1891, Bd. 1, p. 330.

Von Kraflt-Ebing, Psyc-liopaUila Sexualis, p. 39. ' Hammoud, Sexual Impotence.

10 SEXUAL HYPERiESTHESIA.

this kind of excitation, and who have no erection in the normal way. As a rule, this hyperajsthesia occurs after masturbatic or other sexual excesses ; so that Jthe matter is one of memory- pictures in different variations. One of my patients is also able to indulge in the pleasure of this ideal coitus at any time. A quiet, comfortable position, either lying or sitting, is the pre- paratory measure necessary for success. Then he allows his fancy free rein, and dreams intensely though consciousness is intact that he is in the desired situation, until ejacvdation takes place. This calls to mind the artificial induction of dreams by narcotics. In " The Significance of Narcotics in Hypnotism " ^ I have shown that narcotics (alcohol, opium, etc.), especially Indian hemp, induce a condition favorable for the acceptance of suggestions, even for auto-suggestions ; hence tlie use of haschish by Orientals when they wish to give themselves up entirely to a drunken imagination in which ideas of a sexual character play the principal role.

Too, such pollutions in the female sex, which are most frequently induced in sleep by erotic dreams, are not without importance. At the height of sexual excitement an abundant secretion is emptied from the glands of Bartholini. In many women, as Robinson^ states, a lustful, convulsive sensation, which is also painful, occurs, which Robinson attributes to con- traction of the constrictor cunni. In his opinion, previous masturbation and regular coitus are to be regarded as tlie etio- logical factors. Many of these patients experience a subsequent feeling of relief, and the next morning are refreshed; many others awake with pain in the back after pollution.

The induction of orgasm by erotic ideas is of especial interest by reason of the religious significance that has been given it in the imagination of ignorant peoples. " There is an uncommonly wide-spread belief that evil spirits of a certain kind possess the power to visit young maidens and wives, and also youths and husbands, while in bed at night, of course always in

' Scbriften der Gesellschafll Vat Psychologlscbe Forschang (Leipzig, Abel, 1891), Heftl.

• Robinson, " Klin. Beob. fiber Pollutionen beim Weibl. Oescblecht," Med. Ag.,

1889, No. 7.

ONANISM. 11

the seductive form of the opposite sex, in order to perform coitus with them.' The feeling of depression on the day following the pollutions is ascribed to the power of the evil spirit of the night to sap the strength. These demons, which during the middle ages were known as incubus and succubus, as ephialtes and hypJuaUes^ as night-power or weight, as night-mare, etc., were known to the civilized peoples of Western Asia many centuries before the beginning of our historical reckoning, and they were feared under the names of night-men and night-women." Ac- cording to Ploss, in the ruins of Ninevah were found a great number of tablets of terra-cotta from the library of Assurbanip- alus (Sardanapalus of the Bible) on which there were cuneiform inscriptions. Among them were formulae for exorcism and prayers in Accadian characters, with an Assyrian translation inscribed, above them, which were directed against the night- men (lillal) and the night-women (kiel-lillal). We are justified in assuming that there was a belief in the possibility of cohabi- tation with a god, where we find that mature maidens who were approaching marriage sacrificed their maidenhood in the temple as a custom. Legendary demoniacal animals are also frequently held to be the progenitors of whole tribes, especially among the Indians and Polynesians. The consorting with the devil for years, which comes to us from the fourteenth and fifteenth centuries, is well known. Usually this sexual congress took place at night ; but women were even " found in broad daylight in the fields entirely naked, and sometimes their husbands found them in the embrace of the devil," etc.

The forest has always been regarded as the place of prefer- ence for the attacks of demons upon women. The lust of satyrs, fauns, and sylvan s is well known; and the Druids of the ancient Gauls and the forest-god of the Germans may be recalled.

In the islands of Aaro the unchaste forest-god has power only over menstruating women, who, therefore, dare not enter a forest. The states of eitcitement in the genital apparatus at the time of puberty in both sexes, and at the time of menstruation

Ploes, Das Welb, Leipzig, 1891, Bd. 1, p. 883.

12 SEXUAL HYPERiESTHESIA.

in maidens and women, have a reflex effbct upon the central nervous system, and induce erotic ideas that may attain the intensity of halhicinations, which tlien correspond with tlie re- Hgious belief of the individuals. The centrifugal effect of such ideas is to induce, either in the sleeping or waking state, should they be intense enough, the well-known lustful feelings ; and this differs from voluntary psychical onanism only in the uncon- scious and latent excitation of the imagination. Essentially, however, in both cases it is ideal cohabitation, the induction of orgasm by sexual ideas which on their part are conditioned by organic or psychical causes, and which, therefore, are physical in any case.

3. Onanism hy Means of a Combination of Sensory and Ideational Excitation. In onanists of the third group the im- agination alone is inadequate for the induction of sexual orgasm. On the contrary, the imagination must be intensely excited by a sensory impression in order to induce a sufficient degree of sensual excitement in the nervous system. Often sensory im- pressions that appear to have no relation to the sexual life (optical and tactile impressions, odors, and tastes) are sufficient to excite the psycho-sexual mechanism. That, as von Kraff*t- Ebing^ thinks, in all cases lascivious ideas are induced, according to my experience, seems questionable. With hyperexcitation of the genital centres, ejaculation occurs without otlier tactile irri- tation of the sexual organs, as in psychical onanists. In other cases ideas alone are not sufficient to induce the. orgasm, which takes place only with mechanical assistance (masturbation, press- ing and rubbing of tlie thighs).

Too, in some individuals a variation is to be noticed, in that with extraordinary excitation the imagination is sufficient to conclude the act, while in other cases manipulations complete the work. Tlius, one of my patients reports that when he was 18 he excited himself sexually by looking at obscene photo- graphs; on one occasion only did the excitement become so intense as to cause spontaneous ejaculation, and then it was with a feeling of lustful pleasure such as he had never before experi-

' VoD Kraflft-Ebing, Fsychopathia Sexaalis.

ONANISM. 13

enced. Another patient, who is at the same time of contrary sexuality, has erection only when he sees naked male nates. The idea ol" the nates is not sufficient, at least, in the waking state, though it is efficient in dreams. Two female onanists, seen in my practice, without any friction induced sexual orgasm by sensory impressions which had no sexual relation whatever. One practiced onanism in this way while hearing music, or while regarding landscape paintings, and that without anything like a lascivious idea. The other was sensually excited at the sight of the grandeurs of nature, such as the sea. Both patients indulged in onanism in the street, in cafes, in the theatre, and in street-cars, without in any way attracting the notice of those about them. While with the first there was no knowl- edge of ^^.vual intercourse, with the second occurred ideas of a sexual nature. When she became attracted by the sight of an especially strong and handsome male form, orgasm would occur in one minute at most. The touch of the physician in the first examination induced it. Another patient is able to have ideal cohabitation at a distance. For example, he seats himself in the theatre vis cb vis a lady attractive to him ; then he allows his fancy free rein, and thus enjoys the pleasures of love by picturing so intensely to himself all the positions of coitus with the person that ejaculation results.

According to Hammond,^ it seems that in America such persons form a kind of a union or society, and have certain signs by which they recognize one another. They call themselves by a common name, which signifies " a man wlio indulges in ideal coitus." They say that they can tell by a man's face whether he belongs to their society or not.

One of my patients, of contrary sexuality, had an ejacula- tion when the man who was the object of his love, and who had no suspicion of the condition of his friend, felt his pulse on an occasion of illness.

In another case of contrary sexuality the man experienced orgasm on merely shaking hands with a man especially attractive to him.

• Comp. Hammoud, loc. eit.

14 SEXUAL HYPERiESTHESIA.

Hammond's ' observation in the case of an epileptic is also remarkable: " He took employment with a dealer in vegetables whom he liked to visit, in order to see beautiful women. When lie had chosen his partner, he would concentrate his thoughts on her and imagine her in the most various exciting positions. It was not difficult, he said, to fancy her before his eyes entirely nude. Then he would make voluntary contractions of the glutei, the accelerator urina3, and other muscles, and usually after no longer than a minute orgasm would occur. He could also induce sexual excitement when he thought of a lady ho had just seen, without having her before his eyes. Natural sexual intercourse, on the other hand, afforded him no pleasure ; on the contrary, he was absolutely impotent with women, and not even with the help of fancy was he able to have sensual pleasure in coitus. Finally he became absolutely unable to prevent the excitement which came on, and that without erec- tion, merely at the sight of an attractive woman. Likewise a painting or wood-cut of a woman, dressed, nude, or lialf-nude, induced orgasm, with or without erection and ejaculation."

In the cases mentioned, optical, auditory, and tactile per- ceptions (examples of olfactory and gustatory impressions acting in this way are not known to me) are the causal factors in the excitation of the sexual sense, and, indeed, regularly with devi- ation from physiological conditions, and often without any rela- tion in content to sexual matters. Many authors presume a more intimate relation between the olfactory and sensory senses (von Krafft-Ebing,^ Althaus,^ Cloquet*).

In his latest work, Moir* opposes this. In his opinion the relationship between olfactory impressions and the sexual in- stinct is not more intimate than that of many other sensory im- pressions, and that of sight with the sexual sense is much closer tlian that of smell ; especially since it is questionable whether there is a special centre for sexual sensations.

' Hammond, loc. cit.

• Von Kraflt-Ebincr, Psychopathia Sexualis, p. 26.

• Altbaus, " Beltrage zur Physiol, und Pathol, des Olfactorlus," Arch, fur Psych.,

xll, H. 1.

• Cloquet, Osphrdsiologie, Paris, 1826.

• Moll, Die contrare Qexualempfiuduug, Berlin, 1891, pp. 183, 18i.

ONANISM. 16

The sensory impressions mentioned induce in the cerebral cortex sexual ideas, feelings, and impulses which, in hyperaes- thetic individuals, may give rise to complete sexual satisfaction. When it is present in sufficient intensity, a memory-picture alone may have the same effect. While in this chapter, to a certain extent, only the exterior of unphysiological excitation and abnormal intensity of the sexual instinct interest us, in Section III we shall learn the great importance which is to be attributed to the content of the ideas which accompany the sexual excitement in giving perverse direction to the vita sexualis.

Dangers and Results of Onanism^ with Especial Reference to Insanity. Though onanism, where it is not a symptom of a psychopathic or neuropathic predisposition, may always be regarded from a moral stand-point as a vice, still the physician, as a rule, will be concerned only with such cases of it as present more or less profound disturbance of the nervous system. From a more humane point of view, this " error," this "sin of youth," is to be looked upon as a malady, as a disease presenting char- acteristic symptoms. Concerning the real cause of this injuri- ous practice authors differ. Thus, Erb^ regards the single onanistic act as no more harmful than that of normal coitus. He says: "The effect upon the nervous system in a man must be essentially the same, whether the friction of the glans takes place in the vagina or is otherwise carried out; the nervous shock in ejaculation remains the same ; it might well be pre- sumed that the nervous excitement would be greater where the female is used."

But in reply to this it may be stated that masturbatic acts, with the exception of such infrequent cases as those of Magnan,^ which must be regarded as instances of psychoses, have a much more intense psychical effect than does coitus. The content of the ideas in everv sinjjle onanistic act must overcome realitv, and thus a much more intense strain of the imagination is necessary. And the imagination itself, even with infrequent practice of onanism, with respect to the accompanying psycho-

' Erb, Handbuch dcr Rdrkcumarkskrankbeiten, p. 163,

• Comp. p. 5.

16 SEXUAL HYPERiESTHESIA.

r

sexual product, the content of ideas, becomes artificially accustomed to a single direction of activity. We sliall learn in Chapter IX the deleterious influence of the content of the ideas of masturbators in cases of severe psycho-sexual disease. Be- sides, the fact of self-indulgence, save witli infrequent perform- ance of the act, brings onanists into a peculiar and, I might say, unphysiological rchition to the opposite sex. In that it destroys the sexual relation with the opposite sex, it weakens sexual desire and attacks the most powerful natural instinct love's impulse at its very root; it injures the whole sexual foundation, the basis of all ideal activities ; it extinguishes the fire of sensual feeling, the most powerful incentive to the putting forth of strength, in both individual and social existence, in the world of beauty and morality.^ Masturbation moderately prac- ticed exercises, on a good constitution, no direct destroying effect, but it changes, when it is long indulged in, the character, the imagination, and the whole mental existence in a way that is unmistakable and, so to speak, necessary. These evil effects of onanism seem to us to be greater than those lesser disturb- ances which seldom affect materially the general health, and which Dr. Lowenfeld'^ describes in detail.

Still, in purely a physical sense, it seems questionable whether coitus and masturbation are equivalent acts. Gyurko- vechky^ found a history of greater depression and weariness after occasional indulgence in onanism than after considerable excessive coitus. According to the expression of many patients, the act of indulgence which leaves behind it the most intense feeling of well-being is that in which the semen is expelled with the greatest energy and strength. Any delay in the expulsion, anything like weakness or lack of energy in the completion of the act, has an incomparably weakening effect upon the nervous system. But Hammond* assumes that the sexual act, in that it requires a greater expenditure of muscular power, must certainly be more injurious than onanism with like froquonoy of indulg-

' Cotnp. Ton Krafft-Ebing, Ppyrhopatbia SextialiB, p. 5.

L6wenfeld, Die nervdsen Stdningen sex. Ursprungs, pp. 89-94.

Gyurkovechky, Impotenz, p. 103,

Hammond, loe. cU.

ONANISM. 17

ence; at least, with reference to ejaculation and orgasm. " For, witli tlie orgasm and the loss of Semen, it is a matter of indiffer- ence where tlie semen is deposited, wlietlier in the vagina or in any other receptacle." This conflict in tlie opinions of the authors is easily overcome when we proj>erly consider the accompanying effect of the psychical factor, which varies with the individuals, but which is constantly in play. Experience shows that mastur- bation, since opportunity for it is constantly present, is much more frequently practiced than natural sexual indulgence. The exhaustion of strength induced by frequent indulgence points to the frequent and severe material injury of the nervous system. When, by reason of defective or incomplete erection, an indi- vidual is incapable of coitus, masturbatic friction of the glans may still be performed with a flaccid member. The majority of cases of impotence (on this point all authors agree) depend upon excessive and early indulgence in onanism.

Hammond states that he observed complete impotence in married men who had practiced masturbation moderately with- out noteworthy injury to their general health. There are many young men, strange to say, who see nothing in self-abuse that is immoral, or who, at least, in case they understand the evil, are unable to resist it. Naturally, after marriage they find that legitimate intercourse only imperfectly satisfies their sexual in- stinct, and that it excites their sensual feeling much less than did the evil habit in which they previously indulged (Hammond).^ The dreams which accompany the onanistic act are not realized in marriage, and to the great surprise of such patients their virility is well-nigh extinguished.

At thp same time, between the sexual instinct longing for satisfaction and the effort to remain pure, there arises a terrible struggle, whicli, unfortunately, only too often ends in victory for the vice.^ From this arises the moral de])ression of those who abstain. This and the ever-renewed struggle, as well as the onanistic stimulation, gradually undermine the nervous system.'

' Hammond, loe. cit.

Corop. Leopold Caspar, Impotentia et Sterilitas Vlriles, Mftnchen, 1890, p. 77. Comp. Beard, Sexual Neurasthenia ; and von KrafTt-Ebing, " Neurosen und Pbjt- chosen durch BexucUe Abbtincnz," Jahrb. fur Psycbiatrie, Bd. viil, pp. 1, 2.

%

18 SEXUAL HYPERiBSTHESIA.

In the course of time weakness of the wliole nervous system occurs.* At the same time it is important whetlier tlie peniicious liabit has been practiced from early youth or only from after about the twentieth year. The earlier the vice is indulged in, the more serious are its effects. In the functional injury to the central nervous system, the loss of semen is not of any essential pathogenetic significance. " While in coitus the act is quasi-reflex and automatic, onanism is voluntary, and must be attended by activity and expenditure of nervous material which possesses a higher functional value " (von Krafft-Ebing^). Meyer ^ thinks that the impulse to masturbate is stronger and more obstinate when the result of psychical predisposition, weaker when it is accidentally provoked. In the first instance, therefore, it has a more injurious effect upon the mental con- dition.

With reference to the deleterious effect of onanism on children, alienists and those versed in the hygiene of childhood agree that masturbation, besides inducing motor, sensory, and circulatory disturbances, etc., may give rise to lack of feeling; want of desire for child-like play, in as far as this does not give opportunity for the vice ; a shy, retiring disposition ; psychical irritability; inclination to paroxysms of anger and rage; and weakness of memory and judgment.

When it is remembered that abnormal precocity of sexual desire is one of the peculiarities of a neuropathic con- stitution, the conclusion seems justified that the children whose insanity arises from onanism have been under the influence of

' Only orthodox oiie-sideducss of view and complete ignorance of physiological cou- ditions of life make such a statement as the following explicable : " Not even the shadow of a proof has been cast to show that a nervous man is made nervous or insane by a moral life, <.., complete abstinence from sexual intercourse." (Comp. A. Romer, M.D., Die Sit- tenreinheit vor dem Richtcrstuhl eiiicr arztliclien Autoritat, Streitfragen, wisseuschaftliches Fachorgan der deutscheu Sittllchkeltsvercine, Berlin, 189*2.) The pamphlet is opjwsed to the works of Moll and von Kraift-Ebing, and states that sexual errors arise cither from " seduction " or from " personal evil " (ic!). But those who show a tendency to yield to " the evil inclinations of the human tieart" (p. 13) should, according to the receipt of Dr. ROmer, call to mind " the grand words of the Apostle Paul in the Epistles to the Romans (1, 26, 27, 32), as well as in those to the Galatians (v, 16 and 24)."

' Von Kraffl-Ebing, Ueber Irresein dnrch onanic bei Miinnem, v. ntpra.

• Ludwig Meyer, Die Beziehungen der krankh. Zustande und Vorgange in den Sex-

ualerg. des Weibes za den Oeistesetorungcn, Berlin, 1S6Q, p. 15 et teq.

ONANISM. 19

that evil ah ovo^^ (Vogel,^ UfFelmann'^). In young children masturbation causes convulsions, choreic conditions, and mental weakness. According to Spitzka,^ between the fifth and tenth years the nutrition of the brain suffers. Such cliildren are wanting in independent thought and action. At tlie age of 20 to 25 the majority of onanists feel the effects most seriously. Actual nosomania may result. If such cases develop actual insanity, they can be called cases of masturbatic insanity only when tlie connection with the excesses is a direct one.

Spitzka occasionally observed mania, melancholia, epi- lepsy, stupor, and katatonia in young onanists. " There is also a form of delusional insanity, developing during and after puberty, which deserves the name of masturbatic insanity. It is chronic, has a tendency to a restless form of dementia, and in its beginning it is characterized by anxiety, fear, suspicion, and depression. Later, confusion and motor excitement occur ; and, still later, rage and destructiveness " (Spitzka*).

Through habitual indulgence, onanism becomes instinctive ; and the vain efforts of the individual to overcome it under- mine his strength of character. Thus, with this victory, it becomes a genuine pathological manifestation, whether it exist alone or in connection with nervous disturbances; and then it is to be regarded as the expression of a cerebral disease. The most frequent results of masturbatic excesses are : excessive pollutions (day and night), spermatorrlioea, premature ejacu- lation in attempts at coitus, hypersesthesia of the genital centres, spinal neurasthenia, congestion of the prostate, inflammation of the urethra, hyperaemia and swelling of the mucous membranes, and intense sensitiveness of the glans. In young children, besides, there may readily occur vesical tenesmus, wetting of the bed, spasm of the compressor urethrae, and urinary incontinence. Further results are urethritis, prostatorrhoea, spermatorrhoea, and impotence.

• Vogel, Lehrbuch der Kinderkrankh., 5 aufl., p. 387.

• Uffelmann, Haudbuch der dffentl. und privaten Hygiene des Kindes, Leipzig, 1881,

p. 868.

' Spitzka, " Self-Abose In Relation to Insanity," The Dublin Medical Journal, 1887.

• SpiUka, {oc. eit.

20 SEXUAL HYPERiflSTHESIA.

The neurosis of the himbar portion of the cord leads to geneml neurasthenia, tachycardia, pains, praecordial distress, feelings of pressure and weight, or pains in the eyelids,' spasm of the lids, photopliobia or subjective sensations of light, dimi- nution of the acuity of central vision, neurastlienic asthenopia, etc. To these disturbances Lowenfeld" adds the so-called eye-

aine.

In the female sex there are similar neurasthenic and hys- terical disturbances, such as hysterical attacks, paralyses (vesical paralysis), vesical tenesmus and spasm, ovarian neuralgia, weak- ness of the legs, and spinal irritation. Among local disturb- ances may be mentioned hypersemia of the labia minom and the vaginal orifice, desquamation of the epithelium, fluor albus, cer- vical catarrh, intense hypersesthesia, pruritus vulvue, hypertrophy of the clitoris, and irritable conditions of the uterus and adnexa.

A condition that has thus far been too little studied, and which in its significance is one of the most important and frequent results of masturbation in the female, is a form of im- potence in which the orgasm no longer occurs during the sexual act, even when it is performed witli several men, but in many cases may be induced ^?o,9^coiV*7W by masturbation. In the chapter on impotence I shall consider the matter more in detail. The above-mentioned change of cliaracter, depending upon ini- physiological stimulation, may occur in woman as well as in man, and in the female it may manifest itself in a more serious disinclination to marry (Tissot).

Steinbacher^ speaks very caustically of such a disposition : " They think they can satisfy themselves with tlieir unnatuml stimulation, and it is owing to tliis circumstance that so many remain unmarried, of course iniconscious that health and life are destroyed by the unnatural satisfaction of their desires. One sees only too many of such erring old maids to comi)are with the wife, who has been the faithful companion of her husband, chaste and moderate in indulgence and moral, and the mother

' Comp. Cohn, " Augenkrankheiten bei Masturbunten," Archiv f&r Augenbcilkunde, von Knapp und Schwelzer, 1882, p. 198. ' Lowenfeld, loc. cit., p. 83.

• Steinbacber, Die mannliche Impotenz, M&nchen, 1877, p. 84.

ONANISM. 21

of children. It is astonish in j^ how much better women Hving a full life are preserved up to an old a<^c, and how much fresher and more joyous they appear than those old maids who suffer with all the female ills ; who are so hysterical, convulsive, yellow, and bigoted; who, insufferahle m their eccentricities, live in close friendship only with dogs and cats."

The question whether onanism as an etiological factor lends specific features to insanity which make it possible, from the clinical symptoms, to ascertain the particular cause, von Krafft-Ebing, on the basis of large experience, answers in the negative, stating that, where the onanism is only a symptom of disease, or where it is an exciting cause operating with a neuro- patliic and degenerate constitution, it exercises no influence upon the clinical form of the malady ; and that it is the same when it induces the outbreak of insanity and rapidly hastens the psychical and physical degeneration. In cases of the third category, where onanism forms the predisposing causal factor of the disease, the multitude of hallucinations and the ease with which they arise are striking.

In another place ^ the same author distinguishes two forms in the pathogenesis of masturbatic psychoses :

(a) A psychical, through assisting mental causes. These are spontaneous mental feelings, remorse, shame, and fear of the results of the vice, with the painful consciousness of being unable to overcome the habit by strength of w^ill. In such cases melancholias arise with intense liypochondriacal features in harmony with the predoniinating symptoms of the accompany- ing neurasthenia.

(b) The cause is somatic, through the addition of other weakening influences (insufficient nourishment, sleeplessness, physical diseases, mental and physical strain). The form of the disease here seems to be essentially conditioned by constitutional factors. If these be slight in degree, pure exhaustion-neuroses, stupor, and delusional states occur ; upon a degenerate founda- tion are developed states of primary dementia, paranoia, and insanity with imperative conceptions.

' VoD Krafft-EblDg, Lehrbuch der Psychiatrle, 3 aufl., p. 308.

22 SEXUAL HYPER^.STHESIA.

All the symptoms occurring in the sexual psychoses are more or less those of neurastlienia, as are olfactory halhicinations of a repulsive character.

In confirmation of von KrafFt-Ebing's views, Krapelin ^ de- scribes tlic psy(;hical degeneration in the following words : " Most frequently in onanists tliere occurs a progressive loss of mental activity, or inabihty to comprehend and elaborate mentally external impressions, weakness of memory, lack of interest, or dullness. In other cases symptoms of aggravated irritability become more prominent ; or strange associations of ideas, incli- nation to mysticism, and exalted enthusiasm ; or hypochondri- acal and melancholic depression. With these are associated" various nervous disturbances, especially abnormal sensations, from which not infrequently absurd delusions of demoniacal or secret or physical (magnetic, electrical, sympathetic) influences are developed."

From what has gone before, it is plain that onanism is to be regarded as the causal or exciting factor in the origin and outbreak of numerous forms of mental disturbance; that is, in all cases with a neuropathic constitution or in connection with other assisting causes, it is capable of inflicting serious injury on the mind, often accomplishing its complete destruction. The following figures place in a still clearer light the relation of masturbation to insanity. According to Ribbing's^ state- ments, the admissions of insane patients to the asylums of Sweden were :

1883 . .

. 643

cases,

of

' which 25

1884 . .

. 704

19

1885 . .

. 744

" 22

1886 . .

. 741

" 35

1887 . .

. 791

" 35

Total, .

. 3623

" 136

This constitutes 3.7 per i

cent In

In this computation those cases are also included in which onanism was only an accessory cause, and not the only exciting factor in the induction of insanity.

' Krapelin, Psychiatric, 3 aufl., p. 33.

'Ribbing, Die sexuelle Hygiene, 3 aufl., p. 128 (Robbing, Leipzig, 1891).

ONANISM. 23

The figures for three years in England were :

1885 . . . 13,158 cases, of which 160 were due to onanism.

1886 . . . 13,624 " " " 163 " " " "

1887 . . . 14,336 " " " 203 " " " "

And the percentages for each year were ;

1885 . . . 1.2 percent, (males, 2.2 per cent. ; females, 0,3 per cent.).

1886 . . .1.1 " " ( " 2.0 " " " 0.3 " " ). 188T . . .1.4 " " ( " 2.6 " " " 0.2 " ).

Ellin ger ^ states that masturbation was an accessory cause in 83 cases out of 383 cases of insanity. On the other hand, von Krafft-Ebing points to the fact tliat, in 38 of his cases of insanity due to onanism, 31 were notoriously predisposed by heredity; that in only 3 of these cases did the insanity begin before the fifteenth year, though onanism had been practiced by almost all the patients from early childhood.

Ludwig Meyer ^ observed 7 cases of onanism in girls ranging in age from 1 to 9 years. Of these, 4 remained men- tally intact; in 3 children there were psychopathic symptoms, and of these 2 had a neuropathic predisposition, and the tliird child was born of a criminal mother and presented the clinical picture of psychical degeneration.

Dr. Peretti^ found, among 300 male patients in asylums, 59, or 19|^ per cent., in whom onanism could be regarded as an accessory cause of the development of the mental disturbance (Ellinger reckoned 21.5 per cent.; Dahl, 21.25 per cent.). Thirty-three out of the 59 became insane between the ages of 15 and 25 ; and, of all the cases admitted between the ages of 15 and 25, 45.2 per cent, were onanists.*

According to Peretti's statements, onanism induces a loss of the resistive power of the mind, so that the latter is thrown out of balance by a very slight additional disturbing influence. The first signs of mental disturbance are a retiring disposition, apathy and irritability, and an hypochondriacal mood. An

' Ellinger, Allgcm. Zeitschr. fur Psychiatric, Bd. 11, cited by vou Krafll-Ebiog, " Ueber Irresolu durcb Onanie."

• Ludwig Meyer, loc. eit.

Peretti, " Ueber Geieteskrankheit bei Onauisten," Die prakt. Arzt., 1881, xl.

• Comp. Lombroso's statements on page 4 of this book.

24 SEXUAL HYPER^KSTHESIA.

insignificant circumstance may be sufficient to induce a com- plete outbui*st of desimir, fear, or an attempt at suicide. Tlie hypochondriacal depression may go even to the extent of hypo- chondriacal paranoia. Pure melancliolia is infrequent. The mind is weakened, and tlie attempts at suicide have a theatrical character. To the inconstancy and apathy are added, later, hallucinations and ideas of persecution and conceit. And the suspicion and mistrust lead to the idea of being watched, fear of persecutors, and to attacks on those supposed to be inimical. This goes to tlie extent of senseless confusion and violence. In silent patients who have a disinclination to employ themselves, this may go on to hallucinations. Peretti calls this " mastur- batic insanity," moodiness, with sudden clianges ; excitability ; phantasms of all the senses, of which olfactory hallucinations are especially frequent; fantastic ideas; epigrammatic phrases and use of foreign words in letters ; increased feeling of per- sonal importance without self-knowledge ; idealistic and imprac- tical plans for the future, both for self and humanity.

Among physical symptoms, Peretti found a blowing sys- tolic murmur, apex-sound remarkably loud, cardiac dullness normal, changeable pulse-rate, cerebral congestions, and anaemia.

Finally, we may here allude to the well-known form of masturbatic paranoia which goes by the name "erotomania." This name of a psychical degeneration means a tendency to fall in love. A neuropathic and hysterical predisposition and cere- bml diseases may favor the development of such a condition. The love of such individuals is purely platonic; it manifests itself in " enthusiasm for a person of the opposite sex who gives Aesthetic satisfaction, or, indeed, sometimes for a picture or statue," etc. (von KrafFt-Ebing). They are unable to gratify their passion with the object of affection. For the most part, masturbation gives satisfaction to the unbridled fancy. The patient deifies the object of desire, worships it, and bores his friends with unremitting talk of the object of his abnormal en- thusiasm. Gradually and unnoticed the pathological disposition becomes actual disease. Since such persons constantly inflame their imagination, and in solitude resort to onanistic stimuli.

ONANISM. 25

they frequently come to have actual illusions and hallucinations. " The delusions of love become complicated with ideas of grandeur ; or they become transformed into those of perse- cution, in that the ideas of love may alternate with hypochon- driacal fears " (Tarnowsky).^

Cases of erotomania belong to Magnan's^ fourth group. In such patients the lower sexual instincts of the occipital and spinal centres are completely at rest, while perverse sexual ideas are produced in the frontal region without becoming transformed into actual sexual stimuli through the spinal centres.

The points made may be summarized as follows :

A. Onanism in Healthy Individuals.

1. The single act of onanism, in comparison with normal coitus, is injurious to the central nervous system ; for an effort of the imagination must overcome reality, thus requiring the activity and waste of nervous material which possesses a* higher functional value.

2. Masturbation, when practiced no more freqiiently than normal coitus, i.e., with moderation, aside from the injurious influence* on the nervous system mentioned, injures the character of the individual ; for it undermines the physiological relations with the opposite sex, and thus perverts one of the most impor- tant sources from which spring the impulses to exert the powers, both in individual and social existence (celibacy, etc.) ; and by habitual cultivation the unphysiological excitement may attain an instinctive character. This victory of an anomaly of habit over the will must be looked upon as a sign of cerebral disease. Besides, the memory-pictures cultivated by onanism may become imperative conceptions, and force the individual's sexual impulse into a perverse direction.

3. Excessive masturbation leads, also, especially where there has been premature awakening of the sexual instinct, to spinal and general neurasthenia., to genital diseases (pollutions, etc.), and to early impotence ; it injures seriously the mental

' Tarnowpky, oj). cit., p. 58.

• Conip. Magiian, loe. cU.

26 SEXUAL HYI'ERiBSTHESIA.

development of the individual, and it may, with the occurrence of other accidental deleterious influences of slight importiince per 6, directly induce insanity.

B. Onanism in Persons of Hereditary and Neuropathic Predisposition.

As a rule, here it is practiced excessively, and in all cases it has the deleterious influence upon the nervous and mental condition of such patients mentioned under 1, 2, and 3. In accordance with tlie condition and age of such onanists the ^'mptoms enumerated occur with increased intensity, lead to progressive loss of mental power, and hasten the outbreak of sexual psychoses.

Under some circumstances the diagnosis of onanism is attended with difficulties. Shame, ignorance, false notions, ex- cessive anxiety, and the tendency to lie are often sufficient to vitiate the statements of patients. In many cases it is years before the parents have any suspicion of the child's vicious habit. In many families no attention is ever given to tlie matter, and, unfortunately, the number of patients who come to understand it only when they have reached years of maturity is only too great. A lady of my clientele, who had masturbated from her eighteenth year, reached the age of forty before a medical book, which accidentally fell into her hands, explained the matter to her. Another of my patients had practiced onanism eight years, and completely destroyed her nervous system, before the physician discovered the cause of licr trouble.

Vogel,^ Uff*elmann, and Emminghaus think tliat, without exception, at a very early age children have an instinctive notion that self-abuse is wrong ; for they practice it in secret, and a confession can seldom be obtained. Owing to the great prevalence of this evil habit, when there is anything suspicious in the conduct of the child, or where the mcntjil development leaves anything to be desired, a most careful watch should be kept. The places where onanism is cultivated are schools, academies, prisons, and all places of confinement ; and, too, the educational institutes for girls are not to be excepted.

• Comp. Vogel, Uffelmann, loc. clt.

ONANISM. 27

Wherever children show a shy, dreamy, retiring disposition, and are slow in school and difficult to induce to rise betimes in the morning, the possibility of the existence of* the habit of self- abuse should be entertained. Owing to the establishment of an automatic habit, many patients masturbate in sleep. In such cases the diagnosis has been made certain by discovery under such circumstances. One of my patients often awojce with her finger in the vagina. Spots of semen on the linen,^ spots of blood on female linen, redness of the labia minora and the vaginal orifice, the occurrence of spinal pains and affections of the eye, fluor albus, etc., are important indices.

Griinfeld states that he has quite constantly observed hypersemia of the coUiculus seminalis. The usual symptoms are dark-red or scarlet coloring of the colliculus seminalis, with increase of its size and tenderness. According to Gyurko- vechky,^ onanistic excesses lead to flaccidity and anaemia of the penis and testicles, make the scrotum smooth, and, owing to relaxation of the muscle of the tunica dartos, cause the testicles to hang low. The meatus is reddened, the rest of the urethi^a pale, and the colliculus inflamed in various degrees.

The mental and physical peculiarities enumerated, and consideration of the symptoms referable to its results that have been given in detail, should make it possible to make a certain diagnosis of onanism.

The prognosis depends upon the health and age of the patient. Infrequent indulgence in onanism by healthy indi- viduals may in all cases be overcome by natural sexual inter- course. Too, even where there is a habit of frequent indulg- ence in self-abuse in individuals of healthy constitution during the years of puberty, it is abandoned as soon as there is oppor- tunity for hetero-sexual intercourse. Daily experience lends the best proof of this. The earlier the habit is begun, the more the mind has become implicated, and the longer and more frequently the practice of self-abuse has been indulged

' One of Dr. Franz Carl Mailer's patients ejaculated in his stockings in order to escape detection. (Verbal communication.)

• Gyurkovechky, loe. c., p. 138.

• 2S SEXUAL HYPEKJiSTHESIA.

in, the more unfavorable is the prognosis. But even patients in whom the vice has become instinctive have some pros[XJct oi' cure when there is still a possibility of normal sexual inter- course. However, in relation to this, it must be remembered that in young girls this equivalent cannot be provided except by marriage, which does not always rest merely with the desire of the sufferers. Even with a neuropathic constitution there is some prospect of cure and improvement, as long as the neuras- thenic condition has not reached the intensity of a psychosis. Where masturbation is to be regarded as the symptom of a psychosis, the prognosis depends entirely upon the fundamental disease.

The prognosis^ of masturbatic insanity (paranoia mastur- batoria), especially in elderly persons, is not very favorable, even though remissions do occur and tonic treatment is possible. However, even here cures have been reported. According to von Krafft-Ebing,^ the prognosis of masturbatic melancholia is not unfavorable.

On the whole, therefore, the prognosis, in all cases where complete mental and sexual deterioration has not taken place, is decidedly favorable ; for even in the worst cases considerable improvement is possible.

B. Satyriasis and Nymphomania.

Abnormal sexual desire is an intense disturbance in the domain of the feelings and the will, called satyriasis in men and nymphomania in women.^ Von Krafft-Ebing regards this sexual symptom-complex as a part of a psychosis which rests upon a psychical hyperaesthesia (in hysteria, states of mental exaltation, and senile and paretic dementia). Here, too, the transitions from physiological to reckless expressions of the sexual in- stinct, with loss of all normal deterring influences, are gradual. Emminghaus* regards the immediate re-awakening of desire,

Perettl, loe. cit.

' Von Krafll-EI)ing, Lehrbuch der Psyclilatrle, 3 aiifl., p. 519.

I follow, in the main, von Krafft-Ebing's exposition. Comp. Psychopathia Sex- nalis, p. 373, and Lehrbuch der Psychiatric, p. 87.

EmminghauB, Psychopathologie, p. 87.

SATYRIASIS. 29

after satisfaction of it, with pre-occupation of the entire atten- tion, as abnormal.

In Magnan's ^ classification these symptoms belong to the second group, i.e., disturbances which originate in those sen- sory regions of the cortex which lie behind the central con^olu- tions, where, according to this author, the zone of the desires and instincts lies, and which are influenced quasi-automatically by the genito-spinal centre as soon as tlie forebrain for any reason ceases to act. As examples, Magnan gives two cases of women suffering with extraordinary sexual excitement. One locked herself in her room to avoid the sight of men, who excited her desires to the utmost ; the other, the mother of five children, driven by similar animal desires, would surrender her- self on the first opportunity, and at last, in despair at her suffering, she attempted suicide.

Causes and Symptoms. While married life bridles the desire, sexual intercourse with different persons increases it. The imagination creates sexual scenes which go on to phan- tasms of the senses with hallucinatory delirium. " Everything calls up sensual thoughts, and the lustful coloring of ideas and apperceptions is intense. Feeling and will are entirely under the control of the psycho-sexual excitement " (von Krafft- Ebing).

The man affected with satyriasis seeks to satisfy his desire at any price, and thus becomes dangerous. Here enforced ab- stinence^ must be also regarded as a cause; it leads to neuras- thenia, and may, with an increase of sexual desire, endanger the freedom of the will.

In animals, too, during the time of rutting, the procreative impulse overcomes all otlier desires and feelings, and, if it be not satisfied, leads to sexual fury and perverse acts. Thus, accord- ing to liOmbroso,^ nymphomania has been observed in cows, mares, hens, angora cats, camels, and spiders ; satyriasis, in buffaloes, dogs, storks, and doves. At the time of the sexual

' Comp, Magnan, loe. eit.

• Von Kraift-Ebing, " Ncurosen und Psychoeen darch sexuelle Abstineos," Jahrb.

Mr Psychlatrle, Bd. viii, 1, 2.

Lombroso, Der Verbrecher, p. 20 etuq.

30 SEXUAL HYPERiESTHESIA.

erethism the animals are uncontrollable, and bite and kill any- thing that comes in their way ; or they tear their own flesh, tear up the ground, etc. In dogs and monkeys onanism originates in this way.

Even violent sexual attacks upon immature animals, and sodomitic acts, have not infrequently been observed (for ex- ample, in large studs) as a result of unsatisfied sexual passion. Houzeau saw a cock attack an immature pullet. In Egypt, Lessona saw an ass perform sodomitic acts in the absence of a female. For the same reason, faate de mieux, sexual union occurs between the swan and goose, between the elk or buffalo and the cow, and between the dog and wolf.

Likewise in man, enforced abstinence may endanger the freedom of the will and lead to perversity in the sexual act. Thus, a case is known to me where a criminal, who had s'pent several years in prison, immediately after his dismissal raped an old woman of 73 years in an open field. A second case was one of my patients. He was neurasthenic and previously a mastur- bator, and lie took a vow in a students' society to preserve his chastity, determined to abstain at any cost. After he had been able to restrain his sexual desires for some time, one evening libido came over him with all-conquering force, and clouded consciousness. He was unable to resist, and, in a confused state of mind, he followed the first prostitute he met. The result was that he had great moral anguish and fear of having infected himself; for he had performed the act without any precautions. The patient stated that he was beside himself while in this state, which resembled intoxication. A third case, in which impotence followed abstinence of five years' duration, is reported in Section II.

Tarnowsky^ also refers the origin of satyriasis principally to sexual abstinence, especially under the influence of religious ideas. " For example, there is the confession of the Abbe de Cours, which was written by himself and published by Buff'on.^ After long struggles, fasting, and prayer, all women began to

' TaniowBky, loe. cU., p. 61.

' BuffoD, Histoire uaturelle de I'homme.

NYMPHOMANIA. 31

appear to him as if surrounded by electric light. Their glance made a confusing impression on him. Later, definite hallucina- tions occurred : he imagined that the governor of the court set all women after him in order to induce him to break his vows of abstinence. The visions of St. Anthony were much more remarkable than this confession " (Tarnowsky).

There may arise from satyriasis, priapism, perversity of sexual acts, exhibition, rape, lust-murder, or excessive and shameless masturbation. The genital erethism may occur in attacks, intermittently and periodically (Magnan).

Sexual hypersesthesia occurs more frequently in women than in men. "The nymphomaniacal woman seeks to attract men to her by exhibition or lascivious conduct, and at the sight of a man she becomes intensely excited sexually, and satisfies herself by imitation of coitus or by masturbation " (von Krafit- Ebing).

Here, too, weak-mindedness is a condition which consti- tutes a favoring predisposition. Thus, Sollier reports : '* Marie B., imbecile, aged 22; tall, of delicate build. She stutters slightly ; she regards herself as sharper than any of her asso- ciates. When 13 she consorted with one of her father's ser- vants, and since then she has associated very frequently with other men. She imagines that every man she sees, no matter what his social position, loves and wishes to marry her. She stands at the window and throws kisses to men passing. She practices masturbation excessively, and she becomes angry and excited when kept from seeking the men who happen to be in the house, in order to surrender herself to them."

One of my patients, at merely the sight or touch (pressure of hand) of a man, would become excessively excited sexually, and satisfy herself by means of ideal cohabitation or niasturbatic rubbing with the thighs. For a long time the genital erethism occurred in attacks every morning, once at my ofiice. In spite of the presence of three male witnesses, she threw herself on an ottoman, and in hysterical convulsions masturbated several times before our eyes. In these attiicks consciousness is clouded.

• ' In women the intensification of sexual desire is expressed also

32 SEXUAL HYPER.ESTHESIA.

in shameless exhibition ; in constant washing with water, saUva, and urine; in combing and undoing tlie liair; in the milder forms of self-adornment and flirting ; in vacillation between forwardness and modesty or sentimentiility ; or in hand-squeez- ing, letter-writing, suggestive glances, etc." (Kraepelin).' The most frequent consequence of nymphomania is prostitution. Von Krafft-Ebing calls particular attention to the role of the sexual sphere in relation to physicians. Nymphomaniacal women desire gynaecological examinations, simulate retention of urine, etc. Post-menstrually, sexual desire is increased; and, according to von Krafft-Ebing, at such times in neuro- pathic individuals the excitement may attain a pathological degree.

In harmony with him, Neumann" holds tlie opinion that religious fervor and an inclination to indul";e in religious devo- tions are to be regarded as clinical equivalents. " The religious idea of sexual union in the form of marriage ; the relation of the Church and Christ, which is looked upon as that existing between the bride and groom ; the period of puberty, when a state of feeling arising from indistinct sexual sensations is fre- quently expressed in religious enthusiasm ; the history of the saints, in which are told the efforts to subdue the flesh ; and the practices of certain sects, whose revivals and meetings often become terrible orgies, are proofs of the physiological and inner organic relations existing between religious fervor and sexual desire. Of the same nature is the impulse in maniacal virgins to make pilgrimages and do missionary work, or to become nuns or, at least, the servants of priests; and they commoiUy talk much of virtue and virginity"^ (von Krafl't-Ebing).

The relation of religion, lust, and cruelty von Krafft-Ebing* reduces to the following formula : " States of religious and sexual excitement, at the height of their development, exhibit a correspondence in quantity and quality of excitement, and therefore, under favoring circumstances, one may take the place

' Kraepelin, loe, cU., p. 1.39.

Neumann, Lehrbuch der Psychiatric, p. 80. Von Krafft-Ebing, Psycliiatrle, p. 89.

• Von Krafft-Ebing, Psycliopathla Sexualls, p. 8.

NYMPHOMANIA. 33

of the other. Both, under patliological conditions, may become transformed into cruelty."

The diagnosis of this form of sexual hyperajsthesia pre- sents no difficulties.

In relation to prognosis, what has been said concerning masturbation must be recalled ; for the abnormal sexual desire may result from it, just as onanism may be symptomatic of liyperaBsthesia ; and, too, the fundamental psychopatliic or neuro- pathic disposition must be taken into account.

CHAPTER II.

THERAPEUTIC SUGGESTION IN THE TREATMENT

OF ABNORMAL INTENSIFICATION OF

SEXUAL DESIRE.

The close relationship of the various forms of onanism among themselves and with those of sexual hyperajsthesia (satyriasis, nymphomania, erotomania, etc.), and the similarity of therapeutic procedures in the groups of symptoms described in Section I, make it seem best to give, in a single chapter, a com- prehensive description of tlie curative metliods and the problems wliich meet the physician in the treatment of the various forms in which sexual excitement is expressed.

First of all, the cause of the sexual erethism, of the mas- turbation and its consequences, of the premature arousing of libido sexualis, must be removed. The most important duty of parents and teachers, and one -which, ini fortunately, through ignorance or false modesty, is neglected, consists in prophylaxis, ^in a rational sexual education suitable to the process of sexual development.

In many schools and academies masturbation and vice are actually cultivated. To-day too little attention is given to the mental and moral condition of pupils. If tlie lessons are learned, the principal requirement is fulfilled. That many pupils are thus ruined in body and soul is never considered. With silly prudery the sexual life is veiled from the developing children, and not the slightest notice is taken of the excitation of their sexual instinct. It is thought best to leave all to nature. In the meantime nature rises in her miglit and leads astray (von Krafft-Ebing.)^ With children strict and intelligent oversight is necessary, and when there arc indications of com- mencing onanism or other signs of premature awakening of sexual instinct, energetic treatment should begin immediately, if possible under the direction of a physician educated in psy-

• Von Krafll-Ebing, Psychopatbia Sexualis, p. 321.

(34)

ABNORMAL INTENSIFICATION OF SEXUAL DESIRE. 35

chology, and capable of the employment of suggestion. The means for the detection of onanism, for the most part at least, have been made clear in the exposition of the symptomatology and diagnosis of masturbation. Fournier's^ work also gives more details.

The children should be observed while at play, to ascertain whether they there give evidence of sexual excitement, and whether the manner of play corresponds with the sex. Thus, playing " papa and mamma " or ' being engaged " may attain pathological significance. Preference by boys for girlish games and employments, and vice versd by girls, may, with indulgence on the part of the parents, in further development lead to a change of character in the sense of contrary sexuality. A typical example of this kind is offered in the celebrated case of Count Sandor (alias Countess Sarolta V.). The father of the countess allowed her from childhood to go about in boys* attire, educated her as a boy, had her ride, drive, and hunt, and said to her : " Why, you are a man ; witli your energy, that is at once evident." Her tutor, Daniel K., most inaptly gave her sensuality a perverse direction. The child's mother had no influence in her education.^ With full weight given to the hereditary taint, the mental weakness, etc., it still seems questionable whether the disease of the Countess Sarolta V., without these artificial influences, would have taken the same fatal direction.

The pathological importance of educational influence in originating such conditions will be later placed in the clearest light by numerous sad cases of contrary sexuality. In youth a cure, or at least compensation, may be most hoix'fuUy sought. At the first sign of puberty children should be taught to under- stand the sexual relations and tlie results of abuse. Their fancy should be supplied with pure nutriment, and the education at school should avoid those things mentioned above which may play the role of seducer. Where there is a perverse and neuro- pathic disposition great care must be exercised in order that the

' Fournler, De I'oiiauisine. 4th ed. Paris, 1885.

• Comp. Friedreich's Blatter fur gerichU. Medicin, 1891, Heft i, p. 8.

36 SEXUAL HYPERESTHESIA.

development of tlie instinct be delayed as long as possible. Such exixjiienced physicians as Moll' and Tamowsky express themselves to this effect. Furthermore, separation of the sexes is to be avoided as far as possible, though the training must be devoid of all influences wliich lead to sexual excitement. Moreover, the relation of servants to children must be strictly watched. The cases in which infants who cry are quieted by genital manipulation are none too infrequent, as are instances of seduction of immature children to attempt coitus, onan- ism, etc.

The question whether indulgence in coitus is to be allowed in mature individuals has given rise to many conflicting opinions, which, owing to the importance of the subject, we cannot over- look. Several investigators, as Acton,'^ Beale,^ Paget,* and Gowers,* contend tliat abstinence has no injurious eft'ect upon the health. They permit sexual intercourse only in marriage. Augagneur ^ remarks : " In order to stamp prostitution as a crime under all circumstances, it is necessary, by unequivocal laws, to make sexual intercourse outside of the marriage rela- tion a crime." llibbing would combat onanism by hygienic, moral, and religious instruction. He has seen cases in which such individuals were really successful in overcoming their sad malady, "without resorting to a life of debauchery or marriage."^ The same author says further : " Chastity harms neither mind nor body. Little as I should advise a Don Juan to give him- self to onanism, I sliould be as far from attempting to cure onanism by means of debauchery." He pleads for the punish- ment of prostitution, but lias to confess (p. 184) "that we are far from the state of nature, and have found no modus vlvendl in accord with culture and its requirements." Forel,* who, in

' Moll, Contrare Scxualempflndung, 1891, p. 214.

Acton, On the Reproductive Organs.

Beale, Our Morality and the Moral Question, 1887.

Paget, Cited by Beale.

Oowers, London Lancet, 1889.

- Prophylaxe publlque de la Syphilis, par A. Poumier, Paris, 1887, pp. 10, 11.

' Ribbing, Sexuelle Hygiene und ihre ethischen Consequenzen, Leipzig, 3 aufl., pp. 127, 131, et $eq.

• Forel, " Einige Worte iiber die reglementirte Prostitution," Correspondenzbl. fUr

Qchweizer Aerzte, Jahrg. zlx, 1889.

ABNORMAL INTENSIFICATION OF SEXUAL DESIRE. 37

general, is an opponent of prostitution, allows that there are sexual neurasthenics who are intensely excited by pollutions, but who find relief in normal intercourse." Lowenfeld ^ con- firm's Forel's experience with the observation that occasional interruption of customary regular intercourse has a deleterious effect upon neumsthenic conditions. Von Kruff't-Ebing has shown, though it be with a series of cases that might be con- sidered not entirely sufficient, that a state of general nervous excitement may arise as a result of repression of one of the most powerful instincts, and that in individuals of neuropathic predisposition enforced abstinence may give rise to danger of nervous and mental diseases.^ Thus, continued sexual exci- tation without adequate satisfaction of it affects the health injuriously, as occurs not infrequently in marriages between elderly men and young women. As a result of the constant excitement and hyperaemia of the genital organs, without gratification, irritable weakness of the genital apparatus and its nerve-centres may ensue. According to von Kraff't-Ebing, in predisposed individuals the results of abstinence are essen- tially the same as those of onanism.^ Of course, very few men possess sufl[icient strength of will to come off" conquerors in the conflict between sensuality and reason. The vast majority, when opportunity for normal sexual indulgence is not offered, fall into the vice of self-abuse or perverse gratification of the sexual impulse, thus choosing if non-marital, but normal, sexual intercourse may be called an evil the greater of two evils.

The entire process of development of the human organism tends to put the individual into the most favorable condition for the |)erformance of the sexual functions. The conditions of life standing in opposition to a physiological need, to an instinct possessing the same justification and strength as the desire for food, can be of no possible use to the organism, of which medi- cal experience offers the best proof " The idea of complete health includes complete and regular satisfaction of all the

LSwenfeld, loc. eU., p. 17.

' Krafft-Ebiiig, Jalirbucher fur Psychlatrle, vlil, pp. 1, 8.

Krafll-Ebing, Psycbiatrie, p. 209.

38 SEXUAL HYPERiBSTHESIA.

needs of man, and that is the goal for which hygiene must strive, and not seek to stifle one of the most important func- tions of the organism, like tlie sexual instinct. The recom- mendation to voluntarily destroy any function like the idea of love is a suhject for the fanatic, but directly opposed to hy- giene " (Tarnowsky). ^

As long as society is not in a position to offer to every mature individual satisfiiction of tlie sexual appetite in some generally-recognized form, as in marriage, it is senseless to oppose non-marital sexual intercourse, and, in societies for abolitionism, to seek to cultivate absolute sexual continence. To combat prostitution with police regulations and laws is but a way in which to withdraw from medical and organized legal supervision immorality and contagious disease and transfer them to the family, as Tarnowsky, in his instructive work,^ with the presentation of abundant evidence, shows. Forel,^ likewise with resort to statistical material, makes an opposite statement. In his opinion, secret prostitution is neither so dishonoring nor so abnormal and dangerous as public prostitution.^ The roots of this phenomenon, which is still especially favored by the constitution of modern social life, are to be souglit in the varied intensity of sexual instinct; in the varying strength of the need to satisfy it ; in the variation of power of resistance in different individuals to passionate desires; in physical and mental defects of development (therefore in defect of moral sense) ; and, finally, in poverty and ignorance. The limitation of the evil to a minimum, which seems to every one of any knowledge of the subject both desirable and attainable, with any prospect of relative success, can only be brought about through an inner reform of society ; through correct education

• Tarnowsky, Prostitution und Abolitionismus, Hamburg, 1890.

76W.,p. 31.

• Forel, Zur Frage der staatl. RegoUrung der Prostitution (Bremerhaven und Leip-

zig, Lienken), 1892, p. 18. Unfortunately, I was unable to obtain, in time to use tliem for this work, the books recommend^ by Forel, " Fiaux, Les maisons de tol6rence " (Paris, 1892).

• In the consideration of this qnestion, the proportion of public to private prosti-

tution in Berlin is important. While more than 5000 prostitutes are registered, according to police estimates more than 50,000 live by prostitution. Comp. Aerztl. Vereinsblatt, Mirz, 1892, p. 93.

ABNORMAL INTENSIFICATION OF SEXUAL DESIRE. 39

of the young and the ignorant ; and through an increase of facihty of marriage and amelioration of conditions of life. " For the more undeveloi>ed an individual is, the more reckless he is in the gratification of his desires." We should institute a real sexual education, and lead the matured sexual instinct, by means of the preservation of rational indulgence, into paths devoid of danger; we should make needful concession to the natural impulse ; and, thus, public vice, witli its results, the unlimited spread of venereal diseases and the increasing number of crimes against morality, would be greatly diminished, and become more and more confined to the step-children of nature (those subject to congenital viciousness). But, more than all, the foundation would be removed upon which rest masturbation and the development of the sexual instinct in perverse direc- tions. ^

We might thus dispel the greater evil with the lesser ; for it is nonsense to think of abolishing the evil entirely. The best cure for onanism and other manifestations of sexual hyperses- thesia with few exceptions, there can be no doubt upon this point lies in regular sexual indulgence. The condition of society to-day, of course, allows a man much more freedom and opportunity in this direction than a woman, with the unques- tioned acknowledgment that his sexual desires are much more intense than hers. " In the highly-civilized state of the social life of to-day, woman in a sexual role and serving the social and moral interests of society can be thought of only as a wife" (von KrafFt-Ebing). The nini and ideal of a woman is, and remains, marriage. For, as Mantegazza justly remarks, she demands not only satisfaction of her sensual desires, but also protection and maintenance for herself and her children. However, upon con-

' The Committee of Management of the Prussian Society of Pbysiciaus, in ita meeting of December 13, 1891, in considering the question of prostitution, touched upon the subject of sexual education. There was no diflference of opinion as to the fact that the sensual impulses which lead to non-marital intercourse can in no way be restrained by public police regulations. On this occasion, attention was drawn to Lassar's deserving work, who, in two articles ("Prostitution und Geschlechtskrankheiten," Hygienische Rundschau, 1891, No. 23; and "Die gesundheiteschadliche Tragweite der Prostitution," Berlin, A. Hirschwald), points teachers to the duty of having courage to teach developing youths and warn them against the dangers of infection. Tlie committee appointed a com- mlasion to make a report upon measures for prerenting the further spread of syphilis.

46 SEXUAL HYPEHiflSTnESIA.

sideling the obstacles to matrimony which exist in the social relations of to-day, and which, on the one hand, make marriage impossible for many women ; and upon considering the extraor- dinary dangers and disadvantages which attend all manner of unnatural sexual indulgence, must we not acknowledge that it is better, as Steinbacher ^ says, to give to the world the healthy fruit of a passionate love than, througli sins against self, against nature and health, " in invalidism and misery, to stamp youthful years with the most repulsive mark of old age ? "

The strength and intensity of the sexual instinct, like moral and physical individuality, are too various to make it necessary to give a general application to the foregoing state- ments. Such a misunderstanding might become a welcome license and cloak for all possible expressions of vice, and it would open the door to sensuality. While one, thanks to the inherent peculiarities of his organization, can easily practice abstinence, another is led to onanism, and, as a result of it, is utterly ruined if he has no opportunity for natural sexual indulgence. Only after the most careful study of the single case can it be determined how far and in what way the sexual appetite should be satisfied. From the stand-point of sexual hygiene, the principle of the weakest force must be as deter- minate here as in nature in general. Therefore, the chaste youth should exercise sexual abstinence as long as he is able to restrain the instinct without injury to his health. Should he be in danger, owing to increasing strength of his sexual impulse, of onanism, of falling a victim to satyriasis, or perverse sexual indulgence, then it becomes the duty of his teacher and his physician to cause indulgence in coitus and, too, to acquaint the neophyte with precautionary measures Avhich will guard against excesses, infection, and the procreation of illegitimate offspring which, under certain circumstances (e.^., with contrary sexu- ality), may be hereditarily tainted. Individual sexual capa- bilities should determine the frequency of sexual indulgence. It is impossible to fix a normal standard. Acton allows but one act of coitus a week ; Martin Luther allows two ; but, on the

• Steinbacher, loc. eit., p. 85.

ABNORMAL INTENSIFICATION OF SEXUAL DESIRE. 41

other hand, the Queen of Aragon recommended six sexual acts a day. " The Talmud directs one coitns a day for a man who is well and strong and not working hard ; for mechanics, two a week ; while students and laborers are to indulge but once a week."^

Concerning the advisability and injurious effects of so-called " preventives," opinions also differ. Gyurkovechky^ allows that only those who have some idea of what it is to have " eight children and little bread " have any right to speak for or against the employment of such measures. A means which is much lauded, and used especially in France, for the prevention of con- ception (known by the name " fiaudiren," coitus interruptus), consists in withdrawing the penis from the vagina immediately before ejaculation, which then takes place. In my opinion, there is no doubt that congressus interruptus is an act harmful to health. Peyer^ saw fourteen patients suffering with spinal neurasthenia, spermatorrhoea, neuralgia testis, sexual asthma, cardiac palpitation, etc., resulting from it. At the instant of most intense excitement the ejaculation is voluntarily postponed as long as possible ; complete retreat takes place with a great expenditure of physical and mental energy. " The action of the prostatic muscle and the bidbo- and ischio- cavernosus mus- cles is no longer natural, unobstructed, and energetic, but modi- fied and weakened." In a woman, the sudden cessation of friction during the height of orgasm, before the feeling of ejaculation, with its consequent sense of satisfaction, has taken place, may induce disturbances of the nervous and sexual systems.* In contrast with this theory of Peyer and Bergeret, Gyurkovechky states that he has seen persons who bore this procedure well.

Of all the means for the prevention of conception, the condom seems relatively the least injurious for botli parties; and it affords relatively the greatest protection against infection and pregnancy. Therefore, as does Gyurkovechky,^ we can recommend to our patients a well-made, elastic condom.

'Comp. Gyurkovechky, loc. dt., p. 88.

• Gyurkovechky, loe. cit., p. 143.

• Peyer, Der unvollstandige Belschlaf, Enke, Stuttgart, 1890.

• Bergeret, Des fraudea dans I'accom pi lament des fonctioDB g^ndratrices, Paris, 1884.

• Gyurkovechky, loa. cU., p. 144.

42 SEXUAL HYPERESTHESIA.

In the foregoing, the fundamental features of sexual pro- phylaxis have been sketched in all its most essential points, in accordance with the principles of hygiene. To emphasize it again, the most important princi])le is, and remains, individuali- zation. No prudery, no i'alse modesty, should keep us from giving the same care and attention to the most powerful of natural instincts which everybody gives to other physical func- tions, such as is given to nutrition ! Wliolc libraries are written about appropriate and healthful diet, but there is hardly to be found a single book resting on a strictly physiological basis concerning the care of the sexual functions ! Numerous popular and error-breeding works and the products of an ex- treme asceticism are the only substitutes that have yet been offered to youth seeking knowledge.

A sexual education which takes account of all the physio- logical needs, in all therapeutic measures directed against psycho-sexual disorders, is an important and indispensable part of the psycliical treatment. The application of suggestion is for the physician an excellent means of methodically disciplining, in the most effectual and quickest manner, the patient's feelings in accordance with these educational measures. Above all, this is true in those cases in which psychical treatment in the non- hypnotic state progresses slowly or is ineffectual. For this reason, in this book, sexual education, as an important part of psycho- therapeutics, must be considered.

Before we pass on to therapeutic suggestion in its narrower sense, we may review briefly other customary methods of treat- ment, since it is often necessary to use combined means. Here we may limit ourselves to a review of the most necessary meas- ures, with citation of several excellent works on impotence, neurasthenia sexualis, etc., which give other methods of treat- ment in detail.

We have an important aid in hygienic measures. The patients should lead a life tending to strengthen them. The diet must be nutritious and unstimulating, and digestion must be regulated. Meats must be taken moderately, and there must be great moderation in the use of alcoholics. Supper should be

ABNORMAL INTENSIFICATION OF SEXUAL DESIRE. 43

taken three hours before retiring. Onanists should not sleep more than seven or eight hours, and they must be compelled to rise early. Persons who masturbate automatically in sleep are to be provided with appropriate mechanical devices for arms and feet to prevent the act, and the genitals should be protected with a proper bandage.^ Above all things, the onanist must avoid solitude and have no opportunity to dream. The imagi- nation must be given healthful food, and the patient must be usefully employed from morning until night. Rational gym- nastic exercise and long walking tours lessen the excitability of the sexual centres. In addition, there should be massage, swim- ming, etc. In the choice of diversions, according to the indi- vidual, such things are to be scrupulously avoided as tend to excite the imagination to psychical onanism. First of all, the cause of the habit is to be removed: remedy a phimosis; obviate other conditions, induced by bodily conditions or external cir- cumstances, which cause excitement, pruritus, etc. The results of onanism spermatorrhoea, etc. are to be treated locally.

Hydrotlierapeutic procedures are to be recommended in almost all cases of sexual hj'peraesthesia. Thus Caspar^ recom- mends cold baths, followed by cold douches to the spinal column ; also cold rubbing with wet towels. Prolonged warm baths have a calmative eflfect on the nervous svstem in cases of satyriasis and nymphomania. Concerning the use of sponge-, shower-, and douche- baths, and hip-, steam-, and sea- baths, compare Gyurkovechky,^ Beard,* Lowenfeld,^ and Winternitz.*

' For description of mechanical means for the prevention of masturbation, compare Foamier, De I'oiianisme, Paris, 1875. This author gives a long list of devices; for ex- ample, shirts that are closed in various ways, trousers or drawers without openings, etc. Mantegazza, Foumier, and Porro recommend the subcutaneous insertion of a ring in the prepuce (near the frenulum). The wound heals and the ring is allowed to remain. Mechanical irritation causes tension at the base of the glans, and gives rise to pain. Inflammatory oedema follows attempts at onanism, and attracts the attention of the parents. According to Mantegazza, the ring is applicable to girls. Here the ring must be inserted between the middle and superior third of the labia majora, so that the labia are brought in contact with each other by the ring at the point indicated. Compare Mantegazza, Die Hygiene der Liebe, 3 Aufl., Jena, Costenoble, p. 82. But no mechanical devices can overcome psychical onanism.

' Caspar, Impotentla et sterilitas virilis, Manchen, 1890, p. 104.

• Loc. cit., pp. 158, 160.

• Sexual Neurasthenia.

• Loc. cU., p. 154.

• Die Hydrotheraple, 1879, Bd. U.

44 SEXUAL HYPERESTHESIA.

Too, treatment with sounds, injections, rectal treatment, and, in fen^ales, irrigations and otlier local applications, may be necessary.

Various forms of application of electricity in the con- ditions which result from onanism, especially neurasthenia, are highly recommended by all authors in the form of faradiza- tion as well as of central galvanization (Beard and Lowenfeld). Almost every author has his own method, which may be learned by consulting tlic special works. Moll's work,^ which lately appeared (" Is Electro-Therapeutics a Scientific llemedial Pro- cedure'?"), should be consulted; and also the controversy of Mobius and Eulenburg^ concerning the role of suggestion in the application of electricity. Moll declares that, though he does not regard electro-therapeutics as a scientific remedial pro- cedure, it is still the physician's duty, even though it be based only on empiricism, to use electricity in appropriate cases.

Among the articles of the materia medica, the various prepamtions of bromine have a calmative effect upon the genito-urinary system. Other known anaphrodisiacs are : bel- ladonna, lupulin, camphor, opiates, and salicylic acid with pro- longed use. On the other hand, cantliarides, phosphorus, and atropine exert an exciting efi'ect on the genitals ; and for this purpose Hammond^ recommends strychnia.

Psychical Treatment in the Non-Hypnotic State. In the last part of this section we come to psychical treatment in general, in so far as it has not been considered with reference to sexual liygicne, and to therapeutic suggestion in its strict sense as the most important part of it. All authors that have written on onanism, sexual neurasthenia, etc., agree concerning the effect of psychical treatment. In the non-hypnotic state, with due consideration of the individual concerned, such treatment must first be in the direction of an explanation to the patient of the nature and the results of his disease. To eonvince the patient that he or she has become the victim of an abnormal,

' Berliner Elinik, Heft 41, November, 1891.

Berliner kiln. Wocbenschrm, 1892, No. 8.

• Loe.cU.

ABNORMAL INTENSIFICATION OF SEXUAL DESIRE. 46

dominating impulse, whether an onanist or a nympliomaniac, that is, seli'-knowledge, constitutes an important step toward improvement. The mistrust of the patient is to be removed and his hope awakened by analyzing his case for him. All exciting influences, like obscene reading, bad company, por- nographic pictures, etc., capable of exerting a detrimental influ- ence on the patient's imagination, must be avoided. An attempt must be made to win the entire confidence of the patient, to strengthen his self-reliance, and to overcome his erroneous ideas by repeated explanations and educational means. The patient must learn to control himself, to strengtlien his will, and, by practice, gradually become master of his sexual impulses. The diversion of his attention plays a role the value of which should not be underestimated. Experience teaches tliat mere diversion of the mind, even during coitus, may overcome erection. Cases of impotence due to mental preoccupation are not very infre- quent ; it occurs with especial frequency as a result of intense thought on abstract subjects. Broussais ^ asserts that mathe- matical studies diminish sexual power. Grimaud de Coux^ and Martin Saint-Ange recommended the study of mathematics as one of the most effectual means of repressing intense libido sexualis. These authors report a case in wliich a celebrated mathematician was always restrained from completion of the act of coitus by the sudden recurrence in his mind of problems of geometry or proportion with which he had been occupied during the day. Hammond^ reports the same thing in the case of a card-player who, during cohabitjition, always was seized with the thought of a technical manipulation of cards, which destroyed his sexual power. Active business operations make a large demand upon tliought, and thus the sexual impulse is repressed.

Rosenthal* and Bernheim'^ speak in favor of the "larvated" form of psycho-therapeutics in the non-hypnotic state and for

' Coun de phr^nologle, Paris, 1826, p. 783.

• Histoire de la g6n6ratIon de I'homme, Paris, 1847, p. 294.

• Loe. cU.

• " Ueber peychisclie Theraple Innerer Krankhelten," Berliner KUnik, No. 25, 1890.
• Neue Studien uber Ilypnotismus, etc., Wieu, 1898.

46 SEXUAL HYPERESTHESIA.

that form which excites pain. Such forms depend, for their effect, upon the excitation of ideas of cure, by means of intense sensory impressions, such as cold douches to the genitals, faradic pencihng, or other instrumental procedures, and fright and fear (with children). Tlie means used may be medical, mechanical, electrical, and religious ' and mystical. The patient's thought with regard to the cure should be altered. The patient, though seemingly passively, in reality brings about the cure actively. A quiet demeanor on the part of the physician that invites the confidence of tlie patient, an understanding of the latter's in- dividuality, and great patience are indispensable.

The principal means of psycho-therapeutics, in the non- hypnotic state, seem to gain more and more recognition, especially among such investigators as undervahie the effects of hypnotic procedures. The various mechanical and other remedial procedures, above alluded to, may unconsciously (with- out the knowledge of physician or patient) exert a suggestive influence, a statement which the effect of tlie measures them- selves does not controvert. Lowenfeld^ believes that quinine, iron, arsenic, and the bromides, as remedial agents in obstinate cases of nervous weakness (of sexual origin), are effectual for the most part through suggestive effect; and he recommends static electricity as an excellent means of inducing psychical effects.

In the various forms of psycho-therapeutics, psycho-therapy by suggestion forms the most effectual remedial measure. It fulfills all the requirements of such treatment, and gains a more speedy and surer entrance into the patient's mind than is pos- sible to any of the other forms. Therefore, it may be regarded as an abridged and condensed procedure possessing all the advantages of psyclio-therapeutics. Witli von Krafft-Ebing, among the authors repeatedly mentioned in this work, Caspar^

' There is no doubt, in spite of numerous exceptions, that a strict relipious educa- tion with many persons is an excellent prophylactic against sexual errors. Compare the brochures of Rdmer, previously mentioned.

• Loc. cit., p. 152.

• Loc. cit., p. 98 : "I doubt not that suggestive therapy (in impotence and sexual

disturbances) will give invaluable resulU."

ABNORMAL INTENSIFICATION OF SEXUAL DESIRE. 47

and Lowenfeld^ principally speak in favor of hypnotic sugges- tion in sexual neuroses.

Tessie's ^ remarkable experiment shows that erotic feelings can be awakened and removed by hypnotic suggestion. To an hypnotized subject he suggested : " The right ring-finger repre- sents lust ; the left, chastity. He awakened the patient with- out speaking, and then pinched the right ring-finger. At this the patient gradually became erotic, and he overcame the feeling by pinching the left ring-finger. Tessie forgot to remove this suggestion. The next day the patient presented himself, worn out and scarcely able to stand. The patient stated that the preceding day he met a friend who pressed his right hand, and a few minutes afterward he was taken with an overmastering desire for coitus. He noticed that this desire arose from the right ring-finger, which he liad pressed many times during the twenty-four hours. Excited by this means, he had practiced onanism several times and had coitus several times during the night ; and on the day on which he came to Tessie he had had several ejaculations, for on the way he had pressed his right ring-finger."

The physiological basis of therapeutic suggestion in hyper- aesthesia sexualis is demonstrated by those experiments that show the possibility of voluntarily increasing and diminishing by suggestion vasomotor and secretory processes, as well as emo- tions, impulses, and mental aftects. Dreams of a sexual con- tent, which, as is well known, may induce ejaculations, may be called physiological auto-suggestions, and are analogues of the suggested dream in hypnosis.

Notwithstanding the insufficiency of the material at hand, the collection of previous experiences answers this question in the affirmative.

' Loc. cit., p. 157 : " In hypnotlzable persons hypnotic suargestlon Is cai)ab1e of the greatest service. In the case mentioned above, of a girl who, after abandoning masturba- tion that had been long practiced, suffered with occasional sleeplessness and greater sexual excitability, a single hypnosis with appropriate suggestions was rei)eatedly successful in giving sleep and freedom from sexual excitement for weeks iit a time. Still, this patient was an excellent soniunmbullst, who could be placed in deep liypnosis in a few seconds. In other cases In which only slighter degrees of hypnosis could be secured, the results were not so brilliant."

• La France, 1889, p. 109, cited by Caspar, loe. cit., p. 90.

48 SEXUAL HYPERvESTIIESIA.

Charles Richet' demonstrated that it is possible to induce ejaculation by merely awakening a belief that coitus is being l)erformed. Sexual psycho-pathology, in ideal cohabitation, pre- sents analogous examples of orgasm indnced by auto-suggestion. Merely the direction of the attention to the performance of coitus, in association with lively images of sexual content, induces vasomotor changes in the genitals, as any one may demonstrate on himself Purely as a result of idea, excitation of the dilators of tlie penis occurs, exactly in the manner that blushing and pallor are brought about by psychical impressions.

While witliout hypnosis the vasomotor nerve-centres may be intensely influenced by ideas, in hypnosis there is a marked increase in the intensity of tliis physiological manifestation, which may attain overpowering force. This occurs as a result of the removal or weakening of the regulating inhibitory mech- anisms, associative and opposing ideas. Natural reaction, i.e., the transformation of idea into a certain form of movement, may take place with more energy and rapidity. Vasomotor effects induced by suggestion may, in certain persons, become so intense as to cause haemorrhages, mense*s, etc. ForeP shows that it is possible to induce and prevent erection by suggestion, and that thus pollutions may be controlled. In the same way, the well-known physiological fact of the waking state that simply ideas, feelings, and impulses call up desires or inhibit them, e.ff., appetite (at sight of food), thirst, joy, excitation of libido sexualis at siglit of a woman, etc., is intensified in hyp- nosis. In an hypnotized woman I was able to induce the greatest expressions of joy by suggestion, and at the height of the emotion change it by the same means to the opposite ex- treme of feeling, i.e., to sadness with passionate weeping. In a similar manner, we may affect the psychical part of the sexual mechanism more easily and enduringly in hypnosis than in the waking state.

The memory-pictures, which in all psycho-sexual patients are influential in inducing sexual feelings, may be weakened in

MolJ, Der Hypnotlsmus.

• Forel, HjpDOtlsrauB, 2 Aufl., Euke, Stuttgart, 1891, p. 60.

ABNORMAL INTENSIFICATION OF SEXUAL DESIRE. 49

their effect or rendered impotent by suggestion. In onanists, for example, we may successfully suggest repentance and open confession (e.g., in hypnosis to control the statements made in the waking state), and thus successfully oppose their weakness of will, in so far as it does not arise from deep, inherited consti- tutional conditions. The impulse to self-abuse, or the patho- logical impulse to homo-sexual intercourse, may have become a habit which imperatively and unconsciously controls the patient, he being unable to resist it. In such cases we must strive to combat the pathological auto-suggestion in accordance with its manner of origin, for habit is to be regarded as auto- suggestion. The ideational excitant imparted in therapeutic suggestion must be intensified by repeated hypnotization, until it acts automatically from the brain and has become a habit. Through consequent discipline it finally becomes a habit having the same force as the pathological auto-suggestion, and thus compensates the central pathological excitant. Unfortunately, hereditary disposition sets a limit here also which therapeutic efforts cannot pass. In correct and skillful use of ideas induced in hypnosis lies the power of suggestion as a pedagogic aid. In the same way we are able to effectually combat the patliological results which manifest themselves in neurasthenic symptoms and alterations of the normal subjective feeling.

The nearer the anomaly approaches actual mental disease, the more difficult the physician's task becomes. The disturb- ance of attention makes hypnosis impossible, and the influence of the operator, unfortunately, is not always sufficient to equal the power of the auto-suggestions which in many patients arise from organic conditions. As we have seen from the foregoing consideration, the ideas implanted in the brain during hypnosis correct the disturbances of the sexual life, the causes of which in a great number of cases are psychical, and the secondary results of which manifest themselves in symptoms of functional weakness of the nervous system ; or the psychical factors play the principal role in the disease. In comparison with other indirect remedial measures, we may characterize therapeutic suggestion in manifestations of sexual hyperaesthesia from

60 SEXUAL HYPER.ESTIIESIA.

psychical causes as the most direct remedial measure, and one which attacks the evil at its root. In cases of onanism no otlier method of treatment can be compared Avith therapeutic suggestion in rapidity and certainty of action ; psychical them- peutics in the waking state often does not succeed wliere hyi^ notic suggestion is successiul. Since onanists are, as a rule, children, it is very easy to see that the categorical command of the suggestive impulse, owing to their sensitiveness to hypnosis, is mucli more effectual than the circumstiuitial procedure in the waking state. Besides, tlie latter method, in the matter of self- knowledge, strength of will, etc., makes demands upon the juvenile mind whicli reacli beyond the mental horizon and ability of many children. After these tlieoretical considerations there can no longer be any doubt tliat psycho-tlierapeutics by suggestion is destined in tlie future to play the principal role in the treatment of onanists, while former methods of treatment are to be employed only lor the sake of completeness.

In a more limited sense, the same is true of satyriasis and nympliomania in their milder forms ; severe cases and those due to organic conditions a,re to be treated in asylums as cases of insanity, where in such cases suggestion may also possibly prove of benefit. Practical experience fully confirms our opinion based on pathogenesis.

CHAPTER III.

CASES ILLUSTRATING THE SUGGESTIVE TREATMENT OF SEXUAL HYPE11J!:STHESIA.

Twenty cases from the experience of others and myself follow, which, with the exception of Case 9, are published togetlier for the first time from the manuscripts of the autliors. Tlie grouping of the cases corresponds with the foregoing classification.

Onanism by Means of Tactile Irritation. (Cases 1 to 16, 1 to 9 by other authors; 10 to 16 by the author.)

Case 1. Onanislic Inclinations in a Child Overcome by Hypnotic Sug- gestion^ without Relapse. Reported by Dr. Liebeault, Nancy. L., a boy aged 3, in July, 1887, was cured of his onanistie inclinations in three sittings. He piissed into light sleep. In September, 1888, relapse. I cured him of his vice by suggestion in eight sittings. According to his grandfather's statement, there has since been no relapse.

Case 2. Onanism in a Boy Cured by Hypnotic Suggestion. Reported by Dr. Liebeault. Another bo}', aged 7, passed at once into somnambu- lism, and in five sittings was cured of his onanistie tendencies. He has not been brought for treatment again ; hence, I hold his cure to be lasting.

Case 3. Masturbation and Enuresis Nocturna in a Qirl Cured by Hypnotic Suggestion. Reported by Dr. Liebeault. A., aged 8, female, masturbated b}' touching the genitals with her hands from early child- hood, and surtered with enuresis nocturna. After three hypnotic sittings (somnambulism) the evil habit and the enuresis disappeared. Has she relapsed? I have heard nothing of it. Still, to avoid relapse in such obstinate cases, from time to time they should be treated by hypnosis as a prophylactic measure.

Case 4. Onanism and Chorea Improved by Suggestion. Reported by Dr. Liebeault. X., a bo}' aged 9, was seduced to onanism by an old woman. He was also subject to choreiform movements. Suggestive treatment improved him from sitting to sitting. Unfortunately, the treatment was interrupted, and I could not learn whether he was completely cured.

Case 5. Unsuccessful Hypnotic Treatment of a Weak-minded Onan- ist. Reported by Dr. Liebeault. B., a young man aged 30, became weak- minded at the age of 12, and had masturbated for years. In spite of all

(51)

52 SEXUAL HTPERiESTHESIA.

treatment, he continued the vice. At the first nttempt at hypnosis he passed into deep sleep. Notwithstanding the fact tiiat for months I daily subjected him to treatment by suggestion, I obtained no result.

Case 6. Masturbation in a Qifl Cured by Suggestion. Reported by Dr. Wetterstrand, Stockholm. A girl aged 26, scliool-teacher from the province, was given to ujasturbiitioii from cliildhood. In three weeks of treatment she was cured bv hypnotic suggestion. W. could not ascer- tain whether she had since married.

Case 7. Temporary Improvement by Hypnotic Suggestion in a Boy, Predisposed by Heredity, Suffering with the Habit of Onanism, liej^orted by Dr. Bernheim, Nancy. A child aged about 8, Russian, was brought to me by his mother three 3'ears ago. The boy had masturbated for years. This tendency was probably hereditary ; for, as a mature man, his father was unable to overcome this evil habit. The child was pale, seemed lymphatic and nervous, and had been badly trained. It was eas}' to produce hypnosis deep enough to leave no memory of it after waking. But during the hypnosis he threw and turned himself about. Quieting suggestions were without effect. I treated him three or four weeks continuously. During this time he seemed to have abandoned his habit; at least, his mother, who watched him carefully, noticed nothing. But after interruption of the treatment he renewed liis habit. All medical, h^'gienic, and other treatment remained futile.

Case 8. Lasting Bemoval of Habitual Onanism by Hypnotic Sug- gestion in a Boy. Reported by Dr. Bernheim. X., aged 8, a pupil at Bar-le-Duc, was brought to me by his father, April 9, 1891, on account of habitual onanism, which he had practiced for tliree 3'ears. A boy of 16 had taught it to him. Seven montlis previously' his parents had discovered his vice. They surprised the child in flagranti, while he was apparent!}' sleeping in bed. The boy masturbated as often as five times in a night; as a rule, three times, and as often during the day. Ejacu- lation began in the preceding October. Many methods of treatment had been tried (bromides, threats, baths, removal of all excitement, etc.). For three months he had drunk only water. Nothing had been success- ful. The child seemed very intelligent, obedient, and well trained. For two months it had been noticed that his mental powers were failing. Since then he had not been sent to school ; for, in spite of the watchful- ness of the teacher, he masturbated. Still, the patient had a desire to be cured. But the passion was stronger than his will, which was power- less. According to his statement, the act was performed in sleep at night involuntarily. Whenever he desired to enter the closet, he re- quested his father to accompany him, since, otherwise, he could not with- stand the temptation to masturbate. Aside from rotheln and scarlet fever, X. had had no diseases. He had never shown sj'mptoms of nerv-

ONANISM BY MEANS OF TACTILE IRRITATION. 53

ousness, and was devoid of nervous heredity. At the first sitting, on April 9th, I phieed him in deep sleep, with amnesia on awaking. I sug- gested to him tlmt neither b^' day nor by night was he to iiuve a thought of touching himself, and that he would be able to withstand nil tempta- tion. I repeated these suggestions every day until the 23d of Ai)ril. From the first sitting the child continued cured. The thought to mas- turbate did not occur again (according to his own statement). April 11th he weighed 44^ pounds; on April 13th, 45 -f; April 16lh,4G-j-; April 21st, 47 -|-. Before his departure, I suggested to him to write nie concerning the duration of his cure. I received a letter dated Ma}' 23d. The cure remained lasting. At that time he had gained slightly in weight. Some months later I met the family' physician. According to his statement, the cure had continued lasting. The child, previously shy, and who would never look at the doctor, then met him without embarrassmeut, with open mien and a good conscience.

Case 9. Moral Perversity {and Onanism) Cured by Hypnotic Sug- gestion. Reported by Dr. Aug. Voisin,^ Paris. A boy, aged 16, was brought to me June 9, 1888, witii the desire that I cure him of evil instincts by hypnotism. At the age of 13 he had tetanus. Since that time he had suftered with nystagmus and had stuttered ; but before that, and since his sixth or seventh year, his evil peculiarities of character had made him unendurable. He lied, stole, was disobedient and vicious. His evil instincts had grown worse from year to year. In several schools he could not be endured. All efforts of his mother to improve him were vain. It was impossible to get him to take the first communion. Of late 3'ears he had stolen more frequentl}', and led a vicious life. He stole from his mother in order to run after girls. Onanism in him was a passion to which he gave himself in the same room with his mother without shame. He imagined that he loved evil, and stated that he felt no remorse. His parents consulted a great number of teachers and priests without effect.

The discipline of the houses of correction was too weak for him. Finally, I was consulted in the matter.

At the first examination, the existence of convergent strabisnuis of the left eye, nystagmus, and stuttering was ascertained. Ears, hands, and feet normal. No tumefied glands ; no bronchocele. The tongue was deflected to left when protruded. He read only with difficulty, and had but an elementary knowledge of geography. Memoiy good, on the whole.

June 9th, first hypnotic treatment. Fixation of a shining ball that was hung over his he.id, in connection with sleep-suggestions, induced hypnosis in the fifth sitting. After the occurrence of sleep I began to combat the tendency to steal and to change his character by suggestion.

' Dr. Aug:. Voisin, Medloin de 1ft SalpStrl^re, " Un cas de perversity morale guM par la suggestioD hyptiotique," Revue de I'liypuotisme, 1888, p. ISO.

64 SEXUAL HYPERiKSTHESIA.

After the first sitting be censed to steal, and his character underwent a favorable clianj^e. The treatment was continued every tliird dny, and the suggestions were directed in turn against his vicious diameter, his evil instincts, unanisni,and his immoral habits.

July 6th the young man was like a dillerent person. All thougiit of doing evil had disappeared and given place to the best principles. His disobedience and incorrigibility gave place to a desire to be pleasant to his mother. So to speak, he was no longer the same young man, and he expressed to me his delight at the change.

On October 20th, after absence of six weeks, the cure continued, though there had l)een no treatment in the interval.

The further continuance of tlie cure and the fact of a complete inner transformation were confirmed by a letter to Dr. Voisin, based upon observation, which was written by a former teacher of the patient after his discharge.

The foregoing case seems to me worthy to be reported, because the onanistic tendencies are to be regarded as a symptom of the boy's char- acter. With the successful and lasting change of character the root of the evil was removed. This remarkable result offers hope to such unfortunates in whom masturbation is favored b}' hereditar}* predis- position.

Case 10. Personal Observation. Successful Hypnotic Treatment of an Onanist in Three Sittings. V., aged 14, pupil of a foreign school, was sent to me, April 20, 1889, with a letter from his mother. Parents healthy; V. had li;ul no severe illnesses; moderate left inguinal hernia; truss. Genitals normally develoi)ed. Patient is suspected of masturba- tion, and after rigid questioning he confessed his vice. For a 3'ear or two he had practiced it frequently (seduced to it). Unfavorable effect on the nervous system. Remarkable and increasing dullness in school. Sleepy, inattentive, dreamy, etc.

During his stay of nine dsxys in Munich the patient could be hypno- tized only three times, on April 22d, 24th, and 27th. He passed into somnambulism ; suggestions to remove his vice. During the treatnient the patient made no attempt to masturbate. He stated that he felt dis- gust, and i^romised me repeatcdl}' to masturbate no more.

April 28th he returned to school. After the three sittings I could onl}' discharge the patient as improved, the more because it was clear that the unavoidable stimulus of seduction would still influence him. I called the attention of his relatives to the probabilit}- of relapse, and explained that a perfect cure might be obtained by frequent regular repetition of the procedure, together with strict control of the jiatient.

In September, 1891, I learned that further treatment of the patient for his vice had not been necessary. Influenced b^- the psychical treat- ment in 1889, probably, he had entirely abandoned the evil.

ONANISM BY MEANS OF TACTILE IRRITATION. 55

Case 11. Personal Observation. Temporary Improvement, Lasting Six Months, of an Onanist by Hypnotic Treatment, Patient aged 18, without hereditary or pathological aniecedents. Given to onanism since his thirteenth jear ; masturbates daily, usually mornings. He rises late, has no desire to work, and suffers with pressure in the head and pain in the back. Dreamy; memory weak. He had fallen behind in school. Dei)ressed state alternating with causeless intense excitement (violent outbursts of anger). Patient was first hypnotized on February 18, 1889. Complete h^-potaxis. Cataleptic symptoms. Energetic suggestions to give up the abnormal imi)ulse and satisfy his desires with women. Up to March 11th, masturbation but once (previously daily).

Gonorrhoea from second coitus, which was cured by injections and bougies in the course of the following weeks. Up to May 20th the patient was hypnotized twenty-six times, at first dail3',then two or three times a week, and finally every week or fortnight.

On May 20th the patient was discharged as essentially improved. The complaint nientioned had disappeared entirely of late. Mood agree- able. No onanistic relapses, but from time to time normal cohabitation. He stated that famil}' circumstances made it very difficult for him to satisfj' his libido regular]}-. After six months the patient reported that he was well. On my last inquiry (two ^ears after) he reported that he had relapsed.

This relapse cannot alter the fact that a decided improvement was brought about by the treatment in 1889. If the patient and his relatives did not take pains to carry out proper sexual hygienic measures and provide prolonged medical control, the relapse can onl}' be ascribed to this failure; the result of therapeutic suggestion is not altered b}- it.

Case 12. Personal Observation. Lasting Cure of an Onanist by Hypnotic Suggestion, and his Preparation for Examination by Suggestion. B. S., medical stiulent, aged 20. Parents and other members of family healthy. No diseases except measles and chicken-pox in earl}- child- hood. Moderate skolio-kyphosis due to rachitis treated surgicallj-. Sexual desire began in his twelfth 3'ear; gratification of it since that time bj' masturbation, as a result of seduction. Patient had never felt the need of hetero-sexual intercourse. Though this constituted the con- tent of his sexual imagination, he had never had the courage and self- confidence to substitute coitus for onanism. The patient still mastur- bated at least three times a week. For a long time S. had noticed the injurious effect of this sexual condition upon his nervous system. Great inclination to dream, languid appearance, retiring habits, anxiety. Great lack of energy and diminution of mental activity. S. often remained in a doze mornings until 11 o'clock, and, as a rule, rose late. Remarkable inattentiveness and mental weakness, which had made itself felt very unpleasantly in the preparatory studies he was making in the face of

66 SEXUAL HYl'EKiESTUESIA.

his approaching medical examination. lie looked forward to the exam- ination with anxiety, convinced that he could not pass it. The patient was very easily confused, and had lost self-confidence. Great timidit}'. He consulted me not about his onanism, but to have his courage and confldence strengthened for the examination by suggestion. In other respects the patient presented no noteworthy physical or mental abnormality.

June n, 1891, first hypnotic attempt. In spite of unconscious resistance to the suggestive sleep, in a few minutes he passed into the second stage (Forel), catalepsy, with inability to interrupt it voluntaril}'. Complete hypotaxis, but consciousness retained.

Suggestions : 1. Repugnance for onanistic manipulations. 2. In- clination for coitus and comi)lete faith in its successful performance. 3. Indifference about the result of the examination ; perfectly-clear head during it, and the presence in mind of knowledge accjuired. 4. Post- hjpnotic feeling of well-being.

June 18tli S. joyfully told me that the previous da^' he had ventured to attempt coitus for the first time, and had succeeded [jerfectl}'. No thought of onanism since. Increased self-confidence and belief in the cure.

Repetition of the treatment and suggestions of June Hth.

June 19th, three hypnotic sittings. No onanistic inclinations. Voluntarily the patient gave me his word of honor that he would never masturbate again, and set out for Austria to take his examination at a provincial university.

June 26, 1891, he wrote in a letter: "It is my pleasant dut}' to inform you that your efforts in my behalf were crowned with the best results to-day. I [)assed my examination with distinction. For this I have to thank only your excellent application of suggestion ; for what you suggested to me was fulfilled perfectly : I had a clear head and not the confusion which had previously hindered me in study and recapitula- tion of what I had learned. Since I had studied much, and, owing to tlie suggestion, was certain of being able to apply what I had acquired at the proper place, I went to the examination with a feeling of indiffer- ence. By such a result my faith in h^'pnotism was greatl^'^ increased. As for my former vice, I can assure you that, since I had the honor to be treated b}' you, I have not masturbated and have felt no desire to do so. I now have the best prospect of inducing m}' chamber-maid to accede to my desire. We kiss eacii other, etc. I mention this merely to show you tli.at in this direction the suggestion has had the greatest success. With very kind regai'ds, I remain, most respectfully, 3'our ever-grateful patient." \ ^^

Earl3' in August, S, again presented himself. He liacTnot mastur- bated again. He was better physically and mentally, and from time to

ONANISM BY MEANS OF TACTILE IRRITATION. 67

time wft8 accustomed to visit the demi-monde to gratify his lively sexual desire. I think I may regard the patient as cured of onanistic ten- dencies.

Tiie hypnotic treatment, owing to the youth of the patient, under- taken sufficiently ejirly, removed in only three sittings the fully-developed masturbatic excesses that had existed for seven years. Besides, there was the remarkable influence of suggestion upon the mental condition of the patient during his examination.

It seems very questionable whether psychical treatment in the waking state (which, as Rosenbach^ has shown in his instructive work, must, as a rule, avail itself of indirect methods, medicaments, mechan- ical and electrical means) would have been attended in the foregoing case, in the same brief period, with a similar prompt result. To over- come a man's one-sided thought and feeling, that had been habitual for seven years, b^- means of awakening hopeful ideas and persuasion, would at least be much more tedious than to remove the injurious associations by means of hypnotic suggestion, even if the first method were possible in a medically-educated skeptic.

Case 13. Personal Observation. Successful Suggestive Ti-eatment of an Onanist. H.,aged 24 ; mother gouty, father nervous. A paternal great-uncle a drinker; other members of famil}- healthj'. At the age of 8 patient had t3'phoid fever, and was nervous after it for two years. The patient learned to masturbate as a result of itching of the genitals induced b3' a superficial sore on the prepuce. Touch induced erection, and further friction ejaculation. The patient is very powerfuU}- built, tall, and, aside from phimosis, presents no abnormalities or anomalous svmptoms.

For two years he masturbated dail}-, and during the act thought of coitus with a lady to whom he was attracted. Masturbation was ahvaj's accompanied b}- the same idea. Unfavorable eflect on the nervous sys- tem. The patient likes to lie abed late dozing. Memor}^ and understand- ing suffered. Headaclie, loss of energy, depression, irritability, and pressure in back of head were added. The neurasthenic troubles hin- dered his studies. Since learning its meaning, onanism was less frequent, at times only three or four times a week. In a students' society he had taken a vow of chastity, and he had numerous inward struggles between moral thoughts and sensual excitement.

Owing to the fact that his ability to work had diminished during the last two months, he had taken an antineurasthenic hydropathic cure, by which his gener.al condition had been improved. But his onanistic ten- denc}' is unchanged. During the last week he had masturbated three times; pollutions occurred at night once or twice a week.

' Comp. " Ueber psychisclie Theraple innerer Krankheiten," Berliner Klinik, July, p. 28 (Fischer, 1890).

58 SEXUAL HYPERiESTHESIA.

On the evening of November 20tli, when a prostitute addressed him, his sensujil excitement overmastered him as never before, overcame his resolutions, and clouded his brain ; so that, as if " drunk or in a dream," and devoid of will, he followed her and had coitus for the first time. When he awoke from his dream, severe self-accusation, remorse, fear of infection. On the morning of the 2Ist H. consulted me to learn whether he had been infected. The psychical ini[)ressions left by the events of the da}' before were so strong that at the examination the patient sank into a chair, almost fainting and disheartened. Encouraging words and explanation of the sexual relations quieted him somewhat. The patient then came under my treatment, which consisted of three measures : (o) operation for phimosis; (6) antineurasthenic therapy; (c) removal of onanistic inclinations by suggestion.

I began with c on November 24th, after I had explained matters to the patient, considering his religious convictions and scruples of con- science. The duty of the physician required him to warn against onan- ism ; normal intercourse performed with prostitutes, with measures against infection, was the lesser of two evils, but the physician had no right to oppose the patient's moral principles by recommending coitus. The [)atient, therefore, must struggle against his sexual instinct, and the struggle could be lightened b}' hypnotic suggestion ; if, however, the patient could not thus overcome it, coitus was to be preferred to mas- turbation.

November 24th, first hj-pnotic attempt. Deep somnolence (stage II). Imperfect memor}'. Suggestions against onanistic thoughts and depression. Strengthening of self-confidence and resistive power by suggestion. Excellent result. After hypnosis and during the following da^'S the patient felt well and had no inclinations to onanism. Spirits raised.

Repetition of the procedure on November 28th and December Ist. The patient passed at once into somnambulism.

December 30th, operation for phimosis. My intention to perform it during hypnosis was not carried out, because the patient was too excited. In all the patient was subjected to twelve sittings; was discharged toward the end of January, 1892, as cured. Up to that time it had been unnecessary for him to repeat coitus. He has been under observa- tion, and there has been no relapse so far.

Case 14. Personal Observation. Onanism and Neurasthenic Troubles. Lasting Cure by Suggestion. N., aged 28. Father drinker, uncle and brother contrar3'-sexual, sister hysterical. Neuropathic disposition due to hereditary taint. Patient stated that since his twentieth year lie liad had pulmonary hiemorrhage five times. Until three years ago he had lived abroad, where there had been smnll opportunity for hetero-sexual intercourse, on account of the small number of women and the diseases

ONANISM BY MEANS OF TACTILE IRRITATION. 59

among them. lie recovered from his pulmonary affection, and after his tweutietli year gave himself to miisturbation, as he said, /au/e de mieux, from enforced abstinence. Since that time for eight years he had masturbated several times a week ; habit continued. According to his statement, severe mental strain attending disappointed affections, together with the psycho-sexual auomal}', had essentially contributed to the development of the present state of nervous exhaustion. The patient had become conscious of his abnormal condition about a year before.

Mental depression with melancholic paroxysms of weeping, bodily weakness, no desire to work; feeling of lack of energ3' especially noticeable; inability to complete an}* work; want of pleasure in life; thoughts of suicide ; avoidance of people ; moodiness ; inclination to hypochondria; spinal irritation and headache following niastnrbatic excesses. There was an unconquerable fear of hetero-sexual inter- course; last coitus performed nine years before without functional dis- turbance, but with embarrassment.

Patient of delicate constitution, well nourished, of medium size. Thorax well developed. Right supra-clavicular groove somewhat sunken. Percussion and auscultation afford no indication of existent lung disease. Heart-sounds pure; cardiac dullness normal. Genitals of medium size; phimosis. The prepuce cannot be completely reti'acte<l without pain, and this is an obstacle to the performance of the sexual function.

Appetite, digestion, and sleep good ; but rising early in the morn- ing requires much resolution. Wakes frequently with erections, which lead to onanism. Masturbation twice during the last week.

The patient has great faith in hypnotic treatment, and wishes to have his desire for work and his sexual function restored hy suggestive treatment.

From November 3, 1890, he is treated daily. He passes into the second stage, hypotaxis and suggestive catalepsy. Gradual deepening of h)'pnosi8. The patient remains in the hypnotic state about half an hour, and passes gradually into natural sleep. Suggestive removal of the s^'mptoms and the inclination to onanism. Repetition of the influ- ence upon the feeling and the desire to work.

November 14th, operation for phimosis; wound healed at the end of the month.

In spite of the removal of the obstacle, there is still a certain reluct- ance to perform coitus. Still, graduall}', through suggestive treatment, it became possible to induce the patient to make several successful attempts (during the first part of December). Besides, the patient, from the first day of treatment, began to employ himself in mental work with exact regulation of hours. Gradually the sense of pleasure in

60 SEXUAL HVPER.ESTHESIA.

work came as a result of the suggestions. Tlie onauistic tendencies were at first successfully fought against, and then they became less fre- quent. The gloomy thoughts disappeared.

December 18th the patient def)arted, and, as the most important result of thirty-eight hypnotic sittings, there was an essential inward change in the patient. He masturbated no more, and began to take pleasure in hetero-sexual intercourse. He took up a regulated occupation without injurious influence on his nervous system. The depression dis- appeared, and there were no more physical complaints. On December 15th rheumatism of the right shoulder was overcome in two hypnotic sittings. N. also believed that he had gained in resistive power, for he was able to endure quietly a very painful misfortune; in his opinion, the same misfortune previously would have been the source of violent emotional excitement.

The patient went home delighted with his unmistakable improve- ment. After his return, on January 27th, at his desire, the treatment was resumed to change his improvement into an actual cure. Though the sexual act is successful, still the patient has no desire for it ; and the satisfaction it gives, notwithstanding complete erection and ejacula- tion-at the proper time, is not like that afforded by onanistic manipula- tions, an observation which has been made by experienced physicians in women.*

Up to March 9th the patient was subjected to thirty-two more hyp- notic sittings, with the most favorable result on his general condition. During this last period he performed coitus twice weekly, as a rule. He 'was no longer ta'oubled witii onanistic inclinations. Finally, satisfaction in the sexual act and libido sexualis came up to the patient's desire. In spite of my advice to be careful, he gave himself up to the pleasures of the carnival, and during the month of February had headache removed by suggestion three times. The headache was referable to carousing all night. '

March 9th I made the following entr}' in m}' journal : " Ideas opposed to coitus have entirely disappeared. Libido and satisfaction perfect. Embarrassment, shyness, and melancholic tendencies no longer present. Desire for work and pleasure in life have returned. Onanism overcome; spinal irritation removed. Migraine occurs only after especial excesses. The nervous system is strengthened, has resistive power, and the patient is now fully able to follow his occupation and conclude a marriage which he desires."

He is to be regarded as completehj cured of his onanism ; on the other hand, with reference to his neurasthenia, considering his hereditary neuropathic disposition, I can regard him on)}- as relatively cured.

The patient retiirned home March 9th.

Com p. Dr. Lahmann, " Ueber OnanismtiR b-lm Wclbe als einer bcsoiideren Form von verkehrter Richtung des GescblechUtriebes," Therapeut. Monatsbefte, April, 1890.

ONANISM BY MEANS OF TACTILE IRRITATION. 61

Although, in the foregoing case, hypnosis was repeated seventy times, there were never any injurious effects observed: no loss of resistance to external influence, no spontaneous hyi> nosis, no breaking up of the personality (Ik'ncdikt) ; on the contrary, the patient, who had been shy, languid, devoid of energy, and without pleasure in work, became a happy, indus- trious man, energetic, and with normal sexual functions, which gave him physical and mental equilibrium and made him capable of resuming his place in life. .

In this case suggestive therapy did all that was possible. Whether the patient's congenital condition, the neuropathic disposition, which in itself is unalterable, and the tendency to pulmonary disease will again lead to a renewal of symptoms remains to be seen. Thus far, we can only say that, according to the patient's reports, up to the present time he follows his occupation industriously.

Case 15. Personal Observation. Successful Suggestive Removal of Imperative Sensations Due to Onanism. G., male, aged 26. Paternal grandfather drinker ; maternal grandparents died of tubercnlosis. Mother nenrasthenic, timid, easily- excited. Father, brother, and sister healthy. Father's relatives subject to heart disease. In childhood patient had measles and plenritis, and later several attacks of fever (malaria?). G. is robust and strong, and weighs 200 pounds. Greatly developed pan- niculus adiposus. Heart and lungs without demonstrable disease. G. presents an hereditarj' neuropathic constitution. According to his auto- biography, as a child he was easily excited and remarkably irritable, and was eccentric. From his twelfth to his fourteenth year he masturbated several times dail}^, without noticeable unfavorable effect on his physical health. On the other hand, the onanistic excesses seem to have been the exciting cause of development of psycho-neurasthenic S3'mptom8; for since that time the patient's memory had grown remarkably weak, and he had lost energ}'. As a child shy and retiring, he now kept more and more to himself, and his timidity often became the object of joke by his companions. A book on "self-protection" explained to \\'\m the injurious effects of onanism, and he abandoned the vice. G. gives the impression of an apathetic, weak-willed man, devoid of self-confidence. Without advice, he gave himself to the study of medicine. In spite of his fourteen semesters, he is still a diligent student. Two years and a half ago, after nine semesters, he passed the physicum. He is constantly troubled with the knowledge of having been left behind by his com-

62 SEXUAL HYPERiESTHESIA.

panions, and avoids, as far as possible, his former comrades, who have become practicing physicians. He has also abandoned his best friends. He likes best to take long, solitary walks, and, without thinking more deeply of his fate, lives, as he expresses himself, " 2'ag fiir Tag ins Blaue hinein."

He has no desire for sexual intercourse, but from time to time he performs coitus normally, in order to prevent pollutions, which otherwise are frequent (three weekly). He is potent or impotent according to the mental condition at the moment. Physicall}', the patient complains that on the slightest excitement he has cardiac palpitation and outbreaks of perspiration. At school he was timid and blushed whenever his name was called. These imperative states of anxiety are at present prominent in his trouble. When he is called upon by one of his clinical teachers to examine a case, this feeling of anxiety overcomes him, so that he feels paralyzed and wholly unable to answer or even to leave the auditorium. Owing to this, the patient has not been able to obtain the eight certifi- cates of practice necessary to allow him to take the State examination. He has put off this duty from semester to semester. At the present time (June) he has the alternative of losing a year or of overcoming the impediment dtiring the last month (July) of the semester.

This painful position, which makes G. incapable of doing anything and brings his future in question, induced him to consult me on June 22d.

June 25tli, first hypnotic attempt (method of Bernheim-Lidbeault). G. passes into the second stage, i.e., in spite of retained consciousness, he is unable to resist the suggestions. Suggestions: (a) After waking, you will ask me for a cigarette. (6) You must obey unconditionally the next call to " practice," like an automaton, and will be unable to keep your seat.

After waking, the patient declared that he had not slept, but that, only to please me, he had kept the position suggested. He thought this first attempt had been entirely unsuccessful, in accordance with his pre- conceived notion of hypnosis and the actual. Apparentl}', he took me for a credulous person, and left without performing the post-hypnotic suggestion. As the later statements of G. revealed, after leaving me, he went to a friend about 4 o'clock. Strange to sa}', here the thought of a cigarette came and did not leave him. Unwilling and annoyed, he left his friend's house at 5 o'clock to find himself, a little later, in the park in front of my dwelling. For an hour he struggled, walking in the park, against the impulse to regain his equilibrium by visiting me. At 6 o'clock he called, but did not find me in. The next morning, at 10 o'clock, the patient entered with the words, " A cigarette, please; and I promise to really ' practice ' from this time forward." The self-deception of many patients concerning the events of hypnosis, to which, also.

ONANISM BY MEANS OF TACTILE IRRITATION. 63

Bernheim and Forel have repeatedly called attention, could not be more clearly illustrated than by this experience with a person who, owing to his medical education, was the more entitled to express an opinion.

As early as June 26th the patient was able to master his imperative feelings, i.e., to practice.

G. was thereafter hypnotized five times: on June 26th, 27th, and 30th, and July 2d and 11th.

Relapse between the 4th and 11th of July. Inability to respond to his name in the gyneecological clinic. After energetic suggestion on July 11th, the patient went voluntarily to the assistants at the clinic, and a few days alter this hypnosis he obtained the needed certificate.

August 1st G. informed me, with delight, that he had all eight cer- tificates necessary to allow the State examination. He was of the opinion that he never could have obtained them with his own efforts without the suggestive stimulation.

The psychical after-effect of this success upon the patient's self- consciousness was unexpectedly favorable. His mood was lightened and hope raised. Although, from th^ stand-point of the physician, the patient was b}' no means to be regarded as cured, still, I had to follow the wishes of the patient, who, relying upon his own powers, thought he could dispense with further suggestive treatment, and desired to attempt his own cure.

I regard this case, so instructive for suggestive therap}', as worthy of report, because, between the onanistic excesses and the development of the psycho-neurasthenic 83mptoms which became especiall}' promi- nent on June 22d, and, though weakened, are still present to a certain extent, there seemed to be an etiological relation.

Case 16. Personal Observation. Masturhalic Inclinations and Neu- rasthenic Symptoms. Successful Treatment by Suggestion. A., male, aged 19 years. Mother nervous. Father and other members of famil}* health)'. No severe illness aside from diseases of childhood. He mas- turbated from his fourteenth jear with the idea of coitus, at first dailj', later once or twice a week.

A. finds that his mental strength suffers. He grows weak-willed and has no more power of endurance. Easily tired mentally. Inability to carry on his studies regularly. Great confusion. He has seldom performed coitus and has a remarkable shyness about intercourse. He is treated in twelve hypnotic sittings; passes into hypotaxis at the first attempt. He relapsed but once during the course of treatment. The masturbatic inclinations disappeared, and he performed coitus once a week. His ability to work returned. Subjective feeling of well-being returned, and at the present time complaints of neurasthenic symptoms have ceased. He is still under observation, but he may already be regarded as essentially improved.

64 SEXUAL HYPERESTHESIA.

Onanism tiibouqh Psychical Stimuli. (Cases 17 and 18.)

Case 17. Observation by Dr. Welterstrand. Psychical OnanUm Es- sentially Improved by Suggestive Treatment. X. X., medical student, aged 26 years. While during a year he was engaged to be married he noticed that sometimes lascivious thoughts came to him. He fought against them strenuously, but without success. His fancy was filled with frivolous images, and, at the sight of his fiancee and otlier ladies of attractive appearance, he experienced irritation and tickling on his penis, which were accom[)anied by erection, often ending with ejacula- tion. He suffered with this inability to control his imagination, and therefore consulted me on October 22, 1889. He was hypnotized five times, and, although the time was so short, he was still considerably improved.

On December 14th tlie patient wrote: "I feel that my trouble has been considerablj' ameliorated, and therefore I would once more ex[)re8s to you my warmest thanks."

Case 18. Personal Observation. Psychical Onanism (due to Mastur- bation Practiced during Eight Years), with Hysterical Symptoms and Beginning Apathy, Cured by Suggestion. A., female, aged 20. Mother nervous. Father died three years ago with apoplex}'. Grandfather health}'. A. has had no especial diseases. She has menstruated since her fourteenth year, and has masturbated about as long. She seems to have had pruritus vulvae, which the sexual irritation followed. Uncer- tain on her legs for years. Tiie emotional shock caused by the death of her father, three years ago, was very severe in its effects on her. She became nervous, often aphonic; complained much of headache and pain in the abdomen ; restless 8lee|), loss of appetite, dizziness. A. became more quiet and apathetic, and took less interest in everything. She was treated by the family physician with medicines and electricity without result. Repeated attempts to hypnotize her were unsuccessful. She then came to X., and was treated by Dr. P., to whom I am indebted for these facts. To the complaints mentioned were added vomiting, diar- rhoea, anaemia. At the sjune time there w.as great desire for medicines (phenacetin, antipyrin, and bromides). It was difficult to keep her from using these medicines. The hysterical attacks recurred again and again ; in September, 1890, quite severe h3Sterical attacks, with weeping, cr3ing out, confusion, but with retained consciousness. At that time Dr. P. had but a suspicion of masturbation. Si>ots of blood on the linen that had been partially rubbed out and a careful questioning induced the patient to confess.

During this period she masturbated very frequentl}' ; at least, several times a day she rubbed the vulva and clitoris, and at night she always had a finger in the vulva or vagina. Irritation and itching became

ONANISM THROUGH PSYCHICAL STIMULL 65

especially intense immediately before and after menstruation. The whole vulva was greatly swollen and there was fluor albus. Applications of carbolic acid, cocaine, and glycerin with chloroform, were without effect. Faradization of the vulva was temporaril}' beneficial, and it was used twice daily until she was sent to Munich. Owing to her great lack of voluntary control, she was placed under the constant care of a nurse, and day and night her arms and legs were secured. For sleep she was given sulphonal gr. xxx and paraldehyde 5iss, alternatel}'. The tendency to masturbate continued strong. Whenever it was possible she made shoving, rubbing movements with the legs, the pelvis (on the edge of the chair), masturbated through her clothing (hand in pocket) while out walking, and used every opportunity in the bath, etc. One night she succeeded in releasing herself, and in the morning she was again found with her finger in her vagina. During the last six or seven weeks of her stay in X., she did not directly touch the vulva with the finger or hand, and she also tried to give up the movement on chairs. She walked out often and slept without medicine; but she was often restrained during the day, and always at night.

In Ma}', 1891, Dr. P. made three attempts to hypnotize the patient ; at the third she went to sleep, but suggestion was unsuccessful. Further attempts were not made. Weight, when received, 90 pounds; January, 1891, 100 pounds; September, 1891, 92 pounds. Even thougii there had been unmistakable improvement, Dr. P. thought that hypnotic treatment might lead to complete recovery, and sent the patient to me in Munich in the middle of September.

After personal examination on September 17th and 18th, I was able to extend Dr. P.'s observations and statements, as follows : Heart and lungs apparentlj' health}'. The patient appears as about 16 years old. Sensation to painful impressions increased on the flexor surface of extremities ; reduced on the extensor surface, and in part absent. The tactile sense at some points, especially on the extensor surface of the upper arm, is diminished. No disturbance of temperature sense, localization, or muscular sense. Uterus and ovaries sensitive to press- ure ; intense hyperaesthesia of the vulva. Bilateral peripheral narrow- ing of the visual field. Color sense normal; likewise acuity of vision and hearing, but easily fatigued. Smell and taste normal. There is constant headache, pain in the abdomen, and unbearable itching of the genitals. Weight, 93 pounds. Heemoglobin, 75 per cent, (estimated with Gowers's hremoglobinometer).

Patient seems depressed mentally. Complete weakness of memory ; so that the patient, for. example, cannot recapitulate the words and meaning of a short written extract. Want of energj' and dull apathy for all external impressions. She performs automaticall}' what she is told to do. She has no interest whatever in employment or pleasures

66 SEXUAL HYPERiESTHESIA.

(theatres, concerts). Luck of all spontaneity. She asks no questions and opposes all ettbrts to rouse her from her indolence. Occasional transformation of this state to exaltation, loud hysterical laughing, and crann)-like convulsions.

Observation for several days and careful examination of the patient show that the present form of gratification is psychical onanism. The idea of a male person, one of her relatives, as well as his caresses, induce sexual orgasm, witliout mechanical he\\) of movement of the limbs, which is manifested in slight convulsive jerking. The patient knows nothing of sexual intercourse, conception, etc., and therefore her imagination is never filled with lascivious images and scenes ; but, in remarkable contrast with her libido sexualis, it has remained pure, like that of a child. Pleasant or intense lustful sense-impressions of various kinds are capable of inducing orgasm; thus, for example, scenes at the theatre, musical impressions, or the sight of beautiful pictures, which need contain nofigui-es (human), like beautiful landscapes, suffice. Like- wise, simple bodily contact (hand-pressure) with attractive persons induces lustful trembling. The patient masturbated near me three times in the horse-cars, and that without any noticeable movement. At the same time, like many hysterical persons, she was not without great cunning, and only after close questioning did she confess the truth with reference to the number of her sexual attacks.

September 18, 1891, first hyphotic experiment (Li^beault-Bernheim method). Hypotaxis, suggestive cataleptic phenomena, with inability to resist the suggestions. No post-hj'pnotic amnesia. Owing to the marked apathy, the patient comprehends the suggestions with diffi- culty; the ideational stimuli must be made very energetically^ and often repeated, in order to make them effectual. From this time she received the following suggestions daily : (a) abhorrence of ever}' kind of onan- ism ; (6) purity of thoughts ; (c) cessation of headache, abdominal pain, and itching ; interest in external affairs.

After going into the hypnotic state, the patient daily continues in hypnosis from a half-hour to an hour and a half. Besides, with the con- sent of her mother, the sexual relations and the dangers of self-abuse are rationally explained to her.

Patient states that she does not dream ; at least, she has no memory of dreaming; but her restless sleep and violent headache on awakening daily, as well as the depression associated with it, give rise to the pre- sumption that, even with restrained arms and legs, the psychical onanism is continued in dreams.

According to my notes, with daily continuance of the hypnotic treatment, the decrease in the frequency of the onanistic attacks was as follows :

Auto-sexual satisfaction by means of idea : September 2l8t (for the

ONANISM THROUGH PSYCHICAL STIMUU. 67

last twenty-four hours), 6 attacks (1 by means of friction); September 22d, 3 attacks; September 23(1, 2 attacks; September 24tli, 1 attack; September 25tU, 2 attacks ; September 27 tli, 4 attacks; September 29th and 30th, none; October 1st, 2 attacks (from looking at paintings); October 2d, none ; October 3d, none, and none on tlie days following.

During October there was unmistakable improvement. She stated that she avoided all ideas that could have induced attacks, and relapse was infrequent. This improvement was recognizable objectively in the patient's general condition. She became more lively ; asked questions of those about her and of the physician ; employed herself in reading, read- ing aloud, and letter-writing, and her mood and mind became brighter and more active.

Relatively, the most favorable time in the patient's condition was alwaj's immediately after hypnosis ; in contrast with her restless sleep at night, she slept in perfect quiet. During these post-h3-pnotic periods, which at first lasted an hour, then four hours, and finally the remainder of the day, the stimulus to masturbate and the itching were absent, pain ceased, and her mood was pleasant. Thus, suggestive treatment showed itself to be the most effectual of all curative means, and always gave the patient great relief To overcome the h3'per8esthesia of the genitals and the pruritus vulvae, daily sitz-baths gradually cooled, frequent use of vaginal tampons, application of cocaine solution, ointments with calo- mel, frequent cold bathing, etc. Besides, on retiring, bromides and sul- phonal were given to induce quiet sleep, and to have an anaphrodisiac effect. The application of the galvanic current was also finally used to combat the headache and the feeling of pressure in the occipital region (especiallj' mornings after waking). Further, in order to stimulate her mind and divert her attention from her favorite dreams, the patient was taught in several studies. Gj'mnastic exercises, within the customary limits for young girls, completed the general treatment.

The patient is still treated in this manner, and her improvement is to be attributed in greater part to the forty-two hypnotic sittings. She grows brighter mentally ; sleep grows quieter ; pain becomes less fre- quent and intense ; the post-hypnotic remissions grow longer ; the hyper- aesthesiaof the vulva is essentially diminished. The stimulus to mastur- bate and the itching occur less frequently, and they are weaker. Of late there are no more onanistic relapses, though the patient is still restrained at night as a precaution. Gradually the patient has developed an intense repugnance for onanism, so that finally every question on the subject is answered with irritation and repugnance for the vice. The progress is slow, but constant, and she may alread}' be regarded as essentially im- proved. Present weight, 98 pounds ; haemoglobin, 80 per cent.

From September, 1891, to April, 1892. the patient was treated with about one hundred and fifty-two hypnotic sittings, and during the last

68 SEXUAL HYPEKitlSTHESIA.

four months she regularly passed into deep somnambulisin. Since this time she has masturbated no more, and may be regarded as essentially cured. For a month there has been endometritis, which has yielded to local treatment. Headache and abdominal pain have disappeared en- tirely, as well as tlie troublesome itcliing. From a languid, apathetic patient, she has become a bright 3'oung girl of gay mood, with a fresh, blooming appearance, and full of interest in all that takes place around her. She will be sent home in a few days as cured.

Satyriasis and Nymphomania. (Gases 19 and 20.)

Case 19. Professor Forel, Zurich. Satyriasis, with Weakness of Will and Inability to Work, Lastingly Cured by Hypnotic Suggestion. Mr. X., student, aged 25, came to me in July, 1889, for consultation. Since 1885 he had committed sexual excesses, either with women or in onanism. The impulse became irresistible two or three days after the last indulgence; he was forced to masturbate. Mentall}' affected by it (probably by the mental impression, through auto-suggestion, rather than by the number of emissions) ; since the summer of 1888 he had become so languid and weak of will that he was absolutely incapable of work. He remained in his room, listless and abulic, and did nothing, totally neglecting his studies, and he could not continue his work for the doctorate.

In this condition, which had existed for a year, he came to me, told all, and asked for help. In July, 1889, I hypnotized him, and brought about hypotaxis (without amnesia). Ability to work returned imme- diately ; the spell was broken. Mr. X. was hypnotized six or eight times in all. There was likewise great iniprovement as regarded onanism; at first it gradually diminished. Now and then it was still practiced, and for the last time in Februar}', 1890. However, the sexual instinct lost, as a result of suggestion, its violent, impulsive character, and soon be- came perfectly normal, i.e., aside from infrequent coitus, at the most, there was but one pollution a week. Since the first hypnotic sittings (Jul}', 1889) his ability to work has continued undisturbed and unlimited up to the present time (July, 1890). He was not hypnotized thereafter. Mr. X. was alwa^-^s nervous, but otherwise of genial temperament and normal.

Case 20. Personal Observation. Nymphomania vnth Hystero-Mastur- batic Attacks. Cured by Suggestion. M., aged 22, teacher. Father died of spinal disease. Mother health}'. Two cousins insane. Brothers and sisters healthy. The eldest sister is said to be remarkably apathetic. M. was healthy in her early youth. When she was about 5 years old and living in a large city, for a long time an officer was accustomed daily to take her up from play with her companions immediately after closing

SATYRIASIS AND NYMPUOMANIA. 69

his office. He took the innocent child to his room, caressed her, touched lier geniUils, and, after liaving covered her eyes and mouth, he committed immoral acts with her, masturbated her, undressed her, and became intensely excited sexually, probably with orgasm. The pleasant feelings which he caused the child by his manipulations, on the one hand, and threats to kill her if she were to tell on him, on the other, caused M. to keep silent concerning the matter. In this way, during the two years of continued intercourse, the childish imagination was thoroughly pois- oned. After the relation ceased, the child began to practice auto-mas- turbation excessively. At the age of 11 the menses began. At the age of 17 she went to France as a teacher, and at 18 she was deflowered, and, up to the present time, states that she has had coitus about ten times. A relative accompanied her to my office, and I noted the nervous ex- citement of the former, A short examination showed that her companion was more seriously affected than M.

During the last ten years the onanistic manipulations have been practiced from eight to twelve times dail}', and have seriously affected M.'s predisposed nervous system. She states that she has never touched her genitals with her hands, but she induces the orgasm by movements of the thighs ; its occurrence is often accompanied by hysterical convul- sions and loss of consciousness. The patient feels much fatigued after these onanistic attacks. The ideas accompanying such attacks often consist of the thought of having intercourse with some man. The in- tensity of such thoughts often reaches that of hallucination. The severest attacks occur in the morning, while the patient is lying on her abdomen in bed. She states that at such times the impulse is irresistible. She is absolutely unable voluntarily to control the impulse, and thus she has become the slave of the psycho-sexual reflex mechanism, which is thrown into action b}' all kinds of sensor}^ impressions and ideas. For some years orgasm has taken place without tactile stimulation of the genitals at the occurrence of certain perceptions, accompanied b}' intense pleas- urable feeling (psj'chical onanism) ; thus, for example, when the patient sits dreaming on the sea-shore watching the play of the waves; while lost in contemplation of the river Isar; while looking at certain paint- ings containing nude figures, or even at landscapes devoid of figures; at the sight of attractive male forms; or even at the mere contact with a man (pressure of hand). These ideas in the form of memory-pictures are also sufficient, without mechanical friction, to induce the sexual orgasm.

In general, all sensory impressions and ideas which induce pleas- urable sensations are capable of bringing about lustful feelings. The patient's dreams are also edectual in the same way. She states that a short time ago she dreamed that she was in the arms of the emperor. Her whole thought is directed to the sexual sphere. Her impulsive

70 SEXUAL HYPERiESTHESIA.

excitement reaches the intensity of nymphomania, with an inclination to attack men. She fears iier own passion, and begs me never to leave her alone with a man in the waiting-room. In such st:ites of excitement it is only with the greatest difficulty that she controls herself. Increased cardiac action, rapid breathing, and^ suffusion of the face are the object- ive signs of her exaltation, llepeuted onanism during the first visits to the physician, as well as during the physical examination.

Her mental condition has seriously suffered under the constant in- fluence of this sexual hyperffisthesia that has existed for years. Weak- ness of memory, absent-mindedness, inability to follow out a thought, hysterical change of mood, etc., make it impossible for her at present to follow any eniplo3ment. Nevertheless, with due consideration of her hysterical state of mind, she does not impress one as being a person degraded or morally defective. She feels that she is ill, and has an earnest desire to get well, but that she cannot attain this by means of her own strength. She has by no means lost her sense of modest3', and, in spite of her violent sexual impulses, she has not prostituted herself. The dramatic dream-life of the patient, as fully revealed later during hypnosis, gave the observer a view of the patient's secret mental life and many opportunities for interesting psychological studies. These experi- ences confirmed the judgment made of her character in the waking state.

M.'s form is stately ; full bust. Panniculus adiposus well developed. Mucous membrane ruddy. Heart and lungs normal. On the posterior surface of the right forearm there is an area of anaesthesia, pear-shaped, fifteen centimetres long and seven centimetres wide. In the right axil- lary line, at the level of the fourth rib, there is a point sensitive to press u i-e ; right ovary also sensitive to pressure. Genitals normal, not especially sensitive ; moderate turgor of the clitoris, which is remarkably large. Occasional pruritus vulvae. Color-ldind for blue and red. The right visual field concentrically narrowed. Olfactor}' and gustatory aneesthesia on the right side. Quinine and salt are not tasted on the right side of the tongue ; asafoetida, violet perfume, and smelling-salts are not smelled on the right side. On the other hand, on the left side, these substances induce lively reaction, with correct recognition of them. No olfactory hallucinations. Hearing intact on both sides.

The menses increase the hypersesthesia, last four days, and cause pain and weariness in the legs. Repeated vesicular spasm with active retention of urine (attributable to reflex irritation after onanistic ex- cesses) on attempting to urinate. As a rule, the spasm ceases after flve minutes.

September 25th I attempted to hypnotize her for the first time, but without success. With face suffused and excited, she threw herself about in her chair, and the attempt ended with an hystero-onanistic

SATYRIASIS AND NYMPHOMANIA. 71

attack. I then had her come every day, and showed other hypnotized patients, and suggested to her in the waking state that she was not to become excited when visiting the physician. Thereafter she became much quieter, and 1 could touch her without causing her sexual excite- ment. She then asked to be hypnotized.

September 30th, second hypnotic attempt (Li^beault-Bernheim method). In less than a minute M. goes to sleep and passes into deep somnambulism, with post-hypnotic amnesia. She carries out all sug- gestions, hallucinations, acts, and commands in the domain of the body with perfect precision. She is one of the best somnambulists I have ever seen (sonambule agitee). As a rule, if no contra-suggestion is given, she acts out her dreams, speaks of the events of her daily life, and takes up, from time to time, an imaginary glass from the table to strengthen herself, and has hallucinations of all possible situations. After I have suggested to her abhorrence for onanism, she always saj's to herself the following sentences : " Ugh 1 that is bad ; you must not be naught3' ; the doctor does not allow you to be; I abhor it." In the following sittings, auto-suggestive recapitulation of the suggestive com- mands of previous sittings. She twice struggles successfully against the impulse to onanism in hypnotic dreams. Once, in a dream, she allows the im.nginary glass to fall to the floor; she begs pardon, and w^ishes to take up the pieces. When it is suggested to her that a lead- pencil is a red-hot iron with which she is to be burned on the arm, the touch is followed by violent painful reaction, manifested bj- jerking the arm away and crying out. Sometimes the places touched on the arm clearly showed a red line (the first degree of burning) ; at other times there was nothing apparent. On one occasion desquamation of the superficial la^er of the skin, with formation of crusts for some days; but it is not certain whether or not this process was hastened or brought about b}-^ scratching or rubbing at times when she was not under observa- tion. In one instance she blew on the spot that appeared burned (not yet erj'thematous), and poured the contents of this imaginarj^ glass over it, in her imagination thus overcoming the irritation, all this without the skin reacting with redness.

Every one of the stigmatic experiments tried by me on this patient underwent correction when I ascertained that in the waking, as well as in the sleeping, state every modorntely-intense tactile impression induced circumscribed h3'peraemia of the skin, whether there was any suggestion at the same time or not. With moderate pressure with a piece of wood (lead-pencil) one can draw on the skin of the arm, breast, etc., any kind of a figure, which, in half a minute, appears as an erythema trauraaticum in the form of the figure drawn. In this way the word " Otto " appeared in red letters on the left breast; likewise the number " I " which I had written on her arm over the sleeve. Still, the possi-

72 SEXUAL HYPER JiSTHESIA.

bility that this may be induced by the ideational stimulus is not thus denied.

We see other vasomotor changes brought about by psychical stim- ulus as well as by tactile irritation : for example, erection. Careful exclusion of mechanical irritation is necessary to establish the occur- rence of erythema as a result of suggestion. Though some of the sug- gestive experiments made in the vasomotor domain seem to have ex- cluded mechanical irritation, still, I must confess that I have not yet reached a final judgment. This class of experiments is not continued with the patient.

The importance and the infrequency of the phenomenon in question, which forms a part of the patient's history, constitute my excuse for this digression.

October 2d and 3d, repetition of suggestions against onanistic incli- nations. October 2d, M. masturbated while looking at a picture (Tann- hauser in the Mountain of Venus), though since the first sitting the attacks had decreased in frequenc}'. October 3d it was suggested to her: You will have a severe pain in the region of the left ovary every time you attempt to masturbate, and will be able to overcome the impulse. The following three da^'s there was not a single attempt to masturbate, though the patient remained in bed until 10 a.m. When, on October 4th, she made an attempt to masturbate, there was violent pain in the left ovary.

From October 8th to 15th, daily repetition of the therapeutic sug- gestions ; successful suggestive removal of the anaesthesia of the right arm ; no more onanistic attacks. October 16th, relapse, with violent ovarian pain. From October 16th to 31st, further h3'pnotic sittings without relapse. The general health improves ; nymphomaniacal incli- nations have been absent since the beginning of October,

At the present time the patient ma}' be regarded as capable of fol- lowing her employment, and has begun to resume it. Her sexual hyper- aesthesia is much diminished ; her general physical and mental state is essentially improved ; the inclination to onanism has decreased. The patient is still treated intermittently.

At this period it may be stated with exact certnint}' that the im- provement, in the sense of a relative cure, is to be ascribed to hypnotic treatment.

December 15th. The patient is to be regarded as completely cured of nymphomania. She does not practice onanism any more, but at the time of the menses she is excitable sexually, and, to avoid a relapse, at these times it is necessary to treat her prophylactically.

March 10, 1892. The cure of the onanism in about forty hypnotic sittings is complete. No relapse anticipated. The patient is still under treatment.

SATYRIASIS AND NYMPHOMANIA.

73

1

aged 28.

15. Medical student,

aged 26.

16. Student, aged 19.

17. Psychical onanist,

aged 28.

18. Psycliical onanist,

aged 20.

11. SATYRIASIS.

19. Student, aged 23.

m. NYMPHOMANIA.

aO. Teacher, aged 22.

I. ONANISM.

1. Boy, aged 8.

2. Boy, aged 7.

8. Girl, aged 8, with enuresis noc- turna.

4. Boy, aged 9, with

chorea.

5. Imbecile, aged 30.

6. Teacher, aged 26.

7. Neuropath,aged8.

8. Pupil, aged 8.

9. Cruniiial, aged 16.

10. Pupil, aged 14.

11. Pupil, aged 18.

12. Medical student,

aged '20. 18. Student, aged 24.

14. Npiirajthpnir>.

ladbeault.

Li^beault. Lidbeault.

Li^beault.

U^beault.

Wetterstrand.

Bemheim.

Bemheim. Voisin. Author. Author.

Author.

Author.

Author.

Author.

Author. Wetterstrand.

Author.

Forel. Author.

\ ^^ ^ ^ ^ ^ ^^^^ H-: - - : H- -

Male.

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Sittings.

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. Hyiwtaxis.

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With Later Report.

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13= 66 per cent.

74 SEXUAL HYPERESTHESIA.

CoNCLUDiNo Remarks. The foregoing table gives tlie following results :

Cured, with subsequent report, . 10

(2 still treated prophylactically ;

1 case with relapse.) Cured, witiiout subsequent report, 3 Greatly improved, 5= 25 per cent.

(3 with subsequent report; 1

case still under treatment ; 1

case relapsed.)

Temporary' improvement, 1=5 per cent.

Complete failure, 1 = 5 per cent.

20 100 per cent.

Of the 20 cases of onanism (among which the cases of satyriasis and nymphomania are reckoned), 1 1 passed into som- nambulism, 6 into hypotaxis, and in 3 cases no degree of hyp- nosis is given. The number of hypnotic sittings extends from 3 to 152. Of the 20 cases, 10 were completely cured, with subsequent reports; 3 without later reports, in all, 13 cures. In addition, 3 were lastingly improved, with subsequent re- ports. According to this, the probability of lasting cure of onanism or sexual hyperaesthesia by hypnotic suggestion may be expressed as 65 per cent. ; the probability of some success, as 90 per cent.

For the sake of a rSsumi^ the two cases of satyriasis and nymphomania in which onanism plays an important part were included.

The great susceptibility of onanists to hypnosis seems re- markable, of whom eleven passed into somnambulism. This is in part due to the youth of the patients. But even the milder degree of hypnosis does not prejudice the result, as Case 14 shows. In spite of the seventy sittings, the patient did not go beyond the second stage ; yet the therapeutic effect is among the best obtained.

Owing to the great excitability of hysterical and neuras- thenic persons, the first attempt to hypnotize thorn is not always successful. In Case 20 the patient could not be hypnotized on

CONCLUDING REMARKS. 75

the first trial, owing to an intense degree of psychical erethism. Only after she had seen several hypnotized patients did she have a desire to be hypnotized. I artfully increased this desire by having her come several times and making her wait for a long time, so that her requests became more urgent. I thus induced a favorable psychical predisposition, and at the second attempt she passed immediately into somnambulism.

In Case 18 several physicians had previously made attempts to induce hypnosis, but without success, because she laughed at them. Slight hypotaxis at the first trial. I regularly allowed the patient to lie asleep for half an hour, as a result of which the hypnosis gradually deepened, so that later deep somnambulism always occurred. Owing to the apathy which excessive onanists show for all impressions, suggestibility is much diminished, and Case 18 shows that the depth of hyp- nosis, in spite of the existing rapport., does not always correspond with the degree of suggestibility.

The more the patients are accustomed to masturbate auto- matically, as in sleep, the more difficult it is to affect them. In such cases we cannot dispense entirely with other therapeutic measures. Appropriate bandages, belts to prevent masturba- tion, etc., are of the greatest service in such cases. Berillon has also lately advocated this view, he having successfully treated about thirty cases of confirmed onanism by suggestion.^ It is also well, where the patients present erethism, to prepare them for hypnosis by large doses of bromides. At least, I was repeatedly successful in deepening tlie hypnosis by this means. In addition, general treatment of the nervous system for ex- ample, by hydro- therapeutic procedures should not be spared.

Case 15 demonstrates beautifully that suggestion may force its way into the patient's mind in a state of complete con-

' Comp. Revue de rhypnotiemc, Dec., 1891, p. 180. In the reported discussion of a paper by Professor Bernheim, Dumontpallier and Gorodichze report cures of severe cases of onanism by means of psycho-therapeutic treatment. Since tlie article mentioned appeared after the conclusion of this work, the cases could not be considered in detail. The same is true of a case mentioned by Schmidkunz In his work, " Psychologic der Suggestion " (Enke, Stuttgart, 1892, p. 898). The case is one of involuntary masturbation, whii-h was successfully treated in four hypnotic sittings by Dr. G. The patient was able to overcome later relapses partly by means of aato-suggestion and partly by mechanical means.

76 SEXUAL HYPERiESTHESIA.

sciousness, though tlie patient thought that he had held his arm cataleptic merely to please. It is also well, in good somnambu- lists, to give tlie suggestion that pain will occur upon the first attempt to masturbate. Case 20 gives a noteworthy proof of this.

The more the onanistic habit is the result of hereditary disposition or of an existing psychopatliic condition, the more difficult the thempeutic task and the more unfavorable the prognosis. Tluis, in the single case of complete failure (Case 5), the patient was an imbecile ; and in Case 7, in wliich there was but slight temporary improvement, there was marked heredi- tary disposition, for the father \vas likewise an onanist, and there were several otiier symptoms of hereditary taint.

One case of melancholia masturbatoria with beginning dementia I had to refuse as inappropriate for hypnotic treat- ment. Onanism had been practiced more than thirty years, and there was hereditary disposition. The age of the patient (female), her absent-mindedness, and her mental decay contm- indicated the use of hypnosis. Since no attempt at hypnosis was made with this patient, her case is not included in the report.

In none of the cases reported was there any injurious effect attributable to hypnosis. Of course, the cases are reported by recognized specialists in suggestive therapeutics. On the other hand, I was able to observe, in seveml cases, that the hours of relatively the best condition were those immediately succeeding hypnosis. These favorable intervals increased in length, in the course of treatment, from several hours to half a day, then to several days.

Without regarding hypnosis as a universal remedy for onanists, I think, from the practical experiences confirming our theoretical considerations, that we may conclude that, with reference to certainty and rapidity of effect, as well as with reference to the permanence of success, no other therapeutic method has given similar results in sexual hyperaesthesia. As little as we can dispense with other means as a supi)lcment, the application of suggestion seems to me to be, to a certain extent,

CONCLUDING REMARKS. 77

indicated as a specific remedy, since abnormal symptoms in the domain of thought and instinct, in cases of sexual liyperaes- thesia, especially in the form of onanism, may thus be cor- rected. If other means and methods are not successful, then failure to use suggestive therapeutics out of prejudice and ignorance must be regarded as inexcusable negligence on the part of the physician toward his patients.

/ /

II. SEXUAL IMPOTENCE AND ANESTHESIA.

CHAPTER IV. PATHOLOGICAL CONSIDERATIONS.

By impotence we understand complete or partial defect of power to perform coitus in a normal way with an individual of the opposite sex.^ This is called impotentia coeundi, in con- trast with impotentia generandi, which relates to the fertility of the semen.

Physiology. The experiments of Eckhard'^ and Goltz' have demonstrated the interrelationship of the cerebral cortex and the sexual organs. The impulses necessary for erection arise in the cerebrum, and pass through the crura and pons to the spinal cord. The erection-centre in the lumbar portion of the cord may be excited by cerebral (sexual ideas and percep- tions), spinal (stimulation of the conducting paths in the cord), and peripheral stimuli (reflex irritation from the glans penis). Ideas and sensory impressions constitute the most frequent form of excitation. The erection-centre in the lumbar portion of the cord is likewise subject to inhibitory influences arising in the brain. In dogs, section of the cord between the dorsal and lumbar regions allows more prompt and rapid occurrence of erection. Unpleasant cerebral excitement (fear of failure in coitus) intensifies the eflect of the inhibitory nerves, i.e., hinders erection. The accessions of blood to the corpora cavernosa of the penis, to which erection is due, is regulated by the contrac- tion and relaxation of the organic (involuntary) muscular fibres of the tissue : the nervi erigentes relax the muscular fibres and the spaces fill with blood. Contraction of the ischio-cavemosus muscles compresses the penis near the symphysis pubis, so that the backward flow of blood is impeded ; and these muscles

• Comp. Caspar, loc. cU., p. 3.

• Beitr&ge zur ADatomio und Pbysiologie, Bd. ill, iv, vll.

• Pflfiger'B Archlv, Bd. vjll.

(78)

PATHOLOGICAL CONSIDERATIONS. 79

elevate the penis, and erection occurs. After ejaculation the muscles relax and the penis collapses. The distended bladder may oppose the return-flow of blood (morning erections). When there is insufficiency of tlie muscular apparatus, there is premature return of blood, resulting in partial relaxation of the organ.

Causes and Forms of Impotence. Sexual power may be interfered with by the most various circumstances. The phys- ical mechanism of the sexual act requires a normal condition in all the parts concerned in it. Congenital or acquired faults or defects of the sexual organs may cause impotence (impotentia coeundi e defectus sen deformatione^): for example, injuries of the brain or spinal cord. Consecutively, other serious maladies, like diabetes, anaemia, obesity, etc., may lead to it. Alteration of sexual power takes place as a result of toxic influences (alcohol, nicotine, opium, etc.).

The organic changes which, as a result of anatomical lesions of the muscular or nervous parts of the genital appa- ratus, or of the nervous centres and paths which control erec- tion, become the causes of impotence, should be mentioned here merely for the sake of completeness ; for our purpose, however, they are important only in that in such conditions there can be no thought of therapeutic effect by psychical means. In a wider sense, congenital anaesthesia sexualis belongs here, abso- lute defect of sexual instinct, notwithstanding normal develop- ment of sexual organs.'^ According to von Kraffl-Ebing, a milder form of this defect is presented in the so-called " naturae frigidae," who show disinclination or very slight inclination for sexual in- tercourse, and experience no lustful or psychical excitement in coitus. AVhether such cases are amenable to psychical treat- ment remains to be seen ; at any rate, the original condition sets the natural limits for the possibility of improvement.

What is true in the case of congenital anaesthesia also holds good in the case of acquired anaesthesia, when the latter is the result of degeneration of the nervous conducting paths

' Caspar, loc. cit., p. 11.

• Comp. Pay. Sexualis, p. 31 ; Hammond, p. 2.

80 SEXUAL IMPOTENCE AND ANJiSTHESIA.

and the genito-spinal centres as a result of castration, atropliy of* tlie testicles, or central lesions (paretic dementia). On the other hand, cases of diminished or temporary absence of libido, belonging to this class, form the transition to the forms of impotence to be discussed later.

Hereditary disposition, physical condition, and age play a predisposing part in the occurrence of impotence. The sexual power begins, on an average, in males at the age of 18 ; in females, in our climate, at the age of 16, sometimes a year earlier. After the age of 40 sexual power dinnnishes, and is extinguished in men at the age of 65, in women at the age of 50. There are exceptions to this, in accordance with individ- uality and constitution.

Hereditary predisposition to impotence, with respect to intercourse with the opposite sex, is found in persons of con- trary sexuality. Such cases are repeatedly described under the term "Impotence,"^ and in monographs on "Impotence" are usually considered. This class of psycho-sexual diseases, be- longing to relative impotence, will, owing to their great practical importance, be given separate consideration in Section III, and therefore no further reference is made to them here.

Fiirbinger^ examined 200 cases of impotence, aged from 18 to 52, and found that 50 per cent, of all cases occun'ed in the fourth decade of life. All these cases were from private practice; on the other hand, out of 15,000 patients treated at Friedrichshain during the last three years, only two came for defective facultas cocundi. Among such patients young single men exceed married men in number. Officers, merchants, and physicians make up the largest contingent; theologians and teachers the smallest. The cause was, in 28 per cent., onanism ; in 38 per cent., gonorrhoea; in 13 per cent., both of these fac- tors ; 10 per cent, were given to great excess in venery. In accordance with these figures, 89 per cent, of cases of impotence occurred in patients who attributed their malady to onanism,

• Comp. Leonpacber, " Psy. Impotenz," Friedreich's Blatter f&r ^richt. Medizin.,

1887, p. 290.

• ' Ueber Impotentia vlrilis," Med. chirurg. Rundschau, 1890, p. 188.

PATHOLOGICAL CONSIDERATIONS. 81

gonorrhoea, and excesses. Only 10 per cent, showed a blame- less past life. Fiirbinger was also able to note variation of sexual power in the same individual, in accordance with physical and mentiil conditions and external circumstances. I can con- firm this observation from my own experience. As a rule, im- potence goes hand in hand with neurasthenia. " It may be the only symptom of neurasthenia" (Fiirbinger). For this reason it is difficult to separate impotentia coeundi psychica from impo- tentia cceundi nervosa irritativa (sexual neurasthenia), as Cas- par ^ does, even though it must be allowed that this distinction, in accordance with the predominance of symptoms of sexual neumsthenia, or purely psychical symptoms, is practically useful.

In pure functional disturbances of virility the condition of the external genitals is negative, though sensory disturbances in the glans may be discovered, frequently hypcrsesthesia. The functions which go to make up the sexual act may be disturbed singly or in various combinations :

1. Erection may be incomplete or wanting, so that the member becomes lax ante-introitum or after immission.

2. Ejaculation may be premature, too quick (praecox), or delayed, and take place with insufficient ejection of semen.

3. Orgasm may be diminished, and it is seldom intensified.

4. Libido sexualis may be diminished or increased.

In accordance as 1, 2, 3, or 4 occurs alone or in various combinations with the others, we have various varieties. Thus, for example, we may have libido sexualis increased and power of erection simultaneously diminished ; or ejaculation and or- gasm may be interfered with where libido and erection are normal ; or libido may be almost extinguished and, power of erection being retained to a certain extent, erection occurs from peripheral stimulation, with ejaculation which is nearly normal. Fiirbinger saw cases of the latter character.

The forms of impotence may be classified in accordance with other peculiarities, as total and partial^ constant and tem- porary^ absolute and relative^ original and consecutive^ depending

Loc. eU., p. 11

ft

82 SEXUAL IJiPOTENCE AND ANiESTHESIA.

upon the view of the case held. In partial impotence one or more of the factors just mentioned are intact. Constant im- potence signifies defective power with woman at all times ; the temporary form is that in which there is occasional failure of erection, for example, as a result of intense preoccupation of the mind by urgent business or of occasional mental preoccu- pation. According to his contemporaries, Newton was constantly affected with the latter form. Tliis form has also been called real psychical impotence^ or moral or hypochondriacal impotence. It presumes increased excitability of the inhibitory centre. A thought, a doubt, concerning the successful performance of coitus is sufficient to destroy erection. Cases are not infrequent where young married men, who have had intercourse before marriage only witli votaries of Venus, are impotent in the mar- riage-bed. The absence of approach on the part of the young wife on the one hand and the fear of exposure on the other excite the inhibitory mechanism. As has been before men- tioned (Section I), intense preoccupation with abstract subjects {e.g.^ mathematics) has a paralyzing effect on the sexual function.

Absolute impotence means that the patient is impotent alike for all women, while relative impotence is applied to cases where the defect is manifested only with respect to certain per- sons ; like those young husbands who can have intercourse with a puella, but not with their wives. There are also married men who are impotent outside of marriage relations, probably as a result of the custom of intensified association of ideas. There are also men who can perform coitus under definite circum- stances, for example, with dressed women, while they are absolutely impotent with a nude puella.

Not only mental, but also severe physical, labor and great fatigue may induce temporary impotence. Gyurkovechky^ si>eaks of an occupation impotence. Thus, according to him, book-worms are weak in sexiialibus. " With intense mental activity the thinking portions of the central nervous system are thus exercised at the expense of the sensory and motor por- tions and consecutively developed."

• Loc. eU., p. 132.

PATHOLOGICAL CONSIDERATIONS. 83

Sensuality and virility, in accordance with the foregoing scheme, may stand in a certain contradiction to each other, in such cases as are most frequently observed among artists and men of learning, painters, actors, authors, physicians, and professors. Abstinence^ also leads to impotence (consecutive atrophy of the testes), as we have seen in the preceding section.

The original form of impotence is found, for example, in individuals affected with congenital sexual weakness, the forms of which have been previously mentioned. Consecutive impo- tence signifies the occurrence of a functional weakness of the muscular and nervous apparatus of erection, resulting from geneml neurasthenia or some other primary disease.

In addition to this, we may mention the form of impo- tence depending upon delusion, and due to groundless imagina- tion, which should be classified as belonging to the psychoses. Hammond^ reports a case of hypochondriacal mania, in which the patient imagined that his genitals degenerated, while in fact they were perfectly healthy.

Functional weakness of the genital reflex arc and of the

• The results of abstinence Induced by erroneous education are clearly shown by the

following communication, received during: the publication of this work from the brother of the subject of Case 67 : At the age of 15 years, X., while at school, made an attack on a servant-girl (aged 22). On touching her person he had an ejaculation. The strict disci- pline of his elder married brother restrained all sexual tendency at home. While serving his apprenticeship as a merchant, owing to enforced abstinence, he became hyperexclted sex- ually and made an attempt at rape ; the approach of persons prevented its completion. He fled. After his return to a large city, a visit to a brothel. However, he found, as he believed, that his virility was much diminished by abstinence. A single act of coitus weakened him so that he was forced to keep his bed several days. Con fession and a violent scene at home. HI brother and guardian had practiced abstinence until marriage (in his twenty-fifth year) with- out harm, and demanded the same of him. Though the patient felt himself In the right, by energetic self-control he practiced abstinence five years. During the first nine mouths fre- quent tickling sensation in the glans. Frequent dreams at night, with pollutions, which grad- ually ceased. ^ATiile bathing he accidentally came to masturbate (self-pollution), which he only practiced three times. He found that this weakened him still more. During the latter part of the five years sexual desire gradually disappeared entirely, and after absti- nence for five years he made another trial in a brothel. He was impotent, and. In spite of several attempts, remained so up to the time of making this report, though not yet 30 years old. Accident so decreed that the strict guardian and brother should learn the fruits of his plan of education on the same day. He received, almost simultaneously, news that one brother had begun treatment for contrary sexual instinct, and that the other was Impotent as a result of the abstinence he had enforced. Owing to the congenital neu- ropathic disposition of both these patients, their sexual education should have been moat painstaking, In order to prevent functional disturbance.

• Loc. eU.

84 SEXUAL IMPOTENCE AND ANAESTHESIA.

muscular and nervous apparatus in relation to it may result in lasting loss of sexual power, a form known as paralgtic impo- tence. On the other hand, when it represcMits but a temporary exhaustion of nerve-cells, it is called atcniic impotence.^ In the latter form there is erection occasionally, but it lasts but a short time and is insufficient for coitus.

Impotence in the Female Sex. Sexual impotence in women is far less frequently the object of the physician's treat- ment than that in men. The lesser intensity of tlie sexual imi)ulse and the form of the genitals in the female sex, as well as natural modesty, are probably sufficient to account for this. Hammond^ j'^stly points out that our education and social con- ditions effect a development of the sexual impulse in the male sex much beyond the limits demanded by the interests of future generations ; while, on the contrary, feminine education in civil- ized lands is entirely directed to restraining and limiting sexual desire.

As in the male sex, organic defects (absence or incomplete development of the clitoris) may cause absence or diminution of sexual desire. It must be remembered, however, that the mucous membrane of the vulva, the cervix, and the os uteri possesses sensibility similar to that of the clitoris, and that therefore the operative removal of the clitoris does not prevent lustful excitement (Hammond). Congenital defect of sexual instinct {frigiditas organica idiopatliica), according to Ham- mond, also occurs, though it is exceedingly rare.

An anomalous formation of the genitals may render im- missio penis impossible, and thus cause impotence, as may acquired anatomical defects (syphilitic growths, hernia of the labia majora, etc.).

The most frequent functional hinderance to cohabitation is vaginismus (hyperajsthesia of the hymen and the vulva, with involuntary spasmodic contraction of the sphincter vaginae). Pain and spasm make the sexual intercourse of such patients a burden.

Usually, vaginismus occurs only after attempts at coitus as

' Caspar, loc. at., p. 75. *Loc. cit.

PATHOLOGICAL CONSIDERATIONS. 86

a result, for example, of spinal irritation or hysteria, but most frequently after masturbation.

Sexual excesses and want of correspondence in the size of the genitals also play a part in its etiology.

Tlie most frequent form of impotence, and that which in its practical bearings has not been sufficiently recognized, is that due to defect or absence of the female orgasm, whether it be due to a want of sympathy with the husband or to the fact that the stimulus caused by the friction of the penis, witli complete desire and intense sympathy, is not sufficient to bring on the acme of the sexual paroxysm in the woman. The man has already passed the acme, the penis becomes relaxed, while the woman is still in a state of strained expectation without having experienced the characteristic lustful feeling. This difficulty in the occurrence of the orgasm may be congenital, or and tliis is the most frequent form it may be due to sexual excesses and masturbation, or to local disease, as after childbirth. In such cases there is exhaustion of related central ganglion- cells, whicli no longer react promptly to the stimulus. Erec- tion of the clitoris may also be involved. Finally, lustful sen- sation, just as in the male, even though it occur, may be weakened and remain incomplete.

The forms of impotence here described have excited a controversy among gynaecologists in the Archiv fiir Gynd' kologie^ the TherapeiUwche Monatsheften^ and the Allege' meine medicin. Centralzeitung,^ in that an attempt is made to regard such cases as " perversions," and, in support of this error, to account for it by assuming a deviation in the distribution of the nerves of lustful sensation like the hypothesis of some authors (Mantegazza) that in pederasts the terminal bmnches of the pudic nen'e are distributed to the rectum and anus. Dr. Carl I^ker gives the following characteristics of the peculiar sexual perversion of the female described by him :

' Archiv f. Gynakologrie, Bd. xxxiv, Heft 2, 188!, p. 293. Laker, Ueber due beaondere Form von verkehrter Richtuiip (Perversion) des weibllclien Geschleclitetriebes.

• Therapcutlsche Monntsheften, 1890, p. 165. Dr. Guetav Lelmann, Ucl>er Onanismiu

beinn Welb als einer bes. Form von verkehrt<'r Kichtung des Gepohlechtstrlebea.

• Wiener med. Wocluiiscbrlft, 1889, No. 28, and AUpem. med. Centralztf:., 1889, p. JW.

Franz Torggler, Casulstlseber Beltrage zur Perversion des welblichen Geschlechtestriebes.

86 SEXUAL IMPOTENCE AND AN.BSTHESIA.

1. Normally developed and frequently increased sexual desire.

2. Normal inclination toward the opposite sex and absence of any pathological inclination toward the same sex.

3. Complete absence of sexual satisfaction in normal inter- course (never has been experienced).

4. Complete satisfaction of sexual desire in solitary and mutual onanism.

5. Consciousness of the abnormal condition and desire for a cure.

6. Absence of states of psychical degeneration. Laker gives three cases as examples :

Case 1. Sexual inclinations began in her twelfth 3'ear. Sexual in- tercourse in her fifteenth year without satisfaction. Seduced into mutual onanism bj' friends (several months later). She experienced complete gratification. Married at 22 years of age. Never any lustful feeling in coitus ; always in onanism. This patient knew several who suffered like herself.

Case 2, Seduced to mutual onanism in her fourteenth year. Nat- ural intercourse in her nineteenth year, without lustful pleasure. In- creased libido. Bore two children. Owing to her anomaly, she cannot bring herself to marry again.

Case 3. Seduced to onanism at the age of 11 j-ears. Abnormally increased desire. Intercourse with several men without ever being satis- fied by coitus. Orgasm bj' means of auto-masturbation. According to Laker's experience, this form is quite frequent in women. To explain the anomaly, the author assumes the existence of an anatomical devia- tion in the distribution of the sensory nerve-endings. For this " t3'pical common form" he recommends local surgical treatment, and thinks that perversion of the sexual instinct may develop from mutual onanism.

Franz Torggler confirms Laker's experience :

Cose 4. The patient was seduced to onanism in her fourteenth year, and was a slave to it until her sixteenth year. Then a platonic love- affair. After six months' acquaintance with her lover, mutu.al onanism with him, which gave her more pleasure when the clitoris alone was stim- ulated than when the vulva and vagina were manipulated. Coitus avoided for social reasons. Seduction in her eighteenth 3'ear. Frequent coitus; excessivelv-increased sexual desire without satisfaction in coitus ; after ever3' attempt at coitus, she masturbated in order to experience the acme of the sexual paroxysm. After the relation ended, resort to onanism

PATHOLOGICAL CONSIDERATIONS. 87

again. Then marriage to a man she loved. Again no sutisfaction in coitus. She tiien came to phice her hand on her clitoris during the conjugal act, in order to induce orgasm by manipulation.

Gustav Loiraaiiii gives tliree cases, of which the first is essentially like those reported. The second case is instructive in relation to explaining the anomaly, and for that reason may be repeated briefly here :

The patient menstruated first at the age of 17; marriage at 20. Happy married life for ten years. Eight children. Complete satisfac- tion in coitus. Widow at 30. Intense sexual desire ; no chance to marry again. Faute des mieux, onanism, which was injurious to her mental and phjsical health. On the advice of a ph3sician, she entered into a relation with a student, aged IS, who had been entrusted to her care, without thought of consequences. The former satisfaction did not occur. She attributed this to the inexperience of her lover, and sought another and another. The desired satisfaction never came, but she dcA^eloped a chronic vaginal catarrh. At commencement of treat- ment masturbation was practiced as inordinately as before.

In its principal features, the third case is similar to the second : at first complete satisfaction in marital intercourse ; death of the husband; onanism; later, failure of orgasm in coitus.

Conceming the etiology of this misunderstood form of dis- ease, which, according to the statements of gynaecologists, is frequent, it is noteworthy that in all the cases reported, with the exception of the first by Laker, auto-masturbation or mutual onanism preceded the defect of orgasm in coitus. Loimann's patients, as far as the sexual paroxysm was concerned, were potent for years until the beginning of habitual onanistic in- dulgence. Through frequent unnatural stimulation, the im- pressionability of the centres influencing lustful feeling in woman is greatly altered and diminished in power to respond to normal stimulation, a fact wliich Loimann has correctly recognized. In every instance it is a form of genuine female impotence in which the orgasm is no longer induced by the sexual act. By manual friction the excitability of the clitoris is increased as compared with that of the vaginal mucous mem- brane and of the os uteri, and that without necessity to assume

88 SEXUAL IMPOTENCE AND ANiflSTHESIA.

unequal distribution of nerves to account for the variation of sensitiveness.

The question whether masturbation by means of objects resembling the penis in form, and which, therefore, do not stim- ulate the clitoris exclusively, but also those parts of tlie vagina which are subjected to friction in coitus, is likewise capable of inducing impotence, cannot be answered from tlie cases at hand. By analogy, it might be presumed that this form of stimulation could not cause impotence unless male ejaculations were to take place too quickly. Concerning Laker's first case, which seems to be an exception, it may be remarked that in woman lustful feeling is not always brought about by the first coitus, but that it occurs sometimes only after repetition of the act. In accord- ance with individual peculiarity, it requires a longer or shorter time before the various phases of cohabitation occur in a normal way. Loimann saw cases in which marriage led to complete satisfaction only after many months or after childbearing. I can confirm this from my own observation. At the present time I am treating a woman in pregnancy (aged 17), who, in intercourse during several months with her seducer, never had lustful feeling; and she experienced it first, after the occurrence of pregnancy, in intercourse with another man. Another patient assures me that of her various lovers only a few were able to induce in her the acme of the sexual paroxysm in coitus. It is the same with prostitutes, who very soon pass from the stage of hyperaesthesia to that of anaestliesia and relative impotence.^

In the cases described by Laker it is to be considered that auto-masturbation began only a few months after defloration, with which the pathogenesis of impotence had its beginning. Finally, want of satisfaction in the concrete case, which might be explained by speedy ejaculation of the man after immissio penis, is to be strictly distinguislied from absolute impossibility. One of my patients was satisfied by her husband only at the beginning of married life, and after the birth of her child

' In that prostitution usually excludes the physiological condition of the sexual rela- tion, namely, excitation of love, the participation of the psycho-sexual centres favorable for normal coitus being either diminished in intensity or absolutely impossible, it may be regarded as pathological and classifled as one of the forms of impotence described.

PATHOLOGICAL CONSIDERATIONS. 89

remained relatively impotent with him, while she was fully satisfied by the stronger stimulus of coitus with another.

In many women orgasm occurs only after prolonged coitus or after repetition of it after a short pause. The psychical con- dition of women in all cases of impotence requires much more careful study than in the case of men. Sexual intercourse in woman, as a rule, includes a much more intense psychical par- ticipation than in a man. " A woman loves with her whole soul. To her love is life ; to a man it is the joy of life." Un- requited love wounds him, but it costs a woman her life, or, at least, her happiness. At any rate, the mental tendency of woman is monogamous, while man tends to polygamy (von Kraft't-Ebing^). Therefore the occurrence of relative impotence in women sliouldlbe much more frequent than in men.

The pathological explanation of female impotence is often only an expression to cover up our want of knowledge of the marital relations. We are not able to ascertain how often the wife's disinclination to sexual intercourse and her apparent passiveness are due to the sexual weakness of the husband, who makes it impossible for the wife to complete the act, and thus, by nervous excitement, without subsequent completion of it, lays the foundation of nervous troubles. In judging female impotence, we must also take into consideration the decisive part played by the sexual functions in the mental life and development of woman. We should remember the numerous unhappy marriages brought about by our social conditions, the frequency of which, according to the statements of certain statisticians, is 75 per cent. The question of female impotence, in a broader sense, touches most intimately both private and social life. Upon the coiTect judgment of the physician, which, in the case of women, must be reached after the most careful psychological analysis of the sexual life, depends the happiness of the family and the therapeutic treatment. This often makes heavier demands upon the psychiatrist than upon the gyna3- cologist, who looks at everything through the spectacles of local anatomy. Thus may be explained the error of attempting to

• Psychopathia Sexualis, p. 14.

90 SEXUAL IMPOTENCE AND ANiKSTHESTA.

make a uew class ol' sexual perversions out of cases of simple female impotence!

Didijnosls. A careiul local examination must first deter- mine with what form of impotence the patient is aftiicted. In the majority of cases, endoscopical examination of the urethra reveals nothing. The majority of disturbances of the sexual mechanism are thus of a functional nature, and reveal them- selves, tlierefore, in the subjective sensations and observations of the patients. The discovery of the cause points out the method of therapeutic procedure. In making a diagnosis, attention should be given principally to constitution, manner of life, and the state of the nervous system in general. Often, signs of flaccidity and weakness of the genitals are to be ob- served ; for example, in neurasthenia sexualis and after sexual excesses. In the forms of impotence resulting from abstinence, Gyurkovechky^ found that the testicles were smaller than they formerly were. The mental condition of such patients requires the most study. The feeling of lustful pleasure may be altered or entirely absent without the necessity, for' that reason, to call the patient directly impotent. If the fulfillment of marital duty become an unpleasant necessity, or if the sexual act with prostitutes is done with repugnance, lustful feeling is either much diminished or absent. There are persons who naturally possess but a slight degree of lustful sensibility. Individual disposition and the intensification of sexual desire by love determine the intensity of lustful feeling.

The foregoing points may be extended by reference to the diagnosis of sexual hyperaestliesia in Section I.

The prognosis depends upon the conditions in each indi- vidual case. Cases of impotence due to organic causes are to be treated locally, and are not amenable to psychical thera- peutics. Congenital defect of the sexual mechanism permits only a doubtful prognosis. The prognosis in cases of impotence due to abstinence is unfavorable if the testicles are shrunken. In consecutive impotence the prognosis depends entirely upon the primary disease. Impotentia nervosa irritativa presents

• 2x)e.ci<.,p. 188.

PATHOLOGICAL CONSIDER ATIONS. 91

opportunity for treatment; for example, in general treatment of the nervous system and in the effort to re-adjust the want of relation between the various functions which make up the sexual act. Atonic impotence also permits complete cure, while in the pamlytic form the organic changes in nerve-centres and paths which control erection make the prognosis unfavorable. In psychical impotence it should first be determined whether the central disturbance is primary or secondary. Gonorrhoea, diseases of the prostate, inflammation of the testicles, and onanism affect the mind secondarily ; while impotence due to imperative ideas, absent-mindedness, etc., is primary. On the whole, in the cerebral neuroses the prognosis is favorable, if they are understood and treated with reference to their etiology. At the same time, hereditary disposition, in these cases, must also be taken into consideration ; acquired psycliical impotence, in the absence of symptoms of other serious disease of the ner- vous system, offers a fertile field for psycho-therapeutists. Rela- tive impotence in married persons, for example, as a result of lack of acquiescence on the part of the wife, touches delicate ground, and offers prospect of success only in cases where both parties submit to systematic psychical treatment. The delusion of impotence belongs in the domain of the psychoses, and is to be judged and treated from that stand-point.

CHAPTER V.

THE ROLE OP SUGGESTIVE THERAPEUTICS IN THE TREATMENT OF FUNCTIONAL SEXUAL WEAKNESS.

The causes and forms of impotence determine in each case the direction of therapeutic measures. The majority of sexual invalids (according to Fiirbinger, 89 per cent.) attribute their malady to sexual excesses, onanism, and gonorrhcea. The principles of prophylaxis here are exactly the same as those laid down in the pathological states described in Section I (compare what has been said concerning sexual education, page 34).

Among the methods of treatment in vogue, coiTect hygi- enic measures are the most important. The most important means of cure is rest to the exhausted genitals. Coitus must not be indulged in for a period long enough to permit recovery. Sufficient sleep must be obtained, and diet tending to produce superfluous fat, which injures sexual power, must be avoided, as must stimulants. In addition, the measures described in the therapeutics of sexual hyperaesthesia are indicated.

If there are symptoms of neurasthenia universalis (cerebral or spinal), general treatment (climatic, hydro-therapeutic, gym- nastic, electrical, etc.) is advisable. In case of combination of spermatorrhoea, chronic gonorrhcea, etc., the local treatment is given in so much detail in all special works on impotence that it is unnecessary to consider it further here. Concerning strict individualization in the application of balneo-hydro-therapeutical measures, consult the foregoing section and special works ; also for the various methods of application of electrical currents, which, locally as well as generally, may have the happiest eflect ; for example, in anaesthesia of the glans, in the beginning of atro- phy of the testicles.* Electricity in the treatment of impotence is also indispensable to the psycho-therapeutist. Here it is only necessary to refer to the medicaments that are briefly alluded to

' Hammond, loe. eit.

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FUNCTIONAL SEXUAL WEAKNESS. 93

in Section I. A detailed treatment would lead us away from our subject and be but a repetition of what is familiar. Gyur- kovechky ' thinks that medicaments are not the means in the treatment of impotence which most frequently and surely lead to success. And Hammond compares the effect of substances of various properties in many forms of impotence with that of bread-pills. However, we must here examine one method of treatment which of late years, especially among French writers, has led to much discussion, viz., Brown-Sequard's method of treating impotence.^

The subcutaneous injection of the testicular juice of various animals in the impotence of males, according to the assertion of the celebrated physiologist, exerts a favorable influence upon diminished sexual power. There is said to be an eflective prin- ciple in the semen that is capable of stimulating great power. Brown-Sequard attributed the loss of virility in old men to the diminished activity of the testicles. He (aged 72) injected on himself during three weeks an extract of testicular juice ten times. This painful procedure had a favorable effect upon him, troubled as he was by the weaknesses of old age. "In place of states of exhaustion came a feeling of strength like that of twenty years before. Again, he was able to stand without fatigue for hours. Muscular power, measured with a dyna- mometer, showed a decided increase. The stream of urine was stronger and of greater length. Defecation was essentially stronger. After four weeks the old conditions of weakness re- turned." Variot observed the favorable effect on the sexual functions in five men. An extract from the ovaries, it was pre- sumed, would have a similar favorable effect in women. Though numerous objections were oflfered to tliis theory, by assuming that suggestion and peripheral irritation through pain played a part in the results (Fere and Dumontpallier), Brown-Sequard's reports fell on fertile soil. Chemists sought to isolate the active principle of sperma (Parke, Davis & Co.); it was called sper- min or spermatin (Schreiner). The newspapers hailed Brown-

' Loe. cU., p. 153.

Furblnger, *' Zur Wunlipunp der Brown-S^'quard'schen Bebandlung der Impo- tens," Deutsche med.-Ztg., vom. 22, Junl, 1891, p. 583.

94 SEXUAL IMPOTENCE AND ANAESTHESIA.

Sequard's discovery as the givei of perpetual youth. And a year later the discoverer liimself was forced to flee to England to escape from the impotent horde that assailed him.

A great and celebrated manufactory applied to Furbinger, as he states, to obtain the testicles of all men subjected to autopsy in the hospitals of Friedrichshain, in order tliat they might meet the demand for spermatin. Later, Brown-Sequard recommended the use of the testicular fluid by enema as pro- ducing wonderful results. Reaction was not wanting. The better representatives of medical literature, even in France, kept silent. Against his inclination, Fiirbin^er at last decided to te^t the new method of treatment. In order to eliminate the psychical factor, Fiirbinger took old men and patients from the lower classes who were not acquainted with the object of the treatment. He mixed fresh semen of healthy men with five times its amount of a solution of thymol, added a drop of potas- sium hydrate, boiled, and then filtered the whole. The solution was then used for injection. He treated eighteen men, aged from 24 to 72 years, and patients or old men affected with skin diseases, rheumatism, etc. In three days the injections were increased to five. In one-half the cases pain occurred at the seat of injection ; once violent inflammation was induced. Four patients felt depressed. Two consumptives became greatly excited and had no sleep. " Not a single instance of sexual excitement reported or confessed." The failure of this test, according to Fiirbinger, needs no comment. According to these experiments, the exciting and youth-giving power of Brown- Sequard's treatment seems to rest upon an erroneous assumption- All the effects may be directly attributed to auto-suggestion, as Fiirbinger, Forel, and others assume.

Psycho-therapeutics. For affecting the imagination of im- potent men, there could hardly be a more effectual psycho-thera- peutic procedure than this of a belief in the secret and youth- giving effect of an extract of the testicles. The very sexual origin of the substance awakens hopes and intensifies the patient's expectation. The entire attention is directed to the parts diseased, and intensified by the exciting and painful injec-

FUNCTIONAL SEXUAL WEAKNESS. 96

tions. The patient feels something taking place in him ; his faith grows; the mysterious effect of the youth-giving juice excites his fancy in the most lively fashion. I^et us remember that the cerebral part of the sexual act in almost all cases of impotence also suffers, if it be not the cause alone of impo- tence ! Thus, the possibility cannot be denied that these factors may overcome the psychical functional disturbance and completely cure many cases of impotence. Other means used to conceal our psycho-therapeutic procedures in the waking state speak in favor of tliis explanation.

In the majority of cases of so-called psychical impotence, the object is to remove the influence of excited brain activity from the inhibitory nerves. If, for example, it is possible to demonstrate to the patient that he is capable of an erection, the fii*st step toward recovery has been taken. The patient's self- confidence is thus strengthened in the most marked manner. Faradization of the genitals ; the use of larger and larger metal sounds, that are left in place ten or fifteen minutes ; supposito- ries of silver and tannin in the posterior urethra ; clysters, etc., induce erection. All these means, like Brown-Sequard's, affect the patient's mind, and demonstrate the principles of psychical treatment in the waking state, which we have described in the treatment of sexual hyperaesthesia. Fear, distrust, superstition, hopelessness, and hypochondriacal mood often, as causes of psychical impotence, present insurmountable difficulties. Suc- cess with such patients depends entirely upon correct individu- alization and the acuteness of the physician. It is necessary to so influence the patient that he is not constantly pre-occupied with himself; that he takes his malady and any possible failure with indifference. Useless sexual excitement (for example, with Q, fiancee) must be absolutely avoided. Every forced act on the part of the patient paralyzes the erection-centre only the more. Rest of mind is the most essential thing for the patient. But one must be careful not to attempt to cure a real disease by argument; this would only make matters worse. The phy- sician's task is to have a well-considered plan for the cure of the patient carried out. Cold rubbing, baths, medicines, and

96 SEXUAL IMPOTENCE AND ANiESTHESIA.

local treatment must conceal the method of cure. The patient must gain the impression that the means used are helping him. Occasional abstinence is of use in this direction.

Patients that have become impotent as a result of severe mental work must give up their occupations for a time. A sojourn in the country should be recommended to such. In other cases they should be advised to perform coitus in a state of partial intoxication, in the hope that the alcoliol will effect a partial paralysis of the mental activities. Regulation of sexual intercourse also plays a part. A suitable marriage is in all cases an excellent preventive of impotence.

WaJcing- Suggestion and Hypnotic Treatment. The use of the cerebral functions for the purpose of cure consists of () psycho-therapeutics in the waking state, the special value of which in impotence is shown in the foregoing paragraphs ; (/>) suggestive therapeutics. The fundamental principles and dif- ferences of these two methods of treatment have been given in detail in Section I (Therapeutics), and they are as applicable here as there. Psycho-therapeutics takes account of the patient's judgment, the co-ordinating cerebral activity, and sets in motion his will, his attention, and his judgment. Sugges- tions, on the contrary, have the special tendency to cause the idea imparted to be transformed into an act. Tlien, the more cerebral activity is dissociated, the less is the activity of the con- trolling inhibitory apparatus of the brain, and thus the more the intensity of the ideo-motor, ideo-sensory, and ideo-sensorial reflex activity is increased; that is, suggestibility. Per se, it is a matter of no consequence whether sleep exists or not, even though it must be allowed that, in spite of notable exceptions, sleep in general increases the receptivity for suggestions. Waking-suggestion that is, the unqualifiod acceptance and appropriation of an idea always indicates a weakening of the associative and contrasting ideas, or extinction of intra-cerebral reflex excitability ; that is, strictly speaking, it may be defined as hypnosis. The increasing degree of faith presumes a diminu- tion of judgment and reflection. The results obtained with the help of imagination, in cases of impotence, show the

FUNCTIONAL SEXUAL WEAKNESS. 97

peculiar cerebral pliability of hypnosis ; as suggestions in the waking state, they form the transition to hypnosis. Therefore, our series of cases of cures by suggestion in the waking state are placed by the side of those cured by hypnosis as a class belonging to the latter. The psycho-therapeutics of the waking state, as we have seen, pass without definite limitfition into waking-suggestion, and the latter into hypnosis (in its narrower sense). The physiological basis of suggestive therapeutic effect in sexual weakness is the same as in sexual hypera^sthesia. In the patients of Section I there is increased activity of the sexual functions; in impotence, a diminution. Our introductory re- marks in Chapter IV show that ideas have an exciting and an inhibitory influence on the sexual mechanism, especially on that of erection. The sexual functions stand in a dependent relation to the cerebral cortex. Ideas, desires, and images of sexual content cause sexual excitement, weaken the influence of the inhibitory centre, and, through the effect on the erection- centre, induce the well-known vasomotor and motor effects which give rise to the filling of the penis with blood.

From this it will be seen that the object of the treatment is to strengthen such ideas as induce sexual erethism, and that by weakening habitual associated and pathologically intense oppos- ing ideas (cause of psychical impotence), as well as to increase their peripheral effect (influence on erection and ejaculation). As a result of the removal, the weakening, the dissociation " of the organically associated ideas maintaining the equilibrium," the suggested idea becomes all-powerful. The facilitation of the process of transformation of an idea into a feeling (libido sexualis) and movement, thus brought about, is, of course, not subject to observation.

However, in order to overcome the mastery of the inhibi- tory centres over the sexual mechanism that has existed for years, or, by means of ideational stimuli, to excite the weak- ened sexual functions to renewed activity, a few hypnotic sit- tings are not sufficient, as so many patients believe, but the unhindered ideational stimulus of suggestion must be repeated until, through cumulative effect, its intensity and lasting influ-

98 SEXUAL IMPOTENCE AND ANAESTHESIA.

ence seem assured ; until it acts automatically from the brain. An impotent patient who has been able to perform coitus once, as a result of suggestive treatment, can only be regarded as con- valescent ; only repeated and habitual success in sexual congress constitutes a cure. Length of treatment and prognosis must follow these principles.

Ringier^ very justly remarks that in no form of medical treatment is the tendency to break it off so pronounced as in hypnotic treatment. The patient expects wonders, and, as a rule, is disappointed. The simplicity of the procedure does not come up to his expectations. Besides, the first symp- toms of improvement often come unnoticed and unconsciously to the patient, in contrast with the more marked effect of physical and medicinal procedures. Besides, many patients at first, during hypnotic treatment, are inclined to ascribe the more frequent occurrence of sexual desire and erections to other causes. The causal relation of cure and suggestive treatment escapes the observation of the patient, and often it is only the constant association in time of improvement with the suggestive treatment which causes an actual recognition of the psycho-therapeutic effect. An occasional pause in treatment, as a rule, convinces such patients ; for, as soon as they attempt to be independent, they recognize the assistance afforded them by suggestion.

On the whole, then, it is best to treat patients for chronic impotence with suggestion only when they will engage not to discontinue the treatment prematurely, for, by so doing, they increase their want of confidence in themselves, make a repe- tition of the procedure more difficult by auto-suggestion, and injure the reputation of psycho-therapeutics, sufficiently at- tacked and misunderstood witliout this. The great principle in the treatment of psychical or functional impotence is strict individualization with both men and women. The foregoing general principles wUl suffice; details will be found in the histories contained in the following chapter.

• Erfolge des therapeutischeD HypnotismuB In der Landpraxlji. Lebmann, M&ncben, 1891,

CHAPTER VI.

CASES ILLUSTRATING SUGGESTIVE TREATMENT OF SOME FORMS OF IMPOTENCE.

The following eighteen cases include all instances known to the writer of suggestive treatment of impotence. By "functional" impotence in the following cases is meant a state of sexual weakness without demonstrable anatomical founda- tion, in so far as it is not exclusively and demonstrably of psychical origin.

Results in PsYcmcAL, Functional, Relative, and Paralytic

Impotence.

Case 21. Reported by Dr. Van Benterghem (Amsterdam). Psychical Impotence. Lasting Cure by Means of Larvated Waking-Suggestion. G. S., engineer, aged 29, married, fell from a height of five feet to the floor. Without being severely injin-ed, he received several painful con- tusions, one in the region of the perineum. He was treated at home. For the first few days he suffered with trouble on defecation, which was soon overcome by appropriate treatment. Pains had disappeared two weeks after his fall, and he only complained that his genital functions were out of order. On April 3, 1891, his physician sent him to me. Present con- dition : Strong constitution. Apparently in robust health. No ante- cedents, either nervous or in the domain of the vita sexualis. He com- plains of impotence. Genitals perfectly normal. No disturbance of urina- tion. The man is married, loves his wife, and has always lived with her in perfect harmony ; and he has led a regular life, both before and since his marriage. He confesses that he attempted coitus two days after the accident, but that it was not successful, owing to pain, a fact that caused him great anxiety. A second and third attempt, some time later, met with no better success. He thinks, therefore, that, as a result of the fall, some disturbance of the genitals has occurred which has caused the impotence. Patient is much depressed and suffers on account of the disturbance of his marital relations. I was successful in quieting him with the assurance that if some hindrance to ejaculation had resulted, it could be removed by repeated introduction of a sound. At the first attempt I introduced a sound with ease. I allowed the instrument to remain in the urethra one minute. Before the patient left he promised me not to have congress with his wife until I gave him permission.

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100 , SEXUAL IMPOTENCE AND ANAESTHESIA.

April 7th. Though occupying a bed with his wife, he did not ap- proach her last night ; but erection occurred repeatedly. Introduction of sound.

April 10th. He asks for permission to attempt coitus. I refuse it. Use of sound.

April 14th. Patient does not appear.

April nth. Patient excuses his absence on the 14th as a result of business. Introduction of sound. After this, he confesses thsit he dis- regarded my instructions and had congress with his wife. Coitus was perfectly successful. When asked why he had not told me this before, as it would have made the use of the instrument superfluous, he answered that he had postponed his confession purposely, fearing that I would be unwilling to continue the treatment, upon which all his faitli rested.

It is to be noted that to bring about a permanent cure I introduced the sound but three times, and that at long intervals.

Case 22. Reported by Dr. Van Renterghem. Psychical Impotence Treated without Success by Suggestion in One Sitting. B., civil engineer, aged 28, was sent to me July 8, 1889, by his physician, to have his belief in his impotence removed. The young man (one montli married) seemed very nervous, was uncommunicative, and so anxious that m}' efforts to hypnotize him were entirely unsuccessful. He did not return.

Case 23. Reported by Dr. Van Renterghem. Functional Impotence

Treated in Thirty Hypnotic Sittings without Success J. K., merchant,

married, aged 42. Gonorrhoea. Growths in the urethra had been removed by galvano-cautery. He suffers with emphysema and chronic bronchial catarrh. Frequent (several times a day) attacks, which are sometimes accompanied by loss of consciousness. Remissions, which, however, never last more than two or three weeks. Besides, states of great anxiety, disturbed digestion, fluid stools, etc. Unliappy married life. Separate sleeping-apartments. While abroad he was treated for a long time for psychical impotence. His present physician (specalist in genito-urinary diseases) states that the impotence does not depend upon any demonstrable anatomical causes. K. sleeps well.

June 7, 1888. Pollution occurs from time to time, always preceded by complete erection. Still, K. does not venture to approach his wife sexually. He asks me to hypnotize him and suggest forcibl3' that he perform coitus. He thinks he cannot be hypnotized, because Donato was not successful in fascinating him.

Hypnotic sittings were had between June 18th and July 12th. However, he never passed Jnto hypnosis deeper than the third degree of Bemheim's classification (ninth degree), and was little susceptible. The result was negative. The patient promised to inform me of any subse- quent success.

TREATMENT OF PSYCHICAL IMPOTENCE. 101

Case 24. Beported by Dr. Van Renterghem. Relative Impotence Cured by Hypnotic Suggestion. J. K., bridge engineer, aged 44; mar- ried at 26. He lost his wife after nine years of married life. Since this time he had had intimate intercourse with a single woman. Four months ago these relations were interrupted by a project of marriage. Since this time he had had, possibly from disinclination, only irregular inter- course. On the very first attempt coitus was incomplete, and did not give him the accustomed pleasure ; and he thought himself subject to premature impotence. At second time erection occurred, but not ejacu- lation ; a third time there was not even erection. This impotence was accompanied by an indescribable feeling of illness, and was followed by a host of nervous symptoms, anxiety, sleeplessness, pain in the region of the kidnejs, excitability, etc.

May 19, 1888, I began to treat K. He came to me in a state of great excitement. I was successful in quieting him in h^'^pnosis. I sug- gested to him " disappearunce of the nervous symptoms," and the assur- ance that his impotence had no tangible cause, but depended entirely upon his mental excitement.

May 20th. Patient has become much quieter since yesterday. He had a good night, and awoke without the feeling of anxiety. Before going to sleep he had a complete erection, and also on awaking. Repe- tition of the suggestions of yesterday.

Ma}' 21st. More excited than yesterda3% Some sleep last night, but not quiet. Pain in back and languor. I hypnotized him and induced catalepsy. Suggestibility increases. After waking he states that he has felt the sensations of sleep. I suggested to him to find his former mistress and perform the sexual act with her, assuring him that he would succeed in it.

May 23d. K. excuses himself for having missed the sitting yester- day by attributing his absence to business. He had followed my advice, and coitus took place to his entire satisfaction. I hypnotize him again, and suggest that he perform coitus this evening with another woman, giving assurance that it would be successful.

May 24th. Yesterday's attempt was perfectly satisfactorj'. Some months later I received notice of his marriage.

Case 25. Reported by Dr. Li'ebeauU. Psychical Impotence Improved by Hypnotic Suggestion. B., aged 20 3'ears, health}', has powerful erec- tions when he thinks of the woman he loves, but as soon as he is in her arms he grows so excited that erection is no longer possible.

On the first attempt at hypnosis B. passes into light sleep, and, in five sittings, is so influenced that he is able to perform coitus for some time. Later he relapsed ; but he had to leave Nancy, and treatment could not be continued.

Case 26. Reported by Dr. Liebeault. Impotence Caused by Auditory

102 SEXUAL IMPOTENCE AND ANAESTHESIA.

Hallucinations Cured by Suggestion. L., aged 60 years, with other im- perative ideas, has suddenly developed the notion that he can no longer fulfill his marital duties. He hears voices that keep him from it. I succeeded in removing his hallucinations by means of suggestion. There- after the patient was capable of intercourse with his wife to his entire satisfaction.

Case 27. Reported by Professor Bernheim. Psychical Impotence Treated by Suggestion without Success. For seven weeks I treated with hypnotic suggestion (second degree) a young man aged 26 years. He was hypochondriacal, sad, and preoccupied with self. He complained, also, of sexual impotence, though there had still been erections for two or three years. Complete failure.

Case 28. Reported by Professor Bernheim. Psychical Impotence Cured by Suggestion. Male, aged 25 years ; neurasthenic ; has thoughts of suicide. For about two years he has suffered with impotence. His mother is nervous. On the first attempt at hypnosis he passed into deep sleep. He was completely cured in ten days by suggestion.

Case 29. Reported by Professor Bernheim. Relative Impotence. Probable Success by Means of Hypnotic Treatment. A Belgian mer- chant consulted me three years ago on the following subject : Married three years and loving his wife, he has never been able to satisfy her. Erection incomplete in spite of all efforts. Still, he is not impotent; for, when he makes the attempt with another woman, he can perform coitus three times in a night. Patient is 38 years of age, in good health, and without nervous antecedents. Probably the emotional excitement on the marriage-night, on the first attempt, paral^-zed erection, and im- conscious auto-suggestion, on each new attempt, reproduces, to a certain extent, as a reflex act, the paralysis of the genito-spinal centre. I hyp- notized the patient easil}'. Deep sleep, with partial post-h^^pnotic amne- sia. He could remain in Nancy but three da3's. I gave him six hypnotic sittings, and made him promise, in case of failure with his wife, that he would return, that an attempt might be made again under the direct influence of new suggestive treatment. The patient departed, and no word was received from him. He was probably cured (von Schrenk).

Case 30. Reported by Professor Bernheim. Psychical Impotence Cured by Suggestion. X., laborer, of Nancy, in November, 1890, seeks my aid on account of impotence. He had never been able to perform coitus. Erections, especially at night; great desire to perform coitus. He wishes to marry ; but every time he visits a woman erection fails to occur. He is tall, aged 26 years, of good constitution, very nervous and impressionable. He often sufTers with sleeplessness. His mother, also, is said to be nervous. He states that he has never been ill and has never masturbated. His genitals are well formed.

tUEATMENT OF PSYCHICAL IMPOTENCE. lOd

I hypnotized him. He passed easily into the second stage (cata lepsy, automatism, memory after waking). Later he passed into som- nambulism several times without memory on awaking. I hypnotized him daily for fifteen days. Sleep at night returned. Nervous excit- ability diminished, but impotence continued in spite of all efforts. I continued the treatment once or twice a week for two or three months. In March, when I recognized that in this way I should obtain no imme- diate result, I sought to strengthen the idea in him that he was perfectly cured, but that he must not make further attempt at coitus. " One fine day, without your thinking about it, this thing will take place of itself." I had him visit me every ten or fifteen days, and each time I suggested to him that the cure would take place without his thinking about it. In July, 1891, he informed me that he had been successful. While sleeping with a woman he had no erections during the night, but in the morning he was able to perform coitus twice. I enjoined him not to abuse his powers and to wait patiently for complete cure. Six months later he learned to accommodate himself to his erections, and he no longer felt powerless in the presence of a woman.

Case 31. Reported by Professor Bernheim} Psychical Impotence Cured by Hypnotic Suggestion. X., merchant, aged 27, consulted me October 10, 1889. He came from the Urals, and was several weeks on the way before he found me. He complained of absolute impotence and had never been able to perform coitus. At the same time erections are powerful, but in the presence of a woman he begins to tremble with ex- citement and erection disappears. It is apparently a case of psj-chical impotence ; mental excitement has an inhibitory effect. Besides, he tells me that he has masturbated a few times, but rather unconsciously, at night in sleep. Sometimes this would occur three nights in succession, then it would not occur again perhaps for ten or fifteen days or more. X. seems very nervous. He is very impressionable ; he speaks often suddenly and easily begins to tremble. In his excitement he shoots be3'ond the mark. His constitution is excellent. He has never been ill, and has always been free from nervous disease. Examination negative.

I easily succeeded in placing him in deep sleep. I suggested phys- ical and mental rest. " There will be no inclination to masturbate at night; in the presence of a woman erection will last until the completion of the act, without the occurrence of excitement. You will be cool, have no trace of fear, and be able to perform the act." The patient was able to remain in Nancy only from October 10th to 23d, when his vaca- tion expired. I repeated the same suggestions daily. After the first sitting he masturbated no more at night. Once, on the night of October 13th, he awoke with his hand on his penis and was about to masturbate ; he immediately stopped, and the act has not been repeated.

• Hypnotism, Suggestion, etc., Paris, 1891, p. 836.

104 SEXUAL IMPOTENCE AND ANAESTHESIA.

October 20th, at suggestion, he attempted coitus, when he noticed that fear and tremor did not come as formerly. Therefore he thought his object nearly attained. I suggested to him now energetically repe- tition of the attempt on October 32d, with the assunuice that he would have complete success this time. October 23d he told me of his success, the first of the kind in his life. Though erection diminished toward the end of the act, yet he was still able to complete ejaculation. Now I suggested that, once freed from his excitement, in the future he would make no failures. He returned home satisfied.

Case 32. Reported by Dr. Moll^^ Berlin. Functional Impotence Cured by Hypnotic Suggestion. J., aged 31, noticed nine months ago that in coitus he had ejaculation either before immissio penis in vaginam, or that when it took place at the proper time ejaculation was devoid of pleasurable feeling. After about forty trials I was successful in hyp- notizing the patient so deeplj' that with eyes closed he was obnoxious to the most various suggested hallucinations. After this, the attempt, repeated for several days, to induce him to perform coitus by post- hypnotic suggestion, was so successful that within four days the patient was able to perform coitus twice with immissio penis and normal lustful feeling. Unfortunately, I lost sight of the patient, who showed no objective signs of disturbance of the sexual organs or nervous system ; for in the second coitus he acquired gonorrhoea after having dispensed with preventive measures, against my advice.

Case 33. Personal Observation. Functional Sexual Weakness Treated in One Sitting by Suggestion without Success. T., aged 31. Father nervous. Had measles ischias lasting two or three years, but no other diseases. Masturbated since his twentieth year. After self- abuse continued five 3ears, first attempt at coitus; ejaculatio prsecox with incomplete erection. States that he has not masturbated for a year ; often awakes in the morning with complete erection. Pollutions at night once or twice a week. Moderate hyperaesthesia of the glans. Neurasthenic complaints; easily tired; tinnitus auriuni. Great weari- ness on awaking in the morning; rising requires great resolution. Cardiac palpitation. Depression, with entire loss of self-confidence. Patient was never in love. Genitals uormallj- developed. Water, elec- tricity, and sounds have been used for his ps3'chical impotence in vain. Patient was sent to me by Dr. Kopp. January 12, 1891, first attempt at hypnosis. T. has an idiosyncrasy against hypnosis. He cannot make himself passive; consequently, allows his attention to be diverted, and conceals his apparent anxiety and excitement by effectual resistance. On January 13th the patient writes me that it is impossible for him to overcome his idiosyncrasy, and therefore will not take any further treatment.

• Reported by Caspar, Impotentia et sterilitas viriliB, Moncben, 1890, p. 99.

TREATMENT OP PSYCHICAL IMPOTENCE. 105

Of course, the negative result of a single trial is of no value in answering the question whether and in what length of time psychical impotence can be cured by suggestion. In spite of the prejudice of the patient in the foregoing case, the prognosis with psychical treatment did not seem to me at all unfavorable. A series of sittings would have taught the pa- tient to submit to the influence, and thus his suggestibility would have proportionately increased. The gradual occurrence of quiet by means of suggestion, and the removal of neuras- thenic symptoms in connection with careful attempts at coitus, in my opinion would have brought about a cure in spite of the difiiculties.

Case 34. Personal Observation. Tmpotentia Paralytica (?) Treated Experimentally in Four Sittings. Temporary Improvement. Male, aged 41, Mother died of heart disease. Father and brothers and sisters living and health3\ B. has never had other illness than the diseases of childhood and emphysema that causes little trouble. From his tenth to his sixteenth year he practiced onanism excessivel}'. As a result, irrita- ble weakness of the lumbar cord came on. Frequent pollutions in climb- ing, riding, and in sleep. B.'s hyperexcitability is so much developed that when he merely thinks of a woman ejaculation results with a relaxed or half-erect organ. In attempts at coitus, ejaculatio ante introitum va- ginae; imniissio has never been accomplished, though in previous years, especially nights and mornings, erections were not infrequent. The pa- tient can onl}' recall having had one actual erection in the last two years. Nevertheless, in the last four years he had attempted coitus four times, always with great psychical excitement. There is pain in the back after pollutions, which still occur frequently. Besides great depression there are no other abnormal nervous symptoms. Genitals normally developed.

The patient has tried in vain all kinds of treatment at the hands of celebrated specialists, hygienic, electrical, medical, hydropathic, and now, as a last resort, wishes to try suggestion, thinking tliat his impo- tence may be of psychical origin; that, if his excitement on attempting coitus can be overcome, perhaps he will succeed. In spite of an unfavorable prognosis, in order not to destroy- all the patient's hope, I made four hypnotic attempts from September 16 to 19, 1889. In these sittings the patient did not pass beyond slight somnolence. On the night of September 16th and 17th he noticed the beginning of erection, which increased the next night. Attempt at coitus September 18th. Weak erection made immissio penis in vaginara possible, but only for a short distance. But ejaculation took place in the vagina. On Septem-

106 SEXUAL iMrOTENCE AND AN^ESTHfigtA.

ber 19th the patient was called away from Munich, and could only be discharged as essentially improved. In spite of the unfavorable con- ditions, owing to the slight improvement, continuance of treatment would have been advisable.

Case 35. Personal Observation. Psychical Impotence Essentially Improved in Three Hypnotic Sittings. Favorable Prognosis. K., aged 29. No hereditary taint. Parents and brothers and sisters healthy. Dis- eases of childhood, scarlet fever, dropsy, scabies, till his twelfth year. He began masturbation in his fourteenth year, taught by a companion, and he practiced it daily until his twenty-first year, always fancying him- self in the sexual act with women. Onanism less frequent since his twen- tieth year, and abandonment of the habit since his twenty-fourth j^ear. The patient has never noticed any injurious effect from the vice on his physical or mental health. Physically he seems entirely health}'. Pollu- tions every three or four weeks. Nights and mornings erections are fre- quent, and they also occur during the day at thought of a woman. In spite of numerous attempts, the patient has not been able (in ten years) to per- form immlssio penis and complete coitus. Ejaculatio praecox and relaxa- tion of the organ before introduction have made all attempts futile. His libido sexualis is very intense ; he loves a girl and wishes to marry, but the thought of failure has become an imperative idea. At each new trial there is such intense psychical excitement that lie breaks out in a per- spiration. The patient came to consult me September 26th, and, though desiring help, he was so much under the influence of auto-suggestion that he could not be hypnotized. First trial, September 26th. Very slight somnolence. He denies the influence and wants to be put in a deeper sleep. On this occasion quiet and success in coitus were sug- gested. On the same day he sought a puella, but immediately lost his libido when he saw her padded breasts while undressing. The first trial was a failure, because no erection occurred in spite of tactile stimulus.

After a time, second trial. For the first time in his life the patient sacceeds in bringing about immissio penis, but ejaculation took place with ft relaxed organ immediately after its introduction ; so that there was no gratification, though the emission took place in the vagina. Nevertheless, this is to be regarded as some progress.

September 2Tth the hypnotic procedures had a negative result, as did another attempt at coitus. At the door of a brothel the patient is overcome with fear and repugnance, and turns away,

October 4th, third hj'pnotic trial with the help of chloroform to overcome the unconscious but obstinate resistance, K. passes into the stage of excitement, which, by suggestion, I transform into hypnosis. Suggestive cataleptic symptoms. Energetic suggestion that coitus will be successful. On awaking the patient declares that he has not been influenced in the least, but he has but a partial memory of it. He is

TREATMENT OP PSYCHICAL IMPOTENCE. 107

still possessed by the imperative idea that he cannot be hypnotized. An attempt at coitus on the same day was a fiasco. Since the patient can come only once a week, owing to his living out of the city, therefore he proposes to take a vacation for several weeks, that suggestions may be repeated daily and thus have a more powerful effect on his condition. In spite of the three first trials, the patient is but little improved. Con- sidering his general condition, age, etc., the prognosis seems favorable. Before his departure I assure the patient that with a regular continuance of his efforts certainly coitus will gradually become successful ; that he must not allow himself to be discouraged by failure.

November 15, 1891, the patient writes : " Unfortunately, I have not yet had any completely satisfactory results, though I must confess that since my first visit to j'ou I have made some progress. I regularly have half an immission and can make five or six movements, but emission takes place after three or four. It is my intention to continue my efforts this winter by myself, and then next year to take your treatment. I think then to have success in a week."

January 30, 1892, the patient writes: "After many attempts with this single person, I was so far successful that, with proper approach, I was able to perform the act fully. However, whether I could perform coitus with others at any time seems doubtful to me. As soon as I can subject myself to further suggestive treatment at your hands, I think I shall be completely cured."

In this case absolute impotence has become relative. The improvement of November, which in the table is given as slight improvement, has become a relative cure, due to suggestive treatment.

Case 36. Personal Observation. Relative Impotentia Coeundi Psy- chica with Neurasthenic Symptoms. Suggestive Ti-eatment. Negative Re- sult with Reference to Sexual Weakness ; Positive with Reference to the Nervous Symptoms. X., aged 36, landed proprietor, married, childless. Parents, especially father, nervous. In youth, masturbation. Patient very much " spoiled " in rearing ; anxious about his health to the extent of silliness. Constantly in fear of apoplexy because of congestive symptoms due to rich food. Strongly built, large, abundant adipose. Internal organs, lungs, heart, without demonstrable disturbance ; sometimes nervous, disagreeable cardiac palpitation. Abdominal organs normal. Penis and testicles somewhat small, but, according to statement of phy- sician, functionally capable. Trials have proved this. Sleep and appe- tite, with few exceptions, excellent. In short, the patient maj' be called a healthy man physically ; on the other hand, his great anxiety is a mental abnormality, causing changing hypochondriacal moods with rel-

108 SEXUAL IMPOTENCE AND ANAESTHESIA.

live impoteuce. Energetic advice and dietetic rules have, thus far, always hnd a good influence, but have been insuflicient to bring about cure. Aphrodisiucs (mild) proved worthless. This from his physician, who sent him to me October It, 1889.

The patient was remarkably anxious and very reticent in his com- munications. Therefore, on the first day it was not possible for me to learn the details and causes of his psychical impotence. The first sit- ting, therefore, could be regarded only as a test whether the patient was susceptible to suggestions or not.

With the use of the method of Bernheim and Li^beault, the patient passed into somnambulism. Complete hjpotaxis, suggestive catalepsy, and post-hj'pnotic amnesia. Decrease of nervous excitability and anxiety and disappearance of palpitation suggested. Success in coitus in the future. The patient left the same day. The effect on his general condition was favorable. According to the statement of his physician, the patient was much improved by the sittings held during the next week; was less excited, and made no complaint. Still, his impotence remained unchanged, as I had foreseen. The patient could not follow my advice to submit himself to treatment for several weeks for his impotence.

On the occasion of a visit to his home, October 27th and 28th, I h3'pnotized the patient twice, with the same success as on the iTth. Again, according to the physician's statement, the suggestions quieted him and improved his condition, without having any special influence on his sexual sphere. In a letter of December 7, 1890, the physician reports his condition as " very satisfactory'. "

The foregoing case, on its negative side, is not especially instructive. As T learned in the course of treatment, the patient was able to have congress with other women, but not with his wife. His wife seemed to be a natura frigida ; at any rate, she does not know how to respond to her husband. In such a deli- cate case, as long as there is no sympathetic assistance on the part of the wife, the treatment of the husband alone must remain fruitless.

In such cases it is always the part of the physician to prepare the wife mentally, eventually by means of hypnotic suggestion ; that is, to remove any possible indifference or want of proper interest constituting a mental impediment. I am convinced that in the foregoing case the married life could be made happier if both parties could be subjected to systematic treatment.

TREATMENT OP PSYCHICAL IMPOTENCE. 109

Case 37. Personal Observation. Impolentia Coeundi Psychica on a Neurasthenic Basis Cured by Suggestion. A. B,, aged 33, physician, without hereditary taint. The patient has liad no severe diseases aside from typhus in his youth. Sexual desire appeared in his tenth year. From this time, onanism without noticeable effect on the nervous sys- tem. Abandonment of the habit with the beginning of hetero-sexual intercourse. Congress was successful without especial diflQculty till his thirtieth year. Patient is without libido niraia, moderate on the whole. Gonorrhoea, which lasted a long time, made coitus impossible for a long period. After recovery, hj'persesthesia of the glans remained, with irri- table weakness of the sphincter vesicfle. On attempting coitus, violent mental excitement, with feeling of anxiety; erection impossible. Impo- tentia coeundi. The patient was treated for a long time by noted special- ists with cold sounds, electricity, etc., without noticeable success.

B. is about to become engaged, and is unhappy over his condition, which constantly takes up all his thoughts. His sleep is undisturbed, though he has erections and pollutions. At Professor Forel's advice, he seeks help from me b}* means of hj'pnotic treatment.

October 29, 1889, first attempt. Complete hj'potaxis, suggestive catalepsy, and impossibility to voluntarily overcome contractures. Pa- tient quieted b}' suggestion ; prospect of complete virility given with diminution of the troublesome sensations. No post-h3pnotic amnesia. On the same day coitus is twice performed with a prostitute without the former excitement.

October 30th. The hypersesthesia, which compels the patient to think constantly of his trouble, is unchanged. Second hypnosis ; sug- gestions tlie same as on the 29th. Sexual congress again to-day ; com- plete erection, but ejaculation premature.

October 31st, Hypersesthesia unchanged. On this day and on No- vember Ist removal of his attention from his own person energetically commanded ; other suggestions the same. The patient thinks less about his condition ; weakness of the sphincter of the bladder does not cause any more complaint; simultaneous diminution of the hypertesthesia, though it is still present. Business calls the patient away before conclu- sion of treatment. He wrote me December 3, 1889, that " shortly before taking the train I performed coitus perfectly," but, unfortunately, he con- tracted gonorrhoja, which prevented further efforts. At the conclusion of his letter the patient expresses a desire to return to Munich, as soon as circumstances allow, to perfect the success alread}' obtained. When I met him, about a 3ear later, the patient informed me that he required no further treatment after his recovery from the gonorrhoea. Power continued permanent, and the troublesome symptoms gradually disap- peared.

110 SEXUAL IMPOTENCE AND ANAESTHESIA.

In the foregoing case, in four hypnotic sittings, all that was possible was attained; that is, by removing the psychical inhibition the patient was lastingly convinced of his sexual power, which exercised a favorable influence on the hyper- sesthesia, also probably due to psychical causes.

The patient owes his cure to suggestion. It was perma- nent. Exactly two years later, in October, 1891, the patient relapsed as a result of severe nervous disease.

Case 38. Personal Observation. Impotentia Gopundi Psychica et Ner^ vosa Irritativa (Atonica?) of Twelve Years' Duration Cured in Two Months by Suggestive Treatment. S., aged 34. Mother died of dropsy, father of tuberculosis. One sister healthy, a second has diseased eyes. Maternal uncle and his son epileptic. S. was healthy as a child. At the age of 15 was manustuprated by a servant-girl ; this led him to mutual onanism, without, however, allowing the boy to perform immissio penis. " I stood," as he said, "at the well without being able to dip from it." This intense excitation of his libido sexnalis led him to auto-mastur- bation, wliich for the first two or three months he practiced two or three times a day ; later, several times a week. At 18 he practiced it but once a week. At that time he reveled in lascivious pictures, and in- creased his power of fancy by looking at obscene photographs and arti- ficially retarded ejaculation in the onanistic act. As a result, intense sexual hyperaesthesia, infrequently ejaculation through mental stimulus alone with intense lustful feeling. At the age of 22 he gave up mastur- bation. First coitus fairly successful, but without the expected satisfac- tion. He was much occupied with erotic thoughts, and from this time experienced impotence growing more and more pronounced. He remem- bers to have performed coitus only once with complete satisfaction, and that with an attractive servant-girl. Defect and want of erection, pre- mature ejaculation, sometimes with relaxed organ, and diminution and complete absence of pleasurable feeling sent him, at the age of 23, to phy- sicians ; and he has now been treated for eleven 3'ears without any essen- tial change in his condition, and that in spite of a favorable prognosis in general. Hydi'opathic and electrical treatment in all possible forms fruitless. In 1889, gonorrhoea from an attempt at coitus, which lasted till February, 1890. Orchitis due to the use of sounds (?), but probably the result of the gonorrhoea. Previous to beginning treatment with me, careful treatment with bougies for five months with galvanism. Gymnastic exercises, in spite of prescription, were not carried out systematically enough.

The patient appears intelligent, but his memory has suffered much. Depressed, confused ; want of energy, incapable of determination, a cer-

TREATMENT OF PSYCHICAL IMPOTENCE. Ill

tain apathy. He has no interest in anything. Phlegmatic temperament. Very corpulent. Genitals fully developed. Right hernia ; tendency to it on the left side. Penis short and thick ; glans blue and remarkably insensitive. Both testicles sensitive to hard pressure. Left epididymi- tis ; cord harder than usual on palpation. Spermatozoa are present, but with diminished vitality. It is also demonstrated microscopically that there is no remnant of gonorrhoea. Patient has occasional pollutions (about once a month), especially frequent nights and mornings, some- times during the day, with powerful erections. His libido sexualis is very lively, but in attempts at coitus inhibitory ideas and feelings of anxiety (fear of infection, of impotence) are so dominant tliat erections do not occur, and his libido is changed to an irresistible disinclination for the act. The merest trifle want of neatness in the puella, etc. may call the inhibitory mechanism into action. Looked at from this stand-point, especially considering the erections and the living spermato- zoa, the patient, as all physicians have declared, has impotentia coeundi psychica ; but he also certainly exhibits the result of onanism (as described above) in signs of irritable weakness, as well as a diminution of virility manifest in his character, which depends not only on psychi- cal inhibition, but is in contrast with his intense libido sexualis. The want of lustful feeling and anaesthesia of the glans are due undoubtedly to the hyperexcitation of the reflex arc by onanistic excesses. There- fore, the diagnosis is impotentia coeundi nervosa irritativa et psychica.

October 1, 1891, first hypnotic attempt. Somnolence which, from sitting to sitting, aided by darkness and a pleasant reclining attitude, is deepened to sleep. Suggestive catalepsy. During October daily hyp- notic sittings, lasting from one-half to three-fourths of an hour. Sugges- tions : Self-confidence in coitus ; assurance of success in it ; increasing pleasure ; pleasanter mood. Daily repetitions of these suggestions. Frequently, after the end of these sittings, erections and libido sexualis occur. During the night of October 14th the patient had a pollution, with increased pleasurable sensation.

October 18th, on the wa}' to a brothel, he was seized with fear of making a fiasco. He turned back ; depressed. During the first half of October, two visits to a puella without the occurrence of erection. Forbidden to induce erection by tactile stimulation. During October the patient had powerful erections either at night or on waking in the morning, sometimes during the day.

October 27th, first attempt at coitus. On my advice, the patient waited (without tactile stimulation) for the spontaneous occurrence of erection. After it came on, perfect immissio penis, but disappearance of the erection during the act. Thereafter help at the hands of the puella. Then followed correct performance of the act, with ejaculation at the proper time (neither premature nor retarded), and a feeling of satisfac-

112 SEXUAL IMPOTENCE AND ANESTHESIA.

tion, even though the intensity of lustful feeling was not up to what the patient desired. Post-coitum and the next day, a feeling of repugnance at thought of sexual congress, with depression. The sexual indillerence disappeared in two days. Awakening of self-confidence by suggestive stimulation. Early in November renewal of erections. After November 5th, faradic penciling of the glans to increase sensation.

November 9th, a visit of two hours with a puella without the occur- rence of erection. Depressed by the failure. The night of November 12th the patient spent with a puella. Again complete failure. The assurance that he had not made a proper choice, and daily treatment with faradic electricity and hypnosis caused tlie patient to make a new attempt with a prostitute known for her attractive qualities. During the night of November 20th, which he spent with her, erection occurred spontaneously. Complete immissio penis. Continuance of erection. Friction was really felt, and ejaculation was not premature. More lustful pleasure than usual, but still not intense enough to satisfy the patient. The mechanical part of the act had been perfectly success- ful. Tlie patient is happy ; self-confidence increases. The next day after the act erection occurred twice, in complete contrast with the repug- nance for everything sexual which had previously occurred and lasted several days after such an attempt. Treatment with hypnosis and elec- tricity continued.

November 24th, he comes and delightedly reports that he had per- formed coitus the preceding night to his entire satisfaction. Erection spontaneous and continuous, without any aid ; immissio penis and ejaculation perfectly normal. This time the patient experienced a pro- nounced lustful feeling. Erection occurred five times on the day follow- ing this attempt. He had experienced nothing like this in ten years. Performance of coitus again on the night of November 26tli, with the same success.

Since the patient has performed coitus perfectly three times in the last three weeks without depressing or weakening effect, he can be dis- charged as essentially cured. In other respects the hypnotic treatment has benefited him. He was hypnotized twenty-six times, and electricity was used twenty times.

I take the following from notes of his condition sent me by the patient :

" The undersigned, who was under medical treatment for twelve years for impotence, without having received the slightest benefit, began suggestive treatment September 30th. Suggestion exerted a beneficial influence at once, for erections occurred normally and more frequently than formerlj'. After a week a pollution occurred, which was repeated in four or five days, while of late years such an event was extremely

CONCLUDING REMARKS. 113

infrequent. About the end of November it became possible to perform coitus three times in seven days. On tlie second occasion lustful pleasure was perceptibly greater than the former minimal pleasure. The disease which for twelve years defied medical art may be regarded as cured by suggestion.".

Several months after discharge tlie patient wrote me that the power of erection had only increased after his departure (every night three or four erections, sometimes five or six). He performed coitus repeatedly satisfactorily in all respects; on some occasions it was not completely successfid, for which he blamed the other party. Later, he contracted gonorrhoea. Thus, the power of erection and to perform coitus remained perfect in all essential points after discharge. The patient, therefore, may very justly be regarded as cured.

Concluding Remarks.

As the table (next page) shows, of 18 patients there were :

_, , (with later report, 4) , .. . Cured, ^ .^, ^ , ^ ^ r 10 = 55.56 per cent.

' (without later report, . . 6j

Essentially improved, ..... 1 = 5.56 per cent.

Slightly or temporaril}^ improved, . 2= 11.11 per cent.

Treated without success, .... 5 = 27.77 per cent.

18 100.00 per cent.

Of the 18 patients, 6 passed into somnambulism, 5 into hypotaxis, and 3 into somnolence ; in 2 cases hypnosis could not be induced. One patient was treated in the waking state. In another case the degree of hypnosis was not given. No case in a female was treated. The number of sittings varied from one to tifty-six. Ten patients were cured. According to the foregoing figures, the prospect of success in the treatment of functional or psychical impotence by hypnotic suggestion is 60 per cent. At the same time, it should be remembered that in some cases systematic treatment could not be carried out ; and that other cases, owing to the want of success by other methods of treatment, are to be regarded as having been given up or as especially difficult.

Almost all impotent individuals (according to Fiirbinger, without exception) are neurasthenic, and are, therefore, difficult

114

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to hypnotize. The increased sensitiveness to auto-suggestion, the result of irritable weakness of the brain, may be regarded as a direct symptom of the neurasthenia. The inhibitory im- perative idea of sexual inability, as an auto-suggestion, especially resists suggestion from without, if it is not possible so to mask the psychical procedure that the brain, in spite of mistrust, will accept it ; or if the psychical erethism, which is constantly or occasionally present in the majority of neurasthenics, prevents the necessary concentration of the attention and the beginning of the hypnotic state. To hypnotize neurasthenics is one of the most difficult tasks for the psycho-therapeutist, demanding great circumspection, practice, patience, and time. Only after forty sittings (Case 31) did Moll succeed in inducing hypnosis deep enough to permit the suggestive induction of the most various hallucinations. In one of my patients (Case 33) the disincli- nation to be hypnotized (probably as a result of perverse ideas connected with it) was so great that the patient would not allow a second attempt. In another case (35) the patient had con- vinced himself (auto-suggestion) that he could not be hypno- tized, and I required the assistance of chloroform. This im- perative idea was so strong that, in spite of partial amnesia after waking, the patient declared that he had not been influenced in the least.

The word " hypnosis " and the prevalent opinions con- cerning it lead many patients to believe that sleep is necessary for the success of the therapeutic suggestions ; and there is no idea of sleep for them when, after waking, they remember the events of the hypnosis. Though sleep favors the objectivity of suggestions, it is not necessary, and actual sleep occurs in only about a third or a fourth of all patients hypnotized. Many somnambulists are minds awake, but without memory after the hypnosis ; they speak, walk, and do not present the appearance of sleep in any way, but think that they have slept because they remember nothing. The opposite of this illusion of sleep is presented by those persons who actually apj>ear to sleep, dream, snore, etc., and still, after waking, protest that they have not been really asleep. Such patients often have but an

116 SEXUAL IMPOTENCE AND ANAESTHESIA.

indistinct memory of the events of the hypnotic state, and are often deceived concerning the time sleep lias lasted. How little weight is to be given to the memory of patients in this state of self-deception is shown by the fact that suggestion may awaken or destroy post-hypnotic memories. The word " hypnosis," in its reference to sleep, does not comprehend clearly enough all sug- gestive phenomena. Therefore, 1 can only agree with Professor Beniheim when he suggests that the word " hypnosis " be aban- doned, and proposes as a substitute the expression " state of suggestibility."

The false views which neurasthenics especially have formed of hypnotism, which they often look upon as dangerous, may be the starting-point of bad effects due to auto-suggestion, which, however, have nothing to do with hypnosis per se. In the cases reported there were no unfavorable effects of any kind ; on the contrary, in cases where the impotence was not afl'ected, the influence on the general condition and nervous symptoms was favoi-able.

Aftr the details set forth in this section there can no longer be any doubt that, if need be, in psychical and func- tional impotence, suggestive treatment in hypnosis is indicated as the most effectual procedure in psycho-therapeutics, and that henceforth it should be more extensively used and receive more careful consideration than heretofore.

III. SEXUAL PARiESTHESIA.

CHAPTER VII.

THE FORMS OF SEXUAL PERVERSION WI-TII REFERENCE TO THE THEORY OF PROFESSOR VON KRAFFT-EBING.

Definitions and Classification. Von KmfFt-Ebing desig- nates sexual parsesthesia as the excitability of tlie sexual instinct to inadequate stimuli. Every expression of sexual desire which does not correspond witli the purpose of nature procreation is perverse. This manifestation of the sexual impulse often occurs in connection with hyperaesthesia, and may find satisfaction with the opposite or the same sex; in accordance with which von Kraft't-Ebing distinguishes hetero- sexual perversion and homo-sexuality. The impulse toward the same sex with diminution or entire absence of feeling for the opposite sex is, in accordance with Westphal's ^ suggestion, called " contrary sexual feeling." By this expression Westphal means that the phenomenon does not always affect simultane- ously the sexual desire as such, but that merely the feeling, the whole inner disposition, becomes different from that of the sex, as a simultaneous, undeveloped degree of the pathological phe- nomenon. In our opinion, to which we shall later recur in more detail, in all genuine cases of contrary sexual feeling the sexual instinct is implicated ; so to speak, it is the starting-point, the centre around which all other symptoms are grouj)ed. Therefore, changes of character approximating that of the opposite sex, without implication of the sexual sphere, do not seem to us to deserve the name of contrary sexual feeling.

In the manifestations of paraesthesia sexualis, according to their practical significance, we difi^erentiate two groups :

I. Inversion of the sexual feeling (contrary, or homo-sexual, feeling).

' Westphal, " ContrSre Sexualempfindung," Archir far Psychlatrie, Berlin, 1889, Bd. 11, Heft 1, p. 107.

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118 SEXUAL PARiESTHESIA.

II. Perverse activity of the sexual impulse (without refer- ence to the object.)

I. Inversion of Sexual Feeling} Group I is divided by von KrafFt-Ebing into two important classes:

((t) Acquired abnormal contrary sexual feeling.

{h) Congenital .abnormal contrary sexual feeling.

The prerequisite for the development of homo-sexuality is a neuropathic nervous system (Moll and von KrafFt-Ebing), which may be either acquired or congenital. Besides the pre- disposing cause, the neuropathic condition, according to von Krafft-Ebing, there must be an exciting cause, to induce the manifestation of contrary sexual feeling. According to the same author, as an acquired abnormal phenomenon, it occurs but in- frequently. He gives only four cases ^ as the result of cultiva- tion, in contrast with forty-three cases in which inheritance plays a role. Acquired contrary sexual feeling passes through the same stages as does the congenital. In development tlie fol- lowing varieties are to be differentiated (von KrafFt-Ebing) :

1. With predominating homo-sexual feeling there are traces of hetero-sexual feeling (psycho-sexual hermaphroditism).

2. There is inclination only toward the same sex (homo- sexuality), horror feminae (limited to the vita sexualis).

3. The whole mental existence (character) corresponds with the abnormal sexual feeling (efFemination and viraginity ^).

' In the eighth edition of Psychopathia Sexualis, von Kraffb-Ebiug distinguishes four stages in the process of transformation of sexual feeling :

I Degree : Simple inversion of the sexual feeling. The patient is still in an active rSU, and looks upon the impulse toward the same sex as an aberration.

II Degree : Eviration and defcmi nation. Transformation of the character, the feelings, and the inclinations to those of a female, or vice versa.

III Degree : Transformation to metamorphosis sexualis paranoica. The bodily feeling changed in the sense of a transmutatio sexus.

IV Degree : Metamorphosis sexualis paranoica. Delusion of sexual transformation. 'In Moll's opinion (loc. cU., p. 157) of these four cases, three are not proof of the

theory of cultivation, for in them there were traces of perversion during childhood and puberty.

Tamowsky (Die krankhaftcn Erscheinungen dcs Geschlechtssinnes, Berlin, 1886, pp. 11-14) describes the development of effemination as follows : " The first expression of hame Is not in relation to girls or women, but toward grown men. The boy is ashamed to undress before a grown man. Dreams with pollutions are of embracing, kissing, and caressing men. Owing to the irritable weakness of these subjects, their love is violent and passionate. The youth is actuated by the desire to appear feminine, loves to put on femftle attire, to wear his hair long, and to go about with open neck and laced waist ; he

FORMS OF SEXUAL PERVERSION. 119

4. The bodily form approaclies that with which the abnor- mal sexual feeling corresponds. There is never, however, actual hermaphroditism (androgyny and gynandry). Femi- nine type (broad hips, rounded form, abundant development of adipose tissue, growtli of beard spare or absent, feminine features, fine complexion, falsetto voice) in the male ; develop- ment of mammoB, with production of milk at puberty (Case 80, " Psychopathia Sexualis").

As the most important influences contributing to the de- velopment of acquired contrary sexual feeling, the authorities mentioned enumerate: excessive masturbation, which injures character, instincts, and nervous system, and leads to mutual masturbation ; and fear of pregnancy and venereal infection. Moll regards as acquired contrary sexual feeling only those cases where there was first manifested an inclination toward women, and later toward men.

When the inversion of sexual feeling appears as a partial manifestation of a " neuro-psychopathic " condition which is hereditary, the following signs are, according to von Kraflft- Ebing's theory, distinctive :

(a) Premature awakening of the sexual instinct.

(b) Enthusiastic exaltation; overpowering strength of desire ; sexual hyperaesthesia.

(c) Functional and anatomical signs of degeneration.

(d) Neuroses (hysteria, neurasthenia, epileptoid states); irritable weakness of the lumbar portion of the spinal cord.

(e) Psychical anomalies (original eccentricities and deficient intellect, with one-sided mental endowment), even to the extent of weak-mindedness and moral insanity.

likes to perfume and powder himself, and to paint and pencil the eyebrows. There is developed that type of feminine male so diso^usting to men and so repugnant to women, whom it is not difQcult to recognize in the outward appearance. Of medium or small build ; with broad pelvis, narrow shoulders, feminine gait, and a peculiar movement of the hips ; with smoothed locks and ludicrous attire, the arms bearing bracelets ; with smirks and gestures and volubility, they seek to attract the attention of men. The unfor- tunate creature, especially if he have a relatively weak mental endowment, does not understand that he is the more disgusting to normal men the more he seeks to imitate women. Since he is whimsical to the verge of hysteria, cowardly, pusillanimous, vindict- ive, and willful, he unites in himself all the defects of woman without her virtues, and possesses not a single one of the attractive features of the male character. Therefore, he is M repulsive to men as to women."

120 SEXUAL PAKifiSTUESlA.

(/) Neuroses, psychoses, and signs of degeneration in progenitors.

" The hereditary element is tlie acquired abnormal inclina- tion to the same sex, which in descendants is manifested as a congenitiil abnormal phenomenon." Tliis hypothesis is sup- ported by the facts that mental peculiarities and defects may be transmitted, and that individuals of contrary sexuality may beget children. In an observation by von Krafft-Ebing, father and son are affected with contrary sexuality.

According to von Krafft-Ebing, the first three degrees of congenital contmry sexual feeling correspond genetically with the developmental stages of the acquired anomaly.

The most frequent sexual acts in which such individuals find satisfaction are: coitus inter femora, in anum, in os; mutual, psychical, and tactile onanism ; simple caresses ; exhi- bition. Enforced intercourse with a woman is burdensome, while inadequate homo-sexual acts afford complete satisfaction. As a rule, there is no inclination toward immature individuals.

In homo-sexual intercourse the perverse activity of the sexual instinct may take the same form as in hetero-sexual relations; the manner of expression of the instinct and the excitation of it by means of partial impressions coming from the beloved object are the essential elements, while the sex of the individual giving rise to the impressions is subsidiary.

According to von Krafft-Ebing's brilliant explanations, in the various forms of tliis anomaly the combination of lust and cruelty is very striking. The two most intense emotions, love and anger, seek to expend themselves physically on their object ; both throw the psychomotor sphere into violent excitement, and through this excitement attain their normal expression. Exal- tation of the sexual emotion induces intense excitation of the whole psychomotor sphere, and gives rise to the impulse to exhaust itself in senseless and seemingly hostile acts, which are to be regarded, in a measure, as accompanying psychical emo- tions. The most powerful means with which to affect an indi- vidual are those which inflict pain. The aggressive role of the man may, where there is defect of moral feeling and absence of

FORMS OF SEXUAL PERVERSION. 121

normal deterrents, become so intensified as to end in the murder of the object of love. This pathological intensification of the manifestations accompanying the vita sexualis, following French usage, von KrafFt-Ebing designates sadism. Acts of violence are colored with lustful feelings.

Pathological predominance of the specific feminine ele- ment, the instinct of subordination, to the extent of desire to endure pain and to submit absolutely to its power to the extent of experiencing lustful pleasure in abuse (overcompensation of physical pain by psychical lust), the same author calls masochism.

The terms sadism and masochism are derived from the names of the novelists. Marquis de Sade and Sacher-Masoch, who described the perversions. Even should these terms be adopted, although they do not follow the usual rules of scientific terminology, it seems essential to form a word the composition of which shall indicate the nature of these sexual anomalies. Such a word is offered in the term algolagnia^ or algolagni/, derived from dXyog = pain (adopted medically in this sense, as in analgesia, cephalalgia, and neuralgia) and ?M,yv6g = sexually-excited lust ; from the latter T^ayveia is derived, used by Hippocrates and Aristotle in the sense of seminal emission, by Xenophon in the sense of lust (Max Ofi'ner^). While algo- lagnia would designate the combination of cruelty and lust as a special variety of sexual perversion, active algolagnia would signify sadism, and passive algolagnia masochism (ma^ochist = passive algolagnist, and masochistic = passively algolagnistic).

Lustful pleasure in inflicting pain and lustful pleasure in the endurance of pain are but two aspects of the same mental process, of which, according to von Kraff't-Ebing, the essential element is the consciousness of active or passive subjection. Passive algolagnia in a man is the development of a sexual characteristic which, in accordance with her nature, belongs to woman, and it is to be regarded as partial effemination or rudi- mentary contrary sexual feeling. Cruel acts are the most in- tense means with which to express the relation of subjection.

Max Offner, whose philological knowledge agisted In the formation of the abore word, also proposed the terms " aeklalagnia "^masochism, and " tekizolaguia " ^sadism (from aUta aud a6a{to), bat they seem to me less suitable.

122 SEXUAL PARitSTHESIA.

Though active and passive flagellation is the means most fre- quently used as an cxcitiint by algolagnists, still there are other cases m which the relation of subjection is, to a certain extent, indicated symbolically, and as an accessory group of psychical liermaphroditism are those cases in which the passive inclina- tions of algolagnia are combined with others that are active.

The last group of phenomena of parsesthesia sexualis is designated "erotic fetichism" (von KrafFt-Ebing and Binet), i.e., individual valuation of the fetich a part of the beloved person to the extent of actual enthusiasm. Here the essential ele- ment is the emotional coloring of the idea of a portion of the beloved person, in a sense of sexual pleasure, which is peculiar to the individual. For the development of this form hyperaes- thesia is necessary, and the substitute for coitus is usually found in onanistic acts.

Von Kraff't-Ebing avails himself of Binet's theory of associ- ation to explain this variety of perversions. Sensual excitement occurs simultaneously with the sight of a portion of the beloved person. Sensory and optical impressions are associatively con- nected, and this connection is confirmed in proportion as fre- quent repetition of the feeling arouses the optical memory- picture. The fetich is an individual symbol wliich induces sexual excitement. It may consist of (a) a portion of the body (hand, foot, hair) ; (h) peculiar mental characteristics ; (c) lifeless objects, articles of use which, as a rule, originally stood in some relation to "a" (derived from) ; as, for example, aprons and shoes. Von Kraff't-Ebing, however, classifies shoe-fetichists as masochists (passive algolagnists), because the act of allowing one's self to be trod upon expresses masochistic desires.

Fetichism becomes pathological as soon as it is no longer exclusively a means of attraction, but a conditio sine qua nan of virility (von Kraff't-Ebing).

The foregoing resume includes all the essential forms of parsesthesia sexualis in accordance with the classification of von Kraffl-Ebing, with their various distinctive features, and suffices for this work and the following chapters, the purpose of which is to modify and enlarge this theory in some particulars.

CHAPTER VIII.

HISTORY OF TUE DEVELOPMENT OF CONTRARY SEXUAL FEELING AMONG THE ANCIENTS.

In order to form a judgment concerning contrary sexual feeling, that is, witli reference to prognosis and thempy, its etiology is of the utmost importance. The causes and the con- ditions of development of this pathological phenomenon are to be studied not only in the individual, but it is of tlie highest scientific interest to understand the influences which, in the history of peoples, caused and favored this perverse activity of the sexual instinct. For we find love between persons of the same sex in all times and among all peoples.

Age and Extent of Sexual Inversion. In ancient times Asia was looked upon as the land of origin of pederasty. From here it spread westward. The most ancient historical sources give evidence of the existence of the vice in question. But the first discoverers of America found the vice among the aborigines. Thus, it was generally spread throughout the inhabitants of Panama ; ^ in northern Mexico marriages took place between men, and tliose who were dressed as women were forbidden to bear arms. Travelers in North America^ found among the aborigines men, attired like women, doing feminine household duties. According to Mantegazza, pederasty, mostly in the form of male prostitution, is spread among the natives of Alaska, Darien, the Aleutians, Madagascar, etc. ; and, ac- cording to Hammond,^ it is made use of for religious purposes by the Pueblo Indians of New Mexico. On the island of Ilamrih,* on the other hand, women acted like men in order to stand at the head of affairs, and attached themselves to other women, with whom they lived as man and wife.

• Mantegazza, Anthropologiscb. culturhistorlscbe Studlen ober die Gescblechtfiver-

baltnisse dcr Menschen, Jena, Costenoble, p. 118.

• Tbis vice is so little tbe product of excessiye civilization thftt it has been met In

North America. Comp. Virey, Historie natarelle da genre bumaln, Paris, 1824, vol. i, p. 273.

• Hammond, op. cU.

• SiUung der Berl. Psychol. Ges. Tom. 15 Okt., 1868.

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124 SEXUAL PARESTHESIA.

In liis work, " Contriire Sexualem])fiiKlung " (Berlin, Kom- feld, 1891), Dr. Moll gives, in its essential points, a resume of the history of contrary sexual instinct, which, beginning with the Bible and Greek mythology, he traces through ancient litera- ture (Greece and Rome) to the cloister-life of the middle ages, and thence to modern times, giving interesting facts concerning historical personages who are under the suspicion of uranism (e.gr,, Rudolf of Hapsburg, Michael Angelo, Shakespeare, Hein- rich von Kleist, and others.). To avoid unnecessary repetition, I may permit this reference to suffice, and allow the reader to peruse for himself the exceedingly instructive historical portion of that work. The following statements, however, come in place here, since they are either deviations from the opinions of that writer or additions to his material.

Historical Conditions of Development. History and folk- lore show tliat there has been spontaneous and, to a certain extent, idiopathic occurrence of male-love ^ and pederasty among various peoples and at various times, where there has been no possibility of a spread of the disease by means of communica- tion between the natives of various regions of the globe. Uranism occurs as the product of a special development, for which the conditioning causes must be given in the relation of the sexes and, perhaps, too, in climatic conditions.

Most authors, especially Moll, state that the most impor- tant etiological influence in contrary sexual instinct is degenera- tion of the central nervous system, as that is understood with reference to neurotic or psychical taint. To be sure, it cannot be gainsaid that the majority of contrary sexual individuals are, at the same time, neuropathic. But this explanation does not show why the degeneration must be expressed in this kind of sexual perversion. Moreover, it is quite possible that the neuropathy occurs as a result of the feminine role. Finally, it seems to me by no means demonstrated that savage peoples in which homo-sexuality occurs manifested primarily a neuropathic disposition, upon which this vice was secondarily engrafted ; it

' Contrary sexual instinct in women never attained such practical importance, socially or medically, as it has in men. Therefore, in this book, it receives but subsidiary treatment.

CONTRARY SEXUAL FEELING AMONG THE ANCIENTS. 125

is necessary to show other signs of degeneration in them. And why must just this single deviation of the sexual instinct occur primarily as a sign of a neuropathic or psychopathic state"? Why not, with the same right, include all the other sexual vices which the lively fancy of sensual Asiatics created, deified in the cult of Lingam and Phallus, and worshiped in the most licentious way in orgies in honor of Astarte (or Mylitta) ? To make hereditary disposition alone or principally account for the origin of contrary sexual instinct is to push back the riddle and regard it as atavistic, but not to solve it. Then, the question is : What circumstances first caused the savage to seek gratifi- cation of his instinct in intercourse with his own sex 1 For, as with other hereditary peculiarities, it is certain that in the developmental history of man pederasty must once have been primarily acquired.

In proportion as the natural purpose of coitus, procreation, gave place to lustful lasciviousness, as we again and again find in folk-lore that it has, the usual manner of gratification lost the stimulus of novelty. The effort to bring about varia- tions of the simple act of coitus called to life the theories of an unnatural Venus (Venus illegitima), in which, according to Rosenbaum,^ every trace of the real purpose of the genitals finally disappeared. Wherever the impressionability of the genital centres has become weakened or dulled by sexual excess, we see that the human imagination seeks new and more intense means of stimulation in order to bring about the desired gratification.'^ Thus, for example, to-day there is scarcely a doubt that tribadism is most frequently encountered among prostitutes, and that, too, without the necessity of any previous predisposition. Moll cannot account for the transition to the same sex ; still, the experiences in prisons show that unsatisfied sexual desire resorts, fatUe de mieux^ to immediate compan-

' Ploes (Das Weib, Leipzig, 1891, p. 315) also shows that the lower a people is, the more disgusting the expressiou of their lust and animal sensuality becomes. Many primi> live peoples made use of excessive means of excitation in order to incite feminine lust. As Cubary states, " On the island of Ponape, some men go so far as to place a piece of fish in the wife's vulva, so that they may gradually eat it out. This revolting act is continued until the wife begins to urinate, and then coitus is performed."

• Rosenbaum, Qescblchte der Lustseucbe, 1888, p. 119.

126 SEXUAL PARiESTHESIA.

ions, and that mutual onanism and pederasty are frequently met in penitentiaries among relatives of tlie same sex. Here, at least, the original of primary homo-sexual j)ederasty forms the transition to pedicatio mulierum. This view also finds support in historical sources, which, however, are anything but abundant.

Pederasty as a Cause of Homo-sexudlity and Castration. In Asia, as in Italy and Spain, the female genitals, like the whole body, are greatly relaxed.^ The sphincter ani is much more powerful than the constrictor cunni. And, with respect to this, we may consider Forberg's^ statement: "Et voluptas quidem paediconis facile intelligitur, cum omnis voluptas men- tulae pendeat ex frictione." The following passage from Paul's Epistle to the Romans (chap, i : 24, 26, 27) also indicates that paedicatio mulierum preceded actual pederasty : " Wherefore God also gave them up to uncleanness, through the lusts of their own hearts, to dishonor their own bodies between them- selves : ... for even their women did change the natural use into that which is against nature : And likewise also the men, leaving the natural use of the woman, burned in their lust one toward another ; men with men working that which is unseemly."

After the unusual manner of obtaining gratification with women had once been exhausted, the feminine appearance of boyhood gave a new charm. Therefore, still to-day, as formerly, active pederasts prefer, as a rule, beautiful boys of an age when the masculine characteristics (beard, voice, etc.) have not yet become pronounced. "They have the same glance, the same delicacy of skin and form, the same breath of innocence as the maiden " (Max Dessoir). Next, only feminine charms in the male person became attractive, which, on account of the peculiar combination, were especially enticing to persons with perverse inclinations. In this way pederasty with males was learned,

' Comp. Martlalla, lib. xl, Eplprams 28 and 79.

• Antonii Panormltae nermaphioditus, ed. F. C. Forberg. The apophoieta of the

editor treats of " De flguris veneris," " De fututlone," " De paedicatlone," " De irru- mando," " De masturbando," " De cunnlUngls," " De tribadibus," " De coitu cum brutis," " De spiutris." Comp., also, Roseubaum, loe. cU., p. 121.

CONTRARY SEXUAL FEELING AMONG THE ANCIENTS. 127

and from it, later, arose castration and gynandry. The degen- erative transformation of the male character while in the stage of development (puberty) first occurred as a result of adaptation to the necessary role. Therelbre, the sexual instinct became transformed secondarily as a result of artificial cultivation. Effemination is, therefore, originally a phenomenon resulting from pederasty, and then, where, in spite of the sexual trans- formation, procreation took place, it may have exercised heredi- tary influence. With this view, the following citation from Lucian (Amor, chaps, xx, xxi) is of interest in connection with the history of pederasty :

"Gradually descending from the height of morality into the abyss of sensuality, strange and unusual manners of gratifi- cation were practiced. Debauchery, which attacked everything, transgressed even the laws of nature, and a man teas taken for a woman. Either animal passion was satisfied by force or cunning was used to obtain consent. One of the same sex thus placed himself in the power of another. But to each the sight of his own sex in his companion did not cause him to be ashamed of what he did or permitted. The boldness of some, in their despotic manner of life, went so far that they robbed themselves of masculinity with the knife. They reached the goal of their sensual desires only when they, as men, had removed their manhood. But the unfortunates, in remaining boys longer, are no longer men, an equivocal expression of a double nature ; for they know not to what they were bom nor what they are," etc. Gradually, in Asia, pedemsty became embodied in the worship of Venus.

According to the excellent descriptions by Rosenbaum, tlie expressions evvovxol and dv6p6yvvoL at first signified nothing but " Kinaden " or " Pathici," i.e., persons who sacrificed themselves in the temple in honor of the deity.^ Thus is explained the teaching of the priests of Cybele, who emasculated themselves, it is said, in honor of the deity.

'Later, Id Rome, the term "exuleti" (castrated) was used in the same aense. Comp, Aristotle, Pollt, v, 8, 9. This fact seems to be little known. Thus, Mantepajuui, who has written a long chapter upon sexual mutilation, does not mention it. Comp. Anthropol. Kult.-8t., p. 132.

128 SEXUAL PARiESTHESIA.

According to Hellicanus/ the practice of emasculating boys was derived from the Babylonians. The origin of the custom is attributed to Semiramis." Still, as Stent"' believes, it is proba- bly much more ancient. Herodotus states (iii, 92) that the Babylonians were required to send the Persian kings each year five hundred eunuchs as tribute. At any rate, the traffic in eunuchs was very wide-spread. Tavernier relates (according to Stent, p. 8) that in the kingdom of Bootan twenty thousand eunuchs were made every year to be sold to other nations. Philo * also holds to the opinion that castmtion was principally a result of pederasty. " Some had such esteem for youthful beauty that they (the androgynists) desired complete transforma- tion into females, amputated the penis, dressed themselves in purple garments, etc." Only at a later period was castration practiced after maturity had been attained, so that eunuchs could still the erotic desires of women without the possibility of producing pregnancy (Rosenbaum).

Eunuchism. Stent, who, in his work, " Chinese Eunuchs," describes in detail the character, habits, duties, and preparation of the Chinese eunuchs, does not once mention their sexual intercourse with men ; but he gives interesting explanations of the inner and outer transformations, in the sense of effemination, which occur in the eunuchs. He says (p. 38) : " All eunuchs lose their natural voice ; those that have been subjected to the operation in childhood have a voice which can scarcely be dis- tinguished from the voice of a young woman, while those so treated after reaching maturity speak in a kind of broken fal- setto. In general, the Chinese are not troubled with an abun- dance of hair, but the eunuchs are devoid of even the slightest trace of hair on the face. If one be possessed of a beard at the time of his castration, the hair gradually falls out, and, finally, the face is as smooth as a billiard-ball. It is scarcely necessary to mention that on the face of those castrated in childhood hair of no kind ever appears." When operated

' Donat. Terent. Eunucb., 1, 2, 87.

• MarcclI, xlv, 6.

• 8teut, Chinesische Eunucheii (Lcipzljj, Schulze), p. 6.

• Phllo, Opera, ed. Mangeg., ii, p. 465.

CONTRARY SEXUAL FEELING AMONG THE ANCIENTS. 129

upon early, eunuchs often become coi*pulent, but their flesh is soft and relaxed. With advancing years they become thinner and terribly wrinkled. Castration seems to rob them of all that is manly ; they grow old rapidly, and at the age of 40 look to be 60 years old. ,

In the performance of certain natural acts, eunuchs are very modest ; and they will endure great inconvenience until they gain an opportunity to perform them unobserved. " This peculiarity is the more to be praised, since usually the Chinese are not in the least embarrassed when observed under such cir- cumstances." They are not at all blood-thirsty, but much rather the opposite. Harmless and affectionate, they love all sorts of amusement. Tlie slightest thing moves them to tears. They are loving to women and children, and exceedingly kind to the little dog with which almost every one is provided. In spite of their timorousness, they are u-ritable and excitable and cross, like women, but they are easily appeased ; a trifle which another person would scarcely notice may throw them into an ungoverned rage. In general, the appearance of eunuchs may be called repulsive; yet young eunuchs are often very pretty and feminine. In fact, they might be taken for young women in male attire. As they grow older, one cannot lielp thinking that they resemble old women that have forgotten their sex and age and masquerade in the garments of the opposite sex. Too, they may be recognized at a distance by their gait. They take short steps, and hold the legs close together. In this way an independent observer describes the complete eflemination of the eunuchs resulting from castration, without recognizing the original object, i.e., the cultivation of the female type in the male body ibr the purpose of pederasty.

Another reason for the occurrence of pederasty may be found in a deficiency in the number of women and in dif- ficulties in the performance of coitus. Mantegazza ^ seems to have stated the truth when he says : " The errors of physical love all originate in two sources, either in the difficulty or impossibility of gratifying it in the natural way, or in the desire

• ^utegazza, loe. cU., p. 100.

8

130 SEXUAL PARiBSTElESIA.

to experience a new pleasure. That, in simple words, is the psychology of sexual vice, from Sodom to Lesbos, from Babylon to the island of Capri."

TJie Historical Origin of Uranism in Europe. The Jews seem to have become acquainted with boy-love in Syria.^ Ac- cording to ancient authorities, the Persians," the Celts,^ and even the Germans* were acquainted with it. Pederasty, as already mentioned, was most practiced in ancient Babylon, in Sodom,^ and by the inhabitants of Tyre.*' From Asia uranism was spread by the Phoenicians or Lydians^ (Welcher) first to Crete, and from there over all Greece.^ According to Suidas," the Italians were again the discoverers of boy-love, which was prac- ticed in the most vicious manner, especially by the Etruscans, Samites, and Messipians. In the year 433 ^^ after the founding of Rome, this vice was practiced there. In the year 585 (B.C. 169), on the other hand, the Lex scantinia " was promul- gated, which is indicative of the great extent of pederasty.

During the Empire, as is known, this vice took on an unrestrained character, and the horrible scenes under Nero, Tiberius, and Caligula mock all description.^^

Greek Boy-Love. The boy-love of ancient Greece is of the greatest historical significance. And, in our opinion, in the development and training of the Greeks, even during its period of greatest prevalence, this vice could never have played so important a role, even though, as with other people, it had been manifested only in coarse sensual enjoyment. The idealizing faculty of the Greeks was capable of ennobling a phenomenon which had its origin in common sensuality, and of transforming

' Genesis, xlx, 4 ; Levlt., xvlll, 2; xzix, 18. Sext. Empiric, P. H. 1, 152.

Ari8tot.,Pal.,il,6; and DIodor. (v, 82). . . . " In spite of the great beauty of their women."

• Sext. Empiric, P. H. ill, 199. Described by tbe author only as " rumors."

• Genesis, xlx, 4.

Athen.,xli, 517e.

' iEschylus, Trilogy, p. 856.

• Athenaus, Deipnosoph, p. 602.
• Pnd.,\\\y. xii, p. 5\7 etteq.

"Dlonyslus Helicarn. Exc, p. 2836, and Valer. Max., lib. vi, 1, 9,

"Juven., 11, 44a.

"Comp. SuetoD, Nero, 28, 29; Dio, CassiuB, Juvenal, Tacitus, and others.

CONTRARY SEXUAL FEELING AMONG TUE ANCIENTS. 131

it into an incentive to progress both in the individual and the masses, and to-day it stands unique in the history of that people. Like the idealized worship oi* Venus, uranism took on a spiritual form; in Athens pederasty ^^ became *' pedophily" The reckless violation of boys and honorable boy-love are to be strictly distinguished from each other in judging the male relations which existed in ancient Greece. Pedemsty was not approved by the Greeks ; on the contrary, originally, in Athens and Sparta, it was punished with dishonor, exile, and death. ^

Still, the basis of the relations between youths and men remained sensual. Spiritual communion, pleasure in physical beauty, affection more intense than pure friendship, and close ties of fraternity (associations), though sensual enjoyment could never be more than that of the eyes, were the original features of pedophily. Nowhere do we find such a purification and idealization of this institution in education, philosophy, poetry, and art as among the Greeks ; nowhere a similar respect for it on the part of the State and laws. Too, this fact is not altered by the circumstance that the limits of moderation the bridling of sensual passion set by individuals were also exceeded, ^a condition which led to legal regulation of these relations.

Above all, according to historical evidence, pederasty, as long as it maintained its independent position, seems to have been regarded as a disgraceful vice by the Greeks (Sparta and Athens).^ On the other hand, it cannot be denied that, in some Grecian States, boy-love never became elevated above the state of unnatural vice ; for example, in Crete (kidnapping of boys and pederasty), Elis, and Eoeotia,^ and also in Phocis, Thessaly, Lesbos, Chalcis (^a^xiSl^eLv =. TtaiSe^arelr)^ etc.* But in the Ionic cities boy-love was absolutely forbidden.*^

From the way in which boy-love first manifested itself in Athens and Sparta, when it was most intimately connected,

' Comp. Realencyclopadie von Ersch und Qruber, " Paderastie," von Meier, who adduces abundant evidence of this.

• Comp. Rosenbaum, loc. eit., p. 196.

' " Bdotlsche Knabenliebe " was, according to Plato, Xeuophon, and Cicero, an equivalent of violation of boys. Comp. Ersch and Gruber, loc. cU.

• Comp. Theopomp. ap. Athens, 605a.

'Plato, Symposium, 182b.

132 SEXUAL PARiESTHESIA.

during the golden age of Greece, with the greatest works of art and science, and that without e?idangering in any way masciir line stroigtJi and activity displayed in numerous wars and in the games, it is clear that this was not yet a degenerative trans- formation of the man into a woman (homo-sexuality) upon the hasis of neuropathic disposition, even tliough sensual passion, frequently enough, may have surpassed the bounds of morality and law. Rather, the conditions of Greece give evidence that there, as everywhere, effemination was the direct result of pederasty. During the golden age of Athens pederasty and homo-sexuality were already quite well known and wide-spread ; during the period of decadence and political dependence of Greece, pedophily lost its significance and male-love was known only in its vicious form. The vice of male prostitution was surpassed only by that of females during the period of decay.

Many authors, Moll among them, express the opinion that the prevalence of male-love is in inverse proportion to the esteem in which woman is held ; and numerous examples in support of this view may be cited from the history of Asiatic peoples. It is certain that this factor played an important part in the peculiar development of Greek boy-love. The isolation of the women; their exclusion from the benefits of education and interest in the welfare of the nation, and from participation in the later education of children ; the limitation of their activities to the simplest household duties ; and their exclusion from the influence of improving and elevating social intercourse, rendered them incapable of taking part in the intellectual life of the men. The education of boys lay in the hands of the State ; the relation between teacher and pupil necessarily took the place of paternal influence ; the lover was the second father of the beloved.

Pedophily reached its highest perfection where gymnastics was most assiduously cultivated in the gymnasia and palesta.^ The sight of the nude beauty of the youthful body in the high- est state of strength and activity gave pleasure to the artistic sense of the Greeks and aflected sensuality. This feeling was

• Plato, Legg, 1, 636b.

CONTRARY SEXUAL FEELING AMONG THE ANCIENTS. 133

(k^'l>eiicd by the intellectual element which was fostered by edu- cation. Each lover necessarily became an example and guide for the beloved one in all that was beautiful and good. In Athens, the seat of philosophical boy-love, there were no public educational institutions, and all scientific and professional edu- cation was given by some approved elderly man to youths who became attached to him. This relation was brouj:ht about solelv by inclination ; for no honorarium was offered for such instruc- tion^ ; and it took the place of our higher education. Finally, the necessity for the exercise of political influence by means of fmternities (associations) favored the development of boy-love. Indeed, in Sparta the members of the royal families were the beloved in boyhood and lovers when matured. In a sensual sense, the restraint between lovers was compared with that between parents and children, or between children of the same family. In Sparta, for example, the lover represented^ the be- loved in the popular assemblies, and kept by his side in battle ; and there were instances of faithfulness unto death. The influence of the lover, in its effect upon the development of manly virtue in the beloved, was so great that not infrequently the lover was punished for the beloved. The mixture of a sexual element in these relations, originally so pure, induced a warmth of feeling which otherwise exists only between man and woman ; the efforts to win favor led to the most violent jealousy ; the delicate playfulness and the ways in which the lover expressed his feeling call to mind contrary sexual feeling, spending the night at the door of the beloved; serenades; carving the beloved name on walls, on trees, and doors ;' swing- ing garlands on the house of the beloved; presents of vases* on which were inscribed confessions of love.

This coquettish playfulness also expressed itself in poetry. The lyric poets, Pindar, Alceus, Anacreon, and Ibycus sang of boy-love. Epic, elegiac, and bucolic poetry, and, later, the drama, each contributed its share. Even a woman, the Syci-

' Comp. Ersch and Gruber, Realencyclopadle, " Paderastie," von Meier, p. 887.

• Plutarch, De educ. puer., 14.

• Plato, Symposium, 184a ; and Xenophon, Hien., 1, 8S.

• B5etlg, Sabin., 1, 49, 7060.

134 SEXUAL PARJ^STIIESIA.

onian poetess, Praxilla/ sang of male-love. The Greek gods and heroes glorified the fraternity of arms and the relations of the lovers.

Of the more familiar examples may be mentioned Zeus and Ganymede, Pelops and Poseidon, Achilles and Patrocles, Orestes and Pylades, Heracles and Hylas, Apollo and Admet ; Adonis is beloved by Dionysius, Theseus by Minas, etc.

The most illustrious men Greece produced stood in the closest relation to the peculiar institution of boy-love. It will suffice here to allude to the following examples, which by their influence attained historical significance, and, in a measure, became the basis of political movements.

Solon'* is reputed to have loved Pisistratus; Pisistratus,' Charmus; Charmus, Hippias, etc. The love of Harmodius*and Aristogeiton became the cause of the liberation of Athens from the tyrants (Aristogeiton's jealousy of the tyrant Hippias).

Aristides and Themistocles both sought the favor of Ste- sileos, which became the cause of their rivalry. The three great tragic poets, ^scylus, Sophocles, and Euripides, glorified boy-love both in poetry and life, as did Agathon and Aristopha- nes. The greatest sculptor of Athens, Phidias, loved Agora- critus and Pautarches.*

Of the famous statesmen who were devotees of boy-love, there were Alcibiades, ^schines, Timarch, Demosthenes, and Demetrius. Likewise, the most celebrated philosophers were given to it, Socrates, Parmenides,^ Plato, Dion, Phedrus, A-lexis. Zeno,' the founder of the Stoa, seldom or never had intercourse with women, but only with beautiful boys, which must be regarded as a sign of beginning homo-sexuality. The Stoics were often reproached with having followed the example of their founder with only too much zeal.

' AthenauB, xlil, p. fiOSa.

' Plutarch, Erotic, 5, and Sol., I. ' Plato, Symposium, ix, p. 182b.

• Plutarch, Aristides, 2 ; Themistocles, 3.

• Pausanlas, Ix, .34 ; I and v. It ; iii and vi, 10b.

• Plato, Parmenidcs, 52d. Diogenes, LaSrt, ix, 25.

• AtheuauB, 663c.

CONTRARY SEXUAL FEELING AMONG THE ANCIENTS. 135

Impure Male-Love in Greece. Tlie fact tliat Socrates^ sought to elevate the wide-spread relation of pedophily and give it a moral direction illustrates clearly enough the frequent occurrence of pederasty during his time. On the contrary, in his philosopliy, Zeno'^ goes so far as to place unnatural intercourse of boys and men on a level with natuml sexual congress. It is no wonder that the adherents of immoral boy- love have ever sought to cover themselves with the mantle of Socratic and Stoic philosophy. This is not the place to deter- mine to what extent, in individual cases, pedophily was abused for sexual purposes. There was no want, in comedy (Aristoph- anes) and in literary productions, of attacks, denunciations, formal complaints, and punishments directed against this form of indulgence ; the whole of Greek literature gives clear evi- dence that, during the period of highest morality, immoral boy-love was regarded as a disgrace.

Solon showed his respect for boy-love ^ by the enactment of a law which denied it to slaves, and thus elevated it to be a prerogative only of free individuals. If, however, an Attic citi- zen voluntarily .prostituted his person* for gain, the law punished him with life-long loss of all the rights of citizenship. Still severer punishments were inflicted upon those who committed the crime with minors. Between sunset and sunrise the gram- mar- and wrestling- schools were closed by law,^ in order that, during the darkness, there might be no opportunity for the seduction of boys. Likewise, the children-festivals and attend- ance at the gymnasia were carefully regulated. On the other hand, barber-shops, ointment-shops, drug-stores, and bath-houses seem to have been the places of show where men in love dallied. The good old morality and education gradually gave place to effeminate practices, and male-love, previously regarded only as an cn*or and indulged in secret, became more and more shamelessly prevalent. With this process of development, in ancient Greece, the history of contrary sexual feeling reached the stage where, on the foundation of base immorality and

' Plato, Symposiam. ' Plato, Sympoeium, 182b.

Athen., 563c. * i^scliines, contra Tim. fin., p. 44.

• iEscbines, op. cU., p. 36.

186 SEXUAL PARiESTIIESIA.

previous pederasty, homo-sexuality and cfFemination began to manifest themselves, owing to attempts to approach the required female sexual role.

Youths, as Aristophanes ^ says, sold their bodies for money, and boy-love became a means of livelihood. The pathici began to attract the attention of lovers by means of low, coquettish arts, and did not despise those of the toilet, xa/l/UjTti^fa^ai. If possible, they deprived their persons of every mark of mascu- linity ; they gave themselves to vile uses in secluded s])ots, in private houses, on the walls, etc. Handsome young slaves were forced ^ to yield their bodies to their masters for gain, and live in actual houses of prostitution. The extent to which tlie puer venalis was characterized by his external appearance is shown by the Greek proverb : " It is easier to take five elephants under the arm than to conceal a pathicus."^ Then male pros- titution became a trade * that was taxed. The Senate of the Five Hundred farmed out this tax yearly to a man .who collected it. Thus we see how the originally pure boy-love found its end in prostitution and effemination.

0>7?wf/a vovaoc,. The following facts present ns with the important proof, from historical sources, that the theory of con- trary sexual instinct, as to-day set forth by von KrafFt-Ebing, for example, was known to the ancients in all its essential points, both patliological and moml. Indeed, Rosen baum,^ by a care- ful investigation of various statements by credible authors, has shown that, for designating this class of men, the Greeks had a term which in meaning is identical with what Westphal named " contrary sexual feeling." Herodotus first applied this term to the Scythians, who learned pederasty in Asia (Ascalon in Syria), returned as pathici, and widely developed the vice in their native land. He says : " The goddess Venus Umnia let 3>7/lefav vovaov fall upon them, i.e., the passion or disease which transformed them into tcomen." Among a people like the Greeks, whose intellectual development was of the highest order, male sexual intercourse was practiced only by a certain percentage of the

' Aristophanes, Plut., 153, 169. ' Lucian, adv. Indoct., 23.

Diog., Lart., vl, 54. * iEschines, p. 134 et neq.

• Roseiibaum, loc. cU., p. 177 d eq.

CONTRARY SEXUAL FEELING AMONG THE ANCIENTS. 137

people ; on tlic other hand, with a race of small resistive force, like the Scythians, whose sexual character was never markedly developed, the whole transformation to tlie feminine type, both mentally and physically, took place much more readily in gen- eral, and thus became more striking to the foreign observer.

Spontaneous Origin and Cultivation of the Feminine Type in the Male. Hippocrates referred this Scythian disease to con- stant riding, which induced frequent pollutions. Too, it was thought that nomadic life contributed to this, for the Scythians were not accompanied by their wives on their expeditions.^ Many authors, Hammond^ included, are of the opinion that excessive riding induces atrophy of the testes and consequent im- potence. Those affected with the disease lost the physical and mental peculiarities of the male sex ; impotence occurred, the beard disappeared, and the penis and testes atrophied. " Finally, the mind becomes so much affected that these individuals look upon themselves as women, dress like women, and assume the habits and pursuits of the female sex " (Hammond).

Too, among the modern descendants of the Scythians, the inhabitants of the Caucasus, impotence is said to be of frequent occurrence. Constant compression of the vesiculae seminales and the prostate induces frequent pollutions, irritable weakness, and, as a final consequence, impotence.^

Two cases of Hammond's* are classical examples of the possibility of artificial transformation of a man into a Avoman ; and they are briefly given here because they are of fundamental importance in the consideration of the origin of contrary sexual instinct. According to Hammond's report, among tlie Pueblo Indians of New Mexico it is customary to induce impotence in one native in each village and use him for pederastic pui^poses. This person is called a mujerado (mujeriego = changed into a woman). The first case was that of an individual, aged 35, dressed as a woman ; the breasts were unusally developed and looked like those of a pregnant woman. He told Hammond

• Sprengel, Apologie des Hippocrates, Leipzig, 1793, Part II, p. 610.

• Hammond, loc. cU., p. 106.

' I^lemand, Des pertes seminales, Paris, 1836, Part I, p. 581.

• Hammond, loe. eU., p. HI et teq.

138 SEXUAL PARESTHESIA.

tlmt he had nursed several cliildreii wliose mothers had died, and that he was able to furnish them mucli milk from his breasts. No pubic hair; penis much reduced in size; the scrotum contained the remnants of testicles ; slight varicocele. He had been a mujerado for seven years ; but, up to the begin- ning of that period, he had possessed all the sexual attributes of masculinity. At first his testicles became smaller, and with their atrophy he lost sexual desire and all inclination for mascu- line pursuits, and, therefore, sought female society. At first his penis retained its normal size. After the loss of erectile power the member soon became atrophic. He said that before he became a mujerado he had a large penis and testicles of the size of eggs, a statement confirmed by his companion. His voice was high and thin.

The second mujerado examined by Hammond had atro- phied penis and testicles, " which apparently consisted of con- nective tissue." Pubic region free from hair; breasts not espe- cially developed ; limbs full and round ; hair only on the head ; voice high and weak. His nude appearance was more that of a woman than that of a man. He was 36 or 37 years old.

As in the religious orgies of the ancients (priests of Cybele), among those of this race of Indians the mujerado is indispens- able for the performance of the passive role in pederastic prac- tices. For the production of a mujerado usually one of the most powerful men is chosen, and masturbation is practiced on him many times daily. At the same time he must ride con- stantly, and that without a saddle. Irritable weakness and diminution of the nutrition of the genitals set in. Then, in spite of orgasm, ejaculation becomes impossible, and finally it is no longer possible to induce orgasm. Then atrophic shrink- ing of the penis and testicles occurs. Simultaneously the man's courage disappears; he becomes timorous; all his influence and responsibility are removed, and he bears himself like the women of his race. Besides this, he tries to divest himself of all masculine characteristics.

Tlfe victim of the vovaoc, ^ri'Keia, the Scythian disease, differs from the mujerado only in that what took place in the

CONTRARY SEXUAL FEELING AMONG THE ANCIENTS. 139

former as the accidental result of certain customs and habits was artificially brought about in the latter for a distinct purpose. After this diversion, important for an understanding of contmry sexual instinct, we may return to the ancients.

Vieics of Some Ancient Writers Concerning the PatJiicns. The liistorical facts of the development of jx'derasty among the Greeks, as among the Scythians, confirm our view, previously expressed, that its artificial introduction among them, and the forcible performance of pederasty on boys, form the origin of contrary sexual instinct and effemination ; and that then, through its effects, seriously injure the manly virtues of the people, a process appropriately called " eviration." The transformation of the masculine type into the feminine, as a result of pederasty, was commonly looked upon as the revenge of outraged Venus.^

It was known to the ancients that the vice of pederasts was capable of transmission hereditarily to the members of a family in the form of disposition, a confirmation of von Krafft-Ebing's theory of heredity. However, the same form of perversion did not necessarily appear. The case of Heliades,^ who had been punished by Venus in the manner mentioned, had this reputa- tion. Thus the orator Lysias^ says of the family of Alcibiades : " The majority of its members had been prostitutes." Indeed, there was even a view that the pathici inight be born with a predisposition to the vice, an opinion which Parmenides* (509) expressed. While the author mentioned looked 'upon the basis of the disorder as mental, other writers, as Aristotle,^ regarded the vice as a disease of the rectum. According to x\ristotle, the seminal vessels conveyed the semen not to the rectum, but to the anus, and there excited pleasure and libido. Those affected in this way were, in his opinion, congenital pathici, from whom he distinguished those produced by habit (7te<pvx6rg and e^ i^vg). Here we see the theory of Mantegazza foreshadowed, who looks upon the cause of a certain form of contrary sexual iustinct as

• Euripides, Hlppolyt, 5.

• Tragedy, Hippolyt, VZi ; and Lucian, Amoreo, c, 2.

• Lysias, Orat. contra Alcibiad., i, p. 550. *

• CseliuB AureliauuB, de morb. acut. et cbron., lib. tU.

• Aristotle, Problem Iv, 26.

140 SEXUAL PARiESTHESIA.

an abnormal distribution of nerves (to tlie rectum). Stjitements concerning the pliysiognomy and otlier marks of androgynes and pederasts are numerous ; whicJi, aside from the external ap- pearances given them by the race and the customs of tlie times, in all essential features are compamble with those peculiar to the sexual perverts of our day.

Polemon^ calls attention to the enticing, lustful glance of the androgyn, and says: "The hips are in constant motion. He speaks in a voice that is high and shrill, forced and tremulous."

Dio Chrysostom^ thought he could detect pederasts by their sneeze. He says : " Tims sneezing revealed a man's real char- acter, and in spite of all else would betray him." Rosenbaum thinks that during the act of sneezing the pederast attempted to control the sphincter ani, since it was weakened or destroyed, and could no longer perform its function. " Even with a normal sphincter it is often hardly possible, during the act of sneezing, to restrain the expulsion of gas or even fluid faeces."^

Lucian satirizes the customs and laws of the pederasts ; " how they care for their persons, and pull out their hair ; how pederasty is practiced, passively and actively " ; their features, gait, voice ; the bowed head ; the powder, mastic, paint, with which they adorned themselves, etc.

According to Martial,* " these male prostitutes had their beards shaved* as closely as possible, and the hair removed not only from about the anus, but from the whole body as well, in order to simulate the female person." They dressed entirely like women.

One of the most noted pederasts of Athens was Cleisthenes. Aristophanes made him the object of his satire. Later his name became a designation for pederasts.

According to the evidence adduced by Rosenbaum, out- raged nature revenged herself on the pathicus by assisting him

Polemon, Physiognora., lib. 11, 9, 1, c, p. 290. ' Dlo ChrysostomuB, Tarsica, i, p. 410.

Clemens Alexander, T&ed&g., lib. 11, c, 7.

Martial, lib. vll, epigram, 57.

Rosenbaum, loc. cU.,p. 179.

CONTRARY SEXUAL FEELING AMONG THE ANCIENTS. 141

in his efforts. " Through distension of the anus the nates grow "broader below, the intermediate space wider, so that the hips assume more the form of those of a woman ; and tlie pelvis itself seems to widen. The thighs change their direction and the knees turn inward more and more; in short, the whole inferior half of the body takes on the feminine type. The mind follows the body ; the character becomes feminine. The pathicus detests coitus with women, and does not marry as long as he can satisfy his lust. When increasing years deny him the ability to satisfy his desires, nature at last has denied him the power of procreation ; the genitals refuse to perform their functions " (shrinkage from disuse, and paralytic impotence).

But psychical hermaphroditism a transitional stage in the process of effemination was also known to the ancients. Al- cibiades held intercourse with both sexes ; Dionysius practiced normal coitus and passive pederasty.^ Therefore, the latter was called dvSpoyvvog. While for the passive party in pederasty, the pathicus, there was an inclination to find an excuse in regard- ing the phenomenon as a pathological result of artificial culti- vation, as a person suffering with a voaog (disease), dvdvSpia, for the active party there was no excuse. He was regarded as a debauchee " who destroyed the virtues of manhood most useful in war and peace ; who in their place substituted in the mind the vovcog ^riXeia and created androgynes ; and who, destroying manly virtues, and giving them the peculiarities and character- istics of an object of love, injured the lover in the most precious things of life, body, soul, and possessions."^

The passion to become a woman evidenced by all author- ities is everywhere manifest later in history than the practice of pederastic acts with boys and men, which, as a rule, are at first enforced. The spread of this perverse activity of the sexual instinct may therefore be regarded as the cause of the congenital disposition to play the role of a woman and become a pathicus. For the androgynes (psychical hermaphrodites) allow themselves to be used as women, and, besides, beget

' Luclan, De ilea Syra, c. xvl.

• Phllo, Ue vita coutemplativa, p. 480, cited by Roscubaum, loe. eU.

142 SEXUAL PARiESTHESIA.

children; they do not, like the pathicus, need to siiflfer with vovaog ^^Xeia, but they may, for the sake of gain, prostitute themselves.

One of the best and most complete confirmations of the correctness of the foregoing views which throws a clear liglit upon the etiology of contrary sexual instinct among the masses is Philo's description of tlie unrestrained lust and vice of the Sodomites. " Not only did those taken with a passion for women dishonor the marriage-bed of others, but men even approached men ; pedemsts of the same sex were not ashamed to consort with tlie pathicus ; expending useless seed, they despised the begetting of children. Disgrace was without effect upon those controlled by so powerful a passion. Later, those born as men accustomed themselves to play the role of women, and took to tliemselves the vovaog ^^Xeia as a vice against which it was vain to struggle. For not only the body, as a result of feminine conduct and manner of life, became feminine, but the mind as well was deprived of all male chai'acteristics, and they destroyed, as far as they could, all masculinity." In another place Philo ^ speaks of tliose to wliom the law-giver refused per- mission to frequent holy precincts : " He kept all unworthy persons from visiting the temples ; he began with the andro- gynes, those who were affected with the vovaog ^i^Xeta ; who distorted nature's order and assumed the desires and a])pearance of lascivious women. He expelled those whose testicles were concealed and whose genitals had been removed with the thought of preserving a youthful appearance and changing the masculine to the feminine type," etc.

RSsume of Conclusions. Pederasty, as the foregoing cita- tions show, had its origin in Asia ; it was adopted by the Greeks and changed into the form of ideal pedopliily. This peculiar institution exerted great influence in the development of the Greek nation, on politics, art, and science. But, as soon as pedopliily degenerated into violation of boys, the results of the vice were not wanting. It then was looked upon as the curse of Venus for a sin against nature. Thus there arose the class

• Pbilo, Dc sacrificsatlbuB, p. 261.

CONTRARY SEXUAL FEELING AMONG THE ANCIENTS. 143

called pathici. These individuals correspond with our ideas of those affected witli contrary sexuality in our day. But the necessary artificial role of woman caused destruction of manly virtues. " Since a man of sound reason could not possibly allow himself to be used as a woman, when he does so he must be suffering with a disease, a v6aog which changes him to a woman (^riXeia) " (Rosenbaum).

Later, matured men became pathici, which was the first clear indication that this phenomenon was pathological, and, at the same time, nervous and mental affections occurred simul- taneously, or as its results (impotence, dementia, etc.). Still, among the Greeks effemination never became general, as among the Scythians. Castration originated, as we have seen, from the desire of the pathicus to preserve the characteristics of youth, and, as I surmise, to prevent the development of the secondary sexual peculiarities (voice, beard), which, according to the Dar- winian theory, make their appearance at the time of sexual ma- turity, that the greatest possible resemblance to woman might be attained. Further, the foregoing detailed account shows that the whole theory of contrary sexuality, with reference to cultivation and heredity as well as to the forms in which it man- ifests itself, psychical hermaphroditism and effemination in its various degrees, was known to the ancients. Contrary sexual instinct, however, historically considered, appears as the direct result of pederasty ; and the latter, in the primary practice of it, is nothing more than a vice practiced on youth or man (per- haps by force), instigated by immoral motives. Only habitual practice of pederasty leads to degeneration and changes the sexual character of the passive party to that of the female, i.e., it induces an inversion of sexual feeling, which, once de- veloped to a fixed peculiarity, is in a condition to exercise further effects through heredity.

During the decadence of the Greeks and Romans and of other nations, neuropathy and increasing degeneration gave the broadest basis for tlie prevalence of all forms of immorality, and, therefore, during the periods of moral decadence of the people, contrary sexual instinct appeared everywhere in the form of

144 SEXUAL PAR^.STHESIA.

complete effemination and public prostitution, often in com- bination with symptoms of insanity (Cajsarian insanity), and it is difficult in individual case? to determine to what extent this perversion of the sexual instinct represents the product of the practice of degenerate customs (prostitution) or of hereditary predisposition. This difficulty also explains the views of au- thorities, by whom contrary dexual instinct is regarded as the symptom, as a rule, of a degeneration of the central nervous system.

In sexual development, however, the original course, as we have shown, is different : as a result of moral contagion or other external cause, a normal race may come to practice pederasty ; this gives birth to contrary sexual instinct, and the latter then leads, through transformation of character, to degeneration of the individual. Therefore, only secondarily can contrary sexual instinct, on the basis of hereditary predisposition of the central nervous system, become developed as a symptom of this taint.

CHAPTER IX.

HEREDITY AND EDUCATION IN THEIR ETIOLOGICAL RELATIONS TO SEXUAL PERVERSIONS.

The Importance of the Part Played hy Heredity in Anom- alies of the Sexual Instinct. Owing to the frequency of their occurrence and the legal enactments concerning coitus-like acts between men, in the literature of anomalies of the sexual in- stinct contrary sexual instinct takes the most important place. Too, there is hardly another error of the sexual appetite be- sides that of sexual inversion that is so powerful in transforming the whole personality and character. The question concerning the causes and origin of this perversion, as shown by the opin- ions given in the celebrated case of the Countess V.,^ is still unsettled ; and, in spite of the valuable review of the etiology which Moll" gives after a careful consideration of the majority of the authorities, the question still seems to us to be an open one.

The more the number of cases increases in which perma- nent therapeutic results have been obtained, the less seems, in our opinion, the influence of hereditary disposition in the origin of this anomaly. The discovery and exact estimation of the hereditary factor and of the extraneous influences tlmt have had a baneful effect on development form the basis of diagnosis and prognosis. As von Krafft-Ebing justly remarks, it might be presumed a priori that it would be impossible to remove or modify a congenital perversion. Hence the hopeless prospect offered to such patients by text-books on psychiatry, such as Krapelin's.^ He says, " There can be no thought of treatment of an anomaly like this, which has developed with the develop- ment of the personality and has its origin deep within it." If, however, in cases which are presumably due to hereditary disposition, a complete transformation of the psycho-sexual

Friedreich's Blatter f. ger. Med., 1891, Heft 1, pp. 32, 83. Moll, ;<xr. cit., p. \S6etteq.

Psychiatric, 2 Aufl., p. 576.

'" (145)

146 SEXUAL PARiESTHESIA.

character is brought about, there can be but two ways in which to exphiiu it: either, in comparison with extraneous influences, the effect of heredittiry disposition has been over- estimated, or it is actually possible to corajKjnsate by suggestion the dire effect of hereditiiry factors.

For therapeutic nihilism, of course, the theory of heredity is the most convenient, and individuals of contrary sexuality, who, in numerous instances, have no consciousness of their abnormality (contrary to Westphal's idea), find in it a \ery welcome excuse for their peculiarity : they believe that they are justified in obeying an impulse for the manifestations of which, owing to its hereditary origin, they regard themselves as irre- sponsible. And therein also lies the reason why such persons, happy in their peculiarity, will know nothing of treatment. Usually it is not tlie anomaly of tlieir feeling tliat brings them to the physician, but fear of conflict with the law, and sexual hyperaesthesia which threatens to betray them ; or symptoms of progressive neurasthenia, which interfere with occupation and daily life, are the causes which lead them to seek medical advice.

Hereditary Disposition in General. If the cliaracter of the child were determined in the mother's womb, to continu- ously unfold in post-natal life, then the influence of education would be illusory. To speak with precision, hereditary inclina- tions are nothing but the results of the liabits of our ancestors acquired through repeated and multiplied ac.ts, i.e., capitiilized activity that lives and constantly grows by its own activity. This fact is also demonstrated, as we have seen in the foregoing chapter, by the history of tlie origin of contrary sexual instinct. Every individual benefits or injures his descendants tlirough the series of acts which make up liis life, and wliich, through habit, become transformed in descendants into hereditary dis- position. The mechanism of heredity and our intelligence con- tinually exert a reciprocal influence on eacli other. Custom, through heredity, becomes racial instinct, in so far as in the past a repeated act, which at first is to a certain extent reflex in the process of adaptation to surroundings, may become typical for the future.

HEREDITY AND EDUCATION. 147

Racial morality is the condition of our progress and self- preservation ; the object of education is to influence our moral and immoral hereditary tendencies, i.e., to seek to control our animal instincts. The education of centuries is fixed in the present generation by heredity, and yet we see the mighty power of racial instinct continuously working atavistically. Thus, the war-hke tendencies manifested in duels to-day are but the natural result of the battles of our ancestors. Still, every hereditary disposition, to become active, requires its specific excitant ; and from this may be estimated the enormous force which education acquires in the selection of the influences which affect us. Every organism passes through developmental or retrograde changes in accordance with the multitudinous adaptations made inevitable by the struggle for existence. Physical peculiarities (constitution, stoutness, longevity) are inheritable, like tempera- ment, lack of power of resistance to external influences, and certain diseases and dispositions to disease. However, within the broad realm of inexorable law there is still left sufficient room for the exercise of human influences. Pseudo-heredity depending upon the imitative tendency of children must also be taken into account. In large measure inheritance is something possible, but by no means certain. Defect in the father may be compensated by corresponding perfection in the mother.

For the most part, as von Krafft-Ebing also allows in con- trary sexual instinct, only the disposition to disease is inherited. Whether and to what extent it is developed largely depends upon later extraneous influences. The theory of atavism makes it probable that genemtions apparently free from it still bore the disposition undeveloped and transmitted it. Of all nervous and mental diseases, irritable weakness of the nervous system is most frequently transmitted as a neuropathic disposition, and it may develop into neurasthenia, and thus become the foundation of nervous diseases, according to the kind and intensity of the injurious influences of life. But, on the otiier hand, a proper mode of life may do much to prevent the development of the hereditary disposition, and thus, in a measure, compensate it.

PrediapositUm and Pathogenetic Excitants. In coustitu-

148 SEXUAL PARiESTIIESIA.

tional diseases, as in tuberculosis, only a predisposition to them is transmitted. It is very seldom, even though it be demon- strated, that tuberculosis is directly congenital. Thus, the reports of Brehmer's sanatorium (Wiesbaden, 1889), gathered from 506 cases of tuberculosis, show that the cliildren of tuberculous parents are by no means always tuberculous, but, on the contrary, the grandcliildren relatively often. As Dr. Krocker^ reports. Dr. Sommerbrodt treated, in 1885, a lady who was pregnant ibr the fourth time, but subject to progressive tuberculosis. The first three children had died of more or less pronounced tuberculosis. By a rigid observance of all means to prevent infection, not only was there success in saving the life of the fourth child, born in December, 1886, and preventing infection, but the same means were successful in the case of the fifth. One child is now 3 and the other nearly 4 years old, and both are blooming and healthy.

There could be no clearer demonstration of the fact that with inherited disposition to a disease there must also be the specific pathogenetic excitant in order to produce the actual disease. The etiological factors of predisposition and exciting influence operate analogously in contrary sexual instinct.

Heredity and Exciting Causes in Mental Diseases. Like the majority of psychoses, the heredity of contrary sexual in- stinct presents the picture of polymorphia. Only in one case (von Krafft-Ebing) was the father said to be affected in the same way. As a rule, only a neuropathic disposition, a slight degree of mental weakness, or (according to Kocli) psycho- pathic inadequacy is congenital. Whether, on the basis of this hereditary lack of resistive power, contrary sexual instinct must necessarily develop as the hereditarily-conditioned product seems questionable. MolP avoids the answer, when he says; "Why in the one case the degeneration expresses itself in epilepsy, and in the other as contrary sexual instinct, we are as little able to answer as the question why, in taking cold, one has catarrh and another rheumatism."

• Comp. Krocker, Krankheitsursachen und deren Bekampfung, Paetel, Berlin, 1891.

Zoc.d/., p. 163.

HEREDITY AND EDUCATION. 149

In his very instructive work on direct heredity,^ E. Sioli differentiates a class of psychoses in which hereditary transmis- sion is complete ; the same kind of delusions, like instinctive impulses, and a like fatal tendency to suicide are manifested at a like period of life, under the influence of definite causes of a similar nature. We shall see, later, whether in literature cases of contrary sexual instinct are to be found which can be assigned to this class.

More important for us, however, is Sioli's collection of families in whi(;li ancestors and descendants were affected with mental diseases which were, in descendants, caused more by demonstrable extraneous influences the effect of which could be ascertained, than by inheritance. Only new and additional in- jurious influences, or subsidiary causes, induced a psychosis in those descendants that showed no demonstrable disposition, or in those that presented signs of degeneration and lessened power of resistance ; and the form of the psychosis either coiTesponded with that in ancestors or was transformed. Such subsidiary causes are: puerperium, puerperal diseases, unjust punishment, illegal pregnancy, head-injuries, etc.

These exciting causes may, when sufficiently intense, determine the form of the disease; still, the number of such psychoses is much smaller than those essentially determined by heredity.

The literature of contrary sexual instinct, especially the autobiographies of urnings, leads us to think tliat hereditary disposition, as a rule, has been overestimated, to the detriment of exciting causes. The possibility of direct inheritance of con- trary sexual instinct, which, in infrequent cases, may develop in spite of all training, cannot be gainsaid, though a convincing proof of it has not yet been given. On the other hand, it will be our object to ascertain what influence exciting causes, especially of a sexual nature, may exert in themselves on the origin of this perversion.

In order to estimate fully and differentiate the causal factors (hereditary disposition and education) in the origin of

Archlv fttr Psychiatric u. NervenkranklicltcD, Bd. xvl, Heft 1-3.

160 SEXUAL PARif;STHESIA.

the perversions of the sexual instinct, it seems necessai^ to consider man's normal sexual development.

Physiology of the Development of the Sexual Instinct. The procreative instinct, corresponding witli anatomico-physio- logical processes, develops relatively late in man.

The functional development and growth of the generative organs sUmd in definite interrelation to the cerehral cortex, where sensations and ideas (impulses) arise. Actual puherty begins, in the female, at the age of 13; in the male, at the age of 15. Until this time is readied there is usually no knowledge of sexual matters. Under normal conditions, with the help of education and imitation, the mental type corresponding with the sex is developed, which per se does not depend upon the processes in the generative organs alone. In early years the individuals are sexually neuter, a state which Max Dessoir calls " undifferentiated sexual feeling."

We can neither assume that there is innate knowledge of the difference of the sexes nor the possibility of the inlierit- ance of ideas at all. In this sense, from a strict psychological stand-point, there is really no " congenital contrary sexual instinct."

Like all animals, man acquires the most through practice and experience. Like the sexual instinct, tlie instinct for food, in its first blind expressions, is an impulse the purpose of which is only gradually comprehended, in that, striving for fulfillment, it brings about external impressions. Sense-impressions are at first necessary for the expression of the instincts ; according to Wundt,' they alone bring about sensation and feeling. The idea of the mother's breast is not innate in the nursling, but an ill-defined sense of hunger'^ causes movements which finally bring about the satisfaction of the need. " With the first satisfaction comes an indistinct idea of external objects wliich present them- selves in the act, and thus, with tlie sense of hunger, at once the reproduction of the image of these impressions becomes asso-

' Physlologiache Psychologle, 1887, p. 2.31.

' Why speak of a sense of hunger bore at all ? It cannot be a sense or feeling of any kind. The moTemeuta are purely reflex, arising from organic conditions which at first, at this period of life, can hare no relation to sense or sensibility. Tbans.

HEREDITY AND EDUCATION. 151

dated with the desire." Thus are developed the simple in- stinctive acts.

The development of the sexual instinct is to be conceived in the same way. AH ideas in relation to it are tlie product of experience, even though the impulse belong to tlie congenital instincts. According to Wundt, only the conditions necessary for tlie origin of definite general sensations, and for the associa- tion of definite movements with these sensations, can be con- genital. Thus the sexual instinct, in its first indistinct expres- sions, is conscious of no definite purpose, and, at first, there are only purposeless feelings (physically produced by the generative organs) and emotions, which are called longings and impulses, and to which, through sensory impressions, the strengthening materials are supplied. The instinct induces movements which, to a certain extent, are reflex, and leads to instinctive acts. The disposition to these movements is congenital; it requires only excitation by external impressions to bring it to complete development.

A pronounced feeling in consciousness accompanies the in- stinctive act. After organic sensations have excited the atten- tion of the individual, the presentiments are transformed into clear ideas by sensory perceptions. The sight of his own person or of animals may, at first, satisfy the vague impulses, and contains elements from which the imagination creates images corresponding with the feelings.

Among animals the instinctive expressions, in accordance with the accompanying individuul sensory impressions, may go astray. " Darwin reports that young pointers point at other dogs, a thing that experienced pointers never do. The scent of game induces the irresistible impulse to point, though there is no idea of the game itself" (Wundt).

Pathological Determination of the Undifferentiated Sexual Feeling hy External Impressimia. In the indefiniteness of the original impulses the sexual instinct as well as the instinct for food lies the nucleus of the various errors to which the indi- vidual is subject. If, owing to external circumstances and edu- cation, the object which nature has created to induce sexual

152 SEXUAL PARiESTUESIA.

excitement does not present itself to gratify the longing Ibr satisfaction, then the desire for satisfaction, /?<<e de viieux^ turns to the next best means, especially when there is ignorance of the sexual relations.

With premature awakening of the sexual appetite, as a rule, the oi)portunity for normal sexual intercourse is wanting. Therefore, onanism, brought about by tickling sensations in the glans and erections, is the most frequent result of this sexual precocity. The sense-impression which accompanies the first orgasm, brought about by tactile or psychical onanism, owing to the intensity of the feeling, is much deeper than the ma- jority of impressions. The new perception, owing to the feelings accompanying it, is retained, no matter how great dis- parity there may be in it. According to the intensity of the feeling, the individual judges of the value of the perception for the Ego. The perceptions, both in content and in time, are so intensely associated in thought that, thereafter the lust- ful feeling is regularly accompanied by the reproduced image of the external accompanying conditions. For the very reason that the individual has experienced nothing of this kind before, he will the more recklessly abandon himself to the most intense pleasurable emotion that nature affords, the less resistive power there is in his nervous system as a result of hereditary disjK)- sition. There is, too, no other possibility than that the onan- istic act of an inexperienced individual will reproduce the impressions, once discovered and brought about by external stimuli, until experience offers other material. For " nihil est in intellectu, quod non prius fuerit in sensu."

Simultaneously, owing to the nature of the feeling, occurs the impulse to repeat this experience for the benefit of the Ego. Thus it is deepened and completed. The thoughts which have arisen from inadequate external excitation are joined with others, brought into definite relation with tlie Ego, and the sum of these states of ernotion becomes an enduring object for the personality. Through the frequency of its reproduction the definite idea may finally become imperative, and at last in itself be sufficient to produce sexual excitement. In dreams it

HEREDITY AND EDUCATION. 153

accompanies pollutions, and becomes, the starting-point of sexual perversions. Since, in the schools, education has brought about a strict separation of the sexes,^ it is highly prob- able that the first sexual promptings where there is complete ignomnce of sexual matters will be directed anywhere rather than toward the opposite sex. The longings and promptings of puberty are intensified at first in the presence of another person, no matter whether it be a girl, a friend, a much-loved rela- tive, or an honored teacher (Mme. Lambercier and Rousseau). The person in whom there is the greatest confidence and with whom there is the closest sympathy, and who is at hand at the moments of excitement, will, according to sex and accompany- ing circumstances, play the determining part in the origin of the perversion,^ The close boy-and-girl friendships that may be seen in every school, owing to sexual coloring, take on a sexual character, even though the individuals be unconscious of it ; and, therefore, kissing, embraces, jealousy, tears, etc., are common events. Then all that is necessary is sexual hyper- excitation, or tickling sensations in the genitals induced by masturbatic frictions (with the thighs), to intensify this sensa- tion to an unknown lustful feeling, and, with reference to the accompanying thoughts, the sexual instinct is determined, i.e., the impulse, seeking satisfaction, has become conscious of its object, even though it be erroneous.

The accompanying psychical manifestations of sexual exci- tation that is, the sexual thoughts always depend upon external impressions, the objects of which are brought into material relation to sexual feelings. The nature of the object determines by content the direction of the sexual impulse. The form of the perversion i.e., the object to which the perverted impulse has been directed is determined by external circum- stances, accidental events ; and, in our opinion, as a rule, and

' Not true of the public schools of the United States. Trans.

' This statement seems too broad ; if this be true, in the histories of cases of sexual perversion we should more frequently meet instances of incestuous tendencies ; for often relatives stand in just the relation to the boy or girl indicated in the text. Compare the translator's article, " Incest," in "A System of Legal Medicine," vol. il, E. B. Treat, N. Y. Tbans.

154 SEXUAL PARiESTHESIA.

in the majority of cases, it is not to be ascribed to natural tendency.

Hereditary Lack of Resistive Power, and Pathological Association. In all forms of parsesthesia, without respect to whether it be contrary sexual instinct, algolagny, or fetichism, it seems to us that an essential factor is the fact of the origin of the perverse expression of the sexual instinct. It is entirely subsidiary that the same patient who, as a result of external circumstances, in one instance acquires contrary sexuality, in another might have become an algolagnist, or perverse in hetero-sexual intercourse. Natural disposition alone cannot explain why one becomes a lover of shoe-nails, another of ladies' eyes. The theory of pathological association which Binet^ advocates, allowed in the case of fetichism, but not for contrary sexual instinct, would be inconsequential. The advo- cate of the theory of heredity is justified in laying the cliief stress upon congenital predisposition, which supplies the basis for the development of any form of psycho-sexual disease, and, at the same time, there is no need to stretch this to include the form of the disease. With a normal nervous system, we see how events coupled with intense emotions in early youth become determinate for our whole lives. As Binet correctly remarks, when a child has once been frightened by a cat with no help at hand, or when it has been given a headache by the intense odor of a rose, the aversion for cats or roses may have been impressed upon the brain for life.

A pathological nervous system is usually more easily and in- tensely impressed; the neuropath is much less able to offer resist- ance to the sensations that have been intensely impressed upon him in youth. The idea created by the first strong impression of a sexual nature gains a growing mastery over him, and, for want of inhibitory opposition, forces him in a pathological direction. " Such a pathological inclination, as Lombroso says of criminals, in some evil liour develops, especially during childhood, and disappears under the influence of proper training. When, however, it has a favorable foundation (predisposition due to

Revue Phllosophlque, Paris, 1887, No. 8.

HEREDITY AND EDUCATION. 155

faults of development), and when it is not opposed, it remains. While, in the majority of men, the reminiscences of such im- pressions, for the most part, influence them in a subordinate way through association of ideas, in the individual under con- sideration they operate like certain kinds of virus ; since they not only become fixed, but also permeate the whole organism until they absolutely control it and irresistibly compel acts which are usually of a criminal chamcter. Thus are explained the strange perversions in the direction of obscenity and love which we see develop in hereditarily predisposed individuals in their youth."'

The repetition, perhaps voluntary, of the first experience, if this induced sexual orgasm, and the reproduction of the per- ception with the onanistic act to which the majority of such individuals give themselves, change the vice into a habit, give the impulses the strength of imperative feelings," and leave but one direction for desire. On the other hand, in the same degree in which the psycho-sexual anomaly is engrafted in them, such persons feel themselves impotent in normal intercourse. AVomen cannot charm them as long as they find satisfaction in the per- verse activity of their sexual appetite.

Psycho-sexual Diseases^ Moral Insanity^ and WeaJe-mind' edness. The common characteristic of sexual perverts, there- fore, consists of this: in comparison with the normally-developed man they have lost the power to compensate the pathological stimuhis by means of the experiences of physiological sexual life and the multitudinous perceptions of life ; or they have never possessed it, as in hereditary weak-mindedness.

' Comp. Lombroso, Der Verbrecher, Hamburg, 1887, p. 119.

' During the publication of this work there appeared, In the Miincheuer med. Wochenschrlft (1892, No. 11, p. 188), a notice of the works by Moll and Krafll-Ebing. The reviewer, Dr. Blculer, happily comes to an opinion similar to my own ; at least, as a result of the opinion given by Professor Meynert on the case of Count Sandor, Bleuler says : " If, as a result of any accidental circumstances, these associations, which usually condition the exclusive inclination toward the normal sexual act, are so directed that the pleasure, In a broader sense, accompanying the activity of the sexual instinct becomes associatively connected with the idea of an ' unnatural ' act, or of aseociatlon with a person of the same sex, neurasthenic individuals and those predisposed to Imperative thoughts often cannot rid themselves of this association, and there arises an endttring abnormality of the sexual instinct." The correctness of this idea of the reviewer is confirmed by example* given later.

156 SEXUAL PARiESTHESIA.

From the stand-point of lack of resistive power to patho- logical excitation, and from the stand-point of lack of inhibitory influence of our intelligence against intense stimuli, the various forms of sexual hypersesthesia appear, from a single point of view, as members of one family, ac symptoms of a patliologi- cal condition which has been designated moral insanity. Moral insanity itself is but a symptomatic name for certain pathologi- cal manifestations which arise from a defect of mental endow- ment, or which, in their course, lead to destruction of the mental powers. According to the views of Mendel, Meynert, and Binswanger, moral insanity signifies a variety of weak-minded- ness which is characterized by an abnormal tendency to immoral acts ; a sign of a low grade of idiocy which is known under the name of "imbecility." The lack of inhibitory ideas (judg- ment) presumes a defect in the development of intelligence, in the mental energy, and it goes hand-in-hand with active stimu- lation of the animal instinct. The ethical weakness exists without disturbance of the understanding, but is often associated with great emotional irritability, and makes such persons in- capable of recognizing and understanding immoral and illegal acts as such. Therein, in our opinion, lies also the reason why urnings but seldom designate their sexual instinct (comp. Moll, p. 205) as abnormal.

The instinctive and usually premature stimulation of the sexual sphere leads to perverse acts and onanism. Therefore, the perverse activity is always to be regarded as merely one of tlie manifestations of a nervous or mental disease. Too, the impossibility in some cases of demonstrating other abnormal symptoms than those of the sexual sphere must not lead us astray. For, as in all other diseases, in the perverse manifesta- tions of the sexual instinct there are numerous transitional forms and varieties, from tlie slightest deviation from the physi- ological condition to the ])ronounced psychosis. Thus the old question whether contrary sexual instinct is to be regarded as " neuropathic " or " psychopathic " becomes meaningless. For it may be met as a symptom in apparently normal individuals as well as in cases of psychopathic weakness dependent upon

HEREDITY AND EDUCATION. 157

congenital disposition, taint, and degeneration, and in pro- nounced psychoses (paralytic, senile, epileptic pederasty).

Transitional Cases and Lessened Responsibility/. As it is impossible to regard crime in all cases as the result of patho- logical conditions, in spite of the correctness of the view that many crimes owe their origin to abnormal mental conditions, i.e., abnormalities of "those complex activities of brain which are inherited and automatic, and which we call character " (Forel), so the medical expert is not called upon to allow that the isolated existence of perverse expressions of the sexual in- stinct occasions "irresponsibility." On the other hand, the unequivocal proof of psychopathic weakness should justify the assumption forensically, if not of temporary complete suspension of the freedom of the will, at least of lessened responsibility.

In case of gradually-developing mental weakness, the diag- nosis is more difficult. In such individuals it is necessary to compare the present state of lessened mental activity with the former normal state. " Defective power of judgment, insuffi- cient acuteness of critique, inability to distinguish the essential from the unessential, want of independent effi)rt to investigate the cause and nature of things, mental one-sidedness, loss of creative power and originality of thought, are expressions of mental deterioration and diminished intelligence of various de- grees which it is difficult to grasp. The manner of receiving external impressions and their fixation in consciousness, memory, understanding, logical powers, mood, all must be taken into consideration in forming such an opinion. With diminution of intelligence and blunting of the feelings there is a want of the most powerful means of opposing the desires, the morality of which is judged by the understanding and estimated by the feelings " (Taraowsky).

There are sensual persons in whom, at certain j^riods of life, the sexual functions are the most important thing in life. As soon as sexual power begins to diminish, as a result of ex- cesses, they resort to various means to increase them. In this way tliere may arise a combination of impotence and sexual debauchery. Imitation is here one of the most powerful means

158 SEXUAL PARiESTHESIA.

of spreading vice. Here the abnormal kinds of sexual activity do not arise impulsively from personal need, from organic neces- sity. The debased man employs all means that can add to his lustful pleasure, but, notwitlistanding the greatest recklessness, is still able to control himself on occasion. Indefinitely marked transitional cases, in wliich it is impossible to decide where vice ceases and disease begins, are likewise not infrequent. But false philanthropy, in doubtful cases of " pathological viciousness," can only lead to the spread of immorality.

Sexual Instinct in Imbeciles. In numerous cases which we find in literature, namely, in those where effemination has reached full development, there is, doubtless, mental weakness. Sollier^ finds absence and perversion of the sexual instinct in idiots, but in imbeciles principally excessive intensification and inversion of it. The imbeciles often present an infantile con- dition of the sexual organs (Count Sandor), defect of sexual power, cryptorcliism, phimosis, hypospadiasis, varicocele, arrest of development and atrophy of the testicles, defective develoi)- ment of the penis, etc.

The onanism of idiots, as a rule, is not to be regarded as an expression of the sexual instinct, as we have shown (Mag- nan). On the other liand, imbeciles oflen manifest premature development of the instinct and sexual perversions. Onanism is most frequent in the form of automatic masturbation as well as for sexual satisfaction ; also, mutual onanism and pederasty. Too, there may be observed in them an especial tendency of the mind to obscene talk and gestures, which would be repugnant to a normally-developed person.

The alterations of sexual activity may also occur period- ically and in the form of attacks, while during long intervals all is normal, as in periodical psychoses.

Original Disposition in Para?stheia Sexualis and its Proofs. If now, in accordance with the foregoing view of the causes and development of the anomalies of the sexual instinct, we once more consider the hereditary relations previously de-

• Der Idiot and Imbecile (Voss, Hamburg, 1891), p. 75, and Bounieville and Sollier,

Det anomalies de or;g;an8 gdnitaux cbez lea idiots et epileptlques (Progrte M6d., 1887).

HEREDITY AND EDUCATION. 159

Scribed, we may express our opinion as follows : Since only in the worst forms of hereditary degeneration are pathological states, as such, transmitted, it cannot be denied that there is a possi- bility of a repetition of the same form of disease, the same symptom-complex, directly or atavistically, in descendants. In accordance with this, therefore, in contrary sexual instinct there might be such a thing as the preformation of the feminine type in the male body without the influence of education and example. Quite analogously, the son of a shoe-fetichist might be a shoe-fetichist, and thus algolagny arise from an original disposition.

These cases, however, even if they occur at all, are the exception in common practice. As a rule, the transmission must be regarded as that of an hereditary lack of resistive power, which may well affect the sexual sphere by preference. On the other hand, the full development of the anomaly in the in- dividual depends upon various accidental factors. The influ- ences of the individual's life are, in the majority of such patients, determinate for the development of the form of the psycho-sexual disease.

But if, as acknowledged, the possibiHty of the occurrence of contrary sexual instinct as an hereditary symptom-complex, without or in spite of opposing education, cannot be denied, still, literature does not yet afford an incontestable example of it. Moll (p. 159) gives, as evidence of the original disposition, the circumstance that " in most pederasts and urnings the per- version dates back to tlie earliest childhood." The same author looks upon acquired cases as those in whom there was first inclination toward women, later toward men. This assumption seems to derive further support from the fact that the impulse to play the feminine ivle occurs prior to the time of the first sexual promptings, and that in spite of education. If, in such cases, the sexual feeling is directed toward the same sex, and without the occurrence of hetero-sexual feelings, then the " hereditarily-conditioned process " seems to complete its nat- ural development.

This anthropological transformation reaches its acme when

160 SEXUAL PARiESTHESIA.

not only the cliaracter, but also the skeleton, face, and voice correspond with the abnormal sexual type (defective develop- ment of beard, development of mamma3, abundant development of adipose tissue), to which, as a rule, other anatomical and functional signs of degeneration are added.

Objecfions. But there may be serious objections raised to these considerations. The significance of the sexual factor in the development of mind and character is, of course, too important and determinate to be overlooked. Neverthe- less, it seems to us to be necessary, in the interest of precise definition, to decide the question which Westphal raised, and which has been much defended by urnings, whether an indi- vidual with inclinations toward feminine pursuits, but feeling normal sexually, is to be regarded as of contrary sexuality. In our opinion, only the sexual element is to be looked upon as the determining one, and, to a certain extent, it insures the diagnosis. Thus, for example, I am acquainted with a cavalry officer who is a happy father and devoid of sexual anomalies ; but he shows a great liking for feminine pursuits ; he embroid- ered all the coverings of his furniture himself. In spite of his feminine habits, I do not regard him as of contrary sexuality. Likewise, I know a male nurse who knits his own stockings, cooks, and shows preference for other kinds of female work. He is perfectly normal sexually (verbal examination), and the happy father of nine children. Therefore, so long as the devia- tion from the same sex does not involve the sexual feeling, we are not justified, even in cases of the most remarkable opposite peculiarities which nature presents in many individuals, in speaking of a pathological phenomenon. Even when the femi- nine inclinations go to the extent of self-adornment, to the habitual use of perfumes and other unmanly arts of the toilet, the same position holds good. Skill in cooking, knitting, and sewing, without teaching and imitation, is impossible, and therefore, for the most part, the result of education.

In support of the above-mentioned anatomical transforma- tion (development of mammae, absence of beard, masculine feet in women) we may cite the observations made on eunuchs (who

_ HEREDITY AND EDUCATION. 161

lose the secondary sexual chamctcristics after emasculation) and the cultivation of mujerados. Here it cannot be denied that there is a certain correspondence between the physical phenom- ena and the psycho-pathological symptoms. But, as von Kraift- Ebing expressly points out, with contrary sexual instinct physical hermaphroditism has never been observed ; and, on the other hand, in hermaphrodites there have always been found the char- acteristics and psycho-sexual peculiarities of but one sex.^ Too, in this respect, nature presents remarkable variations ; so that, with consideration of these conflicting facts, conclusions are to be drawn only with the greatest care. Thus, I know seveml cases in which, in perfect (physically and sexually) mas- culine individuals, there was development of female mammae. One of my patients presented this remarkable condition ; he also had a high, thin voice, was slenderly formed and neuro- pathic, but devoid of psycho-sexual anomaly.

The following personal observation, made in October of last year, also speaks against the rule of anatomical correspond- ence. It was the case of a bearded woman. She was tall; pelvis ferainine ; hands and feet large. Abundant development of subcutaneous adipose tissue ; breasts well developed ; hair thick and long and dark ; cheeks, chin, and lips covered with a thick blonde beard of soft hair about six or seven centimetres long; voice deep and rough (like a man's); genitals perfectly feminine ; age 34 years ; menses began at the age of 20 years. She had been happily married nine years, and was the mother of one child. She loved her husband, and, with the exception of a strong will, she presented no masculine characteristics. She was entirely indifferent to the female sex, and had intense lustful pleasure in hetero-sexual intercourse.

Arrests of development of organs well differentiated sexu- ally, as occasionally observed in individuals of contrary sexu- ality, are to be regarded as degenerative signs, as, for example, when observed in' imbeciles. They exist independently of the psycho-sexual anomaly.

The etiological role of the educational factors and imagino/-

'Tardieu et Langier, Diet, de m6d., art. " Hermaphrodisme." XI

162 SEXUAL PARiESTHESIA.

tiofi may be more precisely defined from experience that is at hand. The influences exerted on tlie child may, with defect of understanding, liave an effect exactly opposite to that intended; unconscious suggestion, in the education of children, plays at least as important a role as systematic instruction. The ques- tion is, whether a child devoid of hereditary taint can become contrary sexually by cultivation ; the possibility of artificial transformation the extraordinary extent of human influences after the historical and ethnographical facts adduced, can no longer be doubted.

The importance of the educational factor becomes perfectly clear after a consideration of cases in which this point is brought out, and we shall later make some contributions bearing on this point. Unfortunately, in the majority of histories of cases, this important point is not sufficiently considered. As a rule, such persons, as already mentioned, consult the pliysician only after they are forced to by nervous or other symptoms. The physician sees before him a many-sided symptom-complex ; and if, with difficulty, he is able in every case to determine the degree of the deviation from the normal, and to recognize the anomaly of feeling as one of the phenomena of a deeper proc- ess, still it will be often impossible to decide what is primary, what is hereditarily conditioned, and what has developed secondarily. Thus, according to our view, tlie manifestations of effemination occur, as a rule, secondarily, as a product of accommodation. Besides, the physician, in examining the patient, has to depend largely upon his statements, and, owing to the required discretion, cannot control them by statements of the relatives. Too, almost every urning has formed his own theory ; as the autobiographies in the " Psychopathia Sexualis " of Professor von Kraff't-Ebing show, the persons of contrary sexuality who have not read that work are the exceptions. Unconscious auto-suggestion and retro-active illusions of memory concerning the events of early years give tlie histories a very uncertain basis. To this is added the pathologically intensified auto-suggestibility of such neurasthenics, which liiuders in every way objective judgment.

HEREDITY AND EDUCATION. 163

The essential influences which determined the patient's sexual development are forgotten ; the theory of heredity shields him from responsibility ; concerning the time of the first occur- rence of sexual inclinations he is often unable to make any definite statements, because the knowledge of the sexual re- lations followed only years after, and thus he seeks to explain the first signs of effemination by his original disposition, while, in fact, they are only resultant phenomena. If these auto- biographical data are indispensable to the physician, still their value should not be placed so high that they are made the foundation of a wide-reaching scientific theory. The explana- tory principles should not be increased unnecessarily; and to heredity, that unknown factor for us, phenomena should not be ascribed which may be easily explained by education and the effect of life.

The first intense sexual excitement may very easily occur in contact with an attractive male, without the necessity for the presence of hereditary predisposition, even though the latter can be demonstrated in the majority of cases. The previously un- difFejentiated feeling now has an object, and may, as a result of external influences, easily become developed into contrary sexual feeling before hetero-sexual feelings manifest themselves ; and if in such a case the latter occur, which in healthy, un- tainted individuals must be the rule, the inclination toward women is later than that toward men, a contradiction of Moll's view previously mentioned, according to whom this factor is of decisive diagnostic significance for the original disposition. An imperative idea may be the starting-point of final complete effemination. If, among the perverse manifestations of the sexual appetite, contrary sexual instinct cover the broadest field, and seem, for the most part, to be a peculiar freak of nature, or to form a special pathological group, so that it has led to the expression " a feminine soul in a masculine body," still this depends principally upon modem education and the injurious separation of the sexes in schools.

Those persons in whose presence, or in whose companion- ship, the first sexual excitement is experienced, are, in these

164 SEXUAL PARiflSTIIESIA.

cases, of like sex ; too, the fetichist, before he has erections at the siglit of hfeless objects, primarily, at least as a rule, becomes attached to some living person. The accidental causes, even in spite of the lively emotional accompaniment, are often for- gotten by the patients; still in some cases, in which detailed biographies of urnings had been furnished, and from which no other explanation could be drawn than that of a congenital abnormality, I succeeded, after repeated careful examination, in awakening memory of apparently inconsequential events which were the keys to the ])hysiological understanding of the disease. The fact that the remarkable perversions of taste of fctichists cannot be explained without the assumption of pathological association should point to the importance and the presence of a similar phenomenon in sexual inversion. The symptomatic picture which the patient presents to the physician on exami- nation, usually in all the forms of paraesthesia, represents the ultimate product of an abnormal development that has existed several years or even decades, the result of a great number of experiences and influences. Compared with its beghming, the result is totally different ; and there may be nothing in tlie Jatter to recall the first associations, so important for the psychological analysis.

Thus, too, the most horrible of the sexual perversions, necrophilia, confirms the above-mentioned disastrous effect of the ideas accompanying the onanistic act, which, with a lively fancy, calls up changing images, any one of which, in a brain easily influenced by suggestion, may finally become an impera- tive idea. The auto-suggestive idea may induce an instinctive impulse to act, a state of temporary im])ulsive insanity. The performance of the ideal act, auto-suggested or produced by external impressions, depends upon whether moral conscience is strong enough to balance the great suggestibility.

Thus, Tardieu^ reports the case of an onanist whose hetero- sexual instinct was well developed, but who masturbated seven or eight times daily. He said : " While masturbating, my

• Attentats aux Moeurs, Paris, 1878, p. 114 ; also reported at length In Psychopathia

Sezualis, p. 69, Case 23.

HEREDITY AND EDUCATION. 165

imagination places me in a room filled with women in my power. While I satisfied my lust on them, in thought, I sacri- ficed them always in the same way to my lust ; imagined them dead, and then violated their bodies. Sometimes the thought came to me to cut up a male body ; but that was always seldom, and disgusted me." The patient then began to carry out his fancies practically. At first he masturbated at the sight of the bodies of animals that had been cut open ; then he killed dogs, and finally exhumed liuman corpses. "All that one experiences with a living woman," said he, " is nothing in comparison with the pleasure I enjoyed. I covered their bodies with kisses, pressed them wildly to my heart; in a word, I overwhelmed them with the most passionate caresses. Then I would cut up the body, tear out the entrails," etc.

Fetichism offers instructive examples for the theory of patho- logical association. In the well-known case of the lover of night- caps, the occurrence of the first sexual excitement coincided with the sight of a night-cap wliich was put on by au aged relative who slept in the same bed. The next erection occurred when the patient saw an old female servant put on her night-cap. Thus a mental association was formed at an age when mental im- pressions are always very deep. An apron-fetichist, at the age of 15, saw an apron fluttering in the wind ; he took it and put it around himself, in order to masturbate while in it. Mental associations thus formed become imperative ideas, because the patients are hereditarily predisposed, and in this way determine the direction of the sexual life.

The psychical condition in which associations of such sig- nificance occur Binet has appropriately compared to a state of intensified suggestibility. In themselves, the objects with which sexual excitement becomes associated are often incapable of affording satisfaction ; it is the reproduction of the associated ideas and feelings which give them their significance. Thus, the desire for generalization and abstraction, which is constantly recurring in these perversions, becomes explicable ; and this, in the course of time, may entirely change the content of the perversion. A man who loved a red-haired woman finally

166 SEXUAL PAR^ESTHESIA.

could not see red hair without becoming sexually excited. The former lover of an lUilian girl always had an erection at the sight of an Italian costume. An original lover of white aprons was finally excited by every white apron he saw, and at last by white alone (on a mason). From the time of his first love Descartes had a partiality for squinting eyes. In general, the peculiarities which we have once loved in one j)erson always have the greatest attraction for us in others.

The tendency to separate the object of love from its sur- roundings, as it is manifested in pathological fetichism, may be regarded as abstraction. The shoe-fetichist shows next a prefer- ence for the nude female foot, an inclination which, without striving for isolation and without separate sexual excitement, is still physiological. Tlie dressed female foot forms tlie transition, and the love of shoe-nails the pathological ultimate result. Tarnowsky ^ reports that the inclination for furs, in a mastur- bator 12 years of age, arose from the bodily contact with a dog that he sometimes took to bed with him. Transition : coinci- dence of onanism and the touch of the dog. Finally, the touch of the dog alone induced excitement and ejaculation. Later, only by means of touching fur could he induce sexual excite- ment. Here, also, we have to do with the effect of pathological association and the tendency to generalization in a degenerate individual.

The effort to intensify the cause of the pleasure and the sexual excitement indicates a longing for more powerful stim- uli, and this, according to Binet, presumes a weakening of the power of reaction of the nerves, and therefore, in the history and in physiology, it is to be regarded as a sign of decadence. Even savages make prominent those portions of the body which they especially prefer ; the natives of western America form the hair in knots in order to enlarge the head ; the Chinese seek to make the feet small ; Europeans try to make the breasts more promi- nent by means of tight lacing. The courtesan colors her eye- lids to enlarge the eyes and accentuate the brilliancy of the sclerotic. Also, among individuals of contrary sexuality there

• Op. eU., p. 22.

HEREDITY AND EDUCATION. 167

is the effort to magnify. Thus, the urning who tries to copy woman exaggerates the specific feminine pecuHarities, often to caricature; and, vice vei'sd, the female in male attire (Count Sandor) those of man.

The restraint which is often enough connected with the fact of specific sexual reaction to stimuli that are not always attainable intensifies the sexual pervert's power of imagination and longing for satisfaction. From this may be recognized the correctness of the experience that regulated sexual intercourse is the most eftectual antidote against the development of the anomaly.

The foregoing considerations show that the changes which the content of the sexual perversions may undergo in the course of time are essentially to be referred to the tendency of such patients to generalize, to isolate, and to exaggerate. These three peculiarities, however, are at bottom only different forms of expression of a single tendency peculiar to the human imagi- nation, namely, that of exaggeration. It may be intensified by pathological relations and abstinence.

The Exciting Cause iii the Histories of Urnings and Other Sexual Pei'verts. It remains to give a critical review of the known cases of sexual pargesthesia, and in them to try the cor- rectness of the view here set forth, and especially to point out such cases as are exceptions.

In his "Clinical Novels," Caspar reports the autobiogra- phy of an inveterate pederast, from which we borrow the fol- lowing passage, so important in showing the etiology of this case :

" As a school-boy of eight I sat near a boj' somewhat older. How happy I was when he touched me 1 It was the undefined feeling of an inclination which was a secret to me until my nineteenth year. 1 have never masturbated nor committed abuse with otlier bo3's. There were some certain ones toward whom I felt an unconquerable inclination, and to whom I indited my verses."

In sexual intercourse with women (at eighteen) he thought of his friend, and tiierefore had no pleasure ; but "a wonderful feeling of joy " came over him when an unknown man in the Zoological Garden first satisfied him by means of masturbation.

168 SEXUAL PAKiESTHESIA.

Here we observe premature tnvalveiiiiig of sexual impulses, transference of the undifferentiated feeling to the pupil touching Iiim, passive onanism, and definite perversion of the instinct in a predisposed individual.

From Westphal's first case we take the following passage :

" N., it is said, sufters, since her eighth year, witli a passion to love women, and, besides kissing and joking with them, to masturbate. She states that she has never had intercourse and never any inclination to it. Pla3'ing with tliera gave her sncli a sensual delight that she had actual orgasm. Wlien a child she liked to play boys' games and dressed like a boy. She had experienced sexual excitement since puberty in kissing girls." *

She masturbated shortly before and after menstruation. In other respects the patient presented the female type.

Though in this case more exact details could be desired, still it may be seen from the report that there were (a) prema- ture awakening of the sexual instinct, (b) relation to the same sex, and (c) masturbation. On the otlier hand, it is not clear whether the inclination to boys' play was present before or after the sexual inclinations for the female sex. Too, this case does not contradict our theory, and, like Caspar's case, does not require a forced explanation.

At this place it may also be pointed out that the theory of the development of the female character in the male body really owes its origin to the dualistic ideas of urnings (Ulrichs). West- phaP cites a number of passages from " Numa Numantius's " investigations of the enigma of male sexual love of males,^ and,

' Westphal, loc. dt.

' Loc. cU.

• Compare the following writings of the author mentioned : " Forschungen iiber das

Ratheel der mannannlichen Liebe : Numa Numaiitius (Karl Hdiir. Ulrichs)." " Vin- dex " : Social and legal studies of male love of males. Proof that it deserves punishment as little as love of women, and that, accordinsj to the existing laws of Germany, it cutmot be legally punished. Leipzig, 1864. " Inclusa " : Antliropologieal studies of male love of males. Proof that in a certain class of individuals of masculine form sexual love of males is congenital sexually. Leipzig, 1864. " Vindicata" : Struggle for freedom from persecu- tion. Criminal details and legislative proposals, looking to a revision of existing criminal laws. Diary of an urning, Leipzig, 18t).5. " Formatrix " : Anthroimlogical studies of the love of urnings. Description of the sexual nature of urnings in detail. Key to the riddle of uranism and its varieties. Leipzig, 186.5. " Ara spei " : Studies in moral and social phi- losophy In relation to the love of uniings. Relation of the urning's love to morality, Chris- tianity, and the moral arrangement of the world. Moral justification of the urning's love.

HEREDlTy AND EDUCATION. 169

therefore, was, perliaps, under the influence of the unconscious suggestion of this theory. He emphasizes that the feminine type is, embryologically, preformed in the infant, and favors the monistic and untenable conception of the imprisonment of a feminine soul in a male body. These writhigs lay stress upon the feminine inclinations of boys, and seek in every way to defend uranism. The time of the primary sexual excitation and accidental factors, education, etc., receive so little consider- ation that these studies, though highly interesting from the stand-point of present investigation, carry with them no weight of demonstration.

All the latest literature of uranism shows traces of the in- fluence of Ulrich's theory. Important and fundamental as Westphal's observations are for psychopathia sexualis, they do not, as he himself states, afford an incontestable proof that con- trary sexual instinct is cgngenital ; still, both cases show great hereditary taint, which, however, only under the directing in- fluence of exciting causes, became developed into contrary sexual instinct. Both patients, from youth up, presented a slight degree of psychical weakness; and, as one of the symp- toms of it, the sexual perversion was developed as a result of external excitation.

Too, in Westphal's second case there was premature awakening of the sexual instinct (in the eighth year). The patient who states that in his youth he had a preference for feminine pursuits, says himself: " I have had some inclination for sexual intercourse with women, though seldom ; for I feared to become ugly."

According to this, then, there was desire for women.

Love-bond of urnings. The conflict of urnings and its solution. The exceptional place of love in the moral status of the world. Hope. Leipzig, 1865. " Gladius furens " : The enigma of nature in the uming's love, and error as a maker of laws. An arraignment of German laws. Kassel, 1868. " Memnon " : The sexual nature of the male-loving urnlng. Psycho-physical hermaphroditism. Ami7ia tntdiebiis virili corjMva incluta. A study in natu- ral science. Two parts, Schleiz, 1868. " Incubus " : Uming's love and blood-thirstiness. A consideration of abnormal states of mind and responsibility, occasioned by the case of Zastrow, Berlin ; with fifteen allied cases. Leipzig, 1869. "Argonauticus" : Zastrow and the urnings belonging to the camp of the pietists, ultranioutanes, and free-thinkers, with considerations concerning blood-thirstiness and responsibility and brief reports from the world of urnings and the criminal cases : Bishop Morell, of Edinburgh ; Count Czaruechy, of Poseu ; Superintendent Forstner, of Vienna. Leipzig, 1869.

no SEXUAL PARiBSTIIESIA.

as his later relations with females show. As he says him- self, the patient did not give himself to men, in spite of many solicitations. On the other hand, he masturbated in youth ; but we have no statements concernmg the ideas that accom- panied the act. This case is one of entire moral defect; it was not a desire for men (whose solicitations previously, and later wliile in the hospital, he actively repelled), but merely his desire for money which induced him to dress like a woman. And it was only after this, for the sake of material gain, that he assumed the feminine ro/e, still, however, having intercourse with prostitutes, " who in a drunken state accompanied him home." Besides this, he stated tliat he once slept with a cook without touching her (?). Finally he became guilty of a series of thefts.

Here, as Westphal justly remarks, apparently we have to do with a weak-minded individual. . When arrested he was suffering with gonorrhoea. In his case the sexual element cer- tainly cannot be regarded as congenital contrary sexual instinct. His preference for female attire and his playing the feminine role are sufficiently explained by the circumstance tliat he was thus afforded a convenient source of revenue. Finally, we are not constrained to believe every statement made by a swindler ; and we may remember, also, that deceptions of- the imagination (pseudologia phantastica) occur in the weak-minded. The sexual feeling of the patient was originally normal ; in our opinion it is a case of congenital weak-mindedness whicli, with other symptoms, but later, presented that of contrary sexual inclinations as a result of definite influences.

Dr. Schminke^ reports another case* of contmry sexual in- stinct in the Arcliiv fur PsycJdatrie :

This case likewise speaks more in favor of the gradual development of the contrary sexual phenomena, with original normal tendenc}', on the basis of neuropathic disposition, than of original predisposition to con- trary sexual instinct. The patient had no sexual intercourse until his twenty -fourth year. He became nervously ill as a result of typhus, and in Paris he fell into religious compan}'. " Here, on one occasion, he was sitting on a sofa witii a friend, both being in nigiit-shirts. Suddenly he

ArchiT f&r Psychlatrie, Bd. HI, Heft 1, 1871, p. 827.

HEREDITY AND EDUCATION. 171

was seized with such a feeling of desire that he embraced his friend passionately, and at this instant he had a pollution." The reporter says : " However, it was remarkable to me that the patient also immedi- ately had erections and slight emissions (of semen ?) at the sight of beau- tiful girls ; also when reading obscene books."

Here also the long-restrained sexual impulse becanae directed to the nearest object ; friendly feelings and momentary intense excitement explain the perversion of the otherwise normal instinct. Both cases that Gock^ contributes show that the mental weakness upon which contrary sexual instinct may develop is congenital :

The first case is that of a servant-girl aged 28. She comes of a mother suffering with dementia. In school she was frivolous and did many foolish things; she masturbated from the time menstruation began (by means of tactile or psychical excitation). At the same time there was awakened a preference for joung girls who attracted her by the expression of their eyes. This desire occurred, as a rule, before or after the menses. When she could kiss and embrace such a girl, she ex- perienced lustful sensations in the genitals. If not satisfied in this way, she would think of the girl and masturbate.

She stated that, as a child, she preferred boj's' games ; whether this was the case after puberty is not stated. Later, she slept with girls and touched their genitals, which gave her the greatest lustful pleasure. With repression of her sexual excitement, she several times passed into a state of intense exaltation, undressed herself, and cried out ; she grew quiet, when in bed with another girl, only after gratifying herself by means of onanism. States of excitement alternated with intense depres- sion at the time of the menses. No feeling for men.

The first orgasm induced by onanism became associated with the sense-impression made by persons of the same sex that happened to be present. The irritable weakness of the psycho- sexual and genito-spinal centres, explainable by congenital neuropathic disposition, made possible the occurrence of lustful feeling as a result of the reproduction of the idea of girls' eyes. The memory-picture became habitual, and secondarily acted automatically. It then played the roU of an im iterative idea, and, owing to the lack of inhibitory opposing ideas, the patient became the victim of a cerebral process that had become inde-

' " Ein Beitrag zur Kenntniss der contraren Sexualempflndung, ausder W&rzbui^r Psychiatr. Kllnik," Archlv fur Psychiatric, 1876, Bd. v, Heft 2, p. 664.

172 SEXUAL PARiBSTHESIA.

pendent. The fancy elaborated the imperative idea, and the latter finally dominated the entire sexual existence, i.e., it became determinate for the individual sexual ex' itability.

Gock's second case illustrates the delusion of sexual trans- formation, and, with the other psychopathic symptoms, belongs entirely to the psychoses.

We find a further confirmation of our view in the case reported by Servaes,^ which recalls the origin of contrary sexual instinct among the ancients :

Franz B. was misused for pederasty in his ninth year by the tutor of his friend, and from that time was not able to give it up. Arrest on account of suspicion of immoral relations with a night-watchman. To him carnal intercourse with men is the highest pleasure in the world. Unmitigated cynicism. Stole from his room-mates. Unconquerable aversion for women. Onanism. Exaltation alternated with depression until death. Female inclinations. He made ornamental covers out of linen. Increasing weakness ; ideas of persecution. Death due to tuberculosis.

This case, likewise, does not strengthen the theory of heredity. The fact that the patient allowed himself to be used for pederasty may be regarded as a sign of lack of resistive power dependent upon inherited weak-mindedness. If, how- ever, we assume that the case is one of acquired contrary sexual instinct, with congenital imbecility, in favor of which the theft and other peculiarities speak, then it clearly demon- strates that the feminine character may be the result of the assumption of the female role, in the same way that devotional or theatrical employment cultivates a certain type.

In the second case reported by Servaes, there were maniacal out- breaks alternating with states of melancholic depression. Sexual incli- nations were manifested during the outbreaks of excitement; she threw herself on the female nurses and overwhelmed them with caresses. The first evidence of menstruation came after the second attack. Maniacal excitement, with contrary sexual instinct at the time of puberty. Re- covery.

The brain, powerfully stimulated by indifferent sensual excitants, convulsively seeks for some compensation, and accepts

' " Zur Kenntnlss von der contraren Sexualempflndung," Archiv fur Psychiatrie, 1876, Bd. vi, Hefl 2, p. 484.

HEREDITY AND EDUCATION. 173

the first person at hand. This person is a female, the more a reason why a girl, perhaps unacquainted with the sexual rela- tions, should trustl'ully make an approach. Convulsive effort of nature to complete sexual maturity. The intensity of the sensation attending the first orgasm may continue determinate in weak and hereditarily-disposed hrains ; hut in persons other- wise normal it becomes compensated by further normal develop- ment, which was the case in this instance.

The following case, reported by Friinkel,^ speaks still more forcibly for the transformation of the male into the female type, possibly by means of cultivation, and facilitated by congenital defect of resistive power :

The patient at first bad assisted his mother in sewing and embroid- ering, and then became so proficient in all kinds of feminine work that he obtained a great reputation and some return for his embroidery aiid hanging of curtains. As a result of his occupation in feminine work, he gave himself to feminine vanit}'^, carefully destro3'ed his beard, dressed his hair in curls, padded his bosom and hips, and used everj' opportunity to mask as a woman. What at first was merel}' sill3' affectation gradually assumed another nature : the tone of his voice, naturally low, became high and shrill ; the gait, tripping. Blank made application for per- mission to dress as a woman, and, though dismissed, he one day showed his betrothal to a foreign mechanic under the name of " Friederike Blank." The patient, whose genitals were normallj' formed, approached men and, dressed like a woman, performed coitus with young men whom he was able to deceive so skillfully that they thought they were engaged with^ woman. The anus was much dilated and torn. When arrested he killed himself by jumping into the water.

According to these statements it would seem that Blank becama feminine as a result of his engagement in feminine pur- suits to which his mother introduced liim. At least, as West- phal remarks, it is a case of imbecility and moral insanity, which is also confirmed by other perverse inclinations (theft). Why, in this instance, with the demonstration of the influence of training, contrary sexual instinct must be assumed to have arisen from original disposition is not clear.

Interesting and confirmatory of our view is the report of

' Medic. Ztg., herausgegeben vom Verein far Heilkunde in Preassen, Bd. zzli, 1853, p. 102 ; Homo mollis.

174 SEXUAL PARiflSTHESIA.

the Director of the Penal Institution of Brandenburg, West- phalia, which is to the effect that the pract'ce of feminine occupations by men in the institution may occasion feminine conduct.^

As we have seen in the cases reported, congenital im- becility constitutes an important basis upon which, with appro- priate external influence, contrary sexual instinct, with the secondary phenomena of effemination, may develop. In this development we see the predominance of imperative feelings, conceptions, and acts. Further, states of depression and ex- altation, alternating periodically, are observed. The unusual intensity and the premature manifestation of the sexual instinct, resulting from hereditary disposition, fill the fancy and drive such individuals to act on the impulse, in which the stimulus of the unusual may also play a role. Always, however, after close study of the history, we find how external circumstances exer- cise a determinate influence upon the form of the perversion. If, however, in such cases external influences seem to play a greater or as great a part as hereditary predisposition, still it must be allowed, on the other hand, tliat in other cases the original disposition is the determining factor. This is true, for example, of many cases of lust-murder (anthropophagy), viola- tion of corpses, etc., reported by von Kraff't-Ebing. To a certain extent algolagnists constitute a transition ; in some cases patho- logical association seems to play the principal part ; in otliers it is not possible to demonstrate determinate educational causes, and the congenital disposition seems to exercise the principal influence. Thus, Case 29 of " Psychopathia Sexualis " favors association :

An hereditarily-predisposed neurasthenic was present by accident when his mother's servant cut her finger on a broken pane, while wash- ing windows. When helping to stop the bleeding, he could not keep from sucking up the blood from the wound ; in the act he became vio- lently excited sexually, experiencing complete orgasm and ejaculation.

In this case it is quite possible that the servant-girl had previously excited the boy sexually, who was given to onanism;

Comp. Westpbal, loc. cU.

HEREDITY AND EDUCATION. 175

and he may have been unconscious of it. The accident brouglit them into bodily contact. Violent erection and psychical onan- ism. The idea of sucking blood may have been derived from reading ; for such an act is described as customary after snake- bites and other kinds of poisoning. The patient became an active algolagnist.

In the case reported by Moll (Case 30, in " Ps3'cliopathia Sexu- alis "), the patient, when a boy, read of the abuse of Roman slaves, and the thoughts of whipping and subjection formed the content of- ideas accompanying onanistic acts. In this way the patient became a sadist, which, upon the theory of pathological association, is easily explained.

Acts of a purely symbolic nature with an algolagnistic purpose, which merely indicate the relation of subjection, are, as von Krafft-Ebing shows, fully explainable by pathological intensification of accompanying phenomena of the vita sexualis. Very often we find that algolagnistic inclinations arise at the sight of boys being whipped at school, where accidental sexual excitement is associated with the perception of the flogging, then to become effectual in psychical onanism, and, finally, to become an imperative idea.

Von Krafft-Ebing regards foot- and shoe- fetichism as a transitional form of masochism (passive algolagny) to fetich- ism ; elements of both anomalies are combined in it. And he allows Binet's theory of association to hold good for pure fetichism. The first awakening of the sexual instinct is con- nected with a partial sexual impression ; it becomes inde- pendent, and finally becomes a conditio sine qua 7ion of sexual power ; and it is then pathological. " The occasion," says von Kraff't-Ebing, " on which the association occurred is, as a rule, forgotten." Therefore, it is clear that many cases of the autobiographical kind are unable to answer the question con- cerning the origin of the anomaly.

The significance of the exciting causes is placed in the clearest light by careful observation of contrary sexual indi- viduals.

In Case 95 of " Psychopathia Sexualis," we have to do with lima S., who is very sensual, but of normal feeling, made

176 SEXUAL PARiESTHESIA.

familiar by von KrafFt-Ebing's " Experimental Study in the Domain of Hypnotism."^ To support herself slie donned male attire, became a tutor, and finally gave up her place ; but she at last became accustomed to her role. Instinct and inclina- tion for the same sex, but without transformation of character.

In Case 72 (mutual onanism) and in Case 73 ^ the desire for change, which came with increasing sexual decadence, became the starting-point of the instinct and inclination for the opposite sex.

In Case 72 the patient had been an excessive onanist since his eleventh year, as a result of seduction. Nothing is said con- cerning the ideas accompanying the act. In a brothel he was impotent, which, in my experience, may occur in youths with- out perverse disposition. Seduced to mutual onanism, he became contrary sexually and his cliaracter feminine. Von KrafFt-Ebing correctly remarks that this is a case of acquired contrary sexual instinct.

In Case 75 the first sexual excitement of the patient (female) became connected in a platonic way with a lady, without any idea of the sexual relations. Marital intercourse compensated the instinctive impulse entirely, which appeared again only with abstinence (widowhood), and became expressed in auto-masturbation. In my opinion, the exciting cause in this woman, neuropathic by heredity, was alone determinate for her homo-sexual inclinations.

In Case 76, the patient, T., masturbated from his eighth year. What role his fancy played in this whether it conjured up for him male persons as a result of accidental association, or not he does not say, though that may have been the starting- point of his perversion. That the feminine inclinations occurred before the first indulgence in masturbation also seems question- able.

The origin of the perversion in Case 77 is very character- istic. A small boy saw his sister change her hose. When she

'Translated by Chaddock. G. P. Putnam's Sons, New York, 1889.

• These numbers refer to cases in the sixth German edition of Psychopathia Sezu-

11b, and cannot be identified in the English edition.

HEREDITY AND EDUCATION. 177

quickly concealed her feet it excited the boy's attention (prob- ably the first sexual excitement). Soon the sight of her feet to the ankles became the object of his desire. Since the sister objected, tliere was soon a struggle, which the patient carried on " with all the wiles of cunning and flattery, even to explosions of anger, until his seventeenth year" (beginning of sadistic incli- nations). Faute de mieux^ he availed himself of the feet of servants ; had lustful dreams about cutting corns and toe-nails (beginning of fetichism). When the patient was about 13 years of age, a comrade, who was sleeping with him in tlie same bed, kicked at him with his naked foot. The patient seized the foot. Intense sexual excitement ; first pollution. After that many male persons excited the patient sexually (psy- chological cause of contrary sexual instinct). The idea of a girl getting a thorn in her foot and its being removed by a boy gave him an erection when a mere child. This mixture of contrary sexual, sadistic, and fetichistic elements was compen- sated by normal sexual intercourse. Owing to his lack of resistive power in sexual relations, the patient became the slave of external influences, the quality of which determined the nature of the perversion: an excellent example of the origin of each of these perversions in pathological association.

In Case 78 the contrary sexual instinct was likewise ac- quired as a result of mutual onanism. Details will be found in the therapeutic section.

The subject of Case 79 was a shoe-fetichist from his fourth year (so stated), with contrary sexual instinct. Hetero-sexual intercourse is possible with the help of ideas of shoes. There is no doubt of the hereditary predisposition of the patient : his father is said to have had a preference for handsome lackeys. In this case, if the perversion actually a[)peared complete in liis fourth year, there could be some thought of original disposition due to heredity.

In Case 80 the sexual instinct appears in the eighth year, and becomes connected with (the nearest object) the sight of his brother's genitals. Mutual handling until the patient had erection. Repetition ; mutual onanism ; coitus inter femoni

12

178 SEXUAL PARiESTHESIA.

when 13 years of age. Later, horror feminse. After the great- est difficulty, coitus is finally performed ; but it never satisfies him, though the patient marries and becomes the father of four children. In this case, likewise, the contrary sexual instinct is not necessarily due to original disposition. The sexual educa- tion of this man, wanting in resistive power because of heredi- tary taint, seems to us to afford the explanation : the instinctive anomaly rules too completely the patient's entire existence to allow compensation by normal sexual intercourse.

The subject of Case 81 noticed the awakening of his sexual instinct in his sixth or seventh year; at that time he induced a playmate of his own age to show him his genitals. Mutual handling, mutual onanism. During the next ten years unin- terrupted sexual relations with friends; knowledge came in his eighteenth year. Horror feminae. Complete homo-sexuality.

In the fact that children, as soon as they become aware of their sex, look at their genitals, I can see no indication of con- genital sexual perversion, nor in the curious handling of the genitals of their playmates, that leads to sexual excitement and mutual onanism. In Case 81, also, external influences are suffi- cient to account for the pathological direction of the instinct ; for systematic cultivation could not be more effectually prac- ticed than it was in this case as a consequence of unfortunate relations.

In Case 82, likewise, the sexual associations, with intense feelings, seem to have arisen accidentally when the patient was in bed with a companion (handling of the erected penis).

The subject of Case 84 states that in his third year (if there is not an illusion of memory) he took an interest in the handsome male forms depicted in fashion journals. Inclinations to play with dolls. From the age of 13 to 15 the patient slept with a man and masturbated. Even though this circumstance may have given opportunity for pathological association, still the patient's statements seem, allowing that they are correct for the conditions existing before his tenth year, to speak in favor of original predisposition.

In Case 84, a schoolmate, aged 15, placed the patient's

HEREDITY AND EDUCATION. 179

hand (aged 1 3) to his open trousers with onanistic intent. The patient's sexual feeling, until that time indifferent, became in- tensely excited and perverted. From that time his friendships took on a sexual character. At the age of 19, mutual onanism and development into an urning.

In a similar manner, in Case 85, this subject learns onanism at the age of 6 by having his genitals handled by an elder play- mate. Enthusiasm for handsome playmates, desire to touch their genitals, etc. When tlie patient came to play with girls, his impulse to onanism had already become so powerful that no compensation took place.

In the writer of the autobiography of Case 87 the awak- ening of the sexual impulse occurred in his third year, without, however, being directed to the male sex. He often sought, for example, to look under women's skirts, to touch a friend's gen- itals, and to stroke the anus of the coachman's son. At the age of 5, inclination toward a playmate (perhaps induced by manip- ulations of the genitals). At 14 the patient became a psycho- sexual hermaphrodite ; he loved young girls, but no more than he did boys. Then came solitary and mutual onanism. After touching male genitals his ideas in sexual matters were about persons of the same sex. Complete development into an urning.

The writer of Case 88 asserts that he has been an urning from the beginning, and doubts whether onanism practiced from youth could induce inversion. According to his statement, his first sexual promptings occurred in his tenth year and were directed exclusively to men. Onanism began in his twelfth year. It is not' stated what external circumstances influenced the indifferent impulse. If illusions of memory as to the time of the first sexual excitement are not in play here, this case may also be explained, in spite of its defects, in the same manner as the preceding.

The autobiographer of Case 89 experienced the first sexual excitement at the age of 9 or 10, when his tutor let him " ride horse " on his leg. The impulse then remained directed to men. Whether the inclination for feminine pursuits occurred before or simultaneously with the excitement (which is the more

180 SEXUAL PARiESTHESIA.

probable) is not stated. The impulse became confirmed by onanism with thoughts about men. Coitus possible, but devoid of satisfaction ; successful only with the ]w\\) of thought of men.

In Case 90 an original disposition may be presumed. A cousin of the patient is contrary sexually, and he states that he took the part of a girl before the occurrence of his sexual per- version. Mutual onanism from his thirteenth year.

The subject of Case 91 (female), greatly predisposed, suf- fering with imperative ideas, remains neutral sexually until her twenty-eighth year, then falls in love with a lady five years younger. Mutual onanism. As in the majority of cases, in this instance the first sexual excitation exercises the most en- during influence upon the patient's life. Marriage and the duties of a mother later are incapable of erasing the primary impression. She is unhappy in married life.

The patient (female) in Case 92 shows signs of intense sexual excitement in her thirteenth year, which is expressed in enthusiastic love for a friend of her own age. By this means her sexual peculiarity seems to Tiave been determined. Mar- riage does not cure her. She goes on to inversion and probably gratifies herself in mutual onanism. Nothing is said of mas- ^turbation from her thirteenth to her eighteenth year.

This completes the review of the cases reported by von KrafFt-Ebing as congenital contrary sexual instinct (homo-sexual individuals, or uraings). Class I (inversion of the sexual in- stinct). From this resume we see that the influences of edu- cation, with two or three exceptions, can be shown to have exercised a determining effect.

Neuropathy or psychopathy was hereditary. The few ex- ceptions are perhaps to be explained by imperfect history or the self-deception of umings, which, according to Binswanger's^ view, in " conscious " or " unconscious " form is nowhere more probable than in the sexual sphere.

Not one of the cases cited has impressed us as if the woman had been develoj)ed ah ovo in the male body.

We come now to the class of " Effomination and Vim-

" The Employment of Hypnosis In Asylums," Therap. Monatshefte, Heft 3, 4, p. 167.

HEREDITY AND EDUCATION. 181

ginity." Case 93 seems to speak in favor of the isolated influ- ence of educational factors, for the patient's father states tliat the patient became interested in female toilettes, and helped his sisters do dress-cutting, etc. Unfortunately, we learn nothing on the most essential point. From the description it is possible that the patient's effemination was developed as a result of causes forgotten, causes which directed his sexual feeling to male persons. In that case, his feminine employment may have been but a secondary accommodation to his assumed role, and thus explainable like previous cases.

The writer of Case 94 did not experience ejaculation until his twenty-eighth year, but from his thirteenth had directed his sexual feeling to boys ; and his character had developed into that of a woman, sexually, vvithout the occurrence of compen- sation of this platonic tendency by association with women. Concerning the first association the patient gives no satisfactory statements. It remains doubtful, therefore, whether accidental cause or original disposition was of greater influence in the pro- duction of effemination. In conclusion, the patient himself asks the question whether this result was not brought about by too great laxity of training.

The patient in Case 95 makes such incomplete statements concerning the awakening and association of his first sexual excitement that we cannot use this report which represents the final result of a long process of development,, under the influ- ence of which it is written for our purpose. We learn only that inclinations for men appeared in his thirteenth year; nothing is said of onanism.

The abnormal instinctive tendency of the writer of Case 96, according to the description, seems especially to have arisen from original disposition. An uncle contrary sexually; no emission until the twenty-s>xth year ; no onanism. Still, there were violent erections from the age of 13, which would not cease, and which ended with nightly pollutions in erotic dreams of male persons. Whether, in this instance, the original sexual neutrality was given a perverse direction toward men by ex- ternal circumstances, and thus the imagination became occupied

182 SEXUAL PARiTilSTHESIA.

in the same way, remains doubtful. In such case the effemi- nation was liere also to be attributed solely as a result. As far back as the patient could remember, his development of char- acter had been feminine.

Count Z., subject of Case 97, began masturbation at the age of 11, and during that year, in church, a man made a fasci- nating impression on him. At the age of 13, neurasthenia spinalis and inclinations toward men. Preference for dolls and girls' games. -Horror feminae. Great hereditary taint.

Two sisters of the patient who is the subject of Case 98 love men. At the age of 13 the patient was seized with a passionate love for an elderly officer. He remained true to his perversion after this incident. Onanism and impotence with women. In this instance, also, the possibility of cultivation does not seem to me to be excluded.

If it be possible to defend original disposition in the two cases last mentioned, it does not seem possible in Case 99. The patient felt his sexual instinct awaken in his eighth year, and had the idea penem aliorum puerorum in os arrigere, to which he may have been brought by circumstances that are not men- tioned. Great pleasure, and determination of his feeling toward men. Later, he was able to perform coitus, and he became the father of two children. The efFemination seems to have been developed secondarily. Educational influences operating upon one hereditarily predisposed may here be taken as offering an explanation.

The subject of Case 100 found, as early as at the age of 5, his greatest pleasure in seeing a penis, and for this pui-pose he lounged about appropriate places. Onanism before puberty. In this case, apparently, circumstances not mentioned must have turned the boy's attention to the pciiis (exactly as in the case of one of my patien<^"). Later, love of friends ; sexual intercourse with men ; efFemination, in spite of complete devel- opment of the male sexual character (beard and voice).

Cases 101 and 102 contain only notes without etiological points. The last case of this class, Case 103, is that of a servant-girl afflicted with original paranoia and hysteria, who

HEREDITY AND EDUCATION. 183

never had felt inclination for men, but for female friends. Enthusiastic love for persons of her own sex from the time of puberty. The report contains no more detailed description of the origin of the sexual perversion ; so that the question whether the original disposition or educational influence was more largely responsible for the origin of gy nan dry must remain open.

As we have seen from the foregoing review, there has been no absolute proof in any case of the origin of contrary sexual inclinations and efiemination with exclusion of the influence of training. Even the doubtful cases could possibly be explained, on closer examination of the pathological association of the first sexual excitement and the person immediately at hand. In every instance we find inability to overcome, by opposing ideas and normal sexual intercourse, the confirmed perversion (as a rule, by onanism with corresponding dream-pollutions) that has arisen as a result of some accidental impression, a weak- ness that is to be ascribed to the hereditary predisposition, as is the premature awakening of the sexual instinct which is in these patients.

In his " Psychopathia Sexualis," von Kraff't-Ebing gives three cases of gynandry and androgyny.

The subject of Case 104 is a person defective ah origine^ affected with neurasthenia spinalis, which is ascribed to the causal influence of masturbation. At the age of 22 the patient associates with women, performs coitus normally, but, owing to imperfect satisfaction, he turns away from the female sex. Thorax and pelvis of feminine form ; slight growth of hair on the mons veneris, which is prominent and plump. Voice high, without masculine timbre. Patient is neuropathic in such a way that the sexual perversion represents but a partial symptom of his condition. It seems to arise from abnormal organic conditions.

The patient (female) in Case 105, aside from masculine manner, presents coarse features and a rough, deep voice. Bosom and pelvis feminine. She grew up with a preference for mascu- line pursuits, but there are no other details given of educational influences. CoiTesponding with her ro/c, she feels like a man, and later becomes associated with women.

184 SEXUAL rAK/liSrUKSIA.

It seems to me questionable wliether the few physical signs (voice and coarse features) alone justify the assumption of gynandry in the presence of a type otherwise feminine. It would be interesting to know how the patient came to assume the masculine role. The history of the case does not deny the possibility that the inversion of sexual feeling was brought about by educational influences.

The subject of the last detailed description (Case 106) is the notorious Count Sandor S. ; in reality, Countess Sarplta V. The details of this history are too well known to require repe- tition here. The physical signs indicative of gynandry in the patient, according to Birnbacher, are : (a) general narrowing of the diameters of the pelvis, which is of the male type; (h) straight thighs, infantile female genitals, trunk devoid of waist, voice deep and rough, breast fairly developed.

The opinion of Dr. Birnbacher and Dr. Josch was to the eflfect that Countess V. was suffering with congenital neuras- thenia, congenital mental disease in the nature of elementary disturbance of mental function, and contrary sexual instinct depending upon the same basis ; and that therefore she was to be regarded as insane.

In a supplementary statement the same authors state that the acts related to the sexual instinct arose from a kind of organic necessity which recalls the so-called imperative acts of certain insane patients.

The opinion giwen in the higher court by the faculty of Vienna, signed by Theodor INIeynert ^ as referee, declares that the patient is irresponsible, but contains another view of the disease. The facial bones, the position of tlie teeth, and the pelvis are called rachitic. "Owing to the fatlicr's influence she was early educated as a boy, and, as a result of this, deprived of the educational influences of an ethical orientation of the simplest things connected with her station in life and her duties to her fellow-beings. . . . Carried away with poetical fancies, she gave herself the fonn of a man dressed in her boys' garments, like Don Juan. Besides male garments, her conduct was allowed

Comp. Friedreich's Blatter far gerlcht. Medlcln., Numberg, 1891, Heft 1, p. 36.

HEREDITY AND EDUCATION. 185

to be unrestrained, tlie very opposite of a girl^s education." Sexual feeling at the age of 12, which, corresponding with her early preparation, found its first satisfaction in contact with a young English school-girl. Thereafter, comradeship with males. Relations with women, while men were indifferent. Drinking, smoking, night-cai'ousals, etc. " By using a glove a penis was imitated. She retired behind trees to give the impression of urinating like a man ; said her menstruation was due to hsem- oiThoids, etc. She once stated that she had to engage in mili- tary drill, and said she had a scar on her arm from a wound received in a duel." The referee opposes the theory of congen- ital masculinity with female genitals, and empliasizes that the countess is practiced in the imitation of masculinity; that doubtless she directs the tone of her voice accordingly; that she imitates masculine immomlity, and "overdoes the matter."

The fact of growing up in male attire is not given suffi- cient weight by the experts. According to this view, Countess Sarolta V. suffers with imbecility with excitement, and, owing to her weak-mindedness, she is unable to judge her own acts, etc.

" In combination with other excesses tricks, absolute social looseness, prevarication, dininkenness the symptom of contmry sexual instinct constitutes the patient's degeneracy, for which the name ' moral insanity ' is largely in use. The latter is but a symptom of congenital imbecility."

The occuiTcnce of Westphal's contrary sexual instinct Meynert holds always to be accidental. The sex with which early sexual impressions happen tc become connected, in abnor- mal individuals, determines the occurrence of this symptom. Imitation and education develop all the ultimate characteristics of the sexes. At any rate, and we agree with Meynert in this, this case is very instructive as showing the exciting cause of contrary sexual instinct.

The remaining cases of contrary sexual instinct reported in "Psychopathia Sexualis " are concerned with therapeutics, and are considered in the therapeutic part of this section.

The foregoing critical review with respect to the influence

186 SEXUAL PARiESTHESIA.

of education is sufficient to confirm our theoretical propositions concerning sexual development ; and, therefore, for the sake of brevity as well, it does not seem necessary to extend this exam- ination to cases in von KrafFt-Ebing's " New Investigations in Psychopathia Sexualis."

Wliile, as we have seen, in the cases given in " Psycho- pathia Sexualis," the principal emphasis is laid upon the origi- nal disposition dependent upon hereditary influences, some of the reports of perverse sexual instinct made by Hammond are instructive for us, owing to the consideration of the exciting causes. At least, Hammond^ points out that in cases in which individuals entertain the delusion that they belong to tlie oppo- site sex (vide von KrafFt-Ebing's " delusions of sexual transfor- mation "^) are not to be confounded with cases of this kind, " for they are cases of actual monomania, and are seldom combined witli other pathological sexual symptoms."

The importance which educational factors and external influences may attain in tlie origin of sexual perversions, as a result of pathological associations in the case of hereditary neuropaths, is illustrated by tlie following cases, reported by Hammond :

A bo3', aged 7 years, who was hereditarily predisposed, was taught to masturbate by a servant-girl. At first she induced erection by touch- ing his penis with her foot with the shoe on, and thus the patient experi- enced his first sexual pleasure. From that time sexual excitement and erections at the sight of women's shoes ; later, at the mere thought of them. Onanism in the midst of women's shoes, which he placed about himself in all sorts of positions. Then psychical onanism by means of the thought of women's shoes. At school, sexual excitement dne to the teacher's shoes. Partial concealment of the shoes by long skirts induced especial pleasure. In order to intensify his sensual excitement he one day seized his teacher's shoe, and experienced greater pleasure tlian ever. Sexual orgasm. In spite of punishment, repetition of the act, with like result. Later, the mere memoi'y of his teacher's shoe induced ejacula- tion. After that he purloined the servant-girl's shoe and ejaculated in it. New variations by using a different shoe with each act of onanism. He stole shoes for this purpose. Nnde women or men excited only feel- ings of disgust. He never thought of sexual intercourse. Finally, he

' Loc. rit.

• KrafiTt-Eblng's " New InveBtigations " gives very pregnant examples.

HEREDITY AND EDUCATION. 187

sold shoes in a store. Sexual excitement while fitting them. On one occasion, while fitting a pair of shoes, powerful erection without orgasm ; loss of consciousness and an epileptic attack. Determination to marry. Impotence in marriage. On Hammond's advice he hung a shoe over his head ; simultaneous treatment with bromides. Coitus was then success- ful, and without epileptic attack. Later, regular sexual intercourse once in ten days. The thoughts of women's shoes came to him still now and then, but without exciting him sexually.

This very remarkable case, as Hammond remarks, shows that a strong will, even in a man of no great intelligence, is capable of redirecting an abnormal instinct into its normal path.

Another of Hammond's patients, a cigar-dealer, in childhood saw a dog and bitch copulate. Believing that tins took place by means of the anus, he passed a lead-pencil into his own rectum. " This caused him local pain, but also a peculiar feeling of pleasure, the localization of which he could not at first make out." After a few days he repeated the experiment with similar result, but this time used the handle of a tooth-brush which he had previously oiled well. Again he experienced a pleasurable feeling, and that in the penis. From this passive pederasty was developed.

Moll,^ who " will not deny that accidental causes are not without value," assumes that there was doubtless an abnormal disposition in the boy. " How could he," asks Moll, " otherwise have had such a pleasurable feeling on inserting the lead-pencil in his anus as to be led to repeat it so frequently 1 " Even if the patient were the subject of an inherited neuropathic dispo- sition, which Hammond's report does not make clear, it would not be necessarj' to regard it as an original inclination to pederasty. Local irritation of the rectum alone is sufficient to induce erection, and therefore causes sexual excitement, as has been repeatedly demonstrated on impotent debauchees in re- moving foreign bodies from the rectum.

From pederasty contrary sexual instinct was developed in the patient ; he put on feminine attire, called himself " Lida," and never had inclination for women after the imdifferentiated sexual feeling had been given a definite direction. He later had epileptiform attacks. He stated that he had performed pederasty at least ten thousand times, actively and passively.

Loc. cU., p. 163.

188 SEXUAL PARiESTHESIA.

The desire to be a woman became so intense (as in the patliici of the ancients and in some of von Kraft"t-Ebing's patients) that lie repeatedly thought of amputating his genitals.

In the following case, by Hammond, accidental local irri- tation (of erogenous areas) seems to have been the starting- point of the perversion :

A boy, aged 12, was severely punished in school for a mischievous prank ; soon after he had an erection lasting half an hour, with a peculiar feeling in the glans which he had never before experienced. The same afternoon he went bathing with a companion, and while in the water he placed his hands on his companion's shoulders. He had often done this before without experiencing sexual excitement. On this occasion his penis touched his friend's gluteal region, and immediately he experienced the same feeling with erection that he had had after being punished. They were near the bank, and, without being conscious of it, he performed pederasty (immissio penis in anum?). From this time he continued the vice, partly passively, but for the most part actively by preference. Sexual excitement induced by nude men ; onanism. Ideas : male gluteal region ; dream-pollutions of a pederastic nature. Women had no power to excite him. He remained an active pederast.

Hammond's treatment freed him entirely of his perverse tendencies. It consisted of" study of mathematics, hydrotherapy ; cauterization of the cervical, dorsal, and lumbar regions ; bromides, and family social life." After a few months essentially improved ; sexual inclinations for women ; marriage.

The following case is also interesting, though in some respects it seems to speak in favor of the theory of original predisposition :

The patient, father of four healthy children, the issue of an ex- tremely happy marriage, according to his own statements, before puberty had a decided preference for household work and feminine games and dress, though he came only to wear girls' shoes. His preference for feminine attire grew later, as well as that for acting feminine 7-6les on the stage by men. At the age of 21 he wore corsets, laced himself, and stated that he thus experienced great sensual satisfaction. No onanism, but involuntary'ejaculation three times while putting on and buttoning a pair of very tight shoes (ladies' shoes with French heels). After his marriage he no longer wore corsets.

In spite of a happv marriage, after several years the same ideas re- turned. He was accustomed to put on and button ladies' high-heeled shoes, which induced erection and ejaculation. Ideal cohabitation at the

HEREDITY AND EDUCATION. 189

sight of a lady tightly laced and with elegant feet. Again he wore cor- sets, and, to increase the pleasure by novelty, he bought other articles of feminine apparel, a black-silk gown, curls, hoops, false hair, and ear- rings. He padded his breasts, laced, and put on an enormous bustle. He had his hair dressed fantastically in the ladies' fashion for hours at a time. He persuaded his wife to lace. He dressed himself up as a ballet- dancer, Queen Elizabeth, a Polish lady, an old maid, the Goddess of Liberty, Julia, etc.

In this very interesting case, unfortunately, we learn noth- ing of the manner of origin of the pathological association, that is, notliing of the external circumstances which were oper- ative in inducing the preference for feminine dress. In this case, as was remarked in opposition to Westphal's view, in our opinion, we are not concerned with a case of contrary sexual instinct, for the sexual feeling, as the happy marriage and the four chil- dren show, was perfectly normal, and underwent no essential alteration as a result of the imperative ideas. At most, the case might be called one of psycho-sexual hermaphroditism. In spite of the feminine Q-oIe and the erotic fetichism, the sexual feeling remained normal, and the imperative idea only concerned dress. Had the patient masturbated excessively, and thus in- tensified his perverse tendencies, he might possibly have come to assume also the feminine sexual oSle. This case shows clearly that we are justified in speaking of contrary sexual instinct only when the sexual feeling is demonstrably implicated. Subsidiary symptoms, like preference for ornament and feminine work, or specific feminine peculiarities of character, are not by themselves sufiicient to justify a diagnosis of sexual inversion, though they may easily become the starting-point of it, for proof of which, in the foregoing case, the erections and ejaculations may be noted.

How very influential external circumstances are in deter- mining the sexual character is shown by the following case, reported by Rouboud ^ :

A general's son, while a pupil at a military school, at the age of 14 was introduced to the pleasures of love by a young lady, a friend of the

• Rouboud : Traite de I'impuissance et de la Bt6rilit6, 3 6d., Paris, 1876 ; and Ham-

mond, loc. cit.

190 SEXUAL PARESTHESIA.

family. This lady, then 21, was a blonde, wearing her hair in the English fasliion, in twisted locks; and, to avoid detection, she had sexual intercourse with her young lover only while dressed in her usual garments, skirts, corsets, and a silk gown. All these peculiarities finally had the greatest influence not only on the intensity of excite- ment, but also merel}' on its occurrence. This exceedingly sensual young lady exhausted the boy's strength, and only the strict discipline of the military school was capable of restoring the sexual organs, which had been overstiraulated by too early and too frequent use. Finally, after leaving the school, the patient noticed that his sexual desire could be excited only under definite conditions, by certain women. A bru- nette could not excite him ; a female in night-costume might stifle all desire in him. In order to excite his desire, the woman had to be a blonde, and wear skirts, a corset, and a silk-dress; in short, be dressed like the woman who had first excited him sexually.

Similar pathological associations may so operate as to render a husband virile only with his wife, or to make a debauchee impotent on his marriage-night. This relative impotence is due to one-sided determination of sexual feeling which, in many instances, has previously been undetermined, and it may attain the intensity of imperative feelings. Psycho- logically, it is to be explained like the pathological association of fetichism and the impotence of persons of contrary sexuality.

Concluding Remarks. A review of the cases already given, and of those still to be given in the therapeutic portion of this work, clearly shows the extraordinary importance of accidental factors of education and external influences in the etiology of paraesthesia sexualis, a fact which, I think, is greatly undervalued by some authors.

We have seen that many cases that have been regarded by their reporters as abnormality of hereditary disposition were developed as a result of accessory causes ; that the proof of the existence of' a congenital predisposition, such as that of the female type of character in a male body, for example, rests entirely upon statements made by patients, and therefore is defective. The historical and developmental theory of anthro- pological transformation (androgyny and gynandry) seems to us least entitled to support by experience.

On the other hand, as a rule, pathological association was

HEREDITY AND EDUCATION. 191

capable of developing the evil results only where a nervous system of sliglit resistive power the most frequent symptom of hereditary taint offered favorable ground. The exjieriences with fetichists taught us, first of all, what part may be played by the object of the perversion, in determining its form as a cause of imperative ideas and feelings with their consequences (effemination, for example).

The part played by the accessory factor in the etiology of the habitual impulse to perverse sexual acts is usually more important than that played by hereditary disposition. And the latter, in the class of psycho-sexual anomalies we ha\e consid- ered, and which, in comparison with those resulting from demon- strable original brain constitution, includes the larger number of cases, represents a general pathological disposition (imbecility or irritable weakness), and a want of resistive power to com- pensate the pathogenetic excitations by normal opposing con- cepts or inhibition of impulse. With this, I tljink, we have reached a more general and a clearer conception of a large class of psycho-sexual disturbances and diseases, more satisfactory with reference to prognosis and therapeutics.

CHAPTER X.

DIAGNOSIS AND PROGNOSIS.

Remarks on Perverse Activity^ Original Disposition, Ac- cessory Causes, and Neuropathic and PsycJiopathic Symptoms. Diagnosis in the case of fetichists and algolagnists is rela- tively easier than in the case of contrary sexuality ; for, as a rule, their sexual power is associated with the perverse activity of the instinct, and normal intercourse is impossible. There are some exceptions to this. Perverse activity is to be regarded as pathological in every case where it is a conditio sine qua non of sexual power.

In algolagny, as pointed out in the foregoing chapter, it must be ascertained whether the acts expressing cruelty are active or passive in nature ; also, when they are merely sym- bolic, whether they signify subjection.

Too, the abnormal manifestations of the sexual instinct largely arise from pathological intensification of the inclination, very common in healthy men, to experience variations in the sexual relations. In such cases the object and the manner of the perverse activity change; the object of it may belong to both sexes.

In all perversions, uranism as well as fetichism and algo- lagny, the question of hereditary taint, as shown by our con- siderations, must be studied most carefully. Therefore the following question is of the utmost importance. Is the perver- sion the result of an original abnormality of cerebral constitu- tion, or has it developed as a result of accessory injurious influences of education upon the predisposing basis of a neuro- pathic hereditary taint "?

Too, the states of original degeneration may become de- veloped only in the course of life from the inherited dis- position. In order to form a judgment of the "plastic capability of adequate adaptation to external circumstances" (Forol), the most exact knowledge of the accidental influences

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DIAGNOSIS AND PROGNOSIS. 193

of education is necessary. The occurrence of the first sexual excitement (indefinite feelings and erection), which may, as we have seen, take place as early as from the fifth to the eighth year, especially in those hereditarily predisposed ; the external circumstances accompanying it, which often lead to the fatal association ; further, the occurrence of the first sexual orgasm with its associated perceptions ; and, finally, the ethical and emotional reactions, all are of the greatest importance. Where, however, in spite of all favorable educational influences, and without demonstrable external causes, the perversion progres- sively develops, congenital disposition seems to bring about the result. Still, it must be remembered that the exciting causes are often forgotten. The idea accompanying the onanistic act (whether psychical or mechanical) should be studied, for by practice and habit the abnormal thought may become an imperative idea.

But the absence of onanism does not exclude cultivation. For the fancies accompanying dream-pollutions are likewise merely recapitulations of the individual's experience. If, in their first sexual association, these are of a perverse nature, they may then assume the role of cultivation.

Such cases, also, as those in which no hetero-sexual rudi- ments of any kind can be discovered are by no means decisive as evidence of the original character of contrary sexual instinct ; they may likewise be the result of external influences which, from the first perverse association, completely appropriated the undifferentiated sexual feeling, and thus left no opportunity for other sexual feelings and ex|^riences.

On the other hand, very important in establishing the original tendency of contrary sexual instinct is the proof that the feminine characteristics of the male child were developed before the occurrence of the first sexual excitement (not before puberty, as many urnings think), and that feminine sexual feeling arose from these characteristics witliput tlie aid of external in- fluences. On this point, however, the statements of urnings their confessions are to be accepted only with great reserve. For, while writing the autobiography, these individuals are under

13

194 SEXUAL PARiESTHESIA.

the subjective influence of a sexual development resting upon numerous experiences; perhaps, too, they are subject to the unconscious suggestion of voa Kraft't-Ebing's theory of hered- ity, and thus enlarge the history retrospectively, without distinc- tion in time of the subjective events.^ On this point, no error is easier than to date the beginning of effcmination before the time of the first sexual excitement ; while effemination as a sec- ondary product of sexual inversion would speak in favor of the theory of cultivation. Standing alone, without sexual inversion, manifestations of effemination prove the existence of contrary sexual instinct as little as do physical peculiarities which rcsemble those of women.

We may distinguish three possible etiological develop- mental factors in the production of contrary sexual instinct : (1) original cerebral constitution ; (2) a neuropathic disposition with educational influences ; (3) pure cultivation in normal in- dividuals. Class 2 is by far the most numerous.

In sexual inversion the following important diagnostic points should be considered : (a) the episodical occurrence of homo-sexual impulses in individuals of hetero-sexuality ; (b) psycho-sexual hermaphroditism ; (c) the content of sexual dreams ; (d) the complete absence of hetero-sexuality as a pathological phenomenon (Moll).

It is of the greatest importance in diagnosis to demonstrate the existence of other neuropathic or psychopathic symptoms, signs of degeneracy, etc. ; that is, to ascertain whether the per- version occurs as a symptom of moral insanity, congenital im- becility, etc., or whether the disturbance of the sexual instinct seems to be isolated and independent in an individual otherwise normal mentally.

Besides, there is also the question of responsibility. The fact of disease of the sexual instinct does not in itself render the

' Binswanger Tery justly expresses his mistrust of such " auto-suggestions of doubt- ful value " ; for, In his opinion, they might arise especially In connection with the " amal- gamation of abnormal sexual inclinations with increased physiological excitability." Nowhere, according to Binswanger, is there a greater effort to be excused morally and legally, and to cover with the mantle of abnormal constitution acts which are not In accord with modem morality, than in this domain.

DIAGNOSIS AND PROGNOSIS. 195

individual affected irresponsible. Only the proof that the indi- vidual has committed a criminal act as a result of organic neces- sity, as if forced to it, and, owing to his cerebral constitution, was incapable to developing (or acquiring) tlie necessary in- hibitory (or restraining) ideas, will allow him to be held as devoid of free will. Very many individuals of contrary sexuality are well able to control their impulses. The broad leniency which Moll accords such patients, in this respect, seems to me to be unjustified ; and it could be misused as permission for the justification of the most vicious practices.

Further diagnostic details are given in the works of von KrafFt-Ebing and Moll, and in the preceding chapter.

Dependence of Pi'ognosis upon the Causes of Origin. The development of the perversion depends upon the lack of a rational development of the mind and will. The abnormal congenital disposition to perverse activity of the instinct, since it must be regarded as dependent upon cerebral organization, can scarcely be removed by any remedial measure. Still, in this, the severest form of predisposition, properly-directed measures may be successful in hindering the perverse tendency; in preventing the premature awakening of the sexual instinct ; and eventually in establishing normal sexual intercourse by artificial cultivation. In isolated affection of the sexual instinct the prospects of cure are better than in individuals of defective constitution (Binswanger).

If the form of the perversion is not predetermined by the organization, but developed by exciting causes on a neuropathic basis, a favorable prognosis may be given. For the result of education may, in its turn, be overcome by education. The general condition of the nervous system will determine whether merely improvement of a deeply-rooted malady or complete cure is possible.

According to von KrafFt-Ebing, the occurrence of effemi- nation in individuals of contrary sexuality is the limit beyond which there is no hope in therapeutics. The more closely the abnormal inclinations are united with the constitutional pecu- liarity of the individual, the slighter the prospect of lasting

196 SEXUAL PARiESTHESIA.

benefit. But this question still seems to us an open one ; in- creasing observations of the favbrable results of suggestive therai)eutics make it seem possible, perliaps, to bring about a relative limitation and diminution of the acquired feriiinine char- acter. Psycho-sexual hermaphroditism, cultivated pederasty, and acquired contrary sexual instinct in untainted individuals offer prospects of complete cure. Also, hetero-sexual rudiments in homo-sexual individuals permit a hope of awakening normal sexual feelings.

The intensity of the impulse and the past duration of the condition must be taken into consideration in the concrete case ; as well as irritable weakness of the genito-spinal centres, which is a frequent accompanying symptom. Thus, even degenerate individuals may possibly be benefited to a certain extent. Whether, however, the completely-developed delusion of sexual transformation, and likewise algolagny in its highest degree of development (necrophilia and lust-murder), can be influenced, seems questionable. But we are not justified in stating that there is no hope while no attempts have been made in such cases with hypnosis. In a developed psychosis, in accordance with present views, psycho-therapeutics can accomplish little ; therefore, where sexual perversion occurs as one of the symp- toms of a psychosis, an unfavorable prognosis is to be given, as in epileptic pederasty, in the perversities of paretic dementia, and in those occurring in certain states of periodical excitement.

CHAPTER XI.

PSYCHICAL AND SUGGESTIVE TREATMENT OP SEXUAL PERVERSION.

Consciousness of Moral Duty as a Prophylactic^ with Re- marks on Education in Morals^ fix)m the Stand-])oint of the Tlieory of Suggestion. The principal task in the prophylaxis of sexual errors lies in education. A good moral character is the best preventive of psychoses. For passions and vices ex- haust the brain and alter its constitution. Through yielding to dissipation and want of self-control many an insane patient has been, in part, responsible for his disease. The importance of moral education for mankind is shown by the facts of heredity. Congenital pathological changes of the brain, however, cannot be influenced either by the whole armament of moral treatment or by other means. No form of education is capable of com- pensating for the congenital defect of ethical ideas. In such a case, the strict discipline of a well-conducted institution is indicated.

Apparent cures of psychical degeneracy, as they are occa- sionally reported, in case of correctness of diagnosis, are ex- plicable as marked remissions such as occur in moral insanity. For, according to the agreement of all alienists, original psychical degeneracy is incurable.

As a rule, however, we have to do merely with predis- position to perverse actions, and here correct education and control of the impulse may bring about improvement. Con- cerning the degree to which tempemment and character can be influenced by pedagogic means, there are various opinions. That instincts can be overcome there is no doubt.^ Taking the idea of suggestion in its widest sense, all education may be re- garded as a combination of co-ordinated and well-considered " suggestions." It does not, of course, consist of merely the

' Comp. Guyau, Education et Her6dit6, Paris, 1890. This book gives excellent re- marks on this subject, but it seems to us to contain some errors concerning the concep- tion and significance of suggestion.

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198 SEXUAL PARESTHESIA.

teacliings of parents and teachers ; morality, religious faith, and related conversation and social intercourse have an effect on the brain that is to a certain extent latent, and thus direct our liabits. But education cannot create genius, though it may develop it.

Moml health is more important than intellectual qualities for the progress of the individual and the race. Vicious moral instinct leads to deterioration and extinction. Therefore, the creation of moral duties *may be regarded as the necessary object of individual development. The Darwinian selection of the useful, in social life of animals, for example, also leads to the development or predominance, even though in a broader sense, of minor capability or peculiarity, by sexual selection.

Our acts are directed by what we call " duty " ; this is the result of morals and reflection, the product of harmony brought about between our dominant inclinations and the formulae that have been suggested to us by the influences of education. With children, it is sufficient to empliasize this or that good peculiarity that is found in them in order to induce them to develop this faith. Every lively image (idea) in con- sciousness strives to make itself real in acts. It is necessary to make the child believe that it is morally free and master of itself. The opposite of this is moral abulia, an active yielding to the first strong impulse. To give a child bad feelings, to blame it unjustly (compare Case 67), is to bring about the opposite result, to point out evil and develop it. Often the child is not conscious of doing wrong. In such cases it is necessary to convince the child that it did not choose to act so, but did it in mistake. Just as with hypnotized subjects, it is necessary to presume the existence of the peculiarities we wish the pupil to possess. Among the most powerful means of sug- gestion are public respect an*d self-respect, since daily experience shows that this means alone is effective in imjn'oving individ- uals. The abandonment of evil ways, perhaps, at first through external influence, at last becomes a habit, and the simultaneous direction of the attention to good contributes its share to the modification of conviction. And in the same manner an inner transformation may likewise take place.

PSYCHICAL AND SUGGESTIVE TREATMENT. 199

Suggestion is merely the introduction of a corresponding belief to be later realized ; the effect of suggestion, tlierefore, con- sists of the art of convincing an individual that things are or may be different from what they actually are. Thus, it is necessary to convince children that they are only capable of good, and absolutely incapable of evil. The suggestions of early years are the most powerful of all. There are good and bad instincts in every human being ; and it is only necessary to guard the child on occasion from receiving the formula for the evil instincts. The consciousness of evil inclinations, of perverse tendencies in the vita sexualis, as a rule, intensifies them. Therefore, um- ings try to excuse and justify their passion, as we have seen, by the aid of the theory of uranism originating with Ulrichs. The educator must also awaken the conviction that the individual is capable of understanding his acts. To cause any one to believe that he is a fool and incapable of this or that act is to system- atically cultivate foolishness. Self-confidence must be increased by assurance. Through independent solution of difficulties the child becomes accustomed to being able to do what it wills ; to school its will. Unfortunately, self-confidence is wanting in many men, especially in neuropaths, as is shown daily in medical observation. Mistrust of one's self finally becomes complete inner powerlessness. The conviction that one is perverse as a result of original cerebral constitution undermines all resistance to sensual impulses. Indeed, too intense a feeling of deficiency may lead to complete moral paralysis and suicide.

Thus, the great object of education is to create a series of habits by means of direct persuasion, acts, imitation, and admiration. Parents and teachers have an intense effect upon children through example ; for children always imitate the per- sons about them. And these should always stand on a moral plane above that of the child. A firm will, leaning to justice and goodness, impresses children ; that which astonishes most the child imitates. Thus, merely the example of goodness may actually improve an individual. It is not mechanical obedience, as enforced by the disciplinarian, but conviction and introduc- tion by means of authority that are the connect factors in educa-

200 SEXUAL PARiBSTHESIA.

tioii. When education has been successful in creating good habits, it remains to awaken the belief tiiat these habits are valuable.

Every occupation, every social condition, has an educational influence. It forces us to act in conformity with a general idea. Our conduct is always accommodated to social relations. By this means, also, our hereditary tendencies undergo modifica- tion, llegular occupation in a calling has a general moral effect. Want of occupation, on the contrary, removes the individual I'rom the influence of many social deterrents and abandons him to his inclinations and hereditary tendencies. Therefore, in the education of a child, the idea of sociability should be inculcated as strongly as possible from youth up. The ideal of humanity must be to direct hereditary instincts. In the sense here described moral and social suggestions may prevent the formation of a fixed idea, no matter whether it be related to crime or i>erversion. Natures tliat have lost equilib- rium frequently are wanting in altruistic feeling (e.g., the com- plete absence of compassion in criminals). And if such a feeling were present, in only a rudimentary form, in such an unfortunate being, still education could develop it and thus restore equilibrium.

Well-organized and regulated suggestions are capable of repressing or favoring the effects of heredity, no matter whether they be imparted during artificial sleep or in the waking state. For nothing takes place in hypnosis that could not be done in the waking state, more or less perfectly, even tliough in a rudi- mentary manner. Suggestion, therefore, does not present any isolated and remarkable phenomena. We are all sensitive to suggestions ; and social life may be regarded as a state of equi- librium maintained by opposing suggestions. The possibility of personal resistance to suggestion varies considerably in accord- ance with individual peculiarities. The suggestive impulse may be looked upon as an imperative feeling in statu nascendi., which to a certain extent, like a rebel battles with pre-existing intense inclinations, and seeks, at the moment of suggestion, to turn the whole mind in the direction of a fixed idea which more and

PSYCHICAL AND SUGGESTIVE TREATMENT. 20l

more impresses the brain. At first suggestion always induces a temporary emotion, wliich, by cumulative effect, as in frequent hypnotic sittings, becomes a habit in the individual. The effect of suggestions during our childliood extends throughout our lives. Thus suggestion is a means through which a passive organism seeks to equalize itself with an active organism. The state of credulity in a child is comparable with the lack of re- sistive power in the hypnotized individual. At any rate, every- body believes most thoroughly what he convinces himself of; and therefore auto-suggestions often offer the most effectual re- sistance to therapeutic suggestions. The ability to suggest finally becomes ability to assure. The deep tone of conviction has tlie greatest suggestive power. Those persons that seem to assure the most by gestures and emphasis are the best hypnotic operators. An energetic w ill operates upon weaker natures like a command, and awakens corresponding feelings. Without the expectation of a definite result, without faith in one's self, there can be no activity. Consciousness of action is, at bottom, nothing more than the belief that one acts. Even a doubt may disturb habitual reflex acts. Thus, conscious life depends, in part, upon a relation in which we stand with ourselves.

Virtue and moral consciousness are not inherited ; we in- herit only the disposition to goodness and right-willing, as we may that to cruelty ; education is more powerful in morals than in intellect. Every man, during the course of his life, comes to formulate rules for his own conduct, which vary in accordance with tastes, preferences, habits, and needs. The criminal, like the philanthropist, is directed by constant rules which, at bottom, represent the theoretical formula of his conduct. In harmony with the manner in which the nucleus of the soul is stimulated in the child, moral consciousness is developed. Since practice precedes theory, it is an important principle in education to direct the acts of children in a moral sense, before fundamental principles are impressed upon them. It is best if, as Herbert proposes, children formulate rules for themselves from their own experience.

True morality can never be the product of heredity. It

202 SEXUAL PARESTHESIA.

only results from education, when our reason gains possession of us. Tlierelbre, consciousness of a moral duty signifies con- sciousness of inner and well-considered knowledge wliich directs our acts, the presence of iddas which strive to become real by virtue of tlieir own power, and the presence of feehngs wliich, as a result of their development, have in view the well-being of fellow-beings.

Other Means for the Prevejition of Sexual Errors. If the principles of education here laid down and studied with reference to the theory of suggestion are important in general for the de- velopment of the character in the cliild, it is still much more so for neuropathic individuals, in whom the vita sexualis seems to be tlie locus minoris resistentiw, and which, under the influence of unfavorable conditions, is directed into i^erverse lines. Sexual education, then, besides observance of the measures given in Section I, with careful watching must endeavor to delay as long as possible the appearance of sexual instinct, and to diminish its intensity as much as possible. Pathogenetic stimuli, as offered in seduction and example, are to be prevented. In order to pre- vent pathological determination, care must be taken that the boy is accustomed to the society of female companions. Notice- ably close friendship with boys and indifference toward girls require the most careful watching by jJarents and teacher, and should arouse suspicion.

Especially in abnormal individuals, the will must be schooled to control sensual impulses. But the inculcation of moral principles, great as their worth may be, must not go to the extent of the ascetic development of abstinence physiologi- cally unattainable. In one of my cases the opposite love of men was artificially induced. It has been previously men- tioned that, at the time of puberty, a rational explanation of the sexual relations is a powerful prophylactic. Unfortunately, in most families, this point is overlooked. With a negligence for which there can be no excuse, the determination of this instinct, so important for procreation, is left to accident; hence the intractable undifferentiated sexual feeling, excessive onan- ism, and the cultivation of perversions. Ask such unfortunate

PSYCHICAL AND SUGGESTIVE TREATMENT. 203

persons who lias explained their malady to them, and it will be found that it is seldom parent or teacher, but popular books, friends, etc. I believe that, in severe forms of sexual perver- sion, help and cure are possible as long as the individual is still undergoing development. The earlier the individual treading a false path is treated, the better the prognosis. Where there is a certain amount of ethical weakness, or inability to form inhibitory ideas, an attempt should be made to associate such individuals with normal comrades possessed of strong wills, to whom passive natures easily accommodate themselves. Tar- nowsky thinks that slight ridicule of boys that manifest a pref- erence for female occupations may prevent the development of perversion. At least, it should be remembered that the activity of feminine inclinations cannot occur without some fault in edu- cation. In all these questions, as von Krafft-Ebing remarks, the family physician can give assistance and exercise prevention, provided his advice is sought.

SJiould Urnings he Treated ? A question of prophylaxis from the stand-point of coming generations involves the pro and con of the treatment of urnings. MolP raises the question whether contrary sexual instinct should be treated medically ; indeed, does not pederasty, according to Schopenhauer's view, serve nature's purpose, in that, as a vice, it prevents the beget- ting of unfortunate descendants by " old and sexually-depraved men""? Moll thinks that it would be possible to bring about disharmony in the pronounced efFcmination of an uming!

The writer mentioned does not feel justified in giving a positive answer to this question, but leaves it for social and legal determination.

Mariiage. I hold that, under all circumstances, medical treatment of such unfortunates is indicated as long as it is not attempted to carry it beyond impossible limits. That coming generations must suffer as a result is, as our study of the matter has shown, quite possible, but it is by no means proven. Be- sides, the union with a female character may compensate the peculiarity. Such individuals should be directed to marry emo-

• Loc. cU., p. 209

204 SEXUAL PARiBSTHESIA.

tional women possessed of lively sexual desires. The opposing characteristics of the mother, in accordance with the law of inheritance, compensate the defect in the father, and thus the descendant more nearly approaches the normal standard.

Still, one must be aware that marriage is not a cure, for psycho-sexual hermaphrodites are not so infrequent among the married. Tarnowsky saw cases in which youths with " con- genital sexual perversion," aged from 25 to 30 years, became capable of intercourse with women, married, and begat children. Moll doubts that these persons became normal. I think Tar- nowsky is right; only they were not cases of original disposition, but perversions in predisposed individuals, induced by exciting causes.

Onanism and Exciting Ca^ises. Owing to the extremely injurious effect of onanism, which plays a part in almost all forms of sexual perversion, youths must be most carefully watched on this point, in accordance with the advice given iji Section I (schools and academies). But the dream-life and pollutions at night must not escape attention. For in case of some pathological association with abstinence from onanistic acts, a dream-picture of perverse content with simultaneous pollutions, as a result of continued repetition, may assume the role of ideas accompanying masturbation. The abnormality of these ideas is the starting-point of psycho-sexual disease. They must, therefore, not be allowed to become the imperative product of habit.

Prophylaxis against the injurious influences described in Chapter IX is to be carried out in accordance with the pecu- liarities of each case, without any thouglit to make a general application of the measures here described. Thus, for example, in the case of a predisposed boy, spanking should not be prac- ticed, if it induce sexual excitement, in order to nip algolagnistic inclinations in the bud.

The therapeutics of the anomalies of the sexual instinct, according to von Krafft-Ebing, may be advantageously divided into three parts :

1. Treatment of the constitutional disease forming the

PSYCniCAL AND SUGGESTIVE TREATMENT. 205

basis of the sexual perversion (neurasthenia sexuahs or univer- sahs).

2. Removal of onanism and other influences injurious to the vita sexualis.

3. Specihc treatment of the abnormal instinct.

Antineurasthenic treatment, the means of wliich are suf- ficiently well known, under certain circumstances, is alone sufficient to cure cases that have made but slight progress. Besides hydro- therapeutic, electrical, and medicinal means, severe mountain-walks, extending over months, are especially to be commended. In addition to strengthening the constitution, they also strengthen the will.

The treatment of onanism is given in detail in Section I, and therefore we may omit it here, as well as that of sexual hyperaisthesia and impotence, the most frequent accompanying symptoms of sexual parsesthesia.

In respect to the two points mentioned, almost all sexual perversions seem to us amenable to medical treatment ; perhaps cases of advanced dementia are exceptions, as they are rather to be met with in asylums than in private practice.

Psycho-therapeutics in Cases of Perverse Instinct. The treatment of an abnormal instinct can be only psychical. Where psychical treatment in the waking state is not successful, sug- gestion in hypnosis may be advantageously brought into requi- sition. In all cases the patient should be made to school his will, that he may tlius be able to control his impulses. The patient should be advised, by energetically conquering himself, to think of woman and tlie sexual act, and in any sexual excite- ment attempt to substitute woman for man. Many patients are finally able, in the struggle with themselves, to experience pleasant feelings and erection in the thought of hetero-sexual relations. When this is attained the victory over the abnormal instinct is practically won.

In the process of recovery, every person of contmry sexu- ality passes through the stage of psycho-sexual hermaphroditism, a condition in wliich he is excited by both sexes. What at first gives rise to the greatest repugnance (feeling of disgust) by

^

/

206 SEXUAL PARESTHESIA.

patient repetition finally becomes habitual; and many patients give the assurance that, in sexual excitement, they are able, with- out the slightest difficulty, to substitute female for male fancies. Some of the cases reported in the following series clearly illus- trate psycho-therapy without hypnosis.

In the treatment of urnings, Moll correctly distinguishes two objects : (a) overcoming the instinct itself; (b) repression of its activity.

Of course, the first that is, the removal of perverse feel- ing is the more important. I agree with Moll's view that, on the whole, it is advantageous first to suggest hetero-sexual feel- ings until the patient himself feels the need to attempt coitus. That is the natural manner of cure. The performance of coitus, even when, in spite of repugnance and with the help of the {per- verse imagination, it is successful, is in reality no cure. Want of success, on the other hand, causes a feeling of depression and makes further treatment more difficult. From this is de- rived, as a fundamental principle of treatment, the combating of hetero-sexual feelings and the creation and promotion of hetero-sexual feelings ; and, in the second place, the direction of the activity of the instinct in a normal way. Further, it should be remembered that in neurasthenics with perverse in- stincts weakness of sexual power is frequent, and that several months of abstinence essentially contribute to the restoration of the weakened sexual function.

Regulated Sexual Intercourse. With complete acknowl- edgment of Moll's caution mentioned, regulated sexual inter- course seems to us to be advantageous where the instinct and effemination, or other perversion, are complete. It is very dif- ficult, sometimes impossible, for example, in persons of fully- developed effemination, to induce by suggestion alone hetero- sexual feelings and ideas of such intensity that erections occur where the corresponding sensory perceptions are wanting to the patient. Cases in my experience, on the other hand, show me that patients who, in the first attempt at coitus, had feelings of disgust and were impotent, in the second, made on my advice, under the influence of alcohol, were successful ; and in the third

PSYCHICAL AND SUGGESTIVE TREATMENT. 207

attempt proved potent, even though erection was brought about only after manipulation by the puella. Thus the ice was broken, and the patient's sexual impulses were made harmless in spite of himself. Sexual intercourse, begun under such difficulties, must be regularly continued by tlie patient until it becomes a habit.

In patients that are not weakened sexually, finally spon- taneous erections occur, and the psychical equivalent that is, the psycho-sexual reflex effect must occur. Whether this com- pletely compensates the perverse tendency depends upon the degree of the malady and individual conditions. A diminution of the abnormal ideas takes place, however, in all cases. Thus, Binet also observed, in fetichists, that from the moment of regu- lated sexual intercourse the image of the fetich paled and lost its harmful influence. For abstinence from natural sexual congress induces sexual hyperaesthesia and intensifies the im- pulse in its perverse direction. Conversely, inclination for women may arise from regulated coitus. Indeed, I have ob- served that the patients were able to resist homo-sexual temp- tation as long as intercourse with women was continued ; but as soon as a long pause occurred, the impulse, /aw^e de mieux, took its old direction.

The relapses noted in my patients occurred at a time when they were abstaining (illness, absence of the physician, long ab- sence of the wife, etc.). In few severe cases will it be possible to obtain a relative cure in this way. In severe cases, for example, in well-developed efi'emination, at least, it will be possible to bring about a compensation of the perverse instinct in sexual relations. The patient regains his inner equilibrium, and at last finds himself in the desired situation. In occasional relapses he finds no pleasure in homo-sexual relations. More- over, in many patients the occurrence of imperative sexual ideas of perverse content corresponds witli tlicir pliysical con- dition. Deterioration of bodily health goes hand-in-hand with the recurrence of homo-sexual images. Not every case of psy- chical impotence in sexual perverts has its cause in perversion of the mstinct. Rather, there are also neurasthenics in whom

208 SEXUAL PAR.f:STIIESrA.

virility alteniates with impotence periodically, as does depression and exaltation. Such neurasthenic impotence may also exist in individuals of contrary sexuality without the causative influ- ence of the abnormality of the instinct.

But the transformation of the sexual feeling is not without effect on the character. In one case I observed that there was an increase of self-confidence and energy, the want of wliich was previously characteristic of the patient's malady; these char- acteristics were influenced by duties of occupation which called all his manly powers into requisition. In one case of complete effemination, likewise, there was an unmistakable weakening of feminine peculiarities. Powder and paint were no longer used ; the pictures of urnings disappeared from the wall ; the feminine articles of toilet were given away ; and in some situations the patient's conduct was much more decided ; and, besides, a cer- tain diminution of inner lack of control was noticeable. Still, as before, there was interest in men, though it was not much colored sexually.

Tarnowsky also confirms the great importance of regulated sexual intercourse. He says : ^ " With continuance of sexual intercourse, especially with the same person, the sexual perver- sion gradually weakens ; and, finally, the youth, who from birth was disposed to perverse sexual activity, becomes a man with normal sexual functions, capable of family life."

Suggestive Treatment in Hijpnosis. With most patients, energetic advice that is, the psycho-therapeutics of the waking state is not sufficient ; and it then only remains to make use of hypnotic suggestion. Von Kraff-Ebing regards it as the only " means of salvation " in desperate cases. Where rudiments of hetero-sexual feeling are still present, these must be strengthened by suggestion ; where they are wanting, the hetero-sexual feel- ing must be artificially created. In suggestion, as the writer mentioned justly remarks, we have an excellent means with which to destroy the abnormal psycho-sexual existence and create a new. Whether, however, as von Krafl't-Ebing thinks, a deepening of hypnosis to somnambtiUsm is necessary for this,

^ Loc. eit.f p. 18.

CONCLUDING REMARKS.

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304 SEXUAL PAKiESTIIESIA.

The certainty of tliis manner of observation and the care- ful report of relapses, which are seldom to be met witli in other branches of therapeutics, justify us in drawhig almost certain conclusions from the material at hand concerning the prospects of cure in cases of sexual paraesthesia. The probability of success with suggestion may be expressed as 70 per cent., that of cure as 34: per cent. ; but, as a rule, one should prepare such patients for the necessity of prolonged treatment. In one case one hundred and forty-two sittings were necessary, and in another two hun- dred and four. Too, it may be recommended that, in order to make the cure lasting, the patient should, as a prophylactic, be hypnotized once every week or two for a year after the cure has been established, and care be taken that sexual intercourse be practiced regularly. It should always be remembered that the period of treatment for confirmed habits is dependent upon the time required by the perversion for its full development.

Too, in the severest cases, as we have seen, it is possible to remove onanistic inclinations and sexual hyperaesthesia. In cases of contrary sexuality, as a rule, after a certain period of treatment a state of sexual neutrality is established, in which the patients have become indifferent to homo-sexual charms, but are still insensitive to women. With the beginning of regulated normal sexual intercourse, which, in my opinion, is the conditio sine qua non of cure, the feelings of disgust, present at first, gradually disappear entirely ; tlie fancy of tlie patients becomes more and more impressionable and excitable to femi- nine charms, and in the transitional stage of psycho-sexual her- maphroditism care must be taken, in external circumstances, tliat the product of suggestive cultivation gradually compensates the deeply-rooted inclination. The mental rudiments grow more and more indistinct, and only cause relapses where occasionally sexual impulses, unsatisfied in the normal way, gain a renewed mastery over the individual and, to a certain extent, furnish new material to the old inclination, whether this be homo- sexual, algolagnistic, or fetichistic in nature. If, as we have previously tried to show, effemination is a secondary manifesta- tion of homo-sexuality, then, logically, the sexual transforma-

CONCLUDING UEMARKS. 305

tion, in the sense of a male-feeling individual, cannot take place without affecting the mental life of the individual concerned, even thougli it must also be admitted that such secondary changes of character, in the sense of weakening, are perhaps only fully developed in the course of years, and always require long periods of time. The theory of contrary sexual instinct and its possible cure is still too young to allow a judgment of it in this respect, based on practical results.

When, in case of contrary sexual instinct, cure is spoken of, it is to be understood only as a relative cure. For absolute cure would presume complete removal of the homo-sexuality, its memory-pietares^ and a physical reflex eftect of them which occurs episodically in many patients. This, however, is not within human power. One may be satisfied if these pictures fade and become innocuous rudiments, and if the sexual life is led into the path of regular and natural activity.

If we have been successful m demonstrating that this ther- apeutic result, so important for the life of such unfortunates, may be obtained by suggestive treatment ; that useful members of society can be made of such perverted individuals, then the object of this work has been attained. May it contribute to the success of the struggle with this dark side of our social life, and open to workers in the domain of suggestive therapeutics a new and productive field of activity and humane striving !

20

APPENDIX.

Pbepabed fob the English Edition in Octobeb, 1894; Tbanslated fbom THE Author's Manuscript.

The studies in the pathology and therapy of psycho-sexual anomaUes contained in the ibregoing work were pubUshed in the German for the first time two and one-half years ago. Though, during the period that has elapsed, many new and im- portant additions have been made to the question of sexual per- versions, and though views opposed to those advanced by the author have not been wanting, still the contents of the book have retained the value at first attributed to them. The pur- pose of this appendix is, therefore, the addition of some not unimportant supplements to several of the sections, as well as to a number of histories. The following notes are arranged in accordance with the chapters of the book, and are made as brief as possible.

Case 14^ Section I. Since this patient was discharged three and one-half years have passed. At first the patient re- mained cured as long as he had opportunity for sexual inter- course ; however, when for any reason this was not possible, he masturbated, but during two years he did not do this more than three or four times. During the last year and a half this lias not occurred. He attends to his calling and feels himself per- fectly well.

Case 15, Section I. In the meantime the patient has be- come a physician and follows his calling without further need of medical lielp.

Case 18, Section L During the two years and a half since discharge, the patient has remained well ; a visit to her home convinced me of this. She has now been happily married several months. This case, which has now been under observa- tion more than three years, may be regarded as one of the most brilliant examples of the efficacy of suggestive therapeutics.

(307)

308 APPENDIX.

Case 20, Section I. This patient has remained cured during the two and one-halt' years that have passed. She resumed her calhng and removed to another city. The last written rei)ort was received three months ago.

Case 35, Section II. In June, 1894, two and one-half years after discharge, this patient visited me again to express his thanks that the mental treatment in 1891-92 had put him on the right road to recovery. The patient is happily married, and already the father of one cliild ; he has made himself inde- pendent, and may be regarded as definitely recovered.

Case 37, Section II. As may be seen from the text, after remaining well two years, in October, 1891, as a result of severe nervous trouble the patient had a relapse, but fortunately he came under my treatment immediately again. A few hypnotic suggestions again restored his virility, and he has remained well.

Case 38, Section II. In November, 1892, the patient again presented himself and desired to have the hypnotic treat- ment resumed, though the success of the previous treatment had been lasting, mainly with a view to have it become more stable, in reality, through fear of a possible relapse. Twenty-two additional hypnotic sittings. At the first coitus during the period, erection by means of manipulation by the puella; then slight emission. On the other hand, on three other occasions the patient had intercourse with complete satisfaction. On November 27tli the patient went home with the re-assuring consciousness of complete virility.

Case 62, Section III. Since this patient was discharged nearly four years and six months have passed. As I ascertained by a personal interview with him, in the interval he has be- come the happy father of three healthy children, whom he is educating carefully, and whom he observes with a view of a possible existence of any hereditary disposition. As long as R. remains with his family and is required to lead a regular life in the small town where he lives, he feels perfectly normal and balanced. He is bound by love to his wife and children, and his sexual functions leave nothing to be desired. Occasional

APPENDIX. 309

homo-sexual importunities, as on meeting former friends, he suc- cessfully withstands. However, if R. be on a journey alone for any length of time, which occurs perhaps once a year, he still finds pleasure in homo-sexual practices ; but this is not from an irresistible impulse, nor from a love of the male sex or of any man, but to excite his nervous system by the enjoyment of for- bidden fruit. Therefore, in this case, we have to do not with an abnormal impulse, not with a relapse, but with the induc- tion of ne\v and exciting sexual situations from pure sensu- ality, wherein, however, the re-awakening of sensual memory- pictures from the past plays an exciting and intensifying, though not determinate, role. The acts whicli five years ago indicated desire of the sexual instinct have now become simply acts of vice.

Case 63, Section III. One year after the appearance of the foregoing work in Germany, that is, about three years after the beginning of treatment, I received the following report from the patient :

March 22, 1893.

Honored Baron : In meeting your wishes by writing you a few lines concerning my health, I must think what I have to write, so thor- oughl}" have I become accustomed to my new life. I have intercourse regularly with women, but it is only within the last few months that it has been regular, since that with prostitutes graduall}' became repugnant to me. What I formerly regarded as impossible, and what a priori I was forced to repel, I now entertain. I am thinking much of marriage ; I imagine myself married ; long for children and a family ; and I think I should make a good, too good, father.

I have no erotic fancies, since libido has greatly decreased ; the ac- companying symptoms of the former disease migraine, depression, and anxiety have entirely disappeared, so that I am now in a stable emo- tional condition, and I could be entirely satisfied were it not for ray past. This, however, constantly comes up threatening, and to my fear of it is added disgust and repugnance of myself and my former acts, such as a normal man must always feel for contrary sexual persons. The memory of this frightful, debasing period will probably always poison my life. Always obligated to you, honored Baron, in deepest gratitude I remain. Respectfully, A.

Since the receipt of this report one year and eight months have passed, and during that time the patient has kept me in-

310 APPENDIX.

formed at long intervals concerning his condition. To-day A. feels masculine ; neither in his sexual nor in his psychical con- dition during this time has he relapsed, but he has intercourse regularly, and has a horror of sexual acts with his former com- panions. The symptoms of efFemination have all disappeared, as have all the neuropatliic troubles ; his appearance is healthy (brown complexion) ; his manner shows more certainty and assurance; his energy has increased and has withstood many trials successfully. This latest verbal report I have no reason to doubt; the more because of the patient's demonstrated love of tmth, and because his whole physical condition corroborated his statement. A. has now been under my observation five years without relapse in the last three years. Certainly th6 most careful skeptic would allow the justice of regarding this patient as cured. This case, on account of a complete effemina- tion, is the worst case of contrary sexual instinct that has ever been reported cured ; at the same time, no case where cure has been reported has been so long under observation.

Case 66^ Section III. One year after the appearance of the German edition of this work, or two and one-half years after the beginning of treatment, I received the following letter from this patient:

March 1, 1893.

Honored Baron : A full year has now passed since I ceased your treatment. I am delighted that I can give you a most satisfactory report. I got on so well that I soon forgot what a sad condition I was formerly in, and I no longer thought of giving j'ou a report. Since I left 30U I have continued intercourse with women unchanged. Gradually I felt increasing assurance, and in the whole period it occurred but once that erection was not so prompt and spontaneous as usual. In this instance I attribute the failure to great fatigue. While, during the first months, I sought women only because I thought I should, now I require no such stimulus; on the contrary, coitus always gives me intense pleasure. In proportion as pleasure increased, the memory-pictures of former tiipes became less distinct. I have often had occasion to come in contact with men whose appearance would formerly have immediately inflamed my passion ; now I can be associated with them without feeling the slightest excitement. The following seems to me worthy of special note :

In May I fell ill with rheumatism, and part of the time here and part of the time at home I was in bed till the end of June. Until my

APPENDIX. 311

return to Munich, toward the end of August, during convalescence, circumstances denied me all possibility of coitus. During this time I was undoubtedly more excitable than usual ; but, notwithstanding this, a meet- ing with a former friend left me entirely cold sexually, though otherwise I thought much of him. I was, at the same time, as little disturbed by the sight of attractive forms; I remained completely cold-hearted. Briefly, the transformation in my entire manner of feeling is so marked that I formerly should have regarded it as impossible. In the future I hope to be able to give you as good a report. With expressions of constant gratitude, I remain, Respectfully, H.

Since the date of this letter one year and eight months have passed; or, since the beginning of treatment, /owr and one' half years. Some weeks ago (September, 1894) the patient passed through Munich on his wedding-journey and visited me. My expectation that at that critical moment H. would require renewal of treatment was entirely uncalled for. H., on the con- trary, seemed to be lastingly cured, and had not had a single relapse. Intercourse with his young wife was successful without the help of contrary sexual ideas. He loves his wife dearly, and their sexual relations are perfectly normal. Besides, his outward appearance is that of blooming health and manliness. The pa- tient's brother, who is acquainted with his entire sexual life and who observed his transformation, confirms H.'s statements. I am also justified in regarding this patient as completely cured.

Case 67, Section III. Soon after the appearance of the German edition of this book (summer of 1892) this patient dis- continued treatment, notwithstanding the fact that the improve- ment obtained justified a favorable prognosis as to cure.

Impelled by unfortunate circumstances of business and finances, in the fall of 1892, the patient carried out the idea he had long entertained, and brought his unfortunate life to an end by shooting.

Case 68, Section III. The restoration of this patient by suggestive treatment has not been undertaken because business circumstances have not allowed liim time for treatment. In December, 1893, he informed me also that he was convinced of the hopelessness of his condition (a belief with whicli I can- not agree). He states that he has never been successl'ul in the

312 APPENDIX.

onanistic act; at the same time he is doubtful about mar- riage, because of the possibiUty of tainting descendants. Led by reading Moll's work, he forced himself to entertain hetero- sexual fancies. In his opinion this led only to neurasthenic troubles. He continues: " In contrast with all this I liave the greatest desire to have a family, but I must accustom myself to the inevitable. I repeat wliat I told you verbally, tliat I suffer most from this deprivation, while the contrary sexual feeling per se and the necessary abstinence cause me no trouble. Apparently this is due to my moderate sensuality, which is satisfied by the sight and occasional hand-pressure and touch of the party in question. My general condition is good ; there is no trace of neurasthenic trouble," etc.

Thus, my conclusions reached in this case in the text are still justified.

Case 69, Section III, The sexual condition of this patient became perfectly normal througli regulated sexual intercourse, as he informed me some years after discharge. To-day he is happily married and the father of several children.

Case 70, Section III. This patient died, one and a half years after the appearance of the German edition of tliis work, of tuberculosis ; and he never fully recovered, in the interval, from the effects of the influenza mentioned in the text.

Concerning the cases in the text not mentioned here, it has been impossible for me to obtain later information.

Numerous new cases likewise confirm the author in the correctness of the etiological and therapeutic deductions of the text. However, von Krafft-Ebing,^ though the ninth edition of his work has already appeared in German, has not changed his views, but has sought to strengthen his theory of herdi- tary taint by embryological and anthropological facts. Thus he recalls the original bisexual nature of tlie human sexual glands with the related sexual organs, and also that the beginning of

' Von Kraflft-Eblng, " Zur Erklarung der Contraren Sexualempfindung," Jahr- b&cber fur Psychiatric u. Nervenkrankhelten, Bd. xlil, Heft 1.

APPENDIX. 313

development in a mono-sexual sense takes place first at the end of the third month of foetal life. Too, in accordance with von KrafFt-Ebing's hypothesis, the spinal and cerebral centres stand- ing in relation with the sexual organs must also embryonically be possessed of a bisexual nature ("?). Half of this embryonic possibility becomes latent ; normally the other half, correspond- ing with the sexual glands which attain development, develops fully. In the male, the residua which indicate the original ontogenetic and phylogenetic bisexual possibility are the Miil- lerian ducts, the utriculus masculinus (vesicula prostatua) ; in the female, the paroophoron as the remains of the original nephritic portion of the Wolffian body and as the analogue of the male epididymis. Under pathological conditions, the author (von Krafft-Ebing) assumes the virtual continued existence of the hypothetical cerebral and spinal centres corresponding with the latter, as a result of imperfect inhibition of them, which may even be of such degree as to allow active exercise of their influence upon the production of the physical and psychical sexual characteristics, indeed, in infrequent cases, deposing the former from their normal domination, and leading to the devel- opment of a sexuality corresponding with the latter centres and out of harmony with the sexual organs.

The correctness of this new and ingenious hypothetical ex- planation can only be allowed after the existence of rudimentary spinal and cerebral centres has been anatomically demonstrated. However, the psycho-sexual condition of hermaphrodites, which von Kraff't-Ebing also seeks to use as a support for this view, speaks much rather for an opposite opinion, namely, for the great importance of exogenous factors. Laurent,* in his latest work, collects all the known cases of hermaphroditism, and, concerning the determining role of education in the sexual life, expresses himself as follows : " In many cases education is capa- ble of forcing the sexual instinct in a direction opposed to that which should be taken, and of producing thus a kind of sexual inversion." On the whole, however, he regards such cases as degenerates of inferior mental endowment, who much more

' LaureDt, Les bisexu^s. Paris, Carr6, 1894.

314 APPENDIX.

iVequently become the victims of vice and prostitution than of love ; the majority are, in his opinion, indifferent from a sexual stand-point. The same autlior designates tliose men asgynaeco- masts wliose sexual organs liave not attained complete develop- ment. As the only bodily attribute of the female, they possess feminine breasts. While in conformity with the anthropological transformation, according to the theory of von Kraff't-Ebing, one would be led to assume at least the existence of a partial inver- sion of the vita sexualis in these cases, Laurent gives a number of detailed observations in which the sexual life was entirely developed in a masculine direction ; and the observations of the author (von Schrenck) of bearded women and of men with feminine breasts are in entire accord with those of Laurent. Laurent questioned all gynaecomasts that came under his obser- vation concerning their vita sexualis.

In spite of their emphatic denials, and without any certain proof, Laurent presumed that but two (!) of them had inclina- tions to sodomy (p. 97). From this the occurrence of an invariable or frequent correspondence of feminine physical char- acteristics with feminine sexual feelings in the male, and the opposite in the female, must be regarded as in nowise demon- strated. AVith each single case that speaks in favor of it, similar cases with an opposite psychical condition may be brought in contrast. The determination of this question will depend prin- cipally upon the embryological and psychological conception of the sexual instinct.

Meynert,^ in his clinical lectures (not cited in the text), ex- presses himself on this point as follows : " There is little sense in assuming an inborn tendency with peculiarity of organization that leads to the idea of a female soul in a male body or a male soul in a female body. Instincts (impulses) are in no sense the result of bur brain activity, but merely words. There is a feeling of hunger, but no instinct for food. In the feeling of hunger the child has no notion of tlie means to still it ; it leads to death, or the child is suckled. Then the sucking-reflex acts, and the child experiences the sensation of satisfied hunger with

' EllulBche VorlesuDgen iiber Psychiatrie. Wien, Braanmaller, 1890.

APPENDIX. 315

which the act of sucking is associated, which now becomes a cortical movement, associated with the feeUng of hunger, the odor of the nipple, and the taste of the milk. Where, between reflex and cortical movement, lies the third factor the instinct a congenital idea? There are tactile sexual sensations arising from tlie corpora cavernosa, but no inborn histinct in them. The influences which from them develop sexual activity are occasional perceptions, tradition, imitation, but never any con- genital ideas, and, therefore, never any congenital anomalies of thought." Meynert was also always able to prove the exciting cause of contrary sexual feeling in his patients.

While Moll,^ in the second edition of his work, emphasizes still more the theory of hereditary taint of von Krafft-Ebing, and regards our demonstration as weak, a new capitatio henev- olentice for the numerous homo-sexual individuals, Eulen- burg,^ in a recent publication, however, declares that in the future, in the judgment of such patients, the exciting and acci- dental factors and their influence upon development will require more careful investigation than has heretofore been used. He holds it unproven that such factors can alone lead to contrary sexual feeling. On the other hand, in the precocious awaken- ing of the sexual instinct, Eulenburg sees a clear indication of the presence of pronounced contrary sexual instinct. In opposition to this, as has been emphasized in tlie text, the neu- ropathic taint present in such persons, which allows the prema- ture awakening of the sexual impulse, but without reference to its object, is to be taken into consideration. In the abnormal neuro-psychical taint, or, better, weakness, which Eulenburg regards as a conditio sine qua non in all these patients, also lies the impossibility of correction by means of later opposing per- ceptions of the sexual life. My explanations, which rest upon the psychological (folk) origin of uranism and upon pathological association, which my opponents allow in fetichism, have not as yet been vitiated by either Eulenburg, Moll, or von KrafFt- Ebing. The fact remains unchanged: "Through exogenous

' Die contrarie Sexualempfliiduujj. Berlin, Kornfeld, 1893.

' " Neuropathla sexualis viroruin," Klinisches Handbuch der Ham- und Sezual- organe, Abth. iv, 1893. Leipzig, Vogel.

316 APPENDIX.

stimuli and perceptions the content of such sexual imperative feelings, or ideas, are supplied to such tainted persons, and through these a complete- sexual transformation may take place."

Eulenburg designates parsesthesia sexualis as parerosia, and correctly concludes, from his premises, that a transformation of the pathological homo-sexual condition to a normal hetero- sexual condition is not artificially possible. My three cured cases (62, 63, 66), observed almost five years continuously, prove exactly the opposite. However, Eulenburg speaks warmly in favor of psychical treatment by suggestion. Appreciation and sympathy with such patients are necessary for the attainment of decided effects. From a number of recent cases the author (von Schrenck) is forced to regard the establishment of regular sexual intercourse as the principal requirement for cure. In cases in which, out of repugnance and whim, sucli patients did not fulfill this requirement, no deep and lasting success could be attained. The favorable reaction of hetero-sexual relations upon the mind of these patients, even though had at first without marked feeling of pleasure, was very seldom wanting. There are infrequent exceptions, as in persons devoid of lively sexual impulse, or in those that are more than 40 years old. But even in such individuals sometimes the dream-life is lastingly influenced. The dream-pictures accompanying occasional pol- lutions take their subjects rather from mental associations, strengthened by habit and deepened sensory impressions from the past, than from the weaker (so to speak) and purely theoretical influences of verbal suggestion.

Among the authors that have accepted the etiological explanation set forth in this work, Kriipelin ^ should be men- tioned first. He is in accord with the writer in this, that the abnormality in the so-called contrary sexual feeling resting upon hereditary taint depends upon the peculiar impressionability of the prematurely-awakened instinct, which in turn depends upon the degeneracy. Through this the youthful sensibility is last- ingly influenced by the first excitation of sensual feeling. In

Psychiatric, 4te Aufl., Leipzig, 1893, p. 691.

APPENDIX. 317

accordance with this, the prognosis in such cases is the more favorable.

Without reference to our etiological explanation, following Meynert and Binet, and published in 1892, Sioli,^ in 1894, in an article on perverse sexual instinct, expresses the same view. " There is the same weakness of judgment, of association, which we conceive from an anatomico-physiological stand-point, as (1) a deficiency, (2) a weakness, of the association-paths, as the foundation of all cases, which we are accustomed to desig- nate in common as hereditarily degenerate, as predisposed ; in all these cases the perverse impulses arise only as a result of the circumstance that with the increase and union of memory- pictures the normal correction, the influence upon thought and action of the subsidiary, inhibitory, and opposing ideas, by means of the association-paths present in normal persons, are wanting, because these paths in these cases are absent." Thus, according to Sioli, arise the abnormal manifestations and acts which have led to the assumption of abnormal instincts, while, in fact, the cases are no more than instances of mental weak- ness and inability to correct the association of external impres- sions which determine all acts. As a result of the weakness of psychical association, the bodily sensations enter into conscious- ness that is, into general thought and feeling in a greatly- intensified degree.

The organic sensations arising from the sexual organs, in those patients afllicted with a weakened associative system, early exercise a powerful influence. As a result of these sensations, at first indefinite, arise handling and onanistic manipulations.

Accidental circumstances become associated with the sexual stimulus. Then, as soon as the pathological impulse has become a habit, the individual, as a result of his weakness of associa- tion, is incapable of attaining to an understanding of the normal relations with woman. Sioli finally very justly calls attention to the symptom of fallacy of memory, which is likewise explained by the weakness of association, a symptom that, for the most part, has been insufficiently considered.

' " Ueber perverse Sexualempflndung," Zeltschr. fur rsycblatrle, 1894, Bd. 1, Heft 5.

318 APPENDIX.

GeilP takes a middle ground. He fully allows the impor- tance of injurious sexual influences in neuropathic individuals during development. However, according to him, such influ- ences have no significance in' congenital contrary sexual instinct. Such individuals exhibit a congenital weakness of the vita sexualis, indeed, often of the entire feeling.

For the perverse manifestations of the sexual life included by von Krafft-Ebing in the terms sadism and masocliism Eulen- burg has adopted the word algoJagni/, suggested by the writer, in his work previously cited. As a reason for this, Eulenburg rightly states that tlie active commission of painful acts for the purpose of sexual gratification is in no sense characteristic of the stories of the Marquis de Sade, and that the passive o'ole is as Httle so of the heroes and heroines of tlie novels of Sacher- Masoch. Besides (and in this I agree fully with Eulenburg), the acts of sexual cruelty are by no means exhausted by the active and passive roles. In opposition to the terms used by v. KrafFt- Ebing, the writer would remark that this manner of sexual gratification is much older than the works of Sade and Masoch, and that it has played an important part in history {e.g., in the Church), especially in ancient history. Moreover, there is an 07ianistic algolagny, which I have lately had opportunity to observe, and under which many cases of auto-flagellation are to be classified ; further, a visual algolagny., i.e., sexual excitement at the sight of punishment; and a zoophlUa and bestial algo- lagiii/, as soon as the lust for cruelty is related to animals. Where there is merely the intensification of such a scene, the condition could be called symbolic algolagny. The violation of corpses, in this sense, when maltreatment of tlie body was associated with it, would be necropliilic algolagny, and it would be diff'erentiated from simple necrophilia in that the latter, as the word signifies, includes only caresses of the body. Further, I have had opportunity to observe cases in which the pain per se played the principal role, without reference to its active or passive nature. Such patients are algolagnists in the true sense.

" Die Lehre von der Psychopathla Sexualis und Ihre gerichtaarztllche Bedeutung," Ugeskrlft for Lagert, R. xxvil, Nr. 37-33.

APPENDIX. 319

Moreover, the tyrannical feeling of absolute mastery or of com- plete subjection, which von KrafFt-Ebing regards as character- istic of sadism and masochism, is by no means always combined with algolagny, and therefore it can in no way be used to deter- mine the condition. So much for the strengthening of the term proposed.

On the question of the responsibility of sexual perverts, in Section III of this work the view was expressed that the isolated existence of perverse manifestations of the sexual instinct gave rise in no sense to irresponsibility. This statement, further emphasized in Chapter X, has received new support in the excellent expositions of Sommer^ concerning criminal psychol- ogy and penal laws. According to his view, the proof of the endojrenous nature of a certain mental state is not sufficient to establish the existence of mental disease. He extends this thesis especially to the domain of psycho-sexual anomalies. According to Sommer, when it is proven that a person, from endogenous disposition, is perverse,: e.g.^ when a man is excited (sexually) by another, he should be punished for a correspond- ing act when the act falls within those that are punishable. " Human society has the same right," he continues, " to demand control of the endogenous impulse in general that it has to demand it in cases of congenital allo-sexual instinct when it is directed against a child of the. opposite sex; or that the impulses to possess the property of others be repressed. There- fore, if these perverts are to be made free from punishment, this is not to be done during the existence of the present laws by declaring them insane, but by changing the laws. The decision of this question is not to be made by psychiatry, but by public opinion, in so far as it may be the expression of the actual moral will of the great majority of the people. As long as the moral ideas of the majority of the people are opposed to homo-sexual acts and the laws give expression to these ideas, the so-called contrary-sexual persons must control their impulses, as the man who, hungry, must control his impulse to possess

' " Kiiminalpsychologle und Strafgesetzgebung," Deutsch. Medlclnalzeltung, Oct, JO, 1894, p. 890 et seq.

320 APPENDIX.

liiniself of tlie property of others. At most, it might be said that the gratification of homo-sexual indinations was a private matter between two persons, which does not harm society as long as scandal is not excited by it. 'J'here seems to be no doubt, however, that among those persons that indulge in homo- sexual acts there are many insane individuals."

Accordhig to Sommcr, endogenous antisocial impulses (among which those in question are to be reckoned), like en- dogenous instincts, should not be punished, but they should not be taken as evidence of insanity.

The notes in this appendix in all respects confirm and enlarge the facts published in this work two years ago. The principal task of further investigation must be the publication of additional observations, in order to decide definitely the question of congenital contrary sexuality and other varieties of ])erverse sexual feeling in their psychological, pathological, and forensic aspects.

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See also

• Paresthesia