fornia nal .ty '' THERAPEUTIC SUGGESTION IN PSYCHOPATHIA SfiXUALIS (PATHOLOGICAL MANIFESTATIONS OF THE SEXUAL SENSE), WITH ESPECIAL REFERENCE TO CONTRARY SEXUAL INSTINCT. BT Dr. A. von SCHRENCK-NOTZING, PRACTICING PHYSICIAN IN MUNICH. Tira.tasla.tion. CHARLES GILBERT CHADDOCK, M.D., PROFESSOR OF DISEASES OF THE NERVOUS SYSTEM, MARION-SIMS COLLEGE OF MEDICINE; MEMBER OF THE AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION; MEMBER OF THE ST. LOUIS MEDICAL SOCIETY; ATTENDING NEUROLOGIST TO THE REBEKAH HOSPITAL : FELLOW OF THE CHICAGO ACADEMY OF MEDICINE; CORRESPONDING- MEMBER OF THE DETROIT ACADEMY OF MEDICINE, ETC. '' PHILADELPHIA : THE P. A. DAVIS COMPANY, PUBLISHERS. LONDON : F. J. REBMAN. 1895. COPYRIGHT, 1895, THE F. A. DAVIS COMPANY. [Registered at Stationers' Hall, London, England.] Philadelphia, Pa., U. 8. A. The Medical Bulletin Printing-House, 1916 Cherry Street. DEDICATED DR. AUGUST FOREL, PROFESSOR or PSYCHIATRY IN THE UNIVERSITY OF ZURICH AND DIRECTOR OF THE ASYLCM FOR THE INSANE AT BDRGHOLZLI, RESPECT AND GRATITUDE, BT THE AUTHOR. PREFACE. 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" urn- ings 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 educa- tional influences. Thus it became necessary to examine more carefully the etiology and pathogenesis 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 pathologi- cally and therapeutically, as far as is necessary for an under- standing of parsesthesia 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 opportunity for personal observation of them. 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 the 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-point ; 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) VI PREFACE. pathology, and one offering richest returns, is undoubtedly the establishment of precise indications for the employment of psychical therapeutics ; to which Wilhelm Erb, with clearness of view, has lately called attention, both with reference to psy- chical treatment in the waking state, as well as to hypnotic suggestion. 1 Though, in spite of the obstinate opposition and continued indifference of prominent clinicians, all the greater series of experiments 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 ; 2 and though thus the question concerning the justification of hyp- notic suggestion and its admission among the available means of our therapeutic 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 important 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. 1 Wilhelm Erb, " Die nachten Aufgaben der Nervenpathologie," Deutsche Zeitschrift fur Nervenheilkunde, Vogel, Leipzig, 1891, p. 3. 5 (a) Comp. Ringier : Erfolge des therapeutischen Hypnotismus in der Landpraxis (Lehmann, Miinchen, 1891). The author reviews 210 cases in his practice, which fulfill all requirements with reference to details of description, numerical grouping, continuance of observation after discharge, etc. He has never seen hypnosis have an injurious influence. (6) Van Renterghem and von Eeden : Comte rendu des r6sultats obtenus pendant la premiere periode bisannuelle, 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 praktischen Medicin " (Urban und Schwarzenberg, Leipzig and Vienna), in the course of the last few years, has subjected 3200 persons to hypnotic procedures, and induced hypnosis some 60,000 times, without observing any injurious results. (rf) Von Corval (" Suggest! vetherapie," Realencyclopadie der gesammten Heil- kunde, von Eulenburg, Eucyclopad. Jahrbucher, Bd. i, Urban and Schwarzcnberir) gives a complete review of this branch of therapeutics, and, from liis own as- well as from the experience of others in general, comes to the conclusion that hypnosis, correctly employed, is unaccompanied by any danger. PREFACE. VU If, as Erb justly remarks, this limitation to certain fields dispels many illusions ; still, the results ot 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 this work. The duration of the effects of suggestive treatment seems of great importance. Like Ringier, the author gave especial t (e) Minde, in his learued work, " Ueber Hypnotismus " (Diepolder, Miiuchen, 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 experimentation, and the desire to satisfy curiosity and vanity by public ex- hibitions for amusement, and they are usually to be ascribed to dilettautic 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. (/) 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), in 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." (<7) Preyer (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 unskillfully used." (A) 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 1'hypnot., i, p. 105 et seq. (t) Professor Bernheim, from his observations on several thousand patients, has lately expressed himself as follows : " Suggestion often cures; when it does not cure, it ameli- orates ; and if it does not benefit, it is still harmless." Comp. Hypnotisme, Suggestion, Psy- chotherapie, Doin, Paris, 1891, p. 18. (/fc) Grossmann 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. (I) Professor Hirt (Breslau), from August, 1889, to the middle of April, 1890, made hypnotic experiments for therapeutic purposes on 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 opposed to allow ing 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 30. (TO) The evidence mentioned is augmented by the wide experiences of Forel, Moll, and numerous other experimenters, all of which leads to the conclusion that, with proper individualization of hypnotism for therapeutic purposes, it is devoid of any disadvantages. Observations of the author on more than 300 persons, of whom many were hypno- tized more than 100 times and some 200 or 300 times, also speak in favor of the harm- lessness of therapeutic suggestion. Vlll PREFACE. attention to the duration of the suggestive-therapeutic 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 Krafft-Ebing, to continue to observe many patients for several 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 lor 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 pain, 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. I And though a com- mendable attempt has lately been made to establish objective signs in certain cases of neurasthenia, still, in his work, Lowen- feld 1 designates neurasthenia as that affection for which the very 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, they 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 terra incognita. Exact knowledge of the causes and conditions of development of sexual aberra- tions, and of the influence on them of hereditary constitution, education, the impressions of every-day life, and our modern, 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 1 Lowenfeld : Die objectiven Zeichen der Neurasthenic, Lehmann, Munchen, 1892. X PREFACE. development of sexual anomalies, 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 understanding of the ethical develop- 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. While 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 "psychopathia 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 their 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, how- ever, reaches its limits in inherited constitution or predis- position of the brain, having its root in "organic conditions; and likewise in " phenomena having a very deep foundation in the psychical mechanism " (von KrafFt-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 the work. When one considers the 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. speak of their asking for treatment, especially hypnotic treat- ment, then a series of seventy cases, therapeutically considered, forms a basis, in a measure, sufficient for the formation 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 this 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 therapeutics, 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 Bernheim-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 Bernheim 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. Somnolence. 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. Hypotaxis. The individual is no longer able to resist suggestions. No amnesia. III. Somnambulism. 1 With the manifestations of the 1 In order to give an idea of the susceptibility to hypnosis in general, I give here the numerical results 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. Xlll second degree there is also amnesia, or susceptibility to hallu- cination, or both. Post-hypnotic phenomena 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-operation 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 Zurich, 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 literary communications and advice by the following gentle- Refractory, Somnolence, Hypotaxis, Somnambulism, Persons. 29 42 ioo 69 240 Per Cent. 12.08 17.5 41.67 28.75 100.00 The results at Nancy (Liebeault), Amsterdam (Van Renterghem), and in Switzer- land (Ringier), in comparison, are as follow: Liebeault, 1011 Persons. Liebeault, 753 Persons. Van Renterghem, 178 Persons. Ringier, 221 Persons. Sohrenck- Notzing, 240 Persons. Per Cent. Per Cent. Per Cent. Per Cent. Per Cent. Refractory .... Somnolence . . . Hypotaxis .... Somnambulism . 2.67 3.26 78.04 16.02 7.97 10.09 63.21 18.73 3.93 5.06 79.77 11.24 5.43 7.24 52.49 34.84 12.08 17.50 41.67 28.75 99.99 100.00 100.00 100.00 100.00 According to my preliminary summary, the susceptibility to hypnosis of 8705 per- sons, of various nationalities, is shown by the following figures : Persons. Refractory, 519 Somnolence, -'...-'. 2557 Hypotaxis, 4316 Somnambulism, 1313 8705 Per Cent. = 6 = 29 = 49 = 15 100 Advanced years, on the whole, diminish susceptibility, while the figures for earliest youth do not quite reach those for middle life. XIV PREFACE. men : Dr. Bernheim, Professor of Internal Medicine at Nancy ; Dr. Stumpf, Professor of Philosophy (Munich) ; Dr. Gussman (Stuttgart); the privat-docenten, Dr. Kopp (Munich) and Dr. Max Dessoir (Berlin) ; Dr. Liebeault (Nancy) ; Dr. Wetter- strand (Stockholm); Dr. Van Renterghem (Amsterdam); Dr. Rosenberg (Carlsruhe) ; Dr. von Hosslin (Neuwittelsbach, near Munich); Max OfFner (Munich); and Mr. X. X., urn ing. I here express- my thanks to them all for their friendly and helpful co-operation. THE AUTHOR. MUNICH, October, 1894. TRANSLATOR'S PREFACE. THE favorable reception given von Krafft-Ebing's " Psycho- pathia Sexualis " induced me to undertake an English version of the 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 " Psychopathia Sexualis." The importance of the question treated in these works cannot be overestimated ; for upon the 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. Louis, Mo., December, 1894. (XV) TABLE OF CONTENTS. PAGE PREFACE, . . . . iii-xiv SECTION I. SEXUAL HYPERESTHESIA, .;,,..'. . . , . 1-7 T CHAPTER I. PATHOLOGY, ... . . . . , . . . 1-33 A. ONANISM, . . , ' . . . . . . . . . 2 Causes and predisposition, 3 ; forms, 7 ; onanism by means of tactile excitation, 7 ; through psychical stimuli, 9 ; through combination of both, 12 ; clangers 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 HYPER^ES- 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 ANESTHESIA, .. . . . 78-116 CHAPTER IV. PATHOLOGY, '..- ' 78-91 Physiology, 78 ; causes and forms of impotence, 79 ; female impo- tence, 84 ; diagnosis, 90 ; prognosis, 90. (xvii) Xviii TABLE OF CONTENTS. CHAPTER V. PA OK THE ROLE OF SUGGESTIVE THERAPEUTICS IN THE TREATMENT OF FUNCTIONAL SEXUAL WEAKNESS, . . . . 92-98 Methods of treatment, 92 ; suggestion in the method of Brown- Sequard, 93 ; psycho-therapy, 94 ; waking suggestion and hypnotic treatment, 96. CHAPTER VI. CASES ILLUSTRATING SUGGESTIVE TREATMENT OF SOME FORMS OF IMPOTENCE, . 99-116 Therapeutic results in psychical, functional, relative, and paralytic impotence, Cases 21 to 38, 99 ; tabular review, 114 ; conclusions, 113. SECTION III. SEXUAL PAR.ESTHESIA, . . . .... . . 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, 130 ; Greek boy-love, 130 ; impure male-love in Greece, 135 ; GiJXeia vowrot, 136 ; spontaneous origin and cultivation of the feminine type in the male, 137 ; views of some ancient writers concerning the pathicus, 139 ; conclusions, 142. CHAPTER IX. HEREDITY AND EDUCATION IN THEIR 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 undiflferentiated sexual feeling by ex- ternal excitants, 151 ; hereditary lack of resistive power, and patho- logical association, 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 paraes- thesia sexualis, and its proofs, 158; objections, 160; tbe 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 mean's 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, 303 ; conclusions, 302. APPENDIX, 307-319 I. SEXUAL HYPER^ESTHESIA. 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 differentiates sexual instinct arising in childhood and sexual desire re-awakened in old age (paradoxia) from abnormal intensification of it (hypersesthesia *). 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 Krafft-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 " hypersesthesia of the sexual instinct." But, also 1 Comp. von Krafft-Ebing, " Psychopathia Sexualis," Chaddock's translation (F. A. Davis Co., Phila., 1893), pp. 48, 51-55. (i) 2 SEXUAL HYPERAESTHESIA. in so far as onanism in itself presumes an unconquerable im- pulse, and incapability to control it, it may be classified as hyperaesthesia sexualis. In spite of full recognition of the theoretical and clinical importance of von Krafft-Ebing's classification, practical con- siderations in the main have induced me to unite the cases at my command under the title of " Sexual Hyperaesthesia," and, for the sake of clearness, to divide them into two classes : 1. Onanism (auto-sexual indulgence). 2. Satyriasis and nymphomania (heterosexual indulgence). Upon the opinions we entertain of the nature of these 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 other methods 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. 1 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. Therefore, coitus in os, coitus inter mammae, mutual masturbation, etc., may be designated as onanistic acts performed by means of the body of another 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. 1 Comp. Christian (Charenton), Extr. du Hist, encyclop. des scienc. m6dic. ; and Centralb. fur Nervenheilk., 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 this manner of sexual indulgence, which is the most common, will occupy us here. Causes and 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, 1 etc., while wearing too close-fitting clothing. In such 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 1 Comp. Fournier, De 1'onanisme. 4th ed. Paris, 1885, p. 67. 4 SEXUAL HTPER^STHESIA. crying children, manipulate their genitals. 1 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 2 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 faute de mieux. In the majority of cases which come for medical treatment, however, the individuals are of tainted heredity. Lombroso 3 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 Krafft-EbingV experience, which is no less extensive, in untainted individuals the limits of an asthenic neuropsychosis 1 Comp. Gyurkovechky, Path, und Theraple der Maiml. Impotenz, Urban und Schwarzenberg. Wien, 1889, p. 106. 9 Loc. c.,p. 108. 1 Lombroeo, Der Verbrecher, Hamburg, 1887, p. 128. 4 Von Krafft-Ebing, Psychiatric, 3 aufl. Stuttgart, p. 308. 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 the 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. 1 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 the girl masturbated as a result of irritation seated in the genito-spinal centre ; for all sensorial cerebral functions were to be regarded as absent. 2 Here it may be advantageous to review the anomalies of the sexual instinct in imbeciles and idiots. In relation to the symptoms of par- adoxical expression of the sexual appetite, sexual hyperaBS- thesia in general, according to the statements of Sollier 3 and Bourneville, 4 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 the 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 1 Magnan, " Des anomalies, des aberrations, et des perversions sexuelles," Progres M6dical, 1885. a Comp. von Krafft-Eblng, " Ueber Irresein durch Onanie bei Mannern," Allgem. Zeitschrift fur Psychiatric, 1874, p. 425. 1 Paul Sollier, Der Idiot und der Imbecilles, Leipzig, 1891, p. 75 et seq. * Bourneville and Sollier, " Des anomalies des organs g6nitaux chez les idiots et lea epileptiques," Progres M6dical, 1887. 6 SEXUAL HYPER^ESTHESIA. 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. Often there are seen malformations that are in nowise related to the sexual instinct. On the other 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 demenj;s. 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, especially with the occurrence of puberty and as a result of education. Even though 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. In 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 their 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 after 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 the practice so long that the skin became gangrenous, and the surface of the sores could never be entirely healed." According to the later psychiatric investigations (Christian, Kraepelin, Forel, Vogel, Lowenfeld, UfFelmann, von Krafft- Ebing, etc. 1 ) 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 simultaneously. From a practical stand-point, three groups may be distinguished:. 1. Onanism by means of tactile excitation. 2. Onanism by means of psychical excitation. 3. Onanism by means of a combination of sensory and ideational excitation. 1. Onanism by Means of Tactile Excitation (Masturbation, Manustupration).^W\n\e 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 mammae ; in men : the skin of the external genitals, and, according to some authors, under pathological conditions, the anus), according to Hammond's 2 opinion, is not sufficient to induce the necessary degree of sensual excitation; rather, the peripheral stimulus induces ideas 1 Christian, Onanisme (Extr. du diction, encyclop. des sciences m6dicales) ; reference in Erlenmeyer's Centralbl. fur Nervenheilkuude, 1882, p. 198. Kraepelin, Lehrbuch der Psychiatric, p. 32. Forel, " Einige Worte iiber die reglementirte Prostitution in Kiew und fiber sexuelle Hygiene," Separatabdruck ausdem Correspondenzblatt fur Schweizer Aerzte, 1889. Vogel, Lehrbuch fur Kinderkrankheiten, 5 aufl., p. 387. Uffelmann, Handbuch der offentl. und privaten Hygiene des Kindes, 1881, p. 368. Lowenfeld, Die nervosen Stor- angen sexuellen Ursprungs, Wiesbaden, 1891, pp. 64, 65. 9 Hammond, Sexual Impotence. 8 SEXUAL HYPER^ESTHESIA. with which 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 the genitals consists of rubbing, press- ing, swinging movements of the thighs, or of fondling and friction with the hands. Females 1 make use of the most vari- ous objects for masturbation; 2 they insert large and small objects into the vagina, such as hairpins, crochet-hooks, needle-cases, lead-pencils, radishes, spools, and candles. " Married women," according to Winckel, 3 " choose fir-twigs, artificial penes made of bacon, and even pomade-jars and drinking-glasses. The 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, which 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 Ehe anthropological significance 4 of masturbation. Among the Khoikhoin (Nama Hottentots), according to Ploss, 5 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 1 Pouillet, De 1'Onanisme de la femme. 3d cd. Paris, 1877. 3 De Giovanni, Di una causa posa valutata nella patogenesi di alcune infirm! ta mull- ebri (Gazz. Mod. Lombarda, 1877, No. 15, p. 141). 1 Comp. Wlnckcl, Diseases of Women. 4 According to Mantegazza (Hygiene der Liebe, p. 83), the English physician, Cope- land, has stated : " The 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 experience of Mantegazza and others. ' Ploss, Das Weib, Leipzig, 1891, Bd. 1, p. 330. Fritsch, Die Eingeboren Siidafrikas, Breslau, 1873, pp. Ill, 380. ONANISM. 9 desires, and they had other similar means for the satisfaction of their unnatural lust (Blumentritt 1 ). 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 Floss, 2 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 form. 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 by Means of Psychical Stimuli (Psychical Onanism}. Central excitation of the sexual orgasm, as by simple memory-pictures, is always a sign of psycho-sexual hypersesthesia, and is to be regarded as occurring, 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, 3 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." 4 According to Hammond, there are men who know only 1 Blumentritt, " Der Ahnencultus und die religiosen Auschauungen des Philippinen archipels," Mitth. d. 12, 12 geog. Gesellsch. in Wien, 1885, xxviii, 2. 9 Ploss, Das Weib, Leipzig, 1891, Bd. i, p. 330. 1 Von Kraflt-Ebing, Psychopathia Sexualis, p. 39. * Hammond, Sexual Impotence. 10 SEXUAL HYPERJESTHESIA. this kind of excitation, and who have no erection in the normal way. As a rule, this hypersesthesia occurs after masturbatic or other sexual excesses ; so that the 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 ejaculation takes place. This calls to mind the artificial induction of dreams by narcotics. In " The Significance of Narcotics in Hypnotism " 1 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 the 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 2 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 the 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 1 Schriften der GesellschafTt fur Psycliologische Forschung (Leipzig, Abel, 1891), Heft 1. Robinson, "Klin. Beob. iiber Pollutionen beim Weibl. Gescblecht," Med. Ag., 1889, No. 7. ONANISM. 11 the seductive form of the opposite sex, in order to perform coitus with them. 1 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 ephiaUes and hypliialtes, 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 Floss, 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 sylvans 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 excitement in the genital apparatus at the time of puberty in both sexes, and at the time of menstruation 1 Ploes, Das Weib, Leipzig, 1891, Bd. i, p. 332. 12 SEXUAL HYPEILESTHESIA. in maidens and women, have a reflex effect upon the central nervous system, and induce erotic ideas that may attain the intensity of hallucinations, which then correspond with the re- ligious 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 by Means of a Combination of Sensory and Ideational Excitation. In orianists 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 Krafft- Ebing 1 thinks, in all cases lascivious ideas are induced, according to my experience, seems questionable. With hyperexcitation of the genital centres, ejaculation occurs without other 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 the 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. Thus, 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- 1 Von Krafft-Ebing, Psychopathia Sexualis. 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 of 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 sexual 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 d, 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, 1 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 who 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. 1 Comp. Hammond, loc. cit. 14 SEXUAL HYPER^ESTHESIA. 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 he 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 urinae, 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 he 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 half-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, 2 Althaus, 3 Cloquet 4 ). In his latest work, Moll 5 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 than that of smell ; especially since it is questionable whether there is a special centre for sexual sensations. 1 Hammond, loc. cit. 4 Von Krafl't-Ebing, PsycRopathia Sexualis, p. 26. 1 Althaus, " Beitrage zur Physiol. und Pathol. des Olfactorius," Arch, fur Psych., xii, H. 1. * Cloquet, Osphr6siologie, Paris, 1826. 1 Moll, Die contrare Sexualempfindung, Berlin, 1891, pp. 188, 184. ONANISM. 15 The sensory impressions mentioned induce in the cerebral cortex sexual ideas, feelings, and impulses which, in hyperses- 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 1 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, 2 which must be regarded as instances of psychoses, have a much more intense psychical effect than does coitus. The content of the ideas in every single onanistic act must overcome reality, 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- 1 Erb, Handbuch der RuckenmarkskrankLeiten, p. 163. ' Comp. p. 5. 16 SEXUAL HYPERyESTHESIA. sexual product, the content of ideas, becomes artificially accustomed to a single direction of activity. We shall 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 with infrequent perform- ance of the act, brings onanists into a peculiar and, I might say, unphysiological relation 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. 1 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 2 describes in detail. Still, in purely a physical sense, it seems questionable whether coitus and masturbation are equivalent acts. Gyurko- vechky 3 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 4 assumes that the sexual act, in that it requires a greater expenditure of muscular power, must certainly be more injurious than onanism with like frequency of indulg- 1 Comp. von Krafft-Ebing, Psyc-hopathia Sexualis, p. 5. 3 LSwenfeld, "Die nervosen Storungen sex. Ursprungs, pp. 89-94. 1 Gyurkovechky, Impotenz, p. 103. 4 Hammond, loc. cit. ONANISM. 17 ence; at least, with reference to ejaculation and orgasm. " For, with the orgasm and the loss of semen, it is a matter of indiffer- ence, where the semen is deposited, whether in the vagina or in any other receptacle." This conflict in the opinions of the authors is easily overcome when we properly 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). 1 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 the same time, between the sexual instinct longing for satisfaction and the effort to remain pure, there arises a terrible struggle, which, unfortunately, only too often ends in victory for the vice. 2 From this arises the moral depression of those who abstain. This and the ever-renewed struggle, as well as the onanistic stimulation, gradually undermine the nervous system. 3 1 Hammond, loc. cit. * Comp. Leopold Caspar, Impotentia et Sterilitas Viriles, Miinchen, 1890, p. 77. ' Comp. Beard, -Sexual Neurasthenia; and von Krafft-Ebing, " Neurosen und Psy- chosen durch sexuelle Abstinenz," Jahrb. fur Psychiatric, Bd. viii, pp. 1, 2. 2 18 SEXUAL HYPER^ESTHESIA. In the course of time weakness of the whole nervous system occurs. 1 At the same time it is important whether the pernicious habit 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 2 ). Meyer 3 thinks that the impulse to masturbate is stronger and more obstinate when the result of psychical predisposition, weaker when it is accidentally p'rovoked. 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 1 Only orthodox one-sided ness of view and complete ignorance of physiological con- 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, i.e., complete abstinence from sexual intercourse." (Comp. A. Rorner, M.D., Die Sit- tenreinheit vor dem Richterstuhl einer arztliflien Autoritat, Streitfragen, wisseuschaftliches Fachorgan der deutschen Sittlichkeitsvereine, Berlin, 1892.) The pamphlet is opposed to the works of Moll and von Krafft-Ebing, and states that sexual errors arise either from " seduction " or from " personal evil " (sic.')- But those who show a tendency to yield to " the evil inclinations of the human heart" (p. 12) should, according to the receipt of Dr. Romer, call to mind " the grand words of the Apostle Paul in the Epistles to the Romans (i, 26, 27, 33), as well as in those to the Galatians (v, 16 and 24)." a Von Krafft-Ebing, Ueber Irresein durch onanie bei Mannern, v. mpra. * Ludwig Meyer, Die Beziehungen der krankh. Zustande und 1 Vorgange in den Sex- ualerg. des Weibes zu den Geistesstorungen, Berlin, 1869, p. 15 et seq. ONANISM. 19 that evil db ovo" (Vogel, 1 UfFelmann 2 ). In young children masturbation causes convulsions, choreic conditions, and mental weakness. According to Spitzka, 3 between the fifth and tenth years the nutrition of the brain suffers,, Such children are wanting in independent thought and action. At the 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 the 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 4 ). Through habitual indulgence, on an ism 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), spermatorrhoea, premature ejacu- lation in attempts at coitus, hyperaesthesia of the genital centres, spinal neurasthenia, congestion of the prostate, inflammation of the urethra, hyperamia 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 urethra), and urinary incontinence. Further results are urethritis, prostatorrhcea, spermatorrhoea, and impotence. * 1 Vogel, Lehrbuch der Kinderkrankh., 5 aufl., p. 387. 1 Uffelmann, Handbuch der offentl. und privaten Hygiene des Kindes. Leipzig, 1881, p. 368. ' Spitzka, " Self-A'onse in Relation to Insanity," The Dublin Medical Journal, 1887. 4 Spitzka, loc. cU. 20 SEXUAL HYPEILESTHESIA. The neurosis of the lumbar portion of the cord leads to general neurasthenia, tachycardia, pains, praecordial distress, feelings of pressure and weight or pains in the eyelids, 1 spasm of the lids, photophobia or subjective sensations of light, dimi- nution of the acuity of central vision, neurasthenic asthenopia, etc. To these disturbances Lowenfeld 2 adds the so-called eye- migraine. 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 minora and the vaginal orifice, desquamation of the epithelium, fluor albus, cer- vical catarrh, intense hyperaesthesia, pruritus vulvae, 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 with several men, but in many cases may be induced post-coitum by masturbation. In the chapter on impotence I shall consider the matter more in detail. The above-mentioned change of character, depending upon un- 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 3 speaks very caustically of such a disposition : " They think they can satisfy themselves with their unnatural stimulation, and it is owing to this circumstance that so many remain unmarried, of course unconscious that health and life are destroyed by the unnatural satisfaction of their desires. One sees only too many of such erring old maids to compare with the wife, who has been the faithful companion of her husband, chaste and moderate in indulgence and moral, and the mother 1 Comp. Cohn, " Augenkraukheiten bei Masturbanten," Archiv fur Augenlieilkunde, you Knapp und Schweizer, 1882, p. 198. 9 Lowenfeld, loc. cit., p. 83. 1 Steinbacher, Die mannliche Impotenz, Munchen, 1877, p. 84. , ONANISM. 21 of children. It is astonishing how much better women living a full life are preserved up to an old age, 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, insufferable in 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- pathic 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 l 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 will. In such cases melancholias arise with intense hypochondriacal features in harmony with the predominating symptoms of the accompany- ing neurasthenia. (6) 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. 1 Von Krafft-Ebing, Lehrbuch der Psychiatric, 3 aufl., p. 208. 22 SEXUAL HYPER^STHESIA. All the symptoms occurring in the sexual psychoses are more or less those of neurasthenia, as are olfactory hallucinations of a repulsive character. In confirmation of von Krafft-Ebing's views, Krapelin l de- scribes the psychical degeneration in the following words : " Most frequently in onanists there occurs a progressive loss of mental activity, or inability 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 2 state- ments, the admissions of insane patients to the asylums of Sweden were : 1883 . . . 643 cases, of which 25 were due to onanism. 1884 ... 704 " " " 19 " " " " 1885 ... 744 " " " 22 " " " " 1886 ... 741 " " " 35 " " " " 1887 ... 791 " " " 35 " " " " Total, . . 3623 " " " 136 " " " " This constitutes 3.7 per cent. 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. 1 Krapelin, Psychiatric, 3 aufl., p. 33. Ribbing, Die sexuelle Hygiene, 3 aufl., p. 128 (Hobbing, 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 " " ). 1887 . . .1.4 " " ( " 2.6 " " " 0.2 " " ). Ellinger 1 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 that, 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 2 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 third child was born of a criminal mother and presented the clinical picture of psychical degeneration. Dr. Peretti 3 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. 4 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 hypochondriacs! mood. An 1 Ellinger, Allgem. Zeitschr. fur Psychiatric, Bd. ii, cited by von Krafft-Ebing, " Ueber Irresein durch Onanie." * Ludwig Meyer, loc. cit. ' Peretti, " Ueber Geisteskrankheit bei Onanfeteu," Die prakt. Arzt., 1881, ri. * Comp. Lombroso's statements on page 4 of this book. 24 SEXUAL HYPER^ESTHESIA. insignificant circumstance may be sufficient to induce a com- plete outburst of despair, fear, or an attempt at suicide. The hypochondriacal depression may go even to the extent of hypo- chondriacal paranoia. Pure melancholia is infrequent. The mind is weakened, and the 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 the 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 changes ; 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- bral 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 " (Tarnovvsky). 1 Cases of erotomania belong to Magnan's 2 fourth group. In such patients the lower sexual instincts of the occipital arid 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 frequently 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 1 Tarnowsky, op. cit., p. 58. * Comp. Magnan, loc. ctt. 26 SEXUAL HYPER^ESTHESIA. development of the individual, and it may, with the occurrence of other accidental deleterious influences of slight importance per se, 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 the condition and age of such onanists the symptoms 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 the 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 her trouble. Vogel, 1 Uffelmann, and Emminghaus think that, 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 mental 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. 1 Comp. Vogel, Uffelmann, loc. cit. 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 awoke with her finger in the vagina. Spots of semen on the linen, 1 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 hyperaemia of the colliculus 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, 2 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 urethra 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 1 One of Dr. Franz Carl Mailer's patients ejaculated in his stockings in order to escape detection. (Verbal communication.) * Gyurkovechky, loc. cit., p. 138. 28 SEXUAL HYPER^ESTHESIA. in, the more unfavorable is the prognosis. But even patients in whom the vice has become instinctive have some prospect of 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 1 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, 2 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. 3 Von Krafft-Ebing regards this sexual symptom-complex as a part of a psychosis which rests upon a psychical hypersesthesia (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 4 regards the immediate re-awakening of desire, 1 Peretti, loc. cit. a Von Krafft-Ebing, Lehrbuch der Psychiatric, 3 aufl., p. 519. ' I follow, in the main, voti Krafft-Ebing's exposition. Comp. Psychopathia Sex- ualis, p. 373, and Lehrbuch der Psychiatric, p. 87. ' Emminghaus, Psychopathologie, p. 87. SATYRIASIS. 29 after satisfaction of it, with pre-occupation of the entire atten- tion, as abnormal. In Magnan's l 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 convolu- 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 the 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 2 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 other desires and feelings, and, if it be not satisfied, leads to sexual fury and perverse acts. Thus, accord- ing to Lombroso, 3 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 1 Comp. Magnan, loc. cit. 9 Von Krafft-Ebing, " Neurosen und Psychosen durch sexuelle Abstinenz," Jahrb. fur Psychiatric, Bd. viii, 1, 2. 1 Lombroso, Der Verbrecher, p. 20 et seq. 30 SEXUAL HYPER^ESTHESIA. 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, faute 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 spent 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 he 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 lie 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 1 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 Buffbn. 2 After long struggles, fasting, and prayer, all women began to 1 Tarnowsky, loc. ctt., p. 61. 2 Buffon, Histoire naturelle de 1'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 Krafft- 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 masturbatic rubbing with the thighs. For a long time the genital erethism occurred in attacks every morning, once at my office. 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 attacks 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, saliva, and urine ; in combing and undoing the hair ; in the milder forms of self-adornment and flirting; in vacillation between forwardness and modesty or sentimentality ; or in 'hand-squeez- ing, letter-writing, suggestive glances, etc." (Kraepelin). 1 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 2 holds the opinion that religious fervor and an inclination to indulge 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 commonly talk much of virtue and virginity" 3 (von Krafft-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 1 Kraepelin, loc. ctt., p. 139. 'Neumann, Lehrbuch der Psychiatric, p. 80. 1 Von Krafft-Ebing, Psychiatric, p. 89. 4 Von Krafft-Ebing, Psychopathia Sexualis, p. 8. NTMPHOMANIA. 33 of the other. Both, under pathological conditions, may become transformed into cruelty." The diagnosis of this form of sexual hypersesthesia 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 hyperajsthesia ; and, too, the fundamental psychopathic 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 hyperaesthesia (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 the curative methods and the problems which 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, unfortunately, 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 the 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 might and leads astray (von Krafft-Ebing.) 1 With children strict and intelligent oversight is necessary, and when there are 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- 1 Vou Krafft-Ebiug, Psychopathia 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 1 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 ; with 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. 2 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 hopefully sought. At the first sign of puberty children should be taught to under- stand the sexual relations and the 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 1 Fournier, De 1'onanisme. 4th ed. Paris, 1885. 1 Comp. Friedreich's Blatter fur gerichtl. Mediciu, 1891, Heft I, p. 8. 36 SEXUAL HYPEILESTHESIA. development of the instinct be delayed as long as possible. Such experienced physicians as Moll 1 and Tarnowsky 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 which 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 manyconflicting opinions, which, owing to the importance of the subject, we cannot over- look. Several investigators, as Acton, 2 Beale, 3 Paget, 4 and Govvers, 5 contend that abstinence has no injurious effect upon the health. They permit sexual intercourse only in marriage. Augagneur 6 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." Ribbing 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." 7 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 should be as far from attempting to cure onanism by means of debauchery." He pleads for the punish- ment of prostitution, but has to confess (p. 184) "that we are far from the state of nature, and have found no modus vivendi in accord with culture and its requirements." Forel, 8 who, in 1 Moll, Contrare Sexualeinpfiriduug, 1891, p. 214. a Acton, On the Reproductive Organs. 1 Beale, Our Morality and the Moral Question, 1887. 4 Paget, Cited by Beale. * Gowers, London Lancet, 1889. Prophylaxe publique de la Syphilis, par A. Fournier, Paris. 1887, pp. 10, 11. 1 Ribbing, Sexuelle Hygiene und ihre ethischen Consequenzen, Leipzig, 3 aufl., pp. 127, 131, et seq. Forel, " Einige Worte iiber die reglementirte Prostitution," Correspondeuzbl. fur Schweizer Aerzte, Jahrg. xix, 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 1 con- firm's Forel's experience with the observation that occasional interruption of customary regular intercourse has a deleterious effect upon neurasthenic conditions. Von Krafft-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. 2 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 hypersemia of the genital organs, without gratification, irritable weakness of the genital apparatus and its nerve-centres may ensue. According to von Krafft-Ebing, in predisposed individuals the results of abstinence are essen- tially the same as those of onanism. 3 Of course, very few men possess sufficient 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 performance 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 1 Lowenfeld, loc. cit., p. 17. 1 Krafft-Ebing, Jahrbucher fur Psychiatric, viii, pp. 1, 2. 1 Krafft-Ebing, Psychiatric, p. 209. 38 SEXUAL HYPER^STHESIA. 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 the sexual instinct. The recom- mendation to voluntarily destroy any function like the idea of love is a subject for the fanatic, but directly opposed to hy- giene " (Tarnowsky). l As long as society is not in a position to offer to every mature individual satisfaction of the 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, 2 with the presentation of abundant evidence, shows. Forel, 3 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. 4 The roots of this phenomenon, which is still especially favored by the constitution of modern social life, are to be sought 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 1 Tarnowsky, Prostitution und Abolitionismus, Hamburg, 1890. 9 Ibid., p. 31. "Forel, Zur Frage der etaatl. Regulirung der Prostitution (Bremerhaven und Leip- zig, Lienken), 1892, p. 18. Unfortunately, I was unable to obtain, in time to use them for this work, the books recommended by Forel, " Fiaux, Les maisons de tolerence " (Paris, 1892). 4 In the consideration of this question, 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, Marz, 1892, p. 93. ABNORMAL INTENSIFICATION OF SEXUAL DESIRE. 39 of the young and the ignorant ; and through an increase of facility of marriage and amelioration of conditions of life. " For the more undeveloped 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, with 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. 1 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 hyperaes- 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 aim 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- 1 The Committee of Management of the Prussian Society of Physicians, in its meeting of December 13, 1891, in considering the question of prostitution, touched upou the subject of sexual education. There was no difference 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. The committee appointed a com- mission to make a report upon measures for preventing the further spread of syphilis. 40 SEXUAL HYPEK^STHESIA. sidering 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 l says, ,to give to the world the healthy fruit of a passionate love than, through sins against self, against nature and health, " in invalidism and misery, to stamp youthful years with the most repulsive mark of old age 1 " 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 which will guard against excesses, infection, and the procreation of illegitimate offspring which, under certain circumstances (e.g., 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 1 Steinbacher, loc. cit., p. 85. ABNORMAL INTENSIFICATION OF SEXUAL DESIRE. 41 other hand, the Queen of Aragon recommended six sexual acts a day. " The Talmud directs one coitus 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." 1 Concerning the advisability and injurious effects of so-called " preventives," opinions also differ. Gyurkovechky 2 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 " fraudiren," 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 3 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 bulbo- 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. 4 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 both parties ; and it affords relatively the greatest protection against infection and pregnancy. Therefore, as does Gyurkovechky, 5 we can recommend to our patients a well-made, elastic condom. 'Comp. Gyurkovechky, loc. cit., p. 88. " Gyurkovechky, loc. cit., p. 143. 1 Peyer, Der unvollstaridige Beischlaf, Enke, Stuttgart, 1890. * Bergeret, Des fraudes dans 1'accomplisment des fractions generatrices, Paris, 1884. ' Gyurkovechky, loc. cit., p. 144. 42 SEXUAL HYPER^ESTHESIA. 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 principle is, and remains, individuali- zation. No prudery, no false 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 ! Whole 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 psychical 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. 1 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. HydrotJierapeutic procedures are to be recommended in almost all cases of sexual hyperaesthesia. Thus Caspar 2 recom- mends cold baths, followed by cold douches to the spinal column ; also cold rubbing with wet towels. Prolonged warm baths have a calmative effect on the nervous system in cases of satyriasis and nymphomania. Concerning the use of sponge-, shower-, and douche- baths, and hip-, steam-, and sea- baths, compare Gyurkovechky, 3 Beard, 4 Lowenfeld, 5 and Winternitz. 6 1 For description of mechanical means for the prevention of masturbation, compare Fournier, De 1'onanisme, 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, Fournier, 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, Impotentia et sterilitas virilis, Munchen, 1890, p. 104. * Loc. cti., pp. 158, 160. 4 Sexual Neurasthenia. Loc. ctf., p. 154. Die Hydrotherapie, 1879, Bd. ii. 44 SEXUAL HYPER^ESTHESIA. Too, treatment with sounds, injections, rectal treatment, and, in females, irrigations and other 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 the special works. Moll's work, 1 which lately appeared (" Is Electro-Therapeutics a Scientific Remedial Pro- cedure I "), should be consulted ; and also the controversy of Mobius and Eulenburg 2 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 preparations 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, cantharides, phosphorus, and atropine exert an exciting effect on the genitals ; and for this purpose Hammond 3 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 hygiene, 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 convince the patient that he or she has become the victim of an abnormal, 1 Berliner KHnik, Heft 41, November, 1891. 3 Berliner klin. Wochenschrift, 1892, No. 8. * Loc. cit. ABNORMAL INTENSIFICATION OF SEXUAL DESIRE. 45 dominating impulse, whether an onanist or a nymphomaniac, that is, self-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 strengthen 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 that 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 l asserts that mathe- matical studies diminish sexual power. Grimaud de Coux 2 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 which 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 3 reports the same thing in the case of a card-player who, during cohabitation, 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 thought, and thus the sexual impulse is repressed. Rosen thai 4 and Bernheim 5 speak in favor of the "larvated" form of psycho-therapeutics in the non-hypnotic state and for 1 Cours de phr6nologie, Paris, 1826, p. 783. Histoire de la g6n6ration de I'homme, Paris, 1847, p. 294. 1 Zoc. ctf . * " Ueber psychische Therapie innerer Krankheiten," Berliner Klinik, No. 25, 1890. 'Neue Studien fiber Hypnotismus, etc., Wien, 1892. 46 SEXUAL HYPER^STHESIA. 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 penciling, or other instrumental procedures, and fright and fear (with children). The means used may be medical, mechanical, electrical, and religious 1 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 the 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 undervalue 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 the measures them- selves does not controvert. Lowenfeld 2 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 psycho-therapeutics. With von Krafft-Ebing, among the authors repeatedly mentioned in this work, Caspar 3 1 There Is no doubt, in spite of numerous exceptions, that a strict religious educa- tion with many persons is an excellent prophylactic against sexual errors. Compare the brochures of Romer, previously mentioned. * Loc. ctt.,p. 152. 1 Loc. cit., p. 98 : "I doubt not that suggestive therapy (in impotence and sexual disturbances) will give invaluable results." ABNORMAL INTENSIFICATION OF SEXUAL DESIRE. 47 and Lowenfeld 1 principally speak in favor of hypnotic sugges- tion in sexual neuroses. Tessie's 2 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 had 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- sesthesia 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 affects. 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. 1 Loc. cit., p. 157 : " In hypnotizable persons hypnotic suggestion is capable 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 repeatedly successful in giving sleep and freedom from sexual excitement for weeks at a time. Still, this patient was an. excellent somnambulist, who could be placed in deep hypnosis 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, loc. cit., p. 99. 48 SEXUAL HTPER^STHESIA. Charles Richet 1 demonstrated that it is possible to induce ejaculation by merely awakening a belief that coitus is being performed. Sexual psycho-pathology, in ideal cohabitation, pre- sents analogous examples of orgasm induced by auto-suggestion. Merely the direction of the attention to the performance of coitus, in association with lively images of sexual content, induces vaso motor changes in the genitals, as any one may demonstrate on himself. Purely as a result of idea, excitation of the dilators of the penis occurs, exactly in the manner that blushing and pallor are brought about by psychical impressions. While without hypnosis the vasomotor nerve-centres may be intensely influenced by ideas, in hypnosis there is a marked increase in the intensity of this 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 hemorrhages, menses, etc. Forel 2 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.g., appetite (at sight of food), thirst, joy, excitation of libido sexualis at sight 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 1 Moll, Der Hypnotismus. a Forel, Hypnotismus, 2 Aufl., Enke, Stuttgart, 1891, p. 56. 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 pathological 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 50 SEXUAL HYPER.ESTHESIA. psychical causes as the most direct remedial measure, and one which attacks the evil at its root. In cases of onanism no other method of treatment can be compared with therapeutic suggestion in rapidity and certainty of action ; psychical thera- peutics in the waking state often does not succeed where hyp- notic suggestion is successful. 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 much more effectual than the circumstantial procedure in the waking state. Besides, the latter method, in the matter of self- knowledge, strength of will, etc., makes demands upon the juvenile mind which reach beyond the mental horizon and ability of many children. After these theoretical considerations there can no longer be any doubt that psycho-therapeutics by suggestion is destined in the future to play the principal role in the treatment of onanists, while former methods of treatment are to be employed only for the sake of completeness. In a more limited sense, the same is true of satyriasis and nymphomania in their milder forms ; severe cases and those due to organic conditions are 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 HYPER^ESTHESIA. TWENTY cases from the experience of others and myself follow, which, with the exception of Case 9, are published together for the first time from the manuscripts of the authors. The grouping of the cases corresponds with the foregoing classification, ONANISM BY MEANS OP TACTILE IRRITATION. (Cases 1 to 16, 1 to 9 by other authors ; 10 to 16 by the author.) Case 1. Onanistic 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 onanistic inclinations in three sittings. He passed 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 boy, aged 7, passed at once into somnambu- lism, and in five sittings was cured of his onanistic 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 Girl Cured by Hypnotic Suggestion. Reported by Dr. Liebeault. A., aged 8, female, masturbated by touching the genitals with her hands from early child- hood, and suffered 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 boy 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 we.ik- minded at the age of 12, and had masturbated for years. In spite of all (51) 52 SEXUAL HYPER^STHESIA. treatment, he continued the vice. At the first attempt at hypnosis he passed into deep sleep. Notwithstanding the fact that for months I daily subjected him to treatment by suggestion, I obtained no result. Case 6. Masturbation in a Girl Cured by Suggestion. Reported by Dr. Wetter strand, Stockholm. A girl aged 26, school-teacher from the province, was given to masturbation from childhood. In three weeks of treatment she was cured by 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. Reported by Dr. Bernheim, Nancy. A child aged about 8, Russian, was brought to me by his mother three years 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 easy 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 his habit. All medical, hygienic, and other treatment remained futile. Case 8. Lasting Removal of Habitual Onanism by Hypnotic 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 three years. A boy of 16 had taught it to him. Seven months previously his parents had discovered his vice. They surprised the child inflagranti, while he was apparently 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 symptoms of nerv- ONANISM BY MEANS OF TACTILE IRRITATION. 53 ousness, and was devoid of nervous heredity. At the first sitting, on April 9th, I placed him in deep sleep, with amnesia on awaking. I sug- gested to him that neither by day nor by night was he to have a thought of touching himself, and that he would be able to withstand all tempta- tion. I repeated these suggestions every day until the 23d of April. From the first sitting the child continued cured. The thought to mas- turbate did not occur again (according to his own statement). April llth he weighed 44 pounds; on April 13th, 45-}-; April 16th, 46 -f; April 21st, 47 -)- Before his departure, I suggested to him to write me concerning the duration of his cure. I received a letter dated May 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 embarrassment, 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, with the desire that I cure him of evil instincts by hypnotism. At the age of 13 he had tetanus. Since that time he had suffered 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 years he had stolen more frequently, 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 strabismus 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. Memory good, on the whole. June 9th, first hypnotic treatment. Fixation of a shining ball that was hung over his head, 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. 1 Dr. Aug. Voisin, M6dicin de la SalpStriere, " Un cas de perversity morale guri par la suggestion hypnotique," Revue de 1'bypnotisme, 1888, p. 130. 54 SEXUAL HYPER^ESTHESIA. After the first sitting he ceased to steal, and his character underwent a favorable change. The treatment was continued every third day, and the suggestions were directed in turn against his vicious character, his evil instincts, onanism,and his immoral habits. July 6th the young man was like a different person. All thought 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 been no treatment in the interval. The further continuance of the 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 by hereditary 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 had no severe illnesses; moderate left inguinal hernia; truss. Genitals normally developed. Patient is suspected of masturba- tion, and after rigid questioning he confessed his vice. For a year 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 days 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 treatment the patient made no attempt to masturbate. He stated that he felt dis- gust, and promised me repeatedl}" to masturbate no more. April 28th he returned to school. After the three sittings I could only 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 probability of relapse, and explained that a perfect cure might be obtained by frequent regular repetition of the procedure, together with strict control of the patient. In September, 1891, I learned that further treatment of the patient for his vice had not been necessary. Influenced by 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 antecedents. Given to onanism since his thirteenth year ; 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. Depressed state alternating with causeless intense excitement (violent outbursts of anger). Patient was first hypnotized on February 18, 1889. Complete hypotaxis. Cataleptic symptoms. Energetic suggestions to give up the abnormal impulse and satisfy his desires with women. Up to March llth, 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 M&y 20th the patient was hypnotized twenty-six times, at first daily, 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 mentioned had disappeared entirely of late. Mood agree- able. No ouanistic relapses, but from time to time normal cohabitation. He stated that family circumstances made it very difficult for him to satisfy his libido regularly. After six months the patient reported that he was well. On my last inquiry (two years 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 only be ascribed to this failure ; the result of therapeutic suggestion is not altered by it. Case 12. Personal Observation. Lasting Cure of an Onanist by Hypnotic Suggestion, and his Preparation for Examination by Suggestion. B. S., medical student, aged 20. Parents and other members of family healthy. No diseases except measles and chicken-pox in early child- hood. Moderate skolio-kj'phosis due to rachitis treated surgically. Sexual desire began in his twelfth year; gratification of it since that time by 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 56 SEXUAL HYPEILESTHESIA. his approaching medical examination. He 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 timidity. He consulted me not about his onanism, but to have his courage and confidence strengthened for the examination by suggestion. In other respects the patient presented no noteworthy physical or mental abnormality. June 11, 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 voluntarily. Complete hypotaxis, but consciousness retained. Suggestions : 1. Repugnance for onanistic manipulations. 2. In- clination for coitus and complete 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 acquired. 4. Post- hypnotic feeling of well-being. June 18th S. joyfully told me that the previous day he had ventured to attempt coitus for the first time, and had succeeded perfectly. No thought of onanism since. Increased self-confidence and belief in the cure. Repetition of the treatment and suggestions of June iTth. 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 duty to inform you that your efforts in my behalf were crowned with the best results to-day. I passed 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 the 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 hypnotism was greatly increased. As for my former vice, I can assure you that, since I -had the honor to be treated by you, I have not masturbated and have felt no desire to do so. I now have the best prospect of inducing my chamber-maid to accede to my desire. We kiss each other, etc. I mention this merely to show you that in this direction the suggestion has had the greatest success. With very kind regards, I remain, most respectfully, your ever-grateful patient." Early in August, S. again presented himself. He had not mastur- bated again. He was better physically and mentally, and from time to ONANISM BY MEANS OP TACTILE IRRITATION. 57 time was 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. The hypnotic treatment, owing to the youth of the patient, under- taken sufficiently early, 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 1 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, by 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 Treatment of an Onanist. H., aged 24 ; mother gouty, father nervous. A paternal great-uncle a drinker; other members of family healthy. At the age of 8 patient had typhoid fever, and was nervous after it for two j'ears. The patient learned to masturbate as a result of itching of the genitals induced by a superficial sore on the prepuce. Touch induced erection, and further friction ejaculation. The patient is very powerfully built, tall, and, aside from phimosis, presents no abnormalities or anomalous S3 r mptoms. For two years he masturbated daily, and during the act thought of coitus with a lady to whom he was attracted. Masturbation was always accompanied by the same idea. Unfavorable effect on the nervous sys- tem. The patient likes to lie abed late dozing. Memory and understand- ing suffered. Headache, 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' societ\ r 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 general condition had been improved. But his onanistic ten- dency is unchanged. During the last week he had masturbated three times ; pollutions occurred at night once or twice a week. 1 Comp. " Ueber psychische Therapie innerer Krankheiten," Berliner Klinik, July, p. 23 (Fischer, 1890). 58 SEXUAL HYPER^ESTHESIA. On the evening of November 20th, when a prostitute addressed him, his sensual 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 21st H. consulted me to learn whether he had been infected. The psychical impressions left by the events of the day 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 : (a) 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 patient, therefore, must struggle against his sexual instinct, and the struggle could be lightened by hypnotic suggestion ; if, however, the patient could not thus overcome it, coitus was to be preferred to mas- turbation. November 24th, first hypnotic attempt. Deep somnolence (stage II). Imperfect memory. Suggestions against onanistic thoughts and depression. Strengthening of self-confidence and resistive power by suggestion. Excellent result. After hypnosis and during the following days the patient felt well and had no inclinations to onanism. Spirits raised. Repetition of the procedure on November 28th and December 1st. 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 contrary-sexual, sister hysterical. Neuropathic disposition due to hereditary taint. Patient stated that since his twentieth year he had had pulmonary haemorrhage five times. Until three years ago he had lived abroad, where there had been small 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. He recovered from his pulmonary affection, and after bis twentieth year gave himself to masturbation, as he said,/cmte de mieux, from enforced abstinence. Since that time for eight years he liad masturbated several times a week ; habit continued. According to his statement, severe mental strain attending disappointed affections, together with the psycho-sexual anomaly, 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 paroxj'sms of weeping, bodily weakness, no desire to work ; feeling of lack of energy especially noticeable ; inability to complete any work-; want of pleasure in life ; thoughts of suicide; avoidance of people; moodiness; inclination to hypochondria; spinal irritation and headache following masturbatic excesses. There was an unconquerable fear of hetero-sexual inter- course; last coitus performed nine j T ears 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 retracted 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 by suggestive treatment. From November 3, 1890, he is treated daily. He passes into the second stage, hypotaxis and suggestive catalepsy. Gradual deepening of hypnosis. The patient remains in the hypnotic state about half an hour, and passes gradually into natural sleep. Suggestive removal of the symptoms 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, gradually, 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 emploj 7 himself in mental work with exact regulation of hours. Gradually the sense of pleasure in 60 SEXUAL HYPER^ESTHESIA. work came as a result of the suggestions. The onanistic tendencies were at first successfully fought against, and then they became less fre- quent. The gloomy thoughts disappeared. December 18th the patient departed, 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. 1 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 troubled with 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 entry in my 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 completely cured of his onanism ; on the other hand, with reference to his neurasthenia, considering his hereditary neuropathic disposition, I can regard him only as relatively cured. The patient returned home March 9th. 1 Comp. Dr. Lahmann, " Ueber Onanismus beim Welbe als einer besonderen Form von verkehrter Richtung des Geschlechtstriebes," Therapeut. Monatehefte, 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 hyp- nosis, no breaking up of the personality (Benedikt) ; 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 tuberculosis. Mother neurasthenic, timid, easily excited. Father, brother, and sister healthy. Father's relatives subject to heart disease. In childhood patient had measles and pleuritis, 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 hereditary 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 daily, 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 symptoms; for since that time the patient's memory had grown remarkably weak, and he had lost energy. 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 him 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 HYPER^ESTHESIA. 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, " Tag fur 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. Physically, 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 during 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 25th, fir^t hypnotic attempt (method of Bernheim-Lie'beault). 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 u 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. Apparently, 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 say, 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 llth. Relapse between the 4th and llth of July. Inability to respond to his name in the gynaecological clinic. After energetic suggestion on July llth, the patient went voluntarily to the assistants at the clinic, and a few days after 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 the stand-point of the physician, the patient was by 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 therapy, as worthy of report, because, between the onanistic excesses and the development of the psycho-neurasthenic symptoms which became especially 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. Masturbatic Inclinations and Neu- rasthenic Symptoms. Successful Treatment by Suggestion. A., male, aged 19 years. Mother nervous. Father and other members of family healthy. No severe illness aside from diseases of childhood. He mas- turbated from his fourteenth j'ear with the idea of coitus, at first daily, 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 h} T pnotic 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 HYPER.ESTHESIA. ONANISM THROUGH PSYCHICAL STIMULI. (Cases 17 and 18.) Case 17. Observation by Dr. Wetter strand. Psychical Onanism 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 other ladies of attractive appearance, he experienced irritation and tickling on his penis, which were accompanied 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 the patient wrote : " I feel that my trouble has been considerably ameliorated, and therefore I would once more express 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 apoplexy. Grandfather healthy. 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 vulvse, which the sexual irritation followed. Uncer- tain on her legs for years. The 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 sleep, 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 same time there .was 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 hysterical attacks, with weeping, crying out, confusion, but with retained consciousness. At that time Dr. P. had but a suspicion of masturbation. Spots 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 frequently ; 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 STIMULI. 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 temporarily 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 Siss, alternately. 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 May, 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 though 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 apparently healthy. 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. Haemoglobin, 75 per cent, (estimated with Gowers's haemoglobinometer). 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 energy and dull apathy for all external impressions. She performs automatically what she is told to do. She has no interest whatever in employment or pleasures 5 66 SEXUAL HYPER^ESTHESIA. (theatres, concerts). Lack of all spontaneity. She asks no questions and opposes all efforts to rouse her from her indolence. Occasional transformation of this state to exaltation, loud hysterical laughing, and cramp-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, without mechanical help 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 no figures (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 hypnotic experiment (Lie*beault-Bernheim method). Hypotaxis, suggestive cataleptic phenomena, with inability to resist the suggestions. No post-hypnotic amnesia. Owing to tiie 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 every 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 21st (for the ONANISM THROUGH PSYCHICAL STIMULI. 67 last twenty-four hours), 6 attacks (1 by means of friction); September 22d, 3 attacks; September 23d, 2 attacks; September 24th, 1 attack; September 25th, 2 attacks ; September 27th, 4 attacks ; September 29th and 30th, none; October 1st, 2 attacks (from looking at paintings); October 2d, none ; October 3d, none, and none on the 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 always immediately after hypnosis ; in contrast with her restless sleep at night, she slept in perfect quiet. During these post-hypnotic 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 hypersesthesia 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 (especially 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. Gymnastic 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 the}' 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 HYPER^ESTHESIA. four months she regularly passed into deep somnambulism. 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 the troublesome itching. From a languid, apathetic patient, she has become a bright young 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. (Cases 19 and 20.) Case 19. Professor For el, 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. Mentally aifected 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 improvement as regarded onanism ; at first it gradually diminished. Now and then it was still practiced, and for the last time in February, 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 (July, 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 always nervous, but otherwise of genial temperament and normal. Case 20. Personal Observation. Nymphomania with Hystero-Mastur- batic Attacks. Cured by Suggestion. M., aged 22, teacher. Father died of spinal disease. Mother healthy. 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 NYMPHOMANIA. 69 his office. He took the innocent child to his room, caressed her, touched her genitals, and, after having 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 3' ears the onanistic manipulations have been practiced from eight to twelve times dail3', and have seriously affected M.'s predisposed nervous S3 r stem. 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 l^sterical 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 tying 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, whichjs thrown into action by all kinds of sensoiy impressions and ideas. For some years orgasm has taken phice without tactile stimulation of the genitals at the occurrence of certain perceptions, accompanied by intense pleas- urable feeling (psychical onanism) ; thus, for example, when the patient sits dreaming on the sea-shore watching the pla}' 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 effectual in the same wa3 r . 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 HYPER^STHESIA. excitement reaches the intensity of nymphomania, with an inclination to attack men. She fears her own passion, and begs me never to leave her alone with a man in the waiting-room. In such states 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. Repeated 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 hypenesthesia 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 employment. 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 modesty, 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 pressure ; -right ovary also sensitive to pressure. Genitals normal, not especially sensitive ; moderate turgor of the clitoris, which is remarkably large. Occasional pruritus vulvse. Color-blind for blue and red. The right visual field concentrically narrowed. Olfactory and gustatory anaesthesia 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 hyperaesthesia, 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 five 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 clay, 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 I could touch her without causing her sexual excite- ment. She then asked to be hypnotized. September 30th, second hypnotic attempt (Liebeault-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 centra-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 says to herself the following sentences : " Ugh ! that is bad ; you must not be naughty ; 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 imaginary glass to fall to the floor; she begs pardon, and wishes 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 by 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} r 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 by 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 erythematous), and poured the contents of this imaginary 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 moderately-intense tactile impression induced circumscribed hypersemia 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 traumaticum in the form of the figure drawn. In this way the word " Otto " appeared in red letters on the left breast; likewise the number " 1 " which I had written on her arm over the sleeve. Still, the possi- 72 SEXUAL HYPER^ISTHESIA. 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 frequency. 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 days 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 hypnotic 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} 7 be regarded as capable of fol- lowing her employment, and has begun to resume it. Her sexual l^per- 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 certainty that the im- provement, in the sense of a relative cure, is to be ascribed to hj-pnotic 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 I & S w > g. . h-. Female. OS . . - >. . I-" >-'!-' t-t 1-10. o H \ '. M : M : : : M M M*. : : : : : : : 10-20. 00 l-i M . -. I-" H- t-" K-l . ... 20-30. : ::::::::::::::: :: : 30-80. .IV Q3 ,_! - | - t t *IOH^CO O M li CntO OS O to CO C-.WX>4- h'OOO -o COCn CO Sittings. : ;::::::::::::: :: : Somnolence. o> Hypotaxis. t: - : i- : : : : - ; : -- ~'.~'. MM M Somnambulism. M Failure. ,_, h- : : :::::::::::-:: : : : Temporary. IMPROVE- MENT. Cn : : : ~~ : : : : : : : : - : : : Great. CO F'th'r Co'rse Unknown. 5 ,_, ,_, (^ . . I-" I-" (-" I-" . l-ih- . . . . -" With Later Report. CURE. CO .1-" -')-' Without Later Report. *. " - ' M * M* * * M Relapse. o'S'S o2 " 3 g pp cS^SLp' "* * 1 i." ' 3 w a *. j J M 5 s O rio 8 s > HE a-o P feri OK - a S! a a rH tnsiinqnreuraog aouaiouraog 1 \ H ^ 8 '08-09 09-oe ri Of-OS 'OS-OS OS-OT OT-I 00 a a a ^ . , w o>2o;i^s SSSSS c 4 u ^ h ^ H t f T'L Tl C''. *7l *7! *Q? ^4 O O O O O O MMMMgcs %%AA%-BaaAAaa I I I I I I III S |||J|I 00060 Ssoogocioo'clooaa -= o, a a a, a, c 2 6> I a a a a s a a s .2 5 a aaaasi^asaaaagaas.^^g; 03 " ' TO .*" ' u g.S ftS ?? 5r -S - - .^ .!O^^ flOQ5 ^ ^ .5 5 2 (-( .^ .C^S^C' 1 "*'-] WQJWqjWqjj^qjQQjJ-^j'^O^t^.S^.qpCJ^OQJWQjC^+i^O^jQj *tf> P flj ^ I a ^ gj s s "' " "' "' ~' '' J "' " "' ~ '' "' CONCLUDING REMARKS. 115 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 appear 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 has 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, I can only agree with Professor Bernheim 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 affected, the influence on the general condition and nervous symptoms was favorable. After 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 PA&ESTHESIA. CHAPTER VII. THE FORMS OF SEXUAL PERVERSION WITH REFERENCE TO THE THEORY OF PROFESSOR VON KRAFFT-EBING. Definitions and Classification. Von Krafft-Ebing desig- nates sexual paraesthesia as the excitability of the sexual instinct to inadequate stimuli. Every expression of sexual desire which does not correspond with the purpose of nature procreation is perverse. This manifestation of the sexual impulse often occurs in connection with hypersesthesia, and may find satisfaction with the opposite or the same sex; in accordance with which von Krafft-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 l 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 grouped. 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 differentiate two groups: I. Inversion of the sexual feeling (contrary, or homo-sexual, feeling). 1 Westphal, " Contrare Sexualempfindung," Archiv fur Psychiatric, Berlin, 1869, Bd. ii, Heft 1, p. 107. (117) 118 SEXUAL PAR^STHESIA. 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 : (a) Acquired abnormal contrary sexual feeling. (&) 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 Kraffb-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 2 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 the 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 feminse (limited to the vita sexualis). 3. The whole mental existence (character) corresponds with the abnormal sexual feeling (effemination and viraginity 3 ). 1 In the eighth edition of Psychopathia Sexualis, von Krafft-Ebing 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 rdk, and looks upon the impulse toward the same sex as an aberration. II Degree : Eviration and defemination. Transformation of the character, the feelings, and the inclinations to those of a female, or vice vers&. 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. cit., 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. * Tarnowsky (Die krankhaften Erscheinungen des Geschlechtssinnes, Berlin, 1886, pp. 11-14) describes the development of effemination as follows : " The first expression of shame 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 female 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 approaches 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, growth of beard spare or absent, feminine features, fine complexion, falsetto voice) in the male ; develop- ment of mammae, 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 Krafft- Ebing's theory, distinctive : (a) Premature awakening of the sexual instinct. (&) Enthusiastic exaltation ; overpowering strength of desire ; sexual hypersesthesia. (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 disgusting to men and so repugnant to women, whom it is not difficult 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 as repulsive to men as to women." 120 SEXUAL PAK^ESTHEStA. (/) Neuroses, psychoses, and signs of degeneration in progenitors. " The hereditary element is the acquired abnormal inclina- tion to the same sex, which in descendants is manifested as a congenital abnormal phenomenon." This 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 contrary 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 this 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 algolagny, derived from d/l^o$ = pain (adopted medically in this sense, as in analgesia, cephalalgia, and neuralgia) and hayvog = sexually-excited lust ; from the latter hayvsLa is derived, used by Hippocrates and Aristotle in the sense of seminal emission, by Xenophon in the sense of lust (Max Offner *). 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 (masochist = 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 Krafft-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. 1 Max Offner, whose philological knowledge assisted in the formation of the above word, also proposed the terms " aekialagnia " = masochism, and " aekizolagnia " = sadism (from aUta and aiVtu>), but they seem to me less suitable. 1 22 SEXUAL PAR^ISTHESIA. Though active and passive flagellation is the means most fre- quently used as an excitant by algolagnists, still there are other cases in 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 paraesthesia 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 Krafft-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 which induces sexual excitement. It may consist of () a portion of the body (hand, foot, hair) ; (&) 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 Krafft-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 non of virility (von Krafft-Ebing). The foregoing resume includes all the essential forms of paraesthesia sexualis in accordance with the classification of von Krafft-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 THE DEVELOPMENT OF CONTRARY SEXUAL FEELING AMONG THE ANCIENTS. IN order to form a judgment concerning contrary sexual feeling, that is, with reference to prognosis and therapy, 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 the 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 those who were dressed as women were forbidden to bear arms. Travelers in North America 2 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, 3 it is made use of for religious purposes by the Pueblo Indians of New Mexico. On the island of Ramrih, 4 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. 1 Mantegazza, Anthropologisch. culturhistorische Studien uber die Geschlechtever- haltuisse der Menschen, Jena, Costenoble, p. 118. a This vice is so little the product of excessive civilization that it has been met in North America. Comp. Virey, Historic naturelle du genre humain, Paris, 1824, vol. 1, p. 273. 1 Hammond, op. cti. 4 Sitzung der Berl. Psychol. Ges. vom. 15 Okt., 1868. (123) 124 SEXUAL PAR^STHESU. In his work, " Contrare Sexualempfindung " (Berlin, Korn- 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.g., 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 that there has been spontaneous and, to a certain extent, idiopathic occurrence of male-love 1 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 1 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) I 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 ? 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, 1 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. 2 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, faute de mieux, to immediate compan- 1 Ploss (Das Weib, Leipzig, 1891, p. 315) also shows that the lower a people is, the more disgusting the expression of their lust and animal sensuality becomes. Many primi- tive 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." 1 Rosenbaum, Geschichte der Lustseuche, 1888, p. 119. 126 SEXUAL PAR^ESTHESIA. ions, and that mutual onanism and pederasty are frequently met in penitentiaries among relatives of the same sex. Here, at least, the original of primary homo-sexual pederasty 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-sexuality and Castration. In Asia, as in Italy and Spain, the female genitals, like the whole body, are greatly relaxed. 1 The sphincter ani is much more powerful than the constrictor cunni. And, with respect to this, we may consider Forberg's 2 statement: " Et voluptas quidem paediconis facile intelligitur, cum omnis voluptas men- tula3 pendeat ex frictione." The following passage from Paul's Epistle to the Romans (chap, i : 24, 26, 27) also indicates that psedicatio 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 innocenoe 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, 1 Comp. Martialis, lib. xl, Epigrams 28 and 79. * Autonii Panormitae Hermaphroditus, ed. F. C. Forberg. The apophoreta of the editor treats of " De flguris veneris," " De fututione," " De paedicatione," " De irru- mando," " De masturbando," " De cunnilingis," " De tribadibus," " De coitu cum brutis," " De spintris." Comp., also, Roseubaum, loc. cit., 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. Therefore, 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 was 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 born nor what they are," etc. Gradually, in Asia, pederasty became embodied in the worship of Venus. According to the excellent descriptions by Rosenbaum, the expressions svvov%oi and avfyoyvvoi at first signified nothing but " Kinaden " or " Pathici," i.e., persons who sacrificed themselves in the temple in honor of the deity. 1 Thus is explained the teaching of the priests of Cybele, who emasculated themselves, it is said, in honor of the deity. 1 Later, in Rome, the term " exoleti " (castrated) was used In the same sense. Comp. Aristotle, Polit, v, 8, 9. This fact seems to be little known. Thus, Mantegazza. who has written a long chapter upon sexual mutilation, does not mention it. Comp. Anthropol. Kult.-St., p. 132. 128 SEXUAL PARJESTHESIA. According to Hellicanus, 1 the practice of emasculating boys was derived from the Babylonians. The origin of the custom is attributed to Semiramis. 2 Still, as Steut 3 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 Steut, p. 8) that \n the kingdom of Bootan twenty thousand eunuchs were made every year to be sold to other nations. Philo 4 also holds to the opinion that castration 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. Steut, 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 1 Donat. Terent. Eunuch., i, 2, 87. 3 Marcell, xiv, 6. 'Steut, Chinesische Eunuchen (Leipzig, Schulze), p. 6. 4 Philo, Opera, ed. Maugeg., ii, p. 465. CONTRARY SEXUAL FEELING AMONG THE ANCIENTS. 129 upon early, eunuchs often become corpulent, 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. The 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 irritable 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 help 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 effemination of the eunuchs resulting from castration, without recognizing the original object, i.e., the cultivation of the female type in the male body for 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 1 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 1 Mantegazza, loc. ctt. , p. 106. 9 130 SEXUAL PAR^ESTHESIA. 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." The Historical Origin of Uranism in Europe. The Jews seem to have become acquainted with boy-love in Syria. 1 Ac- cording to ancient authorities, the Persians, 2 the Celts, 3 and even the Germans 4 were acquainted with it. Pederasty, as already mentioned, was most practiced in ancient Babylon, in Sodom, 5 and by the inhabitants of Tyre. 6 From Asia uranism was spread by the Phoenicians or Lydians 7 (Welcher) first to Crete, and from there over all Greece. 8 According to Suidas, 9 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 10 after the founding of Rome, this vice was practiced there. In the year 585 (B.C. 169), on the other hand, the Lex scantinia 11 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. 12 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 1 Genesis, xix, 4; Levit., xviii, 2; xxix, 13. 3 Sext. Empiric., P. H. i, 152. * Aristot., Pal., ii, 6 ; and Diodor. (v, 32). . . . "in spite of the great beauty of their women." 4 Sext Empiric., P. H. iii, 199. Described by the author only as "rumors." 6 Genesis, xix, 4. "Athen.,xii, 517e. 1 ^Eschylus, Trilogy, p. 356. * Athenaus, Deipnosoph, p. 602. *7Wd.,lib. xii, p. 5l7etseq. "Dionyeius Helicarn. Exc., p. 2336, and Valer. Max., lib. vi, 1, 9. 11 Juven., ii, 44a. " Comp. Sueton, Nero, 28, 29 ; Dio, Cassius, Juvenal, Tacitus, and others. CONTRARY SEXUAL FEELING AMONG THE 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 of 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. Pederasty was not approved by the Greeks ; on the contrary, originally, in Athens and Sparta, it was punished with dishonor, exile, and death. 1 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). 2 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 Bceotia, 3 and also in Phocis, Thessaly, Lesbos, Chalcis (%a%,xibi%Lv naibspaarelv), etc. 4 But in the Ionic cities boy-love was absolutely forbidden. 5 From the way in which boy-love first manifested itself in Athens and Sparta, when it was most intimately connected, 1 Comp. Realencyclopadie von Ersch und Gruber, "Paderastie," von Meier, who adduces abundant evidence of this. 3 Comp. Rosenbaum, loc tit., p. 196. * " Bootische Knabenliebe " was, according to Plato, Xenophon, and Cicero, an equivalent of violation of boys. Comp. Ersch and Gruber, loc. cit. 4 Comp. Theopomp. ap. Athens, 605a. ' Plato, Symposium, 182b. 132 SEXUAL PAFLESTHESIA. during the golden age of Greece, with the greatest works of art and science, and that without endangering in any way mascu- line strength 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 basis of neuropathic disposition, even though 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. 1 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 affected sensuality. This feeling was 1 Plato, Legg, i, 636b. CONTRARY SEXUAL FEELING AMONG THE ANCIENTS. 133 deepened 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 brought about solely by inclination ; for no honorarium was offered for such instruc- tion 1 ; and it took the place of our higher education. Finally, the necessity for the exercise of political influence by means of fraternities (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 witli that between parents and children, or between children of the same family. In Sparta, for example, the lover represented 2 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 duly 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 ; 3 swing- ing garlands on the house of the beloved; presents of vases 4 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- 1 Comp. Ersch and Gruber, Realencyclopadie, " Paderastie," von Meier, p. 837. 3 Plutarch, De educ. puer., 14. "Plato, Symposium, 184a; and Xenophon, Hiers., 1, 35. 4 Boetig, Sabin., i, 49, 7050. 134 SEXUAL PARjESTHESIA. onian poetess, Praxilla, 1 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 2 is reputed to have loved Pisistratus; Pisistratus, 3 Charmus; Charmus, Hippias, etc. The love of Harmodius 4 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, ^Escylus, 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. 6 Of the famous statesmen who were devotees of boy-love, there were Alcibiades, ^Eschines, Timarch, Demosthenes, and Demetrius. Likewise, the most celebrated philosophers were given to it, Socrates, Parmenides, 6 Plato, Dion, Phedrus, Alexis. Zeno, 7 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. 1 Athenaus, xiii, p. 603a. 3 Plutarch, Erotic, 5, and Sol., i. 1 Plato, Symposium, ix, p. 182b. 'Plutarch, Aristides, 2 ; Themistocles, 3. 1 Pausanias, ix, 34 ; i and v, 11 ; iii and vi, lOb. ' Plato, Parmenides. 52u. Diogenes, LaSrt, ix, 25. 1 Athenaus, 563c. CONTRARY SEXUAL FEELING AMONG THE ANCIENTS. 135 Impure Male- Love in Greece. The fact that Socrates 1 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 philosophy, Zeno 2 goes so far as to place unnatural intercourse of boys and men on a level with natural 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 3 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 4 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, 5 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 error 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 1 Plato, Symposium. ' Plato, Symposium, 182b. * Athen., 563c. * ^Eschines, contra Tim. fin., p. 44. 1 ^Eschines, op. cit,, p. 36. 136 SEXUAL PAR^ESTHESIA. previous pederasty, homo-sexuality and effemination began to manifest themselves, owing to attempts to approach the required female sexual role. Youths, as Aristophanes 1 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, m/UUjTM^fcrSai. If possible, they deprived their persons of every mark of mascu- linity ; they gave themselves to vile uses in secluded spots, in private houses, on the walls, etc. Handsome young slaves were forced 2 to yield their bodies to their masters for gain, and live in actual houses of prostitution. The extent to which the 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." 3 Then male pros- titution became'a trade 4 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/leia VOVGO$. The following facts present us 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 pathological and moral. Indeed, Rosen baum, 5 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 Urania let Sfaziav vovcov fall upon them, i.e., the passion or disease which transformed them into women" 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 1 Aristophanes, Plut., 153, 159. ' Lucian, adv. Indoct., 23. a Diog., LaBrt., vi, 54. * ^Eschines, p. 134 etseq. * Rosenbaum, loc. cit., p. 177 d seq. CONTRARY SEXUAL FEELING AMONG THE ANCIENTS. 137 people ; on the other hand, with a race of small resistive force, like the Scythians, whose sexual character was never markedly developed, the whole transformation to the 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. 1 Many authors, Hammond 2 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 vesiculse seminales and the prostate induces frequent pollutions, irritable weakness, and, as a final consequence, impotence. 3 Two cases of Hammond's 4 are classical examples of the possibility of artificial transformation of a man into a woman ; 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 the Pueblo Indians of New Mexico it is customary to induce impotence in one native in each village and use him for pederastic purposes. 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 1 Sprengel, Apologie des Hippocrates, Leipzig, 1793, Part II, p. 610. 3 Hammond, loc. cit., p. 106. 1 Lallemand, Des pertes sdminales, Paris, 1836, Part I, p. 581. 4 Hammond, loc. cit., p. Ill et seq. 138 SEXUAL PAR^ESTHESIA. that he had nursed several children whose mothers had died, and that he was able to furnish them much 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 mnjerado 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.. The victim of the vovdog $>?/leia, 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 contrary sexual instinct, we may return to the ancients. Views of Some Ancient Writers Concerning the Pathicus. The historical facts of the development of pederasty 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. 1 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, 2 who had been punished by Venus in the manner mentioned, had this reputa- tion. Thus the orator Lysias 3 says of the family of Alcibiades : " The majority of its members had been prostitutes." Indeed, there was even a view that the pathici might be born with a predisposition to the vice, an opinion which Parmenides 4 (509) expressed. While the author mentioned looked upon the basis of the disorder as mental, other writers, as Aristotle, 5 regarded the vice as a disease of the rectum. According to Aristotle, 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 (jtefyvxoreg and E$ e&ov$). Here we see the theory of Mantegazza foreshadowed, who looks upon the cause of a certain form of contrary sexual instinct as 1 Euripides, Hippolyt, 5. ' Tragedy, Hippolyt, 124 ; and Lucian, Amores, c, 2. ' Lysias, Orat. contra Alcibiad., i, p. 550. ' Caelius Aurelianus, de morb. acut. et chron., lib. vii. ' Aristotle, Problem iv, 26. 140 SEXUAL PARyESTHESIA. an abnormal distribution of nerves (to the rectum). Statements concerning the physiognomy and other marks of androgynes and pederasts are numerous ; which, aside from the external ap- pearances given them by the race and the customs of the times, in all essential features are comparable with those peculiar to the sexual perverts of our day. Polemon 1 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 2 thought he could detect pederasts by their sneeze. He says : " Thus 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." 3 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, 4 " 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, 5 out- raged nature revenged herself on the pathicus by assisting him 'Polemon, Physiognom., lib. ii, 9, 1, c, p. 290. 3 Dio Chrysostomus, Tarsica, i, p. 410. 1 Clemens Alexander, Paedag., lib. ii, c, 7. * Martial, lib. vii, epigram, 57. * Rosenbaum, loc. cit.,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 the 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. 1 Therefore, the latter was called dvfy&ywo$. 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 voao$ (disease), dvdv&pta, 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 vovaog Sfaeia 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." 2 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 1 Lucian, De dea Syra, c. xvi. 1 Philo, De vita contemplativa, p. 480, cited by Rosenbaum, loc. cit. 142 SEXUAL PARJSSTHESIA. children ; they do not, like the pathicus, need to suffer with vovao$ 3>7/leia, 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 light upon the etiology of contrary sexual instinct among the masses is Philo's description of the 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 ; pederasts of the same sex were not ashamed to consort with the 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 themselves the vovaog 3>?/leia 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 characteristics, and they destroyed, as far as they could, all masculinity." In another place Philo l speaks of those to whom 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 vovao$ Sfaeia ; who distorted nature's order and assumed the desires and appearance of lascivious women. He expelled those whose testicles were concealed and whose genitals had been removed with the thought of preserving a youthful appearance arid changing the masculine to the feminine type," etc. R6sume 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 pedophily. This peculiar institution exerted great influence in the development of the Greek nation, on politics, art, and science. But, as soon as pedophily 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 Philo, De sacrificautibus, p. 261. CONTRARY SEXUAL FEELING AMONG THE ANCIENTS. 143 called pathici. These individuals correspond with our ideas of those affected with 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 VOGO$ which changes him to a woman (Sh^eia) " (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 the 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^ESTHESIA. complete effemination and public prostitution, often in com- bination with symptoms of insanity (Caesarian insanity), and it is difficult in individual cases to determine to what extent this perversion of the sexual instinct represents the product of the practice of degenerate customs (prostitution) or of m hereditary predisposition. This difficulty also explains the views of au- thorities, by whom contrary sexual 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 by 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., 1 is still unsettled ; and, in spite of the valuable review of the etiology which Moll 2 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 that 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. 3 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 1 Friedreich's Blatter f. ger. Mert., 1891, Heft 1, pp. 32, 83. 9 Moll, loe. cit., p. 156 et seq. ' Psychiatric, 2 Aufl., p. 576. (145) 146 SEXUAL PAR^ESTHESIA. character is brought about, there can be but two ways in which to explain it : either, in comparison with extraneous influences, the effect of hereditary disposition has been over- estimated, or it is actually possible to compensate by suggestion the dire effect of hereditary 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 very 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 the anomaly of their feeling that 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 character 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 habits of our ancestors acquired through repeated and multiplied acts, i.e., capitalized 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 the origin of contrary sexual instinct. Every individual benefits or injures his descendants through the series of acts which make up his life, and which, through habit, become transformed in descendants into hereditary dis- position. The mechanism of heredity and our intelligence con- tinually exert a reciprocal influence on each 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-like 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 generations apparently free from it still bore the disposition undeveloped arid 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 other hand, a proper mode of life may do much to prevent the development of the hereditary disposition, and thus, in a measure, compensate it. Predisposition and Patlwgenetic Excitants. In constitu- 148 SEXUAL PARJESTHESIA. % 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 children of tuberculous parents are by no means always tuberculous, but, on the contrary, the grandchildren relatively often. As Dr. Krocker 1 reports, Dr. Sommerbrodt treated, in 1885, a lady who was pregnant for 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 Koch) 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. Moll 2 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, Krankheitsuraachen und deren Bekampfung, Paetel, Berlin, 1891. * Loc. dt., p. 162. HEREDITY AND EDUCATION. 149 In his very instructive work on direct heredity, 1 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 which ancestors and descendants were aifected 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 corresponded 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 that 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 1 Archiv far Psychiatric u. Nervenkrankheiten, Bd. ivi, Heft 1-3. 150 SEXUAL PAR^STHESIA. the perversions of the sexual instinct, it seems necessary to consider man's normal sexual development. Physiology of the Development of the Sexual Instinct. The procreative instinct, corresponding with anatomico-physio- logical processes, develops relatively late in man. The functional development and growth of the generative organs stand in definite interrelation to the cerebral cortex, where sensations and ideas (impulses) arise. Actual puberty begins, in the female, at the age of 13 ; in the male, at the age of 1 5. Until this time is reached 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 inherit- 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, the 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, 1 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 2 causes movements which finally bring about the satisfaction of the need. " With the first satisfaction comes an indistinct idea of external objects which present them- selves in the act, and thus, with the sense of hunger, at once the reproduction of the image of these impressions becomes asso- 1 Physiologische Psychologic, 1887, p. 231. ' Why speak of a sense of hunger here at all ? It cannot be a sense or feeling of any kind. The movements are purely reflex, arising from organic conditions which at first, at this period of life, can have no relation to sense or sensibility. TRANS. HEREDITY AND EDUCATION. 151 elated 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. All ideas in relation to it are the product of experience, even though the impulse belong to the congenital instincts. According to Wundt, only the conditions necessary for the 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 individual 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 by External Impressions. 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 PARJSSTHESIA. excitement does not present itself to gratify the longing for satisfaction, then the desire for satisfaction, faute de mieux^ 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 opportunity 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 dispo- 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 the Ego, and the sum of these states of emotion 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, 1 it is highly prob- able that the first sexual promptings where there is complete ignorance 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. 2 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 1 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. ii, E. B. Treat, N. Y. TKANS. 154 SEXUAL PAR^ESTHESIA. 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 1 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 chief 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 hour develops, especially during childhood, and disappears under the influence of proper training. When, however, it has a favorable foundation (predisposition due to 1 Revue Philoeophique, 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 character. Thus are explained the strange perversions in the direction of obscenity and love which we see develop in hereditarily predisposed individuals in their youth." 1 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, 2 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. Women cannot charm them as long as they find satisfaction in the per- verse activity of their sexual appetite. Psycho-sexual Diseases, Moral Insanity ', and Weak-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 stimulus 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. 1 Comp. Lombroso, Der Verbrecher, Hamburg, 1887, p. 119. a During the publication of this work there appeared, in the Munchener med. Wochenschrift (1892, No. 11, p. 188), a notice of the works by Moll and Krafft-Ebing. The reviewer, Dr. Bleuler, 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 Couut 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 association 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 enduring abnormality of the sexual instinct." The correctness of this idea of the reviewer is confirmed by examples given later. 156 SEXUAL PAR^ISTHESIA. 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 pathologi- cal condition wjiich 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 the 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 the slightest deviation from the physi- ological condition to the pronounced 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 effort to investigate the cause and nature of things, mental one-srdedness, 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 " (Tarnowsky). There are sensual persons in whom, at certain periods 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 there may arise a combination of impotence and sexual debauchery. Imitation is here one of the most powerful means 158 SEXUAL PAR^ESTHESIA. 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, notwithstanding the greatest recklessness, is still able to control himself on occasion. Indefinitely marked transitional cases, in which 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 1 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, cryptorchism, phimosis, hypospadiasis, varicocele, arrest of development and atrophy of the testicles, defective develop- 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 hand, imbeciles often 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 Parmsthesia 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- 1 Der Idiot und Imbecile (Voss, -Hamburg, 1891), p. 75, and Bournevllle and Sollier, Des anomalies dee organs g6ultaux chez les idiots et epileptiques (Progres 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 possibility 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 riot 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 the 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 role 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 PAR^ESTHESIA. not only the character, but also the skeleton, face, and voice correspond with the abnormal sexual type (defective develop- ment of beard, development of mammae, abundant development of adipose tissue), to which, as a rule, other anatomical and functional signs of degeneration are added. Objections. 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 characteristics 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 Krafft- 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. 1 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 several 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 feminine ; 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 imagines "Tardieu et Langier, Diet, de m6d., art. " Hermaphrodisme." 11 162 SEXUAL PAR^STHESIA. tion may be more precisely defined from experience that is at hand. The influences exerted on the child may, with defect of understanding, have 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 physician 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, the manifestations of eflemination 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 Kraft'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 the histories a very uncertain basis. To this is added the pathologically intensified auto-suggestibility of such neurasthenics, which hinders 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- differentiated 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 modern 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 PAR^ESTHESIA. cases, of like sex ; too, the fetichist, before he has erections at the sight of lifeless 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 physiological understanding of the disease. The fact that the remarkable perversions of taste of fetichists 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 parassthesia, 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 beginning, the result is totally different ; and there may be nothing in the latter 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 filially become an impera- tive idea. The auto-suggestive idea may induce an instinctive impulse to act, a state of temporary impulsive 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 1 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 1 Attentats aux Mceurs, Paris, 1878, p. 114 ; also reported at length in Psychopathia Sexualis, p. 69, Case 28. 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 fhe 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 human 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 which was put on by an 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 PARJESTHESIA. could not see red hair without becoming sexually excited. The former lover of an Italian 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 person 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. The dressed female foot forms the transition, and the love of shoe-nails the pathological ultimate result. Tarnowsky l 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 1 Op. ctt., p. 22. HEREDITY AND EDUCATION. 167 is the effort to magnify. Thus, the urning who tries to copy woman exaggerates the specific feminine peculiarities, often to caricature; and, vice versd, 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 effectual 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 in the Histories of Timings and Other Sexual Perverts. It remains to give a critical review of the known cases of sexual parsesthesia, 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 boy somewhat older. How happy I was when he touched me ! It was the undefined feeling of an inclination which was a secret to me until my nineteenth year. I have never masturbated nor committed abuse with other boys. 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 therefore 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 PAR^ESTHESIA. Here we observe premature awakening of sexual impulses, transference of the undifferentiated feeling to the pupil touching him, passive onanism, and definite perversion of the instinct in a predisposed individual. From WestphaPs first case we take the following passage : " N., it is said, suffers, since her eighth year, with 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. Playing with them gave her such a sensual delight that she had actual orgasm. When a child she liked to play boys' games and dressed like a boy. She had experienced sexual excitement since puberty in kissing girls." 1 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, (5) relation to the same sex, and (c) masturbation. On the other 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 timings (Ulricas). West- phal 2 cites a number of passages from " Numa Numantius's " investigations of the enigma of male sexual love of males, 3 and, 1 Westphal, loc. eit. * Loc. cit. * Compare the following writings of the author mentioned : " Forschungen iiber das Rathsel der mannannlichen Liebe : Numa Numantius (Karl Heinr. 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, according to the existing laws of Germany, it cannot be legally punished. Leipzig, 1864. " Inclusa " : Anthropological 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, 18fJ5. " Formatrix " : Anthropological studies of the love of urnings. Description of the sexual nature of uruings in detail. Key to the riddle of uranism and its varieties. Leipzig, 1865. " Ara spei " : Studies in moral and social phi- losophy in relation to the love of urnings. Relation of the urning's love to morality, Chris- tianity, and the moral arrangement of the world. Moral justification of the urning's love. HEREDITY AND EDUCATION. 169 therefore, was, perhaps, 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 writings 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 congenital ; 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 WestphaPs 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 urniugs 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 urning's love, and error as a maker of laws. An arraignment of German laws. Kassel, 1868. " Memnoii " : The sexual nature of the male-loving urning. Psycho-physical hermaphroditism. Ainina mitliebrte virili corpora inclusa. A study in natu- ral science. Two parts, Schleiz, 1868. " Incubus " : Urniug'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, ultramoutaues, 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 Czarnechy, of Posen ; Superintendent Forstner, of Vienna. Leipzig, 1869. 110 SEXUAL PAR^ESTHESIA. 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 concerning 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 while 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 role, still, however, having intercourse with prostitutes, " who in a drunken state accompanied him home." Besides this, he stated that 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 that 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 which, with other symptoms, but later, presented that of contrary sexual inclinations as a result of definite influences. Dr. Schminke 1 reports another case of contrary sexual in- stinct in the .Archiv fur Psycliiatrie: This case likewise speaks more in favor of the gradual development of the contrary sexual phenomena, with original normal tendency, 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 company. " Here, on one occasion, he was sitting on a sofa with a friend, both being in night-shirts. Suddenly he 1 Archiv fur Psychiatric, Bd. iii, Heft 1, 1871, p. 227. 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 became directed to the nearest object ; friendly feelings and momentary intense excitement explain the perversion of the otherwise normal instinct. Both cases that Gock 1 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 young 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 boys' 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 role of an imperative idea, and, owing to the lack of inhibitory opposing ideas, the patient became the victim of a cerebral process that had become inde- 1 " Ein Beitrag zur Kenntniss der contraren Sexualempfindung, aus der Wurzburger Psychiatr. Klinik," Archiv fur Psychiatric, 1875, Bd. v, Heft 2, p. 564. 172 SEXUAL PAR^STHESIA. 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 excitability. 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, 1 which recalls the origin of contrary sexual instinct among the ancients : Franz E. 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- cover}'. The brain, powerfully stimulated "by indifferent sensual excitants, convulsively seeks for some compensation, and accepts 1 " Zur Kenntnlss von der contraren Sexualempflndung," Archiv fur Psychiatric, 1876, Bd. vi, Heft 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 trustfully 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 brains ; but 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 Frankel, 1 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 and hanging of curtains. As a result of his occupation in feminine work, he gave himself to feminine vanit}*, carefully destroyed his beard, dressed his hair in curls, padded his bosom and hips, and used every opportunity to mask as a woman. What at first was merely sill3 r 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 normally 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 a 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 became feminine as a result of his engagement in feminine pur- suits to which his mother introduced him. 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 1 Medic. Ztg., herausgegeben vora Vereiu fur Heilkunde in Preusscii, Bd.xxii, 1853, p. 102 ; Homo mollis. 174 SEXUAL PAILESTHESIA. the Director of the Penal Institution of Brandenburg, West- phalia, which is to the effect that the practice of feminine occupations by men in the institution may occasion feminine conduct. 1 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 sucli 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, that 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 Krafft-Ebing. To a certain extent algolagnists constitute a transition ; in some cases patho- logical association seems to play the principal part; in others 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 pi-esent 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 ; 1 Comp. Westphal, loc. cit. HEREDITY AND EDUCATION. 175 and he may have been unconscious of it. The accident brought 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 " Psychopathia 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 non of sexual power ; and it is then pathological. " The occasion," says von Krafft-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 PAR^ESTHESIA. familiar by von Krafft-Ebing's " Experimental Study in the Domain of Hypnotism." 1 To support herself she 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 2 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 character 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 Sexu- alis, 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, there 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 the 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 appeared complete in his 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 femora 178 SEXUAL PARyESTHESIA. 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 feminse. 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 the 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 PAK^ESTHESIA. probable) is not stated. The impulse became confirmed by onanism with thoughts about men. Coitus possible, but devoid of satisfaction ; successful only with the help 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 liave 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 urnings), 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 urnings, which, according to Binswanger's 1 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 developed db ovo in the male body. We come now to the class of " Effemination and Vira- 1 " The Employment of Hypnosis In Asylums," Therap. Monatsliefte, Heft 3, 4, p. 167. HEREDITY AND EDUCATION. 18^ ginity." Case 93 seems to speak in favor of the isolated influ- ence of educational factors, for the patient's father states that 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, without 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-sixth 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 PAR^ESTHESIA. in the same way, remains doubtful. In such case the effemi- nation was here 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 feminse. 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 purpose he lounged about appropriate places. Onanism before puberty. In this case, apparently, circumstances not mentioned must have turned the boy's attention to the penis (exactly as in the case of one of my patients). 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 gynandry 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 effemination 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 Krafft-Ebing gives three cases of gynandry and androgyny. The subject of Case 104 is a person defective db 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. Corresponding with her ?*o/e, she feels like a man, and later becomes associated with women. 184 SEXUAL PAR^STHESlA. It seems to me questionable whether 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 Sarolta 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; (b) 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 effect 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 given in the higher court by the faculty of Vienna, signed by Theodor Meynert 1 as referee, declares that the patient is irresponsible, but contains another view of the disease. The facial bones, the position of the teeth, and the pelvis are called rachitic. "Owing to the father'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 form of a man dressed in her boys' garments, like Don Juan. Besides male garments, her conduct was allowed 1 Comp. Friedreich's Blatter fur gericht. Medicin., Nurnberg, 1891, Heft 1, p. 36. HEREDITY AND EDUCATION. 185 to be unrestrained, the 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-carousals, 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 haem- orrhoids, 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 emphasizes that the countess is practiced in the imitation of masculinity ; that doubtless she directs the tone of her voice accordingly; that she imitates masculine immorality, 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, drunkenness the symptom of contrary 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 occurrence 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 PAR.ESTHESIA. 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." While, 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 1 points out that in cases in which individuals entertain the delusion that they belong to the oppo- site sex (vide von Krafft-Ebing's " delusions of sexual transfor- mation" 2 ) are not to be confounded with cases of this kind, " for they are cases of actual monomania, and are seldom combined with other pathological sexual symptoms." The importance which educational factors and external influences may attain in the origin of sexual perversions, as a result of pathological associations in the case of hereditary neuropaths, is illustrated by the following cases, reported by Hammond : A bo}', 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 iu 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 due 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 than ever. Sexual orgasm. In spite of punishment, repetition of the act, with like result. Later, the mere memory 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. Nude women or men excited only feel- ings of disgust. He never thought of sexual intercourse. Finally, he 1 Loc. cit. 8 Krafft-Ebing's " New Investigations " 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 this 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, 1 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 necessary 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 undifferentiated 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. 1 Loc. cit., p. 163. 188 SEXUAL PAR^STHESIA. The desire to be a woman became so intense (as in the pathici of the ancients and in some of von Krafft-Ebing's patients) that he 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; di'eam-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 pubert}' 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 roles 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 slices (ladies' shoes with French heels). After his marriage he no longer wore corsets. In spite of a happy 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, nothing of the external circumstances which were oper- ative in inducing the preference for feminine dress. In this case, as was remarked in opposition to WestphaPs 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 role 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 role. This case shows clearly that we are justified in speaking of contrary sexual instinct only when the sexual feeling is demon strably implicated. Subsidiary symptoms, like preference for ornament and feminine work, or specific feminine peculiarities of character, are not by themselves sufficient 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 1 Rouboud : Traite de 1'impuissance et de la st6rilit6, 3 6d., Paris, 1876 ; and Ham- mond, loc. cit. 190 SEXUAL PAR^STHESIA. family. This lady, then 21, was a blonde, wearing her hair in the English fashion, 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 oil the intensity of excite- ment, but also merely 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 overstimulated 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 slight resistive power the most frequent symptom of hereditary taint offered favorable ground. The experiences 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 have 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 think, 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 Psychopathic 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 he 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 I 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" (Forel), the most exact knowledge of the accidental influences (192) 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 experiences. 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 without the 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 194 SEXUAL PAR^ESTHESIA. the subjective influence of a sexual development resting upon numerous experiences ; perhaps, too, they are subject to the unconscious suggestion of von Krafft-Ebing's theory of hered- ity, and thus enlarge the history retrospectively, without distinc- tion in time of the subjective events. 1 On this point, no error is easier than to date the beginning of effemination 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 resemble 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 ; (6) psycho-sexual hermaphroditism ; (c) the content of sexual dreams ; (df) 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 1 Binswanger very 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 modern 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) the 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 Prognosis 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 PAILESTHESIA. benefit. But this question still seems to us an open one ; in- creasing observations of the favorable results of suggestive therapeutics make it seem possible, perhaps, to bring about a relative limitation and diminution of the acquired feminine 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 XL PSYCHICAL AND SUGGESTIVE TREATMENT OF SEXUAL PERVERSION. Consciousness of Moral Duty as a Prophylactic, with Re- marks on Education in Morals, from the Stand-point 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 temperament and character can be influenced by pedagogic means, there are various opinions. That instincts can be overcome there is no doubt. 1 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 riot, of course, consist of merely the 1 Comp. Guyau, Education et Herdit6, 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. (197) 198 SEXUAL PAR^ESTHESIA. teachings 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 habits. But education cannot create genius, though it may develop it. Moral 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 emphasize 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 and self-respect, since daily experience shows that this means alone is effective in improving 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, therefore, 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, urn- 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 oP authority that are the correct factors in educa- 200 SEXUAL PAR^STHESIA. tion. When education has been successful in creating good habits, it remains to awaken the belief that 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. Regular occupation in a calling has a general moral effect. Want of occupation, on the contrary, removes the individual from 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 perversion. Natures that 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 though 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 instatu 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. 201 more impresses the brain. At first suggestion always induces a temporary emotion, which, by cumulative effect, as in frequent hypnotic sittings, becomes a habit in the individual. The effect of suggestions during our childhood 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 the greatest suggestive power. Those persons that seem to assure the most by gestures and emphasis are the best hypnotic operators. An energetic will 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 PARyESTHESIA. only results from education, when our reason gains possession of us. Therefore, consciousness of a moral duty signifies con- sciousness of inner and well-considered knowledge which directs our acts, the presence of ideas which strive to become real by virtue of their own power, and the presence of feelings which, as a result of their development, have in view the well-being of fellow-beings. Other Means for the Prevention 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 child, it is still much more so for neuropathic individuals, in whom the vita sexualis seems to be the locus minor is resistentice, and which, under the influence of unfavorable conditions, is directed into perverse 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 parents 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 has 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. Should Urnings be Treated ? A question of prophylaxis from the stand-point of coming generations involves the pro and con of the treatment of urn ings. Moll 1 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 effemination of an urning! The writer mentioned does not feel justified in giving a positive answer to this question, but leaves it for social and legal determination.. Marriage. 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- 1 Loc. cit., p. 209 204 SEXUAL PAR^STHESIA. 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 Causes. 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 in 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 thought 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 PSYCHICAL AND SUGGESTIVE TREATMENT. 205 basis of the sexual perversion (neurasthenia sexualis or univer- salis). 2. Removal of onanism and other influences injurious to the vita sexualis. 3. Specific treatment of the abnormal instinct. Antineurasthenic treatment, the means of which 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 hyperaesthesia and impotence, the most frequent accompanying symptoms of sexual paraesthesia. 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 thus be able to control his impulses. The patient should be advised, by energetically conquering himself, to think of woman and the 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 contrary sexu- ality passes through the stage of psycho-sexual hermaphroditism, r a condition in which he is excited by both sexes. What at first gives rise to the greatest repugnance (feeling of disgust) by 206 SEXUAL PAR^ESTHESIA. 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; (6) 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 the 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 hypereesthesia 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, fante 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 effemination, 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 with their physical 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 instinct. Rather, there are also neurasthenics in whom 208 SEXUAL PAR^ESTHESIA. virility alternates 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-corifidence and energy, the want of which 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 : l " 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 Hypnosis. 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 Kraff't-Ebing thinks, a deepening of hypnosis to somnambulism is necessary for this, l Loc. cit., p. 18. PSYCHICAL AND SUGGESTIVE TREATMENT. 209 seems questionable. The figures of the table appended to the following chapter give some points concerning the susceptibility to hypnosis in cases of sexual paraesthesia. Binswanger 1 regards the " murky domain of perverse sexual instinct," in spite of the available results of experience, as not conducive to exact knowledge of the curative effect of hypnotic suggestion ; and he doubts the complete transformation of sexual feelings and inclinations by means of hypnosis, because he gives no credit to the statements of such patients concerning such changes. In this case he should have given some other ac- ceptable criterion, with which such changes could be judged objectively. On the whole, neurasthenics and it is with such indi- viduals that we are, for the most part, concerned are, as" has been mentioned, difficult to hypnotize, and often it is necessary to bring about hypnosis 2 with the help of narcotics. But even in deep hypnosis it is not always easy to implant normal sexual feeling. Often the sexual abnormality dominates the whole personality when such patients have at last come to submit to medical treatment. In his work Moll mentions a philologist, afflicted with contrary sexual feeling, who violently resisted the suggestion to visit a certain woman at a certain hour. Moll believes that the fear of coming in contact with a woman may so rule the Timing, even in deep hypnosis, that he tries to avoid any possibility of it. I have seen similar fear of coitus in some onanists, as in some persons of contrary sexuality. I have always succeeded, however, with the exception of one case of uranism treated only a week, in inducing the patients to attempt coitus. When hetero-sexual intercourse has once been suc- cessful, as has been said, it may be regarded as the turning- point for improvement, in spite of the initial disgust during and after coitus. Since the histories given in the following chapter offer opportunity for special therapeutic details, we may here con- clude the general consideration of the principles of treatment. 1 Loc. cit. 1 Comp. von Schrenck-Notzing : Die Bedeutung der Narcotica far den Hypnotlsmus. Abel. Leipzig, 1891. CHAPTER XII. HISTORIES ILLUSTRATING SUGGESTIVE THERAPEUTICS IN PERVERSIONS OF THE SEXUAL INSTINCT. THE following thirty-two cases show the importance of suggestion in the most frequent form of sexual paraesthesia. Two cases (40 and 46) illustrate psychical and auto-suggestive treatment in the waking state. Among the following cases, those that have been previously published in other works are indicated with their sources. PSYCHO-SEXUAL HERMAPHKODITISM. Case 39. Psychical Hermaphrodite Treated in Six Sittings without Success (Prof, von Krafft-Ebiny}. F., aged 33 years ; large ; stately ; abundant beard. Mother and sister nervous. At the age of 12 years he suffered with fits of depression. Attempt at suicide at 13 years of age. For seven years attracted to males, especially to male servants. At the age of 12 years he slept in a room with a male servant. This ex- cited him excessively sexually, and he caressed the servant until the latter consented to mutual masturbation (pathological determination of the undifferentiated sexual feeling by the first object at hand. Von Sck.). In spite of inclination toward the male sex, rudiments of hetero-sexual impulses. When a-small boy he felt a desire to fondle little girls lust- fully. At the age of 17 he was in love with a young girl of beautiful form, but a year later he was incapable of coitus with a prostitute. Five years ago he performed coitus with a girl who charmed him with her beautiful form. Indulgence in masturbation from his thirteenth year. Embracing and kissing cultivated urnings always induced ejaculation. Dream-pollutions due to dreaming of men. Abhorrence of his perverse sexual impulse. Krafft-Ebing's advice to this patient consisted of: 1. Avoidance of sexual excitement. Resistance to contrary sexual feelings and abandon- ment of onanism. 2. Strengthening of the neurasthenic nervous system by suitable hydro-therapeutic and other cures. Attempt at hypnotic treatment for the purpose of imparting suggestions. In six sittings both physician and patient tried in vain to induce hypnosis, and further attempts were abandoned. Case 40. Successful Auto-suggestive Opposition of Homo-sexual Inclinations by a Psychical Hermaphrodite (von Krajft-Ebing). Father apoplectic ; mother suffered with anaemia and melancholia. The patient (210) PSYCHO-SEXUAL HERMAPHRODITISM. 211 had enuresis nocturna in childhood, and played with his genitals, for which his father tied him in bed. No onanism until his fifteenth year. Only platonic inclinations toward women. At the age of 18 sexual congress with a woman, without special inclination, but quite frequently. After the occurrence, old-looking, melancholic conduct. The patient liked to imagine himself as humiliated. Love of young men. Opposi- tion to it at first. Then the patient became a genuine urning and was greatly depressed. Taedium vitae and misanthropy. He became a socialist and carried on dramatic studies. Shame kept him from submitting to hypnotic treatment. " Now I persuaded myself that I was frightfully weak to have so little confidence in myself, and I began in earnest to overcome my homo-sexual desires. At the same time I fought against my nervousness by leading a proper life. I rowed, fenced, was much in the open air, and had the delight, finally, on awaking, to find myself another man. When I thought of the time from my twenti- eth to my twenty-sixth year, it seemed to me that a strange, disgusting man had occupied my body during that period. I was astounded that the handsomest male waiter excited no interest in me. I was disgusted when I thought how such men had once impressed me. My self-respect increased ; and since my twentieth year my appearance has constantly- improved. Relapses of my homo-sexual desires occurred, but I re- pressed them energetically. I satisfy my libido in coitus, and I hope, by continuing to lead a proper life, that my pleasure in it will increase." Case 41. Psychical Hermaphroditism. Essential Improvement by Suggestion (von Krafft-Ebing}. Mr. von P., aged 25, single, Pole, suf- fered with convulsions when a child. Weakly, emotional, irritable. No serious diseases. Awakening of the sexual instinct before his tenth year. His earliest memory of lustful feelings is of those in connection with a male servant. Later, lascivious dreams of men. At the circus, interest in male performers. Contact with a youthful and muscular male form induces ejaculation. Not insensible to feminine charms. He regards man as more beautiful than Woman. Hetero-sexual congress since his twen- tieth year, as a result of excessive libido. No manual, but frequently psychical, onanism. Coitus successful, but devoid of pleasure and lustful feeling. Enforced abstinence from his twenty-second to his twenty- fourth year ; faute de mieux, psychical onauism. For a year there had been defective libido for women, insufficient erection, and premature ejaculation. Coitus given up ; libido for men. Owing to the irritable weakness of the ejaculation-centre, simply the touch of an attractive man induces ejaculation. Family circumstances force him to marrj' ; he regards himself as psj'chically impotent, and seeks help. The patient is masculine in appearance. Cranium slightly hydro- cephalic and rhombic. Abundant beard. Genitals normal. Cremasteric reflex cannot be elicited. No symptoms of neurasthenia. Neuropathic 212 SEXUAL PAR^ESTHESIA. eyes. Pollutions infrequent. Erections occur only on meeting very attractive men. July 16, 1889, first hypnotic sitting. The third sitting, on the 18th, first induces deep lethargy. Suggestions : No inclinations for men ; love for the female sex ; complete virility. The degree of hypnosis never goes beyond lethargy. The suggestions are accepted. On the 24th the patient announces that he has had coitus with enjoy- ment. At the same time, he still thinks man more beautiful than woman. August 1, 1889, the treatment was necessarily interrupted. Result: complete virility; complete indifference for both the male and female sexes. Case 42. Psycho-sexual Hermaphroditism Completely Cured by Sev- eral Months of Treatment by Suggestion. 1 Report of the Duration of the Cure One Year After Discharge (von Krafft-Ebing). Mr. von X., aged 25 ; landed proprietor. He comes from a neuropathic, passionate father ; normal sexually. Mother and two sisters nervous. Maternal grand- mother was nervous, and his maternal grandfather was a roue, much given to venery. Patient is like his mother, and an only child. From birth he was weak, suffered much with migraine, and was nervous. He passed through several illnesses. At 15 he began masturbation without having been taught it. Until his seventeenth year, he sa} T s, he never had feeling for men or, in fact, any sexual inclination; but at this time desire for men arose. He fell in love with a comrade ; his friend returned his love. They embraced and kissed and indulged in mutual onanism. Occasion- ally, patient practiced coitus inter femora viri. He abhorred pederasty. Lascivious dreams were only about men. In the circus and theatre males alone interested him. His inclination was for those of about 20 years of age. Handsome, tall forms were enticing. Given these con- ditions, he was quite indifferent to other characteristics of the man. In his sexual affairs with men, his part was always that of a man. After his eighteenth year the patient was always a source of anxiety to his parents ; for he then began a love-affair with a male waiter, who fleeced him and made him an object of remark and ridicule. He was taken home. He consorted with servants and hostlers. He caused a scandal. He was sent away for travel. In London he got into a " black- mailing scrape," but succeeded in escaping to his home. He profited in no way by this bitter experience, and again showed disgraceful inclinations for men. Patient was sent to me to be cured of his fatal peculiarity (December 12, 1888). Patient is a large, stately, robust young man, of masculine build ; large, well-formed genitals. Gait, voice, and attitude are masculine. He has no pronounced mascul'ine pas- sions. He smokes but little, and only cigarettes ; drinks little, and is fond of confectionery. He loves music, art, aesthetics, flowers, and moves in ladies' society by preference. He wears a moustache, the face being other- 1 Psychopathia Sexual is, Case 139. PSYCHO-SEXUAL HERMAPHRODITISM. 213 wise cleanly shaved. His garments are in nowise remarkable. He is a soft, blase fellow, and a do-nothing. He lies abed mornings, and can scarcely be made to rise before noon. He says he has never regarded his inclination toward his own sex as abnormal. He looks upon it as con- genital ; but, taught by his sad experiences, he wishes to be cured of his perversion. He has little faith in his own will. He has tried to help him- self, but always begins to masturbate. This he finds injurious, inasmuch as it causes slight neurasthenic symptoms. There is no moral defect ; in- telligence a little below the average. Careful education and aristocratic manners are apparent. The exquisite neuropathic eye betrays the nervous constitution. He has hetero-sexual feelings, but his sensual in- clinations toward the opposite sex are weak and infrequent. At the age of 19 he was first taken to a brothel by his friends. No horror feminse ; efficient erections and some pleasure in coitus, but not the instinctive delight he had experienced while embracing men. Since then, the patient states, he has had coitus six times, twice sua sponte. He asserts that he is always capable of it, but he performs it only faute de mieux, as he does masturbation when the sexual impulse troubles him, as a substitute for congress with men. Rudiments of sexual feeling present. The indications were clear enough. Hansen had tried in vain to hypnotize the patient. To the astonishment of the physician, Bernheim ; s method immediately induced deep lethargy, with possibility of post-hypnotic suggestion. At the second sitting somnambulism by simply looking at him. Suggestive contractures possible.- Awakening by counting three. Am- nesia for" the events of the hypnosis. Repetition of the ti'eatment every second or third day, together with moral and hydro-therapeutic treat- ment. Suggestions : Horror of onanism ; repugnance for men ; inclination for women. Patient repeats the suggestions at each sitting. After the fourth sitting it was noticed that the patient paid atten- tions to ladies in the circles to which he was introduced. Soon after he was much taken with a prima-donna. Some days later he sought the address of a brothel. February 17th. Asks to be allowed to perform coitus. Satisfied with his experience with a member of the demi-monde. March 16th. Hypnotic treatment twice a week up to this date. Patient states that he is free from onanism and sexual feelings for men. Since he gives the same answers in hypnosis, e.g., that on such and such a date he practiced onanism for the last time, and that he is too much under the will of the physician to be able to lie, his assertions deserve belief; the more, since he looks well and is free from all neuras- thenic symptoms, and, in the society of men, not the slightest suspicion rests on him. An open, free, and manly bearing is developed. Moreover, since, of his own will, he now and then indulges in 214 SEXUAL PAILESTHESIA. coitus with pleasure, and occasional pollutions are induced by lascivious dreams which concern women, there can be no doubt of the favorable change of his vita sexualis ; and it is presumable that the hypnotic sug- gestions have developed into auto-suggestive inclinations, which direct his feelings, thoughts, and will. Probably the patient will always remain a natura frigida ; but he more often speaks of marriage, and of his inten- tion to win a wife as soon as he has become acquainted with a sympathetic lady. Treatment ceased. In July, 1889, a letter from his father told of his good health and conduct. May 24, 1890, accidental meeting on a journey. Patient had never again experienced male-love. Performed coitus occasionally with com- plete enjoyment. He now thought seriously of marriage. I hypnotized the patient, to test him, in the former manner, and asked for the com- mands I had formerly given him. In deep somnambulism, and in the same tone of voice as formerly, the patient repeated the suggestions given him in 1888, an excellent example of the endurance and power of post-hypnotic suggestion. Case 43. Psychical Hermaphroditism ; Improvement by Hypnotic Treatment. 1 K., aged 23; Russian, of prominent family. Well endowed mentally ; scrofulous when a child. Father a roue. Father's brother is said to have been contrary sexually. At the age of 7, love of coachmen and servants wearing moustaches. Close contact with such persons gave him a feeling of delight. In the cadet corps, taught mutual onanism and coitus inter femora viri. At 17, first coitus with a prostitute. He performed the act normally, but without enjoyment. Frequent coitus; gonorrhoea. Growing aversion to the female sex. Then coitus only when male intercourse became impossible. Especial partiality for well- formed men without beards. Coitus buccalis ; active and passive pederasty. Shame caused an attempt to reform by means of coitus with women. Moral strength was insufficient ; women were repugnant to him. Never any dreams of women. When the patient came for consultation, he had last had coitus three weeks previously, but without pleasure. He does not regard his case as hopeless. He gave up his commission as an officer because soldiers excited him so sexually. No degenerative signs. Examination of semen showed abundant spermatozoa. Penis large, well-developed. Hair on genitals and beard abundant. No pleasure in drinking and smoking ; otherwise of mascu- line tastes. Neuropathic eyes. Usually takes the male role in the sexual act with men ; now and then the female. Attempts at hypnosis induced lethargy and cataleptiform state of the muscles. Condition used to impart suggestions. After the fourth sitting he says he is satisfied, and he wonders 1 Psyehopathia Sexualis. PSYCHO-SEXUAL HERMAPHRODITISM. 215 that men no longer interest him. He wants to try his luck with women, but fears impotence. After the sixth sitting he voluntarily tries coitus cum muliere. Great libido ; but in the act this and erection left him. After the ninth sitting the patient discontinued treatment on account of business at home. He feels satisfied in that he is indifferent toward men and capable of resistance. He thinks he is in no danger of relapse. At the time he felt as little interest in women as in men. Case 44. Psychical Hermaphroditism Cured by Hypnotic Sug- gestions. 1 Z., aged 29 years. Mother nervous ; father and grandparents healthy. Only child ; spoiled. At the age of 8 his sexual libido was intensely excited by a male servant, who showed him pornographic pict- ures and his penis. At 12, love of his tutor. When going to sleep his nude form appeared to him. He conceived himself in a feminine situation with reference to him, and reveled in the thought of marrying him some day. At 13 a 3 7 oung governess excited his fancy, and at 15 he fell in love with a young lady. No onanism. Sensually excitable, but only to attractive men. At 20 the patient became neurasthenic (ex abstinentia ?). He attempted coitus without success. On the occasion of a Turkish bath, intense libido at sight of a nude man. This person approached him and performed masturbation on him, which gave the patient intense pleasure. Until he was 25. masturbation once a month by this man. During this time interest in a young peasant, who, however, would not yield to his desires. Separated from his lover, patient began auto-masturbation. Increase of neurasthenia. Inability to work ; shyness, dysthj*mic, and abulic. Unsuccessful treatment by hydro-therapy. Late in February, 1890, he went to Prof, von Krafft-Ebing. Decidedly masculine in appear- ance ; neuropathic. Tall ; large ears, lobules passing into the skin of the cheeks. Genitals normal. Cerebro-spinal neurasthenia of moderate degree. Taedium vitas. Much depressed by his sexual abnormality. No interest in women except intellectual. Dreams were also about per- sons of the opposite sex. The most refined puella could not induce erection in him. Passive or mutual onanism with men ; faute de mieux, auto-masturbation. Abstinence during last five months. No homo- sexual intercourse since August, 1889. An attempt at hypnosis by Bernheim's method failed. Prolonged stroking of the brow produces deep lethargy with catalepsy. Somnam- bulism impossible. In the third sitting, suggestion that onanism and male-love are repulsive, and that woman is beautiful. Dreams of women suggested. Noticeable change in the mental attitude after the sixth sit- ting. Patient quieter, freer; dreams of women. Approaches women, but they do not attract him. He went home March 19th. Returned for treatment May 17, 1890. 1 Psycbopathia Sexualis. 21 6 SEXUAL PAILESTHESIA. No masturbation in the interval. Two platonic dreams of women; cere- bral asthenia increased. He apparently suffers from want of mental and sensual satisfaction of his vita sexualis. Depressed to taedium vitae. Hydro-therapeutic, electrical, and antineurasthenic treatment. During ten weeks gradual disappearance of the troubles and change of his psychical condition. The initiative in hetero-sexual intercourse is left to the patient. He now takes journeys in the mountains and forest ; his boudoir becomes a work-room. In the fourteenth week of treatment, suc- cessful coitus. The patient became a happy man in body and mind. He expressed the best hope for his future, and had thoughts of marriage. He experienced increasing pleasure in normal sexual congress ; had las- civious dreams of women occasionally, but never of men. Cessation of treatment late in September. He feels normal in hetero-sexual congress, free from neurasthenia, and thinks of matrimony. At the same time, he confesses that he still always has erection at the sight of a nude, handsome man ; but he is able to resist his desires easily, and in his dream-life his relations are exclusively dvec lafemme, As Prof, von Krafft-Ebing informed me by letter in October, 1891, in October, 1890, before leaving Vienna, the patient had coitus twice a week with pleasure, and without the assistance of the puella. As a report from the patient, April 8, 1891, stated, he had given up masturba- tion entirely, and made no approaches to men, even though he had not entirely lost all inclination to do so. This inclination showed itself only after coitus, but he dreamed only of women. Antineurasthenic treatment recommended for nervous symptoms that had again appeared of late. Case 45. Psychical Hermaphroditism Improved by Fourteen Hyp- notic Sittings (von Krafft-Ebing'). Male, aged 33 years ; born out of wed- lock. Father and mother were cousins. Father said to have had sexual disease, but not contrary sexually. Mother eccentric ; made journeys in male attire ; very decided character; smoked, and wore short hair ; died unmarried. Appearance masculine. In childhood, hydrocephalus and slow mental development. Taught onanism by a room-mate at tfhe age of 13 years. He practiced it passionately. Ideas of men while mastur- bating and in dreams. Inclination to pederasty. At 19 years of age coitus six times with women ; erection and ejaculation prompt, but with- out special feeling of pleasure. Love of a remarkably beautiful lady at a watering-place made the patient happy and kept him from onanism temporarily. After two years, complete cooling of his feeling for women. Attempts at coitus do not induce ejaculation. A former school-mate attempted immissio penis in anum with the patient, which gave him an unexpected feeling of pleasure. Then mutual onanism with an hussar, and receptio penis ejus in os of the patient. Later, pederasty with a sailor. Love of passive pederasty more and more developed. Lascivious interest caused him to peruse " Psychopathia Sexualis." CONTRARY SEXUAL INSTINCT. 217 Unexpected deep impression. "The description of cultivating mujerados excited me intensely, so that I masturbated five times in the next two days, thinking of myself as a presumptive mujerado. The moral earnest- ness of the book brought me to a decision to seek help of its author." There was even some result from the reading of the book ; for since then the patient had practiced auto-masturbation but twice, and mutual mas- turbation with cavalrymen but twice. Hansen tried in vain to hypnotize the patient. In the spring of 1891 the patient visited Prof, von Krafft-Ebing. " He experiences moral disgust when he performs the act with a man, and yet the look of a handsome soldier actually electrifies him. For years he has had not the slightest sympathy for women, not even mentally." Patient's cranium exquisitely hydrocephalic and plagiocephalic. Hypnosis difficult; only with the help of Braid's method and a few drops of chloroform in the third sitting was it possible to induce deep lethargy. After that, merely looking at a shining light was sufficient. The suggestions consisted of forbiddance of masturbation, removal of homo-sexual feelings, and the assurance that the patient would have inclination for women, and virility and pleasure only in hetero-sexual congress. Masturbation was indulged in but once more. After the eighth sitting the patient dreamed of a woman. When, after the fourteenth sitting, the patient was forced to leave, he declared himself free from inclination to onanism and male-love, but the desire for men was by no means extinguished. He felt returning interest in the female sex, and hoped, by continu- ing treatment, to be finally freed from his vicious peculiarity. CONTRARY SEXUAL INSTINCT. Case 46. Eeported by Gharcot and Magnan. 1 Contrary Sexual Instinct. Successful Psychical Treatment in the Waking State. " My sexual feelings," the patient states, " were manifested from my sixteenth year in an extraordinary impulse to see boys of my own age and men in a state of nudity. It was not difficult for me to gratify this inclination, for my parents lived close to a garrison, and the soldiers took no trouble to conceal their genitals. One day I was then 8 years old I saw a soldier masturbate. I imitated him and experienced, besides the pleas- ure of imitating a soldier, the pleasant sensation of the friction. I again sought the same pleasure by exciting my fancy with the thought of naked men. My parents left N. and moved to B. There I saw the soldiers bathe naked in a small stream. I determined, in order to have the de- sired pleasure, to seat myself on a bench near the stream, pretending to sketch the landscape, while I could thus see the bathers without attract- ing attention. 1 Archiv de Neurologic, No. 7, p. 54. 218 SEXUAL PAR^STHESIA. " At about 15 I attained puberty, and experienced much more satis- faction in onanism ; indeed, I could induce erection and its results as well by my fancy as by friction. More than once I bad erections, sexual excitement, and ejaculation merely on looking at a man's genitals. If my fancy became excited in sleep, the same phenomena occurred. At 20 I gave up onanism ; but all my efforts were incapable of controlling the excitation of my imagination. Muscular, handsome men always excited me intensely ; every beautiful statue of a nude man had the same effect on me. The Apollo Belvidere excited me intensely. When I met a man who excited me by his beauty and youth, I was impelled to show him every attention, and if I did not forcibly control my feelings I could have done anything for him. I should have been delighted to invite him to my house, and to write to him only on perfumed paper. I could have sent him flowers and made him presents, and gladly robbed myself of many things to show him my favor. I have never done all this, but I should only too gladly have done it. I tried stoutly to control myself and overcome the impulse I felt. I was finally successful in banishing the inclinations mentioned, though I was never able to repress the love I felt. Fortunately for me, my love was fickle. " Occupation and study have done much to overpower my sensual thoughts. Still sensuality often triumphs ; then 1 am forced to stop work because a naked form rises in my fancy. I have always fought against this sensuality as much as I could, and often restrained myself from acts to which I have been impelled, but at no time have I been able to ex- tinguish my sensuality entirely. The greatest satisfaction of this feel- ing was experienced when I saw a naked man, especially his penis. At the same time, I have never felt any desire to approach a man or to allow one to use me. The sight of the genitals of a strong young man has always given me the greatest lustful enjoyment. " Women, on the contrary, no matter how beautiful, have never ex- cited the slightest desire in me. I tried to love a girl, thinking thus to direct my thoughts to a natural channel, but, though she was very beau- tiful and reciprocated, I remained entirely indifferent ; and of erections, which occurred so easily at the sight of a man, there was never a trace. No woman has ever excited the slightest sexual feeling in me. I admire their toilettes and like to see a beautifully-dressed woman ; for I think that if I were a woman I would dress so. At the age of 17, at a carnival, I wore female garments, and had a feeling of indescribable pleasure when I felt my skirts slipping along the floor behind me; also when I dressed my false hair and put on my decollete dress. Until my twenty-second year it gave me much delight to dress dolls, and this even still affords me pleasure. Ladies are often astonished to hear my excellent judgment of appropriate and inappropriate toilettes, as well as concerning other things which belong entirely to woman's sphere. The love I may feel CONTRARY SEXUAL INSTINCT. 219 for any one woman soon passes ; for the next one more beautiful erases the memory of the preceding. In the last few months pollutions at night have not been so frequent as formerly. I have had none in the last three weeks, but I still have my customary dreams and my longing to see nude men.'' Charcot and Magnan advised the patient when excited to substitute a woman for a man in his fancy. He tried strenu- ously to do this, but for the most part in vain. After a struggle of several months' duration he finally had a little success, and went so far as to be able to have sexual congress with a woman, which gave him pleasant sensations. The psychical effect was excellent, and in a few days he was free from his former feelings. When, however, he was compelled to leave Paris for a time, and was thus forced to combat his old impulse with his own reason alone, the old inclinations began again to predominate. In this case, besides psychical treatment, hydro-therapy (cold showers and douches) and bromides were used ; which lessened the intensity and duration of the attacks, but did not influence their frequency. The foregoing case seemed to me worthy of report for various reasons. It shows, first, how the eight-year-old boy's attention was excited by external influence to male genitals and onanism. In imitating the act, the person seen was present in the boy's mind. The pathological association was thus formed ; it became associated with lustful feeling and intensified by fre- quency of repetition. And thus the impressionability of the patient's imagination, exercised one-sidedly, for hetero-sexual stimuli, disappeared. The reflex effect on his character was not wanting ; he wore female attire at the carnival, played with dolls, etc. The pathological product of cultivation, probably made possible by an hereditary neuropathic disposition, should then be combated by methodical self-discipline and substitution of ideas of women in contrary sexual excitement. This succeeds to a certain extent ; the right road to recovery is thus undoubt- edly found; but hypnotic treatment would have lightened the patient's task. The time of treatment, as far as can be judged 220 SEXUAL PARJESTHESIA. from the report, stands in no relation to the time required in the development of the malady. In the foregoing case, in my opinion, there was possibility jof a complete cure. The fact that the circumstances of the patient did not allow systematic pursuit of the treatment does not negative this. Case 47. Reported by Dr. Wetter sir and* Stockholm. Contrary Sexual Instinct Cured in Seventeen Hypnotic Sittings. X. X., merchant, aged 32. On the occasion of his visit, August 30, 1889, the patient told me that he had been given to onanism since his thirteenth year, and that he began to have intercourse with his own sex in his twenty-fifth year. He had performed coitus, which caused him disgust and repugnance, but a few times, and not at all for many years. He had a strongly-developed sexual instinct, and found his greatest delight in the embrace of men. Only when he had no opportunity for this did he avail himself of onanism. His greatest desire is for men, and he can spend days seeking them. To satisfy this lust he visits water-closets, where the sight of male genitals gives him pleasure. It seems to him that he has a feminine nature, and not a man's feeling. He is of powerful masculine appear- ance ; genital hair and beard not much developed. His voice is mascu- line, but his character is somewhat feminine. As far as he knows, none of his relatives suffer with a similar malady. He weeps, wrings his hands, and is in despair at his unhappy fate. He had previously tried hypnotic treatment ; but, perceiving no improvement after thirty sittings, he gave it up. Strange to say, I was successful in producing deep sleep on the first trial, with complete amnesia on waking. ' After seventeen sittings, late in September, he was fully recovered. I have often seen him since, and have never met a more grateful man. He calls me his saviour, and now hates what formerly gave him his greatest enjoyment. Case 48. Reported by Dr. Wetter strand. Cultivated Contrary Sex- ual Instinct Cured in Three Weeks by Suggestive Treatment. X. X., aged 34 ; official. " My parents died when I was still a child. I then lived in a family the head of which was dissipated and never at home. He had no interest in his own children or in me. As soon as I began school I was left to the care of an old lady, whose habit it was to go about gossiping from house to house. Thus, I had no father. A tutor who shared my room at night disturbed my rest by teaching me unnatural sexual practices. Without understanding the great danger of his con- duct, and without suspecting the immorality of his acts, I offered no resistance. At the same time, I lost all pleasure in work and study ; I became shy of my companions ; associated with women, and took part in 1 Der Hypnotisrnus und seine Auweudung in der prakt. Med., Wein, 1891, p. 52. CONTRARY SEXUAL INSTINCT. 221 their work, etc. At the age of 20 I formed a close friendship with a young man some years my junior (I had no idea of anything else), and association with him gave me great pleasure. I shared everything with him, but there was nothing immoral in our relation ; strange to say, I took great pleasure in flattery. Parting with my friend was very hard for me. Since then I have never felt so lively an interest in any one ; still, I love to see finely-formed men, and should prefer to see them naked. One day, a woman may excite me to lustful feeling ; the next, I may have the same sensations with a man. Dreams of both males and females have caused me to have pollutions. In the second coitus I acquired gonorrhoea, I believe, because I was not able to complete the act. Besides, I fancy that I suffer with impotence and cannot complete coitus, because sexually I am not constituted like others." Patient has a stately figure, is masculine in his whole appearance, and physically well formed. In a week he was transformed by treatment. Coitus was successful. I can definitely assert that when he left he was entirely cured, and that after treatment for three weeks, from Feb- ruary 1 to 23, 1891. He is about to marry, as his letter of July, 1891, informs me. Case 49. Reported by Dr. Wetter strand. Contrary Sexual Instinct Cured by Suggestive Treatment in Two Months. X. X., aged 20. " Since my earliest childhood I have been inclined to everything feminine. When a small child I played with dolls, and I preferred to associate with girls, while I avoided bo3 r s' games. As I grew older, at 14 or 15, 1 began to love certain men ; my weakness was especially strong, handsome men. I have loved many such. Three times I was violently in love, the last time three years ago. In order to avoid betraying myself, I was forced to avoid the last object of my affections. I have always been inclined by nature to be retiring. At that time I became melancholic and came near suicide, for I feared insanity. My sleep is disturbed by dreams. I practiced onanism passionately, thinking of the male object of my love during the act. This has been my habit as long as I can remember. I often sought to escape from this dangerous habit, but in vain. I always relapsed. Filled with despair, I wept and prayed, and for two months I have not masturbated. I have never had congress with women. I was a poor, eldest child, improperly reared, and the evil in whose grasp 1 am was allowed to develop unhindered. I am poor and live in America. I suffered terrible misery. At the present time I am in Sweden, to bid my old mother farewell. Thus I heard of you. My hope was awakened ; perhaps I can become a new man." To these biographical notes by the patient Wetterstrand adds the following : On his second visit, January 4, 1891, the patient gave me the fore- 222 SEXUAL PAR.ESTHESIA. going statement. The physical examination was negative. The body is well formed ; nothing feminine to be noticed ; genitals well devel- oped. Another physician had made some attempts to hypnotize him. Thus the difficulty of affecting him was increased. Still, I succeeded in inducing deep sleep with amnesia. I asked the patient for a report by letter, and he sent me the following in the early part of February : "During the first two weeks I could notice no change, but gradually my feelings were altered. ... I would ask myself, ' Is not your body like that of other men? Certainly; all else depends upon your imagination which rules you.' At such times, it seems the most natural thing in the world that I am a man ; I am delighted, but I am not capable of feeling love for women. I am satisfied, courageous, and full of hope. The soft, feminine heart is gone ; I now abhor men ; I see in them my own image, and I can no longer love them as I once did." The pa- tient left in the latter part of February, entirely recovered. Since then I have heard no more of him. This case is interesting, because the patient was still so young, and because the treatment was begun so early. Case 50. Reported by Professor Bernheim. Inversion of the Sexual Instinct. Impotence of Seven Years 1 Duration in Marital Relations. Cured by Suggestion in Twenty Days. Mr. von X., from Hungary, aged 36 years, consulted me May 24, 1889, on account of im- potence caused by contrary sexual instinct. The sexual inversion has existed since early youth, and was developed by vicious practices at school. Before his marriage, however, he was still able to have normal sexual congress quite often. He married his present wife for love at the age of 29 years, but for seven years he has not been able to perform the sexual act with her. It was impossible for him to have erection in her presence, or even in the presence of other women. On the other hand, he manifested a marked inclination for men, which showed itself by erec- tions. He found satisfaction in embraces merely. He performed the unnatural sexual act but twice. Until his eighteenth year he had been a moderate onanist, but then gave up the vice. 1 The patient appears intelligent; lymphatic; nervous. Has been healthy until now. A well-bred, moral man, he suffers unspeakably owing to his condition. His efforts, persevered in for years, to over- come his unhappy anomaly have been vain. There is a constant burden on him. All methods of treatment to which he has had resort every- thing he has done to overcome it have been without result. From May 24th I hypnotized him daily. On the first day he easily fell asleep. Catalepsy ; automatic turning ; memory after waking. In the" third sitting he fell into deep sleep, with amnesia. I suggested to him the occurrence of erections in the presence of his wife and the com- plete disappearance of the sexual inversion. These suggestions were 1 Bernheim : Hypuotisine, Suggestion, etc. Paris, 1891, Obs. 38. CONTRARY SEXUAL INSTINCT. 223 daily repeated energetically. After a few days I gave him the definite assurance that, on the night of June 3d, spontaneously an erection would occur, as well as a lively desire for indulgence ; and, in fact, on the night of the 3d he had an erection, but it did not last long enough to make coitus possible. Repetition of the suggestion during the following days. A new trial is set for June 8th. Erection occurred and lasted longer, but not long enough. At the same time the patient becomes convinced that he will attain his object. Trial set for June 13th. On this occasion he actually attained his desire. He said he per- formed the act of marital intercourse easily and satisfactorily, but still not in obedience to an irresistible impulse. The inclination for men diminishes, bnt does not disappear entirely. Patient is happy at his success. On June 16th, for which date repetition of the trial is set by suggestion, he did not yield to the com- mand, because bethought of himself as a satiated man without inclination to either sex. I suggested a trial for the coming night. On June 17th he told me of his success in the preceding night. He awoke with erection, without any suspicion of the suggestion that had been given him, and felt a strong desire for his wife. At present he is indifferent toward men ; however, he is not sure that he would be able to withstand temptation. I now suggest to him gradual increase of his sexual inclination for his wife, and order the next performance of his conjugal duty for the night of June 19th to 20th. Remarkablj r favorable success of the sug- gestion. His preference for unnatural indulgence he says is entirely gone. He remained eight days longer in Nancy, and during this time had congress with his wife twice, with increasing desire. He experienced a complete inner transformation, and could no longer understand his previ- ous taste in sexual matters. I later learned that the cure, both physical and mental, had continued permanent. > Case 51. Reported by Professor Berriheim. Contrary Sexual In- stinct Improved by One Month of Hypnotic Treatment. A young foi'- eigner, aged 23, of good family, consulted me four years ago on account of his passion for smoking, of which he wished to be freed. I put him to sleep (catalepsy ; automatic movements; memory after waking). After only nine sittings he regarded himself cured. At any rate, he no longer had any thought to smoke. Then he confessed to me that he had another anomaly, which he had previously been too shy to confess, namely, an inversion of the sexual instinct. For several years he had indulged in contrary sexual intercourse, following his natural bent. He had never had any feeling for women, though he liked to associate with ladies. On the other hand, his contrary sexual inclinations began spon- taneously, without anything of the kind having been suggested to him 224 SEXUAL PAR^ESTHESIA. in school or elsewhere. According to his statement, he had always fought against this impulse, which, as a man of honor and good educa- tion, he was forced to regard as evil. The patient is intelligent, not eccentric, and without nervous symp- toms or hereditary antecedents of any kind. For a month he was treated daily by suggestion. I sought to give him in hypnosis natural feeling for women and disgust for male-love. After three weeks of treatment he had sexual congress with a woman, without special inclination, but still without aversion, which, up to that time, had been impossible for him. He then declared himself indifferent toward the male sex, though having no aversion for men. Whether the cure was permanent or not I do not know. Case 52. Eeported by Professor Bernheim. Imperative Ideas of Contrary Sexual Content Treated by Suggestion without Result. A pro- fessor, aged about 34, foreigner, consulted me three years ago on account of imperative ideas of a sexual nature. According to his statement, when teaching boys, as soon as he noticed their limbs and bodies, he was seized by obscene ideas of an homo-sexual nature. He could not explain this inclination, and sought in vain to free himself from such ideas. With irresistible persistence this always recurred. It required all his strength to resist the impulse to realize such desires. The patient had a good constitution ; was not nervous or tainted hereditarily, and had had no disease previously. His honor could not be doubted ; his morality was irreproachable. He was not subject to states of sexual excitement except at sight of boys. His sense of right and mor.ils was pained by these struggles. He could stay in Nancy but a week. I hypnotized him eight times (second degree), but without any therapeutic result. Case 53. Reported by Dr. Franz Muller. 1 Homo-sexual Ideas Over- come in One Hypnotic Sitting. A finely-educated man, physically healthy, suffered with sexual perversion. His thoughts were of how he could bring about a union with a person of his own sex. He had not yet attained his desire ; but the continual struggle against these ideas, which in his heart he detested, had made him nervous and injured his health. He was depressed, retiring, and taken with thoughts of suicide. By long treatment with warm, moist packs, followed by cold friction and sitz-baths, the nervous symptoms were fairly overcome. The advice to attempt coitus was not followed, because of lack of determination. While the patient lay in the pack and was inclined to sleep, suggestive induction of sleep by Dr. Muller, after fixation had proved unsuccessful. Suggestion: "After your return home, you will seek to satisfy your sexual desires in the natural way. You will surely succeed." Awakened by verbal suggestion. After waking, the patient says 1 Comp. Muller, Hydrotherapie, Leipzig, 1890, p. 309. CONTRARY SEXUAL INSTINCT. 225 he has been asleep, and he knows nothing of the suggestion. Complete amnesia on succeeding days. Two days after the patient left, a telegram announced that the attempt had been successful. Since then regular sexual intercourse has been indulged in, and the former imperative ideas have diminished in intensity, though they exceptionally manifest them- selves. All the physician's advice while the patient was in the institution had no influence on him. With the best will, he could not bring himself to follow the advice. What the most careful ps3 r chical treatment in the waking state could not accomplish by daily repetition was attained by a single suggestion in the state of* somnambulism. The foregoing case controverts the view of those writers (Benedict, for example) who assert that the same results can be obtained by treating the patient in the waking state as by hypnotic suggestion. Case 54. Reported by Prof, von Krafft-Ebing. Contrary Sexual Instinct Treated without Success in One Hypnotic Sitting. Male, aged 34, merchant. Full beard ; mincing, feminine gait. He neither smokes nor drinks. Moody, nervous, devoid of moral feeling ; disinclination for masculine pursuits. At 12, excited by tight-fitting uniforms. Follows men of muscular build for hours. Onanism accompanied by thoughts of heroic men. Knowledge of his condition at 17. He then had congress with women eight or ten times, but erection occurred only at thought of men. Later this was no longer successful. Very sensual nature. Un- usually cynical and inventive in imagining situations of which homo- sexual intercourse is the subject. Ejaculation has been induced as many as five or six times in a night by this means. Soldiers are preferred. Patient feels entirely like a woman. Parents health}' ; one brother an urning. An attempt to hypnotize the much-excited patient induces but slight somnolence. Case 55. Reported by Prof, von Krafft-Ebing. Contrary Sexual Instinct Acquired through Masturbation. Much Improved in Eight Hypnotic Sittings. X., aged 29 ; merchant. Father irritable ; mother had a rough, masculine voice, and died in childbed. Brother of patient irritable, melancholic, and neutral toward women. The first trace of sexual feeling occurred in his tenth to eleventh year. He learned onanism from other boys, and practiced mutual mas- turbation. First emission at the age of 13 or 14; after his twentieth year, pollutions, in spite of daily onanism. With the pollutions, dreams of sexual congress. Seduced into mutual onanism in his seventeenth year. Satisfac- tion in it, but without love; passive role. After that he thought of the hand of a man in auto-masturbation. Previously, erections at sight of an attractive woman. Coitus avoided for fear of infection. Later, his dreams contained only male forms. 15 226 SEXUAL PA1LESTHESIA. Patient is a gymnast ; smokes, drinks beer, skates. Since June, 1889, neuralgia of the testicles, mainly at night. Fear of onanism. Hope of restoration sexually. No masturbation for five days. Disincli- nation to work ; depression. Body well nourished ; without sign of dis- ease. Von Krafft-Ebing quieted him, and enjoined him to turn his sexual feeling from men to women. Prescription of half-baths (24 to 30 R.). Ext. ergot, aquos., 0.5 ; antipyrin, 1.0, daily; pot. bromidi, 4.0, at night. December 13th. The patient cannot resist his impulse to mastur- bate. Attempt at hypnosis induces deep lethargy. Suggestions : 1. I cannot and must not masturbate. 2. I abhor love of my own sex, and shall think no man handsome. 3. I will and shall become healthy, love a virtuous woman, be happy, and make her happy. Somnambulism in the fourth sitting. In the eighth sitting, full virility is added as a suggestion. The patient feels morally elevated and physically strengthened. Neuralgia of the testicles gone. Absence of sexual feeling. He now thinks himself free from masturbation and con- trary sexual feeling. He feels healthy and potent. Discharged in January, 1890. In March, 1890, the patient wrote that on several occasions it had been necessary for him to exert all his moral strength to overcome his habit, but he had succeeded in keeping free from it. He had performed coitus a few times with moderate pleasure. He looked confidently on his future. Case 56. Reported by Prof, von Krafft-Ebing. Acquired Contrary Sexual Instinct Cured by Suggestion. Two Relapses Overcome by Sug- gestion. Z., aged 32; divorced. Mother hysteropathic ; maternal grand- mother hysterical, and her brothers and sisters were subject to nervous troubles. Patient's brother nervous. Z. poorly endowed ; at 13 taught onanism by a schoolmate. Sexual hyperaesthesia. Coitus at 17 with pleasure and power. Married at 26 for reasons of standing and fortune. Unhappy marriage. Wife incapable of congress, after a few years, owing to uterine disease. Z. indulged himself with other women; faate de mieux, with masturbation. Dissolute life. He drank and gambled. Severe neurasthenia. Cerebral asthenic symptoms spasms of laughing and crying ; globus. Libido nimia undiminished. Disgust for prosti- tutes ; fear of infection. Exceptionally, indulgence in coitus ; usually, in onanism. During the last four years increasing weakness of erection ; decreas- ing libido for women. Dreams of men and other contrary sexual incli- nations. Three years ago masturbation by a bath-attendant on the occasion of massage. Prom that time absolute indifference for women. He now slept with men. Mutual masturbation. Pederasty abhorred. Warned by an anonymous letter. Remorse; thoughts of suicide ; intense shame. CONTRARY SEXUAL INSTINCT. 227 First thought : Sexual rehabilitation in his own eyes. Coitus in a brothel, which, in spite of great difficulties, was finally successful. The unchanged contrary sexual feelings sent the patient to Prof, von Krafft- Ebing. Comforting assurances. Prospect of help quieted him. No signs of degeneration (slightly-retreating brow) ; spinal irritation ; in- creased deep reflexes; pressure in head. Disturbed facial expression; relaxed attitude. Unrestrained state of mind. Half-baths ; rubbings ; ergot with antipyrin ; bromides ; abandonment of onanism and male intercourse and lascivious thoughts of men. Since the patient's will proved too weak for this, hypnotic treatment was begun September 11, 1889. Suggestions : Coitus once a week with full power ; disinclination for men ; inclination for women ; abandonment of onanism. Patient repeats the suggestions. Sitting every second day. From September 15th somnambulism with possibility of any post-hypnotic phenomena desired. Gradual improvement. September 24th. Patient is free from onanism and no longer ex- citable to men, but to women. Normal coitus. Hysterical symptoms gone ; neurasthenic symptoms lessened. October 6th. The patient wrote of his good health. December 9th. Treatment resumed. Lascivious dreams of men twice, but no inclination toward men while awake. He had resisted the inclination to onanism, though living in the country and having no oppor- tunity for sexual congress. Dreams of hetero-sexual content. Cured by three sittings. Second relapse in September, 1890. Antineurasthenic treatment and hypnosis again restore the patient. As stated by the author, Oc- tober, 26, 1891, the cure remained permanent. The patient never mas- turbated again, and, according to a communication of October 19, 1891, he but seldom has homo-sexual thoughts while awake, though sometimes in dreams. Case 57. Reported by Prof. v. Krafft-Ebing. Congenital Contrary Sexual Instinct. Successful Removal of Homo-sexual Feelings by Hyp- notic Suggestion. L., Ph.D., consulted me in February, 1888, for per- verse tendency of his vita sexualis, and wished to be freed from it by means of hypnosis. Mother healthy. Patient resembles his father phys- ically. Brother very passionate sexually, abnormal mentally, and given to drink. Father neuropathic and eccentric ; likewise given to drink. Paternal grandmother was a notorious drinker. Patient from childhood nervous, excitable. Talent for languages, art, poetry, and music. Excellent education. At the age of 13 his father warned him against handling his genitals. The sight of syphilitic pictures in an anatomical museum excited his horror, and, in L.'s opinion, was the cause of his later fear of intercourse with women. The principal cause of the perversion of his vita sexualis the patient seeks in a naturally 228 SEXUAL PAILESTHESIA. defective disposition. Even when a small boy he says he had enthusiastic partiality for his companions. He also remembers that at that time his interest was in feminine games only, and that he preferred to be in the company of girls. He did knitting and embroidery passionately when a boy. Still ignorant sexually, at 14 he fell into the hands of a pederast, and he fled as soon as he discovered what the man intended to do with him. When he was 15 a certain sympathetic school-mate was accustomed to lay his head in the patient's lap. He experienced a strange lustful pleasure in this which he could not understand. At 16, the first erec- tion a* sight of men. At 20 the patient recognized h,is condition. His love was directed to youthful men of the higher classes of society. Hetero-sexual charms neither excited L., nor did they give him any satisfaction. Only when 15 had he had a few dreams, with lustful feeling, about a girl of voluptu- ous figure sitting opposite him on a sofa. At the theatre he admired only the art of actresses ; his interest was excited by the actors. No inclination to drink, smoke, or hunt ; nor for athletics or other manly pursuits. Released from military service by reason of general physical weakness. Patient has small sexual appetite. Some years ago, when a man sought to embrace him lovingly, there was erection and lustful excite- ment, but he controlled himself and repelled the lover. No onanism. A condition of irritable weakness showed itself, some years previously, in ejaculations whenever an attractive man embraced the patient. Attempt at coitus in a brothel a complete failure. Other attempts with the assist- ance of imagining men were likewise unsuccessful. Patient saw that he could not attain his ideal, marriage, and was very unhappy at his painful state. Masculine appearance ; abundant beard ; slight neuras- thenic symptoms ; nothing else worthy of note. The patient is shown the deep constitutional significance of his sexual anomaly. He wishes to have his sexual excitability to men, at least, lessened by hypnotic treatment. Hypnotized by Bernheim's method. The patient passes into deep lethargy. In a drawling tone, he repeats the suggestion : " I feel that, from this time forth, I am sexually indifferent to men ; that men are sexually as indifferent to me as women." Post-hypnotic suggestion succeeds, though consciousness is partly retained. Return of energy and will after five days. Unmistakable change in the patient's manner. Hypnotized on the following seven days. But hypnosis is not so deep as at the first sitting. Suggestions of the same nature are given and accepted. Suggestion to awake necessary. After eight sittings the patient regards himself again in full possession of his self-confidence. L. thinks he can dispense with hypnotic treatment, and gratefully takes his leave, with the promise to return as soon as the power of the CONTRARY SEXUAL INSTINCT. 229 hypnotic suggestion diminishes. Nothing more has been heard from the patient. Case 58. Reported by Prof, von Krofft-Ebing. Efffniination. Single Hypnosis without Effect. Y., aged 30 ; official. Parents healthy. When a child he wore girls' clothes, loved doll-play, etc. At 12, mastur- bation in imitation of a companion. When a youth he coquetted with men. Horror feminae. Attempts at coitus devoid of erection, even with the help of the puella. Early abandonment of efforts to have hetero-sexual intercourse. Patient is dead in love with a man who ignores him and courts women. Thoughts of suicide. He abhors male- love. Beside himself with lust at the sight of a virile member. In dreams he saw only male forms. Satisfaction only in masturba- tion. The patient thinks himself a man with a woman's brain. Great delight in wearing female garments. Ashamed to undress before a man. Abundant beard. Features approach the feminine type. Manner mas- culine. Neither smokes nor drinks. Pelvis broad, feminine ; abundant adipose. Right testicle atrophic (orchitis after typhus). Genitals well formed. Fear of hypnotic treatment, but still wishes to be transformed sex- ually. Indifference to men would suffice him. Attempt at hypnosis an absolute failure. Case 59. Reported by Dr. Ladame (Geneva). Successful Treat- ment of Sexual Inversion by Means of Hypnotic Suggestion. X., aged 33 years; single; tall; small mental endowment; from tainted family. Father died of mental disease at 34 years of age, due to onanism and spermatorrhoea. The patient's father and brother both had disturbance of the sexual functions. Mental disease on the maternal side. Other members of the family were known for their irritable, eccentric char- acter. The patient has a small head, retreating brow, abnormal ears, slight growth of beard; hernia, probably congenital. Great impressionability; neuropathic constitution ; occasional taedium vitae. For several years strange, imperative ideas of being a locomotive, a horse, a bicycle, with impulse to act accordingly. Since earliest youth, at least, congenital contrary sexual instinct. Horror feminae; sexual inclination toward boys. Gratification in lustful handling ; faute de mieux, masturbation ; occasionally, also, active and passive pederasty. One day he had an affair with a boy dressed in gray that made a deep impression on him. After that he reveled in the fancy of a loved boy dressed in gray while masturbating; and he could not see gray garments without having powerful erections. In attempts at coitus inexcitable and impotent, in spite of the help of thinking of a boy dressed in gray. March 27, 1889, first attempt at hypnosis. Slight success. The patient resists, and says his fancies keep him from going to sleep. In a 230 SEXUAL PAR^ESTHESIA. series of further sittings he declares he feels an unfavorable influence ; that he is more troubled with imperative ideas and impulse to mastur- bate. He makes fun of the physician and hypnotism and makes ener- getic resistance, stating that hypnosis is of no use and only makes people crazy. Nevertheless, somnambulism is gradually induced. After twenty- five sittings the patient confesses that he is better; that he has fewer im- perative ideas, and is less troubled with onanism. Continuance of the sittings every week or two. The patient feels well physically and morally and ceases to masturbate, but at the cessation of treatment is still indifferent to the opposite sex. ALGOLAGNY. Case 60. Reported by Dr. Moll, Berlin. Sadism; Improved by Hypnotic Treatment Continued Ten Weeks. L. T., aged 25; merchant; hereditary taint. Quiet, retiring. Sexual desire began at the age of 7. Indulgence in masturbation, during which the patient fancied he was beating a woman on the nates with a rod until ridges were raised, in order that she might feel his power over her. Neither libido nor erection on the first attempt at coitus ; the second likewise a failure. He forced the woman to allow him to beat her. While he was striking her the woman cried out with pain, when erection, orgasm, and ejaculation occurred. While beating the woman he took her between his knees so that his mem- brum virile touched her body, but without immissio penis in vaginam. He continued to perform active flagellation. Passive flagellation also in- duced ejaculation, he thought, without erection. The thought of beating men in dreams also induced pollution. In the first situation this idea caused him little excitement. Dr. Moll treated the patient three months and a half. He advised him never to give himself voluntarily to such ideas, but to divert his thoughts and think of nude women. Treatment for two months and a half with hypnotic suggestion caused the perverse ideas to occur less frequently, and erection occurred often at the thought of nude women, leading to onanism with accompanying thought of coitus. Four attempts at coitus. Dr. Moll advised increasing sexual excitement with tincture of cantharides. At the first attempt prolonged manipulation by the woman was necessary to induce erection ; then followed the performance of the act without thought of flagellation. Second attempt still more successful. On the third trial coitus was successful only after thought of flagellation, but there were no blows. On the fourth attempt the act was successful without manipulation or thought of flagellation. The performance of coitus in a way nearly normal does not signify a cure, and gives no guarantee for the future ; for the thought of flagellation still has a great charm for the patient, though it occurs less frequently than formerly. Still, it is possible that the abnormal impulse, which is ALGOLAGNY. 231 essentially weakened, will remain so in the future, and perhaps dis- appear. Case 61. Reported by Prof, von Krafft-Ebing. Masochism; Im- proved by Suggestion. X., aged 30. Father died by suicide. Mother suffered with periodical mental disturbance. At 14, abnormal sexual inclinations. Punishment at the hands of boys of his own age induced lustful feelings, especially blows on the nates. The same ideas accom- panied daily onanism, which was practiced till his eighteenth year. Young, handsome men, aged from 20 to 22, wearing close-fitting trousers, young officers and hussars, for the most part, played the roles in his thoughts of flagellation. Sexual dreams of similar content and pollu- tions. Women were always a matter of indifference to him, though he felt no disgust at female nudity. Two attempts at coitus were attended only with traces of erection. In spite of his want of success, he was not repelled by the act of tying near a puella. The patient is a skillful dancer. Unhappy about his false existence. Thoughts of suicide. Great love of family life. His only hope lies in cure by hypnosis. At his first meeting with Prof, von Krafft-Ebing the patient adds the follow- ing notes. He remembers distinctly that when he once saw a school- mate beaten by the teacher it caused him lustful pleasure. Thus his masochism was entirely a primary phenomenon, and onanism with thoughts of flagellation was indulged in at first faute de mieux. When he grew up he had not been able to bring himself to have his masochistic inclinations realized. The thought of being beaten by a puella remained devoid of sexual coloring. Sadistic thoughts. He became enthusiastic about the position of teachers. Wished to become one that he might whip boys. Increased knee-jerks ; slight neurasthenic symptoms ; genitals per- fectly normal. Principal features of treatment : 1. Removal of neuras- thenic troubles. 2. Suggestive treatment: (a) avoidance of onanism; (6) indifference for his own sex, and disappearance of ideas of flagel- lation from thought and dreams ; (c) libido exclusively for the opposite sex, the occurrence of erection at the sight of beautiful female forms, full power with women, and dreams of women exclusively. By Bern- heim's method, deep lethargy in the first sitting. In the second sitting, cataleptiform state of the muscles. Sittings daily. Stroking the brow deepens hypnosis. In the third sitting, first therapeutic suggestions, of the nature mentioned. After five days the patient declares he no longer has any interest in men, but in women. He begins to dream of women. Three days later, during the day, the patient feels entirely free from masochism, and without interest in whips. Still weak flagellation- dreams of men at night, but without sexual coloring or pollutions. A short time ago he had a dream, devoid of sexual feeling, to the effect that he was whipping himself. Six days later, attempt at coitus with an 232 SEXUAL PARJESTHESIA. attractive puella. No ejaculation. He gave up the effort. Unhappy about his failure. Still, he hopes for ultimate success, for he feels him- self free from abnormal thoughts and like another man. Owing to duties, he was forced to discontinue treatment. CONTRARY SEXUAL INSTINCT. Case 62. Personal Observation. ( Congenital ?) Contrary Sexual Instinct in an Hereditarily- Tainted Neuropath. Relative Cure in Forty- jive Hypnotic Sittings. Period of Observation, Two Years and Seven Months. " My abnormality consists, in brief, of this : in sexual matters I feel completely like a woman. Since my earliest youth, in my sensual acts and fancies, I have had only images of males and male sexual organs before my eyes. Until I went to the university I found nothing remark- able in this (I had never spoken to others of my fancies ; at the gymna- sium I lived rather alone and retired). At the university it struck me that the females did not excite me in the least. Since then, in brothels, I have often made an attempt to have coitus or even an erection with women, but always in vain. Erection disappeared immediately I was in a room alone with a woman. At first I regarded this as impotence, though, at the same time, I was so excited sexually that I had to mas- turbate several times to enable myself to sleep. " My feelings toward the male sex developed very differently, and each year they have grown stronger and stronger. At first they expressed themselves in a feeling of enthusiastic friendship for certain persons, under whose windows I would wait hours at night, whom I would try in all possible ways to meet upon the street, and with whom I sought to come in contact again and again. I wrote such persons pas- sionate letters, in which, however, I was shy of expressing my feelings clearly. Later, during my years from 20 to 30, 1 became conscious of the sensual nature of my inclinations, principally through the lustful feeling I experienced whenever I came in actual contact with any of these friends. These persons were all handsomely-formed men with dark hair and e3 r es. I have never felt myself excited by boys, and real pederasty is incompre- hensible to me. About this time (twenty-second to twenty-third year) the circle of my loved friends became more and more extended. Now I can scarcely see a handsome man without the wish being excited in me to possess him. I love principally persons of the lower classes, whose powerful forms attract me, soldiers, policemen, car-drivers, etc., namely, all who wear uniforms. If one of these return my look, I feel a kind of thrill through my whole body. Evenings I am especially excitable, and merely the powerful tread of a soldier may give me the most violent erections. For me it is a special kind of pleasure to follow such persons and look at them. As soon as I learn that they are married or that they court girls, my excitement usually ceases. Until a few months ago I CONTRARY SEXUAL INSTINCT. 233 was able so far to control my inclinations that they were not directly noticeable. About this time, however, I saw a soldier, whom I followed, intending to obtain my desire, and I spoke to him. He would do any- thing for money. I was immediately seized with the most intense desire to embrace and kiss him, and the danger of discovery could not restrain me. He had scarcely touched my genitals when ejaculation occurred. With this meeting I had reached the long-desired goal of my life. I knew that my whole nature would find in it happiness and satisfaction, and I proposed from this time to try to find a person whom I could love and from whom I should never part. My acts gave me not the slightest qualms of conscience. Still, in quiet moments, I feel the great difference between my way of thinking and that of the world at large ; and natu- rally, as a lawyer, I recognize the danger of the relation I desire ; but, as long as my whole nature is not changed, I shall not be able to resist the temptations which assail me. Nevertheless, I am ready to subject myself to any cure to raise me from my abnormal state. ' " That I feel like a woman I also recognize in the fact that all sensual feeling with a lady is forced and seems unnatural to me. I am also certain that my respect for a lady I am much in female society, and enjoy it would immediately be changed to repugnance were I to detect in her any sensual feeling for me. In my dreams and sensual fancies of men I always imagine myself in such positions that their faces are toward me. My delight would be most intense were a powerful, naked man to press me in his arms with a force I could not resist. I think of myself, in such situation, alwa3 T s as in a passive role, and I have to force n^self to think myself in any other po- sition. In this I am truly femininely shy. Great as my desire may be to approach this or that person, my effort not to allow this inclinaton to be noticed is as great. Moustache, abundant hair, even dirt are espe- cially attractive to me. I need scarcely sa} r that my condition with refer- ence to society seems to me absolutely desperate, and had I not the hope of finding a person who will understand me I could scarcely endure life. I feel that sexual intercourse with a man is the only means with which to overcome my impulse to onanism. Though this vice is very injurious to me, I cannot abstain from it for any great length of time ; for, as I have often demonstrated, when I thus abstain I am even more weakened by pollutions at night and erections by day, which last for hours at a time. " I have till now but truly loved only two men. Both were officers, very bright, handsome, and slim ; of dark complexion, and with dark eyes. I made the acquaintance of the first at the university. I was insanely in love with him, and suffered unspeakably from his indifference. I would spend half the night under his window, only to be near him. When he was ordered elsewhere I was in despair. 234 SEXUAL PAILESTHESIA. " Soon after, I made the acquaintance of another officer resembling the first, who likewise enchained me at first sight. I sought every oppor- tunity to be with him, and spent the whole day on the streets and about places where I might hope to catch sight of him. I felt the blood mount to my face when I unexpectedly met him. If I saw him friendly with others I could scarcely contain myself for jealousy When I sat near him I was impelled to touch him ; if I touched his knee or thigh my ex- citement could scarcely be concealed. But I never ventured to express my feelings for him ; for, from his manner, I knew he would not have understood or shared them. I am 27 years old, of medium size, well grown, and am considered handsome. My chest is somewhat narrow, my hands and feet are small, and my voice weak. I think I have good mental capabilities, for I passed the State examination with distinction, speak several languages, and am a good painter. In my work I am considered industrious and conscientious. My acquaintances think me cold and peculiar. I do not smoke or take part in any sport, and I cannot sing or whistle. My gait is somewhat affected, as is my speech. I have much taste for elegance ; I love ornament, sweets, and perfumes ; and I prefer to move in the society of ladies." The foregoing autobiography was published in the fifth edition of " Psychopathia Sexualis " as Case 83, and in the sixth edition as Case 118, in connection with a history fur- nished by me, following two articles which I published in the Internationalen Miniscken Rundschau, No. 40, 1889, and No. 15, 1890. The following report is a continuance of these reports in a different form : R., aged 28, an official, called on me January 20, 1889. His sexual perversion seems to have been developed upon an hereditary neuropathic foundation. The paternal great-grandfather and his sister died insane. Grandmother died of apoplex}^. A paternal uncle died insane ; his daughter died of cerebral tuberculosis. Maternal grandfather insane ; a maternal uncle committed suicide while insane. The patient's father is very nervous. A younger brother is neurasthenic and affected with anomalies of the vita sexualis; another brother is affected with contrary sexuality ; a third is eccentric in conduct, and is said to have fixed ideas. One sister is subject to convulsive attacks, and another died of convul- sions in childhood. R. has never had coitus with a woman. The thought of sexual intercourse with a woman is unattractive to him. However, in order to become master of his abnormal feelings, by summoning all his will-power he has repeatedly made the attempt to perform the sexual act with a woman; but he never became excited sexually, and had no erection. t CONTRARY SEXUAL INSTINCT. 235 He continued impotent with women, and he esteemed the society of educated persons of the opposite sex only for their mental qualities. Impulse and inclination toward men have been fully developed since the time of puberty. Merely the touch of persons of his own sex, in some cases, increased the patient's sexual excitement to the extent of inducing ejaculation. By masturbation and frequent intercourse with men of the lower classes, whom he followed at night on the streets, he sought to satisfy his libido. Hindered by social and criminal restrictions, powerless in the face of his feelings, the patient became torn with inner contention. Sexual desire and his better impulses came in conflict. Lascivious, exciting dreams, in which men played the principal roles, in- creased the inner struggle. At times reason conquered ; on such occa- sions R. found strength enough to leave the society of men as soon as his passion threatened to overcome him. As a rule, however, sexual desire was victorious. As a result R. felt exceedingly unhappy. Life became a burden. In. this state of mental depression the patient sought my aid. January 22, 1889, I first attempted to hypnotize R. by means of the method used at Nancy. R. became somnolent, and after a few days, by repetition of the procedure, I was successful in inducing hypotaxis. From that time suggestive catalepsy was induced, but for the most part consciousness was retained. Though the patient was able to recall the commands given him in sleep, still he was no longer able to resist the suggestions, and he followed the inner impulse that was stronger than his will. The results as regards appetite and mood were usually striking. In the later sittings I avoided questions which would awaken his memory after he awoke. This circumstance and the gradual deepening of the sleep, as well as the assurance that he would have no memory, later induced somnambulism. His memory was either cloudy, defective, or entirely absent. Always after waking the patient felt well, possibly as a result of the preventive suggestion of well-being which was never omitted. He declared, indeed, that his activity and his ability to work had increased during the treatment. The suggestions were realized almost without exception with great precision, no matter whether given in a state of somnolence or somnambulism. Suggestive treatment was directed 53^8- tematically against the sexual perversion. First, indifference and re- sistive power in regard to the male sex were suggested, with the assur- ance that the patient's interest in the female sex would continually increase. Strictest forbiddance of inclination to onanism. Females were substituted for males in dreams at night. Even after a few sittings the patient said he found pleasure in seeing female forms, which he had not known before. In the seventh sitting intercourse with a female was arranged and certain success suggested. On the same day, January 29, 1889, the patient performed successful coitus for the first time in his life. From this time R.'s sexual congress was regulated by suggestion, and 236 SEXUAL PAR^ESTHESIA. it was always performed, after definite intervals, with the same success. Fear of a relapse and his hereditary predisposition caused me to con- tinue the suggestions,. with various intervals, for some time. With the help of suggestion he had regained his mental equilibrium ; at least, he felt himself no longer dependent on men. Nevertheless, he had struggles when the pauses between sittings were long. While R. continued under the educational influence of suggestion for three months, and he was mentally and physically in full possession of his sexual powers, on April 22, 18,89, a relapse was caused by a friend, which the patient, in his open-heartedness, confessed to me. Energetic opposing ideas given in hypnosis awakened remorse and disgust. But to test his stability he performed coitus with a woman in the presence of his seducer, and imme- diately broke off his association with him. At this time R. confessed to me that in intercourse with women of inferior education his aesthetic feelings were not satisfied, and he thought to find this only in a happy marriage. I strengthened this thought, and after a few weeks I received notice that he was engaged to a young lady. When he visited me, after marriage, R. assured me that the happi- ness he had in intercourse with his bride made him insensible to other impressions. He thought himself recovered, and up to the present time his mental equilibrium, induced by suggestion, which has endured six months (save for the relapse mentioned), seems to be retained. To what extent psychical treatment has been successful, with the patient's hereditary predisposition, in repressing or limiting; the tendency to abnormal sexual feelings, can only be judged after years. But that, by the systematic application of a new educating influence, a temporary complete inner change lasting six months was attained seems, with reference to the powerlessness of other methods of treatment in sexual anoma- lies, like a step in advance that should not be underestimated; and that the more since, in spite of the relatively large number of forty-five hypnotic sittings, there was not observed any in- jurious effect on a single occasion. And, even should there be the misfortune of a relapse, still a repetition of the procedure hypnotic suggestion would remain the most effectual means of remedy. Soon after the first report was printed, the patient wrote me as follows: " I think I can regard myself as cured ; for, since the conclusion of your treatment, my condition has remained essentially unchanged. If CONTRARY SEXUAL INSTINCT. 237 reminiscences of my previous condition often come up, they are but tran- sitory and inner events. What seems to me the decisive point is that the nervous unrest, in which I was completely without resistive power, as if driven by an inexplicable impulse to gratify my former inclinations, seems, as I hope, to have gone forever. In constant intercourse with one uncom- monly attractive, I now find rest and happiness, which were formerly impossible for me. Be assured that I shall never forget what you have done for me. Gratefully, R." At Professor von Krafft-Ebing's request, in January, 1890, eight months after the cessation of hypnotic treatment, I asked for another detailed report, which follows : " Through the suggestive treatment given me by Baron Schrenck, for the first time I became possessed of the psychical condition that per- mitted me to have intercourse with a woman, which, up to that time, in spite of repeated efforts, I had been unable to do successfully. " Since my aesthetic needs were unsatisfied by intercourse with prostitutes, I thought to find my real salvation in matrimony. An earlier friendly inclination toward a lady known in my youth offered me the opportunity, the more because I believed that she, of all others, would be in a position to awaken feelings for the opposite sex which were absolutely foreign to me. Her character i.e., our harmony is in such accord with my inclinations that I am fully convinced that I shall also find complete psychical satisfaction. This conviction has not changed during the eight months of my engagement. " I intend to be married in about eight weeks, and I shall take the liberty to give a report of the further results soon after my marriage. " As far as my position with respect to my own sex is concerned, my power of resistance and this is the lasting positive result of this treatment is absolutely changed in degree. While previously it was impossible for me to overcome an intense sexual excitation when I saw a finely-formed car-driver, to-day, in the company of my former lovers, I am without sexual excitement. At the same time I must add that now, as formerly, their society has a certain attraction for me, though it is not to be compared with my earlier passion. " On the other hand, I have refused repeated persuasions to indulge in sexual intercourse with men, without expending much force in resist- ance, persuasion I should have been unable to resist. I may say, in- deed, that it is a feeling of compassion for my former lovers, who have proved their devotion to me, which keeps me from directly repulsing them. My action seems to be due to a feeling of duty rather than to inner need. " Since the conclusion of treatment I have not consorted with pros- 238 SEXUAL PAILESTHESIA. titutes. This circumstance and the numerous letters and persuasions from my former lover may well be the reason why, in the eight months that have elapsed, I have allowed him to persuade me to sexual inter- course on three or four occasions. At these times I have always been conscious of being completely master of myself, as compared with earlier passionate conditions in like situations, as the violent reproaches of my friend convinced me. I always feel a certain unconquerable repugnance, which cannot be based on moral grounds, but which, I believe, must be attributed to the treatment. I no longer feel a love for him in the former sense. Besides, since the treatment I have sought no opportunities for sexual intercourse with men, and I feel no need of it. But formerly not a day passed on which I did not do it, so that at times I was unable to think of anything else. Awake or dreaming, ideas of sexual content are very infrequent. " I may express the belief that my marriage, which is .to take place in a few weeks, and the much-desired change of circumstances connected with it, will entirely remove the residuum of my earlier con- dition. I conclude these lines with the honest assurance that, subject- ively, I am another man, and that this change has restored the mental equilibrium that was previously wanting." Still more important in judging the question is, it seems to me, the patient's letter giving a report of his wedding-journey. It is dated March 20, 1890, and is as follows: " HONORED SIR : Having been home some days from my wedding- journey, I wish to send you a short report of my present condition. During the week before my marriage I was in great excitement, because I feared that I should be unable to perform certain duties. The impel- ling thoughts of my friend, who wished another meeting with me at any price, had no effect on me. We have not met since I saw you last (in about two months). However, I was much troubled with the thought that my marriage must be unhappy. Now, however, I have no anxiety. To be sure, on the first night success was difficult (to induce sexual ex- citement in myself) ; but on the following night, and since, the influences needed by a normal man would have been sufficient for me. I am con- vinced that the harmony between us, which, of course, is mentally of long standing, will become more and more complete. A relapse to the former condition seems impossible. It is, perhaps, significant for my present condition that I one night dreamed of my former lover, and that the dream was not sensual, and did not excite me sensually. " I am satisfied with my present circumstances. I am, of course, well aware that my present inclinations are far from being of a degree that equals their former intensity. I believe, however, that they will CONTRARY SEXUAL INSTINCT. 239 grow stronger daily. Already my former life is incomprehensible to me, and I cannot understand why I did not earlier think to overcome my abnormal sexual instinct by normal sexual indulgence. A relapse would now be possible only with an entire change of my mental life ; and, in a word, it seems impossible. Your obedient servant, R." The external circumstances, the patient's changed position in life, and the regular hetero-sexual relation based upon actual sympathy will probably assure him against relapse for years, and probably control the rudiments of homo-sexual feelings still present. In contradiction of the opinion expressed by Professor Benedikt, 1 the foregoing case shows that " pure mental hygienic self-exercise," " simple moral treatment " of the patient in the waking state, did not attain the desired object; and, on the other hand, that the result obtained only by means of hypnotic suggestion neither demoralized the patient nor induced in him " the destructive consciousness of having been the involuntary tool of the physician's art." But it restored the absent moral equilibrium without injurious eifect, which is to be hoped will endure for years. Among the few cases of contrary sexual instinct that have thus far been treated by suggestion and reported, there is none in which, with respect to the intensity of the effect and the permanence of the success, a similar result has been obtained as favorable as that reached in this case. In May of this year exactly two years had passed since the conclusion of treatment. In February, 1891, R. became a happy father. There can be no doubt that the further conduct and condition of the patient are of great importance in forming a judgment of suggestive therapeutics in such cases. There- fore, I addressed him, and on May 3, 1891, exactly two years after the conclusion of treatment, I received the following letter : " HONORED BARON : It is somewhat difficult for me to be perfectly clear about my own condition, for there are almost always slight varia- tions ; however, in what follows, I hope to give you as exact a description as possible. 1 Comp. Internationale klinische Rundschau, III Jahrgang, Nr. 40. " AUB der Pariser Congresszeit." 240 SEXUAL PAR^ESTHESIA. *' You will first ask, probably, whether I still feel the effect of your treatment; and this question I may answer decidedly in the affirmative." A short time ago I had opportunity to test my resistive power with my former lover, who paid me a visit. During hi stay I was entirely cold, and refused decidedly to meet him anywhere in the evening. Still, this indifference may well have been due to the fact that I no longer love him. Whether I could fall in love with any one else I cannot say with cer- tainty ; but, at any rate, I make no attempts to approach any one, and during the day I am quite free from all such ideas, even though I cannot den3' that now and then soldiers, and others, are a pleasing sight to me ; and I well know that no approach between us is possible. At night quite frequently the old dreams come, and fancies of the nature in ques- tion put me to sleep ; but I always feel myself master of the situation, and look upon this unpleasant memory as the residuum of my past, which probably will never be entirely extinguished. I also believe that my original natural condition, though much weakened, will remain ; but I am no less certain that a relapse, as long as present circumstances continue, is excluded. " Now, to pass to the opposite side of my sexual feeling, I find it very peculiar that my sensual excitement at present may be as easily in- duced by the female as by the male sex, only with this difference, that fancies of the latter come spontaneously. Too, it costs me no effort to transform these fancies into those of females, while formerly I noticed that the former were always accompanied by horror feminse, which, as you know, at the time I began your treatment, was constant and unconquerable. " I also notice that the condition described has been thus favorable only since September, that during the time before that I had a relapse, due to the prolonged absence of my wife. However, at that time I was far less potent than formerly. After September I first came to realize that during the first months my marriage was not as happy as it should have been ; at that time spontaneous sensual excitement with the female sex was wanting, and it was always necessai'y for me to induce it arti- ficially. (During the time of your treatment this was not necessary.) Naturally, the product of the will and reflection was very cold. My wife was much struck by the change, which took place quite rapidly. To her mother she said : ' Thank heaven, the ice is broken!' I repeat this ex- pression because it seemed very characteristic ; for I myself felt all at once as if an obstacle between us had been removed. Since that time my conduct has changed very much ; before I was merely polite, now I am like a lover with his beloved. That the old fancies, as I have mentioned, still occur is inexplicable to me ; but you will understand that, at least in the waking state, they have no power over me, for I am always able to paralyze them with their opposites. I had determined, after my wife's CONTRARY SEXUAL INSTINCT. 241 confinement, to abstain from congress with her, but, unfortunately, I have not kept my resolution. " I often study the question as to what I should do if my wife were to die. If I were to remain a. widower I think I should return to my former life, though it would be necessary for me to accustom myself to it again ; still, I am not so sure of the last. " Very truly yours, ." This case, so instructive in its bearings upon the signifi- cance and importance of suggestive therapeutics, leads me to make the following remarks in review of it : 1. As a result of the influence of hypnotic suggestion at least, during the two years that have passed we have the per- manent removal of (a) horror feminse ; (6) the functional in- capability of the erection-centre to hetero-sexual charms (due to cerebral influence) ; (c) the sexual hypersesthesia in relation to the same sex (irresistible yielding to friends, passionate male- love, erection at the sight of powerful men) ; (c?) onanistic inclinations. 2. Systematic hetero-sexual intercourse in marriage, made possible by suggestion, (a) keeps the patient from real relapse. Homo-sexual intercourse, which occurred twice in the two years, was only episodical and without deep psychological motive (faute de mieux), and it was indulged in when the opportunity the patient desired was wanting, as during the prolonged absence of his wife. (Z>) Preserves in him the inability to have intense homo-sexual feeling, which increases with time (in comparison with his former susceptibility to it) ; resthetic satisfaction and lustful feeling in male-love are relatively slight. 3. Remnants of the natural contrary sexual disposition of the patient are present, and manifest themselves (a) in dreams, in considering which it is to be remembered that during hyp- notic treatment the female sex was also the subject of dreams ; (&) in the interest in handsome men which still exists, but which is not accompanied by sexual feelings. Before treatment this interest induced erections, but not after treatment. 4. The treatment, i.e., the hypnotic suggestions, com- bined with systematic hetero-sexual intercourse, continued 16 242 SEXUAL PAR^ESTHESIA. after the conclusion of the sittings, artificially induced (a) a power to resist male temptation, which was repeatedly tried, and complete self-control, which kept the patient from conflict with the law ; (6) the possibility of hetero-sexual feeling, of the existence of which, in the life of the patient before the treat- ment, there were no indications; (c) the need of hetero-sexual intercourse, which increased with time. It was so strong that the patient was unable to keep his resolutions made, presum- ably, on account of the puerperal state. At the present time the patient is in the condition of per- sons subject to acquired contrary sexual instinct. With refer- ence to his natural homo-sexual disposition, assuming that it is really such, his hetero-sexual feelings constitute an artificially cultivated anomaly of habit, similar, for example, to that of smoking, which, as a cultivated habit opposed to the natural reaction (nausea, vomiting, foul taste), may become an irresistible passion. As a rule, patients subject to acquired contrary sexual in- stinct pass through the stage of psychical hermaphroditism ; the cure takes place through a reversal of the same process. Thus, the patient is excitable to both sexes, and thus fancies about men may be voluntarily transformed Avithout opposition into those of females, and with the same physical reflex effect. The addition to the influences affecting the patient determine the direction of further sexual development. It cannot be doubted that, in the fortunate matrimonial relations of the patient, this development will be of an hetero-sexual nature. These cir- cumstances constitute a constant stimulus for him, which has become strong enough to easily paralyze all accidental seductive tendencies. The stronger the feeling for the female sex becomes, the weaker will homo-sexual feeling grow. At the present time it manifests its harmless presence only episodically and in dreams. But, in the degree in which hetero-sexual intercourse results in aesthetic and physical satisfaction, the desire for active sexual satisfaction will be enhanced. The reflex effect of this phenomenon must gradually manifest itself in an intensification of the general feeling and inclinations characteristic of a man, CONTRARY SEXUAL INSTINCT. 243 as a psychical transformation gradually completing itself with the course of time. But to what extent the individual's mental change can go depends, in our case as in all others, upon the congenital defect ; upon the extent of the anatomical and un- alterable degenerative state, if there be really such a condition present. The hetero-sexual feelings existed but two years ; and, in contrast with this, it should be considered that the homo- sexual manner of feeling dominated the period of life from the age of 18 to 28, the most important in sexual development, and therefore lasted twelve years. Natura nee fecit saltum. There- fore the patient's recovery must always be in proportion to the development of his malady. This should be especially empha- sized, owing to the common opinion of the laity that, in a few hypnotic sittings, as if by magic, a patient's old personality, with its inherent diseases and defects, can be eradicated. Nevertheless, in our case, should there arise no abnormal unfavorable influence of an opposite nature, it is to be expected that the patient's psycho-sexual development in relation to the female sex, resting upon the foundation of the last two years, will progress with every ensuing year and become fixed. In this sense, thanks to the help of hypnotic suggestion, the prognosis and treatment of the congenital form of contrary sexual instinct seem less unfavorable than heretofore. Though Krapelin, in his text-book on Psychiatry (p. 576), says, " There can be no thought of treatment of this anomaly, which has developed with the development of the character and has its roots deep in the individuality," without giving his opinion any more solid foundation, still, the logic of facts which have already been confirmed by the experience of other authors speaks a more convincing and persuasive language than that of mere theoretical speculation. In congenital contrary sexual instinct, if such a form actually occur, essential improvement and even relative cure may be attained. Condition. After giving the foregoing history the patient wrote to Professor von Krafft-Ebing and myself, giving some not unimportant additional facts. Thus, in the performance of marital duties, of which he wrote on May 20, 1890, the 244 SEXUAL PAILESTHESIA. patient found that, as he recognized eight weeks later, he had deceived himself. The act which he thought to be that of sexual intercourse was, in fact, only an imitation, namely, coitus inter femora (practiced in homo-sexual intercourse). For this act it was necessary at times (not always) to induce erection artificially or by the aid of contrary sexual ideas. After the error was recognized, there was performance of actual coitus, but still by means of erection artificially induced. After five or six months, on an occasion when his wife had a nervous attack, there was sudden and unexpected occurrence of spon- taneous hetero-sexual feelings and, for the first time, completely satisfactory coitus quoad erection and lustful feeling. At the same time there was a favorable change of the marital relations. From this time the sexual relations became the expression of an irrepressible tender attachment, and they took place without artificial excitation of any kind. Thus, the patient attained, though not in exactly the way described in his letter, the same end. Homo-sexual rudiments manifest themselves now and then in dreams. This concluding description only speaks for the truth of the history, which, owing to the intense suggestibility of the patient, was painted in too favorable colors. Case 63. Personal Observation. Contrary Sexual Instinct, with Complete Effemination (as a Symptom of Moral Imbecility'). Successful Treatment of Homo-sexual Feeling in One Hundred and Forty-two Sit- tings. Time of Observation, One Year and Eight Months. The follow- ing letter led to treatment of the case : "Munich, July 22, 1891. Dear Doctor: After having conquered myself and brought myself to visit you, I was compelled to leave your office on learning that you were absent from town. Therefore, I take the liberty to write you ; for, should I wait for your return, my courage might fail me to report verbally what I can write much more easily. To be brief, I belong to those miserable and unfortunate persons with which von Krafft-Ebing's book is concerned ; and since I only yesterday ob- tained the fifth edition of that work, the resolve which I made in Janu- ary, after your lecture, to ask you for help, and which, from shame and weakness, I did not carry out at that time, was carried out. For the case there described of an urning cured gave me hope that your art might also help me. CONTRARY SEXUAL INSTINCT. 245 "From birth, in all my feelings and actions, I have been more like a female than a male. As a child I played with dolls, and never liked to play with soldiers ; and I used every opportunity to dress like a girl, and I still do this successfully. All my thought is directed to the pos- session of a man ; I am inordinately vain, always seeking to please, and superficial, and, at the same time, what the error of nature necessarily brings with it, very unhappy ; for I never conceal from myself for a moment that I am a despised creature, and that my inclination is low and unnatural. " A complete cure, such as that made by you, and described by von Krafft-Ebing, I do not think possible in my case ; for, were you able to give my sexual instinct another direction, still you would not make a man of me, as I am wanting in everything characteristic of a man : courage, decision, energy, perseverance ; and I desire nothing so much as to be subject to a man, to love him and serve him. Of what use, then, would such an effect be to me? I desire something else. Be- cause I have had no lover, I have had to help myself with onanism ; and it is this, I believe, that has so destroyed my nerves that I am not far from insanity. For the headache that for the most part follows onanism I take antipyrin regularly, 1, 2, or 3 grammes, as may be necessary; and for depression, which is truly frightful, ether and valerian. At first these medicines helped me, giving me a feeling as if two beings were in me ; for I became joyous and excited, and had palpitation ; knowing, though, that I had really no reason to be happy, and that the cause of my depression was not removed by such means. Neither is any longer of assistance tome; for the despair which formerly increased to violence has given place to apathetic hopelessness ; and I know that my way, be it short or long, leads to suicide by drowning. My thoughts follow me in dreams ; and often I wake up from a dream covered witli sweat, in which I stand at the edge of a dark expanse of water into which I must go. I should like your help by means of hypnotic suggestion, that I may, first, cease to practice onanism ; second, that I may cease to think constantly of men. Formerly I occupied myself with literary work. I have published two comedies, and written reviews on art, historical essays, etc. But all that is over. I may say that I am bankrupt intel- lectually. Day and night I think only of gratification in my sense ; I cannot see a j'oung man without the painful desire to possess him. I do not cross the street or enter a cafe without being troubled by this desire. And yet I cannot stay at home ; an indefinite feeling of anxiety drives me out. Only last year I took a long journe}- Paris, Cologne, Brussels, Berlin, Vienna in vain! I could not escape from my sick and weary soul ; I took the poisoned imagination with me everywhere. Do you think 3 r ou can help me in this way; that, even though you can- not cure me, you can make me better ?. When you return, I shall take 246 SEXUAL PAR^STHESIA. the liberty to call on you. This confession will, in a measure, force me; for with it the first step is taken. " Respectfully, A." Autobiographical Sketch of the Patient. " Munich, September, 1890. Dear Doctor : On my first visit you requested me to write my biography for you, and I herewith comply with your wish. I was boru in 1860, in H., the son of a respected official and a mother descended from an old family. I am not, I think, predisposed hereditarily. As far as I know, there has been neither physical nor mental disease either in my mother's family which has given Bavaria several ministers, diplo- mats, and ambassadors or on my father's side. My parents are healthy, as are my sisters ; two brothers are dead. My eldest sister (married) suffers much with migraine. Save for the diseases of childhood measles, scarlet fever, and whooping-cough I have always been healthy. The fact that I am now nervous, and have been so for years, is probably due to my contrary sexual condition and onanism. " From youth I was quiet, avoided all noisy boys' play, and pre- ferred to play with dolls. I was hypersensitive, easily moved, timorous (not to say cowardly), and shy. To my mother I clung, and I do still, with the tenderest, almost deifying, love ; while I feared my father and lived in trembling awe of him. He was excessively strict, and I re- member seldom to have had a kind word from him. If he were in a good mood, however, he liked to joke and tease me until I cried, to the amuse- ment of the other children, relatives, or guests who might be present. He did this for years, and naturally I came to feel that I was a ridiculous, strange creature, afflicted with peculiarities which made me the butt of ridicule to other men. Perhaps my melancholy arose from this early period ; for I know that as a child I was pursued by a sadness which no one could explain, and for which I myself could have given no good reason. Nevertheless, let the cause of it be what it may, melancholy has become my controlling mood ; and I often try to free myself of it, but in vain. Like a weight of lead it rests on me, and I often think I can endure it no longer. " At 5 I entered school and learned easily ; but I was always very lazy, and I liked to read for my amusement rather than to study. Much reading was not good for me; it overstimulated my imagination by giving my mind too much material, and at last, by furnishing me with a mass of the most varied knowledge, it made me vain of my learning. What have I not read? I was scarcely able to read before I read, at the age of 5, my first storj r , ' The Two Baronesses,' by Andersen ; and then followed novels, poems, etc. At 9 I knew Frey tag's ' Pictures of Long Ago '; at 12, Lessing; at 13, Goethe; and, in fact, the whole of the theory of color, morphology, and all the rest. I read everything, CONTRARY SEXUAL INSTINCT. 247 without discrimination. I preferred only one thing, Indian stories. Historical works, like Weber's ' History of the World,' I read with great delight, repeatedly. This fever for reading, which, had it been directed by an experienced hand, would have been of great profit to me, perhaps, abated somewhat when. I was about 20. Then I began to pro- ceed somewhat systematically. Now, for about three years, I have as good as given up reading. At the age of 10 I entered the cadet-corps. I passed the examinations without difficulty, and in some things for example, German and histoi'y I was always the best scholar; in others, like mathematics, always the worst. I should here remark that I have never been able to understand higher arithmetic ; I have never gone beyond the four principles, and even to reckon with these is still difficult for me. After passing through all the classes I passed my examination, but I had no desire to be a soldier; so I became a merchant, and am still. Of my external life I have nothing to record, except some jour- neys to Italy, Paris, Vienna, the Rhine, St. Petersburg, and Denmark. " Now to come to that which, for you, will be the most essential thing, my contrary sexuality. I must confess that I have never felt anything more for the female sex than respect, friendship, and affection- ate regard ; never warm feelings. I early felt a preference for feminine pursuits. Till my fifteenth year I loved to play with dolls, and when- ever I could I dressed like a girl. In questions of female attire I am a judge, and I always know the fashion in material, color, and cut. When in the cadet-corps, I soon learned that my boyish attachments were more than real friendships, though I never went beyond kissing and embracing; and only after I was 16 was I seduced to mutual onanism by a comrade, which I then practiced not only with him, but with several others. The real sexual relations were still unknown to me, and in solitary onanism my ideas were only about persons of the male sex, for my experience had afforded me no other objects. When I left the academy I thought that was the end of it all ; I had no suspicion how many fellow-sufferers I had, and only an accident, which put Ulrich's writings in my hands, opened my eyes and made me very unhappy. I lived in very pleasant surroundings, but without association with persons of my own age, and knew not how to obtain such friends ; and thus, in my eighteenth year, I began to indulge in onanism in earnest. " Unfortunately, I had opportunity to read many lascivious books, and I can boast of a very extensive acquaintance with erotic literature. Nothing is unknown to me, from the tiresome gossip of Casanova to the voluptuous dilettanteism of ' Elegantise Lat. Sermones,' the Alcibiade fanciullo a scuola, the frivolous sophistries of TheYese philosphe, and crazy fancies of Marquis de Sade ; and my memory was indelibly im- pressed by the scenes from these books, till my imagination was poisoned and busy with nothing but images of the lowest and coarsest sensuality. 248 SEXUAL I do not know whether I possessed a trace of what is commonly called morality or not ; if I did, I lost it entirely. I longed to be able to pros- titute myself, to be violated ; and even yet, when a man satisfies himself with me, I think ' you are violated ' the greatest enjoyment. My greatest desire has alwaj's been to be violated by force. " From my eighteenth to my twenty-fourth year I satisfied myself only in onanism, and then entered into a relation really my first with a man somewhat older, who satisfied himself with me in coitus in anum. This relation lasted four months, and, though we were much attached to each other, we have never since had sexual relations with each other. " I then moved to another place, where, either through inex- perience, fear, or shyness, it was a long time before I made the acquaint- ance of persons like myself; but, once started, I became acquainted with many immediately. In this way I learned all manner of sexual indulgence of man with man. The men who gave me the greatest pleasure and the most lustful enjoyment were those who performed coitus in anum with me ; and when the man was handsome, large, and strongly built, he caused me to have true ecstasy of lust. Only one pleasure was wanting to me, the consciousness of being able to bear a child to the loved man ; otherwise I was truly happy, and after the act felt refreshed and strengthened and physically and mentally at ease. Though this manner of congress has been performed with me innumer- able times, I have never experienced the slightest inconvenience in it, and even when the organ inserted has been of unusual size I have felt no pain. The pleasure was so great that I had erection and ejaculation. The latter added very little to my pleasure ; so that I often held myself back that I might be ready for a second and third when the first man had finished. It was like a kind of madness for men that came over me ; I would have even had it killed me given mj'self to a dozen. " I could not write down all these disgraceful details if I did not think, Doctor, that perhaps you will regard them of essential importance for my treatment ; besides, I hope that in me you look at a ' case,' and not at a man. , " My greatest desire, at least, since I have become conscious of my condition, the only object of my striving, has been to be loved, to find the love of a man. I have never found it ; and yet I know that I could have sacrificed all to such a person all. No sacrifice would have been too great for such love ; all that I possessed honor and good name and even my family I would have given up, and never have asked whether the man were old or young, handsome or ugly, low or high ! Sexuality, little as that was to be ignored in the matter, could not have been the most important matter, truly not; but mental union, inner attachment, actual love, not a passing fancy, which I also prized in its way, could have enchained me. It was never mine ; and this eternal, CONTRARY SEXUAL INSTINCT. 249 unsatisfied longing, which has grown more intense with continuance, makes me so miserable that I forget everything but this desire ; it ban- ishes and destroys all mental interest, and all seems vain, empty, and unprofitable. Like a fixed idea, the thought of love always only of love pursues me ! I have become bitter and acrimonious, my dispo- sition gloomy, and as with closed eyes I have gone through a world which could give me but one thing, the hope of death. Suicide came before me in all forms, first as a play of fancy, then more and more dis- tinct and threatening ; awake and sleeping, the thought pursued me. I was forced to think of it ; I fought painfully against it. In vain 1 The fear of becoming insane made voluntary death enticing ; showed it the lesser of two evils. "What have I not done to help myself? To benumb myself, I flew from onevpleasure to another; I sought society, and then fled from it ! I felt that my descent grew faster and faster. I could even calcu- late how long it would last. Then I read in von Kraff't-Ebing's ' Psy- chopathia ' the cure effected by you, and I thought: I will try it; it cannot be worse, it can only be better. I confess that my hope was small ; for even if it were possible to give ray sexual impulse another direction, would I then become a ' man '? I possess no will at all, not a trace of energy ; on the slightest feeling of distaste, I throw up any undertaking. I wait to be influenced ; I have no character, but in judg- ment and opinion, manner and speech, etc., involuntarily I accommodate myself to my surroundings. I cannot refuse a request, but no activity is to be expected of me. In short, Doctor, if you can make a man out of this limp rag, then your art can do wonders. If you cannot, then no harm will be done. I am of use to no one, but the greatest burden to myself, and perhaps it were then better ended 1 " Herewith I submit the history you desired, and in explanation of it I may note that in female attire I feel much better, more at my ease, than in my own. My gait and my manner are such that they would never convey the slightest suspicion of my sex ; and to such attire I am indebted for the happiest hours of dancing, conversing, and flirting with my own sex ; but with real men, not with ' aunts.' " Very respectfully, A." Supplement to the Patient's Development of Homo-sexuality and Character. The foregoing autobiographical notes, in content and form, give a fair picture of Mr. A.'s condition, and, in fact, in more detail and with more truth than would be possible to the physician's pen. There is but little to add. I began to treat the patient, August 30, 1890. Aged 30. One brother is said to have died of cerebral softening at the age of 1 year; otherwise the history of the family presents nothing worthy of note. 250 SEXUAL PAILESTHESIA. Aside from the diseases of childhood and a very intense neuropathic constitution, existing since earty youth, A.'s physical development pro- gressed without interruption. Last year, gonorrhoea from contact with a male. In the patient's history there were not the slightest evidences of hetero-sexual inclination. On the other hand, A. states that in earliest youth he manifested a great disinclination for all kinds of masculine employment and a preference for household work, doll-play, feminine dress, etc. The external cause of the complete development of the homo-sexual disposition was excessive onanism, practiced in the cadet-corps, that hot-house of the most dangerous of sexual errors. His feminine man- ner gave him the nickname of" Lizzie " among his companions. During the time of puberty all external circumstances contributed to fully develop A.'s homo-sexual impulse. For women he had never had anything more than friendly feeling. When he sought their society, it was principally to get advice in ques- tions of dress. Owing to his libido nimia, gradual development of sexual hypersesthesia and neurasthenic symptoms. As we see from his own statement, A. practiced all the acts of male intercourse, in which the detailed performance of the female role and the consciousness of giving a man lustful feeling gave him relatively greater satisfaction than the mere physical act. He never had desire for the active role in the sexual act. At the age of 24, at a time when contrary sexualit}' had attained full develop- ment, for the first time in his life the patient accompanied his beloved friend, a man of masculine feeling who found no pleasure in homo-sexual manipulations, to a prostitute, led by the secret desire to have an oppor- tunity to see naked the man he loved. Greatly excited by the sight he desired, and forced to content himself with a substitute, he performed coitus with a prostitute, never for a moment, however, losing sight of the object of his desire. After that he made two more trials, which failed on account of intense disgust and repugnance, notwithstanding the presence of the man he loved. Since then he has had no sexual contact with women. His great libido goes to the extent of madness for men ; he gives himself to men without choice, but feels disgust for persons of his own sex like himself. The patient's imagination is abnormally excited by obscene reading and unrestrained dissipation. Thus, finally, all his thought, feeling, and desire are directed to the sexual sphere. His sexual desire, intensified to the degree of satyriasis, leads him to all possible perversities of the sexual act (for example, pederasty with several persons in succession, etc.), and makes him a male prostitute. His sleep is disturbed, and for years has been interrupted by lascivious dreams of homo-sexual content. Before falling asleep and on awaking CONTRARY SEXUAL INSTINCT. 251 (from dreams and in the morning) there are always erections (stated to be for years), which, owing to their frequency, are annoying and sometimes painful, and which always lead to a resumption of ominism. Masturba- tion, as a rule, mornings, while A. in a doze .gives himself up to fancies about voluptuous men ; sometimes during the day. As a rule, aside from homo-sexual intercourse, A. masturbates three times a week ; but he has practiced it daily for the last fourteen days. The sight of male genitals, in pictures and on statues, induces erection, while the sight of the female form makes no impression on him. The patient once at- tempted to engage in gymnastic exercise, but had to desist owing to continuous excitement of his libido sexuulis. But not only is A.'s sexual feeling completel}' developed in an homo- sexual direction, but also his whole mind. Character, feeling, and in- clinations, it is stated, have, since earliest youth, developed in a feminine direction. Effemination is complete, as we have already seen from the principal points of the autobiography. A. has always been disinclined to all male employment, and has been opposed to smoking, drinking, and sports. Dramatic representation of the female role gives him the greatest pleasure. His knowledge in matters of female attire is remarkable. He possesses several feminine toilettes, and he loses no opportunity to wear them temporarily as masks. For many years, in the winter he has visited masked balls, etc., attired as a woman. In speech, movement, gait, dance, and attitude, as well as in the whole repertory of feminine thought, as expressed in conversation, he carried out so perfectly the movements of expression and the arts of attraction that, in his mask, his real sex was never suspected. He repeatedly had himself photographed in such attire. Two photographs lie before me ; one represents him in a ball-gown with flowers ; the other in a costume used by a celebrated prima-donna in one of her principal roles. None of the numerous persons to whom the pictures were submitted as a test recognized a man in them. Great preference for ostentation, the theatre, belles-lettres (successful as a writer), especially for all formality and appearance. His room is pro- vided with feminine toilet-articles ; pictures of historical urnings orna- ment the walls. In comparison with the understanding, his emotionality is strongly developed. Great softness of disposition. Earnest advice by me con- cerning his condition moved him to tears. Whimsical, irritable, appre- hensive ; devoid of self-confidence. Patient is vain. Conversation in general superficial. Narrow intellectual horizon. Logic only subjective, and in accord with the feeling of the moment. Capable of self-sacrifice in relation to real male love. Enthusiastic in his inclinations. Sanguine temperament. His glance betrays coquetry, lustfulness, and shyness. 252 SEXUAL PARJESTHESIA. Much depressed, owing to his neuropathic disposition and sexual ex- cesses. Thoughts of suicide,'which the patient has never carried out because of cowardice. Poor self-control. Weak morally ; defective, sometimes blind, in relation to his perverse actions, and incapable of rational thought. Emotion, like the instinctive impulses, sometimes attains pathological intensity. On the whole, great weakness of char- acter. Incapable of forming ethical ideas ; complete lack of resistive power to external impressions. A. is led to consult a physician only by his physical complaints of a neurasthenic nature, due to his sexual excesses, and by his unsatisfied longing for a lover, which gives him hours of bitter despair. Since coming to a full understanding of his condition, he has lost interest in everything, even in the most important questions of life, in as far as they have no relation to his feminine tendency. He fulfills his business duties mechanically and without pleasure. Writing, which formerly gave him complete satisfaction, he has since then entirely abandoned. Too, in artistic mutters he now prefers that which is superficial and easy. He is an assiduous visitor qf varieties and operettas, while he seldom makes his appearance at the theatre and opera ; at most, he might attend a comedy. In this direction all his interest is in men in female parts. Besides the depression mentioned (tsedium vitae), the patient often suffers with migraine. Sleep is restless, interrupted ; attacks of anxiety, especially when he is alone. Therefore, he avoids solitude, and seeks to divert himself with amusements. Lack of desire for, and inability in, mental work. General listlessness, especially mornings. Spinal irrita- tion and tachycardia. Present Condition. Of medium size ; well nourished ; of delicate build. Abundance of superficial adipose tissue. Cranium, on the whole, of masculine type ; nowhere sensitive to pressure. Lobules of ears attached. Growth of hair not remarkably abundant. CRANIAL MEASUREMENTS. 1. Horizontal circumference, . . ..... 60 cm. 2. Posterior half-circumference, . . . . . 24 cm. 3. Anterior half-circumference, . . . . . 32cm. 4. Line over vertex from ear to ear, . . . 39cm. 5. Antero-posterior line over vertex, . . . .28 cm. 6. Ear-chin line, 30 cm. 7. Long diameter, . 20 cm. 8. Greatest lateral diameter, 16 cm. 9. Diameter at auditory meati, 13 cm. 10. Diameter at zygomatic process of frontal bone, . 12 cm. 11. Distance from auditory me:itus to nasal spine, . 12cm. The hair blonde, well cared for ; the moustache from time to time CONTRARY SEXUAL INSTINCT. 253 shaved. Eyes have a neuropathic, swimming expression. Patient is myopic and wears e3'e-glasses. Pupils dilated, normal in reaction. Face handsome, approaching the female type in form. Expression sympathetic. Face pale, and looks as though paint and powder were habitually used, which A. confesses. Skin well cared for, delicate and white. Breasts very well developed ; breast without hair ; hands not feminine. 1 PELVIC MEASUREMENTS. Female. Diameter at anterior superior spines, . 25 cm. 26 cm. Diameter at crests of ilii, . . .27 cm. 28-29 cm. Diameter at tubera ischii, . . . 8-9 cm. 10 cm. Diameter at trochanters, _ .- . 30 cm. 31 cm. Diameter external conjugate, . . 18 cm. 20 cm. Convergent position of thighs. The genitals of medium size and well developed. Mons veneris with abundant hair. Prepuce can be easily retracted. Voice feminine and high. On the whole, the form is well rounded and soft. Attire veiy elegant, almost foppish ; odoriferous with perfume. Gait mincing, tripping. Movements graceful ; gestures feminine. In his general appearance there is something elegant and unmanly. Besides the active stimulation of his instinct, the patient has a demonstrable want of moral understanding, and incapability of forming moral ideas ; so that the existence of a moderate degree of weak-minded- ness may be assumed. The Treatment. In this case of moral insanity, or psychopathic subsidiary defect (anatomical signs of degeneracy, want of moral sense, and complete effemination), the treatment seemed to me to be rendered especially difficult. Therefore I was able to predict only the probability of decided improvement, while complete psycho-sexual transformation was scarcely to be expected. The objects to be attained by treating A. could only be the follow- ing : (a) Thorough removal of the onanistic inclinations and the conse- quent physical troubles. (6) Artificial limitation of the homo-sexual feeling to the extent of complete power of resistance (indifference) to male charms, (c) Establishment of permanent regular hetero-sexual intercourse for the satisfaction of sexual desire. The removal of physical ailments completed the treatment. Only after fulfillment of these conditions could there be any thought of a psy- chical transformation of the manner of feeling in an hetero-sexual sense, with the consequent reflex effect upon the patient's character. The limit of possible development is here also drawn anatomically, owing to the defective organization of the highest psychical centres and the fixitj r of 1 Comp. p. 263, conclusion of letter. 254 SEXUAL PAR^STHESIA. existing associations in the apparatus of ganglion-cells which cannot be influenced. The great importance of psychical therapeutics, of moral treat- ment, of methodical discipline of the feelings in the waking state, in the entire treatment, is not to be undervalued. The physician using hyp- notic treatment often cannot dispense with its effects. But it seems very questionable whether the application of such means will be sufficient. Hypnotic suggestion seems to us as the foundation, as the starting-point, of therapeutic procedure. At any rate, it quickly attains the object sought; and, by removing associated and contrasted ideas, it more effectually influences the mechanism of the brain than do psychological processes in the waking state. But both forms of psychical treatment seek to attain the same end. By developing fixed and permanent asso- ciations (auto-suggestions) they seek to restore to the patient his lost self-cultivation and to give him control of his nervous mechanism ; or to establish them anew. An example given by von Krafft-Ebing shows that milder forms of the anomaly can sometimes be successfully treated by self-education. But he regards such cases as infrequent exceptions, and he cites but one case. Von Krafft-Ebing regards hypnosis as the only means of cure. Therefore, logical correction by reason and sug- gestive command must be completed by the hypnotic state in order to put the patient on the way to improvement. The treatment of our patient, with which many difficulties were associated, was directed in accordance with these principles. September 1, 1890. First attempt at hypnosis (method of Nancy). Complete hypotnxis ; suggestive catalepsy ; somnolence. Suggestions : Disappearance of troublesome erections, which disturb sleep; disappear- ance of onanistic inclinations and depression, pleasure in business, and physical well-being. After awaking, no amnesia, but feeling well. September 2d. For the first time in years the patient went to sleep without erections. In better spirits. Still he masturbated. Hypnosis and suggestions as yesterday. September 3d. Patient went to sleep and awoke without erections. He felt no inclination to masturbate, and does it no more. He awoke twice with annoying erections. Feeling better physically. To the suggestions of September 1st interest in the female sex is added. September 4th. No more onanism ; no erections on falling asleep or on awaking ; sleep disturbed once by erection. Yesterday A. noticed the actresses at the theatre. He is more quiet in mind. Suggestions as on 1st and 3d of September. There is no amnesia to-day, nor in later sittings. September 5th. For the first time A. awoke in the night without erection, but he had one on waking in the morning. A. fights strenu- ously against his inclination to onanism without yielding to it. Sugges- CONTRARY SEXUAL INSTINCT. 255 tions as on the 1st and 3d of September; besides, sexual intercourse with a prostitute to-day is energetically suggested, and perfect success promised. September 7th. On the evening of September 5th the patient reluct- antly visited a prostitute. Erection only after prolonged manipulation. Coitus performed with inner repugnance. Intense physical reaction in an attack of migraine following the act. Great depression ; suicidal thoughts. On the evening of September 6th and the morning of Sep- tember 7th, masturbation. To-day, removal of the physical complaints by suggestion. No more erections, indifference to men, as well as the suggestions of September 1st and 3d. After awaking from the hypnosis, is like one transformed ; no bad feelings ; hope and confidence. September 8th. For the first time entire absence of annoying erec- tions on going to sleep, during the night, and on awaking. To his aston- ishment, A. notices a kind of curious interest in young girls (at the theatre, in the streets, etc.). He still has lascivious fancies while dozing mornings. Struggle against onanistic desires, but he yields and mastur- bates. Again, energetic opposing suggestions with the usual procedure. September 9th to 13th. Daily hypnosis. On the whole, gradual progress. Onanistic inclinations less frequent ; erections gradually cease to occur. Mental improvement, but still homo sexual 'fancies. Once more coitus on September 14th, again giving rise to unfavorable mental and physical symptoms. During the last half of September, in spite of my advice, A. visited me but very irregularly, and several times he presented himself in a state of great depression. On September 21st, third coitus with somewhat better results. States that he has interest in a young woman. His feeling is very variable. September 25th. Violent migraine successfully overcome by sug- gestion. From the end of September to the 10th of October the patient ceases to attend, without any reason. His unusual conduct leads me to write an inquiry concerning his condition, to which I received the following answer : " Munich, October 10, 1890. Dear Doctor: Pardon me if I answer your inquiry, which I have but now received, by letter rather than by word of mouth, for I have not the courage to tell you personally what I can no longer conceal from you. " Until Sunday, September 14th, all went in accordance with my desire, slowly but steadily ; the suggestions were carried out with the greatest precision ; onanism, with all its accompanying symptoms, dis- appeared, and I hoped confidently for improvement, if not recovery. Then came that unlucky Sunday, on which, at your desire, I wrote my autobiography ; and, in coming to a complete understanding of my con- dition, I said to myself, 'You cannot be cured; it is not your sexual 256 SEXUAL PARJESTHESIA. desire for your own sex that predisposes you, but your mental desire.' Then I gave you my autobiography, in which I spoke of myself never so frankly, even to my confessor. My conviction, reached in the biography, as well as your statements, robbed me of courage. I lost all hope of cure. Terribly humiliating as the confession is to me, I can no longer remain silent. Since the 17th of September I have practiced my old vice daily. I have three times been with men ; up to to-day have been with women but three times. A verbal confession would be too painful to me ; hence this letter. I know all that you might say to me ; I realize how bad my conduct is. Thus, since that day the treatment has been without effect. Perhaps this result was in part due to the fact that from Forel I learned how much of its effect was due to auto-sugges- tion, real imagination, and I no longer had faith in it. Since that day all is as it was. " I do not venture to make excuses, for I am well aware of the despicableness of my conduct. The fear of an immediate verbal con- fession outweighed all else. " Please pardon me and give me up. After this confession I could not look you in the face again. I am greatly indebted to you, dear Doctor. How much pains you have taken with me ! But you are not to blame that what you said with the best intention has not had the desired effect on me. Pardon me ! " With feelings of genuine gratitude and of greatest respect, "Sincerely, A." October llth. At my request the patient came again. More care- ful inquiry shows that even during the period of relapse, and in spite of his despair, A. was (a) free from erections at night; (6) was relatively better (fancies and masturbation infrequent) ; (c) and in male intercourse he did not find a satisfaction that could be compared with former similar feelings. On the contrary, his expectations were not fulfilled. After the act he felt a certain repugnance, a kind of moral regret. I reassured A., diverted his thoughts, and removed his misappre- hension, and he showed himself the more amenable to suggestions. From this time till the end of the month he was hypnotized. The sensitiveness to suggestion increases ; post-hypnotic commands are per- formed with precision, but there is never amnesia. General faradization used for his neurasthenic symptoms with good success. As in September, the suggestions are directed to masturbatic in- clinations and erections ; to attempts at successful coitus, with pleasure in it, and inclination for the female sex ; and to physical well-being. Be- sides, greater pleasure in work and resumption of writing are suggested. From October llth to 14th, good success. Unfortunately, on the latter date a new obstacle to the patient's progress arose in the form of gonorrhcea, which the p.atient acquired in coitus. It was cured by injec- CONTRARY SEXUAL INSTINCT. 257 tions by the end of October. Still, this month was one of considerable progress in A.'s general condition. Onanistic tendencies and erections at night, which had troubled the patient for years, disappeared completely under the influence of constant suggestion, and without relapse. His general condition became much better ; there were but slight variations of his mental condition. During this month he had to complain of migraine but once (October 25th). His apprehensiveness, which had driven him from the house, disappeared. He again found pleasure in writing, spent a portion of his evenings at home writing a story he had begun years before. Greater interest in his business. While the interest in the opposite sex became livelier, during this period there was no homo-sexual excitement of any kind. October 31st. Again for the first time intercourse with a prostitute, with unfavorable physical effect, but without repugnance. Continuance of the treatment in the same way till December 21, 1890. Slow, con- tinuous progress. November 9th and 12th, coitus with good success and physical well-being, but erection only after manipulation. Decided increase of hetero-sexual libido. November 16th. In an attempt at coitus, but slight manipulation necessary to induce erection. He describes his condition as an " inner transformation malgre wiol" There is still interest in men, but no longer any desire to possess them. November 20th. Again coitus with satisfactory result and more intense pleasure. In sexual fancies the idea of a woman regularly comes to him. A trip of two weeks to Vienna and Linz interrupts the treatment. After his return, on December 6, 1890, the patient confesses that he has attained the most desired object of his life, namely, to be loved by a man. The second relapse ; the third obstacle to treatment. In the fol- lowing letter the patient tells how it all came about : "Munich, December 10, 1890. Dear Doctor: Before attempting to give a report of the events of my absence of two weeks, I will first try to describe the success of the treatment to which I have now been subjected three months. Try as I may to collect my thoughts and to conceive a picture of the state of mind in which I was before the jour- ney, I can make nothing of it. It seems to me that all that was before had been erased ; as if I had lived only since I loved him. Whether I was joyous or sad, peaceful or depressed ; what I thought of my condi- tion ; whether men charmed me or not all memory of it is gone. All I know is that at W. I was very busy, and that I spent my leisure hours in the society of my relatives and that of a friend (unreasonable). Now all my thoughts are of him. All longing, hope, and desire are about him. Only his image is before my soul ; only love of him fills my heart. 17 258 SEXUAL PARJ3STHESIA. What shall I tell you of the feeling that animates me; that makes me happy or pains me, as I am happy in possessing him or miserable at the thought of losing him ? You wished to know exactly how it had all come about ; and I will try to tell all as clearly as possible. " Before I made his acquaintance I had heard of him, and nothing but good report of his character and his heart; so that I was very anxious to know him. At first I did not please him, for I was chilled after a long journey, and the changes which cold induces in my face are usually not attractive. I hate cold ! But with longer association I pleased him more and more, how I do not know ; he began to be interested in me; he kissed me and told me that I pleased him, that I was pretty, that he loved me. At last ! It had come to me ! My heart, that had long given up hope of being loved, was warmed, and a new, unknown feeling came over me. I saw only him; I wished only for him. Had the world vanished around me I should not have noted it. " Three blissful days followed. In the mornings we were not together, but afternoons, evenings, and the nights. Oh, God, I thank Thee that once in my life Thou hast allowed me to taste the bliss of love! Yes, it was bliss, unspeakable, infinite happiness. I had him; I felt him ; I possessed him. Ah, it would have been too much mercy to allow me to die in his arms ! For years I had prayed for nothing from God and his blessed Mother but to find love. I repeated my prayers mechanically after the formulas, but my heart cried out for only one thing, love ; give me love ! For years I have let everything go, lost all interest, abandoned my literary work, done my business perfunc- torily. Nothing interested me ; nothing attracted me ; without love all seemed empty ! And now I was blessed. All thought and feeling dis- appeared. It was like an ecstasy, full of blessed peace. I lay on his heart, and I had no other desire ; it was all to me. I no longer know whether the time was long or short ; I only know that it passed, and that now it has been long since I have seen him. We do not live in the same city ; we have not the same occupation ; the possibilities of meet- ing are not great; and still I think only of him. I pray only for him. If he is only happy ; if all goes well with him ; if he is only satisfied and well. I can do nothing for him and be little to him ; and yet, if he but wished it, I would give up everything ; I would become dead and lost to my relatives ; I would beg with him, if necessary. " I am too old and know the world too well not to know that one cannot always be at the height of such feeling; but I will not know it; I will be blind ; I will deceive myself; and I tremble at the thought of the moment when, perhaps, he will cease to love me. Oh, God, spare him to me! I know well that physically he cannot remain true to me. I do not desire or expect that, if only his heart, his love, remains mine, CONTRARY SEXUAL INSTINCT. 259 which has nothing in common with the sensual pleasure which, perhaps, he experiences temporarily with others. I remain his; for me no other man exists. His image hovers around me ; he is my first thought on awaking, my last on falling asleep. I stop ; for were I to write ten sheets more I could not express in words the feeling that animates me. " With truest gratitude for your help, that has done so much for me, Sincerely, A." In answer to inquiry, A. added that he lived with his lover three days, and that he repeatedly performed coitus in anum on him, with spontaneous ejaculation. The patient protested against my removing by suggestion this inclination in which he found his perfect happiness. Thinking that this second mood would also pass, that then I should have even a more fertile soil for suggestion, I limited myself to sugges- tions of ability to work and against all other men. The patient's general condition has scarcely suffered by this unfore- seen incident. Now, as before, the nights pass quietly and without the occurrence of erections ; no inclinations to masturbate. The prospect of seeing the lover again is small, owing to wide separation ; and their intercourse is limited to correspondence. In the week after his return the patient refuses to perform coitus with a woman. He regards that as being false to his most sacred feelings. Certain of my final victory, I considered the patient's state and limited in}' treatment to his general condition. December 14th the patient came in great depression, and reported that the very cool tone of his lover's last letter did not in any way meet his expectations. December 18th the patient is in tears because of despair at the conduct of his lover and his decisive refusal to indulge in hetero-sexual congress. He wants to go to see his lover, and longs for the day of his departure. Before going he gives me a written report concerning the final results of treatment up to December 20, 1890, which had not been touched by the " relation." The letter follows : " Munich, December 20, 1890. Dear Doctor: In obedience to your desire, I will attempt to describe the success that has attended your treatment of me during three months. When, late in August, my atten- tion had been excited by the fifth edition of von Krafft-Ebing's work, and I submitted myself to you to gain your help, my condition had cer- tainly reached its acme. The melancholy that ruled me had become complete taedinm vitse ; the thought of suicide never left me, and often became a burden, it seemed so impossible to escape it. Nothing else came but the thought of how most quickly and painlessly, and with least disgrace, I could kill myself. 260 SEXUAL PAILESTHESIA. " In this state of mind there was complete indifference to every- thing; nothing interested or attracted me. I was intensely nervous, very irritable, moody, and incapable of resisting every emotion. Besides, there were migraine, sleeplessness, and the constant feeling of weariness. I masturbated daily, and was so excitable to my own sex that I sought intercourse with men every day. Often I had to use all my strength to control my eyes, which all too clearly betrayed my feelings. The thought of finding no love threw me into complete despair, and made rne miserable physically and mentally. " To-day, after three months, my condition is essentially better. The melancholia with tsedium vitse has disappeared; and if still some- times, owing to the fact that I have very depressing business cares, I think, ' there is nothing for you but to die,' still, that does not ever last long ; after a few moments I have new hope and do not consider myself lost. But formerly such states of mind lasted hours and days ; yes, even weeks. Further, I owe it to your suggestions that I have again begun to write, an occupation which I had entirely abandoned after the first reading of von Krafft-Ebing's book, exactly two years ago (August, 1888) ; to them I owe, thus, the re-awakening of my mental interest. " I have entirely given up onanism and sexual intercourse with men. Above all, I am happy that I am now free from fancies of las- civious images, that prostitution of thought which formerly was busy with nothing but ideas of unnatural congress, violation, etc. ; such thoughts are entirely erased. The neurasthenic troubles are very much better ; only once during my last journey did I have migraine. Antipy- rin and valerian, which I took before the treatment, I no longer take. My power of resistance to my own sex has become so great that, though I could easily find opportunity for it, I neither seek nor miss sexual congress with my own sex. During three months, until this meeting, as you know, I performed coitus with women regularly weekly, which before, up to my thirtieth year, I had performed but three times. My pleasure in my own sex is by no means extinguished .yet; but men do not charm to the extent they did. Now I should not desire to have intercourse with any man, unless a mental sympathy united us. Mere sensuality has lost its charm for me. " For all this I thank you, Doctor, for I should never have known how to help myself; and, too, I have done many things, like sexual inter- course witli women, only as a result of the inner impulse implanted in me by suggestion, an impulse that was at first foreign, but irresistible, and which I obeyed in spite of myself. Both in thought and desire, however, I feel myself too much like a woman to feel fully drawn toward one and to deny my inmost nature. " I remain, respectfully, A." During December there was no hetero-sexual intercourse. Other- CONTRARY SEXUAL INSTINCT. 261 wise his condition was satisfactory. From December 26, 1890, to Jan- uary 4, 1891, the patient was with his lover in W., and reveled in the happiness of requited love. Sexual congress every night. A. returned filled with feelings of tenderest love, and thoroughly satisfied aesthet- ically. The months of January and February, on the whale, were marked with considerable progress. During the first half of January, depression and complaint of cold- ness on me part of the lover, who seemed to be lazy about writing. January 1th, the patient is made happy by postal card; great de- light. The treatment was continued with regularity, as formerly. The patient grows quieter ; his passionate feelings slowly change to those of friendship, and in the second half of January it is possible to induce him to indulge in hetero-sexual intercourse, which thenceforth is prac- ticed regularly. The patient again becomes as he was in November, and the inter- current love-affair leaves no lasting impression. The development pro- ceeds slowly, almost imperceptibly, in the hetero-sexual direction. According to my notes, the patient performed coitus January 14th, 21st, 31st; February 3d, 10th, 14th, 17th, 21st, 24th, 28th ; March 3d, 7th, 10th, 14th, 17th; April 7th, llth, 14th, 17th, 21st, 25th, 29th; May 5th, 7th 12th, 16th, 19th, 21st, 26th, 30th. Erection usually induced by manipulation ; seldom spontaneous. At the end of January, in order to put to the test the psycho-sexual transformation that had been induced in A., during the carnival I allowed him to mask as a woman twice. In this costume he twice visited balls, but he no longer found the same pleasure in his role as for- merly, and he was unable to react on this occasion to the solicitations and allurements which were not to be misunderstood. He felt cold ; what formerly had given him the greatest sensual pleasure seemed to be dead. Too, his meeting with former companions, whose society he had avoided since October, made no impression on him. As. far as I had occasion to observe him at one of these festivals, I may say that his retiring conduct was in contrast with that of other female maskers (notorious urnings). A. thus stood this test successfully. Owing to his continued progress in improvement, after February the patient was hypnotized only once or twice a week. During this period (February) the patient once wrote me as follows : " To my great regret I could not come on Thursday on account of business. I have had the desired congress with a woman, and not once with dislike ; indeed, I begin to have a greater sexual interest in women, so that on the occasions of sexual excitement my imagination is prin- cipally concerned with feminine forms." About the end of March, a journey lasting two weeks, but without relapse. Under the influence of suggestion and hetero-sexual inter- 262 SEXUAL PAR^ESTHESIA. course, there is gradually developed complete inability to react homo- sexually, while, on the other hand, the relatively (as compared with inter- course with men) slight pleasure in coitus gradually increases in intensity, and inclination to perform coitus regularly is developed into a necessity. In May, without special direction, he goes to women spontaneously, and is thoroughly convinced, both practically and theoretically, of the necessity to satisfy his sexual desire in hetero-sexual congress. The number of hypnotic sittings to which the patient was subjected up to the beginning of June was one hundred and eighteen. A.'s psycho- sexual transformation has thus lasted five months without relapse. His mental equilibrium is now (June) entirely restored. His interest in the female sex has not reached its acme, it is true, but its intensity has so much increased that the thought of sexual intercourse, awake or in dreams, is closety associated with the idea of woman. Onanistic incli- nations and painful erections have not occurred in six months. His physical health seldom gives any reason for complaint. His complexion, formerly altered by paint, is now brown and healthy. Now the patient does not dismiss the thought of marriage as formerly ; but as yet a favorable opportunity has not presented itself to him, as to some others of my patients. The patient describes his own improvement in the following letter : " Munich, May 13, 1891. Honored Sir : In attempting, as you desire, to describe the results of your treatment thus far, I must first declare that already all has been attained that I originally hoped for as a result of hypnotic treatment. I masturbate no more and feel no desire to ; the great depression which formerly tormented me has as good as disappeared ; my mind is at rest and perfectly balanced. My feelings for my own sex have essentially changed ; the love-relation of last winter has been as good as completely erased from my memory. Correspond- ence has ceased for two months, and the image of the man, whom I loved with true passion, comes before my mind still now and then ; but his image there seems only as that of something dead and foreign to my inner self. " To be sure, my pleasure in powerful, manly figures has remained unaltered ; but it is no longer accompanied with the desire to possess the person pleasing me ; rather with the thought, ' If I were only like you !' The thought of sexual relations with such a young man no longer meets with any response in me; it is as if it met a barrier. I begin to lose the understanding for such intercourse ; men no longer excite me. Coitus with woman, made possible for me by your successful suggestive treatment, has become a habit ; I perform it regularly; and even though the lustful pleasure I always feel in it is not so strong as that formerly experienced in intercourse with loved men, still it has increased in intensity, and the feeling of satisfaction has become greater. CONTRARY SEXUAL INSTINCT. 263 " The lascivious fancies that formerly troubled me have disappeared ; occasionally such ideas come up while awake and while dreaming; but they have changed ; they no longer are of the sexual act of man with man, but of intercourse of man with woman; and if I myself am con- cerned in it, I take an active, not a passive, part. The feminine charac- teristics that still cling to me are very depressing and disturbing to my comfort ; the more because I often doubt the possibility of a complete transformation of my nature. Adornment and toilettes interest me as much as ever. My appearance is shy, embarrassed, and timorous. Self-confidence is still wanting, and I fear I shall never attain what I admire so much in others, namely, that certain tone of energy and decision so important to young men. " I have become indifferent to my external appearance. Powder and paint, cra3'on and rouge I have long abandoned ; but formerly, even on days when I was nearest despair, I always carefully made my toilet ; the half-genuine, half-feigned airfaue, farde, retape seemed to me indis- pensable to complete my personality. Under the influence of suggestion the physical troubles, painful erections at night, migraine, etc., have disappeared entirely; I feel fresh and health}". After hypnotic sittings I have never felt any way but perfectly well. My interest in my busi- ness, as in my literary work, .is re-awakened; the feeling of anxiety when alone has completely disappeared. I have begun to smoke. The pictures of celebrated urnings have disappeared from my walls to give place to those of a certain celebrated comedienne. " To express in a word all that has thus far been attained, I may say that in sexual relations I feel neutral and healthy. Males no longer charm me ; and though I begin to have interest in girls (which I never did formerly), still they do not excite me. Were I to choose between being a man or a woman, I should certainly choose to be a woman ; and, believe me, I should be a good, virtuous wife. " In gratitude and respect, A." " Postscript : Doctor, please change ' large hands.' I wear 7^ gloves, and that is not large ; and my hands are perfectly white. No one has ever called my hands large. Please cut that out, will you not?" 1 There cannot be the slightest doubt, from the foregoing details, that suggestion exercised the greatest influence in the psycho-sexual transformation and the mental and physical restoration of A. Should the patient continue in the same 1 In the " status praesens " I wrote at first " large hands." When I read the history to the patient he protested against it, and repeated his very characteristic objection in his last letter. 264 SEXUAL PARjESTHESIA. course his defect will give little cause for relapse. It is also to be hoped that the effemination, which continues as before, will gradually undergo a transformation in the sense of a masculine and active-feeling personality, to which, however, the unalter- able fixity of certain existent associations in the central ner- vous system will probably oppose a definite and impassable limit. But in this event the ultimate possibility of human knowledge and therapeutics will have been attained. Additional Notes. My absence from Munich for two months and a half from June to September, 1891 brought about a pause in the treatment of the patient. During this time he had a relapse, though not in the strict sense of the word. Concerning this he wrote, on Sep- tember 1st : " Simply from ennui, and in order to experience erection again, I went to the parks and got up some associations. It would be lying to say that it made me happy and that my heart was in it. Many times it wearied me. The tenderness of the men touched me, but this male intercourse did not charm me as of old." Thus, not in obedience to his abnormal instinct, but merely to break the monotony of female intercourse, the patient sought out the places of former meetings. But, as we see, his attitude toward the homo-sexual acts was inwardly changed. He is undeceived, and only his pity for his partner induces him to continue the relations and not break them off abruptly. At the same time, we see that the patient is not yet able to get on without the moral influence of the physician. Otherwise he is devoid of moral defect, and this deficiency must be overcome by continued help. Resumption of hypnotic treatment in the beginning of September. Interruption of the homo-sexual relations ; normal sexual intercourse regularly once a week. During the eight months since the relapse the patient has not manifested his former inclinations in any way. He is still hypnotized once a week; very busy in his calling. His neurasthenic symptoms have entirely disappeared, and he makes no complaints. In some points his effemination seems to have weakened. He appears calm and earnest and in accord with his surroundings. Up to the present time there have been twenty-four hypnotic sittings (one hundred and twenty-four in all). The patient continues under observation. In this case, in a de- generate individual, who has been under treatment one year and eight months, the result of treatment, in spite of the mental weakness, should be of great interest in the prognosis and treatment of similar severe cases. CONTRARY SEXUAL INSTINCT. 265 Case 64. Personal Observation. Contrary Sexual Instinct Treated in Seven Hypnotic Sittings without Success. W., 1 aged 40 ; artist. His parents were healthy. Father passionate sexually, tour times married. Patient had scarlet fever and typhoid in youth. Otherwise healthy. Asthma, due to corpulence. At the age of 7, he, like his brother, was taught onanism by one of his father's servants. Love of men in his thirteenth year. Neither at that time nor later did women make the slightest impression on him. Complete fiasco in attempt at coitus ; no erection. During his school-days, mutual onanism and auto-masturba- tion. Repeatedly in love with young men aged from 18 to 22. W. re- gards his anomaly as congenital ; feels unhappy. His last relation was with one of his scholars. He met with no return of affection and was tortured with jealousy. On the advice of a celebrated physician, who regarded abstinence as sufficient to induce recovery, he attempted to give up masturbation and homo-sexual love. But this made him only the more unhappy, and caused him to believe that happiness was im- possible for him. The patient dreams but little; pollutions infrequent, though he masturbated two or three times daily. Formerly he liked to associate with ladies, attracted by their mental qualities, though, on the whole, he preferred the society of men. Of late he had become more retiring, out of fear of being discovered. Patient looks upon a cure as his salvation. He applied to Profes- sor von Krafft Ebing, who persuaded him to try hj'pnosis with me. The patient presented himself on August 19th. He is of stately, manly appearance (has made two campaigns), and is devoid of degenerate signs. Pelvis and genitals masculine. Abundance of genital hair; no beard. Tone of voice feminine; dress elegant. Uses a fan to cool himself, a thing he always carries. On the whole he makes an effeminate impression. Movements restless ; gait weaving. The patient is able to remain in Munich but six da3^s more. I tell him that in so short a time no lasting impression can be made upon a trouble that has existed thirty years. Nevertheless he wishes to learn, by means of six sittings, whether he is amenable to suggestion. August 19, 1890. First attempt. Slight symptoms of somnolence. The patient watches procedures with too close attention. Difficult for him to raise his 63'elids. Auto-suggestive catalepsy interrupted volun- tarily. The therapeutic commands are directed only to general health and disinclination to onanism. August 20th. No inclination to masturbate in the first twenty-four hours. He slept remarkably well, which he ascribes to the treatment. To intensify the effect, to-day I have him look at a shining button for five minutes. Sleep-suggestion (Lie*beault-Bernheim). No interruption 1 Comp. von Krafft-Ebing, Neue Forschungen auf dem Gebiete der Psycbopathia Sexualis, 2 Aufl., p. 116, Beob. 6 (Enke, Stuttgart, 1891). 266 SEXUAL PAR^ESTHESIA. of sleep by attempts at catalepsy. Patient sleeps for half an hour, snoring loudly. Suggestions: Repugnance for onanism ; indifference for men ; gradually awakening interest in women. After waking, patient says he has slept well. August 21st. Mood somewhat brighter. No inclination to onan- ism, but no inclination for women. Procedure as on the 20th ; fixation shorter. Suggestion to attempt coitus. August 22d. Last night, though the patient dreamed of men, he did not masturbate in spite of erection. Yesterday he tried to make the acquaintance of a woman in the park, but he was not successful, and is much depressed by his failure. August 23d. Procedure and suggestions as on the 21st. Energetic command to perform coitus. August 24th. Yesterday he was able to overcome his shjmess. He followed a prostitute to her house. Here he had to pass a room in which a man lay asleep. The doors were not locked. This accident at once awakened W.'s suspicions. He immediately lost courage, and departed frightened, without making any attempt. General condition good. Hypnotic procedures as usual. August 25th. Last sitting. Certain success of an attempt at coitus promised. In spite of my request, W. has reported nothing further concerning his condition. In the foregoing case, success after so short a period of treatment was not to be expected. Still, from the sittings it showed that W. was amenable to hypnosis and to suggestions of a sexual nature. In all probability essential improvement would have followed prolonged treatment. Case 65. Personal Observation. Acquired Contrary Sexual In- stinct Improved in Seven Hypnotic Sittings. Mr. P., aged 25 ; official in a manufactory ; brother of the subject of Case 62. (The diseases of other members of the family given there in detail.) Neuropathic taint. Early awakening of sexual instinct ; onanism without teaching. At the age of 16 he visited brothels and enjoj'ed coitus, but he also satisfied him- self with frequent masturbation. After his twentieth year, sexual ex- cesses with prostitutes. Neurasthenia sexualis (weakness of erection, premature ejaculation). Relative impotence. Frequent onanism. In 1888 he fell in love with a man. With this his love of women disap- peared. A second relation followed the first. Once he locked a soldier in a room, commanded him to undress, and to go to bed with him. His demand was immediately complied with. Mutual onanism. The patient abused many men in this way without actually falling in love. Threat- ening letters. Deep depression. Thoughts of suicide. CONTRARY SEXUAL INSTINCT. 267 At the advice of his physician, the patient came to me in Munich, in Ma}% 1889, to be treated bypuoticallj. Besides his perversion, the patient has suffered for more than a year with sleeplessness which has not yielded to medicines, headaches, and other neurasthenic complaints. May 20th. First hypnotic attempt after the method of Bernheim. Slight lethargy. Suggestions: (a) Repugnance for on an ism. (6) Dis- inclination for men. (c) Interest in the female sex. (d) Undisturbed deep sleep at night and subjective feeling of well-being. May 21st. To-day suggestive catalepsj" ; hypotaxis ; no amnesia after waking. Suggestions like those of yesterday. May 22d. Last night the patient slept six hours undisturbed and without dreams, which he regards as a great blessing. Suggestions as yesterday. Diminution of homo-sexual inclinations, according to his statement. May 23d. Five hours of sleep last night. No more inclinations to masturbate. Procedure and suggestions as on the 20th. May 24th. Six hours of excellent sleep last night. He states that there is no more inclination for men. Procedure and suggestion as on the 20th. To-day the patient is given suggestions with reference to undertaking normal sexual intercourse. May 26th. To my surprise, I received the following letter from the patient : " Dear Doctor : I % beg you to allow me to inform you that I am cured of all my trouble to the best of my desires. There is no more sleeplessness. Toothache and armache have gone, and I shall easily overcome the rest, I am convinced. I have already entered into a love- affair. I am about to take a mountain trip to quiet and rest my nerves. Accept my best thanks for this recovery, which I shall never forget. " Very respectfully, P." The foregoing lines I answered by writing that I should be com- pelled to suspend treatment if circumstances made it impossible for him to remain longer in Munich, but that I could not agree with him in regarding temporary slight improvement as a cure. The experience of the next year demonstrated the correctness of my opinion. In March, 1890, a relation of the family consulted me concerning a new relapse of the patient. I strongly advised a resump- tion and long continuance of hypnotic treatment. Since a prolonged stay in Munich was impossible, the patient decided, at my advice, to submit to treatment at the hands of Professor von Krafft-Ebing, in Vienna. The professor began hypnotic treatment April 8, 1890. On April 14th the patient was able to report that " with gratitude and a kind of moral satisfaction " he had had coitus with enjoyment, but had ejaculated tardily. 268 SEXUAL PAR^STHESIA. The following report by letter to Professor von Krafft-Ebing, on October 20th, would indicate that the cure was permanent : " I am completely cured of onanism, and homo-sexual love no longer pleases me. Complete power does not seem to have been attained, though I lead a virtuous life. Nevertheless, I am satisfied." In the spring of 1891 I learned that the patient had had relations with a girl in the country and had become a father. In some respects the foregoing case is instructive. In the first place, like other cases here reported, it clearly shows that contrary sexual instinct is decidedly amenable to treatment by suggestion. Further, it illustrates how such patients may easily deceive themselves, and teaches that with reference to the time, number of sittings, repetition of the procedures, and continuance of observation after discharge, the treatment must be conducted in accordance with the severity and the development of the psycho-sexual anomaly. The results of the sexual relation, as shown in this case in the begetting of a child, which was con- templated neither by physician nor patient, show that sexual relations should be limited to prostitutes, and later to actual marriage, in spite of many opposing considerations. Since we are unable to keep such individuals from propagating descend- ants, the least danger to society, relatively, lies in allowing them sexual gratification in marriage, especially when it is remem- bered that there is a possibility of properly educating and training the children of such parentage, in case they show hereditary taint. The physiological demand for satisfaction of the sexual instinct is usually stronger in man than the power of any moral knowledge ; that is, the desired complete depend- ence of the sexual functions upon ethical ideas. Therefore we are forced to choose the lesser of two evils. Case 66. Personal Observation. Contrary Sexual Instinct De- pending on a Congenital Neuropathic Constitution Cured in Two Hundred and Four Hypnotic Sittings. Period of Observation, One Year and Five Months. Mr. H. consulted me October 9, 1890. His father is a drinker (fatty heart). Mother healthy. An uncle is also subject to contrary sexual instinct. One brother neurasthenic and an onanist; another said to be healthy. Sister (aged 19) hysterical. Be- sides, several relatives on the father's side subject to pulmonar}' disease. Patient, aged 24, born on the island K., near Australia. There he CONTRARY SEXUAL INSTINCT. 269 had the diseases of childhood, and was brought to Europe when 8 years old and placed in school in S. During the time from his eighteenth to his twenty-first year the patient had a severe inflammation of the lungs and pleura and two attacks of rheumatism. H., a merchant by occupa- tion, suffers with congestive attacks, frequent headaches, feelings of fatigue, depression, want of endurance and energy, and at times with absolute inability to work and tachycardia. These neurasthenic troubles have existed for years, and have been a hindrance to regular occupation. Status praesens: Tall, slim, well-nourished. Face ruddy; the form of the cranium shows nothing remarkable. The measurements are : Horizontal circumference, .57 cm. Posterior half-circumference, 24 cm. Anterior half-circumference, 29 cm. Vertex-line, . . . . ' 36 cm. Antero-posterior line, 28 cm. Chin-line, 31 cm. Long diameter, . . 17 cm. Broad diameter, .13 cm. Diameter between the auditory meati, . . .' . 12 cm. Diameter between zygomatic processes, . . .11 cm. Distance from auditory meatus to nasal spine, . . 12 cm. Head nowhere sensitive to pressure. Pupil-reactions normal. Eyes have a neuropathic expression. No objective disturbance of sen- sation or motion. Neck remarkably long; tendency to struma. Chest flat. Breasts masculine in development. The pl^-sical examination of heart and lungs gives a negative result. Genitals well developed, large ; abundance of genital hair. Prepuce easily retracted beyond the glans ; skin well cared for, delicate and fine. The facial type is not very manly, rather boyish. Growth of hair on head abundant ; slight moustache. Hair blonde. Tissues soft ; abundant adipose; muscles fairly developed for age. On the whole, delicate, weak constitution. Position of the thighs straight. MEASUREMENTS OF PELVIS. Diameter at anterior superior spines, . . . .21 cm. Diameter at crests, 25 cm. Diameter at tubera ischii, 8-9 cm. Diameter at trochanters, 29 cm. Diameter external conjugate, 17 cm. Form of pelvis asymmetrical ; slight oblique distortion. On the left side the ilium and the trochanter are 1.5 centimetres higher than on the right. Voice baritone. Attire elegant, without exaggeration for effect. 270 SEXUAL PAR^STHESIA. Development of H.^s Homo-sexual Inclinations and Character. The patient asserts that in his youth he developed in the direction of male- love. He was quiet and retiring ; never had especial pleasure in boys' play, and was always joked about his girlishness. In his boyhood he preferred the society of girls, and when a child he was happy when he could see handsome men. All noisy and boisterous conduct he hated ; on the other hand, he early showed a taste for female toilettes, fashions, and housework. He was always considered an excellent judge and adviser in matters of feminine dress. At the age of 6, seduced to it by a playmate, he first had a thought to touch a companion's genitals, which gave him lustful feelings. Since then he has had sexual intercourse only with men. Immediately after hearing his histoiy,! asked the patient whether the feminine inclinations appeared before or after the first occurrence of sexual excitement. He was not able to remember, but he had the impression that the manifesta- tions of efl'emination, which were not very markedly developed, had resulted from his sexual perversion. In this case, also, the influences of education were determinate in directing H.'s sexual inclination, predisposed as he was by heredity. From his thirteenth to his seventeenth year, while a student at a gym- nasium, he gave himself passionately to solitary and mutual onanism, and it was always accompanied by fancies of homo-sexual content, though at that time he had no clear understanding of the sexual rela- tions. A relation with a sailor, which lasted six months in the year 1883, to which H. alludes in his autobiography, which follows, gave him what he calls the happiest period of his life. He loves to see pow- erful forms, and quite frequently has erections at such a sight. Owing to his weak constitution he was not compelled to take gymnastics, and he avoided manly sports. As a rule, he does not dream, but he remem- bers that in sexual dreams, with pollutions, he always thought of hand- some men. He does not seek to attract attention by striking attire ; on the whole, he is modest, retiring, and of quiet disposition. His libido is not strongly developed. He esteems the female sex, and likes to associate with ladies, but without ever being sexually excited by them ; it was the same in his earliest youth. In the patient's ancestry no indications of an homo- sexual tendency can be discovered, which, according to Moll, would be decisive for the diagnosis of congenital contrary sexual instinct. The patient does not smoke or drink. Great love of art and the theatre. H. is a fine singer. He has talent for languages. Gentle disposition, but irritable. On the whole, a simple, yielding character, somewhat shy. His education and reading gave him an understanding of his condition, though somewhat late. He regards himself as a step-child of nature, and is very unhappy and depressed because he sees his existence a failure, CONTRARY SEXUAL INSTINCT. 271 owing to his powerlessness to overcome bis abnormal impulse. His sexual desires are not so strong as in many other patients, but they are exclusively directed to the male sex. Patient has never performed coitus; hetero-sexual intercourse is inconceivable to him. Horror feminse. He abhors pederasty ; simply touching the genitals of his companion, mutual ouanism, or simply embraces and kisses, induce ejaculation. Besides there are the neurasthenic troubles previously mentioned. Autobiography. " It may have been five years ago that I came to understand my condition through an article by Prof, von Krafft-Ebing. It was as if a bandage had been removed from my eyes ; and the result was that I became quieter. Before that I seemed a criminal in my own eyes. " As far as I can remember, the feelings in question occurred first in my sixth 3'ear. It was in K., in the society of a boy of our neighbor- hood, that I soon came into sexual relations, which consisted of mutual fondling of the genitals. About the same time there was a ship-carpenter working on our square, who was also given work on our place during his stay in the harbor. Since his appearance was very attractive to me, it was not long before I had an intense desire to touch his genitals. I hung around him, and one day expressed to him my desire, which he, of course, refused to fulfill. When I was 8 years old we made the jour- ney to Germany, and we did not take the short way via America, but passed round South America in a sailing-vessel. The voyage lasted four months. Among the sailors I soon found a young man on whom in a short time I was entirely dependent. Whenever he was free I was 'b} r his side, but there were never improper relations. " The first two years and a half in Germany we lived in S., and they passed without special event for me. We later moved to L. During the last summer of our stay there, owing to awakening intense sexual desire, I sought schoolmates who pleased rne by their handsome appear- ance, and seduced them to mutual onanism. From this time until my seventeenth year I masturbated a great deal. I was especially led to it by the following circumstance: From the winter of 1880-81 we again lived in S., where I attended the gymnasium. After a short time our family physician caused me to be taken from school for a term, owing to the fact that the first signs of pulmonary weakness were shown at that time. Owing to the freedom which I now enjo} r ed, I soon came to yield more frequently to my inclinations. Since my mind was not given suf- ficient employment, I had plenty of time to spend in feeding my fancy on the images of the powerful, handsome men I saw. The unsatisfied longing for my beloved objects, whom I only saw afar, drove me to self- abuse for want of something better. During these years I had no inter- course with companions or men. 272 SEXUAL PAR^ESTHESIA. " At the wish of our pli3 ? sician I left the gymnasium, after having obtained the certificate absolving me from all but one year of military service, and began as an apprentice in a business in S. Since I had hard work, during the first year of my service I was not excited sexually. " In 1883 I accidentally made the acquaintance of a sailor who, at the time, was making the so-called " short voyage," and therefore was much at home; that is, he often came to S. He was happily married and had four children. At first sight I was dead in love with the man, and I spared no pains to meet him as often as possible. We soon became intimate friends. I desired nothing more intensely than to be able to associate with him sexually, but I was too shy to speak of such a thing to him. One day he himself gave occasion for it by proposing onanism directly. From that time I passed months of happiness ; for I felt more elastic and more capable of work. I can only explain the conduct of my friend by the fact that he was very strong and had a corresponding need of sexual satisfaction which he could not seek with his wife, owing to the necessities of a growing family. At any rate, he was in no sense male-loving. My intercourse with him was suddenly terminated by my falling ill with pneumonia and pleurisy, which were followed by two attacks of rheumatism, and I was confined to the bed seven months out of twelve. When I had recovered, my lover had been called away and I lost sight of him. Thereafter I was not able to make another friend like him with whom I had found satisfaction for my desires. A certain restraint, as well as the assumption that it was injurious to me, if I could not have natural feelings, to yield to my unnatural impulse, held me a little in check. " Three years ago I became acquainted with a merchant, three years my senior, who is still unmarried. Since we held similar views on many subjects, the relation grew more and more intimate. On his part it seemed to me to be warm friendship ; on my part, from affectionate attachment there was developed a love ready for any sacrifice. I sought to restrain myself, and succeeded. After our friendship had lasted a year I left S., and, after a trip of two months, reached N. with my brother. My stay there lasted eighteen months; and it is remarkable that I lived there very happily and undisturbed. This was due to the simple life of the town, the kind of food, and the nature of the society there. After having taken a position in S., in June of this year, it was soon very different. The quiet life was over. The work in the store was often very taxing, and during leisure hours more social demands than usual were made on me ; and naturally, leading such a life, I was excited more than was well for me. As soon as I arrived in S., one of my first visits was on my friend previously mentioned. My feeling for him had remained unchanged, or was rather intensified. During the summer months we often met, evenings; and, since my passion constantly CONTRARY SEXUAL INSTINCT. 273 increased, I once embraced and kissed him. Contrary to my expecta- tions, he warmly returned my caresses. In this I had an ejaculation. After that I sought such opportunity as often as possible, and I lived in a happiness of requited love. When, however, I once sought to touch his genitals, he would not suffer it ; and since then he has avoided being alone with me. " This is the history of my errors. I longed to be freed from a condition that has so often placed me in the most painful positions, because toward men who were dear to me I felt unnatural love. I would learn to have warm, practical friendship. I will also mention that with my first lover, the sailor, I felt intense jealousy when I saw that he cast friendly glances on other women than his wife. " Since my seventeenth year I have practiced onanism only very infrequent!}'. " It only remains to mention my position in relation to the female sex. As a school-boy I could not understand how my companions could run after girls. On all occasions I showed the girls that they were indifferent to me. Later, my companions visited public prostitutes. It was very unpleasant to me to think of what took place under such circumstances. Fortunately, I was never urged to accompanj' them. I like female societ}^ and I have often been envied for being so fortunate. I can discover no special inclination in myself for feminine work, though I am considered a judge of feminine toilettes. I have always liked to dance, and I never cared whether the girl with whom I danced was pretty or not, as long as she danced well. " From every sport of male youth I was kept by the anxious care of my parents or the family physician, in order to keep me from over- exertion. When I had once passed the time of danger, and I could have devoted myself to rowing, etc., business did not allow me the necessary time. Naturally, my whole constitution is none too strong. Munich, October 21, 1890." Treatment. At the wish of the patient and his relatives, I under- took, with the help of hypnotic suggestion, to free him from his patho- logical feelings. I felt myself justified in giving a relatively favorable prognosis, in case the patient would submit systematically to a course of treatment that would be wearisome and require much time. In this case the principal aims of treatment seemed to me to be the following: 1. To combat homo-sexual feelings. 2. To induce hetero-sexual feelings. 3. To bring about a lasting systematic hetero-sexual relation. 4. To bring about engagement and marriage ; that is, to insure him against relapse by placing him under appropriate external conditions. Another part of the task was to overcome the neurasthenic troubles. October 20, 1890. First attempt at hypnosis by Bernheim's method. In scarcely two minutes H. became somnolent ; complete hypotaxis. 18 274 SEXUAL PAR^ESTHESIA. Suggestive catalepsy and suggestive contracture. Analgesia. Sugges- tions : (a) indifference to men ; (6) gradual awakening of interest in women ; (c) physical well-being. After waking, feeling perfectly well ; pleasant mood ; no amnesia. October 21st. Patient comes with headache. Repetition of the procedure and the suggestions of yesterday ; besides, removal of head- ache by suggestion. Again hypotaxis. No headache after awaking. October 22d. The patient reports that lie feels more capable of re- sistance and less helpless toward men ; besides that lie notices, to his astonishment, an interest in women, though it is only mental. Ou October 23d, 24th, and 25th, repetition of the same suggestions. October 26th. For the coming night an erotic dream of women is suggested. October 27th. The patient reports joyfully that the dream was ful- filled, and that in the dream he experienced a sexual inclination toward women, connected with lustful feelings. On October 28th and 29th, besides the suggestions of October 20th, the awakening of sexual feelings at the sight of women is sug- gested for the 28th, and an attempt at coitus and success in it for the 29th. October 30th. On October 28th horror feminae was still so great that he had nausea when about to visit a brothel with his brother. He could not conquer himself, and turned back. On October 29th, after energetic repetition of the previous suggestions, the patient was able, in spite of great excitement, to visit a brothel. The first meet- ing with a woman was without success. Nausea; intense repugnance; impossibility of erection in spite of mechanical stimulation of the organ by manipulations. Patient, who is much depressed by his failure, is quieted by suggestion. Suggestive treatment as on the 20th. October 31st. In hypnosis, removal by suggestion of dull head, want of appetite, and nausea. Repetition of the usual procedure. November 1st. The patient reports that inwardly he feels as if " cut off" from the male sex ; he feels the loss of something. Treatment as usual. November 3d. Prepared by suggestion, H. visits a prostitute to- day. In spite of energetic stimulation by manipulation and the help of imagination (thought of male forms), erection was impossible; complete failure. Sexual desire of both kinds seems to be destroyed. On November 4th, 5th, 6th, 7th, and 8th, in spite of the want of success thus far, success in coitus, in connection with the usual sugges- tions, is daily suggested. On the night of November 4th, lascivious dream of male forms without pollution. On the 7th and 8th H. visited a dance-hall, without, however, taking one of the girls. November 8th. A new attempt in a brothel for the 8th or 9th is CONTRARY SEXUAL INSTINCT. 275 suggested ; and quiet, power to overcome shyness, and complete success are always suggested. Suggestion : " Erection, to your astonishment and without any act on your part, will suddenly occur." The patient states that November 9th was the most terrible day of his treatment. On the morning of this Sunday he found himself excited. Great depression. Thoughts of suicide. He thinks his life a failure. He thinks himself impotent, the more because after three weeks of treatment there is no noticeable progress. On the night of the 8th he had not the courage to carry out the plan. In order to weaken to some extent the opposing ideas and feelings, this evening H. prepared himself by taking alcohol (beer, etc.), and about 10 o'clock he repaired to the brothel. After he had been with the puella alone for about twenty minutes with- out the occurrence of erection with the help of manipulations, to the patient's astonishment, erection occurred spontaneously. Coitus was performed with lustful pleasure. Of course, the latter was not to be compared in intensity with that of male intercourse; but H. is delighted by his success, and finds pleasure in hetero-sexual congress. On November 10th, llth, and 12th the treatment was continued with the earlier suggestions. On the night of November llth the patient dreamed he was in a brothel, had a powerful erection (actual), and attempted coitus, but was always kept from it by external circumstances (noise, slamming of doors, etc.), which made him very angry. November 12th. Suggestions : Performance of coitus to-day ; in- creasing hetero-sexual libido ; intense lustful feeling. November 13th. Last night, without preparation by alcohol, the patient performed coitus ; spontaneous erection ; more intense lustful feeling. On the 9th and 13th the victory over the patient's homo-sexual feeling was decided ; the most difficult part of the task, namely, the induction of hetero-sexual feeling, was performed. With this the patient passes into the stage of psychical hermuphroditism ; the promotion and fixation of the hetero-sexual way of feeling, which, in comparison with the natural inversion of patient, is still weak, form the second object. Strengthening of his feelings by suggestive influence and systematic hetero-sexual congress should be continued till the predominance of normal sexual feeling is complete, and can no longer be touched b}' even intense homo-sexual stimulus. The patient is now treated with hypnotic suggestions in the manner outlined ; as a rule, he passes only into the stage of hypotaxis, never into somnambulism. November 16th and 19th, successful coitus. November 22d. Coitus does not succeed, in spite of all efforts ; but during the attempt violent headache occurs, which continues to the 24th, and is removed by suggestion. 276 SEXUAL PAR^STHESIA. November 24th. Repetition of sexual congress, as a result of sug- gestion. The first attempt on this evening is a failure, the second a success. November 26th. Coitus successful, but immediately after it nausea and tendency to syncope. The patient still has erections at the sight of powerful men, but much less frequently, and only episodically. Every instance of this kind is conscientiously confessed. November 30th. Premature ejaculation with insufficient erection. Depression. December 2d. The same as on November 30th. December 6th. Complete success in the sexual act. December 10th. Coitus successful; slow progress. There is still always a certain inclination toward the male sex. December 15th. To-day the patient is very well satisfied with the success of his sexual congress with a prostitute yesterday. December 22d. Congress with a very passionate woman. Good success. But the patient prefers women of a quiet temperament. In the hypnotic sittings during December it is daily suggested to the patient that he become engaged to a grand and attractive young lady. This marriage is the secret wish of both families. The patient left on December 22d, to be absent several weeks, with the intention to become engaged immediately. The results of the fifty-two suggestions are: (a) the establishment of a regulated hetero-sexual relation based on artificially induced feel- ings ; (b) the progressive diminution of homo-sexual feelings; (c) the removel of former physical troubles ; (d) the determination to become engaged. Several days before the patient's departure I requested him to give me a written statement of the changes that had taken place in him. This important addition to my observations follows. Report of the Patient on the Course of Treatment, December 17, 1890. " After having been under Dr. Schrenck's treatment for two months, I may report as follows concerning the result : u Led by constantly repeated and appropriate suggestion, I over- came my repugnance for sexual congress with women so that I under- took to indulge in regulated intercourse. I progressed gradually until, as a result of habit and a slowly progressing, but unmistakable, change of feeling, the act of coition was more and more perfectly performed. Simultaneously with this change 1 felt a barrier raised between my present and my former life. I have the sure hope that my love of men will grow less and less, and that I shall soon be free from it. " Formerly I felt an actual repugnance for sexual congress with a woman ; I thought it impossible for me to perform this sexual act. Without suggestion I should never have had the courage to approach a woman. No wonder that the first attempts in obedience to suggestion CONTRARY SEXUAL INSTINCT. 277 were not successful (want of erection) and thaf I was nauseated. Be- sides I also was depressed and melancholic, and had suicidal thoughts. I thought my life a failure, and was very unhappy. First, the suggestive treatment was successful in overcoming the terrible excitement which came on me whenever I attempted to perform the act, as well" as the feeling of repugnance and nausea. As if following an inner impulse, and without its costing any effort of late, I have made two attempts at intercourse weekly. While at first erection was entirely wanting, or occurred only after manipulation, later it occurred spontaneously as a product of sensual excitement. And while at first sexual congress gave me but slight pleasure, during the later weeks lustful feelings and gen- eral sexual excitement became so intense that I think I reached the acme of physical pleasure possible for a normal man ; at least, as far as it is possible, without aesthetic basis, with a prostitute. My depressed moods have entirely disappeared ; I am hopeful of the future, and I now think myself capable of all there is demanded of a man. I am, there- fore, determined to become engaged in a few weeks. " As far as my inclinations toward men are concerned, I have neither a tendency to lascivious dreams nor to onanism. While before the treatment they came to me, since the first day of treatment I have had nothing to complain of in that respect. My previous intense ex- citability to men has given place to a degree of indifference and power of resistance which formerly seemed impossible to me, and which seemed to increase with the feeling of satisfaction in hetero-sexual congress. Still, I am not free from such tendencies; for a few weeks ago, to my astonishment, I discovered myself with an erection at the sight of an attractive man. On the whole, however, an inner transformation has taken place in me ; and I am fully convinced that in the I'egulated sexual relations of marriage the last remnants of my fatal malady will be eradicated. " As for the suggestive treatment in other respects, I can only assert that upon other temporary physical ailments (feeling of nausea, headache) it alwa}'s had a sure effect. I always felt very well after hyp- nosis ; my general feeling, mood, etc., have improved as far as it was possible for them to improve. Munich December 17, 1890." During the course of treatment the neurasthenic complaints, which to a certain extent depended upon the sexual condition of the patient, diminished. Dietetic rules, regulation of occupation, and cold rubbing completed the physical treatment of the patient. In avoiding over- exertion and excesses, such as was practiced by him, against medical advice, during the carnival, the patient kept well. Headache, rheu- matic symptoms, and feelings of dizziness were always removed by sug- gestion when other means were, ineffectual. During the course of treat- ment the patient became able to resume his business ; physical complaints 278 SEXUAL PAR^ESTHESIA. became less frequent ; and though symptoms now sometimes occur (end of Ma}^), they are always due to overexertion in business. Sometimes the patient is kept on his feet all day. New Year's, 1891, I was pleased to learn of H.'s engagement. His letter ran as follows : "January 2, 1891. Dear Doctor: I have the pleasure to inform you of my engagement, though, owing to my fiancee's youth, it has not yet been announced. I joyfully hope that this marriage will bring me com- plete happiness, and that, in a way, it may be regarded as a conclusion of your treatment ; for, in marriage, the last traces of my malady will certainly disappear. " That I am able to enjoy the happiness of marriage I owe to you, and I shall never forget it. " Always gratefully, H." At my request the patient enlarged his letter by sending me the following report : " The feelings which attach me to my fiancee are of an entirely dif- ferent nature deeper and purer from those feelings which were for- merly excited in me by persons of my own sex. I think I shall find a happiness which before seemed impossible, and which I have never known before. Too, the inner bond that holds me differs from the relations of a more sexual nature that thus far I have had with females as a result of sug- gestion, in that I now feel entirely satisfied aesthetically ; and thus a pre- vious want has been supplied. I think it impossible that impulses like the former ones will ever gain the upper hand. I feel cold indifference for the male sex. 1 think I am cured; and it only remains to make the present undoubted result permanent, in order to lay the foundation of my life's happiness. Formerly, I should never have thought this trans- formation possible, and I never should have been strong enough to part so completely with the past. I also think it would have been impossible to have produced such a result by merely moral treatment in the waking state. All efforts of this kind, all ideas, either from others or myself, were absolutely powerless against m}' impulse. This brilliant result, in my opinion, is only to be ascribed to continuous treatment with hypnotic suggestion. I owe to you and to it the happiness of my life, and I close with the wish that many others may be helped as I have been, by the same means." In order to fully develop the patient's hetero-sexual instinct, and to make it permanent, after his return, H. was treated in the months of January and February, and until March 10, 1891, with hypnotic sittings almost daily. During this period he performed coitus about thrice a week as directed. In spite of slight episodical variations in mental equilibrium, the hetero-sexual development slowly progressed. Pause in the treatment from January 17th to 28th on account of catarrh. CONTRARY SEXUAL INSTINCT. 279 As my note-book shows, the patient performed coitus on January 7th, 10th, 14th, 17th, 28th, 31st; on February 3d, 6th, (12th), 13th, 16th, 21st, 26th, 28th; on March 3d, 6th, 9th, 15th, 18th, 22d, 25th (29th), and during April and May usually twice a week. On February 12th and March 29th the attempts at coitus were failures ; possibly because the patient felt very weary physically, for the better he feels physically the more easily he can perform coitus. On some days erection occurred only after mechanical stimulation by manip- ulation ; sometimes ejaculation was tardy. Gradually a need was devel- oped for normal indulgence. The intensity of lustful feeling increased so that on one occasion he performed the act twice in succession. After the act there was great physical buoyancy, as well as quiet, dreamless sleep. During the days following it, no sexual desire, feeling of perfect health, inner satisfaction, and want of reaction to homo-sexual charms. Since March 10th the patient has been employed in Munich, working hard in an office from morning till evening. Sometimes he is greatly ex- hausted in the sexual act at night on account of his hard work during the day. After that date I hypnotized him only once every week or two. At the end of May H. had had one hundred and fourteen sittings. As long as H. has normal congress with automatic regularity twice a week, he feels happy and like a healthy man, and is not reminded of his con- trary natural disposition. If this condition become stable, which, after marriage, it probabty will do. the patient may then be regarded as rela- tively cured. If, owing to circumstances, pauses in sexual indulgence of a week or longer occur, sexual impulses for men episodically appear. Thus, on May 16th, the patient reported that at the end of the week, after a pause of eight days, homo-sexual impulses occurred in a way painful to him, in the form of an erection at the sight of a male associate. During the night following this he dreamed that a man sought to force him to homo-sexual congress against his will and in spite of violent resistance. He experienced an intense feeling of disgust and repugnance for this kind of indulgence. In spite of his resistance the man suc- ceeded in embracing him, but without touching his genitals. This dream was sufficient to induce pollution. The next morning there was great moral distress. The same day the patient visited a prostitute, and performed coitus twice to restore his peace of mind, and was thus successful. Moreover, this psycho-sexual relapse, if it may be called such, for which he blames himself, is the only one in the last four months. It clearly illustrates the necessity of systematic sexual congress. But it also shows, in the resistance of the dream, the association, artificially created by suggestion and sexual intercourse, seeks to declare its inde- pendence in the struggle against the homo-sexual memory-pictures, still 280 SEXUAL PAR^STHESIA. relatively the stronger, which arose from the natural disposition, and were strengthened by habit. With the further development of the new hetero-sexual impulse, the patient's improvement progresses step by step; but the development depends entirely upon the nutriment afforded by the original cerebral condition. Sense-perceptions, ideas, and activity of the imagination must be made to influence the lustful feeling as much as possible. This hetero-sexual mechanism must be kept in systematic activity, if the impulse is to become strong enough to obviate the op- posing ideas of an homo-sexual nature, which are constitutionally conditioned (?), and manifest themselves imperatively. If, in this stage of psycho-sexual hermaphroditism, the increase of libido in relation to females signify a decided diminution of homo-sexual feeling, then it must be the object of the patient and physician to avoid most carefully every stimulus to contrary sexual feeling (cessation of intercourse with males, etc.), in order that atrophy from inactivity may take place in time. As soon as it has shrunken in this way, for want of exercise, to a rudiment which is noticeable only occasionally, but no longer gives rise to disturbance or is felt as abnormal, the product of artificial cultivation has compensated the natural fault. This condition may be regarded as a relative cure. Conclusion. During the months of July and August, 1891, it was necessary to discontinue treatment. During July the patient was kept in bed several weeks by an intestinal malady, and this caused a longer interruption of sexual indulgence. On this occasion ejaculation occurred twice spontaneously when a sympathetic friend was feeling his pulse. Sexual hyperaesthesia, due to abstinence ; faute de mieux, the unsatisfied impulse took its old direction. The patient was very unhappy about this, and lost all hope of cure. September 12th the treatment was re- sumed, and bromides were simultaneously used for some weeks. From that time H. was treated in ninety sittings (two hundred and four in all) ; and at the present time he is hypnotized once a week at his desire as a prophylactic. For several months his sexual life has been entirely regular. Coitus once or twice a week ; no homo-sexual impulse has been manifested in that time. At the beginning of this period erections oc- curred irregularly, but they gradually came spontaneously and promptly, with hetero-sexual thoughts as well as in sexual congress. His interest is entirely directed to women ; indeed, he has developed a distinct taste, and likes to change the object of his attentions from time to time. Now, as formerly, he is in active correspondence with his fiancee, and is attracted to her by real love. Since in the last seven months the former perversion of desire has not expressed itself in an}' way, and whereas the sexual life is fully regulated, the patient may be regarded as cured. The time of observa- tion was one year and five months. CONTRARY SEXUAL INSTINCT. 281 Case 67. Personal Observation. Active Contrary Sexual Instinct with Imperative Ideas, Dependent on Neuropathic Predisposition ; Ex- hibition, Algolagny, and Impulsive Onanism. Essentially Improved in Twenty Sittings. Period of Observation, Two Months. J., aged 27 ; scholar. Mother has religious insanity (in asylum) ; father health}'. Of eight children, two died soon after birth ; one brother died by suicide in his sixteenth year, another is shy and mood}'. The sixth brother is weak-minded ; the seventh is married, father of a family, and healthy. In the family of the patient's father there is said to have been weak- minded members. The average intelligence of ancestors on the mother's side is said to be higher than on the father's side. In his youth the patient had measles, but no other diseases. Right inguinal hernia. The patient describes his first sexual manifestations as follows : "I have no recollection of any sexual excitement before my thir- teenth year; my sexual desire lay completely dormant, though, from expressions of my companions and certain passages in the Old Testa- ment, I knew quite fully the nature of coitus ; but of ejaculation I knew nothing. Otherwise it should be noted that I was very precocious mentally, but very weak physically, and read everything at the age of 9; so that books were kept away from me. Until my ninth } 7 ear I was irri- table, peevish, and a perfect recluse. From that time, with more rapid physical development, I gradually developed a taste for boys' play, and soon I became the leader in all mischief what my aunts called a bad bo} 7 . " At the age of 14, in climbing, by pressure of the thighs, I learned onanism, and I have since then practiced it until a week ago, now fre- quently, now seldom. The sight of semen completed my knowledge of the sexual process, and my imagination was often busy with thoughts of coitus ; and from the beginning only the role of the man interested me. Here I must remark that from the. day of my entrance into the Latin school handsome fellow-pupils attracted me ; and I entered into closer friendship with them than with others by preference, provided that their character was pleasing to me. And even yet handsome men can interest me for long only when their character is sympathetic for me; otherwise sensual excitement caused by the handsomest man is immediately ex- tinguished. " Now dreams of large, handsome men began ; and I loved to follow such persons in the street, to be able to look at them as long as possible. If such a man spoke to me, blackness came before my eyes and I returned shy and foolish answers. At that time it was m} 7 greatest enjoyment to see a man naked or in the act of coitus. When my com- panions began to court the school-girls, it seemed to me strange and tiresome; but, since it was the fashion, I also once undertook it; but when I once realized that I knew not in the least how to proceed, I was 282 SEXUAL PAILESTHESIA. greatly frightened. Besides, in spite of onanism and dreams with pol- lutions, I was not much influenced by sexual feelings, and therefore continued to be the best scholar in the class until I reached the second form. I was loved by my fellow-students ; always ready for mischief and nonsense." The patient's autobiography, which I here interrupt, gave me but an unsatisfactory explanation of the origin of his homo-sexuality ; from this description and its continuation, one might be tempted to believe in the original cerebral constitution, in a greatly-tainted individual, as being the cause of the contrary sexual instinct. Repeated careful questioning, after three days, led to the result that several other accidental influences, which he had regarded as of little moment, occurred to him, and gave me the key to a psychological understanding of his case. At the age of 4 or 5 the patient once went walking with his father. The father drew near to a tree to urinate, and with childish astonishment the boy looked at his father's penis. A sounding box on the ear disturbed his spying. He was not conscious of doing any- thing wrong, and for years he was busy with the thought of why he should have had this punishment. His interest in the male genitals, which seemed to him forbidden fruit, was artificially first aroused by the punishment. As soon as he had opportunity, he looked at male genitals, which, since the box on his ear, had played an important part in his imagination. He remembered regarding the picture of " Apollo pursuing Daphne" in a gallery, because Apollo was figured with an erected penis. Prom the original interest in male genitals there was secondarily developed an interest in male nudity, statues, etc. The fol- lowing important event, and which was also later recalled, completes the etiology of the patient's sexual perversion. At the time of his first onanistic manipulations, in his thirteenth year, he slept in a room with a friend. The desire to see male genitals was shown in the case of this companion, and the patient's rest was disturbed by it. At 4 in the morning, while his room-mate was still in deep sleep, the patient got up, approached his bed, and lightly raised the covers and his friend's shirt. In great sexual excitement he looked at his genitals. Then he returned to bed and masturbated while his imagination was busy with the image of his naked companion and his genitals. He thought of how his friend might perform coitus, without thinking of the part of the female. As we see, external circumstances of intense effect on a childish mind induced the lively fancy of the male member, which, by further experience and accompanying onanistic acts, finally become imperative. All other symptoms which com- pleted the condition of contrary sexuality are of a secondary CONTRARY SEXUAL INSTINCT. 283 nature. The hereditary taint explains the intense excitability of the patient, and his final inability to resist the manifestations which were developed from the experiences enumerated. The unditferentiated sexual feeling, therefore, was made pathological and inverted by accidental influences and the accompanying reflex effect of onanistic habits. But the autobiographical state- ments of the patient are so made that from them alone one would be forced to regard his abnormality as congenital ; the more because the patient wrote them while still under the in- fluence of reading von Krafft-Ebing's " Psychopathia Sexualis." After this digression, necessary for an understanding of this case, and so instructive in its bearing upon the examination of urnings, we may return to the history of the case. In his auto- biography the patient continues: " While I was not yet 17 two, friends persuaded me to take a trip to M., where the nearest brothel was. I had not the slightest desire for the thing ; but I went to avoid hanging back. Before going I drank to gain courage. The woman excited my repugnance by her hanging breasts. I had no erection at all, and only after prolonged manipulation by the woman was I able to perform coitus, and that without the slightest feeling of pleasure After the act I slipped away ; and while the others could not say enough in describing the pleasure they had had, I remained silent, irritable, and ashamed. I now thought myself impotent as a result of my onanism, and I sought to repair this defect by temporary abstinence; but renewed attempts resulted in similar fiascoes, and in despair I returned to onanism. Continued onanistic excitement grad- ually induced a weakness of my mental powers and my energy. I could no longer take the first place. 'The teacher reproached me with want of ambition, and, since I was threatened with imprisonment and the can- silium abeundi for joining a student society and for taking part in various drinking pai'ties, my place in the esteem of the teachers was lost. Still, in mathematics, in which I was about the best, I always took one of the first places, and I passed a respectable final examination. In the fall of 1885 I went to the university. Here, during the first years, I led a pleasant life. Now and then I visited prostitutes, but always with the same lack of success ; so that at last I abandoned the matter entirely. Originally light-hearted, now my thoughts began to be directed to my peculiar sexual disposition, for in time it struck me that my lascivious dreams were so often of men and so very seldom of women, and that in pictures and statues male nudity excited me, while female nudity left me cold. I accidentally read the statement in a book that, aesthetically, the 284 SEXUAL PAILESTHESIA. male body, and especially the male genitals, were more beautiful than the female, and I comforted myself with the thought that my aesthetic feeling was finer than that of my friends, who merely ridiculed me for my asser- tion. In the same way I explained to myself the fact that certain ones of my friends who were especially handsome and well formed, and of amiable character and sympathetic, gave me, at the merest contact, an inexplicable feeling of pleasure (no erections, of which, perhaps as a result of long- continued onanism, I was incapable, but a thrill through my nerves). At that time, in my innocent and happy moods, I loved to place my arm around my friend's neck or waist, or I stroked his hair, which led him to joke me about being a pederast. When it was said " G. (my name among friends) has pederastic inclinations again," I laughed with the rest, and was not in the least irritated. I had not the remotest idea that I had anything in common with pederasts, who, to me, were a kind of fiction, and even up to a year ago I joined in the ridicule about the ' spinalstecher.'' I had a repugnance for these persons ; and still to-day, though I understand my condition, I cannot free myself from this feel- ing ; and this is not the least of the reasons why I feel my perversion as painful. " I now come to the last and most important phase of my con- dition, in that it finally gave me the desired understanding of it; it took place during this year. One after another of my friends left the high- school, to my great distress, for I am dependent on them, and still cor- respond with them all. Only one remained, the one I loved best, my friend A., who has obtained a situation here. He is a thick-set, strongly- built man, with a remarkably handsome face of pure German type, and a complexion uniformly ruddy and healthy ; his temperament is joyous and sunny, and he is an example of truthfulness and frankness, with a determined, manly bearing, all characteristics which irresistibly attract me. " We were always on the best of terms, and now when we were thrown so much together we became more closely attached to each other. Last winter circumstances made it necessary for him to live in my room for weeks at a time. After a week I could not live without him. At 6 in the evening he would come home, where I awaited him with impatience. At 8 or 9 or 10 o'clock in the evening we were ac- customed to go out; until that time he worked and I studied or read. If he had had enough work he would stretch out on the sofa, and I then always felt forced to look at his genitals, which, owing to the tight trousers he wore, were often clearly visible. It was strange that for a long time 1 did not experience this degree of sensual excitement when I saw his genitals exposed, as I often did ; for at first, in his innocence, he made no attempt to conceal them while dressing and undressing. Since, in his jolly way, he was always accustomed to joke, one evening we had CONTRARY SEXUAL INSTINCT. 285 a sham fight. He bolted away and threw himself on my bed ; I followed him, grabbed him by the neck, and choked him hard. In this act I came on top of him, abdomen to abdomen, and suddenly I had a powerful erection, which was quickly followed by an ejaculation. I had never felt such intense lustful pleasure, and I was never so joyous and light-hearted as when we went out to a restaurant immediately sifter. From this time I used every opportunity to strike him on the thighs and nates, or to stroke his hair; but, when I noticed that these things were annoying to him, I got out of the habit. Evenings I began to set him on for a fight, and, since he was much stronger than I, I had to exert myself, and I had thus an excuse for hugging him tightly, which always soon induced ejaculation. This continued for eight or ten evenings. If he were not disposed to tussle, I became cross. Otherwise I was jollj r and much more industrious than usual. It was a delight to me to live. Then, unfor- tunately, I once allowed myself to grasp his genitals while embracing him. How I came to do it I do- not know ; for, with the exception of this one instance, I have never in my whole life attempted this or allowed it done to me. Now, my secret joys were over. He became angry and scolded me, and I felt as if I had been given a sound box on the ear for a low act. In a state of the most terrible depression I told him the whole truth, and begged him to believe that I was not a pederast, and that I did not even understand myself. As well as he could he com- forted me and advised me to visit a girl, but I did not do it. We remained the same good friends, and no allusion was ever made to the incident ; indeed, after this we spoke of sexual matters only with reserve. " But his innocent manner was ended ; he suffered but unwillingly even the most innocent touch, and he was anxiously careful to conceal his genitals from me. But in this waj' he only increased my desire to see them to an insane longing. When at night I lay sleepless in bed listen- ing to his breathing, I suffered terribly. Once I could no longer restrain myself, and went to his bed to touch him. But while standing at his bed, trembling and panting with excitement, the former scene came back to me, and I saw that I was about to commit a much lower, because a secret, act on him while sleeping, and that, were he to awake, it would cost me his friendship forever. The loss of his respect would have cost me my life. I quietly went back to my bed. " I once dared him to undress entirely before me. Strange to sa}-;- I had never seen him naked (on account of his under-garments). His answer was short and to the point : ' I do not respond to such silly dares.' And he was right. The next month we had separate rooms. " The last } r ear, I think, has done more to destroy m}' nerves than all the previous ones together. At least, in previous years I was spon- taneousl} 7 light-hearted ; but now I require stimulants, of which I know two, the jollity of my friend and alcoholics. 286 SEXUAL PAR^STHESIA. " My mood was that of a wasted existence. Impulse unsatisfied ; great moodiness. No man ever had more to suffer than uiy loved friend had in my whims. I suffered unspeakably with this unsatisfied desire, and was petulant in his presence. And yet, in quiet moments, I had to thank him for his reserve and strengthen him in it. But this did not keep me from at last becoming jealous when he for a long time became very friendly with a man who was very umittra&tive to me ; and I could scarcely meet him without finding the hated man with him. I should have preferred to have him entirely to myself, and 1 became irritated when he spoke of other friends whom I had never seen in my life. On the other hand, it did not excite me in the least when he went to have sexual congress or to court a girl ; rather, I noticed with proud joy the advances that were made to him every where, and where possible I helped him in this. All my unpleasant moods he bore with great patience, and willingly forgave me in view of my unlimited sacrifice and friendship. Thus we parted as dearest friends. Had I discovered any unpleasant side of his character, critical judgment necessary for such a thing was not wanting to me even in the warmest love, my sexual feeling for him would have been quickly extinguished. " But my love for him became more and more ideal, like the best type of friendship ; and I thank his determined energy that it saved my weak will from the greatest errors. " Accident determined that on the day following his departure von Krafft-Ebing's book should fall into my hands. Now I first saw clearly my condition. My determination was soon made. I congratulate myself that you live here in Munich, Doctor. I feel as if I had been rescued from an abyss ; and since the two days during which I have had the honor to be your patient, I feel free from sexual desires and much more light-hearted. " After this general description of my sexual development, it re- mains to give a few points in more detail. " 1. Sexual Inclinations. My desires are never directed to bojs or young persons, but always to men from 28 to 50 years of age, but they must have .beards. They may be large and with full beards, or solidly built and with moustaches. In general I prefer blondes (but not flax- blondes). An indispensable condition, however, is a pleasant, manly character. Everything feminine is unattractive to me. " The following incident may be considered characteristic of this : During my first semester, at a ball I made the acquaintance of a gentle- man with whom (luring the evening I became very confiding. During each interval between the dances he sat by my side, and I conversed with him in :i lively and natural way ; for he impressed me as being very amiable, fine-mannered, and devoid of affectation. He seemed very grateful for my attention. When going home he expressed a desire to CONTRARY SEXUAL INSTINCT. 287 walk along with me. This seemed overdoing the matter, for I am not at all of a timorous nature. At the door, when I was about to open it, and with words of thanks put out my hand to him, he suddenly seized me, embraced me violent!}', and grasped my genitals. Surprised, I pushed him away and asked him if he were crazy. He stammered a few words and hurried away. I have never seen him since. I did not feel the slightest excitement, though this may have been due to the alcoholics I had taken. " In addition, I have one thing to mention concerning the manner of satisfaction as I conceive it. According to my experience, simple contact is sufficient ; but still, I should prefer to kiss my lover and grasp his penis and scrotum. I think I could easil}' go on to coitus inter femora and masturbation of the other. To have onanism practiced upon me is not desired. I should like coitus inter femora by men who attract me sexually, but whom I do not love ; but with my friend, whom I really love, I can think of myself only in the female role. Never, however, should I allow immissio penis in anum or in os, neither actively nor passively. In sexual relations I am thus usually active. " 2. My attitude toward the female sex is absolutely indifferent. I neither seek nor avoid women. With educated ladies I am for the most part embarrassed, a thing which, in association with men, happens only under unusual circumstances. With young, refined girls, whom I would gladly court, this embarrassment is still greater; but to court them I now feel less capable than ever. With girls of low position, toward whom I have a feeling of social superiority, or with those already engaged, the sexual element is wanting, and I can be friendly and entertaining, and I am much esteemed by them. The sight of female beauty excites my aesthetic interest. If there be associated with it an amiable character and genuine maidenly conduct, I am able to regard such a person for minutes at a time; but an erection would be impossible. All touching of female breasts and limbs, which I have often enough practiced with prostitutes in the hope of finally feeling sexual excitement, has been without avail. " Coitus is possible after manipulation by the woman ; ejaculation occurs as a result of mechanical rubbing of the penis in the vagina ; I cannot value the whole act of coitus as equal to that of onanism, which, sadly enough, is indulged in in case of necessity. Moreover, I have not attempted coitus in four years, at least. The manner in which it is necessar}' for me to force myself to it embarrasses me, and its perform- ance fatigues me very much. "Twice I have come into close contact with the female sex. At the age of 17 I made the acquaintance of a pretty girl, whom I might have possessed. Rendezvous at a garden. Kisses and fondling of the breasts. No erection or sexual approaches. At a ball, great jealousy 288 .SEXUAL PAR^ESTHESIA. of a comrade she preferred ; but I think it was a feeling of injured pride. " On the second occasion the object of my attentions was a baker's daughter, whom I learned to know at a church-festival ; but all at once she began to take hold of me, and I was so frightened that I made my escape. " 3. My dream-life offers but little noteworthy. I dream almost exclusively of men ; very seldom of women. It is peculiar that, at least as far as I can remember, I have never dreamed of myself in ideal sexual intercourse with a man; but men come before my eyes like tifata morgana, do some indifferent act, and again disappear. They are either nude or tlie}^ have their trousers open and the penis is erect, but often not. In the same way, I cannot conceive myself as in the act of coitus with women, but they appear to me nude, with firm, round breasts, and wandering about in a garden. The breasts always please me more than the genitals, which interest me but little. " When I was 10 years old I once saw a woman with large breasts and repulsive, long nipples, nursing her child. As far as I know, erec- tion did not occur, but I experienced a peculiar feeling, made up of a mixture of lust and disgust, which remained in my memory for years. Now the memory of it has no effect on me. " Two years ago I had a lively dream. I sat under a tree in a squatting attitude, and beautiful, nude women fell down from the tree, one after another, into my lap, and I had congress with one after another from behind. At last, it became so intense that I awoke and found that I had had a copious ejaculation. The penis was in an unpleasant erec- tion ; for the whole weight of the bed clothes, rolled into a bundle, had rested on it, and this, perhaps, occasioned the dream. " 4. My Character and Appearance. Voice usually baritone, but of higher quality. Abundant growth of hair everywhere. My inclina- tions are entirely masculine. I smoke, drink, and like to swim ; and I should have liked to learn to fence and ride, had my means permitted it. " In my present state of depression 1 avoid dancing, but formerly I was passionately fond of it, and was considered a good dancer. I have never yet had any desire to dance with a man. " I am very fond of music. Since coming here I have been at the opera probably three hundred times. Too, I am much interested in languages, but my interest in poetry and belles-lettres is not above the average among educated people. My education is not very thorough ; I do not know much outside of the subjects pertaining to my occupa- tion. In conversation I like earnest subjects, but I do not object to variety. " In reading the newspapers I confine m3 r self to politics, and am well up in such matters ; but I do not despise a novel by a recognized CONTRARY SEXUAL INSTINCT. 289 author. In general my reading is directed to political, historical, lin- guistic, and ethnographic work. " Among my friends I formerly occupied a middle position, but now I prefer to go my own way, and I have gradually come to be consid- ered eccentric. " I love animals, and cannot bear to do harm to any creature. Mod- esty was once one of my virtues ; and even now I lay much store by good morals and respectability, and I can be very severe when an acquaintance offends against them seriously. Ribaldry is repugnant to me; but, on the other hand, I am fond of elegant equivocation. I am not cowardly, but good-hearted, and all my friends find fault with my lack of egoism. " I can think logically. Great love of truth and justice, in defense of which I had a duel with pistols, in which three shots were exchanged. I am not easily moved, and never weep. I am easily embarrassed. No preference for soldiers. My gait is firm and manly. Still, it seems to me that in the course of my disease my feeling of honor has suffered. I am less scrupulous in the acceptance of favors and money. While formerly I was quick to react to insults, I now pass over much." The autobiographical statement of the patient should be com- pleted in some particulars. The sight of male genitals excites him sexually only when the face is attractive. He states that he has never had erections at the sight or thought of a woman. Psychical and tac- tile onanism, which at present is practiced on an average once or twice a day, helped to invalidate the predisposed nervous system. Power of erection has suffered ; occasional priapism. No pollutions at night. But there is spinal irritation, and painful sensations after onanistic excesses. The patient also presents symptoms of cerebro-spinal neurasthenia. Dragged appearance ; relaxed attitude. Great irritability ; slight frontal headache on slight exertion, also after taking small amounts of alco- holics. Mornings he often lies in bed till 10 o'clock in a doze. Tired on awaking. Great apathy. Shy and suspicious. Want of energy. Depressed. Under the influence of painful depression he attempted suicide two years ago by means of opium. The dose was insufficient, and the patient was saved by medical skill. Again the patient stands on the verge of a catastroph} 7 . At a later visit the patient informed me that he had come to me with the determination to shoot himself should my prognosis be unfavorable. His ability to work has suffered seriously. He is not able to follow the lectures at the university. Great confusion. Asthmatic troubles. Obstipation alternates with diarrhrea. Unable to pass his examinations. Sexual organs normally formed and of medium size. Mons veneris covered with abundant hair. Somewhat anaemic in appearance. Myopic. 290 SEXUAL PAR.ESTHESIA. MEASUREMENTS OF HEAD. Horizontal circumference, . . . . . .58 cm. Posterior half-circumference, . . . . .23 cm. Anterior half-circumference, 32 cm. Lateral line over vertex, 41 cm. Antero-posterior line over vertex, . . . .30 cm. ' Ear-chin line, . . . . . . . .30 cm. Greatest antero-posterior diameter, . . . .19 cm. Greatest lateral diameter, . . ;-, . . 15cm. Diameter at auditory meati, 12 cm. Diameter at zygomatic process of frontal bone, . 12 cm. Distance from auditory meatus to root of nose, , 12 cm. MEASUREMENTS OF PELVIS. Diameter at anterior superior spines, . , . ... 23 cm. Diameter at crests, . . . ... .27 cm. Diameter at tubera ischii, . . . . . .10 cm. Diameter external conjugate, . . . . 11 cm. Diameter at trochanters, . . . .... 28 cm. A favorable prognosis could be given, because the patient's homo- sexual tendency, which depends upon the imperative idea of male genitals, is to be regai'ded as the product of unfortunate educational influences affecting an individual neuropathic by heredity. All other symptoms onanism, neurasthenic troubles, tendencies to algolagny and exhibition are essentially of a secondary nature. There is the more reason for expectation of improvement or cure in this case, since hetero- sexual inclinations are proved to exist, and because the masculine char- acter, as such, has not been involved. Other. changes (apathy, etc.) are to be regarded as neurasthenic symptoms due to onanism. Probable duration of treatment, one year. The treatment, which was begun on January 29, 1892, while the author was engaged on the concluding portions of this work, was anti- neurasthenic with respect to the secondaiy symptoms. Three points were made in the suggestive therapy (in hypnosis) : 1. To overcome the impulsive onanism. 2. To remove the imperative idea of male genitals and the homo-sexual inclinations. 3. Systematic cultivation of hetero-sexuul inclination. On the first attempt the patient became somnolent. Itypotaxis. Arms fixed. Suggestive catalepsy. Deepening of the sleep by frequent repetition. Up to the present time the patient has been subjected to twenty sittings, with very notable success. Since the first day of hypnosis (during four weeks) complete absence of onanistic tendencies, without relapse as yet ; mood pleasant ; full of hope. During the treatment to ALGOLAGNY. 291 the present time there have been no homo-sexual inclinations, and ho imperative ideas of male genitals. Twice dreams of men without pollution. On the other hand, awakening of interest and desire for women. He paints fancies of hetero-sexual congress, and repeatedly dreams of sexual situations with women, in which he plays the active role in coitus. After a few weeks, desire to go to a ball, which he is advised to do. Erections become more frequent, become stronger, and finally occur spontaneously in connection with hetero-sexual ideas. February 19th, following a suggestion, he overcomes his shyness and seeks a prostitute. At the house, great shyness and a desire to turn back. The patient, who soon overcame his embarrassment in the pres- ence of the woman, was led to drink too much wine, and the absence of erection he attributes to this. Nevertheless he is well satisfied that his performance of the masculine role was so successful, and on the follow- ing morning, in the memory of the pleasures he might have had, he had " one erection after another." His sexual desire for women becomes more and more prominent ; his general condition gives no cause for complaint ; and the patient may at present be considered as essentially improved. He is still treated in hypnosis daily. ALGOLAGNY. Case 68. Personal Observation. Active Algolagny and Contrary Sexual Instinct in an Individual Predisposed by Heredity. Improve- ment of the Algolagnistic Inclinations by Suggestion. A., aged 30 ; phy- sician, Poland. In his youth his father had a psychosis, recovered com- pletely, and reached a great age. Father's sister was also insane, but recovered and remained well. The father's character was hard, despotic, and quick-tempered ; he was normal sexually, though not passionate. He was able to keep from intercourse five years. Mother, natura frigida ; never had lustful pleasure in coitus. Four of the children died, one brother by suicide ; another brother is normal, married, and the happy father of several children. One married sister is likewise a natura frigida ; another, though unmarried, seems to be passionate sexually ; and three sisters seem normal. One of the patient's brothers seems to be a psychical hermaphrodite ; at least, he is given to exceedingly warm friendships with persons of his own age, and is said to have lately fallen in love with a girl. The patient is most closely attached to his mother. He does not remember to have been ill before the age of 10. At the age of 9 A. shared his sleeping-room with a comrade, who often got in bed with him. On such occasions, in joke, A. grabbed his friend in the nates and then smelled of his fingers. Patient cannot remember that this gave him unusual feeling of pleasure. This may have happened four or five times. 292 SEXUAL PAK^ESTHESIA. Alxnit this time the patient introduced a lead-pencil into his anus, and he remembers that this gave him a pleasant sensation. The patient does not know whether it caused an erection or not. At any rate, the events mentioned seem to have directed the attention of the hereditarily pre- disposed boy to the nates ; for, since this time, the gluteal region has played an important role in the patient's imagination. It seems as if the first premature sexual excitation had occurred simultaneously with the fancies mentioned. Also at school from this time the nates p^ed a role. The patient inquired of his companions whether they had been beaten on the nates. On the other hand, A. does not remember that he was ever punished in this way. With reference to this point, the patient says in his biog- raphy : " I remember with distinctness that at that time I often dreamed for hours of how I should do with my children ; in what cases they would be punished, how I should do it, etc. I cannot remember to have had erection or ejaculation in connection with this." When 10 and 11, the patient " now and then" introduced objects like lead-pencils, penholders, etc., into his anus, but without experiencing pleasant sensations or erections as on the first occasion. When a child, he had the bad habit of playing with his genitals, which once induced erection, but never ejaculation. " When," the patient continues, " at the primary school I saw pupils punished on the nates, as far as I remember, I experienced no feeling of pleasure. During my time at the gymnasium, I struck myself several times, as well as I could, with a Spanish tube." At the age of 15 he developed imperative ideas of another kind. " I can still remember that at a time when I had not yet developed neuras- thenic symptoms, in the hours of worship, whenever the teacher spoke of the Holy Ghost, I thought, ' D you, Holy Ghost 1' And this gave me intense pangs of conscience. Now I no longer doubt that at that time I was afflicted with an imperative idea. I also read and re-read letters after they were finished, to be sure that they contained no error in orthog- raphy. I sometimes opened, for this purpose, letters that had been sealed." Between the age of 16 and 20, when A. bathed with companions, he experienced an irresistible impulse to spank them with their trunks on, an act which excited him sexually, but it did not induce erection. " Once I fell in love," he continues, " with a very handsome schoolmate, but without meeting with a return of affection. A friend did the same thing. I am sure that, in this matter with us both, the sexual element was not in play. My friend is now the happy father of a family. I desired to kiss my handsome schoolmate. Erections did not occur with the thought. At 19 I now and then had pollutions in sleep, which were accompanied by dreams of beating a boy on the nates with a switch. At that time I never had opportunity to talk of sexual matters, and thus ALGOL AGNT. 293 did not think of the dreams. That as I grew older the desii-e for women would occur, seemed a matter of course." After graduating from the gymnasium A. went to the university and began the study of medicine. While at school he had thought much of chastity, and regarded non-marital intercourse as u unprinci- pled." In this particular his education at the hands of his father, who was very strict, may have been to blame. Too, his mother's influence had a very retarding effect upon his development. Against his father's will A. entered a societ3' which had chastit}^ as a principle. The patient cannot remember to have been in love with any member of the society. As a student of medicine, he first had oppor- tunity to see nude female and male forms. At that time examination and touch of the persons of both sexes induced neither erection nor ejaculation. A. passed his examinations, and only when a physician, two years after his examination, did he come to understand his sexual charactei 1 . On examining the male chest, spontaneous erections with ejaculations occurred. On this point the patient writes: " At that time I read Niemeyer's text-book for an explanation of the matter, but found there but a short, encouraging note concerning it, according to which congenital inversion of the instinct was a condition easily over- come, with the help of the imagination. Soon after that I saw von Krafft-Ebing's ' Psychopathia Sexualis,' and thus at last the scales fell from my eyes. Then came hours of misery. The thought of never being able to marry often troubled me ; for I am as one created for family life; delighted if I can but stay with the family for a short time." When a student the patient fought in several student-duels, and was known as a skillful fencer. He served as a one-year volunteer, and took delight in manly sports. When a soldier, it so happened that he was once forced to spend the night in a room with a friend. Though no deep feeling attached him to this 3 T oung man, one evening, after he was in bed and while his friend had not yet come in, he thought he would induce his companion to beat him on the nates. For this purpose A. left the light burning, and, pretending to be asleep, he uncovered his gluteal region and placed himself so that his nates would immediatelj" catch his friend's eye as he entered. The patient hoped that he would give him a sounding blow. But, to his chagrin, he made no use of his opportunity. In medical practice boys from 10 to 14 years old have the prin- cipal charm for the patient. In no case are such persons to be more than 26 3 T ears of age. Absence of beard is another condition ; but a small moustache does not prevent excitement. Whenever the patient is concerned in his practice with young persons fulfilling these conditions, he feels an impulse to beat them on the nates ; but the impossibility of 294 SEXUAL PARJESTHESIA. performing such an act does not trouble him. Tn pi-actice, whenever possible, he gets a sight of the nates. And he never fails to ask his patients whether they have been punished at school. During such questioning he has frequently had erections with subsequent ejacula- tions. In his autobiography the patient thus describes his sadistic inclina- tions : " A handsome, youthful face; finely-developed thorax; powerful thighs, but especially beati fully-rounded nates, charm me. On the other hand, male genitals are indifferent. Once I saw a friend's penis in erec- tion. A boy of 14 once had erection on lowering his trousers to facili- tate examination. The boy had ejaculation. In this, however, I experi- enced no lustful pleasure, but rather a feeling of disgust. The thought came to me that he certainly was given to onanism, and that I should spank him soundly. " Whenever I have opportunity I cannot resist the temptation to touch the nates with my hand. The anus also charms me to a certain extent, in spite of my aesthetic disgust. Whenever I have occasion to make a digital examination (for haemorrhoids and the like), I have in the act a feeling of lustful pleasure, which, however, is followed by a feeling of disgust. Vaginal examinations, or female nudity in general, have not the slightest sensual effect on me. I have no horror feminae ; only one specific female odor is unpleasant to me. " I must mention here that last year I had erection while reading in a newspaper how in London certain parents sold their daughters to persons to beat ad nates." These statements are to be supplemented as follows: The patient' is excited sensually only when he can give pain to young persons aged from 10 to 26 years. At the same time he is contrary sexually and actively algolagnistic. Though the nates play the principal role in his fancy, still other acts which inflict pain cause him sexual excitement. These are especially all operations on persons having the characteristics previously mentioned. For example, in scraping out the ear for lupus and in making injections of all kinds A. has erections and ejaculations. His lust in giving pain is so great that of late years the patient has several times sought to beat himself, but without experiencing any intense excitement. On the other hand, the same longing drove l\'\m,faute de mieux, to practice injections of distilled water on himself. Orgasm and ejaculation on the second attempt. No week of his practice passes without the occurrence of sexual excitement of this kind. He never has any desire to kiss the object causing him excitement, but merely the sight of the thighs and nates immediately induces erection. A. makes the following statement concerning his character: "My mental endowment is that of the average man. Desire for comfort ; I am soft and yielding. I 'am but little touched by the suffering of others. ALGOLAGNY. 295 It is difficult for me to refuse a request to any one. As for the rest, I have no feminine inclinations. For female toilettes I have not the slightest taste, and thus have often angered this or that lady of my acquaintance. I am not vain or anxious to please. I have no under- standing of feminine occupations. Aside from my occupation, my interest is principally in politics, history, and legal matters. I was a skillful fencer, and took part in live student-duels. To physical pain, operations on the teeth, the suturing of gashes, I am almost insensitive. In the society of women I am shy, that is, with young ladies unknown to me. On the contrary, I like to associate with married and unmarried ladies with whom I am intimate. The thought of marriage with a young girl is attractive. I have often had waking dreams about it ; how nice it must be to have a pretty wife at one's side in bed. But always the thought would come, ' You cannot have congress,' and this would make an end of my dream." Neurasthenic symptoms had only been noticed by the patient of late. Incited by Moll's work, " Contrary Sexual Instinct," which the patient read with interest, he began to cultivate hetero-sexual thoughts, the object of which was an attractive friend of his sister. During the night of October 20, 1891, he dreamed that he must begin hetero- sexual intercourse, and he awoke with a dull head. During the next week the patient felt neutral sexually. On the other hand, every night lie had feelings of anxiety which " apparently depended upon the idea that he must be insane." Then erections at the sight of boys again occurred. " Now," says the patient, " came the thought, ' You cannot be normal if you are excited sexually by men.' That passed away. On the other hand, unexpectedly came this imperative idea, ' You are not insane.' Darting pains, restless sleep, and disquieting thoughts of sui- cide and the asylum troubled me." A journey brought him to Munich, and he visited me on November 19, 1891. The patient's appearance was thoroughly masculine. Abundant development of adipose tissue; beardless; abundant growth of hair. Hair blonde. No noticeable approach to the female type in the form of the pelvis or the position of the thighs. Internal organs healthy. FORM AND MEASUREMENTS OP HEAD. Male. Female. 1. Horizontal circumference, . . 60.0 cm. 55.0 cm. 53.0 cm. 2. Posterior half-circumference, . 23.0 cm. 24.0 cm. 22.0 cm. 3. Anterior half-circumference, . 32.0 cm. 30.0 cm. 28.0 cm. 4. Lateral line over vertex, . . 33.0 cm. 36.0 cm. 34.0 cm. 5. Long line over vertex, . . . 36.0 cm. 35.0 cm. 33.0 cm. 6. Ear-chin line, . . . . 29.0cm. 30.0cm. 28.0cm. 296 SEXUAL PAR^ESTHESIA. CALIPER-MEASUREMENTS. Male. Female. 1. Long diameter, .... 18.0cm. 18.0cm. 17.5cm. 2. Greatest lateral diameter, . . 16.0 cm. 15.0 cm. 14.0 cm. 3. Diameter at auditory meati, . . 12.0 cm. 12.5 cm. 11.5 cm. 4. Diameter at zygomatic process, . 12.5cm. 11.0cm. 11.0cm. 5. Distance from auditory meatus to nasal spine, . . . . 12.0 cm. 12.0 cm. 11.0 cm. 6. Breadth-index, .... 88.0 80.0 70.0 PELVIC MEASUREMENTS. Diameter at anterior superior spines, . . . 26.0 cm. Diameter at crests, 28.5 cm. Diameter at trochanters, 31.5 cm. Diameter external conjugate, . . . . . 21.5 cm. The foregoing history, made up of the patient's statements and autobiography, requires but few additions. The patient's dreams are infrequent and are usually about whip- ping. After reading von Krafft-Ebing's " Psychopathia Sexualis," patient twice dreamed of performing pederasty with boys, which induced ejaculation ; more frequently, however, ejaculation occurred when he dreamed that lie beat the boy on the nates with his penis. In the waking state he abhors the act of pederasty. A. often takes his genitals in his hands and looks at the reflexion of his nates in a mirror, finding great pleasure in the procedure. It gives him special pleasure, during the heat of summer, to walk about his room naked. Stroking his nates, even when he does it himself, gives him lustful pleasure. With the exception of rheumatism and typhoid fever in 1885, the patient has had no illness. Besides the neurasthenic troubles mentioned, he is often troubled with pressure in his head. He does not smoke, but he drinks five or six glasses of beer daily (a glass contains about ^ litre). With the masculine character of the patient, and in that he had never attempted coitus, it was possible to give a favorable prognosis. November 21st. First attempt at hypnosis. A. immediately be- comes somnolent, and, with a correct understanding of the hypnotic procedure, seeks to increase the influence auto-suggestively. He passes into hypotaxis. Suggestions : (a) Abhorrence of male nates, the inflic- tion of pain, and homo-sexual desires. (6) Interest in women and pref- erence of them. Occurrence of erection at ideas of hetero-sexual char- acter, (c) Cessation of imperative ideas and neurasthenic symptoms. November 22d. The patient has thought much of female nates without experiencing any feeling of repugnance. Otherwise, condition unchanged. Treatment and suggestion as yesterday. ALGOLAGNY. 297 November 23d. Last night A. dreamed, as a result of suggestion, that he abhorred men, and that boys' nates no longer made any impres- sion on him. To-day the patient developed the imperative idea that he could not be hypnotized if he put on any other than the suit of clothes he wore yesterday. Repetition of the procedures of yesterday. November 24th. No progress of importance. To-day coitus and success in it are suggested. Hypnosis and suggestions as usual. November 25th. Yesterda} r the patient was in a brothel, and had no success whatever. Tlie puella continued manipulation ad genitalia for twenty minutes without inducing erection. The patient tried to induce excitement by looking at the woman's nates ; but this was also without effect. Complete fiasco. Energetic suggestive treatment looking to progress, and to quiet A. November 26th. Last night A. dreamed of women, and had erec- tion on waking, but he could not state that there was an}' relation be- tween them. Hypnotic treatment as usual. November 27th. Last night dreams of boys, with erection. The general condition improves ; imperative ideas disappear. Repetition of the procedure. November 28th. The same treatment as yesterday. November 29th. Last night dreams of whipping and of women, with erection. Pollution without dreams. Suggestive treatment. Success in coitus promised for to-night. November 30th. The patient spent all last night with a puella. Toward morning erection occurred, but it disappeared as soon as the girl touched the organ. Complete fiasco. General condition better. Treatment as usual. Homo-sexual dreams the next night. December 1st, 2d, and 3d. Hypnosis daily. During the night of December 3d erection occurred with a puella, and immissio penis was successful, but erection disappeared without the occurrence of ejaculation, a little progress. December 4th. The usual procedure. December 5th. Last night another attempt with a member of the demi-monde. Again erection and immissio penis. Friction continued four minutes without the occurrence of ejaculation. Attempt abandoned. H3 T pnotic treatment. December 6th. The patient attempted to induce ejaculation by means of onanism, in order to facilitate it with a woman. But he does not succeed. Erection occurs, but not ejaculation. Hypnotic treatment. December 8th, 9th, and 10th. Daily hypnosis without essential change. Onanistic attempts always unsuccessful. Careful local examina- tion of the genitals, made b}* a specialist at my instance, gives a negative result. December llth and 12th. Hypnosis. 298 SEXUAL PARyESTHESIA. December 14th, owing to his business, the patient was forced to suspend treatment, but he intended to submit himself to further treat- ment as soon as he could have time for it. He was discharged as slightly improved. Three weeks after his departure A. wrote me as follows: "Here, during the first few days, I noticed immediately that the contrary sexual feeling was scarcel}' changed. I have at various times had erection and ejaculation while examining young men ; but, expressing myself with caution, it seems to me that the sadistic tendencies have disappeared. After a longer period of observation I shall be able to send you a more exact report. My general condition is much better ; I am much less troubled by imperative ideas. Appetite and sleep are excellent." I advised the patient to use the erection induced b3 T the sight of male nates to attempt coitus. Four weeks later, on January 3, 1892, the patient again confirms his former statement, and says, " The sadistic inclinations seem to have actualty disappeared." From this the patient must be regarded as improved with respect to his algolagnistic desires ; likewise in respect to his general condition. On the other hand, the con- traiy sexual instinct still exists unchanged, and, in my opinion, will not be overcome until regular hetero-sexual intercourse has become possible. While the power of erection has improved, it is still difficult to excite the ejaculation-centre.. In spite of the relatively slight success, the case offers prospect of cure, or of essential improvement. This task, which is none too easy, remains for a future repetition of the suggestive procedure. Case 69. Personal Observation, A Case of Paraesthesia Sexualis (Rudimentary Passive Algolagny?) Successfully Treated by Suggestion. Male, aged 27 ; official. No hereditary predisposition. Diseases of childhood. Onanism since his eighth year. In his sixteenth year the patient once had a pollution while having his hair cut in a barber-shop, due, as he says, to pressing his thighs together while his fancy was occu- pied with lascivious images. From his eighteenth to his twenty-third year, normal intercourse with women. At the same time there were long periods (six to nine months) in which there was no intercourse at all. In these periods of continence especially he was often subject to the thought of having his hair cut, and this was accompanied by erection. The inadequate stimulus of hair-cutting became a factor in inducing excitement of the sexual sphere, usually inducing lustful feelings, some- times ejaculation. Too, in his dreams the shears of the barber pla3 - ed a more effectual part in inducing pollutions than did ideas of hetero- sexual intercourse. The patient had often clearly seen the repulsive and unnatural character of his ideas, but he became powerless in combating this imperative idea. Whether the psycho-sexual process mentioned is ALGOLAGNT. 299 to be regarded as a symbolic act of the nature of masochism (vide von Krafft-Ebing) i.e., passive algolagny or merely as an associated result, due to habit, of an accidental occurrence accompanied by intense emo- tion, cannot be determined with certainty. Too, this case was observed one year before the appearance of von Krafft-Ebing 's first publication on masochism. In coitus erection is incomplete, ejaculation delayed. The patient painfully realizes the perversity of his sexual character, is much depressed, and complains of neurasthenic symptoms, which are to be regarded as a result of his sexual anomaly, especially his onanism. Melancholy ; hypochondria ; frequent physical examinations by several physicians merely out of anxiety, but with negative results ; loss of self-confidence ; sleeplessness due to grubelsucht. Neuropathic expression of eyes ; changeable subjective complaints. Physically the patient appears to be in blooming health. Tendency to extremes ; unnatural, feverish ambi- tion in his occupation, which he has changed several times. Formerly imagined heart disease, concerning the absence of which the patient is now re-assured. His inconstant character and his dependence upon the mood of the moment make the possibility of systematic treatment seem doubtful. Like so man}' others, the patient believes that he cannot be influenced in an h3 - pnotic sitting. In October, 1889, the patient submitted to irregular hypnotic treatment. In the time from October llth to 22d the sleeplessness was overcome by suggestion. At the same time, quieting psycho-therapy in the waking state. Increase of self-confidence. The first attempt at coitus, after a long period of continence, was made October 20th, as a result of hypnotic suggestion. Moderate lustful feeling; incomplete erection ; delayed ejaculation. From this time until the middle of No- vember the patient discontinued treatment without any reason, and sub- mitted to hypnosis but three times more, from the 9th to the 16th of November. On November 15th coitus was more successful and gave him more satisfaction. Inclination to have his hair cut opposed \)y suggestion in each sitting, and also fanciful ideas of that nature both while awake and in dreams ; on the other hand, lively interest in women and greater self-confidence were suggested. Gonorrhoea brought our efforts to an involuntary end ; and there has since been no hypnotic treatment. The patient always passed only into a state of slight lethargy ; no amnesia, but he always felt very well after waking. The result of psy- chical treatment both in the waking and hypnotic state (fourteen sit- tings) is : disappearance of subjective troubles, especially sleeplessness, and the depression and hypochondriacal preoccupation. Suggestion in the slightest degree of hypnosis proved to be more effectual than simple advice. 300 SEXUAL PAR^ESTHESIA. The ideas of hair-cutting retired into the background, and during treatment played no part at all. After the patient had been induced, by means of suggestion, to repeatedly perform coitus, and after these attempts had proved so successful, even though not brilliantly, that the patient had regained self-confidence, as soon as the gonorrhoea was cured he entered into a relation, as he informed me later. The consequent regular sexual congress exercised a favorable ps}-clio-sexual reflex effect ; it grew more and more successful, finally satisfied the patient completely, and prevented all return of the perverse ideas previously mentioned. After six months the patient presented himself as cured ; and when I saw him, in May, 1891, he was satisfied in every way with his state of health and his sexual power. In this case hypnotic therapy could not be employed systematically enough, but it nevertheless brought about essential improvement, though in combination with psychical treatment in the waking state. Case 70. Personal Observation. Passive Algolagny (Flagellation) and Other Perverse Hetero-sexual Activity of the Instinct Essentialty Improved by Suggestive Treatment. S., aged 31 ; married. Father died of cerebral softening. Mother and other members of family healthy. At 18 pneumonia, with serious relapse ; since then weakness of lungs, cardiac palpitation, and asthmatic symptoms. Condition otherwise satisfactory. The patient appears weak and delicate. Relaxed muscular system ; general nutrition good. Inclination to dyspepsia; flatulence; obstipa- tion ; unstable ; pulse increased by the slightest emotion. According to S.'s autobiographical statement, his sexual appetite appeared in his tenth year, but his desires were directed exclusively to active and passive flagellation. In his thirteenth and fourteenth years these ideas disappeared. First pollution in his fifteenth year. One year later, first masturbation. After that onanism was practiced regu- larly until his eighteenth year, but without ideas of coitus. " But my only desire," writes the patient, " was masturbation performed by a female, or some other unnatural satisfaction, flagellation by her, for example." In the various sexual acts the patient was alwa}'s in the passive role. He says, farther, " Coitus seemed unattractive to me. In my twenty-first year I tried it for the first time, but was unsuccess- ful ; thereafter it was somewhat better, and I then had congress quite regularly with women, but without real pleasure (onanistic acts on the person of the woman) ; for a certain fear disturbed me, and three years ago I was very unsuccessful several times in succession. Since this time I have avoided it, and I have not had the moral courage to venture farther trial of it. Since then I have limited myself in hetero-sexual congress, which is very passionate, to some unnatural act of indulgence, and in these acts I feel extraordinarily potent. In these cases erection, ALGOLAGNY. 301 which formerly was delayed, occurs instantly. After such intercourse I always feel well mentally, and morally satisfied, if the thought that the thing is abnormal does not trouble me." D Irritable weakness of the ejaculation-centre, probably due to sexual abuse. Insufficient erection and premature ejaculation in attempts at coitus. The patient tries to find other reasons for the perverse act of sexual gratification. Thus, he declares that his companions prefer the perverse manner of indulgence, and do not permit him to attain to coitus ; besides, he wishes to avoid causing pregnancy. The perverse substitutes consist of passive flagellation by the hand of the woman, mutual masturbation, and coitus in os. In these, as mentioned, he is always potent. Impotence in the natural act increased with the frequent and regular repetition of these acts. The pathological sexuality, which may be regarded as partly due to the inherited neuropathic constitution, and partly to unfavorable educational influences, is felt to be a hindrance to married life. Therefore he desires help through psycho-therapeutic procedures. From the 19th of October to the 21st of December, 1889, nineteen sittings. At the first attempt great somnolence, hypotaxis. After waking, indistinct memory. Energetic suggestions : (a) Abhorrence of the perverse acts. (6) Increasing inclination to natural intercourse, (c) Complete power in coitus, self-confidence, and erection, (d) Physical health. After the second hypnosis, attempt at coitus in a cab. Complete fiasco ; premature ejaculation with relaxed organ. The suggestions of October 29th are regularly repeated in the following sittings. Hypnosis increasing to somnambulism. There were sittings October 31st, November 2d, 4th, 5th, 6th, 7th, 9th, llth, 12th, 19th, 28th, 30th, 31st, and December 2d, 10th, 16th, 18th, 21st. November 2d. Erection better, but it disappears in the perform- ance of the act. November 4th. Relapse; coitus in os. November 6th. Normal coitus performed, though with incomplete erection, and without lustful pleasure like that experienced in perverse acts. November 9th. Erection better. The patient has congress in the normal way, but the abnormal equivalent is still pleasanter, in spite of energetic opposing suggestion. November 12th. S. has more pleasure in natural .intercourse ; erection improves. November 19th. Relapse at a woman's instance. My advice to break off the relations with this woman he rejects. November 28th. Very deep somnambulism is induced by means of 302 SEXUAL PAR^STHESIA. longer continuance of the hypnosis (half an hour). Very energetic idea, as already imparted. After this sitting moderate feeling of dullness, which disappears when he gets out into the open air. December 2d. Coitus again, normal and with good success and complete satisfaction. In the following sittings up to December 21st permanent success suggested. Treatment had to be discontinued on account of an attack of in- fluenza, and was not resumed. I have had no opportunity to get any news of the patient's subsequent condition. During the last two weeks of treatment the patient's inclination to perverse acts had decreased considerably. At any rate, suggestive treatment made the patient able to perform coitus in a normal way, which previously had been impossible ; though, owing to the short time he was treated, it is not to be expected that in the future erection will be complete and occur regularly. Nevertheless, in this case the essential improvement attained by suggestion is note- worthy, and, like the other cases, it points out the way in which com- plete cure is to be produced. CONCLUDING REMARKS. The table on the opposite page shows the results in thirty- two cases, which may be arranged as follows : Failures, 5 = 15.625 per cent. Slightly improved, 4 = 12.5 per cent. Essentially improved, 11 = 34.375 per cent. n , ( with later report, . 10) 10 0>T e Cured, < } 12 = 37.5 per cent, (.without later report, 2) 32 100.0 per cent. Of the 32 patients 5 were not amenable to hypnosis ; 8 passed into somnambulism, 13 into hypotaxis, and 3 became only somnolent. In 3 cases the degree of susceptibility is not given by the authors. More than one-third of the cases that is, 12 of the 32 were completely cured; and in 10 of these it was possible to determine, by later observation, that the cure was persistent. In several cases the period of observation ex- tended over a year. Indeed, von Kraft't-Ebing observed one case two years ; and I had opportunity to watch a discharged patient two years and seven months. Four other patients were kept under observation more than a year, and a somewhat larger number longer than six months. CONCLUDING REMARKS. 303 ? viO^O^^C^O^C^^OO^AC^CnCTi Q7 1 cncnoiCnCnOi ^- ^- _ i^-. ^- ^. j* co o5o^i3:;j>4*'W't5H-oOD*j w o^wio^-o < OOMOI ***c*3bo^-o55 GASES. |.| ssss j.| :s . , ;;;;;; \ : j | | | | 1 | | III !|l ' 1 ! 11* el? g 1 D '** '3 o o o J ffi 1 I 9 OVO M f>r*5 t* rig o eo ?^ H H O i F 5" S* P*s g Male. Sax. . ^. ^H-h-. . h-. h-. *-. . H-. . . H-. h- . . h-. h-h-H-. . . 20-30. O w s: N-; M*. 1 1 1 -! *-i ~i ! - !-!-!- ; h-h-: - . : : : ~~ 30-40. M 40-50. i *^, Sittings. co Somnolence. .i- 1 .. .t- 1 ..-.. .'-'.. 5 Hypotaxis. 00 Somnambulism. O< !- . . I-" t . l-l . . . - Failure. * Temporary. IMPROVE- MENT. h*. 1-". . I-". ..I- 1 ... .. p ,_,* ' * ,_,' ' ^,,_, " ,_, ^^ " " ^j' * p_,|_i " ,_i" ,_i" * Great. CO F'th'r Co'rse Unknown. . . .. ' , With Later Report. O H M Without Later Report. : : : : : : : >- ^ - - -"i-i i-o. ta ^ ~>^. Relapse. CC> CC^O M^ H > Sr'tIO H CtHC H H >5* "i *3 'S 2 -3 f I 2 5 ? = ? o ~-'^" 5~n'.2:r-' :0 -??> S 5 * 2.2.2. s 2.3 = 3 19 S fie 3 f?& *ffx5 ? ^ ^J 2: 2. s o s = n o o" g 3 s. i--Sws3so^^g- <<_ _^ i" g> rt slf. g c -I* Sxial i Igfl^l 11 s" Z 3-^ frg-S & g3 s rt2. ft g&' g,S "So : g*< 2 E S x?P I =-g|92o o^S g : vS T3 Q. B 1^ ^3 ^* o fl5 *^ o r* ? 3 i* ^ s s l."5 = ?= 5 ,B-onc-f |^ IB O / ... * ? & if* &P.P, REMARKS. 304 SEXUAL PAR^STHESIA. The certainty of this manner of observation and the care- ful report of relapses, which are seldom to be met with in other branches of therapeutics, justify us in drawing almost certain conclusions from the material at hand concerning the prospects of cure in cases of sexual parsesthesia. 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 hypereesthesia. 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 ; the fancy of the 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, that 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, erTemination is a secondary manifesta- tion of homo-sexuality, then, logically, the sexual transforma- CONCLUDING REMARKS. 305 tion, in the sense of a male-feeling individual, cannot take place without affecting the mental life of the individual concerned, even though 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-pictures, and a physical reflex effect 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 in 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 ! APPENDIX. PREPARED FOB THE ENGLISH EDITION IN OCTOBER, 1894 ; TRANSLATED FROM THE AUTHOR'S MANUSCRIPT. THE studies in the pathology and therapy of psycho-sexual anomalies contained in the foregoing work were published 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 has 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 help. Case 18, Section I. 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-half years that have passed. She resumed her calling and removed to another city. The last written report 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 child ; 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 27th 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 B,. 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 new 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 which 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- oughly 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 gradually 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 my 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 neuropathic , 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 truth, 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 the 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 you a report. Since I left you 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 times 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, four 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 him time for treatment. In December, 1893, he informed me also that he was convinced of the hopelessness of his condition (a belief with which I can- not agree). He states that he has never been successful in the 312 APPENDIX. onanistic act ; at the same time he is doubtful about mar- riage, because of the possibility 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 have the greatest desire to have a family, but I must accustom myself to the inevitable. I repeat what I told you verbally, that 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 IIL The sexual condition of this patient became perfectly normal through 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 IIL This patient died, one and a half years after the appearance of the German edition of this 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, 1 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 the human sexual glands with the related sexual organs, and also that the beginning of 1 Von Krafft-Ebing, " Zur Erklarung der Contraren Sexualempflndung," Jahr- bucher far Psychiatric u. Nervenkrankheiten, Bd. xiii, 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 KrafFt-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, 1 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 1 Laurent, Les bisexues. Paris, Carre, 1894. 314 APPENDIX. frequently become the victims of vice and prostitution than of love ; the majority are, in his opinion, indifferent from a sexual stand-point. The same author designates those men as gynseco- masts whose sexual organs have 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 Krafft-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. With 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, 1 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 our 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 the 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 1 Klinische Vorlesungen iiber Psychiatric. Wien, Braunmiiller, 1890. APPENDIX. 315 which the act of sucking is associated, which now becomes a cortical movement, associated with the feeling 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 1 ? There are tactile sexual sensations arising from the corpora cavernosa, but no inborn instinct 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, 1 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 benev- olentice for the numerous homo-sexual individuals, Eulen- burg, 2 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 the 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 1 Die contrarie Sexualempfindung. Berlin, Kornfeld, 1893. 5 " Neuropathia sexualis virorum," Klinieches Haudbuch der Harn- und Sexual- orgaue, 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, such patients did not fulfill this requirement, no deep and lasting success could be attained. The favorable reaction of hetero-sextial 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, Krapelin l 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 1 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, 1 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 afflicted 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,^ 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. 1 " Ueber perverse Sexualempflndung," Zeitschr. fur Psychiatric, 1894, Bd. 1, Heft 5. 318 APPENDIX. Geill 1 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 masochism Eulen- burg has adopted the word algolagny, suggested by the writer, in his work previously cited. As a reason for this, Eulenburg rightly states that the 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 role is as little so of the heroes and heroines of the 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 onanistic 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 zob'pliilia and bestial algo- lagny, 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 the body was associated with it, would be necrophilic algolagny, and it would be differentiated 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. 1 " Die Lehre von der Psychopathla Sexualis und ihre gerlchtsarztliche Bedeutung," Ugeskrift for Lagert, R. xxvii, Nr. 27-33. 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 1 concerning criminal psychol- ogy and penal laws. According to his view, the proof of the endogenous 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 1 " Krirninalpsychologie und Strafgesetzgebung," Deutech. MediciDalzeitung, Oct. 10, 1894, p. 890 et seq. 320 APPENDIX. himself of the property of others. At most, it might be said that the gratification of homo-sexual inclinations was a private matter between two persons, which does not harm society as long as scandal is not excited by it. There seems to be no doubt, however, that among those persons that indulge in homo- sexual acts there are many insane individuals." According to Sommer, 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 perverse sexual feeling in their psychological, pathological, and forensic aspects. 1896. Catalogue of the Publications of THE F. A. DAVIS CO., /Medical Publishers ^ Booksellers, PHILADELPHIA, PA. PHILADELPHIA : 1914-16 Cherry Street. NEW YORK: 117 W. Forty-Second Street. CHICAGO : 9 Lakeside Building, 214-220 S. Clark Street. ORDER FROM NEAREST OFFICE. FOR SALE BY ALL BOOKSELLERS. 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