For a detailed treatment of the subject of hermaphroditism, reference should be made to the special literature of the subject, and above all to the exhaustive and laborious work of Neugebauer.[66]
CHAPTER VI
ETIOLOGY AND DIAGNOSIS
The last chapter dealt with pathological phenomena in the sexual life of the child. From the considerations urged in this and in earlier chapters, it will have become apparent that sexual manifestations in childhood are not necessarily to be regarded as pathological. This conclusion does not conflict with the assumption that certain factors influence the sexual life of the child. The numerous individual differences suffice to indicate the existence of such factors. Many of these are of a pathological character, but others have no connexion with the domain of pathology. Among the factors thus influencing the sexual life of the child, we can distinguish those affecting the germinal rudiments from those which exercise their influence later. Those of the former group first demand our attention.
In certain families, the early awakening of sexuality is observed with remarkable frequency. These are often neuropathic or psychopathic families, and moreover the early awakening of the sexual life is frequently associated with neuropathic or psychopathic symptoms. But this is by no means always the case, and often enough such persons belong to healthy families and are themselves healthy. We are therefore not entitled to regard the occurrence of sexual manifestations in childhood as a proof of degeneration or of a morbid inheritance. But equally erroneous is the opposite view, that the early awakening of sexuality is an indication of exceptional endowments. It is true that in many persons of genius premature sexual passion has been observed, and such manifestations are by no means always confined to the contrectation impulse. We learn, too, in our consulting rooms, that not infrequently the most diligent schoolboys exhibit at a comparatively early age the phenomena alike of contrectation and of detumescence. But the fallacy of drawing general conclusions from this fact is shown by the additional fact that in idiots and imbeciles premature awakening of the sexual life is also of common occurrence. In cases such as were formerly described as moral insanity, but which in Germany to-day are classed with imbecility, sexual assaults on others are very common at an early age. This is true also of other forms of idiocy and imbecility. In asylums for such patients, feeble-minded children not infrequently make sexual attempts on nurses and on other inmates. In this connexion, we have to consider both components of the sexual impulse, the phenomena of contrectation as well as those of detumescence. In the case of low-grade idiots, we often see the phenomena of pure detumescence, without the accompaniment of any sexual inclination directed towards another person; this is simply physical masturbation, performed under the promptings of an organic impulse. But not only in imbeciles and idiots, and in persons of genius, but also in those with perfectly normal mental endowments, the sexual impulse, and more especially the phenomena of contrectation, may appear at a very early age. Persons with artistic tendencies develop in this way with comparative frequency. We must, for these reasons, guard against the misconception that the early awakening of sexuality is per se pathological. The fact that the study of the sexual life has been undertaken chiefly by medical men, and above all by neurologists and alienists, has inevitably introduced a certain bias into the results of the investigation. Opportunities for the study of the sexual life of normal persons have been comparatively rare; for those in whom the early awakening of sexuality has been recorded have for the most part sought medical advice and treatment for some other reason, and the physician has taken the opportunity to make inquiries into the patient's sexual history. The boundary-line between what is pathological and what is normal can be determined only by an extended study of the sexual life in normal persons. By very numerous inquiries I have done my best to effect this; and a careful examination of the accumulated material leads to the above-mentioned conclusion, that an early awakening of the sexual life is commoner in those with an abnormal nervous system than it is in healthy persons: but it also appears that an abnormal sensitiveness of a non-pathological character, such as is exhibited by persons with the artistic temperament, and likewise a disposition excitable to a degree which cannot yet be called morbid, predispose the subjects to an early awakening of sexuality.
To attain to clear views on this question, it is necessary to bear certain distinctions in mind: first, as regards the different periods of childhood; and, secondly, as regards the two components of the sexual impulse (detumescence and contrectation). My own investigations have led me to draw the following conclusions. During the first period of childhood, that is to say, up to the end of the seventh year of life, the occurrence of manifestations of the sexual impulse must arouse suspicions of the existence of a congenital morbid predisposition. But as regards the phenomena of detumescence, which are confined to the peripheral genital organs, we must make an exception to this rule if they do not appear spontaneously, but result either from local inflammatory or other morbid changes, or from deliberate seduction of the child to the performance of sexual manipulations; at any rate, in such cases, the probability of the existence of congenital morbid predisposition is greatly diminished. I am also forced to regard as suspicious the occurrence of phenomena of contrectation during the first period of childhood, although not to the same extent as are the peripheral manifestation of the sexual impulse—and I hold this view notwithstanding the numerous cases recorded by Sanford Bell. Passing to the second period of childhood, the phenomena of contrectation may appear at the very beginning of this period, that is, during the eighth year of life, without justifying the inference that any morbid predisposition exists. Regarding the phenomena of detumescence, we must not hold them to be necessarily morbid when they make their appearance during the last years of the second period of childhood; but when this occurs earlier, during the tenth or eleventh year of life for instance, some suspicion may reasonably be aroused. In this general survey of the material, it did not appear that any important difference existed between the two sexes in the matters under consideration; but I believe that in girls the phenomena of contrectation often make their appearance somewhat earlier than in boys, whereas, on the other hand, the occurrence of the phenomena of detumescence at an early age is more likely to indicate the existence of congenital morbid predisposition in girls than it is in boys.
In the delimitation of the pathological from the healthy, I have endeavoured to lay down broad general lines. It must not be supposed that precisely at the close of the first period of childhood, that is to say, at the end of the seventh year of life, the sexual life, and our opinions as to the significance of its manifestations, undergo sudden alterations. Our estimates as to the significance of phenomena occurring during the early months of the eighth year of life, will not differ materially from our estimates as to the significance of the same phenomena when they occur during the last months of the seventh year. My conclusions have no more than a general application, based as they are on the recorded experiences and on my own personal observations of numerous persons, healthy and diseased.
Let us consider further what are the factors favouring an early awakening of the sexual life. I have previously mentioned the fact that in certain families a remarkably early sexual development is quite common. This is true also of certain races. But the data bearing on this question are not quite so trustworthy as might be wished. The fact that among certain nations marriage sometimes takes place at a remarkably early age, is no certain proof of the early awakening of sexuality in persons of this nationality; for the marriage may be a purely ceremonial affair, and may be effected long before the individual is ripe for sexual intercourse or for procreation; and the first act of intercourse may not take place until several years after the ceremony of marriage. Among ourselves, marriage, especially in the case of men, does not as a rule take place until long after the age of puberty, and it therefore seems to us very remarkable when, in another race, men marry ten years earlier; but this must not be taken as a proof that sexual development occurs at an earlier age. We can gain some knowledge of the subject from the statistical inquiries which have been made regarding the appearance of that manifestation of puberty which is most readily available for such inquiries, namely, the first occurrence of menstruation. Ribbing[67] has made a study of this question, and gives the following figures regarding the commencement of menstruation in women of different nationalities in various places: Swedish Lapland, 18 years; Christiania, 16 years, 9 months, 25 days; Berlin, 15 years, 7 months, 6 days; Paris 15 years, 7 months, 18 days, and 14 years, 5 months, and 17 days; Madeira, 14 years, 3 months; Sierra Leone and Egypt, 10 years. From these data we should naturally he led to infer that there would be great variations in the age at which other manifestations of the sexual life first make their appearance, and experience justifies this inference.