SEXUAL PSYCHOSES BY MORTON PRTNCP], M.D., PHYSICIAN FOR DISEASES OF THE NERVOUS SYSTEM, BOSTON CITY HOSPITAL CLINICAL INSTRUCTOR IN DISEASES OF THE NERVOUS SYSTEM, HARVARD MEDICAL SCHOOL, BOSTON. EXTRACTED FROM The American System of Practical Medicine. Edited by LOOMIS AND THOMPSON. LEA BROTHERS & CO., Publishers, PHILADELPHIA AND NEW YORK. SEXUAL PSYCHOSES. MORTON PRINCE, M. D. SEXUAL PERVERSION; CONTRARY SEXUAL INSTINCT; SADISM; MASOCHISM; FETICHISM. Sexual Perversion. The subject of sexual perversion is important medically, socially, and forensically—medically, because it may form part of a group of symptoms manifested by the insane or degenerate, or, as some writers hold, may be a psychopathy in itself; socially, because it may in its consequences deleteriously affect social decency and order; forensically, because it sometimes leads to murder, theft, and other crimes, the motive for which cannot be understood without a knowledge of the per- verted instinct and of the underlying psychopathy when this is present, as is usually the case. So far as this perversion is the expression of pathological conditions of the nervous system, it is important that it should be considered in this work. The consideration of the subject here is still further made desirable by the fact that even when the deformed instinct can be looked upon as only a cultivated vice, nevertheless in many such instances the individuals who practise it are affected with some form of insanity or imbecility, so that they are properly the subjects of medical study. Then, too, even if we may take the ground that it is almost always through perversity or cultivation that psychopathic individuals develop a perversion of the sexual instinct, nevertheless it is difficult to deny that the final residt may be a true psychosis or perversion which may have the force of imperative feelings. Thus, though vice may be the road traversed, the last stage may be disease. The sexual instinct may be associated with and excited by thoughts, feelings, and acts which to a normal individual are repulsive or without any sexual association ; in other words, the sexual instinct is perverted. Tt may be excited by (and therefore lead to) acts of cruelty or violence inflicted upon the opposite sex (sadism), or by the opposite state, the passive suffering of pain which has been inflicted by the opposite sex (masochism); or it may be excited by certain objects, whether a part of the female body or dress or other objects (fetichism). Perversion may further take the form of homo-sexuality; that is, the substitution or coexistence of sexual feeling for the same sex in place of, or by the side of, that for the opposite sex. This is also known as contrary sexual instinct or sexual inversion. These different forms of perversion have also been classed as varieties of sexual parsesthesia. Before entering Vol. IV.—56 882 SEXUAL PSYCHOSES. into a further analysis of these conditions it will be well to briefly con- sider the pathological groundwork upon which they rest. We shall then understand better the relation of the perverted instinct to the individual. The first important question is, How far are these perversions the necessary expression of a disordered nervous system, and how far do they represent merely indulgences in vice and cultivated habits ? So far as they are simply vicious habits, they can only be regarded as per- versity, not perversion; that is, as vice, not disease. This view is not altered even in the case of individuals who have degenerated or in other ways diseased nervous systems, provided that they have cultivated the habits, and that the habits are the direct result of such cultivation, as may occur in normal individuals. A paranoiac or an imbecile may cultivate vice as well as a sound-minded person. Degenerate people may not be morally or legally responsible, but this is not a question of responsibility, but of genesis. What is the origin, and what influences have developed the sexual aberrations? If these aberrations are the manifestation of a diseased nervous sys- tem in the same sense as hysteria is the manifestation of a neuropathic condition, then these sexual phenomena are true perversions and path- ological. On the other hand, as far as these perverted instincts are merely cultivated habits of feeling or acts—that is, are modes of per- versity—they do not properly belong to the subject matter of a medical work, unless, perhaps, the individuals otherwise exhibit pathological defects. Blit if they are the symptomatic expression of disease, they properly constitute a part of medicine. There are two views regarding the nature of perversion which are radically opposed, and which from a social and therapeutic point of view have respectively important consequences. The one leads to therapeutic nihilism and social hopelessness, the other offers hope and possibilities. The theory that has been most widely accepted by writers on the subject is that sexual perversion has its basis in a diseased nervous sys- tem, which in most cases is the result of inheritance. A psychopathic or neuropathic groundwork is in almost all cases essential, but the per- verse phenomenon arises spontaneously without external cause. Its origin is therefore entirely independent of cultivation by vicious habits, education, or seduction. In some instances, it is equally maintained, these perversions are acquired as the result of cultivation, with or with- out the co-operation of an inherited neuropathic condition. But it would seem that with the exception of fetichism, which is always acquired, the acquired cases are a distinct minority. In most cases nascitur non jit. “ This perverse sexuality,” says von Krafft-Ebing, speaking of the contrary sexual instinct, “appears spontaneously, without external cause, with the development of sexual life, as an individual manifesta- tion of an abnormal form of the vita sexualis, and then has the form of a, congenital phenomenon ; or it develops upon a sexuality the beginning of which was normal, as a result of any definite injurious influences, and then appears as an acquired anomaly. Careful examination of the so-called acquired cases make it probable that the predisposition, also present here, consists of a latent homo-sexuality, or at least bi-sexuality, which for its manifestation requires the influence of accidental causes to SEXUAL PERVERSION. 883 rouse it from its slumber.1 While objections may be made to this theory when applied to homo-sexuality, the theory has considerable strength when we seek for an explanation of sadism and masochism. Between the homo-sexual influences and the sadistic influences which lead to murder and mutilation of the victim’s body there is a wide gulf, and we should not necessarily expect a similar pathological condition as a basis of both. As to sadism, von Krafft-Ebing expresses the opinion that, “ as a rule, it may be safely assumed that the psychopathic state (per- verse instinct) exists ab origine.” Von Krafft-Ebing’s2 work being almost the first to treat systemati- cally the subject of sexual perversion, and presenting the matter with great erudition, has been very widely drawn upon by subsequent writers. The interpretation of these aberrations given by this author has very profoundly influenced medical opinion, and has been quite extensively accepted. This work was soon followed by a publication on the contrary sexual instinct by A. Moll,3 who also adopted the congenital theory originally proposed for this anomaly, it is true, by Casper,4 in 1852. In America, Kiernan (1888), Chaddock, and Lydston (1889) have advocated the congenital theory. Quite a large number of contributors to the sub- ject, with reports of numerous cases of different kinds of perversion, have appeared since von Krafft-Ebing’s work. More lately a strong protest against these views has appeared in the work of von Sehrenek- Notzing.5 This author, in opposition to the opinion of the writers just cited and of others, has urged with great force that sexual perversion, instead of being an original psychopathy, is a cultivated instinct. Hered- ity and a neuropathic constitution play an important part, but this part is only that of weakened power of resistance to external influences. The contrary sexual instinct is, as such, not inherited, nor is it congenital any more than are the majority of psychoses, but only that tainted or degenerated nervous system in consequence of which the individual offers a mental weakness, a lack of resistive power to external influences, and a lack of control over desires, however excited. By a process of cultivation the neuropath develops feelings and gives them expression in outward acts over which he sooner or later may lose all control. The first awakening of the perverse instinct maybe entirely fortuitous or by auto-suggestion, or it may be by seduction or other accidental external circumstances; from this time on it is a process of education. Von Schrenck-Notzing would explain in this way the origin of all forms of sexual perversion, although in the exposition of his theory his argument is devoted almost entirely to the contrary sexual instinct. The influence of von Krafft-Ebing’s able exposition of the subject, as just said, has colored much of the writings of others, but I think the 1 Psychopathia Sexualis, translated by Charles Gilbert Chaddock, M. D., 1893. See, also, “ Zur Erkliirung der Contrliren Sexual Enipfindung,” Jahrbueher fur Psychiatric und Neurologie, 1895. 2 According to von Krafft-Ebing, the most important previous writings were those of Moreau (Des aberrations du sens genesique) and Tarnowski (Die Krankhaften erscheinungen des Geschlechts-Sinnes). 3 Die Contrare Sexual Empfindung, Berlin, 1891. 4 Westphal adopted the congenital theory for contrary sexuality. 5 Suggestive Therapeutics in Psychopathia Sexualis, translated by Charles Gilbert Chad- dock, M. I)., 1895. 884 SEXUAL PSYCHOSES. conviction must be forced upon the careful student of these writings that the attempt to make vicious habits the result of congenital anoma- lies has been based upon evidence that from its very nature must be incomplete and unreliable. Rather, the cultivation theory, modified perhaps, is that which must commend itself to the intelligent and common-sense mind. As von Schrenck-Notzing has pointed out in his careful study of von Krafft-Ebing’s published cases of contrary sex- uality, very few of them will stand analysis. The autobiographies of such individuals are untrustworthy, and probably there is no class of people whose statements will less stand the test of a searching cross- examination than the moral pervert. The historical evidence further tells in favor of the cultivation theory. It would appear that homo- sexuality has prevailed in different times and amongst different peoples to an extent as to almost make of it a social custom. It was, for ex- ample, extensively practised amongst the ancient Greeks and Romans. To assume that ancient society was made up of degenerates is to reduce the theory to an absurdity. But while the congenital theory seems far- fetched in connection with contrary sexuality, it is not so easy to put it aside, even though we may not wholly accept it, when we seek an explanation of sadism and masochism. There are certain physiological facts which would seem to indicate that at times, at least, the association of lust and cruelty may be a sort of freak of development—i. e. of the association of feelings—although cultivation must play a tremendous part in the final evolution of the freak-like association. Von Krafft-Ebing explains the origin of this, the worst of the perversions, as follows : “ In an attempt to explain the association of lust and cruelty, it is necessary to return to a consideration of the quasi-physiological cases in which, at the moment of most intense lust, very excitable individuals, who are other- wise normal, commit such acts as biting and scratching, which are usually the result of anger. It must further be remembered that love and anger are not only the most intense emotions, but also the only two forms of active (sthenic) emotion. Both seek their object, try to possess themselves of it, and naturally exhaust themselves in a physical effect on it; both throw the psychomotor sphere into the most intense excite- ment, and then, by means of this excitation, reach their normal expression. From this standpoint it is clear how lust impels to acts that otherwise are expressions of anger. The one, like the other, is a state of exalta- tion, an intense excitation of the whole psychomotor sphere.” 1 “ Sadism is, then, nothing else than an excessive and monstrous pathological intensification of phenomena—possible, too, in normal con- ditions in rudimentary forms—which accompany the psychical vita sexualis, particularly in males.” 2 The same writer lays stress on the weakness or absence of all nor- mal restraining ideas in the psychopath, while free hand is given to the development and expression of the congenital perversion. But he neglects the influence which a deliberate cultivation may have upon a mild impulse or sensory association at the beginning. If sadism is an “excessive and monstrous intensification of phenomena ‘existing’ in a rudimentary form ” in normal individuals, then the perversion is the intensification, and the question is, To what is this intensification due ? 1 Psychopathia Sexualis, p. 58. 2 Ibid., p. 60. SEXUAL PERVERSION. 885 Does it exist ab origine in its intense form as a result of pathological development, or is the intensification due to cultivation by a normally depraved and mentally weakened individual? or may it be due to both? The autobiographies and histories of cases found in the literature do not allow of the first interpretation. It is possible that certain anomalous sensory associations may be the starting-point of such perversion, and cultivation does the rest. For example, the case was brought to my attention of a perfectly healthy, mentally and physically, medical man who was sexually excited by the sight of a surgical operation. This person is a typically strong and healthy-minded man. Suppose him to have been a mental degenerate, how easy it would have been for him to cultivate sadistic impulses ! The origin of sadistic impulses is of less practical importance than is that of contrary sexuality, as most of the individuals who exhibit the former are otherwise psychopaths (e. g. imbeciles, degenerates, or insane), though the question is of some importance, forensically, as bearing on the question of responsibility. It is obvious that forensically it is of great importance to determine the origin of these perversions, especially contrary sexuality, for upon the view taken must largely—not entirely—depend the matter of re- sponsibility. If this condition is congenital, responsibility must hinge upon the resisting power present in any individual case; but if it be the result of cultivation, the matter assumes a different aspect, for then we are dealing not with a perversion, but a perversity, a vice rather than a disease. From one standpoint this view may be modified. It is well recog- nized that symptoms may by constant repetition become organized into independent habit neuroses or psychoses, which persist long after the original disease condition which gave rise to them has subsided. In the same way, nervous processes which originally were the expression of physiological stimulation of the nervous system may become so intensely cultivated as to become in time true psychoses and independent of voli- tional control in weak-minded subjects. Thus it is conceivable that sexual feelings and actions may by constant excitation (cultivation) be- come associated together and developed into a sort of quasi-independent neural activity which may thus become practically independent of the will, or, in other words, a psychosis. Thus, what was originally an accidental association may by cultivation become a true pathological condition. This is exemplified by other neuroses and psychoses. Mor- phinism, alcoholism, and various habit neuroses may originate in this way. Thus it may happen that through perversity a true perver- sion may become developed. Such a perversion may acquire all the force of imperative ideas or feelings, as von Schrenck-Notzing thinks. If the aberration of sexual panesthesise are to be regarded as pathologi- cal (psychoses), this is unquestionably their true mode of origin and their true relation to perverse habits. It must still remain an open question, perhaps one of definition, whether mental habits thus formed are not to be still regarded as vice, and it must always be difficult to decide in individual cases whether or not cultivation has resulted in a psychosis. Perhaps the answer will depend upon whether the perverted feelings are really imperative or not—a matter not easy to determine. Finally, the important point, clinically, socially, and forensically, is the 886 SEXUAL PSYCHOSES. recognition of the fact that many perverts, mostly sadists, are insane, hopeless degenerates, and that their acts, even if cultivated, are the result of a lack of the power of the use of self-restraint. Sadism and masochism are the association of cruelty and suffering with lust; but in the former the expression of this instinct takes an active form in the infliction of the suffering on another ; in the latter the opposite occurs—namely, the lustful feeling is excited by the passive endurance of suffering. The term algolagny («/}or, pain, and /avvoc, sexually-excited lust) has been suggested bv von Schrenck-Notzing to include both these perversions, active algolagnia signifying sadism, and passive algolagny masochism. There are several forms in which each of these perversions finds expression. Sadism.—The desire to satisfy the instinct may lead to murder—so- called lust-murder. It is probable that many murders, the motives for which have seemed enigmatical or which have been overlooked, have been of this kind. In true sadistic murders the victim is killed, not for the sake of concealing crime or accomplishing rape, but because the act of killing excites intensely lustful sensations. In the most monstrous development of this perversion the sadist may commit the most bestial acts, such as cutting up and mutilating the body of his victim. Some- times portions of the body, especially the genitalia, are carried off. The Whitechapel murderer is probably a sadist. Sadism may be confined to an ideational form, without actual com- mission of violence. This is illustrated by a case of my own : A boy aged 22, with bad heredity, was in the habit of lying on the bed and indulging in sort of day dreams of the most vivid kind. He would then imagine himself killing young girls, tearing them to pieces, and eating them. This gave him great sexual excitement—in fact, was a method of practising onanism. His ideas grew until he imagined him- self living in towns and countries where, it being the custom for the men to destroy all the women in this way, great slaughter and cannibal- istic feasts were held. The boy in other respects was hopelessly insane, but he had managed to conceal his morbid condition for years. He was sent to an asylum and his mind has since become still more de- generated.1 Tardieu reports much the same sort of a case. Other forms which this perversion takes are—the mutilation of corpses ; cut- ting or stabbing (without killing), whipping,2 and defilement of women ; whipping of boys; torturing of animals, etc. It is hardly necessary to narrate here instances of these different acts, many of which are dis- gustingly repulsive. Details of cases may be found in monographs on the subject. A symbolic form of sadism has been described in which the perverse inclination expends itself in what are senseless and silly acts. Von Krafft- Ebing cites, amongst others (Case 35), the instance of “ a man in Vienna who regularly visits several prostitutes only to lather their faces, and Sadism and Masochism. 1 Reported in full in Boston Med. and Sure/. Journ., Aug. 20, 1896. 2 The writer is cognizant of the case of a man who regularly visits a prostitute, pay- ing her for the privilege of spanking her with a shingle, at the rate of a dollar a blow. SADISM AND MASOCHISM. 887 then to remove the lather with a razor, as if he were shaving them. He never hurts the girls,” etc. Masochism is the excitation of sexual feelings by the passive suffer- ing of pain or abuse. A common mode of having the pain inflicted is by flagellation, but it may take almost any form—e. g. being trodden upon, cut, beaten, etc. But often this perversion consists of more than this : then the- pleasurable sensations are excited by the idea of sub- jection to a woman, by whom the masochist is humiliated and made to feel that he is under her absolute power. In such cases the flagellation, or whatever be the mode of infliction of suffering, is only a symbol or evidence of subjection; it is merely an expression of the relationship. In fact, some masochists assert that when they have tried to realize their fancies by subjecting themselves to corporal punishment, the result has been a failure. It has been inferred from the statements of masochists that this idea of subjection is always the essence of this perversion. But this is hardly correct. It is not possible to recognize this idea in the accounts given in many cases, or if it is to be made out, it is only by a psychological subtlety that is hardly worth the analysis. Un- doubtedly, many sexually enjoy the brute suffering of pain ; on the other hand, with those who revel in the feeling of subjection the perversion may take a purely ideational form, without any attempt at realization of masochistic fancies. In this it is analogous to one form of sadism. It has been thought that a distinction should be made between true masochism and the reflex stimulation of weakened powers by flagellation of the nates. But it can scarcely be necessary or possible to make this distinction practically, as it is hard to believe that any one would have himself painfully whipped for such a purpose unless the [tain is accom- panied by pleasurable feelings, in which case it becomes masochism. A masochist may or may not be psychically impotent for natural coitus. As an example of the pure fancies of which this perversion some- times consists, and which are made use of to excite sexual feelings, the following from the autobiography of a masochist is typical: “ ‘ She ’ is a peasant-woman, a rough, tall, large-boned woman of forty or fifty years. She is the possessor of a small remote farm, which she works Avith the help of her slave alone. The work begins before sunrise. At four o’clock in the morning she opens the shed where she has kept me shut up over night, and wakens me, as I lie on the ground, with a kick; then she leads me out and harnesses me to a milk-cart bound for town. She leads me by a halter, and urges me along. On the road she gets on the heavily-loaded wagon and sleeps until the destination is reached. Then in the open market-place of the town, still harnessed to the wagon, I lie down on the bare ground to rest. Those passing knock against me or step on me, without giving me any attention. After the stock is sold we start homeward. After a short rest the work begins again, always under the direction of the mistress, who holds me by the halter and urges me on. At seven or eight o’clock at night I am put up to rest, and sleep until the next morning, when the same thing begins again. Work and blows, blows and work—no pleasure, no recreation day in and day out. “ Another time I fancy myself in the role of a paid lover of an elderly female roud, who makes use of me sexually in the most reckless 888 SEXUAL PSYCHOSES. manner, and in this direction makes the most shameful demands on me. If I do not submit to these willingly I am beaten and punished, and at the same time she despises me unspeakably, gives me tbe lowest household work to do, and on every occasion shows me how low an opinion she has of my manhood.” 1 Masochists who enjoy the actual infliction of pain usually employ prostitutes to abuse them, and for the purpose devise all sorts of schemes, sometimes curious comedies. Like sadism, there is a symbolic form of masochism, consisting of the various devices to represent subjection, as where a man has himself thrown out of the house or shaved by a woman. With this perversion there may be united greater or less tendencies to sadism and fetichism and contrary sexual instinct. Some cases seem to show a transitional state between masochism and fetichism, as when along with the association of pleasurable feelings with women’s shoes there is the desire to be trodden upon. Masochism seems to be a very common perversion if the state- ments of those who are subject to it and the evidence of prostitutes can be believed. In the form of flagellation it is common in this city (Boston), as in the large capitals of Europe, if the statements of those who should know can be believed. It certainly appears as a most extraordinary psychical phenomenon when it is considered in all its phases. Mode of Origin of Masochism and Sadism.—In seeking for an explanation of masochism we must recognize certain facts and phases of its development. In the first place, an analysis of the cases shows there is almost always a neuropathic basis, usually the result of a tainted heredity. The depth of this degeneracy does not, however, seem to be as great as it is in the extrepie forms of sadism. In the second place, the perversion begins at an early period of life with certain unusual asso- ciations of sexual, or other pleasurable feelings, with the idea of mental or physical suffering, subjection or pain at the hands of a person of the opposite sex (a woman). Starting with this primitive association of feelings, in process of time there becomes developed, on the one hand, most complicated mental states consisting of fancies, mental pictures, recreations, imaginary actions, etc., and, on the other hand, various forms of corporal punishment. Both may exist together or each sep- arately. We have to explain both the primitive feelings and its later development. Further, I think it must be admitted that, practically, masochism consists not in the primitive association, but in the final development. The sexual perversion consists in the often monstrous expression of the original association of feelings, rather than in the rudimentary association. So long as this association does not find expression in active mental fancies and physical acts, or at least so long as these fancies and acts which are used by the masochists to sexually excite themselves have not been created, masochism can hardly, with strictness, be said to exist otherwise than potentially. In other words, the perversion consists in the sexual excitation, and is a form of mas- turbation. Now, a study of the autobiographies of masochists shows plainly that the development and expression of the original primitive 1 Case 50, von Krafft-Ebing, trans. by Chaddock. SADISM AND MASOCHISM. 889 association have always been brought about by cultivation. The accounts plainly indicate that the masochist has wilfully and deliberately used all his endeavors to cultivate to the acutest form his imagination, to generate sensual images and dreams that would by association excite his sexual feelings, and when physical pain has been of service he has invented all sorts of devices for this purpose. In this way an associa- tion which primarily was loose has become so rigid, while the feel- ings which are united have become so acute, that an overmastering passion has become created that finally overwhelms the individual. This passion may then perhaps be called a psychosis, and possibly imper- ative, but, given the original association, the mode by which this devel- opment is brought about is perversity or vice. As to the primitive association of lustful feeling with passive suffer- ing it is not so easy to speak of its origin. It may well be that it may often, if not always, be congenital, something that exists ab ovo. But it does not follow from this that it is to be looked upon as necessarily patho- logical. There are a great many curious anomalous associations between customarily unrelated mental states which are experienced by healthy individuals, and which therefore can scarcely be regarded as more pathological than physiological. For instance, I have already men- tioned the otherwise healthy medical man who was sexually affected by surgical operations. This connection between the sight of blood and the sexual sense is apparently tolerably common. In Case 54 of von Krafft-Ebing it was the primitive association, and gave rise to the maso- chism, which in this case, it is interesting to notice, was the idea of being killed, the counterpart of sadistic murder. It is highly possible that such associations are analogous to anomalous physiological associations between the functions of other parts of the nervous system. For instance, colored hearing is an unusual but physiological phenomenon. Galton has shown that the power of visualization exists in a curious way in some people who see figures before them when thinking of numbers. I know of an individual who has a queer and exceedingly disagreeable sensation in the testicles whenever he hears of any violent accident that involves mutilation of the body. The sight of ugly wounds causes the same sensation. It is exceedingly probable that if a census were taken similar to that made by Galton, it would be found that anomalous associations between the sexual instinct and other sensa- tions and ordinarily unrelated ideas are fairly common and quite within the field of physiology. In the absence of definite knowledge on this point any attempt to explain the sexual perversion must be largely speculative. But it is easy to see that if, for instance, a person who was endowed with colored hearing should derive great and pleasurable excitement therefrom as from the sexual instinct, he might by cultiva- tion develop it into what would be called a perversion. Some writers might then feel justified in speaking of it as a congenital psychosis. In other instances the starting-point of primitive association may be in reflex stimulation of the sexual centres by spanking, as in Case 49 (K.-E.). A physiological connection of this kind is admitted. Binet would explain the perversion in this way. Again, it is not impossible that the sexual instinct may be awakened indirectly through the general emotional state that is common to the sexual instinct on the one hand, 890 SEXUAL PSYCHOSES. and pain, fear, anger, etc. on the other. Kiernan’s atavistic theory, by which it is a survival of the cannibalistic tendency of lower animals, should be mentioned, though hardly acceptable. Krafft-Ebing has offered a theory which is extremely ingenious, though somewhat far- fetched. The chief element in this theory is “ sexual bondage.” By “ sexual bondage ” is meant that dependence of one person upon another of the opposite sex which in normal individuals may occur in a very extraordinary and remarkable manner, even to the loss of all inde- pendent will—a dependence which forces the party in subjection to acts and suffering which greatly prejudice personal interest, and often enough to offences against morality and law. A dependence of this kind is abnormal, but not perversion. This “ abnormality is hered- itarily transferred to a psychopathic individual in such a way that it becomes transformed into a perversion. The agent perfecting this trans- formation is the tendency of sexually hypersesthetic natures to associate all impressions coming from the beloved person with the sexual impres- sion.” This theory, although ingenious, is hardly intellectually satisfy- ing, nor are the different steps in the process made clear. This author, whose writings have given such prominence to sexual psychoses, also has overlooked the fact that, whatever the origin of the early asso- ciation, the evolution of the “psychosis” is due to pure cultivation. According to von Krafft-Ebing’s views, the whole completely devel- oped psychosis (excepting in a small minority of cases) is congenital and the result of pathological conditions. If this were the case, there would be no way of accounting for the growth, both in diversity and intensity, of the psychosis, excepting by increase of degeneration of the nervous system. But this increasing degeneration is not the rule, but, on the contrary, recovery may take place. For the determination of the beginning of the masochistic feelings reliance has been placed upon the statements and autobiographies of perverts. To rely upon the mem- ory of a person for the feelings that he had under particular circum- stances in his childhood, to trust to any one’s introspective memory in such matters, is risky business. Every one has forgotten much that is essential, and few, if any, can say what and when was the first begin- ning of masochism, or even of the sexual instinct, which he had as a child. Therefore, not knowing the exact circumstances, it is difficult to decide in individual cases on the question of origin. Much that has been said applies to sadism. A primitive association of sexual feeling with pain arises either as the result of an accidental event, anomalous physiological condition, auto-suggestion or external suggestion, or a normal physiological state. By cultivation the final condition of sadism results. Fetichism. Fetichism is the association and excitement of Inst with certain articles of female attire or certain portions of the female body. Thus far, fetichism has only been observed in men. When the fetich is an article of dress, the perversity is seen in its purest forms, for then the excitation of sexual feelings may occur when the object is isolated from and not connected in idea with any particular person. When the FETICHISM. 891 object is a part of the human body, excepting in the case of hair, it is not, of course, possible to separate the fetich from the individual to whom it belongs, and hence the associations are complex. But with articles of dress the fetich becomes a sexual excitant in itself. The most common objects of this kind are handkerchiefs, shoes, under-gar- ments, petticoats, aprons, etc. Handkerchiefs and shoes are said to be the most common objects. The fondling, and even the sight, of the fet- ich is capable of causing great erotic excitement, and the fetichist seeks to possess these objects for this purpose. Thus it happens that fetich- ism sometimes has forensic importance because individuals are some- times driven to thefts for the purpose of acquiring their favorite objects and the satisfaction of their desires. One man was found to have stolen three hundred articles of female apparel, including chemises, drawers, garters, etc. ; when arrested he was wearing a chemise (Passow and Krauss1). Most commonly the desire is for a single object. A hand- kerchief-fetichist is excited by and steals only handkerchiefs. One man was found, when his house was searched, to have four hundred and forty- six ladies’ handkerchiefs; he had also stolen many others (von Krafft- Ebing). A shoe-fetichist may spend much of his time trying to catch a glimpse of women’s shoes or gazing iiyto the windows of shoeshops. Another class of objects is some particular material, commonly fur, vel- vet, and silk, which at first sight seems to have the power in some people to tactilely excite erotic feelings, entirely aside from any relations to the human body. These materials may have this effect even when not made up into garments, but from the statements of some fetichists it would appear as if the effect were the stronger when they are worn as garments by women. Von Krafft-Ebing thinks that this fetichism can- not be due to original accidental association, as are the others, but that u it must be presumed that certain tactile sensations (a kind of tickling which stands in some distant relation to lustful sensations (?)) in hyper- aesthetic individuals furnish the occasion for the origin of this fetichism.” An analogy for this idea may be found in the curious sensations felt by some people from eating the skin of a peach, or in those similarly asso- ciated with the scratching of a slate-pencil. Perhaps the sexual feel- ings may be a like anomalous association. But it is not possible to dis- prove associations in early youth, for the circumstance of erotic feelings caused by a female clad in fur or velvet or other material might well be forgotten. Less pure forms of fetichism are those where sexual feelings are excited by a woman only when completely dressed or clad in a particular cos- tume. The most common parts of the female body that may serve as objects of this perversion are the hand, foot, and hair, less frequently the eyes, ears, and mouth. In such cases the hand-fetichist, for example, is excited by the touch of beautiful hands irrespective of the owner, and he seeks in every way to see and press them. According to Binet, hand-fetichists are very common. Hair is more like dress or fur in that it can be cut off and cherished as a thing apart. In consequence of this certain perverts are known as “ hair-despoilers.” These people are impelled by their erotic feelings to forcibly cut off and steal the hair of women. One man when arrested was found to have sixty-five switches 1 Quoted by von Krafft-Ebing. 892 SEXUAL PSYCHOSES. and tresses of hair.1 Individuals with fetichism may also be tainted with sadism, masochism, or contrary sexuality. The practical importance of fetichism is threefold : it may cause psy- chical impotence—that is, the pervert may be impotent for normal sexual relations or unless his fetich can in some way be brought into associa- tion with these relations; secondly, it may lead to theft; and thirdly, the mental suffering that may be indirectly caused may be intense. The psychical impotence in all marriage relations, the attacks of erotic ex- citement under the influence of the fetich, the induced onanism, the feeling of after-mortification, the self-recrimination, may in certain per- sons of a sensitive temperament cause a mental suffering which may be truly pitiable. As to the origin of fetichism, Binet’s explanation has been generally accepted—namely, that it is always due to some circumstance which in early youth excited the sexual instinct in association with the presence of the object that afterward became the fetich. This association, being once formed, persists, so that, the object always excites the instinct. Fetichism is thus acquired, and is not congenital. The intensity which this association attains, so that it becomes a sort of imperative feeling or idea, must not let us forget that the histories of fetichists show that this intensity has been reached by deliberate cultivation or perversity. In the great majority, if not all cases, there is a neuropathic base, usually through heredity, for the perversity, so that the fetichist has less resistive power than normal people. In such a substratum associations are easily formed, feelings and ideas acquire great intensity and fixed- ness, and the whole forms a quasi-psychosis of a more or less imperative nature. Contrary Sexual Instinct (Homo-sexuality, Sexual Inver- sion, Hermaphroditism). Tliis aberration consists in the existence of sexual feeling for the same sex, coexisting in its fully developed form with entire absence of sexual feeling for the opposite sex. In the more moderate form there may still be inclination toward the opposite sex, but in the higher de- grees of the perversion there maybe a feeling of actual repulsion for the opposite sex, while the whole psychical personality, the tastes, feelings, and modes of thought of the individual may become changed to corre- spond with the sexual perversion; that is, the character of the male becomes feminine, and vice versd. The justification for this aberration to be considered as a true psychosis depends upon the thesis that in a certain proportion (great majority) of cases it is congenital and a “ partial manifestation of a neuro-psychopathic state, in most cases hereditary.” It is therefore a functional sign of degeneration. According to this view, this manifestation in these cases is not acquired and is in no sense a perversity or vice, but a true anomaly or perversion of instinct in the sense that it is the product of maldevelopment, in the same way that any of the normal instincts, tastes, or sensory functions are the product of normal development. In other words, with “ a normal anatomical and physiological state of the (genital) organs a sexual in- 1 Voisin, Socquet, Motet, quoted by von Ivrafft-Ebing. CONTRARY SEXUAL INSTINCT. 893 stinct maybe developed which is the exact opposite of that characteristic of the sex to which the individual belongs.” It appears spontaneously, without external cause, with the development of sexual life. Various theories, many of them fanciful, have been proposed to ac- count for the origin of this (according to this view) anomalous condition. Ulrich, himself a pervert, thought a female mind was enclosed in a male body. This condition he considered due to atavism. This fanciful notion, which reminds one of some of the early legends of human beings appearing in the form of animals, is maintained even by later medical writers (Mag- nan, Gley). This same idea appears in a new form in the hypothesis of Kiernan,1 adopted by Lydston,2 that contrary sexuality is a reversion to the primitive type of the lowest forms of life, which are bisexual. This bisexuality appears in a rudimentary form in adult human beings, as shown by the rudimentary female organs in the male. In contrary sexuality, while there is a differentiation of anatomical form, the nervous system is developed on the female type. One of Krafft-Ebing’s patients independently suggested this explanation, the inadequacy of which is apparent when one considers that there can be no reversion, as, at the time when bisexuality existed there was no nervous system worth speak- ing of—nothing that corresponded with the human psychical sexuality. Atavism can therefore scarcely be accepted. A modification of this theory has been proposed by Chevalier. The human embryo is bisexual. In its later development one or the other factor, male or female, pushes ahead at the expense of the other, but traces of the undeveloped sexual factor persist. Sometimes both develop, but in different directions, so that while the sexual organs of one sex are formed, the nervous system of the other is developed, and thus con- trary sexuality results. All such theories are of course only another way of putting the original idea of the female soul in a male body. Kiernan writes : “ It seems certain that a femininely functionating brain can occupy a male body, and vice versa.” These theories assume, what is probably not true, that there is a difference in the brain of the two sexes corresponding to the difference in the bodily form. Westphal, who first gave the name of contrary sexuality, thought the condition congenital, but refrained from hypothesis. The most sensible congenital hypothesis is undoubtedly that of von Krafft-Ebing, who thinks that an explanation “ may perhaps be found in the fact that it represents a pe- culiarity bred in descendants, but arising in ancestry. The hereditary factor might be an acquired abnormal inclination for the same sex in the ancestors, which, being transmitted, becomes fixed as a congenital abnormal manifestation in the descendants.” Kiernan had also suggested this possibility for certain cases. The absence of proof of the ancestral facts, excepting in particular instances, prevents the acceptance of this hypothesis. More in accordance with our psychological knowledge is the theory of Binet, although it is, nevertheless, rejected by most writers. By this theory the whole perversion is acquired through the force of association of ideas. Amongst the names of those contributing to the subject are to be found many of well-known writers in neurology and psychiatry. But 1 Mtd. Standard, Nov., 1888. 2 Med. and Surg. Reporter, Sept., 1889. 894 SEXUAL PSYCHOSES. the most important contributions are those already mentioned, and espe- cially the works of Moll,1 von Krafft-Ebing,2 and von Schrenck-Notz- ing.3 The difference in the views of these writers has already been pointed out above when speaking of the pathology of the perversions in general. Besides the fact that the manifestations of contrary sexu- ality are acquired, von Schrenck-Notzing holds that, nevertheless, these manifestations become in time imperative sensations and imperative ideas, and thus from this point of view may be looked upon as psychoses artificially created, in a neuropathic soil in most instances. This opens a very wide field for discussion, as it is no easy matter to settle what decisive element constitutes an imperative idea. The familiar language of the pervert, which is stereotyped in “irresistible impnlse,” too often should be written, “ I don’t want to.4 ” Still, we must allow, as we see in the alcoholic and opium habit, that for weakened resisting powers sensations may be well educated to such an extent as to become impera- tive. I have elsewhere5 stated what appear to me to be the chief objections to the congenital or perversion theory as opposed to perversity, and, as I cannot more briefly express them, I may be permitted to repeat here what was said: Now, putting aside hypotheses of the How, an examination of the congenital-perversion theory shows that it rests entirely upon the auto- biographies of perverts and certain assumptions (to be presently men- tioned) regarding the normal development of the vita sexualis, and of the tastes, habits, and modes of thought peculiar to each sex. It is believed that a person is capable of remembering all the cir- cumstances attending the gradual growth of the sexual functions in early childhood—has a distinct recollection of the causes which first called it forth, and that a failure to remember possible excitants is equivalent to their non-existence. A reliance upon evidence of this kind in any other department of human knowledge, whether medical or non-medical, I am sure, would only excite surprise. Even in taking an ordinary medical history we should hesitate to accept such testimony as final, and I think we should be even more cautious in our examination of autobiographies which attempt to give an analysis founded on introspection of the feel- ings, passions, and tastes of degenerate individuals who attempt to ex- plain their first beginnings in early childhood and attribute each to its proper excitant. As von Schrenck-Notzing has pointed out in his care- ful study of the published cases, very few of these autobiographies will stand analysis. Probably there is no class of people whose statements will less stand the test of a searching cross-examination than the moral pervert. One cannot help feeling that if the pervert was thus examined by an independent observer, instead of being allowed to tell his own 1 Contrdre Sexual Empfindung. 2 Psychopathia Sexualis and Zur Erkldrung der Contrdren Sexual Empfindung. * Suggestive Therapeutics in Psychopathia Sexualis. 4 “I wish to state expressly that, though I am conscious of the abnormality of my inclinations, I have no desire to change them ; I long only for a time when more easily and with less danger of discovery I can give rein to rnv desires and experience a delight that will harm no one.”—Autobiography, Case 149, v. K.-E. 5 “ Sexual Perversion or Vice?” Journ. of Nerv. and Merit-. Dis.} 1898. I have made free use of this contribution for the purposes of this article. CONTRARY SEXUAL INSTINCT. 895 story without interruption, a different tale would he told, or great gaps would be found which are now nicely bridged, or many asserted facts would be resolved into pure inferences. Taking one point alone, it is extremely doubtful whether any one can remember the first beginnings of the vita sexualis. He may remem- ber certain occasions which, from the special intensity of the excitation or from peculiar associations, persist as vivid mental pictures, just as we remember certain pleasurable experiences of boyhood connected with sports, but not all or the first. The second error of those who maintain the congenital theory is that they overlook the influence which casual external circumstances have in suggesting feelings and ideas to the mind and in directing thoughts which appear to be spontaneous.1 These external circumstances may be trivial or not, and may be forgotten. Even when very prominent for the moment in consciousness, they may be forgotten, while the effects may persist. The enlargement of our knowledge of the substrata of consciousness and the after-influence of such subconscious states upon the personality of the individual has made it possible for us to under- stand the genesis of certain neuroses which before were inexplicable. Janet has demonstrated “ this influence in the productions of some of the manifestations of hysteria. With this knowledge it is next to impos- sible to say that sexual aberrations were not originally suggested by ex- ternal conditions in individual cases or the product of auto-suggestion.2 A very suggestive example of the influence of this kind upon the lower strata of consciousness in producing psychoses is the following from the writer’s experience : A young girl about sixteen years old was pursued with an uncontrollable fear of vomiting. As a matter of fact, she never did vomit, but the fear was so intense that she was unwilling to leave the house alone, or, for that matter, even when accompanied, go to places like theatres or to such distances from home that she could not quickly reach her house. The fear, although always present, was subject to exacerbations. In such attacks her suffering was very great and the mental shite uncontrollable. She would take off' her clothes, and run up and down the room crying and begging her mother not to let her vomit. This fear had apparently developed spontaneously during early girlhood, and might easily have been considered congenital if the original history as given by the patient herself and mother had been believed. But from the mother, after persistent inquiry, I obtained the following history, till that moment forgotten. When the patient was a child, sav five years old, her sister was taken ill with scarlet fever, the first symptom of which was violent vomiting. In order to prevent the child from catching the disease, she was told that if she went near her 1 Whether or not a neuropathic taint is necessary, as has been maintained, is a second- ary matter. The existence of an hereditary taint has, however, been sometimes accepted on insufficient evidence. 2 A capital illustration of the influence of forgotten causes of producing psychical phenomena is the following: A lady told me of a dream which she had in which she saw distinctly the face of a person whom she had never seen. Her description of the person being very accurate, I insisted, to test the matter, that she must have seen or heard of the person before. On assuring me the impossibility of this, I told her, as was the fact, that a few days previously I had described this person to her, using the same language that she now used for the same description. She had no recollection of it. Sexual suggestions and excitants might be similarly forgotten. 896 SEXUAL PSYCHOSES. sister she would be taken with vomiting in the same way. This had the desired effect, but when the sister recovered it was with some difficulty that my patient could be induced to come in her presence. She ran away and hid in a closet, exhibiting considerable fear. It is reasonable to suppose that the impression made upon the mind at that time had left a subconscious idea which was the cause of the apparently motiveless fear later exhibited. The patient has no memory of all this. The excita- tion of abnormal sexual feelings may well have similar external causes long since forgotten. The third error of this school is that it assumes that normally there is a hard and sharp line drawn by nature between the normal personali- ties of the sexes. As a matter of fact, sharp lines of demarcation do not occur any more than in the length of the nose or size of the hand. Taking a large number of people, the male personality normally shades into the female, and vice versd. What I mean to say is, that taking a large number of normal males and an equal number of normal females, we might place them in a row so that at one end would come the males, with strong vigorous masculine characters ; in the middle, but at the extreme end of the male line, the men with feminine personalities; ad- joining these the masculine females, differing but slightly, excepting in anatomical configuration, from the males ; while at the extreme end of the female line would come those with strongly marked feminine characteristics. Fourthly, the effect of education, meaning by this the total environ- ment, intentional education, unconscious mimicry, external suggestion, example, etc., etc.—the effect of this, I repeat, in moulding the tastes and habits of thought and manners of the child, and thus differentiating those of one sex from those of the other, has been overlooked. I think it is extremely probable that if a boy were brought up as a girl and a girl as a boy, and absolutely freed from all counter-influences—such as the unconscious influence of public criticism, etc.—each would have the non-sexual tastes and manners of the other sex. Fifthly, it is questionable whether only abnormally the vita sex- ualis of the male is excited by the female, and conversely. There is every reason to believe that in some perfectly healthy individuals some degree of erotic feeling or ideas may be excited by the sight or touch of the form of a person of the same sex, and, at any rate, thoughts (per- taining to anatomy) so excited may very naturally awaken secondarily associated sexual feelings. For instance, the vita sexualis in a boy is at first associated with his own sexual organs; later, the sight of those of another boy awakens this association of ideas by the well-known law, and then, in a degenerate, cultivation does the rest. Von Krafift- Ebing’s very first case (106) of a girl with hypcnesthesia sexualis and homo-sexuality is readily explainable in this way. As von Krafft- Ebing points out, in the beginning of sexual development in the child “ the psychical relation to persons of the opposite sex is still absolutely wanting, and the sexual acts during this period partake more or less of a reflex spinal nature.” “ With the inception of anatomical and func- tional development of the generative organs, and the differentiation of form belonging to each sex which goes hand in hand with it in the boy or girl, rudiments of a mental feeling corresponding with the sex are 'CONTRARY SEXUAL INSTINCT. 897 developed; and in this, of course, education and external influences in general have a powerful effect upon the individual, who is now all attention.” Now, in a person of perfectly healthy mind and body all social customs, habits of thought, unwritten laws, and moral precepts tend to suppress any existing homo-sexual feeling and its gratification, and to encourage hetero-sexual feeling. On the other hand, the person of tainted constitution does everything in his power to foster, indulge, and cultivate the perverse instinct, while in such a soil the feelings themselves acquire monstrous force. That the future development of this perversity is due to cultivation there is no question. We have only to read the autobiographies to be convinced of it. Thus may arise a perversity that had its origin in a normal reflex, but the acci- dental cause of which is forgotten with much else of the psychical life of childhood, or, if not forgotten, considered abnormal because of its future monstrous development. Such a reflex, it may be said, if nor- mal, is congenital. This much is in strictness true, but an entirely different aspect is given to the congenital theory. What is really patho- logical in this aberration is the extraordinary intensification of the sexual feelings and the unbridled lack of restraint with which the sub- ject indulges his senses and seeks every opportunity for gratification. These, without doubt, depend upon the neuropathic constitution. The contrast in this respect with normal hetero-sexual persons brings the difference into strong relief. Finally, the fact must not be lost sight of—it is not questioned— that cultivation is capable of generating this aberration and developing it to its most intense degree, even to the feeling of repulsion for the opposite sex and to the acquisition of contrary tastes and habits. Ac- quired cases of this kind are recognized and illustrated by Cases 94, 95, 96, 99, etc. of von Krafft-Ebing. It is not, then, a question of the sufficiency of this influence. The only question is, Are all cases due to this influence, or are those cases in which there is no evidence in the histories, .so far as obtained, of cultivation, and in which there is an apparent spontaneous origin, properly to be regarded as congenital ? One logical consequence of the cultivation theory has been over- looked, as it seems to me, by von Schrenck-Notzing. It follows as a necessary corollary that this so-called perversion is not really a perver- sion, but a perversity—a vice rather than a disease. From one standpoint the view may be modified. It has already been said that a habit may be so intensely cultivated as to become in time almost automatic and independent of volitional control. The nervous processes involved may thus become shunted off from the rest of the psychical life as true psychoses. It is tenable that in some per- sons these aberrations may become by cultivation real imperative sensa- tions and ideas. Though vice may be the road traversed, the final stage may be disease. Analogy with what takes place in other fields of the nervous system would make it intelligible that sexual feelings and actions may by con- stant repetition (cultivation) become associated together, and developed into a sort of quasi-independent neural activities which may then become practically independent of the will, or, in other words, a psychosis. Sexual perversion, then, may, from the point of view of pathogenesis, Vol. IV.—57 898 SEXUAL PSYCHOSES. be [nit in the same class with many of the manifestations of hysteria and other psycho-neuropathic states. The constant excitation of various bodily symptoms by the neurasthenic tends to cultivate them into im- perative habits which control his organism. The hysteric, dwelling on certain ideas, whether they relate to herself or her environment, tends to nurture and cultivate them till they may acquire such monstrous intensification that they control her psychical life. From small beginnings it is possible that even most intense doubts and fears may be evolved by this cultivation, culminating perhaps in imperative ideas (insanity of doubt, folie de toucher, etc.). By constant indulgence of her feelings, revelling in morbid retrospection, giving her- self up to egotistical debauches, self-pity, and wrong inferences, the degenerate cultivates her body and mind into becoming such a sensitive machine that she can no longer adapt herself to her environment, but must be removed to an institution where her environment can be adapted to her: of course I am drawing an extreme picture, but such extreme pic- tures exist. Therapeutically, the point of view which we take of the genesis of these psychoses, whether sexual or non-sexual, is of extreme importance. If they are the manifestations of a diseased nervous system in the sense that they are the necessary expression of a diseased body, whether con- genital or not, then there is no escape from therapeutic hopelessness so long as the psychopathic state continues. But if psychoses of this kind are the result of cultivation, whether by the influence of external sur- roundings or by the subject’s own conduct—cultivated into psychoses because the soil is a psychopathic one—then we may fairly hope by counter-ed ucation in many instances to replace the morbid processes by healthy ones. The manifestations of contrary sexuality need only be briefly con- sidered. In the great majority of instances an hereditary taint will be found. One or more members of the immediate family or ancestors will be found to have been affected with one of the neuroses or psychoses— hysteria, neurasthenia, hypochondriasis, alcoholism, or even some form of insanity. In bad cases several members of the family may have been affected. For example, in one case the father was a drinker and com- mitted suicide ; a sister had hysteria; a brother and sister also committed suicide; a maternal aunt was insane and committed suicide ; the mother was sickly and died of apoplexy, and the patient had grave hysteria. On the other hand, in some cases no hereditary history can be obtained. The subjects of the perversion maybe apparently strong and healthy, exhibit- ing perhaps only sexual weakness as the result of the perverse indul- gence. But more often symptoms of neurasthenia or hysteria will be found. In the former case they pursue their vocation without giving rise, excepting by indiscretion, to any suspicion of their habits. Other individuals, again, may exhibit evidences of insanity, especially paranoia. As paranoiacs they may have hallucinations of actually being of the opposite sex, but then these hallucinations should not be classed as a part of contrary sexuality, but rather like any other hallucination of the insane. The neurasthenic condition may be primary or may appear later secondarily, as a result of perverse habits. As a rule, these people are given to onanism, which plays a part in the development of the aberra- TREATMENT. 899 tion. The modes in which the perverse instinct finds expression are the same as in vice, and do not need description. The subjects give them- selves up to the gratification of their sensual feelings without apparently feeling any moral obligation to control or suppress them. For this the presence of a hypertesthesia sexualis, which commonly is present, and a lack of resisting power, are responsible. The latter is a result of the psychopathic constitution. When the erotic feelings are associated with certain ideas the pervert voluntarily gives himself up to the cultivation of the exciting thoughts, which thus grow by practice: a sort of idea- tional debauch may thus be indulged in. In this way intense feelings and thoughts may become uncontrollable, and the subject be unable to resist indulgence in them. Then they may be looked upon as impera- tive. They may come on periodically, with intermissions of freedom. In personality the subject of these aberrations may exhibit a tendency to femininity. The male shows a taste for dolls and girls’ playthings and games, and later for feminine dress, ornaments, and occupations, such as crocheting, knitting, etc. The female may similarly exhibit mas- culine tastes. But this is not the rule, and beyond the sexual perversion there may be no change in personality relative to sex. It is open to question whether these tastes are secondary to the perversion or are not accidentally associated. With this perversion there may be psychical impotence for the opposite sex or not, or a person may be potent only by the help of contrary mental images. Impotence may therefore play a part in the domestic drama. Homo-sexuality may coexist with hetero- sexuality (psychical hermaphroditism), but in more highly developed cases only homo-sexuality may exist. In such cases the individual may feel all the longings and passionate feelings for a person of the same sex that normally are, as expressions of love, felt for an individual of the opposite sex. A person of the opposite sex may be sexually repelling and disgusting to such a person. Such a person, having deified the object of his love, feels all the jealousies, pangs of unrequited love, heart-burnings, etc. normally experienced in hetero-sexuality. These people are called urnings.1 When in such people these feelings coexist with the above-mentioned tastes for the sports, dress, and occupations of the opposite sex, the appearance is created of complete change of sexual character (effe mi nation and viraginity). The common expression of such people is that they feel as if they had a female soul in a male body, or vice versd. These cases lend more support to the theory of con- genital origin than ordinary hermaphroditism. But it must not be for- gotten that the real perversion is that of the sexual instinct—that is to say, femininity without change of sexual instinct is not a perversion. The development of feminine or masculine tastes in male and female respect- ively in psychopathic individuals is easily accounted for by the facility with which fixed ideas and feelings take possession of such people. Cultivation is easy in such people. A somewhat fanciful attempt has been made to associate a bodily conformation resembling more or less that of the opposite sex (hips, breasts, deficient or abundant beard, fea- tures, voice, etc.) with homo-sexuality. Treatment of Sexual, Psychoses.—Far from being hopeless, as 1 A good illustration will be found in the article on “ Psychical Hermaphroditism,” by W. L. Howard, M. D., Alien, and Neurol., April, 1897. 900 SEXUAL PSYCHOSES. the congenital theory would imply, the treatment of sexual paresthesia is attended in a large proportion of cases with encouraging results, which contradict the congenital theory. When the sexual aberration is only a part of great central degeneration, such as imbecility, dementia, or paranoia, of course any attempt must be hopeless. But where the psychopathic basis is of a minor degree and the intellect is not mate- rially affected, it must appear, if we are to judge by the reports of pub- lished cases, that improvement or cure may be accomplished. This of course presupposes that a person desires to be cured. It is highly improbable that a person can be cured against his will, and it is evident that many do not want to be cured. The chief and most effective thera- peutic remedy is hypnotic suggestion. In the hands of von Schrenck- Notzing and others this remedy has given decidedly favorable results. The total number of cases collected by von Schrenck-Notzing is 32. The results of treatment were as follows: Failures. 5 = 15.625 per cent. Slightly improved 4=12.5 “ “ Essentially improved “ “ Cured, with later report, 10; without later report, 2 . .12 = 37.5 “ “ 100 per cent. Thus, about 70 per cent, were essentially improved or cured. The fact that of the 12 cures later reports were obtained, sometimes after con- siderable periods of time (four to five years), in 10 makes these statistics of considerable value. Of the 32 patients, 5 were not amenable to hyp- nosis, 7 were cases of psycho-sexual hermaphroditism, 20 of contrary sexual instinct, 2 of sadism, 3 of masochism. Treatment must be prolonged. For instance, in 1 ease one hundred and fifty-two, and in another, two hundred and four, sittings were necessary. Deep hypnosis is not always necessary. It is also undoubt- edly true that in using hypnotic suggestion in this as in other psychoses much depends upon the way and form in which suggestions are given. Considerable judgment is required for this, and the manner and charac- ter of the physician count for much. That is, a “ suggestion ” given by one person will be effective, while from another, perhaps because of lack of confidence, it will be no suggestion at all or suggest the opposite. The earnest and faithful co-operation of the patient also counts for much. Without this it may be questioned whether success is attainable. Besides direct suggestion, other forms of mental therapeutics should be employed for the purpose of strengthening the will power and develop- ing the character of the patient. He should be made to feel that the perverted instinct is one that should not be cultivated, and to wish not to do so. For this a sufficient motive should be given. The mode of doing this must be determined in each case by the physician according to the character of the person with whom he is dealing. The more the patient is under the personal influence of the physician the better. It is a great service if the latter can be a sort of moral confidant to whom the patient can almost daily turn for advice, help, and confession. Finally, the physical health must be improved when neurasthenia is present. So long as a neurasthenic condition exists, ideas tend to fix themselves, and have an automaticity far in excess of what occurs in TREATMENT. 901 well people. There will probably always remain a considerable propor- tion of patients who cannot, or do not want to, be cured. When distinct evidences of insanity are present an asylum may be the only and the best resort. When sadistic tendencies are exhibited the safety of the com- munity may render this course imperative. The question of marriage will often be one for decision. Undoubtedly, as a therapeutic measure, marriage is often of the greatest benefit, and perhaps normal coitus may be essential to bring about a cure; but the patient is not the only per- son to be considered. The responsibility of a physician in recommend- ing marriage is great, as this may mean the wrecking of other and inno- cent lives. Then, too, as perverts are usually by inheritance psycho- or neuropathic, marriage means the generation of more miserable stock and the probable perpetuation of nervous disease in some form. Al- though it is true that in some instances persons with sexual perversion have married and lived happily, still the risk is great, and, excepting in individual instances, marriage should not be advised, even though the pervert may gain thereby.