In the course of the years 1866–68, the delusions of persecution became less and less apparent, and were for the most part replaced by erotic ideas. The somatic and mental basis was a lasting and powerful excitation of the sexual sphere. The patient fell in love with every woman he saw, heard voices which told him to approach her, and begged to be allowed to marry, declaring that, if he was not given a wife, he would waste away. With continuance of masturbation, in 1869, signs of future effemination made themselves manifest. “He would, if he should get a wife, love her only platonically.” The patient grows more and more peculiar, lives in a circle of erotic ideas, sees prostitution practiced in the asylum, and now and then hears voices which impute immoral conduct with women to him. For this reason he avoids the society of women, and only associates with them for the sake of music when two witnesses are with him.
In the course of the year 1872, the neurasthenic condition became markedly increased. Now paranoia persecutoria again comes into the foreground, and takes on a clinical coloring from the neurotic basis. Olfactory hallucinations occur. Magnetic influences are at work on him (false interpretation of sensations due to spinal asthenia). With continued and intense sexual excitement and excess in masturbation, the process of effemination constantly progresses. Only episodically is he a man and inclined toward a woman, complaining that the shameless prostitution of the men in the house makes it impossible for a lady to come to him. He is dying of magnetically poisoned air and unsatisfied love. Without love he cannot live. He is poisoned by lewd poison that affects his sexual desire. The lady that he loves is sunk in the lowest vice. The prostitutes in the house have fortune-chains; that is, chains in which, without moving, a man can indulge in lustful pleasure. He is ready now to satisfy himself with prostitutes. He is possessed of a wonderful ray of thought that emanates from his eyes, which is worth twenty millions. His compositions are worth 500,000 francs. With these indications of delusions of grandeur, there are also those of persecution—the food is poisoned by venereal excrement; he tastes and smells poison, hears infamous accusations, and asks for instruments to close his ears. From August, 1872, however, the signs of effemination become more and more frequent. He acts somewhat affected, declaring that he can no longer live among men that drink and smoke. He thinks and feels like a woman. He must thenceforth be treated like a woman and transferred to a female ward. He asks for confections and delicate desserts. Occasionally, on account of tenesmus and cystospasm, he asks to be transferred to a lying-in hospital and treated as a woman very ill in pregnancy. The abnormal magnetism of masculine attendants has an unfavorable effect on him. At times he still feels himself to be a man, but in a way which indicates his abnormally altered sexual feeling. He pleads only for satisfaction by means of masturbation, or for marriage without coitus. Marriage is a sensual institution. The girl that he would take for a wife must be a masturbator. About the end of December, 1872, his personality became completely feminine. From that time he remained a woman. He had always been a woman, but in his babyhood a French Quaker, an artist, had put masculine genitals on him, and by rubbing and distorting his thorax had prevented the development of his breasts. After this he demanded to be transferred to the female department, protection from men that wished to violate him, and asked for female clothing. Eventually he also desired to be given employment in a toy-shop, with crocheting and embroidery work to do, or a place in a dress-making establishment with female work. From the time of the transformatio sexus, the patient begins a new reckoning of time. He conceives his previous personality in memory as that of a cousin.
He always speaks of himself in the third person, and calls himself the Countess V., the dearest friend of the Empress Eugenie; asks for perfumes, corsets, etc. He takes the other men of the ward for girls, tries to raise a head of hair, and demands “Oriental Hair-Remover,” in order that no one may doubt his gender. He takes delight in praising onanism, for “she had been an onanist from fifteen, and had never desired any other kind of sexual satisfaction.” Occasionally neurasthenic symptoms, olfactory hallucinations, and persecutory delusions are observed. All the events up to the time of December, 1872, belong to the personality of the cousin.
The patient’s delusion that he is the Countess V. can no longer be corrected. She proves her identity by the fact that the nurse has examined her, and finds her to be a lady. The countess will not marry, because she hates men. Since he is not provided with female clothing and shoes, he spends the greatest part of the day in bed, acts like an invalid lady of position, affectedly and modestly, and asks for bon-bons and the like. His hair is done, up in a knot as well as it allows, and the beard is pulled out. Breasts are made out of biscuits.
In 1874 caries began in the left knee-joint, to which pulmonary tuberculosis was soon added. Death on December 2, 1874. Skull normal. Frontal lobes atrophic. Brain anæmic. Microscopical (Dr. Schüle): In the superior layer of the frontal lobe, ganglion cells somewhat shrunken; in the adventitia of the vessels, numerous fat-corpuscles; glia unchanged; isolated pigment particles and colloid bodies. The lower layers of the cortex normal. Genitals very large; testicles small, lax, and show no change macroscopically on section.
The delusion of sexual transformation, displayed, in its conditions and phases of development, in the foregoing case, is a manifestation remarkably infrequent in the pathology of the human mind. Besides the foregoing cases, personally observed, I have seen such a case, as an episodical phenomenon, in a lady having contrary sexuality (Case 92 of the sixth edition of this work), one in a girl affected with original paranoia, and another in a lady suffering with original paranoia.
Save for a case briefly reported by Arndt, in his text-book (p. 172), and one quite superficially described by Sérieux (“Recherches Clinique,” p. 33), and the two cases known to Esquirol, I cannot recall any cases of delusion of sexual transformation in literature. Arndt’s case may be briefly given here, though, like Esquirol’s cases, it gives nothing concerning the genesis of the delusion:—
Case 103. A middle-aged woman in the asylum at Greifswald thought she was a man, and acted out her belief. She cut her hair short, and parted it on one side in the military fashion. A sharply-cut profile, a nose somewhat large, and a certain heaviness of all the features gave the face something characteristic, and, in combination with the short hair combed smoothly over the ears, gave the whole head a decidedly masculine appearance. She was tall and lean; her voice low and rough; the larynx angularly prominent; her attitude erect; her gait, like all her movements, heavy, but not awkward. She looked like a man in female dress. Asked how she had come to think she was a man, she would almost always cry excitedly: “Just look at me! Don’t I look like a man? I feel like a man, too. I have always felt so, but I only gradually came to understand it clearly. The man who should be my husband is not a real man. I raised my children myself. I always felt somewhat like this, but I came to understand later. Did I not always work like a man? The man who passed for my husband only helped. He did what I planned. From my youth I have been more masculine than feminine. I have always had more liking for the garden and farm than for work in the house and kitchen. But I never understood the reason. Now I know I am a man, and I shall bear myself like one. It is a shame to make me always wear women’s clothes.”
Case 104. X., aged 26, tall, and of handsome appearance. Since his earliest youth he has loved to wear female attire. As he grew up, he managed it so that, when he was a participant in theatricals, he always had a female part. After an attack of mental excitement, he imagined that he was actually a woman, and tried to convince others of it.
He liked to undress himself, and dress his hair and put on female clothing. In this state he wished to go out on the street. In other respects he was perfectly reasonable. He would spend the whole day arranging his hair and looking at himself in the glass, costuming himself in a night-dress as much like a woman as possible. In walking he imitated women. One day, when Esquirol acted as if about to lift up his dress, he flew into a passion and upbraided him for his want of modesty (Esquirol).