VIII

HEREDITY AND THE ÆTIOLOGY OF THE
NEUROSES:

(1896)

am addressing the pupils of J. M. Charcot espec-
| to bring to their attention some objections

to the theory concerning the ætiology of the neur-
oses which was passed on to us by our master.

The part ascribed to neurotic heredity in this
theory is well known. It is the only true and indis-
pensable cause of nervous disease; other etiological
factors may aspire only to the title of precipitating
causes. Thus the master himself and his pupils,
Guinon, Gilles de la Tourette, Janet and others, have
promulgated this doctrine for the major neurosis,
hysteria; I believe that the same opinion is held
in France and to some extent everywhere for the
other neuroses, although it has not been laid down
quite so solemnly and decidedly for conditions
analogous to hysteria.

For a long time I have entertained suspicions in
this matter, but I had to wait to find corroborating
facts in my daily medical experience. My objections
are now of two kinds, arguments based upon facts
and arguments of a more speculative order. I will
begin with the former, arranging them according
to the importance that I ascribe to them.

I. (a) Sometimes diseases which are often enough
foreign to the sphere of neuropathology and which
do not necessarily depend upon disease of the nerv-

1 First published in the Revue Neurologique, 1896, +. IV [Trans-
lated by M. Meyer.]

1896 HEREDITY AND ÆTIOLOGY 139

ous system have been considered nervous and
indicative of neuropathic heredity. Thus, true facial
neuralgias and many headaches have been considered
nervous which are caused rather by post-infectious
pathological changes and by suppuration in the nasal
sinuses. I am convinced that these patients would
profit if we were more often to leave the treatment
of these conditions to rhinologists.

(5) All nervous diseases found in the patient's
family, without reference to their frequency or their
gravity, have been accepted as justifying the accu-
sation of nervous hereditary taint. Does not this
point of view seem to imply a sharp distinction
between families that are free from any nervous
predisposition and families that are subject to it
without limit or restriction? And do not the facts
speak rather in favour of the opposite opinion,
namely, that there are transitions and degrees of
nervous predisposition and that no family escapes
it entirely ?

(c) Our opinion as to the ætiological rôle of hered-
ity in nervous disease must assuredly be the result
of an impartial statistical study and not of a petitio
principii. Until this study has been made, the
existence of acquired neuropathies should be con-
sidered as probable as that of hereditary neuro-
pathies. But if the existence of neuropathies acquired
by persons not predisposed to them is possible, it
can no longer be denied that some of the nervous
diseases found among the relatives of our patients
may have such an origin. They can then no longer
be called upon as conclusive proofs of the hereditary
predisposition that is imputed to the patient by
virtue of his family history, for a retrospective
diagnosis of the diseases of ancestors or of absent
members of the family is only very rarely successful.

140 COLLECTED PAPERS VIII

(d) Those who are adherents of the view of Four-
nier and of Erb, concerning the part played by
syphilis in the causation of tabes dorsalis and in
progressive paralysis, have learned that powerful
ætiological factors must be recognized the presence of
which is indispensable in the pathogenesis of certain
diseases that heredity alone could not cause. Charcot
remained to the end, however, as I learned through
a private letter from him, strictly opposed to Four-
nier's theory, which, nevertheless, gains ground day
by day.

(e) There is no doubt that certain neuropathies.
may develop in a man who was perfectly sound and
of untainted family. One observes this every day
in Beard's neurasthenia; if neurasthenia were limited
to predisposed people, it would never have gained
the importance and prevalence with which we are
familiar.

(f) In nervous pathology there is a so-called similar
and a so-called dissimilar heredity. No fault will be
found with the former concept; it is even very re-
markable that in the affections that depend upon
similar heredity (Thomsen's disease, Friedreich's
disease, Huntington’s chorea, the myopathies, etc.),
no trace of any accessory ætiological factor is ever
found. But the much more important concept of
dissimilar heredity has gaps that must be filled out
to arrive at a satisfactory solution of the ætiological
problems. They consist of the fact that members
of the same family prove to be afflicted with the
most varied forms of nervous disease, functional and
organic, without our being able to discover a law
that determines the substitution of one disease for
another or the order in which they follow one another
in successive generations. There are in these families,
beside the affected members, persons who remain

1896 HEREDITY AND ÆTIOLOGY ェ ④ エ

sound. The theory of dissimilar heredity tells us
neither why one person carried the same hereditary
taint without succumbing to it, nor why another
selects, among the diseases that constitute the great
family of neuropathies, one particular nervous affec-
tion instead of another, hysteria instead of epilepsy,
insanity, etc. Since there is no such thing as chance
in the pathogenesis of nervous disease any more
than elsewhere, it must be admitted that it is not
heredity that controls the choice of a neuropathy
developing in a member of a predisposed family,
and that there is ground for suspecting the existence
of other etiological factors of a less incomprehensible
nature which deserve to rank as the specific ætiology
of any such nervous disease. Without the existence
of this special atiological factor heredity would have
been powerless; it would have lent itself to the pro-
duction of a different neuropathy if the specific
«etiology in a given case had been replaced by any
other.

II. These specific, determining causes of neuropathy
have been too little investigated, for the vision of
physicians has been dazzled by the imposing pro-
spect of the hereditary factor in etiology. Never-
theless, they are well worth making the object of
careful study; although their pathogenic power may
be in general only auxiliary to that of heredity, great
practical interest centres on the understanding of
this specific etiology. It affords a point of attack
for our therapeutic efforts, while hereditary predis-
position, predetermined for the patient from birth,
frustrates all our efforts by the strength of its position.

I have been engaged for years in a study of the
ætiology of the major neuroses (functional nervous
states analogous to hysteria), and in what follows
I shall report the result of these studies. In order

142 COLLECTED PAPERS VIII

to avoid all possible misunderstanding, I shall begin
by making two observations on the nosography of
the neuroses and on their atiology in general.

I had to start my work with an innovation in noso-
graphy. I have found reason to place the obsessional
neurosis upon the same footing as hysteria, as an
independent and autonomous disease, although the
majority of authors classify obsessions among the
syndromes comprising mental degeneration or else
confound them with neurasthenia. I have learned,
by examining their mental mechanism, that these
disorders are much more closely allied to hysteria
than one would have believed.

Hysteria and the obsessional neurosis form the
first group of the major neuroses that I studied.
The second contains Beard’s neurasthenia, which I
split up into two functional conditions differentiated
both ætiologically and symptomatologically: neur-
asthenia proper and anxiety-neurosis—a term, by
the way, which does not altogether please me. I
have given detailed reasons for this differentiation,
which I consider necessary, in a paper published in
1895.

As for the ætiology of the neuroses, I think we
should recognize that the various ætiological factors,
differing in their importance and in the way in which
they are related to the effect they produce, may be
arranged theoretically in three classes: (1) Conditions
that are indispensable for the production of the
disease in question, but which are of a universal
nature and occur as well in the ætiology of many
other diseases. (2) Concurrent causes that share with
the conditions in group (I) the characteristic of
entering into the causation of other diseases as well
as into that of the disease in question, but which

1 See No. V of this volume, above, p. 76.

1896 HEREDITY AND ETIOLOGY 143

are not indispensable for the production of the latter
disease. (3) Specific causes just as indispensable as
the first conditions but appearing only in the ætio-
logy of the disease for which they are specific.

Now, in the pathogenesis of the major neuroses
heredity plays the part of a condition, potent in all
cases and even indispensable in the majority of
them. It cannot do without the assistance of the
specific causes; but the importance of hereditary
predisposition is demonstrated by the fact that
the same specific causes operating on a sound person
would produce no manifest pathological effect, while
its presence in a predisposed person will precipitate
a neurosis, the development of which will in inten-
sity and extent be proportional to the degree of
hereditary predisposition.

The action of heredity is comparable to that of
a multiplier in an electric circuit, which increases the
visible deviation of the needle but which cannot
determine its direction.

There is another point to be noted in the relations
between the hereditary condition and the specific
causes of the neuroses. Experience shows, as might
have been anticipated, that among the problems
of etiology that of the quantitative relationship of
the ætiological factors to one another should not
be neglected. But one would not have guessed the
fact which seems to follow from my observations,
that heredity and the specific causes may replace
one another quantitatively, that the same patho-
logical effect will be produced by the co-existence
of a very grave specific ætiology and a moderate
degree of predisposition as by that of a severe neuro-
pathic heredity with a slight specific factor. So that it is
merely a quite possible extreme in this series when
one finds cases of neurosis in which a tangible degree

144 COLLECTED PAPERS VIII

of hereditary predisposition is looked for in vain,
provided that this deficiency is compensated for by
a powerful specific factor.

As concurrent or accessory causes all those ‘ordinary’
factors found elsewhere may be mentioned: mental
excitement, physical exhaustion, acute illness, in-
toxication, traumatic accidents, intellectual over-
work, etc. I would maintain that none of them, not
even the last, enters regularly or necessarily into
the ætiology of neuroses, well knowing that the
enunciation of this opinion is in direct opposition
to a theory regarded as universal and incontestable.
Since Beard declared neurasthenia to be the pro-
duct of our modern civilization he has found only
believers; but it is impossible for me to accept this
opinion. A painstaking study of the neuroses has
taught me that the specific etiology of the neuroses
has escaped Beard’s attention.

I do not wish to underestimate the etiological
importance of these every-day factors. They are
very varied, of frequent occurrence, and most often
blamed by the patient; they are more manifest than
the specific causes, which are either concealed or
not understood. They often fulfil the function of
precipitating causes bringing the hitherto latent
neurosis to the surface; and a practical interest
attaches to them, since consideration of these ordin-
ary causes may furnish a basis for a therapy that
does not aim at a radical cure, but contents itself
with reducing the disease to its previous latent state.

But a constant and intimate relation between a
given ordinary cause and a given nervous affection
cannot be established; mental excitement, for ex-
ample, is found as often in the ætiology of hysteria,
of obsessions, of neurasthenia, as in that of epilepsy,
Parkinson’s disease, diabetes, and numerous others.

1896 HEREDITY AND ÆTIOLOGY 145

The ordinary concurrent causes can also replace the
specific ætiology quantitatively, but can never com-
pletely supplant it. There are numbers of cases in
which hereditary predisposition and the specific factor
constitute the entire ætiology, the ordinary causes
being absent. In other cases the indispensable ætio-
logical factors are not strong enough in themselves
to precipitate the neurosis and a state of apparent
good health may be maintained for a long time, a
state that is really one of neurotic predisposition.
It requires only the added effect of an ordinary
cause to make the neurosis become manifest. It
must be noted, however, that in such circumstances
the nature of the supervening ordinary factor,
whether it be excitement, trauma, infectious disease,
or any other, is entirely a matter of indifference;
the pathological result does not vary in accordance
with it, and the nature of the neurosis will always
be determined by the pre-existing specific cause.

What then are the specific causes that produce
neuroses? Is there only one or are there several?
And can a constant ætiological relationship be
established between a given cause and a given neur-
osis so that each major neurosis may be referred to
a particular etiology ?

Supported by a painstaking investigation of the
facts, I wish to affirm that this hypothesis agrees
well with the truth, that each of the major neuroses
mentioned has as its immediate cause a special
disturbance of the nervous economy, and that these
pathological functional changes betray, as their com-
mon source, the sexual life of the person concerned,
either a disturbance of his present sexual life or import-
ant events in his past life.

This is, strictly speaking, not a new, unheard-of
proposition. It has always been admitted that sexual

10

146 COLLECTED PAPERS VIII

disturbances were among the causes of nervousness,
but they were grouped together on a level with other
precipitating causes as subordinate to heredity; their
ætiological importance was restricted to a limited
number of the cases studied. Physicians had even
acquired the habit of not looking for them if the
patient did not himself accuse them. The distinctive
characteristic of my point of view lies in my raising
the sexual factors to the rank of specific causes, in
my recognizing their influence in all cases of neurosis,
and finally in my, finding a constant parallelism,
proof of a special ætiological relationship, between
the nature of the sexual factor and the kind of neur-
osis.

I am quite sure that this theory will provoke a
storm of contradiction from my fellow physicians.
But this is not a fitting occasion to present the data
and observations that have imposed my conviction
on me, nor to explain the strict meaning of the
somewhat vague term ‘disturbances of nervous econ-
omy’. This will be done, I hope as thoroughly as
possible, in a work that I am preparing on the sub-
ject. In this paper I shall confine myself to the
presentation of my results.

Pure neurasthenia, which after it has been differ-
entiated from anxiety-neurosis presents a monoton-
ous clinical picture (exhaustion, sense of pressure
on the head, flatulent dyspepsia, constipation, spinal
paræsthesias, sexual weakness, etc.), admits of only
two specific ætiological factors, excessive onanism
and spontaneous emissions.

The prolonged and intense effect of this pernicious
form of sexual satisfaction alone suffices to produce
neurasthenia, or else it stamps the subject with the
specific neurasthenic habitus which later is made
manifest under the influence of a chance accessory

1896 HEREDITY AND ETIOLOGY I47

cause. I have also met persons who showed the
signs of a neurasthenic constitution, but in whom I
did not succeed in demonstrating the ætiology just
mentioned; I was able at least to prove, however,
that in these patients the sexual function had never
developed to a normal degree. They seemed to be
endowed by heredity with a sexual organization
analogous to that which arises in the neurasthenic
as a result of onanism.

The anxiety-neurosis, the clinical picture of which
is much richer (irritability, states of anxious ex-
pectation, phobias, more or less severe panics, fear,
vertigo, trembling, sweats, congestion, dyspnæa,
tachycardia, etc.; chronic diarrhæa, chronic loco-
motor vertigo, hyperæsthesia, insomnia, etc.)! is
easily shown to be the specific result of various
disturbances of sexual life, all having a common
trait. Forced abstinence, frustrated sexual excite-
ment (not gratified by sexual intercourse), incomplete
or interrupted coitus (not attaining gratification),
sexual efforts that exceed the psychical capacity
of the person, etc., all these factors, all too common
in modern life, seem to unite in disturbing the equi-
librium of psychical and somatic functions in sexual
activity, and in hindering the psychical co-operation
necessary to relieve the nervous economy from
sexual tension.

These considerations, which contain perhaps the
nucleus of a theoretical explanation of the functional
mechanism of the neurosis in question, arouse the
suspicion that a complete and really scientific demon-
stration of the matter is not at the moment possible,
and that the problem of the physiology of the sexual
life will first have to be approached from a new angle.

1 For the symptomatology and ætiology of the anxiety-neurosis
see my paper cited above, No. V of this volume, p. 76.

10*

på 48 COLLECTED PAPERS VIII

I will conclude by stating that the presence of
hereditary predisposition is not indispensable in the
pathogenesis of neurasthenia and of the anxiety-
neurosis. This is the result of daily observation; if
the hereditary factor is present, however, the develop-
ment of the neurosis will be strongly influenced
thereby.

In the second class of major neuroses, hysteria and
the obsessional neurosis, the solution of the ætio-
logical problem is surprisingly simple and uniform.
I owe my conclusions to the use of the new psycho-
analytic method, the probing procedure of J. Breuer,
a method that is somewhat subtle but irreplaceable,
so fruitful has it proved to be in explaining obscure
unconscious mental processes. By means of this
method, which cannot be explained here,” hysterical
symptoms are traced to their origin, which invariably
proves to be an experience in the person’s sexual
life well adapted to produce a painful emotional
reaction. Going back into the patient’s life step
by step, guided always by the structural connection
between symptoms, memories, and associations, I
finally came to the starting-point of the pathological
process; and I had to realize that the same factor
was at the bottom of all the cases subjected to
analysis, namely, the effect of an agent that must
be accepted as the specific cause of hysteria.

It is indeed a memory connected with the person’s
sexual life, but one that presents two extremely
important features. The event, the unconscious
image of which the patient has retained, is a premat-
ure sexual experience with actual stimulation of the
genitalia, the result of sexual abuse practised by

1 [The first use of this term by the author to designate his tech-
nique.—Ed.]
? See J. Breuer and Sigmund Freud. Studien über Hysterie. 1895.

1896 HEREDITY AND ETIOLOGY 149

another person, and the period of life in which this
fateful event occurs is early childhood, up to the
age of eight to ten, before the child has attained
sexual maturity.

A passive sexual experience before puberty: this is
the specific etiology of hysteria.

I will at once supplement these conclusions by
some detailed facts and some explanatory remarks,
so as to combat the doubt that I anticipate. I have
been able to analyse thirteen cases of hysteria com-
pletely. Three of this number were true combinations
of hysteria with an obsessional neurosis (I do not
say hysteria with obsessions). The experience men-
tioned above was not lacking in a single case; it was
present either as a brutal attempt committed by
an adult or as a less sudden and less repugnant
seduction, having however the same result. In seven
cases out of the thirteen we were dealing with a
liaison between children, sexual relations between
a little girl and a boy slightly older, generally her
brother who had himself been the victim of an
earlier seduction. These liaisons were sometimes
continued for years, up to puberty, the boy repeating
upon the little girl without alteration those practices
that he had himself experienced at the hands of a
servant or governess; because of this origin they
were often of a disgusting kind. In some cases there
had been both assaults and an infantile liaison or
repeated brutal abuse.

The date of the premature experience was variable:
in two cases it went back to the second year (?) of
the child; in my observations the age of predilection was
the fourth or fifth year. It may be a matter of chance,
but I have the impression from them that a passive
sexual experience occurring after the age of eight or
ten can no longer be the foundation of a neurosis.

150 COLLECTED PAPERS VIII

How can one be convinced of the truth of these
confessions made in analysis and said to be memories
preserved since early childhood, and how can we
protect ourselves against the inclination to fabricate
and the facility for invention ascribed to hysterics?
I would charge myself with blameworthy credulity
if I did not offer more convincing proofs. But the
fact is that patients never relate these histories
spontaneously, and never suddenly offer, in the
course of the treatment, the complete recollection
of such a scene to the physician. The mental image
of the premature sexual experience is recalled only
when most energetic pressure is exerted by the
analytic procedure, against strong resistance; so that
the recollection has to be extracted bit by bit from
the patients, and while it comes back into conscious-
ness they fall prey to emotions difficult to simulate.

If we remain uninfluenced by the patient’s be-
haviour and are able to follow impartially, in detail,
the psycho-analysis of a case of hysteria, we are
finally convinced ourselves.

The premature experience in question has left a
permanent imprint upon the history of the case,
being represented in it by a mass of symptoms and
peculiar features that permit of no other explanation;
the delicate but firm inter-relationship of the struc-
tural elements of the neurosis compel us to accept
this view; the therapeutic result is retarded if we
do not go so deep as this; no other choice exists then
except that of rejecting or believing the whole matter.

Is it to be believed that a premature sexual ex-
perience of this kind, undergone by a person whose
sex is scarcely differentiated, may become the
starting-point of a permanent mental abnormality
like hysteria? And further, how would such a view
harmonize with our present conception of the psych-

1896 HEREDITY AND ETIOLOGY I5I

ical mechanism of that neurosis? A satisfactory
reply can be given to the first question: it is just
because the subject is a child that premature sexual
stimulation produces little or no effect at the time,
but a mental impression of it is retained. Later, at
puberty, when the sexual organs have developed a
degree of activity immeasurably greater than that
of childhood, this unconscious mental impression
is somehow or other reawakened. Owing to the
changes produced by puberty the memory will
exercise a power which was entirely lacking when
the experience itself took place; the memory will
produce the same result as if it were an actual event.
We have, so to speak, the subsequent effect of a sexual
trauma.

As far as I know, the reawakening of a sexual
recollection after puberty, the event itself having
occurred at a time antedating this period, affords
the only psychological conjunction in which the
effect of a memory surpasses that of the event itself.
But it is an abnormal constellation, which attacks
the mind at a weak point and necessarily produces
a pathological result.

I believe that this inverse relation between the
psychical effect of the recollection and that of the
event contains the reason why the memory has
remained unconscious.

We thus approach a very complex psychical
problem, one which, however, if duly appreciated
promises to throw a flood of light some day upon
the most intricate problems of mental life.

The ideas set forth here, based upon the results
of psycho-analysis, namely, that the memory of a
premature sexual experience is always found as the
specific cause of hysteria, do not agree with Janet's
psychological theory of the neurosis, nor with any

152 COLLECTED PAPERS VIII

other; but they harmonize perfectly with my own
hypotheses, described elsewhere, on the 'defence
neuroses’.

All events occurring after puberty to which an
influence on the development of hysteria and the
formation of its symptoms must be ascribed are
only concurrent causes, “agents provocateurs' in the
words of Charcot, to whom neuropathic heredity
occupied the position that I claim for premature
sexual experiences. These accessory factors are not
subject to the strict rules that govern the specific
causes; analysis demonstrates beyond question that
they produce a pathological effect in hysteria only
by virtue of their ability to awaken the unconscious
mental impression of the infantile experience. It is
also because of their connection with the original
pathogenic impression and by its magnetism, so to
speak, that the memory of them becomes unconscious
in turn, and is able to assist the growth of a mental
process withdrawn from the influence of conscious
processes.

The obsessional neurosis arises from a specific
cause closely analogous to that of hysteria. A pre-
mature sexual experience, which has occurred before
puberty and the memory of which becomes active
during or after that period, is also found here and the
same observations and arguments made in reference
to hysteria apply to cases of this neurosis (six cases,
three pure forms). There is only one difference that
seems of capital importance. At the base of the
ætiology of hysteria we found a passive sexual
experience undergone with indifference or with a
slight degree of disgust or fright. In the obsessional
neurosis we are concerned, on the other hand, with
an experience that was pleasurable, with a sexual
aggression inspired by desire (in the case of the

1896 HEREDITY AND ETIOLOGY 153

boy) or with a pleasurable participation in sexual
acts (in the case of the little girl). The obsessive ideas,
whose inner meaning is made recognizable by ana-
lysis, reduced, so to speak, to their simplest form,
are nothing but reproaches that the patient makes
to himself because of that premature sexual pleasure,
but reproaches disguised by an unconscious psychical
work of transformation and substitution.

The very fact that this sexual aggression occurs
at such a tender age seems to betray the effect of
a previous seduction, which would result in pre-
cocity of sexual desire. Analysis has confirmed this
suspicion in the cases I have treated. In this way
an interesting fact always present in these obsessional
cases is explained, namely, the regular way in which
the clinical picture is complicated by a certain
number of purely hysterical symptoms.

The importance of the active sexual attitude as
a cause of obsessions, and that of the passive attitude
in the pathogenesis of hysteria, seems to give the
reason of hysteria’s close association with the female
sex and of the preference of the male for the obsession-
al neurosis. One sometimes comes across a pair of
neurotics who had a liaison in early childhood, the
man suffering from obsessions, the woman from
hysteria; if we are dealing with brother and sister
we may mistake for the result of heredity what is
really derived from premature sexual experience.

There are, unquestionably, pure and isolated cases
of hysteria and obsessional neurosis, independent of
neurasthenia and anxiety-neurosis, but they are not
the rule. More frequently, the psychoneurosis ap-
pears as accessory to the neurasthenic neuroses,
having been provoked by the latter and following
their decline. This happens because the specific
causes of the latter, current disturbances of the

154 COLLECTED PAPERS VIII

sexual life, act at the same time as accessory causes
of the psychoneuroses, the specific cause of which,
the memory of an early sexual experience, they re-
awaken and revive.

As for neurotic heredity, I am far from being able
to estimate accurately its influence in the etiology
of the neuroses. I admit that its presence is indis-
pensable in serious cases; I doubt whether it is a
sine qua non in mild cases, but I am convinced that
neurotic heredity alone cannot cause a psycho-
neurosis if the specific etiology of the latter, premat-
ure sexual stimulation, be lacking. I even believe
that the question which of the two neuroses, hysteria
or obsessional neurosis, will develop in a given case
is determined not by heredity but by the particular
nature of the early sexual experience in childhood.