A Review of Nineteenth Century Medical and
Forensic Antecedents of Post Traumatic Stress Disorder

(Sep 2011)

Authored by Martha Knox-Haly ( Department of Work and Organisational Studies, Faculty of Economics, Sydney University)

Abstract

Post traumatic stress disorder became the most popularly litigated psychiatric disorder in the twentieth and early twenty first centuries. This paper explores historical influences of law and psychiatry shaping conceptualisations of trauma during 1775 – 1920. Disturbances in magnetic fluid, hypnotic trances, neurological legions, hysteria, neuroses and shell shock, as well as the continual tension between materialists and mentalists are considered. Legal codification and civil suits are identified as a significant influence in creating litigated disorders. Such reforms facilitated forensic evaluation mental illness in determination of judgements for civil and criminal cases. Many of the problems encountered in contemporary litigation around trauma, were also present in the nineteenth century. For example, the intangible nature of the causes of mental illness meant that malingering was a long standing concern for courts.

Introduction

Trauma as Hysteria: A Forensic Perspective from 1775 to 1918

The historical precursors of post traumatic stress disorder are examined from the period of 1775 (or the late Enlightenment) to 1920 (Modernism). This is not to imply that documentary evidence of trauma symptoms only began to emerge in this period. For example, writing thirteen days after the Great Fire of London, Samuel Pepys noted that he was ‘much terrified in the nights now-a-days with dreams of fire, and falling down of houses’. There is reference in court testimony of the Salem witch trials in 1692, to nightmares about the Indians. Virginia settlers had been burned alive by the local Indian population in the early years of American settlement. However the late eighteenth century created a unique context which facilitated the growth of forensic psychiatric enquiry and dynamic psychiatry. The Enlightenment (1687 – 1789) had promoted reason and causality which could be expressed through universal principles as the defining knowledge standard. The Romantic period in the late eighteenth century, represented a revolt against rationality and the reductionism, and it took self development and emotions as its point of focus. The junction of the Enlightenment and Romantic periods set the scene for the development of dynamic psychiatry and contemporary theories of psychological trauma. With some exceptions, a broad historical treatment narrative can be traced from this point. This can be described as exorcism versus magnetism (in the late eighteenth century), to magnetism versus hysteria, hysteria versus neuroticism, and finally neuroticism from unconscious causes to consciously realised anxiety states. The historical legal narrative for this period (for several western European countries) incorporates shifts from roman-medieval law to legal codes, and from ancient droit to rights of citizenship. From the mid sixteenth century, many German legal academics came to regard Natural law as a superior alternative to roman civil law. The codification of laws in France (1804), Prussia (1792) and Austria (1811) were influenced by the assumption that natural law could generate universal principals. The promise of radical simplification was appealing as nation state leaders were faced with the need to reform archaic bodies of medieval law. Although codification had its supporters in Britain and America, the legislature was generally reluctant to engage in codification during the early nineteenth century. The second dimension affecting European legal evolution was the shift from ‘ancien droit’ (or rights allocated on the basis of birth and class), to the idea that each individual was granted inalienable rights by nature and reason within the nation state.

This prompted legal inquiry about the characteristics of the individual and their capacity for reason. According to researchers, Steinberg, Schmidt-Recla and Schmideler, German medico-legal texts became increasingly common in the seventeenth century, with the first medicolegal journal being produced in Berlin in 1782. Eighteenth century forensic debates wrestled with the question of whether sanity was a legal, philosophical or psychological question. This had ramifications for who could be regarded as an authoritative source on insanity.

The core assumption of dynamic psychiatry, is that exposure to distressing events creates psychic conflict and resistance, the outer manifestations of which may be regarded as dysfunctional. Ellenberger argues that the foundations for dynamic psychiatry began in 1775, with a clash between the exorcist and faith based healer Father Johann Joseph Gasner and the physician Franz Anton Mesmer (1734 – 1813) in 1775. As an extension of his doctoral research on the influence of planetary systems on moods, Mesmer had discovered magnetic fluid or ‘magnétisme animal’, which could be used for curative effect. In July 1775, Gasner had toured Northern Europe demonstrating miraculous healings, invoked by the power of faith. Mesmer followed in Gasner’s path, with Mesmer generating his own remarkable cures – based on Enlightenment science. When Mesmer was called by the Prince Elector to provide testimony in about Gasner’s work in 1775, Mesmer demonstrated that comparable results could be obtained through magnetism. Mesmer’s testimony represented another example of where science had resolved a religious mystery.

As a metaphysical philosophy, Mesmerism was equally attractive to scientists and those concerned with occult mysteries. The romantic period was associated with a religious resurgence. Religiously inclined academics (such as the German Romantic Psychiatrists) and practitioners remained prominent in the scientific debates around mesmerism in the early nineteenth century. Their contribution lay in the creation of psychological systems to explain the effects of magnetism and mental illness. The Portuguese priest l’Abbé Faria (1746 – 1819) was responsible for introducing the concept of individual susceptibility to ‘auto-suggestion’. Faria attributed the beneficial effects of ‘magnetism’ to the personality of those being placed in ‘sommeil lucide’ or lucid sleep. Professor of Internal Medicine and theologist Johann Christian August Heinroth (1773 - 1843) adopted a holistic perspective, asserting that psychic disorders arose because their sufferers had led a sinful existence. When mental illness arose, the sufferer was weakened through previous moral laxity, to resist the assault of mental or physical illness. Heinroth and l’Abbé Faria were just two of a number of religious men participating in what was now a scientific medical debate. There was no reference in either Faria’s or Heinroth’s writings to mental illness being caused by spiritual possession, instead their analysis is predominantly psychological.

Shifting the field from religious mystery to scientific enquiry introduced questions of agency. Mesmer’s followers had divided on whether organic or psychological factors underpinned disease. The Fluidists believed in magnetic fluid, whilst Animists attributed disturbance to psychological phenomena. The division occurred after Armand-Marie-Jacques de Chastenet, Marquis de Puységur (1751 - 1825), and a follower of Mesmer, discovered ‘magnetic sleep’ or artificial somnambulism, after inducing trance like states in a peasant, Victor Race. Puységur recognised that secrets could be pathenogenic: where the mind split into an ordinarily accessible state, and an alternate consciousness, without either state possessing an awareness of the other. The significance of dissociated states such somnambulism and trances, was that they could potentially be regarded as evidence of partial incapacity, which was not considered in medieval law. For instance, under the medieval Saxon criminal code, an individual had to be completely mentally incapable, otherwise Saxon courts would apply full culpability for man slaughter.

The first wave of ‘academic infrastructure’ for the study of animal magnetism was created during the Romantic period. In contrast to France where Mesmer’s work was never accepted by the scientific establishment, German Universities, such as the University of Berlin, Halle and Jena, sought to systematize the study of animal magnetism. German intellectuals such as Gmelin, Kluge, the brothers Hufeland, Kieser, Nasse, Passavant and Wolfart explored the interrelationship of animal magnetism, mental illness, spirituality and creativity in the journal Askläpeion, which was established in 1811.

They recognised that the success of such techniques as magnetism was determined by therapeutic rapport within an interdependent, self contained treatment system. Dietrich Georg Kiesner (Professor of Pathology and Rector of the University of Jena) compared the magnetic circle to spiritual marriage, and saw the disruption of the therapeutic relationship as a form of spiritual infidelity.

Johann August Heinroth (1773 – 1843) held the first Chair of Psychiatry, which had been established in 1811 in the University of Leipzig, Saxony. The contribution of Heinroth’s religious background to forensic psychiatry, was apparent in his concern with free will and guilt. Heinroth believed that disengagement from the conscience was a conscious choice, and the original cause of mental illness. Therefore those who committed crimes whilst mentally ill were still guilty. However as the crime had been committed whilst the person was “unfree” (disconnected from the freedom provided by reason), full punishment was inappropriate. Heinroth provided a psychological understanding of trauma, as he listed shock as a catylst of mental illness. He construed both mental disorder and organic disease, as a disorder of the soul, using the term ‘psychosomatic’ to describe physical manifestation of a deteriorated soul.

Heinroth’s second contribution to forensic psychiatry and trauma lay in the articulation of assessment principals for partial states of insanity. Heinroth saw the law as being responsible for protecting the freedom of the person and holding them accountable for their deeds. When the person was clearly ‘unfree’ through either partial or full insanity, the state could not hold the person accountable.
Heinroth was concerned with the possibility of malingering, as a strategy to avoid culpability. He insisted that this possibility could only be averted through a detailed assessment of the whole person. This assessment needed to be informed by the physician’s expertise with abnormal mental conditions and detailed experience of psychiatric cases. This laid the foundation for German courts to routinely call for the report of expert witnesses in ambiguous cases.

British courts continued to rely on common law, with the judiciary being the ultimate authorities and deciders on how common law should be interpreted. It was comparatively rare to call expert forensic witnesses in criminal matters. Gutheil notes that between 1760 and 1845, 350 criminal defendants claimed that mental disturbance had influenced their actions. Less than a quarter of these cases called medical witnesses, and court assessments relied on evidence from defendants, neighbours and relatives.

The role of forensic psychological and psychiatric experts in France was profoundly impacted by revolutionary politics. There were two general groups - materialists and metaphysicians - associated with the study of insanity and mental disorder in post revolutionary France. The materialists or positivists were usually physicians, who attributed mental disturbance to brain irritation or neurological legions. Phrenology and dissection as were the materialists’ main research methods. The metaphysicians studied mental disorder by cataloguing of symptoms. Each group was associated with an explicitely political position. The physicians stood for the Enlightenment reforms, and their opponents accused them of atheism, republicanism and liberalism during the Bourbon restoration from 1814 to 1830. The Bourbon Restoration ultimately closed the Paris medical faculty during 1822-23, removing academics suspected of revolutionary sentiment. The metaphysicians stood for the restoration, Catholicism/ spiritism and psychology. They argued that altered states of consciousness could be a pathway for spiritual wisdom and transcendence. Altered states of consciousness and hallucinations represented a challenge to the materialists, who argued that they were evidence of physical brain injury or disease. However practitioners such as l’Abbé Faria and Puységur, were producing these symptoms in public exhibitions of hypnotism and mesmerism. Given this perspective, it is understandable that the physicians regarded Mesmerists as frauds.

These contextual aspects complicated the inter-section of psychiatry and law. The Napoleonic Code represented that most comprehensive reform of medieval law in Europe, but provided no guidance to the judiciary around determination of insanity. There was simply a stipulation that insane individuals should not be held responsible.

Physicians Esquirol and Georget had produced a forensic text arguing that monomania was a basis for clemency and partial insanity. The physician Broussais claimed that magistrates’ religiousity prevented them from acknowledging monomania. The galvanizing case was that of Henriette Cornier, a domestic who had decapitated an eighteen month old girl. When asked why she had done this, Cornier calmly replied that her thoughts had caused her actions. Georget and others unsuccessfully argued that Cornier was suffering from monomania, the metaphysicians blamed Cornier’s actions on a lack of piety and confession with her priest, which would have defused the realization of her homicidal ideation.

Psychiatry would not be fully accepted by the French state, until the physicians worked closely with the Ministry of the Interior to produce the Law on Alienated Persons on June 30 1838. This legislation established a state wide network of psychiatric hospitals, with staff appointed by the Minister of the Interior, with the exclusion of the judiciary from the scheduling process. Before the revolution, detention of insane persons could be either undertaken through royal order (lettre de cachet) or justice order. The former method ceased in 1790, and the administrative gap was filled by the Ministry of the Interior.

The split between physicians and metaphysicians had implications for the forensic acceptance of certain mental conditions as grounds for clemency. In his 1938 treatise, Des Maladies Mentales, Esquirol addresses five different forms of madness. There was no reference to hysteria, which the physicians did not regard as a form of mental illness, as hysteria was caused by disturbances in neural extremities. There is no mention of the forensic application of hysteria in France in the first half of the nineteenth century. This does not really change until the advent of the Nancy school and the great neurologists of the 1870s.

There was one thinker whose research bridged the divide between the mesmerists and the physicians. The French physician and engineer, Alexandre Bertrand (1795 – 1831) explored the systematic application of magnetic somnambulism in his 1823 book ‘Traité du somnambulisme et des différentes modifications qu'il présente’ (Treatise on sleepwalking and the various changes it presents). Bertrand recognised the human mind’s capacity for producing thoughts outside of the thinker’s awareness, and that these thoughts could only be inferred through the physical effects that they produced. Bertrand noted that somnambulists referred to themselves in the third person, as though the alternate consciousness as entirely separate from the waking consciousness. Suggestions delivered to the somnambulist could achieve resolution of psychic and psychosomatic illnesses. Betrand’s work would influence Pierre Janet’s thinking around dissociation some sixty-six years later. Bertrand was initially a supporter of animal magnetism, but ultimately concluded that somnambulic states were a psychological phenomenon.

Magnestism’s attractiveness for those individuals with an interest in the occult meant that it became associated with quackery and fraud by the mid nineteenth century. Despite the work of German universities, both magnetism and hypnosis were regarded by many medical practitioners as lacking a scientific basis. Still the work of Bertrande and the German Romantic thinkers was an important foundation for cumulative knowledge and theory building around the therapeutic treatment of trance phenomena and trauma. This is not to suggest that the practices of hypnosis were to entirely abandoned. Instead somnambulism and hysteria was to be explored through an entirely different medical speciality – neurology.

New research on the materialist nature of somnambulism, hysteria and hypnotism was completed by the neurologists of Britain and Northern Europe between 1840 and 1893. Realization of the forensic application of trauma/hysteria is traceable through four formative influences on the most powerful neurologist on the nineteenth century, Jean Marie Charcot (Medical Director of the Pitié Salpêtrière). The first of these influences was the Scottish neurosurgeon Doctor James Braid (1795 - 1860), who provided an alternative organic explaination for the effects of Mesmerism. Braid had previously been an adherent of phrenology, but was impressed by the French Mesmerist Charles La Fontaine in 1841. Mesmerism was a possible method for surgical pain in Braid’s neurosurgical practice. Braid proposed that the effects of altered consciousness came from 'neuro-hypnotism or a sleep of the nerves which was activated by a continued fixed stare, by paralyzing nervous centres in the eyes and their appendages.’ Braid would later reject organic explanations, concluding that hypnosis was a purely suggestive mental phenomenon.

The second influence was Pierre Briquet (1796 – 1881), a physician and neurologist with the Hospital of Paris, who documented 430 cases of patients suffering from hysteria or neurosis of the brain. Hysterical symptoms were broad ranging, and according to Briquet, occurred in vulnerable individuals when traumatic events impacted the emotional areas of the brain. Briquet and Braid’s work was part of a growing focus on hysteria in the 1840s and 1850s. Hysteria was not a new term, as there had always been patients with a variety of puzzling and unresponsive symptoms. There had also been substantial confusion over what was actually meant by the term ‘hysteria’. Chodoff and Lyons identified no less than five different uses for the term hysteria. Most commonly in the nineteenth century, hysteria referred to behaviour patterns exhibited by individuals with hysterical personalities, or hysteria could manifest as a psychosomatic or conversion disorder.

The Austro-Hungarian neurologist Benedikt would be the third notable influence on Charcot’s work on hysteria. Moritz Benedikt (1835 – 1920), Professor of Neurology at the University of Vienna. Benedikt was best known for his work on the organic difference between the brains of non-criminal and criminal minds, arguing that morality could be physically located within a defective covering of the cerebellum by the occipital lobes. The implication being that criminals were born and therefore unresponsive to punishment. This perspective was unpopular within the legal profession. Benedikt’s work on criminal anthropology was attacked as ‘sensational fiction’ by Professor of Penal Law, Wilhelm Wahlberg. Wahlberg’s writings were essential reading for all legal professionals in Vienna, and so his criticisms of Benedikt’s work were devastating.

Benedikt proposed a physiological basis for hysteria, attributing its cause to secret fantasy, frustrated desire and functional disturbance of the genital area. Benedikt believed that a patient’s symptoms could be alleviated, if they could be bought to unburden themselves of their secrets. Ellenberger regards Benedikt as responsible for the systematic analysis of the pathogenic secret and its treatment. Benedikt’s work on criminal anthropology, psychiatry and neurology was admired by Charcot. Freud and Breuer also paid homage to Benedikt’s work in their Preliminary Communications.

The Anglo-american railway surgeons were the fourth source of influence on Charcot’s conceptualization of hysteria. American railways were more dangerous than British and European railways (which were under more pressure to address safety issues in higher population density areas). American railways had to provide their own medical services in areas where sparse population could not sustain hospitals, Baltimore and Ohio Rail was the first to establish a contractual arrangement with a surgeon in 1834. By 1865, Chicago and North Western had developed a medical department with salaried superintending surgeon and attendants. Railway surgeons continued to grow in number, such that by world war one, the railways employed 14,000 surgeons or one twelth of the American surgical workforce.

Law reformer and Senator David Dudley Field had overseen the enactment of the Field Code of Civil Procedure on 1 January 1850. This reform made it possible for civil litigants to conduct combined suits for monetary and non-monetary damages, and facilitated opportunities for civil litigation by injured railway passengers. One fifth of railway medical departments reported to either the legal or claims department. The railway surgeons were in a complex position of providing effective medical care, whilst reducing passenger claims costs and acting as effective expert witnesses in court cases. Incorporation of claims determination duties meant that railway surgeons were vigilliant to conscious malingering for financial gain. The majority of railway surgeons regarded assertions of psychological agency with suspicion. Other surgeons believed that caring common sense could resolve these injuries.

Nineteenth century railway accidents had generated a number of victims who would present with extensive clinical symptomatology, but no organic injury. The neurological basis for trauma symptoms (or railway spine) were first described in 1865, and formalised in an 1882 publication by British Professor of Surgery, John Erichsen. Erichsen’s book ‘On Concussion of the Spine: nervous shock and other obscure injuries of the nervous system in their clinical and medico-legal aspects,’ was frequently cited in nineteenth century British and American compensation cases. Erichsen concluded that ‘these (symptoms of irritiability, fretfulness and an inability to confine attention) can only be the result of derangement in the higher cerebral centres’. A year later, Dr Herbert Page, (Chief Surgeon to the London and North West Railway) refuted Erichsen’s arguments in the book, ‘Injuries of the Spine and Spinal Chord without Apparent Mechanical Lesion’. Page argued that the psychological agency of fright was responsible, and he ridiculed the view that trauma symptoms arose from ‘molecular disturbance.’ Page recognised that the sufferer might not be consciously aware that they were simulating injuries. The writings of Erichsen, Page and the American railway surgeons would particularly influence Charcot’s thinking around male hysteria.

The brilliant neurologist Jean-Martin Charcot (1825 – 1893) headed the Pitié Salpêtrière from 1882 till 1892. Charcot was originally a Professor of Pathological Anatomy, who developed a fascination with hysteria from 1872 onwards, regarding susceptibility to hypnosis as a diagnostic signature for hysteria. Gynaecologically based models of hysteria dominated medical thinking. By 1879 Charcot was beginning to challenge these models of hysteria, with cases of male hysteria. Charcot’s model of male hysteria was based on neuropathy or neural lesions, and stressed symptoms of paralyses, anaesthesias and contractures. His model would drive American and European medical thinking on hysteria throughout the 1870s and 1880s. His clinical writing covered different subcategories, including spontaneous hysteria, grand hysterié and traumatic hysteria.

Charcot argued that hysteria could arise from an organic abnormality, which could be a nutritional deficiency, molecular alteration, an electrophysical imbalance or a dynamic lesion located in the cortical substrate. Whilst Charcot was best known for his work on female hysteria, his conceptualisation of ‘traumatic hysteria’ was derived from a population of physically injured male patients. Sufferers presented with agitation, insomnia, paralyses and partial or total memory loss around the traumatic event. Charcot speculated that there might be an inverse relationship between pathology and loss of consciousness. Ultimately, Charcot was unable to articulate a clear neurological mechanism for hysteria, even in his final paper in 1893. Charcot asked rhetorically "What, then, is hysteria? We know nothing of its nature, nor about any lesions producing it. We know it only through its manifestations and are therefore only able to characterize it by its symptoms, for the more hysteria is subjective, the more it is necessary to make it objective in order to recognize it. Shortly before his death, Charcot would consider psychological trauma as a causal factor for hysteria.

Charcot’s work provided a rich and detailed study of conversion disorders and hysterical symptom formation as the expression of psychological problems. His work was a major contribution to Freud’s understanding that neurosis resulted from repression of traumatic conflict and conversion into masquerading symptoms.

According to Micale, there were several schools offering a counterview to Charcot’s theories. However Bernheim and Liebault, (also known as the Nancy School of hypnosis) represents perhaps the best documented criticism of Charcot’s work. Whilst animal magnetism almost completely disappeared by the late nineteenth century, the credibility of hypnosis as a therapeutic tool was being explored by Hippolyte Bernheim (1840 - 1919). Berheim had been impressed by the work of Ambroise-August Liébault, a medical practitioner who had practiced mass hypnosis at Pont St Vincent outside of Nancy. Both Liébault and Bernheim were influenced by Braid’s and l’Abbé Faria’s work on hypnosis. Bernheim had been appointed to the role of Professor of Internal Medicine at Nancy University in 1879, and introduced hypnosis into university lectures from 1882. Bernheim disputed Charcot’s neurologically based theory of hysteria, and that hypnotisability was a symptom of pathology predominantly found in women. Instead, Bernheim, like l’Abbé Faria sixty-nine years previously, saw hypnosis as an expression of suggestibility, a trait that could be found across many demographic groups. Bernheim commented ‘It is wrong to believe that the subjects influenced are all weak nerved, weak brained, hysterical, or women. Most of my observations relate to men, whom I have chosen on purpose to controvert this belief. Without doubt, impressionability varies. Common people, those of gentle disposition, old soldiers, artisans, people accustomed to passive obedience, have seemed to me, as well as to M. Liébault, more ready to receive the suggestion than preoccupied people.’ Bernheim would later conclude that the same beneficial effects could be obtained without hypnotic induction. His practice became known as ‘psychotherapeutics’, and was a hallmark of what became known as the Nancy School.

The rivalry between Charcot and the Nancy School spilled into the forensic domain. Bernheim, and two colleagues, the lawyer Jules Liegeois and medico legal expert Henri Beaunis argued that it was possible for crimes to be committed under hypnosis. Charcot had disagreed. Charcot’s protégé, Georges Gille De la Tourette argued that hypnosis could only be associated with the crime of rape, where the rapist had hypnotized the victim leaving them in a lethargic state. Charcot emphasized that hypnotized subjects could not be made to perform acts against their will. A series of criminal cases occurred between 1888 and 1890, such as the Affaire Chambige and the Eyraud-Bompard case, where it was unsuccessfully argued by Bernheim in the first case, and Liegeois in the second, that the murders had been committed whilst the perpetrators were under a state of hypnosis. Although, de la Tourette publicly criticized Liegeois’s court room displays of individuals using fake weapons to commit murders, de la Tourette himself had conducted similar experiments in 1887.

Soon after Charcot’s death in 1893, his work on hysteria was revealed as flawed. Charcot’s subordinates had coached particular patients in hysterical presentations. Bernheim’s views that susceptibility to hypnosis was a purely psychological phenomenon prevailed. Hysteria came to be regarded by successive medical directors at the Pitié Salpêtrière as a form of malingering.

The materialists still contributed to the understanding of trauma, by exploring biological and genetic contributions to trauma, as well as improved diagnostic classification systems. The work of psychiatrist Emile Kraepelin bought a particular observational richness and diagnostic rigour to the evaluation of traumatic neurosis. Kraepelin (1856 – 1926) was appointed as Professor of Psychiatry at the University of Dorpat in 1882. Instead of providing a diagnosis of the basis of major symptoms, Kraepelin mapped symptom patterns, classing diseases through total symptom profiles. Indeed the diagnostic systems within DSM III and the biomedical focus of psychiatry have been attributed to Kraepelin’s work.

Kraepelin presented startlingly detailed accounts of what is clearly recognisable as a case post traumatic stress disorder after railway accidents. In another clinical study of a young male acrobat who had fallen off the trapeze, Kraepelin attributed the delayed symptom onset, to the ‘special predisposition’ of the patient, claiming that the patient’s symptoms all pointed to a ‘hysterical source’. Kraepelin’s work implied that even though there were different agencies of injury, the collective symptom patterns of these different cases suggested that they stemmed from a single condition. Kraepelin would change his position on the organic basis of trauma at the end of World War One, but his genius for diagnostic classification helped Kraepelin recognise that combat neuroses, compensation neurosis and railway spine shared the same mechanism of psychopathology. Kraepelin noted ‘doubtlessly, however, mental disorders that make up one clearly defined group do have a psychic origin. The most important of these generally brought to light by strong emotions, are the Hysterical Disorders, known since Charcot and Mobius, Accident Neuroses (following the enactment of compensation laws) and, closely related to the latter, Combat Neuroses’.

Charcot had been responsible for introducing two young neurologists Freud and Janet to each other during Freud’s visit to Pitié Salpêtrière in 1884-1885. The meeting of these minds created a fertile forum for discussion on hysteria, neuroses, and the foundation role of the unconscious. For Pierre Janet (1859 – 1947) hysteria was a brain disease, comparable to catalepsy, characterized by physical shock induced by emotional distress. Janet had referred to hysteria as ‘a disorder of the brain, intermittent, febrile, characterized by the suspension of the understanding and sensitivity and the ability of muscles to receive and keep all the degrees of contraction given them. This definition, while not perfect, gives a pretty good general idea of a disease state that occurs naturally in some susceptible individuals, following a shock or emotion and that is produced artificially in some subjects by various processes well known.’ Janet attained his doctorate in philosophy in 1889, and subsequently published his medical doctoral thesis in the area of hypnosis and dissociation in 1889.

Janet’s doctoral work formulated a crucial connection between dissociation and traumatic memories. The mind performed two functions – the preservation of past activities and the integrative function based on synthesis and creation of new mental phenomena. Many of Janet’s patients had a breakdown in this integrative function, being unable to process traumatic aspects of their past. Janet developed the term ‘dissociation’ to describe how certain individuals might respond to an inescapable danger. Janet draw on the work of Alexandre Bertrand, as well as Moreau de Tours (1845) which introduced dissociation (désagrégation psychologique) in reference to splitting of psychological states from shock or distress.

Janet pioneered the use of abreactive techniques for processing of traumatic memories. Despite the use of verbally mediated techniques, Janet still considered that there was an organic contribution to traumatic symptoms arguing the sufferer’s brain displayed abnormal characteristics. Janet’s understanding of dissociation was similar to contemporary views: dissociation was a continuum ranging from a thought to a fully-fledged state that could reason and converse (see the diagnosis of ‘multiple personality disorder’ in his article ‘Une Félida Artificielle’).

Janet argued that dissociation, or splitting traumatic memories, represented the initial stages of responding to a trauma, and would determine the level of ultimate adjustment to a traumatic event representing a habitual coping mechanism. This explains the emotionally constricted and psychically brittle quality of dissociating/traumatized individuals. Janet explored “the direct relationship between the ‘secondary self’ (the self that appears during hypnosis), and the development of somatic symptoms (false paralyses and shifting anaesthesias)”. Dissociation explained a patient’s inability to account for his or her behaviour during trance states.

The Charcot-Janet Somnambule (female hysteric) was different from shell shock victims. Somnambule’s have a habitual diminution of the primary awareness during repetitive work, and secondary awareness comes from the ‘subconscious’. In contrast, shell shock cases were viewed as cases of transient, situational diminution of primary awareness. Many of Janet’s patients engaged in fixed ideas, where dissociating patients would re-enact aspects of the original traumatic experience. Freud and Breuer would acknowledge Janet’s work on the mental structures involved in primary awareness, the subconscious, dissociation, traumatic adaptation and hysterical predisposition in their text, “Studies in Hysteria”. Pierre Janet had continued to study hypnosis and hysteria after Charcot’s death, despite these areas falling from favour. Unfortunately, Janet was ultimately forced to leave the Pitié Salpêtrière in 1910, as his research focus was deemed unacceptable.

Sigmund Freud (1856 – 1939) was credited as being the founder of psychoanalysis, representing a synthesis of influences from Charcot, Janet, Benedikt, the Nancy School and German Romantic Psychiatry. It is beyond the scope of this article to comprehensively address the prolific range of Freud’s work. The objective of psychoanalysis was to facilitate resolution by making the unconscious conscious. Hysteria arose from a neurotic repression of infantile psychic needs. Freud’s theory of psychosexual development, was based on infants having different development objects (oral, anal and phallic) prior to achieving mature adult sexuality (the genital stage). In his later book, the Ego and the Id (originally written in 1923), Freud proposed a tripartite model of personality consisting of the Id (infantile and pleasure seeking), Ego (the application of reason) and Super-Ego (the higher self or conscience). The Ego seeks reconciliation between the Id’s desires, the limitations of reality and the demands of the superego.

Wilson argues that Freud’s conceptualization of trauma determined medical thinking from 1895 to the end of the Vietnam War era in 1975. In his first two publications, Studies in Hysteria (published in 1895) and Aetiology of Neuroses (published in 1896), Freud speculated that infants experienced many traumatic events (such as sexual abuse), which were repressed from consciousness. The confronting nature of Freud’s early work resulted in significant criticism. By 1897, Freud resiled from his earlier views the trauma was associated with actual seduction. He concluded that patients’ memories were infantile fantasies arising intrapsychic conflicts.

Freud would have been all too aware of the scandals emanating around Charcot’s work on the ‘grande hysterie’. After 1895, he began to distance himself from the study of hysteria, taking neurosis as his main focus (albeit that the diversity of neurotic symptoms was remarkably similar to the diagnostic profile for hysteria). Neurotic symptoms were not a response to objectively stressful events; instead, they were a manifestation of psychic repression. Freud even applied this view to war neurosis. Trauma symptoms were neurotic reactions from soldiers’ defence mechanisms being overwhelmed. Freud acknowledged that associated war neurosis was different from spontaneous neurosis, but was intially unable to articulate the source of this difference. Writing in 1920, Freud would however decisively discount neurological organic legions as the cause of traumatic neurosis.

Freud stated “the terrible war which has just ended gave rise to a great number of illnesses of this kind, but it at least put an end to the temptation to attribute the cause of the disorder to organic lesions of the nervous system brought about by mechanical force. The symptomatic picture presented by traumatic neurosis approaches that of hysteria in the wealth of its similar motor symptoms, but surpasses it as a rule in its strongly marked signs of subjective ailment (in which it resembles hypochondria or melancholia) as well as in the evidence it gives of a far more comprehensive general enfeeblement and disturbance of the mental capacities. No complete explanation has yet been reached either of war neuroses or of the traumatic neuroses of peace.”

Freud’s examination of shell shock cases established the psychoanalytic concept of mastery through repetition. Hysterics consciously engaged in painful reminiscence, whilst traumatized patients tried to avoid the painful event. Instead trauma sufferers experienced, and would awaken from terrifying dreams, about the traumatic episode. Freud distinguished between fright and anxiety in etiology of traumatic neurosis, arguing that anxiety was a protective factor against traumatic neuroses, as the individual was prepared for danger. Fright was the result of shock and surprise associated with danger, and the basis of permanent physical impairment in nervous shock.

Writing later in his introduction to ‘Psycho-analysis and the War Neurosis’, Freud conceptualized traumatic neurosis and war neurosis as arising from external threats to the ego, whilst transference neuroses arose from internal threats to the ego posed by unacceptable libidinal desires. Although these were two different causes, Freud establishing a unifying explanation by attributing war neurosis to the psychically generated fear of annihilation. In testimony to the Austrian War Ministry, Freud argued that soldiers with war neurosis were not malingering, rather they were responding to a conflict between their unconscious drive to stay alive, and a conscious commitment to military duty. One of Freud’s followers, Ferenzci extended this reasoning, arguing that war neurosis was triggered by narcissistic injury, or the emotional drive for self preservation.

The latter half of the nineteenth century was characterized by growing labour organization, and the creation of workers compensation schemes in different northern European states. The French company, the Sécurité Générale established in 1865, had been the first to offer a combined workers compensation and liability insurance. The first extensive employer liability scheme was introduced by Bismark in Prussia in 1871, and was followed by introduction of a state managed workers compensation scheme in 1884. Bismark had shrewdly recognized that his ruthless oppression of the socialist party, could be offset with partial co-opting of the socialist’s welfare platforms.

The process of emerging workers compensation law would result in critiques of the diagnostic process, the prevalence of trauma neurosis and agency of injury. Kraepelin was concerned about the possibility of intentional malingering for compensatory gain through psychic illness. He believed that the shamming of psychic accidents were of paramount consideration following the introduction of compensation laws. Kraepelin concluded that society was fortunately protected against this possibility by the rareity of traumatic neurosis. Kraepelin would also directly link the emergence of compensation neurosis and railway spine with the development of compensation laws.

The clinical debate on whether trauma had an organic or psychic origin had an important implication in early British workers’ compensation cases. British unions had successfully advocated the introduction of the Employer’s Liability Bill in 1880, and this was followed by Chamberlain’s Workmen’s Compensation Bill in 1897. Initially trade unions objected to the limited number of workers and conditions covered by this legislation. They employed a concerted campaign of political lobbying and funded court cases between 1906 – 1918 to extend the application of this legislation. These court cases included compensation for nervous shock. It is also noteworthy that the significant trauma cases were conducted in the Superior Courts of Common Law, suggesting that there were a number of challenging legal issues around agency of injury in providing compensation for psychic injuries. The right to worker’s compensation for nervous shock was highlighted by a Court of Appeal case, Eaves v. Blaenclydach Colliery Company Limited. The applicant, a coal miner, had a large stone crush and pin his foot, whilst he was standing on a tramline. Blaenclydach Colliery paid for the applicant’s physical injury, but refused compensation for nervous shock and hysterical paralysis. The County Court concluded that as there was no physical injury, the applicant should have returned to work. The Court of Appeal overturned the decision of the lower court, recognizing the applicant’s condition as legitimate and compensable.

In the case of Yates v. South Kirkby and Collieries Limited, a coal miner found himself unable to work after rescuing a workmate, who later died as a consequence of being struck by a falling prop (C.A. Kings Bench Division, 1910). Counsel for the Collieries, Simon K.C. questioned whether a personal injury caused by accident had actually occurred within the meaning of the Workmen’s’ Compensation Act, 1906. The miner had not witnessed the accident and had only tended to the aftermath. Simon argued that for an accident to have occurred, there needed to be a physical mechanism of injury.” The Bench upheld the County Court Decision, which designated nervous shock, (as opposed emotional impulse) as the cause of accident arising out of, and in the course of employment. In both these cases, it had been strongly argued that the applicants were malingering.

Kraepelin’s views on the rarity of Trauma Neurosis, and therefore the limited risk of malingering, were commonly held by the psychiatric profession. One early exception to this view, was the work of Edouard Stierlin, a psychiatrist who studied trauma responses amongst survivors of the Messina Earth Quake, which occurred in Southern Italy in 1908. Stierlin documented Trauma reactions amongst twenty-five percent of the population. Stierlin observed that sleep disturbance and nightmares often developed in individuals who had no pre-existing pathology. Stierlin’s views on the commonality of trauma symptoms would not be corroborated until post World War Two research on concentration camp survivors.

The First World War provided the next major impetus for contemporary understanding of trauma. Medical officers treating shell shock cases relied on combinations of the insights provided by the compensation specialists and academic clinicians. Some medical officers attributed shell shock to neurological damage from exposure to exploding shells. Still these symptoms often developed in soldiers who had not been exposed to exploding shells. The conservative British military doctors questioned the usefulness of Freudian heuristics in explaining trauma symptoms; regarding attributions of shell shock to conflicting infantile psychosexual desires with some reserve.

C.S. Myers provided a comprehensive description of trauma symptoms during World War One. Myers was originally an anthropologist who researched recordings of Australian Aboriginal music at Cambridge, before he left academic life to practice psychotherapy in military hospitals in France. His dairy notes how soldiers’ conditions often became chronic through poor case management. Some of his patients had been shifted through as many as six different hospitals, before coming under his care. Myers felt psychoanalytic explainations of conflicts of desires were inadequate in explaining shell shock. Myers wrote ‘in the most obviously psychopathic patients, the sexual origin of the vast majority of shell shock cases is more than doubtful.’ Most crucially, Myers recognised that a severe emotional trauma could arise from objectively dangerous circumstances. Trauma symptoms were not simply an effect of a neurotic or poorly ordered host personality repressing infantile desires; rather that patients were responding to an objectively harmful set of circumstances.

Myers conceptualised shell shock as consisting of either (i) hysteria (ii) neurasthenia or (iii) graver temporary mental disorder. There was a level of class consciousness in Myers’ thinking - hysteria was more common amongst enlisted men, whilst officers were more likely to be neurasthenic. Myers attributed this to the allegedly higher educational levels and self-control of officers. Myers also noted ‘the frequency of shell shock in a unit reflected the unit’s discipline and loyalty. This was a precursor of later research findings on emergency services personnel, indicating that trauma symptoms are more likely to develop where employees feel unsupported by workplace management.

Myers used dissociation to explaining trauma symptoms, arguing that healing came from integration of trauma (or ‘emotional personality memories’) with non-trauma memory systems. Myers still drew on Erichsen’s work implying that traumatic responses could be caused by micro-lesions to the spine, or the molecular disturbances from vibration of exploding shells.

The work of Smith and Pear was also notable in the treatment of ‘war strain cases’. Pear was a Lecturer in Experimental Psychology, and Smith was a professor of anatomy. Pear and Smith referred to trauma as ‘war strain’ - an emotional disorder caused by the complexities of fear, anger and sadness. Smith and Pear concluded that neurasthenia was an accumulation of stressors, such as the sleeplessness, combat fatalities and physical discomfort. Smith and Pear called for restructuring of the traditional medical visits to the wards. Traumatised patients would not raise symptoms of disturbed sleep and nightmares to a procession of the treating medical officer and his assistants. A patient’s difficulties should be discussed in a private confidential interview. The British triaged trauma cases through receiving centres on the Continent. Handling delays often resulted in cases becoming more intractable. Myers had also pushed for specialised clinics on the grounds that ‘war strain’ cases were exacerbated by hospitalisation with psychotic or retarded patients.

Mismanagement of cases was partly attributable to poor training of assistant medical officers in asylums and the army. Smith and Pear felt that it was unfortunate that relevant medical associations had only begun to give serious consideration to psychiatric training several weeks before the war. These considerations had moved into the background once Britain was involved in hostilities.

Like Myers, Smith and Pear discounted the Freudian notion of trauma as stemming from blocked psychosexual development. Hysteria suffered by affluent ladies in comfortable homes, was an entirely different situation from trench warfare. Smith and Pear believed that psychoneurosis could occur in anyone confronted with dangerous circumstances. Like Kraepelin, the work of Smith and Pear foretold that different trauma populations would eventually be grouped under the one heading.

These authors provided an insight that many of the symptoms suffered by enlisted soldiers were comparable to the ‘emotional disturbances in children, due to the cruelty of drunken parents; a rankling sense of injustice; a terrifying experience, which may have been an accident or deliberate maltreatment by some human being, or again to the appalling conditions created in some of these homes by nervous and irritable parents, as the real trauma which the ‘shock’ had served to awaken.’

Freud would given an opportunity to rebuff his detractors in the military medical hierarchy. Freud presented evidence to a Commission of Inquiry by the Austrian War Ministry on whether army doctors had mistreated cases of war neurosis. Freud was scathing is his assessment of military medical professionals generally.

His crushing assessment was that ‘the psychological education of medical men is in general decidedly deficient and more than one of them may have forgotten that the patient whom he was seeking to treat as a malingerer was, after all, not one….Here medicine was serving purposes foreign to its essence. The physician himself was under military command and had his own personal dangers to fear….The insoluble conflict between the claims for humanity, which normally carry decisive weight for a physician, and the demands of a national war were bound to confuse his activity’,

There were indications that the expression of trauma changed after World War One. Janet Somnambule Hysterics became extremely rare following world war one. Clinical perception had changed from ‘trauma as hysteria’ to ‘trauma as conscious anxiety and obsession'. Trauma reactions had been legitimised as an understandable response to objectively dangerous circumstances, (as opposed to unconscious fantasies about escape from dangerous circumstances). This seemed to make it permissible for individuals to be consciously fearful. In the post war years, medical officers treating civilians concluded that as hysteria diminished, anxiety and obsessionality rose. Chodoff and Lyons commented on the same phenomenon, and but are reluctant to speculate on what might underlie the changing perception of the frequency of hysterical diagnoses.

Conclusion
Mesmerism shifted the province of mental health away from the religious sphere, placing emotional disturbance into the realm of scientific consideration. Codification of the law in some western European countries made it more common for forensic experts to be used as expert witnesses.
Subsequent medical debates centred around whether mental health conditions were arouse from psychological versus neurological wounding; as well as the acknowledgement that mental ailments could be expressed through psychosomatic symptoms. The intangible nature of exactly what was being evaluated, meant that the reputations of those associated with this field of study were often excoriated. Malingering would remain a concern for forensic experts in all jurisdictions from the criminal courts, to compensation cases in British common law to the War tribunals of World War One.

The work of German romantic psychiatrists and Bertrand had contributed a critical foundation of systematic study and application of scientific method to magnetism and its effects on emotional disturbance and trances.

Despite this work, mesmerism and hypnotism fell into disrepute, but the medical interest in trauma continued through the study of hysteria and hypnosis from the 1840s onwards. Medical experts, such as Benedikt, Briquet, Erichsen and Page addressed either the problem of trauma (either as a conversion disorder in susceptible personalities or hysteria).

The study of hysteria really achieved critical mass with the involvement of the Charcot and the development of compensation cases from mid nineteenth century railway accidents. Charcot, Erichsen and Page’s work contains an acknowledgement threat and fear of significant injury could be associated with paralysis and somatic symptoms, even in the absence of substantial physical injury. Bernheim laid the foundations for modern psychotherapy with his practice of psychotherapeutics – and an understanding that individuals could commit crimes against the will of the primary consciousness. Janet contributed the understanding of dissociation as a continuum from normal day dreaming to pathological splits of multiple states of consciousness, promoting the idea of a susceptible predisposition.

Freud disavowed Janet’s perspective on predisposition, arguing instead for a mechanism of repression of infantile fantasy, rather than the objective event of trauma in symptom formation. Freud’s work established a framework for understanding how the shattering of the ego and overwhelming of psychic defence mechanisms (as occurs in traumatic exposure) could cause an individual to decompensate.

The development of workers compensation schemes through Northern Europe and Britain, as well as civil litigation by American railway passengers promoted a new rigour in diagnostic profiling. Kraepelin contributed the paradigm of psychiatric symptom profiling and acute clinical observation in the understanding of trauma.

Military medical practitioners, Myers, Pear and Smith, validated the experience of trauma sufferers as an understandable response to the horrors of war. This seemed to mark a critical turning point where emotional reactions to trauma were realised as conscious anxiety and obsession, rather than a form of conversion disorder.

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