Stress and Health

Stress and Health 19: 17–26 (2003)

Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/smi.952

Early historical literature for

p o s t-t r a u m a t i c s y m p t o m a t o l o g y
Philippe Birmes,1,2Ł,† Leah Hatton,2 Alain Brunet2 and Laurent Schmitt1
1
Service Universitaire de Psychiatrie et Psychologie Médicale, Hôpital Casselardit-La
Grave, CHU de Toulouse, Toulouse cedex, France
2
McGill University/Douglas Hospital Research Center, Psychosocial Research Division,
6875 LaSalle Boulevard, Montréal (QC) H4H 1R3, Canada

Summary
The early historical evolution of the concept of psychological trauma is relevant to the establishment
of PTSD as a syndrome. The authors conducted selective computerized and manual reviews of
the literature concerning the history of trauma-related disorders. Exposure to overwhelming terror
can lead to troubling memories, which has been a central theme in the literature since the time of
Gilgamesh. Reexperiencing was well known and conversion reactions were described, but until the
18th century chroniclers and philosophers essentially reported anecdotes. Nostalgia and traumatic
neurosis were first identified during the American Civil War and after the first railway crashes
in the 19th century. The isolated anecdote thus evolved into a clinical entity whose medical and
psychiatric complexity underwent large-scale development during and immediately after World War
I. An historical approach of traumatic disorders identification provides an integrated view of multiple
psychological symptoms, some included and others not included in current post-traumatic syndromes.
Copyright  2003 John Wiley & Sons, Ltd.

Key Words
history; psychological trauma; PTSD; traumatic stress

Introduction arousal (APA, 1994; WHO, 1992). Acute dissocia-

Currently, international classifications of mental
disorders designate two specific diagnostic cate-
gories following exposure to a traumatic event.
The first is acute stress reaction with a dissociative
spectrum (stupor, numbing, detachment, deperson-
alization, derealization and dissociative amnesia)
symptom re-experiencing, avoidance and increased
Ł
Correspondence to: Dr Philippe Birmes, Service Uni-
versitaire de Psychiatrie et Psychologie Médicale,
Hôpital Casselardit-La Grave, Centre Hospitalier Uni-
versitaire de Toulouse, 170, avenue de Casselardit,
F-31059 Toulouse cedex, France.
Tel: 33 5 61 77 23 51. Fax: 33 5 61 77 76 46.
†
E-mail: philippe.birmes@wanadoo.fr
Copyright  2003 John Wiley & Sons, Ltd.
tive experiences and acute stress reactions are risk
factors for the development of later post-traumatic
stress disorder (Birmes et al., 2001). The second
category is post-traumatic stress disorder (PTSD),
with persistent re-experiencing, persistent avoid-
ance with a sense of a foreshortened future, and
persistent symptoms of increased arousal (APA,
1994; WHO, 1992).
Initially thought to be a purely organic disor-
der caused by brain concussion, traumatic neurosis
was first identified in the 19th century in connec-
tion with the after-effects of railway crashes (Crocq,
1999; Van der Kolk, Weisaeth, & Van der Hart,
1996). However, traumatic stress symptoms have
been described since man first began recollecting
Received 26 June 2002
Accepted 21 October 2002
 P. Birmes et al.
past catastrophes and waging war. From Antiq-
uity onwards, chroniclers, sensitive to unusual
behaviour in their heroes, reported isolated cases of
agitation or stupor sometimes associated with ter-
rifying nightmares. It was on the basis of emotions
comparable to these that the philosophers devel-
oped their theories on human nature (Lucretius,
1951). In the 17th century, Descartes (1989, 1990)
remarked in his research on The Passions of the Soul
that events causing fear can affect human behaviour
long after their occurrence (Tomb, 1994). Until the
18th century, the main references to psychological
trauma were still restricted to literary or philosoph-
ical writings, while observers essentially reported
anecdotes that could not, at the time, constitute a
nosology. Gradually, medical doctors became more
aware of psychic post-traumatic injuries. In parallel
with the development of psychiatry, the wars of the
Republic and the Empire swept through Europe,
providing a large number of psychological trauma
cases for the surgeons of Napoleon’s Grande Armée
(Briole, Lebigot, & Lafont, 1998; Hastings, 1985a).
Fought several decades later, the American Civil
War provided the opportunity for observing not
only isolated cases (Turnbull, 1998), but a whole
category of disorders affecting a great number of
individuals. These are the foundations necessary for
the birth of a true nosology. The isolated anecdote
thus evolved into a clinical entity whose medical
and psychiatric complexity underwent large-scale
development during and after World War I. Numer-
ous descriptions of soldiers at the time of World
War II focused on psychophysiological reactions
and loss of impulse control. Moreover, individu-
als who suffered concentration camp experiences
showed severe biological, psychological and social
consequences (Van de Kolk et al., 1996). However,
the authors have chosen to limit their review to the
beginning of World War I, which demonstrates the
initial stages of post-traumatic symptom integra-
tion. The history presented here aims to map these
successive stages according to two main nosograph-
ical axes: the notion of psychological trauma and
the concept of traumatic stress. The several histori-
cal anecdotes and medical observations described in
this article were chosen for their descriptive power.
The authors conducted reviews of the literature
concerning trauma-related psychological disorders.
A manual and computerized search (using MED-
LINE, PILOTS, PASCAL and GALLICA) identified
English and French language articles. PILOTS is a
bibliographical database covering Published Inter-
national Literature On Traumatic Stress. PASCAL
is a French multidisciplinary bibliographic database
18 Copyright  2003 John Wiley & Sons, Ltd.
covering the core literature in science, technol-
ogy, and medicine. GALLICA is an Internet server
covering the digitized collections of ‘Bibliothèque
nationale de France’. Searches were performed to
examine the literature on the history, phenomenol-
ogy, clinical reviews, and classifications of trauma
and stress related psychological disorders.
Psychological trauma
Traumatic exposure to death
In ancient literary sources, the vast majority of all
pathological conditions pertain to traumatology, in
view of the heroic nature and tragic affects in the
aftermath of violence. The most famous work of
Mesopotamia, author of the ancient Epic of Gil-
gamesh, which dates from the third millennium BC,
already stresses the traumatic intensity experienced
when facing violent death. On witnessing the death
throws of his companion, who has been defeated in
battle, Gilgamesh experiences a profound feeling of
despair (Bottero, 1992; Malbran-Labat, 1982; San-
dars, 1972; Tomb, 1994). During a grief reaction
some time afterwards, this traumatic event is persis-
tently re-experienced with recurrent and intrusive
recollections of Enkidu’s death and a great many
questions about Gilgamesh’s own possible death:
‘I wept for him seven days and nights till the
worm fastened on him. Because of my brother
I am afraid of death, because of my brother
I stray through the wilderness. His fate lies
heavy upon me. How can I be silent, how
can I rest? He is dust and I too shall die and
be laid in the earth for ever. I am afraid of
death. . . ’ (Sandars, 1972).
A feeling of detachment with a sense of a foreshort-
ened future is then observed, eventually leading
to aimless roaming, leaving the hero feeling help-
less. These criteria, including persistent distressing
recollection of the event and numbing of gen-
eral responsiveness, reflect those of the current
definition of PTSD in the American Psychiatric
Association classification (APA, 1994).
Conversion reaction and somatization
Acute conversion reactions are described in other
accounts. Herodotus gives a brilliant description of
an acute psychic traumatic blindness case afflicting
an Athenian warrior frightened during the battle of
Marathon in 490 BC (Herodotus, 1992):
Stress and Health 19: 17–26 (2003)

‘Epizelus, the son of Cuphagoras, an Athenian
soldier, was fighting bravely when he sud-
denly lost the sight of both eyes, though noth-
ing had touched him anywhere neither sword,
spear, nor missile. From that moment he con-
tinued blind as long as he lived. I have heard
that in speaking about what happened to him
he used to say that he thought he was opposed
by a man of great stature in heavy armour,
whose beard overshadowed his shield; but the
phantom passed him by, and killed the man
at his side’ (Herodotus, 1996).
Conversion reactions are not a criterion of PTSD;
however, the threat to life, and the act of wit-
nessing a brutal death with a dream-like quality,
associated with chronic recurrent recollections, are
characteristic of post-traumatic reactions.
Many centuries later, during the American Civil
War, heart palpitations and chest pains were
so frequently encountered that they formed a
nosographic classification. These troubles were a
presumed biological condition thought to be due
to physical stress and referred to variously as
soldier’s heart, irritable heart, effort syndrome and
DaCosta’s syndrome (Choy & de Bosset, 1992;
Tomb, 1994; Turnbull, 1998; Van der Kolk et al.,
1996). Generalized weakness and battle fatigue
syndromes with numbing of general responsiveness
are described.
Sleep disturbances
Nightmares and traumatic dreams are also found in
certain philosophical works, particularly the works
of Lucretius (98–55 BC) in which battle dreams are
reported in De Natura Rerum (Lucretius, 1985):
‘Whatever employment has the strongest hold
on our interest or has last filled our waking
hours, so as to engage the mind’s attention,
that is what seems most often to keep us occu-
pied in dreams. . . Generals lead their troops
into action. Sailors continue their pitched bat-
tle with the winds’ (Lucretius, 1951);
‘Very similar as a rule is the behaviour in sleep
of human minds, whose mighty machinations
produce massive feats. Kings take cities by
storm, are themselves taken captive, join in
battle and cry aloud as though their throats
were being slit—and all without stirring from
the spot’ (Lucretius, 1951).
Copyright  2003 John Wiley & Sons, Ltd.
Early historical post-traumatic symptoms
It should be noted that re-experiencing is signif-
icant in all of the translations (Lucretius, 1951,
1964, 1985).
In book XXIV of Homer’s Iliad (850 BC),
Achilles becomes prey to recollections about his
friend Patroclus who is killed in combat (book
XVI). These recollections are recurrent and cause
very agitated sleep (Homer, 1950):
‘But Achilles went on grieving for his friend,
whom he could not banish from his mind,
and all-conquering sleep refused to visit him.
He tossed to one side and the other, thinking
always of his loss, of Patroclus’ manliness
and spirit. . . of fights with the enemy and
adventures on unfriendly seas. As memories
crowded in on him, the warm tears poured
down his cheeks’ (Homer, 1950).
The French chronicler Froissart (1333–1404)
provides us with a living image of the feudal world
between 1325 and 1400. He evokes battle dreams
in 1385 with recurrent distressing nightmares
and dissociative flashback episodes occurring to
Peter of Béarn, brother of the Count of Foix,
who risked wounding his family night after night
when he brandished his sword (Crocq, 1999;
Froissart, 1835):
‘Sir Peter of Béarn has a habit when he is
asleep at night of getting up and arming
himself. Unless great care is taken to prevent
him, he draws his sword and fights, he does
not know with whom. His chamberlains and
servants, who sleep in his room and look after
him, get up when they see or hear him, and
wake him up’ (Froissart, 1978).
These excerpts are anecdotal cases but illus-
trate the ancient age of sleep disturbance with
traumatic dreams, one of the core symptoms of
re-experiencing, subsequent to combat situations.
Pierre Janet and traumatic
dissociation
From a chronological point of view, Janet, with
Freud, was one of the first to emphasize the
role of unconscious memories resulting from the
development of neurotic disorders, particularly
evident in his detailed analysis in the case of
Marie (Bower & Sivers, 1998; Nemiah, 1998).
In Janet’s most significant works, and in particular
L’Automatisme Psychologique (1889), almost one
Stress and Health 19: 17–26 (2003) 19
 P. Birmes et al.
clinical case out of two shows consequences of
psychological trauma. The fear and horror of an
accident or a violent assault, and the absence
of emotional responsiveness while witnessing the
horrible death of another, represent the significant
immediate effects of trauma. The specific clinical
observations change and are labelled according to
the nosology of the time: hysteria, neurasthenia,
obsession, ‘psychasthénie’, etc.
Janet effectively identifies ‘premeditation’ as the
time period between traumatic exposure and the
development of trauma-related symptoms. He also
emphasizes the process of dissociative flashback
episodes, where the victim behaves as if the
traumatic event was re-occurring. According to
Janet, the main problem of severely traumatized
victims who showed adjustment disorders with
dissociative or obsessive-compulsive symptoms is
their inability to emotionally process traumatic
memories (Bower & Sivers, 1998; Nemiah, 1998;
Van der Hart, Brown, & Van der Kolk, 1989).
In this respect, Janet describes specifically, with
the concept of ‘misère psychologique’, a degrading
of the psychic functioning particularly observable
in the wake of emotionally draining traumatic
experiences. The personal self lacks sufficient
strength to incorporate into its structure the
resulting emotions and the traumatic memories
associated with them. They become dissociated and
seem to be major contributors in the development of
traumatic symptoms (Janet, 1889; Nemiah, 1998;
Van der Hart et al., 1989).
Psychic reactions hard to
acknowledge
During the American Civil War (1861–1865),
Weir Mitchel described symptoms of lethargy,
withdrawal and fits of hysterics with excessive
emotionality, some of which are recognized to
be clinical symptoms of PTSD. For a number
of authors, this account is the first medical
reference in the observation of post-traumatic
disorders in soldiers and civilians. These war
situations were reported as a disorder called
nostalgia. Physical and psychological exhaustion
were associated with the disorder, with a large
proportion of victims experiencing conversion
reactions (Davidson, 1995; Fullerton & Ursano,
1997; O’Brien, 1998; Tomb, 1994).
Before taking a closer look at World War I, it is
worth considering the remarks of Adam Cygiel-
strejch on the psychological disorders observed
during the Russian–Japanese war of 1904–1905.
20 Copyright  2003 John Wiley & Sons, Ltd.
The majority of the disorders described during
the Manchurian war are acute reactions, with the
resulting strong emotions causing brief reactive psy-
chosis and the co-occurrence of alcohol abuse and
post-traumatic symptoms (Barrois, 1993).
The first large-scale observations and studies
on traumatic stress were conducted during World
War I. Certain authors brought post-emotional
aetiology to the foreground, as opposed to post-
concussional aetiology which was considered an
honorable organic aetiology. In Germany, although
theoretical discussions were opened, the emphasis
was placed on the desire not to return to combat.
This tendency to equate psychiatric disorders with
weakness and cowardice is a poignant witness to
the difficulty of acknowledging mental illness. The
therapeutic arsenal strove to be therapeutic, but
also coercive, with the use of isolation in a dark-
room and electric shock treatment. Treatment was
sometimes so painful that many soldiers preferred
to return unhealed to the front after being passed
as sound (Briole et al., 1998; O’Brien, 1998; Van
der Kolk et al., 1996). In French hospitals behind
the front lines, potential malingerers were actively
tracked down, as Louis Ferdinand Destouches, alias
Céline, (1894–1961) recounts in his Voyage au
bout de la nuit (Céline, 1952). The author tells
how, after several days of fighting, Ferdinand has
a fit of madness while on leave. He is hospitalized
and tells the army medics that he has been driven
mad by fear. He finds himself in the company of
other psychologically wounded who are submitted
to stringent medical monitoring. After a few days,
the patients were divided into three categories: the
first returned to the front, the second were trans-
ferred to a psychiatric hospital, and the malingerers
were sent to the firing squad (Céline, 1952). The
term ‘injury’ to refer to mental disorders linked
with combat situations was used, but combat-
related psychological injuries were only officially
recognized in France many tens of years later.
Other descriptions in medical and scientific texts,
as well as in visionary literary works, show more
similarity with the traumatic stress criteria of
today’s classifications.
Traumatic stress spectrum
Acute dissociative episodes and acute
stress reactions
Many authors refer to Homer’s Iliad in which
many scenes of combat are vividly depicted. Acute
Stress and Health 19: 17–26 (2003)

dissociative reactions are observed, for example
when Patroclus is struck with stupor in the midst
of battle (Homère, 1975):
‘Patroclus was stunned; his shapely legs
refused to carry him; and as he stood there
in a daze, a Dardanian called Euphorbus
came close behind and struck him with a
sharp spear midway between the shoulders’
(Homer, 1950).
Even if it is attributed to divine intervention,
acute combat stress reaction is recognizable here
with stupor, disorientation, and absence of any
movement. The fighter even succumbs to the blows
he is incapable of avoiding.
The account of the Younger Pliny, present at
Misenum during the eruption of Vesuvius in 79
AD, is also noteworthy. These terrible events
are described in the Letters and allow us to
observe incongruous reactions. The Younger Pliny
presented a subjective sense of numbing with
unsuitable automatic behaviour that exposed him
to danger while the walls of his house were splitting
apart (Pline le Jeune, 1989):
‘I don’t know whether I should call this
courage or folly on my part (I was only
seventeen at the time) but I called for a volume
of Livy and went on reading as if I had nothing
else to do’ (The Younger Pliny, 1969).
During the Napoleonic wars, the military sur-
geons Larrey and Percy describe clinical forms of
war neurosis and acute combat stress reactions,
like the ‘syndrome du vent du boulet’ (cannon-
ball wind syndrome) with the absence of emotional
responsiveness (Briole et al., 1998; Crocq, 1999).
An officer present at the battle of Eylau on 8
February 1807 relates, after a cannonball has just
knocked his headgear off:
‘I seemed to be blotted out of existence, but
I did not fall from my horse. . . nevertheless
I still could hear and see, and I preserved all
my intellectual faculties, although my limbs
were paralysed to such an extent that I could
not move a single finger’ (Hastings, 1985b).
This man reported alterations in the experience of
time and place, with a reduction of awareness to
his surroundings.
These immediate reactions are currently included
with peritraumatic dissociative experiences
Copyright  2003 John Wiley & Sons, Ltd.
Early historical post-traumatic symptoms
occurring at the time of a traumatic event.
Symptoms include: moments of losing track of
time or blanking out; finding oneself acting
on ‘automatic pilot’; a sense of time changing
during the event; the event seeming unreal; a
feeling as if floating above the scene; a feeling
of body distortion; confusion as to what was
happening to the self and others; not being
aware of things that happened during the event;
and disorientation (Marmar, Weiss, & Metzler,
1998). Peritraumatic dissociation is conceptualized
as a way of processing information during the
traumatic experience and studies have prospectively
demonstrated that participants reporting more
peritraumatic or acute dissociative experiences
are at greater risk for developing PTSD (Birmes
et al., 2001).
The secrets confided by Charles IX, king of
France from 1560 to 1574, to his doctor Ambroise
Paré following the Saint Barthélémy massacre,
clearly describe acute stress symptoms. During the
night of 23 to 24 August 1572, the Protestants were
massacred in Paris at the command of Catherine
de Medicis. Less than 1 week after the slaughter,
carried out in his name and against which he was
powerless to act, the king is described as being
extremely shocked and prone to nightmares and
visions of blood-drenched bodies (Simonin, 1995).
These symptoms constitute a true Acute Stress
Disorder with flashback episodes and illusions. The
DSM-IV diagnosis of Acute Stress Disorder (ASD)
includes a set of symptoms experienced within the
first month following trauma exposure and includes
symptoms of dissociation, intrusion, avoidance,
and hyperarousal. Recent studies have shown that
ASD after traffic accidents and violent crimes is a
strong predictor of PTSD (Brewin, Andrews, Rose,
& Kirk, 1999; Harvey & Bryant, 2000).
Post-traumatic stress symptoms
Intrusive thoughts and re-experiencing. The
works of Shakespeare are a good background
for commenting on the history of post-traumatic
disorder. Battle nightmares are first mentioned in
Henry IV (Davidson, 1995; Turnbull, 1998) and
then in Romeo and Juliet. In Henry IV, Lady Percy
reproaches her husband for ignoring her because
he is too preoccupied with his war plans, which
deeply disturb his sleep.
‘In thy faint slumbers I by thee have watch’d,
And heard thee murmur tales of iron wars;
Speak terms of manage to thy bounding steed;
Stress and Health 19: 17–26 (2003) 21
 P. Birmes et al.
Cry ‘Courage! to the field!’ (Shakespeare,
1961).
In Romeo and Juliet, Mercutio evokes Mab, the
dream fairy, who alights on the neck of sleeping
soldiers and makes them re-experience battle.
‘And then dreams he of cutting foreign
throats,
Of breaches, ambuscadoes, Spanish blades,
Of healths five fathom deep; and then anon
Drums in his ear, at which he starts
and wakes,
And being thus frighted swears a prayer
or two,
And sleeps again’ (Shakespeare, 1992).
The disorders depicted in Macbeth are also
remarkable (McFarlane, 1994). Macbeth, and
later Lady Macbeth, develop post-traumatic stress
symptoms as a consequence of their murdering
Duncan, the King of Scotland. Noteworthy are
the severe intrusive recollections with flashback
episodes observed in Lady Macbeth. After showing
mental disturbances for several days, she loses
contact with reality and incessantly attempts to
remove imaginary bloodstains from her hands. The
doctor called to her bedside gives up and commends
her to God.
‘Foul whisp’rings are abroad: unnatural deeds
Do breed unnatural troubles infected minds
To their deaf pillows will discharge their
secrets’ (Shakespeare, 1993).
She suffers from a mental illness resulting from a
crime to which she is a party. The traumatic event
is persistently re-experienced with dissociation and
organic memories (olfactory hallucinations). In a
single sentence, the doctor announces the concept
of traumatic stress.
The Diary of Samuel Pepys is another major tes-
timony in which we are able to recognize recurrent
frightening dreams. Samuel Pepys (1633–1703)
was an English civil servant, who became a key
person in the Navy office and helped to give Great
Britain one of the strongest navies in the world.
Pepys maintained his daily diary for 10 years, cov-
ering 1659 to 1669. This work may be the most
extensive source of information on the Restoration
(Latham, 1985).
During the night of 1 September 1666, the Great
London Fire broke out and raged for 4 days and
4 nights. Pepys, whose house was spared, witnessed
22 Copyright  2003 John Wiley & Sons, Ltd.
the fire and his diary allows us to prospectively
observe the development of these symptoms (Daly,
1983; Pepys, 1994, 1997). Fifteen days after the
fire, the same nightmare recurs:
‘But much terrified in the nights now-a-days
with dreams of fire, and falling down of
houses’ on 15 September 1666 (Pepys, 1997);
‘All nights still mightily troubled in my sleep
with fire and houses pulling down’ on 25
September 1666 (Pepys, 1997);
‘A very furious blowing night all the night;
and my mind still mightily perplexed with
dreams, and burning the rest of the town’ on
27 September 1666 (Pepys, 1997).
Six months after the fire, he recorded:
‘I did within these six days see smoke still
remaining of the late fire in the City; and it is
strange to think how to this very day I cannot
sleep a night without great terrors of fire; and
this very night could not sleep till almost 2 in
the morning through thoughts of fire’ (Daly,
1983; Pepys, 1994).
Samuel Pepys was exposed to a great disaster;
Daly (1983) described his subjective fear and
irritability in the months following the disaster.
One of the core symptoms of PTSD, recurrent
distressing dreams, is experienced repeatedly by
Pepys, but remains quite isolated. There is evidence
of arousal with reminders of the event, and
irritability, although it is not clear that the latter was
associated with the fire (Daly, 1983; O’Brien, 1998;
Pepys, 1994, 1997). Considering the severity of
the traumatic experience and the moderate degree
of disability it produced in Pepys, Daly (1983)
has drawn our attention to Pepys’ high capacity
for recovery.
Avoidance and numbing. The biography of Flo-
rence Nightingale (1820–1910) (Woodham-Smith,
1983) provides us with an outstanding case report
of PTSD avoidance and numbing symptoms. The
English nurse was the founder of modern nurs-
ing; her life was dedicated to the care of the sick
and war wounded. In 1854, she organized a unit
of 38 woman nurses for service in the Crimean
War. Military officers and doctors objected to
her views on reforming military hospitals. Eventu-
ally, Florence Nightingale organized and improved
the quality of the sanitation in the hospitals and
Stress and Health 19: 17–26 (2003)

reduced the death-rate of her patients (Woodham-
Smith, 1983). In 1856 she returned to England as
a national heroine. Following her years of humane
and heroic attendance to countless wounded sol-
diers, she reportedly returned home and remained
confined to her bed for the remainder of her life. In
1856, Florence Nightingale began to be haunted by
the memory of the dead (Barker, 1989). Woodham-
Smith (1983) has described her as a ‘bereaved,
haunted woman’, endlessly pacing up and down in
her room at night, sleepless and withdrawn. She
believed that she would shortly die, planned her
funeral and wrote letters to be distributed after
her death (Barker, 1989). Over 100 years after the
end of the Crimean War, the nurses who returned
from Vietnam exhibited the same symptomatol-
ogy (Barker, 1989), demonstrated by persistent
avoidance and numbing of general responsiveness,
markedly diminished participation in significant
activities and sense of a foreshortened future, which
are included in PTSD C criteria (APA, 1994).
Traumatic neurosis. In his Traité Médico-
Philosophique sur l’Aliénation Mentale, Pinel
(1809) gives history’s first brilliant psychiatric
description of traumatic neurosis afflicting a soldier
who served for 50 years in the cavalry. However,
these symptoms: frightening dreams, strong emo-
tions for the slightest cause, everything becomes a
cause for fright and alarm, had not yet been united
in a single clinical entity.
The civilian psychiatrists Duchesne in France,
Erichsen in England, and Putnam in the USA, pon-
dered half a century later on the origin of the fright
syndromes observed after railway crashes. Sev-
eral hypotheses were suggested to explain ‘railroad
spine’ or ‘railway brain’, including neurological
injuries and fabrication of the symptoms (Keller
& Chapell, 1996; O’Brien, 1998; Turnbull, 1998).
Charles Dickens subsequently described symptoms
after a train crash in which 10 people were killed
and 49 wounded (Courtemanche & Robinow,
1989; Powers, Cruse, Daniels & Stevens, 1994):
‘I am curiously weak. . . I begin to feel it
more in my head. . . but I write half a dozen
notes, and turn faint and ‘‘sick’’. . . driving
into Rochester yesterday I felt more shaken
‘‘than I have since the accident.’’ ‘‘I cannot
bear railway travelling yet’’ ’ (Foster, 1989).
Oppenheim proposes the traumatischen Neu-
rosen concept to define these states. He described
Copyright  2003 John Wiley & Sons, Ltd.
Early historical post-traumatic symptoms
patients suffering from various symptoms, and sev-
eral cases of nightmares and irritable mood with
delayed onset. An appeal was made to the public
authorities for compensation. These disorders were
soon to be grouped under the same mechanical
and organic aetiology, the consequence of ‘molec-
ular degeneration’ of the shaken nervous system
(Davidson, 1995; Van der Kolk et al., 1996).
At the same time, Charcot investigated masculine
hysteria and from 1878 to 1893 published over
20 cases of traumatic hysteria. The links between
hysteria and dissociation are described and studied
while the symptoms are attributed to a traumatic
origin. Charcot opposes traumatic neurosis, seeing
in it only an aetiological form of hysteria (Charcot,
1998; Maldonado & Spiegel, 1998; Micale, 1994).
However, in the sixth edition of his 1899 treatise,
Kraepelin credited much importance to Schreck-
neurose, which he considers an independent entity.
This contributed to the official recognition of
a disorder comprising of recurrent and persis-
tent thoughts, feelings of detachment from others,
diminished interest, hallucinations, and sleep dis-
turbances with recurrent distressing dreams (Van
der Kolk et al., 1996).
Emotional or organic mechanisms? During
World War I, the shell shock theory expressed
the notion of predisposition, weakened reactive
capacities, and a stunned nervous system and mind.
Soldiers exhibited stupor, irritability, trembling,
traumatic dreams, exaggerated startle response
with agitation and conversion reactions. This
organic hypothesis also mentions many cases of
aggravation (Choy & de Bosset, 1992; O’Brien,
1998; Tomb, 1994). The ‘great laboratory’ of the
First World War enabled the first experimental
biological studies to reveal cases of intolerance to
carbon dioxide and exaggerated physiological and
psychological responses to epinephrine (Southwick,
Bremner, Krystal, & Charney, 1994). Damage
to the central nervous system without objective
injuries were grouped together under the name
psychic trauma. In fact, these two categories of
disorders (shell shock and psychic trauma) often
appeared to be intertwined and were responsible
for 20 000 psychiatric hospitalizations amongst the
British (Gersons & Carlier, 1992).
Major breakthroughs were made in the process
whereby classic psychiatry lost ground to neu-
roscience and psychoanalysis, with prime impor-
tance granted to recurrent dreams and nightmares.
French psychologists were present at the front-
lines and brought to the foreground the sheer scale
Stress and Health 19: 17–26 (2003) 23
 P. Birmes et al.
of horror and terror resulting in re-experiencing
symptoms. The correspondence of French soldiers
unquestionably describes war atrocities:
‘In addition to the mental pain of believing
at each instant that death has pounced on
us, physical suffering is there too. Eight days
spent in the midst of a human charnel house,
sleeping in the midst of dead bodies, walking
over our comrades shot the day before’
(Biron, 1998).
At the end of the First World War, on 28 and
29 September in 1918, at the fifth International
Psycho-Analytical Congress in Budapest, Freud
wrote about traumatic neuroses in a way which
illustrated his difficulty in explaining the different
mechanisms which underlie ‘ordinary neuroses’ and
‘war neuroses’ (Wislon, 1994).
Discussion and conclusion
From Gilgamesh to the First World War, more
than 3000 years were necessary to establish a
well-structured nosology of traumatic stress. An
historical survey demonstrates that, even from the
beginning of Antiquity, psychological responses
to extreme trauma have always been the source
of phenomenological and scientific curiosity and
interest. Moreover, some specific symptoms are
observable and can be recorded at the early
stages of development. They are notable and
attract attention because they correspond to certain
effects one experiences when facing death. It
is one of the significant characteristics recorded
today by international classifications to define a
traumatic event. This philosophical and medical
dimension has always reinforced most authors’
feelings and thoughts.
Dreams related to a traumatic experience have
been described since the beginning of literature:
Achilles’ disturbed sleep in the Iliad, dreams of
battle in De Natura Rerum, sudden and violent
awakening with dissociative episodes for Peter of
Béarn and in Shakespeare’s works, and repetitive
nightmares in Samuel Pepys, etc. Intrusive thoughts
are also reported in Charles IX’s biography and
in Macbeth. Severe responses during the impact
phase of a traumatic experience have attracted the
attention of chroniclers: the stupor of Patroclus in
Homer’s Iliad, the numbness of the Younger Pliny
in the Letter to Cornelius Tacitus, the alteration
in the experience of time and place of Baron
24 Copyright  2003 John Wiley & Sons, Ltd.
de Marbot in Hastings’ Military Anecdotes, etc.
Following World War II, similar observations
were described by Solomon in veterans of the
Lebanon war, demonstrating an initial ‘combat
stress reaction’ with anxiety and psychomotor
disorders (Shalev, 1996; Solomon, 1983). These
kinds of individual experiences, occurring at the
time of a traumatic event, have more recently been
referred to as ‘peritraumatic’. These peritraumatic
reactions have received increasing attention in the
last few years as a risk factor for subsequent PTSD
(Marmar et al., 1998).
Until the 19th century, those disorders, some
of which have remained identical in present clas-
sifications, did not integrate the already existing
nosology because the descriptions remained anec-
dotal. In order to be objective, a scientific fact
should be reproducible. When the first industrial
catastrophes and ‘modern’ wars occurred, com-
parable events affected certain groups of people
in similar contexts. When traumatic psychological
reactions involve significant and similar symptoms
(for example, ‘nostalgia’ of the American Civil war,
‘railway-brain’ in railway crashes, ‘shell-shock’ and
hystero-traumatic symptoms during the First World
War) in identical contexts, the beginning of a sci-
entific integration of the traumatic stress entity
appears. Reliable criteria of a syndrome are nec-
essary for research studies. This is particularly
relevant in mental health research because the
uncertain aetiology of many disorders makes it dif-
ficult to validate the syndrome (Marshall, Spitzer,
& Liebowitz, 1999).
The First World War prompted the development
of aetiological theories of traumatic stress. Sig-
mund Freud and Sandor Ferenczi (Ferenczi, 1970;
Freud, 1928) criticize and find absurd the brain
concussion-related concepts that were put forward
immediately after the First World War. In Beyond
the Pleasure Principle, Freud considered traumatic
events to be external stressors that were strong
enough to break through the ‘prospective shield’
and inflict injury (Wilson, 1994). Others empha-
size the theory that the impact of traumatic events
produced a temporary disconnection or dysfunc-
tion of the central nervous system, which led to
the development of traumatic symptoms (Turnbull,
1998). A few years later Hans Selye demonstrated
the pituitary–adrenocortical response to stress, a
current way of examining biological heterogene-
ity following psychological trauma and its clinical
responses. Currently the psychoendocrine model of
Stress and Health 19: 17–26 (2003)

post-traumatic stress is well-developed and con-
firms the specificity of PTSD which represents only
one type of response to trauma (Yehuda, 1998,
2000).
This development of ideas included three main
steps: first, a scientific interest created by clinical
anecdotes; the integration of a syndrome when the
observable scientific facts can be reproduced using
reliable criteria; and finally, a pathogenic specificity
corroborating the base of the clinical observation.
Through this process, the scientific reading of the
historical studies of a clinical, seemingly isolated,
fact takes part in the establishment of a well-
structured syndrome.
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