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The number of 80.000 British shell shock victims, a rarely questioned number

On 15 November 2004 Dr. Leo van Bergen gave a lecture on shell-shock at a conference on War as a Universal Trauma (20th Annual Meeting of the International Society for Traumatic Stress Studies, New Orleans 13-16 November 2004). Van Bergen points his attention on the alleged 80.000 British shell-shock victims, a constantly repeated but rarely questioned number. Van Bergen however explains why in his view this number is build on quicksand.

Leo van Bergen is a medical historian and author of 'Zacht en Eervol. Lijden en sterven in een Grote Oorlog' (Sweet and Honourable. Suffering and dying at the Western Front 1914-1918), a splendid work that definitely deserves an English translation). He works at the Free University Medical Centre in Amsterdam, department of Medical Humanities. 

New book Leo van Bergen - Before My Helpless Sight
Suffering, Dying and Military Medicine on the Western Front, 1914-1918

Contrary to most books in the field this study does not focus on one single issue - such as venereal disease, plastic surgery, shell-shock or the military medical service - but takes a broad view on wounds and illnesses across both sides of the conflict. Drawing on British, French, German and Dutch sources it shows the consequences of modern warfare on the human individuals caught up in it, and the way it influences our thinking on 'humanitarian' activities.

Shell shock 
World War I started in August 1914 and ended in November 1918. In those four years approximately 9.000.000 soldiers were killed and a multitude were wounded. Because of the many countries all over the globe involved in the war it was truly a World War, but it is also known as an insane war, a mad war, a shell shocked war. This has several reasons. Some commentators argue that the war was insane because of its reasons, because of the way it was fought and or because of the treaty that officially ended it in 1919. It was a shell shocked war because the way artillery dominated its battlefields was unseen and unheard of ever before and probably ever since. But the terms have another reason, the reason that got us here: World War I knew as well in hard numbers as in percentages more soldiers than ever before not being able to cope with its hardships, soldiers who first in English speaking countries, but soon enough also in the rest of the world became known as shell shock cases.

Part of the painting L'enfer by Georges Leroux (1917)

When speaking of shell shock in the First World War almost always the number of 80,000 British casualties is mentioned. Seldom however this number is questioned, although there are a lot of reasons why that number should not be trusted, one of them being the simple fact that a neurosis is not a broken leg. It is not something one either has or has not. There are lots of examples of men and officers, clearly struggling with the horrors of war, but who nevertheless were declared fit for battle. 

There was a clear gap between officially recognised war neuroses, between genuine shell shock, and ordinary mental health. That there is a vaguely bordered no man’s land of the mind. A twilight zone between health and neurosis, characterised by loss of morale, cafard, senselessness, fatalism, lassitude, dehumanisation, brutalisation and above all fear, enormous, human fear, fear of dying, fear of mutilation, fear of fear itself. Shell shock therefore only was the top of an iceberg.

In this presentation I will first of all give a short overview of the horrors the First World War had in store for the soldiers fighting it. Then I will go into the 80,000 number a bit further, ending with a pondering on why shell shock has survived time and even has become a term sometimes used for all-day common stress. 

The First World War was the first real industrial war. Al least on the Western Front two industrial powers met and clashed. Material endurance became at least as important as physical endurance. Weapons like the machine-gun, flame-thrower or poison-gas came into its own, but as said artillery ruled the world. As a consequence defence and digging in were the most save and sane things to do, but digging in was cowardly behaviour, contrary to the valour and bravery of real war, at least: as real war should be like in the eyes of the military marching of to battle in 1914. On top of that, most military strategists were convinced that the war could only be won by fierce-less attack, and it should be said, from a military point of view they probably were right. As a result fierce-less attacks there were, and as a result in thousands and thousands of deaths each time they resulted. The 20.000 dead British soldiers on July 1st 1916 are most mentioned, but more typical was that that number was reached every fourth day the entire war through.

But a nice clean death, seen in most war-movies, is one thing, mutilation from shrapnel or pieces of grenades was another, as was asphyxiation from gas or being burned or being buried alive. It were pictures seen by comrades day after day, pictures central in the photographs being shown. These were combined with the sight and burden of thousands and thousands of rats and other vermin like lice or flies; with constant deafening noise caused by the shell flying over from the front to the rear or vice versa; with hunger and thirst caused by constant lack of food and drinking water; with enormous fatigue caused by days without any sleep and a knapsack weighing up to forty or fifty kilo’s. And they were combined with mud that more than ones likened a swamp, a swamp in which the corpses disappeared and the wounded drowned. 

On top of that came the sheer endlessness of the war. A war that should have been a swift and glorious one, became a war of years, years without any visible results. In short: the First World War, being fought on a small territory, was one great source of horrific encounters and therefore one great cause of fear, not to be mixed up with cowardice. The horror dripped in and it was only a matter of time before each man cracked. That not everyone cracked has to do with coincidence. One was called back just in time or the one thing that would have done the trick did not occur. One could be lucky, getting a ‘blighty’ just in time. One could be unlucky, getting severely injured or killed just in time.

All this resulted in tens of thousands of soldiers with recognised psychiatric problems. As said, the number most mentioned is the 80,000 British neurotics, but not everyone sticks to that number, what of course only strengthens the case of questioning it. Unfortunately enough however, most questions only result in a new, as questionable number. For example, in Martin Gilbert’s encyclopaedic The First World War, it is asserted that in 1922 there were an estimated 50,000 war related psychiatric cases in Britain. This means that, in his view, overall the fighting in the First World War must have produced approximately 250,000 cases of mentally damaged soldiers. In my view Gilbert makes three mistakes in this one instance. 

First of all, it is unsafe to assume that the percentage of men suffering from shell shock in the British army is the same as that in the French, German or Belgian armies. Maybe the British numbers were smaller, because they started with an army of professionals; maybe the British numbers were greater, because they were adapt in repressing fear, at least for a time. On top of that, numbers and percentages of other diseases and wounds differed also. The British for instance had an official VD-rate (VD = venereal disease) of about 0.5%, whereas the Canadians at one time counted 20%. 

Furthermore Gilbert does not explain why the British number should be multiplied five times. Is it because British dead were about one-fifth of the total of Germany, France and Britain? It can’t be, because the number of 250,000 was an overall number, Eastern- and Western- and all the other fronts together. British dead were a mere 8% of that total. Was it because British troops contained about one-fifth of the total? No, it wasn’t. At the end of the war about 3.5 million British men had served, whereas much more than 17.5 million soldiers have served altogether. 

Secondly: it is a serious mistake, as Gilbert does, to take pension statistics as a point of reference for calculations of casualties. Pension numbers are always too low, especially in Britain, where it was up to the soldiers themselves to prove that they were mentally disabled in consequence of the war, excluding therefore a family-history of psychiatric disease or having been a bit strange before 1914 as well. 

And thirdly, there are problems in Gilbert’s decision to take figures for the year 1922. Had he taken the 1921 figure of 65,000 pensions awarded on psychiatric grounds, the extrapolation would already have been higher – 325,000. And if he had taken the number of 80,000 that nearly everybody else uses, which also was the pension-rate of 1928, 400,000 would be the resultant estimate of overall psychiatric casualties. For that matter, on another place in his book Gilbert himself used the figure of 80,000 cases at the end of the war, although he then talks of neurotics in general, ‘including what came to be known as “shell shock”. On yet another place he indeed mentions 50,000 ‘genuine cases’ of shell shock in November 1918, which of course leaves the question what a ‘genuine case’ is.

It is my firm conviction that not only the number of 50,000, but also the number of 80,000 shell shock cases is false. There were more, many more. How many, I don’t know, and probably nobody ever will. Why do I think that there were more than 80,000 British cases of shell shock to use the common term , or to use some of the more differentiated medical terminology, neurasthenia, hysteria, Disordered action of the heart, Not yet diagnosed (nervous)? 

First of all, it must be kept in mind that military medical statistics are not the most reliable statistics. In wartime, sickness has a different meaning, and surely in the trench war of 1914 18, sickness had many meanings. In fact almost everybody was sick some of the time, probably even most of the time, but the sickness had to be severe for the soldier to report sick and, indeed, very severe to be acknowledged as such. It was not for nothing that one British doctor called his memoirs ‘Medicine & duty’, being the most common diagnosis. Take a pill and of to the front you go. Psychiatric problems have met this barrier too. Besides: doctors didn’t count people, they counted injuries. How much this has influenced the 80,000 number also will never be known. Another problem is that military medical statistics ended the day the war was over, whereas psychiatric troubles didn’t. After the war some soldiers were granted a pension, although their problems came to the fore only after 11 November 1918. But they had an all but easy time proving the link between their difficulties and their wartime experiences. Many, perhaps even most, did not succeed. Furthermore, because of the military character of the army medical services, one can never be sure what the words ‘treatment succeeded’ meant. Did it mean the soldier was actually cured of his condition, or did it mean he was judged fit enough to be sent to front or weapons factory again?

Secondly: although the subject of the psychiatric difficulties of soldiers is an ancient problem, it was the First World War that became known as the war of madness. As said: never before so many soldiers had been unable to cope with the horrors of it. This was recognised very early in the conflict. Nevertheless, the problem was denied for a couple of months, and, by some officers and medical men, even for some years. A mad soldier was seen by some as a coward, a malingerer, who should be shot instead of hospitalised. And when they were hospitalised, the way doctors looked upon them was not always much better, as Ernst Toller described in his Jugend in Deutschland (German Youth). Many of the shell shocked soldiers therefore will not have been recognised or acknowledged as such, as is proven in the again topical British 'shot at dawn' discussion. How many of the executed soldiers in fact should have been diagnosed shell shock, will again never be known.

Thirdly: although the Russo-Japanese War of 1904-05 had the honour of establishing, on the Russian side, the first military psychiatric service, its knowledge was almost completely lost. Therefore war related psychiatric knowledge had to be learned from scratch in 1914. This will have had its negative effect on recognising psychiatric problems, and on the diagnoses given when problems were recognised. Few military doctors had knowledge of psychiatric problems. Most of them had not, and will therefore have diagnosed wrongly, or not at all. ‘Pull yourself together, man’, is all he will have had in store for the troubled soldier.

Fourth, there is the problem of the uncertainty of diagnosis. Psychiatric problems move from minor to severe. Many soldiers from time to time had difficulties for a long time without going completely berserk. Loss of morale, apathy, dehumanisation, attacks of mortal fear and panic are signs of severe mental problems, but few of the men suffering from these problems will ever have seen a hospital from the inside, nor be diagnosed as war-neurotics. On the scale of normality to insanity a line had to be drawn at some point. At one side of the scale, one is fit for duty, on the other side one is fit for the asylum. The number of 2% shell shocked soldiers stands next to 7 to 10% officers with psychiatric problems every now and then, and 4% of the soldiers. At what point of the scale is someone traumatised enough to be recognised or to be acknowledged as traumatised? This point is highly arbitrary. The line will be drawn by almost everybody on a different point, and by military including the medical officers more closely to the category of absolute madness than to the equally arbitrary category of mental health. Furthermore, it was drawn closer and closer to the category of madness, thereby excluding more and more damaged men, the longer the war lasted, and manpower resources became depleted.

Five: military medical men have a duty to keep up fighting strength. As a result, and as a consequence of their frequently more military than medical disposition, many of them saw it as their duty to prove that a soldier was not insane. The doctor was a servant of the army and the state, not of his patient.

The sixth argument is drawn from the high mortality of the war, drawn from the severe chance one had to be killed in action. How many shell shocked men were killed before their psychiatric injuries were registered? Many shell shocked soldiers will have wandered about the battlefield. Lost in no-mans-land. Many of them were killed before reaching the hospital. Pension statistics will certainly miss them.

On top of all this there is the again highly arbitrary distinction between shell shock wounded and shell shock sick. The figure of 80,000 only contains the ones declared shell shock wounded. They were the ones who were diagnosed as having gone mad as a result of the war, and not as a result of personal character or traumas dating from childhood. One of the tasks of the military medical services was to spare the state as many pensions as possible. Therefore doctors will have had the tendency to declare a shell shocked soldier sick, in stead of wounded. 

This practice did not stop on the 11th of November 1918, although some doctors realised the stigmatising nature of a shell shock sick diagnosis and knew that their knowledge of the problem in fact was too limited to come up with adequate diagnoses. In short: psychiatric care in the beginning of the war was almost absent and in the rest of the war doctors were not always friends of the patient. to put it mildly.

Let us now go back to shell shock, for some closing remarks. 

Why did the term survive despite the wish of most physicians, including Charles Myers, the medical officer who had first used the term officially, to try to occlude it with such euphemisms as ‘Not yet diagnosed (nervous)’? Why did the term survive when military officials considered September 1918 as the end of the period when shell shock could happen? 

The answer must be: because ordinary people such as the soldiers in the trenches wouldn’t listen to such scientific nuances, or, in their words, to such utter bullshit. In their view, war and nothing else was the source of their problems. Therefore the terminology also had to reflect the war. DAH or NYDN didn’t, but shell shock did, as combat-exhaustion in the Second World War, or battle-stress in Vietnam or peace-keeping frustration in the past decade. Furthermore, unlike continental equivalents as Kriegsneurose, Granatshock or choq de guerre, shell shock not only made clear that 1914-1918 was an artillery war, it also sounded like artillery war, it sounded like an exploding grenade. 

As a result the powerful term ‘shell shock’ not only reflected the war, or sounded like the war, it also gave to those using the term the sense that they could reach some small inkling of what that terrible war was or had been like. ‘Shell shock’ has survived because it tells us something about the shock of war, the shock of that particular Great War, a shock that is with us still.

© Leo van Bergen 
- 2004

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