Casualties of war

Throughout history, war has brought destruction and misery to humanity, and left millions dead. Among those who survive, many are broken in body or damaged in mind and spirit. The First World War was Australia’s first major conflict in an age of “total war”, and its first experience of casualties on a mass scale. More than 60,000 would die, but the majority who served did return home. For many bearing the scars of war, the transition back to civilian life would not be an easy one. Those suffering from painful wounds or lingering illness, or haunted by psychological trauma, all presented significant and often long-lasting medical challenges.

Some Figures

It is generally accepted that the First World War killed some 16 million people worldwide, of which military deaths constituted about 9.5 million. It is also estimated that around 20 million were wounded, including 8 million left permanently disabled in some way. This was indeed a shocking toll for just four years. As if this were not enough, disease would then step in to claim an even greater toll in the form of the 1918–20 influenza pandemic, the Spanish flu. 

Although comparatively small in numbers, Australia’s losses from the war were heavy for a nation of just 4.9 million. In round figures, the combined total of all Australian armed forces sent overseas during the war was about 340,000, of whom 331,000 served in the Australian Imperial Force (AIF). Around 213,000 members of the AIF became battle casualties during the conflict: almost 54,000 died, 4,000 were taken prisoner, and 155,000 were wounded. The nature of their wounds ranged from minor to severe, and while most recovered to rejoin their units or at least remain in service of one kind or another, a significant portion were not fit to continue.

When repatriation of the Australian Imperial Force was completed in 1920, 264,000 men and women had returned to Australia, of whom 151,000 were deemed “fit”, and 113,000 “unfit”. Many had returned throughout the war, beginning in 1915 with those suffering from disease and injuries; then as fighting on Gallipoli, Sinai–Palestine and the Western Front progressed, the wounded began steadily returning home as well.

Physical Wounds

The two weapons that caused the most casualties during the First World War were artillery and machine-guns. Shell fragments, shrapnel or even blast concussion from artillery rounds accounted for 51 per cent of Australian battle casualties, while bullets spat from rifles, and particularly machine-guns, made up another 34 per cent. The range of wounds could vary greatly: from neat flesh wounds affecting no vital organs, bones or arteries – to shell fragments inflicting gross mutilation, leaving men torn apart, barely clinging to life.

A wounded man first had to survive the journey to the rear, often carried by stretcher-bearers through a battlefield raked by machine-gun and artillery fire. Patched up and stabilised at regimental aid posts, dressing stations and casualty clearing stations, if he could make it to the field hospital, a soldier’s chance of survival was far better than in previous wars. While significant breakthroughs in medical treatment had been made in the mid-to-late 19th century, by the First World War these were more widely appreciated and had been greatly improved. Better resuscitation and blood transfusion techniques, along with advances in anaesthetics, were all vital in preventing death through shock. General hygiene, antisepsis, debridement and the cleansing of wounds also greatly reduced the incidence of gangrene. These, along with the ability to properly set and mend compound bone fractures, ultimately meant less need for amputations. But despite these advances, the First World War was nevertheless pre-penicillin, and wound infection could still be very difficult to stop.

Legs, arms and heads were the most commonly wounded areas. Head wounds were dangerous for obvious reasons, while the other extremities were important in a functional, if not a vital sense. In some cases the shell fragment performed the amputation on the battlefield, while in others, a leg, an arm, or sometimes multiple limbs were simply too badly damaged to be saved. From the beginning of the war to June 1918, 1,749 amputation cases arrived home in Australia, of which 1,165 were legs and 584 arms. All told, the number of limbless would rise to more than 3,000. A lesser number lost their sight from wounds – around 100, rising to 130 ten years after the war. Some men also suffered terrible facial disfigurement and required extensive surgery over lengthy periods to rebuild their faces. Excellent medical treatment was available in England for the blind, the limbless and the disfigured [see Wartime 80], with further support at home in Australia, which greatly helped these men adjust to their future.

Poison gas was another danger troops had to contend with. Twelve per cent of Australian casualties were caused by this insidious weapon, mostly used on the Western Front. Depending on the type of gas encountered and how much one was exposed, the effects could range from uncomfortable irritation to horrible death. During the war, 16,000 Australians became gas casualties, of whom only 325 died. Yet many thousands who survived the war were plagued by respiratory problems for the remainder of their lives – ailments that could range from mild to chronic and incapacitating.

Unseen Wounds

Psychological and neurological reactions to the trauma of war are as old as the history of human conflict itself. Essentially, they are reactions to innate fear: the dread of battle, of being wounded, and the legacy of war’s assault upon the senses (the horrific sights, sounds and smells) and upon one’s psyche and sense of morality.

Reactions could range from instantaneous combat shock to much longer-term manifestations. “Shell shock” was a term introduced in early 1915 to explain the range of symptoms soldiers were presenting with, such as hysteria, shaking, stuttering, tics, tremors, as well as loss of speech, sight, and hearing. At the time it was thought the concussion of exploding shells caused physical damage to the brain and nervous system. Many soldiers presented with less dramatic symptoms such as fatigue, headaches, confusion and chest pains, which were generally labelled neurasthenia. However, it was gradually accepted that the problems were not being caused by physical shock but by psychic shock. Such episodes could result from a range of experiences, but the more acute were commonly set off by incidents such as witnessing a horrific sight, being subjected to gas attacks, being buried by shell explosions, or enduring relentless heavy shelling.

Australians suffered just as much mental and nervous breakdown as any other troops during the war. It is recorded that among the AIF during 1915 there were about 1,500 soldiers treated for neuroses (traumatic neurasthenia, shock, shell-shock, disordered action of the heart), and psychoses (including melancholia, acute delirium, delusional insanity, exhaustion psychosis etc.). Then on the Western Front the figures grew much greater. Between April 1916 and March 1919, the field ambulances alone treated 7,205 cases of psycho-neuroses and other mental illnesses. Between Gallipoli, France and Belgium, only around 2,200 were actually diagnosed as “shell shock”; however, regardless of which labels were applied then or afterwards, these unseen wounds and mental traumas took a significant toll on the AIF during and after the war. By 1931, they accounted for some 13,500 pensions.

Disease

War creates perfect conditions for a range of diseases to flourish; harsh living conditions, plus poor diet and strain, can quickly lead to a decline in soldiers’ health. The destructiveness of conflict often leads to a breakdown in hygiene, and with large numbers of men living in cramped and unsanitary conditions, deadly epidemics can easily break out. This is made worse by the presence of troops from far-flung regions, some of whom have built little resistance to certain diseases and are therefore highly vulnerable.

Until the beginning of the 20th century, disease almost always claimed many more military lives than combat – often double or more. By far the major killers of armies throughout the ages had been gastro-intestinal infections: dysentery, cholera, and enteric fever (typhoid). It was not until the Russo-Japanese War of 1904–05 that both sides managed to limit deaths from disease to fewer than combat deaths. This was mainly due to some late 19th-century breakthroughs in the understanding of what caused contagious diseases, how they were spread, and how they could be protected against. 

Australians volunteering for the war were subjected to medical tests prior to enlistment, and of the nearly 600,000 men examined for the AIF, some 180,000 were rejected. This could be for a wide range of conditions such as having defective eyesight, tuberculosis, or perhaps some physical defect such as flat feet. While the medical checks were not as stringent as today, those selected were generally fit and healthy, and at an average age of 26.4, in the prime of life. 

Australians were given a range of inoculations when they joined up. The most important jab was to protect against smallpox and typhoid – indeed, having this was an essential precondition of enlisting. In addition, in early 1916 they received the TAB inoculation to guard against recently identified strains of paratyphoid. Further protection against cholera and malaria was also provided as necessary. But despite the relative health of the Australian troops and the precautions taken, many did fall ill – some succumbing multiple times during the war. 

In the cramped and unhealthy conditions on Gallipoli, gastro-intestinal infections were a serious health problem. One estimate indicates that almost three quarters of Australian troops on the peninsula became ill at one time or another. Probably only the ability to evacuate sick men for proper rest and recovery saved a disaster more akin to those of previous centuries. It is a credit to the medical services that only 366 Australians died of such causes during the First World War.

Malaria is endemic to numerous places of the world, but particularly the tropics. When the Australian Naval and Military Force (ANMEF) seized German New Guinea at the beginning of the war, this disease soon became a serious problem. Despite taking quinine, by November 1914 some 60 per cent of the troops at Rabaul and Herbertshöhe were infected. Surprisingly, malaria was also endemic to Belgium, and 228 cases occurred among Australians on the Western Front. All told, 134 Australians died from malaria, the majority in the Sinai–Palestine campaign. Indeed, this disease claimed one of Australia’s highest-ranking casualties of the war. Brigadier-General Samuel Pethebridge, commander of the Tropical Force, died of malaria in January 1918. It could also be difficult to cure entirely, and relapses were common. By 1924, 1,946 veterans were receiving a disability pension for malaria, though that number fell thereafter as better drugs became available.

Most Australian troops who succumbed to disease during the war died from respiratory tract infections – commonly influenza and pneumonia. Combined, they claimed some 3,300 Australian lives during the war, and many more were debilitated by the effects long afterwards. By 1930, almost 8,000 were receiving disability pensions for asthma, bronchitis, pleurisy or pneumonia.

One particular respiratory infection that probably presented the most serious threat to the Australian forces came very late in the war in the shape of the Spanish flu pandemic. Among the AIF in France there were nearly 22,000 cases from the middle of 1918, and ultimately 1,238 died. Most occurred during the pandemic’s second and third waves between October 1918 and March 1919. In early 1919 the first cases appeared at home in Australia. Despite quarantine measures, this deadly influenza would ultimately infect around two million Australians and claim 12,000 to 15,000 lives. The estimates worldwide range from 50 to 100 million deaths, dwarfing wartime losses.

Tuberculosis (TB) presented yet another threat for Australians serving overseas. While men were screened for the disease prior to enlistment, some infected men undoubtedly got through. Harsh wartime living conditions at the front would often result in the disease worsening and becoming active. During the war around 343 Australian troops died of TB, while another 2,000 sufferers were repatriated home. Like malaria, TB is a lingering disease that can take years to become active. Before the discovery of the antibiotic drug streptomycin in the 1940s, TB was eventually fatal for most. How many more died of tuberculosis in the decades after the war is unknown, but by 1930, there were still about 1,000 TB sufferers receiving war disability pensions

Apart from gastro-intestinal infections, the disease that affected the greatest number of Australian troops during the First World War was venereal disease (VD). The statistics are shockingly high, ranging from around 53,000 to 60,000 men who were treated. Even though medical officers did the best they could by giving lectures and issuing vast quantities of prophylactics, the age-old problem remains. When sex is available to troops and alcohol is added to the equation, all forethought and caution go out the window. Early on, men were sent home to special facilities in Australia, such as Langwarrin, Victoria. But by the end of 1915 the decision was made to keep VD cases away from home, so most were sent for treatment to the 1st Australian Dermatological Hospital at Bulford in England.

Before the advent of penicillin, the treatment was imperfect and could be lengthy, painful and not always successful. Apart from the social stigma and embarrassment of contracting VD, men risked infecting future partners or their wives, which could produce birth defects. In many cases, if treatment began quickly, the disease could be cured, but syphilis in particular was difficult to be rid of, once well established. While the rate of venereal disease among Australian troops was notably very high, it should be appreciated that such diseases were prevalent among the civilian population of Australia as well, and some suggest it was at an even higher rate. 

All told, there were nearly 438,000 “non-battle casualties” among the AIF during the war. Of these, 5,363 died of disease, and about 1,000 were killed as a result of accidents. To those must be added the much smaller number of non-battle casualties of the Royal Australian Navy and the ANMEF – perhaps several thousand more.

Rebuilding Lives

Whether a battle or non-battle casualty, anyone deemed unlikely to be fit for duty within six months was returned to Australia for discharge. Specialised hospital ships brought them home, where a system of medical care was in place. The general hospitals were located in the state capitals and most included psychiatric and other specialist wards. These were supplemented by smaller auxiliary hospitals, convalescent centres and sanatoria, plus small workshops to manufacture artificial limbs and appliances. Those living in more distant suburban and country areas could get treatment at regional hospitals or from local medical officers. Civilian medical facilities and the Red Cross augmented this system of care. 

The Australian government introduced a scheme for pensions, benefits and medical treatment as early as 1914, and over the ensuing years this was gradually improved to meet as far as possible the needs of the nation’s veterans and their dependants. A Repatriation Department was set up, which took over the running of the military hospitals in 1921 when the AIF was disbanded. The main hospitals in the cities became known as Repatriation General Hospitals, or simply “Repat” hospitals. 

In 1920 there were around 90,000 Australian veterans receiving war disability pensions. A decade later there were 74,578 but it was estimated 780 were dying per year. The figure would rise to 77,315 in 1938, then steadily fall as the number of deaths began to overtake the number of new pensions granted. Many veterans died during the decade following the war in early middle age – well before reaching age 60. In 1935–36 the average age at death for a non-veteran Australian male was 62.5, while for a veteran it was just 51.9. This gap closed somewhat over the subsequent years; but in 1936, while the pension was available at age 60, a service pension was introduced for veterans turning 55, acknowledging the realities of their shorter life expectancy. Without extensive research, the exact number who died prematurely of war causes will remain unknown. One other clue, however, is the 1933 Census, which indicates a drop in numbers of some 38,000 veterans in the fourteen years since 1919.

For those families whose loved ones had been killed during the war, the shock and grief would in time give way to memories and reflections about someone no longer present. Perhaps a photograph, a letter or a token served as a reminder. But many more families experienced the return of a soldier, often a changed man, someone on whom the war had taken a toll. While medical treatment, pensions and assistance were available from the government, it is worth remembering that in many cases the burden of day-to-day care of disabled or incapacitated veterans fell upon the families. To a great extent it was the parents, wives and children who provided the daily care and endured the hardships of nursing returned soldiers back to health over the years. And for some it meant living with, and enduring, that suffering until the end mercifully came.