This post continues the work of the previous post in analysing the physical and mental condition of the men returning home, having ‘survived’ the War. The focus in the last post was the extent of wounds and it revealed that half of the cohort of 585 were hospitalised, at least once, as the direct result of being wounded in battle.
The focus of this post is the extent of disease, sickness and non-conflict injury across the same cohort. For a start, 478 men or 82% of the cohort were hospitalised at least once as a result of disease, sickness or injury. With men being hospitalised more than once, the total number of hospitalisations for the group was close to 1,000 (960). As with those wounded, some of these conditions were so severe that the soldier was repatriated to Australia and discharged as medically unfit. Equally, many of those discharged as TPE at the end of the War had extensive records of hospitalisation, serious health issues and debility; and their poor health was obviously going to be a negative factor in their future lives.
Injury, sickness and disease are not unique to military service and it can be argued that many of the cases of hospitalisation covered in this analysis would have occurred, in Australia, in normal, everyday life. However, there are two critical points. First, several of the conditions were definitely unique to the experience of war. For example, ‘trench feet’ and ‘trench fever’ can be classified as conditions that soldiers experienced directly because of their military service. Equally, the cases of malaria and other infectious disease such as enteric fever that soldiers suffered were also directly related to war service in a particular geographic location, principally in the Middle East. Second, while many of the sicknesses and diseases were, as it were, ‘universal’ and not defined by either location or military service, the actual conditions of military service intensified both the spread and severity of these conditions. Because the men lived in such close proximity, often in highly compromised conditions of basic comfort, cleanliness, hygiene and sanitation, and because their daily experiences were often so physically and mentally demanding and fraught, diseases and sickness were more likely to occur, more likely to spread both further and faster and more likely to have more significant health effects.
The other critical point is that ‘sickness’ as such was only half the story. We have already seen in the previous post that 50% of the survivors suffered ‘wounds’ of some kind. Now we have more than 80% of the same group of survivors hospitalised, at least once, with some form of sickness. Obviously, many men fell within both categories; and it is reasonable to argue that it was the cumulative impact of these experiences that most affected men’s health, both at the time and into the future.
The range of sickness, disease and injury
What was immediately apparent in the analysis was the extraordinary range of medical conditions described. They ranged from a horse bite to the right ear and concussion of the brain (from a non-combat fall) through every common disease, infectious and non-infectious, to more one-off medical conditions including: (a) enlarged spleen, (b) abdominal swelling/tumour and (c) alcoholic insanity.
Again, it is important to acknowledge the type or records being analysed. As discussed in the previous post, the records here are essentially records that track the soldier’s service – to the day – and both the amount and form of medical information that appear are limited. In some service files there are more detailed medical records such as medical assessments conducted in relation to a medical discharge. However, the primary record employed in the following analysis is the entry in the service file that detailed when an individual was hospitalised and for how long and where.
Categorising the data
To begin, there were cases where the only entry was generic. Specifically, there were 49 cases of hospitalisation where the only detail recorded was sick. Obviously, there would have been a more prescriptive diagnosis later in the period of hospitalisation, but in terms of the record-keeping the only reference is sick. There was a similar situation where for 28 cases the only entry was NYD or Not Yet Determined. Again, presumably, there would have been a determination of the condition at some point; and In some instances you can actually see that the NYD was changed to a definite diagnosis; but NYD is the only record in the file for 28 cases. Lastly, there were 41 cases where the only reference given was PUO (Pyrexia of Unknown Origin). Most likely these cases would have been eventually diagnosed as conditions such as trench fever but, like the previous two generic cases, there is only the acronym PUO in the file. Overall, there were 118 cases of hospitalisation where no specific medical description was given.
At the same time, certain conditions appeared constantly. The following breakdown records those conditions that appeared at least 10 times. The total figure comes to 644 cases of hospitalisation.
Enteric Fever: 19
Trench Feet: 21
Trench Fever: 22 (Many cases designated PUO (41) would have been Trench Fever)
In addition to these cases, there was a very diverse range of less common diseases and sicknesses. The number of hospitalisations involved came to 92.
Chicken Pox: 3
Rheumatic Fever: 2
Scarlet Fever: 2
Small Pox: 2
VDH ( Valvular Disease of the Heart): 5
There was another set of hospitalisations from one-off conditions: varicose veins, asthma, anaemia, heat stroke, sun stroke, neuralgia, myositis, quinsy, hepatitis, rubella, sciatica, neuritis, catarrh, osteoporosis arthritis, fibrositis, fibrosis of lung, colitis, rhinitis, balanitis, thrombosis, neuralgia, intestinal colic, abdominal colic, real colic …
There were 50 hospitalisations stemming from what can be described as general (non combat) injuries, where the the most common injury was sprained ankle (10). Others included fractures, lacerations, burns and scalds, concussion from falls and knocks, and a range of horse-related injuries: kicked, bitten etc.
There were also several hospitalisations that clearly related to mental health issues. For example, there were men hospitalised where the following type of descriptors were used: alcoholic insanity; mentally deficient; mental; premature senility and rheumatism. These cases were separate from the shellshock/neurasthenia cases considered as ‘wounds’ in the previous post.
Clusters of sickness and disease
When considering the extensive range of medical conditions described in the AIF service records, it is helpful to pull the various medical descriptions together and focus on key areas for this particular cohort of 585 men. For example, you can identify a relatively small group (6) suffering from various dental problems. Similarly, there was a slightly larger group (10) suffering from hearing issues and another group (12) with eyesight issues. If you bring together all descriptions relating to the heart – valvular disease of the heart (5), tachycardia (6), angina, heart palpitations, cardiac irritability and heart attack – you also end up with a cluster of about 15. There was a larger cluster of cases (30+) associated with rheumatic disorders, including rheumatism, arthritis, synovitis, rheumatic fever and poliomyelitis.
There were 2 areas where the effect of clustering was very significant. The first related to skin complaints and the second to respiratory system issues.
Scabies, with 41 hospitalisations, was the dominant skin complaint and one of the most common reasons for hospitalisation. However, when you add other skin complaints – impetigo, a range of septic sores (hands, feet and legs), boils and cysts, neuralgia, unspecified skin diseases, plus a series of related ICT (Inflammation of Connective Tissue) conditions in hands and feet – the size of the cluster increases significantly, to approximately 60 hospitalisations. In a sense, the skin acted as a front line defence for the overall health of the body and it was under constant pressure because of the unhygienic conditions and the prevalence of mites, parasites and viruses. Even the simplest cut or laceration could result in infection. Treatment in hospital for scabies was exacting and could even promote more forms of dermatitis. There was also the debilitating effect of re-infection.
For the cohort of 478 men there were at least 200 hospitalisations as a result of respiratory system conditions. The major diseases were Bronchitis (24), Pneumonia (14), Pleurisy (21), and, of course, Influenza (142). There were also cases of tuberculosis, asthma, laryngitis and tonsillitis.
Clearly, influenza stands out as the most common reason for hospitalisation. In terms of influenza, the following is a breakdown of hospitalisations by year. It shows the peak of cases in 1918, principally in the second half of the year. The 1919 cases tend to be concentrated in the first half of the year. The 1919 numbers have to be considered incomplete because by that point men were being returned, or had already been, returned to Australia. There were cases where the men contacted the influenza on the voyage home and were hospitalised in the ship’s hospital.
The incidence of Mumps across the cohort
What might appear as surprising in the breakdown of hospitalisations, was the incidence of mumps (54). In fact, it transpires that in WW1 after influenza and VD, mumps was the most common cause of hospitalisation.
It is worth noting that adults contracting mumps could experience more adverse effects than those experienced by children. Orchitis – testicular swelling and tenderness and even testicular atrophy – was the most common complication for adult males. Obviously, the confined and unhygienic conditions the soldiers experienced increased the transmission of the virus. Typically, mumps involved a 3 week period of hospitalisation.
The incidence of VD across the cohort
There were 120 hospitalisations for VD and the number of individual men involved was 93, or 15% of the cohort of survivors. In general, the records in relation to episodes of VD are highly accurate, principally because pay had to be deducted for every day spent in hospital. Because of the very precise record keeping in relation to VD it is possible to calculate the total number of days involved in hospitalisation. For this cohort of survivors the figure was 6,182 days. It is an extraordinary amount of lost service time. In terms of the 93 individual soldiers involved, the average hospitalisation works out to be 66 days or more than 2 months of military service. Also, the average period of hospitalisation for the 120 cases comes to 51 days.
In a small number of VD cases, where treatment occurred at Langwarrin, the records appear to be incomplete. For example. in one case the person contracted VD before embarkation and was admitted to Langwarrin in November 1916 but it is not clear how long he was kept there. He eventually embarked for overseas on 19/2/17. In another case someone had enlisted in 1914 and contracted VD in Egypt in September 1915. As for many others, he was sent back to Australia and reached Melbourne on 17/10/15. It appears he was then treated in Langwarrin, presumably until early February 1916, before re-embarking for overseas service in early March 1916. A third example also involved someone – he had also enlisted in 1914 – being sent back from Egypt in August 1915. Again he appeared to spend up to 4 months there before being ordered to return to duty on 23/12/15; but at that point he deserted.
Some men experienced very high levels of hospitalisation from VD, both in terms of the number of hospitalisations and their duration. In terms of these ‘repeat’ cases, it is not clear from the records available if it was a case of the same infection flaring up again – medically, this was a definite possibility – or a new, additional infection, possibly following a period of leave. The following are examples of extensive cases:
(a) 25 yo when he enlisted in early 1916. Three periods of hospitalisation with VD: 63 days from May 1918; 84 days from January 1919; 50 days from October 1919. Total number of days: 197
(b) 20 yo when he enlisted in 1914. Three periods of hospitalisation with VD: 178 days from April 1916; 9 days from early May 1917; 46 days from late May 1917. Total number of days: 233
(c) 24 yo when he enlisted in the second half of 1915. Three periods of hospitalisation with VD: 100 days from September 1916; 145 days from June 1917; 17 days from December 1918. Total number of days: 262
(d) 25 yo when he enlisted in 1914. Three periods of hospitalisation with VD: 40 days from October 1915; 48 days from October 1916; 30 days from December 1916. Total number of days: 118
The longest single period of hospitalisation for VD was 253 days from very early December 1918. The soldier involved had enlisted in the second half of 1916 as a 33 yo.
These examples demonstrate the significant impact VD could have on soldiers’ service. They also indicate that VD hardly ended with the Armistice and that cases continued through 1919. In fact, it is possible – but it would be hard to establish – that rates of VD increased after the fighting ended. Certainly, in Australia at the time there was concern over the potential number of men returning with VD who posed significant risk to future partners, wives and children.
One other detail that emerges when you look at the complete picture of men’s health is that VD was only part of the story. It was very rare that VD was the only disease or sickness men suffered. In fact, the general health of men who contracted VD was often very problematic. It would be difficult to establish the connection, if any, between VD and other illnesses; but when you look at the full picture of the individual soldier’s health you are struck by an overall sense of poor health. Some examples will help:
(a) 26 yo when he enlisted in 1914. In August 1915 he was hospitalised – and repatriated to the UK – with dysentery and enteric fever. The hospitalisation lasted 5 months. In July 1917 he was hospitalised again – this time for 3 weeks – with disability/pyrexia. Then in March 1919 he was hospitalised with VD for 28 days.
(b) 21 yo when he enlisted in 1914. In April 1915 he was hospitalised with influenza. In November 1915 he was hospitalised for 5+ weeks with diphtheria. In January 1916 he was hospitalised for 3 weeks with mumps. There was another week in July 1917 with debility. In August 1917 he spent 1 month in hospital with sick contusion leg. There was another month long hospitalisation in May 1918, again with debility. Then in August 1918 there was another 6 weeks with malaria. Finally, at the very end of the War, there was a period of 6 weeks, from 23/10/18, with VD.
(c) 24 yo when he enlisted in the second half of 1915. Hospitalised for 3+ weeks with trench fever in May 1917. Hospitalised for 146 days with VD from February 1918. In February 1919 hospitalised with pleurisy for 2 weeks. On the return journey to Australia he was hospitalised – ship’s hospital – with influenza. Additionally, in July 1916 he had been hospitalised in the UK for 6 weeks with a gsw neck.
Interestingly, none of these men was discharged as medically unfit. All three were discharged as TPE. Yet, from a purely medical perspective, it is clear that at the very least their physical health had been severely compromised by their experience of war.
While VD was treated, medically, as a disease, there was this complex set of perspectives that shaped the authorities’ attitude towards it. Principally, VD was generally seen as the consequences of a moral lapse. It came from behaviour that was ‘licentious’, where, as it were, the individual soldier had not been able to resist the temptation of the ‘sins of the flesh’. As noted earlier, religious authorities referred to VD as an issue of ‘Purity’: the pure soldier, the ‘Soldier of Christ’ would never fall so low. So there was this sense of the individual having to accept personal responsibility for their medical fate. Indeed, in the early days of the War the AIF set out to shame the troops in Egypt who came down with the disease and returned large numbers of them home – to Langwarrin – in disgrace. Equally, those who became infected and had to be hospitalised for treatment deserved to lose their pay. However, over the course of the War, the significant limits of the purely punitive approach became obvious as VD rates stayed high. Social and medical reformers argued that changing people’s behaviour via moral lessons was not effective and that more proactive strategies employing an educative approach to prevent infection in the first place had to be adopted.
There were other major concerns at the time. For example, there was the fear that the disease had the potential to break out of what people perceived to be its own unique social setting – the weak man, overcome by alcohol, frequenting the brothel – and seep into mainstream society, and into the family home, directly affecting the health of both wife and children. There were even claims that VD, unchecked, was a form of ‘race suicide’.
Certainly, at the personal level, cases of VD tended to remain ‘unspoken’ and ‘hidden’. An example will help explain how this played out. This particular soldier enlisted early in 1915 as a 20 yo and he served until he returned to Australia in September 1919 and was discharged as TPE. In May 1920 the the Melbourne Headquarters of the Independent Order of Rechabites (Victoria) – a friendly society committed to the temperance movement – requested from the AIF a ‘certificate showing duration of illness’ of the soldier. Presumably he was making some sort of claim for sickness or disability. In due course a detailed record was provided and it covered hospitalisations for mumps, scabies, dental caries, a serious hernia condition and a gunshot wound to the left thigh. However, what the formal AIF record released to the IOR did not include was 88 days of hospitalisation from February 1919 for VD, s a direct result of contact with a prostitute in London.
Final notes of the extent of sickness
The preceding analysis makes it clear that many of the War’s survivors had their general health compromised by the sickness, disease and (non combat) injuries they experienced over the period of their service. Further, the negative consequences for the men would have continued post their discharge from the AIF. This was true not just for those discharged as ‘medically unfit’ but for the entire cohort generally.
One area that is not adequately covered in this analysis is that of mental health. Admittedly, we have seen that there was some medical sense of ‘psychological trauma’ . For example, in an extreme case, a soldier who was, literally, buried by an artillery barrage and then dug out, suffering from concussion and/or other wounds was likely to be described as suffering from shell shock. Equally, a man could be repatriated to Australia for medical discharge suffering from ‘premature senility’ or even ‘alcoholic insanity’. And, once returned home and discharged, a returned soldier could be described in the local media as someone who had ‘lost their wits’ or someone who had had a ‘breakdown’, so much so that at their welcome home someone else from the local community had had to speak on their behalf. So, such extreme cases of psychological trauma were apparent and noted. But that, of course, was but a part of the true picture. The problem was that the medical science of ‘mental health’ was very much in its infancy and there was no comprehensive mapping of the extent of psychological trauma across the cohort of all those returning. However, the fact that there was no ‘measurement’ at the time hardly denies the reality of such ‘sickness’. Everything about war service – the fear of death, the sight of death and wounds, the trauma of conflict and killing, the wretchedness of living conditions, the sense of powerlessness and blind fate, the tedium of military life and the impact of military discipline, the actual experience of being wounded or suffering serious illness, the loss of those close to you … – inevitably compromised the individual soldier’s mental health. Today, the most common description we would use would be PTSD. One hundred years ago the term was not used and there was no medical science to describe and record the condition; but it did exist and it would continue to have a significant impact on the men’s lives well after discharge.
Final notes on both being wounded and falling sick
The last two posts have focused on, first, the wounds experienced by the cohort of survivors and, second, the pattern of sickness, disease and (non combat) injuries experienced by the same cohort. While this separation is helpful in ordering the material, it is, in another sense, misleading as it can intimate that there was some sort of either/or arrangement. The reality, of course, was that the two conditions overlapped and interacted wth each other. If 50% of our cohort of survivors experienced at least once episode of being wounded and more than 80% of the same cohort were hospitalised at least once with some form of sickness, disease or (non compact) injury, then most men were affected by both possibilities. To understand the cumulative medical impact of war experience, the interaction between these two conditions is a critical consideration. It is only when you start to consider the combined or total medical experiences of the men that a true picture of the impact of the War on the mens’ health – physical and mental – both at the time and into the future begins to emerge.
The analyses in both this and the previous post have pointed to the very high levels of hospitalisation that characterised military service. It was not just the number of hospitalisations – for this particular cohort of 585 survivors the overall number of hospitalisations is in the order of 1,000 – but the length of such hospitalisations, which could easily extend to 2 or more months at a time. Inevitably, there would have been a very significant ‘churn’ effect in the various units in which the men served. Historians tend to assume that there was a strong sense of esprit de corps across the AIF and men identified strongly with their particular unit. However, the overall extent of hospitalisation tends, to some extent at least, challenge this perspective. The reality would have been that men returned to their original unit – sometimes months later – to find mates from their past either dead or now in hospital themselves, and new members added to the unit. There would have been a constant sense of flux. Moreover, significant battles might have taken place in their time in hospital and that sense of ‘shared battle experience’ compromised. The effect of such churn would have been negative for both unit morale and the mental health of the individual soldier.
The last comment relates to the overall health of the AIF. Admittedly, the focus throughout the blog has been on one particular regional area. However, over a number of posts the following points have been made:
1. The large number of men rejected on medical grounds, often with multiple rejections, where the rejections by local doctors began in the very first days of recruiting
2. The number of men still being rejected on medical grounds even in the last months of the war; and the sense that there were virtually no ‘medically fit’ recruits left
3. The ongoing lowering of the medical standards for recruitment
4. The number of men who did enlist but who were then discharged as medically unfit before they could even embark for overseas service
5. The number of men who died ( 22% of the cohort of men who saw overseas service)
the extent of wounds across the cohort of survivors (50%)
6. The extent of sickness, disease and (non combat) injury across the cohort (82%)
7. The number of men discharged, after service overseas, as medically unfit (48%), accepting that many of those discharged as TPE were, in fact, also ‘medically unfit’
The various indicators obviously highlight the immediate and ongoing medical consequences of war service. But there is also the suggestion that the overall quality of mens’ health in Australia at the outbreak of WW1 was more compromised than various myths of the Anzac story have assumed. The narrative about the best and fittest rushing to enlist at the start of the War might have substance; but only if you accept the level of rejection on medical grounds even at that point. Moreover, as the War progressed, there was a significant decline in the medical condition of the men enlisting in the AIF. Over the course of the fighting, the level of hospitalisation associated with both wounds and sickness was remarkably high. Finally, at War’s end the overall health – both physical and mental – of the men leaving the AIF was obviously severely compromised. Against this background, it seems sad to cling to notions of the Digger as some sort of stoic, super-fit and super-human archetype.
As indicated, the principal resource is the individual service file for each soldier.
The consequent illnesses ring a bell with a couple of my ancestors who served in the first world war. They went away healthy but returned with multiple disorders. They were from Meerlieu.
Thanks again Phil for a very interesting article. Some extraordinary figures revealed here. Best wishes Bruce
Bruce W Atkin