Doctors in conflict

Walcheren 1809: a medical catastrophe

Martin R Howard, consultant haematologist. 

Wilberfoss, York Y041 5NN

Marfoss{at}onyxnet.co.uk

In July 1809 the largest British expeditionary force ever assembled weighed anchor off the Kent coast and sailed for the island of Walcheren in the Scheldt estuary. ^{1 2} French naval activity at Antwerp had made the Dutch coast "a pistol held at the head of England," and the government was keen to strike a decisive blow at Napoleon's ambitions. In the event, the preparation of the expedition was ponderous and its strategic aim was redundant before its execution. Napoleon had consolidated his grip on the continent by defeating the Austrians at Wagram earlier in the month.

The potential success of the venture was also compromised by the appointment of senior military and naval staff who appear, almost 200 years later, like characters from a pantomime. The overall commander, Lord Chatham, was elder brother to the late Mr Pitt and was himself nicknamed "the late earl" because of his difficulty in rising from bed in the morning. He was accompanied to Walcheren by his pet turtles. Commodore Sir Home Popham was described by a fellow officer, perhaps unfairly, as being like a hippopotamus"an amfiberous hanimal, wot cannot live on the land, and wot dies in the water." His immediate naval superior, Rear-Admiral Sir Richard Strachan, was somewhat more competent but also out of his depth in the shallow waters of the Scheldt.³

Whatever the military bungling, an account of the Walcheren expedition is essentially a medical history. Within a few weeks, in an apparently innocuous area of the Netherlands, an army of 40 000 men was almost entirely destroyed by disease. The reasons for this disaster, and indeed the disease that caused it, remain open to speculation.

	Onset of fever

Top Onset of fever What was Walcheren fever? Aftermath References

At first the expedition achieved its objectives. The army disembarked on the neighbouring islands of Walcheren and South Beveland, meeting little French resistance, and reduced the siege of the city of Flushing on the south coast of Walcheren. Attempts by the enemy to flood the islands by breaching the dykes were only partly successful, and an air of optimism prevailed. Both soldiers and doctors have left memoirs of their Walcheren experiences, and these reflect a sudden change of mood towards the end of August. Accounts of military achievement and of the local landscape and population are replaced by anguished and unbelieving descriptions of an appalling epidemic of disease. An epidemic which, although catastrophic, was not unpredictable.

The contemporary descriptions of Walcheren seem to describe two different countries. When the troops first landed they saw a "flat fen turned into a garden." William Keep of the 77th Regiment wrote home, "The more I see of this country the better I am pleased with it.... Here we frequently spread our table under the shade of luxuriant fruit trees, and enjoy all the pleasures of rustic life."⁴ Another officer thought the capital, Middelburg, one of the most delightful towns he had ever seen.⁵ However, a British expedition to the region in 1747 had been largely destroyed by an illness well described by the respected military surgeon John Pringle.⁶ John Webbe, an inspector of hospitals, perceived this darker side of Walcheren in a letter of September 1809:

The bottom of every canal that has direct communication with the sea is thickly covered with an ooze which, when the tide is out, emits a most offensive effluvia. Each ditch is filled with water which is loaded with animal and vegetable substances in a state of putrefaction, and the whole island is so flat and near the sea that a large proportion of it is little better than a swamp, and there is scarcely a place where water of tolerably good quality can be procured. The effect of all these causes of disease is strongly marked in the inhabitants, the greater part of whom are pale and listless.⁷

Particularly annoying to the troops were the unexpected swarms of mosquitoes, which bit them until their faces swelled. The medical officers were not overly concerned by these insects, however, one commenting, "the buzzing noise they make is more alarming than the harm they inflict."⁸

The progress of "Walcheren fever" or "Flushing sickness" was relentless. In early August there were fewer than 700 men sick, but by 3 September over 8000 were in hospital. In late October the 9000 troops sick on Walcheren easily outnumbered those fit for duty.⁹ Hospitals were set up in houses, churches, and warehouses, and conditions were appalling. Men were "packed together in hovels, such as would be thought unfit for dogs, exposed to the noxious night airs, and in some cases with only damp straw to lie on."¹⁰ When General William Dyott, second in command of the force, inspected the barracks at Flushing he found 12 ill soldiers in one room with only a couple of blankets between them.¹¹ The sick died almost by the minute, and all burials were ordered to be by night without candles or torches. Even those fortunate enough to be evacuated to England were left lying on the beaches in their own filth. The hospitals at home were overwhelmed by the sudden influx of patients, and some were little improvement on the facilities in Walcheren.

(Credit: NATIONAL MARITIME MUSEUM, LONDON) Pictorial plan of grand expedition in West Scheldt, August 1809, showing difficulty of approach to Antwerp

By the time the expedition ended in February 1810 the fever had caused the death of 60 officers and 3900 soldiers. Over 40% of the force had been struck down by disease, and six months later around 11 000 men were still registered sick. This compared with only 100 killed in the sporadic fighting of what had become an irrelevant military adventure.³ Many of those who survived the disease were left permanently debilitated. It was common knowledge in the subsequent campaigning of the Peninsular war that the Walcheren regiments were always the first to fall ill.

	What was Walcheren fever?

Top Onset of fever What was Walcheren fever? Aftermath References

The nomenclature of disease in the early 19th century now seems obscure, and the retrospective identification of diseases can be difficult. Fevers were commonly divided into four basic types: typhus, intermittent, simple continued, and remittent. Typhus is the disease we know today. Intermittent fever was malaria, and simple continued and remittent fevers were probably a mixture of infectious diseases including malaria, typhoid, relapsing fever, and dysentery. The cause of these diseases was unknown. Some believed that contagion had a role, but most army doctors held the longstanding view that "miasmata," vapours arising from putrid organic matter, were the cause of common fevers. This was easy to believe in the low lying swamps of Walcheren. Treatment was designed to remove these impurities from the blood. The typical "antiphlogistic" regimen included drugs such as laxatives and emetics combined with other treatments such as venesection, blistering, and dousing with cold water. Alcohol and tobacco were regarded as panaceas.

There are three general sources of information that allow an intelligent guess about the nature of Walcheren fever: accounts by the soldiers affected by the epidemic, descriptions of disease by the regimental medical officers, and more specialised medical accounts by senior doctors, which include details of the pathology of disease.¹² William Keep gives a typical soldier's view of an attack of Walcheren fever:

This disease comes on with a cold shivering, so great that the patient feels no benefit from the clothes piled upon him in bed, but continues to shiver still, as if enclosed in ice, the teeth chattering and cheeks blanched. This lasts some time, and is followed by the opposite extremes of heat, so that the pulse rises to 100 in a small space. The face is then flushed and eyes dilated, but with little thirst. It subsides, and then is succeeded by another paroxysm, and so on until the patient's strength is quite reduced, and he sinks into the arms of death.⁴

Splenomegaly was a common physical sign. Rifleman John Harris's spleen was so enlarged that he carried an "extra paunch" for many years.¹³ Another key characteristic of the disease was its propensity to relapse. William Dyott was well when he returned from Walcheren to England, but he then had an attack of fever lasting 14 days. Of 130 members of a light infantry company of the Scots Guards which left England, only 40 marched back into London, and all except two subsequently developed fever.⁹

(Credit: BRITISH LIBRARY) Winding up of the medical report of Walcheren expedition, Thomas Rowlandson, March 1810. The two victims in the pillory are Physician-General Lucas Pepys and Surgeon-General Thomas Keate. "A Jack-Son" is Dr Robert Jackson, a severe critic of the army medical board. The barrels are inscribed "TK" as Thomas Keate was accused of misappropriating luxuries, and the case of "oak bark" is an allusion to the shortage of real bark on Walcheren. The public house "A Goose Cured Here" is presumably a hospital ("agues cured here")

These soldiers' accounts are of a relapsing fever associated with splenomegaly occurring in swamps infested by mosquitoes. Some historians have understandably attributed Walcheren fever to malaria alone. However, there are problems with this hypothesis. The high mortality in such a short period is not compatible with the types of malaria known to have affected the Netherlands at this time.¹⁴ Only virulent falciparum malaria could have caused such decimation, and this was restricted to the tropics.

There is enough evidence to implicate malaria as a major component of Walcheren fever, but a more thorough review of all sources, including the primary medical accounts, suggests that other diseases were present. There are frequent references to dysentery in both military and medical memoirs. English authorities on the fever, including the physicians John Bunnell Davis¹⁵ and Thomas Wright¹⁶ and the surgeon George Pearson Dawson,¹⁷ all stress that the intermittent fever often terminated in dysentery and diarrhoea. The postmortem findings, mostly recounted by Davis, were predominantly of generalised oedema, hepatosplenomegaly, and ulcerated and inflamed intestines. The valuable first hand account of Walcheren by assistant surgeon George Hargrove implies the presence of further infectious diseases.⁸ He describes both a type of fever and the presence of signs, including petechiae, which are compatible with typhoid and typhus. Notably, Hargrove says that these syndromes mainly affected the troops living in crowded and dirty conditions.

Another "statistical" account of the fever states that the remittent fever often transformed to a continued or "typhoid" form with symptoms of severe headache, coated tongue, anorexia, and delirium.¹² French sources also support the presence of multiple infections. The clinician Jean-Baptiste Tresal concluded that whereas strangers to the islands were primarily affected by malaria, the inhabitants contracted other diseases.¹⁸ That some soldiers had immunity to disease, presumably malaria, is implied in a report by three British army doctors, who noted that men who had been recruited from "dry mountainous districts" were more likely to fall victim than those from "flat and fenny countries."¹⁹

Taken as a whole, the available sources suggest that Walcheren fever was not a newly discovered killer disease but a lethal combination of old diseasesmalaria, typhus, typhoid, and dysenteryacting together in a group of men already debilitated by previous campaigning²⁰ and a life of poverty and drunkenness in the lower reaches of society. The reduced mortality in officers compared with the troops (only 3% compared with over 10%) was probably as much due to their better general health as to the more attentive care they undoubtedly received.

	Aftermath

Top Onset of fever What was Walcheren fever? Aftermath References

Walcheren is little remembered now. Unsurprisingly, British military historians have given more attention to Wellington's Peninsular and Waterloo campaigns. However, in early 1810 there was public consternation at the debacle and a parliamentary inquiry was held.²¹ Remarkably, the army medical department had not been informed of the expedition's destination before its departure. Some of the medical men emerged with credit, but the most senior men in the medical department were in the firing line as much as the government and military officers. The medical arrangements were complacent. There were too few doctors, inadequate hospital provision, not enough transport for the sick, and a shortage of vital drugs and supplies. Peruvian bark, one of the few drugs with real efficacy, had to be commandeered from a passing American vessel. The physician general, Sir Lucas Pepys, seemed as much a caricature as his military peers. When asked why he had not attended the sick in Walcheren, he arrogantly replied that he had no personal experience of military medicine. The surgeon general, Thomas Keate, was quick to point out that he was not the appropriate person to visit Walcheren as the matter was "entirely medical." The old army medical board had proved itself incompetent, divided, and overly preoccupied with private practice. Its demise and replacement by an improved "new medical board" was predictable after the disaster of Walcheren, but an earlier inquiry had already suggested it be scrapped.^22-24

The Napoleonic soldier had far more to fear from disease than from the enemy, even when campaigning close to home. It has been estimated that in all theatres of war between 1793 and 1815 the total British losses were in the region of 240 000 men, with probably less than 30 000 of these deaths being caused by wounds.²⁵

	Footnotes

   Competing interests: None declared.

	References

Top Onset of fever What was Walcheren fever? Aftermath References

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18.	Tresal JB. Essai sur la fievre adynamique qui a regne dans l'ile de Walcheren dans l'annee 1809, precede d'un apercu topographique de la meme ile. Paris: Didot Jeune, 1815.
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22.	Chaplin A. Medicine in England during the reign of George III. London: Henry Kimpton, 1919:86.
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24.	Crowe KE. The Walcheren expedition and the new army medical board: a reconsideration. English Historical Review 1973; 88: 770-785.
25.	Hodge WB. On the mortality arising from military operations. Q J Stat Soc 1856; 19: 219-271.