Saving private W. H.: The surgical experiences of Dugald Blair Brown (1847–1896): Lieutenant-Colonel,FRCS,Edin.,AMD

Early training: 1866-1878

Brown’s early career (1866–1878), prior to his South Africa duty, 1879–1881, involved several overlapping periods of activity. The first was the completion of his medical training, 1866 to 1877. The second, from 1872 to 1878, comprised his enlistment and early years in the AMD. Several phases of Brown’s medical training preceded his enlistment. He secured his academic qualifications in medicine and surgery, passing the General Examination, on 1 April 1866, and the Final Examination in April 1868.^16,17 In 1868, he doubly-qualified as Licentiate of the Royal Colleges of Physicians and Surgeons, Edinburgh, and he was elected to Surgical Fellowship in 1876. ² During this period, Lieutenant-Assistant-Surgeon Brown worked, consecutively, at three military base hospitals: in Ceylon, ca. 1872–1874; ¹⁸ in England, at Aldershot, ca. 1874–1878; ¹⁹ and, in March 1878, at the Royal Herbert Military Hospital, Woolwich.^8,20 In all, his academic and medical training spanned 12 years.

Brown visited Germany, in 1871, to confer with surgeons who had practiced during war-time. Bernhard von Langenbeck (1810–1887) and his assistant, F. J. von Esmarch (1823–1908), both of Berlin, were some of the veteran operators who had instructed him.^21,22 These doctors had considerable experience in the Schleswig-Holstein Wars (1848 and 1854) and in the Franco-Prussian War (1870–1871). ²³ Brown gathered valuable information from them on wound treatment during his visit to Berlin Hospitals at the cessation of hostilities in 1871. Before transferring to Woolwich, he visited Russia in 1878. ⁴ Since the Russo-Turkish war had ended that year, Brown took advantage of the opportunity to learn from consulting surgeon, Carl von Reyher (1846–1890), who had modified Lister’s methods during that conflict (1877–1878).^4,24 While in Russia, Brown observed, first-hand, the debridement and antiseptic methods of von Reyher. ^4,25 Moreover, he appreciated the outstanding results his mentor had achieved in the Russo-Turkish war, having treated eighteen penetrating wounds of the knee antiseptically. Brown reports that: “Three deaths only took place amongst these cases, while the remaining fifteen not only recovered, but had mobility in their joints!” ⁸

In the third period of training, prior to his South African deployment of 1878, Brown studied the writings of senior surgeons at home and abroad. He emulated the techniques of colleagues in England, at colonial base hospitals, and during visits to European facilities where war wounded received care. In military medicine, he studied the writings and Crimean-War experiences of Surgeon-General Sir Thomas Longmore (1816–1895).^6,26,27 He recognized the value of Joseph Lister’s (1827–1912) antiseptic system, as well as the related contributions of James Syme (1799–1870), Lister’s mentor and father-in-law.^5,8,28,29 Although Brown questioned the applicability of Lister’s elaborate system to war, he had no doubts about the latter’s exceptional talent, which he had observed, in 1871, during the excision of a knee-joint.^8,30,31

Brown who had reviewed statistical evidence of Lister’s antiseptic system understood its importance. During the Zulu War, however, supply shortages had forced him and his colleagues to improvise. In January 1879, when the War was in its earliest stage, these shortages were sorely felt; for example, at the base hospital at Helpmakaar, located in the coastal province of Kwazulu-Natal, he turned to wood tar, a crude antimicrobial substance, to dress wounds. Creosote, an oily extract from wood tar, answered the immediate need: “A considerable amount of well-tarred tow was found in a box where some wine bottles were packed. This I used as the dressing for all the wounds, and no case did badly … . A few fibres of the tow were used as drains in the wounds, and appeared to serve the purpose as well as anything else.”^3,32 Brown had learned from Lister that tarred oakum, which absorbed discharges and killed bacteria, was a substitute for processed compounds and ideal for dressing wounds. ³³ By the summer of 1879, medical supplies had been replenished. At the battle of Ulundi, on 4 July 1879, Surgeon-Major P. W. Stafford (1838–1925), who had served alongside Brown during the engagement, recounted that carbolic acid (which Lister relied on) had been routinely employed during the Battle: “carbolic-oiled lint (one in forty) was generally used as the primary dressing of wounds.” ³⁴ To absorb discharges and control sepsis, crude dressings of tarred tow and tenax continued to serve as “pads, cushions, or swathes.” The wood-distilled compound had been successfully adapted from Lister’s system and its application modified to meet the contingencies of mobile warfare. ²⁵ When supplies were low during the First Anglo-Boer War, Brown again turned to antimicrobial tar.^5,33

The Anglo-Zulu War: 12 January 1879–4 July 1879

The Anglo-Zulu War was officially declared on 12 January 1879. In anticipation of the conflict, the AMD had directed Brown, in mid-December 1878, to embark for South Africa.^4,19 Upon arriving at Natal, he was placed in charge of the medical department of the 99th Regiment, bound for Durban. ⁴ The order was to join the Centre Column, under the command of Lieutenant-General, Frederic Thesiger, Lord Chelmsford (1827–1905), as it moved eastward towards its military objective: the Zulu kraal of King Cetshwayo ka Mpande (1826–1884). ⁴

Brown’s unit, which had to travel a distance of 242 km, was slowed down considerably by steady rain and poor road conditions. ⁴ If the unit had reached the encampment at the expected time, on the morning of 22 January, he likely would not have survived. The Battle of Islandhlwana, which lasted from 9:00 AM to 2:00 PM, left 858 British and colonial troops and 471 native allies dead at the hands of 20,000 to 25,000 Zulu, who overran the unprepared encampment. ³⁵ Medical supplies were destroyed, and four AMD members were killed, notably Surgeon-Major Peter Shepherd (1841–1879). ³⁶

As the detachment to which Brown had been assigned headed back to Helpmakaar, they became aware, on 22 January, of the attack on Rorke’s Drift, a mission station located approximately 25 km east of their destination. Its garrison of 139 British and colonial men fended off thousands of Zulu warriors in a heroic stand that earned eleven Victoria Crosses.^3,4,37 Brown’s contingent continued in retreat, safely reaching Helpmakaar at midnight on 23 January 1879, ten hours after the Battle of Islandhlwana had ended. ⁴ By 26 January, Brown had begun to treat the sick and injured patients who, prior to hostilities, had been conveyed from Rorke’s Drift to Helpmakaar’s makeshift facility. ¹⁰ It was not long before Brown contracted “the prevailing fever of the place” (enteric or possibly typhoid), which had arisen from unsanitary conditions. He was then transferred to Ladysmith for recuperation.^4,38 When Brown recovered, he returned to Helpmakaar, to organize and administer the hospital. With the arrival of reinforcements, he was placed in charge of the medical staff of the 2nd Division, under the command of Major-General E. Newdigate (1825-1902) and the principal medical officer, Brigade-Surgeon A. Semple (d. 1905). ⁴

From 22 January to 3 July, a series of battles of varying intensity ensued, culminating on 4 July 1879 with the Battle of Ulundi. ³⁹ In Figure 1, the inset’s caption reads, “wounded man brought in, surgeon beside him.” This wood engraving conveys the ordered chaos of battle, in the midst of which the surgeons, who were positioned in marquees (not shown), had to treat a total of 98 men (15 were killed) in the span of 9 hours. ³⁵ During this decisive conflict, and for the first time, Brown attended to wounded soldiers under fire. One of the handful of medical officers on the scene, he worked tirelessly under a rain of overhead projectiles. ⁴⁰ On 21 August 1879, he recalled having seen “all the killed and wounded [113 soldiers]… being in the centre of the square formed by [the] troops … [where] nearly every case … passed under my observation.” ⁴ British troops were manning the perimeter of a “hollow parallelogram”–a four-sided infantry formation supported by artillery, Gatling guns, and cavalry (the 17th Lancers), stationed within its defensive perimeter. ³⁷ The Infantry Brigades and Flying Column, comprising the 2nd Division at Ulundi, amounted to 5,170 British troops, 1,005 native combatants, and 147 camp followers.^35,37 No ambulances, however, had been provided, by order of Lord Chelmsford; consequently, the wounded were without shelter; and the dressing area was vulnerable to a “converging fire of bullets.” ⁴⁰ Despite the danger, Surgeon-Major Semple, in a 5 July 1879 dispatch, remarked that, “nothing could exceed the zeal with which the wounded were attended by Surgeon-Major Stafford and Surgeon Brown.” ⁴¹

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Figure 1.

Battle of Ulundi, part of the Zulu War, South Africa: with a numbered key. Wood Engraving. Wellcome Library 20734i. Attribution: 4.0 International (CC BY 4.0).

The first Anglo-Boer War: 20 December 1880–23 March 1881; a conservative surgical method

Returning to England in February 1880, Brown who would be stationed at Woolwich for the better part of a year received orders to return to South Africa, as British and Boer forces were clashing in the Transvaal.^4,42 Disembarking at the Cape of Good Hope, Brown was initially assigned to the Inniskilling Dragoons. He proceeded with that unit to Natal, bivouacking at Newcastle base hospital on the Transvaal border.^4,43 Directed to leave regimental duty, Brown was stationed in close proximity to the fighting at Laing’s Nek (28 January 1881), at The Ingogo (18 February 1881), and at the Majuba Mountain (27 February 1881). ⁴

While a member of the Natal Field Force, Brown was recognized for his surgical aptitude and for his readiness to depart from established norms in the performance of operations. Adapting treatment to the nature and extent of an injury, he viewed each case as unique. Consistently overwhelmed with wounded, understaffed, under-supplied, and facing a determined enemy, Brown had to adapt quickly, without compromising the level of care. His approach to surgical care, emphasizing the need for fresh air, for promoting natural healing, and for cleanliness, was consistently pragmatic. ⁴⁴ Skilled as an operator, Brown practiced what he had learned from mentors and confrères. In July 1883, he abided by this axiom: “the individual circumstances of cases must guide us.” ⁷

Because war wounds could be complex, treatment required flexibility. In 1883, Brown would write that “expectant” treatment, advocating minimal intervention as a path to cure, was unsuitable in most gunshot-wound cases. Instead, he urged surgeons, especially those coming from civil practice, to diagnose injuries of this kind, immediately and thoroughly, in order to identify where “operative” surgery was indicated. ⁴ Combat injuries received in the Anglo-Zulu War differed in kind and intensity from those of the First Anglo-Boer War. Whereas, in 1879, the British physicians dealt primarily with stab wounds from the Zulu assegai and only secondarily with gunshot wounds, in 1880–1881 they faced the accurate fire of the Boers who were equipped with modern firearms. ⁴ Of particular concern to Brown was how British surgeons, especially those without military training, had been under-estimating the severity of bullet wounds incurred during the First Anglo-Boer War. The small entry wounds of the Boers’ high-velocity, cone-shaped ammunition, for example, had led some to assume that internal injuries were commensurately minimal when often they were not. ⁴ Exploratory surgery had become the norm if there was a doubt about the soldier’s condition.

For the management of gunshot wounds and to correct mistaken assumptions, Brown subscribed to an inclusive surgical plan. Because gunshot wounds to the shoulder were common and the anatomy of the region complex, he determined that rigid conformity either to the “expectant” or to the “operative” method might not always be in the patient’s interest. Brown did not explicitly define expectant, operative, and conservative surgery, although the distinctions between the three modalities are clearly implied in his writings. On the one hand, expectant care avoided the knife and relied on the powers of natural healing. In the case of gunshot wounds, Brown viewed this method as ill-advised. In March 1883, he recollected how, “numerous operations of a more or less severe description,” had been expectantly mismanaged and required reparative procedures. Even though the dry climate and topography of South Africa were not conducive to tetanic and gangrenous infections, post-operative infections, caused by streptococcus and other pathogens, still occurred and could be life-threatening.^5,6,8 Brown acknowledged that the dry climate of South Africa, along with ventilated tents, marquees, and huts, promoted healing.^5,44 The salubrious climate notwithstanding, he discovered that “cases of gangrenous sloughing of flaps after operation, and several cases of well-marked erysipelas [had taken] place in cases of abdominal gunshot wounds.”^9,44

Brown was convinced that “operative” surgery—the mastery of standard procedures, as Longmore, Lister, and von Reyher had demonstrated—was essential to the management of moderate to severe wounds.^5,6,8 Complications often arose when “expectant” supplanted “operative” care. At times, Brown recognized that an amputation was needed to save a life. ⁷ His criticism, in this regard, was reserved for “operative” surgeons who performed radical procedures haphazardly. Skilled operators in this category tended to amputate limbs, perfunctorily, rather than to consider if an extremity could be salvaged and the quality of life optimized.

In response to treatment that either was insufficient or excessive, Brown proposed a “conservative” system which subsumed under a unified plan the practical value of the expectant and operative methods. ⁴ Believing that the “healing of wounds is as much an act of nature as the birth of a child,” he recognized the value of expectancy: “if meddlesome midwifery is bad, needless interference with wounds is equally so.” ⁵ Brown was committed to finding “the best modern method of treating wounds, without reference to theory.” ⁵ His conservative method utilized standard resections, life-saving amputations, limited antisepsis, and the promotion of natural healing, to meet the patient’s needs. The immediate aim was to stabilize the patient; the long-term aim, to conserve function and quality of life.

Saving private W.H.: 8 May 1881 to 30 June 1881

The shoulder is a complex anatomical region. Its mechanism features a ball-and-socket joint (the shaft and head of the humerus), the clavicle, the coracoid and acromial processes, the spine and blade of the scapula, and attached muscles and tendons. The impact of a modern bullet in this region was often quite damaging and, without proper care, potentially life-threatening. Brown’s argument against “expectant” surgery employed for shoulder wounds was grounded on extensive experience. Of the 77 cases of gunshot wounds he describes in his writings, 21% had involved the shoulder and upper extremities which were exposed when firing a rifle. ¹¹ Surgeons treating gunshots of this kind had to make certain that devitalized soft tissue and bone fragments were not left in the wound. Although fragments were exuded with drainage, this process could not be counted on to flush out all dead tissue. Damaged bone, if not extracted, interfered with healing and promoted both infection and chronic disability. Thus, for shoulder injuries of the extremities, Brown called for the immediate use of “the operative means,” by which “carious and [necrotic] portions of bone” would be excised. Failure to operate in this manner could result in the body enduring a “weary course” of partial healing as, “one sequestrum after another is thrown off, and nature [effects] a cure by the total destruction of all the bone in the neighbourhood.” ⁶ If the patient were to survive, the inflammatory exudations would eventually cause the injured joint to fuse together. Ironically, W. H.’s terrible state was the direct result of the knife being “cruelly withheld” (italics added). ⁶ Brown remarked, in 1883, that similarly-afflicted patients, whom he had encountered during the First Anglo-Boer War, had asked for radical amputation to relieve the effects of expectant mismanagement. ⁶

Brown’s conservative plan saved the life of Pvt. W. H. In the July 1883 edition of The EMJ, he describes how this soldier, while storming the hillside of Laing’s Nek, had been struck in the left shoulder. In Figure 2, the artist, Sidney Edward Paget (1860–1908), gives us some sense of the action on that day, as elements of the 58th Regiment charged uphill against the Boer position. The bullet struck the hospitalized soldier at the highest point of the left shoulder–that is, at the base of the neck, where the clavicle and the sternum articulate. Moving on a straight, downward trajectory, it smashed the shoulder blade and the left humerus, and then it exited through the armpit.

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Figure 2.

British 58th Regiment, with their Colours, storming the hillside at the Battle of Laing’s Nek on 28th January 1881 in the First Boer War: picture by S. Paget.

The soldier was wounded on 28 January 1881. Brown recounts that he had seen him in hospital, for the first time, on 8 May, 101 days after the event. ⁷ It was obvious to Brown that, upon admission, W.H. would have benefited from conservative surgery: “In my experience I have never seen a case of gunshot injury of the upper extremity in which ‘conservative surgery’ … could not have been done early in the history of the case, and so saved the limb.” ⁴ Because the Pvt. had received little more than expectant treatment, by 8 May, he was in poor condition: his left arm was useless; the wound and chest wall were infected; and he was placed in isolation. Reduced to “nothing but bone and integument,” he was unable to use both arms (the right had an unrelated injury) and was in excruciating pain. Nevertheless, Brown was not dismayed: “No less hopeful a case could possibly have been met with for operative treatment, which, of course, was urgently called for. On the 8th May I determined to give him the chance, and he was placed under chloroform.” ⁷

Brown cared for W. H. from 8 May to 30 June 1881. ⁷ He had no way of knowing, during the preliminary examination, the extent of the injury or of the infection. To determine whether reconstructive surgery was possible, Brown incised the arm from the entry point, tracing the course of the bullet in order to explore the joint. He found the head of the humerus devoid of cartilage, and the glenoid cup (the socket into which the head fit) fractured and separated from the body of the scapula. With the ball-and-socket anatomy of the shoulder irreparably damaged, Brown realized that saving Pvt. W.H. depended on amputation of the left arm, excision of the glenoid cup, and removal of all bony debris. “Operative” surgery was indicated unequivocally.

The operation was completed on 8 May, and, by 15 May, all seemed well. ⁷ The draining wound gradually healed. Pvt. W.H. was able to sit up in bed, for the first time in four months. Twelve days after the operation (on 20 May), the sutures and ligatures were removed; and, by 26 May, the thoracic-wall abscesses were gone. Brown was delighted to report how, “in a most marvellous manner,” W. H. had gained strength and weight. Moreover, his excruciating pain was gone when dressings were changed, and he could feed himself with his impaired right arm.

The insidious effects of “expectant” medicine, however, were unmistakably evident, on 29 May, when Brown noticed inflammation at the bottom of the stump. ⁷ In the 1883 recollection of the event, he alludes to Sir Thomas Longmore’s observation that, “with regard to the shoulder and elbow joints[,] ‘expectant surgery’ is more fatal, and the results less satisfactory, than after resection’.” ⁶ The residual infection Brown had discovered had to be cleared away immediately. Thus, on 1 June, he began by exploring the deeper recesses of the wound while the patient was chloroformed; on 2 June, he found extensive bone infection; and, on 3 June, he excised the inflamed acromion and coracoid processes, and about half of the clavicle, which had been soft and “destitute of periosteum,” the membranous connective tissue required for bone regrowth. After the dead bone was removed, Brown re-inserted drainage tubes.

For two weeks, the discharge continued, and the patient steadily improved. ⁷ The drainage tubes were finally removed on 27 June. On 30 June, Brown incisively recorded: “Wound healing well; sutures removed”; and, on that day, Pvt. W.H. was out walking and eating voraciously (Figure 3). In March 1882, eight months after recovery, Brown and W.H. met again in England. Once emaciated and near death, Pvt. W.H., now “a very powerful, muscular man,” greeted Dr Brown.

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Figure 3.

Case of Private W. H., of the 58th Regiment, wounded very severely at Laing's Nek. Amputation at the shoulder, and removal of half the clavicle and major portion of the scapula. Recovery. Credit: Dugald Blair Brown. Surgical Experiences in the Zulu and Transvaal Wars, 1879 and 1881. Edinburgh: Oliver and Boyd, 1883. Plate II. 2.

Apparently, those originally entrusted with the Pvt.’s care had applied the “expectant” method to a wound requiring more aggressive intervention. Had they debrided dead tissue, drained the wound properly, and employed antiseptic, the patient likely would not have lost his arm and shoulder.

Brown left Natal on the S. S. Dublin Castle, arriving in England on 13 January 1882. ⁴⁵ Although the First Anglo-Boer War had ended on 23 March 1881, he would be consulted, in June 1882, about an AMD matter involving questionable care provided in the South African base hospital at Newcastle.^4,46 This facility had been under duress during a typhoid outbreak. Florence Nightingale (1820–1910) and her nursing staff at Newcastle responded to the unsanitary conditions by gathering evidence for an enquiry. ⁴⁶ One knowledgeable expert, whom she had been advised to approach, was Dr Brown. In London, Nightingale and Brown would meet on two occasions to deliberate over the matter confidentially, in order to confirm the extent of the “ill treatment.”

Surgical experiences; Burma and India: 1882–1896

Brown’s 1883 book, Surgical Experiences in the Zulu and Transvaal Wars, 1879 and 1881, a compilation of EMJ papers published from March to October of that year, was well received.^4–11 Brown would subsequently rise in rank and reputation as both a physician and military officer, while continuing to learn from his esteemed colleagues. On 24 December 1883, for example, while in London he observed Lister’s masterful operation on a patient suffering from empyema of the lungs. ⁴⁷ I. Burney Yeo (1835–1914), of King’s College Hospital, had consulted Lister over a refractory pneumonia case. Lister agreed to perform the operation. With Brown as an admiring spectator, Yeo stated that, “The result [was] one of the most striking triumphs of antiseptic surgery” that he had ever witnessed.^5,8,9,47

In 1884, Brown resided in Bombay, but the details of his medical activities in India are not well documented.^12,13 Unpublished manuscripts related to this period of his career, however, are archived at the National Library of Scotland. ⁴⁸ It is certain that, by 30 March 1884, Brown held the rank of Surgeon-Major. ⁴⁹ In this period, he would also publish three substantive papers: one on thoracic surgery (1884) and two on venereal disease related to military life (1888).^12–14 In 1885–1886, he was in charge of the General Hospital for European Troops during the Burmese Expedition, under the command of H. N. D. Prendergast (1834–1913).^1,2,50 For his Burmese service as hospital administrator and surgeon, he received the Medal with Clasp.^1,2

After his service in Burma, Brown was transferred to the Piershill Barracks in Scotland. ⁵¹ On 30 March 1892, he was promoted to the rank of Surgeon-Lieutenant Colonel.^52–54 Having returned to India at the summit of his career and in continued service, Brown was thrown from his horse while riding from the Section Hospital, at Meean Meer, Punjab. Tragically, he suffered a fractured skull, died on 27 January 1896, and was interred at the Royal Artillery Cemetery.^1,2,15

Dugald Blair Brown’s contribution to military medicine was his conservative method of surgery, a system which developed over the course of his career, as he consulted with senior practitioners, observed their work, and experienced warfare in the hospitals and in the field. His method informs 77 case studies and related commentaries. Brown criticized those who misapplied the “expectant” method to serious gun-shot wounds of the extremities, when “operative” surgery was indicated. He was equally disparaging of “operative” surgeons who, while following standard guidelines, tended to amputate limbs perfunctorily, without assessing the possibility of limb salvage. In contrast, Brown’s balanced plan progressed directly from diagnosis to an individualized treatment plan, aimed at recovery and improved quality of life. He recognized that, in the case of gun-shot wounds, immediate resection logically preceded expectant care, the latter being more appropriately utilized during recovery.