World War I (1914-18; WWI), aka the “Great War,” brought unimaginable destruction to the world. Whether it was economic resources, manpower, or aid, the sun never set on those affected by the war. Although the mass fighting officially started with Austria-Hungary declaring war on Serbia in July 1914, a decision that would pit countries against one another for the next four years, the turmoil had been building for decades. The impact of the war and the immediate years following the cease-fire would give rise to future global conflicts. To this day, the effects of WWI can still be felt nearly 100 years after the official cessation of the war in 1918 — Armistice Day.
Following the American Civil War (1861-65), healthcare advancements were steadily improving. With the establishment of Bellevue Hospital’s Training School for Nurses in New York City in 1873, the building blocks of standardized nursing practices and regulations began.1 In 1901, the Army Medical Department established the United States Army Nurse Corps following the efforts of Anita Newcomb McGee, MD (1864-1940), and other advocates, which gave women an honest introduction into the military.2 Near this time, German physician Dr. Robert Heinrich Hermann Koch (1843-1910) won a Nobel Prize (1905) for his experiments on bacteria as a cause of disease.3 The Civil War also gave rise to surgical programs, a specialty that had not been formalized before the war,4 in the U.S. The culmination of these three factors amounted into what would become one of the most notable medical advancements to emerge from the Great War that’s still in use today: the Carrel-Dakin Method.5-7
The recipient of the 1912 Nobel Prize in Physiology/Medicine, Alexis Carrel, MD (1873-1944), served as a Major in the French Army Medical Corps during WWI. Carrel had already become known for his innovative thinking, which includes publishing his work on the end-to-end anastomosis of blood vessels in 1902, demonstrating how to use cold storage for preserving blood vessels before transplantation in 1910, and devising methods for transplanting whole organs in 1908, whereby he would go on to build a machine that could supply a sterile respiratory system to organs removed from the body with Charles Lindbergh (1902-74) in 1935.5 Carrel also held honorary doctorates from numerous institutions all over the world, and he worked with the French Ministry of Health at the start of World War II.6
Meanwhile, Henry Drysdale Dakin (1880-1952), a British-born chemist who conducted research in New York, studied the relationship between hydrogen peroxide and amino acids among other physiologically organic compounds.7 During his research, Dakin would observe the production of acetone in the oxidative degradation of leucine, which attributed to β-oxidation of fatty acids and to the theoretical interpretation of the results Georg Franz Knoop (1875-1946) reported a few years prior.7 This work profoundly influenced biochemical theory, and Dakin would continue his research into WWI, when he joined Carrel in a study of antiseptic treatments on wounds at a French military hospital.
Hygiene was hardly the first thought on a man’s mind during WWI, but tending to the wounded was at the forefront. It’s no secret that gunshot wounds were “dirty from the get-go,”4 but WWI brought new wartime developments that were not used during the Civil War: trenches and gases.
Medical professionals knew wounds needed to be cleaned, bandaged, and well cared for (not to mention instilling a “little faith in God”8), but optimal hygiene was impossible during trench warfare.9 All it took was a small cut on the foot and a muddy sock to cause an infected wound, and that small cut would have the potential to lead to more serious infections such as gangrene. The use of gases and trenches in warfare resulted in a severely unhygienic environment for wounded soldiers. Imagine a gun sitting in the trench, caked in mud, being packed by a soldier’s bloody, dirtied hands as he loaded his rifle with bullets that sat next to any number of substances now known as “chemical warfare.” This soldier then aims his weapon, fires, and strikes another human with a bullet that penetrates the skin. The injured soldier now potentially carries the blood of another man internally, along with the mud of the enemy’s trenches and the gases of the chemical warfare the bullet once sat next to. In war, time is a precious commodity, so surgeons only thought to repair the wound of that injured soldier4 — the surgeon didn’t take any possible infections into account.
Lesley Smith, a member of what was known as the Voluntary Aid Detachment, a unit that provided field nursing services, mainly in hospitals, said: “Day after day we cut down stinking bandages and exposed wounds that destroyed the whole original plan of the body. One man had both buttocks blown off, one arm had been amputated at the elbow, and he had a host of smaller wounds from flying metal. Another lay propped on sphagnum moss to absorb the discharge from two large holes in each thigh.”10 This picture that Smith paints could be that of the previously mentioned example. In other words, this was typical during the Great War and, presumably, all those that came before it. Without enough time, amputations were a common surgical outcome for an injured limb that was too far gone. Amputations were more or less pioneered by Ambroise Paré (1510-90) because of the use of guns and gunpowder,11 but the ability to salvage a limb would not be seriously undertaken until Carrel and Dakin during WWI.12
Although amputating limbs proved to be partially effective in combatting sepsis, patients were still dying from shock or suffering permanent disability.8 The surgeons at the time needed a germicide in order to prevent the need for limb amputation, which is where Carrel and Dakin excelled.
By way of the Carrel-Dakin Method, the pair developed Dakin’s solution (ie, Dakin’s fluid or Carrel–Dakin fluid), a wound care treatment that focused on treating sepsis by using an antiseptic solution instilled by the means of small, rubber tubes closed at the end and perforated with 6-8 holes at half-inch intervals.13,14 With the help of a nurse, the solution would be spread over the wound and kept in place by laying a solution-soaked sterilized gauze over top. More dressings were then layered on top of the solution-soaked bandage. For the first three days, the inner dressing was changed, and then every two days after that.13 All instruments and tools used were sterilized and utilized under the authority of a surgeon. As reports of the method increased and became more well known, bacterial infections decreased to a manageable level, so much so that wounded soldiers did not develop necrosis.8,13 In fact, the aftermath of using the Carrel-Dakin Method allowed surgeons to close the wound once the bacterial field was clear — an ability medical professionals during the war did not think possible.13
Dakin is credited with creating the eponymous solution used in this method. The solution is comprised of an antiseptic based on sodium hypochlorite, and Carrel is responsible for developing an intermittent irrigation system for the methodology of application (Figure).8,14 This treatment was used in one hospital in France, the other in Belgium. The French hospital did not have the expected success Carrel and Dakin had hoped for, but the Ambulance of the Ocean in Belgium, one of the most modern hospitals at that time, saw the results they had sought.14
The surgeon at Ocean, Dr. Antoine Depage (1862-1925), instituted this treatment method because he believed in the importance of antiseptic standards through the training of his nurses. The combination of working with sterile instruments and using the Carrel-Dakin Method to treat war wounds made Depage’s hospital the best military hospital in WWI.14 Even a nurse working at Ocean comments on the transformative effects of the treatment: “The initially widespread cases of gas gangrene are seemingly becoming more rare since we’ve been applying the method developed by Carrel, this little man who, like [mathematician Jules Henri] Poincaré, has intelligence flowing from every pore.”14,15
The Carrel-Dakin Method was greatly needed during the time of its development. Once its success and specific supplies were noted, Johnson & Johnson mass produced the necessary supplies for the sterilization of the treatment.16 Although there are no hard numbers to support the notion that the Carrel-Dakin Method saved countless limbs, the continued use of a solution with the name “Dakin’s Solution” is still in use today. By all accounts, that’s should be quite telling of the success rate.
Jaclyn Gaydos is managing editor of WOUNDS.
1. Bradley-Sanders C. Bellevue School of Nursing. Lillian & Clarence de la Chapelle Medical Archives. Accessed online: https://archives.med.nyu.edu/collections/bellevue-school-nursing
2. Army Nurse Corps History. U.S. Army Medical Department: Office of Medical History. Accessed online: http://history.amedd.army.mil/ANCWebsite/anchome.html
3. History of Bacteria Discovery. History of Science. Accessed online: http://historyofsciences.blogspot.com/2011/10/history-of-bacteria-discovery.html
4. Gaydos J. Oral Interview. Robert Slawson, MD. Frederick, MD: National Library of Civil War Medicine. 13 Aug 2016.
5 Awards & Honors: Alexis Carrel. The Rockefeller University. Accessed online: www.rockefeller.edu/about/awards/nobel/acarrel#sidebar
6. Alexis Carrel-Biographical. Nobel Prize.org. Nobel Media AB 2014. Accessed online: https://www.nobelprize.org/nobel_prizes/medicine/laureates/1912/carrel-bio.html
7. Clarke HT. Henry Drysdale Dakin 1880-1952. J Biol Chem. 1952;198:491-94.
8. Simkin J. Amputations in First World War. Spartacus Educational. 1997. Accessed online: http://spartacus-educational.com/FWWamputations.htm
9. Clements IP. How Amputation Works: History of Surgical Amputation. Health. 2008. Accessed online http://health.howstuffworks.com/medicine/modern-treatments/amputation2.htm
10. Norton KM. A brief history of prosthetics. Amputee Coalition. 2007;17(7):11-13. Accessed online: http://www.amputee-coalition.org/resources/a-brief-history-of-prosthetics
11. Editors of Encyclopaedia Britannica. Trench warfare. Encyclopaedia Britannica. Accessed online: www.britannica.com/topic/trench-warfare
12. Moore GA. The Carrel-Dakin Method of treating septic wounds; its application to civil surgery. Boston Med Surg J. 1918;178:109-16.
13. Carrel-Dakin treatment of wounds. Brit Med J. 1917;2(2966):597-9.
14. Pirard M. The Carrel-Dakin method. rtbf.be.com Accessed online: www.rtbf.be/ww1/topics/detail_the-carrel-dakin-method?id=8356084
15. de Launoy J. Infirmières de guerre en service commandé front de 14 à 18. Reliure inconnue. Paris, France: Desclee Brouwer Publishing: 1937.
16. Margaret. Making the Revolutionary New Carrel-Dakin Wound Treatment Available to Save Soldiers’ Lives During World War I. Kilmer House. Accessed online: www.kilmerhouse.com/2013/11/making-the-revolutionary-new-carrel-dakin-wound-treatment-available-to-save-soldiers-lives-during-world-war-i