While gunshot fractures during the U.S. Civil War (1861-1865) did not always result in amputation, soft-tissue damage—even without a fracture—sometimes did, according Dr. Samuel Gross (1805-1884), professor of surgery at Jefferson Medical College [3].
Severe soft-tissue injuries were common; soldiers sustained some 58,000 such wounds to the lower extremities [5]. Although surgeons initially did not consider these wounds as serious as gunshot fractures, tetanus, gangrene, septicemia, erysipelas, and/or hemorrhage, soon proved them wrong. Hundreds of amputations resulted [5]. And since surgeons generally saw amputations as a last resort, contrary to Gross’s advice, more than half of the patients who underwent lower-extremity amputation subsequently died [1, 4].
Physicians often applied carbolic acid to dressings as a means of arresting putrefaction inside the wound. The post-war acceptance of the germ theory caused Civil War surgeon William Keen (1837-1932) later to realize that these complications had been infections caused by microorganisms.
Half a century later, then-Major (Maj.) Keen found himself called to serve in another war. The introduction of the machine gun and high-explosive artillery in World War 1 (WWI; 1914-1918) forced soldiers to burrow into trenches dug into farm soil that had been fertilized with manure, and wounds sustained there consistently were contaminated by that soil. As the United States prepared to enter the war, the National Research Council requested a report by Maj. Keen on the best practices used by allied surgeons to treat such injuries.
He recommended the use of the Carrel-Dakin method (Fig. 1).
Fig. 1.
Wax moulage illustrating shell fragment wound of the lower limb treated with the Carrel-Dakin technique. The model was made by Frank Wallis of the Army Medical Museum in 1918. [M-550.10744] (Disclosure: This image has been cropped to emphasize the subject.) (National Museum of Health and Medicine photo by Matthew Breitbart).
Developed by French surgeon Alexis Carrel (1873-1944), this approach consisted of removing debris from the wound and debriding the necrotic tissue. The surgeons would then irrigate the wound with Dakin’s solution, developed by English chemist Henry Dakin (1880-1952). The diluted sodium hypochlorite solution chemically sterilizes the wound and acted as a solvent against remaining necrotic tissue and pus [2]. Unlike iodine or carbolic acid, Dakin’s solution does not damage healthy tissue. Under the Carrel-Dakin method, closure would only occur only after the bacterial count of the wound showed that it was sterile [4].
The Carrel-Dakin technique was a major breakthrough for fighting infection. During the Battle of Champagne in 1915, 80% of the wounded were infected with gas gangrene bacteria. A year later, when surgeons applied the Carrel-Dakin technique during the Battle of the Somme, that number was 20% [4].
Despite deadlier weapons, as well as more severe and contaminated wounds, an injured soldier was less likely to undergo a limb amputation during WWI than during the U.S. Civil War. Only 35% of soldiers who sustained a femur fracture in WWI underwent amputation, compared with 56% of similarly injured combatants during the U.S. Civil War [1, 4, 6]. A large part of this success can be credited to the Carrel-Dakin technique.
In his 1918 book, Treatment of War Wounds [4], Maj. Keen noted that although surgeons had previously known how to prevent infection, the Carrel-Dakin technique gave surgeons the chance to conquer it.
“For nearly half a century we surgeons have been fighting firmly entrenched infection, but always in vain. It required the stern stimulus of war to enable us to win the victory,” Maj. Keen concluded.
Footnotes
A note from the Editor-in-Chief: We are pleased to present the next installment of ArtiFacts. In each column, the Collections Manager of the Historical Collections Division of the National Museum of Health and Medicine (NMHM) will present a photograph of a visually or historically interesting artifact from the museum’s collection and provide the story behind the picture. The NMHM, whose collection was recognized as a National Historic Landmark, was originally developed from the Army Medical Museum established during the Civil War to collect “specimens of morbid anatomy together with projectiles and foreign bodies removed.” Its mission today is “to preserve and explore the impact of military medicine.”
The author certifies that neither he nor any members of his immediate family have any commercial associations (such as consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article.
All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.
The opinions expressed are those of the writers, and do not reflect the opinion or policy of CORR® or The Association of Bone and Joint Surgeons®.
The opinions or assertions herein are those of the author and do not represent the views of the Department of the Army, Navy, or Air Force or of the Department of Defense.
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