Extreme Medicine by M.D. Kevin Fong

explorers of the heroic age.
    Physicians saw the heart as largely inviolate, a sacred and complex whole that must remain intact and unaltered, an organ with which surgeons could and should not interfere. This dogma was as old as Aristotle’s teachings and remained unchallenged until the very end of the nineteenth century. Medical textbooks warned against tampering with the heart. In his 1896 text,
Surgery of the Chest,
esteemed surgeon Stephen Paget made his position clear: “Surgery of the heart,” he famously declared, “has probably reached the limits set by Nature to all surgery: no new method, and no new discovery, can overcome the natural difficulties that attend a wound of the heart.”
    Overcoming the received wisdom of the past, making that leap of surgical faith, was a feat that required the terrible but unique catalyst of war.
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    I T IS WINTER 1917. Somewhere on the Western Front, a British infantryman is marching forward across the frozen earth of no-man’s-land. There is a blizzard in the air and a biting wind sweeping across the battlefield. His clothes are no match for this weather, but the crack of gunfire presents a more immediate threat. From the German trenches, there is the sound of chattering machine guns; the firing positions are perhaps five hundred yards away. At that range, in this visibility, there is a faint hope that their hail can be avoided.
    The German machine-gun crews fire hundreds of rounds a minute, pausing only to clear stoppages, improve accuracy, and prevent their weapons from overheating. Each bullet can travel half a mile in under a second. They spin around their long axes in flight, held stable by the same law of physics that keeps a child’s spinning top upright, making the machine gun accurate over large distances. It is the velocity of the round and the kinetic energy carried with it that makes the bullet so lethal.
    The soldier advances, a rifle in his right hand. His left is raised in front of his face to shield his eyes from the heavy drifts of snow. Through that blizzard, a spinning machine-gun round finds him.
    The bullet travels through his left arm, just above his elbow, slowed by muscle and flesh. It continues, exiting the arm, piercing first his tunic pocket and then its contents—a notebook and a bundle of letters—before encountering the wall of his chest and finally the substance of his heart.
    At the time of World War I, gunshot wounds to the heart were almost invariably fatal, and cardiac surgery was still looked upon dimly. Back in 1883, Christian Albert Theodor Billroth, one of the founding fathers of abdominal surgery, had these words for would-be pioneers: “A surgeon who tries to suture a heart wound deserves to lose the esteem of his colleagues.”
    Views such as these continued to hold sway well into the Great War. In 1916, Major George Grey Turner, a doctor in the service of the British Royal Army Medical Corps, addressed an audience of surgeons bound for military duty. Although he had plenty of advice on other topics, he had little to say on injuries to the chest. “These,” Grey Turner told his audience, “are commonly thought to be beyond the scope of surgery, and to merit very little attention. . . .”
    Yet the following year, in 1917, Grey Turner received a casualty recently returned from the Western Front, eighteen days after he had been injured by a machine-gun bullet—our infantryman with the bullet holes in his arm and his correspondence.
    The soldier was in surprisingly good health and was indeed embarrassed to have been forced to arrive at the hospital on a stretcher. Grey Turner examined him and found evidence of a bullet’s entry at the front of his chest but, ominously, no exit wound.
    At the time of World War I, medical X-rays were a novel invention, but their value in locating bullets and shrapnel was rapidly recognized, and they were quickly adopted by military