Reprinted from the Archives of Surgery
February 1961, Vol. 82, pp. 175-190

Copyright 1961, by American Medical Association

The All-Soviet
Surgical Congress

of 1960

In Moscow, May 23d to 28th, was held
the 27th All-Soviet Congress of Surgery.
This most important surgical congress in
the Soviet Union is held at indefinite in-
tervals of from 114 to 4 years, the last one
having been held in December, 1958. To
it come 1,500 Russian surgeons from all of
the 15 republics of the Soviet Union and,
indeed, it is deemed a privilege to attend.
The representatives are selected by local
institutes or societies as delegates to the
meeting and when they return home they
give reports of the papers given and the con-
clusions drawn. I was told that if the meet-
ing were thrown open to all members of the
medical profession, there would be over
50,000 doctors demanding admittance. There

Submitted for publication Aug. 8, 1960.

This trip was made possible partly by travel
support from the American Heart Association and
partly through the hospitality of the Minister of
Health of the U.S.S.R.

Details of the program and the management of
the Congress will be found in the article by Dr.
Waltman Walters in this issue of ARCHIVES OF
SURGERY.

HENRY SWAN, M.D.
DENVER

TTT UTE

  

clearly is not an auditorium capable of seat-
ing a medical meeting of such proportions.

A special committee of the Minister of
Health organized and managed the meeting
and a definite effort was made to give it an
international flavor. Representatives of 20
countries outside of the Soviet Union were
present by invitation of the Minister of
Health. India, Red China, most of the coun-
tries of continental Europe, the United
States, and Canada were represented. From
Canada came Dr. Wilfred Bigelow of
Toronto to speak on aortic grafts, and from
the United States came Dr. Michael De
Bakey to speak on arterial occlusive dis-
ease, Dr. Ralph Deterling to speak on the
characteristics of synthetic arterial grafts,
Dr. Waltman Walters to speak on surgery
for peptic ulcer, and I to speak on the use
use of hypothermia and extracorporeal per-
fusion for arterial surgery. I might add that
at the time they were given all of the these
papers received an enthusiastic response
from the large audience.

21/175
The auditorium, called the “Hall of
Columns,” was particularly colorful as at one
time it was said to be the tallest and largest
building in Moscow—three stories high! It
was built before the turn of the century as a
place for the gala social events of Czarist
Russia. The inside is primarily a large
baliroom witn tiered balconies on three sides
of the room. The white enamel finish of the
tall colonades and the beautiful cut-glass
chandeliers gave an aura of elegance to the
proceedings. One could faintly hear in the
background the strains of the Viennese waltz
and the swishing of the silken gowns! For
this occasion, however, the ballroom floor
was filled with red plush seats and a large
podium for the presidium.

To receive an invitation from the Min-
ister of Health of the Soviet Union is an
exciting affair. I was called late in March
on the telephone by Mr. Vladimir Ivanov *
of the Russian Embassy in Washington who
informed me that he had information that
a group of surgeons in Moscow would
like to invite me to attend a surgical congress
about the middle of May and he was calling
to find out whether, if I were invited, I
would accept. Since the dates given con-
flicted with two obligations which I had
previously made, I requested a day to see
if I could clear my schedule. Fortunately,
this was possible, and I replied to Mr.
Ivanov that I would be happy to accept such
an invitation if it were tendered. By the
15th of April, I was beginning to wonder
if the surgeons of Moscow had, indeed,
changed their minds concerning inviting
me. Apparently, the Soviet Union “loses
face” if an invitation is declined. But the
following day there arrived an official letter
in Russian which, upon translation, proved
to be a genuine invitation from the Minister
of Health to be the guest of the Russian

* Throughout this article will appear many Rus-
sian names which I have only heard, and have
never seen in print. I am sure there must be
some grievous mistakes in spelling. I can only
hope that my Soviet friends will understand and
pardon my ignorance of their important language,
“and accept my apologies for such unintentional
~-€rrors.

22/176

ARCHIVES OF SURGERY

government at the Surgical Congress, which,
however, proved to be slated for the 23d
to the 28th, instead of the third week, as
previously stated. Fortunately, it was again
possible to clear this portion of my schedule
in order to attend, and since I proposed to
describe research, a large portion of which
had been done under an American Heart
Association Grant, the Research Committee
graciously permitted the use of additional
travel funds from that grant. Thus, the
21st of May found me leaving Brussels en
route to Moscow. Perhaps excerpts from
my journal might be of some interest at
this point.

DATE: May 21, 1960

PLACE: Brussels, Belgium

At the airport, I joined, by arrangement, Dr.
Wilfred Bigelow of Toronto, Dr. René Fontaine,
of Strasbourg, and Mr. Adler, Economic Legis-
lative Advisor to the White House en route to
Moscow. We boarded the Tu-104 A, a twin-jet
of Aeroflot holding about 70 passengers. The in-
side arrangements are not unlike an old-fashioned
Pullman with brass fixtures. We are sitting at the
front of the Tourist Class at a table with a lamp.
Very comfortable adjustable chairs with more leg
room than in U.S. airplanes. The two stewardesses
take the coats and hang them. There appear also
to be two stewards. The First Class compartment
is forward, separated from us by a smoking-room
kitchenette. The route is over Amsterdam, Copen-
hagen, Riga, and Leningrad, nonstop to Moscow.
(Why does Aeroflot seem to avoid flying over any
part of Germany?)

There are two large toilet-dressingrooms at the
rear of the plane, where the noise is greatest. Soap
is provided, but a single towel does for all, as at
the old pump outside the kitchen door. Only cold
water comes from the tap. Lunch of rye bread,
caviar, beefsteak, and tea was served just after
we flew over Copenhagen.

We landed in Moscow at 18:25. The braking
action in the TU-104A is very powerful, but there
are no reverse jets used. A large reception com-
mittee was on hand to greet us. Boris A. Petrov,
Professor in the Sklifosovskiy Institute; Boris
Ossipov, Professor in the Institute of Postgraduate
Training; P. A. Kuprianov, a two-star General
from Leningrad who is Chairman of the Congress;
and with him Dmitri Venediktov, whom we first
met in Mexico City and again in Munich and who
now works officially for the Ministry of Health;
Drs. Rosanov and Manevitch, Assistants to Ossi-
pov; two woman doctors, Natailla Martinova,
surgeon of Leningrad who speaks fluent French,

Vol. 82, Feb., 1961
ALL-SOVIET SURGICAL CONGRESS

and Isbella Dubinskya, a pediatrician; and finally,
but by no means least, our official guide, Victor
Krilov, who is Petrovsky’s assistant and who is in
charge of the translation side of the conference.
Victor is married and the father of three girls,
aged 12, 9, and 5. We were whisked through
customs and immigration with extraordinary speed
and I was soon in Petrov’s Volga, a 4-cylinder,
middle-priced car costing about $10,000 (at the
regular exchange of four rubles to one dollar).

Dinner was large and long. Fontaine, Krilov,
Dubinskya, Bigelow, and I were joined by Prof.
Milinoj Kostic, of Beograd, with his attractive
young wife, Antonija. She speaks fluent English.
French, however, is the auxiliary language of
choice in many groups, as it was in this one.

My room is about 12X12, with a bath and tiny
closet, a single bed, and a desk and table. A very
small piece of soap was provided, and towels, but
for toilet paper, a piece of today’s Pravda.

The Moscow Hotel is large and very central,
next to Red Square, the Kremlin, etc. Last night
being Saturday, in the dining room was a band
with a girl singer, playing mostly American and
Latin-American jazz. About twenty young couples
were dancing in a style not unlike one would see
in the “Starlite Room” of any American hotel.
No alcoholic beverages of any kind were in evi-
dence—a very sober Saturday night at the Moscow
Hotel.

DATE: Sunday, May 22, 1960
PLACE: Moscow, U.S.S.R.

As I write this at 1:30 am. Monday, Sunday
seems to have been a long, although very pleasant,
day. After leisurely breakfast, I cabled home re-
garding my address, exchanged some money (10
rubles to the buck, as advertised). A short snooze,
and then to lunch, where I had two hours with
Dmitri Venediktov regarding Soviet medical edu-
cation. D. V. may soon be one of the Soviets’ most
influential doctors, I suspect. He is now half-time
in the Ministry of Health and also works in
Petrovsky’s Clinic at the First Medical Institute.
He is already the number two man in the Bureau
of Foreign Relations of the Ministry of Health.

Then with Victor to discuss slides and _ talks,
etc., followed by a tour of the city during which
I was carefully shown (a) the outside of the
Kremlin, (b) the University and its view of the
city, (c) the Hotel Ukraine, and (d) the South-
west residential district of which Krushchev is so
proud, but which consists exclusively of apartment
after apartment after apartment, all prefabricated
and going up by the numbers. No _ individual
houses are being built here. Shops and_ schools
are allotted carefully, population-wise. A family
of six would get “not less than 55 square meters”
and would “have a whole apartment to them-
selves”! This is new policy, as in many of the

Swan

older apartments rooming facilities are shared by
groups larger than a family unit. Victor was
careful, propaganda-wise, and assured me that “in
Russia we prefer social living to individual homes
like in the United States.” But I kept thinking
of those many attractive homes with a car and
a motorboat in the driveway back in Denver and
had my own personal thoughts on the subject.

Then to the hotel to clean up and get ready
for the opening banquet of the Congress. The meal
is always the same—caviar, chicken, and potato
salad, cold meat and fish, meat and potatoes, ice
cream (raspberry and vanilla), and tea or coffee.
Vodka and Georgian wines, white and red, were
available for the following toasts, all of which
required two-stage interpretation:

1. Greetings from the Chairman of the Congress
(Kuprianov) : “Welcome to Russia!”

2. Red China: “We are here.”

3. U.S.A.: (Walters)—“Surgery and knowl-
edge are international.”

4. Belgium (Lorthoior): ‘“Peace.”

5. Czechoslovakia: “We like Russia.”

6. India (Baliga): “Science exchange is good
at a meeting like this, but more important is
personal understanding and good will. Coexistence
and World Peace.”

7. France (Rene Fontaine): Ten minutes.

8. East Germany: “We like Russia.”

9. Scotland (Mackey): “Studied Pavlov, and
glad to be here.”

10. Yugoslavia (Strojanov): “Peace and hu-
manity. Scientific workers must be in the front
line fighting for peace.”

11. Bulgaria: “We are the pupils of the great
Russian Surgery and the Great Russian Science.”

12. Poland: “We are here.”

13. Rumania: “Glad to be here.”

14. Denmark (Husfeldt): “Nothing is won by
war. All effort should be to help mankind here
and now.”

15. Sweden: Tried a few words in Russian, and
achieved good will.

Much talk with Petrovsky regarding medical
education (via Victor, our interpreter). Then to
my room with Bigelow and Husfeldt, where we
heard the extraordinary story of Husfeldt’s am-
bulance mission to Budapest achieved almost
single-handed. The International Red Cross was
totally lacking in ability to help under such circum-
stances.

Bigelow is working on the idea that the Iron
Curtain is not a cover for nefarious deeds, or a
device to prevent fraternization or to withhold
from the people all outside information, but,
rather, a method to keep the guests out on the
porch until Mom can get the livingroom cleaned
up. This concept is largely ignored by our press.
But, also, a holder of this theory closes his eyes
to the complete wall against incoming news and

23/177
outside opinion. For example, on my portable
radio, both the long- and short-wave bands are
useless here—every frequency, except the two
Russian stations, is jammed with a constant harsh
whine. The Voice of America, in addition, has a
penetrating code signal which makes safe eaves-
dropping on this frequency almost impossible!
Apparently it is not yet considered safe to allow
Ivan to even hear what others think. This is
thought control, more than merely keeping prying
eyes out of the back yard. In Moscow, one cannot
hear the Voice of America, or of France, or of
Italy, but only the voice of Moscow.

DATE: Monday, May 23, 1960
PLACE: Moscow, Russia

It is raining and cloudy. It is hard to get used
to the sun’s rising at 4:00 a.m. and setting at
10:30 p.m., but Moscow is very far north.

Kochergin opened the Congress with a semi-
propaganda talk about how great is Russian
surgery. Then “election” of the committees took
place in a manner much as in our societies;
namely, the Chairman of the Nominating Com-
mittee read his report and moved the slate be
elected, then everyone applauded. Very comfortable
way to keep the right people in power!

The talks are translated from Russian into
English via portable transistor radio which has
earphones. However, they will not translate our
talks from English to Russian on these instru-
ments. Therefore, it is proposed that we write
our talks, have them translated, and then some
Soviet Professor will “read” them in Russian.
It will be fun to listen to our own talks, retrans-
lated into English, on the little radio.

After 2:00, lunch of borsht and fish, then to

the room to revise my paper in terms of the new .

rules. It must be cut in half to meet the time
limitations.

Invited by Fedor Uglov to dinner at the Na-
tional Hotel. His room is a suite on the second
floor and displays an extremely elaborate heritage
of Czarist days. Rich rugs and tapestries, hand-
carved furniture, ceiling paintings, etc., allowed
one to dream of days when elegance was ac-
ceptable.

Deterling, Bigelow, Rob, Venedictov, and I
shared Uglov’s charm and great hospitality. Small,
wiry, smiling, and with a great humanity and
charm, he is one of the Soviet’s real ambassadors
of good will. He told several humorous stories
with eclat, and then told of the starvation and
terror of the 900-day siege of Leningrad. He
estimated that 1,000,000 died of starvation, and
no house or building, not one, in all Leningrad,
escaped some form of injury from the incessant
Nazi bombardment.

24/178

ARCHIVES OF SURGERY

DATE: Tuesday, May 24,

WEATHER: Rainy, cold,
thunder is very deep.

1960

and windy. The

This morning we heard Petrov report on his
1,000 esophagéal reconstructions. Without doubt,
he is one of the great esophageal surgeons of the
world. (We will be visiting the Sklifosovkiy on
Friday morning.) Then Petrovsky described his
operation for cardiospasm, and there were many
discussions of the bougie treatment of children
with lye burns with long-term results which seemed
to be extraordinarily good.

The life of Krilov’s 12-year-old daughter was
described at dinner—school at nine on the bus,
home at 2:00 with 20 minutes to eat lunch, piano
practice from 2:30 to 5:30; then 30 minutes
“free” to read the papers, take a walk, etc., dinner,
study, and then to bed. Future career: “The Con-
servatory.” A very dedicated and determined
young lady who apparently does not laugh much.

A light touch in a sea of intensity is Vladik
Tatochenko, a pediatrician. He is a fisherman and
knows the difference between the two types of
pike in the Moscow River and other important
things. It is a relief to find somebody else with
a touch of humor and humanity, so predominantly
to be seen in Uglov.

DATE: Wednesday, May 25, 1960.

This morning for breakfast at 8:30, sardines,
fish cakes, omelette, and coffee. At lunch, “blini”
(pancakes with butter, red caviar, and sour cream).

One of Moscow’s bright young surgeons, trained
by Bakulyev, but now estranged from him, is
Meshalkin. Apparently, he will go soon to Novosi-
bersk to be Director of the Institute of Experi-
mental Biology and Medicine under the new major
branch of the Academy of Science being estab-
lished there to develop Siberia’s resources. A man
can get 4 times pay for working up there for a
year or two. A married friend of Vladik’s, whose
wife was also a physician, came back after two
years with 200,000 rubles saved up. That’s enough
to buy a dacha (summer house).

After the visit to Vishnevsky in the morning,
this afternoon I spent shopping with Vladik
Tatochenko, who grows on one; he is very frank
about life in general. Gum is a big store and we
found many nice presents. Then a taxi to 5 stores,
none of which could sell us sealed or canned
caviar. No caviar to be bought in Moscow to
take home!

Then to dinner with Bigelow (vodka, fish,
tongue, Tokay, and coffee with ice cream) before
the concert which had been especially arranged
for the Congress. Many different acts, some very
good—(1), (2), and (3) I missed. (4): Igor
Besrodnyi, Russia’s “third best” violinist. (5)
Igor Ilyinski, the Charles Laughton of Moscow.
(6) Kousmin and Violet Bovt (ballerina), in the

Vol. 82, Feb., 1961
ALL-SOVIET SURGICAL CONGNI:SS

Adagio from Esmeralda, (7) Humorous mono-
logue by Mouranski from Leningrad. (8) Four
harpists. (9) A soprano. (10) Ballet Sporta
(Amour a la Grec). (11) Lenon Geochlanion: A
very outstanding baritone. (12) The Kiss of
Tschanit: a slick-chick in a sheath, and a square.
(13) Piragot and Pirouette. (14) Puppets.

One idea which Bill Bigelow and I have dis-
cussed is the hidden, highly competitive aspect of
Soviet life. Striving is serious among students
in secondary schools in order for them to be
eligible to continue on to college, and there
to strive so they may go on to graduate study for
a professional life. Then the competition for the
good appointments, etc. The system is ruthlessly
competitive and is designed to reward the in-
dustrious and intelligent. It appears to us that a
really key aspect of the system is this: rewards
in money and in “kudos” go hand-in-hand; they
are intertwined. In our country they are often
separated. A man can make money, achieve recog-
nition, or both. But in Russia, he must seek and
achieve both—or he will get neither.

Then home to write this diary.

The Institute of Surgery in the name of Vish-
nevsky:—We changed our street coats for white
coats, took our cameras into the O.R. The face
mask by American standards was very transparent,
and the regard held for asepsis throughout the
procedure was marginal. Vishnevsky operates with-
out gloves, because of an allergy, it is said. The
O.R. was large. The overhead operating light was
excellent. In the O.R. the audience comprised

20-25 foreign doctors; downstairs in the TV room
(3 screens) were 150-200 Soviet surgeons. The
color TV broadcast was of excellent quality with
running commentary in Russian and English. Elec-
tronic equipment abounded, but some was appar-
ently primarily for show.

 

Vishnevsky did two cases, with a very bountiful
lunch consisting of salad, ham and cheese, vodka,
wine, and cognac, served between the cases
Ghige 1):

Case 1—A 9-year-old girl with Tetralogy.
Could walk 50 yards before dyspnea. Well worked-
up with catheterization and angiocardiograms.
Oxygen saturations were SVC 57%, RV 67%,
BA 69%, RV pressure 103/5, Hgb. 21 grams.
Anesthesia: GOE.

The approach was through the bed of the left
5th rib. Cautery was not used. Because left sub-
clavian artery was small, a lyophilized homograft
1 cm. in diameter was placed between the left
subclavian and the pulmonary artery, end-to-side
in both cases, using the anastomosis ring of
Donetsky. A very slick job taking about 35 min-
utes. This ring, devised in this clinic by Donetsky,
is a very fine gadget,} simple to use and quick to
insert. The vessels, however, must be relatively
free of disease or degenerative changes, which, of
course, limits its clinical usefulness.

The second case was a pericardial cyst done
entirely under local, (14% procaine in limitless
amounts with 2 drops of adrenalin in 100 cc.’s).
The patient seemed quite comfortable except at
the moment the pleura was opened and the lung
collapsed.

Then much picture-taking before we left. The
organization of Vishnevsky’s Clinic is the fol-
lowing :

Director, Vishnevsky; Associates: (1) Scien-
tific, Protopopov; (2) Clinical, Rugov; (3) Ad-
ministrative, Denel.

Other surgeons I met were (1) heart surgeon
and Chief Diagnostician, Galankin; (2) sharp

+ Described and illustrated by Michael De Bakey
in his report in Bull. Am. Coll. Surgeons 44:505,
1959.

Fig. 1—The author
and Wilfred Bigelow eat
lunch between operations
with Vishnevsky and his
associate, Protopopov.

25/179
first assistant, Anna Kudariabceva; (3) bright
young vascular surgeon, Dmitri Donetsky; (4)
candidate who helped interpret for me, Valentin
Zolotazevska; (5) student of hypothermia, Tsedran
Darbinjan, and (6) another assistant surgeon,
Alexanda Haznas.

The operations were done with great skill. It
is interesting that the entire work-up of the
patient, the operation, and the postoperative care
was done by surgeons (Galankin especially). Only
one internist in the Institute—a consultant.

So now, at 1:30 am., to bed!

DATE: May 26, 1960. It is clear and warm, in
fact; hot.

This morning to meet Bakulyev at the Institute
for Thoracic Surgery. A group of 15 touring
American surgeons arrived just as we did, and
were very well received. Spent most of our morn-
ing with Burakovsky; recently with Vishnevsky,
but now at this new Institute.

Set-up: Kolesnikoy, Director. Bakulyev, Hon-
orary Founder. Chairs—(1) Burakovsky, con-
genital heart disease; (2) Kolesnikov, acquired
heart disease; (3) Garazimenka (?), lung; (4)
Bardiozov, esophagus, and (5) Gilstein, cardiology.
Schmoor is now working with Bakulyev at the
City Hospital. Demikov is now at Sklifosovskiy.
Buchtiazov is physiologist in charge of the lab-
oratory.

Projects in the laboratory include deep hypo-
thermia, pump oxygenator systems, aortic valves
(Hufnagel)—replacement of bronchus.

Two interesting postoperative patients seen: a
10-year-old boy, one day postrepair of IVSD,
doing well, and a 5-year-old girl, one week after
repair of atresia of right ventricle. Operation
was to sew superior vena cava to left pulmonary
artery via anastomosis clamp (Glenn procedure).
Patient looked well and was barely cyanotic.

The clamp was demonstrated by Muraniev, a
very dedicated young surgeon, and is, indeed, an
engineering marvel. It is said that one can
anastomose either arteries or veins and that lumen
differences of 1 to 1.5 can be made to match.
Like the old-time patent medicine, good for every-
thing, it was claimed that one could use it for
anastomosing Fallopian tube, ureter, choledochus,
or nerve. However, as noted previously, it is not
used much clinically because of the need for
fairly normal vessels with which to work.

This afternoon at the Congress, my talk was
read by Professor Ognev. I first gave a short
prologue in Russian saying “I’m honored to be
here,” and that “American surgeons are glad we
can communicate with our confreres throughout
the world, because good communications form the
path to peace.” The thought was well received,
and my effort in phonetic Russian, while I am
sure was in the crudest patois, was nontheless

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ARCHIVES OF SURGERY

clearly understood by the audience, or at least so I
was assured by my Moscow friends on the podium.

Then tonight the Bolshoi Ballet: Superb! The
lovely old theatre and the graceful rendition of
“Swan Lake,” some of which I caught in color
movies, left a deep feeling of elation. The seats
cost from $3.50 up, and every seat was filled with
enthusiastic Soviet citizens or tourists. We went
with Ninel, who is one of the interpreters as-
signed to our group, a hard-working, earnest, and
attractive young Jewess. Perhaps the reverse of
Lenin’s name was given her to help her in her
race persecution, which is apparently a_ severe
problem in this country.

DATE: Friday, May 27, 1960

Friday was a day of many visits. In the morn-
ing to Sklifosovskiy where Petrov made an
esophagus out of the right colon and the last
12 inches of ileum in one hour and 45 minutes.
Very slick job, done with great skill and the
familiarity of having been there a few hundred
time before. Petrov and all his team operate in
their street shoes, trousers, etc., covered with a
plastic apron. The aseptic techniques aré relatively
relaxed but the form is there, even though the
mask is only two layers of gauze thick. The rubber
gloves are thin and of good quality. The patient
was a 23-year-old man with a gastrostomy. His
esophagus was burned when he was a child. Blood
was given as needed, although it appeared that a
hypotensive drug had been given.

Petrov operates with great decision and the
confidence born of experience. One of the best
tricks was to put noncrushing clamps on the
ileocolic arteries all during the mobilization of
the right colon, then he was able to look at the
color of the bowel fed only by the midcolic and
see if the color indicated viability. Another was
a bright light so placed at table level as to facilitate
transillumination of the mesenteries.

When we entered the Sklifovoskiy, we first en-
tered a building which was an old church with
beautiful friezes and murals; then to the adjacent
buildings, the O.R. and the Institute of Cadaver
Blood. Visiting at the same time were the previ-
ously mentioned group of American surgeons on
tour of the midcontinent.

Cadaver blood in plastic containers of about
250 cc. each was used. (The patient received
three.) The special instruments of Yudin for the
retrosternal tunnel were of particular interest;
they come in graded sizes, and finally the one
with holes was used as a ligature carrier.

The esophagus was not removed. All of the
abdominal procedures were completed, but the
upper end will wait three days for and end-to-side
ileum to esophagus.

The Sklifovoskiy Institute appears to have the
following personnel: Director, Tarosov; Surgeons,

Vol. 82, Feb., 1961
ALL-SOVIET SURGICAL CONGRESS

   

Fig. 2.—Dr. Waltman Walters and Dr. Andro-
sov at the Sklifosovskiy.

Petrov, Androsov, Arapov, Lobschov; Gynecology,
Alexandrov; Therapeutic Clinic, Suchingen, with
Moysaev, and Glasova, a woman; Pathology,
Smollianikov; X-ray, (current professor very old
and sick, and thus not seen).

Arapov showed us a young woman two years
after coloesophageal replacement who drank water
for us. She was in excellent nutrition and quite
comely.

We next visited the blood institute, where they
were harvesting some cadaver blood. A 67-year-old
man had died suddenly in the Metro two hours
previously. Apparently, all sudden deaths in the
city are brought to the Sklifovoskiy by law.
Large cannulae were put into the jugular vein on
the left and the dead man then tilted into a
steep head-down position. Between two and four
liters can be obtained from a single donor. The
preservative is sugar, water, and antibiotics; no
anticoagulants, since blood after sudden death does
not clot (why?). Blood can be taken up to six
hours after death—no minimal time was described
—and it can be stored five days at 4C. It is
cultured, typed, and cross-matched before use.
Can give 3-4 liters to one patient, preferably all
from one donor. Oxygen-carrying capacity said
to be very good, and no interference with the
clotting mechanism of the recipient. Petrov said
that 3,000-4,000 transfusions have been given
yearly for several years, and he is very satisfied.

We then saw the two-hearted dog with Demikov,
who has just come to the Sklifosovskiy from the
Thoracic Surgery Institute, demonstrating. Among
the projects being studied in the laboratory are
tracheotomy in head injury, artificial esophagus,
portacaval anastomosis with the Donetsky ring,
burns, pancreatitis. No heart surgery being studied
here.

My chief informant was a young candidate
named Juriy Isakov who spoke excellent English.
He was top man in his class at the First Medical
Institute in 1955, and then was permitted to start

Swan

   

ae 2 =

Fig. 3—Arapov, the author, and Jurij Isakov
at the Sklifosovskiy.

his three-year compulsory service at the Sklifov-
oskiy instead of an assignment to practice in the
provinces. (Again, privileges going with achieve-
ment. )

We then had cognac, vodka, wine, and very
good hors d’ceuvre-type sandwiches. Dr. Androsov
and his assistant, Dr. Vladimir Pomeranzev, who
has been riding herd on the foreign visitors to
the 27th Congress all week, drove me to the
Institute for Postgraduate Study. Androsov is an
athletic, dynamic man with his head completely
bald a la Yul Brunner.

Dr. Ossipov greeted me in his office, where we
discussed the Institute and its personnel. In his
section, comprising approximately 235 beds, he
has 30-35 postgraduate students coming to him
each 2 months. In the Institute as a whole, there
are 58 chairs of all kinds, of which three are
General Surgery—(1) Rosanov (the senior), (2)
Ossipov, and (3) Kassanski.

Thoracic, unfilled (Kolesnikov has been invited
from the Thoracic Institute); Pediatric Surgery,
Dolitsky; Neurosurgery, Aranov.

Dr. Ossipov’s staff members are: Assistants,
Manevitch, Rosanov, Malvenov; Docent, Zak;
Thoracic, Tmara Stipanova; Urology, Effengiev.

We saw a few postoperative patients with
Tmara, a very attractive and apparently capable
young lady. The two gastrectomies done that
morning, one by Rosanov for cancer of the cardia,
the other by Manevitch for polyposis, were both
back on the ward, quite alert and comfortable.
Both were done with local anesthesia, and I must
say their condition two hours after surgery was
excellent.

Then to the office again, where cognac and
champagne flowed in copious quantities! Rosanov
has a quiet twinkle in his grey-blue eyes, a well-
trimmed, pointed beard, and a very considerable
capacity for hard liquor.

Later (with some assistance from Bigelow),
we went to the dinner given in our honor by Drs.
Bakulyev and Kolesnikov at one of the better
restaurants. A very good meal with much toasting

27/181
and some singing. It is interesting that diversity
of language has kept the world from having any
song that is truly international, or even which
will do for one continent.

DATE: Saturday, May 28, 1960

Our last day in Moscow dawned clear and
bright. Breakfast of kurd cakes and sour cream.

The First Medical Institute is a rambling series
of old buildings, two of which are made of logs.
(The best building, of course, is for Administra-
tion.) Dr. Petrovsky was exploring a cardiac
aneurysm. When he got in through the left sixth
interspace anterolaterally, sternum cut, he found
diffuse scarring. Instead of excising the myocardial
infarct, therefore, he raised a pedicled flap of
diaphragm and sewed it over the left ventricle.
We then saw a movie of the same operation and
also of his operation for cardiospasm. This is a
complex conception, relative to the cardiac sphinc-
ter. A window is cut from the esophageal muscle
just above the diaphragm. Mucosa remains intact.
A pedicle of full-thickness diaphragm is now
sewed in place. We were told that he had treated
50 patients this way in the last 4 years with
excellent results. It is alleged that the flap of
diaphragm muscle acts as a competent sphincter.

Petrovsky’s operating room is an interesting old
theater three stories high. The level of asepsis
appears to be the most rigid we have seen. We
then had cognac and caviar, and I went to the
laboratory with Krilov and visited with Dr. W.
Ankatov and Dr. Marion Kchodes, who comprise
the “pump” team. Many questions were asked me
concerning perfusion. Their pump is a plastic
bubbler with finger-type rubber internal valves
in the pump. It did not appear to be of very
modern design but is the one made in the Institute
for Research in Surgical Instruments. Uglov also
has one in Leningrad. The best part of the visit,
however, was the dark beauty of Marion.

Petrovsky’s Head of Anesthesia is Dr. Olga
Kolutskoj who, in turn, has 24 anesthetists under
her.

First Moscow Medical Institute——Director, Kov-
anov; (1) Chair of Clinic Surgery (Zhorov),
with 6 to 10 assistants. (In charge of third-year
teaching); (2) Chairs of Faculty Surgery: (In
charge of fourth-year teaching). (a) Surgical
Pathology (lalansky). (b) Topographical Anat-
omy and Operative Surgery (Kovanov). (3) Chair
of Hospital Surgery (Petrovsky). Assisted by
Venedictov, Krilov, and others, including 5
aspirants and 4 ordinators. (In charge of fifth-year
teaching. )

We then went back to the Congress to hear
the report of the chairman of each of the topics.
As in so many other European congresses, the
chairman officially summarizes the “feeling” of
the congress. It is comforting for the delegates

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ARCHIVES OF SURGERY

to have some “official” point of view to take
back with them. It shows, in a way, that the
congress has “accomplished” sométhing.

After lunch, we went to the Academy of Med-
ical Science for a short session of speech-making.
Dr. Bakulyev is no longer president. Now it is
Dr. Blokhin a young (50), capable, personable
man of considerable charm. The Academy is in-
dependent of the Academy of Science, sending
its budget to the Minister of Health directly. Its
president, however, sits in the presidium of the
Academy of Science. Dr. Blokhin said that it is
about 15 years old and has three divisions—(1)
Clinical; (2) Experimental Biology and Medicine,
and (3) Public Health, Bacteriology, and Epi-
demiology. There are about 110 active members
and 150 associate members. New members are
elected once a year, and to be a member it is not
necessary to be working in one of the 30 Institutes
of the Academy.

The purpose is to organize and control work
in the medical sciences and in clinical medicine,
and to teach these subjects. It “works closely”
with the Ministry of Health, which controls cer-
tain medical schools, and with the scientific so-
cieties. Petrovsky and Kuprianov are active
members; Ossipov, Petrov, and Uglov are invited
to meetings (associate members?).

Then to the Hotel Moscow to pack and to dress
for the banquet. One might add that the most use-
less thing in the Soviet Union is a tuxedo. On no
occasion is it apparently de riguer to wear one.
Knowing this earlier would have lightened my
bags by a few pounds!

At the closing of the banquet I met 1. Pro-
fessor Vladimir Negovsky, Chief of Laboratory
of Resuscitation. I promised Dr. Negovsky that
I’ll send him some reprints of our work in this
field. 2. Dr. V. V. Gusov, Department of Inter-
national Scientific Relations of the Academy of
Medical Sciences.

There were innumerable speeches from all
countries. The best was by Baliga, President of
the Society for Indian-Soviet Friendship. “I am
impressed that this meetihg is engaged in discussing
‘open-heart’ surgery while the politicians are dis-
cussing the ‘open-skies.’ I think this meeting is
one of ‘open-heart,’ both scientific and personal.”
Dr. Arthur Mackay, of the
Glasgow, gave a nice talk, too.

Kuprianov is a man with a romantic history.
A young lieutenant medical officer in the Czar’s
guards, a crack outfit, he was in Crimea in 1917.
His soldiers mutinied to join the revolution, and
he joined them—a dynamic choice!

Royal Infirmary,

His own
caste, of course, disowned him, but he became
one of Russia’s great surgeons by sheer force of
ability. A man of great presence of person and

Vol. 82, Feb., 1961
ALL-SOVIET SURGICAL CONGRESS

distinguished mien, he wears the two-star uniform
most of the time.

At the party also was Dr. Ialansky, one of
the biggest men I have ever seen—6 feet, 7 inches
and 400 pounds, I should think. Very friendly.
Many protestations of affection were made to
me by various surgeons, especially Bakulyev and
Petrov. Presents from Petrov (silver snifter),
Bakulyev (book on art), Petrovsky (different
book on art), and Androsov (lacquered box)
embarrassed me by the extent of their hospitable
generosity.

Then off in a rush to the Leningrad station to
catch the Red Arrow. Russia’s crack train is a
very modern fast one. Bigelow and 1 shared
a compartment. The bunks are narrow but com-
fortable. The train is fast and a little rough. I
sat up much of the night writing this diary and
watching the Russian countryside. It is northern
muskeg and forest country. The houses are log
cabins, largely, and it might be Alaska or Sas-
katchewan.

DATE: May 29, 1960. A lovely, sunny Sunday.

Arrived in Leningrad on time at 8:45 to be
met by Uglov, his assistants, and three Intourist
guides. Dr. and Mrs. De Bakey, Dr. and Mrs.
Baliga, of Bombay, Erik Husfeldt of Copenhagen,
Wilfred Bigelow, and I comprised the party. We
proceeded to the Hotel Europa, where I bought
some amber beads in the hotel store.

Then all of us, in two cars, drove to the country
home of Uglov about 40 kilometers north of
Leningrad on the Baltic sea. All of the people
of Leningrad were on the roads walking, bicycling,
going by trains, and driving to get to the beaches
and the woods to sun. They look very pale, so I
guess there is not too much sun to be seen in
Leningrad. Uglov’s house is on two lots of sandy
pine forest about 14 mile from the sea. He built
it himself, for a cost of 200,000 rubles. It is of
good size, but not elaborate construction. We had
on the table a fabulous spread prepared by Mrs.
Uglov. We gorged and then heard her sing to her
own accompaniment on the piano.

A pleasant find was Irene Vitaljerna, a 28-year-
old blonde girl who speaks the best English we
have heard. She graduated as an English teacher
from the Institute of Foreign Languages. She
now works for Dr. Uglov translating articles
for his journal and writing his foreign corre-
spondence. In the party were Dr. Lydia Ivanovna
Krasnotschokova, one of Dr. Uglov’s operative
assistants, and Dr. Mursalova Pherusa Alexandrov,
whom we saw assist Uglov in operation the next
day.

At lunch there was much discussion of the pro-
posed change in the work day in Russia. It was
a six-day week, eight hours a day, except on
Saturday, seven. Proposed is a five-day week,

Swan

 

Fig. 4.—Erik Husfeldt, the author, Fedor Uglov,
and Michael De Bakey, Wilfred Bigelow, and
Dr. Baliga pose in the warm Sunday sunshine in
front of Uglov’s dacha. :

seven hours a day. Krushchev will use, in fact,
already has, used this for socialistic propaganda
purposes.

We returned to Leningrad very full of food
and with difficulty escaped our Intourist guides.
Bill, Erik, and I had a talk far into the night
regarding nations and the world of affairs, etc.
Erik recommends the books by Fitzroy McLean
“The Eastern Approaches,” 1950, and “Return to
Bokahra,” 1959.

DATE: Monday, May 30, 1960

Awakened refreshed and had an omelette with
raspberry jam and whipped sour cream. (It is an
excellent idea to whip the sour cream, as it be-
comes light and seems to taste even better.)

The First Medical Institute of Leningrad (in
honor of Piragov) is directed by Ivanov. The
first clinical year chairman is Filatov, who has a
broad physiological background. Facultative Sur-
gery chairman is Kollenov; Topographic Anatomy
and Operative Surgery chairman is Svaselli, and
finally, of course, Hospital Surgery chairman is
Uglov. There are also chairs in Gynecology and
“Philosophy”! There are 3,000 medical students
(500 times 6) in each of the four medical schools
in Leningrad, which are (1) First Medical Insti-
tute (Uglov); (2) Second Medical Institute; (3)
Military Institute (Kuprianov), and (4) Pediatric
Institute (pediatric surgeons—Korhoff, Rosanov,
Murgolin).

Dr. Uglov has two large operating rooms. The
wards are painted white and blue. About 25 pa-
tients to a ward with moderate crowding, but very
clean and neat. A tour of the laboratories showed
us the biochemical, physiological, and other labora-
tories. The animal operating room was in the

29/183
 

cardiac catheterization room, with a neighboring
room to keep the animals for 48 hours. Danish
polarograph and pH meter, eight-channel poly-
graph with scope control, Van Slykes, pOe’s, and
the Hellig (Freiburg) coagulagraph, were shown,
all very good electronic equipment. The girls in
the biochemical laboratory were having a very
relaxed day with no apparent work to do. There
was a bed, though, as if one technician sleeps in,
and there were many potted plants and flowers.

We were shown also the pathological labora-
tory where a main interest was the study of urine
for cancer cells, in particular, cancer of the lung.
Uglov has been studying this for eight years. It
appears that if you centrifuge urine and make five
slides of the sediment, stained with Giemsa’s
stain, and if you do this 5 times (25 slides), then
in 80% of patients with lung cancer (broncho-
genic), a positive reading for cancer cells in the
urine will be found. They use this diagnostically.

After surgery (pulmonary resection), the tests
mostly became negative, but there is no prognostic
value to the test. Patients can die of widespread
metastasis, but if it is not growing in lung, then
apparently the cells either do not get into the
blood stream or tissue through the glomeruli; at
least they are not seen in the urine.

Dr. Uglov did two cases: 1. Mitral stenosis
in a 39-year-old woman without fibrillation. An-
terior approach, fourth interspace, injected sympa-
thetic chain with 4% procaine (the Vishnevsky
theory of neurogenic shock), clamp on auricle, cut
off tip (big one), stay sutures, no carotid com-
pression, glove off, finger in auricle, no instru-
ment, rapid digitalization of the valve, auricle
sutured, local anesthesia of intercostals, small chest
tube, perichondral and _ pericostal suture. He
showed us a fingernail knife for mitral com-
missurotomy which is quite similar to other finger-
nail knives available from such sources as Pilling,
etc.

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ARCHIVES OF SURGERY

Fig. 5.—Uglov’s  op-
erating theatre at the
First Medical Institute

of Leningrad.

2. Pneumonectomy for a diagnosis of “lung
abscess, chronic.” No bacteriology was announced.
Approach was anterolateral. Difficult dissection,
multiple ligation of all the many venous and ar-
terial branches. Then the stapling device to the
bronchus. (Dr. Uglov was sitting down through-
out the operation.)

The Vishnevsky theory of the nervous etiology
of shock had a real test in this difficult operation.
Multiple injections of the sympathetic chain, the
lung root, etc., were done. But when Uglov really
had trouble, his assistants started to pour blood
into the patient, and, great surgeon he is, even
though the heart rate was uncountable at over
200, he refused to panic, stayed calm, packed the
wound, transfused, and when things got better,
ligated the bleeding azygos vein. In our country,
many surgeons would have preferred in this diffi-
cult case to have made the resection intraperi-
cardially to have achieved a simpler approach to
the problem. The lung resection in this case took
2% hours.

At one stage of the operation, Dr. De Bakey
remarked, “The women assistants of the Russian
surgeons are better assistants than our residents.
They do not try to take over the operation!”

When thé tour of the laboratories was over, we
retired to Dr. Uglov’s office for a beautiful meal
of caviar (red and black), salad, ham, cheese,
pork, salmon, butter, bread, and pastries. Dr.
Uglov gave a fine toast to the need for friendship
and understanding between the U.S.S.R. and the
U.S.A. Today, we also learned the extraordinary
success story of this fine surgeon. He was born
on a farm in Siberia, 600 miles from a railroad.
By industry and achievement in school, he was
awarded a fellowship in the regional school, then
sent to Leningrad for his medical training, where
he was first in his class. Honors and appointments
followed. To have risen from the peasant class
to Professor of Surgery would have been impossi-

Vol. 82, Feb., 1961
ALL-SOVIET SURGICAL CONGRESS

ble under the Czars, but now he even owns a
dacha.

Uglov gave us elaborate farewell presents, as
if his bountiful hospitality had not already been
enough. The evening express is a good train, but
not as deluxe as the Red Arrow, and no sand-
wiches or supper of any kind were served, which
is just as well, perhaps. I must have gained at
least five pounds this week with all the dining
and wining of our very generous hosts.

DATE: Tuesday, May 31, 1960 (clear and
warm).

We arrived in Moscow on the dot, having been
wakened just barely in time. Met at the train at
5:20 by Ninel, who whisked us in a Zim to the
airport. Dmitri Venediktov there to see us off—
Mackay and I to London, Bigelow later this
morning to New York City via London. I sit at
takeoff in the BEA Comet 4B, zooming upward
in that incredible jet takeoff which always is an
impressive experience. We will be 3 hours and
30 minutes to London at 30,000 feet.

The week has been so full of impressions and
moving experiences, that it will take time to digest
and interpret. One remembers over all the extra-
ordinarily deep feeling, respect, and affection for
us as individuals on the part of the Russian
surgeons, and their sincere hospitality. It was, as
Baliga said, a meeting of the “open-heart.”

Some General Impressions

Perhaps the most striking impression
which the visitor to Moscow and Leningrad
obtains at the present time is the realiza-
tion, which comes somewhat as a_ shock,
that the Soviet Union appears not to prac-
tice a form of communism, but, rather, a
very highly socialized form of capitalism.
The economic structure includes banks,
where it is possible to open savings ac-
counts and receive interest up to 5%; in-
deed, such savings accounts are encouraged.
One may make loans for the purpose of
creating personally owned private property,
and private property is beginning to become
more and more abundant now in Russia as
consumer goods are beginning to pour into
the market, where the buying power far
exceeds the goods available. More people
are starting to own cars, have television sets,
and, in the case of the wealthy, dachas
(summer homes). If one has a dacha, it is
possible to rent it during the winter to
other, less fortunate, people, and to keep

Swan

the rent you receive. Tipping (which is the
symbol of one man’s exploitation of an-
other’s labor) is not only permitted, but is,
in fact, expected. This “subversive” growth
of capitalism within the Soviet Union, it
appears to me, is not at all due to the
nefarious infiltration of foreign agitators,
but, rather, to the progressive recognition
on the part of the Soviet government that
the most effective goad to productivity is
the incentive of personal gain. In Russia
there are the very rich and the very poor,
and rewards are dispensed in accordance
with ability and productivity, not in ac-
cordance with need. As mentioned earlier,
it impresses one as being a rigorous and
competitive society. The motivation of self-
interest has been acceeded to, except that
the regulations governing the individual’s
activity are more socialistic than ours, and
the individual cannot inherit, but must earn
his share of the wealth of the country.
Medicine, of course, is completely state-
controlled and has had phenomenal growth.
It is fruitless, really, to compare medicine
in the Soviet with medicine in the United
States. It is more profitable to compare
medicine in the Soviet Union today with
what it was 45 years ago in the last days of
Czarist rule. At that time, it is recorded
that medicine was available only to a small
percentage of the large population of the
country, and then only in the very largest
cities. Some comparative figures relative to
their progress in this regard might be of
interest. There are at present over 360,000
physicians in the Soviet Union, physicians
graduating from medical school at the rate
of over 17,000 a year. Thus, there is one
physician for every 575 Russian citizens.
Seventy-five per cent of these graduates are
women. For comparison in the United
States, there are 250,000 physicians, 7,400
graduating last year, this number including
470 osteopaths. This gives a physician-per-
capita ratio of 1:708. It would appear evi-
dent that the Soviet Union is graduating
doctors at a rate which exceeds the increase
in its population, a situation entirely dif-
ferent from that which prevails in the

31/185
United States, where great worry is held
over the declining ratio of doctors to general
populace and much talk and effort are being
expended toward increasing the output of
physicians.

What will the Soviet Union do with
excess doctors? It seems likely—and this
is only a guess—that it will follow the
example of any country which produces a
commodity in excess—namely, export it.
The exportation of doctors might become
a powerful tool in foreign relations. Perhaps
they will be sent as medical missionaries of
Sovietism to the neighboring countries,
which are backward in health facilities.
Whereas we send money to achieve influence
in a country and often distribute it un-
soundly and with bad grace, the Soviet
Union may begin to export health, a com-
modity much desiréd and gratefully re-
ceived. One can imagine the influence which
this policy might have in cementing the
Soviet sphere of influence in China and
India and gradually molding the vast land
mass of Asia towards political and idea-
logical unity.

We saw very little of medicine as it is
actually practiced in the Soviet Union be-
cause our visits were confined almost ex-
clusively to watching a few of the very
top-level surgeons in the country operate
and to visiting the major teaching and re-
search institutes in the two largest cities
in the U.S.S.R. Thus, we had no oppor-
tunity to observe activities on the broad
front of medical care. Medicine is run by
a strange blend of bureaucracy and de-
mocracy—namely, by the joint activities of
the Ministry of Health of the Government
of the Soviet Union and of the Academy
of Medical Science. The composition of
the Academy and its purposes have been
described above, and it is merely desired
to reemphasize the fact that membership in
this organization is by election. It is both
honorable and financially profitable to be-
come an academician, since election to this
post carries with it a salary of about $4,000
a year in addition to whatever other income
the member may be making. I gather that

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ARCHIVES OF SURGERY

most academicians are of professorship
level and that their incomes are in the
$25,000- to $50,000-a-year category, not to
mention fringe benefits such as state-sup-
plied automobiles with drivers, summer
homes, etc. Medical education is divorced
completely from the universities, but instead
is carried out in Institutes under the direc-
tion either of the Academy or the Ministry.
The leading ones appear to be those under
the direction of the Academy. A professor
is a physician who has received a Doctor
of Medical Science degree and who has
been appointed to one of the chairs in a
teaching institute.

A glance at the method of medical edu-
cation currently in vogue might be of in-
terest. Every child is first required to
attend a ten-year secondary school, and
enough schools are now available so that
everyone may attend. The best students
are eligible to apply for further training to
enter either a profession or a skilled trade.
The incentives to enter science and engi-
neering exceed those which are offered in
medicine, and the majority of those with the
best minds graduating from secondary
school appear still to enter these fields.
Nonetheless, those electing to, go to the
Medical Institute, aged 16 or 17, are very
top-quality students.

Their medical course is six years in
length, the first year of which is primarily
one of broad cultural indoctrination, the
next four of which are extremely similar
to medical courses in our own schools, and
the last of which is essentially parallel to
our internship. Compartmentalization of
function is a basic characteristic of the
system. Thus, a certain chair (professor- -
ship) which exists in a certain building in

-a hospital and has certain clinical facilities,

is totally devoted to the teaching of a spe-
cific class. For example, at the First Mos-
cow Institute, Zhorov holds the Chair of
Clinical Surgery and is responsible entirely
for the teaching of the third-year medical
students, the third being the year in which
they first impinge upon their training in
surgery. The following year, the term

Vol. 82, Feb., 1961
ALL-SOVIET SURGICAL CONGRESS

“Chair of Faculty Surgery” is used, and
often there are two, as, for example, at the
First Medical Institute, where lalansky
holds the Chair in Surgical Pathology and
Kovanov the Chair in Topographical Anat-
omy and Operative Surgery. These men
are in charge of the fourth-year training.
Finally, there is the Chair of Hospital
Surgery occupied in this institute by
Petrovsky, who is in complete charge of
the fifth-year training. In their sixth year,
the students will, as mentioned, act as in-
terns on the various services throughout
the hospital. An Institute, thus, is a firm
blending of medical school facilities and a
hospital, and this, of course, gives it total
strength as a unit for medical education. We
recall the importance to medical education
in our own country when this was first
achieved about 60 years ago at Johns Hop-
kins University. This appears to be true
throughout the country in every community
large enough to support medical education,
and all of the regional hospital centers are
oriented around the teaching institute.

In the third year of medical school, the
student studies the basic principles of sur-
gery, wound healing, infection, trauma,
surgical bacteriology, etc. In the fourth year,
a systematic study of the classical type of
surgical syndromes is made. Patients are
first seen this year, and 70% of the teaching
is bedside. There is no patient responsi-
bility, but the student will scrub in the
operating room two or three days a week
on the days he is assigned to sutgery. He is
roughly eight months on the service, half-
time. In the fifth year, he is assigned full-
time to surgery for three months and this
service approximates our clinical clerkship.
More difficult and complicated cases are
seen and differential diagnosis and treatment
are stressed. The teaching is again largely
at the bedside, but there is still no continu-
ing responsibility for the care of patients.
In the sixth year the student acts essentially
as an intern and rotates through different
services or clinics. As so many other coun-
tries, including our own, Russia is constantly
experimenting with this year. In 1951, it

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consisted of a straight year in either surgery
or medicine. In 1953 it was changed to a
two-year program, one year in medicine
and one in surgery and obstetrics and gyne-
cology. Then in 1956 it became a rotating
internship of one year’s length; four months
each being spent on medicine, surgery, and
obstetrics and gynecology. Then last year
it was converted again to the so-called
straight internship.

Upon completion of this year, the student
is given the title of vrach (physician). She
(75% are women) is between 24 and 26
years of age, and she will be expected to
serve three years at a post assigned her by
the Ministry of Health. The best positions
go to the top students, while the less fortu-
nate find themselves in the hinterlands.

After three years, the top 15% or 20%
may choose to return to the Institute for
further training leading to specialization.
Competition and examinations are held to
settle this matter, and then the doctors can
be allowed to specialize toward one of two
goals—practical surgery or academic sur-
gery.

Practical surgery requires two to three
years in training at an institute as an ordi-
nator under the service of one of the pro-
fessors. The student will then be assigned
to a post somewhere in the U.S.S.R. to
practice surgery. Every three to five years
the student will return for a three to six
month’s refresher course at the Postgrad-
uate Institute in Moscow. Some few may
stay as permanent ordinators (docent) at
the larger Institutes.

In the field of academic surgery, the
student is readmitted to the Institute as an
Aspirant. He will study and receive prac-
tical training in surgery and will attempt
to present an experimental thesis after three
or four years and to defend it in examina-
tion. If successful, he will then receive his
first degree, namely, that of Candidate,
which is quite comparable to our Master of
Science degree. As Candidate, he will work
for three to eight years attempting to achieve
the degree Doctor of Medical Science. This

33/187
requires a genuine contribution of original
work and a stiff examination on his thesis.
Rarely is this degree achieved by:a Candi-
date under the age of 42 or 43. But when
it has been obtained, the Doctor is eligible
to be appointed a professor in one of the
Institutes. Such appointment is for life,
even though the professor may later stop
teaching, or even move to a different post
from the Institute. He usually will be as-
signed to regional or district chairs, since
there are not many jobs available in Moscow
and Leningrad. Some go to regional in-
stitutions and then come back to the capitol.
If a Candidate is not successful in achieving
his Doctor of Science, he may remain for
a long time, perhaps for life, in the teaching
institutes as Assistant to the Professor. In
fact, on the shoulders of Docents, Assist-
ants, and Candidates fall heavy loads in
‘the treatment of patients.

One interesting technicality is that every
Chair is deemed to be vacated automatically
every five years. A professor theoretically
must be reelected by a Committee of Pro-
fessors of the Institute every five years. It
is said, however, that the system is not
effective in removing professors who have
begun to coast because every living (that is,
warm and walking) professor is always re-
elected by such committees.

Small wonder, then, that, having emerged
as leaders, the surgeons we visited were
ambitious, capable, energetic, and proud.
They had to be to have achieved their
positions in such a system.

Their hospital facilities are not modern,
as the Government has diverted construc-
tion funds where the needs are greater,
particularly toward building domiciliary
units for the population as a whole. The
old pavilion-type buildings with large wards
were crowded, but neat and clean. The
number of nurses visible in relation to the
number of patients was impressive, and I
suspect that their nursing service is con-
siderably more adequate than ours. Certainly
the nurses one saw assisting the surgeons in
the operating room were extremely alert,
competent, and agile. It appeared also that

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ARCHIVES OF SURGERY

there was less use of some of the common
adjuncts of postoperative care so common
in our institutions, much less use of intra-
venous fluid solutions, less use of drugs, and
particularly less use of antibiotics. It was
stated that postoperative infection was not
an excessive problem and in none of the
institutes would anyone admit a significant
problem with Staphylococcus.

In addition, the great emphasis on the
neurogenic aspects of shock propounded
by the senior Vishnevskiy (and extremely
reminiscent of the writings of the senior
Crile) has led to the extensive use of local
anesthesia and considerably less use of
blood during the operative procedure than
is customary in our country. Indeed, local
anesthesia is used in from 70% to 80% of
all patients, and for many years before
anesthesia was developed in the Soviet
Union, it was used almost exclusively for
the most major procedures. Much argu-
ment has been made concerning this prac-
tice and it is to be admitted, of course, that
lack of the development of a trained corps
of anesthetists was one of the primary hold-
backs for many years. Even in the insti-
tutes, however, where such anesthesia is
now available, extensive use of local anes-
thesia is continued. One-fourth of one per
cent procaine with two drops of adrenalin
per 100 cc. is administered in copious
amounts and it appears that toxic effects
from overdosage of procaine are rarely
seen when the agent is used in this dilution.
Dr. MacIntosh, distinguished Nestor of
Anesthesia at Oxford, expressed the opinion
that perhaps it is the absence of significant
amounts of added adrenalin to the solution
that may be a major factor contributing to
its apparent safety in their hands. In any
event, observing two patients two hours
after subtotal gastrectomy, both of whom
were completely alert, were not nauseated or
otherwise feeling ill, did not have gastric
tubes in place, and who were already drink-
ing clear fluids, was impressive testimony
to some of the benefits of local anesthesia.
Both operations were performed in less
than 114 hours, and perhaps speed is one

Vol. 82, Feb., 1961
ALL-SOVIET SURGICAL CONGRESS

aspect of the total technique. On the other
hand, it was also interesting that these
patients’ surgeon did not intend to allow
them to walk until the fourth day, although
I suspect they could have walked home
from the operating room.

It is possible that the use of local infiltra-
tion diminishes the blood loss during in-
cision, as we saw several operations, both
thoracic and abdominal, in which very few
clamps and ties were placed during the
exposure. This may help explain the lack
of blood transfusion noted above. How-
ever, copious injection of the lung root and
mediastinum did not protect the patient
from the tachycardia and hypotension of
significant bleeding from the azygous vein,
and under these circumstances Uglov very
wisely ordered vigorous, massive transfu-
sion to control body physiology.

Some of the ancillary aspects of medical
science which I thought of interest will be
briefly commented upon.

Last year, the Soviet description of the
use of an electronic computer as a diag-
nostic tool received much interest and it
then appeared that the United States had
also been evaluating this technique in the
New York Hospital. It is comforting to
know that both the Russian and American
machines have slightly less diagnostic acu-
men than the L.M.D., and the fact that the
machines cost several million dollars helps
also to reassure those physicians who fear
replacement by electronic devices.

In: the application of atomic energy to
medicine, the United States would appear
to be considerably ahead. The Atomic En-
ergy Commission is currently budgeting
$46,000,000 for research in biology and
medicine. Cobalt 60, one of the useful
medical products of such research, is cur-
rently in widespread use in our country. I
did not hear mention of the use of this
agent in Moscow or Leningrad, nor do the
Russians appear to use radioisotopes in re-
search to any extent. Thus, they lack a
very valuable tool.

In psychiatry it appears that they have
a very practical approach which is said to

Swan

be quite successful. First of all, the tre-
mendous emphasis is on home care for
patients, rather than _ institutionalization,
except in extreme circumstances. The fam-
ily is paid 400 rubles ($40.00) a month to
take care of its disturbed member, which
is very much less expensive to the state
than institutional care. With a population
50% larger than ours, they have only
250,000 psychopathic beds, whereas we have
over 770,000. But they do make use of
“colonia,” or “work villages,” for the
chronic and hopeless cases. The state of
affairs in such a village is hard to visualize.
One interesting thing they described was
the Emergency Team in psychiatry. A
group of psychiatrists and nurses in the big
cities is on a continuous-call basis to rush
to the scene of an acute psychiatric emer-
gency, such as attempted suicide or other
behavior of the acutely disturbed. It is said
that such téams are often effective in bring-
ing persons under therapy or observation
and restraint much sooner than might other-
wise be the case.

In the area of dissemination of informa-
tion from foreign countries, the Soviets
have an impressive program. As an integral
function of their determination to equal and
excel all other nations in scientific pursuit,
they have established the Institute of Sci-
entific Information of the Russian Academy
of Science. It is said that this organization
employs 2,300 full-time translators and ab-
stractors and each year publishes and dis-
tributes over 400,000 abstracts of papers
from 10,000 scientific journals from 80
countries. One of the Russian surgeons
stated that most scientific work finds its way
eventually into English and “since most
Russian medical leaders read English, it is
clear that English and Russian are now
the two most important languages in the
world.” Though one might debate this con-
clusion, one cannot deny the effectiveness
of the translation program in comparing
it with the less intense effort in our own
country. The National Institutes of Health
spent approximately $375,000 in 1959 in
its Russian translation program. In addi-

35/189
tion, there are a few small private translat-
ing agencies, but the total effect of this
program does not really suffice to make
Russian medical literature available to
American biological scientists on a large
scale.

Finally, a word might be said of the rela-
tive effectiveness of free enterprise research
versus bureau-determined and _ project-des-
ignated research. This is very hard to
evaluate, for one does not know the over-all
total backing, in terms of either budget or
personnel designated in our country and in
the Soviet Union to medical research. One
objective measurement of quality of re-
search might be the fact that in the past 18
years eleven medical scientists from the
United States have been awarded the Nobel
Prize, whereas the last Russian to be so
honored was Pavlov in 1904. Another cri-
terion might be the state of development of
now frontiers in medical knowledge, and,
in this regard, it is my impression that the
fund of knowledge added to medical science
from research laboratories of the United
States in the last ten years is considerably
in excess of that which has been added from
the laboratories of the Soviet Union. In the
newer fields of surgery, for example, car-
diovascular surgery, we appear to be con-
siderably ahead by a factor of several years.
On the other hand, they are currently
encouraging their top research men by very
pertinent and practical monetary awards.
Some of these men receive salaries of
$20,000 to $40,000 a year, plus fringe bene-
fits. By and large, they usually have envi-
able positions in the teaching institutes and,
relative to the practicing vrach, they are
financially in an enviable position.

Eugene Fleming has recently observed
that the opposite appears to be true in our
country. “In the United States, a first-class
medical researcher receives three or four
times the pay of an average wage earner,

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ARCHIVES OF SURGERY

but real income after taxes is only twice
as much, and‘only about half as much as
that of a fair-to-middling physician in a
metropolitan area. In other words, instead
of offering incentive to talented researchers,
we penalize them, and we just might run
out of dedicated men.”

Our system of awarding research sup-
port, however, to researchers who present
an interest in a subject and offer interesting
ideas in the pursuit of additional knowl-
edge, has been very productive, and, from
the evidence we saw, we had no reason to
believe that planned research in medical sci-
ences was a more effective method of un-
earthing new knowledge.

It was my impression that a very large
number of capable, intelligent, and ambi-
tious younger men are currently sprinkled
liberally through the teaching institutes in
Moscow and Leningrad at the level of
Applicant, Candidate, and Docent, and that
a system of intercommunication between
these men and our own young surgeons,
both through the medium of the written
word and the medium of an exchange of
personnel between our two countries would
be highly beneficial both as a means of
accelerating progress in surgery in both
countries and as a means of improving the
understanding between their citizens. An
Exchange Fellowship program should be
urged in Congress to start as soon as pos-
sible. I, for one, would be delighted to
participate in such a program by exchang-
ing research fellows or residents for a year
with any of the teaching Institutes which
we visited. Both countries’ fellows and in-
stitutes would learn much from the ex-
change. Baliga would be right, if it were
truly a bilateral “open-heart.”

Department of Surgery, University of Colorado

Medical Center, 4200 East Ninth Avenue, Den-
ver 20.

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