9. Principles of Surgical Practice in care of wounded inRed Army.

A: Excision of wound (debridement) is practiced as farforward as possible, usually in sorting-evacuation hospitals, but, in instanceswhere great numbers of wounded exist, this may be done in base hospitals. Thisis best practiced early, but Russian surgeons practice excision up to 10-15days, including compound fractures; relying upon sulfonamides and immobilization to prevent generalized sepsis.

B: Immobilization of large soft part injuries as well asfractures by wooden splints (Deitrich) or Thomas type, for evacuation to placeof first definitive surgical treatment, after which plaster of paris isapplied. Plaster of paris is put on as early as possible and is used directlyover the wound, "skin tight" and without padding. Not usually appliedbefore 3 days after injury.

C: Tetanus-Active immunization with tetanus toxoid ispracticed. The "booster" dose is given at the Regimental Aid Post.

D: Gas gangrene-A potent antiserum is used in all seriouswounds, usually intravenously. A toxoid is in the experimental stage. Severalsurgeons told us that the antiserum was not effective.

E: Sulfonamides-sulfanilamide is used both in forward andin base hospitals by introduction  into the wounds, by mouth and intravenously.It is not carried on the person of the individual soldier. They also have asmall supply of sulfapyridine. Observation of actual patients indicates thatthey use it more profusely in wounds than we do. A special form of sulfanilamide in which the preparation isbroken down into very smallparticles by subjection to ultrasonic wave lengths is used as a cream appliedto gauze and placed into the wound. It is thought to be very efficacious,but it is still in the experimental phase and is not in mass production.

F: Secondary suture is practiced wherever possible evenafter 7-12 days. Skin grafts are used when it seems advisable.

G: Inhalants uncommonly used, usually ether. Novocain commonly used and we saw many patients incompletely anesthetized writhingin pain. Spinal anesthesia used

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chiefly in base hospitals. Hexonal (like Pentothal) usedbut no gas oxygen machines seen and not told anywhere of its use.

10. Principles of Practice in Special Fields of Surgery.

A: Thoracic Surgery-Thoracic wounds treated conservatively.In forward areas sucking chest wounds are closed. Hemothorax treated bytapping; empyema by drainage for three weeks, then 2 or 3 rib fragments areremoved and the wounds packed. Only large foreign bodies are removed. Prof.Levitt gave figure of 6.7 percent as proportion of chest wounds. Lt. GeneralBurdenko said that the original mortality of chest wounds (65 percent) had nowbeen reduced to 18 percent. In 1942, only 19 percent of chest wounds were ofpenetrating type, and of the 12 percent submitted to operation the mortality was 20.5 percent. A simple positive pressure machine was developed by Burdenko(bellows led air via a Wolff bottle (7 cms. of water) to ordinary gas mask).

B: Burns-Use some coagulants (tannic acid and silvernitrate) but prefer open method, in which they dust on a powder containing ananesthetic and an antiseptic (not sulfonamide). Said burns were veryinfrequent and mostly in air force personnel. Placental extract coveringstimulates more rapid covering over with new skin. (??)

C: Fractures-We visited hospitals both in the forward andBase areas where fractures were concentrated. The care given these cases andtheir results made an excellent impression on us, and since plaster has beenthe procedure of choice in Russia ever since Pirogoff, in the Crimean War, wroteabout its wonderful properties (book published in 1865) we found them masters of this technique. Professor Yudin had cared for over 2,000 fractures in the Finnish war before this war began. Their principles of fracture careare: (1) splint in the field with wooden or wire splints or Thomas' splints. They prefer the Dietrich wooden splint which has an axillaand groin crutch; (2) at sorting-evacuation hospital, or mobile hospital, orbase hospital where first definitive treatment is given, all dead anddevitalized tissue is widely excised, sulfanilamide is placed in the wound.They often suture the wound open (skin edges to deep fascia) and prefer nogauze packs; (3) "Skintight" plaster is applied without dressing onthe wound. They do not transport the cases for a few days. They excise wounds 5-10days old in the same way and are not afraid of spreading sepsis. Hospitals upthe line had good fracture tables and one used a piece of rubber over the dorsumof the foot which was later removed after the cast had set. Casts are not splitand never use windows. For best work up the line, a good fracture surgeon with 8 assistants must have three tables going; one for careful preparation, one for the actual operation and one for the application of the cast.

see table

Followup study of 500 cases of wounds of joints showed 58percent incision and drainage and 42 percent resection. Of these 22 percent ofthe first group were unhealed at 6 months and 28 percent of the resections wereunhealed at that time. Arthroplasties were done in 42 percent of the casesincised and drained and in 8 percent of the resections.

D: Supply of Blood and Transfusion Service: The Red Armymedical service uses great amounts of citrated whole fresh blood and littleplasma. The blood is collected in the larger cities, chiefly Moscow (about 2,000pints a day and in one hospital bleed 600 people daily). Use excellenttechnique, physical examination of donors including Wassermann reaction;grouping is done twice; bleed into 250 cc. ampoules with open ends which haverubber tube attachments which are bent over and sealed with paraffin. Blood isrefrigerated at 6 degrees C and flown to fronts where it is distributed inrefrigerated cars and in frontline hospitals is kept in deep cellars iced at 6-10degrees C. It is not used after three weeks.

Cadaver blood is still being used at the SklifossowskyInstitute by Professor Yudin. From 1935 to 1943, 2964 cadavers have been bledyielding 5,092 liters of blood. Of this quantity 1,332 liters were discarded(240 for positive Wassermann reaction; 54 for acute bacterial endocarditis; 80 generalized tuberculosis). Bled from jugular vein inTrendelenburg positionunder aseptic precautions. If yield is small they wash out by injecting Ringer'ssolution in the arterial side. Sulfanilamide .06 percent is added forpreservation. Other medical men do not approve of this method.

At the Central Institute for Blood and Transfusions in Moscow(Director, Professor A. A. Bagdasarov) daily bleeding of donors averages 600 innumber. 250 ccs. is taken by gravity method into 2 ampoules (500 ccs. perdonor); bleed into citrate solution (using 5 percent sodium citrates). Donorsare given a special food ration and some money, but 85 percent of this is givenback for airplane construction and other military purposes. Name of donor goeson each ampoule and often is the source of many romances. The donors arelargely women. The Central Institute has 79 allied institutions and all plasmaand serum is sent to the Central Institute for bacteriological testing before itgoes to the army. Transportation to the army and civilian hospitals is by airand motor. The blood is good for 30 days under refrigeration if it is not moved;if transported, 15 to 17 days. Small insulated boxes with ice container hold 4pints of blood.

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Types of fluids used: (a) Whole blood (5 percent citrate and glucose to isotonicity); (b) Salt solution; (c) Special preservative fluid for use with whole blood which renders it useful twice as long as simple citrated blood but it must be added in proportion of 50 percent special fluid (C.I.B.T.) and 50 percent blood. (This C.I.B.T. fluid contains sodium chloride 7.5 grams, potassium chloride 0.4 gms., magnesium chloride 0.1 gms., sodium potassium phosphate 0.208 gms., sodium acid phosphate 0.119 gms., andglucose 10.0 gms. with distilled water to make 1,000 ccs.); (d) Alcohol-sugar solution (Silsovsky'sSolution); sodium chloride 7.0 gms., potassium chloride 0.2 gms., magnesium sulphate .04gms., Vobel's solution 3.3 ccs., glucose 54 gms. distilled water up to 1,000 ccs. (To this is added 80 ccs. of 96 percent alcohol); (e) Dried plasma-add sugar to isotonicity before drying. (Send forward with sterile distilled water, needle and connections. Plasma is kept labelled by groups-if over 750 ccs., it must be used in a compatible group); (f) Federov's solution-80 percentsaline and 20 percent serum (not used much); (g) Blood serum-allow this to be made in other institutions but not plasma; (h) Colloid solution fromcasein-treat casein to detoxify of antigenic and anaphylactic properties, use as 2 or 4 percent solution; (i) Anesthetic and antishock solution-ephedrine, saltsolution and codeins (amount not given).

In the army, they use plasma at regimental aid posts and transfusions of whole citrated blood at front hospitals. Believe blood is best treatment for traumatic shock and believe Academician Lena Stern's suboccipital injection of potassium phosphate solution purely experimental.

E: Amputations-practiced as little as possible and rarely in the upper extremities. When done short flap technique and early use of bucket and stick to keep muscles in training. Of amputations done in forward hospitals, 50 percent are reamputed in special centers in base area where prosthetic appliances are specialized in. In such base centers they practice some kineplastic amputations such as forearm with ulna and radius separated for useful stump. They continuously improve prostheses by the utilization of new ideas of the patients who work out individual problems according to the type of future work and the length of the stump. Points of election for amputation are roughly our own. Use button of preserved bone inmedullary cavity end of stump.

F: Plastic surgery-Orders are issued in the front areas not to remove bone and skin in jaw and face wounds and not to suture but to leave for experts in base area centers. In facio-maxillary and plastic centers, excellent work is being done, using tubular waltzing grafts well. By the use of early secondary sutures they reduce the plastic work. One specialist, Professor Frumkin, had made 12 new penises out of tubular grafts containing some cartilage from thoracic cage which he waltzed down.

G: Frostbite-The Russian soldier wears woolen wrappings about his feet and thick felt moccasin boots in the winter time. It is in the season of thawing that the large number of frostbite cases occur. Lt. Gen. S. S. Guirgolave, who is accepted as the authority on frostbite in the Red Army, emphasizes the following points:

Damage produced by cold may be divided into the local and general effects. Congelation (formation of ice in the tissues) never follows the local effects even with the descent of the tissue temperature to zero degrees. The pathological processes, and in particular necrosis, are secondary and are a consequence of changes in the viability and metabolism of the tissues and are not an immediate primary effect of refrigeration. The local effects are the result of meteorological and other factors which lower the local and general resistance of the organism, so that the lesions produced are equivalent to those caused by long exposure to intense cold. In thedevelopment of the local effects, there is a "prereactive" period during which, by proper treatment, many of the serious lesions can beprevented.

At a body temperature of plus 26 to plus 28 degrees C, the thermoregulatory mechanism of a homeothermic animal ceases to function and it becomes isothermic. An animal, under such conditions, cannot re-establish a normal temperature by normal means and must be actively heated. By a special technique (electro-thermometrie) in which the centralnervous system plays a specific and preponderant role, the damaging effects of cold can

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be reversed. Carbohydrate metabolism, the adrenal glandsand the sympathetic nervous system play important roles in this treatment.Intensive and active heating of the frozen parts and of the body must becarried out in line with these pathogenic conceptions in order to treatrationally and prevent the lesions produced by cold. Rapid heating for 20 or 30minutes causes no damage to the affected parts or to the body. An animalrapidly heated loses less tissue than one slowly heated. Rapid heating has abeneficial effect upon the functions of the cardiovascular and respiratorysystems.

Longitudinal incisions should be made in necrotictissue within 5-6 days and should extend as far as there is no pain orbleeding. In the presence of subcutaneous edematous fluid such an operation(necrotomy) causes a dry gangrene of the part to develop rapidly. If bones areinvolved amputation of the necrotic portion should be done 6-10 days afterinjury. These procedures reduce by two to three times the length of timenecessary to treat tissue damaged by cold.

H: Neurological Surgery-There are 16 neurological surgeonsat the front who have at their disposal 3,200 beds and there are three largehospitals in the rear with clinics which provide 3,700 beds. In other words there are 6,900 beds inthe Soviet Union devoted to the careof neurosurgical injuries and diseases. At the front, 2.9% of all surgicalbeds are for neurosurgical patients, and in the rear hospitals the percentage is4.3.

Neurosurgical surgeons in the U.S.S.R. have all been trainedunder the supervision of Lt. Gen. (Academician) Burdenko whodictates and directs all policies and the expression thereof.

The sorting and evacuation of neurosurgical injuries tospecial hospitals is practiced as far forward as possible in the combat zoneand the one neurosurgical group inspected by the mission was on the Vyazmasector in Sorting-Evacuation Hospital No. 290 located about 70 kilometers fromthe frontline. The maximum distance for evacuation to such a hospital shouldnot exceed 48-72 hours from the receipt of injury. The most seriously wounded are not movedand not operated upon, and it is concluded that theyare expected to be mortally wounded cases. Those injured in whom an operationis possible but who are in shock are kept until shock is treated and thenevacuated. Hemorrhages and a rise in intracranial pressure are indicationsfor operation on the spot. Neurosurgical definitive care must be located,according to their dictates, at a maximum distance of 2-3 days fromthe frontline with trained neurosurgeons, neurologist, neuropathologist,ophthalmologist and otolaryngologist in attendance. Evacuation must berapid, smooth and preferably by air at altitudes not exceeding 5,000 meters. Itis agreed that craniocerebral wounds stand evacuation better before than afteroperation. Postponed operations in well-equipped and staffed hospitals arepreferred to immediate operations under poor conditions.

Sulfonamides locally placed in craniocerebral wounds isadvocated, but General Burdenko complained that they were not used immediately as systematically atthe front as they should be. Sulfonamidesare also given to the patients orally and intravenously.

In the first 24 hours after injury 21% were treated in the"First Line"; 20% in the "Second Line"; and 14% in the"Third Line." In the second 24 hours the percentages respectivelywere 59, 62, and 65 and in the third 24 hours the percentages were respectively19, 19, and 11. The mortality of craniocerebral wounds in the rear hospitals is8% and for spinal cord injuries 56%.

Indications for operation in spinal cord injuries are notclear, but they are stated as (a) prophylaxis against infection; (b) symptomatic, and (c)morphological. The clinical conditions for whichoperation is advised include progressive paralysis, traumatic edema,subarachnoid space block, pain, and meningitis.

The surgical technique employed in the treatment ofcraniocerebral wounds consists of irrigation of the wound tract with a bulbsyringe and suction removal of the blood and injured brain tissue. Treatment of the dural wound is notconsidered necessary and thelacerated dura is never sutured. Rubber ring pressure dressings are employed totreat cerebral fungi or herniations. Well-encapsulated brain abscesses areremoved in toto by

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electrocoagulation, and drainage is seldom employed. Contrastmedia for the diagnosis of abscesses and the location of fragments around the abscess areused.

Formalin fixed nerve and spinal cord grafts are usedfor the repair of large continuity defects in peripheral nerve injuries. The grafts are fixed successivelyin alcohol, alcoholic ether, alcoholic glycerin, magnesium chloride, and glucose.Twenty-seven patients have beenso operated upon, but none of these were presented for demonstration orexamination of the results obtained. The microscopic evidence of theexperimental studies was not conclusive.

At the Institute of Experimental Medicine, Prof. PropperGraschenko has 150 neurosurgical beds and is conducting problems of clinical research bothin the frontline area and at this Institute so that he has continuous controlover patients selected for study. He is studying (1) the character of headinjuries, their course, and the influence of infection upon the healing of the wounds; (2) theclinical and bacteriological application of sulfonamides to craniocerebralinjuries; (3) the diagnosis of early andlate traumatic encephalitis and cerebral abscess and (4) the rehabilitationtherapy of craniocerebral and peripheral nerve injuries. He has at hisdisposal an auxiliary microbiological laboratory staff, half of which is atthe front and the remainder in the rear zone.

In the short time at his disposal he presented his work upongas gangrene infections and other anaerobic infections of the brain. Underfield conditions, 100 cases of craniocerebral injuries were studiedbacteriologically and in 20.3% pathogenic organisms were present; in 24%aerobic organisms were cultured; in 12.4% sporogenic (putrid anaerobes)organisms were present; in 26.8% coccal infections were present; in 16.5%miscellaneous organisms were found. These cultures were made from 48 to 72hours after receipt of the injury. In 620 cases examined bacteriologically,only 2 were found to be sterile.

After 3 to 4 weeks wounds showed a flora of pathogenicanaerobes in 12%; aerobes in 20%; cocci in 70% and 8 to 10% were infectedwith putrid anerobes. Of the 20.3% in which pathogenic anaerobes werefound, 1.4% died in 6-7 days of severe gas gangrene infections. Subacuteanaerobic infection of the brain is found in all large brain fungi, and of12 such cases, 9 died. Thirty-two cases of chronic anaerobic infection of the brain were studied,and of these 10 died. The course was long 3-4 months, and often encapsulated abscesses formed which often opened on tothe surface or into the ventricles with the production of a severe meningitis. In 34 cases ofmild anaerobic infection of the brain, therewere no deaths.

The types of anaerobic infection of the brain foundincluded Clostridium perfringens (Cl. welchii), Cl. sordellii, Cl. fallax, Cl.oedematiens, Cl. oedematiens maligni and Streptococcus anaerobius. Aserum is used against gas gangrene infection which is polyvalent andcontains Cl. histolyticum, Cl. perfringens, Cl. oedematiens and Cl.oedematiens maligni. A prophylactic dose of 10,000 international units isgiven intramuscularly and therapeutic doses of 3-40,000 units are usedintravenously and intramuscularly.

I: New Clinical Methods under Study-

(a) The injection of 70 percent alcohol with 2 percentNovocain solution about fractures in the early days following injury toincrease blood supply and to stimulate callus formation. (The mission was notconvinced of the usefulness of this procedure.)

(b) The use of placental extract to stimulate healing inchronic wounds or the growth of skin in severe burns.

(c) The use of a cytotoxin made by injecting mesenchymaltissue into a horse and using his antiserum to stimulate the healing of ulcersof the stomach, healing of bone, loosening of scars and stiffness in joints.(The mission was not convinced of the usefulness of this procedure.)

(d) The use of smoke from burning pine wood to stimulate healing (??).

(e) The use of naphthalen (a heavy oil) broken down byultrasonic method to stimulate healing (??).

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(f) Treatment of shock by the suboccipital cistern injectionof potassium phosphate solution to stimulate the [vasomotor] centers inmedulla. (See article by Lena S. Stern in Lancet Nov. 14, 1942, page 572.)

J: City Accident and Medical Service: Here we saw anexcellent demonstration of the Russian ability at organization which surprisedus. The Sklifossowsky Institute is the center of this work for Moscow but has 6 or 7 "district" hospitals. All telephone calls come into a centraltelephone room at this Institute where there are many switch boards and anelaborate system of intercommunication and directing officials. Apparentlypatients, doctors, police or friends may call in and state facts. Ambulances goout immediately either from the Central Institute or from the nearesthospital to patient after the information is relayed to that hospital. If adoctor is not necessary he does not go on ambulance, but if there has been anaccident or if the case is questionable the ambulance contains a doctor, nurse,and driver. As the message leaves the telephone central room in writing, a timeclock is started and officials in the room know when the ambulance leaves,for the doctor, nurse, and driver all press separate buttons [which flashlights on in the central telephone room] as they leave. A check list is alsokept by director of the time consumed by each operator per case and numberof cases per day. Also, the director in a separate room can plug into any lineand listen to incoming and outgoing calls. The system, in part, was like thatof an Air Raid Warden's set up in some American cities.

K: Gifts to U.S.S.R.-At our original meeting with thePeople's Commissar for Public Health we spoke of our gifts, letters, etc.Letters cannot be delivered directly to the individual, and conversation witha Russian is safe for him only when some other Russian is present. Two dayslater Professor Koreisha came to the hotel and took away the penicillin, ourletters, and other gifts. General Smirnov, and General Burdenko came to uspersonally to ask that their thanks be transmitted to General Hawley for hisletter. Both stated they would write him in length. General Smirnov toasted ameeting to General Hawley in Berlin as suggested in the latter's letter. Nomore information regarding the gifts has been forthcoming.

L: Women in Russia: One of the most impressive thingsis the obvious equality of men and women, and the latter do everything that men do. Theyare in the Army as soldiers and officers. In the line, we were told there was nowoman witha higher rank than colonel. We saw several junior officers with artillery andinfantry insignia. In the Medical Service the Inspector General (BrigadierSurgeon Valentina Gorinovskaya) is a woman. Most of the traffic officers allthe way from Moscow to Vyazma were women carrying rifles. Trolley cars are runby women. Women help lay car tracks in the city. The nurses not on duty at the 290Evacuation Sorting Hospital were doing the major share in theconstruction of the new log houses for future wards.

Elliott C. Cutler
ELLIOTT C. CUTLER 
Colonel, Medical Corps, 
Chief Consultant in Surgery

Loyal Davis
LOYAL DAVIS
Lieutenant Colonel, Medical Corps, 
Senior Consultant in Neurological Surgery