Emanuel M. Papper, M.D., Ph.D.

Visit to the USSR

By E.M. Papper, M.D.

10 July - 7 August 1959

Friday, July 10

We left Idlewild Airport on the Scandinavian Airlines Royal Viking DC7C flight to Copenhagen. Eleven hours and several superb meals later, we landed in Copenhagen. It was most pleasant to watch the skillful carving of roast beef in the center aisle of an airplane some 20,000 feet above the sea.

While in Copenhagen airport, I spoke to Dr. Henning Ruben, the Director of Anesthesiology at the Finsen Institute very briefly. I made arrangements for him to join Dr. James Elam as Visiting Professor of Anesthesiology in our Department in October of this year.

A half hour stop over in Copenhagen airport was marred by my leaving a cherished but battered rain hat in the plane. This absentmindedness was quickly corrected by an SAS bicycle-riding courier who dashed to our plane which was bound for Stockholm and delivered it to me. This expedition delayed the Stockholm plane for some minutes but left everybody happy, with complete preservation of Scandinavian efficiency.

The flight to Stockholm (also a DC7C) took 1 1/2 hours, and offered a beautiful view of the Swedish coast and the Baltic sea. Our first evening in Stockholm was spent most pleasantly - dinner at Riche’s Restaurant followed by a walk around town. We heard an outdoor concert in the park, and observed the antics of the Swedish version of the teen-age "teddy boys", peg pants, side-burns and all. This phenomenon of the American "rock" or British "teddy boy" apparently has its counterpart throughout Europe, even as we learned later, in the Soviet Union.

Sunday morning, July 12 (my 44th birthday)

We were met by Dr. Martin Holmdahl, head of the Anesthesiology Department at Uppsala University, and his associate, Dr. Basil Finer, a Briton, who emigrated to Sweden and has actually learned to speak Swedish fluently. The drive to Uppsala, in a large De Soto station wagon provided an opportunity to see the prosperous looking Swedish countryside.

Uppsala has an ancient University, consisting of the traditional four faculties of the European university - namely Theology, Law, Medicine and Natural Philosophy. The Uppsala Cathedral, which dates back to the 10th century, contains the sarcophagus of Gustav I, the great Reformation king of Sweden, and the first of the Vasa Dynasty. The sarcophagus is unusual in that on both sides of the king lies a Queen. He married twice, and since both queens were highly regarded, they were buried with him.

We then visited the anatomical theater of the University which was constructed by the architect Rubeck on the model of the famous 15th century anatomy room of Padua. Public anatomical dissections were performed in this theater. Anybody could attend for a fee. This practice was considered sacrilegious by the Church and eventually banned. We then drove out to the country and visited an ancient Royal Viking Burial Ground in "Gamla Uppsala" or the old city. In this part of the town I drank a brew called "Mjod" from an old Viking horn which had been previously used in 1846 by Oscar the 1st, a King of Sweden. Dr. Holmdahl thought this would be an interesting choice because 1846 was the year of the discovery of ether in the United States. This horn had also been used by Prince Bernadotte in 1914.

The rest of the day was spent in Holmdahl's clinic and laboratory. He had magnificent operating room monitoring equipment. A big overhead boom carried EEG, EKG and several other channels. There was direct recording equipment in the opened closets of the operating rooms. A portable oscilloscope was available for each operating room and induction room.

For open heart surgery, Dr. Viking Bjork, the chief surgeon, and his staff were using a heat exchange with blood reduced to 8°C. In effect, one pump was used for the right side of the heart and another pump for the left side. The patient's lungs were used for oxygenation and excretion of carbon dioxide. This technique is said to be superior to previous methods of extra corporeal circulation. I saw two patients who were operated on in this manner. They were subjected to circulatory arrest for some 45 minutes each. Among the patients I saw, one had an unfortunate postoperative complication. He was a boy with a patent ductus whose aorta became infected. He developed an aortic aneurysm at the site of the infection.

Nurses give anesthesia in this Department and throughout Sweden. The practice of nurse anesthesia is approved in most hospitals in Scandinavia, but not in the rest of Europe. In my opinion, the use of nurses will probably retard the growth of anesthesia in these highly developed countries. A professor or a head of a department is full time, but he may also have private patients. The Swedes have a prepaid insurance medical care system supported by the government. The system is unlike American Blue Cross in that it is government controlled and regulated. It has, however, more features of private practice than in Britain.

Anyone can go to the University to study medicine if he can pass the entrance examinations. Scholarships are given to deserving students frequently. These range from $100 to $1000 per year depending on need. There is no actual tuition charge since the Universities are tax supported. Taxes are high in Sweden. The standard of living is also high, and probably approximates that of Switzerland.

Holmdahl and I had a long discussion about the possibility of his spending six months with us as a Visiting Professor in the research laboratories next year if financial support can be found for him and his family. He should be of great value to our staff in imparting the fruits of his research to us. His presence alone will prove most stimulating. He is very bright, creative, and imaginative.

13th of July

Back to Stockholm. There were six Arabs in full regalia getting into the elevator at the Palace Hotel. Despite a good night's sleep with a late breakfast, I thought I had hallucinations in seeing dark skinned Arabs in this land of blondes. They looked almost unreal. We then visited the “Gamla Stockholm”, the Old City which dates back to the 10th century. It has very old houses and shops. The Stockholm Old City also has something of the air of Greenwich Village or Soho. We then took a boat ride through the canals and saw the Royal Palace, Opera House, the Town Hall, and other landmarks.

We find that boat rides along the waterways of any city are of sociological value - because they reveal many facets of the people's lives - relation of parents to children and vice-versa, status of the elderly in the community, and the attitudes of the teen-agers and young adults. Park-bench observations provide similar interest.

On our return to the hotel at 10:30 p.m., we encountered 50 Iowa farmers, complete with name tags on their lapels and identical traveling cases, en route to observe Swedish farming methods and then on to Moscow to visit the Russian collective farms.

14th of July

Relaxed most of the morning and then were called for by Dr. Stig Dahl and his wife Karin about noon. We lunched at the Djurgarden Restaurant, which is over 350 years old, and visited Prince Eugene's Palace to look at his paintings and household collections. His old paintings were pleasing to this amateur - his themes were exciting and made a visit well worthwhile. We then went to the Skansen, which has old handicrafts and an amusement area. We also visited a church which is 400 years old, where the Dahls had been married. From there we went to the National Gallery and unhappily arrived just at closing time so we couldn't see the Rembrandt in this collection. Next we drove to the Hotel Foresta, a magnificent hotel and restaurant overlooking Lake Malar. The Foresta is near the Millesgarden which contains much of the sculpture of the famous Swedish Sculptor, Carl Milles. There are replicas of many of his works together with some originals. Some of his sculpture is in the Metropolitan Museum of Art in New York.

15th of July

Breakfast at 8:00 and then to the airport, flight 730 SAS from Stockholm to Helsinki. The airplane was a DC6, and on board were three American doctors, who happened to be in the Army together during World War II. They fought the war once again during our one hour flight. Their own roles in the war seemed to have enhanced significantly with the passing of time.

On arrival in Helsinki, we were met by Drs. Savolainen, Telivuo, and Tappura as the result of a letter from Dr. Fink to Dr. Savolainen. They generously drove us around the city and its pleasant suburbs. We had lunch together in a midtown hotel dining room. There was agreeable discussion of many things, mostly anesthesiology, the United States, and friendship. All of them wished to be remembered warmly to Ray Fink, who had been a Fulbright Professor of Anesthesiology in Finland. My new Finnish friends said that they had no information about anesthesia in the Soviet Union. They wanted me to write to them after my return home.

We then drove back to the airfield and had our first introduction to Russia via flight 612B from Helsinki to Leningrad. At first, I was most unhappy about the prospects since the airplane vas non-pressurized and looked like an obsolete plane of World War II vintage and resembled the old Convair 300 series. However, the plane was flown at 2000 feet, most uneventfully. It carried only foreigners, including a physicist from Cornell, who was en route to the Soviet Union for a conference on High Energy in Kiev. As a matter of fact, there were two International Congresses of Physicists in the Soviet Union at that time, one on Cosmic Rays and the other on High Energy, attended by about 300 physicists from many countries. (I saw no mention of these conferences in the Moscow News, an English-language summary of Pravda.) The Soviet customs officers were very polite and almost perfunctory in their inspection. We had to declare foreign currency, Russian rubles, if any, and jewelry.

My notes describe two octogenarian American ladies, the only people who completely defeated the Soviet bureaucracy. In fairness, they could have similarly disarmed any officials anywhere in the world. These ladies just sat down, announced to the Russian Intourist officials that they expected all arrangements to be made to get them to their hotel in Leningrad, and waited. These lovely ladies absolutely whipped the red tape by simply wearing the local boys down.

The hotel Astoria was about a half hour ride from the airport. We had our first of many views of women at work in the Soviet Union - the paving of roads with pneumatic drills, bricklaying, street sweeping, and other heavy work. It was the time of the long "White Night” of Leningrad, when it never turns darker than twilight. I was struck by the city’s cleanliness, its broad avenues, the scarcity of cars, and the multitude of pedestrians. At the hotel our passports and plane tickets were politely asked for by Intourist officials. Despite our unhappiness at this turn of events, the documents were returned several days later. Our suite had a study, a big sitting room, dining room, a bedroom and a bathroom. The furniture was most ornate. The cut-glass ornaments and paintings were equally elaborate. In the bathroom was a tattered Persian rug.

We went to the hotel restaurant at approximately 11:00 p.m. for our first experience with dining in Russia. We finished our meal two hours later while listening to an off-key orchestra, playing American jazz. Russians came in frequently, had some brandy and danced. Unwittingly, we ordered three meals. If one orders vegetables or soup in addition to the main course, one is presented with a meal in each of these courses. We had more green peas than I have ever seen on one table, and more cabbage soup (borscht), both in a bowl and out of it than I have ever seen.

In the course of our rather pea-weighted dinner, a Canadian physicist joined us and told us his impressions. So strong is the air of mystery in Russia that one tends to place too much credence in the opinion of other foreigners. Our Canadian physicist considered himself to be an expert on Moscow, our next city. He had been there all of three days.

16th of July

We met our guide, Lilya, for the first time. (The interpreter guide is the key figure in the world of the foreign tourist. The guide, usually young, polite, very bright, highly indoctrinated and dedicated to the Soviet system, is the eyes, ears and mouthpiece through which the non-Russian speaking tourist sees the Soviet Union). We took a short trip around the city for orientation and saw the Hermitage, the Arts Square, the Palace, Leningrad University, the Neva River and the new housing construction.

As we drove around town, we were struck by the number of TV aerials, which, we learned, were relatively inexpensive ($50-$100). From this fact and other observations on costs, we inferred that prices may be the means by which the Soviet Government controls purchasing and distribution, rather than reflecting the cost of items. For example, a good pair of shoes, if they can be obtained at all, will cost $30 to $50, which is much more than the rent for an apartment (about $3-$10 a month). Alcohol is extremely expensive, an unsuccessful effort to discourage drinking.

One of the Americans at our hotel had lived in Leningrad before the Revolution, and was completely stunned with the improvement in living comforts since her time. However, the living standards in Leningrad seemed poor to me in many ways. Stores look drab, Churches are simply closed and boarded up or used as in warehouses. Food is, in general, unattractively packaged. Some food is expensive. For example, butter costs about $1.50 per pound and sugar 80¢ per pound. However, bread, eggs, fish, and cabbage are inexpensive. Clerks in stores appear to be of good cheer and helpful, but they don't try to encourage sales. Everywhere, including the bank and the post office, the abacus is used for counting. There were no adding machines.

Politeness and the ability to interrupt and be interrupted, characterize the workers in the Customs, Intourist, and the shops. The red tape, I became convinced, is in part due to efforts to be attentive to everyone at once, resulting in a complete halt of progress and in part, to the unwillingness of anyone to make a decision of responsibility for fear or criticism or repercussion from his superiors. You can wander into the middle of a conversation and completely stop all effective headway for the other fellow and vice-versa. Recovery may not ensue at that session.

Some prices in hotel restaurants for foreigners may be of interest. Oranges range in cost from 25¢ to 40¢ each when they are available. Chicken was $1.30, and vodka 75¢ for 100 cc. Food is served very slowly and is of indifferent quality. Waiters work long and hard, with little finesse in the niceties of service. However, they are helpful, willing and cheerful. There is no tipping but food coupons issued by Intourist may exceed the bill by several rubles and one is not offered any change. There is therefore an enforced voluntary donation which is not called tipping. (I described this food system to Herb Rackow and he suggested that we were eating on the American Plan, a twist which is exactly correct).

17th of July

We went to the Hermitage, which was crowded with Russian tourists. The letter from Ted Rousseau to Mrs. Svetlana Vsevologescaia was most helpful in providing us with a wonderful experience. We met a director of the Museum and a Professor in charge of Italian paintings. While we were waiting for Mrs. Svetlana Vsevologescaia, the Professor told us that Lenin's first orders were to preserve all fine art during the 1917 Revolution. In fact, not a single artistic treasure was destroyed in the very bloody fighting during the Civil War between the Whites and the Reds. During World War II, in the three year siege of Leningrad, all objects of art were moved to Siberia. The Hermitage itself, which had previously been the Winter Palace of the Czar, was very heavily damaged, having been hit sixteen times, and yet the damage was completely repaired by 1956.

Mrs. Svetlana Vsevologescaia showed us some wonderful Raphaels, the da Vinci "Madonna", and the spectacular Rembrandt "Prodigal Son". We then went to see the precious gold collection, although we had to get special permission to do so. Among the many arresting things in this collection was a pendant about 1 inch in diameter, which portrayed a carriage with charioteers and horses and required magnification to see. This beautiful piece was made approximately 2500 years ago. The collection also included rare jewels, ceremonial swords, primitive designs, some of the Imperial Jewels.

We also saw some of the excavations from the frozen tombs in the Altai Mountains (about 500 BC) which included a mummy with abdominal wall stitching. There was also an entire wooden chamber with furniture and animals - reminiscent of the contents of funeral chambers in the Egyptian pyramids.

I had difficulty in trying to locate Professor Kuprianov with whom I had some correspondence and letters of introduction. It turned out that Kuprianov was at his summer dacha, and a telegram to him resulted in the appearance of Dr. Juri Schainin. Schainin is the Chief Anesthesiologist in the large military hospital where Kuprianov is Professor of Surgery. (Kuprianov, incidentally is a Lieutenant General in the Soviet Army and an important figure in Soviet surgery. My introduction to him came by way of Sir Robert Macintosh who had met him both in London and in Leningrad. Kuprianov was considered by Macintosh to be one of the most gifted people in Soviet surgery.)

When I was told that the hospital was closed because of Kuprianov’s vacation I thought this was most extraordinary to say the least. When I asked to be taken to see the hospital anyway, Schainin shrugged his shoulders and we went along. He and I were able to converse somewhat in poor German, which both of us knew to a limited degree. Latin served very well for our medical terms. Actually the hospital was closed and we had to get a key to open it! There was a very good chemistry laboratory which was equipped with a flame photometer with filters for sodium, potassium and calcium. The blood bank had many types of stable blood substitutes. There were two large operating rooms with rows of seats for observers. A TV camera was present in one theater. There were two operating tables in each operating room. Anesthesia machines were the Oxford EMO, British made McKessons and the Swedish Aga. Controlled respiration was frequently used either manually, or mechanically. The chief agents were thiopental, nitrous-oxide, oxygen and curare. Schainin complained about the quality of their gas machines and was particularly unhappy that they could not buy equipment in the United States. The use of soda lime in closed circuits was understood quiet well.

There were good endotracheal tubes, some made in Britain, some in Germany and some in Russia. There was a special tube with a bronchial blocker, used to isolate a single pulmonary lobe. It consists of an inflatable balloon which is inserted under direct fluoroscopic control during apnea into the lobe to be isolated from the rest of the lung. I believe this could probably be done more conveniently during topical anesthesia, although Schainin doubted it. Schainin is bright and well informed on ventilatory problems. He had a carboviser, oximeter and EKG, all of which he understood, and all were in good working condition. He had good masks and airways, and had a hypothermia bath and understood its use. Extra corporeal circulation was done in this hospital with equipment which resembled the Melrose Oxygenator. I saw the dog laboratory which was very nicely equipped for anesthesia research. Schainin knew the British literature better than the American via translation into the Russian language.

Schainin said there were four physician anesthesiologists at his hospital and no nurses who gave anesthesia. In fact, he stated that there were no nurse anesthetists in Leningrad.

Anesthesiologists are paid as much as surgeons, but have 12 days more vacation because they are "pioneers" in a new field. There are anesthesia meetings in Leningrad every two weeks and approximately 200 physicians attend. At present, in Schainin's department, two years of practical and theoretical training in medicine or surgery are required prior to beginning the study of anesthesia. Some of these "pioneers" in anesthesiology came from pharmacological or physiological institutes to bring scientific methods to anesthesiology.

Local anesthesia is declining in use and there is no epidural and little nerve block anesthesia. A fair amount of spinal anesthesia is given either by the surgeon or anesthesiologist. Good standard records are kept. The most popular laryngoscope is the Macintosh instrument. Intravenous needles and syringes are not of good quality. Chemical antiseptics are used often in intravenous fluids.

18th of July

Back to the Hermitage Museum with Mrs. Svetlana Vsevologescaia. The Throne Room and the figure of Peter the Great, were quite remarkable. Of particular interest on this visit was the exquisite collection of French impressionistic paintings. One never ceases to wonder how this collection survived both Revolution and War. This afternoon back with Dr. Schainin and then ran into a peculiar stone wall. He could not find the key to the room where the newly manufactured Russian anesthesia apparatus was kept. He said that all other hospitals that use this machine were "closed".

I believe that the new Russian machine (which was shown in the Soviet Exhibition in New York) was more a hope for the future than a reality, and that Schainin's "troubles" with losing keys was simply his way of telling me that they did not yet have the machine in production. This sensitivity about inadequacies was displayed on other occasions and in non-medical spheres. A request for a tin of caviar in a food shop brought the response that "The caviar factory is being fixed", instead of the simple statement that they did not have caviar.

In the afternoon, Schainin took us to the Central Park of Culture and Rest, which is both park and amusement area. We had a pleasant time. At night we went to see Borodin’s "Prince Igor". The theater belonged to the Czar in Imperial Times and was all glitter and gold. The Czar's box was just above us and was occupied by a group of Russian sailors that evening. The opera, like all the theater we saw in Russia, was superb.

19th of July

To Peterhof, the summer palace of Peter I, to see the gardens and the beautiful fountains which are even more spectacular than those at Versailles. Thousands of Russians on holiday were swimming in the Gulf of Finland, yet there were strikingly few cars in the parking lot, 8 to be exact and 4 belonged to tourists.

In the afternoon, we visited the Nicovsky Cathedral and the Jewish Synagogue. The cathedral is one of the 15 churches open for worship. We were shown about by a very well-dressed man, who is the "administrator" for the church. He is not employed by the State and is clearly one of the most prosperous looking people we have seen. He has learned to make religion "pay" in an atheistic land. There are 10 priests, all of whom live out, reminiscent of modern "resident" physicians in a large hospital! Mostly old people come to pray, but there are a few young ones. The icons are very elaborate and ornate and some are extraordinarily beautiful.

The Jewish Synagogue is in very poor repair. The deacon told us that there are 200,000 Jews in Leningrad, and his congregation numbered 900. It was heavily attended on the important holidays, and poorly on the Sabbath. He was unwilling to discuss relations between the Church and State, in contrast to the "administrator" in the Russian Orthodox Church, who volunteered the information that all was cordial between Church and State.

In the evening we went to see the ballet of "The Bronze Horsemen" which was performed with much enthusiasm and skill. Particularly marvelous were the stage sets and the scenic effects. We saw a clear and dramatic presentation of the terrible flood and storm which engulfed Leningrad in 1824. The illusion of people drowning, rowing in boats and swimming on the stage was extraordinary.

20th of July

A short stroll through a local park provided us with a charming view of mothers and young children. Most of the babies were swaddled (up to the age of 8-9 months). The toddlers were dressed in knit hats and wore leggings and sweaters, despite the fact that the temperature was about 80ºF. There was the same ingestion of pebbles and dirt by the children that one finds in parks all over the world and the same concern of mothers in trying to retrieve these "goodies" from the mouths of the young ones. We then rode out to the village of Pushkin, about 20 miles from Leningrad, formerly the Czar's village. Many people were bathing and having a good time at this former palace of Catherine II. Our driver, as did all other drivers, had the habit of shifting gears into neutral at high speeds, including driving across railroad crossings. This technique evidently saves gasoline, while it imperils lives.

In the afternoon, I visited the Pavlov Institute and had a most interesting conversation in English with Professor Anichkov, the Director of the Department of Pharmacology. The laboratory looked very much like the pharmacology laboratory at the Royal College of Surgeons in London. The equipment was good and uncomplicated. There was frequent use of smoked drums instead of electronic recording equipment. In fact, the EEG was the only electronic equipment in regular use. Professor Anichkov’s people developed a new muscle relaxant of the competitive type about which he was enthusiastic. While I was there, he was involved in attempts to get an Argentine visa for the meeting of the International Congress of Physiology in Buenos Aires at the end of August. He has a very bright graduate student whom he is preparing for a career in anesthesiology. Just before I left, he asked me to talk into his tape recorder, which I did. He had recordings of other foreign medical scientists, among them a few Americans, including the pharmacological committee of which Dr. Louis S. Goodman was a member.

Had dinner with an American journalist of Russian birth, one of the emigres who had returned to Russia to visit his birthplace. (At least half of the American tourists were in this category.) He is fluent in Russian and was able to talk freely with many people. He believes, as I do, that most of the people are kind and friendly and very curious about American attitudes and customs. He also found an alarming ignorance among Russians of American points of view and customs. This ignorance is due to the block of language communication, the misinformation about the United States in the Russian press, and the lack of contact with foreigners. For examples we were asked over and over again about 1) The massive unemployment in the United States; 2) The frequent lynchings of Negroes in the United States; 3) The "war-like" aims of the United States; and 4) "Why do the Americans want to kill us?" The usual concept of a labor strike in the United States is that the "capitalists" lock out the workers and don't let them work to starve them into submission. They are also convinced that the Russian workers have the shortest work week in the world – 8 hours a day, 6 days a week. Russian doctors were usually non-political and steered away from controversial subjects. I wondered also about the effectiveness of our "Voice of America" programs, if and when they reach the Russian listener. (Apparently, the Voice programs in the English language are not jammed, but I had no success in finding the proper radio frequency.) Our concept of freedom has little meaning to these people - since they have never experienced it. As our interpreter put it - if the State cares for me and gives me security - why do I need voting machines?"

22nd of July

Awakened by a cheerful phone call at 6:00 a.m. as requested, which surprised me, since personal services like getting mail, telegrams or telephone messages to the tourist were rather casual. We went to the Leningrad airport with an Intourist guide who was most cooperative and agreeable. We got on a Russian built twin engine jet plane for Moscow at 8:30 and the plane promptly started to roll at 8:45 a.m., on time.

The plane had tourist-type equipment and a full complement of 100 passengers. Seats were three abreast on one side and two on the other. The cabin contained no frills, but included the usual safety devices, e.g. seat belts and oxygen. The stewardess' announcement that the seat belts should be fastened provoked much good-natured laughter, but compliance on the part of most people ensued after lively discussion. My neighbor was a robust individualist who thought it silly, to put on the seat belt. It probably was too new fangled for him. He simply would not fasten his seat belt. This was the only evidence I saw in the Soviet Union of direct defiance of authority. As a matter of fact, he went so far as to prevent me from fastening my seat belt and actually unbuckled it for me. He indicated through a combination of sign language and writing that our flight would be at 27,000 feet, and 525 miles per hour. We were the only Americans on this flight and the only other foreigners were several Chinese. We arrived in Moscow after a very pleasant 55 minute flight and were then driven to the Hotel Ukraine.

Air service throughout the trip was excellent. Planes took off on time and landed on time. This was another example of a trait that ran like a central theme through all my experiences - medical and otherwise. Tremendous energies may be invested by the Soviets along specific lines. What they decide is important will be pursued with vigor and often with spectacular success by mobilization of the best talent of the country, facilities of the most modern kind, and the highest of standards. Those areas which are not considered important are handled in desultory fashion. This quality may explain some of their advances in heavy industry, militarism, technology, some aspects of medicine and the theater - and may also explain the relative lack of consumer services - clothes, adequate housing, and food distribution.

At dinner, we met some members of the advance press party assigned to cover the visit of Vice President Nixon. We caught up on the news of the rest of the world from them. It was amazing how completely insulated we were from the news since we could understand nothing over the radio or on television, and the only English language newspaper in the Soviet Union was the Moscow News, a summary of Pravda. The London Daily Worker occasionally appeared on the hotel newsstand in Moscow and was bought at once by English speaking persons. Our Embassy published a short mimeographed information bulletin every few days. One could obtain it only at the Embassy offices.

23rd of July

Had breakfast with a child psychologist and her husband, a business man from Detroit. This was another type of American tourist, who came to the Soviet Union convinced of the magnificent wonders of all things Russian and completely uncritical. The psychologist was particularly impressed with the "natural childbirth" movement in Russia. She remarked on how modern the Russians were and that they were doing so much better than the Americans and British in having developed natural childbirth so completely. When I pointed out to her the medical side of the picture - that there was no anesthesia as yet available for obstetrics thus accounting for the "natural childbirth" movement and that there was very little attention paid to obstetrics at all - she was quite taken aback. What she interpreted as modern natural childbirth was actually the ancient Russian way of child bearing - a woman stops working, has her baby and resumes working again as soon as possible.

In the morning we went to the Pushkin Art Museum with our guide Sergei Tarasenko. Unfortunately Mr. Liebman, the Director, Mr. Rousseau's friend, was on vacation, so we did not have the same benefits that we experienced in Leningrad at the Hermitage through his help. However, we followed Ted Rousseau's suggestions and saw an extraordinary Egyptian collection. I also liked the French pictures which included many of Matisse.

In the afternoon I had an appointment with Dr. D. Venediktov, who is the Minister for Foreign Affairs in the Ministry of Public Health. Dr. Venediktov is a most intelligent person in his late thirties. He generously offered to make arrangements for my visits to hospitals, clinics and the medical institutes. He pointed out that I might have some difficulties because of the vacations of a few of the best people. This in fact did turn out to be the case and I never met Petrov, who, Sir Robert Macintosh told me, is one of the most able surgeons in the Soviet Union.

Dr. Venediktov's English was fluent and rich in vocabulary. He was well informed about my background, my interests and also knew the whereabouts of the Russian physicians and scientists who worked in the fields of interest to me.

After this visit with the Minister of Health, we walked through Gum's Department Store, facing Red Square. It is one of the most incredible shops I have ever seen. We then walked around Red Square. This, we were informed, is a name that goes back to medieval times. It means "beautiful" Square and evidently has nothing directly to do with the Bolshevik Revolution, although the Soviets use the area for the review of troops on May Day and the 7th of November, the anniversary date of the Bolshevik Revolution. On one end of the Square is the famous St. Basil's Cathedral with its onion-shaped golden domes shining in the sunlight.

On the way back from Red Square we noticed that our driver was reading a book, and on inquiry, discovered that it dealt with the McCarthy Trials in the United States. Shortly thereafter we noted a sailor in avid discussion with a Russian-speaking American and, they were, I was told, discussing Dostoyevsky. This observation of ordinary people reading important books was multiplied many times over. There is a terrific thirst for knowledge and much serious reading by many working people. Many Russians seem more interested in culture and learning than does the average person in the United States. This could be symptomatic of a serious problem for us in the future - in the competition of these two ways of life for the minds of men.

Among the permitted, and therefore favorite, English and American authors, as observed in the bookstores, are Dickens, Faulkner, Galsworthy, Jack London, Hemingway, and Willa Cather. Howard Fast is still represented, although he has renounced the Soviets. We also learned that there was a private printing of 40,000 copies of "Dr. Zhivago" in Russian, which was sold out immediately.

A comment about my interpreter may be of interest. Sergei Tarasenko is 22 years old and a member of the Communist Party, of which he is very proud. In the Soviet Union, membership in the Communist Party makes one a member of an elite group. As Sergei described it, membership does not provide privileges, but confers added obligations upon him. He volunteered for work in the "Asiatic virgin lands", and he has also worked in public utility plants and developed an interest in electronics. His major study is philology and teaching, and he is becoming an expert in the English language. His knowledge of good literature both Russian and English is amazingly wide. His knowledge of economic facts is also very broad. He regularly reads the New York Times, Time, U. S. News and World Report and the Survey of Current Business published by the United States Department of Commerce. These publications, he says, are readily available in the Lenin Library (comparable to our New York 42nd Street branch of the Public Library) in Moscow. He is less interested in British magazines and journals of the same type. In other words, he not only is well informed about Marxism - Leninism, but he is also well informed about American politics, economics, and literature from American source material. We would do well to have more of our young people read Soviet material of this sort to improve their understanding of the Soviet Union and Communism. It will make them better Americans to be more completely informed.

24th of July

Had breakfast with a Dutch business man, who, like so many Europeans of small countries, is fluent in English, French, and German, as well as his native language. He described the methods of business barter used by the Soviets and how some American companies conduct their business activities by selling non strategic materials to the Soviet through Holland. He confirmed my belief that there is great development along rather narrow lines in the Soviet Union. On illustration of this point, he described a synthetic rubber in the Soviet Union, which is at least as good and probably better than the similar American product. He also mentioned the relatively unsuccessful efforts of American drug companies to sell drugs to the Soviet Union on a barter basis. Our Dutch friend felt doubtful that the Soviet Union could have modern industrial development on a par with the West because they had insufficient capital.

Spent most of the day with Professor Zhorov [Photo] at the 1st Medical Institute. Zhorov is about 55 years old, very friendly, a handsome, stocky man, and quite attractive in many ways. Zhorov was the Chief Surgeon of the Red Army on the front from Moscow to Berlin. He was a pupil of the great Russian Surgeon, Burdenko and he also had training with the German surgeon Sauerbruch. At present, Zhorov is the President of the Soviet Society of Anesthesiologists, although he is a surgeon. He is considered by the Russians to be the father of modern anesthesia in the Soviet Union. His particular interests, aside from sponsoring the development of anesthesia, are thoracic surgery, the surgery of aneurysms and thyroid surgery.

He has taken on the task, in a way reminiscent of the work of Dr. Arthur M. Wright in New York in 1934, of establishing modern general anesthesia in the USSR. He was one of a small group of Soviet surgeons who went to Britain in 1957 to observe the practice of anesthesia in that country. Zhorov wrote a book on anesthesia and is now completing the second edition of this book which he will send to me. He speaks only Russian.

I visited operating rooms with him, saw anesthetic equipment and made surgical rounds. There were two large operating rooms, 2 tables in one operating room and 2 in the other. There were open electrical connections on the floor and no grounding. The floors were not conductive. I saw one appendectomy with local anesthesia. The patient was moderately uncomfortable but cheerful and tolerant of his discomfort. Two thyroidectomies were performed with the aid of endotracheal general anesthesia. The surgical technical dexterity was excellent.

There are five doctors on the anesthesia staff, the most experienced of whom is a man named Dr. V. M. Jurevich. He is an excellent person, a young man of about 35, speaks French very well and apparently with Zhorov’s encouragement and backing is establishing an anesthesiology service. There are also five nurse anesthetists in his department.

The general approach to a patient is something like this. The nurse inserts an intravenous Gordh needle. Thiopental 0.2 to 0.5 gms. is injected, oxygen is given and curare, 15 mg. is used for "easy" cases. Succinyl choline is given to intubate the trachea in "difficult" cases. I could not discover why succinyl choline was reserved for "difficult" cases and curare for "easy" ones. A folding laryngoscope of the Flagg type was usually used although a Macintosh laryngoscope was available.

Preanesthetic medication was almost always chlorpromazine, phenergan and a narcotic, which is similar to demerol. This influence of Laborit’s methods is great, probably because of Jurevich's familiarity with the French literature. After the anesthesiologist intubates the trachea, the nurse usually conducts the remainder of the anesthesia. An anesthetic chart is kept, and respirations are counted and recorded. Blood pressure is usually not measured, although a cuff is available.

The anesthesia machines were the Danish Dameca (a Boyles type), and McKessons made in Britain. Soda lime was packed poorly and incompletely in all machines. Gas flows are set at 3 liters of oxygen and 3 of nitrous oxide, a practice which suggests that there is an ample supply of gases.

The Ministry of Health recently decided to make anesthesiology an important specialty in the Soviet Union separate from surgery. It prescribed a training course in anesthesiology for doctors of two years duration after two years in rural general practice. This, I was told, was identical in duration and in method with surgical training. It was also decided that there will be one anesthesiologist for each 100 beds for clinical work. Research personnel will be additional in number. There will also be two anesthetic nurses for each 100 beds. The latter will be trained to work in the small rural hospitals of the country. I was told that there were now 200 doctors in the Soviet Union in anesthesia, but I could find little direct knowledge of their training or their locations. One anesthesiologist, Dr. Victor P. Smolnikoff, was trained by the British in Shanghai before World War II (see below). I also know of a female physician who was trained at the WHO course in Copenhagen in 1958. Others were trained by the surgeons, Zhorov, Kuprianov and Petrov. Several good training centers already exist in Leningrad and Moscow.

Professor Zhorov estimates that Soviet anesthesia is five years behind that of Britain, as he judged it from one month’s stay in London. This clearly is seeing things through "Red" colored glasses. However, there is no doubt that the Soviets really mean business about developing anesthesiology and, in keeping with their trait of pushing progress when they want to, they surely will make rapid clinical progress. They will be hampered in research by the unfortunate influence of Laborit’s work and by the difficulties of adherence to Pavlovian physiological dogma.

Postoperative wards in the First Medical Institute are five in number. They are equipped with oxygen and suction. I saw patients who had esophogectomy (1) gastrectomy (1) and appendectomies (3) in the immediate postoperative period. I saw one postoperative pneumonectomy patient, who was given endotracheal general anesthesia as are all the chest cases in this hospital. This man had cupping marks on his chest. He had an excellently performed pneumonectomy, but developed atelectasis in the remaining lung for which he was treated, curiously enough, by cupping. I was also told that cupping was used for transfusion accidents. I heard of a staff member of the United States Information Service who had an appendectomy in Moscow, was most unhappy with the local anesthesia and with the melting of wax on his chest which burned him. Obviously he had also been cupped and didn’t recognize what it was! This is once again an illustration of the medical contrasts in the Soviet Union - the most primitive practices side by side with the most modern methods.

Zhorov is familiar with the British anesthesia literature, but he has less familiarity with American writings. Although he does not speak English, he can read it. Zhorov criticized the Beecher-Todd anesthesia death report quite severely. He said it did not conform to Russian and other European experiences in that muscle relaxants were not responsible for deaths in the manner described in the American monograph. He hoped that American anesthesiologists did not concur with Beecher in the idea that relaxants were dangerous.

In the late afternoon, we rode to the country with Zhorov who is one of the few Russians who owns an automobile. Our destination was a palace that belonged to a Prince in Imperial times and was now a museum. The countryside around Moscow is quite nice. We saw "Tosca" in Russian translation that night and had a very pleasant evening. The opera was beautifully performed, with excellent voices and exquisite settings.

25th of July

Met Dr. Victor P. Smolnikoff, who is a most unusual, alert and intelligent person. Dr. Smolnikoff was one of the relatively few well-dressed men I saw in Russia. He had a career which is almost unbelievable - and most glamorous. The bare outlines are these: He is about 45 and was born in Northern China of Russian parents. His medical education was in a French school in China. He then practiced medicine in Shanghai during the Japanese occupation. He learned anesthesia there and worked with a British surgical team. He was probably the only neutral Occidental in China since he was a Soviet Citizen. (The Soviets didn't enter the War against Japan until the summer of 1945.) Smolnikoff saw the Chinese Communist Revolution at first hand. He is an ardent supporter of the Revolution. He said that the Chinese Communists stopped robbery, inflation and privilege. During his stay in Shanghai he wrote a book on anesthesia in the Russian language, which, he says, was based largely on Burstein’s "Fundamentals of Anesthesia". He gave me a copy of this book. Smolnikoff was invited, probably because of the book, to come to Moscow in 1954, a time which coincides roughly with the beginnings of serious interest in the development of general anesthesia in the Soviet Union. He is, therefore, the first trained specialist in anesthesiology in the Soviet Union, who was not first a surgeon.

In the First Thoracic Surgical Clinic, where Smolnikoff is in charge of anesthesia, high standards of medicine were practiced. The anesthesia machines used by Smolnikoff are the British EMO and some old Russian machines, now largely obsolete. Smolnikoff prefers the EMO and uses it with ether and air in the manner described by Macintosh. He uses relaxants freely, both succinyl choline and curare. British Magill tubes are the most commonly used endotracheal tubes and the British built Mcintosh laryngoscope is used exclusively. The anesthetic technique most generally used consists of light ether, air and muscle relaxants in the Oxford tradition.

Endotracheal general anesthesia is now used for nearly all thoracic surgery in this chest hospital. One thoracic surgeon of the old guard still does his intrapleural operations with local anesthesia. Smolnikoff believes that local anesthesia can be used safely to operate within the chest, although it is uncomfortable. The staff are now convinced (except for one surgeon) that the patients do much better with general anesthesia. This view was confirmed by the Chief Surgeon, who, nonetheless, did not feel justified in interfering with the surgeon who still works with local anesthesia. Smolnikoff thinks that the patients who get local anesthesia breathe satisfactorily because of the stimulus of pain.

Smolnikoff described his idea of "lung massage" which he thinks may be useful for deflation of the chest in acute asthmatic attacks. Some dog experiments have been performed in which tubes are placed into both pleural spaces and a endotracheal tube is inserted into the airway. Positive pressure on the airway is followed alternately by positive pressure in the pleural catheters. This method has worked well in relieving bronchospasm produced by prostigmine in the dog. Plans are ready to study this problem in man. The idea is to inflate the lungs by positive pressure in the airway and to deflate them by positive pleural pressures in an alternating rhythm. It is an interesting idea.

There is one operating room on each floor, each used for patients with the same kind of thoracic disease. It is a beautifully equipped hospital. There is an oximeter, a carbovizer, and EKG, and EEG in each operating room. There is a good laboratory with a physiologist and a pharmacologist assigned to the Anesthesiology Department. Each anesthesia is conducted very lavishly in so far as personnel is concerned. There is a team of one senior and one junior anesthesiologist assisted by a nurse who records all the data on special and detailed charts. These are the best anesthetic records that I have seen anywhere, but they require a full time secretary in the operating room. The possibility of doing this type of recording mechanically should be considered.

I then conducted a staff conference with Smolnikoff's department of some twenty anesthesiologists. The Director of Surgery and several of the basic scientists also came. Smolnikoff acted as the interpreter and was an excellent one because of his wide experience in both the English language and in Anesthesiology. I showed them some American plastic needles, syringes and endotracheal tubes. They could not understand why we were so interested in plastic material and why we made much about the sterilization of endotracheal tubes. This led to a discussion of the relative merits of various methods of sterilization of anesthetic equipment.

They asked many questions, for example, (1) What are the duties of an anesthesiologist in the United States? (2) How can an anesthesiologist work in a capitalist system and still take effective care of his patients? (3) What relaxants do American anesthesiologists use? (4) What are my thoughts about the use of different kinds of relaxants in one patient? (5) What is the reticular formation and how does it relate to problems in anesthesia? (6) How Is the United States Pharmacopeia put together and why does it have conflicting opinions in it? Is this due to capitalistic profit? (7) Are there problems of hypercarbia and hypocarbia during open heart operations? (8) What kind of preanesthetic medication do we use for children? One can see that this is a very alert group, medically well informed and yet there is the curious need to mix politics and economics in medical staff discussion. Possibly, this admixture is due to simple curiosity. I believe I am the second or third American anesthesiologist to visit this hospital, and it is understandable that they might want to satisfy their curiosity about many things in the relatively short time available.

In the afternoon, we went to see the bodies of Lenin and Stalin in the mausoleum. This is a truly remarkable experience. Foreigners step into line ahead of the thousands of Russians, many of whom wait many hours to visit the tomb. The Russians seem delighted to make way for foreigners, even though they may have been waiting patiently for hours. There is an atmosphere of profound religiosity about this mausoleum. People not only stand in line for 5 hours or more, but have done so since Lenin's death regardless of the weather or the time of year. There is a hush as one enters the mausoleum. Guards stand at attention. I whispered something to my interpreter and was quickly hushed by the crowd. The two bodies are remarkably life like, looking as though they are merely sleeping. Lenin's right hand is clenched and shortened, presumably due to the hemiplegia he suffered before his death.

We then visited the Kremlin, an ancient fortress consisting of beautiful old churches which are now museums, government buildings, and delightful gardens. There are courteous police everywhere in the Kremlin. (In this connection, I may say that the policemen we observed in the Soviet Union were most cooperative.) The Kremlin in fact, is not at all the sinister place that many Americans imagine it to be. It is open and one may photograph at will. One can in fact photograph the buildings inside and outside the Kremlin, except for the bridge which is directly below the Kremlin wall.

Met Dr. Donald Martin, United States Air Force, who is the new medical attache to our Embassy in Moscow. He is a very intelligent young physician from Minnesota. I invited him and his wife and the Smolnikoffs to have dinner with us. We had a very pleasant four hour meal with good talk. Martin is a credit to the United States in that he is medically bright, personally charming, comes from the backbone of America, and speaks Russian fluently after only 5 months instruction in Washington, D. C. prior to taking on his Russian assignment.

26th of July

Went in the morning to the American Exhibition in Moscow. Had a very difficult time getting tickets, which we finally obtained from our Embassy. Breakfast first with Miss Rubenstein, a niece of Helena Rubenstein, from whom we learned about the Institute of Cosmetology in Moscow. This is a place where tests of cosmetics are made. There is also a hair-extraction department and a section served by a plastic surgeon and a dermatologist, both of whom are permanently assigned there. Miss Rubenstein thought that the Institute was 20 to 30 years behind the times, as far as equipment and methods are concerned. She believed, however, that the Russians could develop the cosmetics industry very rapidly if they wished. She thought that there was some evidence that there would be increasing interest in good grooming as a result of the American Exhibition.

The American exhibition was jammed by thousands of Russians. All the tickets were free and were distributed by the Soviets via trade unions, factories and other places of employment. This was the only large crowd of Russian people that I saw that was unruly, but not rude. The unruliness was probably due to the intense curiosity about America and about the Exhibition. The exhibition has the defect, in my opinion, of emphasizing consumer goods too much. Those products were, to be sure of great interest to the Russians. However, they have such a worship of science, machinery and heavy equipment that it would have been wise to show how food packaging, medical science, and heavy industry actually operated. They had been warned by Pravda and other channels of communication that the Exhibition was purely propaganda and were told that it was unrepresentative of American life. This warning against propaganda is easy to accept by the average Soviet citizen because he knows that his own exhibitions may be unrepresentative of Russian life. They were also told that the things that were alleged by us to be available to the average worker were far too expensive and could be bought only by capitalists.

The fashion shows were considered immodest, improper and "defiant". I thought, however, that the clothes were excellent even though somewhat meaningless to those Russians. The fashions were a bit too jazzy and showed things that could not have meaning for them - elegant sport clothes, fancy bathing suits and frilly dresses - when the Russians' interests and needs are good house dresses and working clothes at the present time. A good feature about the selection of models was that they were of all ages and both sexes including two very good looking Negro girls, one Negro man, and one Hawaiian girl, in addition to the white models.

Sergei, our guide, was unhappy about this fashion show and he said that it confirmed the belief Russians have that Americans are boors and uncultured (a terrible criticism in Russia). Sergei took me to a fashion show in the permanent Soviet Exhibition to show me the difference. This show had rather drab house dresses, but it was obviously enjoyable to the Soviet people, because these are the things they need at the present time and may represent their present standard of taste.

The Soviet Exhibition, which is not far from the American one, has elegant buildings for each Republic to show its products. There are also exhibits on science, art, medicine and other aspects of life in the Soviet Union. The idea of a permanent exhibition of this sort is a very good one. The United States would do well to have one in Washington, New York, or San Francisco. At night we went to a puppet show, which was very good indeed, in fact the best puppet show that I have ever seen.

27th of July

Up early in the morning to go to work with Smolnikoff by 8:30; I didn't dare take time for breakfast because of the impossibility of eating and getting there on time. As usual, however, the taxi was late so that I arrived late, and in addition, had no breakfast. I had an interesting conversation with Admiral Rickover in the elevator before leaving the hotel. He also skipped breakfast because of an appointment. He is a very pleasant, small and quiet man, quite different from the impression of blunt toughness I had from reading his strong minded statements in the press.

On arrival at the hospital, we started with a patient with mitral stenosis. Anesthesia was induced with thiopental and oxygen and nitrous oxide were added. He was intubated with the aid of curare. A laryngeal spray was used and a little ether added later on. The old model of Russian anesthesia machine was used and controlled respiration was employed. Oxygen was given up to the time of the starting of inhalation anesthesia with the Ruben AmBu hand resuscitator. A surgeon who was a member of the resuscitation team exposed a leg vein and injected relaxants and other drugs at the request of the anesthesiologist. This surgeon stayed with the leg vein throughout the operation, remained scrubbed, and his sole function was to administer fluids or drugs as advised by the anesthesiologist. The infusion material was of rubber. An EKG was used and monitored with an oscilloscope and a direct recorder. A cardiologist and a technician remained throughout the operation to do this task. An oximeter and a carbovisor were used. These were read by the senior anesthesiologist. A junior and senior anesthesiologist and a recording nurse-secretary were employed. This was a glorious splurge of personnel and rather wasteful of people.

I then went to the laboratory of Resuscitation headed by Professor Negovsky. He is a very personable fellow. He had a press photographer there taking pictures of us everywhere we went. We saw the classical experiment of the dog "killed" by hemorrhage and revived after 5 minutes of "clinical death". The principles of resuscitation are artificial respiration with positive-negative mechanical pressures, arterial transfusion of the amount of blood lost, and occasionally the addition of epinephrine to the transfusion. Defibrillation was performed with a condenser DC current discharge of 3000-5000 volts (probably 1000 to the animal). Resuscitation progress after recovery was studied with the aid of responses to conditioned reflex testing. Dogs are usually normal by these standards after 2-3 days. Hypothermia of 27°C. prolongs the ability to restore "life" up to 1 hour of "clinical death".

After this visit, I returned to see Professor Zhorov again where I had lunch. After lunch, he did a thyroidectomy with considerable skill in approximately 12 minutes. A lytic cocktail was used for premedication. Nitrous oxide and oxygen were given via an endotracheal airway. He then operated on a patient with a large arteriovenous fistula of the femoral artery and vein in 1 and a quarter hours. It was beautifully done. I anesthetized this patient at Professor Zhorov’s request. Morphine and atropine had already been given. I used thiopental and succinyl choline intravenously after giving oxygen for three minutes. Curare was used during maintenance. I changed the gas machine from the left to right side of the table, a move which created quite a stir. Another surprise to my hosts was the easy intubation despite the presence of teeth in the patient's mouth. Evidently, these anesthesiologists believe that the presence of teeth causes a serious technical problem.

(A note on primness in the Russians which surprised me. There were many small evidences of it from time to time. The most curious was Professor Zhorov's apologies to me about changing his clothes in my presence before the operation.)

28th of July

In the morning to the Armory in the Kremlin to see a most extraordinary collection of armor. In the afternoon, we went to the Tretkayov Art Gallery. The most striking painting, rather macabre, was of Ivan the Terrible killing his own son. People stare at this painting with morbid curiosity, and one man is alleged to having gone mad while looking at the picture and attempted to destroy it. We also saw modern Soviet paintings. The subject matter was usually devoted to the virtues of labor and farm work. These pictures were on the whole quite dull. However, we saw an interesting collection of modern paintings by a Russian artist named Rerech, the only modern Russian artist whose work showed vitality or originality.

29th of July

To the airport at 4:30 a.m. to leave the Soviet Union on an old twin engine airplane similar to the one we flew into Russia from Helsinki. It was a very pleasant low level flight from Moscow to Kiev, where we saw a curious thing as we were refueling. Four Russians had missed another plane although they were sitting at the airfield waiting. They became highly indignant. The plane that they had missed had been closed, engines were warmed up and the gangway was removed. These engines were then idled, a ladder lowered and the people allowed to get on. This was another of the curious contrasts in the Soviet Union. Imagine this kind of solicitude occurring at Idlewild, Midway or National Airports if our people had missed a plane!

The next leg of the flight was to Lwow, a city formerly in Poland and now within the territory of the Soviet Union. At the airport there was an excellent lunch very rapidly served to keep the plane schedule on time.

At lunch one American couple told us of the theft of a diary in Moscow and the deliberate spoiling of film, which they alleged was sabotage. Another woman, aged 38 or so, very good looking and shapely, described how she was followed in Moscow all the time. She very likely was followed, but I don't think the reasons were political. I had no experiences of this sort, although I openly and freely took pictures and made notes. It seems that the real dangers to our way of life from the Soviet world are grave enough without inventing these petty fantasies.

We went through the Russian customs at Lwow and had to show the postage stamps we had bought (worth $17) but there was no other search of any luggage. One man had some excess rubles, and was told he could take out only 20 rubles ($2 at the tourist rate of exchange). He was advised to buy gifts for the remainder of his Russian currency.

We arrived in Vienna on time after a somewhat bumpy flight over the Carpathian Mountains. The highest altitude achieved by this non-pressurized airplane was 6000 feet. Vienna was hot and muggy. Shortly after we arrived there was a massive rain with hail! We were lucky not to be aloft in the old Russian plane at the time of the hail storm.

We found a delightful letter from Jayne Wrightsman with a complete list of the beautiful things to see in Vienna - a very generous and welcome letter. There was also a letter from Ted Mayrhofer who delayed his vacation to show us something of the city and the University of Vienna.

30th of July

In the morning we went to the Kunsthistorisches Museum to see the beautiful paintings of Breughel, Rubens, and Rembrandt, and the famous "Salt Cellar" of Cellini. These were the lovely things that Jayne suggested we see. In the afternoon Ted and Duglore Mayrhofer picked us up to drive to the country to look at some Roman ruins not far from Vienna. We also visited Haydn’s birthplace and then went to the town of Eisenstadt near the Hungarian frontier. We returned to Vienna and went to a Heurigen, (a wine cellar) called "Der Dritte Mann". This type of wine room is a typical place for the Viennese to enjoy themselves in the evening. One can order young wines and simple foods. There is good music with much community and solo singing. People get quite friendly, sit with strangers at tables, loosen up a good deal and drink rather large quantities of wine. Duglore, Ted and I drank about 750 cc of new wine each and even Julia, who is a total abstainer, was induced to sip approximately 10 cc of wine in the course of the evening. This custom has deservedly given the Viennese the reputation of being friendly people who are fond of music and gaiety.

31st of July

I went to the second surgical clinic at the University of Vienna to watch some anesthesia in Dr. Mayrhofer's department. We visited a boy who had tetanus and was 9 days post-convulsive. He was doing very well, with simple sedation and no longer required muscle relaxants. We then went to the operating rooms and saw a middle-aged patient who had a radical hysterectomy with nitrous oxide-oxygen-curare. The patient did not breathe and did not awaken promptly. The question arose whether this was due to previous and prolonged hyperventilation rather than to anesthetic drugs. She recovered completely in one hour with artificial respiration. Practically all of the machines in Dr. Mayrhofer's clinic are of Dutch manufacture and Boyle's in type. In his department, there are 17 women and 7 men. There are 5 attending anesthesiologists and the remainder are residents. The training period consists of 3 years of hospital work in general medicine and surgery followed by three years of anesthesiology, at least one of which must be in a university clinic. The clinical training program appears to be excellent and opportunities for research are in the process of development.

We had lunch at Professor Antoine's home and met Dr. & Mrs. Steer from South Africa. They discussed the South African race problem and we listened to Dr. Steer’s view of the problems of apartheid in his country. He was of British origin and was unsympathetic to the current policies in the Union of South Africa. This problem is well known to the Soviets and one can imagine how they will seize it as a political issue when the struggle for Africa is joined. This concept of white supremacy will provide much meat for the Soviet grinder in their attempt to take over the former colonial peoples of Africa.

We then had dinner at the Hochhaus overlooking the city and went to the Hofburg Theatre to see "Die Fledermaus". It was a sadly dated piece compared to modern light opera in the United States, but the Strauss music was pleasant, and we had an agreeable time.

1st of August

Drove out with the Mayrhofers to Baden by way of the Vienna Woods. It was beautiful country, and it is easy to understand why music inspired by the Vienna Woods is so popular, not only with the Viennese, but with people in the rest of the world.

On our return to Vienna we saw street fighting and demonstrations by members of the Communist Youth Festival. There were parades and much shouting of "peace and freedom", much of it in the German language, but there were also ambulances whose occupants were casualties of this kind of "peace".

In Moscow we had read and were told that the Youth Festival in Vienna had completely captured the city and was the most important function going on in Vienna. As a of matter of fact, in the four days of our stay in Vienna, we saw only fragments of activities of the Festival. The Austrian press gave it the silent treatment, and there were groups of young anti-communist Austrian students who spent much time debating with other members of the Youth Festival. The Saturday night parade was the only really large scale activity in the main part of Vienna and it was not all "peace and freedom" by a long way. There were well organized anti-communist youth groups from various other countries to oppose the previously unopposed communist activities of other years.

2nd of August

Off to London by way of British European Airways from Vienna on the Viscount, Flight 265. It was an easy flight. We knew we were on British soil when the stewardess asked us to fasten our seat belts as though she really meant it. We landed in London on time and were delighted to see Dr. Francis Turner waiting. We were most grateful for British dependability. He drove us to his home in Hungarton near Leicester a drive of almost 100 miles. He was most kind and generous to do all that traveling on our behalf. En route we had a pleasant dinner in a 16th century Inn.

3rd of August

Up early as usual and breakfast with the Turner family. It was very nice once more to have a hearty breakfast. I weighed 12 3/4 stone (179 lbs). At breakfast, I met Margaret, aged 10 and Robert aged 6, the two younger members of the Turner family. I was the first foreigner the children had ever seen. They knew Americans only as cowboys or Indians in Western films on television. Margaret was crushed when she realized I am not a cowboy and that I did not have an Indian with me.

After breakfast I gave the children some American, Finnish and Russian coins which delighted them no end. We played arithmetic games with them and the children had less difficulty with the metric system of the coins than did their parents. They polished their American coins until they glistened. We became fast friends.

We visited Belvoir Castle, the home of the Duke of Rutland. The castle is actually new (100 years old), the old one having burned down. It was jammed with British tourists on their Bank Holiday. The castle doesn't begin to compare with Russian grandeur, but it had several paintings by Reynolds and Gainsborough and also the famous Holbein painting of Henry VIII, (original I was told).

After this visit to the castle there was "tea" - really a picnic lunch and I watched my first cricket match. It is a pleasant, although leisurely game, and not so ridiculous as most Americans would have it. I think it is even possible for an American to learn the game.

We went back to the Turners for dinner and saw Dr. John Sandison once again. We enjoyed talking over old times of his residency at Presbyterian Hospital. I was delighted to know that he had passed Part I of the Examination of the Faculty of Anaesthetists of the Royal College of Surgeons and will take Part II in January. I also met Dr. Patrick J. O’Neil who will emigrate to the United States and come with us for training on the first of July 1960. He is an alert young physician who had an interesting time in his military service in Malaya and Hong Kong which he described for us.

4th of August

I visited at the Leicester Hospitals with Dr. Francis Turner. There is a small chest hospital of some twenty beds where we met Dr. Brown, an anesthetist, and Dr. Gordon Cruickshank, a thoracic surgeon. They were repairing an inter-atrial septal defect during hypothermia. The patient's esophageal temperature was 30°C. The operation went beautifully. The surgeon used total circulatory occlusion for a period of 6-3/4 minutes in order to repair the defect.

Phenergan and demerol had been used for premedication. Thiopental was given for induction and intubation was accomplished with the aid of 25 mg. of curare. Nitrous oxide and oxygen were used and the patient put into the bath at 18°C. Ice was then added for cooling. Only oxygen was used after the temperature declined below 34°C. The only measurement attempted was the EKG which didn't work because of electrical interference. No blood pressures were measured.

We then went to the other two hospitals and saw a most interesting arrangement of facilities. 30,000 patients are operated upon annually including 6000 in the out-patient department. Operations on veins, dental extractions, and cystoscopic examinations are among the out-patient procedures. Full general anesthesia is used and facilities for recovery are provided. All induction rooms are equipped with wall-fixed machines designed by Dr. Turner.

On the door of the sterilizing room in the corridor next to the operating room was this sign, "If anything is required of extreme urgency, knock quietly and wait". How typically British this is!

We then went to see a Catholic nursing home where private patients are operated upon. It was a very clean, small institution. In Britain, many of the Catholic hospitals have actually become private hospitals, because, being church-sponsored, they were not taken over by the National Health Service.

We then drove down to Stratford-upon-Avon. The village was extraordinarily crowded. As a matter of fact, it was a typical tourist town with shops, souvenirs, boating, and "American bars". We had a pleasant dinner in a restaurant in the theatre, and saw "Coriolanus", a magnificent play done in the grand manner. The sets were designed by Boris Aronson and were wonderful. Among the brilliant cast were Sir Laurence Olivier, Dame Edith Evans and Mary Ure.

5th of August

Up early and another good hearty English breakfast. I was met at the hotel by Mr. Salt, who is Sir Robert Macintosh’s laboratory assistant. He drove us down to Oxford, a very pleasant drive of one hour. Macintosh, as usual, was very generous with his time and attention. He is a remarkably urbane and intelligent person. We saw a patient anesthetized with the EMO anesthetic apparatus and given the azeotropic mixture of ether and halothane. Macintosh is firmly convinced that air is better than oxygen for anesthesia and uses the EMO for ether, fluothane and this new mixture in the lightest possible anesthetic levels with the aid of muscle relaxants. Respiration is controlled with the bellows of the EMO either manually or by a mechanically driven window wiper type of machine. The patient's arms are folded across the chest instead of using arm boards.

Special things I saw in Oxford, (1) A Mitchell non-rebreathing valve designed for controlled respiration. It is controlled by bar magnets in the valve which tend to keep the inspiratory port closed and expiratory port open. Positive pressure opens the inspiratory port easily by overcoming the magnetic force and allows gas to go to the patient, automatically shutting the expiratory port. Relaxation of positive pressure permits the magnetic force of the bar magnets to close the inspiratory and open the exhalation port. When spontaneous respiration starts, an overflow valve must be present in the circuit and the magnetic force rendered non-operative by reversing the valve; (2) Mitchell needle. Dr. Mitchell also designed a needle to replace the Gordh needle. It has a lateral opening and an occluded tip very much like the Sarnoff spinal needle. A spring keeps a rubber guard over the skin and against the vein wall and thus keeps the needle opening free of clotting; (3) Oxford endotracheal tube - the right angle tube (from the base of the tongue to the teeth) is said to prevent the tube from going too deep into the airway; (4) a bicycle pump valve for blowing up endotracheal cuffs and for pumping blood.

I met Dr. Epstein the physicist, and had a good talk with him in his laboratory. His principal interest, as I imagined previously, was to make good mechanical equipment for practical use in anesthesia.

At a most pleasant lunch with Macintosh, we talked about Russia. It was very clear to us that in the 2-1/2 years between our visits, the Russians had made great headway in anesthesia. His views about their ability to develop rapidly when they decide something is worth doing, coincide exactly with mine. He also believed that they should be encouraged and helped in this regard. I might add that Macintosh established excellent relations with prominent surgeons and anesthesiologists in Moscow and Leningrad. His letters of introduction were the most effective of all my contacts in getting to know Russian medical scientists. Macintosh believes that Kuprianov and Petrov are absolutely first class people. Unfortunately, I did not meet Kuprianov or Petrov directly, but Macintosh's view of them was corroborated by others. He also thought most highly of Smolnikoff but did not know Schainin or Jurevich by name. It seemed quite clear to both of us that Smolnikoff was the best person in anesthesiology in Moscow and very likely in the Soviet Union. Smolnikoff's career was discussed previously in these notes. It will be interesting and important to follow this man’s development further.

6th of August

In London, went shopping for some presents for the children, walked around a bit in the heart of London and then drove to the country with the Woolmers and Organes for a very pleasant dinner. Geoffrey Organe agreed to invite the Russians to the Meeting of the World Federation of Societies of Anesthesiologists in Toronto in September of 1960. It is agreed that I will write to various Russians telling them that an invitation to Dr. Venediktov in the Ministry of Health will be forthcoming from Organe. It is important also to invite them to the 1960 Annual Meeting of the American Anesthesiologists in New York. Permission to do so has been requested of our officers in my capacity as General Chairman of the American Annual Meeting for that year.

7th of August

To London Airport and takeoff on the Comet 4, Flight 509. It was an easy ride of 9-1/2 hours from London to New York including one hour on the ground in Newfoundland. This airplane seemed noisier than the Boeing 707, but was very smooth. It had a steep angle of climb, going almost directly vertically into the air. On arrival at Idlewild, some of our luggage was torn but nothing was lost. All of our bags were examined thoroughly by the Customs Officials. It was much more difficult, involved more red tape, and more time for us to clear Idlewild customs than it was to clear the Customs entering or leaving the Soviet Union. I wonder how tough it will be for Russians who come to visit.

Delighted to be home and think the United States is the most wonderful country in the world. I am most grateful and happy to be an American. The experience of the past four weeks was invaluable to my understanding of the world in which we live and of the development of medical science in other countries, particularly the Soviet Union.

SOME THOUGHTS ON ANESTHESIOLOGY IN RUSSIA AND IN THE UNITED STATES

There is an outstanding characteristic of Soviet life, including medicine that impresses the visitor repeatedly. When the Soviets believe something is important, the job is done promptly, and with excellence. To do this they select bright and able men, give them maximum resources and provide total opportunity to accomplish the stated and planned objectives.

In the medical sciences there was almost no interest in getting much done in anesthesiology until recently. This lack of interest probably accounts for all the local anesthesia that previous observers from the United States and Britain had seen. Possibly the satisfaction with local anesthesia may be explained in part by the great influence of Pavlovian theory. This scientific system suggests that local anesthesia, which interrupts undesirable reflexes, may be the best system of anesthesia. Whether the theoretical or practical considerations were more important is impossible to say. It is clear, whatever the motivation, that recent developments will stimulate rapid advances in anesthesiology and the allied field of resuscitation in both clinical and laboratory aspects.

The Ministry of Health has formally decided this year that anesthesiology will become an important independent specialty separated from surgery. It was also decided that there will be one anesthesiologist to every 100 beds throughout the Soviet Union. How this figure was determined I could not ascertain. Possibly it was an estimate based on British experience or determined from a visit to London. The Russians are now completely committed to anesthesiology as an applied science and for the clinical care of the sick. Some suggestions for use:

(1) The National Institutes of Health should increase the translation and summary services of Russian and satellite country medical journals and make them more widely available to our medical scientists in all specialties than they are at present. A suggested list of Soviet journals in surgery and anesthesiology is appended.

(2) Have the National Institutes of Health consider seriously measures to preserve and broaden the educational and research activities of our best medical minds. In many cases, the financial rewards of private practice or industry are so great and income from education and research so meager that the contrast is too seductive for even the most dedicated physicians and medical scientists. It may be that one could keep many of our best men in the universities or the research institutes by long term private or governmental supplementation of researchers' and educators' salaries and significantly greater financial support to university departments. This policy is at least as important to the country as farm supports and probably much less expensive.

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