Civilian Service of Navy Hospital Ships

USNS Mercy Under Way (US Navy Photo)

News of hospital ships Mercy and Comfort being deployed to provide care for civilians during the current Covid-19 pandemic has made the headlines time and again. This prompted me to research the history of such deployments for a post here when, lo, and behold, I came across a blogpost on the topic, written by BuMed historian Andre’ Sobocinski, and posted on the Navy History and Heritage Command blog The Sextant. With Andre’s permission, here is the link to that post.

https://usnhistory.navylive.dodlive.mil/2020/03/31/answering-the-call-stateside-deployments-of-u-s-navy-hospital-ships/

On Social Distancing – Learnings from Naval Training Station, Yerba Buena Island, 1918

I submitted this OpEd piece to the San Francisco Chronicle and the San Jose Mercury-News a week or more before the San Francisco Bay Area counties invoked shelter-in-place orders. Neither outlet picked it up, so you get to see it, well after it was prescient; but it’s still relevant. It’s based largely on work by the History of Medicine shop at the University of Michigan, a result of pandemic research they did during the Bush II Administration.

We beat a viral pandemic 100 years ago the hard way.

Fortunately, we learned from that experience.

By Thomas L. Snyder, MD

Thomas Snyder is a retired surgeon and Naval Reserve Medical Corps officer. He is executive director of the Society for the History of Navy Medicine.

This week the Centers for Disease Control and Prevention (CDC) confirmed a case of community-acquired COVID-19 in Solano County.  This marks the first indication that the coronavirus now spreading around the world has a toehold in the United States.  The prospect of a pandemic is frightening, but it is not novel.  Indeed, many of the public health measures now being implemented were innovated in the Bay Area following the 1918-19 Spanish Flu outbreak.

COVID-19 appears to have emerged in animals, jumped to humans in Wuhan, China, and then spread throughout the world from person to person.  Like the Spanish Flu, mass globalized travel helps the virus spread far very quickly.  At the end of World War I, huge troops movements, War Bond rallies, and the novel popularity of movie theaters and dance halls all abetted the flu’s spread.  By comparison, today millions of newly prosperous travelers can fly across the globe in a single day, taking the virus to nearly every continent.

The Spanish Flu overwhelmed hospitals in the Bay Area.  The Naval Hospital at Mare Island alone cared for more than 1,500 cases at the height of the epidemic.  The Mare Island hospital isolated sick sailors in tents set up on hospital grounds in the hope that removing infected men from the community would help slow or stop the contagion. Desperately ill men suffering from pneumonia were hospitalized.

Curiously, an island in the middle of the San Francisco Bay remained free of the contagion. One day prior to the first reported flu case in San Francisco, the commander of the Naval Training Station on Yerba Buena Island imposed a strict quarantine.  He prohibited travel to and from the island and imposed a “twenty foot rule” – the distance between island personnel and those delivering food and other supplies by boat (it would be nearly 20 more years before the Bay Bridge was constructed).  Only after the worst of the epidemic passed was the quarantine lifted.  Like clockwork, several cases of the flu on the island immediately developed.

While today we have rapid communications, advanced medical treatments, molecular understanding of the virus, and teams worldwide racing for a vaccine, these were not available to medical professionals a century ago.  But remarkably, the public health lessons from the Spanish Flu remain the same today.  We still promote good hygiene, restricted travel and human contact, isolation of the sick and, under extreme circumstances, quarantine of the well.

The Yerba Buena prescription of keeping a distance of 20 feet is not much different from the CDC’s current recommendation of six feet.  The CDC and U.S. State Department have issued “Do Not Travel” warnings for all of China.  To date, they have not recommended limiting domestic travel or attending large public events.  Nor have there been mass quarantines.  But these remain options that are not much different from how public health authorities tried to stem the Spanish Flu by barring sick people from theaters, inspecting ships’ crews for signs of illness, and isolating victims from the general population.

We do have some tools that weren’t available then.  Face masks proved useless in preventing infection during the Spanish Flu.  Today you can buy N95 face masks off the shelf rated to block even tiny viruses from passing through, unlike cloth or common surgical masks.  [NOTE: We want to reserve N95 masks for health workers at high risk for infection. The CDC just announced a change in policy to encourage the general wear of cloth “face covers” (not surgical masks, which also must go to health workers given the current shortage of personal protective equipment) whenever we are out and about. This is to prevent people who have no symptoms but may nevertheless be carrying and shedding virus from spreading the contagion. We understand hygiene better: wash your hands, frequently, for at least 20 seconds using soap and warm water.  If you don’t have access to soap and water, used a hand sanitizer containing at least 60 percent ethanol.  The rest of the advice is common sense.  Cough into your elbow or a tissue if you don’t have a mask. Stay home if you’re sick. And keep your distance.

The Spanish Flu killed at least 20 million worldwide in 1918-19 and 675,000 people in the United States.  It infected a third of the global population.  Medical science and public health have come a long way since then and we have made tremendous progress in destroying diseases like smallpox, polio, malaria, and HIV/AIDS.  We learned some of the lessons the hard way.  But everything that we learned helps us face the COVID-19 virus we see today.

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©2020 Thomas L Snyder

Navy Medicine in Support of Civilian Authorities

In the past, I’ve published a couple of articles on the Navy’s support to civilian medical authorities during the 1918 influenza epidemic, when civil facilities and personnel were overwhelmed by the sheer volume of sick people who needed care. In another article , I added a “what of today” piece in which I discussed civil-military lessons learned from the Hurricane Katrina disaster, and  then-current directives directing or permitting military installations and their personnel to support civil authorities in planning and responding to medical and natural disasters. I also pointed out that such arrangements, at the time, were based pretty much on “handshake” agreements between local military bases and surrounding civilian health and disaster planning agencies.

Late last week, Captain James Bloom, MC, USN (Ret), who regularly emails short naval historical vignettes under the rubric “Today in Naval History”, posted this piece on a Navy diving medicine response, to wit (with Captain Bloom’s permission):

28 JULY 2002

TRAPPED MINERS

The evening of 24 July 2002 was unremarkable for 18 miners working the Quecreek deep shaft coal mine near Somerset, Pennsylvania; that is until they accidentally broke through a thin wall separating them from the nearby Saxon mine. The abandoned, flooded Saxon shaft was errantly shown on maps to be several thousand feet away, but in seconds 150 million gallons water poured into the Quecreek shaft. Nine miners scurried to safety; nine more struggled to reach the highest point within their subterranean tomb. Here the rising water compressed the residual air into a bubble just large enough to keep the nine from drowning. Within hours a six-inch pipe reached the miners through which heated, pressurized air was pumped to hold the chilly, rising water at bay.

Breathing pressurized air at their position 240 feet below the surface made the miners effectively divers, equivalent to an air-saturation dive 40 feet below the sea. Experience with even shallow water marine rescues had taught that the sudden decompression of rescue was likely to result in death or serious injury from “the bends.” The Navy was called and within hours CAPT Dale Molé from the Bureau of Medicine and CAPT Henry Schwartz from Naval Sea Systems Command joined emergency physician LCDR Nick Colovos and 60 Navy personnel from eight commands at the scene. Recompression chambers were quickly flown in–nine multi-place chambers and five transportable “Hyperlite” chambers. Set up in a nearby barn, the assemblage represented the first time so much recompression capability had been assembled in one location.

A special drilling rig had to be transported from West Virginia to sink a 32″ rescue shaft. It would be used to lower a cylindrical basket through which the nine could be raised one-by-one. A steel cap, the “iron maiden,” was built over the site to maintain air pressure in the shaft while the rescue proceeded. At the mine entrance over a mile away high-volume pumps strained to drain as much water as possible from the flooded mine. This paced removal of water proved very helpful as it lowered the pressure in the miner’s air bubble about one foot of seawater each hour–the perfect rate for decompression. But nothing more had been heard from the miners. For two torturous days Navy personnel worked, sympathized with families, and rehearsed their rescue scenarios.

Finally at 2215 on the 27th the rescue shaft reached the trapped miners. Video equipment borrowed from the Navy-Marine Corps News crew and attached to the first rescue basket recorded all nine alive! CAPT Schwartz escorted the first rescued miner to a nearby trauma center, where one of the recompression chambers proved necessary and helpful. By 0245 all nine had been rescued.

Watch for more “Today in Naval History” 1 AUG 19

CAPT James Bloom, Ret.
Molè, Dale, “Steaming to Assist at the Quecreek Mine Disaster.” Navy Medicine, Vol 93 (5), September/October 2002, pp. 18-29.

Oral History, CAPT Dale Molè, MC/USN, August 2002.

ADDITIONAL NOTES: This rescue was the first in the 20-year experience of Pennsylvania Bureau of Deep Mine Safety representative Jeffrey Stancheck in which all the trapped miners were rescued safely. The assistance of the US Navy proved invaluable. Indeed, when the first miner was brought to the surface it quickly be came apparent that some visual screening would be necessary to preserve the privacy of the miners being transported from the shaft opening to the decontamination station. Initially Navy personnel on the scene formed a 70-foot “human shield” until within 15 minutes the SeaBees had constructed a 12′ barrier of wood and “cumshawed” tarpaulins.

Though we usually associate “the bends” with diving activities, the disease was originally described in the 19th century in underground constructions workers building the massive caissons that support the Brooklyn Bridge. It was originally called “caisson’s disease.”

Ironically the site of this Quecreek mine disaster and miraculous rescue is only 15 miles from the crash site of the September 11th, 2001, highjacked United Airlines Flight 93.

I think this is a terrific example of the special expertise the Navy and the other military medical services can bring to bear in emergencies. (I also wrote a short piece on the Army’s medical response to the San Francisco earthquake and fires of 1906 here.)

(You can subscribe to Captain Bloom’s vignettes by emailing him at navalist@aol.com; put Subscribe to “Today in Naval History” in your subject line.)

©2019 Thomas L Snyder

USNS Mercy Completes Mission in Perú

Today, the hospital ship Mercy completed a 6 day visit to the Peruvian port of Callao. While there, according to U.S. Embassy and U.S. Southern Command reports, the medical staff worked in partnership with other Western Hemisphere personnel. They provided health care – including an average of 20 surgeries a day – for more than 4,000 people in “vulnerable populations”, including, explicitly, refugees from the humanitarian disaster in Venezuela. Reportedly, Perú currently harbors about a million Venezuelans who’ve escaped hardship in their home country.

Mercy has made 7 visits to the region since 2007. Over this time, her people have helped build and equip emergency treatment centers in 15 Peruvian locations, and assisted in training the local health professionals who would staff them.

I’ve written about medical diplomacy before. Such activities seek to build friendly relationships with other nations. They can also play interesting propaganda roles, as in this case, where the explicit mention of care for Venezuelan refugees is intended to embarrass the Venezuelan government and help strengthen the coalition of nations opposing that regime.

Perú was the second stop in the ship’s five month mission to visit 12 nations in Latin America and the Caribbean.

(C)2019 Thomas L Snyder

Independence Day

Today we celebrate the birth of this magnificent experiment in self-governance. May it continue to thrive, and ever be a beacon of hope to oppressed people everywhere.

A Memorial Day Reflection

 

As you enjoy the Memorial Day weekend, please take time to remember someone you know who gave his or her life in service to our country. 

 

Search as I might, I couldn’t find any data on medical personnel who’ve died in war time. But we know many have. Those who care also die.

 

On Monday, I’ll have the honor of giving my city’s Memorial Day speech. Here’s my peroration:

 

In conclusion, I ask you – no, I task you:
–every day, to try to memorialize – perhaps by putting on a special pin or necklace, or by saying, out loud, the name or names of someone who died in our nation’s service – our nation’s fallen ones.
–when you do that, give a thought to those who still suffer the ravages of war time experience, and seek advice – the VFW would be a good source – about how you can support their care. Be sure our legislators know that you favor generous medical and psychological benefits for veterans, especially including the homeless and addicted men and women who’ve served.
–finally, hold in your thoughts those who now face danger on our behalf.

Let us be thankful, every day, that we live in this great country, and, let us be especially thankful for the people who defended her then and defend her now. Let us remember them – and thereby preserve them from falling completely out of memory.

(c)2019 Thomas L Snyder

From a Naval Perspective: The Parts of Medicine That Are Like Convoy Work

Before we start: today marks the 148th anniversary of the founding of the U.S. Navy Medical Corps, in which physicians automatically receive Commissions as naval officers. Prior to that time, doctors received their Commissions from individual ship commanders as they saw fit.

Now, back to our original program. In medicine, as in naval operations, the least dramatic undertakings often produce the most dramatic results. Look, for instance, at convoy operations in both World War I and World War II. Despite devastating losses due to submarine attacks on merchant shipping (Britain was only months from suing for peace in World War I due to impending starvation), senior naval officers resisted the use of convoys protected by antisubmarine-enabled escorts, because such prosaic (and both boring and dangerous) work didn’t fit the idea of dashing naval battles. Yet when the convoy system was instituted, in each war, merchant ship losses plummeted.

The story is similar in medicine. It is almost cliché to say that non-combat deaths (from contagion and, interestingly, scurvy) in land war exceeded combat deaths until the Franco-Prussian War (1871), when German attention to hygiene – and vaccination against smallpox – reversed this proportion for the first time in history. This relation held (with the notable exception of the American experience in the Spanish American War) through both World Wars, the Korean War and Vietnam. Only in the recent wars in the Middle East and Afghanistan have advanced combat casualty care and the wide use of body armor brought the proportion of combat to non-combat deaths to near parity, with accidents, not disease causing the largest number of non-combat deaths.

I’m soon to be giving a talk on what I thought would be mostly about combat casualty care – the surgeons’ work in the cockpit – in Nelson’s navy around the time of Trafalgar. As I began to research the matter, it became pretty clear, pretty quickly, that the most significant benefits from the Royal Navy’s medical establishment in the quarter century leading up to that battle were the most pedestrian imaginable, and most definitely not dramatic advances in the surgical art. Pushed by naval physicians and surgeons, and some enlightened line officers, the Royal Navy reformed its victualling to include regular supplies of sauerkraut (a fair source of vitamin C), fresh vegetables whenever possible, and citrus fruits and juices. This reduced the incidence of scurvy to almost non-existent. Surgeons and commanding officers began to demand cleanliness among the sailors (a general issue of soap to ships of the fleet was instituted only after 1795), their clothing and bedding, and of cooking and eating utensils. This reduced the incidence of fever and the fluxes* significantly.

The data are stunning: during the period of the American Revolution, prior to the institution of the reforms victualling and hygiene, non-combat deaths outnumbered KIAs by 18:1. By contrast, for the period between the Glorious First Of June battle (1794) and Trafalgar (1805), the ratio was closer to 3:1. Like boring convoy operations, boring public health measures yield outsized benefits.(1)

 

 *In an era before the causes of most diseases had been elucidated, “fever” was a catch-all diagnosis for any febrile illness. The most significant ones for sailors were

–“putrid” (or ship) fever – epidemic typhus – caused by rickettsia prowasecksii, spread by the bites body lice; and yellow fever and malaria, for men serving in the tropics, and

–“flux” and “bloody flux” – gastroenteritis or dysentery – caused by a variety of bacteria that grow in spoiled food and unclean cooking and eating utensils.

 

(1) Care is warranted in noting these numbers, as naval operations during the American Revolution ranged from the tropical Caribbean to Newfoundland. In the later period, most battles occurred in the northern latitudes. Nevertheless, the beneficial effects of good nutrition and basic cleanliness were significant. This post is based on preliminary research for my lecture project and are drawn from the classic and epic four volume medical history of the Royal Navy started by John J Keevil (Vols 1 & 2), and, following his untimely death in his mid-50s, completed by Christopher Lloyd and Jack Coulter. The material that informed this post is in: Lloyd, Christopher and Jack L. S. Coulter, Medicine and the Navy, 1200-1900, Volume III 1714-1815. London, Livingstone, 1961. Several more sources await my attention.

(c)2019 Thomas L Snyder

Surgical Suite Aboard a Small Ship

Around mid-January, there was a flutter of news that the Spanish frigate ESPS Méndez Núñez (F-104) was in Norfolk and will be integrated into the USS Abraham Lincoln (CVN-72) Carrier Strike Group until November of this year. A review of the ship’s history on Wikipedia shows that since her commissioning in 2006, she has been quite active in international anti-terrorism and anti-piratical activities.

What’s medically interesting about the ship (which, according to an article in USNI News, is being showcased by Spanish shipbuider Navantia to the U.S. Navy, presumably as a possible candidate for its FF(X) future frigate program) is that it has what looks to be a basic surgical suite instead of a simple sick bay.

Sickbay / Operating Suite Aboard ESPS Méndez Núñez (F-104). (USNI News photo)

The ship also has a separate space to accommodate four sick or injured sailors. She typically carries a physician and a nurse when deployed, according to the USNI News article.

This kind of medical space is pretty unusual in a small unit like a Frigate. I recall that the sickbay in my Adams Class guided missile destroyer – I was the staff medical officer for Destroyer Squadron 15 – was no larger than a large closet. Sure, one could evaluate sick sailors there (physical diagnosis only; no Xray or lab) and perhaps do minor surgical procedures such as suturing wounds or draining abscesses, but there was no room to do something as basic as an appendectomy (the crew’s mess deck, a much larger space,  could be fitted out for surgery, but this was intended for combat casualty care, and doing even simple appendectomies was officially discouraged). Most U.S. small units don’t rate medical officers unless they are squadron flagships (and I’m not sure even these ships rate a physician these days). Independent duty corpsmen, specially trained to be the sole “Medical Department Representative” serve on these smaller ships, and have proven to be most capable for tending to the minor surgical and medical needs of the crew. Sailors with more serious problems are typically medically evacuated to an amphibious ship, aircraft carrier, hospital ship (all of which carry qualified surgeons, or would in a potential combat situation) or a facility ashore.

So I’m not sure the operating room in Méndez Núñez would be all that useful. Surely, for instance, there is no way laparoscopic work (the clear trend in abdominal and chest surgery not related to trauma) could be performed in that space. It would be interesting to learn what the Spanish experience has been.

©2019 Thomas L Snyder

A Medical Hero Celebrated

It’s not so often that we see a military medico publicly recognized for life sustaining work in combat. “It’s our job, after all” would be a common rejoinder. It was good, therefore, to read about Royal Navy Surgeon Captain Rick Jolly, who was named OBE for his surgical and leadership exertions in the Falkland War. Jolly recently passed over the bar at age 71. At the time, he was the senior medical officer of 3 Commando Brigade. He and his crew set up a field hospital in an abandoned slaughterhouse at Ajax Bay. There, Jolly and his colleagues treated more than 500 British wounded soldiers and Marines, and about 200 Argentine troops. Only 3 of those wounded died, none while under his care. The Argentine government awarded him the Orden de Mayo for his work.

I remember reading that Argentine surgeons often mismanaged soldiers’ wounds, which, under typically filthy combat situations, were grossly contaminated with dirt, clothing fragments and shrapnel. Already loaded with bacteria, these wounds became terribly infected, so when the Brit surgeons “inherited” the patients, their work was often that of managing these serious infections – truly life-saving work.

Jolly was an outspoken guy. See his interesting comments (and facial expressions) in a two-segment (~4 mins each) interview for Sky News here. I like this quote: “We had only one motto in War – that the wounded MUST survive”. Military medicine at its simple best.

(Hat tip: Cdr Salamander)

(C)2019 Thomas L Snyder

Surgical Specialties Emerging from World War II (Part Two of Two)

Last week I posted the first half – on the development of neurosurgery – of a paper on the surgical specialties that emerged from the Great War I was to give at a symposium at Cal State Channel Islands in late October. The symposium was cancelled as the Woolsey Fire approached. Fortunately, no damage was done to the campus or its wider environs, but the paper “hung fire”, so to speak. So, I post it for a wider audience.

Herewith, the second half. It looks like the footnotes transferred this time (they didn’t last week when I used my iPad), but if you want a copy of the complete paper with footnotes, let me know and I’ll send you a copy.

Trench warfare also saw a huge increase in facial wounds, compared with previous wars. The lore of plastic surgery has Hindu surgeons performing nose reconstructions for men who’ve had their noses cut off as punishment. But the reality is that “[w]hen we entered World War I, there was a total ignorance of plastic surgery in the army, but it must be said, that even in civil hospitals and medical schools of that time, 1917, the appreciation of this branch of surgery as a special subject was also lacking.”[1] Interestingly, the first major influx of facial wounds on the British side came from the Royal Navy after the Battle of Jutland. Up to this point, any reconstructive surgery of the face was in the bailiwick of the otolaryngologists (ear, nose, throat specialists) and dental surgeons, and both Germany and France had put together teams of dentists and surgeons to deal with these problems. As fate would have it, another “great man” of his surgical art, Harold Gillies, a New Zealander trained in ear, nose and throat surgery, serendipitously fell in with August Valadier, a French-American dentist in France in 1915. Valadier had set up a unit to care for soldiers with jaw injuries, and Gillies, intrigued by the challenges of facial reconstructive surgery, went back to England to lobby for a hospital dedicated to these cases.[2] Once granted, Gillies and a team of surgeons, dentists, anesthetists, and technicians he gathered around him, set out – initially “by trial and error”[3] – to work out techniques of reconstruction that gave grievously wounded men – men with noses and jaws blown off – functional and cosmetically satisfactory results. Like Cushing, Gillies acknowledged that when he set out to repair the horribly wounded faces he saw, “…the principles laid down by the fathers of surgery [were] found to be of general application… But our work [was] original in that all of it had to be built up again de novo. …The earlier months, then, were spent in a very thorough trial of the then known methods. It has been illuminating to discover the impracticability of many of these, which would appear to have been put forward on the study of only one case, or even on purely theoretical grounds.”[4] Major accomplishments by Gillies and his team included the successful use of “tube grafts”, by which skin can, in stages, be transferred from, say, the chest to fill large facial defects; and the transplant of cartilage from the ribs into the face to rebuild noses, and more. By the time America came into the war, Gillies and his team had such an extensive experience that our medical officers who spent time with them were prepared to provide knowledgeable care to American doughboys wounded in combat. The U.S. Army set up several centers in France specifically for the care of men with facial wounds. The Army also established Plastic Surgery Centers in 9 hospitals stateside where these men received definitive care, being retained in the Army until they had received “maximal benefit” from the surgeons’ hands.[5] After the war, interest in plastic surgery varied. In England, just four men continued with development and practice of the specialty and these same four were the only experienced plastic surgeons available to British military forces at the outset of World War II. [6] In the U.S. on the other hand, interest was greater, promoted at least in part by increasing numbers of automobile accident victims needing skin grafting and other specialized care. One result was that the U.S. could provide 60 well experienced specialists to the army and the navy prior to our entry into the war. [7] As in the Great War, the Army established a series of short training courses to bring other surgeons up to speed in assessment and technique, and so well did the program work in providing needed talent, that the “short course” system was discontinued before war’s end.[8]

When peace finally came, the value of plastic and reconstructive surgery had been nearly universally appreciated, and training programs found their way into almost all medical schools in the west. Plastic surgery in the Soviet Union languished and was generally performed by general surgeons. Specialty practice existed only in Moscow and Leningrad, and access there limited largely to the political elite, movie stars and the security services.[9] Plastic surgery as a distinct specialty was recognized in Russia only in 2008, and specialty training centers established the same year.[10] China, on the other hand, established training programs in plastic / reconstructive surgery after World War II, and the profession has flourished, especially in the 21^st century as the nation has become more wealthy, and demand for aesthetic surgery has grown. The International Society of Aesthetic Plastic Surgery estimates that more than 23,000,000 cosmetic procedures were performed world-wide in 2016.[11] Nearly 6,000,000 reconstructive surgical operations were performed in the United States in 2017.[12]

Conclusion

Two surgical specialties, for which there had been virtually no antecedent experience, emerged from the unique injuries soldiers in the Great War experienced in high numbers due to their exposure in trench warfare. The experience gained from treating these patients permitted surgeons to lay down principles of practice that inform the practice of neurosurgery and plastic / reconstructive surgery even today. Acceptance of these as separate surgical specialties was not universal until experience in World War II confirmed their value. Every major nation except the Soviet Union saw their advancement in the later 20th century. This progress and acceptance has only expanded in the 21st century.

Copyright 2018 Thomas L Snyder

[1] John Staige Davis, “Plastic Surgery in World War I and in World War II,” Annals of Surgery 123, no. 4 (April 1946): 610-621.

[2] Andrew Bamji, “Sir Harold Gillies: Surgical Pioneer,” Trauma 2006 8, http://www.gilliesarchives.org.uk/traumahdg.pdf (accessed 18October2018).

[3] John Staige Davis, op. cit.

[4] Harold Delf Gillies, Plastic Surgery of the Face Based on Selected Cases of War Injuries of the Face Including Burns, with Original Illustrations (London: Oxford University Press, 1920), reprint by Andesite Press / Creative Media Partners 2015

[5] Davis, op.cit.

[6] Richard Battle, “Plastic Surgery in the Two World Wars and in the Years Between,” Journal of the Royal Medical Society 71 (November 1978), http://journals.sagepub.com/doi/pdf/10.1177/014107687807101115 (accessed 21 October 2018).

[7] Lihani du Plessis, The Influence of World War I on the Development of Reconstructive Plastic Surgery. 2016. Honors Baccalaureate of Science thesis, Oregon State University.

[8] Davis, op. cit.

[9] “Soviet Plastic Surgery: When the USSR Went Under the Scalpel,” The Calvert Journal (22 March 2017), https://www.calvertjournal.com/articles/show/7971/soviet-plastic-surgery-ussr-under-scalpel (accessed 22 October 2018).

[10] Alexander V Melerzanov, “Plastic Surgery in Russia,” Prime – International Journal of Aesthetic and Anti-Aging Medicine (17 January 2014), https://www.prime-journal.com/plastic-surgery-in-russia/ (accessed 22 October 2018).

[11] International Society of Aesthetic Plastic Surgery, “International Study of Aesthetic / Cosmetic Procedures Performed in 2016 (Summary),”

https://www.isaps.org/wp-content/uploads/2017/10/GlobalStatistics.WorldWide.Summary2016s-1.pdf (accessed 22 October 2018).

[12] American Society of Plastic Surgeons, “2017 Plastic Surgery Statistics Report ‘ 2017 Reconstructive Surgery Statistics,” https://www.plasticsurgery.org/documents/News/Statistics/2017/reconstructive-procedure-trends-2017.pdf (accessed 22 October 2018).