Many of us remember another, better known event in this history, when, again, Polish mathematicians played the main role. This is the Enigma Secret. And here’s how it all started. In 1927, or at the beginning of 1928, an innocent package has arrived from the German Reich at a customs office in Warsaw. According to the customs declaration, the package was supposed to be radio equipment. A representative of a German company demanded the return of the package prior to the customs inspection. This awakened a suspicion among the Polish customs officers who instantly contacted the Cipher Bureau of the II Department of the Main Headquarters. This institution was interested in new developments in the area of radio equipment. Since it was Saturday, the officers of the Cipher Office had enough time to examine the package in detail. The package contained a machine, which was subsequently dismantled and reassembled. Yes, it was a trade version of the Enigma ciphering machine patented by Arthur Scherbius. Its military analogue did not exist at that time. What is interesting is that this machine (a trade version) was available on the market.

The first ciphered dispatches were sent into the air space by military broadcasting stations on July 28, 1928. The efforts to decode these dispatches were fruitless. Major F. Pokorny, the head of the Cipher Bureau did not give up and in 1928-29, in Poznan, he organized cryptology lectures for students who spoke fluent German and had graduated in mathematics. Among these students were Marian Rejewski, Jerzy Rozycki, and Henryk Zygalski. After the completion of this course, a division of the Cipher Bureau in Poznan was organized. Starting September 1, 1932, the division was moved to the building of the Main Military Headquarters near Saski Square in Warsaw (since destroyed).

On cylinders, sheets and…beautiful women

As Mr. M. Rejewski recalls, “the military version of the Enigma had the shape of a portable typewriter. It had 26 keys marked with the letters of the Latin alphabet. Instead of individual characters it had a small board with 26 bulbs marked the same way as the keys. It was supplied by a normal battery. Enigma’s most important parts were ciphering cylinders mounted on one axis. A non-moving inverting cylinder was also installed. Each of the cylinders was equipped with a ring with 26 alphabet letters. From a distance it looked like a switch-over mechanism in a racing bicycle. When one was pattering the letters of the text, then the letters of consecutively lit bulbs were creating the coded text, or a cipher. Not going into the details of the construction of Enigma let us remark, that one could create 26! =403291461126605635564000000 different connections .The “Enigma” Secret between ciphering cylinders, adding to this also 7905853580025 possibilities of various invertible cylinders In this way the factory producing the Enigma could deliver to each recipient a machine with unique, non-repeating connections of the cylinders.

In this way the factory producing the Enigma could deliver to each recipient a machine with unique, non-repeating connections of the cylinders.

In contrast, all military versions of the Enigma had the same connections, so that the officers working on ciphers in various military units could easily communicate. This was possible provided these officers had the same key, along with the cylinder connection, the secret of Enigma.

It is estimated that during World War II between 100,000 and 200,000 Enigma machines like this were used.

In order to explain, even in general terms, the details pertaining to the role of the connections of the cylinders, and hence to understand what is happening inside the machine, one has to apply combinatorics, especially permutations. Rejewski and his colleagues were borrowing heavily from the theory of permutations , cycles, transpositions, etc.

Let me now explain the connection to Polish women. Well, our cryptologists noticed certain combinatorial regularities. For example in the following 9-letter long message, FDW KRM KSA, it happens that the fourth and the seventh letter is the same. When the fourth and the seventh letters, or the fifth and the eighth or the sixth and the ninth letters are the same – these situations were termed women. Apparently, 11 or 12 messages out of 100 are women. And why beautiful women? How could it be otherwise? One also has to mention Zygulski’s sheets, genius though time-consuming perforated sheets which were helpful in the determination of the sequence of rotors.

World War II and the Fate of our Cryptologists

With this complex situation, one has to be astonished at the arrogance of the German engineers who were certain that the Enigma codes were unbreakable. Remember, though, that cryptology was still in its infancy and as my colleague, Dr. Tom Korner of Cambridge University writes, even in 1996, Cambridge University Library stores its cryptology acquisitions in the paleography division, between stenography and ancient Greek. It turned out, as Marian Rejewski remarks, that in order to break the Enigma codes, one did not need to know the connections of the cylinders, nor the daily keys; what was needed was a certain number of these dispatches sent the given day – about 60 of them. With such a sample, one could recover the given password. In 1934, in Warsaw, the first (Polish) replica of the Enigma was built, by the company AVA. In July 1939, after a dinner in the restaurant of the Bristol Hotel, there was a secret meeting between French, British, and Polish cryptologists. The meeting took place in Kabackie Lasy, near the village Pyry, south of Warsaw. After a pleasant conversation in German (this was the language common to all the parties involved), the guests saw the Polish copies of the German Enigma. The French and the British could not believe that the Poles had prepared such gifts. Each of the cryptologists received one copy of the Enigma code along with the complete set of the related information.

On the 16th of August 1939, French General Gustave Bertrand carried one Enigma copy from Paris to London and personally delivered it to the head of British Intelligence, Commander Stewart Menzies. Less than two weeks later the German Army invaded Poland. The Polish Cipher Bureau and its employees were evacuated to Romania, whence they were transported to France, where they worked constantly to improve the German Enigma.

After the German invasion of France, our cryptologists tried to evacuate to Great Britain. However, while crossing the Spanish border, some of them fell into German captivity. Major Ciezki and engineer Palluth were arrested. Langner, Ciezki, and Palluth lectured at Adam Mickiewicz University to Rejewski, Zygalski, and Rozycki at the end of the 1920s. The engineer Palluth died on April 19, 1944, hit by a splinter of an Allied bomb during the air raid of the labor camp. Langner and Ciezki were placed in German camps as POWs and were released by the Allies. Jerzy Rozycki, the third of Wroclaw cryptologists was killed even earlier – on January 9th 1942 when the ship that he was on drowned in the Mediterranean Sea. Only Marian Rejewski and Henryk Zygalski made it to Great Britain. There they joined Polish military units. They were working on some German codes, but the British did not assign them to constantly improved Enigma codes. In light of Russian- British agreements even their unit was dismantled. After the war Marian Rejewski returned to Poland.

Before coming to the United States, as a young assistant professor at the Wroclaw University I took part in the meeting of the Polish Mathematical Society in Lodz. The honorary guest of that meeting was Mgr Marian Rejewski. The hall, filled with mathematicians, loudly applauded the modest Mr. Rejewski. He died in 1980. Dr. Zbigniew Piotrowski Translated by Sean Martin

Obesity became epidemic in the United States in recent years. Every forth adult and every sixths child suffers from being fat. Five percent of Americans is morbidly obese, which means their life is at risk. Forty five percent of adult Americans were obese in 1980, while presently this number increased to sixty five percent. 120 billion US dollars is spent yearly to treat obesity-related diseases.

Obesity is usually caused by bad eating habits. We tend to eat whatever, wherever, and in rush. A candy bar, potato chips and hot-dogs are typical daily snacks. In addition, luck of physical activity, free time spent watching TV, leads to decreased calories burn. Obesity secondary to other diseases (like hormonal) is only seen in every seventh obese individual.

The Body Mass Index (BMI) measures weight and height ratio and is commonly used to assess obesity. BMI tells how many kilograms per square meter our body holds. According to researchers, BMI well correlates with a risk of morbidity and mortality. Those with BMI higher then 25 kg/m2 are considered overweight; BMI over 30 kg/m2 means obesity, and over 40 kg/m2   – morbid obesity. Obesity increases risk of death proportionally to the Body Mass Index: folks with BMI over 40 kg/m2 are in twelve-fold increased risk of premature death.

Dietary or pharmacological therapy hardly ever brings satisfactory, sustained weight loss. Majority of patients regain their weight or become even more obese. No wonder if in 1991, the National Institute of Health considered weight loss surgery (so called bariatric surgery) the only effective method of treatment obesity. Bariatric surgery is offered to those, whose BMI exceed 40 or 35 kg/m2 with concomitant, obesity related disorders.

Most often performed bariatric surgery: the Roux-en-Y gastric bypass leads to largely decreased food intake and lowers its absorption from the gut. Patients can not ingest much food due to smaller stomach. Furthermore, swallowed foods are absorbed much slower. These two effects lead to significant and sustained weight loss. Patients admit their appetite is reduced following the surgery. This effect is related to the exclusion of a part of the stomach producing the Ghrelin – the appetite stimulating hormone.

The operation consists of creating a small stomach pouch, while remaining 90% of the stomach is excluded from digestion. The food goes into the stomach pouch first, then into the intestine where it is been digested after transiting about 150 cm of its initial length. The surgery is currently performed laparoscopically.  Special surgical instruments and a small TV camera are introduced to the abdomen through few small incisions. The surgery is observed by the surgeon on TV screens in the operating room. Besides excellent cosmetic results (no scars), patients benefit from short recovery and early return to daily activities and work – much earlier then after traditional surgery.

The effectiveness of surgical treatment is measured by the excess weight loss. Most patients lose about 100 pound within twelve months after surgery, which is equivalent to about seventy percent of their excess weight. Following dietary recommendation, taking vitamins, supplements and physical activity assures persistent effect. Many obesity related comorbidities like diabetes, hypertension, sleep apnea, osteoarthritis, back pain and increased cholesterol, resolve or greatly improve after weight loss surgery.

Gastric banding is another surgical therapy for morbidly obese patients. This operation was already successfully introduced in Europe and Australia and is recently gaining popularity in the United States. It involves placement of a silastic ring around the upper portion of the stomach. It forms a small gastric pouch which is filled with a food. The satiety sensation is achieved early even with small amount of food. This is a minimally invasive procedure, which does not require cutting or stapling the stomach or intestine. The band can be adjusted with a fluid injected into the port located under the skin of the abdomen. It helps accelerating weight loss.

Sleeve gastrectomy is one of the newest methods of surgical treatment of morbid obesity.  It is recommended for very heavy patients whose BMI exceeds 60 kg/m2 with many coexisting diseases. These patients may be at risk of having complications from more complex and longer surgeries. Sleeve gastrectomy is a stage procedure that allows preliminary weigh loss prior to more difficult operation. Sleeve gastrectomy relies on creating a 100 ml tube (sleeve) from the stomach. Consequently, even small amount of food feels such formed stomach causing satiety.  The remaining larger part of the stomach is cut-off and removed from the abdomen.  The surgery is done laparoscopically, without a need of opening the abdomen.

Regardless of method used, surgical treatment of obesity should be done in a specialized center. The Cleveland Clinic Bariatric and Metabolic Institute is a world leading center for treatment of obesity, assuring a multidisciplinary, highest quality professional service. A variety of tests and consultations need to be done prior to surgery. Psychologists and dieticians work with patients to change their life style and eating habits. Patients also attend support groups to share their experience. The Institute recently received a very prestigious certificate “The Center of Excellence” issued by the American Society of Bariatric Surgery and American College of Surgeon. We treat patients from the United States, Canada, Europe and Asia.

Tomasz Rogula, MD, PhD

Forum, 5/2007

Recently, I spoke about the facial transplant with Doctor Maria Siemionow. Thanks to an article in the July issue of the New York Times and recently in Gazeta Wyborcza, her name became known worldwide. Doctor Siemionow heads an experimental plastic surgery group at the Cleveland Clinic, where she perfected microsurgical methods and immunosuppressant techniques that made it possible for the first time ever to plan and prepare a facial skin transplant in a human.
For this interview, I met with doctor Siemionow in a coffee shop at the Museum of Art in the University Circle.  From the outset it became obvious that I met a person who speaks about her life’s passion, about overcoming obstacles, about people that need her help, about authorities that need to be convinced, and about the precision and focus that her work requires. I learned that the skin is the most immunogenic tissue in the organism, as it becomes the first barrier defending our organism against infection. How do we know, then, that skin transplant is possible?  Apparently, there are already several successful cases of transplanting the entire hand from a dead person. Clearly, such transplants also mean the successful transplant of the skin on that hand.  It follows that the acceptance by the recipient body of this type of a transplant proves that the skin transplant is possible.

From the scientific standpoint, there are two types of skin transplant:  skin tissue with blood vessels and skin flaps with no blood vessels. With respect to the facial skin transplant, the transplant that doctor Siemianow plans to perform will include some blood vessels.  The chances for the survival of the transplanted tissue cells increase when such cells are supplied with more nourishment and oxygen thank to the blood vessels.  Prof. Siemianow already conducted a number of experiments on rats, transplanting skin tissue with blood vessels from the eye and face areas including ears. The results have been very promising.

And so, step by step Prof. Siemianow led me through the arcana of her experiments.

I learned that the thread she uses to stitch blood vessels is thinner than a hair, and that she performs most of the surgeries by herself under the microscope.  Also, I looked through articles about her work in a German magazine, with a photo of Prof. Siemianow always with her primary tool – the microscope.

Doctor Siemionow‘s exceptional microsurgery skills are evident. However, after listening to her explanation of transplants and upon glancing over her publications it became clear that she is also among world leading specialists in the immunology and immuno-suppression sciences. She also specializes in peripheral nerve injuries.  Her standing in the scientific world has been recently acknowledged by her election to the Chairmanship position of the American Association of Peripheral Nerves.

My next question was about the desire to help others.  This motivation, to help others, became the driving force for doctor Siemionow over the course of twenty years of her hard experimental work.   The press frequently mentions her early experience when as a young resident in Finland she participated in a hand transplant surgery. It was precisely this “miracle” that seriously impacted her future interest.

The idea to transplant the face skin has been discussed some time ago in England and France.  However, the medical establishment decided against pursuing this type of experiment.  Documentation submitted back then as well as issues raised did not convince the leaders of the profession that the risks involved are worth taking.  Years later, the work, documentation, and solid argumentation that such operation is medically and ethically justified presented by doctor Siemionow broke a new ground.  Her expertise and dedication gave the Committee on Clinical Studies at the Cleveland Clinic enough assurance for success to issue the first in the world permission for such experimental work on the human. That is how doctor Siemionow, dedicated advocate of her patients, broke through yet another barrier in medical science.

The search for the first patient is under way.  Many hurdles still exist however.  The patient must understand the risk of the transplant; such risk is estimated at about 50 percent.  The patient must be mentally healthy, with no history of drug dependency to assure that the organism can handle difficult immunological treatment.  It has been proven that even two-day interruption in the immunological treatment results in the rejection of the transplant. Also, the size of the damaged skin is important to the prospects of success. An option to transplant patient’s own skin in the event of transplant rejection must be available.  That is why only those with no prior skin transplant experience can be considered. Furthermore, the patient must have strong family support because diligent care and cooperation with caretakers is critical in the post-transplant period.  An expert named Life Bank who matches donors with recipients of transplant organs will decide who will be selected for the groundbreaking transplant of the face.

The patient must be informed that the immunosuppressant therapy is dangerous, must understand that in certain circumstances this therapy may become life threatening. In practice, however, the greatest problem is the rejection of the transplant rather than the side effects of the immunological therapy.

The face transplant was held back by the medical scientific community because of one main reason. By definition, this procedure does not save life but only improves its quality.

Professor Siemionow views this ethical problem from a different perspective and raises a different question. Who is in a better position to judge what is in the best interest of the patient: doctor or patient?  She told me stories of her patients who hide in their homes, whose face is so devastated that they cannot close their eyes, and all sorts of transplanted patches of skin create a mosaic that makes their contact with the outside world impossible.  Even doctors themselves with difficulty look at these faces. And yet, they reserve the right to agree or disagree for the treatment that could help those people.  It is precisely this issue that according to professor Siemionow is ethically questionable. Professor Siemionow earned the right to stand up in this debate.  With her knowledge and experience, she knows she can help these people.

Many have a negative reaction to the concept of „face transplant.” This idea rather reminds us of a movie Without Face than of a real problem of the ordinary people. Doctor Siemionow does not have much patience for this kind of thinking. She is too busy dealing with heavy problems of her patients to have any time for movies. She watched the movie only after others kept referring to it, while discussing her work.

Other objections with respect to her procedure deal with the word „face.”  Recommendations were made to transplant just smaller fragments of the face. Doctor Siemionow points out, however, that the immunological therapy is the same for the smaller or larger transplants.  From that standpoint, there is no reason to limit the procedure.  “If only to avoid the word “face,” it doesn’t make sense,” she adds. Other objections deal with the issue of identity with respect to both recipients and donors.  Such discussions will continue. To this day, people debate the identity problem with respect to heart transplants.  Staying within the movie realm, we can point out Return to Me with Minnie Driver and David Duchovny.

Professor Siemionow learned her craft in the Poznań Academy of Medical Sciences where she was promoted to the professorship position at the Surgery Department.  Prof. Siemionow believes that she found the courage to break through the barrier that had restrained her from helping others thanks to her frequent travels and cooperation with exceptional scientists from all over the world.  Her cooperation with Poland and her Alma Mater is of particularly importance to her.  She was the lead advisor on two doctoral dissertations there. Among her close associates and graduate students at the Cleveland Clinic are ten people from Poland. Through exchange and cooperation, she was able to bring on board young specialists who possibly will follow in her footsteps.   Professor Siemionow also became interested in the Polish-American Center that promotes Polish culture and serves Polonia. That is how I met this remarkable scientist who bravely pushes forward medical frontiers, this exceptional ambassador of Polish science of the highest order.

By Dr. Ryszard Romaniuk
Translated by Maria Szonert-Binienda

Forum, 10/2005