Anaesthesiology in the Polish Armed Forces in the West during World War II
*Aleksander Rutkiewicz1, Izabela Duda2, Ewa Musioł2
1Students` Scientific Society at Department of Anaesthesiology and Intensive Therapy, Medical University of Silesia in Katowice
2Department of Anaesthesiology and Intensive Therapy, Medical University of Silesia in Katowice
- Fig 1. Photo: group of PMF lecturers. Roman Reithar - assistant responsible for lectures in anaesthesia methods at PMF (first from the right in the last row) 
- Fig. 2. Photo: Italy 1944 – Casualty Clearing Unit no 3. Professor Szarecki performing surgery (on the left), assisted by captain Massalski (on the right). The anaesthesia supervised by Bolesław Rutkowski – a doyen of Silesian anaesthesiology (courtesy of Bolesław Rutkowski)
- Fig. 3. Photo: Heidbrink anaesthetic machine commonly used in American and British field hospitals. According to Adam Majewski, they were available in Polish FSUs. Such machines were sent to Poland after the War with the UNRRA supplies. The presented model comes from the collection of the Museum of Medical University in Łódź (author’s archive material)
- Table 1. Types of anaesthesia performed in FSUs and casualty clearing units of the 2nd Polish Corps during fights in Italy in June, July and August 1944
ntil the outbreak of WW II, anaesthesiology, as a separate specialty, did not exist in Poland. After the fall of Poland, a large section of the Polish Armed Forces was evacuated to France and after that, to the UK, where Polish military physicians had a unique opportunity to obtain training in modern anaesthesia. The first regular courses were established at the University of Edinburgh. After WW II, doctor Stanislaw Pokrzywnicki, a pioneer of Polish anaesthesiology, who was trained by Sir Robert Macintosh, and doctor Boleslaw Rutkowski, an anaesthesiologist in London, returned to Poland and started regular services. This led to the registering of anaesthesiology as a separate specialty in 1951. In the article, the wartime and post-war stories of the first Polish anaesthesiologists are presented.
During World War II, medicine experienced dynamic advances. Due to the huge influx of casualties, often with numerous complex injuries, new surgical methods had to be elaborated for neurosurgery, general surgery or thoracic surgery. The implementation of novel methods would not be possible without improvements in anaesthetic methods. Anaesthesiology in the United Stated and Great Britain reached the advanced level already in the 30ties of the 20th century and the wartime contributed remarkably to its development in other countries. The wartime was also special for Polish medicine as modern Polish anaesthesiology was born during that period.
The objective of the present article was to describe the work of anaesthetists in the Polish Armed Forces in the West and to evaluate the importance of that period for further development of anaesthesiology in Poland. The paper was mainly based on source materials, accounts of living physicians-veterans and published memoires; the subject, however, was not exhausted.
POLISH ANAESTHESIOLOGY BEFORE WORLD WAR II
Before the outbreak of World War II, Polish anaesthesiology did not exist as a separate medical field. In the 19th century, Teodor Teofil Matecki, head of the surgical ward of the Sisters of Mercy Hospital in Poznań demanded that anaesthesia should be administered by a physician. During the XXII Congress of Polish Surgeons in 1926, Hilary Schramm, professor of surgery, emphasised the need for introduction of specialists administering anaesthesia. In pre-war Poland, general anaesthesia was mainly performed by nurses, nuns and young physicians supervised by operators whereas local and block anaesthetic procedures were carried out by surgeons .
The most popular method of general anaesthesia was open method using ether and a Schimmelbusch mask [1, 2]. However, using this method it was difficult to dose the amount of an anaesthetic, hence to regulate the depth of anaesthesia. The availability of anaesthetic machines posed a problem. Only the richest centres could afford them – in Katowice the Aga apparatus was used ; Butkiewicz mentions the Roth-Drager devices . The most popular intravenous anaesthetic was Evipan (hexobarbital, in Poland produced as Sennarcol Natrium), often applied for intravenous monoanaesthesia and for induction of inhalation anaesthesia [1, 2].
In Poland, the level of anaesthesiology was far behind the Western countries, although some physicians, for instance assistant professor Tadeusz Butkiewicz from the Transfiguration Hospital in Warsaw, checked on the advances in anaesthetic methods abroad , and others, as Mieczysław Justyna, one of the fathers of Polish anaesthesiology, devoted their doctoral dissertations to the issues of anaesthesia . The efficacy of anaesthetic methods was disputed, as there were no guidelines concerning indications and contraindications for particular drugs . This lack of guidelines gave physicians the freedom of action. Each university centre promoted different methods of anaesthesia , which occasionally led to the situations in which some physicians used only certain techniques completely ignoring some other methods, which could provide operators with wider possibilities and ensure higher safety to patients .
The Americans and British led in the field of anaesthesiology. In 1905, T.S. Buchanan from New York was appointed as professor of anaesthesiology and in 1937 this title was awarded to Robert Reynolds Macintosh from Great Britain. In Great Britain, anaesthesiology was registered as a medical speciality in 1912 . On the outbreak of World War II, in the countries in question, there was a group of trained specialists-anaesthetists. Anaesthetic machines, constantly improved, were commonly used and endotracheal intubation became a standard. Furthermore, the range of anaesthetics available in those countries was much wider than that in Poland [1, 2].
ANAESTHETIC EDUCATION IN THE POLISH ARMED FORCES
After the fall of France in 1940, a vast number of Polish physicians, researchers and students of medicine were evacuated to Great Britain, where the Polish Armed Forces were organized de novo. The Polish authorities realised that the medical personnel should be provided with further trainings, the students with further education and scientists with opportunities to continue research. Moreover, a new generation of physicians had to be educated, which could fulfil the needs of post-war Poland where the intelligence was extensively exterminated by Germans and Soviets . Thanks to the involvement of professor Francis Crew, the commandant of the War Hospital in Edinburgh, as well as assistance of Polish authorities and authorities of the University of Edinburgh, the Polish Medical Faculty (PMF) was organized at the University of Edinburgh. The appropriate document was signed on February 24, 1941. Lieutenant colonel Antoni Jurasz – pre-war professor of surgery of the University in Poznań was appointed its Dean.
The University enabled also the pre-war students to continue their studies; both the civilians and military men could start the first year of medical studies [1, 4, 5, 6].
In the PMF, teaching of anaesthetic methods was introduced for the first time into Polish medical curriculum; doctor Roman Rejthar, surgeon and former assistant in the department of professor Jurasz, was responsible for the new classes [1, 5] (Fig. 1). Although Rejthar was listed as a lecturer teaching the methods of anaesthesia , anaesthesiology as a separate subject was not included . Education was not conducted at a high ’British’ level due to the lack of experienced specialists-teachers, which was confirmed by Anna Sokołowska, doctor of psychiatry, presently living in Ottawa, who completed PMF in 1946 . She recollects that the exam in anaesthesiology was not included in the medical curriculum; the basics of anaesthesia were taught during surgery classes and were limited to open inhalation methods without intravenous administration of drugs . Another graduate of PMF, Zbigniew Władysław Sobol, doctor in orthopaedics, remembers that he was taught the basics of ether anaesthesia with the evaluation of its four phases and learnt how to operate the McKesson machine . More advanced knowledge could be gained during work in hospitals . Although the introduction of anaesthesiology into the medical curriculum of PMF was a breakthrough, it should be considered in symbolic terms. The real impact on further development of Polish anaesthesiology was associated with trainings and courses in British hospitals that Polish physicians could attend.
The entire educational effort of PMF was focused on provision of medical personnel for the Polish Armed Forces. Many graduates of the faculty were sent to military units and the front immediately after studies, sometimes without post-graduate trainings . One of them was younger lieutenant Bolesław Rutkowski, sent to the Middle East with the supplements for the 2nd Polish Corps (Fig. 2).
Once the war activities were finished, some physicians were transferred for specialist courses in anaesthesiology. After the Italian Campaign, Rutkowski managed to get a job in one of London hospitals, where on his initiative he had the opportunity to learn about the Boyle`s anaesthetic machine and many other things .
Other doctors, like Stanisław Pokrzywicki, were trained in Oxford under the watchful gaze of famous Sir Robert Macintosh . During the War, doctor Pokrzywicki served in the Polish Air Forces, among others in the 302nd Fighter Squadron .
The mysteries of modern anaesthesia were learnt not only by anaesthetists-to-be but also some experienced surgeons. The development of modern methods of anaesthesia was extremely important for the advances in Polish thoracic surgery, which was fully realized by Wit M. Rzepecki working in the Emergency Hospital in Shotley Bridge near Newcastle, where under the watchful gaze of doctor Joan Millar he performed tens of closed circuit general anaesthetics with cyclopropane . Millar completed her medical studies at the Durham University in 1932. She was the anaesthetist specializing in anaesthesia for thoracic surgeries. During the War, she worked in the hospitals of Northern England anaesthetising soldiers with thoracic injuries . Many years later professor Rzepecki recollects this period: ‘At my request Joan Millar started to introduce me into the arcane knowledge of modern general anaesthesia. First, I prepared myself theoretically and, realising that this field of medicine would be poorly known in Poland, I absorbed all the information like a sponge [….]. Besides Stanisław Pokrzywicki, who as one of a few Poles trained in anaesthesiology in Oxford, and about whom I knew nothing, I was probably the first or one of the first Polish physicians providing modern anaesthesia on my own. Until then I had only known the simple and old method of dropping ether on a metal mask placed over the patient’s face and covered with several layers of gauze. This primitive general anaesthesia had been used in Poland before the War even for the most severe procedures. In Shotley Bridge, I had the chance to learn the most modern ways of inducing sleep as both the United States and Great Britain were the countries where this field of medicine was most highly developed‘.
ANAESTHESIOLOGY AGAINST A BACKGROUND OF MEDICAL SERVICES IN THE POLISH ARMED FORCES
The military units of the Polish Armed Forces were formed according to the British regulations. This also regarded the health services, which were organized based on stage evacuation of casualties. This kind of organization was sanctioned by British regulations, which were translated into Polish and served as an instruction ’Battlefield Health Services’ . The fully developed system of evacuation of casualties based on the Polish units functioned only in the 2nd Polish Corps fighting in the years 1944-45 on the Italian front. The other units of the Polish Armed Forces functioned within bigger Allied tactic systems and evacuation of casualties in those units rested mostly on Canadian and British units. This was the case in the 1st Armoured Division or 1st Parachute Brigade .
Already during the first stage of evacuation, i.e. in the battalion aid stations of medical platoons of battalions and regimens, the basic anaesthetic equipment was supposed to be available. The equipment included Shimmelbush masks, an anaesthetic (ether) and Pentothal, which was sufficient for anaesthesia for simple surgical procedures. However, in practice in the battalion aid stations, interventions were mostly to secure the patients for further transport, administer morphine, anti-tetanus serum, powder the wounds with sulphonamide and apply dressings if not done earlier ; the professional surgical help was administered at further stages. However, there were cases in which evacuation of casualties was impossible. For instance, the fights of 1st Armoured Division, which in August 1944 stopped in the Normandy region of Chambois and mountain 262, blocking the retreating German army. Some Polish units found themselves encircled. Under difficult conditions, the physicians deprived of support and facilities
had to perform life-saving procedures and manage anaesthesias. One of the participants of fights remembers the situation at the aid station: ’physicians had no time to rest. Paramedics worked without a moment’s respite […]. The strengthening injections of coramine and cardiasol, morphine for the wounded, control of haemorrhages, pulse and dressings barely allowed to carry out serious procedures, which had to be performed since the evacuation of casualties to hospitals was impossible. Under primitive conditions, insulting to all principles of surgical art, amputations were performed, blood transfusions were given, and splints were placed on open limb fractures under anaesthesia‘ .
More complex surgical procedures were performed in the main aid stations organised by company or division medical brigades. They were localised in the possibly closest vicinity to the front so the surgical assistance could be provided to the wounded most quickly. Only necessary procedures were carried out, e.g. fracture stabilisation, haemorrhage control or wound toilet. If further transport of the wounded was not possible, he was transported to the Casualty Clearing Station (CCS). CCSs were small 200-place hospitals deferred to the corps authorities (corps units). They had only 50 beds and the rest of casualties were placed on stretchers. In the 2nd Polish Corps, these were the Casualty Clearing Stations no. 3 and 5 . Second lieutenant Bolesław Rutkowski worked in one of them. He remembers that due to the lack of qualified anaesthetic staff, anaesthesia was performed by young physicians (including Rutkowski) or appropriately trained non-commissioned officers – ‘narcotisers’. The most popular method of general anaesthesia in CCS no. 3, in which he worked, was ether ‘dropping’ on a Schimmelbusch mask. Premedication consisted of morphine administered together with atropine. Anaesthesia was induced with Pentothal, the most popular barbiturate in the Allied Army. Pentothal was also used as the leading anaesthetic in shorter procedures . It appears that this standard of anaesthesia dominated at each stage of clearance of casualties and irrespectivel of the types of procedures, which is partly confirmed by monthly reports from hospitals and field surgical units of the 2nd Polish Corps (Table 1). According to them, hexobarbital was also applied although to a lesser extent . As far as the block anaesthesia is concerned, Rutkowski says that ‘it was performed by a surgeon, if he knew how’ .
Furthermore, the Field Surgical Units (FSUs) were noteworthy in organisational terms. They were self-sufficient in carrying our surgical procedures and were corps units. Depending on the needs, they were assigned to the main dressing stations of the division, casualty clearing stations or war hospitals. The field unit included a surgeon (commander) in the rank of major, an anaesthesiologist, also in the rank of major and auxiliary personnel (sub-commissioned officers and privates –theatre nurses, orderlies, clerks, drivers) [16, 19], which shows how important the role of anaesthetists was in the structures of British Army and that anaesthetists and surgeons were treated equally, their ranks included.
The Polish Field Surgical Units functioned within the 2nd Polish Corps and included the units no. 345, 346, 347, 348, 350, and 351. In Polish realities, the ranks of both physicians were lower than the rules defined. The surgeons appointed as commanders of field units were mostly experienced operators but staffing the posts of anaesthetists was a problem. Due to lack of qualified anaesthetic personnel, the physicians for anaesthetist posts in Field Surgical Units were sent for trainings to the British or American units. Adam Majewski commander of the FSU no. 350 wrote: ’captain Bolesław Wierzchoń was appointed for the post of anaesthetist as my deputy. I knew for several months that he was coming to my field unit. He applied for this post. He had my approval and the promise of the head of Corps health services. He was even sent for a course in anaesthesiology in one of American hospitals’ . Field units had a wide range of surgical and anaesthetic equipment: ‘Each unit had its own complete sets of instruments, drugs and devices. [….]. The devices were practical and excellent: two cabinet field machines for endotracheal anaesthesia with spare bottles of oxygen, carbon dioxide or laughing gas (most commonly Boyle, Heidbrink or Oxford devices)…’ . The use of anaesthetic machines in FSUs is confirmed by the future professor of paediatrics and then lieutenant, physician of the 3rd Carpathian Rifle Division, Olech Szczepski in his memoirs .
The majority of physicians serving in the Polish Armed Forces got their degrees before the War. They often used the archaic knowledge acquired before 1939. It is not surprising then that the most popular method of inhalation anaesthesia was that using a Schimmelbusch mask and ether. In this respect, the situation described by Szczepski is also telling: ’around 12.00 the wounded with abdominal injuries was brought from the front line in the condition of collapse. I connected the drip infusion with physiologic saline, had the patient warmed with blankets and paraffin stoves placed over his body and mobilized the transfusion and surgical field unit. The field surgical unit had only two physicians (captain Kanarek, and second lieutenant Sołowiejczyk) and therefore I started inhalation anaesthesia […]. Then I reduced the depth of anaesthesia as I thought that the wounded received too much anaesthetics and the procedure was just about to be finished. After a while, captain Kanarek put ostentatiously the needle-holder over the operating field and taking advantage of the moment of silence said resonantly, clearly and slowly looking in my direction: ’The first principle of anaesthesia is to have a patient and not a narcotiser asleep’. He meant that in the recovering patient, the abdominal integuments started to become tense, which hindered their suturing.’ . Similar situations happened even in specialist Field Surgical Units, although anaesthesia was the responsibility of a physician permanently employed as an anaesthetist.
Polish physicians practicing during World War II in the West had the biggest opportunities to be trained in the anaesthesia, yet it should be noted that slight, ‘step-by-step’ advances were also visible in Polish realities.
Among Polish physians practicing during World War II, those who were members of Polish Armed Forces had biggest opportunities to be trained in anaesthesia, yet the advances in this field were gradual (step-by-step).
It is worth outlining the techniques used by anaesthetists of the British Commonwealth. For short procedures, Pentothal, ethyl chloride and ether administered using open method or closed circuit were mostly applied and anaesthetic machines used. For long procedures, anaesthesia was provided with ether and nitrous oxide with oxygen supported with Pentothal or Trilen in various proportions and combinations. In thoracic surgeries, cyclopropane was commonly used. Accurate dosing of anaesthetic gases was possible thanks to anaesthetic machines, which with the commonly used endotracheal intubation resulted in good anaesthesia outcomes and lower incidence of complications. Anaesthetic machines were actually available already at the first stages of casualty clearance . The machines were gradually miniaturized, which markedly facilitated their use under field conditions. Even a special ESO anaesthetic machine was adjusted to the specificity of parachute actions, which could be carried in a rucksack. However, simple Schimmelbusch masks, which can be used in difficult conditions of the first front line, were not completely abandoned. The specialist centres of neurosurgery, thoracic surgery and maxillofacial surgery were created, in which anaesthesias suitable for given procedures were performed . It is worth mentioning that these centres accommodated casualties from a particular part of front, including the wounded Polish soldiers.
AFTER THE WAR
Only a small part of medical personnel serving in the Polish Armed Forces decided to come back to Poland after the War. The majority stayed abroad undertaking jobs in the countries all over the world. Some took up anaesthesiology, making a brilliant carrier. That was the case of doctor Władysław Wielhorski. After completing the study at the Polish Medical Faculty in Edinburgh in 1945, he served in the 15th Light Artillery Regiman until demobilisation and then started the speciality in anaesthesiology at the London University; after finishing it, he participated in the three-year course of anaesthesia for cardiac surgery at the University of Liverpool. In 1952, he emigrated to Canada where he developed his skills in cardiac anaesthesia, including the techniques of extracorporeal circulation. In 1968, he participated in the first Canadian heart transplantation. He served many important functions in the society of Canadian anaesthesiologists, and was an honorary member of the Institute of Cardiology in Montreal [6, 22].
Another graduate of the Polish Medical Faculty, doctor Stanisław Gańczanowski also started his speciality in anaesthesiology after the War. In the years 1976-81 he held the position of a head of the anaesthesiology department and his carrier was crowned with the title of honorary consultant .
Amongst those physicians who decided to come back to Poland were Stanisław Pokrzywnicki and Bolesław Rutkowski. They brought with them priceless experience and quickly started to work as anaesthetists. Pokrzywicki settled in his native Kutno. On December 11 1947, he used curare for the first time to provide muscle relaxation for abdominal surgery [1, 23] and the Oxford-Vaporiser anaesthetic machine, which he brought from England. This first application of a relaxant was a milestone in the history of Polish anaesthesiology. In 1949, Pokrzywicki received his PhD, in 1955 – the title of associate professor and in 1965 – of professor (the first title in Polish anaesthesiology). In 1961, he was called up to the army and became the head of the Department of Anaesthesiology attached to the Military Medical University in Łódz. He was appointed chief specialist in anaesthesiology of the Polish Army [1, 24].
Rutkowski undertook the job in the Institute of Oncology in Gliwice. In the hospital storeroom, he found the Heidbrink anaesthetic machine from the United Nations Relief and Rehabilitation Administration (UNRRA). The hospital workers, who had no earlier contact with such devices, thought that the machine is for the purpose of intestinal irrigation . Using this machine, closed circuit and endotracheal intubation, Rutkowski carried out anaesthetic procedures in his centre and during numerous visits to Silesian hospitals [1, 10]. The majority of difficult procedures performed in Katowice, Chorzów, Bytom or Świętochłowice which required modern anaesthesia could not do without his assistance. In 1961, Rutkowski received his PhD. He was a pioneer in pain management and organized the first outpatient clinic of pain treatment in Gliwice in the 70ties of the previous century. In the years 1961-1975 he was the regional chief specialist in anaesthesiology in Katowice and Kielce province. Doctor Rutkowski trained tens of physicians from the whole country in anaesthesiology and pain management. He is considered a doyen of Silesian anaesthesiology [1, 10].
In December 1945, while still in Great Britain, Wit Rzepecki was offered the position of the head of sanatorium of Polish Teachers Association in Zakopane and consultant in surgery in all Zakopane sanatoria. He was to deal with surgical treatment of tuberculosis . Before returning to Poland, he bought the most necessary surgical equipment yet ‘could not afford the purchase of a very expensive machine for general anaesthesia’, particularly, that he was not sure ‘whether a trained anaesthesiologist and suitable gas agents, such as nitrous oxide and cyclopropane, will be available in Poland’ . Interestingly, during the first thoracoplasty performed by Rzepecki in post-war Poland, Pokrzywicki offered his assistance and administered anaesthesia .
World War II was the period during which a number of Polish physicians could familiarise themselves with modern anaesthesia. For several years, they were to some degree under the influence of the British medical thinking. Even though according to Rutkowski, ‘Polish anaesthesiology was created in Poland, and not somewhere else’, it is impossible to overrate the importance of trainings of Polish physicians in Great Britain. Those trained there, Pokrzywicki and Rutkowski, in particular, transferred their professional knowledge to the Polish ground and together with other physicians initiated the long way of catching up in the field of anaesthesiology. They trained hundreds of physicians. Among six anaesthesiologists working in Poland in 1951 (Aroński, Justyna, Niewiadomski, Oppeln-Bronikowski, Pokrzywnicki, Rutkowski), two learnt their professional skills in Great Britain .
Moreover, it is worth stressing that immediately after World War II Polish hospitals received abundant supplies of equipment from UNRRA (Fig. 3), including anaesthetic devices from American and British war reserves. Although not many physicians knew how to use them, those gifts fulfilled the Polish needs to some extent.
In the post-war period, the attitudes of Polish physicians towards the issues regarding a person responsible for anaesthesia changed gradually. People started to realize that a suitably trained physician-anaesthetist and not an accidental individual should perform anaesthesia, although for a long time there were still some opinions that we could not afford such luxuries. At present, the words of doctor Pokrzywicki seem symbolic; during the memorable surgical procedure in December 1947, he supposedly told doctor Malinowski, surprised with muscle relaxation, ’not to be interested in anaesthesia; a surgeon is no longer responsible for it’ .
Anaesthesiology as a separate speciality was registered in Poland on October 10, 1952 [1, 25].
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Studenckie Towarzystwo Naukowe
Klinika Anestezjologii i Intensywnej Terapii
Śląski Uniwersytet Medyczny w Katowicach
ul. Medyków 14, 40-752 Katowice-Ligota
tel.: +48 32 789 40 00
received: 16.04.2011 r.
accepted: 21.06.2011 r.