1 II Department of Internal Medicine Kranik and
2 Ethics Institute, Medical University of Lublin, Poland
Jews played an important role in Polish society for over 600 years. From 1918 to 1939 they constituted over 10% of society and 20% of doctors were of Jewish origin. Jewish communities founded their own hospitals, among which The Old Order (Jewish) Hospital in Warsaw was the largest and the most important.
The Old Order (Jewish) Hospital in Warsaw was founded in 1799 on the initiative of a Jewish Commune [1]. In its 150-year history, the hospital changed its location five times. It was founded on Nowolipie Street, and its final site, after 1940, was in the Jewish ghetto. The period of the hospital's greatest development and importance was when it was housed in the buildings on Dworska Street in the Czyste district, to which it was moved in 1902. After Poland regained independence in 1918, the hospital experienced further extensive development. In those days, the hospital was remarkably well equipped. In 1937, with 1174 beds, it was the largest in-patient medical institution in Warsaw [2]. Its development was brutally interrupted by World War II and the holocaust. It is worth mentioning that although the hospital had been transferred to the Warsaw ghetto and operated in poor conditions, it maintained not only therapeutic but also research activities [3]. It is the interest of the hospital's personnel in research that without doubt distinguished the Jewish Hospital from other non-university hospitals in Poland.
The very name of the hospital needs to be explained, especially for the benefit of readers outside Poland. The phrase of the Old Order (to differentiate it from of the New Order, i.e. Christianity), in Polish refers to a person of Mosaic religionwhich does not always mean of Jewish ethnicity. In those days, the majority of Jews, but not all, were of the Old Order. The hospital was open to persons of other nationalities and religions, to which the Christian Chapel, maintained with the hospital's budget, stands as testimony.
Clinical sessions, in which physicians of various departments participated, were held every month from 1903 until 1942. In the period from 1922 until 1938, their contents were reported in the Clinical Quarterly of the Jewish Hospital. The periodical was published in Polish and contained French abstracts (one special issue was partially in English; its title page is presented in Figure 1).
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Many prominent doctors worked in the hospital, among them neurologist E. Flatau (18681932), the author of many research papers, atlases and handbooks. Another was S. Goldflam (18521932), an internist, neurologist and social worker who was renowned for his studies on myasthenia and for elucidating the concept of intermittent claudication. S. Goldflam was the first in Poland to introduce microscopic examination of the nervous system. In the field of nephrology, he is known for describing the shaking symptom of the lumbar region, which in Poland has been referred to by his surname: Goldflam's symptom [4]. Another noteworthy physician, J. Fliederbaum (18981942), deserves recognition not only for his basic study on the starvations of the holocaust period in the Warsaw ghetto, but also for his early, numerous and unusually comprehensive nephrological papers, including those about disorders of water and electrolyte homeostasis, and acidbase equilibrium.
During the monthly clinical sessions at the hospital, interesting cases of patients were discussed, and presentations on world-wide advances in the medicine of diagnostics and therapy were made. Those sessions became the starting point for many clinical and laboratory research projects, which were later published, mostly in the Clinical Quarterly of the Jewish Hospital. This periodical, which according to its founders' intentions served to raise the level of the hospital research, is a true reflection of the clinical practice and scientific achievements of the physicians who worked in the hospital [5].
A noteworthy fact is that after the hospital was relocated to the ghetto, hard work and very difficult conditions did not impede the doctors from resuming scientific work. Clinical sessions were still organized, during which topical questions of the time about tuberculosis, typhus fever and starvation were raised. Lectures and laboratory sessions for students were held and training for medical staff was organized [3]. Unfortunately, because of the tragic events of the holocaust, which resulted in the destruction of the hospital in 1942 and the murder of many physicians, scientific work was discontinued. The great scientific output had, stemmed from the ideal, the necessity to create a visible sign of research, which constituted a guiding principle for the founders of the journal [5]. The research of the physicians of the Jewish Hospital has been made accessible today, although only in a few libraries, and only in Polish, but it deserves the attention of the international medical community.
Although the hospital never had an independent department of nephrology, nephrological issues were widely discussed during the monthly clinical sessions, as well as being debated in publications. The topics of discussion ranged from the specific (mainly tuberculosis) and the non-specific, such as kidney inflammation, urinary defects and neoplasms, to complex ones such as water and electrolyte and acidbasis disorders.
Table 1 shows a list of the nephrology issues raised during the clinical sessions of the hospital, as recorded in the quarterly notebooks accessible in the archives.
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Clinical sessions were the occasions to present especially interesting or problematic cases. The participants dealt with descriptions of diagnostic methods, tests and imaging techniques that no longer are used today, the most popular in those days being pyelography. The doctors practising at the hospital demonstrated extraordinary technical skills in the service of nephrology. For example, W. Dworecki, during one of the sessions, presented his own modifications of the construction of the Ivon appliance, used to indicate the level of urea [6].
The problem of proteinuria, especially of orthostatic albuminuria, was one of the nephrological issues widely discussed during the monthly clinical sessions. Poncz described a patient with bilateral tuberculosis, who had proteinuria whenever he stood. Poncz critically analyzed the hypothesis of analysis Jonson, Senator and Sahlie which suggested anatomical changes in the kidney as the possible reasons for the proteinuria. He also expressed his disapproval for Jehle's mechanical theory about faulty posture, in the form of lumbar lordosis, as the reason for proteinuria (arising from pressure on vessels, especially on the renal vein). He presented his own concept of the aetiology of the proteinuria in associating it with vagotonia, which occurs more often in patients with tuberculosis. He verified his hypothesis by administering to the patients small doses of atropine, which clearly reduced the proteinuria. His reason for the vagotonia was the stimulation by tuberculosis toxins of the parasympathetic system, produced by even the slightest physical effort. This parasympathetic stimulation then causing dilatation of renal blood vessels [7]. Regardless of contemporary views on this reasoning, the originality of the ideas and the persistence in inquiry is impressive.
Schwarcman's idea was equally unusual and interesting. Contrary to the opinions of that time, he related the orthostatic proteinuria of an asthenic patient, who had suffered from chickenpox, to the physical effort the patient made while walking, rather than to an intensification of lumbar lordosis or to an upright posture. In fact, lactic acid, irritating the kidney, played an essential role in the pathophysiological chain of orthostatic proteinuria [8].
Some of the issues discussed were on the borders between the two branches of nephrology and urology. Some atypical forms of nephrolithiasis with symptomatic pyuria described by Szenkier and Wincberg [9], and of renal neoplasm described by Stuckgold [10] should be mentioned. Stuckgold convincingly discredited pyelography, which was presented in the medical books of the time as the preferred method of detecting proliferative processes.
One of the cases presented during the clinical sessions concerned a 2 cm ureteral polyp, which was surgically removed by Szenkier in 1926 [11]probably the first such operation in the world. Szenkier also gave a description of a nephrectomy of one kidney with advanced tuberculous changes, the operation performed despite the fact that the patient had a different disease in the other kidney [12]. This case serves as an example of a daring application of all available therapeutic possibilities to save a patient's life at a time when such means of treatment as dialysis or anti-tuberculous treatment were unavailable.
The scientific and medical way of thinking evinced by the doctors of the Old Jewish Hospitalclearly undergoing development if one closely examines the content of successive clinical sessionsis admirable. The attributes displayed by the doctors during the discussions were an inquisitive approach, healthy curiosity, eagerness to learn the reasons for phenomena under observation, and the ability to make brave hypotheses. We cannot but hold them in high regard.
Acknowledgments
This work was supported by a grant from the International Society of Nephrology Scholarschip in the History of Nephrology. We would like to thank Professor Leon G. Fine for approving the proposal and the grant.
Notes
Correspondence and offprint requests to: K. Marczewski, II Department of Internal Medicine Kranik, Poland. Email: komarcz{at}poczta.onet.pl
References