The life and times ofAlexander Von Lichtenberg

The life and times ofAlexander Von Lichtenberg

HISTORY THE LIFE AND TIMES OF ALEXANDER VON LICHTENBERG HARRY M. SPENCE, M.D. Clinical Professor of Urology, Southwestern Medical School, University ...

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HISTORY

THE LIFE AND TIMES OF ALEXANDER VON LICHTENBERG HARRY M. SPENCE, M.D. Clinical Professor of Urology, Southwestern Medical School, University of Texas Health Science Center, Dallas, Texas

The birth of Urology as a specialty may be said to have begun with the presentation of a workable cystoscope by Nitze in 1877. The embryonic phase of this fledgling branch of medicine received great impetus when in 1895 Roentgen brought forth the xray film whose clinical use was soon to be adapted to the diagnosis of diseases of the urinary tract. Continuous discoveries thereafter relating to the physiology and pathology of the genitourinary organs, therapeutic agents, innovative instruments, enhancement of operative skills, and innumerable further developments have led to the high-tech specialty in which we now bask. Nevertheless we should remember as one medical historian has observed that we see so far today because we stand on the shoulders of the giants who have gone before. Early History

1903 at the age of twenty-three, and moved immediately to Heidelberg to study at this German University under Professor von Czerny (himself a pupil of the famed Billroth) who stimulated Alexander's investigative efforts. These were soon to be directed along urologic lines so that in 1906 with Voelcker as co-author he published the first description of retrograde pyelography 3 (Fig. 1). * In 1908 von Lichtenberg transferred his activities to Strasbourg, another great German surgical center. Here he continued investigative work in the areas of general surgery, urology and orthopedics, all with appropriate publications. His teacher was Professor Madelung who recognized von Lichtenberg's academic talents and recommended him for professorial rank, although when the appointment came through the nominee as a Hungarian citizen was already on active duty in the army of that country. During World War I von Lichtenberg served as a regimental surgeon and later as Director of a large military hospital in Hungary. Indeed, he received several decorations for distinguished military service. At the conclusion of the First World War he was unable to resume his professorship on the Medical Faculty at Strasbourg which had once more become a part of France. In 1917 while World War I was still underway von Lichtenberg married Lilly Schneider, the daughter of a Jewish bank official from Vienna. His wife accompanied him to his military posts in Hungary where his older son, Alexander, was born in 1918; a

One such giant was Alexander von Lichtenberg, destined to become a world-renowned investigator, teacher, author, and practicing urologist in the first part of the present century.1.2 This individual was born in Budapest in 1880, the eldest of 5 children. His father, Kornel, was a well-educated, distinguished otologist who played a prominent role in both medical and civic circles in the Hungarian capital. Numerous honors were accorded Kornel who under the system of the Austro-Hungarian Empire was designated a member of the "midszenti" or lesser nobility and thereby authorized to use the hereditary title of "von" before his surname. Alexander's mother, from whom he derived his Jewish lineage, was the daughter of a banker in Budapest. Reared in such an upper class cultural and medical atmosphere, it was not surprising that the son chose a career in medicine. Soon after graduation from Medical School in Budapest in 1902, young Lichtenberg worked for a time in its Anatomical Institute studying embryology while awaiting his official license to practice. He received this in

*In discussing a paper read by von Lichtenberg at the American Association of Genitourinary Surgeons in 1939, Dr. Joseph McCarthy of New York related that when Professor Voelcker and von Lichtenberg decided to try a retrograde injection for the first time on the human, it was decided that von Lichtenberg who waS younger and whose idea it was would be the first subject. So Voelcker carried out the initial retrograde on Alexander. On Its successful conclusion Dr. Lichtenberg then said, "Now, Professor, I shall pyelograph you." "Oh, no!" the Professor demurred, "YoU haven't had experience enough."

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Established Urology Service in Berlin Following a year in this medical hinterland the highly trained and academically inclined von Lichtenberg decided to move on with his family (a Jewish wife and 2 young sons) to Berlin. Here he practiced initially as an orthopedic surgeon perhaps due to his wartime experiences, but as his accomplishments along urologic lines became evident he was appointed an Associate Professor of Surgery of the Medical Faculty of the University of Berlin in 1922 as well as being elected a member of the German SOciety of Urology, of which he was chosen President a few years later. At about the same time (1922) we find von Lichtenberg listed as a consultant to the Department of Urology at St. Hedwig's Krankenhaus, a seventyfive-year-old Catholic Hospital of 650 beds only 13 of which were assigned to urologic patients. Von Lichtenberg set about enthusiastically to remedy this situation so that the institution soon consisted of a total of 850 beds with entire floors devoted to the

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second son, Franz, was born during the couple's stay in Czechoslovakia where von Lichtenberg engaged in the private practice of surgery after the position in Strasbourg was unavailable.

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Urology Service now a self-contained unit with its own laboratory, radiographic and operative suites. Here by 1924 Professor Alexander von Lichtenberg served as Chief having his own Department which consisted of many private as well as service patients; indeed it was estimated that 200 or more patients were continuously under his personal charge. Many assistants, trainees, students, and visiting physicians from near and far were attracted to this large center of urologic learning from which much research and many publications emanated. Controversy Over Discovery of Excretory Urography From 1929 onward among the foremost of these were those dealing with the successful use of excretory urography (the intravenous pyelogram). Indeed the controversy this sparked and von Lichtenberg's role in the development warrant a brief digression. The circumstances of the discovery of this monumental contribution to modern medical diagnosis have been described in detail by Marshall,4 chairman of a committee of the New York Section of the American Urological Association to select the recipient of its Valentine Award for 1965, and by a committee of the German Urological Society including W Lutzmeyer, who had looked into its history.

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From these we learn that many contributed to its evolution,5 eventually including in 1929 Binz and Rath, biochemists at an agricultural college in Berlin, who were working on intravenously administered anti-infective compounds containing iodine; an internist, professor von Lichtwitz in Hamburg, who was conducting clinical trials of the products; and Moses Swick, holder of a Libman Fellowship from Mt. Sinai Hospital in New York, who at the time was studying Pathology in Berlin. It occurred to Swick upon learning of this work that radiographic visualization of the kidneys (by which these new agents of Binz were excreted) might be possible so he began work under Lichtwitz testing in animals numerous additional compounds supplied by the biochemists. The modifications suggested by Swick to use organic iodine compounds overcame the objections, namely faint x-ray pictures and severe reactions which had followed the use of all substances previously administered parenterally to avoid retrograde instrumentation. Some promising results were obtained by Swick on the Service of von Lichtwitz but more experience with patients was necessary. This was obtained by Swick in von Lichtenberg's Department at St. Hedwig's Hospital

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with permission from the Professor who was then on tour in the United States. Swick cabled to New York the news of the breakthrough to his benefactor, Libman, requesting him to inform Professor von lichtenberg who in turn announced the successful finding to his colleagues in America. Further work with the compound called "Uroselectan" was done cojointly by Swick and von Lichtenberg on the latter's return to Berlin. When presentation before the Ninth Congress of the German Society of Urology in 1929 was decided upon, the question arose as to who should be assigned priority for the discovery of Uroselectan both at its oral presentation at the meeting and as principal author of its subsequent publication in the leading national medical journal. Both Swick and von Lichtenberg laid claim to the honors, the former as having performed the actual early animal and human experimentation under Lichtwitz in Hamburg and the latter as being responsible for its clinical eXtension at St. Hedwig's under his Directorship. After a conference (probably acrimoniouS) including the involved parties and the editor of the Klinische WochenschriJt, the outcome was a compromise in that the first paper was presented by

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Swick entitled "Demonstration of the Kidneys and Urinary Passages by Roentgenograms Using Uroselectan,"6 followed by a joint paper whose title was "Clinical Examination of Uroselectan" by von Lichtenberg and Swick with the latter listed as the junior author 7 (Fig. 2). Thereafter Swick returned to America where he continued his biochemical work on improving media for excretory urography and their subsequent use in visualization of cardiovascular structures. Thus, despite all subsequent controversy as to priority, there is sufficient credit and honor for all involved in this monumental discovery; namely, Binz8 and his associates in biochemistry should be credited with the preparation of the actual compound incorporating suggestions regarding the use of organically bound iodine made by Swick who performed the first successful intravenous pyelograms under Lichtwitz in Hamburg. Publication with von Lichtenberg of further experiences on the latter's Urological Service and under his direction followed. Von Lichtenberg, in turn, spread the news widely of this new modality in his travels and lectures in North and South America and Europe and is generally given credit for the worldwide promotion and acceptance of excretory urography. Swick's contribution was recognized in 1965 when he was chosen to deliver the Valentine Memorial Lecture at the New York Academy of Medicine entitled, "The Discovery of Intravenous Urography: Historical and Developmental Aspects of the Urographic Media and Their Role in Other Diagnostic and Therapeutic Areas."9 He later received the degree of Honorary Doctor of Medicine from the Free University of Berlin in 1975. High Point of Lichtenberg's Career To return to the vignette of Alexander von Lichtenberg, the decade from 1924 when he assumed charge of his own Department of Urology at St. Hedwig's Hospital until the Nazi rise to power in 1934 represented the high point of his career. Many students, residents, assistants, associates, and distinguished visiting urologists from near and far came under his sway as he built up his large prestigious Urology Service. His demeanor in the operating room was typical of the surgeons of the day-namely, a direct speedy approach to the offending lesion with temper tantrums and knuckle rapping not unknown yet always followed by a jovial camaraderie which endeared him to assistants, nurses, and lower rung personnel alike who forgave such untoward outbursts as examples of the Professor's Hungarian temperament. Ward rounds and amphitheater clinics were

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3. Professor and Frau von Lichtenberg (circa 1929). Photo courtesy of Alejandro von Lichtenberg, M.D. FIGURE

routinely well attended by staff and visitors who considered them valuable learning experiences. Always a prolific author, between 1904 and 1945 von Lichtenberg had made no less than 185 contributions to the literature including original articles, reviews, round tables, published formal discussion and chapters in textbooks. In addition he served on the editorial boards of urologic journals in several countries. From 1929 onward excretory urography of course was a favorite topic along with transurethral resection of the prostate and bladder tumors with the newly invented electrotome, yet subject matter ranged widely since von Lichtenberg's knowledge and experience was broad in all phases of urology. In addition to his professional attainments, the social standing and affluent life style of the family (two sons and a daughter with their parents) was of the highest in the Berlin milieu in which they lived (Fig. 3).

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Later Years in Mexico Yet this happy state of affairs was not to last for although never active in political affairs, von Lichtenberg was in his own words "a quarter Jew" married to a Jewess with Jewish children, and the seeds of anti-Semitism were growing ever stronger as Hitler's power increased. First his authority to teach was withdrawn in 1935 on racial grounds, a blow indeed. As further restrictions were applied on von Lichtenberg, he left the oust an ding Urology Service he had built up at St. Hedwig's Hospital * and joined many individuals in situations comparable to his own by returning with his family to Budapest in 1937 where he was able to carryon a private practice of urology for a time in the Siesta Sanatorium. Nazism was on the march, however, so in 1939 von Lichtenberg accepted an invitation to emigrate permanently to Mexico before the outbreak of World War II. His expectation was that the time he spent on leaving Berlin was merely an interlude in his academic career which would be resumed in Mexico. Mexico was selected rather than the United States where von Lichtenberg had many friends because the U.S. was still in the throes of the Great Depression with no position available suitable for a person of his talents. On the other hand on his several visits to North and South America (once he had traveled to Brazil via the newly established transatlantic zeppelin route), he had made lecture tours and conducted operative clinics in Mexico City where he was well known and liked. Indeed, on a visit to that country to give conferences in 1938 he was offered a good academic position by Dr. L. Almazan, a urologist, who had been a former pupil of von Lichtenberg at St. Hedwig's and was now Minister of Health in Mexico as well as being a brother of the person expected to be the next president of Mexico. By 1939 when the turmoil in Europe had mounted, von Lichtenberg accepted the invitation of Almazan to emigrate with his family to Mexico with the implied promise of an important teaching opportunity there. Unfortunately this appointment did not materialize when the opposition candidate Manuel Avila Camacho won the six-year term of the Presidency. Thus, von Lichtenberg was forced once again somewhat against his wishes to take up the private practice of urology in a foreign land; he used the Hospital Londres, the Sanatoria Durango, and the Sanatorio Ortiz Tirado according to the account by Armando del Rio, who served as his assistant in Mexico. He also was active as a consultant without *F. Hudepohl whom one observer described as "a good Nazi" replaced him at St. Hedwig's.

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stipend on the Staff of the Hospital Colonia (which served the Mexico City Central Railway System) where he trained several individuals in urology. * Lack of a formal teaching position in a university setting, however, undoubtedly proved frustrating, and despite his apparent acceptance by the urologic fraternity of his adopted country, von Lichtenberg never achieved the position of leadership he had enjoyed when at St. Hedwig's (he was a member of the Mexican Society of Urology for a time but resigned for reasons unknown). Life apart from its professional side was good to the von Lichtenberg family in Mexico. The elders enjoyed the company of their fellow emigres as well as the Mexican people and were gracious hosts to many notable visitors. Both of his sons attended medical school where they were brilliant students, subsequently enjoying distinguished careers. Thus life went on apace for the von Lichtenbergs in Mexico until 1948 when Alexander experienced abdominal pain; as a known diabetic he did not follow too strict a diet and self-diagnosed himself as having a urinary stone despite all normal radiologic studies obtained by his assistants whom he was reluctant to believe. His old friend, Elmer Belt,lb then was summoned and confirmed the findings of the Mexican urologists that the urinary tract was not at fault but persuaded the Professor to come to the Good Samaritan Hospital in Los Angeles for a complete medical evaluation where regional ileitis secondary to a parasitic infestation was found and treatment instituted. Following this von Lichtenberg returned to Mexico City where he lingered for a time but died April 21, 1949, at age sixty-nine of diabetes, arteriosclerosis, and their complications. Tributes Two thoughtful tributes after his death were those of Belt who wrote, "After his return to Mexico ... a life of inactivity became an intolerable burden to this man of great dreams, intense activity and vast fulfillment. His comfort was the joy he found in Mexico whose warm hospitable people he dearly loved"; and that of AIken, one of von Lichtenberg's last assistants at St. Hedwig's, who reported in 1974 that, "Death came easier for him with the knowledge that his life's work was continued by his disciples who will not forget him." 4533 Lorraine Avenue Dallas, Texas 75205

*These included Ricardo Labardino y Nova, M.D., who furnished valuable information re this period in Mexico.

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ACKNOWLEDGMENT: To Dr. med. F. Schultze-Seeman, Historian of the German Society for Urology; and to the following individuals for valuable personal correspondence bearing on the subject: Dr. Eduardo Castro, Mexico City; Prof. Hubert Frohmuller, Wurzburg; Dr. Willard E. Goodwin, Los Angeles; Dr. Ricardo Labardini, Mexico City; Dr. Victor F. Marshall, Charlottesville; Dr. F. Schultze-Seeman, Berlin; Dr. Alejandro von Lichtenberg, Mexico City; Dr. Franz von Lichtenberg, Boston; and Dr. Egan Wildbolz, Berne. I further acknowledge having received verbal recollections from several urologists who visited Professor von Lichtenberg either in Germany or in Mexico. References 1. Goodwin WE: Alexander von Lichtenberg (1880-1949) Introduction, Urology 3: 381 (1974). la. AIken CE: His life and work, Urology 3: 382 (1974). lb. Belt E: A memoir, Urology 3: 385 (1974). lc. Del Rio A: Von Lichtenberg in Mexico, Urology 3: 388 (1974). 2. Westerman geb. Schuffner B: Alexander von Lichtenberg

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(1880-1949), Biobibliographie eines Urologen. Inaugural Dissertation zur Erlangung der medizinischen Doctorwurde an den Medizinischen Fachbereichen der Freien Universitiit Berlin, 1978, 3. Voelcker F, and Lichtenberg A: Pyelographie (Rontgenographie des Nierenbeckens nach Kollargofiillung), Munchen med Wchnschr 53: 105 (1906), 4, Marshall VF: Methods in urographic diagnosis-the controversial history of excretory urography, in Emmett JL, and Whitten DM (Eds): Clinical Urography, ed 3, Philadelphia, WB Saunders Co, vol 1, 1971, chap 1, p 1. 5, Osborne ED, Sutherland CG, Scholl AI. and Rowntree LG: Roentgenography of urinary tract during excretion of sodium iodide, JAMA 80: 368 (1923). 6. Swick M: Darstellung der Niere und Harnweges im Rontgenbild durch intravenose Einbringung eines neuen Kantrastoffes, des Uroselectans, Klin Wchnschr 8: 2087 (1929). 7. Von Lichtenberg A, and Swick M: Klinische Priifung des Uroselectans, Klin Wchnschr 8: 2089 (1929), 8. Binz A: The chemistry of Uroselectan, J Uro125: 297 (1931). 9, Swick M: The discovery of intravenous urography: historical and developmental aspects of the urographic media and their role in other diagnostic and therapeutic areas, Bull NY Acad Med 42: 128 (1966),

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