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Julius Hirschberg, the Neglected Historian of Ophthalmology
JULIUS HIRSCHBERG, THE NEGLECTED HISTORIAN OF OPHTHALMOLOGY CHARLES SNYDER Boston, Massachusetts
The history of ophthalmology up to the start of World War I is well docu mented, perhaps better documented than the history of any other medical speciality. We owe this fortunate state of affairs primarily to the efforts of one man—Julius Hirschberg, M.D. (Figure). An extraordinary person, certainly a gen ius, he devoted years to the task of recording the past of the medical speciali ty he loved and practiced. Circumstances prevented him from receiving during his life all the recognition and gratitude he deserved. Since his death in 1925, his life, accomplishments, and great gifts to ophthalmology have been treated at length only twice in the medical litera ture—once in English and once in Ger man.1,2 A strange fate indeed for one of the world's major medical historians.
These Hirschberg quickly mastered and he went on to read and enjoy the writings of the ancients. One biographer suggest ed that Hirschberg's lifelong love of the Graeco-Roman world began during his years at the gymnasium.1 His father saw to his education in modern languages. At an early age the boy was reading English, French, and Italian. Later in life he would add Arabic and modern Greek to his list. As a man he was fluent in five modern languages and knowledgeable in
EARLY YEARS
Julius Hirschberg was born Sept. 18, 1843, in Potsdam, Germany.3 His father, a modest merchant, was ambitious for his children. His father recognized young Julius' superior intellect and made plans to give the boy the best education the family purse would allow. At the age of 9 years, he entered the Royal Victoria Gymnasium in Potsdam. A willing and excellent pupil, he usually led his class. The curriculum of the school emphasized the classical languages, Greek and Latin. From the Lucien Howe Library of Ophthalmology, Harvard Medical School, and the Massachusetts Eye and Ear Infirmary, Boston, Massachusetts. Reprint requests to Charles Snyder, Librarian, Lucien Howe Library of Ophthalmology, Harvard Medical School, Massachusetts Eye and Ear Infirmary, 243 Charles St., Boston, MA 02114. 664
Figure (Snyder). Julius Hirschberg at the age of 70 years. (From "Julius Hirschberg's ausgewählte Ab handlungen (1868-1912) zu seinem 70. Gehurtstage ihm überreicht im Namen seiner Schüler von Oskar Fehr und Wihelm Münsam." Leipzig, Veit and Co. 1913.)
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half a dozen others. With such a capacity for learning, it is not surprising that he graduated first in his class. He went to Berlin to study medicine. His family by this time had little money and he had to support himself by tutoring fellow students and acting as stenogra pher to a medical society. During his student days many of the titans of 19th century German medicine were in Ber lin—Helmholtz, Brücke, and DuBoisReymond in physiology, Virchow, Traube, and Frerichs in pathology, and Langenbeck and Junkgen in surgery. When the time came for Hirschberg to have a practice of his own, he, a heroworshipper, placed photographs of all of them on his office walls. It was probably under Virchow's direction that he wrote his doctoral thesis, "Symbolae ad therapiam partus cum placenta praevia complicata. " He graduated and took his degree on March 21, 1866. A year later he passed his qualifying examination. He was ready to meet the man who would shape his life and career—Friedrich Wilhelm Ernst Al brecht von Graefe (1828-1870). As Hirschberg told it, their meeting makes a fascinating story.3'4 During the 1866 war between Prussia and Austria, an epidemic of cholera broke out in northern Germany. Von Graefe was made chief of one of the cholera hospitals in Berlin. His hospital was understaffed so he turned to Virchow, who had charge of another hospital, for an assistant. Hirschberg as a student had worked in Virchow's patho logic laboratory and was at this time working under him in his cholera hospi tal. Virchow transferred Hirschberg to von Graefe's service. Hirschberg and von Graefe had not been together long when Hirschberg, by following von Graefe's orders to the letter, quarrelled with a police surgeon. In Prussia, recently grad uated young doctors did not quarrel with police surgeons. Hirschberg was dis missed. Von Graefe explained the actions
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of his young assistant to higher authori ties and then resigned. Perhaps to make amends, von Graefe then offered Hirsch berg an assistantship in his ocular clinic. Hirschberg was 23 years old when he accepted the appointment. Von Graefe had the rare qualities of earning the devotion of his young associ ates and of drawing out the best that was in them. Like others before him, Hirsch berg was happy and enthusiastic about working under von Graefe; he was will ing, even eager, to do more than his assigned duties. Von Graefe's genius, his extraordinary acumen, his love of work, charitable nature, and complete personal and intellectual honesty all made their mark on Hirschberg's impressionable na ture. As a young man and as a neophyte clinician he could not help but be en riched by the experience. In later years Hirschberg repaid the debt by writing and speaking of his beloved master and his work. Indeed, the last piece of writing to come from Hirschberg's pen was an edited volume of lectures that von Graefe had delivered in 1859-1860.5 T H E "POLICLINIC"
Hirschberg stayed with von Graefe for two years, and then left to start his own private practice and policlinic. Whenev er he could, he used von Graefe's clinic and von Graefe's lifestyle as patterns. In time, he chose a building at 36 Karl strasse.4 On the first floor he conducted his large policlinic and held his lectures. The second floor was occupied by his consulting room, his attractive apart ment, study, and library. The remainder of the building was a hospital with wards and private rooms for 40 patients and a well-equipped operating room. He was especially proud of the operating room, declaring it to be the first aseptic operat ing room in the world. With his own hands he sterilized the instruments and prepared for the operations.
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This building was his world. 1 Within its walls he did all of his work and lived his life. His unvarying schedule called for him to rise early and meet his assistants at 8 A.M. in the operating room because op erations were the first order of the day. Next came rounds and dressings. The time that remained of the morning he spent in his study. He met with his students at 1 P.M., began his policlinic service at 2 P.M., and began to see his private patients at 4 P.M. Rounds were made again later in the evening. He spent a few of his evenings in social activities, but gave most of them to study and writing. Success in his private practice was soon his. Patients came to him from Berlin, from other sections of Germany, and from foreign countries. His practice grew steadily until it was so large that he needed the services of two full-time assistants and a number of volunteer assistants. The Hirschberg Clinic became one of the best known in Europe and he became one of the Continent's most famous ophthalmologists. None of this would have been if he had not had a strong, even domineering, personality, a deep sense of duty, great skill, a willing ness to work hard, and the ability to use his time frugally. His clinical work was always marked by great care and accuracy. 1,4 Those who assisted him had to be equally careful and accurate. He reviewed all important cases in the clinic. If anything was omit ted or overlooked, he was sure to find it. Visual fields were taken with great fre quency and care; every case of diplopia was accurately measured; drawings were made routinely of external and fundus diseases. In his clinic every patient re ceived a urinalysis. Accurate and thor ough work was the hallmark of his institu tion. When he failed with a case, he experienced a deep emotional upset that would last for days. Industrious, careful,
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and observant, he gathered records, clin ical histories, drawings, and pathologic preparations, and then used the material in his many publications. His students were trained to do the same. Hirschberg conducted his policlinic and private practice from 1869 to 1907. During that time he examined and treat ed a total of 256,647 patients. Between 1886 and 1907, the major operations totaled 7,915. These are indeed impres sive figures. Although ophthalmology was Hirschberg's great love, he made the entire field of medicine his province. 1 In his writings he laid great stress on the rela tionship of diseases of the eye to diseases of other parts of the body and systemic diseases. Two such diseases that received his attention were congenital syphilis and diabetes. He reported his findings in 1,000 cases of congenital syphilis. He wrote that a specific type of retinitis could be the first sign of the disease, that the blood vessels that formed on the cornea never disappeared and could often be seen years later, and that small vitre ous opacities and the resulting flicker might be the patient's first sign. As for treatment, he found that an iridectomy relieved the iritis. He could offer his patients nothing except mercury oint ment and potassium iodide. Arsphenamine, Dr. Ehrlich's "magic bullet," was in the future. H e knew all the ocular manifestations of diabetes, but, once again, he could offer his patients no relief. Insulin was in the future. Perhaps his greatest contribution to clinical ophthalmology was his work on the electromagnet and metallic foreign bodies. 6 The modern technique of mag net extraction is based mainly on his work. He improved on the giant magnet and constructed the first practical hand magnet. In his writings he stressed the value of careful preparation before each extraction and advised when to use the
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large magnet and when to use the small magnet. He wrote from experience, for in 28 years he had performed 347 extrac tions. More than 56% of his patients retained good visual acuity. He is credit ed with being the first to give a clear and complete description of siderosis and its development and the first to emphasize the absolute necessity of promptly re moving every metallic foreign body from the interior of the eye. 1 In the years when trachoma was still the curse of much of Europe, Hirschberg headed two commissions to investigate the problem in the eastern and western provinces of his native Prussia. His for eign travels had made him an authority on the distribution of the disease in other parts of the world. He concluded that trachoma was linked to poverty and mal nutrition and that race played no role. His prophylactic recommendations made good sense and his operative recommen dations were the best the times allowed.
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than his German students. They were equal to the Germans in ability and diligence, but were less well prepared. Language difficulties played no decisive role. They learned German rather quick ly and were able to examine patients in a short time. One American, Harry Frie denwald, served as clinical assistant to Hirschberg for three years. Friedenwald tells us that Hirschberg was totally opposed to women in medi cine. 8 When they started to come to Berlin for advanced training, he termed them "intruders" and "adventuresses." He vowed that none would be allowed to enroll in his courses. He did not antici pate, however, the persistence of one, the tall blonde Dr. Hubbard from Bos ton, and her effect on the soft heart of Harry Friedenwald. Hubbard took a pri vate course in ophthalmology with a Privat-Docent, one of Hirschberg's assis tants. With this to her credit, she asked Friedenwald to obtain permission for her to observe in Hirschberg's policlinic. T H E TEACHER Hirschberg was surprised to learn that Hirschberg was a first-class educator. the young woman had been trained by During the last third of the 19th century, one of his assistants. This placed him in Berlin came to rival, if not to surpass, the awkward position of being unable to Vienna as the mecca of foreign medical say no. He told Friedenwald, "She may students. He was one of the attractions come and sit quietly and listen to what I that drew them to the northern city.7 say, and she may take a case now and Once there, many of them came to prefer then and examine it with the ophthalmo his instruction to that offered in the scope, but only women and children, for Berlin University Ophthalmic Clinic. His our men are not satisfied if we allow clinic was found to be most interesting women to examine them." This conces and was always crowded with Americans, sion was all Friedenwald and Hubbard as well as doctors from other countries, wanted. We do not know if Hirschberg who listened to his lectures and studied ever admitted another woman to his his painstaking clinical methods. Short of courses. stature, rotund of form, blond of hair and Despite his talents, qualifications, and beard, he dominated his classes by virtue popularity in certain circles, Hirschberg of his qualities as a teacher and the never attained the rank of Professor in clarity, purity, even the elegance of his Berlin. His first academic appointment, language. In more than 35 years of teach that of Privat-Docent in Ophthalmology, ing, he taught dozens of Americans in his came to him on March 24, 1870. He was regular and special courses. He found too young to succeed von Graefe as that they were, on the average, older Professor when that master died in the
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summer of 1870. The professorship went to Schweigger who held it for 30 years, until 1900. During those years Hirsch berg advanced to the position of Extraor dinary Professor and then to Medical Counsellor (Medizinalrat). On the resig nation of Schweigger, the professorship that perhaps should have gone to Hirsch berg went to Julius Michel. Ordinary Honorary Professor became Hirschberg's academic rank in 1900. His
PERSONALITY
Hirschberg often spoke of himself as "a child of von Graefe." His students and assistants he called "the grandchildren of von Graefe." Two of his assistants, Harry Friedenwald and Oscar Fehr, have left records of what it was like to be an underling of Hirschberg. 1 8 , 9 First, the pay was small, so small that Friedenwald was ashamed to tell his father the exact sum—60 marks a month. Small in money matters, Hirschberg could also be small in giving credit for original work done by an assistant. 8 He required them to be on duty at all times and, if necessary, to come down from their attic bedroom in the middle of the night to tend a restless patient. They met him the first thing in the morning, assisted at his operations, accompanied him on his rounds, made the preliminary examinations of his pri vate patients, and, of course, cared for patients in the policlinic. During his absences, they managed the affairs of the clinic and performed operations. Their time away from hospital duties had to be spent in research, reading medical books and journals, and doing minor writing and editorial chores for Hirschberg's journal, "Centralblatt für praktische Au genheilkunde," and they had to partici pate in the teaching programs as assis tants. They worked seven days a week, holidays were few, and vacations were granted grudgingly and could be termi nated without notice.
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Like assistants since time began, they gossiped about their Chief whenever they had the chance. Friedenwald tells of one session where one of the topics was the rudeness, almost brutality, of Hirsch berg. 8 The young men present thought it necessary to give patients hope and cheer even when they knew that the patients would eventually become blind. One day a patient, a young man 18 or 20 years old who had vitreous opacities, came into Hirschberg's policlinic. Hirschberg ex amined him and then asked if he be longed to a company insurance group. The boy's answer was no. "Well, then," said Hirschberg, "you had better get into one so you can go to their clinic—you are going blind." These cruel words were said with unsympathetic coolness. The boy said nothing, but when the assistant tried to examine him, the examination could not be done because of tears in the boy's eyes. Friedenwald hoped and prayed that he would never cause such pain to any person—that was not his object in becoming a physician. The tale ends with these words—"Hirschberg is a brute." As the story demonstrates, Hirschberg could be harsh in his attitude toward clinic patients. In this he was not alone. There are many accounts of patients receiving what bordered on inhuman treatment at the hands of the chief physi cians of some of the German clinics in the 19th century. 7 Others have written that Hirschberg was a man of charm and of warmth and that his face could be full of love when he saw students or private patients. Both Fehr and Friedenwald submitted to his demands, came to fear him, to respect him, and then to love him dearly throughout his life. When he died, both men wrote warm eulogies. 5,10 When he wished, Hirschberg could be quite charming and almost sociable. He went to the theatre, concerts, or the
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opera, especially if a work of Wagner's was being presented. His extraordinary mind allowed him to memorize pages of German literature, particularly Goethe. Without being asked he recited long passages to some unsuspecting soul and did not know when to stop. Although he enjoyed playing the host, his guests did not always enjoy being guests. One writ er1 stated: He much preferred talking to listening, and expressed his views in a dogmatic way, tolerating no contradiction. He did not converse, he made speeches. If he noticed that somebody was inattentive, he stopped and addressed the per son: "You, listen to what I am saying." He was something of a bore.
John E. Weeks described one evening at the Hirschberg home. 11 The time was 1890 and the occasion was the Interna tional Medical Congress. Hirschberg gave a dinner at his home for ophthalmol ogists from 17 different countries. There were 21 guests. The only woman present was the beautiful and gracious Madame Hirschberg. After an excellent dinner, all the guests were called upon to give short addresses. The host had welcomed the guests and had invited them to speak in five different languages. One guest, an Englishman representing Turkey, sur passed Hirschberg by speaking six lan guages. It seems that Turkish was not one of the languages mastered by Hirschberg. It was his habit to break his year of intense labor by spending long vacations in foreign travel. There were few coun tries in Europe that he did not visit at one time or another. Extensive study preced ed each of his trips. While traveling he took copious notes. When he returned to Berlin, he wrote of his experiences in articles and books. Among these were "Parisian Eye Clinics" (1870), "English Eye Clinics" (1877), "Tunis" (1885), "Egypt, Historical Studies" (1890), "Jour neys to America" (1888 and 1905), "Visits to Greece" (1910), and "Around the
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World" (1894). His publications dealt with ophthalmology and medicine in the various countries; unexpectedly, they also dealt with the geography, economy, social life, and politics of these countries. In his writings on America, for example, he gave his impressions of American railroads, the amazing growth of Chicago, and the influence of German emigrants. Chicago fascinated him, especially its meat packing plants. He commented on the working class and their indepen dence, the lack of servants, and the hopes of blacks.7 Hirschberg was a good observ er and his books are interesting reading. Why did he travel? In order to attend a congress or medical society meeting, or perhaps to give an invited lecture; more often than not, he wanted to examine a rare historical document or book in its home library. Friedenwald relates another interest ing aspect of Hirschberg's personality.8 Although he was Jewish, he seldom con cerned himself with Jewish life other than to contribute annually to the Jewish Char ities of Berlin—until the early weeks of 1914. The Twelfth International Ophthalmological Congress was scheduled to be held in St. Petersberg in August 1914. The Russian authorities sent out a circular stating that the passports of Jewish doc tors planning to attend the Congress would be specially stamped and that their stay in Russia would be limited to one week. No such regulations would exist for non-Jewish doctors. When Hirschberg learned of this he acted quickly. He wrote strong letters to his many col leagues around the world urging them to resign as he was doing unless the restric tions were lifted. Friedenwald joined him in the fray. Before long the Organization Committee in St. Petersburg received protests and resignations from societies and ophthalmologists in Maryland, New York, Brussels, and Naples. The Interna tional Committee of the Congress backed
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Hirschberg. The Russian government was forced to lift the restrictions. Another circular was sent from Russia, one stating that "the Central Bureau announces that the Ministry of the Interior has author ized free entrance and an unlimited stay in Russia to Members of the Congress without exception." One letter of con gratulation that arrived after the incident read, "Gutta cavat lapidem" ("The drop hollows out the stone"). For one of the final issues of the 1914 volume of his "Centralblatt," Hirschberg wrote a history of the International Con gresses of Ophthalmology. When he came to record the Twelfth Congress he wrote, "The Congress in St. Petersberg planned for August 1914 did not take place. The story is over." ("Die Ge schichte ist aus"). His
WRITINGS
In his day no author was cited more frequently than Hirschberg. 5 The vast amount of his writings makes this state ment believable. During his first year in private practice, 1869, he published his first textbook, "Glioma of the Retina." (With two exceptions all of Hirschberg's books are available only in German. I have translated the titles freely.) Five years later he brought out his "Mathe matical Basis of Medical Statistics." This was followed by the three volumes of "Clinical Contributions." His knowledge of Latin, Greek, and Arabic enabled him to compile a "Lexicon of Ophthalmology" in 1887. Later came his two-volume work, "Introduction to Ophthalmology." On his 70th birthday, in 1913, his shorter writings, more than 100 articles, were republished in an 864-page Festschrift. He also wrote four books on Arabic ophthalmology, other historical books, and the 11 volumes of his "History of Ophthalmology." This includes only his writings on medicine and medical histo ry, and not his work in other areas. He
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must have been the most prolific writer about ophthalmology of his generation. As an author and historian Julius Hirschberg's great gift to ophthalmology was his "History of Ophthalmology" ("Geschichte der Augenheilkunde"). This masterpiece, published between 1899 and 1918, forms 11 volumes of the second edition of the "Graefe-Saemisch Hand buch der gesamten Augenheilkunde." (For some reason, most sources list only nine volumes. Of all the publications consulted for this study, only DukeElder's textbook 6 credits Hirschberg with 11 volumes.) Ranging in price from $3.30 to $4.50, the early volumes soon sold out. Circumstances prevented the later vol umes from being so successful. Critics and medical historians called the work "authoritative and exhaustive," "the most complete and scholarly history of the science that has ever been written," and "a wonderful monument to German thor oughness." One said, "His monumental work today remains the authoritative history of ophthalmology. It thorough ness and critical judgment mark it as one of the greatest histories of scientific sub jects." I may add that it is an unfailing lode that has been mined by three gen erations of medical historians. In 1907 he gave up his policlinic and practice and devoted all his time to writing his great history. When he was finished in 1918, at the age of 75, he had written 11 volumes, a total of 4,720 printed pages. Only an individual with Hirschberg's rare combination of talent and industry could have accomplished the task. He was a master of languages, ancient and modern, a student of Egyp tian hieroglyphics, and a translator of Arabic and Greek texts. As a physician and as an ophthalmologist, he was of the first rank. With his knowledge of the present, he could look to the past, read its literature, and judge the worthy and the unworthy. H e had lived and worked
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during a period of great change and productivity in the specialty. He knew all the giants. Over the years he had come to possess one of the largest private libraries of ophthalmic literature in the world. A figure of international note and a world traveler, he could ask others for informa tion and it would be given to him. And, as Duke-Elder put it, "his greatest joy was perhaps his profound knowledge of and sympathy with classical and Arabic schol arship." 6 He loved his work, loved using his mind. And, most important, he had the ability to write in a delightfully attractive style. One critic went so far as to term him "a genial writer. " The first volume of his history was concerned with ancient ophthalmology, that of the Hindus, Babylonians, Egyp tians, Greeks, and Romans. The contri butions of the Arabs, Europe in the Middle Ages, and the beginnings of the modern era were dealt with in the second volume. In the third volume he contin ued the story of the modern era up to 1800. These three volumes are genuine works of scholarship. Information, much of it new to Western readers, was pre sented in a lively yet orderly fashion. The next four volumes told of the develop ment of ophthalmology in Germany, France, England, and Italy from 1800 to 1850. There was one volume for each country. These were followed by a vol ume devoted to the history of ophthal mology in the United States in the 19th century, and another volume on the history of the smaller countries of Europe and Russia from 1800 to 1875. The largest volume of the series came next, the one Hirschberg entitled "Reform in Ophthal mology." The great changes, the refor mation, came to the specialty with the introduction of the ophthalmoscope by Helmholtz, with Donders' work on re fraction, and with von Graefe's pioneer ing clinical work. Hirschberg included lengthy biographies of the three men
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along with analyses of their contributions. The rest of the volume was primarily a history of ophthalmology in Germany and the German-speaking nations up to the beginning of World War I. The last volume contained additions, corrections, and a general index. The enormous scope of Hirschberg's enterprise almost guaranteed that the volumes would not be equal in' quality and scholarship. Nowhere is this better demonstrated than in "American Oph thalmology in the 19th Century." As a work from the pen of a lesser historian it might be acceptable, but it was a poor performance from one such as Hirsch berg. Hirschberg knew America. He had traveled extensively there on three occa sions, visited schools and hospitals, talked with ordinary people, and mingled with professionals. For many years he had reviewed and abstracted ophthalmic studies from the United States for his "Centralblatt. " Thus, when it came time to write the history of American ophthal mology he had personal knowledge to draw on. He was willingly supplied with information by a host of acquaintances he had made. The writings of Hubbell, Friedenwald, and others were his to use. Out of all this something better should have come. Hirschberg confessed that he met with two difficulties in composing his Ameri can history. The first arose from the complicated structure and diversity of the colleges and medical schools. The second arose because ophthalmology in the United States had developed slowly until the 1870s. He wrote that a complete survey would have come very near to his own time, and would have dealt with still unsolved problems and living physicians about whom he felt he had to withhold judgment. It is only fair to agree with him in this. But this could not have been the cause of the errors he allowed to mar his work. These include the following: Wil-
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liam Charles Wells appears as William Charles Bell, James A. Bolten as James A. Bolters, Ezra Dyer as Esra Dyer, Henry Drury Noyes as Henry Dewey Noyes, and Alvin Allace Hubbell, one of his principle sources of information, as Alvin Allace Hubbel. Remembering the great value of his other volumes, perhaps it is wrong to be too critical of this volume, to be too concerned with small errors of fact and spelling. Perhaps it is wiser to agree with the writer who reviewed the book for American readers when it was issued. 12 He felt that all American oculists should be grateful to Hirschberg for having spent time on such an immense labor. He said the book would be read all over the world and would greatly help to correct the erroneous conceptions, or in some instances the complete lack of knowl edge, about America, still largely preva lent abroad. Hirschberg clearly left the writing of a definitive history of American ophthalmology to others. One general criticism concerns the index. The history is in 11 volumes with a total of 4,720 pages divided into 1,312 sections. Each volume was paginated separately and the sections were num bered consecutively. When Hirschberg provided a general index for the whole work, he chose to index the names and subjects by sections rather than by vol ume and page. This can lead to a great deal of frustration. The reader must go through the volumes, locate the right section, and then go through the section, some of which are several pages long, to locate the desired name or fact. Hirschberg's history has often been praised. His former assistant, Harry Frie denwald, summed up all the praise in these words 6 : It is the most comprehensive medical histori cal work that has ever been published, not of ophthalmology alone, but in the whole field of medical history. It is not an exaggeration to claim
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that Hirschberg has produced a complete history of ophthalmology; in doing this he has shown to the medical world the wealth of the heritage of ophthalmology.
Hirschberg's writing on medical histo ry was not confined to his "Geschichte der Augenheilkunde." This amazing man also wrote, translated, and edited studies on ophthalmology in ancient Egypt, on Ibn Sina, Aetius of Amida, Hippocrates, Aristophanes, Shakespeare, von Graefe, and two books on early Arabic ophthal mologists. In addition to these textbooks, he wrote several journal articles and notes on the history of ophthalmic medi cine and surgery. His accomplishments can only be viewed with awe. H e had no children. Perhaps he felt that, "These books shall be my posterity, they shall perpetuate my name." They do. Hirschberg was an editor of note as well as an author. His "Centralblatt für praktische Augenheilkunde" (Leipzig, 43 volumes between 1877 and 1919) was his second great gift to world ophthalmology. In publishing his own journal he followed the pattern of the elite of 19th century German medicine. His two idols, Virchow and von Graefe, had had their journals, and he felt it was his turn. It was a risky business. Considering the number of men practicing ophthalmology at the time, the German language probably had enough journals devoted to the specialty. Hirschberg overcame this problem by including the most attractive features of his rivals in his journal. Each year he brought out 12 issues, totaling 400 or 500 pages, in a volume. A typical issue contained original articles, proceedings of society meetings, clinical case presentations, book reviews, a sur vey of reports in other journals, obituar ies, correspondence, and bibliographies. Something for everyone. Many of the original articles were by Hirschberg or his assistants, although he did not hesi-
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täte to publish worthwhile offerings from as far away as Java. Societies, national, regional, and international, could have an abstract of their proceedings in his jour nal. He made certain that the proceed ings of the Berlin Ophthalmological Soci ety, a society he had founded, appeared regularly. He also made certain that the proceedings of the Colorado Ophthalmo logical Society, a society founded by his friend Edward Jackson, appeared regu larly. The clinical cases came from his own clinic, or from the clinic of someone he knew and respected. His book reviews were brief, factual, and fair. The books themselves, usually sent by authors or publishers, went into his large personal library. When he surveyed a journal, he took an entire issue and abstracted every original article. He surveyed two, three, sometimes four journals in one issue. His gift of languages allowed him to review the publications of all the major Euro pean countries. Hirschberg must have loved obituaries because he wrote so many. Correspondence was selected from letters that crossed his desk. The bibliographies, some of them several pages long, were of subjects he felt would be of interest to his readers. The "Centralblatt" was an excellent production and very much Hirschberg's personal journal. He wrote much of it himself and edited all of it. It was the instrument that made him world-famous. One writer commented that the "Cen tralblatt" was the best guide to the per sonality of Hirschberg, for its 43 volumes demonstrated the universality and versa tility of his mind and the clarity of his judgment. 1 The volumes also disclosed a less attractive side of the man's nature— his penchant for self-promotion. In 1910 Hirschberg published a small monograph on the treatment of myopia. G. Lindsay Johnson, a British ophthal mologist, bought a copy and, during a long voyage from Cape Town to London,
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translated it into English. He wrote a letter to Hirschberg telling him of the translation and of the high regard he had for Hirschberg's work. Hirschberg pub lished the letter in its entirety in the correspondence section of his "Central blatt." A few months later, in the same section, his readers were informed that the Johnson translation of his book had been published. In several subsequent issues his readers were treated to brief laudatory notices of the book taken from reviews and letters. All of these letters and notices were in English, not in German, which was the language of the journal. It was among the readers whose native tongue was English that he hoped to promote and sell his book. He used this same ploy throughout the 1915 vol ume of his "Centralblatt" when his book on the history of ophthalmology in Amer ica was issued. Hirschberg had one other tour of duty as an editor. From 1879 to 1881 he served as co-editor of Herman Knapp's Archives of Ophthalmology (New York) and Archiv für Augenheilkunde (Wiesbaden). Shyness was never a part of Hirsch berg's nature. 1 He was always certain of his importance in the scheme of things, always aware of his dignity, and he ex pected others to be equally aware. He was very much the archetypal "Herr Professor." His many titles and honors gave him inordinate pride. Everyone, regardless of their station, was required to address him as "Geheimer Medizinal rat" ("Privy Medical Counsellor"). He fitted himself to the mold of many of his peers in the ranks of German medicine of the time. Like them, he demanded work, enormous quantities of it, of himself; like them he demanded recognition and honor for what he had done. On one occasion when he wrote of himself, Hirschberg managed to keep his ego under control. The last full volume of his history is concerned with what he
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termed the reformation in ophthalmolo gy, the period after the introduction of the ophthalmoscope. H e often devoted pages to lesser figures of the period; for himself he published his portrait, a brief autobiography—less than half a page— and a list of his publications. The entire piece is little more than an outline. T H E W A R YEARS
The summer of 1914 found Hirschberg at his peak as a figure in international ophthalmology. His journal and his clini cal and historical writings had made his name known throughout the Western world. His travels had served to intro duce him to ophthalmologists as far away as Japan. His students had publicized him wherever they went. His actions against the Russian bureaucracy concerning pass ports for Jewish physicians had marked him as a courageous and liberal man. But after the outbreak of World War I, things were never the same for Julius Hirsch berg. In the August-September 1914 issue of his "Centralblatt" he published the fol lowing notice on the front page: For the Fatherland Since the July number of the "Centralblatt" was dispatched to subscribers at home and abroad, the fearful war has broken out, wickedly forced upon us by our enemies.
The last phrase of this notice indicated that Hirschberg accepted without ques tion the government position that Ger many was the innocent victim of a syste matic, long-planned international plot and that the nation had gone to war to survive. Some of those who had accepted Hirschberg as an international leader expected him to have a different attitude, a more liberal one, not the narrow na tionalism that he did adopt. There is some evidence that Hirschberg suffered be cause of his ultra-patriotism. For exam ple, neither T H E AMERICAN JOURNAL O F OPHTHALMOLOGY nor the British Journal
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of Ophthalmology reviewed his books published during the war or before his death in 1925. During the war years he kept busy. Although 71 years old, he returned to his clinic from time to time; much of the staff had gone to war, and he saw as many private patients as he could. He worked on the last five volumes of his "Ge schichte der Augenheilkunde" and saw them published. He continued the "Cen tralblatt." H e began his study on Shake speare; he lectured. H e received the Leibnitz Silver Medal of the Berlin Acad emy of Science. Meanwhile he confident ly awaited the final victory of his nation. When World War I ended, Hirschberg's life and his country were both in ruins. H e was too old to build anew. H e could rejoice that his great history was finished and safely in print. H e could take no comfort from his "Centralblatt," for he was forced to abandon the journal at the end of 1919 because of competition and the lack of a successor as editor. But it was the fate of his library that must have broken his heart. T H E LIBRARY
The library was one of his proudest possessions. Over the years it had grown until it was one of the largest, most complete and famous ophthalmic librar ies in the world. A catalogue of it pub lished in 1901 consisted of 434 pages. It had always been his plan to leave it after his death to the Berlin Medical Society. His patriotism made this impossible. During the war he had invested much of what he owned in German war bonds. With his nation's defeat, the bonds be came worthless. To obtain funds to live modestly, he was forced to sell his li brary. The sale of Hirschberg's library and its later history is a story in itself.13 Dr. Jujiro Komoto, who had become the first Pro fessor of Ophthalmology at Tokyo Univer sity in 1890, had spent part of his student
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days in Berlin and had come to know Hirschberg. He and Hirschberg became better acquainted after Hirschberg's visit to Japan in 1892 and Komoto's later visit to Berlin. On Dec. 2, 1920, Hirschberg wrote to Komoto offering to sell his library for 40,000 yen. The collection consisted of 3,200 books and 12,500 re prints and included: historical documents covering old Greek, Egyp tian and Roman times, the Middle Ages up to the 19th century works. They are not only of European origin, but also from Eastern and Middle Eastern Countries. There are original papers on discoveries in the 19th century, and books and reprints that cover all possible fields of ophthalmology.u
There were no public funds to make the purchase, so Dr. Komoto decided to buy the library himself, and also to meet the costs of shipping and insurance. The money was to be paid to Hirschberg in 10,000-yen yearly installments. Unfortu nately, Hirschberg died before the last payment reached him. In 1925, just after the Great Earthquake, the collection reached Japan, and Komoto immediately donated it to the Library of Tokyo Uni versity. For a number of reasons the col lection was not completely catalogued and classified until 1938. The collection was then named the Komoto Library and became a part of the Central Library of Tokyo University. Komoto wrote of Hirschberg's collec tion: His Library is the only one of its kind in the world and is the object of envy in many coun tries. We have the Library in Japan and I hope that the Library will continue to be of benefit to ophthalmology in Japan after my death.
The hope of Dr. Komoto has been realized. The respect in which the collec tion is held is demonstrated by this quotation from the Japanese Journal of Ophthalmology.13 It is indeed the world's treasure not only of ophthalmology but also of human art. We are
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very happy that this large, invaluable collection has survived two World Wars and the Great Earthquake, and will be the possession of man kind forever.
Scholars may consult the Komoto Li brary, formerly the Hirschberg Library, by permission of the Library Department of Tokyo University. The name of Julius Hirschberg is an honored one in Japan. T H E LAST YEARS
In 1907 Hirschberg's policlinic build ing was torn down and a new one erected. Wilhelm Mühsam was put in charge. In his last years, Hirschberg made daily visits, walking through the corridors, and observing the activities. He had always dreamed that someday his clinic would be associated with the Berlin University as the "Julius Hirschberg Museum." This, of course, never came to be. After Hitler took power, Mühsam was forbid den to enter the premises. 1 The ocular clinic ceased to exist and the building became a children's ward. In spite of his disappointments and hardships, Hirschberg took old age well. Harry Friedenwald visited him in the summer of 1923 and found him less vigorous but just as interesting; his mind and unfailing memory were just as clear as in the days when it was Friedenwald's privilege to assist him in the clinic.5 He did not seem 80 years old. A year earlier he had given a course of lectures on Hippocratic medicine. He was working on his last book, von Graefe's lectures. On Feb. 17, 1925, Julius Hirschberg, the most brilliant pupil of Albrecht von Graefe, died. 7 His passing was noted in the German medical press. Two of his former assistants, Oscar Fehr and Wil helm Mühsam, wrote eulogies for the German ophthalmic journals.10,14 In the English-language journals there was only one obituary, that of Harry Friedenwald in the Archives of Ophthalmology.5 THE AMERICAN JOURNAL OF OPHTHALMOLOGY
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and the British Journal of Ophthalmology printed brief notices. The Frenchlanguage journals followed suit. A great man had died, a great contribu tor to ophthalmology was no more, and outside of his native land little attention was paid. Why? Hirschberg may have been the victim of the chauvinism of World War I and of the years that fol lowed. Perhaps he had lived too long, with his great days too far in the past. Perhaps the area in which he did his greatest work, the history of ophthalmol ogy, was interesting to only a few in the specialty. How many ophthalmologists were interested in Ali ibn Isa of Baghdad and the translator of his Memorandum Book? Whatever the reason, amends were made some years ago by Sir Stewart Duke-Elder when he wrote of Julius Hirschberg and his history in the "Text book of Ophthalmology. "6 Sir Stewart, ever the master of the felicitous phrase, closed his tribute with these words: "No other branch of medicine—no, indeed, so far as I am aware, of knowledge—has had a disciple so earnest, or has been pre sented with a gift so great."
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REFERENCES 1. Jokl, A.: Julius Hirschberg. Am. J. Ophthalmol. 48:329, 1959. 2. Koelbing, H. M.: Julius Hirschberg (18431925) als Ophthalmologe und Medizinhitoriker. Klin. Monatsbl. Augenheilkd. 168:103, 1976. 3. Hirschberg, J.: Aus jugen Tagen (Erlebnisse und Erinnerungen.) Berlin, W. Junk, 1923. 4. Friedenwald, H.: Julius Hirschberg. Arch. Ophthalmol. 54:418, 1925. 5. Hirschberg, J.: Augenkrankheiten und ihre Behandlung. Vorlesungen 1859-1860 von Albrecht von Graefe. Leipzig, Georg Thieme, 1925. 6. Duke-Elder, S.: Textbook of Ophthalmology. Vol. 6. Injuries. London, Henry Kimpton, 1954, p. 6125. 7. Bonner, T. N. : American Doctors and German Universities. A Chapter in International Relations. Lincoln, University of Nebraska Press, 1963. 8. Levin, A. L. : Vision. A biography of Harry Friedenwald. Philadelphia, Jewish Publishing Soci ety of America, 1964. 9. Jokl, A. : The life of Oscar Fehr. Am. J. Ophthal mol. 54:1011, 1962. 10. Fehr, O.: Julius Hirschberg. Klin. Monatsbl. Augenheilkd. 74:497, 1925. 11. Weeks, J. E.: Autobiography. Portland, Met ropolitan Printing Co., 1954, p. 52. 12. Zimmerman, C : The Oculists of America in the Nineteenth Century, book review. Ophthalmolo gy 12:210, 1915-1916. 13. Kirisawa, N.: The Komoto Library (formerly the Hirschberg Library). Jpn. J. Ophthalmol. 21:528, 1977. 14. Mühsam, W. : Julius Hirschberg. Z. Augen heilkd. 55:289, 1925.
The history of ophthalmology up to the start of World War I is well docu mented, perhaps better documented than the history of any other medical speciality. We owe this fortunate state of affairs primarily to the efforts of one man—Julius Hirschberg, M.D. (Figure). An extraordinary person, certainly a gen ius, he devoted years to the task of recording the past of the medical speciali ty he loved and practiced. Circumstances prevented him from receiving during his life all the recognition and gratitude he deserved. Since his death in 1925, his life, accomplishments, and great gifts to ophthalmology have been treated at length only twice in the medical litera ture—once in English and once in Ger man.1,2 A strange fate indeed for one of the world's major medical historians.
These Hirschberg quickly mastered and he went on to read and enjoy the writings of the ancients. One biographer suggest ed that Hirschberg's lifelong love of the Graeco-Roman world began during his years at the gymnasium.1 His father saw to his education in modern languages. At an early age the boy was reading English, French, and Italian. Later in life he would add Arabic and modern Greek to his list. As a man he was fluent in five modern languages and knowledgeable in
EARLY YEARS
Julius Hirschberg was born Sept. 18, 1843, in Potsdam, Germany.3 His father, a modest merchant, was ambitious for his children. His father recognized young Julius' superior intellect and made plans to give the boy the best education the family purse would allow. At the age of 9 years, he entered the Royal Victoria Gymnasium in Potsdam. A willing and excellent pupil, he usually led his class. The curriculum of the school emphasized the classical languages, Greek and Latin. From the Lucien Howe Library of Ophthalmology, Harvard Medical School, and the Massachusetts Eye and Ear Infirmary, Boston, Massachusetts. Reprint requests to Charles Snyder, Librarian, Lucien Howe Library of Ophthalmology, Harvard Medical School, Massachusetts Eye and Ear Infirmary, 243 Charles St., Boston, MA 02114. 664
Figure (Snyder). Julius Hirschberg at the age of 70 years. (From "Julius Hirschberg's ausgewählte Ab handlungen (1868-1912) zu seinem 70. Gehurtstage ihm überreicht im Namen seiner Schüler von Oskar Fehr und Wihelm Münsam." Leipzig, Veit and Co. 1913.)
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half a dozen others. With such a capacity for learning, it is not surprising that he graduated first in his class. He went to Berlin to study medicine. His family by this time had little money and he had to support himself by tutoring fellow students and acting as stenogra pher to a medical society. During his student days many of the titans of 19th century German medicine were in Ber lin—Helmholtz, Brücke, and DuBoisReymond in physiology, Virchow, Traube, and Frerichs in pathology, and Langenbeck and Junkgen in surgery. When the time came for Hirschberg to have a practice of his own, he, a heroworshipper, placed photographs of all of them on his office walls. It was probably under Virchow's direction that he wrote his doctoral thesis, "Symbolae ad therapiam partus cum placenta praevia complicata. " He graduated and took his degree on March 21, 1866. A year later he passed his qualifying examination. He was ready to meet the man who would shape his life and career—Friedrich Wilhelm Ernst Al brecht von Graefe (1828-1870). As Hirschberg told it, their meeting makes a fascinating story.3'4 During the 1866 war between Prussia and Austria, an epidemic of cholera broke out in northern Germany. Von Graefe was made chief of one of the cholera hospitals in Berlin. His hospital was understaffed so he turned to Virchow, who had charge of another hospital, for an assistant. Hirschberg as a student had worked in Virchow's patho logic laboratory and was at this time working under him in his cholera hospi tal. Virchow transferred Hirschberg to von Graefe's service. Hirschberg and von Graefe had not been together long when Hirschberg, by following von Graefe's orders to the letter, quarrelled with a police surgeon. In Prussia, recently grad uated young doctors did not quarrel with police surgeons. Hirschberg was dis missed. Von Graefe explained the actions
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of his young assistant to higher authori ties and then resigned. Perhaps to make amends, von Graefe then offered Hirsch berg an assistantship in his ocular clinic. Hirschberg was 23 years old when he accepted the appointment. Von Graefe had the rare qualities of earning the devotion of his young associ ates and of drawing out the best that was in them. Like others before him, Hirsch berg was happy and enthusiastic about working under von Graefe; he was will ing, even eager, to do more than his assigned duties. Von Graefe's genius, his extraordinary acumen, his love of work, charitable nature, and complete personal and intellectual honesty all made their mark on Hirschberg's impressionable na ture. As a young man and as a neophyte clinician he could not help but be en riched by the experience. In later years Hirschberg repaid the debt by writing and speaking of his beloved master and his work. Indeed, the last piece of writing to come from Hirschberg's pen was an edited volume of lectures that von Graefe had delivered in 1859-1860.5 T H E "POLICLINIC"
Hirschberg stayed with von Graefe for two years, and then left to start his own private practice and policlinic. Whenev er he could, he used von Graefe's clinic and von Graefe's lifestyle as patterns. In time, he chose a building at 36 Karl strasse.4 On the first floor he conducted his large policlinic and held his lectures. The second floor was occupied by his consulting room, his attractive apart ment, study, and library. The remainder of the building was a hospital with wards and private rooms for 40 patients and a well-equipped operating room. He was especially proud of the operating room, declaring it to be the first aseptic operat ing room in the world. With his own hands he sterilized the instruments and prepared for the operations.
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This building was his world. 1 Within its walls he did all of his work and lived his life. His unvarying schedule called for him to rise early and meet his assistants at 8 A.M. in the operating room because op erations were the first order of the day. Next came rounds and dressings. The time that remained of the morning he spent in his study. He met with his students at 1 P.M., began his policlinic service at 2 P.M., and began to see his private patients at 4 P.M. Rounds were made again later in the evening. He spent a few of his evenings in social activities, but gave most of them to study and writing. Success in his private practice was soon his. Patients came to him from Berlin, from other sections of Germany, and from foreign countries. His practice grew steadily until it was so large that he needed the services of two full-time assistants and a number of volunteer assistants. The Hirschberg Clinic became one of the best known in Europe and he became one of the Continent's most famous ophthalmologists. None of this would have been if he had not had a strong, even domineering, personality, a deep sense of duty, great skill, a willing ness to work hard, and the ability to use his time frugally. His clinical work was always marked by great care and accuracy. 1,4 Those who assisted him had to be equally careful and accurate. He reviewed all important cases in the clinic. If anything was omit ted or overlooked, he was sure to find it. Visual fields were taken with great fre quency and care; every case of diplopia was accurately measured; drawings were made routinely of external and fundus diseases. In his clinic every patient re ceived a urinalysis. Accurate and thor ough work was the hallmark of his institu tion. When he failed with a case, he experienced a deep emotional upset that would last for days. Industrious, careful,
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and observant, he gathered records, clin ical histories, drawings, and pathologic preparations, and then used the material in his many publications. His students were trained to do the same. Hirschberg conducted his policlinic and private practice from 1869 to 1907. During that time he examined and treat ed a total of 256,647 patients. Between 1886 and 1907, the major operations totaled 7,915. These are indeed impres sive figures. Although ophthalmology was Hirschberg's great love, he made the entire field of medicine his province. 1 In his writings he laid great stress on the rela tionship of diseases of the eye to diseases of other parts of the body and systemic diseases. Two such diseases that received his attention were congenital syphilis and diabetes. He reported his findings in 1,000 cases of congenital syphilis. He wrote that a specific type of retinitis could be the first sign of the disease, that the blood vessels that formed on the cornea never disappeared and could often be seen years later, and that small vitre ous opacities and the resulting flicker might be the patient's first sign. As for treatment, he found that an iridectomy relieved the iritis. He could offer his patients nothing except mercury oint ment and potassium iodide. Arsphenamine, Dr. Ehrlich's "magic bullet," was in the future. H e knew all the ocular manifestations of diabetes, but, once again, he could offer his patients no relief. Insulin was in the future. Perhaps his greatest contribution to clinical ophthalmology was his work on the electromagnet and metallic foreign bodies. 6 The modern technique of mag net extraction is based mainly on his work. He improved on the giant magnet and constructed the first practical hand magnet. In his writings he stressed the value of careful preparation before each extraction and advised when to use the
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large magnet and when to use the small magnet. He wrote from experience, for in 28 years he had performed 347 extrac tions. More than 56% of his patients retained good visual acuity. He is credit ed with being the first to give a clear and complete description of siderosis and its development and the first to emphasize the absolute necessity of promptly re moving every metallic foreign body from the interior of the eye. 1 In the years when trachoma was still the curse of much of Europe, Hirschberg headed two commissions to investigate the problem in the eastern and western provinces of his native Prussia. His for eign travels had made him an authority on the distribution of the disease in other parts of the world. He concluded that trachoma was linked to poverty and mal nutrition and that race played no role. His prophylactic recommendations made good sense and his operative recommen dations were the best the times allowed.
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than his German students. They were equal to the Germans in ability and diligence, but were less well prepared. Language difficulties played no decisive role. They learned German rather quick ly and were able to examine patients in a short time. One American, Harry Frie denwald, served as clinical assistant to Hirschberg for three years. Friedenwald tells us that Hirschberg was totally opposed to women in medi cine. 8 When they started to come to Berlin for advanced training, he termed them "intruders" and "adventuresses." He vowed that none would be allowed to enroll in his courses. He did not antici pate, however, the persistence of one, the tall blonde Dr. Hubbard from Bos ton, and her effect on the soft heart of Harry Friedenwald. Hubbard took a pri vate course in ophthalmology with a Privat-Docent, one of Hirschberg's assis tants. With this to her credit, she asked Friedenwald to obtain permission for her to observe in Hirschberg's policlinic. T H E TEACHER Hirschberg was surprised to learn that Hirschberg was a first-class educator. the young woman had been trained by During the last third of the 19th century, one of his assistants. This placed him in Berlin came to rival, if not to surpass, the awkward position of being unable to Vienna as the mecca of foreign medical say no. He told Friedenwald, "She may students. He was one of the attractions come and sit quietly and listen to what I that drew them to the northern city.7 say, and she may take a case now and Once there, many of them came to prefer then and examine it with the ophthalmo his instruction to that offered in the scope, but only women and children, for Berlin University Ophthalmic Clinic. His our men are not satisfied if we allow clinic was found to be most interesting women to examine them." This conces and was always crowded with Americans, sion was all Friedenwald and Hubbard as well as doctors from other countries, wanted. We do not know if Hirschberg who listened to his lectures and studied ever admitted another woman to his his painstaking clinical methods. Short of courses. stature, rotund of form, blond of hair and Despite his talents, qualifications, and beard, he dominated his classes by virtue popularity in certain circles, Hirschberg of his qualities as a teacher and the never attained the rank of Professor in clarity, purity, even the elegance of his Berlin. His first academic appointment, language. In more than 35 years of teach that of Privat-Docent in Ophthalmology, ing, he taught dozens of Americans in his came to him on March 24, 1870. He was regular and special courses. He found too young to succeed von Graefe as that they were, on the average, older Professor when that master died in the
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summer of 1870. The professorship went to Schweigger who held it for 30 years, until 1900. During those years Hirsch berg advanced to the position of Extraor dinary Professor and then to Medical Counsellor (Medizinalrat). On the resig nation of Schweigger, the professorship that perhaps should have gone to Hirsch berg went to Julius Michel. Ordinary Honorary Professor became Hirschberg's academic rank in 1900. His
PERSONALITY
Hirschberg often spoke of himself as "a child of von Graefe." His students and assistants he called "the grandchildren of von Graefe." Two of his assistants, Harry Friedenwald and Oscar Fehr, have left records of what it was like to be an underling of Hirschberg. 1 8 , 9 First, the pay was small, so small that Friedenwald was ashamed to tell his father the exact sum—60 marks a month. Small in money matters, Hirschberg could also be small in giving credit for original work done by an assistant. 8 He required them to be on duty at all times and, if necessary, to come down from their attic bedroom in the middle of the night to tend a restless patient. They met him the first thing in the morning, assisted at his operations, accompanied him on his rounds, made the preliminary examinations of his pri vate patients, and, of course, cared for patients in the policlinic. During his absences, they managed the affairs of the clinic and performed operations. Their time away from hospital duties had to be spent in research, reading medical books and journals, and doing minor writing and editorial chores for Hirschberg's journal, "Centralblatt für praktische Au genheilkunde," and they had to partici pate in the teaching programs as assis tants. They worked seven days a week, holidays were few, and vacations were granted grudgingly and could be termi nated without notice.
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Like assistants since time began, they gossiped about their Chief whenever they had the chance. Friedenwald tells of one session where one of the topics was the rudeness, almost brutality, of Hirsch berg. 8 The young men present thought it necessary to give patients hope and cheer even when they knew that the patients would eventually become blind. One day a patient, a young man 18 or 20 years old who had vitreous opacities, came into Hirschberg's policlinic. Hirschberg ex amined him and then asked if he be longed to a company insurance group. The boy's answer was no. "Well, then," said Hirschberg, "you had better get into one so you can go to their clinic—you are going blind." These cruel words were said with unsympathetic coolness. The boy said nothing, but when the assistant tried to examine him, the examination could not be done because of tears in the boy's eyes. Friedenwald hoped and prayed that he would never cause such pain to any person—that was not his object in becoming a physician. The tale ends with these words—"Hirschberg is a brute." As the story demonstrates, Hirschberg could be harsh in his attitude toward clinic patients. In this he was not alone. There are many accounts of patients receiving what bordered on inhuman treatment at the hands of the chief physi cians of some of the German clinics in the 19th century. 7 Others have written that Hirschberg was a man of charm and of warmth and that his face could be full of love when he saw students or private patients. Both Fehr and Friedenwald submitted to his demands, came to fear him, to respect him, and then to love him dearly throughout his life. When he died, both men wrote warm eulogies. 5,10 When he wished, Hirschberg could be quite charming and almost sociable. He went to the theatre, concerts, or the
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opera, especially if a work of Wagner's was being presented. His extraordinary mind allowed him to memorize pages of German literature, particularly Goethe. Without being asked he recited long passages to some unsuspecting soul and did not know when to stop. Although he enjoyed playing the host, his guests did not always enjoy being guests. One writ er1 stated: He much preferred talking to listening, and expressed his views in a dogmatic way, tolerating no contradiction. He did not converse, he made speeches. If he noticed that somebody was inattentive, he stopped and addressed the per son: "You, listen to what I am saying." He was something of a bore.
John E. Weeks described one evening at the Hirschberg home. 11 The time was 1890 and the occasion was the Interna tional Medical Congress. Hirschberg gave a dinner at his home for ophthalmol ogists from 17 different countries. There were 21 guests. The only woman present was the beautiful and gracious Madame Hirschberg. After an excellent dinner, all the guests were called upon to give short addresses. The host had welcomed the guests and had invited them to speak in five different languages. One guest, an Englishman representing Turkey, sur passed Hirschberg by speaking six lan guages. It seems that Turkish was not one of the languages mastered by Hirschberg. It was his habit to break his year of intense labor by spending long vacations in foreign travel. There were few coun tries in Europe that he did not visit at one time or another. Extensive study preced ed each of his trips. While traveling he took copious notes. When he returned to Berlin, he wrote of his experiences in articles and books. Among these were "Parisian Eye Clinics" (1870), "English Eye Clinics" (1877), "Tunis" (1885), "Egypt, Historical Studies" (1890), "Jour neys to America" (1888 and 1905), "Visits to Greece" (1910), and "Around the
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World" (1894). His publications dealt with ophthalmology and medicine in the various countries; unexpectedly, they also dealt with the geography, economy, social life, and politics of these countries. In his writings on America, for example, he gave his impressions of American railroads, the amazing growth of Chicago, and the influence of German emigrants. Chicago fascinated him, especially its meat packing plants. He commented on the working class and their indepen dence, the lack of servants, and the hopes of blacks.7 Hirschberg was a good observ er and his books are interesting reading. Why did he travel? In order to attend a congress or medical society meeting, or perhaps to give an invited lecture; more often than not, he wanted to examine a rare historical document or book in its home library. Friedenwald relates another interest ing aspect of Hirschberg's personality.8 Although he was Jewish, he seldom con cerned himself with Jewish life other than to contribute annually to the Jewish Char ities of Berlin—until the early weeks of 1914. The Twelfth International Ophthalmological Congress was scheduled to be held in St. Petersberg in August 1914. The Russian authorities sent out a circular stating that the passports of Jewish doc tors planning to attend the Congress would be specially stamped and that their stay in Russia would be limited to one week. No such regulations would exist for non-Jewish doctors. When Hirschberg learned of this he acted quickly. He wrote strong letters to his many col leagues around the world urging them to resign as he was doing unless the restric tions were lifted. Friedenwald joined him in the fray. Before long the Organization Committee in St. Petersburg received protests and resignations from societies and ophthalmologists in Maryland, New York, Brussels, and Naples. The Interna tional Committee of the Congress backed
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Hirschberg. The Russian government was forced to lift the restrictions. Another circular was sent from Russia, one stating that "the Central Bureau announces that the Ministry of the Interior has author ized free entrance and an unlimited stay in Russia to Members of the Congress without exception." One letter of con gratulation that arrived after the incident read, "Gutta cavat lapidem" ("The drop hollows out the stone"). For one of the final issues of the 1914 volume of his "Centralblatt," Hirschberg wrote a history of the International Con gresses of Ophthalmology. When he came to record the Twelfth Congress he wrote, "The Congress in St. Petersberg planned for August 1914 did not take place. The story is over." ("Die Ge schichte ist aus"). His
WRITINGS
In his day no author was cited more frequently than Hirschberg. 5 The vast amount of his writings makes this state ment believable. During his first year in private practice, 1869, he published his first textbook, "Glioma of the Retina." (With two exceptions all of Hirschberg's books are available only in German. I have translated the titles freely.) Five years later he brought out his "Mathe matical Basis of Medical Statistics." This was followed by the three volumes of "Clinical Contributions." His knowledge of Latin, Greek, and Arabic enabled him to compile a "Lexicon of Ophthalmology" in 1887. Later came his two-volume work, "Introduction to Ophthalmology." On his 70th birthday, in 1913, his shorter writings, more than 100 articles, were republished in an 864-page Festschrift. He also wrote four books on Arabic ophthalmology, other historical books, and the 11 volumes of his "History of Ophthalmology." This includes only his writings on medicine and medical histo ry, and not his work in other areas. He
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must have been the most prolific writer about ophthalmology of his generation. As an author and historian Julius Hirschberg's great gift to ophthalmology was his "History of Ophthalmology" ("Geschichte der Augenheilkunde"). This masterpiece, published between 1899 and 1918, forms 11 volumes of the second edition of the "Graefe-Saemisch Hand buch der gesamten Augenheilkunde." (For some reason, most sources list only nine volumes. Of all the publications consulted for this study, only DukeElder's textbook 6 credits Hirschberg with 11 volumes.) Ranging in price from $3.30 to $4.50, the early volumes soon sold out. Circumstances prevented the later vol umes from being so successful. Critics and medical historians called the work "authoritative and exhaustive," "the most complete and scholarly history of the science that has ever been written," and "a wonderful monument to German thor oughness." One said, "His monumental work today remains the authoritative history of ophthalmology. It thorough ness and critical judgment mark it as one of the greatest histories of scientific sub jects." I may add that it is an unfailing lode that has been mined by three gen erations of medical historians. In 1907 he gave up his policlinic and practice and devoted all his time to writing his great history. When he was finished in 1918, at the age of 75, he had written 11 volumes, a total of 4,720 printed pages. Only an individual with Hirschberg's rare combination of talent and industry could have accomplished the task. He was a master of languages, ancient and modern, a student of Egyp tian hieroglyphics, and a translator of Arabic and Greek texts. As a physician and as an ophthalmologist, he was of the first rank. With his knowledge of the present, he could look to the past, read its literature, and judge the worthy and the unworthy. H e had lived and worked
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during a period of great change and productivity in the specialty. He knew all the giants. Over the years he had come to possess one of the largest private libraries of ophthalmic literature in the world. A figure of international note and a world traveler, he could ask others for informa tion and it would be given to him. And, as Duke-Elder put it, "his greatest joy was perhaps his profound knowledge of and sympathy with classical and Arabic schol arship." 6 He loved his work, loved using his mind. And, most important, he had the ability to write in a delightfully attractive style. One critic went so far as to term him "a genial writer. " The first volume of his history was concerned with ancient ophthalmology, that of the Hindus, Babylonians, Egyp tians, Greeks, and Romans. The contri butions of the Arabs, Europe in the Middle Ages, and the beginnings of the modern era were dealt with in the second volume. In the third volume he contin ued the story of the modern era up to 1800. These three volumes are genuine works of scholarship. Information, much of it new to Western readers, was pre sented in a lively yet orderly fashion. The next four volumes told of the develop ment of ophthalmology in Germany, France, England, and Italy from 1800 to 1850. There was one volume for each country. These were followed by a vol ume devoted to the history of ophthal mology in the United States in the 19th century, and another volume on the history of the smaller countries of Europe and Russia from 1800 to 1875. The largest volume of the series came next, the one Hirschberg entitled "Reform in Ophthal mology." The great changes, the refor mation, came to the specialty with the introduction of the ophthalmoscope by Helmholtz, with Donders' work on re fraction, and with von Graefe's pioneer ing clinical work. Hirschberg included lengthy biographies of the three men
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along with analyses of their contributions. The rest of the volume was primarily a history of ophthalmology in Germany and the German-speaking nations up to the beginning of World War I. The last volume contained additions, corrections, and a general index. The enormous scope of Hirschberg's enterprise almost guaranteed that the volumes would not be equal in' quality and scholarship. Nowhere is this better demonstrated than in "American Oph thalmology in the 19th Century." As a work from the pen of a lesser historian it might be acceptable, but it was a poor performance from one such as Hirsch berg. Hirschberg knew America. He had traveled extensively there on three occa sions, visited schools and hospitals, talked with ordinary people, and mingled with professionals. For many years he had reviewed and abstracted ophthalmic studies from the United States for his "Centralblatt. " Thus, when it came time to write the history of American ophthal mology he had personal knowledge to draw on. He was willingly supplied with information by a host of acquaintances he had made. The writings of Hubbell, Friedenwald, and others were his to use. Out of all this something better should have come. Hirschberg confessed that he met with two difficulties in composing his Ameri can history. The first arose from the complicated structure and diversity of the colleges and medical schools. The second arose because ophthalmology in the United States had developed slowly until the 1870s. He wrote that a complete survey would have come very near to his own time, and would have dealt with still unsolved problems and living physicians about whom he felt he had to withhold judgment. It is only fair to agree with him in this. But this could not have been the cause of the errors he allowed to mar his work. These include the following: Wil-
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liam Charles Wells appears as William Charles Bell, James A. Bolten as James A. Bolters, Ezra Dyer as Esra Dyer, Henry Drury Noyes as Henry Dewey Noyes, and Alvin Allace Hubbell, one of his principle sources of information, as Alvin Allace Hubbel. Remembering the great value of his other volumes, perhaps it is wrong to be too critical of this volume, to be too concerned with small errors of fact and spelling. Perhaps it is wiser to agree with the writer who reviewed the book for American readers when it was issued. 12 He felt that all American oculists should be grateful to Hirschberg for having spent time on such an immense labor. He said the book would be read all over the world and would greatly help to correct the erroneous conceptions, or in some instances the complete lack of knowl edge, about America, still largely preva lent abroad. Hirschberg clearly left the writing of a definitive history of American ophthalmology to others. One general criticism concerns the index. The history is in 11 volumes with a total of 4,720 pages divided into 1,312 sections. Each volume was paginated separately and the sections were num bered consecutively. When Hirschberg provided a general index for the whole work, he chose to index the names and subjects by sections rather than by vol ume and page. This can lead to a great deal of frustration. The reader must go through the volumes, locate the right section, and then go through the section, some of which are several pages long, to locate the desired name or fact. Hirschberg's history has often been praised. His former assistant, Harry Frie denwald, summed up all the praise in these words 6 : It is the most comprehensive medical histori cal work that has ever been published, not of ophthalmology alone, but in the whole field of medical history. It is not an exaggeration to claim
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that Hirschberg has produced a complete history of ophthalmology; in doing this he has shown to the medical world the wealth of the heritage of ophthalmology.
Hirschberg's writing on medical histo ry was not confined to his "Geschichte der Augenheilkunde." This amazing man also wrote, translated, and edited studies on ophthalmology in ancient Egypt, on Ibn Sina, Aetius of Amida, Hippocrates, Aristophanes, Shakespeare, von Graefe, and two books on early Arabic ophthal mologists. In addition to these textbooks, he wrote several journal articles and notes on the history of ophthalmic medi cine and surgery. His accomplishments can only be viewed with awe. H e had no children. Perhaps he felt that, "These books shall be my posterity, they shall perpetuate my name." They do. Hirschberg was an editor of note as well as an author. His "Centralblatt für praktische Augenheilkunde" (Leipzig, 43 volumes between 1877 and 1919) was his second great gift to world ophthalmology. In publishing his own journal he followed the pattern of the elite of 19th century German medicine. His two idols, Virchow and von Graefe, had had their journals, and he felt it was his turn. It was a risky business. Considering the number of men practicing ophthalmology at the time, the German language probably had enough journals devoted to the specialty. Hirschberg overcame this problem by including the most attractive features of his rivals in his journal. Each year he brought out 12 issues, totaling 400 or 500 pages, in a volume. A typical issue contained original articles, proceedings of society meetings, clinical case presentations, book reviews, a sur vey of reports in other journals, obituar ies, correspondence, and bibliographies. Something for everyone. Many of the original articles were by Hirschberg or his assistants, although he did not hesi-
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täte to publish worthwhile offerings from as far away as Java. Societies, national, regional, and international, could have an abstract of their proceedings in his jour nal. He made certain that the proceed ings of the Berlin Ophthalmological Soci ety, a society he had founded, appeared regularly. He also made certain that the proceedings of the Colorado Ophthalmo logical Society, a society founded by his friend Edward Jackson, appeared regu larly. The clinical cases came from his own clinic, or from the clinic of someone he knew and respected. His book reviews were brief, factual, and fair. The books themselves, usually sent by authors or publishers, went into his large personal library. When he surveyed a journal, he took an entire issue and abstracted every original article. He surveyed two, three, sometimes four journals in one issue. His gift of languages allowed him to review the publications of all the major Euro pean countries. Hirschberg must have loved obituaries because he wrote so many. Correspondence was selected from letters that crossed his desk. The bibliographies, some of them several pages long, were of subjects he felt would be of interest to his readers. The "Centralblatt" was an excellent production and very much Hirschberg's personal journal. He wrote much of it himself and edited all of it. It was the instrument that made him world-famous. One writer commented that the "Cen tralblatt" was the best guide to the per sonality of Hirschberg, for its 43 volumes demonstrated the universality and versa tility of his mind and the clarity of his judgment. 1 The volumes also disclosed a less attractive side of the man's nature— his penchant for self-promotion. In 1910 Hirschberg published a small monograph on the treatment of myopia. G. Lindsay Johnson, a British ophthal mologist, bought a copy and, during a long voyage from Cape Town to London,
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translated it into English. He wrote a letter to Hirschberg telling him of the translation and of the high regard he had for Hirschberg's work. Hirschberg pub lished the letter in its entirety in the correspondence section of his "Central blatt." A few months later, in the same section, his readers were informed that the Johnson translation of his book had been published. In several subsequent issues his readers were treated to brief laudatory notices of the book taken from reviews and letters. All of these letters and notices were in English, not in German, which was the language of the journal. It was among the readers whose native tongue was English that he hoped to promote and sell his book. He used this same ploy throughout the 1915 vol ume of his "Centralblatt" when his book on the history of ophthalmology in Amer ica was issued. Hirschberg had one other tour of duty as an editor. From 1879 to 1881 he served as co-editor of Herman Knapp's Archives of Ophthalmology (New York) and Archiv für Augenheilkunde (Wiesbaden). Shyness was never a part of Hirsch berg's nature. 1 He was always certain of his importance in the scheme of things, always aware of his dignity, and he ex pected others to be equally aware. He was very much the archetypal "Herr Professor." His many titles and honors gave him inordinate pride. Everyone, regardless of their station, was required to address him as "Geheimer Medizinal rat" ("Privy Medical Counsellor"). He fitted himself to the mold of many of his peers in the ranks of German medicine of the time. Like them, he demanded work, enormous quantities of it, of himself; like them he demanded recognition and honor for what he had done. On one occasion when he wrote of himself, Hirschberg managed to keep his ego under control. The last full volume of his history is concerned with what he
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termed the reformation in ophthalmolo gy, the period after the introduction of the ophthalmoscope. H e often devoted pages to lesser figures of the period; for himself he published his portrait, a brief autobiography—less than half a page— and a list of his publications. The entire piece is little more than an outline. T H E W A R YEARS
The summer of 1914 found Hirschberg at his peak as a figure in international ophthalmology. His journal and his clini cal and historical writings had made his name known throughout the Western world. His travels had served to intro duce him to ophthalmologists as far away as Japan. His students had publicized him wherever they went. His actions against the Russian bureaucracy concerning pass ports for Jewish physicians had marked him as a courageous and liberal man. But after the outbreak of World War I, things were never the same for Julius Hirsch berg. In the August-September 1914 issue of his "Centralblatt" he published the fol lowing notice on the front page: For the Fatherland Since the July number of the "Centralblatt" was dispatched to subscribers at home and abroad, the fearful war has broken out, wickedly forced upon us by our enemies.
The last phrase of this notice indicated that Hirschberg accepted without ques tion the government position that Ger many was the innocent victim of a syste matic, long-planned international plot and that the nation had gone to war to survive. Some of those who had accepted Hirschberg as an international leader expected him to have a different attitude, a more liberal one, not the narrow na tionalism that he did adopt. There is some evidence that Hirschberg suffered be cause of his ultra-patriotism. For exam ple, neither T H E AMERICAN JOURNAL O F OPHTHALMOLOGY nor the British Journal
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of Ophthalmology reviewed his books published during the war or before his death in 1925. During the war years he kept busy. Although 71 years old, he returned to his clinic from time to time; much of the staff had gone to war, and he saw as many private patients as he could. He worked on the last five volumes of his "Ge schichte der Augenheilkunde" and saw them published. He continued the "Cen tralblatt." H e began his study on Shake speare; he lectured. H e received the Leibnitz Silver Medal of the Berlin Acad emy of Science. Meanwhile he confident ly awaited the final victory of his nation. When World War I ended, Hirschberg's life and his country were both in ruins. H e was too old to build anew. H e could rejoice that his great history was finished and safely in print. H e could take no comfort from his "Centralblatt," for he was forced to abandon the journal at the end of 1919 because of competition and the lack of a successor as editor. But it was the fate of his library that must have broken his heart. T H E LIBRARY
The library was one of his proudest possessions. Over the years it had grown until it was one of the largest, most complete and famous ophthalmic librar ies in the world. A catalogue of it pub lished in 1901 consisted of 434 pages. It had always been his plan to leave it after his death to the Berlin Medical Society. His patriotism made this impossible. During the war he had invested much of what he owned in German war bonds. With his nation's defeat, the bonds be came worthless. To obtain funds to live modestly, he was forced to sell his li brary. The sale of Hirschberg's library and its later history is a story in itself.13 Dr. Jujiro Komoto, who had become the first Pro fessor of Ophthalmology at Tokyo Univer sity in 1890, had spent part of his student
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days in Berlin and had come to know Hirschberg. He and Hirschberg became better acquainted after Hirschberg's visit to Japan in 1892 and Komoto's later visit to Berlin. On Dec. 2, 1920, Hirschberg wrote to Komoto offering to sell his library for 40,000 yen. The collection consisted of 3,200 books and 12,500 re prints and included: historical documents covering old Greek, Egyp tian and Roman times, the Middle Ages up to the 19th century works. They are not only of European origin, but also from Eastern and Middle Eastern Countries. There are original papers on discoveries in the 19th century, and books and reprints that cover all possible fields of ophthalmology.u
There were no public funds to make the purchase, so Dr. Komoto decided to buy the library himself, and also to meet the costs of shipping and insurance. The money was to be paid to Hirschberg in 10,000-yen yearly installments. Unfortu nately, Hirschberg died before the last payment reached him. In 1925, just after the Great Earthquake, the collection reached Japan, and Komoto immediately donated it to the Library of Tokyo Uni versity. For a number of reasons the col lection was not completely catalogued and classified until 1938. The collection was then named the Komoto Library and became a part of the Central Library of Tokyo University. Komoto wrote of Hirschberg's collec tion: His Library is the only one of its kind in the world and is the object of envy in many coun tries. We have the Library in Japan and I hope that the Library will continue to be of benefit to ophthalmology in Japan after my death.
The hope of Dr. Komoto has been realized. The respect in which the collec tion is held is demonstrated by this quotation from the Japanese Journal of Ophthalmology.13 It is indeed the world's treasure not only of ophthalmology but also of human art. We are
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very happy that this large, invaluable collection has survived two World Wars and the Great Earthquake, and will be the possession of man kind forever.
Scholars may consult the Komoto Li brary, formerly the Hirschberg Library, by permission of the Library Department of Tokyo University. The name of Julius Hirschberg is an honored one in Japan. T H E LAST YEARS
In 1907 Hirschberg's policlinic build ing was torn down and a new one erected. Wilhelm Mühsam was put in charge. In his last years, Hirschberg made daily visits, walking through the corridors, and observing the activities. He had always dreamed that someday his clinic would be associated with the Berlin University as the "Julius Hirschberg Museum." This, of course, never came to be. After Hitler took power, Mühsam was forbid den to enter the premises. 1 The ocular clinic ceased to exist and the building became a children's ward. In spite of his disappointments and hardships, Hirschberg took old age well. Harry Friedenwald visited him in the summer of 1923 and found him less vigorous but just as interesting; his mind and unfailing memory were just as clear as in the days when it was Friedenwald's privilege to assist him in the clinic.5 He did not seem 80 years old. A year earlier he had given a course of lectures on Hippocratic medicine. He was working on his last book, von Graefe's lectures. On Feb. 17, 1925, Julius Hirschberg, the most brilliant pupil of Albrecht von Graefe, died. 7 His passing was noted in the German medical press. Two of his former assistants, Oscar Fehr and Wil helm Mühsam, wrote eulogies for the German ophthalmic journals.10,14 In the English-language journals there was only one obituary, that of Harry Friedenwald in the Archives of Ophthalmology.5 THE AMERICAN JOURNAL OF OPHTHALMOLOGY
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and the British Journal of Ophthalmology printed brief notices. The Frenchlanguage journals followed suit. A great man had died, a great contribu tor to ophthalmology was no more, and outside of his native land little attention was paid. Why? Hirschberg may have been the victim of the chauvinism of World War I and of the years that fol lowed. Perhaps he had lived too long, with his great days too far in the past. Perhaps the area in which he did his greatest work, the history of ophthalmol ogy, was interesting to only a few in the specialty. How many ophthalmologists were interested in Ali ibn Isa of Baghdad and the translator of his Memorandum Book? Whatever the reason, amends were made some years ago by Sir Stewart Duke-Elder when he wrote of Julius Hirschberg and his history in the "Text book of Ophthalmology. "6 Sir Stewart, ever the master of the felicitous phrase, closed his tribute with these words: "No other branch of medicine—no, indeed, so far as I am aware, of knowledge—has had a disciple so earnest, or has been pre sented with a gift so great."
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REFERENCES 1. Jokl, A.: Julius Hirschberg. Am. J. Ophthalmol. 48:329, 1959. 2. Koelbing, H. M.: Julius Hirschberg (18431925) als Ophthalmologe und Medizinhitoriker. Klin. Monatsbl. Augenheilkd. 168:103, 1976. 3. Hirschberg, J.: Aus jugen Tagen (Erlebnisse und Erinnerungen.) Berlin, W. Junk, 1923. 4. Friedenwald, H.: Julius Hirschberg. Arch. Ophthalmol. 54:418, 1925. 5. Hirschberg, J.: Augenkrankheiten und ihre Behandlung. Vorlesungen 1859-1860 von Albrecht von Graefe. Leipzig, Georg Thieme, 1925. 6. Duke-Elder, S.: Textbook of Ophthalmology. Vol. 6. Injuries. London, Henry Kimpton, 1954, p. 6125. 7. Bonner, T. N. : American Doctors and German Universities. A Chapter in International Relations. Lincoln, University of Nebraska Press, 1963. 8. Levin, A. L. : Vision. A biography of Harry Friedenwald. Philadelphia, Jewish Publishing Soci ety of America, 1964. 9. Jokl, A. : The life of Oscar Fehr. Am. J. Ophthal mol. 54:1011, 1962. 10. Fehr, O.: Julius Hirschberg. Klin. Monatsbl. Augenheilkd. 74:497, 1925. 11. Weeks, J. E.: Autobiography. Portland, Met ropolitan Printing Co., 1954, p. 52. 12. Zimmerman, C : The Oculists of America in the Nineteenth Century, book review. Ophthalmolo gy 12:210, 1915-1916. 13. Kirisawa, N.: The Komoto Library (formerly the Hirschberg Library). Jpn. J. Ophthalmol. 21:528, 1977. 14. Mühsam, W. : Julius Hirschberg. Z. Augen heilkd. 55:289, 1925.