Max Hirsch (1875–1941): His forgotten fate and his contributions to the founding of modern rheumatology

Abstract

Objective

To elucidate the connections between balneology and rheumatology in the founding period of the discipline of rheumatology, and describe the contributions of Max Hirsch, MD in the formation of professional rheumatology societies.

Material and Methods

Historical documents from the medical history collection of Vogelsang–Gommern, Germany, and original personal documents of the Hirsch family and information from the medical and historical period literature were used in developing this report.

Results

The first efforts at organizing rheumatology as a recognized clinical and academic discipline took place in the 1920s. Many of the first proponents were balneologists who cared for patients with chronic arthritic conditions without the benefit of effective medications. Max Hirsch, MD was a major figure in the development of modern rheumatology as it emerged from the provenance of balneology and orthopedics as a recognized organized medical discipline, contributing to the founding of the German Society for Rheumatology and the International League Against Rheumatism.

Conclusion

Max Hirsch made significant contributions to scientific and organized rheumatology in the early days of the discipline. His contributions to the field and his fate as a Jewish physician have only recently come to light.

Introduction

The leaders and founders of rheumatology as a formal academic discipline and the initiators of national and international professional rheumatology societies and organizations are well known and appreciated in the rheumatology and wider medical communities. These include historical figures such as William Heberden, Alfred Garrod, Vladimer Bechterew, Jacques Forestier, and Philip Hench, to name just a few. Others who have made important contributions are less widely known.

Important contributions can be largely unknown because of the social and political circumstances during and after the careers of the contributors. This is the case for Max Hirsch, a leading figure in the early development of the specialty of rheumatology in Germany and across the world. His contributions and his fate have only recently come to light, having been virtually unknown outside of a limited circle of specialists in Germany.

Material and Methods

In preparing this article, historical documents from the medical history collection of Vogelsang–Gommern housed at the Specialty Hospital in Vogelsang, Germany, were accessed, as well as available documents from state and private archives and sources in Germany, including original personal documents of the decendents of the Hirsch family in Stockholm, Sweden. As well, information from the medical and historical period literature were used in developing this report.

Results

Max Hirsch (Figure 1) was a leading figure and founding father of rheumatology in Germany who also had an important influence on the early organization of the International League against Rheumatism (1, 2). Yet, when the founders of the German Society for Rheumatology, including Max Hirsch as their real guiding spirit, were recognized on the occasion of the 75^th anniversary of the society’s inception in 2002, nothing was known about his fate after 1933 (2).

Figure 1.

Portrait of Max Hirsch (Courtesy W. Keitel)

Indeed, in the first paper from the postwar period that dealt with the history of the German Society against Rheumatism, he is mentioned only in a single sentence, which states, “After the resignation of Prof. Dietrich, M.D., Ph.D. and Dr. Hirsch, Prof. H. Vogt, M.D. assumed leadership of the Society” (3). Also, “Hirsch suffered greatly from the loss of his position. He emigrated in 1933 to Russia. Nothing further is known about his fate” (2). Recently, contact with his descendants has succeeded, in part, in establishing the tragic events that led to his death. This contact provides an opportunity to review his meritorious service to balneology and rheumatology.

Max Hirsch was born on April 28, 1875 in Blütenau, West Poland (former province of Posen). Blütenau, known in the past as Kwieciszewo, Poland, was then located in the German province of Poland as a result of the first partition of Poland in 1772 after it fell to Prussia. Hirsch studied medicine from 1895 to 1900 in Berlin. In March 1900, he submitted his doctoral thesis titled “On the Causation of Scarlet Fever” (4). On the title page of his dissertation, he describes himself as a “General practitioner from Kwieciszewo/Poland,” using the Polish name of his birthplace; he was probably then working as an assistant to another physician in Erkelenz, in the Rheinland.

The science of spa treatment undoubtedly played the most important role in the professional life of Max Hirsch, although later, rheumatology would also dominate his attention. He devoted himself not only to his medical practice and scientific endeavors but also to journalistic and organizational work critical to the professional standing of his field.

Earlier than in other medical disciplines, there were efforts in balneology to publish dedicated journals and pursue a more structured organization of the discipline. The Balneology News was established as early as 1847. A “Section for Balneology” was created in the Society of Medicine in July 1878, and it held its first general scientific congress in 1879. The section later became independent, calling itself the Society for Balneology. Two of the prime movers in the field, Eduard Dietrich and Max Hirsch, reported on the history of the Society for Balneology on the occasion of the 40^th Congress of the society (5, 6). At that congress, Hirsch gave his report as secretary-general and took on the role of historian (6).

The diversity of journals in the field grew during this period. The journals established by Dietrich and Hirsch together and by Max Hirsch alone include the Archives of Balneology, Journal of Scientific Balneology, and Journal of Health Resort Science.

In 1905, Hirsch took up practice as a spa physician in Bad Kudowa (known today as Kudowa Zdrój, Poland) (7). In 1906, he married Emma Weissbein. On January 16, 1907, a son, Rudolf Ernst, called Rudi, was born in Berlin-Charlottenburg. A second son, Otto, was born in 1910.

Even as he pursued day–to-day work at the Kudowa spa, Hirsch took time out from his activities at the resort in order to pursue scientific endeavors in Berlin. An example is a publication from March 4, 1912, titled “On the effect of alkaline saline waters on uric acid metabolism in sufferers of gout” (8).

In 1912, Hirsch assumed a new position in Bad Salzschlirf (9). He describes his work at the Zander Institute there: “The importance of mechanical devices in the treatment of joint disorders is well known…. But also in the treatment of medical diseases … mechanical devices aiding physiotherapy have acquired a dominant role” (9). In 1913, Hirsch appeared as a speaker at the memorable IV. International Congress of Physical Therapy, which took place from March 26 to 30 in Berlin and at which Jan van Breemen of Amsterdam proposed the creation of an international rheumatology society (10). Hirsch also discussed his own results at the 35th Meeting of the Society for Balneology, which met from March 11 to 16, 1914, in Hamburg (11). Among the more than 50 lectures, “Mr. Hirsch (Salzschlirf): Associations of gout and arteriosclerosis” is announced as No. 31.

Hirsch was not able to devote himself to his research or to his family for long. At the beginning of World War I, he began service as an Army physician. At age 39 and with a family, it is unlikely that he would have been drafted. Given his nationalistic attitude, as reflected in many of his writings, it is highly probable that he was infected by the prevailing patriotic mood and volunteered, as did many of his fellow Jews.

The first postwar congress of balneologists was held in 1920 and was led by interim president Hermann Strauss (1864–1944) from Berlin. Eduard Dietrich (Figure 2), who was to become Hirsch’s friend and mentor, was elected as the next chairman. Hirsch served as interim Secretary-General of the Society for Balneology and then assumed the full-time role in 1922.

Figure 2.

Prof. Eduard Dietrich, M.D. (Courtesy W. Keitel)

With the assumption of their duties in 1920, the new president and secretary-general pursued the kindling and preservation of national unity among the members of the Society for Balneology. This purpose was also served by the programs of the “Society for Medical Study Tours.” The purpose of selecting venues and destinations in the former imperial German territories that had become separated by the Versailles Treaty was to demonstrate and strengthen the bond and sense of unity with the medical profession in the area that had been cut off from Germany.

In this role, which accounted for the major share of Hirsch’s professional activities, he performed a variety of functions, ranging from organizational work to the resolution of civil matters. As far as is known, he planned and conducted the Annual Meeting of the Society of Balneology for the first time in 1921 and for the last time in 1932 (12, 13).

The first issue of the Archives of Balneology and Medical Climatology appeared in July 1925, published as the “Official Organ of the Society of Balneology and the Central Office for Balneology,” with Dietrich and Hirsch as the editors. In meeting minutes, Hirsch outlines a plan to create so-called “therapies for the middle class” to make spa stays accessible to all and also to save spas and their physicians, who were threatened with insolvency as a result of the financial crisis that followed World War I.

Apparently unhappy with the publisher from the outset, just 18 months after its creation, Hirsch negotiated more favorable conditions for the journal with the Spa Resort and Travel Publishing Company, Ltd. of Berlin. The journal appeared in October 1926 as the Journal of Scientific Balneology. Hirsch officially served as the sole publisher and editor. The size of the journal was considerably expanded, and he increased the advisory board of 30 scientists mainly from around the world—including Danischewski (Moscow), Fox (London), and Jan van Breemen (Amsterdam)—to not less than 81. Rheumatologists now began to take a particularly prominent place among the announcements and reports of the Society of Balneology meetings. The connection was logical, as no effective medical therapies were available for arthritis, and patients were often treated at “medicinal” spas by physicians interested in “rheumatism.”

Hirsch’s first experience on a larger international stage was the establishment of the International Society of Medical Hydrology (ISMH) by Robert F. Fox (1857–1939) and Jan van Breemen (1874–1961), founded December 9, 1921, in London. Hirsch reports on the participation of German balneologists (14). Exclusion of German scientists in international societies was common following World War I. Hirsch writes that the “well-known opposition to the inclusion of Germans in scientific societies” did not occur at this meeting. Dietrich was one of the vice presidents, whereas Hirsch served as executive director of the German group.

From that point on, Hirsch’s frequent contacts and activities in the international arena are well established, first in balneology alone and from 1927 on in rheumatology. He took part in the 1926 ISMH meeting in Prague and Piestany, during which the committee that laid the foundation of the International League against Rheumatism was constituted (15). He was the leading figure and chronicler at the meeting of the German balneologists in January 1927 in Schreiberhau, where the German section of the International Committee Against Rheumatism was brought to life.

Hirsch attended the meeting of the ISMH in 1928 in London and witnessed the official founding of the Ligue Internationale contre le Rhumatisme (16, 17). In 1929, the Executive Board of the ISMH met in Paris; they addressed the organization of future congresses and established a special committee for this purpose. Hirsch chose social issues as the theme of his keynote address on October 28, 1928, titling it “The German spas in the service of social welfare” (18).

During this period, from 1922 to 1933, the Hirsch family lived in Berlin. The family home was therefore the general secretariat of not only the Society for Balneology and its members but also of the rheumatologists in the German Society for Rheumatology after its founding in 1927.

In order to understand the influence of Max Hirsch on the field of rheumatology and his contribution to the establishment of the German professional association for rheumatology, a brief summary of the international context is helpful. This background is inextricably linked to Jan van Breemen (1874–1961), who also saw the ISMH as a rheumatologic forum (19). Like Jan van Breemen at the international level, the surgeon August Bier (1861–1949) of Berlin was Hirsch’s principal advisor at the national level for the establishment of the national rheumatism committee. Bier writes that he became a rheumatologist against his will. In 1920, Bier created the world’s first special department for rheumatism in his ambulatory clinic, located opposite the Charité hospital in Berlin. Max Hirsch frequently came by “as a guest of the August Bier School” (20).

Hirsch describes how it came about that an organization for rheumatology arose in Germany. At the 39^th Congress of the Society for Balneology, held in 1924 in Bad Homburg, he announces, “Mr. van Breemen informed me of the intention to form an international committee to … address the question of the impact of rheumatism on disability. He requests that the German members of the committee be named by the Board of the Society for Balneology” (6).

Hirsch further describes the efforts he personally has pursued at every opportunity and concludes, “A preparatory committee of the Board of Directors, members, and loyal friends of the Society for Balneology was able to call into being the long-awaited constituent assembly to form the German Section of the International League Against Rheumatism for January 28^th in Schreiberhau in the Giant Mountains” (today located in Poland); this assembly was to be the first of seven German rheumatology society meetings between 1927 and 1933 (6).

Since 1927, Hirsch had also been serving in the capacity of Secretary-General of the German Society against Rheumatism. After trying in vain for four years to hold the Society of Balneology congress in Aachen, President Dietrich was able to proclaim in his opening speech on April 7, 1929 in Wiesbaden: “Particular credit goes to our industrious and skillful Secretary-General, Dr. Hirsch, for facilitating the 41^st Congress in this beautiful old imperial city” (21). The featured lecturer, Jan van Breemen, would go on to become the founder of the International League against Rheumatism.

A major focus of the 1929 meeting discussion was the presentation of a nomenclature proposal for rheumatic diseases, which was also presented by Max Hirsch. The nomenclature distinguished between four major subgroups of acute and chronic arthritides (joint inflammation) and also listed myalgias (muscle pain) and neuralgia (nerve pain). The category of arthritis was subdivided into an acute form, which contained only rheumatic fever, recognizing an acute and subacute course, as was then customary in England. The chronic form of arthritis recognized a primary and secondary chronic course. The scheme was intended to be helpful “for mass [population] statistics” and detailed clinical and scientific application and was presented clearly in an article by Hirsch in the Rheumatism Yearbook of 1930/31 (22).

In December 1932, German rheumatologists agreed to hold their next annual meeting in the fall of 1933 in Bad Nauheim. Together with the Kerckhoff Institute there, they intended to address as the conference theme the relationship between rheumatic and heart diseases. However, again, as in 1917, the plans of the rheumatologists came to naught as they were overtaken by political events. Hitler came to power on January 30, 1933. With the Act for the Restoration of the Professional Civil Service of April 7, 1933, all Jewish physicians and political opponents of the National Socialist regime lost their positions in hospitals, public health offices, and other state institutions as well as their licensure in the public health insurance fund (23–25).

Hirsch and Dietrich, the latter the son of a protestant minister, were dismissed from their offices in the Society for Balneology and the German Society Against Rheumatism. They were removed from the list of colleagues of the “International League” and the “Acta Rheumatologica” without comment and without mention of their previous achievements. Their friend van Breemen provided Society members who had emigrated for racial and political reasons (including Max Hirsch) with a platform in the League’s journal, against the opposition of Julius Rother, one of the new German representatives in the international society (19). The following terse note appeared in the “Acta Rheumatologica” of May 1933, under the heading “League News Germany”: “The president and the secretary of the German Society for Arthritis Research have informed us that in the interest of the development of the situation in Germany, they have resigned” (19).

In April 1933, the publisher L. Alterthum informed Hirsch “… that to our great regret, effective immediately, you must withdraw as editor of the journal” (26). Hirsch’s destiny in this first year following Hitler’s seizure of power is otherwise known only from indirect sources. As reported by his son Otto, at the time, Otto requested asylum in Stockholm in December 1937 for himself, his wife, and his two-year-old son Walter: “My father was arrested in 1933 and taken to a concentration camp. After his release, he emigrated in the same year with my mother to Switzerland and then in 1934 to Moscow.” On an index card of the Central Office of the International Tracing Service for 1938, there is only a single entry: “Max Hirsch, born April 28, 1875. German citizenship forfeited by the proclamation of April 19, 1938 ….”

In late 1933, Emma, Max, and their older, unmarried son Rudi fled to Switzerland, where their savings were soon exhausted and they were forced to leave. The younger son Otto married Margot Fleming, who was not Jewish, in December 1933. Hirsch certainly thought about the invitation of his Russian colleagues to the International Rheumatology Congress, planned for the spring of 1934 in Moscow. It is unclear but likely that Hirsch would have written from Switzerland to his Russian colleagues and made an urgent request for an invitation for himself and a commitment of asylum for his whole family (Figure 3). However, the Soviet bureaucracy took time, and the rheumatology meeting in Moscow took place without Hirsch.

Figure 3.

Otto, Emma, Max, and Rudi Hirsch before the family was separated. (Courtesy L. Olsson)

As his surviving son Otto later related, Max, Rudi, and Emma Hirsch did not arrive in Moscow until the end of September 1934. Otto’s daughter Eva and son Walter would relate that Hirsch apparently worked in gastroenterology, a field foreign to his training and interests. The authors have not been able to obtain information about the residence of the family in Moscow and Leningrad from Russian authorities.

In Moscow, life became increasingly uncertain with the ever-increasing domestic terror of the Stalinist purges, which were directed against real or imagined critics and increasingly against Jews. Whether expelled from Moscow, fleeing to a safer province, or following an offer from their son Otto, who by then was working as a department store decorator in Leningrad, Emma, Max, and Rudi Hirsch went to Leningrad in 1937. There, they were reunited with Otto, their daughter-in-law Margot, and their now two-year-old grandson Walter.

In 1937, Max Hirsch was assaulted and robbed in Moscow. The thief cut one of his pockets with a razor blade and took his, Emma’s, and Rudi’s passports. The passports could only be provisionally replaced. As a result, when the entire family was expelled from the Soviet Union in the winter of 1937, only Otto and his small family were able to leave Russia and find a new home in Stockholm. His parents and could not enter Sweden with provisional identification documents, as these were not recognized by the Swedish government.

Max, Emma, and Rudi then fled to Riga, Latvia. It is unclear why they chose Latvia; however, at the beginning of 1938, it was a politically stable country with manifold German cultural roots and seemed to offer a way out of the Soviet Union, especially since the country had a liberal policy on minorities (27).

Documents retrieved for the authors from Riga reveal that “Shmuel Aronson, born on December 13, 1894, in Jelgava (Mitau), resident in Riga, Gertrudes Street 39–7, asked the Minister of the Interior on February 2, 1938, for permission for his relatives Dr. Max Hirsch, 62 years old, his wife Emma, 58 years old, housewife, and her son Rudolf, 31 years old, pianist, to allow entry into Latvia for months-despite nonextended (i.e., invalid) identity cards.” On March 3, 1938, the family arrived in Latvia.

After arrival in Riga, they initially stayed with the Aronsons until they could move into their own apartment on December 23, 1938. The family apparently got along well in Riga. Hirsch could again practice medicine, as the documents reveal: “Dr. Max Hirsch is instructed by the authorities in Riga, due to indispensability as a physician, (that) he is obligated to City Outpatient Clinic No. 6.”

On August 23, 1939, the non-aggression pact between Stalin and the Nazi regime was signed in Moscow. Latvia, Estonia, Finland, and parts of present-day Belarus fell to the Soviet Union. On September 1, 1939, the German invasion of Poland was launched, with Soviet troops invading shortly thereafter. On June 17, 1940, Russian troops invaded Latvia following a provoked border incident.

Only eight days elapsed from the beginning of Hitler’s invasion of the Soviet Union on June 22, 1941, until German troops reached Riga on July 1. Relocation of Jews to the Riga ghetto took place in August 1941. By the time the ghetto was locked down in October 1941, there were about 30,000 people living in it, of which almost half were children and disabled adults (25). Soon thereafter, in mid-November 1941, came the order personally sanctioned by Hitler and Himmler that SS-Obergruppenführer Jeckeln was to completely liquidate the Riga ghetto. As a suitable location for the murders, Jeckeln had personally selected a wooded area near Salaspils which was part of the Rumbula Forest, located about 10 kilometers from Riga (28). An “audience” of about 100 persons, consisting of police, SS troops, and civil administrators, was chosen to attend the exterminations, which began on November 30, 1941, and ended with the killing of about 25,000 Jews by December 8. Max, Rudi, and Emma Hirsch may have been among the victims. They may also have been victims of one of the many pogroms conducted by Lithuanian bands against the Jewish population in and around Riga. These three members of the Hirsch family were officially declared deceased on May 8, 1945.

There are no documents or other information about the family from the spring of 1938 until February 1941. That month, the first of eight letters from the Hirsch family in Riga addressed to their son Otto and his family arrived in Stockholm, where these letters have been preserved. Their last sign of life is a postcard dated May 20, 1941. The family letters, documents of the family and of the harrowing times, seem to indicate that the day to day life of the three Hirsches was for the most part normal, hopeful, and almost carefree in spite of a profoundly uncertain future. In reading the letters, it is important to take into account that the Hirsches did not want their son and his family in Stockholm to be worried, and that they were required to be circumspect in what they wrote because of postal censorship.

The letters of Max and Emma are filled with love and concern for their family and describe something about their current situation in Riga. In one of the letters, Max writes, “Today at the passport office I need a certification from our physician-in-chief that I am indispensable; he added a ‘very’ to it. At the Municipal Health Department I had the possibility to talk about myself and found much kindness. I think that soon everything will settle down and I will get back on track. At work things are in best order, a very nice atmosphere, and the patients are the least concern”.

While we rely on largely on conjecture regarding the fate of the parents and Rudi Hirsch in the first years of their emigration from Germany, much more is known from preserved emigration documents from 1937 and 1938 of the son Otto Hirsch and his family in Stockholm. Unable to remain in France, Switzerland, or the Soviet Union, Otto Hirsch was able to obtain a residency permit for himself and his family from Sweden and emigrated in 1938.

Discussion

Because he was Jewish, Max Hirsch was driven from his posts. He was not alone. Non-Jews such as the distinguished and upstanding Prussian official Eduard Dietrich also were forced from their posts. None of the authors or remaining family ever met Max Hirsch. Through the many testimonies about him, they are nevertheless able to compose a suitable representation of his character. Most notable are his diligence, the pleasure he took in his work, his creativity, and his energy.

In the field which first sparked his interest, Hirsch helped to lay a solid foundation by making important contributions through originating journals and publishing scientific works and commentaries. His constant engagement and promotion among balneologists was critical to the formation of the German Section of the International League against Rheumatism and to launching the new discipline of rheumatology in Germany in the few years between 1927 and 1933.