Ludwig Edelstein (1902–1965): a German historian of medicine in North American exile and the emergence of the modern Hippocratic Oath

Edelstein's Background

Ludwig Edelstein, born in Berlin on 23 April 1902 (Figure 1), spent his childhood in the capital of the German Empire of Kaiser Wilhelm II (1859–1941) whose reign was to last from 1888 until his abdication in the closing days of World War I. In Edelstein's time, Imperial Germany was still a relatively new state, bolstered by the successes of Prussian diplomats and military men. In its people's consciousness, the state's foundation in 1871 had come largely as the result of three victorious wars against its neighbours. These events were a source of nationalistic confidence, directing efforts to aggressive military and economic expansion in the subsequent decades (Figure 2). Historian Hans Delbrück (1848–1920) reflected the viewpoint of the leading German intellectuals and administrators of the period when he argued that Germany had to seek its ‘appropriate share’ of mastery over the globe and redress the ‘cultural monopoly’ of the Anglo-Saxon sphere. ¹ Beneath appearances of solidarity and a shared mission, however, the inflexibility of the authoritarian state apparatus to cope with rapid change brought by industrialization caused deep rifts in German society based on political, economic and class interests. ² There existed wariness among its early leaders like Chancellor Otto von Bismarck (1815–1898) that ‘what had so swiftly been put together could also be undone, that the Empire might never acquire the political or cultural cohesion to safeguard itself against fragmentation from within’. ³ OPEN IN VIEWER

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Figure 2.

Area photograph of the Schloßplatz in Berlin, residential seat of Kaiser Wilhelm II. (1859–1941), as shown in 1900 (Image in the Public Domain).

Whatever social tensions may have existed in Imperial Germany were exacerbated by the strains of economic hardship and political uncertainty in the Weimar Republic. Nonetheless, the rise of the National Socialists to power in 1933, and their directing of the state's animus against Germany's Jews, represent a dramatic and largely unprecedented episode in Germany's history. National Socialist policies had enormous consequences that extended to the arts and sciences. Bringing the universities into line with their national program, the Nazis dismissed thousands of physicians and scholars from academic roles and state positions. ⁴ Moreover, Germany's loss of its modernist intelligentsia was in many ways the English-speaking world's gain in the following decades. The inauguration of the Nazi ‘Law on the Re-Establishment of a Professional Civil Service’ on 30 April 1933 triggered a flood of émigrés, particularly those in scientific and academic roles. ⁵ One of these individuals was Ludwig Edelstein who by 1933 was emerging as a noted historian of medicine and classical philologist at the Friedrich Wilhelms University of Berlin.

Family and early life

Born to parents Isidor (1869–1931), a merchant by trade, and Mathilde (b. 1873? – née Adler), Ludwig Edelstein's childhood was characterized by chronic illness which directed his attention very early to medicine. His earliest education was provided by tutors ⁶ but his subsequent attendance at the Joachim Friedrichs Gymnasium in Berlin, with its emphasis on the study of classical literature in Greek and Latin, played an important role in developing his future career interests in ancient medical topics – a pursuit that was to culminate with his prominent works, the Hippocratic Oath (1943) and Asclepius (1945). ⁷ The Berlin that Edelstein inhabited was a sprawling metropolis of four million inhabitants, the second largest in Europe. The many Eastern European workers and refugees, particularly after World War I, lent it an international quality and Berlin had the largest Jewish population of any city in Germany as indicated by its prominent synagogue in Oranienburger Straße (Figure 3). With the capacity to hold 3000 visitors, the synagogue was a testament to the prosperity and confidence of the assimilated Jewish community. ⁸ In general, Prussia was the province in which the Jews of Germany had tended to settle, with roughly three quarters of the country's 563,000 living in this wide northeastern region of Germany, according to a 1925 census (Figure 4). ⁹ Before World War I there was already anti-Semitism stirring in Germany initially on a religious and, later, racial basis, as was evident in the establishment of the Verein Deutscher Studenten (Union of German Students) in 1881 to foment a type of racial – völkisch – nationalism at colleges. ¹⁰ In fact, it was the long established tradition of ‘patriotic protest’ that National Socialist students were to exploit in the late 1920s and early 1930s to conduct threatening demonstrations against Jewish professors. ¹¹ After the trauma of World War I there also emerged the ‘Dolchstoßlegende’ (Stab-in-the-back-myth), the popular and persistent story that placed the blame for Germany's defeat at the hands of the Jews and Bolsheviks. However, even within that context Prussian policies had urged the Germanization of minorities and when anti-Semitic violence broke out in the West Prussian town of Konitz in 1900, the authorities were quick to suppress it. In 1912 the largest political party in Germany, the Social Democratic Party, was denouncing anti-Semitism as a backward, malevolent ideology, and when World War I broke out many patriotically minded Jews eagerly rushed to the defence of their Fatherland in common cause with other Germans. ¹² In fact, the vast majority of Germany's Jews, including Edelstein's family, had willingly undergone a high degree of cultural assimilation. OPEN IN VIEWER

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Figure 4.

Map of the distribution of the Jewish population in Imperial Germany around 1890. From: Bibliographisches Institut: Meyers Konversationslexikon. 5th ed. Leipzig & Vienna: Bibliographisches Institut, 1892 (Image in the Public Domain).

Encounter with Albert Einstein (1879–1955) in 1920

In about 1920, shortly before beginning his undergraduate studies Edelstein attended a meeting of the Deutsche Akademie der Naturforscher (Leopoldina) at which the physicist Albert Einstein (1879–1955) discussed his theory of special relativity (Figure 5). By his own admission in an interview decades later, Ludwig Edelstein, with his background in the humanities, did not understand the topics being debated. However, what surprised him was the emotion and anger with which German physicist and Nobel Prize laureate Philipp Lenard (1862–1947) attacked Einstein and his theory (Figure 6). When the national-conservative Lenard – who later in the 1930s even advocated for an Aryanised ‘white physics’ – remarked that his opponent's assertions defied common sense, Einstein replied ‘May I point out to my colleague Lenard that common sense is something very relative’. ¹³ Though subsequently Edelstein realized that the hostile atmosphere of the discussion had much to do with ongoing tension between ‘Jewish physics’ and ‘German physics’, at the time he had not the slightest idea that any such divide existed. It was only by 1925, when he heard of ‘incidents’ of anti-Semitism related to student politics in Berlin and Heidelberg, that it became relevant to him. Edelstein, like many others, was not quick to foresee the looming disaster for Germany's Jews. Anti-Semitism, as he understood it in his university days, appeared as a limited issue related to student politics. OPEN IN VIEWER

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Figure 6.

Portrait photograph of Philipp Lenard (1862–1947) (photographer unknown), in 1900 (Image in the Public Domain).

Universities of Berlin (1921–24) and Heidelberg (1924–28)

Ludwig Edelstein attended the University of Berlin from 1921 to 1924 where he studied under the renowned classical philologists, Eduard Norden (1868–1941), who was also Jewish and later forced into exile (Switzerland), and Werner Jaeger (1888–1961) who, although he was Christian-German, ultimately exiled himself permanently to the United States in 1936. It has been argued that this well-known scholar left Nazi Germany involuntarily because his wife was of partial Jewish heritage, but one of Jaeger's students at Harvard has asserted that the government actually wanted him to remain. ¹⁴ In 1924, Ludwig Edelstein continued on to the University of Heidelberg, at this point still pursuing undergraduate studies. There he studied philosophy with the famous psychiatrist and philosopher Karl Jaspers (1883–1969) and classical philology under Otto Regenbogen (1891–1966). ¹⁵ Both of these scholars were to lose their academic positions after the Nazis came to power, ostensibly for having Jewish wives and therefore being racially tainted under the ‘Blood Protection’ and ‘Marriage Health Laws’ that were passed in 1935. ¹⁶ Edelstein, for his part, married Emma Jeanette Levy (1904–1958) on 25 October 1928. ¹⁷ The following year he passed his oral exams and submitted his PhD thesis entitled, ‘πɛρìἀέρων [Peri aerōn] und die Sammlung der Hippokratischen Schriften’ on Hippocrates’ environmental and contextual medical views, though it was not until June 1931 that he formally received his degree. ¹⁸ Peri aerōn contained many of the hallmarks of Edelstein's later works on the history of classical medicine, including a preoccupation with the Hippocratic Corpus and an emphasis on the historical necessity of grasping the context and cultural milieu in which a document was written. ¹⁹ Breaking with the traditional objective of classicists, he argued that it was simply not possible to identify which texts in the Hippocratic Corpus were genuinely authored by Hippocrates. ²⁰

In 1930 the Institute of the History of Medicine (Institut für Geschichte der Medizin und der Naturwissenschaften) was established at the University of Berlin, right at the time when Edelstein had returned to his native city. The Institute was headed by Paul Diepgen (1878–1966) whom he joined as an assistant in November 1930 and, though continuing to suffer frustrations in his attempt to begin a proposed Habilitation project, ²¹ Edelstein remained working for Diepgen as assistant and lecturer until 1933.

Exile

On the eve of his exile, Ludwig Edelstein could be characterized as an expert on the ancient history of medicine and an up-and-coming classicist with his finger very much on the pulse of Germany's intellectual development. His dissertation had already established him as, in the words of a colleague, ‘a man with an acute sense of the historical and sociological implications of his subject, a man who appeared unimpaired by the common tendency to elevate the ancient Greeks into some sort of heroes …’. ²² However, any sense of belonging he might have had at the University of Berlin dissipated shortly after the Nazis rose to power. On 7 April 1933 they passed their first of several anti-Semitic laws, the Berufsbeamtengesetz or ‘Law on the Re-Establishment of the Professional Civil Service’, which banned non-Aryans from government, legal and educational roles. Across Germany, large numbers of professors and researchers suddenly found themselves without jobs. The consequences this had on many facets of the intellectual milieu in Germany are readily apparent when we consider, for instance, that more than 2000 scientists were lost to emigration by 1945. ²³

For Ludwig Edelstein, a letter he wrote indicates that he had already been dismissed in April 1933 from his assistantship role with the Institute, ²⁴ even though Chairman Paul Diepgen formalized the dismissal only in the following months (Figure 7). Diepgen's own culpability in this situation remains a topic of debate; undoubtedly he held stern, right-wing political convictions, and yet there is evidence that he showed concern for the fates of a number of his Jewish colleagues including Edelstein. ²⁵ Regardless of Diepgen's personal views, he complied quickly with the new laws and by September 1933 Edelstein had been officially dismissed also from his unpaid lectureship with the University of Berlin. ²⁶ This, coupled with the still-felt effects of the economic depression that had largely drained the inheritance he had received from his father, put him in a very difficult situation. OPEN IN VIEWER

Following these disappointments, he and his wife Emma planned a trip to Italy with the tentative goal of seeking employment in Italian libraries, as a number of other German-Jewish academics had done. ²⁷ One positive turn of events in this tumultuous year was that Emma, also a classicist, was able to pass her doctoral exams at Heidelberg and thus earned a PhD shortly before their move to Rome in the autumn of 1933. There they lived with friends in constrained financial circumstances while Edelstein sought help from colleagues and the Rockefeller Foundation's refugee assistance fund for academic employment somewhere in Europe.

In fact Edelstein's experiences mirror those of many émigré academics and scientists of the period who were compelled to leave Germany (and later Austria) and eventually arrived in North America. Their journeys were seldom direct, with one or more countries of transition on the way to North America. ²⁸ Most often the country of transition was Great Britain which accepted 5200 refugee health care professionals (including nurses, physicians and scientists, etc.) since 1930, in the process of which, these transformed Britain into an important centre for psychiatric research. ²⁹ The Edelsteins, like many, initially desired to resettle in the UK but their application was unsuccessful, ³⁰ and so they continued to seek assistance. Émigré academics and scientists frequently sought help from the Rockefeller Foundation and the Emergency Committee in Aid of Displaced Foreign Scholars which coordinated their activities to assist the refugees financially and with social and academic support. Lastly, the assistance of their friends and colleagues who were already settled in North America was essential to their successful transition into American or Canadian academic roles. ³¹ In the case of Ludwig Edelstein, it were his fellow émigré medical historians, Henry E. Sigerist (1891–1957) and Owsei Temkin (1902–2002) of the newly established Institute of the History of Medicine in Baltimore – that was destined to become the leading North-American research and teaching centre in the history of medicine – who took great pains to find Edelstein a position. Sigerist at last managed to convince the Dean of Johns Hopkins Medical School to offer him a role and the Edelsteins arrived in 1934 (Figure 8). ³² OPEN IN VIEWER

For 13 years, from 1934 to 1947 Edelstein was at Johns Hopkins, first as Assistant Instructor and from 1939 in the tenured role of an Associate Professor of the History of Medicine. ³³ Safely away from the political tumult of Europe and with a light teaching load, the years of World War II proved to be particularly productive for Edelstein (Figure 9). ³⁴ He collaborated with his wife Emma – who continued to edit nearly all of his books and papers – to produce a monumental two-volume work ³⁵ on Asclepius, demigod and physician of the Greek heroic age, that contained another original idea by suggesting that Asclepius was a patron saint (human figure) of the medical cults of the ancient Greeks. The first volume consists of translated passages taken from classical works that refer to Asclepius. It was largely Emma who collected pre-existing translations and provided new ones whereas the second volume, offering interpretations of the passages, was mainly Ludwig's work. ³⁶ The final product stands out for its excellent organization and accessibility, owing to the fact that the authors made the effort to provide translations of the Greek and Latin passages – testament to the strong German philological research tradition that was still pertinent in the Berlin institute at the time of Edelstein's departure. It is a text that is accessible to a wide readership in both medicine and the humanities. Two years before the publication of Asclepius, in 1943, Edelstein produced what is likely his most important and well-known work – The Hippocratic Oath: Text, Translation, and Interpretation. OPEN IN VIEWER

Edelstein and the Hippocratic Oath

In his 1943 work Edelstein argued that the Hippocratic Oath, which is ‘the exemplar of medical etiquette and as such determined the professional attitude of generations of physicians’, ³⁷ shows the influence of the Pythagorean school of philosophical thought which 'remains the only philosophical dogma that can possibly account for the attitude advocated' in the Oath – with regards to suicide, for instance, which the Pythagoreans alone condemned 'without qualification'. The Greek natural philosophers and physicians of the Pythagoreans also held the embryo to be animate from conception, which would explain the similar prohibition of abortion. As such, Edelstein asserted, the modern tendency ‘to see in the ethical provisions of the Oath the expression of certain general principles the recognition of which is demanded by human decency or by the responsibilities inherent in the physician's art’ fails to see the Oath as what it actually was – a contrary or marginalized approach to medical ethics in its specific historical context.

To demonstrate his argument, Edelstein provided a translation of the Hippocratic Oath and then went through it, point by point, arguing that its tenets are contrary to standard beliefs and practices in antiquity. His writing thereby showed a tendency closely to align philological investigations with an in-depth awareness of the social contexts in which new concepts, theories and practices arose – a contextual approach to the history of medicine that has since been adopted widely. For an example, as it relates to the Oath's aforementioned prohibition against assisted suicide, Edelstein asserted that many people of the period chose to end their lives voluntarily instead of lingering in agony with an incurable illness. Thus, Edelstein sought a philosophical dogma that could possibly account for the many contrarian viewpoints and he came to the conclusion that, taken as a whole, the ‘so-called Oath of Hippocrates is a document, uniformly conceived and thoroughly saturated with Pythagorean philosophy’. ³⁸

There have been many attempts in the literature to discredit Edelstein's views since he published them. He argued that suicide was entirely acceptable in antiquity but statements attributed to thinkers not affiliated with the Pythagoreans such as Socrates, Aristotle and even Lucretius can be found which strongly condemn it. ³⁹ Edelstein's assertion that the importance of confidentiality between physician and patient, found in the Oath, ‘must be the Pythagoreans’ certainly can be questioned as this need not be proof of any particularly Greek school of thought at all, confidentiality existing as a virtue of Indian and Aztec physicians who doubtlessly lacked Pythagorean influences. One could also say that the Pythagorean beliefs are not clearly evinced in the Hippocratic Oath simply because it stresses teaching the healing art. ⁴⁰

Even though later criticisms have been raised ⁴¹ about the philological accuracy of Edelstein's interpretation and analysis of specific Hippocratic notions, his work remains relevant and this in turn poses an interesting question: Why did Edelstein's work attract any attention at all, let alone continue to generate great scholarly interest several decades after its publication?

Part of the attraction of Edelstein's work certainly stems from its innovative integration of traditional philology with the new approaches to social and cultural history of medicine emerging at Johns Hopkins Institute for the History of Medicine under Henry Sigerist's leadership. More significantly, Edelstein's The Hippocratic Oath had, fittingly enough, much to do with the context of the times in which he published it. He wrote it towards the end of World War II when what could be described as the moral failure of Nazi doctors was being exposed gradually in war crimes trials and newsreels. Doctors including Josef Mengele (1911–1979) at Auschwitz, with his bizarre experiments on twin children to investigate heredity, combined with his apparent good humour when selecting people for the gas chambers, ⁴² became a Bluebeard legend of the modern era. The inhumane experiments on human physiology carried out at Dachau shocked a world already inured to years of total war. As American physiology professor Andrew Conway Ivy (1893–1978) remarked after the Nuremberg Medical Trial (1946–1947), it was incredible that physicians had carried out such atrocities in defiance of the unwritten medical ethics that supposedly guided them. ⁴³

For the Nuremberg prosecutors, between 1945 and 1947, it was undeniable that medicine was an important element of the National Socialist regime's racial and social policies. ⁴⁴ Rather than seeing them as opportunists who had exploited the resources of the state to pursue their own research interests, many opted to see the defendants at the Nuremberg Medical Trials as compliant followers of an autocratic and ruthless state. That it was even possible for these physicians to abandon their professional ethics was proof, as Andrew Conway Ivy suggested, of the utterly corrupting effect of Fascist ideology on normally upstanding individuals. ⁴⁵ Since the prosecutors assumed a universally understood code of medical ethics, Edelstein's argument that the Hippocratic Oath represented a marginalized viewpoint in antiquity was not useful to them. ⁴⁶ Edelstein's work on the Hippocratic Oath did not play a role in debates about medical ethics at Nuremberg. It was more convenient to assert that a physician's code had always existed and that the doctors of the National Socialist regime had willingly disregarded it.

If Edelstein's work was overlooked for political expediency in the immediate aftermath of the war, then we might consider it was the larger social and intellectual context of the post-war period that has imbued his work with continuing significance. There has been an explosion of concern and interest surrounding the topic of medical ethics in the post-war period, which was triggered by the criminal activities of scientists and physicians but continued just as modern medicine presents us with ever more ethical dilemmas. ⁴⁷ As an example of this phenomenon, we might consider references to Ethics, medical in the Cumulative Index Medicus, which increased by 650% (sic!) in the years between 1960 and 1975. ⁴⁸ The relevance of medical ethics in the post-war period has been analysed as causally related to the increased prevalence of medical oath taking administered to graduating classes of doctors. Currently, almost every medical school in the world offers some form of oath and humanistic ethical ritual. ⁴⁹

The proliferation of the Hippocratic Oath, or several modified versions of it, in North America and worldwide in the decades after World War II has meant that the origins of these ubiquitous medical oaths undergo much more scrutiny and the conclusions we draw about their origins have important implications for modern physicians and society at large. Edelstein's tract came along at the exact moment when lawmakers and physicians saw a profound need for a strong code of medical ethics. ⁵⁰ Though many have worked to discredit Edelstein's theory, his significance lies more in the challenge he posed to our historical assumptions. Though there is much scholarly debate on this issue, it has been argued convincingly by Vivian Nutton that the first reliable record we have of the Hippocratic Oath being sworn outside of Greece was at Wittenberg in 1508. ⁵¹ While the Declaration of Geneva emerged in 1948, the Hippocratic Oath has persisted in popularity. Of 135 American and 12 Canadian medical schools that responded to a 1993 survey regarding their oath-taking ceremonies, 69 schools purported to use a form of the Hippocratic Oath. ⁵² That Edelstein's translation of it still enjoys currency is suggested by the popular television series ‘NOVA's’ accompanying website which provides his version of the text. ⁵³ Moreover, if a graduating class today opts to use the unmodified Oath, the English translation will often be the plain but fluent rendering of Ludwig Edelstein. He played a role in shaping the cultural context in which the modern Hippocratic Oath was conceived.

Later years

Edelstein taught briefly at the University of Washington in 1947, subsequently lecturing in Greek at the University of California at Berkeley (1948–1950). He was very optimistic about the promising research environment in California but, much as at Berlin, his tenure came to an abrupt end – this time because of a ‘loyalty oath’ that was being forced on all academics. This was owing to the period in the United States associated with Republican Senator Joseph McCarthy (1908–1957) when American government paranoia was rampant in regard to Soviet agents and displays of patriotism were being demanded. Edelstein was among a small group of professors who refused to sign the oath, owing in part to his dislike of authoritarian measures taken by any government. ⁵⁴ Fortunately, Johns Hopkins was able to offer him a visiting professorship which he kept until 1960. His return to Baltimore was a happy event that Ludwig and Emma often referred to as ‘a homecoming’ (Figure 10). ⁵⁵ However, the death of his beloved wife Emma in 1958 caused Ludwig Edelstein increasingly to become withdrawn from the world. His outlook seemed to improve towards the very end of his life since his friends noticed an end to his self-imposed isolation and even the return of a measure of his erstwhile cheerfulness. OPEN IN VIEWER

From 1960 until his death, Edelstein divided his time between the Rockefeller Institute in New York and Johns Hopkins University in Baltimore. He had planned to produce a volume of his works that would include English translations of several research papers he had produced earlier in Germany. Unfortunately this goal was left unfulfilled by Edelstein himself as he died abruptly of a heart attack in New York on 16 August 1965. Subsequently, his close associates Owsei Temkin and his wife, the language teacher C. Lilian Temkin (1905–1992), produced Ancient Medicine: Selected Papers of Ludwig Edelstein, ⁵⁶ a volume of his important works that included many of his earlier German writings translated into English. Several more of Edelstein's posthumously published works appeared including The Meaning of Stoicism ⁵⁷ and The Idea of Progress in Classical Antiquity. ⁵⁸ Besides these, he had produced numerous articles for the American Journal of Philology, Classical Weekly, the Bulletin of the History of Medicine and other journals.

In general, Edelstein was a private and reserved individual. Few associations claimed his membership in his lifetime and those that did, for example the American Philosophical Society, elected him a member. He had left instructions in his will that in the event of his death all his papers were to be turned over to his chosen literary executor, Harold Cherniss (1904–1987), at the Institute of Advanced Study in Princeton. Those materials which Edelstein had ready for publication were to be published. The remainder of his papers were to be destroyed ‘without reading’. ⁵⁹ Based on this, German medical historian Thomas Rütten wonders if it is not a form of ‘outright impiety’ to pursue a biography, a deeper knowledge of the person behind the long list of publications and academic posts. In terms that Edelstein undoubtedly would have approved, Rütten observes the difficulty of untangling the bion (life) from the ergon (work) of this particular historian since his personal life was so ‘alchemically’ linked with his scholarly output. Moreover – even though it would have been a good survival strategy, as Rütten states, for an exiled émigré historian of medicine whose life was so linked with the calamities of his era clearly to delineate the spheres of life and work – it was perhaps Edelstein's actual intention that, as is the case with the author of the Hippocratic Corpus, his own works would fade gradually and inscrutably into his cultural milieu.