Artifical intelligence in surgery: ethical considerations in the light of social trends in the perception of health and medicine

The use of artificial intelligence (AI) in medicine and surgery is currently predicted to be very promising. However, AI has the potential to change the doctor's role and the doctor-patient relationship. It has the potential to support people's desires for health, along with the potential to nudge or push people to behave in a certain way. To understand these potentials, we must see AI in the light of social developments that have brought about changes in how medicine's role, in a given society, is understood. The trends of 'privatisation of medicine' and 'public-healthisation of the private' are proposed as a contextual backdrop to explain why AI raises ethical concerns different from those previously caused by new medical technologies, and which therefore need to be addressed specifically for AI.

Artifical intelligence use in orthopedics: an ethical point of view

Artificial intelligence (AI) is increasingly being utilized in orthopedics practice. Ethical concerns have arisen alongside marked improvements and widespread utilization of AI. Patient privacy, consent, data protection, cybersecurity, data safety and monitoring, bias, and accountability are some of the ethical concerns.

Highly varying concepts and capacities of forensic mental health services across the European Union

Introduction

There is wide variation in the processes, structures and treatment models for dealing with mentally disordered offenders across the European Union. There is a serious lack of data on population levels of need, national service capacities, or treatment outcome. This prevents us from comparing the different management and treatment approaches internationally and from identifying models of good practice and indeed what represents financial efficiency, in a sector that is universally needed.

Methods

From March 2019 till January 2020 we surveyed forensic psychiatric experts from each European Union Member State on basic concepts, service capacities and indicators for the prevalence and incidence of various forensic psychiatric system components. Each expert completed a detailed questionnaire for their respective country using the best available data.

Results

Finally, 22 EU Member States and Switzerland participated in the survey. Due to the frequent lack of a clear definition of what represented a forensic psychiatric bed, exact numbers on bed availability across specialized forensic hospitals or wards, general psychiatric hospitals or prison medical wards were often unknown or could only be estimated in a number of countries. Population-based rates calculated from the survey data suggested a highly variable pattern of forensic psychiatric provision across Europe, ranging from 0.9 forensic psychiatric beds per 100,000 population in Italy to 23.3 in Belgium. Other key service characteristics were similarly heterogeneous.

Discussion

Our results show that systems for detaining and treating mentally disordered offenders are highly diverse across European Union Member States. Systems appear to have been designed and reformed with insufficient evidence. Service designers, managers and health care planners in this field lack the most basic of information to describe their systems and analyse their outcomes. As a basic, minimum standardized national reporting systems must be implemented to inform regular EU wide forensic psychiatry reports as a prerequisite to allow the evaluation and comparison of the various systems to identify models of best practice, effectiveness and efficiency.

Artificial Intelligence in Reproductive Medicine - An Ethical Perspective

Artificial intelligence is steadily being integrated into all areas of medicine. In reproductive medicine, artificial intelligence methods can be utilized to improve the selection and prediction of sperm cells, oocytes, and embryos and to generate better predictive models for in vitro fertilization. The use of artificial intelligence in this field is justified by the suffering of persons or couples who wish to have children but are unable to conceive. However, research into the use of artificial intelligence in reproductive medicine is still in the early experimental stage and furthermore raises complex normative questions. There are ethical research challenges because evidence of the efficacy of certain pertinent systems is often lacking and because of the increased difficulty of ensuring informed consent on the part of the affected persons. Other ethically relevant issues include the potential risks for offspring and the difficulty of providing sufficient information. The opportunity to fulfill the desire to have children affects the welfare of patients and their reproductive autonomy. Ultimately, ensuring more accurate predictions and allowing physicians to devote more time to their patients will have a positive effect. Nevertheless, clinicians must be able to process patient data conscientiously. When using artificial intelligence, numerous actors are involved in making the diagnosis and deciding on the appropriate therapy, raising questions about who is ultimately responsible when mistakes occur. Questions of fairness arise with regard to resource allocation and cost reimbursement. Thus, before implementing artificial intelligence in clinical practice, it is necessary to critically examine the quantity and quality of the data used and to address issues of transparency. In the medium and long term, it would be necessary to confront the undesirable impact and social dynamics that may accompany the use of artificial intelligence in reproductive medicine.

Nicht-Direktivität als Leitkategorie in der humangenetischen Beratung in zeithistorischer Betrachtung

In diesem Beitrag beschreiben und analysieren wir auf der Basis von gedruckten Quellen und Oral History Interviews die Frage der Nicht-Direktivität in der humangenetischen Beratung in Deutschland im Zeitraum von 1970 bis 2010. Dabei steht insbesondere die Frage im Fokus, inwieweit die fachwissenschaftlichen und gesellschaftlichen Diskurse zu ethischen Fragen in der genetischen Beratung von Fachkundigen wahrgenommen und inwieweit Aspekte der nicht-direktiven Beratung diskutiert wurden. Wie die Ergebnisse zeigen, maßen Fachkundige nicht nur rückblickend der Autonomie von Ratsuchenden einen hohen Stellenwert bei und lehnten „direktive“ Beratungen zumindest in öffentlichen Positionierungen ab. Ethische Begründungsansätze betrachteten sie hier als zentral.

[Capable or incapable of giving consent? Assessing a patient's capacity to consent: Procedures and challenges in daily clinical practice]

BACKGROUND/OBJECTIVES

The capacity of patients to give consent (CTC) is an indispensable prerequisite for informed consent to medical measures. When there is doubt about a patient's CTC, careful assessment is therefore required. Despite a broad theoretical discussion about the conception of CTC and possible procedures for its assessment, there is often a lack of orientation towards binding standardized procedural guidelines in everyday clinical practice. As a consequence, the results of CTC assessments are inconsistent, revealing both interdisciplinary and interindividual variability. In order to improve the quality of CTC assessment, more detailed knowledge about the procedures as well as the problems of CTC testing is needed. Therefore, the aim of this explorative telephone survey was to get an impression of the actual procedures that clinicians apply when in doubt about a patient's CTC. In particular, participants in the survey were asked about the weighting of individual CTC criteria and the difficulties with their application.

METHODS

Based on structured questionnaires, telephone interviews with 26 physicians working in German hospitals in the fields of neurology, anaesthesiology, surgery, internal medicine, gynaecology, and reconstructive/aesthetic surgery were conducted. The answers were documented using the paper-and-pencil method, and answers to open questions were summarized with the help of a qualitative data analysis software and a thematic coding scheme.

RESULTS

The majority of respondents reported that "sometimes to very often" they had doubts about their patients' CTC, with the examination being mostly conducted in an individual approach without formalized, standardized specifications. Regarding the question about the weighting of the seven assessment criteria proposed in the questionnaire, their importance was predominantly evaluated as being in the range of "partially important" to "very important". Difficulties in the clinical assessment were indicated in relation to the patients themselves, the relationship between physicians and patients, and the assessment situation. The perception of difficulties in the examination of CTC is apparently independent of the relevance attributed to the specific criterion for CTC.

DISCUSSION AND CONCLUSION

Overall, the results show a high level of agreement with the relevance of the seven CTC criteria included in the survey, but at the same time revealed various verification difficulties. Some of the respondents would like to have more support in determining their patients' CTC. The survey results suggest that precise training and adequate time resources are paramount to this sensitive medical context.

Historical review: the German Neurological Society and its honorary members (1952-1982)

BACKGROUND

As part of a larger project commissioned by the German Neurological Society (DGN), this paper focuses on the DGN's German and Austrian honorary members. In particular, the question of whether former membership in the National Socialist German Workers' Party (NSDAP) or other Nazi organizations was an obstacle to becoming an honorary member in the years 1952-1982, and whether victims of the Nazi regime were also considered for honorary membership.

RESULTS

From the early 1950s to the early 1980s, the DGN awarded honorary membership to 55 individuals. Of these, 27 were German or Austrian citizens who were physicians during the Nazi era, and 17 of the 27 (63%) were members of the NSDAP, Storm Troopers (SA), or Schutzstaffel (SS). In the early postwar period, honorary membership was much less frequently awarded to former Nazi Party members than in the years around 1980. Sir Ludwig Guttmann, the only neurologist forced to emigrate, received his honorary membership in 1971. Brief biographies of Hans Jacob, Gustav Bodechtel, Karl Kleist, and Ludwig Guttmann outline exemplary careers and life histories, in addition to highlighting key issues such as concurrent research on "euthanasia" victims, denazification procedures, forced emigration, and the contemporary mindset in the Federal Republic of Germany.

CONCLUSIONS

Apparently, a "Nazi past" did not play a decisive role in the selection process for honorary members within the DGN until at least the 1980s. Aside from Guttmann, no other neuroscientist expelled from Germany was honored. With these practices, the Society marginalized its Jewish colleagues for a second time.

[A researcher and physician who gained international fame: Otfrid Foerster (1873-1941) as Nobel Prize candidate]

This paper discusses the 17 Nobel Prize nominations for the neurologist and neurosurgeon Otfrid Foerster (1873-1941). Drawing on files from the Stockholm Nobel Prize Archive, primary and secondary literature, it addresses the following questions: what were the reasons given by nominators for Foerster's nominations? What was the relationship between him and his nominators? Why was he ultimately not awarded the Nobel Prize? Most nominators of Foerster's highlighted as the main motive his Handbuch der Neurologie, which he had edited with Oswald Bumke. According to the nominators, this book together with Foerster's neurosurgical work had an enormous impact on contemporary neurology. Furthermore, his "honorable character" was underlined in the nomination letters; however, these reasons were not sufficient for the Nobel Committee: the members classified the handbook as not being original research. Despite this, Foerster's fame is reflected in the present, for example in the Otfrid Foerster Medal, which has been awarded to researchers by the German Society of Neurosurgery since 1953.

[A researcher and physician who gained international fame: Otfrid Foerster (1873-1941) as Nobel Prize candidate]

This paper discusses the 17 Nobel Prize nominations for the neurologist and neurosurgeon Otfrid Foerster (1873-1941). Drawing on files from the Stockholm Nobel Prize Archive, primary and secondary literature, it addresses the following questions: what were the reasons given by nominators for Foerster's nominations? What was the relationship between him and his nominators? Why was he ultimately not awarded the Nobel Prize? Most nominators of Foerster's highlighted as the main motive his Handbuch der Neurologie, which he had edited with Oswald Bumke. According to the nominators, this book together with Foerster's neurosurgical work had an enormous impact on contemporary neurology. Furthermore, his "honorable character" was underlined in the nomination letters; however, these reasons were not sufficient for the Nobel Committee: the members classified the handbook as not being original research. Despite this, Foerster's fame is reflected in the present, for example in the Otfrid Foerster Medal, which has been awarded to researchers by the German Society of Neurosurgery since 1953.

In vitro gametogenesis: A benefit for women at advanced and very advanced age? An ethical perspective

Assisted reproductive technologies (ART) may be supplemented with in vitro gametogenesis (IVG). Although IVG is still experimental the question arises whether IVG offers any moral advantages compared to implemented methods. The aim of the paper is to present the landscape of ethical arguments in favour or against IVG. ART-related ethical issues in relation to reproductive autonomy, health risks for the woman and foetus, the welfare of the future child, the adverse effects of advanced motherhood, gender equality, and justice are similar for IVG, oocyte cryopreservation, and oocyte donation. IVG may have the following advantages: (I) the psychological and physical burden of stimulation and puncture of the oocyte could be avoided; (II) women do not necessarily have to cope with motherhood at young age; (III) ethical doubts associated with oocyte donation would be eliminated; (IV) by using IVG in combination with preimplantation diagnostics, it is more likely to find suitable oocytes or embryos to increase the probability of pregnancy; (V) women would have the opportunity to decide how many oocytes should be generated and how often an attempt should be made to achieve pregnancy. Simultaneously, however, the advent of IVG may lead to new moral disadvantages: pressure on women to give birth at an advanced age or pressure on women to follow 'male' career structures. Additionally, the reimbursement of costs related to IVG is an open question, especially if equal opportunities regarding motherhood are linked to demands for equal access to ART. An early discussion about the ethical, legal, and social consequences for IVG is necessary.

Striving for Health Equity: The Importance of Social Determinants of Health and Ethical Considerations in Pandemic Preparedness Planning

Since the WHO's "Influenza Pandemic Preparedness Plan" in 1999, pandemic preparedness plans at the international and national level have been constantly adapted with the common goal to respond early to outbreaks, identify risks, and outline promising interventions for pandemic containment. Two years into the COVID-19 pandemic, public health experts have started to reflect on the extent to which previous preparations have been helpful as well as on the gaps in pandemic preparedness planning. In the present commentary, we advocate for the inclusion of social and ethical factors in future pandemic planning-factors that have been insufficiently considered so far, although social determinants of infection risk and infectious disease severity contribute to aggravated social inequalities in health.

Leaving the Academic Niche–Rhoda Erdmann (1870–1935) and the Democratization of Tissue Culture Research

In the years after Ross Harrison published his pivotal paper on nerve fiber regeneration in 1907, researchers following his line of research presented tissue culture techniques as an extremely sensitive, difficult, and almost occult methodology. When Philip R. White published a manual on tissue culturing in 1954, he declared that he wanted to disenchant this formerly mystified field of study. With a similar aim Rhoda Erdmann had published a comparable manual more than 30 years before in 1922. Her intention was to offer a book that would make the method “a common property of those who want to do biological research in the future.” When science was about to move from little science to big science, Erdmann tried to democratize tissue culture knowledge. Rhoda Erdmann was in many aspects an extraordinary scholar deviating from the norm. She was one of the few women in the field, working as a low-level assistant at the Robert Koch Institute in Berlin before she took the opportunity to work as a research fellow with Ross Harrison in Yale. She was imprisoned during the First World War on the accusation of being a German spy. After she could return to Germany in 1919, she established a laboratory for experimental cell research in Berlin. In 1929 she was one of the first women to be appointed a professor in Germany. The paper focuses Erdmann’s attempts at distributing practical tissue culturing knowledge. Based on her and other scholars’ research work on nutrient media for cell cultures, and the attempts to optimize these basic tools for different species, this contribution examines the hypothesis that this work constituted an academic niche for underprivileged scientists. The paper analyzes whether Erdmann, due to her extraordinary characteristics, had to use certain niches in the academic world (topics, places, techniques, communities) to pursue her research, and whether her attempts at democratizing her techniques can also be read as an attempt to move out of the niche to gain academic recognition.

Unsettling Realities of Nazism and the Legacy of the German Neurological Society

On behalf of the German Neurological Society (DGN), a study was conducted into how far former chairmen, honorary chairmen, and honorary members could be regarded as incriminated from the National Socialist period. While an online supplement of this journal presents seven individual biographies (in six papers) by way of example, this paper offers an overview summarizing the project results and introducing the biographies. The first part and the methodological section discuss the difficulties of retrospectively identifying neurologists involved in the Nazi movement. Formal characteristics (eg, membership of the Nazi Party (NSDAP) or other Nazi organizations or participation in Nazi crimes) and content-related clues (eg, statements reflecting Nazi ideology, personal contacts with Nazi officials or active support of the system) can be helpful. The second part summarizes the principal results of a study of 28 German and Austrian neuroscientists with regard to their involvement and their post-war careers. Six of the seven "founding fathers" of the DGN were former NSDAP members; 10 of the 13 presidents in office until 1976 had belonged to Nazi organizations-the NSDAP, the SA ("Brownshirts") or the SS ("Blackshirts"). Moreover, seven out of 10 honorary presidents had formal or substantive links to National Socialism. Of the German and Austrian honorary members appointed up to 1985, two-thirds had leanings to Nazi ideology or the National Socialist system. This paper concludes by outlining how the DGN and its members are currently addressing this historical legacy in order to establish a responsible culture of remembrance. ANN NEUROL 2021;90:546-557.

[Why in Koenigsberg, why Samuel Jessner, why 1921? : History of the first university lectureship for sexology in Germany]

The dermatologist and venerologist Samuel Jessner (1895-1929) received a lectureship for sexology at the University of Koenigsberg (today: Russian Калининград, Kaliningrad) in 1921. Since 1928 he was also listed as a urologist in the Reichsmedizinalkalender (German Physician Address Calendar). In this article we trace his life and work and ask how Jessner was able to achieve this academic success in the periphery of German sexology and without close ties to its networks. His weak influence in research, his lack of connection to a "school" of sexual science in German-speaking countries, and his Jewish origin were factors that impaired both the recognition of his work among his contemporaries and his recognition in the discipline-specific historiography until today.

Geschichtsbewusstsein und historische Verantwortung in der deutschen Humangenetik

Historiker*innen haben immer wieder auf personelle und institutionelle Kontinuitäten zwischen der Eugenik in Deutschland vor 1945 und der sich entwickelnden Humangenetik im Nachkriegsdeutschland hingewiesen. Wie aber wurde diese äußere Wahrnehmung unter deutschen Humangenetiker*innen diskutiert und spielte sie für das Selbstbild der Disziplin eine Rolle? Auf der Basis von gedruckten Quellen und biographischen Interviews wurden das Geschichtsbewusstsein und die Übernahme historischer Verantwortung unter deutschen Humangenetiker*innen untersucht, die in der Zeit zwischen den 1970er und den 2010er Jahren im Feld tätig waren. Ein historisches Bewusstsein spielte in der Erinnerung der Zeitzeug*innen schon vor den 1980er Jahren eine Rolle für ihr Fach und seit der Gründung der Deutschen Gesellschaft für Humangenetik im Jahr 1987 wird in der Gesellschaft die Frage der Form einer historischen Verantwortungsübernahme immer wieder diskutiert. Sie findet ihren praktischen Ausdruck z. B. in Diskussionen mit der Öffentlichkeit und in der Umbenennung von Preisen.

Oral-History-Projekt Humangenetik: Historische Forschungsmethode zur Erhebung und Weiterverarbeitung narrativer Interviews

Zwischen 2016 und 2018 wurden mit 33 Personen Interviews zur Geschichte der Humangenetik in Deutschland zwischen 1970 und den 2000er Jahren geführt. 29 Interviewte stimmten einer wissenschaftlichen Analyse zu. Diese Interviews wurden mit den Methoden der qualitativen Inhaltsanalyse und der Grounded Theory ausgewertet. Im Zentrum dieses Beitrags steht die kritische Auseinandersetzung mit der Methode der Oral History und ihrer Anwendung auf die Humangenetik. Das Oral-History-Projekt konzentriert sich auf Fragen zu (1) biographischen Daten und Werdegang der Gesprächspartner*innen, (2) Entwicklung und Anwendung von diagnostischen und therapeutischen Techniken, (3) Etablierung und Ausbau der Institutionen der Humangenetik und (4) der Wahrnehmung der das Fach betreffenden gesellschaftlichen Debatten.

A conceptual approach to the rationale for SARS-CoV-2 vaccine allocation prioritisation

Currently vaccines protecting from COVID-19 are a scarce resource. Prioritising vaccination for certain groups of society is placed in a context of uncertainty due to changing evidence on the available vaccines and changing infection dynamics. To meet accepted ethical standards of procedural justice and individual autonomy, vaccine allocation strategies need to state reasons for prioritisation explicitly while at the same time communicating the expected risks and benefits of vaccination at different times and with different vaccines transparently. In this article, we provide a concept summarising epidemiological considerations underlying current vaccine prioritisation strategies in an accessible way. We define six priority groups (vulnerable individuals, persons in close contact with the vulnerable, key workers with direct work-related contact with the public, key workers without direct work-related contact to the public, dependents of key workers and members of groups with high interpersonal contact rates) and state vaccine priorities for them. Additionally, prioritisation may follow non-epidemiological considerations including the aim to increase intra-societal justice and reducing inequality. While national prioritisation plans integrate many of these concepts, the international community has so far failed to guarantee equitable or procedurally just access to vaccines across settings with different levels of wealth.

A Systematic Review of Non-pharmacological Strategies to Reduce the Risk of Violence in Patients With Schizophrenia Spectrum Disorders in Forensic Settings

Background: The purpose of this systematic review is to systematically investigate which non-pharmacological interventions are effective in reducing violence risk among patients with schizophrenia spectrum disorders (SSD) in forensic settings. Methods: Six electronic data bases were searched. Two researchers independently screened 6,003 abstracts resulting in 143 potential papers. These were analyzed in detail by two independent researchers yielding 10 articles that could be used. Results: Of the 10 articles, four were non-randomized controlled trials, three were pre-post studies without controls, and one was observational. Only two studies applied a randomized controlled trial design. Cognitive behavioral treatment programs were investigated in three studies. A broad range of other interventions were studied. Often outcome measures were specific to each study and sample sizes were small. Frequently, important methodological information was missing from the papers. It was not possible to carry out a meta-analysis due to the heterogeneity of the study designs and outcome measures. Conclusion: Because of methodological limitations it is difficult to draw firm conclusions about the effectiveness of non-pharmacological interventions to reduce the risk of violence in patents with SSD in forensic psychiatry settings. Studies applying better methods in terms of study design, sample sizes and outcome measures are urgently needed.

The enactment of physician-authors in Nobel Prize nominations

Several physicians have been nominated for the Nobel Prize in literature, but so far none of them have received it. Because physicians as women and men of letters have been a major topic of feuilletons, seminars and books for many years, questions arise to what extent medicine was a topic in the proposals for the Nobel Prize and in the Nobel jury evaluations: how were the nominees enacted (or not) as physicians, and why were none of them awarded? Drawing on nomination letters and evaluations by the Nobel committee for literature collected in the archive of the Swedish Academy in Stockholm, this article offers a first overview of nominated physician-author candidates. The focus is on the Austrian historian of medicine Max Neuburger (1868-1955), the German novelist Hans Carossa (1878-1956), and the German poet Gottfried Benn (1886-1956), but it also briefly takes further physician-author nominees into account such as Sigmund Freud (1856-1939) and William Somerset Maugham (1874-1965). The article is part of an interdisciplinary medical humanities project that analyses nominations and committee reports for physicians and natural scientists nominated for the Nobel Prize from 1901 to 1970.

Blood tests to diagnose schizophrenia: self-imposed limits in psychiatry

The naturalisation of mental disorders-ie, their translation into measurable and preferably molecular variables-has not progressed despite breath-taking discoveries in the neurosciences. We ask whether self-inflicted limits exist among psychiatrists that would prevent them from supporting an imaginary perfect blood test with diagnostic specificity, sensitivity, and validity, which was able to replace clinical diagnosis completely. Although relevant for many mental disorders, we use the clinical disease category schizophrenia here as an example to discuss factors that oppose the naturalisation of clinical disease categories. We defend the provocative position that a complete substitution of the clinical diagnosis by a blood test is generally not desired among clinicians because various factors perpetuate the current diagnostic culture. These are (1) methodological problems, such as a falsely presumed homogeneity of biological causes under the umbrella of one clinical diagnosis that prevents efficient subset identification, (2) professional fears, such as loss of importance of interview-diagnostic expert skills, and (3) conceptual problems, such as a dualistic mindset. We posit that doubts regarding the possibility of a blood test for diagnosing schizophrenia can subtly result in a negative self-fulfilling prophecy, discouraging serious scientific efforts to develop one. We give historical examples of how some of these problems have been solved in other medical disciplines. We predict that only blood tests that improve diagnostic accuracy but do not displace the primacy of clinical diagnosis will be successful. In the future, novel professional expertise for orchestrating various biological variables together with clinical criteria will be needed.

Face masks: benefits and risks during the COVID-19 crisis

Background

The German government has made it mandatory to wear respiratory masks covering mouth and nose (MNC) as an effective strategy to fight SARS-CoV-2 infections. In many countries, this directive has been extended on shopping malls or public transportation. The aim of this paper is to critically analyze the statutory regulation to wear protective masks during the COVID-19 crisis from a medical standpoint.

Methods

We performed an extensive query of the most recent publications addressing the prevention of viral infections including the use of face masks in the community as a method to prevent the spread of the infection. We addressed the issues of practicability, professional use, and acceptability based on the community and the environment where the user resided.

Results

Upon our critical review of the available literature, we found only weak evidence for wearing a face mask as an efficient hygienic tool to prevent the spread of a viral infection. However, the use of MNC seems to be linked to relevant protection during close contact scenarios by limiting pathogen-containing aerosol and liquid droplet dissemination. Importantly, we found evidence for significant respiratory compromise in patients with severe obstructive pulmonary disease, secondary to the development of hypercapnia. This could also happen in patients with lung infections, with or without SARS-CoV-2.

Conclusion

Epidemiologists currently emphasize that wearing MNC will effectively interrupt airborne infections in the community. The government and the politicians have followed these recommendations and used them to both advise and, in some cases, mandate the general population to wear MNC in public locations. Overall, the results seem to suggest that there are some clinically relevant scenarios where the use of MNC necessitates more defined recommendations. Our critical evaluation of the literature both highlights the protective effects of certain types of face masks in defined risk groups, and emphasizes their potential risks.

The history and value of face masks

In the human population, social contacts are a key for transmission of bacteria and viruses. The use of face masks seems to be critical to prevent the transmission of SARS-CoV-2 for the period, in which therapeutic interventions are lacking. In this review, we describe the history of masks from the middle age to modern times.

"He Gave Us the Cornerstone of Sexual Medicine": A Nobel Plan but No Nobel Prize for Eugen Steinach

This paper reviews the files in the archive of the Nobel Prize Committee for Physiology or Medicine on the Austrian physiologist and pioneering researcher in the emerging fields of urology and sexual medicine: Eugen Steinach (1861-1944). It reconstructs and analyzes why and by whom Steinach was nominated for the Nobel Prize between 1920 and 1938 and discusses the reasons why he never received the award, although the Nobel Committee judged him as prizeworthy. Steinach's Nobel nominee career is extraordinary - not only because of his strong support by renowned international nominators from different scientific and medical disciplines, but also because of the controversial discussions within the Nobel Committee on his achievements, colored by the debates in the international scientific community. The Nobel Prize story adds a new perspective on how contemporary international scholars evaluated Steinach's research on reproduction, "male-making" females, "female-making" males, homosexuality, and the concept of rejuvenation.

[Heinrich Pette (1887-1964) and the difficult assessment of his role from the Weimar Republic to the Federal Republic of Germany]

For a long time, biographical sketches and obituaries have focused on Pette's instantly recognizable scientific contributions to German neurology and neurovirology; however, they often ignored or marginalized his role as vice-president of the Society of German Neurologists and Psychiatrists (GDNP) during the Nazi era. Recent investigations and reports based on newly discovered records question such one-sided assessments and paint a contradictory picture. Pette joined the National Socialist German Workers' Party (NSDAP) and the NS Medical Association in 1933 and in the same year signed the "vow of allegiance of the professors to Adolf Hitler and the National Socialistic State". In 1934 he succeeded Nonne as professor for neurology in Hamburg and from 1935 headed the neurological branch of the NS-controlled Society of German Neurologists and Psychiatrists (GDNP). As a result, Pette had a strong influence on all activities of this organization and had contact with party leadership and the government. In principle, he was not opposed to the "Law for the Prevention of Genetically Diseased Offspring" and produced various expert reports addressed to the Appellate Hereditary Health Court in Hamburg. Simultaneously, he advocated differentiated diagnostics and rejected hasty sterilizations. He seems to have been acquainted with the "euthanasia" program and concomitant research projects but was not involved in them. During and after a lengthy denazification trial he stylized himself into a nonpolitical scientist representing an "oppositional attitude". In 1950 he was co-founder of the German Neurological Society (DGN) and was president until 1952 and then honorary president. Since 1969 the DGN awards the Heinrich Pette Prize. The Foundation for Research in Spinal Poliomyelitis founded by him shortly after WWII was named after him after his death. Since 2011 it bears the name "Heinrich Pette Institute, Leibniz Institute for Experimental Virology". In future, a prudent dealing with this ambivalent legacy seems to be advisable.

[Neuroscientists at the Kaiser Wilhelm Institute for Brain Research in the "Third Reich": Oskar Vogt-Hugo Spatz-Wilhelm Tönnis]

The Kaiser Wilhelm Institute (KWI) for Brain Research in Berlin-Buch was one of the key institutions enmeshed in the euthanasia program between 1939 and 1945, generating scientific knowledge by dissecting the brains of murdered patients. As a consequence, this institution and its early years have attracted the attention of historians for years. The neuroanatomist Oskar Vogt (1870-1959), director of the KWI until 1937 and his wife Cécile (1875-1962) who were both appointed honorary members of the German Neurological Society (DGN) in 1952, concentrated on the microstructure and brain architecture of healthy and "elite" brains. Vogt's successor, Hugo Spatz (1888-1969), shifted research activities towards pathology of the central nervous system (CNS) and incorporated psychiatric and military institutions into the institute's network. Spatz had been a member of the National Socialist German Workers' Party (NSDAP) since 1938. As acting director of the KWI he was responsible for the dissections performed by Hallervorden on murdered patients. After the war Spatz tried to justify his actions. Years after the unveiling of these relationships the DGN decided in 1998 to rename the Hugo Spatz award. Wilhelm Tönnis (1898-1978), the German pioneer of neurosurgery had been a member of the National Socialist Air Corps since 1933 and a member of the NSDAP since 1937, finally joining the NS Medical Association in 1938. After the war he played down his affiliation to NS divisions. When his denazification trial had ended he pursued his career in the young Federal Republic of Germany. In 1976 he was elected honorary member of the DGN, 2 years before his death.

[Oswald Bumke (1877-1950)-silence as resistance?]

In 1924 Oswald Bumke was appointed as Emil Kraepelins successor to the Chair of Psychiatry at the University of Munich. After 1933 he was a promoting member of the SS and the National Socialist Teachers Federation but he was never a member of the National Socialist German Workers' Party (NSDAP). In 1933 he assumed the presidency of the Society of German Neurologists but only 2 years later he withdrew from the executive board because of scientific and personal differences with Ernst Rüdin, the new "strong man" of the merged Society of German Neurologists and Psychiatrists. After the end of WWII, Bumke affirmed that despite his exposed position as professor of psychiatry during the NS era, he had lacked any influence and that he had sabotaged the "Law for the Prevention of Genetically Diseased Offspring" (GzVeN). He declared that for scientific reasons he had been extremely critical of the GzVeN and even had expressed his views in various publications. Nevertheless, he supported forced sterilization in his treatise "The State and Mental Diseases" published in 1939. His statement that the clinic in Munich had manipulated diagnoses in order to protect patients from eugenic measures and "euthanasia" refers to a potential interference, but as documents are lacking this cannot be substantiated. After 1940 Bumke functioned as a consulting military psychiatrist in expert reports. Political assessments from this period presented him as politically reliable. His biography exemplarily shows that a meticulous juxtaposition of post-war documents with correspondent records stemming from the Nazi period is imperative in order to arrive at a source-critical well-founded and differentiated evaluation.

[The two CVs of Klaus Joachim Zülch (1910-1988)]

Klaus Joachim Zülch's research on the pathology and biology of brain tumors made him one of the outstanding scholars and clinicians in the fields of neurology and neuropathology in the Federal Republic of Germany. The World Health Organization (WHO) drew on his results when laying down its classification. In the years 1961-1962 he was president of the German Neurological Society (DGN), in 1978 he became an honorary member and in 1984 honorary president. In addition to the Zülch Award of the Max Planck Society, the DGN organizes a Zülch lecture at its annual meetings. Archive documents revealed that he was an early adherent of the ideology of National Socialism. He was a member of paramilitary units, joined the SA storm troopers in 1933 and the National Socialist German Workers' Party (NSDAP) in 1937. After having studied under Otfrid Foerster in Breslau and Georg Schaltenbrand in Würzburg he served as a military physician and in army hospitals during and after WWII. Nevertheless, he continued his investigations at the Kaiser Wilhelm Institute for Brain Research with Wilhelm Tönnis. In July 1947 he was dismissed on account of his SA membership but entered an objection to this decision of the Allies. After a lengthy denazification trial he succeeded in being exonerated. This was also due to attestations written in his favor by various neuroscientists. Hence, he could pursue his career in Cologne and from 1959 onwards he acted as director of the newly established department of general neurology of the Max Planck Institute and simultaneously as head of the department for clinical neurology at Cologne-Merheim hospital. The juxtaposition of a CV written by Zülch himself around 1938 with another one composed after the war shows that he tried to conceal incriminating facts and partly reconstructed a new and ultimately successful biography.

[In the "twilight zone": honorary members of the German Neurological Society 1954-1982]

From the mid-1950s to the early 1980s the German Neurological Society (DGN) appointed in addition to international physicians, numerous German physicians as honorary members. From a present day perspective, some of them are to be classified as "incriminated" with their commitment to the National Socialist "movement" and its health policy goals, which at times went far beyond a formal membership of the party and its organizations. Thus, there is no doubt about the völkisch views of the Würzburg psychiatrist Martin Reichardt (1874-1966), which he articulated in lectures and publications. The Erb student Siegfried Schönborn (1874-1966), also a member of the National Socialist German Workers' Party (NSDAP), was in contact with Karl Fahrenkamp, who advised Reichsführer-SS Heinrich Himmler on medical issues. Hamburg-based Hans-Robert Müller (1901-1981), one of the "founding fathers" of the DGN, joined the Hitler party in 1937. In contrast, neurosurgeon Hans Kuhlendahl (1910-1992) was in addition a member of the Storm Troopers (SA). Hans Jacob (1907-1997), SA-Rottenführer, party comrade and head of the Neuropathology Department at Hamburg University, profited by the "euthanasia" action: as part of the so-called concomitant research he examined ca. 40 brains of children who had been killed at the "special departments" in Langenhorn and Lüneburg. Unlike his peers, the renowned neurogeneticist Peter Emil Becker (1908-2000) is today judged as an opportunistic bystander. He was one of the few who faced up to his NS past later in life, but the response he met was ambivalent because he withheld mention of his party membership. With respect to the honorary members, it remains an open question why 40 years after the end of the "Third Reich" the DGN still honored neurologists who in some cases had been heavily involved in the biopolitics of that era.

[Neurologists and neuroscientists: who was a Nazi? Changing perspectives on NS incrimination in the history of German medicine]

The German Neurological Society (DGN) instigated an investigation into potential incrimination of some of the previous leading members regarding their Nazi involvement. The persons in question include former (honorary) presidents and honorary members of the DGN (or the predecessor organizations) and the name givers of prizes awarded by the DGN. This introduction to the following biographies explains the difficulties and the broad discretionary leeway needed to establish an involvement in Nazi activities going beyond justiciable crimes against humanity on the basis of formal criteria (e.g. membership in the NSDAP and/or other NS organizations, involvement in Nazi crimes) and/or substantive indications (e.g. statements advocating the NS ideology, personal contacts to Nazi functionaries, active support of the system). A longitudinal analysis from 1945 until the present day reveals time-related variations in assessing who and why someone was considered to be a Nazi. A current overview of historical projects initiated by medical societies in Germany demonstrates that the endeavor of the DGN to deal with its Nazi involvement will be an integral part of the interdisciplinary "culture to cope with the past" of medical associations. Finally, it should be borne in mind that the fabric of history consists of a different material than clinical medicine or its natural scientific foundations. Checklists or scores for measuring NS involvement thus cannot and will not exist. Instead, balanced historical interpretations are needed as attempted by the biographical reconstructions presented in this volume.

[Max Nonne (1861-1959) and his attitude towards "euthanasia"]

Max Nonne, an internationally renowned German neurologist, acted from 1918 to 1924 as president of the (first) Society of German Neurologists (GDN). Appointed honorary president in 1925, he held this position in the (second) German Neurological Society (DGN) until his death. Since 1961, this association has honored 16 neurologists with a commemorative medal named after Nonne. His outstanding findings in various fields of neurology are uncontested and some of them live on as eponyms (Nonne-Apelt syndrome, Nonne-Froin syndrome, Nonne-Milroy-Meige syndrome); however, recent archival studies and an analysis of individual publications deeply darkened the image of the "grey eminence" of German neurology. Records kept at the Hamburg State Archive prove that in a memorandum from 1941/1942 following the example of Binding and Hoche, Nonne firmly approved the killing of "life absolutely unworthy of living". In a report addressed to the District Court of Hamburg he attested in 1946 that many physicians charged with manslaughter acted in accordance with the regulations governing "child euthanasia", resulting in the withdrawal of the accusation. In a further statement from 1949 he confirmed that the killing of children and the "euthanasia program" during the NS era were consistent with the state of medical science. An earlier book chapter authored by Nonne immediately after World War I suggested that his social-Darwinistically colored concept of mankind was developed clearly before the Nazi era. Notwithstanding the arrangement to which he came with the new powers after 1933 and his acceptance of tributes to him by them, he repeatedly stood up for his Jewish colleagues. He was never a Nazi, nevertheless, he engaged in activities that fostered NS "euthanasia" going far beyond a "mentality of approval".

[Between affirmation and negation: Karl Kleist and Viktor von Weizsäcker between 1933 and 1945]

In 1954 Karl Kleist (1879-1960) became an honorary member of the German Neurological Society (DGN), an honor that was granted 2 years earlier to his colleague Viktor von Weizsäcker (1886-1957). The attempt to classify and assess their careers between 1933 and 1945 led to diametrically opposed results in historical research. This article summarizes the main lines of argumentation and draws a preliminary conclusion. After 1933 Kleist is said to have felt more and more accountable for his non-Aryan colleagues and that he treated his Jewish patients as long as he could. Publications and third party testimonies confirmed that he circumvented at least occasionally the Law for the Prevention of Genetically Diseased Offspring (GzVeN). Furthermore, he is said to have saved patients from "euthanasia" actions by prudently formulated diagnoses. Simultaneously, he worked as an expert at the Appelate Hereditary Health Court in Frankfurt am Main, in 1940 he joined the National Socialist German Workers' Party (NSDAP) and in 1942 the NS Medical Association. Von Weizsäcker used his scope of action in a similarly contradictory way. Certainly, he kept away from central Nazi organizations and was considered "politically unreliable" by those colleagues who had a penchant for the system. But as professor of neurology he formally headed from 1941 onwards exactly that Neuropathological Research Institute in Breslau (Wroclaw) where one of his colleagues examined the brains of minors who had been killed in the course of "child euthanasia", in what was called "concomitant research". To a certain extent von Weizsäcker was also an advocate of the GzVeN. In his lectures and publications between 1933 and 1935 he chose the pertinent NS terminology and he was the first to speak of a "theory of extermination". In either case, even meticulous research could not answer the question where to exactly assign both biographies in a spectrum between criticism and affirmation of National Socialism.

[Men without a past? (Honorary) Presidents of the German Neurological Society and their NS past]

This paper aims at reconstructing the biographies of six German neurologists during and after the "Third Reich". Between 1957 and 1976, five of them were presidents of the German Neurological Society (DGN), the sixth was appointed honorary president in 1981. They all joined the National Socialist German Workers' Party (NSDAP) or Storm Troopers (SA) as young doctors between the ages 20 and 35 years. According to the current state of research they thus have to be classified as formally incriminated, yet none of them developed significant (health) political activities, with the slight exception of Eberhard Bay (1908-1989), who once acted as expert witness in an Hereditary Health Court trial. Gustav Döhring (1909-1963), NSDAP member since 1937, Pette student and co-founder of the DGN, was secretary of the Society for many years and editor of a commemorative publication. Johannes Hirschmann (1910-1991), also a party comrade since 1937, served as an army and military hospital doctor from 1939 to 1945. Richard Jung (1911-1986) had joined the SA in 1934. This entailed his immediate dismissal after the war from the University of Freiburg but benefitting from the support by the dean he could pursue his career not long thereafter. Robert Charles Behrend (1919-1996) became a party member at the age of 20 years and with his time in office in 1975-1976 he was the last of the post-war presidents of the DGN connected to National Socialism in Germany. Older than these five was honorary chairman Gustav Bodechtel (1899-1983) a member of the SA, NSDAP and other Nazi organizations. He was dismissed in 1946 but reinstated just 1 week later due to the interventions by the Medical Academy Düsseldorf and the Mayor of the City. New findings on these personalities are exclusively based on archival research. This underlines the necessity of resorting to sources previously neglected when investigating biographies of twentieth century neurologists.

Frage der „NS-Belastung“ und Mitgliedschaften in NS-Organisationen

Dies ist der erste Teil der Studie „Beziehungen ausgewählter Neurophysiologen zum Nationalsozialismus“. Hier werden die nationalsozialistischen Organisationen vorgestellt, in denen Mediziner typischerweise Mitglieder waren. Dies soll den zweiten Teil vorbereiten, in welchem die wichtigen Neurophysiologen Hans Berger, Paul Hoffmann, Richard Jung und Alois E. Kornmüller näher vorgestellt werden.

[Urology goes electric-electrotherapy : Modern therapies in the treatment of modern diseases-examples from urology]

The significance of electricity for medicine in the modern industrial age should not be underestimated. Particularly in connection with neurasthenia, electrotherapeutic approaches also experienced a boom for domestic use. Thus, electrotherapy reached urology just as it was becoming established as a medical specialty. We analyzed urological manuals and textbooks and objects in the W. P. Didusch Center for Urologic History and the Museum zur Geschichte der Urologie in Berlin to present the wide range of indications for electrotherapy in the emerging field of urology from impotence to urethral strictures and try to highlight the variability of their importance over time.

Neurophysiologen im Nationalsozialismus – Hans Berger, Paul Hoffmann, Richard Jung und Alois E. Kornmüller

Dies ist der zweite Teil der Studie „Beziehungen ausgewählter Neurophysiologen zum Nationalsozialismus“. Hier werden die vier wichtigen Neurophysiologen Hans Berger, Paul Hoffmann, Richard Jung und Alois E. Kornmüller sowie ihr Wirken in der Zeit des Nationalsozialismus näher vorgestellt.

[Otfrid Foerster (1873-1941) and his ambivalent attitude towards National Socialism]

When Adolf Hitler was appointed Chancellor of the Reich Otfrid Foerster was almost 60 years old and an internationally renowned neurologist, neurosurgeon and a pioneer of localization research. Since 1922 he held the chair of neurology in Breslau (Wroclaw) and from 1925 to 1932 he was president (later honorary president) of the first Society of German Neurologists. In 1934 "his" Neurological Research Institute in Breslau was inaugurated. Biographical studies have unanimously established that he has never been a member of the party, that he found himself promptly marginalized after 1933 within his own ranks, and that he never participated in eugenic measures or "euthanasia" activities. A re-reading and analysis of his relevant papers and publications on neurology reveal however reverences paid to the Nazi state, which are surprising in this clarity. A possible explanation for Foerster's overall ambivalent attitude, he was married to a non-Aryan woman (in Nazi jargon), is the threat posed to his relatives by Nazi racial hygiene laws. On the other hand, there are clear indications of his conservative German national patriotism encouraging and supporting a restrengthened state and the National Socialist vision of the German Reich as a "great power". Further investigations will have to show how the numerous influential factors that had a bearing on his biographical characteristics, political attitude, medical research interests and private motivation should be weighted.

European violence risk and mental disorders (EU-VIORMED): a multi-centre prospective cohort study protocol

BACKGROUND

The link between schizophrenia spectrum disorders (SSD) and violence is a core issue for most forensic psychiatric services. However, the drivers of violence in this population remain unclear, and, to date tools to predict violence risk have a range of limitations. Perhaps because of this uncertainty about the nature of violence risk, treatment programmes and care pathways for mentally disordered offenders vary substantially across the European Union, and differences in legal and policy frameworks are highly relevant.

METHODS

The three-year EU-VIORMED project (Grant Number PP-2-3-2016, November 2017-October 2020) involves forensic centres in Italy, Austria, Germany, Poland, and the U.K. It aims to: (a) identify and compare violence risk factors, clinical needs, and decision making capacity in violent (N = 200, "cases") and nonviolent patients with SSD (N = 200; "controls") using a case-control design; (b) test the predictive validity of the HCR-20v3, OxMIS and FoVOx among cases alone (N = 200), using a prospective cohort study; and (c) compare forensic-psychiatric care pathways across the EU, in a continent wide service mapping study.

DISCUSSION

Data collection started in September 2018 and continues. By September 2019, 333 participants have been enrolled (201 cases and 132 controls were recruited). Experts from 23 countries provided data for the service mapping exercise.

TRIAL REGISTRATION

Retrospectively registered on January 2, 2019 as researchregistry4604 January 2, 2019.

[Walking aids seen from a cultural historical perspective : Functional and semantic diversity of assistive systems facilitating locomotion in old age]

BACKGROUND

Assistance systems serving the locomotion of older people interact in many ways with the culture of a society. Since early modern times at the latest, walking aids were tantamount to human frailty; however, the cane also symbolized governmental power or reputation. Nowadays, the cane, the wheelchair, and the rollator have not only a functional significance in terms of a better mobility, they also enable people to take an active part in social life.

OBJECTIVE

This study aimes at tracing back these provisional insights into the history of civilization and thereby analyze the roots, new forms and pictures of the handling and metaphors of these assistance systems. The goal in the context of this special issue is to decipher a central textual and pictorial symbol of old age, comparing it with more recent symbols of assistance in old age.

MATERIAL AND METHODS

Methodologically, the text combines approaches of philology and history of medicine with those of the history of art. It analyzes (after a brief retrospection of ancient times and the Middle Ages) by means of textual and pictorial sources from the sixteenth to the twenty-first centuries the historical development of these aids of locomotion for older people. Additionally, it explores the cultural relevancy of these assistance systems.

RESULTS AND DISCUSSION

In history the medical profession paid relatively late and then only minor attention to the assistive systems analyzed here. Its semantic diversity is closely related to the age roles and stereotypes of age prevailing in certain epochs. The more the respective assistive tool is used by old people, the more suitable it is as a symbol of old age and the more biased and negative the semantic connotation seems to be. The development of a symbol of age connoting frailty, at present symbolized most clearly by the rollator, tends to refer to a pejorative image of age in a society. The cultural historical analysis suggests that a contrasting development will only be possible when the assistive systems will again fulfil a diversity of alternative functions and semantics.

[Carl Posner (1854-1928) : A founder of urology and sexology in Germany]

In this contribution we describe the life and work of the Berlin physician Carl Posner (1854-1928). We present his central role as a member of the founding generation of urology, andrology, and academic sexology in Germany. His clinical work, research and publication illustrate the central role these new disciplines played in the urological field. Finally, we describe how Posner is remembered in the history of urology and sexology.