memories are often clouded by the celebrations of victors and that the political history of science is occasionally less pleasant than we would wish. Funding: United States Holocaust Memorial Museum, Washington, DC; Hamburger Institut fiir Sozialforschung in Hamburg. Conflict of interest: None. 1 Proctor RN. Racial hygiene: medicine under the Nazis. Cambridge, Massachusetts: Harvard University Press, 1988. 2 Kater MH. Doctors under Hider. Chapel Hill: University of North Carolina Press, 1989. 3 Annas G, Grodin M. The Nazi doctors and the Nuremberg code. New York: Oxford University Press, 1992. 4 Smith GD, Strobele SA;Egger M. Smoking and death. BMJ 1995;310:396. 5 Borgers D. Smoking and death. BMJ 1995;310:1536. 6 Proctor RN. Nazi cancer research and policy._JEpidemiol Community Health (in press). 7 Bauer D. So lebt der Diice. Auf der Wacht 1937:19-20. 8 Picker H. Hitters Tischgespr&che im Fahrerhauptquartier. Bonn: AthenaumVerlag, 1951. 9 Lee PN, ed. Tobacco consumption in various countries. 4th ed. London: Tobacco Research Council, 1975. 10 Reid G. Weltanschauung, Haltung, Genussgifte. Genussgsfte 1939;35:64. 11 Kosmos. Bild-Dokumente unsererZeit. Dresden: Kosmos, 1933. 12 Reckert FK. Tabakwarenkunde: Der Tabak, sein Anbau und seine Verarbeittog. Berlin-Schoneberg: Max Schwabe, 1942.
13 Erkennung und Bekfimpfung der Tabakgefahren. Dusch Arzebl 1941;71:183-5. 14 Klarner W. Vom Rauchen: Eine Sucht und ihre Bekdmpfing. Nuremberg: Rudolf Kern, 1940. 15 Rauchverbot fuir die Polizei auf Strassen und in Dienstriumen. Die Genussgifte 1940;36:59. 16 Berlin: alcohol, tobacco and coffee. .AMA 1939;113:1144-5. 17 Kleine Mitteilungen. Vertrauensarzt 1941;9:196. 18 Mitteilungen. Off Gendheirsdienst 1941;7:488. 19 Charman T. The German home front 1939-1945. London: Barrie & Jenkins, 1989. 20 Fromme W. Offentlicher Gesundheitsdienst. In: Rodenwaldt E, ed. Hygiene. Part I. General hygiene. Wiesbaden: Dietrich'sche Verlagpbuchhandlung, 1948:36. 21 Informauonsdienst des Hauptamtes fair oksgesdheit der NSDAP.
1944;April-June:60-1. 22 Muller FH. Tabakmissbrauch und Lungencarcinom. Z Krebsforwch 1939;49:57-85. 23 Schairer E, Schoniger E. Lungenkrebs und Tabakverbrauch. Z Krebsforwch 1943;54:261-9. 24 Kittel W. Hygiene des Rauchens. In: Handloser S, Hoffmann W, eds. lWehrhygiene. Berlin: Springer-Verlag, 1944. 25 Goedel A. Kriegspathologische Beitrige. In: Zimmer A, ed. Kriegschirurgie. Vol 1. Vienna: Franz Deuticke, 1944. 26 Pritzkoleit K. Aufeiner lThge wn Gold: Der 7iumph der WiruschafL Vienna: Verlag Kurt Desch, 1961. 27 Werberat der deutschen Wirtschaft. lksesundheit und 14rbung. Berlin: arl Heymanns, 1939. 28 Peto R. Smoking and death. BMY 1995;310:396.
(Accepted 6 November 1996)
Not a slippery slope or sudden subversion: German medicine and National Socialism in 1933 Hartmut M Hanauske-Abel The history of medicine this century is darkened by the downfall ofthe German medical profession, exposed during the doctors' trial at Nuremberg in 1946. Relying largely on documents published during 1933 in German medical journals, this paper examines two widely accepted notions of those events, metaphorically termed "slippery slope" and "sudden subversion." The first connotes a gradual slide over infinitesimal steps until, suddenly, all footing is lost; the second conveys forced take over ofthe profession's leadership and values. Both concepts imply that the medical profession itself became the victim of circumstances. The slippery slope concept is a prominent figure of argument in the current debate on bioethics. The evidence presented here, however, strongly suggests that the German medical community set its own course in 1933. In some respects this course even outpaced the new government, which had to rein in the profession's eager pursuit ofenforced eugenic sterilisations. In 1933 the convergence of political, scientific, and economic forces dramatically changed the rela-
tionship between the medical community and the government. That same convergence is occurring again and must be approached with great caution if medicine is to remain focused on the preserva-
tion of physical and medical integrity. Die apokalyptische Ansicht der Welt ist eigendich die,
dap sich die Dinge nicht wiederholen.'
LUDWIG WITTGENSTEIN
Department of Paediatrics, Cornell University Medical College-The New York Hospital, New York, NY 10021, United States Hartmut M Hanauske-Abel, assistant professor ofpaediatrics and head of matrix biology laboratory
BMJ 1996;313:1453-63
BMJ VOLUME 313
"The apocalyptic view of the world quintessentially is one in which events do not reoccur." The notion that something will not happen again prepares the ground for cataclysmic re-enactments. In 1946, the year Wittgenstein scrawled this idea into his notebook, leading civilian and military representatives of German medicine were indicted at Nuremberg for crimes against humanity. Among them were assistant and tenured professors; clinic directors and the personal physi-
Cross; the highest ranking physician of the army and of the air force; and biomedical researchers employed by the pharmaceutical industry, the military, and universities. Some of Germany's top physicians killed themselves before interrogation or indictment. Among them was the highest representative of Germany's medical profession, Dr L Conti; the rector of the Christian Albrecht University of Kiel, Professor E Holzl6hner; and the director of the I Medical Clinic of the University of Vienna, Professor H Eppinger, still renowned and honoured as one of the pioneers of hepatology.
Ludwig Wittgenstein (1889-1951) Ludwig Wittgenstein, "one of the world's famousest philosophers,""' wrote the motto at the head of this paper in his native language-the language of those on trial in Nuremberg and also the language he continued to use in all his major analytical treatises, even after many years at Cambridge University. In the late 1930s the actions and proclamations by German politicians had led him to conclude: "I must say that the idea of becoming (or being) a German citizen is APPALLING to me" (emphasis as in the original).'06 On Chamberlain's Munich accord with Hitler he opined, "In case you want an Emetic, there it is."1'' By 1941, during the German aerial attacks on London, he found it intolerable just to teach philosophy in the safety of Trinity College instead of contributing to the British war effort. So at 52 years of age he resigned his academic position to labour at Guy's Hospital, London, often itself a target for firebombs. "He wants the job to be in a blitzed area."1' As a porter, he delivered medicines from the dispensary to the wards full with casualties of the blitz or helped make dermatological creams. "When I finish work, I'm so tired I can hardly move."'' Wittgenstein insisted that "his change of job from Professor of Philosophy at Cambridge to dispensary porter at Guy's Hospital should not be talked about."10'5
cian of the chancellor; the head of the German Red 7 DECEMBER 1996
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