The drawings in the anatomical atlas are seen as unparalleled in their detail of winding nerves and minute blood vessels, and are still used today in medical education and surgery. But the Pernkopf Atlas of Topographical and Applied Human Anatomy, first published around 1940, comes with a tainted, gruesome history: Many of the drawings were based in part on the bodies of people executed by the Nazis, and the Viennese medical illustrators were Nazis themselves.
After a decadeslong saga involving scholars, publishing disagreements, and eventually lawyers, the original illustrations of the Pernkopf atlas have been donated to the Medical University of Vienna by publisher Elsevier — the latest chapter in a slow reckoning over the book’s origins, which started to come to light in the mid-1980s. The illustrations will be part of an exhibition on the history of medicine in the Josephinum, which houses the university’s historical collections and is set to open in April 2022 after renovations are completed, and they will be available for research purposes as historical documents. The December 2019 donation was brought to light in a paper published late last month in Annals of Anatomy.
STAT spoke with experts who have studied the atlas and its origins for years, who said that the donation is a step in the right direction and one many have long hoped for. The exhibition of the Pernkopf atlas will lead more people to find out about and examine its past, they said, as well as prompt increased discussion of its use, Nazi science, and unethical sources of scientific research.
“I’m almost speechless, I’m so grateful,” said Susan Mackinnon, a professor of surgery at Washington University School of Medicine in St. Louis who has grappled with her continued use of the atlas in teaching and procedures — and how best to disclose its origins to students and patients. “I don’t think this is an ending. I think this is just the beginning.”
In 2019, Mackinnon and her colleagues detailed in a case report in the journal Surgery how they wrestled with the ethical dilemma of using the atlas for guidance when a patient was already under anesthesia for a complicated knee surgery in 2014.
Andrew Yee, the lead author of the case report who directs Washington University’s Learn Surgery online program and has assisted Mackinnon with many surgeries, said the donation “should be a lesson” in handling ethical issues in medicine with transparency. When he learned of the atlas’ origins, he didn’t have a strong opinion on whether it should be used, or how.
“I never really questioned the use of it, frankly, because my colleagues were using it, and no one was really talking about it,” he said. “I thought it was part of the system.” But like Mackinnon, he soon realized it wasn’t that simple.
Sabine Hildebrandt was a part of what changed Mackinnon and Yee’s approach. The pair attended a 2015 guest lecture from Hildebrandt, an anatomist and anatomical historian at Harvard Medical School and Boston Children’s Hospital, on a book she wrote on unethical practices in anatomy during the Third Reich. The atlas, of course, came up.
The book is named for Eduard Pernkopf, who was a professor of anatomy at, and later the rector of, the University of Vienna. He became a Nazi storm trooper in 1934, and, upon becoming dean of the university’s medical school in 1938, fired all the school’s Jewish professors. The four illustrators with whom he worked on the atlas incorporated swastikas and SS symbols into many of their signatures in the book.
Hildebrandt doesn’t use the atlas for teaching anatomy, and asks that colleagues who do acknowledge its history and the victims of Nazi terror it portrays.
“We asked [Hildebrandt], is it OK for us to use it in surgery or education?” said Yee. “She introduced us to a lot of people that actually had worked on this question.”
Rabbi Joseph Polak remembers Mackinnon calling him in 2016, worried about if she’d done the right thing in her 2014 knee surgery by using the Pernkopf atlas. Polak, an expert in Jewish law and professor of health law and ethics at Boston University, responded with a foundational Jewish teaching — that human life, particularly saving a life, always comes first.
“That’s the Jewish priority,” he said.
Together with Michael Grodin, a professor of bioethics and health law at the Boston University School of Public Health, Polak wrote a text in 2017 called the Vienna Protocol, which is now regarded as a definitive document on the handling of the atlas. Polak said he is “really pleased” that the illustrations will finally be donated back to the university, and presented in their proper context — he had previously urged the rector of the Medical University of Vienna to take responsibility for the atlas.
Polak said that he particularly appreciates that the illustrations from the atlas will be displayed and studied in a “in a way that will say what this was, which is what I require when anybody uses it, or use it for teaching, or consult with it.” Mackinnon also informs patients and students to give them the chance to object to its use in their operations and her teaching if they don’t feel comfortable with it.
Hildebrandt and Polak both presented their research regarding the atlas at a 2017 symposium at the Medical University of Vienna, and it was there that William Seidelman, a professor emeritus of medicine at the University of the Toronto who has also extensively researched the Pernkopf atlas, first proposed to Elsevier that the atlas originals be donated back to the University of Vienna. The publisher agreed, but Hildebrandt said Elsevier never responded further or took any action after the symposium.
In March 2019, Hildebrandt visited Elsevier’s offices in Munich, Germany. She wasn’t visiting with the donation in mind; she simply wanted to see the original illustrations, mostly to examine the removal of Nazi symbols from the artists’ signatures by previous publishers. When she got there, Hildebrandt was pleasantly surprised at what Andrea Beilmann, a content project manager at Elsevier, and her colleagues had prepared.
“They had brought everything up from the archives that they could possibly find,” said Hildebrandt. “I came into the conference room, and all the files were sitting out there.” Beilmann and her colleagues had also arranged for a videographer to record Hildebrandt’s testimony and thoughts on the atlas’ illustrations.
She was dismayed to find over 500 of the original 925 illustrations seemed to have disappeared over the course of them being moved several times; Herwig Czech, a history of medicine professor at the Medical University of Vienna and the lead author of the Annals of Anatomy paper detailing the donation, notes in the paper that the collection was nearly complete in 1998, when it resided in the previous publisher’s offices. It isn’t clear how they were lost.
Within months of Hildebrandt’s visit, lawyers were involved to facilitate the illustrations’ donation.
“I’m probably most surprised of anybody involved,” Hildebrandt said. After over 15 years researching the atlas, she said she never expected something this major to happen.
In a statement, Elsevier said Hildebrant’s visit “was instrumental in guiding our thinking around the donation.” The company has owned the publishing rights to the atlas since purchasing its previous publisher in 2003.
The donation agreement also gives the Medical University of Vienna limited publishing rights, allowing the university to grant requests from others to publish up to three of the images at a time, provided context is given about the atlas’ history and that no images are used commercially.
Czech said he hopes that the atlas will soon be a purely historical artifact. Still, he said that keeping the illustrations at the Josephinum will allow them to be properly displayed and for the public to be informed about their history.
“Our primary first task is to preserve this in a responsible manner,” said Czech.
Mackinnon, however, doubts whether the atlas could really be replaced by another collection anytime soon, at least for some surgeons. She finds the atlas incredibly useful, and said there is nothing like it to trace the “fine wiring” of the nerves she operates on.
“I’m like the electrician,” she said. “To do this work, you need this book. It gives you the electrical mapping.” Other illustrations, Mackinnon said, even modern ones, are “cartoonish” in comparison.
Leila Lax, a medical illustrator and recently retired professor of biomedical communications at the University of Toronto, said the resources required to produce a comparable replacement for the Pernkopf atlas would be vast. The original illustrators created over 900 drawings based off of thousands of unethically procured bodies — 1,377 victims of the Nazi judicial system and many more from public hospitals. Cadavers now are much rarer, especially those from people who were young and in relatively good health. Lax said the processes used to create detailed anatomical drawings like those in the Pernkopf atlas are incredibly time-consuming, involving hundreds of dissections over many years. It’s not impossible to produce an alternative to the atlas, Lax said, but it wouldn’t be easy.
“I think the creation of beautiful, didactic visualizations for teaching in medicine or in the health sciences, from my perspective, is always of benefit,” said Lax. “But there are numerous barriers in the way.”
Many images from the Pernkopf atlas are still circulating online. Seidelman, who has researched the atlas since the 1990s and called in 2017 for its donation, said a pirated version of the entire atlas was recently uploaded online, and even scattered images are most often stripped of any historical context.
The Internet Archive, a digital archive and collection of online media, allows access to versions of the atlas, including full digital copies of the atlas in English and French. Mark Graham, director of the Wayback Machine at the Internet Archive, wrote in an email to STAT that, “As an archive, and a library, we think context is very important and will look into this as a matter of priority.” In a further response to STAT’s inquiry, Graham said Wednesday that a review post is being added to versions of the atlas on the Internet Archive that link to the recent Annals of Anatomy paper and this article.
When it comes to the internet, Czech said, many are hesitant to limit what they see as free speech and access to information. But even if the images can’t be removed, he thinks it’s important to at least attach some context to them.
“I think people who use the atlas should know what they’re dealing with,” Czech said.
This story has been updated with comments from the Internet Archive. An earlier version of this story misstated that Herwig Czech had contacted the Internet Archive.