Eduard Pernkopf's atlas of topographical and applied human anatomy: The continuing ethical controversy

The study of human anatomy has had a long and checkered history. In the past, many of the ethical issues surrounding the anatomic study of the human body centered around the procurement of cadavers for dissection. Before the 19th century, dissection of the human body was often considered taboo and was, in many cases, illegal. Due to legal and social strictures of the day, anatomists were faced with the problem of obtaining a source of cadaver material for their studies. Often, bodies used for dissection were those of unclaimed paupers or executed criminals. Indeed, cadavers were in such short supply that early anatomists routinely resorted to grave robbing and were occasionally convicted of murdering their subject material (Wade, 1998). By the late 19th century, however, laws permitting use of bodies for teaching purposes were in place in this country and in Europe (Ball, 1989). The advent of World War II and the rise of Adolph Hitler introduced a fresh set of ethical problems into the field of medical and anatomic research. Although the diabolical experiments of Nazi physicians on live prisoners are well known to most people, the anatomic sciences also experienced a less publicized, but equally troubling, period connected to the acquisition of cadavers for dissection. A central figure in this controversy was Eduard Pernkopf. Eduard Pernkopf's atlas of human anatomy has been, and is still considered by many to be, an artistic masterpiece, but to others it is a reminder of the horrors inflicted by the Nazi war machine. Originally published as a four-volume set, Pernkopf wrote the descriptive narrative, and compiled over 800 watercolor paintings produced mainly by a team of four artists between 1933 and 1960. Pernkopf rose to prominence at the University of Vienna, on the basis of not only on his academic credentials but also on his political affiliation with Hitler's Nazi party. In the years that followed, Pernkopf's sordid past came to light, culminating in an inquiry by the University of Vienna into the origins of the bodies used during World War II to produce his atlas. The recently published results of this inquiry failed to prove conclusively that the cadavers used by Pernkopf during the war were those of political prisoners executed by the Nazis (Angetter, 2000). Despite the lack of conclusive evidence against him, the ethical question still remains: Should Pernkopf's atlas be published or banned? Eduard Pernkopf's atlas of human anatomy has been and is still considered by many to be an artistic masterpiece, but to others it is a reminder of the horrors inflicted by the Nazi war machine. Eduard Pernkopf was born in 1888, in Rapottenstein, a small village located in the lower part of Austria. He was the youngest of three siblings whose father was a country doctor. After attending the Horn gymnasium, the German equivalent of a college preparatory high school, he gained admittance to the Vienna Medical School in 1907 and began his medical studies. As a medical student, Pernkopf joined the nationalistic political organization for students called Die Akademische Burschenschaft Allemania (The Student Academic Fraternity of Germany). By 1912, Pernkopf received his medical degree and taught anatomy for the 14 years that followed, which included brief service as a physician during World War I. While a medical student, Pernkopf studied under the noted anatomist Ferdinand Hochstetter (1861–1954), who was then director of the Second Anatomy Institute of the University of Vienna. Later in 1920, Pernkopf became Hochstetter's assistant and lectured to first- and second-year medical students on the peripheral nervous system and the vascular system. Pernkopf apparently thought a great deal of Hochstetter. In the second edition of his atlas, Topographische Anatomie des Menschen (1943), he referred to Hochstetter as “my revered teacher, the greatest master of anatomy” (Williams, 1988). Pernkopf rose quickly up the academic ladder. He became an associate professor in 1926, and 2 years later, in 1928, he achieved full professorship at the University of Vienna. By April of 1933, he followed Hochstetter as director of the Anatomy Institute. In 1938, he became Dean of the Medical School, and by 1943, he was named president (Rektor Magnificus) of the University. Pernkopf's academic success was paralleled by increased involvement in the burgeoning Nazi movement. The same year that Pernkopf became the director of the Anatomy Institute he joined the National Socialist German Worker's Party or Nazi Party, and the following year, he became a member of the Sturmabteilung (Storm Troopers or Brown Shirts). As Dean of the Medical School, Pernkopf insisted that all faculty document their lineage as either Aryan or non-Aryan and swear an oath of loyalty to Adolph Hitler. Pernkopf forwarded a list to the university officials of those who did not take the oath. In March of 1938, all the Jews were, thus, “cleansed” from the University of Vienna (Ernst, 1995). On April 6, 1938, Pernkopf gave a speech to the medical school faculty that would clearly define his political views and hasten his rise to the top position in the University of Vienna (Figure 1). The speech was given just 4 days after Pernkopf became dean and Hitler's Germany annexed (termed the Anschluss) Austria. Pernkopf began his speech entitled “National Socialism and Science” by extolling the virtues of Adolph Hitler, referring to him as a “son of Austria who had to leave Austria in order to bring it back into the family of German speaking nations.” During this long and windy diatribe, Pernkopf attempted to show how heredity and environment produced a “phenotype” that defined a particular race. He pointed out that scientific research should yield both theoretical and practical knowledge that can be applied in “daily life and in particular to questions of sports, occupation, marriage counseling, determination of ancestry, proof of paternity, and suitability for marriage.” He exhorted the physician to use his knowledge to promote “racial hygiene” through methods that consisted of the “control of marriage and the promotion of those whose heredity is more valuable and whose biological constitution due to heredity gives the promise of healthy offspring.” It was the physician's duty to oversee the “prevention of offspring to those who are racially inferior and of those who do not belong” by “the exclusion of those who are racially inferior from the propagation of their offspring by means of sterilization and other means.” In the same manner as he opened the speech, Pernkopf concluded by paying homage to Hitler: “To him who is the proclaimer of national socialist thought and the new way of looking at the world and in whom the legend of history has blossomed and has awakened and who has the heroic spirit within him, the greatest son of our homeland, we wish to give our gratitude and also to say that we doctors with our whole life and our whole soul gladly wish to serve him. So may our call express only what each of us feels from the bottom of his heart; Adolph Hitler, Zieg Heil!, Zieg Heil! Zieg Heil!” (Pernkopf, 1938) This speech was to set the stage for both the highs and lows that Pernkopf would experience later in his life. Eduard Pernkopf presenting a lecture as Dean of the Medical Faculty at the University of Vienna, April 6, 1938. While Pernkopf was an assistant to Hochstetter, he began working on a human anatomy dissection manual for his medical student classes. He continued to develop the manual over time to a point where it became popular with the medical community, resulting in a publication contract with Urban however, all adhered to Pernkopf's instructions to make their paintings look like real dissections. Use of color was key among the techniques used by Pernkopf's artists to enhance the clarity of their illustrations. Artificial color patterns were assigned to various structures in the field that served to increase their visual impact beyond that which could be seen in an actual cadaver. This technique improved the viewer's understanding of key anatomic landmarks in the field of dissection. In addition, special treatment of the paper used for the watercolor painting permitted the artist to work in greater detail than was possible by using ordinary paper. Use of color was key among the techniques used by Pernkopf's artists to enhance the clarity of their illustrations. Artificial color patterns were assigned to various structures that served to increase their visual impact. By 1937, the first volume, consisting of two books, was published. The advent of World War II, however, slowed progress on the atlas. Batke, Endtresser, and Schrott entered active military service in 1941 (Williams, 1988). Lepier, who was denied entry into the service because of varicose veins, served as an air raid warden at home. However, Pernkopf's artists continued their work until their induction into the service, permitting publication of the second volume of the atlas in 1941. Like their boss, Pernkopf's artists were Nazi party members or sympathizers during this period. On occasion, Lepier incorporated a swastika into the end of his signature on illustrations that he produced. Endtresser occasionally signed the two S letters in his name in a manner that suggested the double lightning bolt of the SS troops (Pernkopf, 1964a). Although Batke denied having worked for Pernkopf during the war (Williams, personal communication), several of his signed paintings in the atlas are dated 1940 and 1944 (Pernkopf, 1964b,c). Interviews with Batke by David Williams in the early 1980s suggested that he was and always had been an ardent Nazi sympathizer (Williams, personal communication). The end of the war produced hardship and disillusionment for Pernkopf and his artists. On May 10, 1945, Pernkopf was dismissed as head of the Institute of Anatomy (Malina, 1998). By May of the following year his employment with the university was terminated. After dismissal from the Institute, Pernkopf set out for Strobl/Salzburg on “vacation” but was arrested in August of 1945 by the American military. Although never charged with war crimes, Pernkopf served more than 2 years at hard labor in Glasenbach/Camp Marcus W. Orr, an American prison camp for war criminals near Salzburg (Malina, 1998). Batke, who was wounded at the Russian front, returned to Vienna to recover and later also served time in prison at the end of the war (Williams, 1988). After release from prison, Pernkopf attempted to find a place where he could continue his work. Eventually, he was assigned two rooms at the Institute of Neurology in Vienna by its director, Hans Hoff, a Jewish physician who left the University of Vienna in 1938 (Williams, personal communication). At the Neurology Institute, Pernkopf was rejoined with his four original artists. Pernkopf, Batke, Endtresser, and Schrott worked in one room while Lepier had a second room to himself. Under these conditions, Pernkopf compiled and published a third volume in 1952 on the head and neck region. In 1955, Pernkopf died from a stroke while working on the fourth volume. It was later completed by Werner Platzer and Alexander Pickler, and published in 1960. Pernkopf's artists continued to work at their trade; producing both nonscientific artwork in addition to illustrations that now appear in several other anatomic publications. Lepier's work in particular, as well as other Pernkopf images, have appeared in other texts and atlases, many of which are still in press and widely used in medical education both in the United States and abroad. By 1983, Franze Batke, the last of the original four Pernkopf painters, was dead. He spent his last years living and working in a small room in the Anatomy Institute at the University of Innsbruck (Williams, personal communication). In the early 1960s, the lengthy narratives in Pernkopf's original atlas were edited out by Helmut Ferner. It was subsequently published as a two-volume set of labeled plates. The swastikas were removed from the printing plates of Lepier's illustrations in this and later editions. The atlas was translated from German into several other languages including Italian, Japanese, and English. Distribution and acclaim for Pernkopf's atlas was worldwide. Although Pernkopf's words and deeds were forgotten (or ignored), his atlas lived on and was widely considered a classic in the field. But like its author, the reputation of the atlas would eventually suffer hard times. During the 40-year period after the World War II, little was said or written about Pernkopf's personal history. Then, in the mid-1980s an article titled “Springtime for Pernkopf” was published by Gerald Weissman (Weissmann, 1985). In his article, Weissman provided a detailed analysis of Pernkopf's speech “National Socialism and Science,” focusing on the virulent nationalistic rhetoric as well as the deeds of other Nazi physicians of the time. Three years later, a second article about Pernkopf appeared entitled “The History of Eduard Pernkopf's Topographische Anatomie des Menschen” written by David Williams (Williams, 1988). This publication provided, for the first time, a revealing and detailed biographical account of Pernkopf's life and work, including a description of Pernkopf's political activities before, during, and after the war. In a sense, these two articles lit the fuse for what was later to become an explosion of outrage over Pernkopf and all that he represented. In 1995, presumably based on information published previously by Weissman and Williams, the Jewish Holocaust Remembrance Authority, Yad Vashem, requested that authorities at the University of Vienna conduct an inquiry into the Pernkopf issue. They asked that an inquiry panel be assembled consisting of experts drawn from outside the university. This group would attempt to determine both the identity of the subjects pictured in Pernkopf's atlas and how they died (Israel and Seidelman, 1996). In addition, if the investigation showed that the persons depicted in the atlas died at the hands of the Nazis, a commemoration was to be conducted for them. Of particular interest was the final request, which was that Pernkopf's book continue to be published but that it include a description of Pernkopf's history and a commemoration of the Nazi victims. The following year in a letter to the Journal of the American Medical Association, Howard Israel and William Seidelman added to the growing chorus of anti-Pernkopf sentiment by focusing on Pernkopf's pro-Nazi past (Israel and Seidelman, 1996). They questioned the source of cadavers used during the war to produce his atlas, and they also voiced support for the Yad Vashem's call to investigate the activities of Austrian universities during the war. During the late 1990s, the world view of Pernkopf and his atlas shifted. No longer was it possible to view the contents of the atlas without considering both its history and that of the author. A flurry of articles about Pernkopf followed the Israel and Seidelman letter (Schoettler, 1997; Smale, 1997; Vedantam, 1997). The general press became aware of the issue, which resulted in newspaper and television interviews with Seidelman, Israel, Williams, and others. Citing ethical considerations, several institutions removed the Pernkopf atlas from their shelves (Panush, 1996). Most of the popular media attention centered on the ethical dilemma facing physicians and academics who had used Pernkopf's atlas. On one hand there was the good that resulted from use of the knowledge contained in the atlas to heal and teach. By contrast, there was the very real possibility that such knowledge was obtained at a horrible price (Broder, 1996). Initially, the 1995 Yad Vashem request to the University of Vienna for a Pernkopf inquiry was denied (Seidelman). 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