The surgeon needed to call a time-out. She had already cut into the patient’s knee for what she thought would be a technically challenging but straightforward operation: freeing a nerve that had gotten so badly pinched after several knee replacements that it was causing unbearable pain. If the surgery didn’t work, the 50-year-old patient told Dr. Susan Mackinnon of Washington University in St. Louis, she wanted her leg amputated.

But now Mackinnon, one of the country’s most renowned nerve surgeons, was stumped. She couldn’t trace the saphenous nerve and its branches. To figure out where the nerve wends its way between and around and under muscle and connective tissue and free it, she needed to consult the best anatomical maps of peripheral nerves ever created. So she asked her colleague, Andrew Yee, to dash into her office, grab the Pernkopf Topographic Anatomy of Man, photograph the right illustration with his iPhone, and email it to her in the OR.

Yee did. Mackinnon projected the image on a screen, figured out where the nerve was, and successfully completed the surgery.

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But soon after this 2014 operation, she began worrying whether she had done the right thing. The meticulous, four-color paintings in the Pernkopf book, which she had received as a gift upon graduating from medical school in 1982, were created by Viennese medical illustrators who were such ardent Nazis they included swastikas and lightning-bolt SS symbols in their signatures. The drawings were compiled by an Austrian medical school dean who fired all his Jewish professors after the Anschluss (Nazi Germany’s annexation of Austria in 1938), and were based in part on the bodies of people executed by the Nazis. The first of the two volumes was published in 1937, the second in 1941.

Knowing the book’s history, which came to light in the mid-1980s, Mackinnon and Yee wondered, is it ethical to use the Pernkopf illustrations? They reached out to some of the nation’s leading historians of Nazi medicine, bioethicists, and experts on Jewish law to discuss whether Mackinnon acted ethically, as they describe in the May issue of the journal Surgery.

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Anatomic illustrations from Netter’s Atlas of Human Anatomy (left) and Pernkopf’s Topographical Anatomy of Man — which is more detailed and precise. Screen capture from SURGERY May 2019

The book’s horrific provenance “has been known for a while,” said Yee, who films Mackinnon’s surgeries and founded an online program so others can learn expert techniques. “The publisher stopped reprinting it in 1994,” soon after the University of Vienna (where Nazi Eduard Pernkopf became rector in 1943) traced many of its images to people executed by the Nazis. Investigators were unable to identify the specific people used by Pernkopf’s artists, however, or even determine how he procured most of the bodies. But the investigators found no evidence that any came from concentration camps, and concluded that many were people executed in the city for resistance to the Nazis.

The moral dilemma for surgeons is that, even now, the Pernkopf illustrations are unsurpassed in their accuracy and detail, especially their depiction of peripheral nerves. “I hate to say it, but the illustrations are beyond spectacular,” said bioethicist and Rabbi Joseph Polak of Boston University, whom the Washington University team consulted. “They are really world-class.”

Other anatomy atlases pale by comparison, Yee said, and although a few journal papers may have an equally good, single illustration, finding the right paper takes time that Mackinnon did not have as she stood over her patient. The surgical team had no doubts at the time that they were doing the right thing, but after a visiting scholar gave a talk about the Pernkopf atlas, she and Yee “wanted counsel from respected experts” on the proper way to use it in both education and clinical practice, he recalled.

Scholars and physicians have long debated the use of Nazi medical data, in particular from experiments on hypothermia and phosgene gas (data collected by exposing Jewish prisoners to freezing and poisoning). The U.S. military even redesigned Army flak jackets based on Nazi data so downed airmen had a better chance of surviving the cold, said Dr. Michael Grodin of Boston University School of Public Health, an expert on Nazi medicine and co-author of the Surgery paper.

Much of those data are considered scientifically unreliable (“they’re not worth anything,” Grodin said) and therefore easier to reject 75 years after the Holocaust. Not so with the Pernkopf. Even in 2019, it is considered unsurpassed in comprehensiveness and precision, said Dr. Sabine Hildebrandt, an anatomy lecturer at Harvard Medical School whom the Washington University surgeons also consulted. In part, that’s because anatomy is viewed as 19th-century medicine, and no one has an incentive to put much effort into trying to improve on the classic texts.

Hildebrandt does not use the book in her anatomy lectures, she said, and asks that colleagues who do explain its horrific origins and acknowledge the sacrifice and suffering of the people whose bodies it is based on.

But that didn’t provide much guidance to Mackinnon. When she posed the dilemma to Grodin and Polak, they produced what has become a definitive work on when it is morally acceptable to use the Pernkopf and other knowledge rooted in Nazi medicine. “It relates to the old question, can you derive good from evil?” Grodin said.

The highest value in Jewish law is life. If the illustrations in Pernkopf can save a life or alleviate suffering, Grodin said, “most rabbis would not just permit using it but say it was mandatory” — as long as physicians and educators remember its origins and pay respect to those who were killed to create it. “Every time someone uses one of these pictures, they need to say where it came from,” said Polak, who survived the Bergen-Belsen concentration camp as a child.

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Scholars not involved in Mackinnon’s case agree. “Not every utilization of Nazi-generated data or information is morally out of bounds,” bioethicist Arthur Caplan of New York University wrote in a commentary on the Surgery paper. “This case makes clear that at least a narrow use of tertiary information — paintings of bodies — is morally defensible. If direct, immediate, and substantial patient benefit is being sought from the use of existing information, and if there is no better resource available, then the demands of beneficence create a presumption of use.”

That does not settle the debate over the Pernkopf atlas, however. After a series of corporate takeovers, the plates now belong to scientific publisher Elsevier. When Hildebrandt visited its Munich headquarters in March, and was shown many of the originals, she asked the company to let the Medical University of Vienna display them as part of an exhibition on the Nazi horrors and their lasting influence in medicine. Elsevier is still considering that request, but “lawyers are involved,” Polak said. Elsevier spokesman Tom Reller told STAT, however, that “we’ve decided the pictures should not be published further or lent or donated.”

As for Mackinnon’s patient, she recovered fully and was pain-free for the first time in years. During the usual preoperative discussions about the risks of surgery, Mackinnon didn’t think to ask how the patient would feel if her surgeons consulted a work of Nazi medicine to help them, nor did the surgeon tell the patient afterward that she had consulted Pernkopf. The outside scholars weren’t asked whether it is morally imperative to do so.

“We never thought about it,” said Grodin, who has studied survivors of Dr. Josef Mengele’s experiments at Auschwitz. But informing patients, he said, is a logical next step as scholars continue to grapple with the Nazis’ medical legacy.