CORRESPONDENCE
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In Reply: Nerve Surgeons’ Assessment of the
Role of Eduard Pernkopf’s Atlas of
Topographic and Applied Human Anatomy in
Surgical Practice
To the Editor:
We thank the authors of the letter that was written about our
article.1 We agree that the Jewish principle of Pikuach Nefesh
should not be overgeneralized.2 It requires a thorough, casespecific examination according to Jewish ethics laws before the use
of Pernkopf ’s atlas in surgery can be permitted. We recommend
surgeons study the Vienna Protocol by Rabbi Polak, as it provides
comprehensive guidelines “for when Jewish or possibly Jewish
remains are discovered.”3 While the Vienna Protocol describes
how these materials are to be ethically handled, there is a need for
the deeper examination of the rationale and intentions of surgeons
for using the atlas to navigate a procedure in the operating
room.4 There exist several alternatives to the atlas when a surgeon
encounters difficulty during a case. These include, but are not
limited to, taking an intraoperative timeout to reorientate oneself,
consulting a surgical colleague for assistance, and/or consulting an
anatomical resource other than Pernkopf ’s atlas. We recommend
a stepped approach in an upcoming ethics study, in which the
Pernkopf atlas can be used “only as last resort” if a surgeon uses
the atlas under the condition “to benefit a patient’s life.”
The purpose of our article is to determine whether a 4point proposal addressing significant domains could progress the
Pernkopf controversy. As described, this includes (1) a historical
disclosure,5 (2) facilitating discussions in bioethics on the appropriate use, (3) perspectives and advisory from the Jewish authorities,3 and (4) an official memorial dedicated to the victims
illustrated in the original paintings of the atlas.6 Pernkopf ’s
controversy is further significant because of its circulation as a
printed atlas in the used book markets and unofficial digital
scans passed among surgical peers. More importantly, nerve
surgeons have found a use of the atlas for navigating complex
anatomy, which has not been accurately described elsewhere. We
collectively aspire for a future, when Pernkopf ’s atlas becomes
a memorial to the victims, and its content is replaced by a
new surgically relevant anatomical resource. Until then, we as
moral individuals are considering a multidisciplinary approach for
progressing this controversy.
Disclosure
The authors have no personal, financial, or institutional interest in any of the
drugs, materials, or devices described in this article.
Andrew Yee, BS∗
Demetrius M. Coombs, MD‡
Sabine Hildebrandt, MD§ ¶
William E. Seidelman, MD||
J. Henk Coert, MD, PhD#
Susan E. Mackinnon, MD∗
∗
Division of Plastic and Reconstructive Surgery
Department of Surgery
Washington University School of Medicine
St. Louis, Missouri
‡
Department of Plastic Surgery
The Cleveland Clinic
Cleveland, Ohio
§
Division of General Pediatrics
Department of Medicine
Boston Children’s Hospital
Boston, Massachusetts
¶
Department of Global Health and Social Medicine
Harvard Medical School
Boston, Massachusetts
||
Department of Family and Community Medicine
Faculty of Medicine
University of Toronto
Toronto, Canada
#
Department of Plastic Reconstructive and Hand Surgery
Utrecht University Medical Center
Utrecht, Netherlands
REFERENCES
1. Yee A, Coombs DM, Hildebrandt S, Seidelman WE, Coert JH, Mackinnon S.
Nerve surgeons’ assessment of the role of Eduard Pernkopf ’s atlas of topographic and
applied human anatomy in surgical practice. Neurosurgery. published online ahead
of print: May 8, 2018. (doi: 10.1093/neuros/nyy159)
2. Polak JA, Grodin MA. Letter: Nerve surgeons’ assessment of the role of Eduard
Pernkopf ’s atlas of topographic and applied human anatomy in surgical practice.
Neurosurgery. 2018;83(4):E188.
3. Polak JA. “Vienna Protocol” for when Jewish or possibly-Jewish human remains are
discovered. In: Seidelman WE, Elbaum L, Hildebrandt S, eds. How to Deal with
Holocaust Era Human Remains: Recommendations Arising from a Special symposium.
Boston, MA: Elie Wiesel Center for Jewish Studies, Boston University; 2017,
www.bu.edu/jewishstudies/files/2018/06/Final-How-to-Deal-with-Holocaust-EraHuman-Remains.pdf. Accessed April 7, 2018.
4. Yee A, Zubovic E, Yu J et al. Ethical considerations in the use of pernkopf ’s atlas
of anatomy: a surgical case study (Accepted). Surgery. 2018.
5. Hildebrandt S. The Anatomy of Murder: Ethical Transgressions and Anatomical Science
during the Third Reich. New York: Berghahn Books; 2016.
6. Hildebrandt S, Seidelman WE. To use or not to use: The legitmacy of using unethically obtained scientific results or human tissue from the National Socialist era.
Wiener Klinische Wochenschrift. 2018;130(3):S228-S231.
10.1093/neuros/nyy329
NEUROSURGERY
VOLUME 83 | NUMBER 4 | OCTOBER 2018 | E189