JERUSALEM — The explosion flung him skyward, legs first, before he crashed to the ground.
It was June 2002, at the height of the second Palestinian intifada. Dvir Musai, then a 13-year-old Israeli schoolboy from a religious Jewish settlement, was on a class cherry-picking trip in the southern West Bank. On his way back to the bus, he stepped on a mine laid by Palestinian militants and was gravely wounded, along with two other boys.
“There was a lot of smoke, clumps of earth falling, a smell of burning and gunpowder,” Musai, now 31, recalled.
Decades of agony followed. Musai’s right foot felt as if it were permanently afire. And then last year, a surgeon offered him hope — and a disquieting disclosure.
In pre-op at the Hadassah Medical Centre in Jerusalem, Dr. Madi el-Haj told his patient that the anatomical atlas he would use to guide him through the intricate nerve pathways had been produced by Nazis. Its illustrations are believed to be based on the dissected victims of the Nazi court system under Hitler’s Third Reich.
If there were objections, el-Haj told the Musai family, he could operate without it — but it would be harder. He noted that there was rabbinical approval for the book’s use.
Musai’s mother, Chana, had lost relatives in the Holocaust.
“She said, ‘If it can help now, we’ll use it,’ ” Musai recalled.
That gut-wrenching decision went to the heart of a long-standing debate about the ethics of drawing on knowledge derived from the Nazis’ expansive medical and scientific experimentation — and in this case, the ethics of using the textbook, “Atlas of Topographical and Applied Human Anatomy.”
The book, by Eduard Pernkopf, stands out for its accuracy and detail, and even in an age of state-of-the-art imaging, some surgeons, among them those who perform peripheral nerve procedures, still find its drawings invaluable.
In a perverse twist, the more advanced the relatively new field of peripheral nerve surgery becomes, the more reliant on the atlas some of its practitioners say they find themselves. That is because even high-tech imaging is of limited use to the complex discipline, surgeons said.
The book's illustrations are believed to be based on the dissected victims of the Nazi court system under Hitler's Third Reich. Source: Dan Balilty/The New York Times
Pernkopf began work on the atlas at the University of Vienna, where he became chairman of anatomy in 1933, the year he joined the Nazi party. With Hitler’s 1938 invasion of Austria, he became dean of the medical faculty, then president of the university.
The illustrators to whom Pernkopf turned to produce the atlas were also Nazi enthusiasts. Three of the four illustrators incorporated swastikas, SS lightning bolts and other Nazi insignia into their signatures — hallmarks of evil airbrushed out of later editions. Less is clear about the people whose bodies were dissected so that the illustrators could produce their work. Over the years, there have been questions about whether some had been killed in Hitler’s death camps. Those questions remain unresolved, but many experts believe that most of the prisoners were Austrians condemned in the courts.
After the war, Pernkopf spent three years in an Allied prison camp but was not charged with war crimes. He continued work on the atlas until his death in 1955.
A two-volume edition was published in five languages, with the first American edition coming out in 1963. Elsevier, a European scientific publisher that currently holds the copyright, stopped printing it on ethical grounds, but the volumes can be found in private collections and purchased on eBay and Amazon. Scholars first raised questions about the origins of the atlas in the 1980s as the Cold War’s “Great Silence” about the Nazis’ medical legacy began to crack.
By the 1990s, the controversy was drawing wider public attention.
Dr. Howard Israel, an oral surgeon at Columbia University who had routinely used the atlas, exposed the Nazi symbols in the artists’ signatures included in early editions of the book.
Then he and Dr. William Seidelman, a Toronto physician, turned for help to Israel’s official Holocaust memorial, Yad Vashem, asking it to press the University of Vienna to investigate the background of the atlas — and of the dissected cadavers its authors used. After some initial reluctance, the university agreed.
“Things started to unravel,” recounted Seidelman, who now lives in Jerusalem.
From 1938 to 1945, the university’s anatomical institute received more than 1,370 bodies of prisoners executed by the Vienna court system, according to the findings of an investigative committee. More than half had been political prisoners — people targeted by the Nazi regime. At that time in Austria, joking about Hitler was enough to warrant execution, often by decapitation.
El-Haj, the Hadassah surgeon, said he was first introduced to the atlas while studying under Dr. Susan Mackinnon, a pioneer in peripheral nerve surgery, at Washington University in St. Louis.
“She knew I came from Israel — she thought I was a Jewish guy,” he recalled.
That he was, in fact, an Arab Muslim from the Galilee changed nothing.
“I was shocked,” he said. “It’s a matter of humanity.”
Mackinnon bought her first copy in the early 1980s as a young plastic surgeon in Baltimore, and used it to guide many of her surgical procedures.
But troubled by the provenance of the illustrations, Mackinnon photocopied the first scholarly articles about Pernkopf’s past a few years later and tucked them into the book as a constant reminder.
In 2015, Mackinnon and her longtime associate Andrew Yee wanted to share drawings from the atlas on an online teaching platform, and sought an opinion from Dr. Sabine Hildebrandt, a Boston physician who has studied the Third Reich.
An international effort was already underway to determine how to handle unearthed human remains and medical specimens from the Holocaust era.
Hildebrandt took on Mackinnon’s query and consulted with other experts, giving rise to a special set of recommendations regarding the Pernkopf atlas in a document known as the “Vienna Protocol.” It was written by a prominent American rabbi and ethicist, Joseph A. Polak, and formally adopted by a 2017 symposium of experts at Yad Vashem. Under the protocol, the atlas can be used if there is full disclosure about its origins.
In a recent survey of an international group of nerve surgeons, Mackinnon and Yee found that 59% of the 182 respondents were aware of the Pernkopf atlas, 41% had used it at some point and 13 percent were currently using it.
But the debate is hardly settled.
Dr. Justin M. Sacks, chief of the division of plastic and reconstructive surgery at Washington University, said he had never come across the atlas until he arrived at the department this year. He argued that it was morally and ethically wrong to use it and that there were perfectly adequate substitutes available in print or online.
“I’m not looking to stir a controversy,” he said in an interview, “but I’m looking to put it where it belongs: in a museum.”
El-Haj said that while the alternatives might be good enough in other medical fields, when it came to peripheral nerve surgery, they were no match for Pernkopf. One of eight siblings, el-Haj grew up in a farming village and aspired to become a nerve surgeon, he said, in the hope of helping his father, who as a young man was left with a paralyzed arm and leg by a work accident. After studying in the United States, el-Haj returned to Jerusalem with his own Pernkopf volumes in August 2018.
Around the same time, Musai, who had undergone dozens of operations since his injury, returned to his doctors. Now a married father of two, he could barely walk. His foot could not bear the weight of a sheet at night.
He was referred to el-Haj.
From his days as a medical student at Hadassah, el-Haj, 40, remembered Musai as an angry teenager in terrible pain who harbored a hatred of Arabs.
Musai acknowledges that was the case.
“The truth is if they’d sent me to Madi at the beginning of my injury, I would have said no,” Musai said. “Not because of the atlas, but because I had a big problem with the Arab population. I saw in everyone the terrorist who hurt me.”
But now, years later, el-Haj ran some tests and scheduled surgery. Guided by Pernkopf’s atlas, which he took into the operating room, he found a necklace of shrapnel laced around the nerve, located the main branches causing the pain and took them down, alleviating his suffering.
Dr. Madi el-Haj holds an anatomical atlas outside Hadassah Medical Center in Jerusalem, April 5, 2020. Source: Dan Balilty/The New York Times
“It sounds like a good joke,” Musai said. “The Muslim surgeon with the Nazi atlas operating on a Jew.”
The lives of el-Haj and Musai have since become intertwined.
Musai has visited the doctor’s family in his village. And when el-Haj’s mother was hospitalized at Hadassah, Musai, who now works as a guide there, visited her. El-Haj has taken his children to visit the Musais in their West Bank settlement, too.
El-Haj said he had used the atlas in about 90% of his operations, always explaining its background to the patients.
“No patient has ever refused,” he said. “Not ever. Because these people can make a pact with the devil to get out of their pain.”
