DR JOHN W FERGUSON *
Introduction
Of all the basic sciences that underlie modern medical practice there is none more fundamental than anatomy. Ultimately all other facets of clinical practice are necessarily built upon a good knowledge of human anatomy at both a gross and microscopic level.
Historically, it is of considerable interest to trace the development of our present day knowledge of human anatomy. To start it is necessary to go back nearly five thousand years to the time of Huang Ti or the Yellow Emperor, sometimes called the father of Chinese medicine, and the author of the Nei Ch’ing, or Canon of Medicine.
Amongst other astute observations, Huang Ti stated “all the blood of the body is under the control of the heart. The heart is in accord with the pulse. The pulse regulates all the blood and the blood current flows in a continuous circle and never stops”. Surprisingly, this statement which would seem obvious to virtually everybody today became lost in the dark mists of the middle ages.
Some of the earliest medical records, which were predominantly descriptive, can be sourced back to the Babylonian Empire around 1730 BC. At this time knowledge of human anatomy was largely predicated upon information gained from animal dissections.
During this period, considerable knowledge of gross anatomy was obtained in Egypt, initially through the process of mummification of corpses which involved removal of most of the major internal organs for preservation in urns outside the body. Important recording of anatomy by the Egyptians is also found in two important papyri, these being the Ebers papyrus and the Edmond Smith papyrus. The first of these is essentially an internal medicine reference which contains numerous accurate anatomical descriptions. The Edmond Smith papyrus is more of a treatise on trauma surgery with particular reference to management of fractures and contains some very detailed anatomical observations. One can imagine the considerable anatomical knowledge gained by the trauma surgeons of the time who had to manage the undoubtedly numerous severe injuries suffered by those involved in the building of the great pyramids.
During the 6th century BC, in India, an important anatomical text was compiled by Susruta, and this is essentially a surgical text, but it contains considerable anatomical detail based on dissections of the human body. At that time, preparation of the human body for dissection was obtained by making incisions at numerous points in the body before placing the body inside a bamboo cage and submerged in running water in a river.
During what may be described as the pre-Greek era, further knowledge of anatomy was developed in some of the Mediterranean countries, for example by Alcmaeon in Italy around 500 BC, whose important contributions included identifying and describing the optic nerve and eustachian tubes. Alcmaeon also proposed the brain to be the seat of intelligence, consciousness and emotions. At about the same time, Empedocles in Sicily also undertook detailed anatomical studies but in contrast to Alcmaeon drew a number of wrong conclusions regarding the physiological function of some of the organs being described.
The Role of the Greeks
The founder of the Greek school of anatomy must be regarded as Hippocrates (c.460–377 BC). His anatomical knowledge was obtained and described predominantly by surface observation and inspection of bodily wounds. He was followed by Aristotle (c.384–322 BC), who undertook extensive dissection of large animals, extrapolating from this to draw conclusions regarding human anatomy.
Some of the later Egyptian anatomists founded what is regarded as the Alexandrian School of Anatomy. The Greek city of Alexandria was founded in Egypt by Alexander the Great, king of Macedonia, who was also a pupil of Aristotle. Alexandria became the cultural and intellectual centre of the ancient world and was to remain the capital of Egypt for nearly one thousand years.
One of the most important anatomists in the Alexandrian school was Herophilus (c335–280 BC) who is often described as the "father of anatomy", and was the first physician to undertake systematic dissection of human cadavers often in public. His reputation was unfortunately sullied by the fact that he also undertook vivisections of live condemned criminals in order to obtain a better understanding of physiology.
With the rise of the Roman Empire, Celsus (c.30 BC–45 AD) who was not himself a physician but essentially a writer of great learning, compiled a multi-volume treatise which included virtually all medical knowledge known at that time. This tome, the De Re Medicina was subsequently lost for 14 centuries but ultimately published in the 15th century on the orders of Pope Nicholas V. It was subsequently translated and published in English in 1756 and copies are still available today. These volumes included an outstanding description of the human skeleton and reasonably accurate descriptions of many of the internal abdominal organs including the genitalia and urinary systems.
One of the most important figures in medicine was Galen (c.131–192 AD), a physician of Alexandria, who became a noted anatomist, deriving his knowledge largely from anatomical comparative animal dissection. During his lifetime he wrote some 130 volumes of medical writings of which some 80 survived. These writings remained essentially unchallenged subsequently for some 1400 years. However, this was unfortunate because Galen never achieved a realistic understanding of human physiology. This is obvious from some of the diagrams included with his writings. Amongst other things he believe that blood was formed in the liver and this view subsequently prevailed for some 1600 years, including through the Dark Ages during which time in Europe there was for many centuries minimal record or artistic, cultural or scientific endeavors, including studies in medicine.
The Middle Ages
However, in other parts of the world, particularly in the Mediterranean region, even during the Middle Ages there were significant advances made and amongst the most famous of the anatomists of this time was Mondino De Luzzi (1265–1326 AD) of the University of Bologna. Mondino was the first anatomist to systemically conduct dissection of human cadavers and subsequently prepared the first true text book of anatomy, this being the Anathomia Mundini.
As with other anatomists, many of these dissections were performed in public before both interested citizens and medical students.
During the Renaissance Leonardo da Vinci (1452-519) undertook around 30 complete dissections of the human body during his lifetime. His purpose in doing so was to maximize his knowledge of human anatomy in order to produce the most life-like renditions with his paintings.
Probably the most important anatomist of all times however, from an historical point of view, would be Andreas Vesalius, who in 1543 published his De Humani Corporis Fabrica. This text book contains beautiful anatomical illustrations of every part of the human body, including the skeletal system and all of the internal organs including intracranial.
Up to this time however the key feature missing for a true understanding of the significance of the anatomy of the human body was its correlation with function. In other words up until this time physiology as a discipline did not exist.
William Harvey
Everything changed, however, with the work of the English physician, William Harvey (1578– 1657), often referred to as the "father of physiology". The major contribution of Harvey was to establish by both human dissection and live animal studies the true nature of the circulatory system. This revelation then immediately opened the way to an understanding of the physiology of all of the major systems of the body. Harvey’s work was encapsulated in his landmark publication An Anatomical Dissertation on the Movement of the Heart and Blood in Animals in 1628.
Harvey’s work was then closely followed by the studies of Marcello Milpighi (1628 – 1694). Milpighi was an Italian physician, physiologist and botanist, who developed a keen interest in microscopy following the development of the microscope by Robert Hook and Antony Van Leeuwenhoek. Milpighi established the presence of the capillary circulation, this having previously been postulated, but not demonstrated, by William Harvey and also established the nature and function of the pulmonary alveoli.
From this time onward, with the full knowledge of anatomy and increasingly sophisticated understanding of physiology, understanding of the structure and function of the human body was largely established, this laying the foundations for the steady development towards modern medical practice.
From about the 18th century onward, this knowledge was increasingly focused into various medical texts including text books and atlases of human anatomy. In association with the development of these texts, the formal teaching and learning of human anatomy, particularly by way of systematic dissection of human cadavers, became integrated into and formed a major foundation for all studies by students of medicine. The importance of undertaking dissection of cadavers was maintained and the supply of cadavers came about, as it continues to do so, largely by dissection of donated or unclaimed bodies. Today most countries have specific legislation covering the ethical obtaining and use of such material.
Historically, ethical behavior has not always been so evident, and this was well illustrated during the period of so called “body snatching” which became prevalent in London during the early part of the 19th century, when the provision of cadavers to medical schools became a fruitful source of income for those with no moral scruples. Generally bodies were removed at night from freshly dug graves and swiftly transported to where they could be exchanged for monetary reward.
One of the most celebrated of all cases was that of Burke and Hare, two unscrupulous men who forsook all moral and ethical principles by actually murdering people in order to obtain very fresh cadavers for medical schools and for the supply of such fresh bodies they received what was then the magnificent sum of 8 guineas per corpse. However justice prevailed ultimately with Burke and Hare being caught and suitably punished for their crimes and it is perhaps a form of poetic justice that the executed body of Burke ultimately ended up on the dissecting table of one of the London medical schools.
However, even today ethical principles do not always prevail, and this has been demonstrated in a number of ways but most particularly in recent times by the unethical trade of human organs for transplantation.
Gray's Anatomy
Today numerous text books and atlases of anatomy exist, some with well recognized lineage such as Gray's Anatomy, first published by Henry Gray in 1858. Gray must necessarily be regarded historically as one of the great anatomists, but tragically died of smallpox at the young age of 34 years. One of the better known atlases of anatomy is Grant’s Atlas of Anatomy first published in 1943, and still widely used today. Grant also published two companion texts, one being Grant’s Method of Anatomy and Grant’s Dissector, these two books being co-authored by colleagues of the time. Most of these anatomy text books and atlases contain very good illustrations of dissections some in more diagrammatic form than others and others with a greater leaning toward realistic depiction.
Eduard Pernkopf
Off all human anatomy atlases however there is generally considered to be nothing to rival the Atlas of Topographical and Applied Human Anatomy first published in Vienna in 1943 by Eduard Pernkopf. The illustrations in this text book, of dissections supervised by Pernkopf with illustrations prepared under his direction by his team of talented artists have no equal in the anatomy literature.
This text book was in widespread use until 1995, at which time a publication appeared in the Annals of Internal Medicine authored by E Ernst. The article by Ernst discussed some of Pernkopf’s administrative and political activities but most significantly suggested that some of the material in Pernkopf’s Atlas may have come from both children killed in a Viennese hospital and from cadavers of executed persons.
Subsequently, Howard Israel, in the United States, conducted a careful study of his own copy of Pernkopf’s Atlas, and subsequently wrote a letter to the Journal of the American Medical Association outlining his findings. Israel was appalled to note that the signatures of the artists in some of the illustrations in Pernkopf’s contained expressions of Nazi sympathies such as swastikas and the lightning flash SS insignia.
The artists signatures on the left are examples without Nazi symbols and on the right with the symbols. All these signatures are from the 1943 edition of the Atlas, with the flash "SS" in the top right signature and the swastika after the bottom right signature.
Howard Israel and his co-author William Seidelman, then suggested in no uncertain terms as follows
“The precise origins of the cadavers used in Pernkopf’s work are unknown but evidence suggests they may have been victims of political terror. It is known that the Anatomy Institute of the University of Vienna received the cadavers of prisoners executed at the Vienna District Court and of others put to death at Gestapo execution chambers in Linz, Munich and Prague”.
These suggestions were promptly refuted by a spokesman for the University of the Medical Faculty of Vienna, and the current Dean of the School stated that Pernkopf had protected his Austrian assistants who made the anatomical drawings, in order to avoid their being drafted into the German Army, and that out of gratitude they added swastikas to some of the paintings.
The continuing innuendo however, with regard to the origin of the specimens used in Pernkopf’s Atlas, was intolerable for the University of Vienna and in April 1997, Alfred Ebenbauer, Rector of the University of Vienna responded to the Israel and Seidelman letter, informing the Journal of the American Medical Association of the need for; “the fullest possible clarification of the state of affairs referred to in these accusations”. He announced that a research project entitled “The Anatomical Sciences 1938–1945” had been initiated. He did, however, acknowledge that the Anatomy Department routinely received the corpses of executed persons, among whom reportedly were renowned dissidents. He also stated that brain preparations derived from children under the Nazi euthanasia program were still stored there but would soon be properly interred. In an apparent attempt to deflect some of the mounting criticism, he further stated that the University of Graz and Prague were supplied with corpses of prisoners interred at the Mauthausen Concentration Camp.
On October 1, 1998 the final report of the Commission set up by the University of Vienna medical faculty was issued. It acknowledged the truth of the accusations and stated as follows:
“On the basis of a general decree of February 18, 1939, the bodies of persons executed were assigned to the Department of Anatomy of the nearest University for the purposes of research and teaching”. The report further stated that the Institute of Anatomy of the University of Vienna received at least 1377 bodies of executed persons including victims of Jewish origin and children.
Eduard Pernkopf was born in 1888 in Lower Austria and in 1912 graduated MD from the University of Vienna. He rapidly developed an interest in anatomy and in 1920 was appointed Assistant Director of the Institute of Anatomy of Vienna and subsequently promoted in 1926 to Associate Professor in the University of Vienna. In 1928 he became a full professor of the University of Vienna and in 1933 was appointed Director of the Institute of Anatomy of the University of Vienna. The year 1933 was significant for the rise of Adolf Hitler to power and of the ascendency of the National Socialist Party. In that same year Pernkopf joined the National Socialist Party and the following year joined the Storm Troopers (Brown Shirts). Subsequently in 1938, he became Dean of the Medical Faculty of the University of Vienna and in 1943 Rektor Magnificus (President) of the University of Vienna.
In 1938, at the time of being installed as Dean of the Faculty of Medicine, Eduard Pernkopf delivered his significant inaugural lecture at the University of Vienna. Dressed in his full Storm Trooper uniform, on April 4, 1938 Pernkopf delivered a lecture which stressed a number of important points. These included his main points:
Pernkopf therefore defined the role of medicine in the new state as follows:
These principles as enunciated by Pernkopf were not original, but essentially were the core of the more radical aspects of the so called "science" of eugenics. However, Pernkopf’s actions were to apparently legitimize these principles by installing them as an integral part of the medical curriculum of the University of Vienna. On that basis therefore, medical training at the University of Vienna necessarily required a commitment to these radical principles of eugenics.
Shortly following delivery of his inaugural lecture, Pernkopf undertook a purge of the medical faculty which at that time stood as a total of 197 members. By June 1938, two months later, 153 faculty members (including three Nobel Laureates) were dismissed on grounds that they were Jewish (this being the majority), not prepared to swear an oath of loyalty to Adolf Hitler, or not dedicated to the principals of National Socialism.
It is of interest to speculate on the effect that Pernkopf’s actions had on members of the medical profession in Germany particularly during the time of the Second World War. It has now been well established, following 20 years of meticulous research by the American Psychiatrist Robert J Lifton, that the Nazi Holocaust was developed, implemented and supervised almost wholly by members of the German medical profession with the approval of their political masters. The thrust of Lifton’s work has been to try and gain an understanding of the psychological shift necessary for doctors, with their ethos of healing based upon Hippocratic principles, to become arguably the greatest mass murderers of all time.
Subsequently, Pernkopf published the first edition of his atlas in 1943, but at the end of the war in 1945 was imprisoned by the Allies in Salzburg. In 1948 he was permitted to return to the University of Vienna, stripped of all titles but permitted to continue his anatomical studies. He died in 1955.
Conclusions and Issues
Given some of the shocking breaches of ethical human behavior that have occurred over the centuries, including the 20th century, it could be reasonably asked whether there are alternative ways of learning anatomy other than through the use of the bodies of deceased persons.
One such attempt has been the “Visible Human Project” undertaken by the National Library of Medicine in the United States. This project utilizes contemporary imaging techniques to enable construction of three dimensional images of dissected bodies, which then essentially enable the learning of human anatomy through a computer screen. Even such attempts have been dogged by controversy, particularly because the male body chosen for this particular project was a convicted murderer executed by the state of Texas and the question arose as to whether or not appropriate informed consent for the use of his body in this way had been given, and whether this person was now to be seen as more of a heroic medical figure rather than as a criminal. Interestingly, one of the strongest responses came from the Department of Emergency Medicine in the University of Vienna Medical School, who stated as follows:
“The death penalty and medical participation in an execution are unethical, and informed consent by the condemned person does not dispel the unethical basis of the material used in the project. Immediate withdrawal of the images was morally necessary”.
Finally, it is necessary to ask the critical question: “What do we now do about the Pernkopf Atlas, given what we now know about its development?”
It is possible to identify four positions which may be taken in regard to this question.
The position that will then be taken by any individual regarding this question is one which must be determined by the conscience of that individual.
_______ * John Ferguson is a Melbourne surgeon