True-to-life representation is the top priority

‘ To practise as a doctor without profound anatomical knowledge is unthinkable. For the diagnosing, treatment and prognosis of illnesses, a detailed knowledge of the structure, positional relationships and the neurovascular pathways which supply the regions and organs of the body is central.’

Anatomical knowledge is gained through cognitive, tactile and especially visual learning processes, and can only be fully acquired when working with the human body itself. Images, graphics and three-dimensional programmes depicting the essential elements help to develop a three-dimensional perception of the relationships in the human body, and help the student to memorise and name structures.

The visual principle of learning did not always apply in anatomical teaching. The writings of the great anatomists of antiquity, such as the school of Hippocrates of Kos (460–370 BC) and Galen of Pergamon (131–200), did not include any illustrations of human anatomy, because a lifelike representation of the human form in books was technically impossible; nor did these authors perform dissections on humans. ^{1 , 2 , 3 , 4}

1 Persaud TVN. Early history of human anatomy. Springfield: Charles C Thomas, 1984. Persaud TVN. A history of human anatomy: the post-Vesalian era. Springfield: Charles C Thomas, 1997: 298, 309.

2 Persaud TVN. A history of human anatomy: the post-Vesalian era. Springfield: Charles C Thomas, 1997: 298, 309.

3 Rauber A, Kopsch F. Anatomie des Menschen. 7. Aufl. Leipzig: Thieme, 1906.

4 Roberts KB, Tomlinson JDW. The fabric of the body. Oxford: OxfordUniversity Press, 1992.

Even the reformer of anatomy, Mondino di Luzzi (1270–1326), had to do without illustrations. He introduced the dissection of human bodies for anatomical education in Bologna and wrote the first modern anatomy ‘book’ in 1316. This 77-page collection of folios became the standard reference for medical training for the next few centuries. ^{1 , 4} Images from another contemporary medical compendium were included for visual instruction; however, their lack of detail and overt inaccuracies did not add much of practical value to the volume.

The Renaissance brought an increased awareness of nature and the relevance of trueness to life in art, and in this it was Leonardo da Vinci (1452–1519) who emphasised the visual representation of anatomy. His depictions of human anatomy were based on his own dissections. ⁵

5 Clayton M, Philo R. Leonardo da Vinci Anatomist. London: Royal Collection Trust, 2017.

Unfortunately, he never completed his planned anatomical volume, but did leave behind his anatomical sketches. It was thus in 1543 that Andreas Vesalius’ (1514–1564) ‘ De humani corporis fabrica libri septem ’ became the first book to depict human anatomy entirely based on the dissection of bodies. The numerous illustrations were high-quality woodcut prints but were not coloured. ^{6 , 7}

6 Garrison DH, Hast MH. The fabric of the human body (kommentierte Übersetzung des Werks von Andreas Vesalius). Basel: Karger, 2014.

7 Vollmuth R. Das anatomische Zeitalter. München: Verlag Neuer Merkur, 2004.

Image quality evolved over the next few centuries and reached another peak with the work of anatomist Jean Marc Bourgery (1797–1849) and his draftsman Nicolas Henri Jakob (1782–1871). Bougery and Jakob jointly created an eight-volume anatomy atlas over a period of more than 20 years. However, this work as well as the one created by Vesalius, were published in folio format and thus so expensive and unwieldy that they were – and still are – highly valued by wealthy doctors and art connoisseurs, but unsuitable for students and their foundational anatomy education. In the English-speaking world this changed in 1858, when Henry Gray (1827–1861) published the textbook ‘Anatomy, Descriptive and Surgical’. It contained non-coloured illustrations based on dissections of the human body, and was quickly established as an affordable and popular alternative for students. ⁸

8 Hayes B. The Anatomist: A True story of Gray's Anatomy. Ballantine, 2007. ISBN 978-0-345-45689-2

Around 1900, August Rauber (1841–1917), along with Friedrich Wilhelm Kopsch (1868–1955), Carl Heitzmann (1836–1896), as well as Carl Toldt (1840–1920), Werner Spalteholz (1861–1940) and several other authors, created volumes on anatomy for various publishers. These atlases, sometimes in combination with a textbook, claimed to present human anatomy in full. The anatomist Johannes Sobotta (1869–1945), who worked in Würzburg, complained that the books were too detailed and therefore unsuitable for foundational medical education. In addition, he believed the prices for these volumes were unjustifiably high for the quality of the images. Sobotta therefore endeavored to ‘produce an atlas with lifelike images and suitable for use by medical students in the dissecting room’ . ⁹

9 Sobotta, J. Atlas der Anatomie des Menschen. 1. Aufl. München: J. F. Lehmanns-Verlag, 1904–1907.

The publishers and editors of the Sobotta Atlas have followed this basic principle ever since.

The first edition of the Sobotta Atlas was published in 1904 by J.F. Lehmanns under the title ‘Atlas of the descriptive anatomy of humans in 3 volumes’ and contained 904 mostly coloured illustrations. The majority of these were created by the illustrator Karl Ha j́ ek (1878 –1935), who thus had a large share in the quality and success of the Sobotta Atlas. The atlas seems to have had a ground-breaking effect after its publication in that it brought the further development of anatomical textbooks a big step forward.

At the time of the first edition of the Sobotta Atlas, there were other atlases featuring muscles that were coloured, and neurovascular bundles highlighted in colour. However, it was only the Sobotta atlas which gave a complete and true-to-life colouring of the images of a situs or extremity, and this was only possible through a high-quality printing technique. This is illustrated by Fig. 1 from the first edition with the example of the dissection of an anterior thigh. Even more than 100 years later, these images still look fresh and life-like and are therefore timeless. Many illustrations were added over the following editions, and the existing illustrations were continuously revised and adapted to match contemporary learning habits and aesthetic perceptions.

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Illustration of the ventral femoral musculature based on a dissection (1 ^st edition of the Sobotta Atlas).

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Unfortunately, we cannot mention all the illustrators over the course of 25 editions who have made the Sobotta Atlas what it is today; there are simply too many. Individual artists will therefore be singled out as being representative for all. From 1925, Erich Lepier (1898–1974) worked as illustrator for Urban & Schwarzenberg; first for various clinicians and then for the anatomist Eduard Pernkopf. After the Second World War, when Urban & Schwarzenberg had taken over publication of the Sobotta Atlas from J.F. Lehmanns, Lepier produced numerous illustrations for this atlas. Late in life he was awarded the title of professor because of his outstanding work.

From the 20 ^th edition in 1993, Sonja Klebe contributed to the atlas and her outstanding creations need to be highlighted. The editors still work with her in a productive collaborative team, as can be seen in Fig. 2 , with an image of the topography of the head.

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Illustration by Sonja Klebe of the vascular pathways of the head (25 ^th edition of the Sobotta Atlas, Fig. 8.83).

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For later editions, images from other works by the Elsevier publishing company have also been included in the Sobotta Atlas. Since the turn of the millennium, most anatomical images from many of the publishing houses have been created digitally. Technical advances make it possible to create anatomical images in an inverse way to before. Previously, as in the Sobotta Atlas, new images were drawn exclusively using real human specimens. Schematic representations for simplification were derived by deduction.

Today, simple line drawings and schematics are first drawn up by computer programmes, to then incorporate the textures of various tissues by induction. Ultimately this produces the impression of a real representation of an anatomical specimen. The results are remarkably vivid despite being artificial. It is an attractive option for organisational as well as economic reasons. Today – in contrast to the times leading up to the postwar period – hardly any anatomical institute still employs its own illustrators, who, along with the anatomists and the dissected specimen, would create images of the quality required for the Sobotta Atlas. In addition, there are hardly any anatomists whose work time can be dedicated to producing anatomical specimens of the highest quality. Anatomists today are not only university professors and textbook authors, but scientists who conduct research and depend on performance-oriented financial resources. Due to these developments, it is next to impossible for today’s anatomists to collaborate with illustrators over several months in the creation of a single optimal illustration. As a result, this manner of image creation has been almost entirely abandoned, and there are practically no representations that exceed or even compete with the images in older atlases. This is also the reason for the Sobotta Atlas to continue including images from atlases such as the Pernkopf Atlas as a model for new editions. The quality of some of the Pernkopf images is still unsurpassed, as Fig. 3 shows, with a dissection of the lungs as an example – the editors know of no other comparable illustration of the lung structure and its associated neurovasculature that represents all vascular details, including the lymphatics, correctly.

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Illustration of a dissection of the lungs from the Pernkopf Atlas (25 ^th edition of the Sobotta Atlas, Fig. 5.113).

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This decision to reproduce an illustration from the Pernkopf Atlas can only be justified on the basis of a conscious examination ¹⁰

10 Arbeitskreis »Menschliche Präparate in Sammlungen« (2003): Empfehlungen zum Umgang mit Präparaten aus menschlichem Gewebe in Sammlungen, Museen und öffentlichen Räumen, in: Deutsches Ärzteblatt 2003; 100: A1960–A1965. As well as other points, it explains: ‘If it is shown that the deceased has died because of their genealogy, idealogy or political persuasion due to state-controlled and -managed acts of violence or due to the well-founded probability of this having been the case, this is seen as a grave injury to their personal dignity. If such a context of wrongdoing is established, the specimens from the collections in question will be removed and interred in a dignified manner or will cease to be used, in a comparably dignified manner.’ Distinct priority is especially given to specimens from the Nazi era, ‘dealing with these specimens in a specialised way – after extensive research of the source – indiscriminately removing all dissections from collections between 1933 and 1945.’ For specimens with an uncertain source and date of origin, the following is recommended: ‘If after a first assessment, the specimen is of unknown origin and appears to be from the 20 ^th century, it should then be separated and be subjected to a thorough examination. If no unambiguous allocation can be made, these specimens need to be categorically interred, unless there are certain cases in which contradictory overall aspects can be presented, documented and established.’

of the egregious ethical transgressions of anatomy during National Socialism (Nazi Germany), in memory of the victims of the Nazi regime whose bodies are depicted here. Since this applies to all anatomical representations in atlases that already existed and were further developed during this period, we discuss this historical background in more detail here. ¹¹

11 A full presentation of the history of anatomy in Nazi Germany is here: Hildebrandt S. The Anatomy of Murder: Ethical Transgressions and Anatomical Science in the Third Reich. New York: Berghahn Books, 2016.

Anatomical work in teaching and research, as well as in the production of new teaching materials, including atlases, was and is dependent on an adequate supply of dead human bodies. Traditional legal anatomical body procurement in Germany and worldwide was based on the bodies of so-called ‘unclaimed’ people, i.e. those who died in public institutions and whose relatives did not claim them for a burial. It was only in the second half of the 20 ^th century that this changed fundamentally – in Germany as in other countries – with the advent of effective body donation programmes.

12 Garment A, Lederer S, Rogers N, et al. Let the Dead Teach the Living:The Rise of Body Bequeathal in 20th-century America. Academic Medicine 2007; 82, 1000–1005.

^12,13

13 Habicht JL, Kiessling C, Winkelmann A. Bodies for anatomy education in medical schools: An overview of the sources of cadavers worldwide. Acad Med 2018; 93: 1293–1300.

Before that, the sources of anatomical body procurement primarily included psychiatric institutions, prisons, people who committed suicide and – historically the first legally regulated source – bodies of the executed. Anatomy laws were repeatedly adapted by the respective governments, including Nazi Germany.

14 Stukenbrock K. Der zerstückte Coerper: Zur Sozialgeschichte der anatomischen Sektionen in der frühen Neuzeit (1650–1800). Stuttgart: Franz Steiner Verlag, 2001.

^14,15

15 Hildebrandt S. Capital Punishment and Anatomy: History and Ethics of an Ongoing Association. Clinical Anatomy 2008; 21: 5–14.

With rare exceptions, a constant theme in the history of anatomy has been the lack of bodies for teaching and research. This changed significantly under National Socialism. In the first years after 1933 there were still the usual missives by anatomists to the authorities, complaining about the scant body supply. Very soon, however, their inquiries became specific, and they asked for access to execution sites and the bodies of the executed, or asked for the bodies of prisoners of war to be delivered to their institutes. Thus, anatomists were not only passive recipients of the bodies of Nazi victims, but actively requested them for teaching, and above all for research. ¹⁶

16 Noack T, Heyll U. Der Streit der Fakultäten. Die medizinische Verwertung der Leichen Hingerichteter im Nationalsozialismus. In: Vögele J, Fangerau H, Noack T (Hrsg.). Geschichte der Medizin – Geschichte in der Medizin. Hamburg: Literatur Verlag, 2006: 133–142.

In the ‘Third Reich’, the bodies from psychiatric hospitals included those of people murdered as part of the ‘euthanasia’ killing programme, as documented for various anatomical institutes.

17 Overview in: Hildebrandt S. The Anatomy of Murder: Ethical Transgressions and Anatomical Science in the Third Reich. New York: Berghahn Books, 2016.

^17,18

18 Czech H, Brenner E. Nazi victims on the dissection table – the anatomical institute in Innsbruck. Ann Anat 2019; 226: 84–95.

From 1933 on there was also an increase in persecuted Jewish citizens among the suicides. ¹⁹

19 Goeschel C. Suicide in Nazi Germany. Oxford: Oxford University Press, 2009.

Due to the changes in Nazi legislation and the persecution of the so-called ‘enemies of the German people’, the number of political prisoners increased, not only in the normal penal system and in the Gestapo prisons, but above all in the constantly expanding network of concentration camps and decentralised camps for prisoners of war and forced labourers. The escalating violence and inhumane living conditions in these facilities resulted in high death rates, and the dead were delivered to many of the anatomical institutes. The number of executions after civilian and military trials also rose exponentially under the National Socialists, especially during the war years. ²⁰

20 Numbers in Hildebrandt 2016 , see footnote 17.

All anatomical institutes received the bodies of the executed, without exception, and regardless of the political convictions of the individual anatomists who worked with these bodies.

More than 80% of the anatomists who remained in Nazi Germany had joined the NSDAP, the Nazi party, but not all of them were such avid National Socialist ideologues as Eduard Pernkopf (1888–1955), the Viennese Dean of the Medical Faculty and Director of the Institute of Anatomy. He used the unrestricted access to the bodies of executed Nazi victims not primarily for scientific studies, as many of his colleagues did, but instead created the subsequent volumes of his ‘Topographical Anatomy of Humans’. Together with his assistants and a group of medical illustrators, he had begun this work in the early 1930s. It is highly likely that the majority of the pictures in the atlas created during the war years show victims of the Nazi regime, because Pernkopf’s institute received the bodies of more than 1,377 executed people from the Vienna prison system between 1938 and 1945, more than half of them convicted of treason. ²¹

21 Angetter DC. Anatomical Science at University of Vienna 1938–45. The Lancet 2000; 355: 1445–57.

Erich Lepier and his illustrator colleagues Karl Endtresser (1903–1978) and Franz Batke (1903–1983) left clear signs of their political sympathies with the Nazi regime in their signatures on images that were created during the war. Lepier often integrated a swastika in his signature, and Endtresser and Batke SS runes. These peculiarities of the atlas initially remained without comment, and the work enjoyed great popularity with anatomists, surgeons and medical illustrators alike, due to the true-to-nature details, a colour palette intensified by a new printing process, and Pernkopf’s so-called ‘stratigraphic’ method of representation, in which a body region is presented in dissection steps from the surface to the deep layers in a sequence of dissections. After the war, Lepier copied a number of Pernkopf originals for the Sobotta Atlas to replace illustrations by Karl Haj́ek. Interestingly, very detailed illustrations of the body cavities and their organs which also depicted the neurovascular system were not copied. Leaving out these drawings across many editions of the Sobotta Atlas can be explained by the fact that, for many years, the relevance of neurovascular structures to the diagnostics and treatment of malignant tumours were not fully explored. As this very important function of the lymph vessels is now well-known, the current publishers regard further appropriation of the high-quality Pernkopf images as well-justified.

Soon after the publication of the first American edition of the Pernkopf Atlas in 1963/64, questions arose about the political background of the work. The rumours were only followed up on in the 1980s with investigations by American authors, before a public debate on the ethics of the use of the Pernkopf Atlas ensued in the mid-1990s. ²²

22 Weissmann G. Springtime for Pernkopf. Reprinted 1987. In: Weissmann G (ed.). They All Laughed at Christopher Columbus. New York: Times Books; Williams, 1988: 48–69.

Recommendations ranged from complete removal of the atlas from libraries to its historically informed use. ²³

23 Hildebrandt S. How the Pernkopf Controversy Facilitated a Historical and Ethical Analysis of the Anatomical Sciences in Austria and Germany: A Recommendation for the Continued Use of the Pernkopf Atlas. Clinical Anatomy 2006; 19: 91–100.

Urban and Schwarzenberg ended the publication of the work, but this did not stop its use, especially by surgeons. ^{24 , 25}

24 Yee A, Coombs DM, Hildebrandt S, et al. Nerve surgeons’ assessment of the role of Eduard Pernkopf ’s Atlas of Topographic and Applied Human Anatomy in surgical practice. Neurosurgery 2019; 84: 491–498.

25 Yee A, Li J, Lilly J, et al. Oral and maxillofacial surgeons’ assessment of the role of Pernkopf’s atlas in surgical practice. Ann Anat 2021; 234: 1–10.

When results of the systematic study of anatomy in Nazi Germany became known to a wider audience, a new inquiry emerged about the ethical use of the Pernkopf images in special surgical situations in 2016. ²⁶

26 Complete documentation pertaining to this enquiry and the history of the perception of the Pernkopf Atlas, as well as the ‘Vienna Protocol’ in: Vol. 45 No. 1 (2021): Journal of Biocommunication Special Issue on Legacies of Medicine in the Holocaust and the Pernkopf Atlas, https://journals.uic.edu/ojs/index.php/jbc/article/view/10829 (last assessed: 27. November 2021). (last assessed: 27. November 2021).

This question found an answer, based on Jewish medical ethics, in the Responsum Vienna Protocol by Rabbi Joseph Polak. ^{27 , 28 , 27,28,29}

27 Polak J. A. Vienna Protocol for when Jewish or possibly-Jewish human remains were discovered. Wiener Klinische Wochenschrift 2018; 130: S239–S243.

28 Vienna Protocol 2017. How to deal with Holocaust era human remains: recommendations arising from a special symposium. ‘Vienna Protocol’ for when Jewish or Possibly-Jewish Human Remains are Discovered. Im Internet: https://journals.uic.edu/ojs/index.php/jbc/article/view/10829/9795 (last assessed: 21. October 2021).

29 Hildebrandt S, Polak J, Grodin MA, et al. The history of the Vienna Protocol. In: Hildebrandt S, Offer M, Grodin MA (eds.). Recognizing the past in the present: medicine before, during and after the Holocaust. New York: Berghahn Books, 2021: 354–372.

A responsum is a traditional scholarly and legal answer to a question put to a rabbi. Rabbi Polak concludes that most authorities would certainly allow the use of the Pernkopf images if they help save human life (according to the principle of piku’ach nefesh ). However, this use is tied to the absolute condition that it is made known to one and all what these images are. Only in this way will the dead be granted at least some of the dignity to which they are entitled.

Following the argument of the Vienna Protocol and the condition that the victims of National Socialism whose bodies are shown in the images of the Pernkopf Atlas are remembered explicitly, the editors see it as justifiable to include new re-drawn copies of Pernkopf images in this new edition of the Sobotta Atlas : to save future patients through the best possible anatomical visual instruction, in memory of the victims.

In the 25 ^th edition, the number of images has now grown to 2,500. It remains the highest priority to continue creating images with the various illustrators and graphic artists that are in no aspect inferior to dissected specimens. Fig. 4 shows the example of a plastinated heart from a body donor, which the illustrator Sonja Klebe used, together with photographs from different perspectives, to create a new image. The spatial depth allows for three-dimensional understanding of the anatomy. It is the result of the artist's exploration process, in which she was able to observe, ‘grasp’ and understand the specimen.

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Step-by-step development of one of Sonja Klebe’s drawings of the topography of the heart, based on a plastinate and photos.

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The editors would like to thank all the illustrators and artists involved, as well as the Elsevier publishing team, without whom the atlas would not have been possible in this form.

Boston, Erlangen and Munich, 2022

Sabine Hildebrandt*, Friedrich Paulsen and Jens Waschke