When medical information comes from Nazi atrocities

A century of exercise physiology: concepts that ignited the study of human thermoregulation. Part 3: Heat and cold tolerance during exercise

In this third installment of our four-part historical series, we evaluate contributions that shaped our understanding of heat and cold stress during occupational and athletic pursuits. Our first topic concerns how we tolerate, and sometimes fail to tolerate, exercise-heat stress. By 1900, physical activity with clothing- and climate-induced evaporative impediments led to an extraordinarily high incidence of heat stroke within the military. Fortunately, deep-body temperatures > 40 °C were not always fatal. Thirty years later, water immersion and patient treatments mimicking sweat evaporation were found to be effective, with the adage of cool first, transport later being adopted. We gradually acquired an understanding of thermoeffector function during heat storage, and learned about challenges to other regulatory mechanisms. In our second topic, we explore cold tolerance and intolerance. By the 1930s, hypothermia was known to reduce cutaneous circulation, particularly at the extremities, conserving body heat. Cold-induced vasodilatation hindered heat conservation, but it was protective. Increased metabolic heat production followed, driven by shivering and non-shivering thermogenesis, even during exercise and work. Physical endurance and shivering could both be compromised by hypoglycaemia. Later, treatments for hypothermia and cold injuries were refined, and the thermal after-drop was explained. In our final topic, we critique the numerous indices developed in attempts to numerically rate hot and cold stresses. The criteria for an effective thermal stress index were established by the 1930s. However, few indices satisfied those requirements, either then or now, and the surviving indices, including the unvalidated Wet-Bulb Globe-Thermometer index, do not fully predict thermal strain.

A century of exercise physiology: concepts that ignited the study of human thermoregulation. Part 1: Foundational principles and theories of regulation

This contribution is the first of a four-part, historical series encompassing foundational principles, mechanistic hypotheses and supported facts concerning human thermoregulation during athletic and occupational pursuits, as understood 100 years ago and now. Herein, the emphasis is upon the physical and physiological principles underlying thermoregulation, the goal of which is thermal homeostasis (homeothermy). As one of many homeostatic processes affected by exercise, thermoregulation shares, and competes for, physiological resources. The impact of that sharing is revealed through the physiological measurements that we take (Part 2), in the physiological responses to the thermal stresses to which we are exposed (Part 3) and in the adaptations that increase our tolerance to those stresses (Part 4). Exercising muscles impose our most-powerful heat stress, and the physiological avenues for redistributing heat, and for balancing heat exchange with the environment, must adhere to the laws of physics. The first principles of internal and external heat exchange were established before 1900, yet their full significance is not always recognised. Those physiological processes are governed by a thermoregulatory centre, which employs feedback and feedforward control, and which functions as far more than a thermostat with a set-point, as once was thought. The hypothalamus, today established firmly as the neural seat of thermoregulation, does not regulate deep-body temperature alone, but an integrated temperature to which thermoreceptors from all over the body contribute, including the skin and probably the muscles. No work factor needs to be invoked to explain how body temperature is stabilised during exercise.

Before and After I Knew: Disclosure, Respect, Gratitude, and Solemnity

The Pernkopf anatomical atlas has contributed significantly to the specialty of nerve surgery through its infiltration in surgical training and the development of novel procedures due to the accurate depiction of the nervous system. Until the recent advancements of the Pernkopf controversy, nerve surgeons have struggled with the ethical dilemma presented with its use in surgery and clinical practice. In this article, we explore a personal story and reflection by an individual nerve surgeon, their contribution to the advancement of the Pernkopf controversy, and how different professional domains (surgery, anatomy, ethics, religion, and education) were able to collaborate to address the historical crimes against humanity and issues in the anatomical sciences. This required a structured approach to address this ethical dilemma in surgery, which included (1) an assessment of the use of the Pernkopf atlas in specific surgical specialties (nerve surgery and oral and maxillofacial surgery) and (2) the development of a graduated ethical framework with a religious framework (the Vienna Protocol), if the Pernkopf atlas was to be used in surgery. These studies are reviewed in the context of evolving paradigms in nerve surgery (nerve repair, grafting, and transfers) and influence of anatomy in the advancement of this surgical specialty.

What Should Be Done with Pernkopf's Anatomical Illustrations?: A Commentary from the Medical University of Vienna

Thanks to a recent donation by Elsevier, the Medical University of Vienna now holds in its collections the known existing original paintings for Eduard Pernkopf's Atlas of Topographical and Applied Human Anatomy. The work is widely considered a pinnacle of the art of anatomical illustration. However, it is severely tainted by its historical origins. Pernkopf was a high-ranking National Socialist and co-responsible for the expulsion of hundreds of Jewish scientists and students from the university. Also, the Vienna Institute of Anatomy, which Pernkopf headed, received during the war the bodies of at least 1377 people executed by the regime, many for their political views or acts of resistance, including at least seven Jewish victims. Although it is impossible to individually identify the people used for the atlas, it is to be assumed that a considerable number of the paintings produced during and after the war are based on the bodies of these victims. Against this background, and out of respect for the victims, use of Pernkopf's atlas and its illustrations in medical teaching, training and practice should be - wherever possible without compromising medical outcomes - reduced to a minimum. Given the high variability of human anatomy, even the most detailed anatomical illustrations cannot replace teaching and training in the dissection room. As the experience at the Medical University of Vienna and elsewhere demonstrates, Pernkopf's atlas is far from irreplaceable. In keeping with the stipulations of the contract of donation, the Medical University of Vienna considers the Pernkopf originals primarily as historical artifacts, which will support the investigation, teaching and commemoration of this dark chapter of the history of medicine in Austria, out of a sense of responsibility towards the victims.

Oral and maxillofacial surgeons' assessment of the role of Pernkopf's atlas in surgical practice

BACKGROUND

The use of the Pernkopf atlas of human anatomy in surgery presents ethical challenges due to the author's association with the Nazi regime and the potential depiction of victims of this regime. The atlas was of particular utility to two surgical specialties: nerve surgeons and oral and maxillofacial surgeons. The representation of peripheral nerves and complex head and neck anatomy is probably unequaled in any other atlas of anatomy. While the ethical implications of the use of Pernkopf's atlas among nerve surgeons have been previously assessed, this study focuses on the volume dedicated to detailed images of head and neck dissections, and the ethical implications of using this atlas by oral and maxillofacial surgeons.

OBJECTIVE

To (1) assess the role of the Pernkopf atlas in oral and maxillofacial surgeons' current practice and (2) determine whether a proposal of four conditions would provide ethical guidance for use in surgery and education.

METHODS

Members of three American oral and maxillofacial surgical societies (ACOMS, ASTMJS, AAOMS) were surveyed and 181 responses collected. The survey introduced the historical origin of the Pernkopf atlas, and respondents were asked whether they would use the atlas under specific conditions that could be a recommendation for its ethical handling. An anatomical plate comparison between Netter's and Pernkopf's atlases was performed to compare accuracy and surgical utility.

RESULTS

Forty-nine percent of respondents were aware of the Pernkopf atlas, and 9% of respondents were currently using it. Amongst those aware of the historical facts, 42% were comfortable using the atlas, 33% uncomfortable, and 25% undecided. The four conditions involving disclosure, bioethical and religious considerations, and remembrance led to 75% of those "uncomfortable" and "undecided" becoming "comfortable" with use.

CONCLUSIONS

Amid recent developments and controversy regarding the Pernkopf atlas, a proposal detailing conditions for an ethical approach may provide guidance in surgical planning and education. Furthermore, this approach has implications for the future preparation and publication of anatomical atlases and their use.

Against the use and publication of contemporary unethical research: the case of Chinese transplant research

Recent calls for retraction of a large body of Chinese transplant research and of Dr Jiankui He's gene editing research has led to renewed interest in the question of publication, retraction and use of unethical biomedical research. In Part 1 of this paper, we briefly review the now well-established consequentialist and deontological arguments for and against the use of unethical research. We argue that, while there are potentially compelling justifications for use under some circumstances, these justifications fail when unethical practices are ongoing-as in the case of research involving transplantations in which organs have been procured unethically from executed prisoners. Use of such research displays a lack of respect and concern for the victims and undermines efforts to deter unethical practices. Such use also creates moral taint and renders those who use the research complicit in continuing harm. In Part 2, we distinguish three dimensions of 'non-use' of unethical research: non-use of published unethical research, non-publication, and retraction and argue that all three types of non-use should be upheld in the case of Chinese transplant research. Publishers have responsibilities to not publish contemporary unethical biomedical research, and where this has occurred, to retract publications. Failure to retract the papers implicitly condones the research, while uptake of the research through citations rewards researchers and ongoing circulation of the data in the literature facilitates subsequent use by researchers, policymakers and clinicians.