A Palestinian surgeon, a Jewish patient, a Nazi medical text — and an unlikely bond.

This article by Isabel Kershner appeared in The New York Times, May 12, 2020.

JERUSALEM — The explosion flung him skyward, legs first, before he crashed to the ground.

Dvir Musai was 13 when he stepped on a mine. Dr. el-Haj operated on him years later. Credit: Dan Bality for The New York Times

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,” Mr. Musai, now 31, recalled.

Decades of agony followed. Mr. 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 Center 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, Dr. 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.

Mr. Musai’s mother, Chana, had lost relatives in the Holocaust.

“She said, ‘If it can help now, we’ll use it,’” Mr. Musai recalled.

That gut-wrenching decision went to the heart of a longstanding 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.

Dr. el-Haj with a copy of the textbook, and anatomical atlas by Eduard Pernkopf. Credit: Dan Bality for The New York Times

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, in which doctors treat problems like chronic pain caused by nerves that are damaged or trapped.

Dr. 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, Dr. 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, Dr. 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.

Dr. Hildebrandt took on Dr. 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, Dr. Mackinnon and Mr. Yee found that 59 percent of the 182 respondents were aware of the Pernkopf atlas, 41 percent had used it at some point and 13 percent were currently using it.

But the debate is hardly settled.

The origins of the cadavers used for the book have caused a dilemma for surgeons. Credit: Dan Balilty for The New York Times

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.”

Dr. 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, Dr. 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, Dr. el-Haj returned to Jerusalem with his own Pernkopf volumes in August 2018.

Around the same time, Mr. 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 Dr. el-Haj.

From his days as a medical student at Hadassah, Dr. el-Haj, 40, remembered Mr. Musai as an angry teenager in terrible pain who harbored a hatred of Arabs.

Mr. 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,” Mr. 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, Dr. 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.

“It sounds like a good joke,” Mr. Musai said. “The Muslim surgeon with the Nazi atlas operating on a Jew.”

The lives of Dr. el-Haj and Mr. Musai have since become intertwined.

Mr. Musai has visited the doctor’s family in his village. And when Dr. el-Haj’s mother was hospitalized at Hadassah, Mr. Musai, who now works as a guide there, visited her. Dr. el-Haj has taken his children to visit the Musais in their West Bank settlement, too.

Dr. el-Haj said he had used the atlas in about 90 percent 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.”

Top photo: Dr. Madi el-Haj outside Hadassah Medical Center. Credit: Dan Balilty for The New York Times