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Journal of Audiovisual Media in Medicine, Vol. 20, No. 1, pp. 5-10
A notable anniversary in the history of medical illustration KATHY McFALL
The author argues that medical illustration is not a cross-cultural phenomenon known since ancient times, but a modern tradition born out of the intellectual climate of 18th century Europe. In this climate, photog- raphy was always desirable in theory, and medical illustrators grasped photographic technology as soon as it became available in the 1840s. quickly adapting it to their own purposes. The earliest surviving clinical pho- tograph can be identified as that of a woman with a goitre taken by Hill and Adamson ca. 1847, in which case medical photography has this year reached its 150th anniversary. The author also offers a revised account of the speed and enthusiasm with which early medical illustrators recognized the opportunities afforded by new forms of technology.
It should be remembered that nothing in Nature stands alone; but that every art and science has a relation to some other art or science, and that it requires a knowledge of these others, as far as this connection takes place, to enable us to become perfect in that which engages our particular attention.
John Hunter
Despite the views of eminent authorities such as Olleren- shaw and Maingot,' I believe it is a mistake to assume that graphic illustration has always supported the practice of medicine. Pharaonic Egyptian medicine, for example, was a holistic tradition in which ailments were treated with prayers and supernatural intervention as well as with surgery and drugs.* However, physical treatment focused on insubstantial vessel^,^ and there was no word, in the Egyptian language for studying observable features of the body.4 Anatomical knowledge was disseminated in the form of lists rather than diagram^;^ eleven major medical texts are known from pharaonic Egypt - covering topics as diverse as gynaecology, tumours and dental problems - but none was illustrated, and there can be little disagreement with Reeves' conclusion that:
lished archetypes,8 and contingencies such as disease and suffering were portrayed only rarely, as incidental details within scenes drawn mainly from literature and religious tradition.
There may be an ancient tradition of medical illustration apparent in the work of the artists of classical Greece, who used observational themes in decorative arts; Aristotle, for example, is believed to have used drawings in anatomical teaching, and by the 4th century BC diagrams illustrating medical matters were created by Hellenistic anatomists studying in Alexandria in Egypt.' This tradition was subsequently embodied in the medicine of the Roman Empire, principally through the works of Celsus (fl. AD
15-65) and Galen (AD 129-ca. 200). However, the advent of Christianity, and subsequently the Church's domination of book production, shifted the focus of intellectual endeavour from the body to the soul.1o Thereafter, accord- ing to Maingot:
We do not find any authentic anatomical illustration depicting diseases until the Renaissance, when both medicine and art had a glorious rebirth."
Medical texts from Mediaeval Europe are notably disinter- ested in anatomy, slavishly repeating Galen's archetypes. l 2
It was only when 15th-century artists began to question his authority and rediscover earlier classical traditions that observation of form again came to the fore in European art. There is evidence to suggest that Raphael and Michelangelo performed dissections, whilst Leonardo da Vinci (1452-15 19) published revolutionary anatomical studies. Although Leonardo was interested in the study of propor- tion for artistic ends rather than in anatomy for its own sake,13 his work foreshadowed the artistic milestone of Vesalius' De Humani Corporis Fabrica (1543) - the first complete and systematic description of the human body produced in modern Europe (Figure I). Vesalius acknowl- edged that the 670 pages of text were secondary to the 186 plates, which were both accurate in terms of observation and artistically superb.I4
Nevertheless it would be wrong to conclude that these early
. . . the artist and physician never combined their forces and it would be purely conjectural to imagine otherwise.6
v
More generally, pharaonic art had only a limited interest in human anatomy:7 figures were drawn according to estab-
anatomists were pioneering our modern tradition of medical illustration: to understand their work we must consider the intellectual climate of 16th-century Europe. This was a
General Hospital, 1053 Great Western Road, Glasgow GI2 OYN, UK. and Shakespeare - but also one which accepted the Kathy McFall, MSc AIMI, Medical Illustration Manage6 Gartnavel Of achievement - in Britain, the age Of Bacon,
0140-51 1X/97/010005-06 0 1997 Institute of Medical Illustrators
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Figure 1 Frorri Vesalius’ De Humani Corporis Fabrica 115431.
conimonplxe cu\teiicc ot iiiagic ‘incl mil ,iclc\. and belie\ ed that the dim ot knowledge \ h a \ to i~ndei~t~inrl God’$ created ordei ‘I‘herefoic the \tiid\ ot Man w~ divmunted a5 d
legitiiiiatc wbjcct in i t w i t . ’ ’ The uorld u c i \ ’ f u l l of hidden rnemng\ ‘M ‘iitinp ctectpherment’.’6 and \cholars were
guided by the belief that all God’s creatures were made to resemble each other. Paracelsus of Beme (1493- 1541 ) maintained that a man’s face is a map of the sky whose orifices correspond to the planets;” Paracelsus, however, was no simple mystic, rather he was the most brilliant contempo- rary of Vesalius, and a celebrated writer on surgery, pharmacology and therapeutics.’* Another contemporary, Pierre Belon. produced the first great work of comparative anatomy, Histoire de la Natiire des 0iseau.x (1555), to show how similarities between avian and human skeletons demonstrate the resemblance of God’s creatures.” Later generations of scholars developed this seemingly bizarre metaphysics for two centuries more, and Vesalius himself remained a committed student of Galen, who abandoned his anatomical studies because of opposition from his peers.
By the end of the 18th century, however, belief in resemblance had been tempered by the revolution in ideas which we now term the Enlightenment. The heart of this re\dution was acceptance of the idea that the universe was governed by natural laws, which left no room for divine intervention.’” In science it was manifest in the belief that the universe was not infinitely mysterious, but that every- thinp in it could be described by rational investigation. However. the rational study of Nature demanded accurate observation, and physicians especially began to require accurate records of detailed research. It was in this intellectual environment that photography first became thinkable: science demanded a precision beyond the skills of any human artist, and researchers began to imagine how they could manipulate ‘Nature’s own pencil’ - light - to hamess undistorted images. As a result, the first inkling of the modern tradition of medical illustration can be seen in the 1733 publication of William Cheselden’s Osteogruphia, which contained 56 copper-plate illustrations drawn by the author with the aid of a camera obscura (Figure 2).
Early European clinical photography
The first workable photographic processes were reported to the French Academy of Sciences in January 1839 by the
Figure 2 From William Cheselden‘s Osteographia (1733).
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physicist Arago, who outlined the work of Daguerre and Niepce. Fox Talbot had also been developing photographic techniques and patented the talbotype (later known as the calotype) in 1841; although Daguerre’s process enjoyed considerable popularity for a time, modem photography stems directly from the work of Fox Talbot. Inevitably, the new science was soon adapted to medical subjects: as early as 1845 Alfred DonnC published Cours de Microscopie, illustrated with engravings of 86 photomicrographs made using Daguerre’s techniques.’l The earliest photographs of clinical interest were the work of portrait photographers or even some interested clinicians: from the 1850s British and American medical journals regularly carried items on photography for readers who were enthusiasts.” All these photographers employed artistic conventions derived from portraits and domestic scenes in order to represent doctors, patients and their treatments, as a result of which medical pictures of this early period seem little different to those depicting society in general;23 €or example, a patient’s social class can usually be deduced from his or her dress, demeanour and surroundings. Gurtner has gone so far as to remark that:
Images of the appearance of disease and of patients from the early days of photography are not known and probably were never made. The technical pre-
Figure 3 Woman with goitre. The earliest-known medical photograph, by Hill and Adamson ca. 1847 (The Scottish National Portrait Gallery).
requisites for such images were first available through the discovery of the anastigmatic lens (1889) and of the high-sensitivity negative.34
His conclusion, as we shall see, is too sceptical, but many fundamental conventions which distinguish clinical photo- graphs from other depictions of medicine (or indeed from any other sort of picture) - such as respect for patients’ anonymity, omission from the frame parts of the body which were not diseased, and elimination of indications of social class - were not common until the 1890s.
Broadly defined, modern medical photography embodies many techniques including specimen photography, public relations photography and portraiture; of specific interest in the present article, however, is clinical photography, in the sense that a clinical photograph is one in which the appearance of a disease is its principal subject. Given the problems of distinguishing early medical photographs from other images, it is not surprising to find a lack of agreement amongst authorities as to when the first clinical photograph was taken. However, it is this author’s belief that the earliest known example is a calotype depicting a woman with a large goitre taken by Hill and Adamson in Edinburgh and dated ca. 1847; the calotype is now in the Scottish National Portrait Gallery (Figure 3). The worlung partnership of Hill and Adamson is one of the most famous in early photographic history: during the period 1843-1847 they produced hundreds of calotypes, most of them portraits illustrating the different professions and social classes of Scotland. Compar- ing the calotype in question with others taken by Hill and Adamson shows it to be quite distinct from their typical portraiture, in which the formal artistic arrangement and lighting of the sitter was the main consideration (Figure 4);
Figure 4 Unknown woman, Portrait by Hi / / and Adamson contemporary with Figure 3 (The Scottish National Portrait Gallery).
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X K . McFal i
this particular image, however, is frontally posed creating a detached and observational impression. This does indeed suggest that the goitre was the principal photographic subject. Wilson has even suggested that the photograph was commissioned by Dr James Inglis, although the only evidence for this is the coincidence of the facts (a) that Hill and Adamson had taken a portrait of the doctor, and (b) that he had a specialist interest in goitres.25
In Berlin in 1852 Hermann Wolff Berend began to use photography routinely to document orthopaedic cases pre- and post-treatment (Figure 5);26 in 1855 he published the first major academic paper on clinical photography.” At the same time, Hugh Welch Diamond of the Surrey County Asylum in Twickenham was photographing patients in order to evaluate the physiognomy of insanity.28 Diamond was a founder member of the Royal Photographic Society, and in 1852 had established a darkroom in the asylum. He issued a set of clinical notes illustrated with photographs in 1854, though n o copies have survived.29 G. B. Duchenne of Boulogne photographed patients undergoing electrical stim- ulation of individual muscles as early as 1852 or 185f1,~’ and the first widely published clinical photographs were case illustrations in the second edition of his L’Electrisafion Localis& ( 1862).
At a demonstration of his techniques in 1853. Berend lauded:
[The] use of photography for descriptive pathology whose ability to repre5ent nature faithfully 15
beyond doubt in areas which earlier diagrams, plaster casts etc. 01 erlooked or left open to q ~ e s t i o n . ~ ’
Immediately I understood that the method had now been found which would make the long-perceived defects of limited, unrealistic images irnpossibk3*
The same sentiments were echoed slightly later in the United States by Surgeon John Brinton, curator of the Army Medical Museum.33 In 1856 a report in the Journal qf Photographic Science offered a glowing account of Dia- mond’s paper to the Royal Society concerning his own work:
The metaphysician and moralist, the physician and physiologist, will approach . . . an inquiry with their peculiar views, definitions, and classifications. The photographer, on the other hand, needs, in many cases, no aid from any language but his own, preferring rather to listen, with the picture before him, to the silent but telling language of nature . . . The photographer catches in a moment the permanent cloud, or the passing storm or sunshine of the soul, and thus enables the metaphysician to witness and trace out the connexion between the visible and the invisible in one important branch of his researches into the philosophy of the human mind . . . Photog- raphy . . , confirms and extends this description [of the physiology of insanity], and to such a degree as to warrant the conclusion that permanent records thus furnished are at once the most concise and the most comprehensive.34
It seems apparent, therefore, that the work of Berend and Diamond in the 1850s already anticipated the modern distinction between objective clinical photography and conventional portraiture.
In his 1855 paper he reacted euphorically to the potential benefits of the development of photographic technology for medical illustration:
Early American clinical photography
In a series of articles on early medical photography in America (1839-1883), Burns has attempted to establish that:
American physicians used photography before any- one else to record and document disease and to show surgical results . . . Thus in the area of medical photography, nineteenth century American physicians were ahead of their European colleagues.3s
His argument is based on the observation that previous works on the history of medical photography have estab- lished a gap in the record of development: the emergence of photomicrography can be traced during the period of 1839-1 845, but then there were no significant develop- ments until 1852 when Berend and Diamond began their work. During the same period, however:
Figure 5 Woodcuts after photographs by HW Berend ( 7 859).
America produced more and better daguerreotypes and employed the medium more widely and for a longer period of time than any other nation.3h
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A notable anniversary 9
Burns’ research has uncovered woodcut illustrations based on clinical daguerreotypes, which appeared in print from 1849 onwards - with the suggestion that some were taken as early as 1848 (the present author is not aware that such extensive research has been undertaken in the United Kingdom). Examples include an article published in 1850 in the American Journal of Dental Science by one R. Thompson, with accompanying photographs of the left superior maxillary bone taken in Columbus, Ohio and dated 1848; in the Philadelphia Medical Examiner of 1 April, 1851 an article by Charles Gilbert was illustrated with photographs taken in 1849 and 1850. A portrait of a patient by Gurdon Buck possibly taken as early as 1845 was published in the American Journal of the Medical Sciences: this daguerreotype recorded the post-operative appearance of the patient three days before discharge from the New York Hospital,37 but it conforms to none of the conventions we would now expect of a clinical photograph, and is probably a conventionally posed portrait (Figure 6). Moreo- ver, the surviving copies of the daguerreotype and engrav- ing were not actually published until 1876 in Buck’s Contributions to Reparative Surgery (the original journal is no longer available for consultation): this book has many examples of Buck’s work, all of which otherwise date from 1862 or later. In view of Berend’s career, it strains the evidence to agree with Rogers that Buck was the first surgeon to use pre- and post-operative patient photography routinely.38 In fact Rogers generally overstates Buck’s primacy: for example, he maintains that he should be recognized as the first man to photograph plastic surgery
Figure 6 Woodcut after daguerreotype by Buckca. 1845.
routinely; however, in 1863 the Hungarian Janos Balassa published New Operative Methods of Nose Reconstruction illustrated by plates which included the earliest documented photographic record of a reconstructive series.’9
Other American medical photographs from the 1840s are not strictly clinical images: a group of daguerreotypes from 1847 showing pre-operative etherizations: a photograph of surgery taken by Southworth and Hawes dated some time after March 1847; a daguerreotype showing the dissection of a corpse as early as 1844 or 1845. However, these were intended to illustrate techniques or equipment, and so the specific details of the disease or the patient were irrelevant. Therefore, Bums’ conclusion seems unacceptably emphatic: even if Buck’s doubtful early daguerreotype is taken into account, there is still no evidence of a clinical photograph stricto sensu which can be dated earlier than Hill and Adam’s calotype, nor to suppose that anybody routinely employed clinical photography before Berend and Diamond. It would be more straightforward to conclude that analogous developments took place on both sides of the Atlantic, and that unequivocal evidence of experimentation in both Europe and North America means that the supposed break in the course of development between 1845 and 1852 can no longer be retained.
Conclusion
This brief account of the earliest history of medical illustration suggests that it is a relatively modem tradition born out of a fundamental transformation of the intellectual climate of the 18th-century Europe. Photography has always been a crucial aspect of this tradition - initially as a theoretical aspiration, but since the 1840s as a powerful illustrative tool. Pioneers in Europe and North America were quick to appreciate the clinical potential of photog- raphy, and developed many routine medical applications within 15 years of Arago’s initial description of the new technology. The professional conventions which character- ize clinical photography are first apparent in the calotype of a woman with a goitre gaken by Hill and Adamson c. 1847 in Scotland; in other words, medical photography has reached its 150th anniversary. What more fitting time for British medical photographers to reflect on the history of their discipline, if only to realise how successfully their forebears responded to the advent of revolutionary technol- ogy? Perhaps this is also an appropriate moment to consider what we must do to ensure that henceforth medical illustration is recognized by policy-makers for what it certainly is - a mature and intrinsic aspect of modern medicine in the United Kingdom.
Acknowledgements
The present article is derived from the text of an MSc thesis submitted to the University of Wales College of Medicine; I would like to record my thanks to my thesis supervisor, Steve Young, University Hospital of Wales, for his help and advice. Also to Bill Manley, University of Edinburgh: and to
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Michael Rho&, from the Oti\ Histoncal Archives in Washington. USA. who obligingly allowed me to conwlt l i ir uiipubli\ht 'J papei on the Ann) Medical Muwurn
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