THE DEVELOPMENT OF MEDICAL ILLUSTRATION

THE DEVELOPMENT OF MEDICAL ILLUSTRATION

By CLIFFORD SHEPLEY, D.A.(Edin.) Frotn the Departnrent of Surgery, University of’ Edinhirrgh

PICTURES speak an international language. Their messages can cross all boundaries of nationality and age. There are no “ strange ” expressions in illustrative pictures, no language difficulties. When carefully prepared, each picture or diagram can tell its story to anyone.

Medical illustration has existed as a recognised profession for little more than fifty years. It is a highly technical but limited field of applied art. I n the United States, where it has been most highly developed, its trained practitioners number about one hundred ; in this country there are about thirty medical artists. Previously most pictures in medical textbooks and journals were prepared by untrained, self-taught artists, skilled in ordinary technique and efficient enough in general art, but knowing little or nothing of medical matters. Since there were no others available, generally speaking, illustrations in the medical literature were of poor quality, even when compared with illustrations in such non-medical publications as periodicals and story-books of the same period. The draftsmanship was generally amateurish, the object ineffectually presented and frequently inaccurate in its anatomy and topography. Quite evidently the object was not properly understood by the artist, and in most cases the medical author was unable to help. He could see that something was wrong. but his efforts to suggest corrections usually made matters more confused. I t must be acknowledged that the anatomical atlases were notable exceptions. They were costly volumes, generally of an earlier period. They were beautifully illustrated, the earlier by elaborate copper and steel engravings, then later by lithography, and many of the illustrations were in colour. Much of their beauty is due to the exquisite technique of the engraver or lithographer, and not solely to the artist who drew the originals. The same is true of the really fine wood engravings of the early textbooks. The photo-mechanical method of reproduction ended this period, and cheap reproduc- tions and poorly made drawings made their appearance.

Since the days of Eustachius there have been medical men, surgeons, and anatomists who were also very capable artists. In many cases they prepared their own illustrations, and in others they produced the working drawings from which the final picture was engraved. Names that occur to one include Albinus. Peter Camper, Antonio Scarpa, Cheselden, and the celebrated Sir Charles Bell. I n more recent times there may be mentioned Sappey, Lord Lister, and Sir William Richard Gowers, all eminent in their own profession and all having the artistic talent to produce illustrations for their own publications.

Medical artists may still encounter medical men with this dual ability, the ability to set down on paper in easily understood drawings their surgical and anatomical knowledge. Such drawings are of the utmost value both in themselves and as an aid to the hard-pressed medical artist, who naturally lacks the surgeon’s professional experience and may at any time be confronted with a problem which he will have the greatest difficulty in solving alone.

It is often asked, will photography not male the labours of the medical artist 70

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unnecessary ? Photography is of the greatest value for making faithful records of external lesions of the more dramatic aspects of surgery and of clinical appearances. It is useless to attempt to compete with the camera in the realistic or imitative field, but photography has its limitations, and it is not hard to see where and why it falls short. It is not selective, it can record faithfully only what is placed before it, and-to give an instance-at present it is useless for reproducing quickly changing endoscopic views. The medical illustrator has come to regard the photographer not as a rival to be feared but as a helpful co-worker.

The medical artist has to evolve a quite different kind of picture, one that will show far more than any photograph can ever do, and at the same time lay emphasis on essential points that require to be demonstrated. To make such a picture successfully is difficult. The artist must understand his subject thoroughly from every standpoint-anatomical, histological, pathological, surgical, and topographical. From this accumulated knowledge is formed a mental picture, from which emerges the arrangement of the future drawing. This visual planning should always precede the actual drawing on paper; it follows, therefore, that the planning of the picture is the all-important matter, not the execution. A medical picture may even be entirely synthetic, and yet be drawn with convincing realism. To be able to make such a picture the artist must know his subject so thoroughly that he can visualise a clear mental picture, complete in all its details. He must, of course, be fully equipped technically to reproduce this imaginary image on paper, quickly and accurately. That is medical illustration at its best.

All important techniques must be mastered in order to make original drawings or paintings acceptable to the medical author, to the blockmaker, and to the publisher. The technique to be used in any particular case is usually a matter of choice, influenced to some extent by the subject of the illustration and the author’s requirements. Half-tone, water-colour, oil, lead pencil, simple or elaborate pen-and-ink, or a combination of these may be employed. It must always be remembered, however, that technique, artistic feeling, accurate draftsmanship, neatness, and speed are all of relative unimportance. It is the initial planning of the picture and the registration of the scientific facts that give the drawing its value.

Everything else being taken into consideration, pen-and-ink technique is by far the most useful (Fig. 1) ; it may be either simple or elaborate to meet the requirements of the subject and the author : and of equal importance, a line drawing costs much less to reproduce, and is not easily ruined by inferior reproduction, which may happen to half-tone and colour work.

As a rule, a simple outline drawing is more difficult to prepare than an elaborate plastic picture ; the subject must be reduced to its absolute essentials, and every line must convey its message. It is one of the most useful and eloquent types of medical illustration. Much information, explanation, and analysis can be crowded into a diagram. Diagrams can be prepared to show variations of form, of relationship, of motion, of pressure, of tension, of rupture, of the development of a pathological process, of the sequence of operative steps, and of the placing of ligatures and sutures ; i n short, every clinical phenomenon, every operative procedure can be shown in simple dramatic outlines. Such a drawing may be stripped entirely of all form and structure; it relies for its message on well-chosen key words, figures, and numbers, connected by lines and rendered more expressive by the addition of such symbols as arrows, loops, rings, and the like. The time element can be shown graphically,

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as may cause and effect, and the stages of a disease or of an operation. The use of “ manikin” or “matchstick” figures are also of considerable value as an aid i n medical teaching (Fig. 2). The most instructive pictures can be made in this way. The successful production of a good line diagram holds the secret of the correct conception of a’medical illustrati& ;

n and it is The basis of all such creative drawing.

FIG. I Simple line drawings in Indian ink.

The essentials, the foundations, are there, and when necessary, it is comparatively simple to build on this structure to clothe its contours, to elaborate form and surface texture (Fig. 3).

The beginner in medical art generally finds the greatest difficulty in adjusting himself to its very precise requirements ; moreover, his anatomical knowledge i s quite inadequate. He is confident of being able to draw what he understands, but finds it exceedingly hard to plan a picture so that anyone can understand i t . I t is difficult to select the most appropriate viewpoint, to decide what to show and how to present it, what to emphasise and what to subdue or leave out. By means of rough sketches, no matter how simple or crude, or by demonstration on the specimen, the author for whom the drawing is being done can frequently clarify the position and save much time and heartache for the artist. This again demonstrates very clearly that the initial conception of a picture is the all-important thing, not the plastic


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FIG. 2 The use of .’ manikin *’ figures and other symbols to demonstrate facts

which cannot otherwise be shown.


Fiti. 3 Detailed ink drawing of specimen.


elaboration, the realism, or the technical finish. Another valuable aid is the observation and examination of the various structures of the human body, until the artist is quite familiar with the different textures and qualities of normal and pathological tissues. This naturally cannot be done in the operating theatre, but must be studied in the dissecting room or at autopsy. Hand, brain, and eye must work together to obtain the information which, mentally assembled, is the forerunner of the subsequent picture on paper. There is no easier way, at least for the beginner. If the artist has made sure of his facts, his drawing shows it. I t is a truer, bolder, better picture, and is done usually with greater speed.

In the past the medical profession has been too frequently prepared to accept work which betrays lack of understanding of the subject and the means by which it can be most effectively presented. Until comparatively recently, the prevailing low standard may have been due to a failure to acknowledge that medical illustrating is a task of the specialist, To-day there is a growing recognition of the value of the trained medical artist, and an appreciation that his is an intricate highly specialised form of art, which requires for its mastery systematic study over a period of from two to four years, or even longer, according to the talent, speed, and preliminary training of the novice. The problem of providing adequate training has not yet fully been solved. The majority of medical illustrators in this country, although well trained in fine art, are obliged to undertake their professional work without benefit of formal instruction in medical and surgical subjects. Some of these artists, aware of this handicap and feeling inadequate for their daily duties, have pursued these most essential studies through their own initiative. Every medical artist worthy of the name realises that eventually he has to know the whole human body and the whole field of medical illustrating before he can discover the branch for which his special talent and his chief interest and inclination fit him best. A medical student does the same, and for the same reasons. But an even more important reason is that in the majority of institutions the medical illustrator has to serve many departments and be prepared to draw all types of pictures in every known technique.

Among the many difficult problems that confront the medical artist, one of the most exacting is the accurate presentation of anatomical relationships. In an illustration of a particular condition, in order to give it its greatest instructional value the artist must continually make comparisons with the normal. By this means he recognises and emphasises important deviations from normality, and so gives to his drahing or diagram of the pathological specimen, the case seen in the ward, or the steps of a surgical procedure, its teaching value.

Many structures in human anatomy show a very wide range of variability ; an average or ‘I normal,” resulting from the resolution of many different observations, can provide a basis which will give the illustration its widest application. The standard anatomy books and atlases, with their accumulation of detailed information on the structure of the human body, are indispensable to the medical illustrator. In certain specific instances they may differ in their presentation of anatomical relationships. In preparing his ‘‘ normal,” the illustrator makes many comparisons by referring not only to anatomy books but when possible also to the cadaver and to the living subject.

While making a drawing the conscientious artist has a way of discovering gaps in contemporary knowledge, gaps that can be filled only by original research and


investigation to clear up the obscure points. It is here that the author concerned can be of considerable assistance ; material and facilities for its examination can be supplied and the problem investigated. In this way original work and discoveries of value to the medical profession have been made by the medical illustrator. Some three years ago a valuable piece of original research on " The Development of the Cranial Arteries in the Human Embryo " was contributed by an American artist, D o r m Hager Padget (1948). Max Brodel, of international fame as a medical artist, is the outstanding example of this facility. He was not only a wonderful draftsman. he had a wide knowledge of anatomy and was a born investigator. While working with Dr Howard Kelly at Johns Hopkins, Baltimore, Bradel (1914) did some original

FIG. 4 Half-tone " Ross Board " drawing of kidney, with ink drawing of the same specimen.

research on the vascular supply of the kidney. He demonstrated the avascular iirea on the posterior margin, and first suggested splitting the kidney along this line in nephrolithotomy.

I n his early days as a medical artist, it was Brodel, ever striving to make himself more fitted for his task and to make his drawings better and truer in texture and detail, who began to experiment with different types of paper and drawing materials. He eventually selected a paper with a chalk surface having a granular texture, and with this he evolved his own very personal technique.

On this paper, known to-day as " Ross Board," the structure and detail of the subject can be worked up to a degree unattainable previously (Fig. 4). Ordinary half-tone, colour, pen-and-ink, or a combination of these may be employed. The drawing may be made with the utmost detail and fidelity, or it may be the simplest diagram. The chalk surface permits modifications and erasures of the original conception to be made during the progress of the drawing without affecting its final appearance, a great boon to the harassed artist. The only media for which i t is not suitable are ordinary graphite pencil and crayons, where the greasy base, unless very cautiously applied, tends to clog the surface, restricts the depth of tone, and gives an unpleasantly shiny appearance to the picture. When properly used,

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.* Ross Board” technique gives to the resulting illustrations a depth of tone, a freshness and sparkle, an accuracy of detail and of texture of the various tissues which is unobtainable by any other method (Fig. 5).

In 191 I the first school for the teaching of medical illustration-or art as applied to medicine, as it was called-was started at Johns Hopkins Hospital under the

FIG. 5 Sheet of half-tone ‘I Ross Board ” drawings showing th: stages of an operative

procedure: Indian ink has been used in places for emphasis.

guidance of Brodel. Brodel’s pupils assimilated not only much of his technique and skill, but also acquired the same enthusiasm for and love of their work. Many of the most capable medical illustrators alive to-day received their training in this school or under the tuition of one of its graduates. The article published by Brbdel in 1941 just before his death gives an excellent survey of his methods of teaching and of his technique.

The success of the school has been outstanding.

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Good illustrations in a medical article or book may be likened to a striking window display in an enterprising shop ; they attract the attention. Passers-by stop, look, and then enter. In the same way medical readers, scanning over innumerable publications, may be attracted to an article by its clear and understandable pictures, and then pause to study further the accompanying letterpress. Moreover, just as a clear and well-presented illustration is of the greatest value both in teaching and for the demonstration of facts and hypotheses, so will a bad or inaccurate picture detract from the value of an otherwise admirable article.

In the last fifty years great advances have been made in all fields of human endeavour, and not least in those of medicine and surgery. The time was ripe for improvement in medical illustration. The first and second world wars were considerable factors in drawing attention to the value of the medical illustrator. During both wars, artists worked in the field, in casualty hospitals, and in research centres. The acceleration of research in new treatments and in the development of new surgical techniques in handling war casualties brought about an increased demand for the services of the trained medical artist. This demand is still present, imposed by the continual advancement in surgery and medicine, and by the constant need for fresh illustrations. The value of the artist is coming to be recognised and appreciated i n all the various aspects of medical learning.

REFERENCES BRODEL, MAX ( 1914). In Kelly, H. W., *' Diseases of the Kidneys, Ureters, and Bladder," I , 194, 513,

__ ( I941 ). J . Amer. /tied. Ass., 117, 668. PADGET, DORCAS H. ( 1948).

533, 543. (New York : D. Appleton & Co.)

Carnegie Institute of Washington Publication 575, " Contributions to Embryology," 32, 205.

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THE DEVELOPMENT OF MEDICAL ILLUSTRATION