VIEWS FROM THE PAST

The paintings of pathological anatomy bySir Robert Carswell (1793-1 857)

Arthur Hollman

Robert Carswell MD (fig 1) was a talentedwater-colour artist who created the finest andlargest collections in Britain of illustrations ofpathological conditions. He became a medicalstudent in Glasgow in 1814 and it was therethat he made his "first attempts to represent,by coloured delineations, the healthy and dis-eased appearances of the human body".' Hedid these while attending the lectures of JamesJeffray (1759-1848) the professor of anatomyand physiology who encouraged him todevelop his skills. His ability then came to thenotice of Dr James Thomson (1765-1864),one of the foremost Edinburgh physicians ofthe time, who employed him to make illustra-tions of pathological specimens. For this pur-

pose he went in 1822 to France where thesupply of material was unrivalled and whichwas then in a period of unprecedented bril-liance in pathological research.2 After twoyears in Paris and Lyons he returned toScotland and by 1826 he had made an impres-

Correspondence to:Dr A Hollman, Departmentof Medicine, UniversityCollege London MedicalSchool, 5 University Street,London WC 1E 6JJ.Accepted for publication11 April 1995

Figure 1 Portrait of Sir Robert Carswell. Artist andsource oflithograph unknown. (Reproduced by kindpermission of the President and Council of the RoyalCollege of Surgeons ofEngland).

sively large collection of about 1200 illustra-tions, mostly in water-colour, for DrThomson's lectures on the practice of physic.He took the degree of MD at Aberdeen in1826 and then returned to Paris to studyunder the celebrated physician Pierre C ALouis, and to continue his artistic work. Whilestill there he was appointed in 1828, at the ageof 35, as the first professor of pathologicalanatomy at University College London. TheCollege Council then commissioned him tomake a collection of illustrations for theirmuseum and he stayed in Paris for anotherthree years. By the time he returned in 1831he had completed over 1000 pictures that weresaid at the time to be unequalled for their"artistic skill and accuracy of delineation andcolouring".3 They were also among the last tobe done before the study of morbid anatomywas revolutionised by the introduction of themicroscope. It is this collection which is nowdescribed.

The illustrationsThese are nearly all painted in water-colourwith just a few in pen and ink. They range insize from 4 cm x 4 cm to 45 cm x 30 cm.Most of them are of pathological specimensand some of these are shown in situ at post-mortem examination. Others are of livingpatients, with pictures of the whole body aswell as selected areas, such as the arm or face.The artistic quality is high and they are wellpreserved with little foxing of the paper. Theyare arranged in 17 sections and the number ofpaintings in each section is given in brackets:heart and blood vessels (98); breast and glan-dular system (42); larynx, tongue, thyroid(56); lungs, pleura, bronchi (146); brain,spinal cord (99); organs of locomotion (23);oesophagus, stomach (76); intestines, peri-toneum (109); liver, spleen, pancreas (81);skin (60); urinary system (58); generative sys-tem: male (16); generative system: female(74); venereal disease (33); new formations(33); wounds and injuries (21); miscellaneous(9). The total of 1034 includes 24 paintingsmade in London after 1831.Many of the paintings have a description of

the pathology written in Carswell's own hand,and some also have the clinical history of thepatient. These notes by Carswell were later

Br Heart _7 1995;74:566-570566

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The paintings ofpathological anatomy by Sir Robert Carswell (1793-1857)

copied into bound volumes. The entire (

tion is housed in the DepartmejManuscripts and Rare Books in the librUniversity College London, and it is desin detail by Reckert4 in his book on Cars

HEART AND CIRCULATIONThere is a good range of cardiac and vapathology in this section. There are sexamples of pericardial disease. One is latubercular pericarditis which at that tinyears before Robert Koch discovered thelus, would have been diagnosed from e

ated lesions. There is a fine painting ofpericardial effusion with tremendoustion of the right atrium and superiorcava, entitled "dropsy of the pericardAnother is of "bone in pericardial adhespossibly a case of constrictive pericaRheumatic heart disease is of course weresented with examples of mitral, aortitricuspid valve disease, but surprisinglyare no paintings of acute rheumatic end(tis. Three paintings are labelled "warty ecences" and look like infective endocaOther instances of cardiac infection inclabcess at the apex of the heart and hcysts in the wall of the left ventricle, tthere are no gummata. Naturally, hothere are some striking examples of syraortic aneurysm, one with perforationoesophagus. There is a perforated aorticwithout endocarditis. The painting la"polypus of the heart" (A 5) is clearlyatrial myxoma. Congenital heart diseshown only six times, twice in adults, arreflects the paucity of examples in childthe collection as a whole. Although Caattended two childrens' hospitals in Parifare only 15 paintings from them. Was t

Figure 2 "Ossified semilunar valves". Painting A 532 in the Carswell collection.(Reproduced by permission of the Librarian, University College London).

collec-nt ofrary ofcribed-well.

iscularseveralibelledne, 50bacil-associ-a largedilata-r venalium".,ions",irditis.11 rep-c, andthere

)cardi-xcres-irditis.ade anydatidhoughwever,,hiliticof the

Figure 3 "Schirrhus or cancer of the heart". PaintingA291 in the Carswell collection. (Reproduced by permissionof the Librarian, University College London).

valve reluctance to do necropsies in this age group?belled An unusual example of the tetralogy of Fallota left is called "partial obliteration of orifice of pul-ase is monary artery" and there is a good illustrationid this of pulmonary valve stenosis, and two paintingslren in of young cyanosed patients. There is a fineirswell demonstration in an adult of the arterials there system in coarctation of the aorta, "contrac-here a tion of aorta", and a specimen from a man of

50 (A 532) that shows calcific aortic stenosisin what may be a congenital bicuspid aorticvalve (fig 2).

Coronary heart disease is represented by aspecimen (A 704) labelled "atheroma of thecoronary artery" which shows two thickenedarteries opened longitudinally. A very interest-ing painting (A 291) is called "scirrhus or can-cer of the heart. Thickening of internalmembrane of the left ventricle. Adhesion ofpericardium to the heart" (fig 3). It came froma man of 61 with right and left heart failurewho had dyspnoea on effort, and also"praecordial oppression" which seems fromthe clinical notes not to have been cardiacpain. There is full thickness involvement of theanterior wall of the left ventricle, but becausethe ventricular mass has been divided trans-versly and the lower part turned down it looksat first like two separate lesions. This is proba-bly a myocardial infarct, and if so it could beone of the earliest illustrations of this condi-tion. Another illustration (A 919) which isdescribed as "true aneurism of the heart" (fig4) shows two sacs in the wall of the left ventri-cle communicating with the cavity. Perhapsthese are congenital subvalvar aneurysms. Hespells aneurysm with i not y. There is also apainting showing a rupture of the left ventricle(A 917).

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Figure 4 "True Aneurism of the Heart". PaintingA 919in the Carswell collection. The legend, written by Carswell,reads "True Aneurism of the Heart. The aneurismal saclined by a membrane a,a,continuous with that of theventricle. another smaller aneurism of a similar kind b-both contain portions offibrine". (Reproduced bypermission of the Librarian, University College London).

Figure S "Aneurysmal varix: varicose dilatation of arteries". PaintingA 1032 in theCarswell collection. (Reproduced by permission of the Librarian, University CollegeLondon).

A picture (A 15) labelled "aneursym of theascending aorta" has been identified byProfessor Tom Treasure (personal communi-cation) as being a chronic dissection of the

aorta (De Bakey type 2). The false lumen con-tains laminated clot and the base of the aortahas the characteristic appearance of a healedintimal tear. There is blood in the pericardiumfrom, presumably, a terminal rupture. It isvery likely that this is the first illustration of achronic aortic dissection.Atheroma of the ascending aorta and

aneurysm of the abdominal aorta are wellshown, as is arterial disease with pictures ofcalcified arteries and of gangrene of the legs. Areally fascinating painting (A 1032), labelled"aneurysmal varix: varicose dilatation of arter-ies", shows numerous localised dilatations onthe common iliac arteries and their branches(fig 5). There is no clinical description but itmay be an example of the Ehlers-Danlos syn-drome. Certainly it is a remarkable specimen.Disease of the veins includes obliteration ofthe inferior vena cava, iliac vein compressionby cancer, venous thrombosis, and "pus andcoagula in femoral vein".

OTHER SYSTEMS OF THE BODYCarswell is famous for his illustrations in twosystems other than the heart and blood vessels.He was the first to depict the pathology in

multiple sclerosis in a painting entitled"Circumscribed discolouration induration andtransparency of the pons variolii and medullaspinalis" (D 445). Carswell's note on this caseis as follows, "This remarkable appearancewas observed in a patient who died at La Pitieafter having remained a considerable time withparalysis. Mons. Louis who gave me this piecehas promised to give me the history of thecase". But there is no history, so presumably itwas never sent. Also he made the first colourpictures of the pathology in Hodgkin's disease,which Thomas Hodgkin showed when he readhis classic paper on the malady in London in1832.5There is an interesting early example of iron

therapy in an attractive painting which showsthe face of a young woman with anaemiabefore and after treatment with ferrous car-bonate.

Comments on the paintingsAlthough patients with cyanotic heart diseaseare shown there is no separate delineation ofclubbing of the fingers which is perhaps sur-prising because the sign was known at thistime. For example in 1831 James Hoperecorded in a cyanotic child aged 1 1, that "thelast phalanges of the fingers and toes are bul-bous ... the finger and toe nails grow very fastrequiring to be cut every four or five days".6The specimen (fig 2) of an apparently

bicuspid aortic valve (A 532) shows what maybe a third commissure which could indicate arheumatic origin. But, as Lewis and Grantpointed out, the common form of a congenitalbicuspid valve is that in which a ridge partiallysubdivides a cusp, and they showed that it wasonly by the relation of the annulus to the aorticmedia that the congenital and acquired formscould be distinguished.7 So this specimen mayin fact be one of the earliest pictures of con-genital calcific aortic stenosis.

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The paintings ofpathological anatomy by Sir Robert Carswell (1 793-1857)

The aortic dissection (A 15) requiresfurther comment. Dr Howard Burchell(personal communication) has pointed outthat T R H Laennec, who was the leadingclinician in Paris on the occasion of Carswell'sfirst visit, identified and named dissection ofthe aorta at about that time. So Carswellwould very probably have known of the acutelesion, but understandably he may not haverecognised, and certainly did not label, hisown specimen of the chronic lesion as being adissection.

The atlas of his water-colour drawingsBy 1831 having completed his work in Paris,Carswell took up his post as professor ofpathological anatomy at University CollegeLondon and started to prepare an atlas of hisdrawings. The folio volume was published in1838 with the title Pathological Anatomy.ilustrations of the Elementary Forms ofDisease.' Itwas dedicated to his teacher, Professor JamesJeffray, "to express my gratitude, and toacknowledge the influence you thus exercised indirecting my attention in a special manner to thestudy of Pathological A13atomy". It has 44 beauti-ful coloured plates, each containing several..a .

Figure 6 "Congenital cardiac hypertrophy" reproducedfrom CarsweUl R. Pathologicalanatomy. Ilustrations of the elementary forms of disease. London: Longman Orme BrownGreen and Longman, 1838. Hypertrophy, plate IV, figure 7.

paintings. He was an expert lithographer whoput the illustrations onto stone himself, while thecolouring was done under his immediate supervi-sion.The contents are arranged according to patho-

logical states and not in body systems. There areeleven fasciculi: inflammation, analagous tissues,atrophy, hypertrophy, pus, mortification, haem-morhage, softening, melanoma, carcinoma, andtubercle. Carswell says that there are some sub-jects such as calculi, entozoa and monstrositiesthat he proposes to include if a second edition isrequired-but it never was. The volume washailed as having "brought this branch of medicalscience up to the highest point of which it wassusceptible".8 A few years later Rudolph Virchowfounded the study of cellular pathology using themicroscope.The illustrations that caught my eye are fig-

ures 6 and 7 of plate II on hypertrophy,described as "A case of congenital concentrichypertrophy of the heart, which occurred in awoman above forty years of age" (fig 6). Thetransverse section seems to show hypertrophy ofboth ventricles with a very thick septum andsmall cavities, and the external view shows alarge coronary artery. Was this the first illustra-tion of hypertrophic cardiomyopathy? Sadly, no!On referring to the original drawings (A 531) onefinds this same case described as "atrophy of theheart", measuring "from its apex to its basis onlytwo inches and a half and the broadest part twoand a quarter inches". Quite what it does repre-sent it is difficult to know. Perhaps it came from apatient with severe and chronic wasting. I men-tion it in case someone else also gets led astray.

Other atlases of morbid anatomyThe invention of lithography in 1800 made itmuch easier to produce illustrated books, andseveral atlases of pathology were published in thenext few decades in Europe and Britain. The oneby James Hope (1801-1841)9 is of especial inter-est to us because he made such notable contribu-tions to British cardiology with his identificationof left ventricular failure and his experimentalwork on cardiac murmurs. It comes as a pleasantsurprise to find that Hope too was an accom-plished artist who produced the original paint-ings for the coloured lithographs in his book,which was designed "to facilitate the study ofmorbid anatomy in connexion with symptoms".There are 48 plates containing 260 figures ofwhich 20 illustrate aspects of heart disease.

Carswell's careerHaving taken up his Chair he was appointedphysician to the College's associated hospitalthen named the North London Hospital, laterUniversity College Hospital. But poor health andlack of success in private practice led him toresign both appointments in 1840 and to take upthe post of physician to the King of the Belgians.He married Mlle Marguerite Chardenot in 1850;they had no children. Queen Victoria made him aKnight to show her appreciation of his services toLouis Phillipe, King of the French, while in exilein England. For the rest of his life Carswell lived

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mostly at Lacken near Brussels where he wasgreatly respected for his medical services to thepoor. He did no further scientific work and diedthere in 1857 from chronic lung disease.

1 Carswell R. Pathological anatomy. Illustrations of the elementaryforms of disease. London: Longman Orme Brown Green andLongman, 1838.

2 Cameron GR. Robert Carswell, pathologist. Univ Coil HospMag 1951;36:10-1.

3 President's Address. Sir Robert Carswell. Proc Roy Med ChirSoc London 1858;2:52-4.

4 Reckert H. Das unbekannte Werk des Pathologen Robert Carswell(1793-1857). Cologne: Instituts fur Geschichte der Medizinder Universitat zu Koln, 1982.

5 Dawson PJ. The original illustrations of Hodgkin's disease.Arch Intern Med 1968;121:288.

6 Hope J. A treatise on the diseases of the heart and great vessels. 1sted. London: W Kidd, 1831.

7 Lewis T, Grant RT. Observations relating to subacute infec-tive endocarditis. Heart 1923;10:21-100.

8 JFP. Sir Robert Carswell. Dict Nat Biog 1887;9:191.9 Hope J. Principles and illustrations of morbid anatomy. London:

Whittaker and Co, 1834.

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Robert Carswell (1793-1857).The paintings of pathological anatomy by Sir

A. Hollman

doi: 10.1136/hrt.74.5.5661995 74: 566-570 Br Heart J 

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