The Use of Close-Up Photography in Clinical Medicine

Vol. 3, No. 2, SINGAPORE MEDICAL JOURNAL 100 June, 1962.

THE USE OF CLOSE-UP PHOTOGRAPHY IN CLINICAL MEDICINE

By A. Lim Siew Ming, M.B.,B.S. (Malaya) F.R.C.S. (Department of Opthalmology, Singapore General Hospital.) and Ho Tat Seng, F.R.P.S.

(Department of Medicine , University of Singapore.)

A descriptive writer, writes in "words" todescribe able to describe in words a visible lesion accurate- the scene he sees for the purpose of conveying his ly, all must agree that there are limitations to the impression of the scene to his readers. His readers interpretation of a lesion expressed with "a mass have to imagine, sometimes even to shut their eyes of words". to have a mental picture of such a scene. It is not an easy achievement. When a photographer sees Thus rare diseases, interesting lesions and others a scene he likes, he takes a photograph of it. are to -day being photographed as supplement to Others seeing such a photograph easily conceive written case records as have appeared for articles the scene with all the details especially if the in journals and for other purposes. photograph is well taken with a good camera. (b) Teaching With the vast syllables, crammed Hence the superior claim of a photograph to a des- clinical duties and constant new discoveries that cription in words of the same scene. Similary a a student in medical science has to keep up with good photograph of any ailment is superior to a to -day, there will repeatedly be important lesions description in words of the same ailment, and if and interesting operations which the student will when science has advanced well enough to pre- have to miss. This is particularly true with sub- serve coloured photography from fading, photo- jects like opthalmogy or ear, nose and throat. In graphy in colours will be much more descriptive order to give such students as much knowledge and helpful in the advancement of medical and as possible in the teaching curriculum close-up surgical sciences. photography should be used to contribute to the However even at the present stage of photo- usual clinical teaching not only of under -gradu- graphic science, much can achieved for medical ates but also of the post-graduates. research workers by the scientific use of the camera, especially by taking close-up photographs of ail- Recently, in the United States and other parts retinal ments. In this article we will consider the several of the world. lesions of the eye, including techniques to be used for this purpose. lesion seen through the opthalmoscopes, are pro- jected onto "television" screen for teaching pur- USES OF CLOSE-UP PHOTOGRAPHY IN poses. MEDICINE. (c) Progress and Treatment of Disease. Record- It is well known that the most important re- ing the progress of diseases which naturally will quirement of medical photography is that the influence the treatment thereof, photographs are picture should be critically sharp and should not particularly useful aids especially in dermatology only reveal good surface texture but proper tonal and radiotherapy. In some radiotherapy centres gradation. These requirements are even more im- the area of treatment of each patient is carefully portant in close-up photography, and when outlined and recorded by photographs. Dr. W. colour film is used, the correct hue is essential if Schultze, Professor of Medicine in the University the photography is to be of documentary value. of Giessen wrote "it is useless to state that ... radiation therapy of the right foot was repeated Well -taken photographs of a visible pathological under the following conditions " He stressed lesion are accurate records which can be used for that it is only by careful recording to the exact the following purposes : - area treated that one can evaluate results and protect (1) Documentation. healthy tissue from radiation damage. (2) Teaching. (3) Progress and treatment of disease. Perhaps more dramatic are the results of proper- (4) Medico -legal records. ly recorded plastic surgery, not only to illustrate functional improvement, but cosmetic appearance. (a) Documentation. "A Simple picture is worth For example, a child born with cleft -lip with its a thousand words" and we 'can go further by accompanying speech defects and unpleasant saying that no amount of discription of a lesion appearance, can be shown in photography to have is comparable to a simple well -taken photograph. been reconstructed to normal, except for the almost Much as some clinicians will stress the need to be invisible scar. 101 SINGAPORE MEDICAL JOURNAL

(d) Medico -legal record. When bad injury 4. BACKGROUND The background should be had been inflicted or even when killing had taken plain to avoid distraction. place it was nearly invariable that pathologist re- 5. SCALE This is important especially when an corded the lesions with a series of photographs accurate information of its size is to be of clinical which were used in courts of law as exhibits. significance. There again in Medico -legal matters, a photograph makes itself useful. 6. REPEATED PHOTOGRAPHS These should have the same view, position and lighting and THE USE OF COLOUR PHOTOGRAPHY unless standardized will not be convincing nor be The great advances made in colour photography of satifactory comparision. have encouraged doctors to abandon the use of A few simple techniques to achieve good black and white prints and slides, but while colour close-up medical photographs will be described photography illustrates better in most instances, briefly, to assist doctors, especially General Practi- one should not forget that it costs much more tioners to utilise whatever type of camera he owns and there is no guarantee that the colour will not for his personal picture -taking. fade. It is therefore advisible to use colour photographs only when essential. There is no better CAMERA AND LENS comment on "Coloured Illustrations" than that The trend of our present day inventors and written by D. G. Cogan, Editor -in -Chief, Archi - scientists is to create things with speed and auto- eves of Opthalmology, which reads as follows : mation, and in the photographic field such advance- ments as the complicated structure of fast lenses, "In practice, however, it is often most difficult the exacting mechanism of a camera and the ever to decide whetheror not colour is indicated. Some film, particularly conditions which warrant illustrations can be increasing emulsion speed of have made. The struc- brought out only in colour. These present no pro- colour, all been constantly lenses have more than blem: There are others which can be shown in black ture of fast which elements the ordinary lenses, are designed primarily for and white just as well in colour. These also pre- for candid sent no problem. But then there are those. con- available light photography and are best lens stituting the majority, where colour embellishes shots or photo -journalism. An ordinary f/3.5 is medical photo- something which could be shown, although per- adequate to cover all aspects of graphy. haps well, in shades of gray. Is the esthetic aspect sufficient justification for the additional cost and Cameras designed for ordinary use are usually space of colour reproduction?" not adequate for close-up photography: their maxi- mum focusing distance of "lens is about A GOOD CLOSE-UP MEDICAL -subject" PHOTOGRAPH 3 - 4 feet, which is suitable only for head and shoulder or full length infant cases. To overcome While it is true that a good portraiture photo- this limited range of focusing, a choice of systems grapher may not be a good medical photographer, can be applied to modify the existing camera so it is just as true that a mediocre portraiture may that one can focus at shorter distances than the be a good medical photographer. His standard is normal limited range. There are several ways by judged by his ability to produce an accurate record which this can be achieved : of the condition and not an artistic distortion of what he thinks the photograph should be like. In (a) Clip -on view -finder. Only a few camera short, he must be a good technician and not an manufacturers design special lenses for close-up artist : the latter must find room for expression without the need for additional supplementary elsewhere. lenses or extension tubes, for example the dual range Lietz lens for A good close-up medical photograph should 50mm f/2. Summicron the Leica M2 models. is be or M3 The lens supplied :- with a clip -on optical parrallax compensating 1. SHARP The whole purpose of a close-up of viewfinder which functions with the camera range a lesion is to bring up its details. A photograph finder and close-up photographs can be brought which does not bring up such details has lost down to 19 inches. most of its value for clinical medical use. (b) lenses. To 2. CLEAR Distracting objects such as dressings Cameras with fixed convert camera over wounds, ear -rings or ointment over or around with fixed lens for close-up work, extra lenses the lesion, must be removed. must be placed in front of the normal camera lens to enable it to focus on the subject 3. CONTRAST The contrast must be clear. If closer than the limited range. Because the lens too low the picture will lose its emphasis and if is fixed there is no other way of increasing the too contrasty, details will not be shown. lens -to -film distance to shorten the focal length JUNE. 1962 102

BASIC PRINCIPLES OF CLOSE UP PHOTOGRAPHY

z II

Small diaphragm for depth and sharpness

Il Electronic flash to arrest movement.

0. Different types of close -op gadgets: - Bellows, extention tubes and supplementary lenses

B. Tripod for steadiness.

II a. Focal frame finders are used to define area of focus.

II 103 SINGAPORE MEDICAL JOURNAL JUNE, 1962 l0ï

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Figures 2 and 4 show bilateral Carcinoma of both lids of four years duration. Figures 3 and 5 same patient after treatment with Radiotherapy. Figure 6. Figure 7. of Figures 6 and 7 show Advanced Rodent Ulcer of right lid, with extensive destruction

right orbit 2 nd figure 7 shows ulcer after removal of maggots.

Figure 8 a shows a shallower depth of field with a bigger aperture. and 3 b a greater depth of field is obtained with a smaller aperture. JUNE, 1962 106

Figure 9. Photo shows the use of a "Bipod' for close-up work in the ward. This "Biped" is specially made for bed ridden cases where the setting up of a tripod is a problem. MEDICAL JOURNAL 107 SINGAPORE of the existing camera lens, thus we have to rely electronic flash to remote places where no other on the trickery of the supplementary lens placed source of light is available is a definite advantage. the camera lens. To suit one's choice, in front of A special electronic flash such as a ring light lenses are supplied with dioptre supplementary is designed for extreme close-ups and intra -oral and The bigger the powers of I+, 2+, 3+. work. This is a circular flash tube secured by a lens the larger the figure of the supplementary mount attachment in front of the camera lens. They be used singly or in magnification. can Some models have a set of pilot light built on In the latter application, the more combination. their side for focusing purposes. The source of placed directly in front powerful one should be illumination gives an even and shadowless effect, lens. Furthermore, to achieve sharp of the camera especially recommended for cases beyond the with the best supplementary lenses, results, even reach of any other source of illumination. For to close the diaphram to the smallest it is advisible instance, in photographing a growth in the mouth aperture. or throat, the normal lens with the necessary attach- (c) Single lens reflex cameras with interchange- ments has to come up so near to the patient's form of able lenses. The majority of these are made in the mouth that it would obstruct any other side, with the 35mm. group. Owners of the cameras are for- light that illuminates from one tunate, for the various advantages are already result that half the area only will be lighted. in. There is no fear of parallaxium even built There are many procedures of lighting medical when the camera is advanced to a few inches from subjects. For simplicity and convenience, a single subject. the flash accompanied by an extra length of extension In this system, the image is taken in through cable technique is generally adequate to cover the the taking lens which in turn reflexes the image majority of close-up cases. Of course more lights by a mirror onto the viewfinder and can be focus- can be employed, but these methods are more ed until the instant of exposure. This is of prime elaborate and complicating. Limitations in the importance where critical focusing and accurate movement of the flash lamp is often a problem framing of the object is essential to produce a with the short length of flash cable usually supplied good picture. with each set of electronic flash. This difficulty is easily overcome by the use of an extra length offlash range work there are extension tubes For close cable so that the flash can be moved to the desired bellows. Both of these attach- or variable focusing distance. ments work on the same principle. but the focusing bellow is more convenient and versatile. ARRANGEMENT OF LIGHT For head and shoulder cases, the patient should PROBLEMS OF EXPOSURE sit as far away from the wall as possible. If a A major problem in extending the lens -to -film single light or flash is applied, it must be from distance is the differences in exposure. The mea- a position above the camera and slightly above sured exposure will no longer have its normal the sitter's head. It may be placed from the side values. The lens -to -film distance will be extended or directly from the front so that the shadows back further, as a result, more exposure is required. cast behind the patient will not be shown. If two We have either to widen the aperture or increase lights are to be used, one method is to direct one the exposure time. Increasing time exposure may light as described above and the other from one cause vibration or movement of subject and widen- side. The oblique light should be slightly nearer ing of aperture will lose depth of focus. The and lower. However, the second light can be best solution is to stop movement as well as placed directly behind the patient to kill away the closing down the diaphram to get sharpness, by shadows cast by the frontal light. In this case using flash as a source of illumination. For this, the patient can sit nearer to the wall, about 3ft there are several formulas to calculate the corrected away. Both these lighting procedures are most exposure when the lens -to -film distance is extended. suitable for profile cases.

FLASH BACKGROUND The application of electronic flash in medical In black and white photography, a plain white photography particularly in close-ups overcomes background is essential. Remove pictures or calen- many difficulties encountered. Because of its in- ders from the wall. Avoid a glazed or shining wall, tense illumination of about 1/1000 to 1/5000 sec. as this will result in a glare of the light directed it not only freezes a patient's movement in Pae- from the flash. This is to bring out the subject diatric and Opthalmic cases, but also allows a prominently without distracting details and a white small aperture to be used, resulting in a sharp cardboard sheet or a piece of white bedsheet can negative. The ease in transportation of a set of be used. A black background is sometimes advisible. JUNE, 1962 tos

It is effective for cases when Infra -red film is used, 2. Colour photography and its inpact is briefly and also for multiple exposures to illustrate succes- discussed and the criteria of a good medical sive images such as a patient's arm or leg move- photograph summarized. If is ment. colour used, a coloured background 3. An account of some technique in close-up will separate the subject from 'it giving a three medical photography is described, with special dimensional effect. A blue background is best, stress on the type of camera and lens required, as it separates the human skin tone from the and the most suitable lighting and background contrasting background. Furthermore, the colour arrangement. is pleasing, especially with fresh pathological specimen. ACKNOWLEDGMENT We thank Professor G. A. Ransome, C.B.E., FIXATION OF OBJECT F.RC.P. (LOND) Mr. R. C. K. Loh, F.R.C.S. (ED) very Mainly because of the short depth of focus and Dr. Khoo Oon Teik, M.n,, M.R.C.P. (ED) for in close-up photography and partly because of the use of clinical material and to Mr. Heng HocK great amplitude of even the slightest movement Yong for the art work. We are particularly grate- it is important to fix not only the camera but also ful for the useful comments and invaluable advice the object. Thus the camera should be placed on of Mr. R. C. H. Lim, B.A., Barrister at -law. a tripod and the object fixed. In taking a picture of the eye, it is not enough to fix the head alone REFERENCES but also essential to fix the eyes by asking the COGAN D. G. (1961) Editorial, Archives of Ophtalmology. GIBSON (1952) The Photography of Patients, Charles patient to look at an object some distance away. C. Thomas, U.S.A. HANSEL, PE'L'ER (1957) A System of Opth almic Illustration, SUMMARY Charles C. Thomas, U.S.A. SCHULTZE, WALTHER (1951) The Leica in Professional 1. The uses of close-up photography in medicine Practice, Fountain Press, London, p. 272-361. SCH\VALBERG B. (1957) 35mm Close-up Photography. are discussed. They are for documentations, Popular Photography, p. 2, 62. teaching, illustrating progress and treatment WINKELMAN J. E. and WARMOLTZ N. (1956) Electronic Flash Photography of the Eye, Photographie und For- of disease and medico -legal records. chung, Vol. 7.