The History of Medical Illustration By WILLIAm E. LOECHEL, Director Medical Illustration Section Art Designers, Inc., Washington, D. C. RIMITIVE man, newly equipped with the knowledge of how to make and use fire ... and somehow aware that the wheel and the lever worked to his advantage, gave medical illustration its roughhewn beginning. These ancient artists were mighty hunters whose very survival depended upon their learning something of living machinery. On an ancient cavern wall in the southern part of Europe, amid utensils and the bones of his prey, some artist-hunter depicted an elephant in crude outline and in its chest delineated a vital spot ... the heart. He was aware that his arrows or spear worked more effectively here. On a wall of a Babylonian temple there is a carving of a wounded lion, with arrows lodged in his spine. The hind limbs which once had acted like spring steel to propel the beast are dragging stick-like; blood issues from his wounds, and from his nose, as one arrow apparently entered the lung; the forelimbs support him in his last agonizing movements. Here, too, some artist gave us a record of an animal in pain. These were precivilized artists and the time was roughly 75,000 years ago to 3,000 B.C. As the race prospered, there apparently was time for artistic endeavor. The subject matter was the one most familiar, hunting. Early Persian civilization produced crude biological drawings which were made principally as ornaments or portraiture on vases, columns, and tablets. The Chinese were prevented by both moral and civil law from dissecting bodies and consequently from making anatomical drawings. Greek culture was characterized by mysticism and superstition, and drawings that related to medical sciences were less exact than the sciences; however there was an attempt to organize the illustration and give emphasis to a key subject. As time went on, the Greek art pushed ahead of medicine. The artists saw great beauty in the human form, and their art forms did not imitate previous ones. They strove diligently to create. In their quest for pleasing portrayal of the human form, they were extremely conscious of body proportions. Doubtless, then, the Greeks contributed to medical illustration most because of detail to topography. The Egyptians, though possessing some sound fundamentals in medicine and art, were really never able to achieve the freedom and natural beauty of line as well as the Greeks. They had little, or at least employed little, knowledge 168 HISTORY OF MEDICAL ILLUSTRATION 169 of perspective and their pictures were really two dimensional painstakingly planned maps. Not until Hippocrates (460-370 B.C.) did medicine and medical illustration lurch forward out of a semirestless sleep. Fancied reasoning was the keystone to medical practice and equally fanciful pictures went along as documentary evidence. Animals, not man, were still the subject matter. It was at Alexandria, Egypt, about 280 B.C. that human dissection was initiated by Herophilus, and three scientific flowers began to bloom from the precivilized roots laid down centuries before. Anatomy advanced; physiology kept pace; and medical illustration became their handmaiden because new facts had to be taught and published. Humble and dramatic beginnings had been forged, yet were to languish for half a century until Galen (131-200 A.D.) began to light the way with his work. The Romans produced medical illustrations that were, for the most part, battle scenes or delivery scenes with an attempt at emphasizing the biological subject. As we understand the use of medical illustration today, the Roman pictures would be said to contain an overabundance of visual baggage. The key point of the story is lost in the busy and extensive areas. Figures dominate the scene and there is little chance for the focal point to receive adequate attention. During the Renaissance art in general was a mixture of realism and idealism and medical illustration was no exception. The physician or anatomist of this period had a titanic job on his hands to find an accomplished artist who would undertake to work on cadavers. One must remember that there were no pre- servatives used, and it was therefore remarkable salesmanship on the part of the dissector to persuade an artist to devote time to anatomical material. Few understood it; few cared to understand it; but many had to eat so they became free-lance medical illustrators. Having begun, however, in many cases the artist took an interest and disciplined himself to his unusual task. Other artists were painting nature in the living state, and no doubt the medical artist would have liked to have been doing so too; yet, he could gain new understanding when he painted men and animals. When working arrangements were agreed upon, the physician and artist collaborated. The result was that excellent engravings were produced which had the stamp of artistic competence and scientific investi- gation. Some of the books of this period are more valuable for their exquisite artwork than as medical treatises. But, in general, the Renaissance pro- duced a merging of talents rather than a submerging of them. Not all anatomists were artists or skilled draftsmen, nor were all artists capable of realizing significant features in a dissection. When issues became clear, however, each specialty was a challenge to the other. The result was that not only more artistic detail was achieved, but more perspicuous descriptions were prepared. A plateau of scientific endeavor had been gained from which a chain reaction of development was to follow. 170 WILLIAM E. LOECHEL Two names stand out, DaVinci and Vesalius. So consuming was DaVinci's interest in anatomy that he dissected more than thirty cadavers and made hundreds of drawings, but Vesalius' work stands out as the first true atlas of human anatomy. His work, De humani corporis fabrica, appeared in 1543. It was realized that if certain artistic holdings should be skillfully abandoned, greater scientific value could be achieved in the illustrations. Here we see the co-operation of the practitioners of medicine and art, each willing to yield something so that greater teaching value could be attained. In Vesalius' work, we find the economy of method and composition ideally adapted to the field. A specialty had been established combining the ability to draw beautifully, and the ingenuity to set forth in an understandable fashion the new scientific facts. Well and good ... a new specialty had been established, but there was not always an artist to illustrate the new texts. The great writers who pioneered and published work had to seek diligently for competent (and now specialized) illustrators. As a result, many of the classics were illustrated by the author who coaxed the picture into shape himself. Other men developed the illustrator one could get into a specialist if he had basic facility in drawing. Methods were awkward, with woodcuts being the unwieldy medium. The great post-Renaissance advancement was made possible by lithography. The German, French, and English texts of this period are exquisite things to examine. They transport the observer into another world where the pace was slower than we know it today. Many of them are not too attractively illustrated, but some are painstakingly done, with great emphasis placed not only on form and relationships but textures as well. An examination of color plates in some of these books cannot help leaving the observer with tremendous respect for the artist and printer. Both artist and physician had begun to realize that not only were their specialties useful in combination ... but that a third specialty entered into the sphere of activity, that of the printer. All three were striving to get medical education in books of higher caliber to those who needed them. A book of this period might be anywhere from three by five inches to two by three feet and it was not uncommon to find doubled sheets which opened to portray a subject life sized. These variations presented quite a problem; the little books could easily be lost and the large volumes could come apart because of their own weight. Here, then, was a problem for the practical minded publisher. All of these things were part of the "growing pains" necessary for the continued growth of allied specialties. Just as Vesalius employed illustrators, so the early men of medicine of this country sought to employ them, The Johns Hopkins Hospital acquired Max Br6del in the 1890's, whose work is so well known that he stands as the father of modern medical illustration. What characterized this man and why was his work to influence every medical illustrator since his time? To put it simply, he had everything. There was classic beauty in his drawings; he had the scientific HISTORY OF MEDICAL ILLUSTRATION 171 approach; he was cognizant of the printer and publisher problems; and he was sincerely interested in devoting his life to his work. He employed new methods and established new techniques. His half-tone drawings had the authenticity of a photograph but were better because the camera couldn't think and select. His pen drawings no longer looked like etchings; the lines fairly breathed life and flexibility and natural form. He employed unique devices to present a complex subject in a minimum of space. He did research work of his own, the result of enthusiasm and accomplishment in a field where ingenuity is always a welcome ingredient. Br6del's work had such impact that men of vision saw that the specialty should be taught to others to insure the same kind of thoroughness among future medical authors. Today there are a dozen schools patterned after the Br6del-Hopkins school, many supervised by his former pupils.