Tsafrir - 2001

21/8/23, 0:22 Medical illustration: from caves to cyberspace‡ - Tsafrir - 2001 - Health Information & Libraries Journal - Wiley
nal - Wiley Online Library
Health Information & Libraries Journal / Volume 18, Issue 2 / p. 99-109
Free Access
Medical illustration: from caves to cyberspace‡
Jenni Tsafrir , Avi Ohry
First published: 18 July 2008

https://doi.org/10.1046/j.1471-1842.2001.d01-16.x
Citations: 8
‡ This is an edited version of a paper presented at the 8th International Congress on Medical Librarianship,
London, 2–5 July 2000.
Abstract
The human body has been depicted in ancient cave-paintings, in primitively sculpted figures,
and through all the ages in various forms of artistic expression. The earliest medical texts
were descriptive but not illustrated. Later, as it became clear that knowledge of the human
body and all its systems was essential to the practice of healing, texts were accompanied by
illustrations which became an integral part of the teaching process. The illustrators included
artists, whose interest was primarily artistic, but who were sometimes employed by
surgeons or physicians to illustrate their texts. Occasionally, the physicians or scientists
accompanied their texts with their own illustrations, and in the last century, medical
illustration, in its infinite variety of techniques, has been developed as a profession in its
own right.
As knowledge was extended, permitted by social and cultural change, as well as by

technological advances, the types of illustrations have ranged from gross anatomy through
dissections showing the various organ systems, histological preparations, and radiological
images, right up to the computerized digital imagery that is available today, which allows
both static and dynamic two- and three-dimensional representations to be transmitted
electronically across the world in a matter of seconds.
The techniques used to represent medical knowledge pictorially have been as varied as the
illustrators themselves, involving drawing, engraving, printing, photography,
cinematography and digital processing. Each new technique has built on previous
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21/8/23, 0:22 Medical illustration: from caves to cyberspace‡ - Tsafrir - 2001 - Health Information & Libraries Journal - Wiley Online Library
experience to broaden medical knowledge and make it accessible to an ever-widening

audience. This vast accumulation of pictorial material has posed considerable problems of
storage, cataloguing, retrieval, display and dissemination of the information, as well as
questions of ethics, validity, manipulation and reliability. This paper traces these
developments, illustrating them with representative examples drawn from the inexhaustible
store of documents accumulated over more than two millennia.
Introduction
The recent spate of articles marking the end of the 20th century and the beginning of the 21st
and chronicling the past millennium, has proved a godsend for anyone trying to trace
developments in any field, and the field of medical illustration or imaging is no exception.
The expression ‘one picture is worth more than 1000 words’, believed to be attributable to
Confucius, crops up again and again in history, and nowhere is it more appropriate than in the
history of medical illustration. By its very nature, visual material transcends language barriers
and bypasses technical terminology. It can focus attention and provoke interest and inquiry
that might not be aroused by a dry textual account.
To trace the developments and changes taking place in any field of human endeavour, one has
to go back in time as far as evidence permits. It is believed to be almost instinctive in man to
make pictures or diagrams of his ideas, whether for his own interest or to transmit information.
In prehistoric times, cavemen carved their ideas of the human body in stone, or scratched or
painted them on cave walls. For instance, early cave engravings found in Spain show a rough
illustration of a pregnant woman, with the fetus inside the womb.1
The illustration of medical subjects actually preceded the advent of papyrus and paper. Even
before 1500 bc, the ancient Egyptians, Babylonians, Chinese and Indians recorded medically
related illustrations on stone, bamboo, silk and metal.2
The history of medical illustration in its broadest sense, taking in all visual depictions of the
human body or its separate parts for the purpose of documentation, teaching or in the practice
of medicine, is closely integrated with, and influenced by, historical, social and technological
developments through the ages. These developments affected the content of the illustrations,
the artists themselves and the techniques by which the representations were made,
reproduced and disseminated, from prehistoric and historic times until today.
Anatomy was first recognized as a distinct branch of medical science some 500 years bc, and its
development can be traced through early beginnings in Italy, through Hippocrates and Aristotle
in Greece. The philosophic attitudes to death held by Aristotle and Socrates probably marked
the transition from the beliefs of earlier civilizations in Greece and Egypt, and Aristotle was
probably the first individual in history to use anatomical illustrations based on scientific study,
most likely on animal dissections, to teach and transmit his knowledge of anatomy to his
pupils.1
The general view in the ancient world of Greece, Egypt and China, which regarded the human
body as a sacred entity housing the soul and necessary to enable reunion with ancestors,3
prevailed and persisted well into the 19th century, as schools of science and medicine
throughout all those centuries had to contend with the religious authorities and with angry
mobs protesting against human dissection.
In the last centuries bc, intellectual life had moved from Greece to Egypt, and with it the
possibility of dissecting human bodies, mainly of condemned criminals. Herophilus (350–280 bc)
was the first to base his writings on authorized, legitimate, dissection of the human body.
Despite his great achievements in describing various organs and the relationships between
them, Herophilus did not illustrate the anatomical information he described in his massive
treatizes, which were intended to preserve his observations from dissections, for others to
examine and learn from. Roman Law in the early centuries of the Christian era forbade human
dissection. There were some rare examples of anatomical inquiry during the Roman period,
and although no illustrations can be attributed to it, these inquiries led to the anatomic
nomenclature which illustrators later used to describe their drawings. Galen (130–200 ad), who
believed that dissection was essential to medical understanding, was prohibited by law from
performing human dissection, but he gained limited anatomical knowledge and surgical
experience by attending to wounded gladiators, and became well regarded as a physician. He
was unique amongst his contemporaries in that he combined physical observations of his
patients and their symptoms with pathogenesis—an approach he applied to anatomy too—but
his writings were based mainly on the dissection of animals, especially monkeys.
Consequently, they contained many erroneous descriptions of human anatomy, which were
perpetuated well into the 17th century, even by those who performed human dissection. None
of Galen’s works included illustrations of his descriptions. Dissection at that time was
unpleasant, given the lack of knowledge of preservation, and few artists would have wanted to
illustrate putrefying cadavers.
The acceptance of previously established beliefs based on the reputations of famous

anatomists like Galen, rather than on personal observations, allowed misconceptions to be
perpetuated well into the Middle Ages. In this period, the dissections were performed by
‘barber-surgeons’, who were essentially technicians, and their purpose was mainly to
demonstrate the descriptions handed down by Galen and others, and to further anatomical
knowledge, but no dissections were illustrated. Thus, although human anatomy as a science
actually began some 500 years bc, the earliest examples of human anatomical illustration date
back only to the 12th–14th centuries. The figures were depicted in frog-like positions, to
demonstrate the various systems (Fig. 1).1
Figure 1
Open in figure viewer PowerPoint

Anatomical figure in typical posture showing limited knowledge of circulatory system. MS
Ashmok 399, Fol 19. Figure reproduced with permission of the Bodlian Library, University of
Oxford, UK
The manuscripts of the Middle Ages provide some of the first contributions to medical
illustration that have survived, but by their nature, they existed in single copies only. One
example of such a manuscript was that of John Arderne, an English surgeon, who wrote
extensively throughout his lifetime and recognized the value of illustrating his findings. His
treatize De Arte Physicali et de Cirugia dated 1412, contains illustrations of the human body with
its internal structures.
The gradual acceptance of human dissection to allow illustrators to depict accurately the
structure of the human body in association with texts, using nature as a model, and not
copying from existing manuscripts, was the first significant development in the history of
medical illustration. The second was the advent of printing, which allowed the duplication of
illustrations to accompany texts, without having to copy them arduously by hand, and enabled
the integration of the illustrations into text pages instead of on separate plates, thus saving on
labour and paper.
The illustrators
The early scientific and medical treatizes were thus strictly textual, based on philosophical
suppositions and knowledge gleaned over the centuries and handed down through the
professional healers of all kinds, but seldom on dissection or on personal observation.
Conversely, anatomical drawings were seen as useful in the teaching and apprenticeship of
artists, especially in Northern Italy, long before their practical importance in increasing
knowledge for scientific and medical purposes was recognized.
Frank Netter, a surgeon himself by profession, well known for his beautiful watercolour
illustrations in the widely used anatomical atlases, and considered by some to be one of the
most prominent medical illustrators of the 20th Century, wrote in 1956: ‘Years ago I considered
medical illustration simply a little adjunct—a useful device in the teaching of anatomy, surgery,
pathology and other branches of medical practice. As I delved a little into the history of medical
illustration, I came to realize that pictures have played a vital role not only in teaching but in the
actual development of surgery to its high levels’.4
The early classical and medieval medical texts were illustrated with primitively and
nonrealistically drawn figures. Through the centuries the illustrators of the anatomy of the
human form included some artists, whose interest was primarily artistic, but who were
sometimes employed by surgeons or physicians to illustrate their texts.
The real breakthrough came with the Renaissance artists of the 15th century, who became
increasingly interested in the human form for artistic purposes. In a treatize on art by Leon
Battista Alberti, Della Pittura, published in about 1435, he wrote ‘in painting the nude, we place
first his bones and muscles, which we then cover with flesh … to understand where each
muscle is beneath’.5
One of history’s most versatile men, the true Renaissance man, was Leonardo da Vinci (1452–
1519), who was the first artist to consider anatomy for reasons beyond its applications to his
art. He studied both structure and function in depth, through observation and careful
dissection. He examined bones, joints and muscles separately and in relation to one another,
making drawings from many angles. According to him, the visual demonstrations made from
his observations gave ‘complete and accurate conceptions of the various shapes such as
neither ancient nor modern writers have ever been able to give without an infinitely tedious
and confused prolixity of writing and of time’.6 Leonardo actually invented key techniques in
pictorial representation of the human body, such as the exploded view and the solid section for
the disclosing of natural structures;7 he introduced the idea of drawing an object from four
different angles, to give the sensation of ‘walking around it’, and produced probably the first
cross-section ever employed in anatomical illustration. He completed approximately 30
dissections of human cadavers in his lifetime and was almost unique in that he not only
dissected but could also illustrate from his own observations—most anatomists after him
looked to accomplished artists to illustrate their dissections.
Leonardo devoted about 20 years of his life to anatomical studies. Unfortunately, the large
body of his work—some 12 volumes at least, including about 750 exceptional drawings, was
seen by only a few of his contemporaries, and was not published in his lifetime. These
illustrations, representing the skeleton, muscular, nervous and vascular systems and the
development of the human fetus, all in extraordinary detail, were supplemented with
physiological annotations of amazing scientific accuracy, all the more remarkable when one
considers he used no texts and practically no reference material of any kind to guide him.3 One
could devote several pages to discussing this artist’s representations of the human form, but
there is one fact which is of particular relevance to librarians.
The drawings, which Leonardo had not completed to his satisfaction, and which were
consequently not published as a textbook as he had originally planned, were inherited by one
of his disciples, and after a spell in Spain were eventually purchased by an English nobleman
and brought to England in 1636. Their presence in the British Royal Collection is first
documented in 1690, when Queen Mary is said to have shown them to a guest at Kensington
Palace.8 Here they remained undiscovered until they were finally brought to light by the Royal
Librarian, Robert Dalton, in about 1760. To this day, the almost complete set of about 750
anatomical drawings is owned by the British Crown, and is in the Royal Library at Windsor
Castle.8
Many of them can be viewed on the World Wide Web

(http://www.webgod.net/leonardo/anatomy), and one can only marvel at the depth and
precision of Leonardo’s powers of observation, to say nothing of his artistic mastery.
The 16th century introduced the first illustrated anatomy textbooks, such as that of Berengario
da Carpi (1460–1530), who is the earliest anatomist known to include figures alongside the text,
using anatomical illustrations made consistently from nature. However, at this time, the master
artists employed to illustrate the dissections alongside the anatomists often failed to
understand that the purpose of the drawings accompanying a scientific text was to elucidate
anatomical facts, and they were often fanciful, with elaborate background landscapes bearing
no relation to the main subject.
An exception to them was Albrecht Durer (1471–1528), who was one of the first artists to stress
the issue of accuracy in anatomical illustration, if it was to have any instructional value.
Andreas Vesalius (1514–1564) established a landmark in the history of medical texts. He set out
to revolutionize the teaching of anatomy, at the expense of the teachings of Galen which had
prevailed from the 2nd century through to the 16th, using the medium of anatomical
illustration, based on thorough and meticulous human dissection, which he performed himself.3
His crowning achievement was De Humanis Corporis Fabrica: Librum Septum (‘Seven Books on
the Structure of the Human Body’), published in 1543, which is generally considered to be one
of the most important books in the History of Medicine. For this work, he employed a number
of artists, believed to have been from the school of Titian, to make drawings of his dissections
(Fig. 2).
Figure 2
From De Humanis Corporis Fabrica, showing human body posed against picturesque
background. Courtesy of the New York Academy of Medicine Library (See Ref. 1, Plate 645)
These illustrations often showed gracefully posed figures and elaborate backgrounds, as in
those which preceded them, but Vesalius did not allow these to interfere with the clarity of the
illustrations, and the internal anatomy took precedence over the figure drawing.9
The picturesque backgrounds, incidentally, served to counteract objections to dissection in the

name of medical science, which was still frowned upon, while dissection performed in the
name of art, to increase accuracy in depicting the human form and giving it depth and volume,
was considered acceptable.
Although for anatomical accuracy Leonardo is believed to have outclassed Vesalius, it is the
latter’s monumental treatise, with its detailed illustrations made from wood engravings, which
is regarded as the landmark publication, after which it became virtually inconceivable to
describe anatomy by text alone.
Over the next two to three centuries a number of illustrated texts were produced by physician-
artists or physicians assisted by artists, too numerous to mention. Among the best-known texts
produced in the 19th century is Gray’s Anatomy, which was first published in 1859 and featured
wood-engravings by Henry Vandyke Carter, who was a professor of anatomy and physiology
and himself made significant contributions to tropical medicine. His original drawings have
appeared in every subsequent edition of Gray’s Anatomy to the present day (38th edition,
1995),10 and they were based on dissections done jointly by himself and Gray.
A perhaps lesser known example is Sir Robert Carswell, professor of pathological anatomy at
University College, London, from 1831, who was also a talented watercolour artist, creating a
very fine collection of illustrations of pathological conditions, some in situ at postmortem
examinations, some of living patients. These are held in the Library of University College in
London.11
An important contribution to modern medical illustration came from Professor Max Brodel,
who went to the USA from Germany to serve as illustrator for a professor of gynecology at
Johns Hopkins, and some years later founded the Johns Hopkins School of Medical Illustration,
creating a learning environment where artists could study the intricacies of anatomy and
medical illustration. One of his most gifted pupils was Harvey Cushing (1869–1939), a
prominent surgeon as well as an outstanding illustrator, who filled his notebooks with drawings
of cases he had dealt with in his practice.12
In the last century, medical illustration, in its infinite variety of techniques, has been developed
as a profession in its own right. There is a website for the Association of Medical Illustrators
(http://medical-illustrators.org/state.html) and another for the Institute of Medical Illustrators
(http://www.imi.org.uk) which in September 1999 listed 16 Medical Illustration departments in

Academic centres, 8 Associations and Societies, 15 personal home pages of Medical Illustrators,
5 image databases and a wealth of links to other resources. There is also a Medical Illustrators’
Home Page at http://medartist.com, with crosslinks to other relevant sites.
A number of schools for medical illustration have been set up, both in the States and in Europe
and elsewhere, and today we can find information on the Internet about careers in
photography, videography, graphics and illustration applied to medicine
(http://medico.uwcm.ac.uk/medilledu).
The techniques
Any discussion of the major developments in anatomical and medical illustration must, of
necessity, survey the techniques employed for this purpose, and even an old-new art such as
stone carving can still be called up in the service of health education (Fig. 3).
Figure 3

‘Breast Health for All’, carved in stone by Inuit artist, Lucy Meeko Uppik (Photo: Kathleen
Michalchuk, courtesy of Lona Hegeman, personal communication)
For example, a colour photo of this carving appeared on the cover of the Canadian Medical
Association Journal (October 1999), to illustrate ‘Breast Cancer Awareness Month’. Its origin was
traced to an Inuit artist, Lucy Meeko Uppik, who lives on an island in Hudson Bay, in the remote
North-west of Canada, an area with 11 distinct languages and most people unilingual, where
symbolic representation is of prime importance (Lona Hegeman, 1999, personal
communication).
The ‘what’ and ‘how’ of medical illustration are closely interwoven with socioeconomic factors
as well as technical developments throughout the whole of history. Together with the advent of
woodcuts in the 15th century came the first books printed from type and illustrated with
printed rather than painted pictures.
The techniques used for preparing illustrations for printing went from woodcuts (such as those
which appeared in Vesalius’ treatize), or relief printing, through copper engraving and etching,
and were followed by lithography in about 1800. This technique enabled drawing directly on
stone, and was used throughout the 19th century. Thus, the development of medical
illustration went hand in hand with improvements in the printing and reproduction process—
photoengraving in 1868, the halftone screen in 1880, and finally the 4-colour printing process in
1893.4 It was the invention of the half-tone process for printing photographs on cheap regular
paper, rather than on chemically- or light-sensitive paper, which allowed for mass-production
of illustrated books. The next big step forward in photography came with the development of
the photo CD system in the late 20th century.
Hand-drawn and painted illustrations accompanying medical texts still had their place
throughout the 19th and 20th centuries, and continue to do so to this day, even in the most
progressive of textbooks and medical journals.
One has only to think of Gray’s Anatomy: the first US edition, corresponding to the 8th British
edition, published in 1878, contained 522 illustrations. The 1995 (38th) edition has more than
2500 figures, using all kinds of graphic techniques, ranging from the original engravings to
computer-generated graphics.13
The cost and time involved in producing hand drawn illustrations would probably be prohibitive
in the health sciences today, and photography has largely taken over, although computer-
generated illustrations based on original line or watercolour drawings are bringing this form of
illustration back into fashion, because the detail, focus and precision of a hand-made
illustration cannot easily be surpassed.14 The Journal of Neurosurgery, for instance, in its January
2000 issue, featured a cover article illustrated by an artist from the Department of ‘Art as
Applied to Medicine’, at the Johns Hopkins School of Medicine.
Another outstanding body of illustrations produced in the 20th century is the eight-volume
series of anatomical atlases created by Frank Netter, starting in the 1950s and published by the
CIBA foundation (Netter, FH, CIBA Collection of Medical Illustrations). Netter’s Atlases are now
on interactive CD-ROM, and the illustrations can be viewed three-dimensionally, organized and
manipulated—sections magnified by zooming or revolving.
All the same, it is believed there is still room for the portable hard-copy versions of electronic
atlases, which are often produced in parallel with them,13 and which offer different practical
advantages.
Another important medium which has been used extensively for representing the human body
for educational purposes, aside from the illustrated printed text, is the anatomical model.
Although not ‘illustration’ in the strictest sense of the word, anatomic models were for
centuries the only medium that was able to convey the full complex three-dimensional
relationships of anatomic structures with physical precision not allowed by any other medium,
and they could impart a perception of scale and immediacy not obtainable in two-dimensional
illustrations.15 Early anatomical models were made of wax, an ideal material for this purpose.
The use of wax to model parts of the body can be traced back to ancient Greece (about 300 bc),
when death masks were created as a means of ancestral portraiture. It is thought that the first
anatomical model was created in the early 14th century in the course of investigating the
vascular system—molten wax was injected into the vessels, forming a cast that was carefully
dissected-out from the surrounding tissue.16 Another of the earliest models was created by
none other than Leonardo, who injected wax into the ventricular septum of the brain to bring
out the detailed structures, and carefully recorded the method and his observations in his
notebooks. Some 150 years later, anatomical wax models were made from dissections in
Genoa, but the methods were not recorded, and it was only in the 18th century that this art
reached its peak in Florence, where a ceroplastica studio was founded as part of the school of
anatomy. The museum at La Specola contains a priceless collection of anatomic wax models
created over a period of 100 years by this studio, and a few hundred more may be found today
in museums in Italy, France, Austria and England.
Johann Wolfgang von Goethe, the famous German writer, was perhaps less well-known as a
comparative anatomist, and as an advocate of wax anatomical models instead of using
cadavers.16,17
Today the computer has introduced a new dimension into the concept of anatomic models,
which still have their place for teaching purposes. There are devices which ‘print’ three-
dimensional data sets into realistic solid physical models, using materials as diverse as plastic,
wax and metal.
The internal imaging of the human body became possible only in the 19th century. Wilhelm
Konrad Roentgen, a German physicist and Nobel Laureate, discovered X-rays in 1895, using his
wife’s hand as the subject of the first X-ray photograph.
Since then, imaging science has developed in three overlapping stages:18 Firstly, the
development of imaging techniques helps to define morphological features and the functioning
of internal organs. In addition to X-rays, ultrasonic and radionuclide tracer emissions are used
to visualize disease processes, enhance the precision of therapeutic interventions and improve
our understanding of pathophysiology.
Secondly, the achievement of access to the vascular tree and improved characterization of
tissues—contrast angiography, CT and MRI—permit the resolution of very small structures
throughout the body. Better imaging permitted the development of new treatments for cancer
and cardiovascular diseases, and more accurate determination of the stages of a variety of
processes. Image-guided surgery allows both presurgical planning and real-time interactive
computer-aided navigation, which help to minimize surgical wounds and to avoid damaging
critical tissues.19
Finally, the integration of radiological techniques with the knowledge from basic sciences
contributes to solving medical problems.
The Internet today offers unprecedented and incomparable possibilities for accessing and
transmitting static and dynamic images at the highest speeds to the furthest parts of the globe,
thus revolutionizing the means of communicating and educating and treating. It provides
virtually free access to a wealth of medical images, previously held only in libraries at hospitals
or medical schools, or institutes for medical illustrators.
A list of sites for medical images on the Internet was recently compiled by collaboration
between various members of the Medlib-listserv, and can be found at:
http://www.unmc.edu/library/medimag.html
There are web-based anatomy atlases—going from specific disciplines like haematology
(http://www.med.nagoya-u.ac.jp/pathy/Pictures/atlas.htm), or dermatology
(http://dermis.net/bilddb/index_e.htm), to whole body images, culminating in the Visible
Human Project, which can be considered the ‘ultimate’ in computer-based anatomical
illustration. It consists of MRI, CT and anatomical images —whole-body and cross-sections,
sectional images and scans, obtained at intervals of as little as 0.33 mm, resulting in about 7000
images altogether. Many of these can be viewed via the NLM’s ftp site.
There is a fact sheet providing full information at:

http://www.nlm.nih.gov/pubs/factsheets/visible_human.html
Reliability and validity of medical representations

From the historical point of view we can say that the ethical, social and religious objections to
dissecting human cadavers held back human knowledge for centuries. This clearly led to
misinterpretations and misrepresentations, because knowledge gained on the anatomy of
animals was extrapolated to humans. There are also some examples of intentional and
fraudulent misrepresentations.
One of the best known examples is that which has become commonly termed ‘Haeckel’s
embryos’. In the late 19th century, a German biologist, named Ernst Haeckel, published a set of
drawings to show embryos of various vertebrates (fish, salamander, chicken, rabbit and
human), supposedly at the same stage of embryonic development. These were intended to
prove a common evolutionary origin, and may have misled several generations of students of
biology and medicine. Although Haeckel was forced to admit the fraud at the time, and that he
had used ‘artistic license’, his confession was somehow lost, and the drawings were reproduced
in several textbooks of comparative anatomy for decades. It was only in the 1990s that a
careful study and comparison challenged the idea of a single common embryonic stage for all
the vertebrates.20 This showed that not only had Haeckel added or omitted features, but he
had also ‘fudged the scale’ to exaggerate similarities among the species, even when there were
enormous differences in relative sizes.
The advent of photography supposedly made such fraud much more difficult, because
photographs were supposed to represent the objects ‘as they are’ at a given moment.
However, photographs can clearly be manipulated by changing scales or focusing on specific
angles or details. Because medical photographs have been used to publicize, advertise and
celebrate, as well as to ‘create a record’, they may be open to misinterpretation, and it is
essential to know the purpose for which they were originally meant, before they can be
understood and the information they provide can be analysed.21
On the other hand, manipulation of images, which ‘has become easier to achieve than ever
before in the history of illustration’,22 may be used legitimately, to allow superposition or clarity
enhancement, or for educational or experimental purposes without physical intervention, thus
perhaps avoiding irreversible damage or painful procedures. Such manipulation, however,
questions the credibility of photographic documentation in educational films, textbooks,
medical journals, etc.22
When used as evidence in a court of law, for instance, it has been suggested that the original
photographs be presented alongside any that may have been manipulated to enhance clarity,
so that the extent to which an image has been altered, may be known.23
An interesting ethical debate arose around the illustrations used in a critically acclaimed atlas of
anatomy, the Pernkopf Atlas, published in three volumes in the 1940s and early 1950s. The
original atlas contained more than 800 detailed paintings of dissections performed at the
University of Vienna. Pernkopf was a staunch supporter of the Nazi leaders who had annexed
Austria in 1938, and the original editions of the atlas incorporated Nazi icons such as the letters
‘SS’ or the swastika as part of the signatures of the artists. These were removed in later
editions. Although the precise origin of the cadavers used in these dissections is unknown,
evidence has suggested that they may have been the victims of political terror.24 In view of this
suspicion, debate revolved around whether the atlas should be used at all, or whether, rather
than scrap it altogether, and be deprived of the excellent illustrations, it should continue to be
published, with an acknowledgement in a preface to all future editions to honor the memory of
the victims of Nazi terror. This debate continued through to 1998, with the suggestion that the
use of the atlas is itself the most fitting tribute to those who died for it, whether they were
victims of Nazi repression or not.25 A Commission set up by the University of Vienna in 1997 to
‘clarify the issues and investigate the reproaches’, did not find any evidence of the use of
corpses from concentration camps for ‘producing anatomical preparations for research and
education’, nor was it able to identify the individuals used for the illustrations in the atlas,
despite being supplied with a full list of persons executed at the Provincial Court of Vienna in
the years 1938–45.26
Archiving, storing and cataloguing medical

illustrations
The vast amount of medical illustrations of all types that has accumulated over the last two
millennia, must raise the question of how all this pictorial information can be stored and
catalogued, to enable historians in the fields of art and medicine alike to retrieve and
contemplate them.
Because of the wide variety of formats, ranging from manuscripts, engravings, photographs
and books, right through to digital photography, it seems that no standard system will be
suitable to all. However, the principles of arranging and describing the material are consistent
with the principles applied to archival collections. Manuscript collections are largely collections
of textual records, but they also contain a wide variety of nontext, nonbook media, including
prints, photographs, films, slides, videos and three-dimensional objects.27 It is usual to find
multiple copies of the same image, recorded in different media, such as original artwork,
35 mm slides, transparencies, published photographs or reproductions, etc.—the description
and listing of these must enable one to distinguish between them. Fortunately, in the last half
of the 20th century, computers have helped us to apply the principles of database systems to
image cataloguing and storage, e.g. the OCLC audiovisual media format, which allows one to
record bibliographical data on the images in question.
Collections of medical art can be maintained using an archival arrangement of the collection—
using standard methods for sorting, grouping and arranging, linked to a descriptive system
conforming to pre-existing standards. When applied to illustrations, these descriptive terms
must describe the artistic techniques or styles used, as well as the artists and the content.
Among the largest and best known collections of medical illustrations, both historical and
modern, are those held by NLM in Bethesda, in their History of Medicine Department, and
those at the Wellcome Trust’s Medical Photographic Library in London, though there are
probably other excellent collections in other countries too. The Wellcome Trust’s collection
contains over 75 000 still pictures and sections from nine moving films, as well as slides from
the National Medical Slide Bank. A computer catalogue available on the Internet
(http://www.wellcome.ac.uk) describes some 40 000 of them. The pictures are available for
purchase or loan, depending on the purpose required.
Apart from the historical collections, modern methods of producing and storing medical images
should also be mentioned. The last quarter of the 20th century saw tremendous changes in
medical imaging techniques, alongside the appropriate Picture Archiving and Communications
Systems (PACS). These go beyond the savings implied in ‘filmlessness’, the diminished hazard
from chemical and radiation exposure, and the ability to manipulate images.28 Networked PACS
can link radiology departments, hospital wards, outpatient clinics, laboratories, community-
based clinics, etc., permitting correlation and simultaneous consultations at different sites and
instant responses from specialist physicians and radiologists. This system is not totally without
its disadvantages, as the transmission and downloading of images is still relatively slow, and
when used for teaching, is restricted to the locations where viewing stations with the
appropriate software are available—in contrast to the ‘portable X-ray’ which can be viewed
almost anywhere29, but these problems will no doubt be solved in the very near future.
Thus, the advances in networking and imaging technology, coupled with the availability of
three-dimensional datasets such as the Visible Human, provide a unique opportunity for
developing information systems in anatomy that can deliver relevant knowledge directly to the
clinician, researcher, educator, or student, wherever they may be.30
Conclusion
We have tried to review as briefly as possible the entire history of ‘medical illustration’ in the
broadest sense of the word. It is virtually impossible in such a review to do justice to all the
personalities who have played a part in this history, but we have tried to focus on the most
influential participants, or the most important landmark publications or developments up to
the present. It seems appropriate to end such an overview as did Robert Joy in his article on
‘Occupying the visual cortex’,31 with the words of Max Fisch in an article in the Bulletin of the
MLA in 1943, discussing Vesalius:
“ ‘The picture is itself a statement … the picture says something … which cannot be

said in words; so that it does not merely fix the meanings of the words … but makes
a contribution all its own to a total meaning which the words could not convey alone.
This relation between words and pictures is mutual … together they convey an
integral meaning’.32
”
Acknowledgements
We would like to thank Raya Mor of the Medical Library, and Yael Nissan of the Photographic
Department, at the Chaim Sheba Medical Center, for technical assistance in the preparation of
this paper.
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21/8/23, 0:22 Medical illustration: from caves to cyberspace‡ - Tsafrir - 2001 - Health Information &amp; Libraries Journal - Wiley

nal - Wiley Online Library

Health Information & Libraries Journal / Volume 18, Issue 2 / p. 99-109

Medical illustration: from caves to cyberspace‡

Jenni Tsafrir , Avi Ohry

First published: 18 July 2008

As knowledge was extended, permitted by social and cultural change, as well as by

experience to broaden medical knowledge and make it accessible to an ever-widening

The acceptance of previously established beliefs based on the reputations of famous

Open in figure viewer PowerPoint

Many of them can be viewed on the World Wide Web

Open in figure viewer PowerPoint

The picturesque backgrounds, incidentally, served to counteract objections to dissection in the

(http://www.imi.org.uk) which in September 1999 listed 16 Medical Illustration departments in

Open in figure viewer PowerPoint

There is a fact sheet providing full information at:

Reliability and validity of medical representations

Archiving, storing and cataloguing medical

“ ‘The picture is itself a statement … the picture says something … which cannot be

7 Kemp, M. Vincian velcro. Nature 1998, 18, 25.DOI: 10.1038/23832

12 Rutkow, I. M. The surgeon as illustrator. Archives of Surgery, 1998, 18, 914.

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21/8/23, 0:22 Medical illustration: from caves to cyberspace‡ - Tsafrir - 2001 - Health Information & Libraries Journal - Wiley