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Max Brodel (1870-1941): His Artistic Influence on Surgical Learning at John Hopkins Medical School

by Pia Pace-Asciak, B.A., H.B.Sc., M.A.Sc.
Summer 2006

This study was funded by the Geza Hetenyi Memorial Studentship for the Study of the History of Medicine at the University of Ottawa.

Pia Pace-Asciak is a third year student in the Faculty of Medicine at the University of Ottawa

Acknowledgements

I would like to thank my supervisor Dr. Toby Gelfand for his constant encouragement, enthusiasm and editing during the writing of this paper. With his support, I was able to expand and develop my ideas and seek out rare archives. Also, I am grateful to have received the Geza Hetenyi Memorial Studentship in the History of Medicine at the University of Ottawa because it gave me the opportunity to pursue this fascinating topic during my clerkship year of medical school. I would also like to thank Jamie Topp for his support and thorough editing during my busy third year in medicine.

Figures

Figure 1:

Brodel’s Hospital chart drawing of tactile sense in his own left arm after ulnar nerve injury in 1898.

Figure 2:

Illustration of the musculature of bladder and urethra in 1911.

Figure 3:

Illustration of Samuel Crowe’s tonsillectomy technique.
Brodel’s drawing of the microanatomy of a tonsil.

Figure 4:

William Halsted’s approach to thyroidectomy.
Surgical anatomy pertaining to Halsted’s thyroidectomy procedure.

Figure 5:

Harvey Cushing performing a transsphenoidal hypophysectomy.

Figure 6:

Sagittal section of hypophysectomy procedure showing the Killian incision.

Figure 7:

Otosclerosis works commissioned by Samuel Crowe and Stacey Guild in 1927.

Figure 8:

Laryngectomy operation showing the preservation of the laryngeal perichondrium.
Laryngectomy as described by Crowe and Broyles, illustrated by Brodel in 1938.

Figure 9:

Coronal view of the temporal bone.
One of Brodel’s most recognized illustrations.
Microanatomy of the cochlea.
Temporal bone illustration drawn with the aid of the camera lucida.

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Preface

The power of illustration has been known well before paper was invented whereby ancient Egyptians, Babylonians, Chinese and Indians recorded medically related illustrations on stone, bamboo, silk and metal (1,2,3). Often the written word fails to communicate certain information that pictures easily convey. Throughout history, artists and anatomists such as Leonardo DaVinci or Vesalius have united art and medicine to communicate the details of human anatomy. A more recent example, Max Brodel, is someone whose work had the stamp of artistic competence and the accuracy of a clinician. His work served an invaluable tool for educating students about anatomy, physiology and surgical procedures.

Medical illustration is a highly difficult skill to master. Often the work is generated by an artist without medical training, or by doctors with limited artistic skills. This paper will discuss how Brodel worked hard to strike a balance between having sufficient medically based knowledge and artistic skill. This paper explores Brodel’s early training in Leipzig Germany, and the evolution of his career at Johns Hopkins Medical School.

This topic was of personal interest since it bridges my previous experience as an art student, with my current experience learning anatomy and surgery as a medical student. My interest in this field developed during a summer elective in Otolaryngology when my drawing skills came in handy for a surgeon who wanted a specific rendition of the neurovascular structures in the suprahyoid region of the neck. This project made me appreciate the importance of illustration, and its advantages compared to photography for directing surgical learning. A drawing may not tell the whole story the way a photograph can, but it can highlight the important features of a structure for teaching or discussion purposes. Despite the technical advancements made in imaging, illustration remains a vital tool for selectively communicating disease processes.

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Introduction

‘A picture is worth a thousand words’ (4). Confucius’ expression aptly applies to the field of medical illustration. Images have the ability to bypass language barriers and jargon that may hinder the fluidity of expression. There is no denying the importance of medical illustration in the early training of future surgeons for teaching procedures. According to Ludwig Choulant, a well known expert on the history of medical illustration, “the figuration of the anatomic form of man by the graphic arts aims either to make the teaching of human anatomy more plastic for the anatomist and physiologist, engraving it on the memory, or to give the plastic artist a clear, scientific basis for his studies of the human figure”(5). In other words, according to Thomas Jones, Professor of Medical and Dental Illustration; “Medical illustration can be defined as the graphic representation of any medical subject made for the purpose of communicating medical knowledge” (6).

Medical students depend on illustration to learn anatomical facts and details that may be too subtle for the written or spoken word. For surgical disciplines, learners rely on tools such as language, 2-dimensional illustrations, and 3-dimensional models to pass on important concepts. Although a photograph can convey factual information, illustration can highlight and educate the pertinent details for understanding surgical procedures, neurovascular structures, and the pathological disease processes (7).

Often, medical professionals, residents, and students hear the words anatomical illustration and reflexively think of Frank Netter (1906-1991) (8). Few however, are aware of an earlier figure Max Brodel (1870-1941), a German-raised artist who eventually immigrated to the United States to pursue his career as a medical illustrator. He became recognized as one of America’s most distinguished medical illustrators, who greatly improved the standards of surgical illustration. However, while Brodel may be considered the father of medical illustration, he was not the first to study anatomy for reasons other than purely art.

Leonardo DaVinci (1452-1519) is the most famous example of an artist who devoted 20 years of his life to anatomical studies and drawings of skeleton, muscular, nervous and vascular system, in addition to the development of the human fetus with depth, precision and fine detail (9)a . His work is all the more remarkable when one considers that he had no reference material of any kind other than the human body itself to guide him (10). Historical accounts of his work explain how he studied both structure and function in depth, through observation and careful dissection. According to DaVinci, by drawing various joints, muscles and bones from different angles, “it 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 proclivity of writing and of time” (11,12).

Brodel learned medicine in Baltimore by reading medical texts, performing numerous dissections of cadavers, and working under the guidance of gynecologist Dr. Howard Kelly (1858-1943). Brodel’s dedication led to his creation of artistic techniques that revolutionized the appearance of medical illustration and made illustrated tissue seem alive. After years working as an illustrator at Johns Hopkins University, in 1911, Brodel became the head of the first Department of Art as Applied to Medicine (13). The establishment of this department led to the professionalization of illustration and the subsequent development of the Association of Medical Illustrators in 1946 (14). In collaboration with various physicians, Brodel developed hundreds of drawings for educating surgeons in Obstetrics and Gynecology, and later Urology, and Otolaryngology.

In order to understand the current role of medical illustration in education, one needs to look to the past to see how art has helped solve communication dilemmas when learning medicine. To do this, the artistic training of Max Brodel will be discussed as well as the contributions he made to medical illustration at Johns Hopkins University in the twentieth century. In addition, the changes that have occurred with computer technology will be compared to a century ago, when illustrations were used for teaching anatomy since cadavers were not always available on demand. Moreover, medical illustration served as employment for artists. Today, animated computer based art is synergistically used with medical illustration to educate students about anatomy.

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  1. Leonardo, through his superb draftsmanship produced a series of aesthetic and instructive anatomic studies. His drawings show accurate anatomic structure and suggest function as well.

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Max Brodel’s training with Dr. Ludwig

Max Brodel’s art training conformed to a late 19th Century fine arts education that focused on precision and mastery that was characteristically German. During his vacations and upon graduation from the Leipzig Academy of Fine Arts, Brodel worked on gross anatomical and histological drawings for Dr. Carl Ludwig, the Director of the Institute of Physiology at the University of Leipzig in 1888. Dr. Ludwig was a brilliant physiologist who advanced original evidence on how the kidney acts as a filter (15). Shortly thereafter, he gave a new interpretation of renal function (16). His research also focused on lymph formation, glandular secretion, nervous control of blood pressure and capillary blood pressure. During the eighteen months that Brodel spent in Ludwig’s laboratory, he developed what later became his credo. In one of his diary entries he wrote:

“I did not know then that the only way to plan a picture is to leave paper and pencil alone until the mind has grasped the meaning of the object ….Copying a medical object is not medical illustrating. The camera copies as well, and often better, than the eye and hand….in medical drawing full comprehension must precede execution” (17).

Ludwig was Brodel’s first mentor and helped nurture his future artistic and scientific knowledge (18). According to the literature, it is not clear on what basis Brodel was put forward by the school’s director to work in Ludwig’s laboratory during the summer of 1888 (19). Brodel was either recognized for his skilled draftsmanship, or perhaps, he was one of only a few who showed an interest in physiology. According to one source, his wife Ruth believed that Max sought the job because he needed the money to continue art school (20).

The wide-eyed eighteen year old Max had little training in science, except for a course in artistic anatomy he took in art school that included lectures and demonstrations of dissections by medical students. However, the chief lecturer, famed for his research of the mitochondria was uninterested in teaching gross anatomy (21). Thus, working in Ludwig’s lab enabled Brodel to gain an understanding about cellular structures, and physiological processes such as lymph formation, glandular secretion, nervous control of blood pressure and capillary blood pressure (22). Through Ludgwig, Brodel grasped the basis of physiology which later provided some of the groundwork for his career at Johns Hopkins Medical School.

Ludwig was internationally known and attracted numerous physicians and scientists from abroad. This gave Brodel the opportunity to meet several influential physicians, notably Franklin Mall (1862-1917), a visiting anatomy professor and future head of the anatomy department at Johns Hopkins Medical School in America, who convinced Brodel that his future lay in Baltimore. Mall went to Leipzig to study anatomy and embryology with Wilhelm His and then became a student of Ludwig’s for one year where he studied the villi of intestines (23,24). William Henry Welch (1850-1934), the professor of pathology and the Dean of Johns Hopkins Medical School, who was responsible for bringing together the original of Faculty of Medicine, also played a role in recruiting Brodel and Mall to Baltimoreb . Welch knew Mall prior to meeting him in Ludwig’s laboratory since Mall had been his first fellow in pathology. It was in 1894 when Ludwig became ill and was nearing the end of his life that Mall persuaded Brodel to become an illustrator at the newly opened Johns Hopkins Medical School (25).

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  1. William Henry Welch was the moving force behind the great revolution that took place in American medicine between 1880 and 1930. A distinguished pathologist, teacher and humanitarian, Welch was responsible for the introduction of European developments in bacteriology and pathology into the United States, and for the advancement of medical education throughout the country.

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Max Brodel’s transition to America

Upon arriving in Baltimore, Brodel found that Dr. Mall was occupied with administrative duties. According to Crosby and Cody, Mall took Brodel to meet Dr. Howard Kelly, Professor and Chair of the Gynecology department who was working on his first book, “Operative Gynecology”. Shortly after his arrival, Brodel found himself taking on the formidable task of illustrating the first volume of Kelly’s “Operative Gynecology”. Every morning, Brodel reported to the hospital where Kelly explained what he wanted through simple line drawings. From then on, Brodel acquired most of his medical knowledge on his own. Brodel became a prolific reader of the medical literature. He also spent hours dissecting cadavers so he could fully understand his subjects and the physiology underlying the structure prior drawing them (26, 27)c .

For Brodel, acquiring medical knowledge required hours of observation in the operating and autopsy rooms with little guidance. Ruth Brodel’s biographical sketch comments on her husband’s dedication to his profession:

“Long hours of painstaking studies were necessary for Max to fit him for his work, and in doing so he laid the foundation of a masterful knowledge of anatomy. He was a keen observer of every detail, and had such a retentive memory that he could reproduce on paper what he had seen and observed” (28)d .

Often Brodel had to find creative ways to represent difficult anatomical structures in the absence of model or cadavers for dissecting. Tom Cullen (1868-1953), a surgeon and friend would “assume the position” when it was not possible to locate a suitable model for a particular illustration of a woman in the knee-chest posture with her buttocks in the air. Max would then have to transform Tom’s muscular buttocks into something “graceful and feminine” (29). Despite the limitations Brodel faced, Cullen describes Brodel as a skillful illustrator: “no other man who ever lived has done as much to improve the beauty and accuracy of medical illustration….” (30).

Brodel dissected human bodies without using gloves so he could fully understand his subjects (31). According to Crosby and Cody, rubber gloves were introduced a decade earlier (32). Brodel developed a streptococcus infection on the ulnar side of his left hand (fortunately not his dominant right hand) after mistakenly cutting himself while dissecting an infected cadaver. After four surgeries by the great neurosurgeon Harvey Cushing (1869-1939), and some recovery time, Brodel’s hand improved. Cushing studied surgery under the guidance of the father of American surgery, William Steward Halsted (1852-1922), at the Johns Hopkins Hospital. During recovery, Brodel was fascinated by the loss of sensation in his hand and took to studying ulnar nerve injury. With a pair of forceps, he applied light pressure to different areas on his hands to map out the areas of sensation loss due to ulnar nerve damage. After several drawings on “progress note” paper that physicians use to make notes on patients, Brodel drew the regions of the hand that are supplied by the ulnar nerve (Figure 1) (33). A century later, we can still learn from Brodel’s misfortune.

Under Dr. Kelly’s guidance, Brodel was able to complete 154 illustrations for the first volume of ‘Operative Gynecology’ in 1898. Brodel’s talents were apparent to everyone at Johns Hopkins from the beginning. Crosby and Cody state that “he appears, in every way, to have been treated by the younger men as one of them, as their equal” despite the absence of a medical degree (34)e .

Kelly was described as a born teacher who could speak the artist’s visual language through his own modest sketches. Kelly conveyed gynecological knowledge by sketching operative procedures that could not easily be obtained from reading a medical text. In a biography of Brodel’s early relationship with Kelly, he remarks; “Dr. Kelly had the remarkable gift of explaining with sketches. In a few but simple graphic lines he could show all the new ideas in connection with his operative work”(35). There is no question that Dr. Kelly’s genius for visualization and for sketching paved the way for Brodel’s career as a medical artist (35).

Kelly’s religious beliefs dictated how he practiced medicine (36). He was a fundamentalist Christian and he held a prayer meeting before every operation sometimes reading the Bible in its original Greek and Hebrew (37). He believed, by charging high fees to the wealthy and treating the poor for nothing, his good Christian faith would open the doors to heaven for him. His life was devoted to missionaries, private charities, campaigns to close houses of prostitution, and shelters for women making him a ‘life long moral crusader’ (38). Kelly wrote about his strong beliefs in the Bible and God:

“I believe the Bible to be God’s word, because as I use it day by day as spiritual food...It is as really food for spirit as bread is for the body…Perhaps one of my strongest reasons for believing the Bible is that it reveals to me, as no other book in the world could do, that which appeals to be a physician, a diagnosis of my spiritual condition” (39)f .

Kelly’s spiritual beliefs, in turn, may have influenced Brodel’s work. The artist used delicate, clean and intricate lines with a soft, subtle tone which conveyed a sense of innocence (Figure 2). This served to soften the stark female anatomy of the urethra, vagina and bladder. Moreover, the halftone effects create a striking balance between light and dark shadows which are reminiscent of the battle Kelly had with prostitution and reform. Overall, the use of black and white tones created a dramatic mood or a sense of impending doom that lurked in the shadowy folds of every woman’s tissue. In some respects, Brodel’s art was a vehicle for visually depicting everything that Kelly stood for.

Medical illustration became an important tool for educating students, in part due to the paucity of cadavers for teaching anatomy. In a Johns Hopkins Society meeting (1907), Dr. Kelly lectured to the faculty members about the challenges faced when teaching anatomy: “….picture yourselves at this present theatre crowded with students ready for anatomy demonstration. No one is absent, for it is the greatest day of the year, that on which the dissection of the one corpse (per student) allowed yearly will be made” (40). Cats, dogs, and even monkeys were used when nothing else was available to demonstrate human anatomy, but provided an oversimplification of what really existed.

Grave robbing for learning human anatomy remained a problem in the late nineteenth century. Even though, according to Kelly, ‘the price of gaining such knowledge was prison’, Kelly went on to say that ‘relatives were being auctioned off before they had even died’ (41). There are several accounts of bodies being sold for a mere $15.00 and graves being exhumed when people died of unknown diseases (42). As a result, police were forced to deal with gangs of professional “resurrectionists” whose ranks included medical students (43)g .

It was common for Kelly to receive letters written by people willing to offer their body to medicine in exchange for money: “…I may be of some use to you after I am dead and gone, I think it better for a college to have my remains as it may be a lesson that a good many young and old doctors have never witnessed before. I agree to give my remains. I believe the college ought to give me $106 for my remains in advance….” (44). Under these circumstances, Brodel’s talents as an illustrator were invaluable.

Without cadavers to aid in the demonstration of pelvic anatomy, Kelly recognized that teaching gynecology was problematic. First, it was not in the best interest of the patient to have numerous students in the room during their clinical visit. Second, there was only so much knowledge that a surgeon could impart using the blackboard to explain clinical cases. In an article Kelly wrote describing the methods of teaching gynecology, he states: “I believe that gynecology is, as a rule, very badly taught, and the medical student gains but little from this part of the course (45)”. This dilemma provided the impetus for Kelly to write ‘Operative Gynecology’ with detailed illustrations by Brodel. Subsequently, Brodel’s drawings became valuable educational tools for understanding complicated anatomy and pathologyh .

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  1. Dr. Kelly is best known for his leadership in three areas: as a founding faculty member of Johns Hopkins University Medical School, as a physician who established high standards in gynecology, and as one of the first clinicians to see the medical potential of radium.
  2. In a speech that Max gave for Kelly’s 75th birthday; “The little I had learned in Leipzig was entirely inadequate. Gynecology seemed a colossal subject, full of mysteries. It almost terrified me. All I was able to do was to observe accurately, work hard, and draw with fair technical skill, a meagre equipment of my new task”.
  3. Brodel became involved in medical research and surgical procedures very early in his career. Following dissection studies of the intrinsic blood vessels of the kidney he defined an avascular line for nephrotomy (“Brodel White Line”) and suggested a modified suture technique for nephropexy (“The Brodel Stitch”).
  4. Kelly made several contributions to gynecology and was responsible for establishing it as a specialty at Johns Hopkins Medical School. He invented many medical devices, notable the urinary cystoscopy as well as new surgical approaches in gynecology. In addition, he was one of the first to attempt radium treatments for cancer and to use absorbable sutures. Kelly was active in election reform and also fought organized prostitution, working hard to rehabilitate the “ladies”.
  5. According to Howard Kelly; “Once in Baltimore, two students exhumed a man. They boldly set him up between them on a wagon seat and drove off. It was a chilly night; and they stopped at an inn for a drink, leaving their silent company propped against the wagon side…when a policeman made remarks about the weather and the corpse answered not a word, the policeman playfully prodded him in the stomach to make him speak. He was horrified by a heavy body falling on him and an icy face being pressed to his.”
  6. Kelly acknowledged in the Preface of his book that “the anatomical chapters were written by Max Brodel.

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Funding the future Department of Medical Illustration

By 1903, Brodel’s work with Kelly achieved the highest praise after the publication of the two volumes of ‘Operative Gynecology’. Brodel received several enticing offers from other universities in the United States and The Hopkins faculty was worried about the possibility of losing the acclaimed artisti . It was felt that medical illustration should be taught to others to ensure the same kind of thoroughness among future medical artists (46). Under the driving force of Thomas Cullen, an endowment was raised to support a new venture to be named, “The Department of Art as Applied to Medicine”, the first department of its kind in the world (47). With personal persuasion and promise of funds, Brodel remained at Johns Hopkins, and became the head of the new department.

The endowment was a gift from Henry Walters (1848-1931), a wealthy patron of the arts and founding donor of the Walters Art Museum, that included contributions from J.P. Morgan and the W.B. Saunders Company (48). When Cullen met with Walters in New York to accept the funds, Walters stated: “I am not interested in medical illustrations; I took twenty lectures in medicine at Harvard and nearly vomited my boots up. However, I appreciate the value of medical illustrations and will give the Department of Art as applied to Medicine $5,000 per year for three years” (49,50). Walters wished to remain anonymous and wanted no public acknowledgement of his generosity. With continuous persistence on Cullen’s part to raise funds to support the department in 1921, Walters donated a permanent endowment of $110,000 for the department (51).

Prior to the first endowment by Walters, Brodel established classes in medical illustration with the consent and funding of Dr. Kelly. According to Cullen, classes “had been started simply to help medical students with a gift … but year by year, though it was unofficial, they were drawing talented young artists to Baltimore” (52). Cullen saw that his friend Max was training a new generation of artists in his methods and saw a future in medical illustration. Cullen recalls : “…so I lighted my corncob pipe, went down to my tent by the shore – and dreamed up the new department, the Johns Hopkins Department of Art as Applied to Medicine, the first of its kind anywhere in the world” (53)j . In 1911, the institute was opened to art students for training in medical illustration.

The endowment ultimately led to the production of a legacy of illustrations in several medical fields, notably Otolaryngology. As the department of Medical Illustration gained recognition, other surgical specialties requested Brodel’s services. The complex nature of head and neck structures led to the popular use of surgical illustration to visually explain organs, such as the ear, or the neurovascular structures in the neck. Moreover, the immense detail and superior aesthetic quality of the work made such illustrations advantageous to photography, and easier for teaching surgical procedures.

One of Brodel’s earlier series depicted each step in a tonsillectomy, as taught by surgeon Samuel Crowe (Figure 3A and B) (54). Each frame focused on a different angle to obtain a clear view of the various structures in the head and neck, while also incorporating pathological details such as the palatine tonsil microanatomy and microcirculation. When the tonsillectomy series met with success, the famous Johns Hopkins surgeon William Halstead, asked Brodel in 1917 to prepare an illustrated series showing the steps of a thyroidectomy so the procedure could be taught to the residents (Figure 4A and B).

Brodel also used illustration to visually communicate the common surgical procedures used at the time and to celebrate the famous surgeons at Johns Hopkins by including their face (Dr. Kelly) in the illustrationk . Just before Harvey Cushing left Johns Hopkins for Boston in 1912, Brodel portrays Cushing demonstrating a transsphenoidal hypophysectomy, a procedure used to access the pituitary gland, with an incandescent head lamp to illuminate the surgical site, and a mouth retractor meant for insufflation anesthesia (Figure 5) (55). In another illustration, Brodel portrays a sagittal section of a hypophysectomy procedure showing the Killian incision used in septoplasty, which is an operation done to correct any defects or deformities of the nasal septum (Figure 6) (56).

Brodel’s illustrations were also used to raise money to fund the Otologic Research Laboratory of Drs. Samuel Crowe and Stacey Guild in 1927 (57). A portfolio of drawings demonstrating the areas of the temporal bone affected by otosclerosis, a degenerative disease of the sound conducting bones in the ear, was shown to the DuPont family members who themselves had a history of otosclerosis (Figure 7). These drawings were successful in raising funds for further research and were published many years later in a pediatric otolaryngology text in 1963, still referenced today (Figure 8, Figure 9 A, B and C).

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  1. At the time, the Mayo clinic in Rochester, Minnesota was attempting to recruit Brodel.
  2. Johns Hopkins Medical School was founded by William Henry Welch to train competent practitioners as well as to provide a center for learning and original research.
  3. Brodel incorporated illustrations of Howard Kelly, a reference found in many of Brodel’s drawings. Sometimes Brodel even portrayed himself as the patient in his drawings.

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Max Brodel’s two tone technique

Prior to Brodel’s arrival at Hopkins, photography was the primary medium for visually explaining anatomy. Brodel recognized a role for photography and how it could save him from spending endless hours in the operating room. However, his intention was not to compete with the camera in realistic or imitative quality (58). He believed that the process before the execution was the most important part of creating an illustration:

“The artist must first fully comprehend the subject matter from every standpoint: anatomical, topographical, histological, pathological, medical and surgical. From this accumulated knowledge grows a mental picture, from which again crystallizes the plan for the future drawing. A clear and vivid mental picture must always precede the actual picture on paper (59).”

At the turn of the 20th century, representing tissue accurately was a problem for medical artists. This dilemma was significant in Brodel’s time since “no medium – pencil, crayon, ink, watercolour, gouache, pastel or oil produced the sparkling highlights that characterize wet, living tissue “(60). The challenge lay in finding the perfect technique that would allow Brodel to create highly detailed and visually descriptive work with accuracy for teaching future surgeons.

Brodel was dissatisfied with the way in which the plastic-like effect that oil, or acrylic paint masked tissue structures. Although Brodel felt, “the conception of a picture is the all important thing, not the plastic elaboration, the realism, or the technical finish”, he struggled with the constraints that working with certain medium presented (61). On one hand, painting with media such as ink washes and watercolor allowed artists to ‘highlight with white paint the areas that are meant to glisten or to leave areas of white paper untouched by paint, thus allowing the texture of the paper to play a role in the aesthetics of the image’(62). On the other hand, ‘oil or acrylic paint or pastel creates a more opaque solid seal, masking the texture of the paper, and a uniform surface’ (63,64).

Faced with these limitations, Brodel used lithography as a means making tissue seem alive. His ‘Carbon Dust and Stipple Board Technique’ involved using a special paper (Ross Hand-Stippled Paper No.8) surfaced with heavy white layers of chalk or china clayl . Initially, Brodel would draw the image on tracing paper, and then bring it into direct contact with the stipple board to leave an imprint of the desired image. Generally, the drawing was not made directly on the Ross board in order to maintain its freshness for the final work up. Once the imprint was made, carbon dust was layered in stages to create the sense of depth, background and tonal gradation. The illusion of structures being three dimensional was then created by using an eraser to lift highlights and soften the edges of structures. Fine and precise details were then engraved with the tip of the scalpel blade and with fine dark lines using black watercolor or carbon pencil (65). The overall effect created striking differences between lights and darks (Figure 2).

Brodel’s art is noted by Crosby and Cody to have three hallmark features. First, Brodel’s lines are delicate and painterly. Second, carbon dust creates silvery, soft light which provides transition between lights and darks. This creates the feeling that his subjects are looming out of a transparent shadow. Third, his work has a strong sense of depth and very fine detail. Overall, the final result of his two-tone technique conveys the authenticity of a classic black and white photograph, but with more detail and expression than a photograph conveys (66,67).

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  1. Once Max discovered this method, it became the mainstay of his work, along with pen and ink on scratchboard and more rarely because of the expense of color reproduction, watercolor on paper or on the Ross board. “The first drawings I made on this paper were very crude, but I was sure of its possibilities from the start. It gave me the effect I wanted and it save me much time. There were many minor points in the working of this technique which I discovered from time to time.”

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The use of art in medical education

The earliest historical account of when art and medicine were used as a tool for learning was on ancient cavern walls where animals were crudely drawn with arrows and spears directed at the heart to teach other hunters how to survive (68). For the Chinese, anatomical drawings on tablets, and columns were the only means of learning about human structure since both moral and civil law prevented them from dissecting bodies (69). Aristotle was probably the first individual to use the anatomical illustration of animals to teach anatomy to his pupils (70).

Some art historians believe the Renaissance period marks the initial merging of art and medicine where anatomists and physicians required the help of artists to illustrate the anatomy of cadavers to further anatomical learning (71). For artists, becoming a free lance medical illustrator was a means to make a living, whereas for the physician, medical illustration was useful for education. By the post-Renaissance period, the companionship between art and medicine was consummated, and the artist and the physician realized that their specialties were useful in combination with that of the printer (72,73). Vesalius’s De Humani corporis fabrica libri septem, published in 1543 by Johannes Oporinus in Basel, is both a classic work in the field of medicine and a classic example of the art of printing (74)m .

Although medical illustration was historically used to educate students, it was not always accurate. Errors occurred, mainly because the anatomy of animals was studied and then extrapolated to represent human structures. However, the Renaissance treatises misunderstood that Galen (129-200 AD) had done dissections from animals rather than humans (75). Netter (1906-1991) himself misrepresented the lateral dorsal nuclei incorrectly as being lateral instead of medial (76). Netter (1953) portrayed just eleven nuclei in each thalamus instead of approximately forty nuclei (77). These are two examples of how errors and oversimplifications can be handed down through generations of print. Brodel was exceptional, partly because he used first-hand information acquired by dissecting his own cadavers to learn about anatomy and thus improved the standards in America (78,79).

Traditional illustration and computerized images can co-exist, and in fact, mutually aid one another in medical education. For example, video-assisted surgery seems to be synergistically working with traditional illustration in the current curriculum to enhance the surgical learning experience for students (80). The concept of Websurg was launched by Jacques Marescaux and his team at the European Institute of TeleSurgery in Strasbourg, France and then adopted by McMaster (2001) in order to provide medical teaching centers with information on the latest surgical breakthroughs and the possibility to chat with experts from all over the world. With this in mind, McMaster University created the “World Electronic Book of Surgery” which includes the latest techniques and lectures in Cardiovascular, Gynecological, Thoracic, and Urological surgery (81). The advantage of Websurg is that it’s free, anyone can sign up, and it can be accessed from anywhere in the world through the Internet (82). Brodel may have not taken to the computer since it replaces the authenticity of hand-drawn images.

Today, knowledge that was once confined to the medical profession is being made available to the public through exhibits such as Gunther van Hagens “Body Worlds”. This exhibit displays whole bodies that have been plastinated, and in a sense frozen in time, so viewers can learn about the intricacies of the human body and its complex functions. Just as medical illustration was used for educating physicians in training, “Body Worlds” is used as a tool for communicating the effects of unhealthy living to the general public (83).

According to the President at the first annual meeting of the Association of Medical Illustrators in 1946; motion picture photography was “destined to play a far more important role in medical education than it does now” (84)n . “It is generally agreed by educators, as well as producers that the major development of educational films of the future will be in the field of animation” (85). However, some maintain that “motion picture photography has been pushed about as far as it will go and artists must carry on from here” (86). Sixty years later, web animation has not replaced the role of surgical illustration in education even though many feared it would. In fact, web-based learning has only enhanced our preexisting methods for educating students on clinical procedures and functional anatomy. A century later, Brodel’s achievements remain relevant.

Brodel headed the department at Johns Hopkins University until 1939 and died in 1941 of metastatic pancreatic cancer. The ‘Brodel Archives’ at John Hopkins store most of his artistic work and an uncompleted manuscript (87). His drawings have been reproduced in numerous textbooks, articles, and advertisements for over half a century. Brodel was a true artist who “revolutionized medical illustration in the United States and Canada during his forty eight years in Baltimore” (88,89). Today, there are a dozen schools patterned after the Brodel-Hopkins school, many pioneered by Brodel’s former pupils such as, Dorcas Hager Padget, (1906-1973), a neurosurgical and embryological illustrator; James F. Didusch, (1890-1955), an embryological illustrator; William P Didusch, (1895-1981), a neurological illustrator; and Leon Schlossberg, (1912-1999), a cardiology and general illustratoro . Illustrators today complete a three year course of study, much of it being tied in with a medical course. The idea was to create professionals with an exceptional scientific background, and to be accomplished artists (90).

_______________

  1. At the time he wrote the Fabrica, Andreas Vesalius was a lecturer in surgery at the University of Padua. The Fabrica is a large folio volume of 663 pages, illustrated with more than two hundred woodcuts. There is no other medical text that has been accorded so high a rank in both fields; the art of medicine and the art of printing, at once.
  2. According to the constitution’s objectives for the association; “The objectives of the Association are to promote the study and to encourage the advancement of medical illustration and allied fields of visual education; to advance medical education, and to promote understanding and cooperation with the medical and related professions.”
  3. One of the most famous pupils who attended Brodel’s classes was Harvey Cushing, at that time Associate Professor of Surgery. He had a talent for drawing and later became a close friend of Brodel.

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References

  1. Tsafrir J., Ohry A. Medical Illustration: from caves to cyberspace. Health Information and Libraries Journal. 2001:88:99-109.

  2. Petrucelli, RJ. Art and science. In: Lyons, A.S. & Petrucelli, R.J. (eds) Medicine: an illustrated history. New York: Abradale Press, 1987: 398-419.

  3. Calkins, C.M., Franciosi J.P. & Kolesari, G.L. Human anatomical science and illustration: the origin of two inseparable disciplines. Clinical Anatomy. 1999:12; 120-9.

  4. Tsafrir J., Ohry A. Medical Illustration: from caves to cyberspace. Health Information and Libraries Journal. 2001:88:99-109.

  5. Thornton and Reeves. A short history: Medical book illustration. The Oleander Press, 1983, England:15-17.

  6. Jones, Thomas. The Evolution of Medical Illustration. In: Davis, David J. Essays in the History of Medicine, Davis Lecture Committee, University of Illinois Press, Illinois, 1965:158-167.

  7. Schultheiss D., Udo J. Max Brodel (1870-1941) and Howard A. Kelly (1858-1943) – Urogynecology and the birth of modern medical illustration. European Journal of Obstetrics & gynecology and Reproductive Biology. 1999:86; 113-115.

  8. Calkins, C.M., Franciosi J.P. & Kolesari, G.L. Human anatomical science and illustration: the origin of two inseparable disciplines. Clinical Anatomy. 1999:12;120-9.

  9. Tsafrir J., Ohry A. Medical Illustration: from caves to cyberspace. Health Information and Libraries Journal. 2001;88:99-109.

  10. Ibid

  11. Ibid

  12. Richter, I.A. The Notebooks of Leonardo DaVinci. Oxford:OUP, 1952:150,371.

  13. Schultheiss D., Udo J. Max Brodel (1870-1941) and Howard A. Kelly (1858-1943) – Urogynecology and the birth of modern medical illustration. European Journal of Obstetrics & gynecology and Reproductive Biology. 1999:86; 113-115.

  14. Schultheiss, D., Truss M.S., Jonas U., Engel R.M. Max Brodel and Modern Medical Illustration. The Journal of Urology. 1999:161 (4S), Suppl;April:189.

  15. Crosby, Cody. Max Brodel: the man who put art into medicine. Springer-Verlag, New York, 1991.

  16. Ibid

  17. Ibid

  18. Lucey B.P, Bedell Thomas C., Hutchins G.M. Max Brodel: Illustrating Healed Valve Ring Abscess. Archives of Pathology & Laboratory Medicine. 2005:Sept, 129:9;1155.

  19. Ibid

  20. Crosby, Cody. Max Brodel: the man who put art into medicine. Springer-Verlag, New York, 1991.

  21. Ibid

  22. Lucey B.P, Bedell Thomas C., Hutchins G.M. Max Brodel: Illustrating Healed Valve Ring Abscess. Archives of Pathology & Laboratory Medicine. 2005: Sept, 129:9;1155.

  23. Flexner S., and Flexner J.T. William Henry Welch and the heroic age of American medicine. Dover Publications, Inc., New York.1941:224-226.

  24. Crosby, Cody. Max Brodel: the man who put art into medicine. Springer-Verlag, New York, 1991.

  25. Ibid.

  26. Ibid

  27. Schultheiss D., Udo J. Max Brodel (1870-1941) and Howard A. Kelly (1858-1943) – Urogynecology and the birth of modern medical illustration. European Journal of Obstetrics & gynecology and Reproductive Biology. 1999:86; 113-115.

  28. Crosby, Cody. Max Brodel: the man who put art into medicine. Springer-Verlag, New York, 1991.

  29. Ibid

  30. Robson, Judith. Tom Cullen of Baltimore. Oxford University Press, London;1949:212.

  31. Schultheiss D., Udo J. Max Brodel (1870-1941) and Howard A. Kelly (1858-1943) – Urogynecology and the birth of modern medical illustration. European Journal of Obstetrics & gynecology and Reproductive Biology. 1999:86;113-115.

  32. Crosby, Cody. Max Brodel: the man who put art into medicine. Springer-Verlag, New York, 1991.

  33. Ibid

  34. Ibid

  35. Schultheiss D., Udo J. Max Brodel (1870-1941) and Howard A. Kelly (1858-1943) – Urogynecology and the birth of modern medical illustration. European Journal of Obstetrics & gynecology and Reproductive Biology. 1999:86;113-115.

  36. Koehler B.M., Roderer N.K., Ruggere C. A short history of the Willian H. Welch Medical Library. Neurosurgery. 2004:Vol.54:465-479.

  37. Ibid

  38. Dictionary of American Biography, Supplement 3: 1941-1945. American Council of Learned Societies, 1973.

  39. Kelly, H.A. Out of Uncertainty and Doubt, into Faith. Rare Archives from the Hannah Collection, 1910.

  40. Kelly, Howard. The Barred Road to Anatomy. John Hopkins Hospital Bulletin, Volume XIX, No.208, July 1908. Read at the meeting of the John Hopkins society, October 14, 1907.

  41. Ibid

  42. Ibid

  43. Ibid

  44. Ibid

  45. Kelly, H.A. Methods of Teaching Gynecology. Reprinted from The Philadelphia Medical Journal on medical education, September 1st, 1900.

  46. Loechel W.E. The History of Medical Illustration. The Bulletin of the Medical Library Association. 1960;Apr;48:168-71.

  47. Papel Ira D. Max Brodel’s contributions to otolaryngology – Head and Neck surgery. The American Journal of Otology, 1986; Vol.7;6:460-469.

  48. Ibid

  49. Ibid

  50. Cullen TS : Remarks at the Dinner Given by the W.B. Saunders Co. on the Occasion of its Fiftieth Anniversary in Honor of Max Brodel. Philadelphia, March 4, 1938.

  51. Robson, Judith. Tom Cullen of Baltimore. Oxford University Press, London, 1949:210-223.

  52. Ibid

  53. Ibid

  54. Papel Ira D. Max Brodel’s contributions to otolaryngology – Head and Neck surgery. The American Journal of Otology, 1986; Vol.7;6:460-469.

  55. Ibid

  56. Ibid

  57. Ibid

  58. Ibid

  59. Ibid

  60. Crosby R.W, Cody J. Max Brodel: the man who put art into medicine. Springer-Verlag, New York, 1991.

  61. Ibid

  62. Ibid

  63. Ibid

  64. Lucey B.P, Bedell Thomas C., Hutchins G.M. Max Brodel: Illustrating Healed Valve Ring Abscess. Archives of Pathology & Laboratory Medicine. 2005;Sept, 129:9;1155.

  65. Crosby R.W, Cody J. Max Brodel: the man who put art into medicine. Springer-Verlag, New York, 1991.

  66. Ibid

  67. Loechel W.E. The History of Medical Illustration. The Bulletin of the Medical Library Association. 1960;Apr;48:168-71.

  68. Ibid

  69. Ibid

  70. Tsafrir J., Ohry A. Medical Illustration: from caves to cyberspace. Health Information and Libraries Journal. 2001;88:99-109.

  71. Loechel W.E. The History of Medical Illustration. The Bulletin of the Medical Library Association. 1960;Apr;48:168-71.

  72. Calkins, C.M., Franciosi J.P. & Kolesari, G.L. Human anatomical science and illustration: the origin of two inseparable disciplines. Clinical Anatomy. 1999:12; 120-9.

  73. Loechel W.E. The History of Medical Illustration. The Bulletin of the Medical Library Association. 1960;Apr;48:168-71.

  74. Herrlinger R. History of Medical Illustration: from antiquity to 1600. Editions Medicina Rara Ltd., New York; 1970:103.

  75. Loechel W.E. The History of Medical Illustration. The Bulletin of the Medical Library Association. 1960;Apr;48:168-71.

  76. Bogen J.E. A half century of perpetuating Netter’s anatomic error. Journal of the History of the Neurosciences. 2006:15:53-55.

  77. Ibid

  78. Schultheiss D., Udo J. Max Brodel (1870-1941) and Howard A. Kelly (1858-1943) – Urogynecology and the birth of modern medical illustration. European Journal of Obstetrics & gynecology and Reproductive Biology. 1999;86;113-115.

  79. Tsafrir J., Ohry A. Medical Illustration: from caves to cyberspace. Health Information and Libraries Journal. 2001;88:99-109.

  80. Guttman GD. Animating functional anatomy for the web. The Anatomical Record. 2000:Apr 15: 261(2):57-63.

  81. http://www.websurg.com

  82. Ibid

  83. http://www.bodyworlds.com

  84. Jones, T. Launching of the Association of Medical Illustrators. Bulletin of the Medical Library Association. 1947:Jan;35:1:58-66.

  85. Ibid

  86. Ibid

  87. Schultheiss D., Udo J. Max Brodel (1870-1941) and Howard A. Kelly (1858-1943) – Urogynecology and the birth of modern medical illustration. European Journal of Obstetrics & gynecology and Reproductive Biology.1999;86;113-115.

  88. Robson, Judith. Tom Cullen of Baltimore. Oxford University Press, London, 1949:210-223.

  89. Dictionary of American Biography, Supplement 3: 1941-1945. American Council of Learned Societies, 1973.

  90. Poston, W.R. Book Review: Max Brodel: the man who put art into medicine. Surgical Neurology.1994:42; 362-6.

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Footnotes

  1. Bulbulian A.H. Art in the Service of Anatomy. Bulletin of the Medical Library Association.1961:April; 49:2:178-186.

  2. Flexner S., and Flexner J.T. William Henry Welch and the heroic age of American medicine. Dover Publications, Inc., New York, 1941.

  3. The National Library in Medicine: Current Biographies in Medicine. Howard Atwood Kelly. World of Health. Gale Group, 2000.

  4. Crosby R.W, Cody J. Max Brodel: the man who put art into medicine. Springer-Verlag, New York, 1991:50.
  5. Schultheiss, D., Truss M.S., Jonas U., Engel R.M. Max Brodel and Modern Medical Illustration. The Journal of Urology. 1999:161 (4S), Suppl:April;189.

  6. Lucey B.P, Bedell Thomas C., Hutchins G.M. Max Brodel: Illustrating Healed Valve Ring Abscess. Archives of Pathology & Laboratory Medicine.2005; Sept, 129:9;1155.

  7. Kelly, Howard. The Barred Road to Anatomy. John Hopkins Hospital Bulletin, Volume XIX, No.208, July 1908. Read at the meeting of the John Hopkins society, October 14, 1907.

  8. Crosby R.W, Cody J. Max Brodel: the man who put art into medicine. Springer-Verlag, New York, 1991.

  9. Crosby R.W, Cody J. Max Brodel: the man who put art into medicine. Springer-Verlag, New York, 1991.

  10. Flexner S., and Flexner J.T. William Henry Welch and the heroic age of American medicine. Dover Publications, Inc., New York, 1941:72

  11. Schultheiss D., Udo J. Max Brodel (1870-1941) and Howard A. Kelly (1858-1943) – Urogynecology and the birth of modern medical illustration. European Journal of Obstetrics & gynecology and Reproductive Biology.1999;86; 113-115.

  12. Crosby R.W, Cody J. Max Brodel: the man who put art into medicine. Springer-Verlag, New York, 1991:49.

  13. Herrlinger R. History of Medical Illustration: from antiquity to 1600. Editions Medicina Rara Ltd., New York; 1970:103.

  14. Jones T. Launching of the Association of Medical Illustrators. Bulletin of the Medical Library Association.1947; Jan;35(1):58-66.

  15. Schultheiss D., Udo J. Max Brodel (1870-1941) and Howard A. Kelly (1858-1943) – Urogynecology and the birth of modern medical illustration. European Journal of Obstetrics & gynecology and Reproductive Biology.1999;86;113-115.

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©2006 Pia Pace-Asciak, B.A., H.B.Sc., M.A.Sc.

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