Contemporary Illustration: A Digital Oasis

Part 5 of 6 in a series of articles chronicling medical illustration from antiquity.

The landscape of medical illustration by the end of the last century into the present appears much different from centuries prior. The structure of medical education today places such strong emphasis on proficiency and accuracy of the human anatomy that De fabrica is no longer a classroom competent text. A string of technological feats, rooted in the nineteenth century, has propelled the study of anatomy to a level never dreamed by men even as recent as BRÖDEL.

As new methods emerged in imaging technology, these innovations may appear as replacements to the medical artist. BRÖDEL himself acknowledged monotone photography for its benefits of being a cheap, quick, and realistic for documenting pathology and surgery. However, these images often were too muddled to be effective tools of learning. By the end of his career, BRÖDEL accepted photography as a complement to medical artists. However, he stressed the importance of explanatory sketches to accompany a photograph, regarded by BRÖDEL as an unimaginative product. Not surprisingly, as photographic technology improved by means of color and digital medium, so did its pervasiveness in medical journals for documenting pathology.

Wilhelm Röntgen

Wilhelm Röntgen

Where film and digital cameras are limited to the superficial anatomy in living patients, radiation imaging documents the internal anatomy. WILHELM RÖNTGEN revolutionized medicine in 1896 CE with his invention of X-ray photography. This technology marked the first opportunity to peer inside a living human being noninvasively. However, X-ray films serve better diagnostically than instructively since the physician must impart anatomical knowledge to interpret the image, spawning the field of radiology. Fluoroscopy followed quickly after the X-ray, providing real-time information to practitioners, as well as shoe-salesmen. The two-dimensionality of the X-ray converted to three-dimensions with SIR GODFREY HOUNSFIELD’S computed tomography (CT) scanner, first used clinically in 1973 CE. Four years after the first diagnostic CT scanner came PAUL LAUTERBUR and SIR PETER MANSFIELD’S magnetic resonance imaging (MRI). CT and MRI introduced a new dimension to medicine, providing new perspectives into any part of the body. These technologies cemented the use of computers in medicine, and computing would soon transform medical illustrations.

First Medical X-ray of Anna Bertha Ludwig's Hand

First Medical X-ray of Anna Bertha Ludwig’s Hand

In August of 1991 CE, DR. VICTOR SPITZER at the University of Colorado School of Medicine was awarded a government contract to carry out the Visible Human Project. This venture, the product of DR. MICHAEL ACKERMAN at the National Library of Medicine, sought to generate a three-dimensional map of the human body using techniques similar to BRAUNE. Instead of tracing the cross-sections, the VHP digitally photographed all 1,878 one-millimeter slices generated from a cryomacrotome. Images were made available in 1994 CE, followed by a female version the next year. These images were converted into a three-dimensional model, which represented a blending of past tradition with state-of-the-art technology. Through the pervasiveness of computers in the classroom, limitations in translating three-dimensional models on a computer to printed images in a book resolved. Superficially, the VHP comes across as the definitive replacement to the medical artist. However, the raw data that compromised the VHP would be too complex for students and professionals to analyze without the creatively rendered images from medical artists.

At this juncture, the perspectives provided by three medical artists on the current nature of medical illustration are now considered.

There have been countless images produced over the long history of medical illustration. The reader may question the utility of creating new, fresh images on basic anatomy when there is already an immense catalog of drawings, etchings and models. Publishers desire uniformity in their texts, whether for clarity or copyright (AUSTIN). The past decade has seen an exodus from printed texts to electronic publishing, and medical publishers now are engaging in similar change (BUCK). This change made possible by the Digital Age.

Medical illustration today is an exclusively digital field. In the early-mid 1990’s CE, digital formats entered the education of medical artists (AUSTIN). The transition posed a challenge for those already trained because digital formats required entirely different training in computer software (AUSTIN). Despite the migratory hurdles, the benefits of working in digital formats have improved conditions for artists. Computer software that aids in the design of medical images offers the ability for artists to work in layers. Each layer of a digital canvas allows the artist to make quick changes to their work at the request of their client (AUSTIN). Traditional media does not warrant a quick undoing of mistakes, placing greater emphasis on the artist’s skills to achieve the desired image on the first attempt (BUCK). The plasticity of digital formats has improved the quality of images and communication between the digital industry and medicine (BUCK). In addition, digital storage of information over the internet has enhanced the researching tools to artists, who were once restricted to medical libraries as recent as the early 1990’s (AUSTIN).

Though no medical artist will disavow the existence of digital media, the field is not flawless. Strikingly, one of the major challenges facing medical illustration today has plagued the field since its inception, namely plagiarism. All artists interviewed discuss this issue as the major risk undermining their work. This plagiarism comes on many fronts. First, the aptly named “drag-and-drop” generation, who copy, paste and redistribute images all over the internet, are a source of frustration to artists who do not have the time to litigate every violation (BUCK). The second threat is publishers who reuse a medical artist’s uncopyrighted illustrations in later editions without further compensating the original artist (AUSTIN). Finally, the third being countries oversees, like India, who take an illustrator’s work, modify the image slightly, and resell the new image to a domestic publisher for significantly less money (AUSTIN). As we have mentioned before the perils of plagiarism with VESALIUS, these common occurrences place a stronger burden on medical artists to protect their work and effect morale. Another area that causes unhappiness among artists is the limited exposure of their work, specifically those who publish in journals (SCALI). Only small groups of interested individuals view the illustrations in medical journals, and the subject matter represents little to those outside the medical profession (SCALI). Combine increasing electronic publishing, thus plagiarism, with fractional exposure and the field of medical illustration appears in need of some assistance. While BRÖDEL would find it difficult to sympathize with the later problem, he could empathize with plagiarism, something he himself sought to abolish.

The educational model has remained largely unchanged in philosophy since the early twentieth century. The aspiring medical artist must complete both undergraduate and graduate coursework, attaining degrees in both the sciences and art (AUSTIN). Continuing education in a wide array of medical fields emerges when assignments present new topics and annual conferences through the Association of Medical Illustrators provide additional seminars and workshops (BUCK). There is also the need to maintain fluency with the most current digital formats and software (BUCK).

The response by medical artists to the advent of radiological imaging has been an embrace, largely. Radiographs serve as a starting point for artists looking to gather perspectives not viewable via dissection (SCALI). These films help unify the relationships between the anatomy and pathology (BUCK). In addition, films are often used side-by-side medical-legal illustrations, when the image necessitates specificity toward the patient (BUCK). However, new imaging studies that unnerve the medical artist include advanced CT angiography (AUSTIN). Depending on the model, new generation CT scanners offer increases in temporal and spatial resolution and shorter procedure times. Currently, multi-slice, CT angiography machines are capable of up to 640 slices per rotation with whole-organ mapping, yielding extremely high resolution, three-dimensional models with motion that are patient specific. These models would convince many they were looking at an artist’s rendition, when in fact the model is the direct result of analyzed data using mathematical algorithms. While this technology improves patient-care, its use will not supersede the creative interpretations of medical artists, as long as the artists can adapt and adopt this new information.

As the field of medicine has become more technologically advanced, so too has the field of medical illustration. The move to digital formats not only challenged medical artists to modify their technique, but also improved the quality and efficiency of their work. While artists compete continuously to protect their images with copyright laws, they continue to find their profession enjoyable and rewarding. Despite the high-speed nature of their work today, the qualities that ensure superior artists persist, notably a curious mind and a patient hand.

Next: The future of medical illustration

References

Austin, Mike. Telephone interview. 20 Sept. 2012.

Brödel, Max. “Medical illustration.” Journal of the American Medical Association 117.9 (1941): 668-672.

Buck, Todd, MAMS, FAMI. E-mail interview. 10 Oct. 2012

Richmond, C. “Sir Godfrey Hounsfield.” British Medical Journal 329.7467 (2004): 687.

Rifkin, Benjamin A., Michael J. Ackerman, and Judith Folkenberg. Human Anatomy: From the Renaissance to the Digital Age. New York: Abrams, 2006.

Röntgen, Wilhelm C. “On a New Kind of Rays.” Nature 53.1369 (1896): 274-276.

Scali, Frank, DC. E-mail interview. 23 Sept. 2012.

Spitzer, Victor M. “The Visible Human: Anatomy You Can Grow With.” Visible Human Journal of Endoscopy 1.1 (2002). Web. <http://www.vhjoe.org/Volume1Issue1/1-1-146.htm&gt;

Sugihara, N., J. Hall, J. Mews, and H. Kura. “Image Quality Basics of the Dynamic Volume CT Aquilion ONE.” VISIONS. Toshiba Medical Systems, 2008. 20-23.

United Kingdom. National Health Service. National Institute for Health and Clinical Excellence. New Generation Cardiac CT Scanners (Aquilion ONE, Brilliance ICT, Discovery CT750 HD and Somatom Definition Flash) for Cardiac Imaging in People with Suspected or Known Coronary Artery Disease in Whom Imaging Is Difficult with Earlier Generation CT Scanners. Jan. 2012. Web. <http://publications.nice.org.uk/new-generation-cardiac-ct-scanners-aquilion-one-brilliance-ict-discovery-ct750-hd-and-somatom-dg3&gt;.

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