Book Review: Visualizing Disease: The art and history of pathological illustrations.

Visualizing Disease: The art and history of pathological illustrations. Domenico Bertoloni Meli. The University of Chicago Press, Chicago, IL, USA, 2017. US$ 55, 294 pp. ISBN 978–0–226–11029–5.

It is obvious that anatomy can be learnt only through illustrations, and equally obvious that the statement is true for pathology. That illustrations in modern anatomy began soon after 1543, when Andreas Vesalius redrew (pun unintended) our understanding of human anatomy is known to many of us. But the fact is that illustrations of pathological specimens, which should have been a logical next step, appeared in treatises, only 250 years later! when Eduard Sandifort (‘The father of pathologic illustration’) in 1793 wrote the pioneering work, Museum anatomicum. This is declared by Domenico Bertoloni Meli in this scholarly, well-researched work that deals with the early years of illustrations in pathology (essentially the 18th century and part of the 19th century). This means that even the De Sedibus by Morgagni, which was the beginning of the clinico-pathological correlation revolution, and published in 1769, does not contain any illustrations (I confirmed this with volume 2, a copy of which I possess.); or that Percival Pott did not provide images of cancerous scrota in chimney sweeps in 1775.

Anatomical specimens and hence, images are, of course, easier to obtain than pathological ones. Normal anatomical specimens are more common than diseased body parts; thus, Vesalius was able to produce a book at the age of 28, while Morgagni published his when he was almost 80 years old! Further, with the rudimentary knowledge of disease that we had in the 17th and 18th centuries, cause and effect of disease were not often obvious in the specimens. But a perfect example of changing concepts of disease is clear when you discover that a horseshoe kidney is labelled as a ‘monstrosity’ by Leonardo Botallo in the 16th century, while in 1678, Edward Tyson wonders if a horseshoe kidney created any inconvenience to the patient!

The author discusses, in seven chapters, the backdrop to the entire idea of medical illustrations, and the themes central to the concept, then focuses on bones, soft parts, specific diseases, skin diseases and ends with some treatises on the subject. Heroes, books, methods, outcomes, histories and impact of changing concepts of disease—all of this comprise each chapter. As you would expect, the book is richly illustrated, often in colour. The author discusses fixation techniques and methods of preparation of the specimens, expenses incurred during the production of the books, etc. For instance, bone is naturally dry and it is relatively easy to prepare specimens. Wet tissues, obviously, form the bulk of tissues in the human body but are more difficult to preserve. Finally, lesions of the skin are easy to see and study, especially as they are continually evolving lesions. The rarity of the diseased condition or the part was what often decided the selection of cases in a book.

You will meet some remarkable people—all men, given the times; and all European—in the pages of this book. These include physicians as well as artists, both terms being used in the broadest sense. There is a smorgasbord of names (many of which I had not heard before) and dates, so it’s not an easy read. But that is not a reflection of the author’s capabilities—it only reflects how little is known about this subject. Practically every physician in this book is fascinating. One such person is Frederik Ruysch (1638–1731), who created an amazing anatomical museum, then sold it to Peter the Great—and then established a new one at the age of 78! The treatises discussed include, among others, Everard Homes’ classic Practical observations on the treatment of the diseases of the prostate gland and Rene Laennec’s De l’auscultation mediate. Rivalries—national, regional, professional and personal come to the fore as physicians write atlases. Some scrupulously avoided references to others’ work.

One of the many great pleasures of historical research is that one uncovers nuggets of unusual information that titillates. One such nugget in this book is this—Richard Bright (of Bright’s disease of the kidney) fame and one of the ‘three great men of Guy’s’ (Thomas Hodgkin and Thomas Addison being the other two great physicians that Guy’s Hospital produced in the mid-19th century) was a physician at the Battle of Waterloo. One other fascinating thing that I learnt was that the Honourable East India Company partly sponsored James Annesley’s book, Researches into the cause, nature and treatment of the more prevalent diseases of India and of warm climates generally by buying numerous copies for their many regiments as part of the medical services done by the company. It was reported that it was likely that a buffalo was used by each regiment to transport the large and heavy volumes from place to place. Finally, we discover that we have to be grateful to Napoleon Bonaparte for having occupied the residence of Johann Meckel The Younger, during the Napoleanic wars. Otherwise, Meckel’s pathological specimens and works would have been destroyed.

Try as I might, I could not make a diagnosis in most of the cases, based on their descriptions or illustrations. But I am not alone in this; the author informs us that his medical colleagues who saw these images too could not identify the lesions because the diseases were in far too advanced a condition and are something we do not see today. A rare and obvious exception to this is the figure on page 43 by John Browne from 1685, of a cirrhotic liver—which, in fact, is believed to be the first illustration of alcoholic liver cirrhosis.

The specialist subject of this book indicates that it would be of greatest interest to pathologists and to those with more than a passing interest in the history of medicine. But those who do put in the effort to study this book will not regret the time spent.