Feature Christmas 2012: Evolution of Practice

Gastroscopic painting

BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e8323 (Published 18 December 2012) Cite this as: BMJ 2012;345:e8323
  1. James Rose, consultant gastroenterologist, Ayr Hospital
  1. 113 Racecourse Road, Ayr KA7 2DQ, UK
  1. Correspondence to: J Rose jamesdrrose{at}googlemail.com

James Rose describes a time when science and art intersected with striking results

Early endoscopists realised the importance of recording their findings. Although small cameras had been used to take gastrophotographs in the mid-19th century, the slow film speed and low light intensity of the electric bulbs in gastroscopes made photography impractical.1 Coloured paintings were the only medium that could accurately represent what was seen. During the 30 years before photographic techniques improved, almost 600 coloured paintings were published. Little has been written of the artwork or the artists who enabled the internal world revealed to the gastroscopist to be appreciated by the wider medical community.

Association between painting and endoscopic photography

Endoscopy is an older technique than radiology, but radiology developed more quickly. For a long time the pictures produced by radiology seemed to make the hazardous and limited procedure of gastroscopy redundant. However, advances in endoscopy that allowed safer, clearer views of the stomach rendered photography more difficult. For a brief period painting flourished, only to be replaced by photography again.

An endoscopic photograph appeared in the BMJ as early as 1883,2 and Norbert Henning took gastrophotographs through the rigid endoscope and used them to illustrate his books on gastroscopy and gastritis in the 1930s.3 4 These photographs could be enlarged and coloured for greater effect. But the introduction of the semi-flexible gastroscope proved too much for the photography of the time, when film speeds reached a maximum of ASA 2. This speed compares with a standard fast film of ASA 400 before the advent of digital photography.

In 1937 Rudolf Schindler considered “gastrophotography to be obsolete.”5 Thus, the technical limitations of photography allowed painting to flourish until further technical advances improved the quality of photographs.6 The introduction of fibreoptics into endoscopy once more initially reduced the quality of obtainable photographs, but not for long enough to allow a resurgence of drawing beyond the immediate recording of findings in the notes. With the digitisation of endoscopic images, gastroscopic painting has permanently lost its scientific value but remains of historical and artistic interest.

Historical considerations

Gastroscopy developed almost exclusively in German speaking countries from the end of the 19th century, perhaps because of the highly developed optical industry.7 However, these technical developments and the production of expensively illustrated books took place during the post-war inflation in the German economy. Fortunately, authors, publishers, and artists persisted with their efforts, sometimes being given generous financial assistance both locally and from the United States.8

In 1934, the newly elected German Chancellor, Adolf Hitler, introduced a favourable rate of exchange for foreigners, especially students, which made living and studying in Germany inexpensive. Encouraged by this and the development of the safer semi-flexible Wolf-Schindler gastroscope in 1932,9 a small group of British gastroscopists studied in Germany for a while, mainly with Henning, a pupil of Schindler, who had emigrated to the US.10 The group included Harold Edwards of King’s College Hospital, London; Harold Rodgers of St Bartholomew’s Hospital, London; Dudfield Rose of Newcastle upon Tyne; and Hermon Taylor of the London Hospital. The outbreak of the second world war had an adverse effect on the development of endoscopy. Many gastroscopists became military surgeons, and for those still working in civilian hospitals in the United Kingdom a lack of equipment and glossy paper prevented the development of endoscopic photography.

Technical limitations of early endoscopy

In the early days of endoscopy there were many limitations both for the observer and for the artist: the gastroscopic image was very small; the angle of view narrow; the light dim; and, unless the patient was very cooperative, the examination brief. Illumination was internal with a distal bulb supplied by external batteries. The bulbs became hot, and if used at full power for photography risked burning the mucosa.

The artistic challenge

Unlike the illustrators of the great anatomies, who could portray the static results of the dissection table in life-like poses, painters of endoscopic views usually had just a black circle in which to represent moving, living tissue seen briefly through an endoscope under unusually difficult circumstances. In addition, only a monocular view could be obtained; there was a single light source, always bearing the same relationship to the viewer; the colour range of the material was limited—mucosa appeared in various degrees of pink, with just a little mucus and bile for contrast; the colour of the mucosa altered with the distance from the light source; and the stomach, a living moving organ, would not pose for the benefit of the artist.

All these factors made depth, form, and contrast difficult to reproduce. However, the multiple lenses of the Wolf-Schindler gastroscope, acting as a blue filter, imparted a yellow tinge to the image, making it easier to differentiate the different shades of orange-red.5

Artists’ techniques

In the dark, artists made rapid rough pencil sketches with notes on colouring to be painted later. Patients could tolerate the examination for no more than five minutes, limiting the time during which artists could work from life. Many endoscopists did not have a medical artist. Edwards and Taylor, who illustrated their own observations, sketched during or immediately after the procedure and painted later (fig 1).

Figure1

Fig 1 Sketch (A) and print (B) of painting of lesser curve ulcer by Taylor (1936)

The wet sheen of healthy mucosa is difficult to represent. Most artists relied on careful painting of highlights using brush and pigment, whereas Frank Prosser experimented with painting on a glossy material, such as silk, or mounting the picture behind cellophane (fig 2A). Douglas Kidd used an airbrush to produce a highly characteristic appearance (fig 2B).

Figure2

Fig 2 Mucosal sheen in atrophic gastritis represented by Prosser using painted highlights under cellophane (A) and in gastric carcinoma by Kidd using an airbrush technique (B)11

European contribution

The first printed pictures were probably those in Hans Elsner’s Die Gastroskopie, published in 1911 with 22 coloured endoscopic views of the stomach.12 The next landmark was the publication in 1923 of Schindler’s Lehrbuch und Atlas der Gastroskopie, with 117 gastroscopic paintings of normal and abnormal findings to help the practitioner interpret what was seen.8 The paintings by Erna Walther are crisply drawn and some are very attractive (fig 3A), but they provide no sensation of distance or of the glistening wetness of the mucosa.

Figure3

Fig 3 Gastric diverticulum with mucus pool by Walther (A),8 and hypertrophic gastritis by Rose (B)4 13

In 1935 Schindler’s pupil François Moutier published Traité de Gastroscopie et de Pathologie Endoscopique de L’Estomac illustrated by Claire Escoube (fig 4A).14

Figure4

Fig 4 Aphthoid gastritis by Escoube (A),14 gastric erosions by Strek (B),17 carcinoma by McLarty (C)18

The three dimensional aspect is well reproduced by M Landsberg, however, who worked for Arthur Hűbner, reader in surgery at the University of Berlin. Hűbner’s Gastroskopie included 16 endoscopic paintings, several with corresponding resection specimens.15 Henning’s popular pocket book Lehrbuch der Gastroskopie of 1935 was translated into English in 1937.3 16 It contained gastroscopic photographs, watercolours, and coloured enlarged photographs, which appear darker and duller than the watercolours.

The greatest work of the era, Gastroskopie by Gutzeit and Teitge of Berlin and Breslau, was published in 1937. It contained 155 colour paintings by the university artist, Rose (not related to the author),4 13 and although there were separate illustration pages throughout, for the first time pictures were also integrated into the text, being printed separately and glued into place. The illustrations are of great educational value and are finely drawn, with a beautiful range of colour and a sense of depth (fig 3B).

Endoscopic painting in the UK

In 1935 the first paintings appeared in the UK literature, signed by N Strek, possibly Strek Loweski, one of the medical staff of the Kasr El-Ainy Hospital, Cairo.17 The six paintings are notable for their wide colour range and contrast, and the exotic conditions illustrated, such as the appearance of the gastric mucosa in an “alcohol opium coffee and tea addict heavy smoker” (fig 4B).

A comprehensive review of gastroscopy by Hermon Taylor contained 14 paintings by Margaret McLarty, showing normal appearances, a range of pathology (fig 4C), and the progress of an ulcer as it healed.18 The 40 fine paintings by Kidd demonstrate his characteristic smooth glossy technique.11

Although as early as 1937 Dudfield Rose used nine gastroscopic photographs from his time with Henning to illustrate his findings,19 he employed an amateur artist, Prosser, to illustrate his 1941 papers on the value of gastroscopy.20 21 The paintings are bold, with great depth and realism. These papers, which were published during the war, report on work before its outbreak, but no new pictures were published until P Startup’s 13 paintings of 1945, which show the effect of treatment aimed at healing gastric ulceration. These have a grainy quality but reproduce the perspective and shadows well.22 In 1948 Dorothy M Barber’s beautiful illustrations were the last gastroscopic paintings to be published.23 Barber and her trainees illustrated endoscopic findings in many English hospitals for some decades, although very little of their work has been published.

Influences on endoscopic painting style

The way we see the world is influenced by our culture and personal history; scientists see more easily what has already been described and artists paint the findings in a manner that reflects their personal and artistic heritage. Although gastroscopic painting is a restricted genre, the artists had very different styles, which can be viewed as reflecting identifiable influences.

The German solid reds and blacks recall contemporary expressionist painting (fig 3), whereas the lighter less well defined French pictures seem to be influenced by impressionism (fig 4A). The British artists (fig 4B, C) used similar colours to John Piper, and their modelling reflects that seen in the work of Henry Moore and Barbara Hepworth, who herself illustrated hospital scenes. Standing outside this mainstream tradition is Kidd, whose illustrations bring to mind the post-war illustrations of Dan Dare by Frank Hampson in the Eagle (fig 2B).

With the increased illumination provided by modern instruments, faster film speeds, and eventually digital image capture, the intriguing variation in representation of endoscopic findings that artists provided has vanished, but for several decades science and art intersected with striking results.

Notes

Cite this as: BMJ 2012;345:e8323

Footnotes

  • Competing interests: The author has completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declares: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; JR is the son of Dudfield Rose, who was mentioned in the article; the material formed part of an oral presentation to the Society of Physicians in Wales, “Schleimsee by Lamplight” and a poster presentation for the British Society of Gastroenterology Golden Jubilee in 1987.

References