Abstract
Miss Davison was a medical artist at the Manchester Royal Infirmary and the University of Manchester from around 1918 until her retirement in 1957. She illustrated books and scientific papers on anthropology, anatomy and surgery, and became well known for her striking pictures produced by the ‘Ross board technique’– a difficult process that she helped pioneer from the 1930s and which forms the bulk of the work she undertook for neurosurgeon Geoffrey Jefferson during the 1930s–1950s. His Neurosurgical Department became the main base for her work until his retirement in 1953. She was an active member of the Medical Artist Association (MAA) which she helped found in 1949.
Introduction
Dorothy Davison (Figure 1) was part of a movement of young artists who after the First World War found employment as ‘medical artists’; some worked freelance or for an individual surgeon, but most were employed by universities or hospitals to produce anatomical and medical illustrations. There are many examples of Davison’s pictures in published books and papers although much of her original work has been lost. Fortunately, her drawings for Geoffrey Jefferson
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have survived because for many years they were stored in old X-ray-film boxes at the Manchester Royal Infirmary (MRI) Neurosurgical Department and in 2000 the collection was transferred to University of Manchester Medical School Museum.
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About the same time, a separate collection of 4000 sets of clinical notes of Jefferson’s cases between 1927 and 1940 were deposited in the University library archives.
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The purpose of this paper is to describe the collection of her work and place it in the context of Jefferson’s research publications and clinical work. The author has compiled a database of more than 300 of her finished pictures and where possible linked them to Jefferson’s publications and the clinical notes.
Dorothy Davison (1890–1984). Photograph taken at the time of her retirement in 1957.
Jefferson, along with surgeons Norman Dott (1897–1973) 4 in Edinburgh and Hugh Cairns (1896–1952) 5 in London were the founders of British neurosurgery in the 1920s. They all emphasised the importance of good medical illustration and used professional medical illustrators to document their work and publications. This paper provides a brief summary of Miss Davison’s biography followed by an analysis of her collection and its relationship to Jefferson’s career and to the history of medical art in neurological surgery.
Dorothy Davison’s career, 1918–1939
The chronology of Davison’s early career is sketchy and based on some biographical notes in the 1960s by her friend Jean Perry, a student of Davison and later head of medical art at the North Manchester General Hospital. 6 Davison was an aspiring young artist but had to abandon her course at the Manchester School of Art in order to care for her parents. From around 1917, she earned a small income at the Manchester University Museum by giving talks to schoolchildren on Egyptology, which she illustrated with models and paintings. Grafton Elliot Smith (1871–1937), Professor of Anatomy and Egyptologist, 7 offered her a post in the nearby Anatomy Department at the Manchester Medical School; he helped her develop her anatomical drawing and also encouraged her interest in archaeology. She prepared illustrations for some of his ethnological publications 8 and eventually wrote and illustrated four books of her own on anthropology – a significant contribution to the history of primitive art. 9 After Elliot Smith left for London in 1919, she continued as an anatomical illustrator for Professor JSB Stopford (1888–1961). In 1920 Jefferson, a close friend of Stopford, 10 was appointed as Lecturer in Applied Anatomy and Miss Davison probably first met him while he was doing research at the Medical School into cervical fractures. 11 According to Perry, Jefferson approached her and asked ‘can you paint?’ This was the start of a ‘long partnership resulting in the [collection of] neurological paintings and Ross board drawings’. However, their professional artist-and-surgeon partnership does not really start until after his appointment as Honorary Neurological Surgeon to the MRI in 1926 and she had set-up a small studio in the MRI nurses’ home.
The Ross board technique
The most important examples of her work and the crux of her artistic technique was her use of the ‘Ross board technique’ from around 1932. Ross board 12 is a special type of artist paper coated with gypsum first made by the Charles Ross Paper Co, Philadelphia, in 1882. It was excellent for shading and technical details and was popular for all types of printing and reproducing technical illustrations including the US Geological Survey Maps in the 1920s. It was used by Max Brödel (1870–1941), 13 artist at the Johns Hopkins School of Medicine, Baltimore (JHSM), as the best technique for representing anatomical detail and was popular with neurosurgeon Harvey Cushing (1869–1939) 14 for drawings of the brain and nervous system, especially for his publications. Brödel had trained as an artist in Germany and immigrated to the USA in 1894 to work at the JHSM. In 1911, Brödel founded the first academic department of medical illustration and over the years taught nearly 200 artists from many countries. Audrey Arnott (1901–1974), 15 an artist who worked with Hugh Cairns at the London Hospital, visited Brödel at the JHSM in 1932 to learn the Ross board technique. On her return to England, she passed on the new technique to Davison and another colleague, Margaret McLarty (1908–1996), 16 a freelance artist who had originally trained under Professor Dott. Hester Thom, 17 a Canadian artist and one of Brödel’s students, was Professor Dott’s personal artist until 1939; she taught the Ross technique to Clifford Shepley (1908–1980) 18 who was appointed as medical artist at Edinburgh University in 1934.
Ross board could be used to make accurate anatomical drawings with variation in tone, shading and highlights, which could display a range of textures including the sheen of tendons, the firmness of the brain, the hardness of bone, translucency, etc. Davison described the details of the technique. 19 It was possible to draw directly on to the board but usually the artist, using a carbon pencil, first made a preliminary drawing on paper, which was reversed and traced onto a second sheet. This in turn was placed face down on the Ross board and the outline image transferred to the board by carefully rubbing along the lines with the thumb nail or a flat implement. This ‘double transfer method’ 20 left an outline image to which tone, shading and depth were added by brushing on thin layers of fine carbon powder which can then be rubbed away to produce highlights or details added by more powder, a pencil or ink. Colouring with pastel chalks or watercolour was sometime used but the earlier works were generally considered better as ‘black and white’ and regarded as having a photographic appearance. The final picture was mounted, spray-fixed and covered with cellophane for protection. The technique required great care and Davison warned that corrections were difficult to make. Sometimes there was disagreement with the surgeon about composition and what the pictures were meant to show. Finished pictures were sometimes lost, so all sketches and pictures were carefully stored by her for many years. Finally, she commented that some British printers and engravers failed to reproduce the detailed drawings to a satisfactory standard – sometimes so distorted that ‘artists do not always recognise their own drawings’!
Dorothy Davison’s career, 1939–1957
There is no early record of her having any contractual arrangement with the University or the MRI; indeed it appears that most of the work done during the 1920s–1930s was probably on a freelance basis. The University offered her a contract 21 in 1939 but during the War there was little medical art work and she was employed mainly in the Geography Department drawing and cataloguing maps. She had time to compile a BBC Schools serial, ‘how things began’ (1941), based on her book Men of dawn. 22 She also spent much of this period drawing up plans for the training of medical artists and the need to establish ‘medical illustration’ on a professional footing. From 1947, she built up a network of colleagues who became the founder-members of the Medical Artists’ Association of Great Britain (MAA).
Jefferson had been made Professor of Neurosurgery in 1939 and after the War Miss Davison was able to take up her appointment as ‘medical artist’ and returned to her neurosurgical work at the MRI. During the 1940s, Jefferson and Cairns had been fully occupied organising provision for neurosurgical and head injury cases for the Emergency Medical Service. When he returned to the MRI Jefferson was at the peak of his career with an international reputation; from 1945 until his death in 1961 he travelled widely and was in great demand as a guest lecturer. These high profile lectures were heavily illustrated with Davison’s best drawings and many of her pictures can be found in his publications and lectures. Jefferson, in the forward to his Selected Papers, acknowledges that ‘the University medical departments, especially the neurosurgical, owe so much for her unsurpassed skill’. 23 Her work for other departments also expanded: she illustrated several textbooks, most notably complex Ross drawings for Anatomy of the Autonomic Nervous System, Basic Anatomy and Cardiovascular Innervation for Professor George Mitchell (1906–1993), 24 and painted images for the Atlas of Bone Marrow Pathology by Professor Martin Israëls (1906–1979). 25 In addition, she completed a large series of paintings of bone tumour for Professor Harry Platt (1886–1996) 26 and ran a programme of teaching medical art students until her retirement in 1957.
Dorothy Davison’s picture collection
An example of a Ross board drawing of the inferior aspect of a post-mortem brain. There is a large acoustic neuroma deforming the brainstem with fatal results, 1937.
An example of a sketch of an operation to remove an oligiodendroglioma. The craniotomy flap and dura are turned back and the tumour has been retracted and separated from the brain beneath. A pilot sketch shows the location of the operation, 1938 (the cellophane cover has been torn).
An example of a watercolour painting of an operation for an arteriovenous malformation. The burr holes are shown and the dura is turned back to show the tumour. A small pilot sketch shows the location of the craniotomy on the scalp, 1953 (the cellophane cover has been torn)
The back of many of the pictures is annotated although the information is often unclear. There is never a hospital number but it is usually possible to match the surname, diagnosis and year on the back of a picture to a set of case notes in the Jefferson clinical notes archive. This archive contains more than 4000 patient files and it has been estimated that about 3% of these notes will have had a Ross picture for that particular case. The database of about 300 of the finished pictures was checked against the names and details of a random sample of a 1000 case notes.
Most of the Ross board drawings are of neuropathology specimens, removed post-mortem or at surgery, and a smaller number are of neurosurgical operations, mainly craniotomies. Drawing a specimen was much easier than an operative picture for Miss Davison to process. She could ‘light’ the specimen as required and take the time to make several detailed sketches. A picture of an operation site was much more difficult; she would ‘gown-up’ and try to make a few quick sketches in theatre but she was handicapped by the lack of time and complained it was difficult to get a good view of the operation site – Jefferson, who was much taller than her, would often quip ‘but I can feel it’! 28 After the operation Jefferson would check the sketches and add comments to ensure the important features were included.
The range of pathology covered by her pictures is a reflection of Jefferson’s special interests and some of her best Ross pictures can be traced to Jefferson’s publications, especially his Selected papers (1960) that were liberally illustrated with her line drawings and pictures. Her drawings highlight the main points and help to clarify his often long and complex text. For example, in his paper on pituitary tumours her Ross drawings show nicely how the tumour bursts out to compresses the optic nerves and surrounding brain structures, thus illustrating vividly how the symptoms are produced. 29 In another paper, her drawings of a brain tumour causing brainstem compression instantly make clear the mechanism of fatal ‘brain coning’. Jefferson was especially interested in meningiomas and neuromas – both potentially removable although the surgery was often a challenge. Davison’s operation pictures show the skull flap, the exposure of the tumour, and the adjacent blood vessels and other structures that the surgeon must negotiate for successful removal (Figures 3 and 4). The main operative picture is usually accompanied by a small ‘pilot drawing’ indicating the location of the initial incision on the scalp. Acoustic neuromas, although non-malignant, could be difficult to remove and sometimes had a fatal outcome; Ross drawings of the post-mortem brain reveal how these ‘benign’ tumours were locally invasive and compressed vital structures in the brainstem (Figure 2). Trigeminal neurinomas were the subject of special study by Jefferson; they were difficult to remove because of their position. In 1953, they were the subject of his flagship lecture to the Congress of Neurological Surgeons in New Orleans which he illustrated with a dozen of Davison’s drawings – some of the best examples of her work. During the 1930s, Jefferson pioneered new surgical techniques to remove frontal lobe tumours and to treat ruptured intracranial arterial aneurysms and it was often difficult for the surgeon to pin-point the location of such lesions; in these papers Davison combines her Ross pictures with simple line-drawings and X-rays to show how difficult it was sometimes to visualise the lesion at operation and distinguish it from surrounding structures. Indeed her illustrations can be found throughout Jefferson’s publications; the above examples related mainly to cerebral pathology but excellent examples of her work can also be found in his cases of diseases of the spinal cord. The quality of the pictures is rather mixed and varies from first sketches to finished Ross boards. Some are incomplete, prepared on Ross board but still awaiting completion. Others are marked with editing and cropping notes. While many are very good, examples of her very best work, such as the original of the trigeminal neurinomas illustrations, are absent from the collection. Most likely, these were never returned from the publishers or kept by the surgeon.
Apart from her contributions to Jefferson’s surgical publications, some of the pictures in the collection can also be linked directly to individual patients in his clinical notes archive. A review of a 1000 sets of case notes used surnames and diagnosis to link the notes to 35 sketches and pictures in the Davison picture database. The collection of Jefferson’s case notes provides a window into the history of British neurosurgery during the first half of the twentieth century. The various letters and reports document the day-to-day work of Jefferson and his junior staff and the problems they faced of diagnosis and deciding to operate or not. In this era before modern brain imaging, the best way to confirm the location of a brain tumour was to perform a ventriculogram – regarded as routine and carried out before nearly every craniotomy. Air encephalograms and carotid angiography were undertaken less frequently and mainly on none-tumour suspects. These procedures carried some risk, as did the subsequent surgery; the overall operative mortality was high and most of the Davison’s pictures matched to the notes survey were of post-mortem specimens, mainly brain tumours, but also some rare conditions including Rathke’s pouch, tuberculomas and vascular malformations. Davison’s pictures and sketches add a visual dimension to the clinical notes – her ability to clarify and enlighten the surgeon’s account is best seen in the drawings of the more inaccessible parts; the pictures of tumours and cysts around the base of the brain, the optic nerves and along the brainstem, illustrate the difficulties of intracranial surgery with constricted access, swelling of the brain etc, not just as some general example but for specific, individual patients – as one pathologist wrote in the notes, ‘Miss Davison has drawn these features’. 30
Dorothy Davison had definite views on the value of medical art to medical teaching and research. A good drawing or painting stimulated the students’ interest and aided memory; it could elucidate obscure points of anatomy and widened understanding of disease processes. Such art work was especially of value for reproducing the details of microscopic work, pathological and anatomical specimens, and views of internal structures including gastroscopic paintings of the stomach. 31 In the 1930s, operation photographs were rarely used by neurosurgeons; it disrupted the operation, disturbed the surgeon’s lighting and could not show details buried in the depths of a craniotomy – it was easier to use a medical artist and the finished illustration showed the relevant features in startling clarity. Davison was not opposed to photography but refuted any suggestion that it was somehow more accurate or ‘truthful’. Medical photography had its place; Jefferson often included clinical photographs of his patients in their notes, and photographs of pathology specimens were sometimes displayed alongside Davison’s Ross drawings. She thought there was a place for all types of visual teaching aids and regarded medical art work as complementary to photographs, film, lantern slides, illustrated books, charts, etc. She envisaged a library of illustrative material in which paintings and drawings would work alongside specimens, photographs, charts, etc. She suggested that such a collection would grow over time and be available to students and medical staff. Nevertheless, there was some tension between medical photographers and artists, and issues of funding and resources became a problem after her retirement. 32
Conclusion
Miss Davison’s collection of sketches and pictures only avoided destruction because after her retirement in 1957 they were transferred to the Neurosurgical Department at the MRI and were carefully stored in an office. Despite been well used they have survived in reasonable condition; some sketches are creased, some cellophane covers torn and about 50 pictures found loose in desk drawers had been handled many times. The collection is a valuable source for medical historians; the surviving body of work of one of the leading professional medical artists. Her career spanned four decades. Certainly she will be remembered for her contribution to the founding of the Medical Artists’ Association (1949) and helping other artists to establish themselves. She set up the university department of medical illustration and a training scheme for medical art students, wrote books and scripted a BBC schools programme on anthropology, and illustrated medical and anatomical textbooks and papers. However, her most important work was for Geoffrey Jefferson and neurosurgery; she was indefatigable in her effort to document his surgery, cases and publications and the collection of her Ross board drawings deserves special attention. They are the only known surviving original pictures; a lot of her work must have been lost or thrown out, probably after she retired. For example, it is known that she prepared about 60 paintings of bone tumours for Professor Harry Platt; copies of these can be found in his collection of lantern slides, yet only handful of the originals are in the picture collection.
Certainly most of her work was done in Manchester but it is arguable that she was part of the wider development of British neurosurgery during the first half of the twentieth century. Normal Dott, Hugh Cairns and Geoffrey Jefferson all spent time training with Harvey Cushing before taking up their British hospital posts in 1924–1926. They brought back not just Cushing’s new surgical techniques but also his ideas on record keeping, teaching and publications – the importance of Max Brödel’s illustrations in these areas would have been noted. In particular, Cairns was ‘convinced of the value of really intelligent illustrations’ and was determined to have an artist on his staff. Medical illustration was an attractive career for some young artists: Audrey Arnott joined with Cairns at the London Hospital and later followed him to Oxford University. Professor Dott at Edinburgh Royal Infirmary used a number of artists – Margaret McLarty, Hester Thom, Clifford Shepley and others at the Infirmary or the University. It is understandable that Arnott and her colleagues were influenced by Brödel’s techniques: he introduced the Ross board method to illustrate Cushing’s neurosurgical cases and it was taken up by the medical artists to provide the same service for their surgeon colleagues. Jefferson and Davison were part of this ‘Ross board movement’, a network of artists and surgeons; although small, it was important in promoting the careers of both surgeon and artist; the striking and attractive illustrations not only helped interpret difficult technical articles but also showcased the work of both parties. Their work required intelligence and skill, so not surprisingly these artists were the main founder members of the MAA.
Miss Davison’s work is known within the medical artist community and to a few medical historians. There have been a few small local exhibitions of her Ross pictures including the Wellcome ‘brain and mind’ exhibition at the Manchester Museum of Science and Industry (2013) but her portfolio deserves wider recognition and requires further study. Her sketches and pictures need to be fully catalogued and put in proper conservation storage. The sketches need to be sorted and linked to the finished pictures, and Jefferson’s clinical notes need to be fully catalogued and linked to the pictures and sketches. The completion of such a project would be a fitting tribute to her long career and her work for neurosurgery and medical education.
Footnotes
Acknowledgments
The author owes his thanks to James Peters and Janet Wallwork of the University of Manchester Archives and to Stephanie Seville, Heritage Officer of the Museum of Medicine and Health, for their generous assistance and encouragement. I am grateful to the University of Manchester for their permission to use the illustrations.