Handbook of Clinical Neurology, Vol. 95 (3rd series)History of NeurologyS. Finger, F. Boller, K.L. Tyler, Editors# 2010 Elsevier B.V. All rights reserved

Chapter 19

Visual images and neurological illustration

AMY IONE*

The Diatrope Institute, Berkeley, CA, USA

INTRODUCTION

In his book, The Anatomy of the Brain, Explained in aSeries of Engravings (1802), the Scottish anatomist,surgeon, physiologist, and artist, Sir Charles Bell(1774–1842), wrote:

[I]n the Brain the appearance is so peculiar, andso little capable of illustration from other partsof the body, the surfaces are so soft, and soeasily destroyed by rude dissection, and it is sodifficult to follow an abstract description merely,that this part of Anatomy cannot be studied with-out the help of engravings. (Bell, 1802, p. v)

Bell further explained that the 12 engravings included inthe book were intended to “form a comprehensive Sys-tem of the Anatomy of the Brain” (Bell, 1802, p. vi),demonstrating the value of a visual component withinbrain studies.

Vesalius’ (1514–1564) De Humani Corporis Fabrica(1543), considered a milestone in the history of scienti-fic thought, is germane to Bell’s point. The magnifi-cent drawings used to illustrate the text (see Fig. 19.1for example) provided a foundation for the moderndisciplines of human and comparative anatomy andphysiology, while also serving as an adjunct to the bio-logical research (Singer, 1952). His joining of observa-tional elements with science marked a radical changefrom earlier times (Singer, 1952). Furthermore,although the text of the Fabrica was not widely read,the illustrations firmly established that visual methodswere essential for understanding bodily structure.

Bell and Vesalius before him were not unique inrecognizing the importance of illustrations. Others,too, amplify Bell’s point that visual images offer excel-lent material for studying the brain in health and in dis-ease. Indeed, comprehensively surveying historical

*Correspondence to: Amy Ione, 2342 Shattuck Ave, #527, Berkel

898-1933.

examples of neurological conditions and the brain’sform and function confirms that representations havelong served as teaching tools and as an historical refer-ence point for neurological events.

EARLY HISTORY TOPRINTINGTECHNOLOGY

Prehistoric and ancient imagery

Although scarce, existing prehistoric and ancientimages provide a window through which we can probeneurological history. Broadly speaking, these represen-tations suggest that early civilizations often combinedmyth with medicine, associated disease with spiritualpossession, and sometimes included a measure of“rational” investigation in their analyses of pathologi-cal conditions. Interpretations of these older artifacts,however, are open to debate.

The funeral stele of the priest Ruma (or Rem), at asanctuary of the goddess Astarte in Memphis, Egypt,shows this well. Thought to be from the 19th Dynasty(about 2000 BCE), the stele depicts a priest walkingwith a shortened leg, and his foot appears to beatrophic (McHenry, 1969). It has long been hypothe-sized that Ruma needed a staff to support himselfbecause his leg muscles had atrophied from poliomye-litis (McHenry, 1969). Although this may seem possi-ble, some individuals have questioned the conclusion.For example, the neurologist Kinnier Wilson proposeda clubfoot theory, and his explanation has the backingof Dennis Browne, the late British orthopedic surgeonat the Hospital for Sick Children, Great OrmondStreet, London (Rose, 2004). Rose writes that one rea-son for questioning the tentative diagnosis of polio-myelitis is that there are no good descriptions ofpolio in the literature until the 18th century. In this

ey, CA 97404, USA. E-mail: ione@diatrope.com, Tel: +1-510-

Fig. 19.1. Andreas Vesalius. De Humani Corporis Fabrica,1543, Plate 49. Brain with seven cranial nerves. Woodcut.

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case, while the attribution of a neurological conditionto Ruma is questionable, the debate does serve as areminder that ongoing re-evaluation has repeatedly cor-rected conclusions and pointed out omissions. Egyptian

ideas reinforce this point. Like Biblical and early Greekthinkers, the Egyptians largely assigned cognition andsensation to the heart rather than the brain.

The Dying Lioness, another ancient stele, is a stonerelief found on an Assyrian masterpiece. From thePalace of Assurbanipal (c. 650 BCE), this object offersa less controversial example of the long history of neu-rological illustration. This stone, now at the BritishMuseum, depicts a lioness with paralyzed hind limbs.Arrows have severed the lioness’s spinal cord as shenonetheless crawls toward her tormentors, snarling(McHenry, 1969). (See Ch. 2.)

The oldest extant image of the eye and visual systemis a diagram attributed to Ibn al-Haytham’s (965–1039)Book of Optics. It is unclear whether his diagram is cop-ied from a Greek original or derived from Galen’sdescription, with which it is consistent (Gross, 1998).The first diagram of a brain probably appeared in amanuscript around 1100 AD. This description dividesthe cerebrum into three sections, labeled fantasia, intel-lectus and memoria. In addition, Garrison’s History ofNeurology provides an illustration from a Persian manu-script, believed to date to about 1400 AD, which offers asomewhat crude depiction of the brain and nervous sys-tem (see McHenry, 1969, p. 28 for a reproduction). Thisimage depicts the brain and the peripheral nerves in out-line form arising from the segmented vertebral column.Four separate nerves passing to the arm are included.They possibly represent auxiliary, radial, median andulnar nerves (McHenry, 1969).

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Pre-Renaissance thinking

Knowledge transmission limitations also had a pro-found impact on early neurological thinking, due inpart to the need to handcraft documentation. Indeed,it is often said that the process of copying by hand ele-vated textual description over visual presentation,while slowing science and medicine down significantly(Eisenstein, 1993). Source material confirms the chal-lenge images posed. According to Pliny’s Natural His-tory, even before Roman times we find that the Greekssubstituted words for images because of the problemsin reproducing visual content (Pliny the Elder, 1991;Tessman and Suarez, 2002). No doubt, this was par-tially due to the challenges non-specialists faced in pro-viding complex technical illustrations.

Whether or not the lack of imagery bears someresponsibility for early theoretical missteps is open todebate. Regardless of one’s position, it is clear thatmany thinkers reached incorrect conclusions from theearliest times. As noted, the Egyptian, Biblical, andearly Greek thinkers largely assigned cognition andsensation to the heart, rather than the brain. Most nota-bly, Aristotle (384–322 BCE) reached this conclusion.

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He reasoned that one loses consciousness upon exces-sive bleeding and many emotions are experienced visc-erally (e.g., one has a “gut feeling” or an emotional“heartache”). Thus, and for numerous other reasons,he gave the heart primacy.

Contrary to Aristotle’s conclusion that the heart isthe seat of intelligence and the ruling organ, Galen(130–200) is credited with showing the brain’s domi-nant role, a role previously promoted by Hippocraticphysicians. Due to the extraordinary body of work heleft behind, Galen is frequently characterized as thefounder of experimental physiology. He delineatedmany of the senses, discussed the cranial nerves, andmade a distinction between the sensory and motornerves. Galen also proposed that, because the cerebrumwas softer than the cerebellum, the former housed thesenses and the latter controlled motor function. Aninfluential Roman physician, Galen wrote 500–600treatises, many of which were lost in the Roman firein 191 (Finger, 1994). Historically, his authority wasthe foundation of thought from the 2nd century intothe Renaissance, despite the many errors we can iden-tify within his analyses.

His missteps are better understood in context. Thelaws of Imperial Rome forbade human autopsies,a circumstance that significantly limited his knowl-edge base. Unable to perform human dissections,Galen worked on cattle, sheep, pigs, cats, dogs, theBarbary ape, and other animals. Errors in transposi-tion resulted. One of the most noteworthy within hiscorpus was the attribution of the rete mirabile tohumans. The term itself means “wonderful net,” andthis structure is a complex of arteries and veins foundunder the brain in a number of vertebrates, but not inhumans.

VISUAL IMAGES AND NEU

Printing and printmaking

Well into the Middle Ages, texts included only limitedimagery, with the images tending to be schematicrather than realistic in style. Moreover, a higher pro-portion of the medieval texts that do include illustra-tions are better characterized in terms of popularmedicine, rather than robust examples of scholarlymedical investigations. Although two-thirds of thepre-Renaissance medical manuscripts contain someform of illustration, in most cases the text is an adjunctto the picture, rather than vice versa (Jones, 1990).

Around the 14th century, as dissection restrictionsbegan to ease, the seeds for the significant re-thinkingof Galen’s authority began to fall in place. A more pro-nounced relationship with visual imagery began to takeform, marked by a movement from schematic repre-sentations of the brain and its ventricles to the produc-tion of illustrations aiming to depict morphological

features. Printed materials now began to circulatemore easily as well, aided by new technologies thateased the replication of ideas and imagery.

The first “published” images that demonstratedadvanced image-making capabilities were woodblockprints, or woodcuts, typically used to depict religiousthemes. Made by drawing on a block of wood, carvingout areas not drawn on, inking the portions thatremained raised, and pressing the paper against theink block, this technology resolved the problem ofreplicating images, which many said had led to thestagnation of botany and scientific pursuits.

By the end of the 15th century, experiments withmetal plates allowed for even greater refinement ofvisual description. One major leap forward is evidentin the intaglio processes of engraving, drypoint, andetching. Unfortunately, these largely de-coupled thetext and image, because of the difficulty of integratingthe text with the intaglio approach on a large scale. Bythe mid-16th century, copper engravings began toreplace woodcuts as the predominant print technologyin scholarly publications, despite the fact that wood-cuts were cheaper to produce and more durable.Reproductions of all kinds of multiples then began toappear, accelerating exchanges within the medical andscientific communities.

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RENAISSANCE ILLUSTRATION

Leonardo da Vinci

Not all scholars, however, took advantage of the newprinting technologies. Leonardo da Vinci (1452–1519),who did many extraordinary drawings of the brain justas printing and printmaking were aiding in the dissemi-nation of ideas, strangely, did not reproduce any of hiswork using the intaglio processes. In part for this rea-son, his attempts to understand the brain’s form andfunction were not circulated and remained virtuallyunknown to the medical community of his time. Thispolymath’s failure to play a prominent role in the med-ical discourse of his era no doubt also stemmed fromhis failure to synthesize his theories and offer a com-prehensive treatise. Some researchers have wonderedif the lack of timely publication of his contributions,eventually published between 1898 and 1916 (Pevsner,2002), reflected Leonardo’s disdain for mechanicalreproductions (Reti, 1971). This possibility seems unli-kely given his delight in technology overall and the evi-dence that he owned many printed books.

Despite the minor influence of Leonardo’s drawingswhile he lived, his work provides important sourcematerial in the chronology of neurological illustration.Leonardo’s earliest surviving neuroanatomical studiesconsisted of a series of drawings of the skull that date

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from about 1489. These contain the first accurate depic-tions of the anterior and middle meningeal arteries andanterior, middle, and posterior cranial fossae. Heincluded the frontal vein, which was traditionally usedby surgeons and barbers in bloodletting to treat headpain and mental conditions, and the optic, auditory,and other cranial nerves emerging from the bone (Pevs-ner, 2002). Another drawing shows the proportions ofthe skull, including the hole of the cranium. His inclu-sion of the frontal sinus, shown from the side, withthe vault bisected, represents another original discovery.

Also of note are da Vinci’s drawings of the ventri-cles, for which he presents a much more modernappearance than the “cartoons” and diagrams of his pre-decessors. The exceptional realism of Leonardo’s ren-derings underscores that he had seen their true form, afeat he accomplished by injecting hot wax into the brainsof oxen, which provided a cast of the ventricles.Although there is some disagreement on the actual datesof the experiments (the range given extends from 1503to 1510), it is clear that this work is the first knownuse of a solidifying medium to define the shape and sizeof an internal body structure. It is clear that the waxtechnique employed by Leonardo was more commonlyemployed by artists studying anatomy, rather than bymembers of the medical community (Haviland andParish, 1970). (His drawing of the ventricles is availablein many books: see McHenry, 1969, p. 36; Finger, 1994,p. 21; Pevsner, 2002, p. 218. Pevsner’s article includesseveral other drawings as well [p. 218]).

Leonardo’s theoretical conclusions are less revolu-tionary. While his extraordinary visual contributions pro-vided physical explanations of how the brain processesvisual and other sensory input, his theories show a desireto place his theories within the Galenic scheme. Thus, heconcluded that the ventricles house the soul. He alsoassigned perception, cognition, and memory to them.

It is said that Leonardo planned to publish a textbookthat would have included his studies in collaborationwith Marcantonio della Torre (1481–1512). Had this col-laboration produced a book, there is no doubt it wouldhave revolutionized anatomy and physiology. Instead,his remarkable sketches remained hidden in the Ambro-sian Library of Milan and the Royal Library at Windsorfor centuries (Saunders and O’Malley, 1950), and Vesa-lius is largely credited with the anatomical transforma-tion that took place during the Renaissance.

Andreas Vesalius

Andreas Vesalius (1514–1564), born 5 years beforeLeonardo’s death, fully understood the benefits offeredby the new state-of-the-art printing technologies. He isone of the most important figures in neurological

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illustration, and hisDe Humani Corporis Fabrica (1543)is generally characterized as the first modern anatomytextbook. Like Copernicus’ De Revolutionibus OrbiumCoelestium, published in the same year, Vesalius’detailed plates of the brain and nervous system triggereda revolution in thought. Indeed, Vesalius introduced asound basis for human anatomical teaching, which washelped with more precise graphic treatments. It has beensaid that this book is one of the most remarkable in thehistory of medicine and science, and it is one of the mostmagnificent volumes in the history of printmaking aswell (Saunders and O’Malley, 1950).

Vesalius’ comprehension of all that visual documen-tation can do was expressed in the preface to theFabrica, where he informs the reader:

How much pictures aid the understanding of thesethings and place a subject before the eyes moreprecisely than the most explicit language, noone knows who has not had this experience ingeometry and other branches of mathematics.Our pictures of the body’s parts will especiallysatisfy those who do not always have the opportu-nity to dissect a human body, or if they do, have anature so delicate and unsuitable in a doctor . . .[that they] cannot bring themselves actually toattend an occasional dissection. (Vesalius,

1543/2003b, Nutton translation, p. 4r)

Vesalius, directions to his printer, Johannes Oporinus,underscore that blending the formal typography andillustration was not accidental. His focus on the needto vividly portray the complexity of the featuresinscribed within the illustrations was conveyed in a noteto Oporinus:

Special attention will have to be paid while printingthe plates, because they are not just simple outlinesdrawn in the common schoolbook manner; theartistic style (except sometimes where the surfaceis outlined on which the specimens are resting)is nowhere neglected. Although here your judgmentis sound and I have the highest expectations regard-ing your meticulous craftsmanship, I cherish thisone hope, that while printing you imitate as closelyas possible the sample made by the engraver ashis proof copy, which you will find packed togetherwith the wooden forms. Thus no identifying charac-ter, however hidden in shading, will escape thesharp-eyed and careful reader; and the thick-ness of the lines in certain parts, which is the mostartful feature of these illustrations and thoroughlydelightful for me to view, will appear along withthe elegant darkening of the shadows. (Vesalius,

1543/2003a, Nutton translation, p. vii)

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The Fabrica’s magnificent illustrations, contained in663 folio pages, are set off by the fine cutting and thehigh quality of the original woodcuts and later etchings.No artists were directly credited in this publication, andthere are no identifying marks on the plates, which hasled to much speculation. Many credit the Flemish pain-ter Jan Stefan van Calear (1499–1546/1550), and possiblystudents of the great Venetian painter Titian, with thework. Others claim the Fabrica was a plagiarism ofLeonardo da Vinci’s work, a conclusion that seemsunlikely given the difference in how the two menapproached their studies (Saunders and O’Malley,1950). Whereas Leonardo da Vinci used wax casts andcould thus observe the intact ventricles when the brainwas removed, Vesalius did not attempt to preserve theventricles in their 3-dimensional shape, but systemati-cally placed axial cuts through them to reach the deepercortical and subcortical structures (Linden, 2002).

What is clear is that Vesalius was uniquely posi-tioned to remake anatomical thinking. As noted above,medical advancement was hindered prior to Vesaliusby artwork that lacked realism, as well as by theprevailing influence of Galenic theories (with subse-quent Moslem and Christian modifications). Vesalius’accomplishments highlight new views that were open-ing up studies in general. In his quest to examine thebody, Vesalius was aided by his position. Even thoughdissection was still largely forbidden in his age, theSenate of the Republic of Venice gave him permissionto conduct public dissections and provided him withcadavers (usually of executed criminals).

In addition, although the teachings of Galen werestressed while he was a student, and dissections wereless frequently performed in Northern Europe, wherehe began his studies, Vesalius’ urge to examine thehuman body first-hand led him to seek out human bonesand cadavers for hands-on analysis. At 23, shortly afterhe accepted a chair of senior lecturer of surgery inPadua, Vesalius published three brief works. The mostimportant, the Tabulae Anatomicae of 1538 (also knownas Tabulae Sex), contained six large woodcuts, and themost detailed drawings of the human body publishedup to that date (Vesalius, 1538). Vesalius drew the firstthree figures showing the internal organs. Jan Stephanvan Calcar, who was a Dutch pupil of Titian, the GreatItalian painter of the high Renaissance, drew views ofthe human skeleton. Plagiarisms followed immediatelyafter its printing, attesting to the book’s great success.

It was during the preparation of Tabulae Anatomi-cae that Vesalius began to realize Galenic anatomywas problematic, when compared with the human bodyhis dissections revealed. Several visual anomalies heencountered raised the question of how an observeras skillful as Galen could have made so many errors

VISUAL IMAGES AND NEU

in the field of human anatomy (Finger, 2000). Indeed,the notes of a medical student who attended some ofhis dissections in Bologna, Baldasar Hesele, reveal thatVesalius openly questioned some of Galen’s statementsduring the teaching sessions. In one instance, forexample, Vesalius was forced to use a sheep’s headto show the vascular structure of the rete mirabile,which was not found in humans (Finger, 2000).

Vesalius’ questioning of Galenic conclusionsbecame more public with the Fabrica, where he wrote:

To this man [Galen] they have all so entrustedtheir faith that no doctor has been found whobelieves he has ever discovered even the slight-est error in all the anatomical volumes of Galen,much less that such a discovery is possible . . .even though it is just now known to us from thereborn art of dissection, from the careful readingof Galen’s books, and from the welcome restora-tion of many portions thereof, that he himselfnever dissected a human body, but in fact wasdeceived by his monkeys . . . (Vesalius, 1543/

2003b, Nutton translation, p. 3r)

Within the Fabrica itself, Vesalius wrote of, and illu-strated, the human brain and its parts as they wererevealed through skillful top-to-bottom dissections. Thefourth book “explains not only the distribution of nervesthat go to the muscles, but the branches of the others aswell,” with the seventh examining “the harmony of thebrain and the organs of sense in such a way that the ser-ies of nerves taking their origin from the brain,explained in the fourth book, is not repeated” (Vesalius,1543/2003b). Figure 19.2 offers some understanding ofhow Vesalius worked. Fig. 19.2A (Plate 66), the first fig-ure in the seventh book, “represents the human headarranged for the purpose of demonstrating the brain inwhich manner it is freed by neatly severing it from theneck and lower jaw” (Vesalius, 1543, 66:1–2 [VII: Fig.1, Saunders translation, p. 186]). With Fig. 19.2B (Plate67), as Vesalius explains:

The second figure follows the first in thesequence of dissection and shows the third sinus[superior sagittal] of the dural membrane laidopen by a long incision carried in the length ofthe head. In addition, at the sides of the thirdsinus I have led two incisions also in the lengthof the head, that is, one on either side of thesinus, which penetrate the dural membrane onlyand separate the sides of the dural membranefrom that process [falx cerebri] of the membranewhich divides the right part of the brain from theleft . . . (Vesalius, 1543, 67:1 [VII: Fig. 2,

Saunders translation, p. 188])

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While respectful of Galen, the text also explains thatGalen had departed more than 200 times from a truedescription of the harmony, use, and function of thehuman parts, and that he gave special attention to theventricles, although actual dissections show humans donot possess any special cavity in the brain. And whereasin the Tabluae Anatomicae Vesalius depicted the retemirabile in a way that corresponded to Galen’s descrip-tion, he questioned its very existence in humans in theFabrica, following Jacopo Berengario da Carpi, whohad also begun to doubt its existence (Saunders andO’Malley, 1950; Finger, 2000). By systematically com-paring human findings with those from dogs and otheranimals, Vesalius was able to show that Galen and hisfollowers had never adequately described human beings.

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Fig. 19.2. Andreas Vesalius. De Humani Corporis Fabrica, 1543in the Fabrica. (A) Plate 66, the first figure of the seventh book, r

strating the brain. Woodcut.

The Fabrica also depicted the cranial nerves thatwere originally described by Galen and mentions theGalenic concept of pituita. The pneuma that enters thebody through the lungs supposedly enters the vascularsystem to become the “vital spirits,” and then pass uptoward the brain, where they are changed into “animalspirits” in the rete mirabile. Pituita was thought to beformed during the transformation of the vital into theanimal spirits, and this waste product found its wayinto the nose and pharynx. Our term pituitary isderived from this ancient idea (McHenry, 1969).

Despite the large number of anatomical errorsabout humans that Vesalius would catalogue, Galen’simpact on the field still remained far-reaching. Indeed,the persistence of Galen’s views demonstrates that it is

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. The dura is shown in many of the figures Vesalius presented

epresents the human head arranged for the purpose of demon-

(Continued)

Fig. 19.2 Cont’d. (B) Plate 67, follows the first in the sequence of dissection. Woodcut.

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often difficult to refute established ideas. Vesalius, forexample, questioned the ventricular doctrine of brainfunction, although he depicted the ventricles with moredetail and care than the cerebral cortex. Thus, the ghostof Galen is evident in many instances where Vesalius’famous woodcuts of the brain and the body reproduceoddities. We also find that Vesalius’ illustration of the“sixth pair” of cranial nerves in the Fabrica shows thesympathetic trunk arising as a branch of the vagus, in aposition corresponding to the top of the thorax. Somesay this error came about because the drawing isderived from one he had made as a teaching aid forhis early dissections, and that it was simply incorpo-rated into the Fabrica without revision. This idea isreinforced by the text, which seems to mirror the dia-gram (French, 1971). In other words:

Issues of mind or soul, endlessly debated by phi-losophers and theologians, and ideas pertainingto physiology, were beyond his immediate grasp.He seemed to know that the old physiologicaltheories were wrong, but could not formulatenew ones of his own with so few observable factsto go on. (Finger, 2000, p. 65)

As Finger notes, Vesalius was basically an empiricist, aman who showed complete faith only in the observable.His importance cannot be underestimated. Aside fromLeonardo da Vinci (1452–1519), there was relatively lit-tle progress in the anatomical field from the time ofMondino (c. 1275–1326), who wrote a compendium ofanatomy that served as a guide for understandingGalen, to the time of Vesalius.

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Other noteworthy contributions

After the Fabrica, many anatomists contributed originalworks, often using them as starting points for their illus-trations, and, as with the Tabulae Anatomicae, there wasalso a flood of plagiarisms. Charles Estienne (CarolusStephanus; c. 1504–1564), an anatomist and prominentpublisher of medical books during the Renaissance, wasamong those doing original work. The son of HenriEstienne, a famous French painter, Charles lectured onanatomy at the Faculty of Medicine from 1544 to 1547.HisDeDissectione PartiumCorporis Humani Libri Tres,an anatomical work illustrated with approximately 60woodcuts, was published in 1545, although largely com-pleted by 1539, before the Fabrica. Because Estienne’sbook appeared after rather than before Vesalius’Fabrica,it had significantly less impact.

Like Vesalius, Estienne was raised within the Gale-nic tradition. Yet, in looking more closely, we see ana-tomical works that offer a great variety of images ofparts of the body, and several refute Galenic teachings(Estienne’s description and drawings of the humansternum, for example; see Tubbs and Salter, 2006).Compositional qualities also distinguish Estienne’sdrawings from those of Vesalius. Due to his mannerof presentation, Estienne’s brain dissection illustrationsat first glance appear strikingly less scientific thanthose of Vesalius. In many cases, the details directlyrelated to the brain come from small wood blocks care-fully inserted into already existing larger blocks, asFig. 19.3 shows. This technique somewhat obscuresthe clinical information. Why Estienne chose thisapproach remains a mystery. Some argue that his prin-ter, Simone de Colines, was simply using a set ofblocks originally prepared for another book. Otherssuggest the classical backgrounds found on someblocks, and the use of male and female nudes in heroicposes on others, were Estienne’s choice. Whatever thereason for this creative approach, these prints are pos-sibly the first examples of “neuroartistry” (McHenry,1969). (Examples of other images are available in Fin-ger, 1994, p. 23. Also see http://clendening.kumc.edu/dc/rti/human_body_1545_estienne.html.)

Reviewing Estienne’s eight dissections of the brainfrom 1539 shows he provided more anatomical detailsthan had previously appeared for some structures. Parti-cularly notable is the first graphical presentation of thedifference between the convolution patterns of the cere-brum and cerebellum (McHenry, 1969). His copperplates also show the passage from the lateral to the thirdventricle, and that from the third to the fourth ventri-cles. In addition to a crude representation of the cranialnerves, Estienne furnished a good description of thecanal of the spinal cord and of the condition known

later as syringomyelia, a condition that would be moreclosely associated with Senac in 1724 (McHenry, 1969).

Bartolomeo Eustachio or Estachius (1520–1574), whoprovided some of the most accurate Renaissance studiesof the base of the brain, also made noteworthy contribu-tions. After beginning his career as a physician to theDuke of Urbino, Eustachio went on to teach anatomy asa part of the medical faculty of La Sapienza. Eustachio’suse of copper engraving permitted great subtlety, as isevident in his magnificent depiction of the sympathetic,cranial, and spinal nerves (see Fig. 19.4). Prepared in1552 and published in 1714, this is probably his best-knownwork. This diagram is so remarkable that it continued toappear even into the 19th century (in Wistar’s anatomytext) and was published in the 1817Encyclopaedia Britan-nica, despite his incorrect depiction of the sympatheticchain, which is shown arising from the brain stem. Thecranial nerves arise from the base of the brain and the bra-chial plexus from the spinal column (McHenry, 1969).

Unfortunately, as with Leonardo, the impact ofEustachio’s exquisite images was limited, since they lar-gely remained unpublished until the early-18th century.His position was further complicated by his use of cop-per plates, because they made it necessary to print hisimages separately from the text. Unfortunately, theentire text of the work has been lost. Finally, Eustachiois remembered for introducing a graduated border toframe the image and orient the viewer (Tomlinson,2001). This allows one to identify specific features byusing coordinates along the frame, much as one wouldwhen finding a position on a map. Many see this deviceas a great improvement over the labeling systems of ear-lier illustrators, which required the viewer to search forletters within the image (McHenry, 1969).

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EARLYMODERNANDMODERNILLUSTRATION

Thomas Willis and the 17th century

Thomas Willis’ (1621–1675) Cerebri Anatome is oftencompared with Vesalius’ Fabrica, due to the revolu-tionary qualities of each. Considered the “father ofneurology” by many, this outstanding figure of the17th century was one of a new breed of medicalmen who were influenced more by clinical and labora-tory insights, and by a new medical chemistry, than byGreco-Roman theories held sacred by their fore-fathers (Finger, 2000). The “Willis Brain” associatedwith Cerebri Anatome (1664) is perhaps the best-known single historical work combining illustrationand neuroscience. The book itself provided the mostcomplete and accurate accounts of the nervous sys-tem that to date.

Fig. 19.3. Charles Estienne. 1546. This copper engraving by Estienne shows that the plate of the brain dissection had been

reproduced separately and then placed on the larger portrait. The faint outlines of the margin of the smaller plate can still

be seen. This dissection shows the cerebellum and the origin of the choroid plexus in the ventricular system.

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Fig. 19.4. Commissioned by Bartolomeo Eustachio for Tabulae Anatomicae, 1728. This copper plate depicts the sympathetic,

cranial, and spinal nerves.

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Focused on the brain, the spinal cord, and thenerves, Cerebri Anatome contains Willis’ descriptionof the arteries at the base of the brain and includeshis classification of the cranial nerves into nine pairs.Among the noteworthy contributions were the shiftof the trochlear nerve from position eight to its properplace as the fourth cranial nerve and the first descrip-tion of the eleventh (spinal accessory) cranial nerve.This was the first major reclassification of the cranialnerves since Galen, and it prevailed until Soemerring’sclassification over a century later, (Sommerring, 1801).It should also be noted that Willis coined the term opticthalamus, was the first to use the terms lentiformbodies and corpus striatum for the basal ganglia, anddescribed the ciliary ganglia and the intercostal nerves.

One of the most remarkable aspects of Willis’ workwas his handling of the brain. Vesalius essentiallydestroyed the brain as he worked. His top-to-bottomdissection was a primitive technique of cutting throughthis organ, hopefully before it rotted. Willis, however,was able to adopt a different approach due to improve-ment in preservation. His esteemed colleague RobertBoyle (1627–1691), today better remembered in physicsand chemistry, discovered that the process of decaycould be halted by immersing the organ in pure alco-hol. Using this procedure, Willis could preserve a brainfor as long as he wished and study it slowly. Hisresearch also benefited from the microscopic experi-ments of another person he knew well, Robert Hooke(1635–1703).

The input by several members of the Virtuosi, aninformal group of experimental scientists in Oxford,helped the project immensely. The extent of eachman’s contributions has raised the question of whetherit is in fact Willis’ work. While the group includedBoyle, Christopher Wren (1632–1723), Thomas Milling-ton (1621–1675), and others, the controversy largely cen-ters on the role of Richard Lower (1631–1691), thetalented experimentalist who performed the first bloodtransfusion. It is agreed that Lower assisted Willis withhis anatomy and physiology studies. Whether he was lar-gely responsible for the entire work is harder to ascer-tain, although this seems doubtful.

What we know is that Willis warmly praised Lowerin the introduction to Cerebri Anatome, calling him adoctor of outstanding learning and an anatomist ofsupreme skill, whose untiring perseverance and won-derful dexterity had been of especial value in the dis-section of the nervous system (Symonds, 1960). Someallege that this praise obscures the degree to whichWillis depended on Lower and suggest it is Lowerwho actually deserves the credit. The arguments areinconsistent, however. For example, Henry Stubbe saidWillis could not have found the time to do this work given

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his busy practice, but then contradicted this in a post-script, adding that although Lower did the dissections,Willis was themastermind who had inspired and directedthe work. Stubbe’s initial question of attribution waslater published by Anthony Wood, in his AthenaeOxonienses (1813–1820), without mention of the post-script. Wood claimed that Lower helped or instructedWillis on some parts of anatomy and thus should becredited with the accomplishment. Wood, a neighbor ofWillis, had a disagreement with him that may have preju-diced him against the physician. Lower’s defense ofWillis’ work a year afterCerebri Anatomewas publishedreinforces the view that it was in fact Willis’ work.Lower’s words of praise also suggest there were nobad feelings (Symonds, 1960; Stubbe, 1670).

Somewhat less controversial are the drawings ofChristopher Wren, later noted as an artist and thearchitect of St. Paul’s Cathedral in London. His contri-butions to neurological illustration are of particularinterest in light of the reputation he established in theseother fields. After completing his studies in astron-omy at Gresham College in 1657, Wren became amedical student at Oxford under the mentorship ofWillis. A prodigy, he quickly earned respect for hisquick mind, keen eyes, and detailed drawings of thenervous system. Many of these, including Fig. 19.5of the neurovascular structure called the circle ofWillis, are considered among the most magnificentneurological studies ever produced. Broadly speaking,the more “modern” look of the Wren contributionmatches the methodological approach Willis appliedto his studies overall. Wren deserves much credit forthe book’s visual quality. His magnificent detailedand exact illustrations, printed on copper plates, wereworks of art in their own terms and yet appear morescientific than earlier illustrations. Indeed, Wren’stantalizing drawings are so fine that they are stillreproduced in textbooks today.

It is also instructive to compare Willis with Des-cartes (1596–1650) and William Harvey (1578–1657),both of whom contributed tremendously as sciencemoved into the modern era. Like Descartes, Willisaccepted the idea that there are specialized controllingstructures in the brain. But unlike Descartes, whosingled out the pineal gland in this context, Willisemphasized that the brain can best be understood byenvisioning different levels of function (Finger, 2000).

Willis’ debt to William Harvey is more direct. Highlyimpressed by Harvey’s work on circulation, Willis aimedto produce a similar result through an analysis of thearteries of the brain. He achieved this with great skill.Thus, although the arterial circle at the base of the brainthat became known as the “circle of Willis” hadbeen depicted before Willis, by Fallopius (1523–1562),

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Fig. 19.5. The Willis Brain. From Thomas Willis’ Cerebri Anatome, 1664. This engraving depicts the arteries of the brain.

Artist: Christopher Wren.

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Casserio (1552–1616), Vesling (1598–1649) and Wepfer(1620–1695),Willis was able to prove the interconnectivityof the vessels by injecting dyes into the arteries to trace thecirculation. When administered to the circle of Willis,these dyes spread “into every corner and secret place ofthe brain” (Tomlinson, 2001, p. 8). In his experiments withanimals, he showed that dye injected into one carotid

artery stained all the vessels, and that ligation of one caro-tid was compatible with life, thus confirming the func-tional importance of the circle.

His clinical highlights included a man who died of amesenteric tumor, who in life had had no neurologicalsymptoms. The published case report inCerebri Anatometells us:

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When his skull was opened we noted amongst theusual intracranial findings, the right carotidartery, in its intracranial part, bony or even hard,its lumen being almost totally occluded; so thatthe influx of the blood being denied by this route,it seemed remarkable that this person had not diedpreviously of an apoplexy: which indeed he was sofar from, that he enjoyed to the last moments of hislife, the free exercise of his mental and bodily func-tions. For indeed, nature had provided a sufficientremedy against the risk of apoplexy in the vertebralartery of the same side in which the carotid waswanting, since the size of this vessel was enlarged,becoming thrice that of the contralateral vessel.(Willis, 1664/1964, p. 82)

Equally remarkable was Willis’ accurate rejection ofthe ventricles in favor of the cerebrum as the centerof memory, cognition, volition and imagination. Healso correctly distinguished between the functions ofthe gray and white matter of the cerebral hemispheres.Not all of his conclusions were correct. For example,he incorrectly concluded that the brain’s crust, withits abundance of blood vessels, plays a key role in theformation of ethereal spirits (Ustun, 2004).

Another 17th-century figure of note is FrederickRuysch (1638–1731), a fellow-student, friend and contem-porary of Jan Swammerdam. Until the late 17th century,many still subscribed to Galen’s belief that several partsof the body are devoid of blood supplies. This largelychanged, onceRuysch’s experiments provedGalenwrongand demonstrated the subarachnoid arterial anastomosesbetween the major cerebral vessels. His method combinedwax injections with preservation techniques in a way thatmaintained the color of the specimen (Haviland andParish, 1970). Some of the most accurate 18th-centurydemonstrations were prepared by this Dutch anatomistand illustrated by Johannes Ladmiral.

After Ruysch’s death, two 3-page pamphlets appearedwith illustrations of the specimens (Tomlinson, 2001).Based on a method developed by J.C. Le Blon, these earlyanatomical illustrations were among the first in color. Onepamphlet offered a view of the internal (concave) surfaceof the encephalic dura mater in a fetus of 8 months. A sec-ond depicted the concave exterior. Ruysch’s success wasapparently influenced by the technique developed byLeonardo to solidify masses to determine structure.

Charles Bell

Another key figure in neurological illustration was SirCharles Bell (1774–1842), the Scottish anatomist, surgeon,physiologist, theologian and artist cited at the start of thischapter. Today his accomplishments are recognizedthrough several eponyms including Bell’s nerve, Bell’s

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palsy, Bell’s phenomenon, Bell’s paralysis, Bell’s spasm,and the Bell–Magendie law. (A recent article, “The Artof Sir Charles Bell” by Christopher Gardner-Thorpe, con-tains a number of reproductions of his drawings andpaintings. It is available in F. Clifford Rose’s book, Neu-rology of the Arts: Painting, Music, Literature [2004].)

Like his brother John (1763–1820), Charles was a sur-geon with exceptional artistic ability. While still a stu-dent in Edinburgh, and under the guidance of hisbrother, he published the self-illustrated A System ofDissection Explaining the Anatomy of the Human Body,to accompany a course on this subject. Shortly there-after, he went to London. In 1804, he completed theplates for his book, Essays on the Anatomy of Expres-sion in Painting, which appeared in 1806. His best-known illustrated publications are The Anatomy of theBrain, Explained in a Series of Engravings (1802) andEngravings of the Arteries (1801), which contain coloredengravings of his dissections of the head and the brain.

In An Idea of a New Anatomy of the Brain (1811),termed the “Magna Carta of Neurology” (Kazi andRhys-Evans, 2004), Bell discussed the function of thebrain and the cerebellum, and described the double rootsof the spinal nerves, including how he experimentallyinvestigated their different functions on a donkey. Healso demonstrated that the fifth cranial nerve is sensory-motor, and discovered the long thoracic nerve or “Bell’snerve” (McHenry, 1969). His extraordinary plates weremainly reproduced from his original drawings.

Equally remarkable are the works he did on site,which we know through sketches, watercolors, andpaintings (Gardner-Thorpe, 2004). When word of theBattle of Waterloo reached him, he set out for the bat-tlefield to aid the wounded. Once there, it is said thathe removed a musket ball from the right hemisphereof the brain of a 27-year-old soldier, who somehowsurvived. This was probably represented in his originalwatercolor drawings, not all of which survived.

Some of his fieldwork notes and drawings werelater developed into educational materials. In 1836,for example, a few years before the invention ofphotography, Bell prepared 17 life-size watercolorsbased on his Waterloo sketchbook to use as teachingaids, 45 of his Waterloo watercolor sketches survivedin a notebook that was donated to the Army by Bell’swidow, and many of his oil paintings and etchingsare on display at the Royal College of Surgeons ofEdinburgh, as are a number of his scenic watercolors.

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The road to modern illustration

No survey of neurological illustration can concludewithout mentioning a few later figures. Jean-MartinCharcot (1825–1893), like Charles Bell, displayed an

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exceptionally developed visual sense and memory,accompanied by his exceptional artistic gifts. First pur-sued as a hobby in his youth, his talent for drawingsubsequently served as a tool in his profession. Hold-ing the first French chair in the Clinique des Maladiesdu Système Nerveux (diseases of the nervous system)at La Salpetriere Hospital in Paris, Charcot wasuniquely positioned to combine his talent in art withneurological study. A sketch by Brissaud (1875) showsCharcot examining a brain in the amphitheater of theSalpetriere.

Charcot quickly brought his delight in drawing rapidsketches into his clinical teaching and research activ-ities. (Several representative illustrations are availablein Julien Bogousslavsky’s “Charcot and art: from ahobby to science”; see European Neurology, 2004.)At the beginning of his career, when photographywas not available, he applied his artistic gifts to captur-ing clinical cases, anatomical views, and microscopicstudies (Bogousslavsky, 2004). Throughout his careerhis lessons were accompanied by chalk drawings on aboard – with him often imitating anomalies, move-ments, gaits and other characteristics of specific dis-eases (Bogousslavsky, 2004). He also integrated hisyouthful research on the styles of artists from all peri-ods into his research. Looking more closely at the worklater in life, as a scientist, Charcot was able to spot“impossibilities” and to point them out. For example,he criticized the inaccurate representation of musculartone of a “possessed” boy in the painting La Transfig-uration, completed by Raphael in 1520. Charles Bellhad previously alluded to this anomaly (Bogous-slavsky, 2004).

In addition, Charcot’s talents in caricature led to athorough study of artistic representations of “pos-sessed states,” which allowed him to discuss earlierexamples of hysteria. Designated as an authorityin several fields of medicine, his work on hysteria isespecially recognized today, as is his influence on Sig-mund Freud’s turn to this area (Freud translated someof Charcot’s lectures into German and later named hisfirst son Jean Martin in Charcot’s honor). Writing afew years after Charcot’s death, his student HenryMeige summed up his work with the words, “Charcotthe artist is inseparable from Charcot the physician”(Meige, 1925, p. 82; Bogousslavsky, 2004).

Another key figure, Jan Evangelista Purkyne (1787–1869), an experimental physiologist from Czechoslova-kia, helped create a modern understanding of the eyeand vision, brain and heart function, mammalianreproduction, and the composition of the cells that bearhis name (in 1837). He provided one of the earliestillustrations of a neuron and its parts. This researchmarked a point of departure for the histological inves-

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tigation of specific regions of the brain. (Finger [1994,p. 43] reproduces cerebellar cells drawn by Jan Purkynefor the Congress of Physicians and Scientists in Praguein 1837 and published in 1838.) The Golgi stain openedthe door further. Described by Camillo Golgi (1843–1926) in 1873, the staining process allowed an observerto see all parts of the structure and understand thecomplexity of nerve tissue.

Finally, with the Spanish neurohistologist SantiagoRamon y Cajal (1852–1934), we find another major fig-ure who trained in art and later decided to use histalents in medicine. Cajal perfected Golgi’s silver stainand championed the neuron doctrine, arguing that neu-rons are not fused together but are independent units,like other cells. His prolific efforts to disprove ideasthat had been long accepted are complemented byhandmade, beautiful illustrations, which add immea-surably to his work. (Several of his drawings areincluded in his Nobel Prize summary; see http://nobel;prize.org/nobel_prizes/medicine/articles/cajal.) Theseartistic renderings are also noteworthy in representingthe culmination of decades of research into neuronsand how they function.

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NEUROLOGICALLY DESCRIPTIVEILLUSTRATIONS

Images that are an adjunct to scientific research formonly a portion of historical neurological imagery. Alsoof note are images of brain diseases and emotional dis-orders that are associated with behavioral abnormal-ities. As noted, Charcot and Bell had applied theirscientific gazes to medical conditions and capturedthem in their art. Others, too, have pointed out condi-tions, and have made corrections as well.

Masolino da Panicale (c. 1383–1447) and Masaccio(1410–1428), for example, are two painters whoinitiated experiments with perspective and light. Theirmost famous works are the six frescoes painted inthe Brancacci Chapel of Santa Maria del Carmine,Florence. Masaccio’s St. Peter Healing the Sick withHis Shadow includes a beggar with a crippled leg,based on an episode in the “Acts of the Apostles”(5:15–16). It has been claimed that the disease repre-sented is polio. As with the Funeral stele of Ruma,however, some people have challenged this conclusion.The critics argue, in part, that there is no good descrip-tion of polio prior to the 18th century (Rose, 2004).Healing of the Cripple and Raising of Tabitha fromthe Dead by Masolino also appears to depict polio.Whether or not this is the case, the painting is directly con-nected to the trajectory of neurological history througha 1912 photograph of Sigmund Freud, which shows himseated with a framed reproduction of the Healing of

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the Cripple and the Raising of Tabitha behind him.Given Freud’s influence on the course of neurology itwould be fascinating to know why he chose this speci-fic image.

Clownism, opisthotonos, gait disturbances, and var-ious forms of what some claim is hysteria are found inthe works of Peter Brueghel (dancing mania, or St.Vitus dance), those of Hieronymous Bosch (e.g., hisProcession of Cripples shows a variety of gait distur-bances), and Matthias Grunewald’s 16th-century Isen-heim altarpiece (which glorified suffering and offeredcomfort to those afflicted with St. Anthony’s Fire orergotism) (McHenry, 1969). Rose (2004) points outthat St. Anthony’s Fire likely included other disorders,such as erysipelas. It could affect either the brain,causing convulsions, or constrict the arteries to thelimbs, giving, in its extreme form, gangrene. In lesssevere form, it causes redness and blistering of theextremities, which explains the appellation “St.Anthony’s Fire.” In the case of Grunewald’s Isenheimaltarpiece, the hands show a bluish atrophy, considereda sign of peripheral vascular disease, which can lead togangrene (Rose, 2004). During the Middle Ages, thenervous and convulsive syndromes we now attributeto ergotism were bewildering. Since diseases of thebrain and nervous system often affect the motor sys-tem, producing distortions and deformities, as theseworks show, they lend themselves in a unique mannerto portrayal by artists, as many works by Bruegheland Bosch emphasize.

Other noteworthy artistic contributions include LePied Bot (The Clubfoot) by Jose Ribera (1591–1652),now at the Louvre. In this painting, the beggar-boyappears to have a right hemiplegia. The note in hisleft hand says, “Give me alms, for the love of God,”and suggests that he cannot speak and has aphasia.The posture of his right hand and foot could indicatea long-standing lesion of the left cerebral hemisphere.Both Rose (2004) and McHenry (1969) postulatethat this image represents the first such portrayal ofaphasia.

Another Spanish artist, Velazquez (1599–1660),painted Calabazas: Court Jester to Phillip IV ofSpain. Here we see a young man with bilateral footdrop and paralysis of the left lateral rectus muscle.Several etiologies for his neurological disorder arepossible, among them peroneal muscular atrophy(McHenry, 1969).

Printmakers have similarly contributed to this genre.Beggar on His Crutches, from Behind, by the Frenchprintmaker Jacques Callot (1592–1635), is an exquisiteexample of the art. This etching presents a man witha left hemiplegia with circumduction of his leg(McHenry, 1969). Engravings depicting seizure disor-

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ders and an epileptic-type of hysteria were very com-mon during the 17th and 18th centuries. WilliamHogarth (1697–1764) offers a tantalizing example inThe Election. This print shows a woman at a votingbooth with a movement disorder, probably hereditarychorea (McHenry, 1969). A 19th-century example isThe Epileptic, an engraving by Jean Duplessi-Bertaux(McHenry, 1969).

Finally, the neurological imagery is placed within alarger context in some cases. Another Hogarth, Credu-lity, Superstition, and Fanaticism, A Medley, includesa brain thermometer in the lower right corner that islikely adapted from Christopher Wren’s illustration inThomas Willis’ The Anatomy of the Brain and Nerves.Also, on the title page of the second edition of HelkiahCrooke’s Description of the Body of Man (1631), wefind a plate showing the first public demonstrationof brain anatomy. Crooke is seated in front of thetable using his hands in a gesticulating manner whileteaching. The dissection itself is done by the demon-strator standing at the back of the table, with Crookepointing to the cut surface of the brain. The termdemonstrator is used because the teacher or professordid not do the dissection. It was actually performedby a demonstrator. (This illustration is available inMcHenry, 1969, p. 54.)

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HISTORICAL ILLUSTRATIONANDCONTEMPORARY RESEARCH

Researchers have examined the neurological traits ofartists throughout history through the objects they haveleft behind, and have added some thought-provokingdata to our studies. Rembrandt’s works, for example,have fostered several fascinating studies. The AnatomyLesson of Dr Joan Deyman (1656) was the fifth in aseries of group portraits of doctors and surgeonsperforming public dissections in the 17th century.Supposedly, this 1656 work shows two anatomists,Dr Deijman and his assistant, Dr Calkoen, dissectingthe brain of a man whose abdominal cavity is alsoexposed. In 2000, Laurence Garey and Mei Guanattempted to reconstruct the painting using anembalmed cadaver. They found that Rembrandt hadeliminated at least a cubic meter of space between thepatient’s head and feet, and concluded the work depict-ing an intact body represented a scientific impossibility(Garey et al., 2000; Reed, 2000).

Another study, by the neurobiologist Margaret S.Livingstone, published in 2004 in the New EnglandJournal of Medicine, suggests that Rembrandt’s eyesfailed to align correctly. She and her student Bevil Con-way studied 36 Rembrandt self-portraits and comparedthem with the etchings he made. All showed the same

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outward displacement of the left eye (although itappeared on the right in the etchings, because the printsare reversed from the plates). This reversal indicatedthat Rembrandt was not consciously depicting the eye-displacement, but was depicting what he saw in the mir-ror to great accuracy. The authors speculated that theexotropia indicated that he did not see binocularly in anormal fashion, because his brain automaticallyswitched to one eye for such visual tasks. This disabilitycould have helped him to perceive the kinds of flattenedimages he translated onto the 2-dimensional canvas.

CONCLUSIONS

This survey hardly touches upon the numerous examplesof visual illustration throughout history and pre-historythat we can identify as having aided medical investigationand informed cultural awareness. These examples do,however, demonstrate that visual contributions are a partof a trend in science and medicine that continues to thisday. Many artists mentioned above, and many of thoseexcluded (e.g., Goya, Gericault, and van Gogh), offer fer-tile ground for considering the relationship between neu-rological disorders and visual images.

Particular themes (for example epilepsy as repre-sented by artists such as Raphael in The Transfigura-tion, and Peter Paul Rubens’ The Miracle of St.Ignatius of Loyola) could have been detailed as well.Also omitted is the robust trajectory that extends visualimagery into the 21st century. Forms like photographyand film further establish that visual images continueto impact neurology in significant ways (see Ch. 20).Adding movement to images aided invaluably in captur-ing life-like dynamics. Advances include photographs ofpatients during an induced epileptic seizure made byFrancis X. Dercum as a part of Edward Muybridge’s1884 treatise on Animal Locomotion (McHenry, 1969).Also of note are Muybridge’s 1895 photos of “spasticdiplegia and choreiform and athetoid movements.”Film, too, has allowed practitioners to document rare,eradicated, and geographically local disease.

It should also be noted that innovative tools of the19th and 20th centuries extended illustration to micro-scopic and macroscopic dimensions, yielding knowl-edge about the microstructure of the nervous system.Non-invasive techniques allowed an advancement of3-dimensional visualization, just as photography andfilm aided in recording motion and capturing case stu-dies of remote or rare events. This is not to say thatinnovations have solved all the basic problems facedby earlier artists. Some, including 2-dimensional repre-sentations of what are essentially 3-dimensional mor-phologic features, remain problematic (Linden, 2002).Despite the remaining challenges, it is clear that visual

286 A.

imagery and illustration offers a unique point of viewfor entry into neurological history and for understand-ing the development of the field.

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