Robert Carswell: the first illustrator of MS.
Abstract: The first illustration of multiple sclerosis (MS) was by a young Scottish physician and artist, Dr Robert Carswell. Recognized as a talented illustrator by his teachers, he was encouraged to create an anatomy and pathology atlas. He spent years in the hospitals and mortuaries of Paris and Lyon painting watercolours and pen and ink drawings of patients and post mortem preparations. Of the 1034 paintings, 99 are of the brain and spinal cord and Plate 4, figure 4.4 in the atlas (Figure 2), is of MS. Carswell indicated he saw two examples of this pathology, but had not examined either patient, but illustrated one of them. We know little about the clinical history other than that the patient was paralyzed. About 200 of the atlases were printed, and it is still regarded as one of the greatest and most beautiful of all medical books. Carswell was appointed as the first Professor of Anatomy at the North London Hospital, later renamed the University College Hospital UK, where the original copy of his great atlas is archived. Due to ill health he resigned after a few years to reside in the healthier air outside Brussels, Belgium. He was appointed physician to King Leopold, but was also noted for his care of the poor. Queen Victoria knighted him for his care of King Louis Philippe of France when he was in exile. Although English journals did not note his passing at the age of 64 years, his great atlas remains as his memorial.
Article Type: Brief biography
Subject: Multiple sclerosis (Portrayals)
Pathologists (Works)
Author: Murray, T.J.
Pub Date: 11/01/2009
Publication: Name: The International MS Journal Publisher: PAREXEL MMS Europe Ltd. Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2009 PAREXEL MMS Europe Ltd. ISSN: 1352-8963
Issue: Date: Nov, 2009 Source Volume: 16 Source Issue: 3
Topic: NamedWork: Pathological Anatomy: Illustrations of the Elementary Forms of Disease (Nonfiction work)
Persons: Named Person: Carswell, Robert (British pathologist)
Geographic: Geographic Scope: United Kingdom Geographic Code: 4EUUK United Kingdom
Accession Number: 217847868
Full Text: 'These illustrations have, for artistic merit and for fidelity, never been surpassed, while the matter represents the highest point which the science of morbid anatomy had reached before the introduction of the microscope.'

Sir William Osler

Introduction

After a century of confusion and alternate claims, it is now clear that the first illustration of multiple sclerosis (MS) in the medical literature was by Robert Carswell in 1838 (Figure 1). (1,2) Physicians have long had an obsession about 'firsts' and although in MS there are many firsts (the first description in a patient; the first mention of the disorder in the medical literature; the first illustration), Carswell's contribution is just part of a progression, and perhaps of significance only in retrospect. Even before his atlas, there was a case description by Charles Prosper Olivier d'Angers in his monumental work on the spinal cord, De la Moelle Epiniere et de ses Maladies (1824). (3)

Born in Thornliebank, Scotland on 3 February 1793, Robert Carswell was noted early by his teachers to be a talented artist. Dr James Jeffray, an eccentric and theatrical Professor of Anatomy and Physiology in Glasgow, Scotland, asked Carswell to illustrate his invention to propel boats on the Clyde River (the boat sank), and later to draw anatomical teaching models. He also encouraged Carswell to enter medical school.

Carswell's medical education involved studies at Glasgow, Edinburgh, Paris and Lyon. He was a family friend of Dr John Thompson (1765-1864) of Edinburgh, a prominent surgeon and pathologist, who encouraged Carswell, as well as his two sons, to study in Paris. Thompson wanted illustrations for teaching and encouraged the creation of an atlas of pathological conditions.

In the English traditions of the Hunter brothers and Robert Hooper in London, and Thompson in Edinburgh, and incorporating the techniques of the French, Carswell entered the huge hospitals and mortuaries of Paris and Lyon to depict the pathology seen on the clinical services and at autopsy. He was most interested in the pathology, less in the clinical aspects of the cases, and Jacna says he foreshadowed the 'pure pathologist' of the future. (4)

At the same time and in the same hospitals and mortuaries, Jean Cruveilhier was also producing a great atlas of pathology but was also interested in incorporating clinical aspects of the cases. It is likely (but undocumented) that they met in the course of their similar work. (5)

Carswell carried out his work in Paris and Lyon in 1822-1831 at the pleasure of the French and returned to Paris when he had received his MD from Aberdeen in 1826, remaining there until 1831. He then had over 1000 watercolour paintings of pathology, remarkable for their 'artistic skill and accuracy of delineation and colouring. (6)' Based on his work, he was appointed at age 35 to the inaugural Chair of Pathology at London University when the anatomist JF Meckel refused the offer, but stayed on in Paris to complete his atlas and to study with Pierre Louis, father of medical statistics.

His atlas, Pathological Anatomy: Illustrations of the Elementary Forms of Disease, was published in 1838 in 12 separately printed fascicles, each of four plates in its own wrappers, and dedicated to his early inspiration, Dr James Jeffray. (7) The beautifully illustrated watercolours were reproduced by the technique of lithography which had been invented in Germany in 1790. About 200 atlases were printed. The original atlas is at University College Hospital, London and was recently moved to their archives.

Some of the drawings were signed by Carswell and some annotated as drawn directly onto the lithographic stone. Some were drawn on the stone by Haghe and he neglected to reverse the lesions in the medulla when doing the illustrations of MS. The earlier plates, including the depiction of MS, have a notation saying they were printed by 'lithographers to the King', indicating they were done before 1836 and printed before June 1837 when Queen Victoria took the throne. (1)

The illustrations are mostly watercolours, with a few in pen and ink. The 1034 paintings are of each anatomical area, and there are 99 of the brain and spinal cord. (6) Plate 4, figure 4.4 in the atlas is of the spinal cord, pons and medulla, titled 'Brown transparent discolouration without softening of the spinal cord', depicting a condition he said was 'a peculiar diseased state of the cord and pons variolii' (Figure 2). There were both fresh and old scars, which he thought were due to deficiency of blood supply. The patient was paralyzed, but we know no more clinical details.

[FIGURE 1 OMITTED]

[FIGURE 2 OMITTED]

In the text accompanying Plate 4 he wrote:

I have met with two cases of a remarkable lesion of the spinal cord accompanied with atrophy. One of the patients was under the care of Mons. Louis, in the Hospital of La Pitie, the other under the care of Mons. Chomel, in the hospital of La Charite, both of them affected with paralysis. I did not see either of the patients but I could not ascertain that there was anything in the character of the paralysis or the history of the cases to throw any light on the nature of the lesion found in the region of the spinal cord. I have represented the appearances observed in one case in Plate 4, fig 4, in which the pons variolii was also affected, and which convey an accurate idea of the physical characteristics of the lesion. In this case a distinct portion of the cord was affected with softening which of itself would no doubt have accounted for the paralysis; but in the other case there was no other lesion than that to which I allude, to which the paralysis could be attributed. The anterior surface of the spinal cord presented a number of spots, from a quarter of an inch to a half an inch in breadth of an irregular form of a yellowish brown colour, smooth, glossy, without vascularity or any alteration in the colour or consistency of the surrounding medullary substance. The medullary substance thus affected was very firm, somewhat transparent, and atrophied. At the root of the medulla oblongata, these changes occupied the whole breadth of both the medullary fasciculi to the extent of half an inch in breadth from above downwards.

Further down, they were confined to distinct spots on each fasciculus, and several of the same kind, but smaller, occupied the pons variolii. The depth in which the medullary substance was affected in the manner varied from half a line to three or four lines, and on dividing the cord, it was seen to penetrate as far as the grey substance. (7)

The cases must have been seen before 1831 when Carswell left Paris and published in fascicle form in 1837 and in book form in 1838. (2) Carswell did not think he was describing a new disease or a separate entity, but another case of spinal cord atrophy, which was a very general category. (8) Carswell is known for his atlas, but also published a 30-page description of the changes to the lining of the stomach after death. (9)

Charcot credited Cruveilhier with the first illustration of MS, the second to Carswell, but it is evident that Carswell published first. (1,2) The atlas was prominent in a century when many great atlases would be published, but the illustration of MS had little impact on the recognition or understanding of the disease, and was mostly of interest to later authors as a historical footnote.

Carswell said he planned a new edition of the atlas, but he never returned to this work. As well as his professorship of anatomy, he was appointed physician to the North London Hospital, later renamed University College Hospital. Due to ill health from pulmonary problems, he resigned in 1840 and moved to the healthier air of Belgium, residing at Laeken, near Brussels. He was appointed physician to King Leopold, but was also noted for his care of the poor. He married Marguerite Chardenot in 1850 when he was aged 57 but had no children. (6) He visited London a number of times and during one visit was knighted by Queen Victoria for his care of King Louis Philippe of France while he was in exile. (10,11) He did no further academic work, lived quietly and died in 1857 at the age of 64 years. None of the prominent English journals saw fit to publish an obituary, but his great atlas will be a lasting memorial.

Acknowledgements

I am grateful to Demos Publications for permission to use much of the research incorporated in my book Multiple Sclerosis: the History of a Disease (2005), and to the Wellcome Library, the British Library and Royal College of Physicians of London. Arthur Hollman kindly shared with me his information on Carswell and his interest in the cardiac conditions in the atlas.

Conflicts of Interest

No conflicts of interest were declared in relation to this article.

References

(1.) Putnam TJ. The centenary of multiple sclerosis. Arch Neurol Psych 1938; 40: 806-813.

(2.) Compston A. The 150th anniversary of the first depiction of the lesions of multiple sclerosis. J Neurol Neurosurg Psychiatry 1988; 51: 1249-1252.

(3.) d'Angers CPO. De la Moelle Epiniere et de ses Maladies. Paris: Chevot, 1824.

(4.) Jacna LS, Carswell R, Thompson W. At the Hotel Dieu of Lyon: Scottish views of French Medicine. In: British Medicine in an Age of Reform (French R, Wear A, eds). London / New York: Routledge 1991; pp110-155.

(5.) Murray TJ. Multiple Sclerosis: the History of a Disease. New York: Demos, 2005.

(6.) Hollman A. The paintings of pathological anatomy by Sir Robert Carswell (1793-1857). Br Heart J 1995; 74: 566-570.

(7.) Carswell R. Pathological Anatomy: Illustrations of the Elemental Forms of Disease. London; Longman, Orme, Brown, Green and Longman, 1938.

(8.) Cameron GR. Robert Carswell, pathologist. Univ Coll Hosp Mag 1951; 36: 10.

(9.) Carswell R. An inquiry on the chemical solution or digestion of the coats of the stomach in man and animals. Edin Med J 1830; 34: 282-311.

(10.) Carswell papers, Edinburgh University Library. MS gen 590 and 59.

(11.) Behan PO, Behan WMH. Sir Robert Carswell: Scotland's Pioneer Pathologist. In: Historical Aspects of the Neurosciences: a Festschrift for Macdonald Critchley (Rose FC, Bynum WF, eds). New York: Raven Press 1982; pp273-292.

TJ Murray

Dalhousie University, Halifax, Nova Scotia, Canada

Address for Correspondence

T Jock Murray, Room 2L-A2, 2nd Floor Link, Sir Charles Tupper Medical Building, Dalhousie University, Halifax B3H 4H7, Canada

E-mail: jock.murray@dal.ca

Received: 29 January 2009

Accepted: 19 March 2009
Gale Copyright: Copyright 2009 Gale, Cengage Learning. All rights reserved.