19th-century portraits provide dermatology residents a lesson in looking
An oil painting by 19th-century Cantonese artist Lam Qua shows a woman with a young child seated on her lap. The pair appears healthy at first glance. Fancy blue earrings dangle from the woman’s ears. Red and white flowers adorn her hair.
She gazes down at the child, who has a serene expression. Nothing seems amiss until one notices the child’s feet, which are dark brown and are attached to the lower legs by two bare bones or pegs. The flesh above the ankles is receded and ragged.
Dr. Anna Eisenstein, a first-year dermatology resident at Yale New Haven Hospital, stood before an audience of physicians and fellow residents at the Cushing/Whitney Medical Library’s Historical Library and described the painting in detail. Then she attempted to diagnose the child’s condition, first suggesting that the brown feet could be wooden prosthetics, noting that all the toes had a normal shape aside from the discoloration. Dr. Irwin Braverman suggested that perhaps the artist had taken some liberty in depicting gangrene.
The child was a patient of Dr. Peter Parker, a Yale-trained physician and Presbyterian minister who arrived in China four months after earning his medical degree in 1834 and established a hospital in Canton, a southern province now called Guangzhou. He was the first Protestant medical missionary in China and commissioned Lam Qua, a successful commercial artist, to paint portraits of his patients. He used the paintings to promote his hospital’s services and for fundraising. The medical library houses a collection of 86 of Lam Qua’s portraits — the world’s largest repository of his work.
Ten of the paintings, depicting nine patients, were the subject of Dermatology Grand Rounds held at the library on April 4. Dr. Jean Bolognia, professor of dermatology, and Braverman, professor emeritus of dermatology, led the session, using the 19th-century paintings to train 21st-century physicians.
When Eisenstein had finished her assessment of the wounded child, Braverman identified the child’s affliction as described by Parker, 1831 B.A., 1834 M.D.
“This was the result of binding the feet too tightly,” Braverman said, referencing the Chinese custom, practiced over many centuries, of binding young girls’ feet to restrict their growth — tiny feet were considered a hallmark of feminine beauty.
By the time the child’s parents brought her to the hospital, her feet were black from gangrene because the binding had cut off circulation to them and they were about to fall off, Braverman said, adding that Parker’s final report indicates that, at her last recorded examination, the child’s right stump had nearly healed while the left was progressing more slowly.
Grand Rounds are a teaching exercise in which physicians and medical residents discuss the clinical cases of patients. Dermatology Grand Rounds are typically held at the Yale Physicians Building, where live patients are examined. During the exercise, residents and physicians cannot ask the patients questions about their symptoms but must base a diagnosis purely on observations. For each patient, a history of the illness is provided only after a discussion of the physical findings, differential diagnosis, and histopathologic features — microscopic tissue changes that accompany disease. The next step is clinicopathologic correlation — a summary and correlation of clinical and laboratory findings — followed by suggestions for therapy.
Bolognia had encountered a selection of Lam Qua’s portraits while visiting the medical library on an unrelated matter and thought the paintings would make a compelling subject for Dermatology Grand Rounds. She worked with Susan Wheeler, the library’s curator of prints and drawings, to organize the session, which was the first time Grand Rounds were held at the library.
The patients in Lam Qua’s portraits provided the residents a rich opportunity to hone their observational skills, which are crucial to making an accurate diagnosis, Bolognia said.
Residents must learn to spot all the details, no matter how minute, she said.
“Even though you’re drawn to this,” she said, pointing to a massive and lumpy abdominal tumor depicted in a portrait of a middle-aged man. “You need to step back and look beyond it. Anything you miss elsewhere may affect the differential diagnosis.”
The residents noted the patients’ age and gender; their posture; whether they appeared gaunt or discolored; the presence of any smaller lesions, tumors or other abnormalities; and any evidence of their social status, such as their dress. A resident was praised for noting that a patient with a badly disfigured leg was also missing a finger — evidence that indicated the man had probably suffered a traumatic injury. With the assistance of Dr. Gary Friedlaender, the Wayne O. Southwick Professor of Orthopedics and Rehabilitation, they concluded his injuries were the result of a severe burn.
“It’s almost like being Sherlock Holmes,” Bolognia said. “You need to find every clue you can within the paintings.”
Braverman has pioneered the use of artwork in Yale’s collections to support medical education. He developed a class at the Yale Center for British Art with Linda Friedlaender, the center’s senior curator of education, in which medical students hone their observational skills by studying works, such as landscapes and portraits, in the center’s collections that are not medically related. The program has been replicated at medical schools across the country.
At the start of the session, he pointed out that the patients in Lam Qua’s portraits were suffering severe pathologies, such as immense and disfiguring tumors. People in the 19th century through the mid-20th century would allow a disease to run its course before seeing a doctor, while patients today tend to seek medical care early on when signs and symptoms are subtle, he explained.
The young girl with the gangrenous feet was the sole patient among the nine presented whose diagnosis was described in detail in the historical records. Some of Parker’s patients were easier to diagnose than others. The physicians and residents quickly agreed that a woman with a large, gruesome tumor on her left breast was suffering from terminal breast cancer. Other patients, including the man with the severe abdominal tumor, triggered discussions that continued after the session had ended.
The 86 portraits in the library’s collection feature 80 patients. A few patients are depicted twice, before and after surgery. The Grand Rounds included one “before and after” pair featuring a man with a tumor on his upper lip. The post-surgery portrait demonstrates a marked improvement in the gentleman’s appearance.
Lam Qua, who operated a major studio in Canton, was the third generation of a family of artists who made Western-style paintings — portraits, port scenes, landscapes, miniatures — for export and a western audience, said Wheeler, who provided background about the collection at the start of the Grand Rounds discussion.
“During the time he collaborated with Peter Parker, Lam Qua was the best known of the Cantonese commercial painters. It is often quoted that Lam Qua created the portraits pro bono because Parker’s hospital provided free medical care,” said Wheeler.
Parker displayed the paintings in the hospital’s entrance corridor, which doubled as a waiting room, she said.
“The portraits, particularly the ‘before and after’ pairs, illustrated the seemingly miraculous cures the hospital could achieve,” she said.
When Parker returned to the United States in 1840 at the outbreak of the First Opium War, he brought Lam Qua’s paintings with him. He exhibited them at fundraising events in major American and European cities and met with prominent political leaders, such as Daniel Webster, Henry Clay, and President Martin Van Buren, Wheeler said. Parker returned to Canton in 1842 and reopened the hospital.
Parker’s collection of paintings was bequeathed to Yale and, in 1899, delivered to the Department of Pathology. In the early 1970s they were transferred to the medical library. Today, the Lam Qua paintings of Peter Parker’s patients is one of the library’s most studied collections, according to Wheeler.
“The paintings are actively used in teaching both undergraduates and graduate students,” she said. “The collection draws researchers from all over the world, who study the paintings from the standpoint of medical history, art history, bioethics and religion.”
Dr. Sara Perkins, a dermatology resident who participated in the Grand Rounds, said studying paintings is good training for capturing every detail, including those on the periphery.
“It trains us to not miss anything,” she said. “You translate that to a patient, who comes in to the hospital complaining about a spot on her hand, and you don’t forget to examine her beyond that specific complaint.”
Eisenstein, who had examined the portrait of the child with the gangrenous feet, said she was not surprised to learn the injury was caused by foot binding — one of the other physicians had suggested the possibility to her. She noted that this was one of the benefits of working with the portraits.
“Exercises like this are important because it makes us think outside of the box,” she said.