To see inside

Scanning electron micrograph of a Perkinje nerve cell in a rat brain by Prof. M Hausser, Sarah Rieubland and Arnd Roth (UCL) Confocal micrograph using fluorescent dyes, showing medicine microparticle delivery in a mouse lung, by Gregory Szeto, Adelaide Tovar and Jeffrey Wyckoff (Koch Inst/MIT). "Creativity is part of any imaging process. There’s a big push for striking visuals to convey the power and beauty of science," says Szeto Photograph of 3D printed lungs in a ribcage. The image was created by multimedia artist Dave Farnham for a friend who was undergoing chemotherapy. Farnham says his aim was to create "something beautiful and tangible" for her, using CT scans and other medical images Clinical photograph showing curvature of the spine in a 79-year-old patient, by Mark Bartley, (Cambridge University Hospitals NHS Foundation Trust) Microscopic image of colour-coded metabolic reactions in the cells a mouse kidney by Jefferson Brown, Robert Marc, Bryan Jones, Glen Prusky and Nazia Alam. Marc commented how "beauty is truth" in images where we wonder at the accomplishment of what is revealed Photograph of the honeycomb-patterned interior of a goat stomach chamber, a specimin at the Royal Veterinary College, by Michael Frank Transmission electron micrographs create a colour-coded map of part of the nervous system, in this Jackson Polleck-esque image by Albert Cardona (HHMI Janelia Research Campus, Virgina, USA)

Medical imaging and illustration provide a rich visual rhetoric to help us understand health, life, and, ultimately, death. Prior to the development of imaging and its surrounding technology, doctors had to diagnose patients without being able to look inside their bodies at all. Occasionally, exploratory procedures may have been used but, pre-anaesthetic, they were both risky and excruciatingly painful. Imaging techniques have since changed medical practice so fundamentally that they are now seen as an indispensable part of contemporary medical practice.

Medical imaging is a particularly interdisciplinary field. Many of the techniques use concepts from mathematics, physics, statistics, engineering, biology, and medicine. The media used range from photography to MRI scans, super-resolution microscopy to hand-drawn illustration, x-ray to 3D modelling and more.

Since 1997, the Wellcome Image Awards have helped champion the best new images in biomedical science and contemporary healthcare. These images now form a comprehensive collection to complement the historical images held in the Wellcome Library, part of the Wellcome Trust, a global charitable foundation for human and animal health. Any image submitted to the Library is eligible and anyone is allowed to enter.

Images must be intriguing, spark imagination, and bring a level of understanding of the beauty and the fascination of science to the general public. “We are judging them on their impact and ability to tell a story, then on the technical quality in terms of the medium in which they are created,” says Catherine Draycott, head of Wellcome Images and a member of the judging panel. “So its ability to convey content in a way that will, a, attract the eye to draw someone in, and, b, prompt people to ask ‘what is this?’ because a lot of them aren’t self explanatory. You have to read the caption, even if you’re a scientist in many cases.”

“We are looking for something which is visually compelling, but we also value originality highly,” says James Cutmore, another judge, and picture editor of BBC Focus science and technology magazine. “We are looking for something that piques our interest, but can sustain it once we know the processes involved in capturing the image.”

Cutmore remarks on the high quality and depth of images produced by ever more advanced imaging technology, which impacts on the education of new generations of medical students. However, he also says that, “the most interesting medical images have been produced when creativity is also a concern”. For instance, this could be when false colour is added in post to help clarify an otherwise black-and-white image, which is largely the case with microscopy. In other images, fluorescent chemicals are added to the specimen itself, marking out particular elements within tissue.

Awards entries include an array of innovative imaging techniques from a diverse selection of artists and research professionals. “The technical attributes of each technique are very different, so we have to apply different rules,” Draycott explains. “When you are trying to compare something, a very creative image like photography or illustration is very different to something that somebody has created by mounting a specimen on a microscopic stage and scanning the surface with a SEM [scanning electron micrograph], where the creativity comes in the selection of the sample, the way it’s imaged, and the composition.”

Draycott acknowledges a certain scientific novelty around being able to see more than we could see before, with greater magnification and higher resolutions, fuelling desire “to find out more, to discover more, to reveal more, and communicate more”, she says. However, applications of these images now have potential beyond simple diagnosis and education, to improving therapies and treatments, as artists and scientists collaborate in new ways. For instance, the Wellcome funded a project recently that brought together plastic surgeons working on reconstructive surgery with artists who were able to work with patients and their self-perception, to put together the facial features they felt were most familiar.

This year’s overall winner was artist Michael Frank for his photograph of a pregnant pony uterus, a specimen from the Royal Veterinary College, with the jar and fluids carefully removed in post. “I was completely fascinated by these [specimen] pots that seemed to be like an open window on creation. When you remove the entanglement of surrounding tissue and fat, you are left with something so pure and delicately artistic,” he says. “My aim was to take these pots from the museum shelves, remove the package (digitally, you can’t open them) and through careful lighting, elevate them to a piece of art. There is a beauty within that shows how complex and frail we are, yet also the most amazing and perfect ‘machinery’ ever created.”

Although fine art photographs, the images give students and the general public access to artefacts that would otherwise remain largely unseen, and his work also allows for far greater creativity than traditional clinical photographers. “When dealing with such surreal and unusual images there is a certain creative freedom. There is no conventional approach to post-production and you have to think of new ways of bringing out the best of the image. How to get the lighting right to reflect the delicacy of the membrane for example,” he says.

“Medical photography is both science and art,” remarks another of this year’s winners, clinical photographer Mark Bartley. His image depicts curvature of the spine in a 79-year-old female patient, created as part of the consultant’s documentation of the condition. In this case, a little extra creativity led to both a more striking and more informative image. “The main light was set at an oblique angle to allow shadows to form, helping doctors to see the profile of the spine. It was my intention to avoid showing the patient’s face and show only the back to preserve her dignity.” Bartley explains. “Creativity often takes a backseat in medical photography as our primary goal is to provide a realistic likeness of a subject – there are often set protocols we follow to ensure we get standardised images that doctors use to evaluate patients. However, on occasions like this, by also taking more creative shots there is an added dimension that may help their decision making.”

But as Draycott goes on to suggest, there are still obstacles to the successful collaboration between science and art – often still considered to be at opposite ends of the human spectrum of understanding. Artists from the Renaissance onwards have aided our understanding of anatomy, but the medical profession is now often far more cautious, and artists no longer have access to dissecting rooms. “I think they had problems with some artists abusing their position. There’s a lack of communication and a lack of understanding. It seems fundamental to me that artists would study the human body and not just scientists,” she says. “You’ve only got to look at a photo of a body being dissected and then look at a Renaissance illustration and tell me which is clearest, which one shows the muscles better.”

Imaging comes with a variety of challenges and ethical problems itself. There are benefits to sharing research between clinicians online, as Draycott suggests: “One of the biggest trends in science since it’s been possible to communicate better with the internet, has been the extent to which collaboration can facilitate the speed of discovery.” However, she is acutely aware of the privacy issues that can arise, particularly when it comes to a lack of funding leading to clinicians taking images themselves. “The ethical dangers of doing that are just huge. You can’t just store them on the cloud,” she says. “You just don’t know what the consequences are when you put something out there, you can’t predict or control what will happen to it,” she continues.

The context in which images are seen is also important. The library was approached for images not long ago by TV programme Embarrassing Bodies, and although Draycott initially declined, after watching an episode she discovered its usefulness as public health information, and agreed for Wellcome images to be used.

Some of the appeal of this imagery lies in our enduring fascination and curiosity around seeing the unseen. Take the hugely popular but controversial example of Gunther Von Hagen’s Body Worlds, an exhibition of real human bodies preserved using his technique of ‘plastination’, for example. Body Worlds could be seen as a very literal, physical, modern translation of Renaissance anatomical drawings, such as the flayed man.

Von Hagen has been criticised for the macabre, invasive nature of his work, but some screening techniques allow us to look inside the body without any contact whatsoever. Draycott says these techniques have potential for forensic use. “In a murder inquiry you can almost certainly, depending on how someone died, find out a lot about the cause of death without even touching a body. And that’s really valuable because as soon as you start touching a body you are disrupting things. As soon as you make an incision you let out all the air bubbles which can apparently tell you a lot about the way somebody died.” There are benefits for living patients too. “Quite often with the techniques improving as they are, when you are imaging a live patient you can find things you weren’t even looking for, and at a much earlier stage,” she says.

However, this type of screening throws up a whole new set of issues. Professor Anders Persson, winner of last year’s awards and pioneer of medical imaging, considered some of these concerns in a provocative Royal Photographic Society Combined Royal Colleges Lecture last year. “He said that there is a danger with this type of screening,” Draycott recalls. “It has to be managed somehow, because, a, can we afford to do all the screening? B, who gets the screening and when? And, c, if we find ten times [as many problems], can we afford to treat them all? It’s scary. There are implications – are we now seeing more than we want to see?”

The Wellcome Image Awards 2015 will be exhibited around the UK and US,