Sutures in Ancient Surgery: differing historical perspectives

Duffin and Li in their medical historical study of the highly successful Great Moments ad campaign mounted by the pharmaceutical company Parke, Davis in the 1950s and 1960s addressed Hiller's Sutures in passing, dismissing this work as ‘dated-looking, elaborated posed photographs … that now seem to have been selected to provide medico-historical pretext for depicting the female breast’ with such depicting ‘nude or seminude young women, most in the bloom of health despite being victims of bubonic plague or dissection’.Footnote ⁸ But such an assessment is normative and restrictive. First, Sutures preceded by several decades the Great Moments ad campaign; indeed, it probably inspired it. Secondly, these historians charge Hiller with ‘flagrant transgressions of verisimilitude’ in his depictions, but the same could be said of the wooden and contrived, painted imagined images of the Parke, Davis series. And if the former can be charged with being sexist by today's standards, the latter has been deemed to exhibit medical violence towards women and to be racist.Footnote ⁹ That said, Hiller might be deemed racist too. In the tableaux of the Aztec empire and ‘South American natives’, both of which are dated 1936, we are told that the Aztecs observed good wound hygiene, used human hair to suture and could splint fractures effectively. The accompanying image shows three men in ceremonial costumes with elaborately plumed headdresses who, presumably, were physicians tending to a male patient. Sitting beside the patient is a woman in a skirt who is also wearing a wide necklace that partially conceals her breasts (Figure 1). The latter tableau has three men dressed in loin cloths, along with two women wearing only grass skirts tied around their waists. One of the women is the patient and is lying on the ground; a hut made from palm leaves is in the background. This indeterminate group of ‘South American natives’ was known for its use of a species of ant with ‘tenaculum-like jaws’ that aided in wound closure. ‘A row of these ants heads and lo! – they have Nature's challenge to the modern skin clip’ the copy read (Figure 2). Perhaps the main issue with these tableaux is less that of their portrayal of women's bodies, as their overall (mis)representation or stereotyping of ‘other’ ethnic cultures or civilisations. For ill or not, Hiller's portrayals of ‘natives’ and/or non-whites was not inconsistent with pictorial representations of the day, as the pages of National Geographic magazine illustrated with respect to indigenous peoples across the globe.Footnote ¹⁰

Figure 1. This 1936 tableau by Hiller was explained by noting that Aztec physicians were important in the empire, but ‘their practice contained some mysticism’.

Figure 2. This Hiller tableau of 1936 portrayed an indeterminate group of ‘South American natives’ that was known to use a species of ant with ‘tenaculum-like jaws’ to aid in wound closure.

Thirdly, referring to Sutures as ‘dated-looking’ wholly misses the point. Rather, as I shall explain, the images are emblematic of their period yet have also had lasting popular appeal. In comparison, the style of the Great Moments series has been derisively dismissed as the artwork did ‘not always carry entire conviction; the women look undeviatingly 20th Century Fox [sic] whether they be Babylonian, Greco-Roman or lunatic’ – a reference to the garish Hollywood historical film epics of the early 1960s.Footnote ¹¹ Finally, that women appearing to be in the ‘bloom of health’ were cast in the role of cadavers for dissection situates Hiller within a long-standing art/anatomical tradition. Eighteenth-century life-size wax figurines of women that could be displayed and disassembled (disembowelled) for instruction were beautiful in form and seductive in appearance.Footnote ¹² While disturbing, this concatenation of contexts shows that the oeuvre of Hiller had its artistic antecedents.

More probative is Bert Hansen's discussion of Sutures, medical history and art photography.Footnote ¹³ Overall, Hansen is appreciative of Hiller's Sutures series by contextualising it within the histories of art and medicine. Along with a nod to changing advertising techniques, Hansen ensures that his readers and any viewers of Hiller's works understand and appreciate them. A recurring theme of his discussion is the issue of female nudity in Sutures. ‘As I have learned from conversations with colleagues’,’ Hansen writes, ‘many of us in the field today find their images slightly creepy, whether for excess female nudity and simulated violence or because photography did not exist in the eras they would seem to record.’Footnote ¹⁴ Indeed, Hansen revealed that one of his anonymous journal peer reviewers ‘suggested that I consider labelling these surgical photographs “doctor porn.”’ Although not concurring with that evaluation, Hansen conceded that ‘Hiller's images surely resonated with the unquestioned superiority of male surgeons over their female patients, and the visual possession of their bodies, whether in staged photographs or in the actual examining rooms and lecture halls.’Footnote ¹⁵ Yet Hansen concludes rightly that Hiller's nude figures ‘were neither needless nor inappropriate, nor were they present simply because he liked it that way. They were no idiosyncratic whim, but an explicit sign that the photographs he was creating were not documents or illustrations; they were works of art.’Footnote ¹⁶

Drawing from Hiller's archive preserved in Rochester's Visual Studies Workshop (VSW), Doug Manchee demonstrates how well-trained, innovative, talented and exacting Hiller was an artist, designer and photographer. And, owing to its extensive and lavish use of illustrations that includes photographs of Hiller's finished work, candid and staged shots of him actually at work, and previously unpublished reproductions of his preliminary planning artwork, the book is also valuable as a primary historical source. Regarding the elaborate advertising commission for DG sutures, Manchee concludes that it ‘remains a pioneering advertising campaign. That it ran for nearly twenty-five years attests to its effectiveness as a selling tool for the client. And its over-the-top theatricality in combination with remarkable production values established its importance in the history of American photographic illustration.’Footnote ¹⁷ Such a positive evaluation of Hiller's contributions serves as a springboard for my analysis.

Manchee's remarks on the use of nude female models is apposite. He is aware that some of Hiller's Sutures series have raised controversy, quoting scholars of advertising, business and photography history as saying, respectively, that the Sutures series was ‘merely an exercise in sexual titillation’, consisting of ‘semi-pornographic images masquerading as art’, and how Hiller was ‘best known for his humorous and slightly erotic ad campaign, now considered sexist’. For Manchee it is ‘irrefutable’ that Hiller ‘cast young and attractive members (of both sexes) to model’ in the series, but such an advertising tactic dated back to the nineteenth century. Moreover, such critical comments ‘weaken’ when the whole series of almost ninety images is considered. In Manchee's estimation only about fifteen of the series depict women unclothed (in varying degrees); of these by his undefined standards, ‘perhaps half could be seen as having erotic overtones’.Footnote ¹⁸ If Hiller was ‘guilty of anything, it may have been of naiveté’, for he had sketched nudes from his early student days and perhaps failed to appreciate the difference in viewers’ reactions to a drawn figure from a photographic one. In any case, in Manchee's opinion, ‘by the time a serious dialogue began regarding the portrayal of women in advertising imagery, Hiller had been out of the industry for more than twenty years’. If Hiller himself is to be believed, he was nonchalant about such matters. In an undated interview with a reporter who observed male and female models in various states of undress in his studio, Hiller stated that he employed a matron and that ‘we are so used or seeing the human figure in the altogether that we look upon it much as a medical man looks at his patient – entirely impersonally. We are only concerned in line and form’Footnote ¹⁹ But, as will be discussed, not all those who viewed the product of Hiller's ‘line and form’ did so ‘as a medical man … entirely impersonally’.’ Indeed, the juxtaposition of the concepts of medical men, patients and female nudes was and remains problematical.

The artist and his medium: Lejaren à Hiller (1880–1969)

John Arthur Hiller, born in Milwaukee, Wisconsin in 1880, planned to be an artist when from the age of 15 so he began art and printing apprenticeships in his home town where he assisted in the design and production of various advertising and promotional printed material. In 1900 he studied at the School of the Chicago Art Institute, where he trained in classical fine arts and commercial art. Hiller's extracurricular activities centred on theatrical stage design and lighting techniques for school productions; he also acquired skills in photography: shooting personal portraits, groups and artist's models, many of which he was able to sell. Art Institute personnel also encouraged an understanding of photography as an art form, while they also sponsored exhibitions featuring notable photographers such as Alfred Stieglitz. As Doug Manchee concludes, upon completion of Hiller's training in 1904 he was already ‘experimenting’ with techniques and effects that would become his future hallmarks, such as the use of soft-focus lenses and hand-painting on photographic prints. For the next three years Hiller worked as peripatetic commercial artist and photographer across the United States and elsewhere, but in 1907 he settled permanently in New York City. In this period John A. Hiller underwent frenchification (he had travelled in Europe and spent considerable time sketching in the bohemian sections and nightclubs of Paris) and officially styled himself as Lejaren à Hiller, presumably based on his family nickname of Jaren. Initially, Hiller freelanced as a commercial illustrator and produced drawings that appeared as magazine covers in Cosmopolitan and Harper's Bazaar. Around 1913 he adopted photography as his preferred medium and secured a contract to illustrate a short story in a magazine. These illustrations were highly original in both style and construction, for Hiller superimposed a staged studio photograph of a man and a woman who portrayed characters in the story on another photograph of an outdoors street scene that also pertained to the magazine storyline. The resultant composite image was further enhanced by a chiaroscuro effect to make it dark, moody and dramatic.Footnote ²⁰ The process of combination printing as it was called had been devised in the nineteenth century by two photographers in England, although Hiller's use of the process created a novel and original genre of commercial illustration, which was immediately appreciated by readers and publishers alike.Footnote ²¹ Hiller then quickly became successful as a photographic artist-illustrator.

Interviews conducted by the New York Times in 1918, based mainly on the words of his then business partner and fellow artist-illustrator, Henry Guy Fangel (1875–1945), relayed how the ‘idea of illustrating fiction with photographs for which models are posed under expert stage management to represent the story's characters … is attracting the attention of publishers and editors’. Fangel further explained: ‘We study the composition of the photograph as an artist would plan the composition of a drawing. We give special and careful attention to lighting, and we work often like stage directors to get the right expression on a model.’ The use of models was critical; a card-index of over 3,000 men and women was maintained, which included movie and stage actors, along with many ordinary ‘working girls and men’. A scout sought suitable ‘original’ characters for assignments, for example ‘real east side tradesmen, real farmers from the high grass’.Footnote ²² Hiller's eccentricity and sense of theatre developed, as did his success. In 1939, he was described as ‘dean of American illustrative photographers’ and perhaps the highest-paid illustrator in the United States. Hiller's three-storey studio consisted in part of Mayan ruins, igloos, totem poles, pyramids and the occasional camel; his personal New York City house was also part menagerie, part museum. Sharing this lifestyle was Hiller's wife, Anita Plummer, who had modelled for him and was a Ziegfeld Follies dancer, and whom he described as having ‘the craziest notions’.Footnote ²³

Hiller's commercial innovation: tableaux vivants and the pictorialist ‘social tableaux’

Hiller had retired by the early 1950s and died in 1969, his work mostly forgotten. But in the mid-1980s his work underwent a revival when the VSW curated an exhibition consisting of about sixty of his works, which it and the Rochester Institute of Technology had rescued and preserved. The exhibition and its catalogue highlighted his career through his novel technical achievements, in particular his trademark style of creating the ‘entire photograph’ using exotic sets, his directing of human models and his supervision of the photographic production process. All of this work resulted in ‘elegantly pre-visualised images’. The exhibit's curator declared that ‘anyone with interest in the evolution of photographic illustration in America or in the production of fictive images will appreciate Hiller's seminal and long-term influence on this genre’.Footnote ²⁴

Photography historian and New York Times writer/critic Gene Thornton further explicated Hiller's important place in and contribution to commercial photographic illustration. The works of Hiller, ‘one of the forgotten masters’ of twentieth-century photography, were ‘so well known in the magazine-reading public of the 1920's, 30's, and 40's, that they will undoubtedly be remembered by middle-aged and elderly visitors’ to the exhibit. Thornton highlighted Hiller's use of tableaux vivants, while using dramatic lighting and unusual camera angles; he maintained that ‘By and large … Hiller's constructed tableaux are still remarkably convincing even when seen in the large original prints of the exhibition rather than the smaller half-tone reproductions for which they were intended.’Footnote ²⁵ Thus far from being ‘dated-looking’ as Duffin and Li opined, Hiller's tableaux were still clearly considered remarkably current.

The aesthetics of Hiller's work notwithstanding, the use of tableaux vivants, as Thornton also identified, was to sell products, for Hiller increasingly moved from illustrating stories in magazines to creating arresting images for advertisers. In this regard, Roland Marchand has coined the term ‘social tableaux’, which he derived from tableaux vivants, the photographic components of ads that began to appear in the 1920s. Typically, they depict a person or group of people in a scenario that produces an emotional response in the viewer, even if any accompanying text or copy is not read. There is a story or feeling imbedded or implied in the photograph that engages the viewer. Visual clichés that evoked family values, comfort, security or social identity were common. Owing to the universality of this emotive advertising approach ever since, its novelty may now not be fully appreciated. In contrast before about 1920, ads were mostly text-based (perhaps with a simple graphic of the product) and were grounded in logic and facts: the appeal to the reader was to be mostly rational rather than emotional.Footnote ²⁶

An important point to underscore in this context is that the employment of tableaux vivants was a long-standing tradition in amateur and professional theatre, then photography and other visual arts. Recreation of historic, literary or classical Greek scenes along with great works of art would be staged by actors in costume, who did not move as they posed in their assigned roles; some tableaux were staged with large frames around them and gauze in front to simulate paint varnish. A special form of tableau was the pose plastique, which typically consisted of nude women draped in diaphanous veils – erotic but publicly acceptable as the women were stationary and deemed to be artistic.Footnote ²⁷ As Lori Pauli makes clear, ‘theatricality’ should be recognised as a photographic feature as much as it has been in painting and sculpture. With this in mind, the themes of ‘actor’, ‘artist’ and ‘storyteller’ ought to be considered in the interpretation of staged photographs aka tableaux vivants or social tableaux.Footnote ²⁸ Hiller's novelty very much rested on his imaginative and creative adherence to the importance of these themes, in particular his skills respecting mise en scène, or setting the stage – something he had honed from his extensive experience with previous projects in several visual media.

The ‘new’ advertising with its focus on the use of social tableaux saw the rapid ascendancy of illustrative photographs to sell products. Lejaren à Hiller now was poised to exploit this trend commercially, if not drive it. His experience as a magazine illustrator, his use of innovative photographic techniques, and his understanding of how tableaux vivants were created and staged, and how the models in them needed to be directed, all played to his advantage. Hiller, as Elspeth Brown notes, was fundamentally pictorialist in style. She further explains how adherents of this early twentieth-century popular movement believed that the camera and photography were artists’ tools that could be used to break away from the ‘tyranny of fact’. Furthermore, the ‘preference for classical tableaux … pushed the camera image beyond the mechanical recording of social fact to express intimacy, ecstasy, ambiguity, and revelation’. One major outcome of this was the blurring of boundaries and motives: ‘[T]he line between fiction and advertising, between the material and the nonmaterial worlds, were growing profitably indistinct’, again according to Brown.Footnote ²⁹ Hiller was cognisant of the changing times and his role in them. Writing in 1920 in Printer's Ink Monthly, he expressed what might be tantamount to a manifesto:

Three other major projects undertaken by Hiller reinforced his skill in the creation and construction of tableaux. In the 1915 photopoetry book Bypaths in Arcady, Hiller undertook the accompanying original photographs. In this genre, text and image equally complement and explain each other, but by all accounts, Hiller's illustrations overpowered the verses. One commentary notes that his ‘lush photogravures act almost as stills from pantomimic performances and, in their sparing use of costume, are risqué in their representation of partially nude male and female figures’.Footnote ³¹ Next, Hiller ventured into cinema when from 1920 to 1922 he created five silent films, four of which have survived; he was their art director and, on occasion, cameraman. Film archivist and historian D. J. Turner concludes that while the surviving films were ‘consciously artistic or “arty”’ they were also ‘somewhat slow and sentimental’. More importantly, they were ‘of a high professional and artistic standard and drew praise for their photographic and plastic qualities’, for which Hiller was duly credited.Footnote ³² While the fifth film remains lost, a series of about forty black and white and hand-coloured stills have survived, which ‘bear elegant witness to Hiller's mastery of decoration and composition as well as his treatment of the then-popular subject of Orientalism depicted in the film’.Footnote ³³ Underscoring Hiller's skills, most of these films were structured around a similar narrative that illustrated how a famous painting was created by its artist, allowing Hiller to design and construct numerous historical tableaux in his studio, which would then become scenes in the film. In effect, his ‘movies’ may best be understood as a series of ‘stills’ (tableaux vivants) connected in a logical sequence (à la Peter Greenaway sixty years on). Understanding this technique helps explain the appeal of his later advertising campaign such as the Sutures series.

Hiller's distinctive style permeated Time Telling Through the Ages. This book, sponsored by the Ingersoll watch company to celebrate its twenty-fifth anniversary, appeared in 1919. Each chapter described a mode of telling time in a particular era. The accompanying photographs by Hiller consisted of painted backdrops, live models in period costume, miniature models and full-size objects, which he designed and arranged, sometimes with these elements superimposed on each other. Although Hiller was not officially credited on the book's title page, the author's preface noted that the ‘photographic compositions are the result of the enthusiasm, the understanding and the art’ of Hiller; each image also bore his signature. Time Telling Through the Ages was not an advertising commission per se, but it clearly was a promotional package for the Ingersoll company.Footnote ³⁴ By the early 1920s, Hiller's repertoire of artistic techniques – set design, properties construction, book illustration, special effects photography, historical interpretation, direction of live models (including nudes) and advertising knowledge – was comprehensive, if not unique in the business. In 1925 he joined Underwood & Underwood of New York City as its corporate vice president.Footnote ³⁵ Beginning in the late nineteenth century, this company made its name by making and selling dramatic stereographic photographs of the wonders of the world, along with narrative tales.Footnote ³⁶ That the New York City company of Davis & Geck would approach Hiller to undertake a wholly new advertising campaign to promote its line of surgical sutures is logical.

Davis & Geck and its Sutures in Ancient Surgery series

Charles T. Davis and Fred A. Geck founded their company in 1909 in New York City, which would become the second largest manufacturer of surgical sutures. The success of the company owed much to its mass production of sterilised, pre-packaged sutures with needles attached, all of which were contained in hermetically sealed glass tubes. Doctors and hospitals found these innovations convenient to use, along with being time- and cost-saving. In 1930 the company was sold to the American Cyanamid Corporation conglomerate.Footnote ³⁷ The ads of 1916, when DG patented and began promoting its brand of sutures, imitated the format and fonts of silent move subtitles. They were excessively text-heavy with a detailed description of the science and technology behind the product as an ad from The Modern Hospital of April 1916 illustrated (Figure 3). Later ads just prior to the release of the Sutures series remained text-based, were fact- and figure-laden, and geared to appeal to a logical not an emotional response from potential buyers. Copy consisted of item catalogue numbers, product description and size, cost and ordering information, and a brief account of manufacturing processes and an explanation of technical terms employed; any illustrations used were limited to line drawings of the actual product and graphs or charts. Ad captions aimed to persuade were direct, informative, and blandly descriptive: ‘A wholesale discount of 25% is accorded hospitals and surgeons on any quantity of sutures down to one gross’ (Figure 4).Footnote ³⁸ Or they might incorporate a simple graphic (Figure 5). The contrast with the planned Sutures campaign could not be more striking. Within the style and mentalité of advertising of the late 1920s, the marketing strategy of Sutures, with its use of tableaux vivants and social tableaux, is noteworthy. In its images, Hiller's notion of luxuries of the mind and of the body abounded. Replacing the recitation of dry facts about heat sterilised surgical sutures were new ads which featured one of Hiller's arresting photographic tableaux accompanied by a brief essay caption explaining the scene that also would allude in some way to suturing techniques or ligatures in the era depicted. A stylised logo for ‘D&G Sutures’ along with the tag line ‘THEY ARE HEAT STERILIZED’ rounded out the formulaic layout.

Figure 3. A 1916 ad from The Modern Hospital for DG sutures illustrating the initial text-heavy format.

Figure 4. Later ads dating from 1922 remained text-based, were fact- and figure-laden, and geared to appeal to a logical not an emotional response from potential buyers.

Figure 5. Occasionally a simple graphic might have been used in DG ads as this one from The Modern Hospital of 1922 illustrates.

Hiller's artistic photographs are central to the Sutures series, but they became more meaningful through the accompanying historical vignettes. Hiller may have been artistically gifted, but he was obviously not a medical historian. Who, then, was responsible for the ideas and accompanying text? Robert E. Skinner has identified that the key person was Dr Samuel Clark Harvey, a claim based on information provided to him by Charles T. Riall.Footnote ³⁹ Riall, a long-standing DG employee, was involved in the physical production of Sutures; he would become head of advertising at DG, then director of company professional relations.Footnote ⁴⁰ Samuel Clark Harvey (1886–1953) was a surgeon and a scholar. After graduation from Yale Medical School in 1907, he became a member of its department of surgery in 1919; Harvey also edited the Yale Journal of Biology and Medicine. His interest in medical history was long-standing.Footnote ⁴¹

Sutures had the financial backing of an established company; Hiller's creativity was indisputable; changed attitudes and styles of advertising bode well for it; and the consultancy of someone highly connected with, and respected in, American surgery who also had a recognised penchant for medical history was an additional bonus. Further boosting the project was the apparent attention to technical detail in production. To highlight his set designs and the use of theatrical properties, Hiller used long lenses on his cameras to make the ‘spectator feel that he is actually in the picture and transmits a feeling of sympathy with and for the characters’. Hiller's use of ‘simple, dramatic lighting’ was also crucial to create the right effect.Footnote ⁴² He apparently eschewed electronic or any other type of flash lighting, which further added to his skill in lighting.Footnote ⁴³ Using such flexible fill-in lighting also allowed Hiller to have his medical historical art imitate or gesture to other medical historical art. Most notable was his rendition of Joseph Lister of antiseptic/aseptic surgery fame in which Hiller had the British Victorian surgeon bathed in the light from a period lamp angled towards him. The resultant image resonated with Sir Luke Fildes's Victorian painting of The Doctor, reproductions of which were ubiquitous. Charles Riall's recollections are again useful here. In 1997 when he was 83 years old, Riall described the intricate photogravure (and halftone) production process:

Examples of the engraved plates themselves, along with the resultant ads, are available to view online. Both reveal how the format of the Sutures ads during the 1930s were wholly in contrast to early company promotions: the image of the staged tableau is central and dominant, with the accompanying historical text underneath it and to left of centre. To the bottom right of the ad still appears the phrase ‘D & G Sutures’, but now along with the new slogan or tag line of ‘THIS ONE THING WE DO’.Footnote ⁴⁵ Other configurations and layout designs were also used, perhaps around 1940.Footnote ⁴⁶

Riall also compiled an inventory of the almost 100 images that comprised the Sutures project. In sum, the scenes depicted and their text constituted an encyclopaedic survey of medical history ranging from prehistoric times, classical Greece and Rome, the Middle Ages, and through to the nineteenth century; nothing is featured from the twentieth century. Typically, great medical men who hailed from eastern and western traditions were portrayed: Albucasis, Avicenna, Celsus, Fallopius, Fabricius, Galen, Harvey, Hunter, Rhazes and Vesalius, for example, all take a bow. And the great moments in medicine associated with these names were explained within their respective fields of anatomy, physiology, pathology and medical practice. Occasionally, ads might address medicine with respect to different cultures in a past era such those of the Aztec empire, Egypt and India. The place of women in Sutures will be explored more below, but suffice it to say for the moment that only Dame Trotula (an eleventh-century woman to whom is attributed one of the earliest textbooks on gynaecology) appeared as a central, identified medical character in these advertising tableaux. The Whiggish historiographical bias of Sutures towards great, dead (and mostly white) men, and their good deeds, along with a message of the progress of medicine and surgery may not resonate with today's tenets of medical history, but it fully reflected the aims, approach and standards of the period.

Understanding Sutures within the academic milieu of history of medicine of the late 1920s and early 1930s, especially in America, allows it to be judged as more than a curiosity, a commercial ad campaign promoting a particular product, or archival ephemera. History of medicine at this time was not an historical field; rather, it was a subfield of medicine: it was supported not by scholars per se, but by practising doctors who were devotees and amateurs in the truest sense, and who wrote about the inexorable rise and triumph of scientific medicine. Yale's Dr Harvey as Sutures’ consultant was a good example. Critical organisational activities in the history of medicine also occurred at this time. In 1925 a small group of physicians formed the American Section of the International Society for the History of Medicine; in 1928 the group reorganised as the independent American Association of the History of Medicine.Footnote ⁴⁷

The years around the appearance of Sutures were a heyday for medical history, seeing the publication of many tomes of encyclopaedic length and style, which were typically authored by physicians.Footnote ⁴⁸ Might these books might have been sources of material for Sutures? Their sweeping nature would have allowed Samuel Harvey to select topics for inclusion; certainly the content of both the books and the ad campaign vignettes overlapped. As historian Bert Hansen reasonably believes, Garrison's Introduction to the History of Medicine was a regular go-to source.Footnote ⁴⁹ Hiller himself once wrote that it took ‘considerable rummaging through old medical and historical books to find out the sort of clothes he [the surgeon subject] wore, his surgical tools, the furnishings of the time, little idiosyncrasies of the, man, how he looked, operating methods of the period, and so on’.Footnote ⁵⁰ More important, however, was the overlapping of the explicit messaging to the medical profession contained in the two media. Medicine around 1930 represented the new, the advanced and the modern as epitomised in a new generation of sophisticated technological hospital complexes and medical schools with both institutions grounded in laboratory science, but along with this came a realisation that it had a history which was cast not just as the past but as the primitive.Footnote ⁵¹ In this context it can be more readily understood why the phrase ‘ancient surgery’ was used in the series title even though it depicted events up to the nineteenth century.

This period around 1930 remains remarkable. Thus an additional reason to appreciate Sutures was not only that it contributed to this first wave of medical history by introducing medicine's history to its practitioners, but that it could also symbiotically ride its crest for commercial purposes. The take-home message for doctors viewing these ads, whether they consciously realised it or not, was that they were modern, so were DG sutures, along with the whole enterprise of medicine, which was now a pillar of modern civilisation. A concluding passage in Haggard's 1929 study of the history of medicine underscored that primitivism, progress, civilisation and medicine were interconnected, but he warned that:

The notion that progressive times could easily regress to a more primitive era when people are inattentive suggests how the Sutures images may be viewed or interpreted as allegories. The use of light and darkness in many of the images invokes a sense of good and evil, as also those that have religious characters or symbolism. Thus in many there are implied binary opposites that are in tension with each other such as, it can be argued, the progressive and the primitive. The typical viewer of Sutures – medical doctors – represented the progressive and the scientific, while what was portrayed, even when the scene was a ‘great moment in medicine’, was the primitive. Hiller's elaborative use of costume and props ensured that the scene was distinctly disconnected from the modern present. Yet his use of real people whom we know little about personally, except that they ranged from ‘derelicts, to actors, to high-priced models … [and] students of a nature dancing school’,Footnote ⁵³ suggested the constancy of humanity in Hiller's photographic time travels. Here was the new advertising in full gear using emotion, not logic, to connect and appeal. But did this approach sell more sutures? In the absence of annual sales figures this question remains unanswerable. In a way, however, it is irrelevant. Even if the money spent of Sutures did not result in a spike in the sales of products, it was not wasted. The Sutures campaign was as much about public relations as anything to make clear that DG was corporately friendly to the medical enterprise (regardless of any self-interest); in some ways it may be likened to a Big Pharma company today giving a goodwill unconditional donation to a medical school or hospital, thereby keeping its name and brand prominent throughout the institution without actually selling or promoting any specific product.

Hiller and the female nude

Women figured prominently in many Sutures images. Their roles, however, generally were passive and their poses were recumbent and submissive; occasionally, they feigned death. Often, too, Hiller's female models were partially or wholly nude (in comparison there were no fully nude male models) – leading to the already cited criticism by Duffin and Li that these particular vignettes were a ‘medico-historical pretext for depicting the female breast’. Perhaps one might merely shrug this off as an example of the adage that sex sells. Historian of advertising Stewart Ewen has analysed how from the 1920s sex was entering the advertising world more overtly using ‘veiled nudes and women in auto-erotic stances’.Footnote ⁵⁴ And in the context of the new advertising, which was emotion-based using visual clichés, perhaps making the selling of sterilised surgical sutures sexy is cause for wonderment. Yet, dismissing Hiller's artwork in this way is to discount it. To address this matter, several of the examples of tableaux featuring women ought to be examined more completely, allowing a discussion of how text and image interact in the ads.

The tableau about dame Trotula (1930) shows a group of four women in medieval costume clustered around a female patient who is clothed but lies on a bed; the ‘matron of Salerno’ is identifiable through her more elaborate dress. One of Trotula's assistants holds a new-born baby up to the recumbent women for her to view. Complementing the image, the copy notes that Trotula ‘became the most famous woman in early medical history’ as a result of her contributions to the study of obstetrics and gynaecology through writings such as Concerning the Cure of the Diseases of Women before, during and after Delivery. Contained in this treatise, the text highlighted, was the earliest description of perineorrhaphy in which Trotula noted that lacerated tissues due to childbirth could be repaired using silk sutures. These elements were formulaic: a historical tableau containing a visual cliché (a safe birth and motherhood); a medical history reference for context; and a link to a surgical procedure that alludes to sutures.

Contrasting with this ensemble was another of a cluster of women, young and slender in classical Greek costume. In this 1933 tableau, a bucolic setting, a Greek column and scrolls add to the scene's atmosphere. Another distinguishing part of the image is that each of the women has her right breast prominently displayed from under loosely draped robes. Trying to reconcile this tableau with the accompanying medical history copy that relates to obstetrics, gynaecology, diseases of women and the use of ligatures in venesection might reasonably be considered as a bit of a reach! The key, however, is confusion around the ‘legendary figure’ of Aspasia, which was the title of this ad. On the one hand, inspiration for the image may have derived from the entry on Aspasia by Haggard in his contemporary Devils, Drugs, and Doctors, which described her as a courtesan and high-class prostitute who operated an Athenian brothel that was much frequented by the likes of Pericles during the fifth century bce.Footnote ⁵⁵ On the other hand, physician and early feminist Kate Campbell Hurd-Mead, who wrote on women in the history of medicine, noted the obstetric contributions of Aspasia that were known only through quotations by Aetius (527–566 ce). Hurd-Mead also makes clear that there were probably three Aspasias over time, with the earliest being the Athenian courtesan who was not the later one concerned about women's health matters.Footnote ⁵⁶ This ad is thus a historical mash-up based on historical material that would have been available to Hiller at the time. While this may not entirely explain away any notion of the gratuitous display of women's body parts by Hiller, it certainly explicates his rationale. It also addresses an implicit criticism by Hansen of Hiller for including this image.Footnote ⁵⁷

A final group of six tableaux dating from 1927 to 1935 is particularly noteworthy. All portray activities by European surgeons from around the sixteenth century, and all except one depict a surgical procedure in progress. Further uniting this selection is the presence and roles of women. In all six tableaux, wholly or partially naked women are depicted as the patient or victim of disease; in four, other women are also present as onlookers, who may be assistants or nuns. In all scenes male characters other than the highlighted surgeon are also present, usually assisting by restraining the female patient. Two of the scenes also include men as dying or deceased. Further unifying these tableaux are religious icons and imagery. In ‘Jeremias Trautman of Wittenberg’ (1929), the surgeon is depicted performing the ‘first cesarean section of record’ in 1610 with a bishop in attendance. A religious triptych in ‘Giovanni Andrea Dalla Croce’ (1932) overlooks the struggling naked body of a woman probably undergoing the first hysterectomy (Figure 6). And in ‘Ambrose Paré’ (1935), a life-sized Christ on a crucifix and two nuns in full religious habit are prominent, along with the sixteenth-century surgeon who kneels at the side of a tangle of the naked dead and dying (Figure 7). In addition to including overt religious symbols, Hiller's artwork in these six tableaux also contains a suggested theme or allusion. Although there are variations, the women portrayed typically have their heads tossed back and tilted with their mouths slightly open; they are in a sensual swoon. And in almost all instances these patients are being subjected to pain inflicted by a sharp bladed instrument.

Figure 6. Tableau vivant of Giovanni Andrea Dalla Croce performing a hysterectomy in 1610 (1932).

Figure 7. Tableau vivant of Ambrose Paré the sixteenth-century surgeon kneeling at the side of a tangle of the naked dead and dying (1935).

To my mind, the inferential leap from these scenes to Bernini's Ecstasy of Saint Teresa is a short one. In the seventeenth-century religious sculpture, based on the memoir of the Carmelite nun Teresa, a male angel repeatedly thrusts and withdraws his spear into her body with the result that ‘the pain was so great, that it made me moan; and yet so surpassing was the sweetness of this excessive pain, that I could not wish to be rid of it. The soul is satisfied now with nothing less than God. The pain is not bodily, but spiritual; though the body has its share in it.’Footnote ⁵⁸ Teresa's words combined the spiritual with the somatic; Bernini's sculpted rendition of eroticised them (but admittedly maybe not all early modernists might agree with this assessment).Footnote ⁵⁹ For Hiller to capture these various sentiments, emotions, responses and moods in his photographic tableaux as a trained artist is totally plausible. His image of the female patient in the ad under the title of ‘Felix Würtz’ (1935) is particularly apposite in this context. While it may have been a pretext to display her ample bosom in an alluring way, the composition, her facial expression and her clasped hands lying on her lap signifying surrender all channel the Ecstasy of Saint Teresa (Figure 8). What might Sister Wendy, the world-renowned and popular art historian, who was also a Carmelite nun like Saint Teresa, conclude about Hiller's works? On sexual imagery in art she commented how it can stand for ‘life which presses on … this is what we live in, the chaos, we have to live among death and disaster and the possibility that our lives will come to nothing’.Footnote ⁶⁰ Maybe on occasion Hiller overshot the mark, but the fact remains that this advertising commission in his hands and mind ended up perhaps being more than DG originally conceived. At the most fundamental level the Sutures project is about pain and suffering; life and death; hope and fear; order and chaos; and bodily decay and restoration – across time and cultures.

Figure 8. Tableau vivant of Felix Würtz which channels the ‘Ecstasy of Saint Teresa’ (1935).

These paired opposites also allow us to make sense of Hiller's homage to the sixteenth-century French doctor Etienne Gourmelin, which was already criticised for its gendered nudity at the time (Figure 9). At first glance it is an over-the-top, dramatic scene of plague in Paris in 1581 with several corpses in carts or lying in the street; more corpses being handled by hooded men; and other plague sufferers being treated by, presumably, Gourmelen. In the background is a stylised painted backdrop of period houses that are in obvious disrepair and perhaps abandoned. Adding to the scene's inventive illusion is the healthy appearance of the five lithe, naked and unmarred bodies of women who had apparently died from the plague; bare breasts here visibly outnumber buboes (the dark swellings that are the tell-tale physical signs of bubonic plague – the Black Death). When this photograph, along with a few others of Hiller's, was later reproduced in Life magazine in 1939, readers reacted through letters. One reader drew attention to the ‘beautiful’ nudes, but wondered why only the women were naked. Similarly, another noted sarcastically how ‘good old bubonic plague’ was discriminatory based on gender as ‘male victims died with their boots on but the gals stripped before kicking in’. Life also printed Hiller's response to these observations. On the one hand, he invoked an historical explanation by noting that thieves often stripped corpses, while on the hand he responded glibly and rhetorically: ‘If you were doing the pictures, which would you undress?’Footnote ⁶¹

Figure 9. Tableau vivant of the sixteenth-century French doctor Etienne Gourmelen attending the plague-stricken in Paris (1934).

Focusing on the sexualised nature of this image is understandable and may be unavoidable – and Hiller's flippant remark, for good or ill, reinforces it. Such mockery, by reducing the tableau to its pornographic component, obscures as much as it reveals. The staged scene is much better described as choreographed. Overall, the style is redolent of German Expressionist theatre, dance and film, along with related cultural movements of the 1920s and 1930s. Firstly, what might appear to be a makeshift and cartoonish backdrop was actually a design feature. The distortion and exaggeration of the painted houses was a style characteristic of Expressionism, which sought to favour a sense of inner emotionalism rather than surface realties. Secondly, the dramatic use of lighting to create brooding shadows as well as to foreground detail was another element (again, think film noir). Thirdly, the bodily positions of the naked female victims may be static, but they might better be described as motion that is frozen in time: in particular the woman who is being carried aloft by the hooded men with arms extended is almost flying. Her pose can be likened to Expressionist dance of the era, which challenged traditional dance and ballet by its sweeping and exaggerated movements. This is not surprising as it is known that Hiller recruited students from a nature dancing school as models. As Karl Toepfer explained, performance involving nudity, movement and dance was tagged to an ideal of modernity.Footnote ⁶²

The notions of modernity and ecstasy have previously been mentioned in connection to Hiller's images, but in the plague tableau they resurface albeit in other cultural and artistic contexts. Finally, the whole tableau, blending as it does techniques that are photographic, cinematographic, theatrical and choreographic, is testament to the power of spectacle of which Hiller was capable. For some viewers specific examples of Hiller's work might be excessive in style, perhaps moving into the realm of kitsch. In my view, the closest we get to Hiller crossing that boundary is his depiction of ‘Giovanni Andrea Dalla Croce’ (1932), already referred to for its religious imagery. In this tableau several men restrain the naked female patient despite the fact that it appears that she is shackled at the ankles to the operating table. Her back is arched, her chest and bare breasts thrust upwards; here surgery perhaps bleeds into violation and torture. Violence against women by men driven by sexual desire and social anxiety regarding modernity was certainly another element of the film, art and literature of German culture at this time. Even here, the motivations fuelling the genre of lustmord (mutilation culminating in sex murder) cannot credibly be read into Hiller's work.Footnote ⁶³

That Hiller was influenced by aspects of German Expressionism may be circumstantial, but the notion is helpful in further appreciating his work; similarly, the possible influence of Fritz Lang's Metropolis, which had its debut in New York City in 1927. Did the New York Times’ review of the film which noted that ‘its scenes bristle with cinematic imagination, with hordes of men and women and astounding stage settings’ or the New Yorker's evaluation that ‘the setting, the use of people and their movement, and various bits of action stand out as extraordinary’ strike a chord with him as an artist?Footnote ⁶⁴ Possibly, Hiller, who had been an art film maker from which his stills survived and who lived close to the Rialto theatre where Metropolis was screened, was similarly moved. As Weimar German ‘decadent’ culture was dismantled under National Socialism, many artists, including Fritz Lang, settled in America, which influenced art trends. What can be said with certainty is that Hiller's tableaux could, in isolation, easily be mistaken as ‘movie stills’ taken from films of the era and were influenced by the art of the times. Again, invoking Metropolis is important, as stills were derived from the filming while in progress and used to illustrate a magazine-serialised version of the original novel on which the film screenplay was based. Thus such stills were not just promotional images for use in cinemas at the time of showing the film, but in effect were tableaux vivants of scenes used ahead of release as illustrations in a magazine to accompany text. Hiller's images used in potential ad campaigns other than Sutures bears out the fluid use of such stylistic images. In one, a mob of over a dozen men, women and children display expressions of open hostility, disgruntlement and anger; many are armed with rifles, cudgels and other weapons. One member of the group holds up a placard reading ‘Down with Law and Order’,’ while others are shouting and gesticulating violently, with one woman with arms outstretched upwards.Footnote ⁶⁵ By itself, one might readily conclude that this still was from a movie from the late 1920s or 1930s; the composition and message of this particular shot are particularly reminiscent of the workers’ revolt and other scenes in Metropolis.

But what of the primary audience for these images – did doctors discern the art behind the ads? These practitioners probably never appreciated the subtleties of German Expressionism or visual references to Bernini arguably embedded in Sutures as they perused the portfolio of images given to them by a detail man, but something nonetheless resonated with them. Perhaps it was primarily the medical history they contained; or their visual clichés. Recall that in the late 1990s DG employee Charles Riall mused that ‘there probably are thousands [of images] still on doctors [sic] walls’. This seems likely to be an overly inflated estimate, but the Sutures portfolio currently circulates in rare book circles where it is still considered of interest and value. Perhaps another gauge of their contemporary cultural value is to be found in the fact that the portfolio of images used as the basis of the present study was part of a donation of artefacts on behalf of a deceased doctor who graduated in 1936, which was contemporaneous with the DG ad campaign; that Sutures made it as far as the North Atlantic island and then independent country of Newfoundland, was not discarded and was among his prized possessions, also including a group portrait of his medical fraternity brothers, is noteworthy.

Hiller, Sutures, female (nude) bodies, art, eroticism and medicine: stitching everything together (as best I can)

At its root, Sutures was an advertising medium that connected a seller to a potential buyer. The content and presentation of the project also connected medicine present with medicine past, which also may have helped physicians to connect with the then blossoming field of medical history. The images through their creation and composition connected differing art forms. While Sutures can be dated to a specific era, it does possess a distinct look; the criticism of it being ‘dated looking’ is problematic: the 1939 Life magazine feature of Hiller's work noted that ‘medical men repeatedly mistake the photographs for fine reproductions of old masterpieces which never existed’, suggesting that that they were modern remakes of Renaissance paintings.Footnote ⁶⁶ The resurgence of tableaux vivants by avant-garde photographers and artists attests to the endurance of this art form.Footnote ⁶⁷ Sutures may be classified in an archival sense as ephemera, yet the portfolio is not ephemeral, for in its entirety it acts as a bridge connecting sensibilities over time. As historians, our role is to interpret and contextualise the past: Sutures images, whether selected or all-encompassing, allow an additional insight into the mindset of medicine past.

That notion notwithstanding, a similar ad campaign would probably not be mounted by any reputable medical supply company in our current more inclusive and less overtly sexist and gender-exploitative culture. Whatever appeal Sutures may have had for a past male medical culture, it would probably not resonate with the medical profession of today in which women are numerically dominant.Footnote ⁶⁸ So was Hiller's use of women gratuitous and meant to titillate? Or were his compositions genuinely contextualised in various artistic traditions? If his work occasionally appeared risqué, was it appropriate for a mostly male medical audience of his era? Bert Hansen also identified these issues in his analysis. As noted, he concluded that Hiller's tableaux ought to be considered as ‘works of art’ and justifies this position in part by offering a brief history of the long-standing tradition of the posed nude woman in many works of fine art. Yet, perhaps displaying some ambivalence, he also acknowledges that even up to the 1970s the ‘open and unembarrassed display of provocative female images within the medical profession’ and in textbooks continued.Footnote ⁶⁹ Hansen's reference to thirteen of Hiller's Sutures images reproduced in the May 1954 issue of Playboy magazine is also suggestive, but he does not comment further so the matter is left hanging.Footnote ⁷⁰ A cursory survey of collectors’ websites relating to Playboy magazine, however, reveals that the four-page article on Hiller is typically classified as sadomasochism. Moreover, when David Lambkin analysed issues of the first year of Playboy (1953-4) to study its rhetorical construction of masculine sexuality, he referred to the Hiller piece. The images of nude female patients attended by clothed male doctors in a ‘men's magazine’ was ‘Smuggling a little pornography into a text under the cover of “art.”’ Lambkin's assessment was arrived at without historical context, but his reaction to Hiller's works illustrate how they can easily be interpreted less as pastiche and more as pornographic.Footnote ⁷¹ Such an assessment resonates with one previously quoted when Hansen noted that one of the external reviewers for his article referred to Hiller's work as ‘doctor porn’. Just as apposite was the insight offered by an external reader for this essay who seized upon DG employee Charles Riall's assertion that ‘there probably are thousands [of images] still on doctors [sic] walls’ thereby concluding that Hiller's nudes could be classified as ‘pin-up girls’.

To pluck selected images for republication in a magazine such as Playboy, for example, and label them as pornography, pin up girls or cheesecake, perhaps does a disservice to his reputation.Footnote ⁷² Yet the fact that that happened is instructive and points to why many people might find the images unsettling. More important than any personal reaction, however, is a much larger discussion of the associations of the female nude image in art, especially photographs, and medicine/doctors/patients.

Ludmilla Jordanova, who embraces multiple fields as feminist, cultural historian and historian of medicine when generally analysing gendered images in art and biomedicine, brings many insights to this discussion. One of her conclusions might have resonated with some of Hiller's thoughts on preferences for unclothed models; she writes that ‘Unveiling men makes no sense, possibly because neither mystery nor modesty are male preserves.’Footnote ⁷³ This comment is grounded in her larger gendered argument centring on the centuries-old personification of Nature as a veiled beautiful woman that Man seeks/needs to unveil as manifest in numerous works of sculpture and visual art. ‘Science and medicine, since they claimed special truth status for themselves’, Jordanova explains, ‘were drawn both to personification of nature as woman and to the image of unveiling in order to represent their privileged relationship to Truth and to Nature. They thereby become the domains strong enough, as a power nexus, to grapple with the complex forces that nakedness unleashed.’Footnote ⁷⁴ Likewise, art historian Mary Hunter describes how the Paris Académie de Médecine is home to numerous female nude statues ‘scattered around’ it, including Nature unveiling herself before Science.Footnote ⁷⁵

Such visual tropes when connected to medicine clearly fall within the realm of art and in and of themselves are respectable and in no meaningful sense might they be construed as obscene or pornographic. Hunter continues, however, to note that art when applied to medicine can have its seamier side. Her discussion of the making and display of realistic wax body parts including female genitalia depicting various diseases illustrates how these teaching objects and other medical objets d'art when viewed out of their clinical context could easily glide into the erotic, if not the pornographic: ‘fantasy, and pleasure’ were in tension with the ‘rational façade of modern scientific medicine and professional duty’.Footnote ⁷⁶ Similarly, Rebecca Whitely in her analysis of a nineteenth-century text on obstetrics illustrated with coloured plates that were actually movable flaps demonstrated how this work ‘intertwined issues of sex, nakedness, pornography, and the nude’.Footnote ⁷⁷ These perspectives help us to understand how selective images of Hiller's work can take on a pictorial life other than what he originally intended or was commissioned to do. But the real lesson is in the medium Hiller chose: photography – not sculpture, wax models or printed text. Recall that Duffin and Li criticised Hiller for the lack of ‘verisimilitude’ in his images, but I would argue that part of their problem is not so much its lack as its presence in the form of live human models qua photographs. Similarly, Hansen, as already noted, stated that some people with whom he was in contact invoked the nature of the medium as the basis for criticism ‘because photography did not exist in the eras they [the images] would seem to record’. And one of his peer reviewers took exception to ‘these surgical photographs’ (my italics). Even Doug Manchee circled around this issue. In his defence of Hiller's use of naked women, he wondered if Hiller failed to appreciate the differences in an audience's reaction to a drawn nude and a photographed one.

Sander Gilman has demonstrated how erotic or sexual art in various visual media existed before and after the invention of photography, but his discussion of a daguerreotype (an early photographic technique) dating from 1855 depicting a naked male with an erection kissing a naked female while also fondling her breasts and vulva, however, illustrates how this new medium was novel with respect to vicarious sexuality. The image presents ‘in the most direct manner … an early example of the sexualized touch captured in the most “realistic” of media, the photograph, a medium that was endowed in the mid-nineteenth century with the claim of immediacy of verisimilitude’.Footnote ⁷⁸ Despite the theatricality and contrived historicity of Hiller's images, maybe it is the ‘immediacy of verisimilitude’ that is their key. Art historian Lynda Nead is emphatic and unequivocal about the power of photography in relation to eroticism and pornography with respect to the female nude. She argues how a photograph is an ‘unmediated image … If the object in question is the female body, then the photograph can be seen to afford direct access to that body, and sexual arousal with the minimum interference from the medium itself.’Footnote ⁷⁹ To recast Marshall McLuhan's dictum in this context, the medium certainly is the message. But when both medium and message are medical, the intellectual and social stakes are raised considerably, for notions of sexual arousal vis-à-vis doctors, who supposedly are assumed to be professionally detached from such thoughts and actions when on the job, is cause for social anxiety.

To see ‘pin-ups’ or an advertising cheesecake calendar on the walls of an all-male locker room or on those of an automotive repair shop might well cause no more than a raised eyebrow for most persons, but today to view similar images in a doctor's office might be a bit of a ‘Wow!’ moment, especially while current viewers would have no knowledge of the original historical milieu and context respecting medicine and modernity. But that is now. What about then? Perhaps the allure and success of Hiller's Sutures in Ancient Surgery in its time is an unexpected historical insight into the expectations of professional propriety and demeanour of that era. If indeed there were ‘thousands’ of Hiller's images on doctors’ walls during his time which did not occasion any public outcry, then apparently such photographic renditions, erotic or otherwise, were acceptable. The past may be a foreign country; certainly the medical past is.