• A Medical Illustrator Reflects Upon His Career Working with Albert L. Rhoton Jr.

    Author: David A. Peace

    Very few medical illustrators are given the opportunity to spend their entire career working primarily for one employer; I am one of the fortunate few to have that distinction. In my case, that employer happened to be a world-renowned neurosurgeon and neuroanatomist. I am extremely proud to have spent 35 years of my professional career producing medical illustrations for Albert L. Rhoton Jr., a man who literally changed the world of neurosurgery. Additionally, by having my name associated with his research, I attribute the substantial amount of recognition I have enjoyed, in both the medical illustration and neurosurgery communities, to Dr. Rhoton.

    I knew from an early age that I wanted to be an artist, but I didn’t always want to be a medical illustrator. In fact, it wasn’t until my junior year in undergraduate education that I started seriously looking into the field of medical and biological illustration. As a studio art major at the University of North Carolina at Pembroke, also minoring in biology, I had few prospects for employment upon graduation outside of teaching in one or both of those areas. Having grown up in and around Washington, DC, the Smithsonian Natural History Museum was my favorite place to visit, and I was very impressed with the artwork produced by the natural science illustrators working there. When I called the Smithsonian and inquired as to what techniques I needed to master in order to work there, they said many of their artists were trained as medical illustrators. That prompted me to call the National Institutes of Health and speak with the head of their medical illustration department. Howard Bartner, the department head and a classically trained medical illustrator, gave me a list of the five graduate schools granting degrees in medical and biological illustration. I chose the Medical College of Georgia and in 1978 graduated with a master of science degree in medical and biological illustration. During my three years at MCG, I became fascinated with human anatomy and consequently changed my thoughts about becoming a natural science illustrator, focusing entirely on medical illustration instead. While at MCG, I found the challenge of incorporating artistic sensitivity into surgical and anatomical teaching images provided me with an additional incentive to excel. Upon graduation I was offered a staff illustrator position in MCG’s medical illustration services department. I continued working in that department for an additional eight months until I became aware of the position with the neurosurgery department at the University of Florida.

    Dr. Albert L. Rhoton knew the value of working with professional medical illustrators. By the time I interviewed for the full-time medical illustrator position in the Department of Neurosurgery, he had already utilized the services of many excellent medical artists. During his tenure at the Mayo Clinic and there at University of Florida, Dr. Rhoton had worked with Robert Benassi, John Hutcheson, Bill Westwood, Robert Beach, and the most famous medical artist at that time, Frank Netter (Figure 1). Those of us in the Association of Medical Illustrators were very familiar with these names, and for me, someone just a year out of graduate school, they were mighty big shoes to fill.


    Figure 1. Medical illustrator Frank Netter, MD, and two of his illustrations created for Dr. Rhoton. Clinical Symposia, 1977.

    After glancing over my meager portfolio and asking me a few questions about my desire to be part of his team, Dr. Rhoton offered me the position. I started March 1, 1979, just in time to work on the illustrations for one of Dr. Rhoton’s research fellows, David G. Hardy, and his paper titled “Microsurgical Anatomy of the Superior Cerebellar Artery.” This would be the first of many peer-reviewed journal articles to have my name included as a contributing author. Dr. Rhoton was very generous in granting my request that medical illustrators receive co-authorship on certain papers due to the huge amount of time and skill that went into the preparation of artwork for publication. In those days, a typical Rhoton paper would consist of 60 to 70 black and white matte photographs re-touched by the artist (Figure 2) and six to eight full-color acrylic or watercolor paintings (Figures 3).


    Figure 2. Early photo of the author at his drawing board utilizing an anatomical specimen while retouching a B/W matte photograph. c. 1982.


    Figure 3. Artwork, shown prior to the addition of labeling and leader lines, illustrating the veins of the posterior fossa in a midsagittal section of the cerebellum and fourth ventricle. Acrylic painting on illustration board.

    When Dr. Rhoton had any free time away from the hospital, he could be found in his microsurgical anatomy lab, overseeing the progress of his research fellows. At any given time, there were at least four fellows working on anatomical dissections for their research papers—all requiring artwork. It soon became obvious that the services of a second illustrator were needed. My work station was situated in a small closet in the rear of the Theodore Gildred Microneurosurgical Laboratory, a space that I shared with Margaret “Robin” Barry, our newly hired medical illustrator. Robin was a very talented artist and recent graduate of the Art as Applied to Medicine program at Johns Hopkins University. I owe a huge debt of gratitude to Robin for being able to work, literally elbow-to-elbow, with me in such confined quarters. In fact, it wasn’t until 1998, when the department moved into the newly opened McKnight Brain Institute, that Robin and I were finally able to work in a spacious new illustration studio. At some point in every day, Dr. Rhoton would stop by the studio and check on the progress of our illustrations to make sure the anatomy was not only correct but pleasing to his eye. I think that Robin would agree with me that it felt like Dr. Rhoton was constantly over our shoulders pointing out changes and additions to our artwork (Figure 4).


    Figure 4. Dr. Rhoton critiquing the author’s illustration in the confined quarters of the old art studio.

    Albeit small, my work station was very much like what could be found in the average illustrator’s studio. I worked primarily in wet media, so my drawing board was surrounded by a cluttered pile of art supplies: paint brushes, watercolor and acrylic paints, several airbrushes, and color pencils (Figure 5). My color illustrations in the early 1980s, long before the advent of computer workstations, graphic tablets, and illustration software, were a combination of airbrushed watercolors and acrylic paint applied to illustration board. This was the standard technique for color illustrations at that time and, although tedious and laborious, produced pleasing results (Figure 6).


    Figure 5. The author’s work area in the early days prior to computer work stations.


    Figure 6. Illustration depicting brain anatomy using airbrushed watercolors on illustration board.

    In 1995, I started using the computer to assist in the production of medical art, and my workstation changed dramatically. Programs such as Adobe Photoshop and Illustrator changed forever the way medical illustrations would be created. That software, used in combination with the Wacom pressure-sensitive graphics tablet, made the production of artwork easier and more efficient. Each illustration would start with a very comprehensive pencil sketch that would be scanned into Photoshop and rendered in multiple layers above the background sketch (Figure 7). Many times over the years, prior to Photoshop, I would have an illustration nearly finished only to have Dr. Rhoton want drastic changes that could only be corrected by starting over. By rendering illustrations in Photoshop layers, I could easily make those changes without sacrificing the total image, especially when working with large, multi-image illustrations, such as a plate (Figure 8) demonstrating the anatomy encountered during the initial stages of a middle cranial fossa approach. As the years passed and digital photography became the journal submission standard, our research fellows would document their beautiful brain dissections and save them as TIFF files. This eliminated the need to scan 35mm slides and proved to be the perfect format for me to adapt and modify with the computer.


    Figure 7.  A 600 dpi scan of the comprehensive pencil sketch (left) serves as the background or base for the final rendering created in Photoshop (right).

    Despite many arguments over the years about what the perfect medical illustration should be, Dr. Rhoton and I became good friends. When he was not working he enjoyed a good laugh, often at his own expense. For example, of all of his distinguishing characteristics, Dr. Rhoton had a distinctive and recognizable speaking voice that he knew many of the residents would imitate. Occasionally Dr. Rhoton would have the illustrators working on the weekends, so not surprisingly, one Sunday morning my phone rang and it was Dr. Rhoton wanting to know if I would come in and work on the posterior inferior cerebellar artery (P.I.C.A.) paper. I started laughing, as I thought it was my friend Richard Lister having a bit of fun. Dr. Lister was the senior resident and first author on the P.I.C.A. paper, and particularly good at imitating Dr. Rhoton’s voice. When I realized it was in fact Dr. Rhoton, I gathered my composure and said I could be there in half an hour. Later that afternoon, after working on the figures, we laughed about which of the residents was best at imitating his voice and concluded that, when heard over the phone, Dr. Lister held that distinction.


    Figure 8. Illustration of surgical anatomy encountered in the initial stages of a middle cranial fossa approach. Photoshop.

    Dr. Rhoton lost his fight with cancer almost two years to the day after I retired from the neurosurgery department in February of 2014. During those two years we stayed in touch, and I often visited the lab, where I would find him busy working on another paper. I happened to catch Al in his office three weeks prior to his passing, and we spent about half an hour talking about many things. With a smile, he asked me when I was coming out of retirement and returning to work. He asked me if I was doing any artwork for my own enjoyment, and he was pleased to hear that I am getting back into oil painting. We talked about our friendship and collaboration with the more than 100 research fellows that had studied in his lab and the colossal amount of published work we had produced over the years. We found it difficult to even speculate on the total number of illustrations I had created for him and the department as a whole.

    Dr. Rhoton remained totally dedicated to his research fellows and continued working and editing their manuscripts up until a week before his death. The world has lost arguably the greatest neuroanatomist of our time, and I have lost a friend (Figure 9). The opportunity to learn neuroanatomy from this man, and artistically translate his ideas into teaching images, was indeed a gift. I am proud of the working relationship that Dr. Rhoton and I developed over the years and, as a medical illustrator, truly honored to have contributed to his legacy.


    Figure 9. A line drawing of Dr. Rhoton by the author. Photoshop.

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