Special Feature

World Journal for Pediatric and

Congenital Heart Surgery
Medical Illustration in the Era 2020, Vol. 11(2) 204-214
ª The Author(s) 2020
Article reuse guidelines:
of Cardiac Surgery sagepub.com/journals-permissions
DOI: 10.1177/2150135119893671
journals.sagepub.com/home/pch

Constantine Mavroudis, MD1, Gary P. Lees, MS, CMI, FAMI2,

and Rachid Idriss, MFA3

Abstract
This article reviews the collaboration between clinician and illustrator throughout the ages while highlighting the era of cardiac
surgery. Historical notes are based on Professor Sanjib Kumar Ghosh’s extensive review, literature searches, and the archives of
the Johns Hopkins University Department of Art as related to Medicine in Baltimore. Personal communications were explored
with medical illustrators and medical practitioners, many of whom are colleagues and trainees, to further chronicle the history of
medical illustration and education in the era of cardiac surgery. Medical illustrators use their talents and expressive ideas to
demonstrate procedures and give them life. These methods are (1) hovering technique; (2) hidden anatomy, ghosted views, or
transparency; (3) centrally focused perspective; (4) action techniques to give life to the procedure; (5) use of insets to highlight
one part of the drawing; (6) human proportionality using hands or known objects to show size; and (7) step-by-step educational
process to depict the stages of a procedure. Vivid examples showing these techniques are demonstrated. The result of this
observational analysis underscores the importance of the collaboration between clinician and illustrator to accurately describe
intricate pathoanatomy, three-dimensional interrelated anatomic detail, and complex operations. While there are few data to
measure the impact of the atlas on medical education, it is an undeniable assertion that anatomical and surgical illustrations have
helped to educate and train the modern-day surgeon, cardiologist, and related health-care professionals.

Keywords
medication illustration, era of cardiac surgery, pathoanatomy, complex operations

Submitted August 19, 2019; Accepted November 18, 2019.

Introduction
The purpose of this article is to review the collaboration between
clinicians and illustrators throughout the ages and concentrate on
the contributions that chronicled the era of cardiac surgery.
Much of the historical notes from antiquity to the dawn of the
20th century have been referenced in, Evolution of Illustrations
in Anatomy: A Study from the Classical Period in Europe to
Modern Times,1 by Sanjib Kumar Ghosh of the Department of
Anatomy, Medical College, Joka, Kolkata, India. His literature
review of historical sources allowed insight into further investi-
gation. Inquiries with administrators of the Maude Abbott
Museum in Montreal and archives of the Johns Hopkins Univer-
sity Department of Art as Applied to Medicine in Baltimore
were made and examined. Personal communications were
explored with medical illustrators and medical practitioners,
many of whom are colleagues and trainees, to further chronicle
the history of medical illustration in the era of cardiac surgery
The result of this observational analysis should signal to the
reader the importance of the collaboration between clinician
and illustrator to accurately describe intricate pathoanatomy,
3-dimensional interrelated anatomic detail, and complex
operations. While there are few data to measure the impact
of the atlas on medical education, it is an undeniable assertion
that anatomical and surgical illustrations have helped to edu-
cate and train the modern-day surgeon, cardiologist, and related
health-care professionals.
Historical Notes Leading Up To the
Era of Cardiac Surgery
Medical illustration has been incorporated into anatomic study
for centuries. Hippocrates of Cos (*460 to *377 BCE), long
1
Department of Surgery, Johns Hopkins University School of Medicine, Johns
Hopkins All Children’s Hospital, St Petersburg, FL, USA
2
Department of Art as Applied to Medicine, Archivist: Max Brödel Archives,
Johns Hopkins University School of Medicine, Baltimore, MD, USA
3
Thanatoworks, Chicago, IL, USA
Corresponding Author:
Constantine Mavroudis, Department of Surgery, Johns Hopkins University
School of Medicine, Johns Hopkins All Children’s Hospital, St Petersburg, FL
33701, USA.
Email: constantinemavroudis@gmail.com
Mavroudis et al
thought to be the Father of Medicine, introduced the concept
that “sickness arises from the environment or the patient; not
from supernatural influences.” This led practitioners to catalog
symptoms and physical findings in order to solve the mysteries
of illness. He and his followers were responsible for the Hippo-
cratic Corpus, which was written over a 200-year period.2,3 The
Hippocratics left detailed descriptions of disease entities, but
no drawings have survived owing to the difficulty in artistic
reproductions.
Galen of Pergamum (130-210 ACE) had an enormous influ-
ence on medical research and practice up until the early 19th
century.4 He performed experiments by careful observation
and wrote some 22 volumes cataloging his observations and
findings.5,6 His presence and experimentation were so exten-
sive that no one dared contradict him. The anatomic findings of
his texts were exclusively descriptive and contained no draw-
ings as noted by scholars.7 Most of the illustrations ascribed to
his work have been chronicled and preserved by medieval art-
ists who interpreted his findings. Figure S1 is a facsimile of his
likeness. A drawing of his comprehensive internal anatomy is
shown in Figure S2, which attempts to interpret anatomy and
physiology. His understanding of the circulation however was
never proven nor was it accurate at any level. Figure S3 is an
anatomic analysis depicting the physiology of the circulation
which, according to Galen, was propelled by the liver.8 As was
proven by Harvey in 1628, Galen’s physiology of the heart and
circulation was completely wrong9!
The Post-Galenic Era and Introduction
of Human Dissection
In subsequent centuries, great advances were made in anatomic
and physiologic studies that were chronicled by descriptive
passages and artistic examples. Artists associated with anato-
mists, practitioners, and surgeons to offer a visual understand-
ing of the intricate interrelationship between anatomy and
physiology. The study of medicine during the late medieval
period (1300-1450), while highly influenced by Galen, showed
signs of scientific advances and rational inquiry. There were
enclaves of study, later to become universities, which started to
emerge as organized institutions of free study. King Frederick
II, the Holy Roman Emperor (1194-1250), was influential in
advancing the cause of medical education and human dissec-
tion.10 During this period, Mondino de Liuzzi (1275-1326)
performed systematic human dissection which resulted in his
classic text, Anathomia Mondini. This publication advanced
insights and perceptions of human anatomy; however, there
were no illustrations within the text.11,12 It was left to Liuzzi’s
student, Guido da Vigevano (1280-1349), to introduce, for the
first time, the idea that illustration could enhance the study of
anatomy.10 Vigevano published his manuscript, Anathomia, in
1345 which contained six drawings highlighting trephination
and brain structure.13 This manuscript established the begin-
ning of this new idea of illustration to accompany description
and was carried into the late Middle Ages, although the ana-
tomic artistic interpretations were largely unrealistic,
205
elementary, and oftentimes wrong.1,14 During this period, there
was no reliable method to reproduce drawings; they were there-
fore made manually by the artist. The introduction of wood-cut
illustrations in the late 15th century allowed publication of
multiple copies of the text and associated drawings.14
The Renaissance
The change away from Galenic Medicine came with the
Renaissance that was highlighted by a return of interest in the
human body; a return to Greek art, literature, and music; and
the rise of the great universities that were the focus of a new-
found inquiry into philosophy, arts, and medicine, to name only
a few.2 A greater understanding of the human body, through
human dissection, was necessary to understand anatomy and to
postulate physiology based on observed disease patterns in life.
The celebrated University of Padua was among the first
universities to make inquiries into these principles, which was
supported by Pope Sixtus IV who in 1482 issued a papal bull
that allowed human dissection.2 The influence on artistic
expression and medical study was enormous.
Artists as Dissectors, Anatomists as Artists
It was Leonardo da Vinci (1452-1519) who produced anatomi-
cal drawings based on human dissection between 1510 and
1511. 15,16 His famous drawing of the heart (Figure S4)
included all the characteristics of topical cardiac anatomy
including the sinuses of Valsalva. Leonardo, who was an
incomparable painter and sculptor, introduced a system of
drawings that allowed the observer to appreciate the anatomic
details of limbs from different viewpoints (Figure S5) that had
the effect of a three-dimensional recreation.17,18 These princi-
ples were to be developed in the ensuing centuries resulting in
computed tomographic three-dimensional imaging19,20 and
three-dimensional printed models of congenital heart disease
lesions.21 Other famous artists who performed human dissec-
tion to maximize their interpretation and expression of human
anatomy included Albrecht Durer (1471-1528), Michelangelo
(1475-1564), and Raphael (1483-1521).
The idea that anatomists could create their own illustrations
had its origins much later, probably owing to educational
emphasis on the sciences rather than the applied arts such as
drawing, painting, and sculpture. The same is true nowadays,
although that chasm has been bridged by some physician-
anatomists with artistic talents. Notable anatomists who have
published their own illustrations include Robert Hooke (1635-
1703), Antonio Scarpa (1747-1832), John Bell (1763-1820),
and Sir Charles Bell (1774-1842).
Anatomists and Artist Collaborators:
Renaissance Into the 18th Century
The first recorded collaboration between an artist and an ana-
tomist became manifest in the 16th century. Andrea Vesalius
(1514-1564) was the fifth generation of a long line of Flemish
206
Figure 1. Collage of drawings showing Vesalius, Jon van Calcar, and anatomical plates from their book, “De Corporis Fabrica.” Vesalius “Epistola
rationem . . . ,” 1546; portrait of Vesalius. Portrait of Van Calcar, Fair use policy; Courtesy of Wikimedia. Van Calcar Plate Vesalius, De Humani
corporis fabrica libri septem; Courtesy of Wellcome Collection. Creative Commons Attribution (CC BY 4.0).
doctors.22 After his education at the Universities of Paris and
Padua, he became professor of anatomy. Unlike the established
norms, Vesalius (Figure 1) preferred performing dissections
himself, oftentimes using live animal vivisection alongside of
the human dissection, to prove anatomical details and physio-
logic principles.22 Recognizing the power of illustration, he
partnered with Jon van Calcar (Figure 1) who was a protégé
of the famous Renaissance painter, Titian. They produced six
huge anatomical plates that survive. Figure S6 shows van Cal-
car’s drawings from “De Corporis Fabrica” published in
1538.23 Using these principles, Vesalius was able to system-
atically disprove many of Galen’s physiologic interpretations.
Other important anatomist-artist teams included Giulio Casseri
(ca. 1552-1616) and Odoardo Fialetti; Bernhard Siegfried
Albinus (1697-1770) and Jan Wanderlaar (1690-1759); and
William Hunter (1718-1783) and Jan van Riemsdyk
(ca.1750-1788; Figure S7).
This tradition continued into the 17th and 18th centuries.
Govert Bidloo (1649-1713) was a Dutch physician at the Uni-
versities of Hague and Leiden who performed dissections on
executed criminals.24 He published an anatomical atlas in
1685, Anatomia Humani Corporis,25 which was illustrated by
the Dutch painter Gerard De Lairesse (1640-1711), a pupil of
Rembrandt (1606-1669). The collaboration between anatomist
and illustrator however was fraught with controversy,26,27 since
the descriptive narrative was often discordant from the illustra-
tion, leading to confusion and disorder.
Another Dutch anatomist, Bernard Siefgired Albinus (1697-
1770) professor of anatomy and surgery in the Univesity of
Leiden,28 published Tablua sceleti et musculorum corpris
humani in association with the well-known artist Jan Wande-
laar (1690-1759).29 Albinus was a perfectionist whose work
was described as “ivory cut” and “attic perfection” by Samuel
Thomas Soemmerring (1755-1830) who incorporated this tech-
nique into his own illustrations.30
World Journal for Pediatric and Congenital Heart Surgery 11(2)
William Hunter (1718-1783) was a celebrated Scottish
anatomist and physician not to be confused with his equally
famous brother, the noted surgeon, John Hunter. William
Hunter was professor of anatomy to the Royal Academy
where he published Anatomia uteri humani gradidi in asso-
ciation with Jan van Rymsdyk (1730-1790),31–33 a noted
artist. Hunter’s style was noted by the term “grand nat-
uralism,” which depicted the illustrations in a perfected
style, often misrepresenting the actual reality of the anato-
mical details.27
The French Anatomist and social reformer, Felix Vicq
d”Azyr (1748-1794), concentrated his work in neuroanatomy.
His comprehensive work on the anatomy of the human brain34
reproduced life-sized sections of the brain in the axial plane.
These were colored by aquatint35 and were the first compre-
hensive and accurate coronal sections of the brain.36 At about
the same time in Italy, Paolo Mascagni (1755-1815) published
Vasorum lymphaticum which was the first description of the
lymphatic system. He partnered with Antonio Serantoni (1780-
1837), a well-known artist to create intricate sets of anatomical
drawings.11
At the end of the 18th century in Scotland, John Bell (1763-
1820) distinguished himself as an anatomist and surgeon in
Edinburgh. He became known as the “father of surgical anat-
omy” for his enthusiasm for teaching anatomy and perfecting
surgical techniques. His drawings were more diagrammatic
than ornate and as such ushered in a new era of illustration that
reflected a sort of “pleable naturalism,” which became popular
among other anatomists.27
Nineteenth Century
The dawn of the 19th century was highlighted by surgeon-
anatomists who further defined the anatomic and technical
aspects of surgical procedures. The French anatomist-
Mavroudis et al
Figure 2. Collage of historical notes and drawings showing Max Brödel and his depictions of hysterectomy and otolaryngeal procedures. Brödel
established the first Department as Applied to Medicine in the United States at Johns Hopkins University. From left to right: Max Brödel arriving
in Baltimore, demonstrations of hysterectomy, and fibroma resection of the head and neck. All illustrations have been reproduced with
permission from The Max Brödel Archives of the Department of Art as Applied to Medicine.
surgeon, Jules Germain Cloquet (1790-1883), developed
illustrations of hernial sac disorders that were instrumental
in developing innovative reparative operations.37 Also in
France, Jean-Baptiste Marc Bourgery (1797-1849), a fellow
anatomist-surgeon, published his treatise on human anatomy,
Traite complet de l’anatomie, which was comprised of some
2,109 pages of folio-sized text and 726 hand-colored litho-
graphs that were completed by the artist, Nichlas Henri Jacob
(1782-1871).38 Bourgery’s student, Ludwik Maurycy Hirsch-
feld (1814-1876), excelled as a dissector that enabled him to
associate with the French artist, Francois Leveille (1769-
1829).39 These two partnerships resulted in excellent illustra-
tive plates and precise descriptions, as they set new standards
in illustration.38
The later half of the 19th century saw further evolution of
anatomic illustration. Henry Gray (1827-1861), an English ana-
tomist and surgeon, performed his own intricate human dissec-
tions and with his friend, Henry Vandyke Carter (1831-1897), a
noted illustrator, published Anatomy: Descriptive and Surgical
in 1858.39 His masterful work has been carried on into the
modern age as Gray’s Anatomy.40 The illustrations used in
Gray’s Anatomy were accurate and used sectional anatomy
techniques to characterize the localized portions of the body.41
This concept was later developed further by Christian Wilhelm
Braune (1831-1892), a German anatomist who introduced the
use of frozen cadavers for precise anatomical inquiry by using
the sections to facilitate drawings over transparent paper that
added to the detail.42 Also in Leipzig at the time were Werner
Spalteolz43 and Wilhelm His, Professor der Anatomie an der
Universität Leipzig who invented the microtome. The tradition
continued in Leipzig. Wilhelm His Jr, a cardiologist and ana-
tomist, discovered the function of the cells that transmit elec-
trical impulses from the AV (Atrioventricular) node in the heart
to the muscle cells of the heart wall in 1893 known epony-
mously as the bundle of His.44
207
Twentieth-Century Developments Leading
to the Era of Cardiac Surgery
The beginning of the 20th century saw a transformation of
medical illustration in North America that established the foun-
dation of the Era of Medical Illustration in Cardiac Surgery.
Shortly after the establishment of the Johns Hopkins University
School of Medicine (1893), Max Brödel arrived in Baltimore in
1894.45,46 He was an art student under Dr Carl Ludwig, Direc-
tor of the Physiological Institute in Leipzig. Drs Franklin Mall,
Howard Kelly, and William Welch recruited him to Johns
Hopkins. When he arrived, Brödel began illustrating for
Howard Kelly, Professor of Gynecology, William Halsted, Pro-
fessor of Surgery, and Harvey Cushing, Professor of Surgery.
Upon Howard Kelly’s retirement, Dr Thomas Cullen created an
endowment fund from Mr Henry Walters to establish the first
Department of Art as Applied to Medicine with Max Brödel as
the Director in 1911.47 Brödel was responsible for introducing
the technique of “carbon dust drawing on Ross stipple board,”
which had the effect of making medical, grayscale, tonal illus-
trations appear like living tissue. Figure 2 shows a collage of
Max Brödel and his well-illustrated reproductions of hysterect-
omy and laryngeal pathology. This was revolutionary, since it
reproduced well in an era of mainly black-and-white printing.
He incorporated tissue realism with cross-sectional anatomy to
emphasize the interrelational anatomy. His teaching style was
effective and produced many students who excelled in their
own careers. His was a concentrated, instructive, and didactic
pattern of medical illustration, and he is considered by many as
the father of medical illustration47 (Figure S8).
Frank H. Netter (1906-1991) was a legendary American
illustrator and surgeon who broadened medical illustration by
meticulous research, an understanding of pathoanatomy/phy-
siology, and reproduction of inter-relational anatomy. Netter’s
Atlas of Human Anatomy was published in 1989 48,49 and
208 World Journal for Pediatric and Congenital Heart Surgery 11(2)

rapidly became the most widely used atlas of anatomy in Amer-

ican medical schools.50
The field of congenital heart study is thought to be started by
Maude Abbott, MD, who was a pathologist at McGill Univer-
sity in Montreal. She classified diseases by careful observation
and clinical correlation.51 Maude Abbott published her Atlas of
Congenital Cardiac Disease (Figure S9) in 1936. 52 The
descriptions were accurate, and the drawings were expertly
performed by J. Blankstock and Hortense Douglas Cantile.
Hortense studied with Brödel at Johns Hopkins where she mas-
tered the technique of “carbon dust.” Figure S10 shows the
exquisite anatomic details of double-inlet left ventricle and
pulmonary stenosis. The Osler Library History of Medicine
at McGill University has the original carbon dust drawings.
Helen Taussig was the daughter of a well-known Boston phy-
sician who urged her to pursue nursing as a career. She chose
otherwise. After she was rejected at Harvard Medical School, she
was accepted to Johns Hopkins University School of Medicine
where she excelled and became interested in congenital heart
disease. She correlated history, symptoms, and physical findings
of her patients with their autopsy findings upon their death.53 She
published Congenital Malformations of the Heart (Figure S11),
which was principally illustrated by Elizabeth Browning, also
known as “BJ.” BJ used carbon dusting techniques with coronal
Figure 3. Detailed coronal views of specimens of aortic stenosis by
section (Figure 3) to show intracardiac pathoanatomy.54
Elizabeth Browning, also known as “BJ.” BJ used carbon dusting tech-
niques with coronal sections. Reproduced with permission from
Oxford University Press. Helen B. Taussig. Congenital Malformations
The Era of Cardiac Surgery of the Heart, Volume II: Specific Malformations. Cambridge, Massachu-
It was Crafoord,55 Gross,56 and Blalock57 whose intrepid setts: Harvard University Press, Copyright © 1947, 1960 by The Com-
efforts with closed heart surgery started the path to open- monwealth Fund.
heart surgery. Some historic photographs are worthy of men-
tion. Figure S12 is a collage of the legendary figures who
participated in the first Blalock-Taussig shunt, which included
William Longmire (Chief Resident), Alfred Blalock (Surgeon),
Hellen Taussig (Pediatric Cardiologist), Vivien Thomas
(Laboratory Director), and Denton Cooley (Intern). The oper-
ation showing the anatomy, new clamps, and suturing tech-
nique was illustrated by Leon Schlossberg (Figure 4), a
student of Brödel (1935).58 He learned the “carbon dust” on
Ross board technique and worked closely with Alfred Blalock,
Hopkins Professors, and later Paul A. Ebert59 to accurately
assess and illustrate the intricate cardiac surgical methods; the
new clamps and tools that were developed to perform the oper-
ations; and the ingenious methods to show depth, texture, and
anatomic relationships. His career was interrupted by World
War II in which he served as a Lieutenant Commander in the
Navy as Officer-In-Charge of Medical Illustration. He returned Figure 4. Leon Schlossberg documented the Blalock-Taussig shunt as
to Hopkins in the late 1940s to be the principle illustrator for shown in this drawing. New clamps and tissue texture are highlighted
Alfred Blalock. He carried on the traditions of carbon dusting using carbon testing technique. Reproduced with permission from the
until the Ross board material was no longer available. He Journal of the American College of Surgeons, formerly Surgery, Gynecology
& Obstetrics.
developed his own material using calcium-coated board
applied by a spray gun and gave him the same effect as Ross
board. For his efforts, this technique came to be known as used to repair them.57–59 Examples of these talents are shown in
“Schlossboard.” His knowledge of the three-dimensional con- Figure S13, which describes surgical treatments of cyanotic
cepts of the heart and vascular system aided surgeons in under- congenital cyanotic disease (blue babies) and Blalock-
standing complex abnormalities and the operative approaches Taussig shunt. The dynamic realism is displayed by tissue
Mavroudis et al
reaction to retraction and vessel clamping. New instruments are
highlighted and show the technique of vascular mobilization
and intracardiac anatomy.
Ted Bloodheart trained under Max Brödel in 1939 and
became one of the first medical illustrators in Los Angeles.
He associated with Dr Burt Mayer, John C. Jones, George
Lindesmith, and Winfield Wells at the Los Angeles Chil-
dren’s Hospital, where he utilized new media to create his
carbon dust on LetraMax 4000-coated board, similar to the
Brödel technique on Ross board. Examples of his work are
noted in Figure S14.60
Gerald P. Hodge graduated from Johns Hopkins under
Ranice Crosby in 1949.61 Ranice Crosby (Figure S15) was the
third chairman of the Department of Art as Applied to Medi-
cine at Johns Hopkins62 and maintained the carbon dust tech-
niques that were established by Brödel. In addition to Hodge’s
artistic skills, while at the University of Michigan, he estab-
lished a training program in 1965 in medical and biological
illustration that revealed his alma mater, Johns Hopkins. His
award-winning art that was created in association with Drs
Herbert Sloan and Otto B. Gago highlighted the techniques
of active suturing, hovering perspective, and epicardial texture
that was prepared with carbon dusting on video paper (Figure
S16). He was a consummate artist and dedicated mentor.
Herb Smith and Barry Baker, both graduates of the Johns
Hopkins tradition under Ranice Crosby, accepted medical illus-
tration positions at Baylor College of Medicine in Houston
(*1965) under Dr Michael DeBakey and his celebrated staff
which included Drs Crawford, Dietrich, and Denton Cooley until
the separation that created The Texas Children’s Hospital and the
Institute at St Luke’s Hospital. This was a time of rapid surgical
innovation. Both artists chose as their technique line drawings
that had the dual effect of portraying accuracy and rapid execution
for publication. Herb Smith’s technical highlights included a
sequential educational process that was created by using multiple
drawings highlighting the specific area of surgical intervention.
Figure S17 shows resection of a ventricular aneurysm from inci-
sion to closure. Barry Baker portrayed his art using inserts and
multiple steps in a single image as noted in Figure S17, which
shows aortic valve replacement with coronary artery bypass.
Tim Hengst who also trained at Hopkins under Ranice
Crosby in 1974 accepted a position at the Texas Heart Institute
under Denton Cooley and was followed by William Andrews
who studied at The University of Texas Southwestern Medical
School in Dallas. Their illustrations were characterized by full
range of values in line with pen and ink. Drawings (Figure S18)
by Tim Hengst are shown by highlighted areas of action,
sequential illustrations, and human (hand) proportionality. Tim
Hengst was eventually recruited back to Hopkins in 1976,
where he continued his robust career.
Late 20th Century Leading to the
Early 21st Century
The era that spanned the late 20th and early 21st centuries was
characterized by a sea change in surgical therapy for patients
209
with transposition of the great arteries, functionally single ven-
tricle, left ventricular outflow tract obstruction, and tetralogy of
Fallot, among others. Innovative procedures such as arterial
switch operation (ASO), Norwood operation, extracardiac Fon-
tan, Fontan Conversion with arrhythmia surgery, Ross-Konno,
and pulmonary valve sparing/restoration for tetralogy of Fallot
repair have emerged.63 Scientific reports were generated with
illustrations that demonstrated the fine parts of each operation.
While there were many programs and medical illustrators who
participated in these advances, concentrated efforts were cen-
tered in Chicago at Children’s Memorial Hospital (CMH) start-
ing first with Willis J. Potts whose pioneering efforts with the
Potts’ shunt and coarctation of the aorta were illustrated by
Virginia Samter, a talented medical illustrator who was grad-
uated from University of Illinois at Chicago Medical Illustra-
tion School in 1947.64 Her drawings showed the step-by-step
procedures, highlighting the surgical techniques and new
clamps made especially for the operations (Figure S19). Dr
Farouk Idriss succeeded Dr Potts at CMH and concentrated his
research and clinical efforts on anatomical correction of TGA.
The initial drawings were illustrated by Virginia Samter
(Figure 5). Subsequently, during the evolving clinical experi-
ence with the ASO, it was Zelda Zelinsky65 who illustrated the
progressive steps of the ASO in shades of grey (Figure 6).
Interestingly, Zelda Zelinsky and Virginia Samter were both
graduated from the University of Illinois at Chicago Medical
Illustration School in the same class of 1947. In 1989, Dr
Constantine Mavroudis succeeded Dr Farouk Idriss, assumed
the research and clinical directions that were established at
CMH, and brought his own vision of medical education
through publication and illustration. It was at this time that
Rachid Idriss, the son of Dr Farouk Idriss, completed his edu-
cation in medical illustration and associated with Drs Mavrou-
dis and Backer at CMH. Concurrently, Dr Mavroudis assumed
the editorship of the textbook, Pediatric Cardiac Surgery from
Arciniegas who edited the first edition.66 The second, third,
fourth,63 and soon to be fifth editions followed and were prin-
cipally illustrated by Rachid Idriss. In the later stages of this
association, the Atlas of Pediatric Cardiac Surgery67 was pub-
lished and was followed by the Atlas of Adult Congenital Heart
Surgery.68 Idriss’s style is grounded in his educational experi-
ence and his own unique understanding of the anatomy and
expression of the details.
Annotated Techniques That Highlight
Medical Illustration
We have categorized seven different methods how medical
illustrators use their talents and expressive ideas to demonstrate
procedures and give them life. These methods are (1) hovering
technique; (2) hidden anatomy, ghosted views, or transparency;
(3) centrally focused perspective; (4) action techniques to give
life to the procedure; (5) use of insets to highlight one part of
the drawing; (6) human proportionality using hands or known
objects to show relative size; and (7) step-by-step educational
process to depict the stages of a procedure.
210 World Journal for Pediatric and Congenital Heart Surgery 11(2)

Figure 5. Virginia Sumpter also worked with Dr Farouk Idriss, whose pioneering efforts to develop the arterial switch operation started in
1961. Her rendition of Idriss’s notion of the arterial switch operation is shown in four drawings, depicting the important steps of the procedure.
Of some interest is that cardioplegia was not yet introduced and that arterial blood gas determination was not clinically available. Reproduced
with permission from Elsevier. Arterial switch published by Hanley and Belfus. Mavroudis C, Backer CL, eds. The Arterial Switch Operation.
Philadelphia, PA: Hanley & Belfus, Inc; Cardiac Surgery: State of the Art Review. Vol. 5; 1991.

Figure 6. Zelda Zelensky started to work with Farouk Idriss shortly after Virginia Sumpter. Her style was tonal grades of gray and was depicted
to give more texture to the illustration. Shown here are Zelensky’s rendition of steps of the arterial switch operation, which were perfected
after the introduction of cardioplegia, arterial blood gas determination, and fine suture techniques. Left panel shows the coronary artery
dissection after great vessel transection. Middle panel shows the maneuver of Lecompte portrayed by the “Ghost” clamp that was moved from
the distal ascending aorta (ghosted clamp) to the proximal ascending aorta (actual clamp). The dissected coronary artery buttons are shown in
preparation for the neoaortic reconstruction. Right panel shows the completed neoaortic reconstruction, with the inset demonstrating the
suturing technique that was introduced by Dr Idriss. Reproduced with permission from Dr Constantine Mavroudis who retains the copyright.
Mavroudis et al 211

Figure 7. This series of drawings depicts the initial complex steps of the arterial switch operation as illustrated by Rachid Idriss. The important
preliminary stages of the operation leading up to coronary artery dissection, which is shown herein (upper left panel), have been omitted. This
first drawing (upper left panel) takes up the technique of coronary artery dissection and coronary button creation. The important aspects of this
illustration are preparation of the coronary buttons from the ascending aorta with eventual reimplantation to the ascending pulmonary artery,
shown with dashed lines, which will become the neoaorta. In the right upper panel, the aorta, soon to be the neopulmonary artery, is shown
retracted to confer attention to the neoaortic reconstruction that is shown in progress by aligning the coronary buttons to their proposed
reimplantation sites. Low-set electrocautery is shown freeing the right coronary artery attachments for complete mobilization. The smoke is a
subtle technique to show action. In the left lower panel, the neoaortic sinuses of Valsalva are being prepared for coronary reimplantation. The
indication is that the surgeon removes no more than two-third the size of the coronary button. This principle is shown very nicely in the
drawing. In the right lower panel, the left coronary button is being reimplanted into the facing sinus of Valsalva. The idea here is to start the
anastomosis as noted to avoid time delays with visualizing the repair. From Atlas of Pediatric Cardiac Surgery, 2015. Reproduced with permission
from Springer Nature.

The “hovering technique” may have been introduced by
Schlossberg in his illustration of the Blalock-Taussig shunt and
Paul Ebert’s description of ventricular septal defect (VSD)
closure. These methods (not shown) allow the observer to
visualize the safe location of suture placement en route to VSD
closure. These techniques can also facilitate the understanding
of complex operations such as the Konno procedure. Hovering
techniques show the aortic valve prosthesis being implanted,
ventricular augmentation patch being sutured, and pulmonary
outflow tract patch completing the operation. Rachid Idriss’s
hovering technique for VSD closure (Figure S20) follows the
same principles. Idriss takes the hovering technique one step
further in his demonstration of the Florida Sleeve Operation68
(Figures S21-S23). This detailed series of step-by-step expla-
nation of a complex operation shows numerous techniques
leading to a comprehensive educational experience. In partic-
ular, the hovering technique visualizes how the graft can be
openly displayed with appropriately placed pledgetted sutures,
which when tied will produce the desired effect.
The technique of showing “hidden anatomy” is also known
as “ghost views” and “transparency.” This effect is particularly
important in congenital heart surgery, since internal anatomy
can be so challenging to the conduct of the operation. Figure
S24 shows the technique using lighter tones to mimic a ghost
212
appearance. Other methods use dotted lines to indicate a struc-
ture that is anatomically behind another. The spatial interrela-
tionships allow the observer to visualize and imagine in three
dimensions that aid in the understanding of the anatomy and the
operation that is being explained.
The “centrally focused perspective” allows the artist to
deemphasize the periphery of the operative field and call atten-
tion to the important part of the operation that is directed to the
center of the illustration. The camera sees all; the medical
illustrator focuses the important elements of the message to the
viewer. This is beautifully shown in the greater majority of all
the illustrations shown herein.
“Action techniques” animates the drawing that adds life to
the procedure. The combination of shades of gray that connote
texture along with sutures that are shown in space as serpigi-
nous forms gives the impression that the sutures are in the act
of being placed. The result is an active display of the ASO.
Figure 7 and Figures S25 to S28 show the serpiginous display
of sutures in action.
“Insets” in an illustration have the same effects of a mar-
itime map that uses a focused explanation of a complex water
passage, hazardous harbor, or mooring site. This method allows
the observer the ability to visualize both the Olympian view of
the process while making quick references to the focused dis-
play, all in one illustration.
“Human proportionality” is a method to indicate the size
relationship between the operative subject and the human. The
idea is that the observer knows more or less how large her hand,
a Kelly clamp, and a scalpel is compared to the anatomic
structure.
Perhaps one of the most important techniques of cardiac
surgery illustration is the “step-by-step” technique, which
depicts, in an organized educational process, the stages of an
operation. This illustrative technique is shown for the critical
steps of total arch reconstruction and debranching for aortic
dissections involving the ascending aorta and transverse arch
(Figure S29, S30). Critical to understanding the steps of this
operation is minimizing circulatory arrest times and absence of
cerebral flow.
Modern Times and the Medical Illustrator
Rachid Idriss is joined by many other medical illustrators69–71
who have made sentinel contributions during times of great
advances in surgical procedures. Rebekah Dodson69 is the prin-
ciple medical illustrator for Comprehensive Surgical Manage-
ment of Congenital Heart Disease, 2nd edition, by Dr Richard
Jonas72 (Figure S31). She is a talented illustrator who is as
comfortable with continuous tone techniques as well as pen
and ink watercolor demonstrations. Other medical illustrators
include Robert Benassi,70 who worked at the Mayo Clinic, and
Jack Desley,71 who was the principle illustrator for Dr John
Kirklin.73
There is no intent to exclude any illustrator’s work from this
analysis. Our purpose was to present a focused historic over-
view of selected medical illustrators and their creations,
World Journal for Pediatric and Congenital Heart Surgery 11(2)
highlight the techniques of medical illustration leading up to
the era of cardiac surgery, and to extoll the importance of
medical illustrators in the educational process of learning com-
plex open-heart procedures. While new technologies of medi-
cal imaging are extant74 and developing rapidly, these methods
are the “cameras” of anatomical reproduction. The camera,
computed tomography scan, magnetic resonance imaging,
reconstructed heart models, and arteriograms are clearly impor-
tant for diagnosis, operative planning, and therapeutic interven-
tions; however, they do not “illustrate.” Illustration focuses,
interprets, emphasizes, directs, cautions, explains, and, in the
most fundamental way, teaches. The association between med-
ical illustrator and clinician has ancient roots. There is no sub-
stitute for human interaction, spatial interpretation, and
medical education in its most robust form, illustration.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
Supplemental Material
Supplemental material for this article is available online.
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