Articles almost select themselves for the Christmas issue. The ones with any chance of publication get externally peer reviewed, and the survivors get discussed by our five person editorial committee. Our hope is that the cream finds its way to the top.

The illustrations for the articles are a different matter. Some come with great illustrations, some with tentative suggestions, and some with no illustrations at all. Since the journal is committed to having a picture on every journal page (an echo of Hoover’s presidential campaign slogan for “a chicken in every pot”) we have our work cut out for us.

Sometimes, the journey taken in search of the “right” illustration for an article ends up being almost as interesting as the article itself. Take John Hayman’s (tentative) suggestion for a photograph to illustrate his article on Darwin’s gastroenterological illness in last year’s Christmas BMJ.

In Darwin’s later years, he became almost a recluse because travel, social contact, and meetings could trigger an attack of his illness. Reputedly, he had a mirror strategically placed in his study at Down House to see who was visiting and shun them if he wished. The two Darwinologists I consulted made opposite calls on the great mirror question:

Darwinologist 1:  “The mirror was in order to spot the postman coming up the drive, not for the avoidance of visitors (although that is surely useful for everybody at some time or another, and not necessarily sociopathic behaviour) and may anyway be apocryphal.”

Darwinologist 2:  “The mirror. Perfectly correct. The mirror was installed up on a bookshelf for a good view. Parslow, the butler would either have asked CD whether he was ‘ expecting visitors’ that day and if not any unexpected callers would be given a polite apology. If anyone pitched up completely unannounced CD would have spotted them and probably made his mind up on the spot OR asked Parslow to deal with them. Any big deal visitor(s) – the Lyells, the Hookers, the Haeckels – would have been planned weeks in advance and the hope then would simply have been that CD didn’t have to leave the table or excuse himself during conversation to rush out to the ‘ necessary house.'”

The picture of the study didn’t make the final cut, because I did not want to mislead readers with a possibly apocryphal story, but if you’re interested you can see it here.

This year, Markowiak’s Modest Proposal for exterminating America’s 300 000 primary care physicians was particularly challenging to illustrate. The only images of industrial scale extermination that came readily to mind had a distinctly unChristmassy feel to them. The proposal sounded so grim that the image had to be joky. From the distant recesses of my mind came a German or French cartoon of an endless line of sailors queuing up outside a brothel (don’t ask). From there I leapt to pirates/primary care doctors being forced to walk the plank and to the American illustrators of pirate books. I thought the elder Wyeth might have covered the subject, but some Googling later I located the illustration that was in my mind’s eye, by Howard Pyle. (It turns out Wyeth was his student.) You can see another great example of Pyle’s pirate work on the Rogue’s Gallery CD of pirate ballads, sea songs and chanteys.

With fine art, the question of copyright is never far away. If the Pyle wasn’t out of copyright and we couldn’t get permission to use it, I was already mentally preparing to commission a cartoonist to do a pastiche of it. But I needn’t have bothered; it was out of copyright.

Famous and very much alive, artist Jack Vettriano immediately agreed to our using his painting “On the Border” to illustrate the fascinating story of British medical students evacuated to North America during the second world war. I’d spotted it first in his 2011 diary, and I still can’t imagine a better illustration. Why can’t all living artists be as unprecious as Vettriano about being reproduced? (I’ve spent a lot of time gazing at “On the Border” since then – his treatment of figures, together yet apart, reminds me of Caspar David Friedrich’s.)

The article on the New Zealand medical first XV rugby team seemed to be heading in a traditional direction – grainy, slightly out of focus, black and white portraits clipped from group photographs. There’s something undeniably poignant and AE Housmanesque about such images, but they’re over familiar to anyone who has ever strayed inside a sports clubhouse. Our senior art worker, Adam di Chiara, rescued us from the mundane by inserting the photographs into the classic rugby team diagram, but by then I was becoming obsessed with the exploits of the captain, Ron Elvidge.

“He once suffered from sternal and rib fractures and a head laceration during a match against the British Lions in 1950 but returned to the field, despite being in great pain, due to other injured players which had reduced the All Blacks to 14 men already. He went on to score the only try of the match as the All Blacks won 6-3.”

When I initially read the article, I thought that some ephemera (say match tickets or programmes) would be visually more interesting than black and white photos. Now I knew which match I wanted to feature: the scene of Ron Elvidge’s heroism, the third test in Wellington. Rugby Relics (“the world’s leading supplier of Rugby memorabilia”) had programmes only for the second and fourth tests. Because the colours of the programme for the fourth test (green and red) were likely to feature on the journal cover (of which more later), I let aesthetics divert me from the paths of rugby righteousness. Dai Richards, of Rugby Relics, was extraordinarily generous in foregoing a possible purchase of the programme (listed on his site with a price tag of £145) and sent me a scanned in image of its cover. He also had a great caricature of Elvidge, which made it into our pages.

He told me that the Lions captain of 1950, had, like Elvidge, been a gynaecologist. In addition, an Irish farmer had published details of Irish internationals who were doctors. A few days later I received an email from Willow Murray, honorary archivist of the Irish Rugby Football Union:

“I have located over 190 Irish internationals who were doctors including the team that played against Scotland in 1920 when there were 11 Doctors/Medical students on the side. I am sure that there are many more among those players that I have no occupation for.”

Which is where “the challenge” came from for other rugby playing to dream up their fantasy medical first XVs.

The Elvidge caricature reminds me of our reliance on cartoonists; sometimes there aren’t images in existence to illustrate an article. The homunculus splayed out over the buttocks (cartoon by Claudia Bentley) is an obvious case in point, but how about an unhappy Santa consulting his GP (Duncan Smith), Or the visit from the PCT to a general practice (Richard Williams): she (big hair, smart dress) he (grey suit) in a GTi.

And then the cover. I thought last year’s cover was great, featuring 19th century typography on what was an explicitly “historical” issue. But I couldn’t help noticing that the contents pages, with its scatter of images taken from various journal articles, worked pretty well, too. I filed that thought away. Early in the year I was looking at a couple of Swedish websites that were doing interesting things with faux 3-D effects. See this example.

In March I encountered a wonderful trompe l’oeil in an expensive art book in a gallery bookshop. I think it was probably this one by Collier. Lying around the house was the spring Lapham’s Quarterly, which had a small trompe l’oeil painting on its cover.

I can’t date the “aha” moment; at some point, I just knew I wanted a trompe l’oeil cover, featuring objects from some of the articles. To my relief, the magazine team seemed delighted at the suggestion, and the search was on to find an artist to paint it.

I once heard Polanski’s producer say that wherever you were you could find all the locations you needed within a 20 mile radius. The world has shrunk since then: our art director, Jane Walker, finds most things she needs in her small Norfolk village. Just up the road was Mary MacCarthy, trompe l’oeil artist.

Rounding up the objects for illustration was the easy part: the fondue stick from one of my household’s two fondue sets (wedding presents, naturally); the alligator/crocodile/ gharial forceps lent by a helpful theatre sister, the cheeky eighteenth century engraving, first encountered at the Rude Britannia exhibition earlier in the year. MacCarthy’s end result surpassed my hopes.

Then came the inevitable last minute request: a picture to illustrate my editor’s choice, a riff on Alain de Botton’s article on the medieval feast of fools. I remembered some absurd medieval caricature, which I could have sworn I’d seen reproduced in a book or magazine recently. But which one? After skimming through the usual suspects, I thought it might have been in Andrew Graham-Dixon’s book on the Art of Germany, accompanying his television programme – except that the book doesn’t yet exist. I remembered the caricature was paired with another caricature, featuring spotty buttocks and a thistle. So ever dodgier search terms were entered into Google Images, until I was led to … Andrew Graham-Dixon’s website. Job done, with 24 hours to spare.

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Coming up with the ideas is the easy part, and is almost unrelieved fun. High resolution copies of the images still have to be located and negotiated over -which is where our picture researcher, Vanessa Fletcher, comes in. I can’t recall an image we really, really wanted for a Christmas issue that Vanessa couldn’t get. When everyone else ran out of ideas, Vanessa could come up with l’image juste . Praise for a picture researcher comes no higher.

Tony Delamothe is deputy editor, BMJ.