These photo-essays were featured on the home page. They combine description, allusion and narrative, transforming medical photography into visual metaphors of surgical care.
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Arms, hands, fingers, feet…
The surgeon is dressed in scrubs, cap and mask but has no
sterile gown or surgical gloves. He is a seated solitary figure
beyond the surgical lights, separated from the patient by a void
of darkness.
The surgeon is hunched over what appears to be a video game. His
face is swallowed by the control console as he views a magnified
3-D image of the inside of an abdomen. Small motions of his
hands move the micro-tools pushing aside the organs and cutting
the tissues with a precision and dexterity not possible without
this technology.
The surgeon’s empty shoes lie on the floor near his chair. His
stocking feet press six foot pedals which control the robotic
arms, the laparoscopic camera, an image capture device and the
cautery. As we watch urologist Raymond J. Leveillee, MD perform
robotic laparoscopic surgery, our minds imagine a concert
organist performing a fugue in a darkened church. Arms, hands, fingers, feet… (2008) |
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Clamp, cut, tie… The basic tools of the surgeon are simple, much like the basic tools of the artist. The artist uses brushes, paint and canvas and the surgeon uses scalpels, clamps and sutures. The complex products of these simple tools are the result of many repetitive motions driven by knowledge, experience and, at times, creativity. Clamp, cut, tie… The neck is one of many intricate parts of the body which challenges the surgeon’s skill. The muscles which control the motion of the head divide the neck into several anatomic spaces. Through these spaces pass the blood vessels which connect the heart with the brain as well as sensory and motor branches of cranial nerves. Treatments of various cancers of the head and neck require removal of parts of the neck. The surgery requires hours of careful, tedious dissection. Clamp, cut, tie… (2007) |
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Laparoscopy has profoundly altered the image of the operating theater. Artists began defining the surgical space with streaming skylight and later with the focused illumination from surgical lamps. The new image of surgery is darkness interrupted by coiled light guides, video displays and physiologic monitors. Were it not for scarce patches of color, the operating room would seem black and white as in a daguerreotype. This image shows a robotic laparoscopic prostatectomy. The surgeon, not seen, is seated several feet from the operating table behind a console which could be mistaken for a video game. The surgical assistant stands next to the patient with the blue lights of manipulators dancing in space as if divined by an unseen spirit. The nurses and anesthesiologist borrow the surgical lights to illuminate their machines and equipment. (2008) |
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Every July while most young adults in the northern hemisphere are enjoying summer holidays, future doctors are experiencing an annual rite of passage in an educational cycle. July marks the month when medical school graduates become interns and interns advance into residency training programs. Like the transformation of pupae into butterflies, this cycle admits acolytes and graduates medical and surgical specialists. Medical educators in clinics and hospitals guide these novitiates during the 3 to 8 years of internship and residency and mold them into skilled practitioners. Increasingly, medical education includes training in the use of intricate and expensive diagnostic and therapeutic equipment. The fledgling physicians learn to respect their teachers, their craft, their patients and their complex equipment… Fragile!! Handle with Care. (2007) |
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Vorticism, an abstract British artistic movement (1914-1917), distorted objects as if they were viewed through a glass bottle. It bridged the avant-garde styles of cubism and futurism bringing to the flat canvas new geometries of perspective and motion. Generations of surgical patients who underwent diethyl ether anesthesia experienced the imagery of Vorticism. They never forgot their experience of spinning and falling into a vortex during the induction of anesthesia and their vertigo and nausea when they awakened. Fortunately, modern combinations of inhalation with intravenous anesthetics have made these distressful memories rare occurrences. This image shows anesthesiologist, Miguel Cobas, MD, examining a patient with a fiber optic laryngoscope. All lines swirl around the patient, the physician and the equipment creating a vortex of motion as the physician prepares to intubate the trachea and induce general anesthesia (2008). |
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When asked to name the qualities they seek in a surgeon, patients usually list skill as the most important. But after skill what are the next most important qualities? Frequently, humility and compassion tie for second and third spot. This image shows a surgeon intensely focused on the tissue held in his hands. The posture is simple, resembling prayer more than labor. The appearance is not of arrogance or ego but of years of experience and quiet self-control and determination. We witness general and vascular surgeon, Howard Katzman, MD, as he intervenes in a process which has progressively reduced the circulation of blood to the leg to a point where the foot cannot survive without surgery. (2007) |
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Insects see many images of the world through compound eyes. Humans see only two images, one originating from each eye. Our minds superimpose these two images to create a three dimensional world. Through art humans can admire the world of multiple copies seen by insects. Compound designs with repetitive graphic elements are the signature style of many famous artists including EM Escher and Andy Warhol. Difficulty superimposing the two visual images is called diplopia and is cause for alarm. Double vision can result from neuromuscular disease and inebriation or in the case of anesthesia, it can be caused by sedatives and muscle relaxants.The image uses mirrored duplicate images to dramatize the two surgeons, Giovana R. Thomas MD and Tareck Ayad, MD, removing a tumor from the parotid gland. (2008) |
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After the surgery commences, after the offending tissue or organ is removed, but before the conclusion of the operation, a surgeon steps away from the operating table to take a last look at his handiwork and reassure himself that he has achieved the goal of the operation. In this photo, Laurence Sands, MD examines the length of colon he has removed. Later the specimen is sent to surgical pathology for microscopic, biochemical and perhaps genetic studies in order to offer a studied opinion about diagnosis, treatment and prognosis. The surgical team waits for Dr. Sands to return his attention to the patient and finish the operation. (2008) |
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Post-operative wound infections are a major cause of surgical morbidity and are difficult to treat when associated with orthopedic joint replacement. Attempts to reduce the incidence of infections have caused orthopedic surgeons to wear protective “spacesuits.” The suit protects the patient from the skin and lung microbes of the surgeon and protects the surgeon from the blood and tissue microbes of the patient. As medicine is increasingly exposed to public scrutiny, the operating room walls become more like walls of glass. The public wants to know the frequency of surgery and its aftermath, i.e., the successes, the failures and the incidence of post-operative wound infections. (2008) |
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Six hands, thirty fingers are visible in an area no larger than a dinner plate. Few human endeavors other than surgery require so many people to work together in such close proximity. What education, experience, language and culture allow these hands to move together toward a shared goal? Robotic surgery, which is becoming increasingly more common, replaces these arms and hands with servo electric actuators. Within a generation this image of hands holding simple instruments may reside in medical archives as an example of obsolete technology. In surgery, as in many other human activities, computers and technology are being placed between the self and direct experience. (2007) |
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The introduction of photography in the mid 19th century quickened the paradigm shift in painting from the required duplication of reality to the many subsequent ism’s, including impressionism, expressionism and cubism. The works of Pablo Picasso (1881-1973) exemplify these new artistic languages which freed form and color from reality. His somber blue distorted images of people and objects from his early years exposed this new vision to the 20th century. Like the color palette of Picasso, the colors of this image have been transformed to mostly blues with small areas of red and yellow. The contrast of forms and lines has been altered to suggest abstraction. We watch a dream-like story enfold as orthopedic surgeon, James J. Hutson, MD, adjusts the Ilizarov apparatus to lengthen a deformed leg. (2007) |
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Digital photography and computer graphic design programs such as Adobe© Photoshop provide the photographer with most of the tools of the classical painter. Photographers who refined their craft through improvement of composition and lighting now become artists as they impose their vision of reality on their images using post-production image manipulation. They can alter the color, saturation, contrast, texture and focus to infuse the photograph with impression, memory and narrative. This image of surgery illustrates a number of these digital tools. As our eyes go from the top of the image to the bottom, we go from a limited color palate of black and white to full color. Likewise, the saturation, contrast, texture and focus progressively increase as our attention moves from the surgeon to the surgery.(2007) |
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Even though photography for medical teaching and documentation probably began in the mid 19th century, it is uncertain when photography was first used in operating rooms. Historical records indicate that a photographer was present during the demonstration of ether anesthesia in 1846. The first color photograph was displayed in 1861, 35 years after the first monochrome photograph. Because of the complexity of the color process, color photography of surgery probably did not begin until after the introduction of Kodachrome film in 1935. The image shows an orthopedic surgical procedure. The central color image is within a monochrome rendition. The circles of red, yellow and green symbolize the RGB and CYMK division of the visible spectrum on digital cameras, color prints and film. (2006) |
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Less than a decade old, surgical treatment of morbid obesity is a last resort when diet and exercise fail. Benefits include improvement in type 2 diabetes, obstructive sleep apnea, hypertension and hypercholesterolemia. The surgical technique has evolved from permanently bypassing the stomach to constricting the stomach with an adjustable band, from a laparotomy lasting two to four hours to a laparoscopy lasting one to two hours, from a large abdominal incision to small holes in the abdominal wall, from a hospital stay of weeks to several days. As with many surgical treatments, bariatric surgery awaits its own obsolescence, an effective biochemical treatment, a pill for morbid obesity. The collage shows the gloved hands of surgeons superimposed upon the obese patient. (2004) |
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Images of Hindu gods combine the human form with the forms of birds and animals. One of the most familiar Hindu gods is Maa Kali, the multi-armed enigmatic Hindu goddess of time. Among her divine attributes, she assists mortals in their quest for knowledge, separates the solar and lunar life forces and mitigates the fear of death. Like a surgeon or anesthesiologist, Kali has great power to do good. But within that power lays the power to do harm. Her many arms make her an original multi-tasker, an asset to every surgical team. This surreal image began as a portrait of anesthesiologist, Jasjit Katariya, MD, as she watches over an anesthetized mortal. (2006) |
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Just as the jumble of branches in a bird’s nest belies the care of its construction, the jumble of red tubes in this image conceals the skill and experience needed to bypass the flow of blood around the heart. Modern cardiac surgery has evolved in no small part due to the successful engineering of the cardiopulmonary bypass machine which temporarily replaces the heart, permitting the drainage of blood from the heart and the suspension of cardiac contractions. The foreground of the image shows tubing filled with arterial and venous blood, syringes for administration of drugs, the blood filter, and the reservoir which balances the flow of blood into and out of the patient’s body. In the distance above and behind this equipment lies the covered patient and the surgical technician illuminated by the surgical lights. (2007) |
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The vigilance of the anesthesiologist continues after the surgeon completes the last stitch, after masks have been lowered and as the surgical team prepares to transfer the patient to the recovery area. This transitional period may require the administration of drugs and fluids as the patient’s body and nervous system adjust to the surgery and awaken from the effects of the anesthesia. The image shows anesthesiologist Jorge Orta, MD, nearly hidden by the vertical rows of intravenous tubing, preparing to transport a patient to the Cardiac Intensive Care Unit following the completion of an aortic valve replacement. (2007) |
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Turning the anesthetized patient from the supine position required for the induction of general anesthesia to the position determined by the site of surgery requires many helpers. Everyone in the operating room assists: the nurses, the physicians, the surgical technicians and the orderlies. Once the patient is positioned, the weight supporting parts of the body are padded. The head, arms and legs are placed in stress free positions. The task appears simple. However, even when the positioning is done correctly, there may be injury which is discovered only when the patient regains consciousness. The same positions which can be temporarily tolerated during a few hours of natural sleep may not be tolerated during several hours of anesthesia and surgery. The image shows the turning of an anesthetized patient to the lateral position. The surgery does not commence until the nurses and physicians are satisfied with the positioning. (2006) |
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We seem to be viewing the profile of the surgical nurse painted by Richard Artschwager (1923- ) in his Study of Nurse (1967). Her surgical mask with diagonal straps that point to the edges of the frame conceals what we suppose is a compassionate nose and mouth. A wisp of hair protrudes from the surgical cap which further obscures her identity. The bright eye visible in the profile appears attentive, vigilant and alert and contrasts with the background of passive medical equipment. The photo shows an operating room darkened for laparoscopic surgery with the face of Candace J. Brown, CRNA illuminated by the soft glow of the monitoring screen of the anesthesia machine. (2007) |
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If a nineteenth century surgeon entered a modern operating room, he would find himself in an unfamiliar setting. He would certainly recognize the human anatomy and exposed organs and perhaps identify some of the mechanical surgical instruments, but modern anesthesia would seem like magic. The image shows anesthesiologist Keith A. Candiotti, MD demonstrating the light wand technique of tracheal intubation. The room is dark except for the faces illuminated by the wand. As the light wand and tracheal tube pass through the mouth, through the larynx and into the trachea, a magical glow emanates from the lower portion of the neck, confirming the entry into the trachea. (2006) |
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Medicine is seldom black and white. More often it is practiced and experienced in shades of gray. A specialist in anesthesiology spends years becoming proficient in placing a breathing tube into the trachea. This is repeated in many different patients and under various medical and surgical situations. But once the tube is correctly placed in the trachea, a final adjustment is required. The tube needs to be positioned and secured at the correct depth which in this patient is marked by the number 22. (2007) |
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Eadweard Muybridge (1830-1904), aka Muggeridge and Muygridge, explored the illusion of time years before Albert Einstein. In spite of his troubled life, his technological and artistic skills gained him fame. His panoramic historical landscapes and biomechanical motion studies were highly valued during his lifetime and remain so today. Muybridge witnessed and contributed to the transition from salon painting to wet plate photography, stop motion, time lapse, and, finally, motion picture photography. Muybridge was sought after by the great artists, photographers and scientists of the time including Thomas Eakins, Marcel Duchamp and Thomas Edison. The image is in the style of a Muybridge motion study. We see multiple stages of an orthopedic procedure on the ankle as the patient is moved to the table, positioned on the side, has a leg tourniquet applied and, in the final frame, undergoes surgery. (2006) |
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The muted background of complex unrecognizable details and the foreground of colored faces and hands remind many of the lunar landscape seen in the first images of man’s walk on the moon. Others find this image resembles the later work of the French avant-garde painter, Jean Dubuffet (1901-1985), who populated his prints, painting and sculptures with complex humanoid forms using a palette of grays and blues interrupted by bursts of primary colors. The bas-relief monotone background of this surgical image draws one’s eyes to Bruce Kava, MD and Pablo Gomez, MD as they finish their urologic procedure. (2006) |
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By translating linear arrays of digital bits into three dimensional forms, modern medical imaging devices, such as CAT, MRI and PET scans, create detailed images that diagnose disease and guide the surgeon. Even without the addition of surface textures, these images resemble the alien images of the Swiss surrealist, H. R. Giger (1940- ). Is art defined by the elements of its creation or by the circumstances of its perception? At what point does an image produced by a computer become recognized as a work of art? The human form has always been a favorite subject of western art. Thus, this threshold of computer image as art may have already been achieved in the medical imagery of modern radiology. The foreground of this image is the three dimensional reconstruction of a CAT scan of a skull used during the surgical repair of traumatic facial fractures. (2006) |
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In the mid-20th century, artists such as Victor Vasarely (1908-1997), Richard Anuszkiewicz (1930- ) and Bridget Louise Riley (1931- ) experimented with various types of visual tricks and illusions. In 1965, a show called The Responsive Eye, comprised entirely of Optical Art, was held in New York City thus securing a place for Op Art in the history of modern art. This geometric image of eye, face and hands, in the style of Optical Art, displays a rare disease of the eye, carcinoma of the conjunctiva. (2005) |
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Wrong side surgery is in part a consequence of the symmetry and paired limbs and organs of the mammalian body. The octopus might have a greater problem (ignoring regeneration) and the earthworm less. Wrong sided surgery is also a consequence of ambiguity in language. In English the word “right” can mean the opposite of “wrong” or the opposite of “left”. “No” upside down looks like “on”. Further confusion results from a common inability to identify the right and left side of a rotated or mirrored object. Hence, we have the nautical terms “port” and “starboard” and the theatrical terms “stage right” and “stage left”. Surgical disease and anesthesia drugs add to these difficulties, particularly when the surgical disease is not superficial or occurs at multiple sites. Furthermore, the best source of information about the correct side is the patient who may be impaired by disease, sedation or anesthesia. The surgical team has responded to the problem of wrong side surgery with educational programs, redundant documentation and requiring the surgeon to sign or initial the operative site. The image of Marisela Rubio, RN, was used as part of a hospital exhibit emphasizing the necessity of identifying the operative site. (2004) |
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The mammalian vascular system is like a double exposed photograph of a many branched tree. One exposure is the arteries and the other is the veins. These vessels supply every tissue of the body with the cells which carry oxygen, the cells which battle infections and the cells which repair injury. Without a continual supply of these cells, the tissues lose their vital entropy and undergo decay. Until diabetes and atherosclerosis have responded to treatments based on diet, exercise or pharmaceuticals, these diseases will continue to afflict patients who require the skills of vascular surgeons. An x-ray of the diseased arteries of the ankle and foot divide the images of vascular surgeon Ignacio Rua, MD and assistant Hugo Corrales, MD, as they create a new conduit for the flow of blood from the upper leg to the foot. (2006) |
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Dame Barbara Hepworth (1903-1975), is more noted for her abstract sculptures than her paintings. She battled carcinoma of the larynx for several years prior to dying in a fire in her studio. She created six images of surgery in her Fenestration series, all minimalist images with swirling smoky muted shades (sfumato) of blue and grey with a sense of place dramatized by gloved hands and focused eyes above surgical masks. In her painting, Fenestration, The Microscope (1948), she coarsely renders in pencil and oil the forms, textures and motions of the surgical team as they use a binocular microscope to perform an operation on the middle ear for otosclerosis. My image of an eye surgeon and a microscope pays homage to her perceptions and paintings of the operating theater. Ophthalmologist, Alejandro Espaillat, MD, peers through the surgical microscope while Stephanie Sanchez, ORT prepares his instruments for the replacement of a cataract with an intraocular lens. The image is roughly sketched as with a pencil. The eyes and hands are detailed in focus and the background is washed with muted blues and grays.(2006) |
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In difficult times we look for a leader with a clear and certain vision of a better future. We look for an Abraham Lincoln, a Winston Churchill, a Jesus, a Moses. We look for a leader who is able to put aside the demons of fear and uncertainty and guide us along the path to recovery. Often, for the seriously ill patient, the surgeon fulfills this role. Surgeons demonstrate self confidence but know the limitations of their skills and live with the knowledge that once their surgical journey begins, there may be no turning back. A wizen long haired man dressed in a white robe points his outstretched arm to the left as demonic snakes rise from the depths and a patient sleeps, awaiting the insertion of an implanted defibrillator. This is the second image in the Orozco series which merges a scene from a modern operating room with the dramatic Orozco murals (1932-1934), "An Epic of American Civilization," at Dartmouth College Baker Library. (2006) |
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As the theatre lights dim and the drama unfolds, the natural and supernatural merge. Into this new reality come images and behaviors which are denied in our daily lives. A stranger experiences a similar sense of altered reality when first entering the operating theatre. And yet there are times when even the most experienced surgeons, anesthesiologists and nurses witness an astonishing sight they have never seen before. This large mass adjacent to the hands of the surgeons suggests a strange life form from a foreign galaxy If the mass is not supernatural, then at least it must be a deadly malignancy. Quite the contrary. The tumor is a large benign renal cyst which increased to this extreme size because doctors believed the patient’s renal failure and severe heart disease precluded surgical intervention. The patient finally found a surgical team at Jackson Memorial Hospital willing to attempt this long and complex operation. (2004) |
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The surgical pathologist is an unsung member of the surgical team. Working without surgical cap or mask and lacking the theatrical lights of the operating rooms, the surgical pathologist is usually found in casual attire stooped over a microscope, a glass slide or a bloody specimen. The size of the surgical specimen is sometimes barely visible and at other times consists of a significant portion of a body cavity. As the surgical pathologist works, the surgeon waits for answers to critical questions. Is the tumor malignant? Is the disease best treated by other medical specialists? Has the tumor been completely removed? Are there more tumors elsewhere? The image shows surgical pathologist, William E. Smothermon, MD, preparing to examine a pelvic leiomyosarcoma, the product of hours of surgical exploration and resection. (2006) |
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Pictures of surgery vary in style from primitive realism reminding us of our corporeal mortality to images of modern technology offering the promise of immortality. Jose Clemente Orozco (1883-1949), the controversial Mexican muralist, believed that technology does not solve social injustice, and he associated the continued mechanization of society with a devaluation of human life. His art portrays the political and economic reality of these conflicts. This image is based on the “Human Sacrifice” panel from “An Epic of American Civilization” (1932-1934) mural at the Baker Library at Dartmouth College. The image describes an Aztec priest removing the beating heart of a human sacrifice. Superimposed are images of surgical lights and a surgical procedure on the heart. At the speed of light these images bridge centuries of cultural history and technological progress. This image first appeared in Dartmouth Medicine which may be accessed through the Published Images page on this web site. (2003) |
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To an outsider, a cardiac surgical procedure appears to be a carefully choreographed dance. The surgeon and the scrub nurse are continually on the stage performing small movements of their arms and legs. The circulating nurse traverses the corners, frequently going on and off stage. With shiny containers and transparent tubes, the cardiopulmonary bypass team is absent during the first and last acts but command our attention as the middle act enfolds. The anesthesiologist is very active during the first and last acts but remains still during the majority of the performance, occasionally startling into action responding to imperceptible cues. The image is a glimpse at the first act of a coronary bypass procedure with anesthesiologist, Julio E. Menendez, MD (1965-2006), watching a video monitor as he positions an ultrasound probe in the esophagus. The surgeons and the nurses seen in the background are engaged in their part of the dance. (2005) |
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Viewers’ interpretation of this collage range from the familiar to the exotic, from the comforting to the frightening, from the sacred to the secular and from the temporal to the eternal. Some viewers see this collage as an allusion to a holiday wreath with a perimeter of green surrounding the central red. Other viewers see the green vegetation and the gloved hands of the surgeons as a biblical allegory to the partaking of fruit from the tree of knowledge in the Garden of Eden. Just as the violin maker can not know all the melodies which will flow from his musical instrument, the visual artist can not know all the interpretations which will flow from his imagery. This image of contrasting serenity, color and subject matter leaves a great deal to the viewer’s imagination. (2004) |
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What appears as bizarre or ludicrous to an adult may appear comical or cheerful to a child. Similarly, the anatomy, physiology and pharmacology of a child differ from an adult. Residents in anesthesia spend months learning how to anesthetize adults before learning the skills to anesthetize children. Residents may continue to develop this proficiency during an optional year of fellowship. A child undergoing anesthesia is a serious matter for the parents and the surgical team. A playful costume at holiday time contrasts with the seriousness of the scene as anesthesiologist, Sarah P. Kafi, MD, completes the induction of general anesthesia and positions the child for surgery. (2004) |
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The phrase “the man behind the mask” is laden with meanings. These meanings range from a fabric mask covering a physical deformity, as in the “Phantom of the Opera”, to an emotional mask covering feelings of anger or insincerity. But for the anesthesiologist the meanings of “the man behind the mask” are less metaphorical. First, a surgical mask is worn by the anesthesiologist to protect the patient from contagion. Secondly, an anesthesia mask covers the nose and mouth of the patient providing the interface between the patient’s airway and the anesthesia breathing apparatus. The earliest anesthesia apparatus consisted of a gauze anesthesia mask and a bottle of ether or chloroform. In this image we look through an anesthesia mask at the surgical mask and eyes of anesthesiologist Francisco Izaguirre, MD as he initiates the placement of the breathing tube into the trachea. (2002) |
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Images of our modern world continually intersect with images which evoke the primitive world. Flip through the pages of a news magazine and see a picture of an elemental particle traversing a cloud chamber adjacent to a picture of strangely dressed men participating in a fraternity hazing. View a photograph of a primitive village in which a bare breasted native woman converses on a cellular phone. Albert C. Barnes, M.D. (1872-1951), believing that aesthetic traditions could bridge the modern and the primitive worlds, mixed French Impressionist art with African art in “wall ensembles” at the Barnes Foundation in Philadelphia, Pennsylvania. This haunting image shows otolaryngologist, Paul Kleidermacher, MD, with his head light and optical loops set against the blue sky of a high mountain lake. In a dream-like panorama, we can imagine an angulated medical headdress morphing into a tribal mask suspended above a landscape we once saw while on vacation. (2004) |
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The surgeon begins an abdominal procedure by placing a large surgical retractor over the patient’s abdomen and anchoring it to the side of the bed. Additional devices attach to the sides of the retractor to push aside abdominal contents to maximize the visual exposure of the organs and tissues. But even with this stretching and pushing, the surgical disease may only be identified and removed by using the tactile sensations of the fingers. The hands of the surgeon become extensions of his eyes traveling in the less accessible corners of the body beyond the reach of light. Like a found object in the artwork of Marcel Duchamp (1887-1968), the Bookwalter Retractor, which normally exposes the abdominal contents to surgical inspection, surrounds the surgeon, Joe U. Levi, MD, as he removes part of the liver from a patient with metastatic cancer. (2003) |
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Sir Isaac Newton (1642-1727) noted that all objects are drawn toward the center of the earth. The fruit from the trees, the water from the mountains and the birds from the sky all fall to the earth governed by the laws of gravity. Gravity also weighs on every tissue and organ of our bodies. Plastic surgeons have responded to a culture which values youthful appearances by providing treatments to conceal the effect of gravity on wrinkled and loose tissues. But some tissues such as the breasts may in adolescence grow so large that their heaviness causes discomfort to the spine that labors to hold them erect. This image shows two plastic surgeons, Seth R. Thaller, MD and Alberto S. Gallerani, MD, as they remove a large portion of both breasts prior to recreating the contours of the breasts in a smaller size and weight. (2003) |
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The story of surgical care is told not only by bright lights, masked faces and gloved hands. The story is also described by the hopes and dreams of the patient. Will I be free of pain? Will I live a long life? Will I be beautiful? Will I be loved? In the foreground we see three faces of anesthesiologists, Stephan A. Klumpp, MD, Stacy J. Bax, MD and Peter A. Chin, MD gazing at the video monitor. The anesthesiologist in the center manipulates the endoscope and guides a breathing tube into the motionless child. Later, the surgeon will place a tube to drain the excess fluid inside the brain into the abdomen. This tense and medically complex foreground contrasts with the serene background of a public park where a mother watches her child descend a slide. (2004) |
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Operating rooms require a manager to supervise the flow of surgical cases through the daily schedule. Surgical procedures have uncertain durations; therefore, the surgical schedule undergoes modification throughout the day. Cancellations and emergencies require additional changes. The reassignment of staff is constrained by their skill levels and personalities. The manager coordinates these activities and provides the staff with bathroom, lunch and coffee relief. An effective manager is perceived as supportive of the unique needs of the various groups of physicians, nurses and staff without favoring one group’s special interests over another. And the manager certainly must strive to avoid conflict. The manager needs to coax all the fish to swim in the same direction, unbothered by cats lurking nearby. The design of some suites of operating rooms includes a highly visible, windowed administrative office which is affectionately called “the fishbowl”. The image shows a glistening school of herring in an aquarium as Janet L. Randolph, RN pensively studies the yellow and red highlighted surgical schedule. (2002) |
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If cancer had a face, what would it look like? Would it have a geometric elegance like the spiral staircase of the translocation on the DNA molecules? Would the face be framed by absent hair? Would strands of hair be neatly combed or reach wildly beyond the margins of canvas? Would the tired lines of the face softly blend from one tone to another or abruptly change with contrasting colors? Would the reflections in the eyes be the colors of winter’s grays or autumn’s browns? Who would paint the portrait of cancer? What style would we choose? Would we commission an expressionist like Vincent Van Gogh, Edvard Munch or Francis Bacon? A cubist like Pablo Picasso? A surrealist like Salvador Dali? Perhaps the portrait of cancer transcends artistic style and remains to be painted. (2004) |
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From the perspective of the kidneys the body seems like a giant swimming pool. The kidneys function like a pool maintenance man, balancing the chemicals and acidity of the body fluids. When both kidneys fail, toxic constituents of the blood rise to levels which impair all the metabolic processes of the body; particularly the ability of the brain to process information and the ability of the muscles to do the brain’s bidding. Renal dialysis removes the offending chemicals for a few days at which time the treatment is repeated. Renal transplantation offers the opportunity of a life without frequent dialysis by replacing a diseased kidney with one from a live or recently deceased donor. The mastery of this complex surgical and immunologic treatment is one of the triumphs of modern medicine. The image shows transplant surgeon, George W. Burke III, MD and transplant fellow, Hector G. Illanes, MD, replacing a diseased kidney. The harsh light of the surgical foreground contrasts with the serene nighttime illumination of one of the grandest swimming pools in the world, the pool at the Biltmore Hotel in Coral Gables, Florida. (2004) |
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The triptych is an art form popular during the Italian Renaissance. By honoring the icons of the Catholic Church, displaying the mysteries of the trinity and framing the altar, the three panel composition became one of the highest forms of Renaissance art surviving to modern times. This triptych shows oncologic surgeon, Adrian Legaspi, MD, and surgical assistant, Lara Mitchell, PAC, gazing down at the contents of the upper abdomen framed by the reflections of surgical retractors. The image of the abdomen is repeated in narrow transformations on the gowns of the surgeon and his assistant. Humility acquired by age and experience replaces the vanity gleaned during years of apprenticeships. We gradually realize that the diseases of our patients will one day become the diseases of ourselves and our loved ones. (2002) |
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Surgery to correct an opacity in the lens of an eye is one of the wonders of modern surgery. Cataract surgery once required 2 hours in the operating room followed by days of hospitalization. Now an equally effective surgical treatment requires 20 minutes in an operating room without further hospitalization. This increased productivity has had a profound impact on the practice of ophthalmology, the surgeon’s office and the ambulatory surgical facility. Each place has been redesigned to permit the safe and efficient care of an increased volume of patients. The new technology required the purchase of new equipment and special training of surgical nurses. The foreground of this image shows Stephanie C. Sanchez, ORT, preparing an intraocular lens prior to placement in the eye. The phacoemulsification machine and the surgeon are in the background. (2004) |
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Like an insect trapped in a ball of amber, the surgeon appears frozen for eternity in the light from the surgical lamp. Like an insect attracted to these rays of light, the surgeon's eyes and hands pursue the light as it explores the cavities of the body. At the conclusion of the operation, when the dimming theatrical light extinguishes our view of the leading actor, the surgeon, now estranged from this heavenly light, returns to a life measured by appointments and earthly chores. Within the perimeter of the amber light, we see two views of Beethoven Brown, MD as he performs an operation on the heart. (2003) |
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Physicians use their senses and humanity as they search for the diseases which burden their patients. Sight, sound, smell, touch culture and language comprise the essentials of physical diagnosis. But the disease may have a weak voice and remain undiscovered using these skills. Nevertheless, that which cannot be seen or cannot be felt does not hide from the diagnostic techniques of x-ray, magnetic resonance and ultrasound. The absorption and reflection of invisible waves of radiation compel the body to reveal its hidden burdens. The light transmitted through the chest X-ray from the view box illuminates the face of a woman. The X-ray and the woman alternate between positive and negative as Anique M. Bryan, MD studies the X-ray, seeking out the unseen. (2004) |
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Like the clouds in the sky which we seldom pause to appreciate, the scrub nurse is present during every operation and is essential to the success of the surgery. Also known as surgical tech or instrument nurse, a good scrub nurse knows every step of the surgery and knows which instruments to give to the surgeon without being asked. No wonder that surgeons carefully train and cultivate the right scrub nurse to assist them. By stripping away the walls of the operating room except for the high windows to the scrub room, we see a view of the world popularized by Rene Magritte (1898-1967), the Belgian surrealist painter. The serene clouds in boundless blue sky contrast with the anxious and constrained space of the operating theatre. This image shows Teresa Santos, RN, sitting behind her instruments. Her arms crossed as if in meditation, she waits for the anesthesiologist to complete the first phase of the operation. (2003) |
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Fragments of memory, like reflections from the shards of a broken mirror, appear before our eyes. We see disjointed faces, lights, and colors. And yet we easily recognize the enfolding surgical story. Does the mind record images like photographic film or does the mind disassemble an image by a complex algorithm and reassemble the image when needed for recall? In what way does anesthesia impair this recording and playback of memory? The image shows the fragments of otolaryngologist, Horacio P. Groisman, MD and surgical assistant, Esperanza Gomez, MD, as they remove a cancerous lesion from the side of the nose. (2002) |
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Some say the image resembles the mythical Minotaur, part man and part beast. Others liken the image to Ganesh , the Hindu elephant-headed god of wisdom and learning. In both cases the body of the ophthalmologist appears joined to a primordial head constructed from the branching optics of the surgical microscope. As the intense light measured by candle power penetrates the fluids of the eye, the clouded lens is replaced with a transparent piece of plastic. (2005) |
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Although the surgeon gets the top billing, a great performance requires a skillful supporting cast. The circulating nurse circulates within the operating room and the adjacent surgical supply areas, obtaining those items which are required for the surgery but cannot be selected before the surgery begins. While wheeling the patient to the operating room from the preoperative area, the circulating nurse calms the patient's anxiety with reassuring words. Once the patient has undergone anesthesia, the circulating nurse prepares the surgical site by scrubbing the area with antiseptic solution. The picture shows circulating nurse, Lauren K. Schwan, RN, scrubbing the left leg of a patient undergoing a below the knee amputation. Enclosing a darkened foot, a transparent plastic bag reveals the gangrenous area which needs to be removed to preserve the life of the patient. The accompanying image shows the leg after the diseased tissues have been removed but before the skin is closed to form the stump which can accommodate a prosthetic leg. (2002) |
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Since the beginning of time, breathing has been acknowledged as an essential attribute of human life. In Hebrew the word neshamah has the dual meaning of breathing and soul. The ancient people understood that when breathing stops, the soul departs the body. The association of breathing with life impacts the practice of anesthesiology. Nearly every drug that produces unconsciousness impairs breathing. Furthermore, a separate class of drugs, the muscle relaxants, produces the flaccid conditions required for the surgical entry into the body cavities. The patient’s breathing is taken away during the initiation of general anesthesia and then returned at the end of the surgical procedure. Just as the auscultation of the heart sounds is a defining skill of a cardiologist, intubation of the trachea is a defining skill of an anesthesiologist. By placing a breathing tube through the mouth, between the vocal cords and into the trachea, the anesthesiologist transforms a human capable of breathing and making sounds into a silent flaccid mass of vital organs. The tension and physical effort of this procedure is captured in this picture as anesthesiologist, Christopher J. Gallagher MD, and resident, Ali M. Elamin, MD, intubate the trachea of a patient about to undergo lung surgery. (2004) |
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Quilts hold a special fascination for many doctors and nurses. The basic skills of cutting and sewing are shared by the surgeon and the quilt maker. Technology has replaced the hand sewn quilt with a computer controlled machine sewn quilt and the hand sewn bowel anastomosis with a surgically stapled bowel anastomosis. But in both cases the final placement of the intricate parts remains as much an art as a skill. The replication of shapes and recognition of colors rotated in two dimensions requires the special perceptual skills of both the surgeon and the quilt maker. As more surgical procedures are performed through endoscopes, more of the surgeon’s three dimensional view of the inside of the body appears like a two dimensional quilt. This image shows a patchwork of yellow gloved hands of orthopedic surgeon Walid Mananymneh, MD and surgical resident Howard S. Richter, M.D. as they complete an above the knee amputation. (2000) |
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Some artists see our world with new eyes. Yet we readily understand their unique and bizarre transformation of the visual experience. One such artist was Vincent Van Gogh (1853-1890). We immediately recognize his paintings of later years by their vivid primary colors and untamed brush strokes. And even as Van Gogh descended into lunacy, he rendered on canvas a vision of the world which is highly valued. Two Van Gogh paintings inspired this surgical image. The frontal view of a man with a wide brimmed hat in Portrait of Armand Roulin (1888) is replaced by a surgeon wearing magnifying lenses. The ghostly stars in Starry Night Over The Rhone (1888) are replaced by blurred clusters of surgical lights. The dark blue sky joins the two allusions together as vascular surgeon, Ignacio Rua, MD, focusing on the surgical repair, holds the forceps in his left hand and the electrocautery stylus in his right. The illuminations from the starry sky echo the bright reflections from the surgical glasses. (2002) |
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Just as the tracks of an animal on fresh fallen snow show us where the animal has been, the surgical sponges tell us the story of a complex surgical journey. The color of the sponges, red for blood, green for bile, and brown for bowel are signposts along the surgical path. The quantity of sponges and their redness with blood suggest the difficulty of the procedure.The tree-like structures are constructed from sheets of plastic pockets. Dry white sponges change to red after soaking up blood from the surgical field. The wet sponges are placed into the horizontal pockets of the plastic sheets, five sponges per sheet. These vertical sheets of five sponges are hung from a pole to facilitate counting at the end of the procedure thereby reducing the likelihood of leaving a sponge in the patient. The trees of sponges grow as the hours of surgery pass. The red life force of blood contrasts with the gray senescence of the winter landscape. Neither the sponges nor the winter sky discloses whether we are viewing the beginning or the end of a new day, as the surgical transplant team replaces the failed liver with a better one. (2004) |
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Costumes have been a part of folk medicine since the beginning of time. Shamans, sorcerers and witches donned bizarre headdress and masks which transformed them from ordinary people into powerful healers. As apprentices, they mastered the costumes, gestures and words, which established their authenticity and promoted public confidence in their treatments. Our modern day surgical costumes are bland by comparison and treatments are seldom performed with incantations. Within the operating theatre any magical benefit from costuming is overshadowed by requirements for hygiene and cleanliness. At holiday time this organizational sterility is relaxed to permit individual expressions of humor and humanity. The image shows Maria C. Gonzalez, RN inserting an intravenous catheter in the hand of an anesthetized child. The conventional face mask and gown contrast with the playful cap and antlers. Francisco A. Ong, RN watches Maria’s experienced hands perform the procedure. (2003) |
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Surgical treatment for diseases of the urinary system are recorded at the time of Hippocrates (460-370 BCE) who segregated "stone cutters" (urologists) from other medical practitioners. In modern times urologists continue to treat kidney and bladder stones but also treat prostatic hypertrophy, urinary incontinence and erectile dysfunction. These latter maladies are household words thanks to the television advertisements which advocate particular drug therapies. Since the urinary tract is an integral part of the male and female organs of reproduction, the urologist continually balances the needs of medical diagnosis with the needs of patients for modesty. This same balance is sought in medical advertisements and medical photography. This image is reminiscent of the sculpture, Fountain (1917), by Marcel Duchamp (1887-1968), regarded as one of most influential works of art in the 20th century. Duchamp championed the artistic school of Dadaism which created layers of meaning by juxtaposing incongruous objects. The picture shows urologist, Manuel Camacho, MD, framed by blue plastic drapes covering raised knees. The procedure does not require a surgical mask and we see his eyes and face focused on the video screen which displays the textures of the urinary bladder. The urinals define the surgical specialty and suggest the symptoms which may have caused the patient to seek medical attention. (2002) |
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The colorful background shows the gothic stained glass windows of Saint Chappelle in Paris. These famous relics of the medieval world assert the divine sovereignty of the Catholic monarchs of France by linking their monarchy through the Davidic Covenant to the patriarchs of the Torah, to the kings of Judea, and to Jesus. While some surgeons may claim divine sovereignty of the operating room, others perform their leading role in the surgical team with sincere humility. If the surgery succeeds, the patient may attribute the cure to the divine powers of the surgeon. If the surgery fails, the patient may have little recourse than spiritual sustenance derived from prayer. Among the many similarities between surgeons and priests are their costumes. The cap of the surgeon looks like the skull cap of a priest and the yarmulka of the rabbi. The loose fit gown of the surgeon resembles the robe of the clergy. The position of the surgeon’s arms and hands as he prepares for the surgery resembles the clergy during the priestly benediction. The foreground of the image shows an oncologic surgeon, Daniel Weingrad, MD, performing surgery on a breast. After he removes the malignant tumor, a plastic surgeon will restore the breast to a normal appearance. (2002) |
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Cancer is one of the most feared diseases. Like an alien force, cancer transforms the miraculous life forces into instruments of disfigurement and death. In contrast to degenerative diseases which sap our strength in imperceptible increments, cancer bursts forth into our personal reality from out of nowhere. The diagnosis of cancer is a defining time in our lives when our wishful assumptions of immortality vanish forever. The patient is a young woman whose two year old child was in the care of grandparents. She was crying before surgery with little hope of being saved from a shortened life and unable to accept well meaning reassurances from her doctors and nurses. Small cancers can be fatal, yet the tumor in this image is so large that we immediately sense great danger. Perhaps this intuitive fear originates during childhood when we learn to fear large objects which we do not understand. The background view shows the tumor contained within the abdomen as the surgeons carefully separate the tumor from the surrounding vital structures. The foreground view shows the tumor removed from the abdomen with gynecologic oncologist, Giselle Ghurani, MD, holding the large red mass. Assisting surgeon, Matt Pearson, MD, looks on with astonishment. Despite the complete resection of the tumor, the patient succumbed to her sarcoma several months later.(2004) |
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Although residents of Miami Beach are continually exposed to the images of art deco, they do not expect to see these icons of the 1920’s paired with their 21st century ophthalmologist. This futuristic image brings together two ancient visual themes. The first is the fascination with glass as it transmits, bends and reflects all light that shines upon it. The second is the pathos of blindness with its limitless nuance that has stirred poets and inspired legends. The image shows the surgeon encapsulated within a reflecting sphere, perched on the top of a golden glowing pedestal, suggesting both a position of prestige and a sense of isolation. The eye is illuminated by the surgical microscope as the surgeon prepares to remove the clouded cataract, insert an intraocular lens, and restore sight. The composition of this image was suggested by the surgeon in the image, Louis R. Keilson, MD. (2004) |
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The scene of an orthopedic surgeons reconstructing bones and joints dressed in hooded spacesuits appears other worldly, even to the people who work daily in the operating rooms. The spacesuits provide a sterile barrier between the surgeon and the patient permitting the surgeon to work close to the surgical field without fear of infection. Through the transparent panel in the front of the hood we see the face of the surgeon, Carlos Lavernia, M.D. We are able to see the facial expressions associated with mental concentration and physical effort. The fan which blows room air into the hood is seldom strong enough to prevent the formation of beads of sweat on the forehead and face. (2002) |
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Andy Warhol (1928-1987) brought together art, photography and graphic design in an irresistible visual package. Like images from the faceted vision of an insect, Warhol’s repetitive serial images are immediately recognizable. His large scale works include a range of subjects from portraits of the rich and famous to portraits of soup cans. His serial technique is frequently imitated and easily adapted to digital design. This image began with a photograph of a neurosurgeon at work. The elements of cap, mask, face and magnifying glasses were extracted from the picture and assigned a unique color. The image was then serially reproduced into a 4 by 4 matrix. Although hidden by the glasses, the eyes of the surgeon appear red and seem to extend diabolically from the glasses. Warhol died following complications of gall bladder surgery. Perhaps for his last image he would have created this portrait of a surgeon. (1999) |
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The cover and the feature article in the Spring 2004 issue of Dartmouth Medicine exhibit the photographic images of Alfred Feingold, M.D. and are available on line (go to Publications). The cover image shows three surgeons engaged in the correction of vascular insufficiency of the leg. The team is illuminated by the daylight from a portico window found elsewhere at the Dartmouth-Hitchcock Medical Center. The juxtaposition of these two images, one deep within the most private area of the hospital and the other from a public area, emphasizes the unique status of the surgeon in the medical world. The portico window resembles a spider web, an additional characterization of the complexity of surgical care. (2003) |
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M.C. Escher (1893-1972) was a Dutch graphic artist known for his intricate and compelling spatial paradoxes. His famous lithograph, Drawing Hands (1948), illustrates this cunning ability to merge reality with fantasy. The featured image shows a surgical operation on a wrist. Reality and fantasy merge as the hands of the surgeons merge with the hand of the patient. The name of this image is Escher’s Hands, in tribute to M.C. Escher.(2001) |
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The retinal surgeon, Jay H. Levy, MD, lives in a Lilliputian world of intense light and color: pupil black, sclera white, iris blue, retina red. His surgical vision is enhanced by a powerful microscope. The dexterity of his fingers is transformed by tiny instruments as he opens a path of light through the vitreous humor to repair the retina. The loss of blood, measured by most surgeons in liters, is measured in drops. With the room lights dim, the surgeon blends into the dark background, the precise movements of his fingers and instruments intermittently catching the stray light from the microscope. (2000) |