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Annotated Images

These photo-essays were featured on the home page. They combine description, allusion and narrative,

transforming medical photography into visual metaphors of surgical care.

(Click image to enlarge/shrink)

Surgical Teams In teaching hospitals, physicians work in teams. A surgical team consists of an attending surgeon, a fellow, a senior resident, a junior resident and maybe an intern and a medical student. The team provides the educational and cultural milieu in which future surgeons learn their skills. After surgeons complete their residencies, most will work as individuals but some will have opportunities to participate in team efforts. The more complex the surgery, the more likely the surgeon will be part of the team. Some surgical procedures are best accomplished when the teams work in sequential order, completing one step before going on to the next. Other surgical procedures are best accomplished when the surgical teams work in parallel, working at the same time but on different parts of the patient. Working in parallel is more time saving and is used whenever possible. The panoramic image shows two surgical teams led by head and neck surgeon Dr. Z. Sargi. One team is removing the cancer from the patient's mandible and surrounding tissues. The second team is taking a free graft of skin and muscle from the left leg which will be used to cover the residual hole in the patient's face. Even with the surgical teams working in parallel, the procedure will last for many hours. (2011)

Green Laser The prominent green "X" on this image does not represent a letter of the alphabet. It marks an essential component of this surgical procedure. Surgical lasers have been available for decades and are designed to produce different energy profiles for different procedures. Lasers once had large rigid tubular arms articulated at several joints with carefully aligned mirrors and prisms. Now, laser energy can be conducted to the tissue through flexible tubing. Lasers vaporize tissues with precision unmatched by other surgical tools, such as knives, scissors or electrocautery. With a tiny spot of sentinel light, the surgeon identifies the offending tissue and then with a flash of light vaporizes the tissue. The green "X'" shows the light of the carbon dioxide laser passing through the light guide and crossing the back of otolaryngologist David E. Rosow, MD. The laser energy continues to the patient's mouth into the throat and on to the larynx. The surgeon and staff watch the monitor as the laser vaporizes the tumor.(2011)

Surgical Time The elapsed time that is recorded on the anesthesia record is measured in regular intervals by clocks and computers. In contrast to this recorded time is the elapsed time of the anesthetized patient which is subjective and may even appear to stop. From birth onward we experience few gaps in consciousness and few interruptions in the memory of passing time. Even when we sleep there is an experience of elapsed time; one dream follows another into a more or less coherent night's sleep. Only under anesthesia is this continuity of consciousness broken and with it comes the cessation of the experience of elapsed time. The patient remembers the nurse who starts the intravenous and perhaps the physician or nurse who injects a small dose of drug into the IV. But after that there is nothingness until the patient awakens in the recovery room.This is a picture of Simon Angeli, MD and Christine Dinh, MD using a surgical microscope to perform a lateral temporal bone dissection as part of a radical head and neck operation, a procedure which has many steps with multiple doctors and nurses contributing to its success. From beginning to end of the surgical procedure, the clock on the wall measured an elapsed time of 14 hours. The patient, however, experienced the passage of only a few moments. (2011)

Textured Surgeon The digital media offer a plasticity never previously experienced by photographers. One can start with a photograph and transform its appearance into a sketch, a cartoon, a serigraph, an abstraction or even a painting on canvas. The tools are relatively simple and the results are limited only by the imagination of the photographer. These transformations break down the aesthetic barriers between figure and background, representation and abstraction, pixels and paint. They demand as much from the post-processing of the image as from the image acquisition by the camera and the arrangement of lighting. We greatly admire the portraiture of Rembrandt both for its technical virtuosity and its interpretative sensitivity. These same standards can be applied to our appreciation of digital portraiture. The image shows neurosurgeon Louis Pagan, MD performing spine surgery. But added to the photograph is a textured vignette simulating a painting on canvas. Perhaps we have transformed a photograph into portraiture. Or maybe the transformation is only a distraction and has degraded an otherwise iconic image of a surgeon at work? You are the judge. (2011)

Virtual Surgeon There are several types of images of robotic surgery. One type shows a surgeon at a computer console watching a video monitor display of a body cavity while using his hands and feet like an organ virtuoso to control the devices. This image conveys a feeling of a virtual world populated with pixels and bits rather than a surgical world of bones and blood. It suggests science fiction possibilities where we could walk through a device resembling an airport security scanner and emerge with our appendix removed from our abdomen or wrinkles removed from our face. A second realm of images of robotic surgery focuses on the sleek and mysterious robotic machine pod. Several manipulators extend from a pedestal base, resembling the multiple serpentine arms of an Indian goddess or a broad shouldered cartoon transformer soldier ready to do battle. Then there is the real image of robotic surgery which not only includes the aforementioned imagery but also the hours of preparation which necessarily precede the robotic cardiac surgery: the induction of anesthesia, the collapse of one lung, the insertion of monitoring devices and the careful and precise placement of retractors, video cameras and manipulators. We see in sketchy outline Drs de Cannière and Medina as they prepare a patient for robot assisted mitral valve replacement. (2011)

Surgeon Warrior The romance of the power and courage of the lone warrior continues long after he may have become irrelevant. In modern warfare there is little opportunity for the mano a mano, ninja style combat which we enjoy in video games and movies. The design of equipment of modern warfare is a marriage of man with machine and may be beyond the understanding of the individual warrior. Modern warfare is increasingly conducted with remote controlled drones, million dollar cruise missiles and billion dollar aircraft. Surgery is also undergoing a transformation from simple, relatively inexpensive hand-held tools such as scalpels, clamps and sutures to expensive man machine devices with complex designs requiring considerable technical support.The image shows light transmitted through a complex web of billowing sheets of sterile plastic which covers the arms of a million dollar robotic surgical device. The masked face of cardiac surgeon, Didier P. De Canniere, MD, is dwarfed by this machine as he positions the robotic arms into the heart and begins the repair of the mitral valve.(2011)

Surgical Reconstruction We first look at this image and see an unfamiliar scribble of lines and blotches of color. As we further engage the image, we discern a room, overhead lights and the outlines of human forms. As we try to comprehend this image, we repeat the developmental steps of visual perception studied by Jean Piaget (1896 -1980), a Swiss developmental psychologist known for his studies of cognition in children. Cascading stages of cognition organize our knowledge into increasingly complex structures. Newborn infants see the world in blurred shades of gray. Within a few days of birth, they recognize high-contrast images such as the boundary between a parents' hairline and face. Later infants develop sharper vision, distinguish colors and shift their gaze from one object to another without moving their heads. Now we further study this image. We recognize a surgical room with people in blue gowns. We recognize faces, human tissue, surgical instruments and heads covered with protective hoods. As we finally organize and decode this image, we see a team of orthopedic surgeons led by David Pitcher, MD reconstructing the hip of an oncologic patient. (2011)

Cardiac Tapestry Long before history was memorialized by molecules on film or electrons in silicon wafers, artists used colored threads of wool, silk, linen, cotton, silver and gold to record events on tapestries. Early tapestries were portable art which hung on the walls of medieval homes and castles. A famous 12th century fabric, the Bayeux Tapestry, depicts the events surrounding the Battle of Hastings in 1066 (strictly speaking this is not a tapestry, but embroidery). This image depicts a percutaneous aortic valve replacement, a new medical procedure for extending the life of a patient with a failing heart. The interventional cardiologist inserts a catheter containing a folded replacement valve into the large artery in the leg. The catheter is advanced to above the aortic valve where the new valve is opened like an umbrella. The procedure is complex and requires a support team of cardiac surgeons, anesthesiologists, surgical nurses and technicians. The word tapestry is also used to describe colorful and complicated situations, a description apropos of this procedure. The image echoes back to a tapestry as we commemorate this new and complex way of extending the thread of life of a failing heart. (2011)

Surgical Mythology Two ancient symbols are associated with medicine, the caduceus and the rod of Asclepius (Aesculapius). The mythological allusions of these symbols reflect core ideas and beliefs about medicine. The caduceus, a winged staff wrapped with two snakes, was an ancient astrological symbol associated with the Greek god Hermes (Mercury). Hermes was the messenger of the gods, conductor of the dead and protector of merchants and thieves. In the seventh century, the caduceus became associated with Hermetic theosophy and with treatments based on astrology, alchemy and the occult. The prominence of the caduceus as a medical symbol results from its adoption by the United States Army in 1902 as the insignia for its Medical Corp. The rod of Asclepius, a staff wrapped with a single snake, symbolized healing in the ancient world. Asclepius was the son of Hermes and a healer. The sisters of Hermes were also healers: Hygieia (hygiene), Iaso (medicine), Aceso (healing), Aglaea (healthy glow) and Panacea (universal remedy). Hippocrates was a worshipper of Asclepius. The image embraces these mythological symbols of ancient folklore. We see general surgeon, Gustavo Leon, MD, performing a tracheotomy. The surgical lights, like constellations of stars, bathe his hands with magical radiance (2011).

Sufmato Surgery In contrast to contemporary high definition (HD) imaging which emphasizes sharpness and clarity, classical paintings emphasize memory and imagination. Classical painters used two popular painting techniques to achieve this effect: sfumato and chiaroscuro. Sfumato is from the Italian meaning "to smoke, vanish or shade". Leonardo da Vinci described sfumato as "without lines or borders, in the manner of smoke". Areas blend into one another through miniscule brushstrokes creating a hazy depiction of light and color. Chiaroscuro is also Italian and means "light-dark". Paintings by Caravaggio, Correggio and Rembrandt demonstrate the chiaroscuro technique. The eyes of the viewer are drawn from the dark and somber background to focus on the part which is illuminated, as if by spotlight. In this image we see both techniques. We peer through haze as we see Podiatrist Thomas G. Zwick, DPM performing a bunionectomy under the bright illumination of the surgical lights (2011).

Robotic Surgery Like a spectator at a theatrical performance, we look past the heads of the two surgical assistants to the strange forms and colors of the illuminated interior of the abdomen displayed on the video monitor. Our view is framed by ribbons of tubes of compressed gases and sterile solutions. The light is dim and saturated colors are barely discernable. But where is the principal actor in this performance? Where is the surgeon who normally occupies center stage and anchors the image? The surgeon sits hidden in a dark corner of the room, silently moving his hands and feet, appearing to play a video game as he guides the many arms of the robotic through their surreal dance. Robotic technology removes the proximity of the surgeon to the patient, permitting the surgeon, in theory, to be in a different room, a different hospital or even a different country. The room which once echoed social conversations between people working side by side is now quiet except for rare instructions from the surgeon to the staff. The sights and sounds in the room are mostly the moving robotic manipulators accompanied by the faint whine of servo motors (2011).

X-ray Easel What the easel is to the artist the x-ray light box is to the surgeon. Both the artist's canvas and the surgeon's x-ray are capable of telling a story, even though the ability to decode the story requires years of education and experience. This image began as a surgical x-ray hanging on a light box in an operating room. The x-ray reveals the interior of the chest of a 77 year old man with a diseased heart. The silhouette of ribbon-like wires, like a nighttime highway outlined by the lights of motor vehicles, marks the brief journey of electricity from the geometric forms of the pacemaker defibrillator into the chambers of the heart. The x-ray tells the story of a failing heart, frequent visits to doctors, blood tests, electrocardiograms, fear of stroke and complications of anticoagulation. The variations in density of the bones and sternal wires narrate the story of fractured ribs and mended bones with weeks of post-operative discomfort. The image whispers strange names of medical diagnoses and surgical interventions. The image also shouts the triumphs of thoracic surgery, medical technology and biomedical engineering. (2010)

Colorful Surgery Fauvism (1904-1908) was a short lived, avant-garde movement in French painting that revolutionized 20th century art. Fauves earned their name (les fauves-wild beasts) by shocking the visitors at the Salon d'Automne in 1905. The Fauves rejected the semi-realistic color palette and brush strokes of the Impressionist masters such as Van Gogh, Cezanne, Gauguin and Matisse in favor of violent, intense, vivid, non-naturalistic and exuberant colors applied with bold brush strokes, distortion and abstraction. The Fauvist movement was an essential stepping stone to German Expressionism (1910-1940), emphasizing emotional content, brilliant colors and spontaneous brushwork with less concern for formal pictorial organization and depiction. The photo is in the style of Georges Henri Rouault (1871-1958), a French Fauvist painter and printmaker. Rouault apprenticed as a glass painter and restorer. Many of his paintings are likened to light shining through stained glass. The image depicts a surgical scene with bold colors, distortions and abstractions blending the palettes of symbolism and reality. (2010)

Surgical Reflections The Symbolism art movement in the 18th century stressed subjective experience over literal depiction, imagination over logic and feelings over photographic accuracy. Central themes of this early form of modernism were the reduction of reality into essences, the use of color, line, form, texture and space to give iconic majesty to ordinary visual scenes. The creation of a dreamlike mirror of reality which is both esthetically pleasing and perceptually recognizable required a careful balance between depiction and abstraction. The image shows an oversized mythic head of a surgeon enclosed within a protective hood. We see a human form dressed in the cloaks of science. The bright reflection from the convex visor reveals the operation taking place between the comparatively small hands. A palate of dark blues transforms the volumes into vanishing darkness. We see plastic shapes merging with undulating fabrics as orthopedic oncologic surgeon David Pitcher, MD attempts a complex replacement of a hip joint. (2010)

Optimal Light Shadow and luminance, darkness and light, are literary allusions found often in poetry and prose. To a surgeon, however, these powerful metaphors seldom rise beyond a simple meaning. With few exceptions, surgeons cannot cut what they cannot see. For this reason, surgeons have always sought the optimal light for their work. In the early days light came in from a nearby window or streamed down from a skylight. Later, with the invention of incandescent lights, surgeons no longer needed daylight and were able to operate at any hour of the day or night. Manufacturers have gone to extraordinary efforts to provide optimal lighting. The light needs to mimic daylight (3600K to 5000K) so that organs and body fluids can be recognized by their natural colors. The light housing needs to minimize the radiant heat from the light to protect the patient's tissue and to improve the comfort of the surgical team. The light needs to pivot and focus into body cavities while at the same time minimizing shadows. The image shows Hernan Carrion, MD, performing a urologic procedure below star-like LED clusters from the latest innovation in surgical lights. (2010)

Surgical Contrast Contemporary portrait photography has been profoundly influenced by the styles of two American photographers. Arnold Abner Newman (1918-2006) is noted for his environmental portraiture, in which his subjects share their likeness with representative visual elements of their professions and personalities. Newman used a large-format camera and available lighting without the benefit of studio lights or strobes. His compositions lacked symmetry and violated conventional rules for framing the subject within the print. Andy Warhol (1928-1987) combined the skills of an illustrator, photographer and commercial artist. His silk-screen portraits were drawn from photographs taken with a Polaroid camera. His signature styles transformed photographs into high contrast, two-dimensional pixilated cartoons. These had a profound influence on modern art as well as digital photography. (2010)

Surgical Mosaic Gustav Klimt 1862-1918), the fin de siècle Viennese art nouveau painter and illustrator, was the son of a gold engraver. In 1894, Klimt gained recognition when he was commissioned to create three ceiling murals for the University of Vienna, Philosophy (1900), Medicine (1901) and Jurisprudence(1902). However, his composition studies were regarded as too radical and pornographic and the murals were never displayed. Klimt is also known for being the cofounder of the Vienna Secession movement (Wiener Sezession) which furthered his eclectic synthesis of classicism, realism and symbolism. Love and death, Eros and Thanatos, are dominant themes in Klimt's paintings. His stylish women display elegant gold decorations and erotic shapes which then dissolve into Byzantine mosaic abstractions. Klimt's paintings have brought some of the highest prices for individual works of art.The image shows a robot-assisted surgery to remove a tumor beneath the tongue. The protective goggles define a human head which then dissolves into a maze of gold and blue mosaic streaks of plastic drapes and robotic arms. (2010) ...more about Klimt

Surgical Paradigm The Emmy Award winning 2004 HBO film, Something the Lord Made, describes the collaboration of surgeon, Alfred Blalock, MD (1899-1964), his assistant, Vivien T. Thomas (1910 -1985) and pediatrician, Helen B. Taussig, MD (1898-1986), in the development of the Blalock-Taussig Shunt for the surgical correction of Tetralogy of Fallot. Three stories unfold in this docudrama. One story is their compassion, courage and determination as they attempt surgery thought impossible. The second story describes an uneducated black carpenter who becomes a lab technician, rises above the prejudices of his time and becomes the co-discover of this surgical procedure. The third story is that of a compassionate, deaf, dyslexic pediatrician who becomes a founder of pediatric cardiology. Paradigm shifts in the natural sciences can happen over night while changes in social sciences require generations. In medicine the stakeholders of prior paradigms vanish in the presence of convincing proof. In social science the proof is seldom convincing and the stakeholders may cling to their beliefs for generations. This story about the development of the Blalock-Taussig Shunt for the blue baby syndrome in the 1940's illustrates both these phenomena. The image shows cardiovascular surgeon, Didier De Cannière, MD, performing a modern cardiac surgery procedure. The sepia toning echoes back to an aesthetic developed in the 1880's and gives the photograph a warmer tone and enhances its archival appearance. (2010)

Decisive Moment For more than four decades Norman Percevel Rockwell (1894-1978), American painter and illustrator, created cover illustrations for The Saturday Evening Post. His oeuvre strongly influenced photojournalism and linked depression era photorealism with commercial illustration. Like French photographer Henri Cartier-Bresson (1908-2004), Rockwell showed photographers how to turn decisive moments of everyday experiences into unforgettable images. His illustrations of family doctors caring for children survived the derision of critics who thought the images were banal and contrived. In the style of Norman Rockwell, this surgical image shows a fleeting event in the daily life of operating room doctors and nurses. The surgery on the patient's lung has stopped. Five pairs of eyes watch the video monitor as anesthesiologist Lebron Cooper, MD uses a fiberoptic device to replace a bronchial blocker in the patient's airway. They wait and watch until the surgery can start once more. (2010)

Electrical Procedures The use of electricity for treating human diseases has evolved from quackery to mainstream medicine. In 1746 Jean Jallabert (1712-1768) claimed the first successful electrical treatment for the paralysis of an injured arm. Jallabert suggested that the current stimulated muscle regeneration and increase blood flow. In the mid 1800's Charles Pravaz (1791-1853) and others experimented with galvano-cautery devices to reduce the blood loss during surgery. As surgeons recognized the benefit of cautery over ligature, electricity was linked to surgery forever. But these early therapies were little clue to the wide and novel uses of electricity in modern medicine. Not only is electro-cautery used in nearly every surgical procedure but cautery catheters are now passed into cavities of the body, ablating diseased tissues from within the organ. Stimulation of nerves has gone from speculation to practical use. Implanted cardiac pacemakers and defibrillators deliver precisely timed electrical currents into the heart, allowing many otherwise invalid patients to enjoy normal lives. One recent use of nerve stimulation is sacral neuromodulation for patients who haven't had success with suffer urinary urge incontinence, urinary urgency-frequency or non-obstructive urinary retention. The image shows the placement of a temporary sacral nerve stimulator which, if successful, will be followed by the insertion of a permanent stimulator. We watch the placement of the stimulator wires, performed with local anesthesia and monitored by fluoroscopy and electromyography of the foot. (2010)

Surgical Prayer Like a highly trained athlete mentally preparing for a competitive event, the surgeon pauses for a moment of reflection and introspection. Where will he make the incision? What instruments will he need? Which of several possible diagnoses will be correct? What is the worst possible outcome? What is the most likely result? We watch Athanassios I. Tsoukas, MD, his gloved hands clenched together to keep them from touching something unsterile, appearing to be in prayer, as the nurses prepare the patient for an operation to treat a bowel obstruction caused by an incarcerated femoral hernia. (2010)

Hernia Surgery The treatment of inguinal or groin hernias has a long history. Ancient Greeks and Egyptians used tight bands and trusses to support and reduce bulging and painful hernias. The concept of a hernia as a rupture of the abdominal contents is attributed to Galen (129-199 CE). This concept led Byzantine physicians in the sixth and seventh century to describe techniques for removal of the prolapsed peritoneum, including cauterization of the groin with amputation of the hernia sac, the spermatic cord and testicle. With the arrival of general anesthesia and asepsis, surgical techniques evolved which spared the spermatic cord and testicle by using the patient's own tissues to reinforce the abdominal wall and tighten the inguinal ring. In recent years this technique has been improved by using fabric mesh to strengthen the abdominal wall. The image shows the video monitor during a laparoscopic hernia repair. Advances of laparoscopic surgery now permit the repair of inguinal hernias from within the abdomen. The glistening mesh fabric is positioned over the area of prolapsed peritoneum and then stapled to the abdominal wall. Were it not for the control console and the folded silver mesh around the laparoscopic instrument, the image would resemble the lines and colored two-dimensional forms of a Neo-plasticism (1917-1928) painting by Piet Mondrian (1872-1944).

Tummy Surgery In cosmetic surgery communication between the surgeon and the patient is unique. Patients may name their disorder and engage a surgeon to perform a particular treatment. In other surgical specialties the patient approaches a surgeon with a set of symptoms and laboratory tests for which the surgeon names the disorder and names the treatment. A patient does not go to a surgeon asking for an appendectomy or craniotomy. Abdominal lipectomy or tummy tuck. Rhtydectomy with blepharoplasty or face lift with eye lids. Rhinoplasty or nose job. These are the names of the surgical procedures used by cosmetic surgeons paired with the common descriptions, joining the unique and specific language of the cosmetic surgeon with commonly used words of the patient. The image shows cosmetic surgeon, Jack D. Norman, MD, coagulating the blood vessels on the interior wall of the abdomen as he performs an abdominal lipectomy, commonly called a tummy tuck. (2009)

Surgical Gender Until recently surgery was a profession mostly of men. Was this a result of prejudice of the program directors or self-selection by the medical students? Did women avoid surgical specialties due to the arduous residencies, long hours and demanding life styles? The Association of Women Surgeons was founded in 1981 "to inspire, encourage and enable women surgeons" and remove these barriers, whether real or imaginary. In some surgical specialties such as obstetrics and gynecology, woman applicants may be preferred to men. In nearly all surgical specialties woman are finding opportunities which did not exist a few years ago. The image shows chief resident in Oral Surgery, Mary E. Hein, DDS, her gender nearly concealed, assisting on a Le Fort advancement of a mandible (2009).

Robotic Perspective Bright glistening plastic drapes reflect angular patterns beside fragmented structures that dissolve into darkness. Vertical rods with blue eyes dance to a silent melody. Visitors witnessing robot-assisted laparoscopic surgery might think they have wandered back in time into the visual space of 20thcentury Cubism. Cubism (1906-1921) breaks and reconstructs objects into geometric forms, depicting them from multiple viewpoints and layering them on top of a shallow ambiguous background. Surfaces intersect at random angles, removing a coherent binocular perception of depth. This radical avant-garde art movement was pioneered by Pablo Picasso (1881-1973), Georges Braque (1882-1963) and Juan Gris (1887-1927). Just as Cubism altered the boundaries of our visual experience from traditional three dimensional perspectives, robotic surgery moves our image of surgery to new challenges of perspective and depiction. (2009)

Surgical Logo All businesses desire to have a logo with the recognition and prestige of Coca Cola or Apple. These successful trademarks signify quality, innovation and value. It's not surprising that medical practices have attempted to "brand" their practices with trademarks and logos. But can the business school marketing lessons about widgets be readily transferred to a service industry such as healthcare? How much quality control can be built into a multispecialty medical practice? Does the success of the clinical encounter mostly depend on the final common pathway, the doctor or nurse? Even successful group medical practices have had difficulty addressing these questions and extending their brand beyond their core geographic locality. The image shows otolaryngologist, Jose W. Ruiz, MD, wearing a cap sporting the logo of the University of Miami and its University of Miami Health System, UHealth, a new South Florida regional network of physician, outpatient facilities and hospitals. (2009)

Wound Infections Wind, water, walk, wound is the mnemonic alliteration learned by surgical students to remember the temporal order of post-operative infections. Within the first days after surgery there is vigilance for atelectasis in the lungs (wind). In the next few days urinary tract infections (water) may occur. Leg pain and fever on subsequent days may mean deep vein thrombosis in the legs (walk). Lastly are the infections of the surgical procedure (wound) which may be discovered weeks or months after surgery. Wound infections are particularly difficult to treat when they are associated with a prosthetic joint replacement. These infections can transform a swift and bearable recovery into one which is complex and arduous. The image shows orthopedic surgeon, Hari K. Parvataneni, MD, covered with sterile head gear, preparing a knee for the insertion of a new prosthesis. After months of antibiotic treatment and disability, this patient now undergoes a second chance for a pain free and flexible knee. (2009)

Orthopedic Oncology In 1973 the world watched as young Edward Kennedy, Jr. underwent at Georgetown University Hospital an amputation of his right leg to remove what was thought to be an osteogenic sarcoma. Approximately the same year Memorial Sloan-Kettering and the Massachusetts General Hospitals began graduating the first specialists in Orthopedic (Orthopaedic) Oncology. In the 1980's the Musculoskeletal Tumor Society was formed for communicating advances in the treatment of bone cancers. Today nearly every urban teaching hospital has a specialist in treating patients with benign and malignant tumors of the bone. They use complex surgical approaches to remove the cancer and special techniques of limb salvage for the preservation of function. Within one generation of physicians, Orthopedic Oncology has grown from infancy to maturity, commanding a mastery of a frightening category of human afflictions. The image shows the lower leg of a patient with a rare metaplastic synovial chondromatosis undergoing an excision with total knee replacement by J. David Pitcher, MD. (2009)

Surgical Pictorialism Max Thorek, MD (1880-1960) was an internationally recognized surgeon, a famous amateur photographer of the Pictorialist movement and a master of the paper negative printing process. His photographic books include Creative Camera Art (1937)and Camera Art as a Means of Self-Expression (1947). His most enduring images are dramatic black and white studio poses of men and women enhanced with soft focus and chiaroscuro tonality. Thorek was born in Hungary and immigrated to Chicago where he finished his medical degree and practiced general surgery. In 1935 he founded the International College of Surgeons and has a Chicago hospital named after him. This black and white image of general surgeon Floriano Marchetti, MD is my homage to the Pictorialism photography of Max Thorek, MD. (2009)

Sinus Surgery Functional endoscopic sinus surgery (FESS), developed in the 1950's, has revolutionized the surgical treatment of sinus disease. Like most surgical innovations, it is the result of a convergence of scientific technologies; in this case, optical and radiologic imagery. Some procedures were once performed through an incision beneath the upper lip and required extensive packing, discomfort and a slow recovery. The modern technique uses an endoscope and CT scans to enter the obstructed sinuses through the nose. The sinuses, particularly the ethmoid, are close to the brain, the eye and major arteries, areas of major concern with FESS. In some procedures a three-dimensional mapping system combines CT scans and real-time information about the exact position of surgical instruments to navigate the instruments through complex sinus passages. The image shows the red sinus seen with the endoscope superimposed over multiple CT views of the sinuses displayed on a monitor. (2009)

Surgical Economics The possibility that accountants control industry and society was disturbing to Mexican muralist, Diego Rivera (1886-1957). On the south wall of the Detroit Institute of Arts (DIA) we see murals of automobile workers, scientists and physicians adjacent to secretaries and accountants; brain surgery Historical Images (1933) below an adding machine. Medical decisions are increasingly influenced by economic considerations. The productivity and economies of scale of the automobile assembly line pioneered by Henry Ford (1863-1947) are seldom achieved in healthcare. Furthermore, the cost of new innovative technology seldom is balanced by a reduction in medical costs. This image is a collage of a Diego Rivera DIA mural overlaid with a contemporary image of robotic assisted laparoscopic surgery. (2009)

Surgical Screen Screensaver programs, designed to prevent damage to computer monitors, filled the screen with moving images when the computer was not in use. This is no longer necessary with LCD monitors. Images on contemporary desktops are stationery and decorative with a range of displays including wistful landscapes of the Grand Canyon or the surface of the moon. But what may be decorative or wistful to a surgeon seems macabre to the conventional viewer. In the process of experiencing the many layers of the body, its inner organs and colors and x-ray shadows, the surgeon's perception of human form is permanently changed. In this image a surgeon sits next to the familiar computer desktop display with several dozen icons aligned in columns. However, the desktop image is not a scenic landscape but a panoramic x-ray view of a human skull, a skull with a large part of the mandible removed. (2009)

Surgical Puzzles A puzzle is defined as a toy, a problem or other contrivance which presents difficulties to be solved by ingenuity and persistence. Medical students gain stature and personal satisfaction when they learn to match a list of symptoms with a list of physical findings, x-rays and laboratory results, arrive at a diagnosis and solve a clinical puzzle. All physicians share the continual challenge to solve the clinical puzzles of their patients. Surgeons engage a unique dimension of a puzzle. Not only do they attempt to solve the puzzle, they also create the pieces of the puzzle. Their surgical treatment includes the design of shapes and pieces of tissues that they will later reassemble to restore function. The image shows a surgical correction of a hydrocoele with the superimposition of layers of rectangles creating an illusion of a solved puzzle. (2009)

Preemptive Analgesia Anesthesia has evolved beyond the single purpose of providing pain relief during surgery. Today many anesthesiologists undergo additional training to provide treatments for acute and chronic pain conditions. One area of expanding interest is preemptive analgesia for post surgical pain. In theory, the introduction of analgesia before the onset of surgical pain can prevent the sensitization and amplification of subsequent pain. This preemptive use of local anesthetics and narcotics might hasten recovery, speed mobilization and reduce the need for hospitalization. However, each pair of surgical and analgesic procedures needs to be carefully evaluated with respect to risk, cost and benefit. The image shows an anesthesiologist and trainee in the post anesthesia recovery room administering an interscalene brachial plexus block to a patient who is recovering from shoulder rotator cuff surgery. (2008)

Skin Incisions The skin, the outer covering of the body, is the largest organ of the body. It consists of multiple layers of tissues which guard and contain the underlying muscles, bones and visceral organs. Surgeons routinely violate this epidermal barrier each time they perform a surgical procedure. Surgical residents quickly learn that patient satisfaction can be related as much to the appearance of the healed incision as to the success of the operation. Endoscopic surgery, also called minimally invasive, Band-Aid, keyhole, or pinhole surgery, is a modern surgical technique in which a body cavity is entered through multiple small incisions (usually 1-2 cm). Several small incisions strategically located can produce a more rapid recovery with less pain than one large incision. The additional cost of the surgical equipment and duration of surgery are balanced by a reduced duration of post-operative hospitalization. In this image we sense the concentration as Bradlee Johnson, MD meticulously closes one of several small incisions used for an endoscopic urologic procedure. (2009)

Spine Surgery Bones do not rise to the poetic heights of the heart, brain, spleen or liver. And yet without this biologic equivalent to steel, the mightiest of human bodies crumbles. Upright posture, a legacy of Homo erectus, depends on a healthy spine. Disability of the spine increases with longevity and, therefore, is seen more frequently. Surgery, seldom the first choice of treatment, is performed when other treatments have failed. With modern intra-operative X-ray equipment as their handmaiden, spine surgeons offer treatments otherwise impossible. We peer through the virtual windows of X-ray images as Drs Trembly and Wang place and adjust screws and plates to stabilize three levels of the patient's lumbar spine. (2008)

Parallel Tubes Eleven parallel tubes piercing muscle and skin, aligned like the strings of a harp, the vertical cables of a suspension bridge or a 1930's string construction of artist Charles Biederman (1906-2004). The orthopedic surgeon and radiation oncologist rely as much on engineering as on surgery as they combine their skills to treat a cancer which has no cure. Someday the treatment for sarcoma of the femur will offer better alternatives, but for this patient the best choice is brachytherapy. Over subsequent days radioactive pellets will repeatedly traverse each tiny tube, concentrating their deadly radiation on the tumor cells while preserving the structural integrity and function of the patient's leg. (2008)

Surgical Collage In November 1932 the world's economies were in shambles. Capitalism and socialism vied for supremacy. Franklin Delano Roosevelt (1882–1945) was soon to be installed as the 32nd president of the United States. Poverty, rising nationalism, failed economic plans and public disillusionment would push world leaders into policies which would lead a decade later to World War II. And Jose Clemente Orozco (1883-1949), artist-in-residence at Dartmouth College in Hanover, New Hampshire, began design of a 150-foot mural, "The Epic of American Civilization." Orozco saw political ambiguities and failed truths through the eyes of a skeptic. He saw beneath the daily headlines a deeper existential failure of science, economics, humanism, religion and government. He used his primitive artistic style to shout a clarion call of despair to all who would listen. With the possible exception of Francisco Goya (1746-1828), no artist depicted the human condition of his times with more passion and skill than Orozco. Perhaps the most dramatic panel of his Dartmouth frescos is the next to last panel. Orozco portrays a morally bankrupt science and education with gleeful robed skeletons and test tube babies. The collage leaps over these 76 years and links this provocative Orozco fresco with a contemporary operating room. (2003)

Video Surgery 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 hidden 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 revolutionary 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)

Neck Surgery 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)

Surgical Darkness 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)

Fragile Surgery 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)

Surgical Vortex 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).

Surgical Compassion 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)

Double Vision 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)

Specimen Examination 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 R. 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)

Glass Walls 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)

Six Hands 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)

Ilizarov Surgery 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)

Surgical Manipulation 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)

Surgical Color 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)

Bariatric Surgery 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)

Anesthesia Goddess 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)

Cardiac Pump 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)

Transfer Tubing 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)

Patient Positioning 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)

Monitoring Glow 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)

Surgical Wand 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)

Position 22 Medical results are usually qualitative and difficult to quantitate with a number. A specialist in anesthesiology spends years becoming proficient in placing a breathing tube into the trachea. During a residency a trainee repeats the procedure in many different patients and under various medical and surgical situations. Once the tube is correctly placed in the trachea, a final adjustment may be required. The tube is positioned and secured at the correct depth which in this patient is marked by the number 22. (2007)

Orthopedic Motion 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)

Complex Surgery 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)

Scan Art 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)

Optical Art 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)

Surgical Ambiguity 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)

Vascular Tree 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)

Surgical Textures 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)

Surgical Journey 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.

Benign Reality 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. 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 Hospital willing to attempt this long and complex operation. (2004)

Surgical Pathology 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)

Primitive Surgery 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)

Surgical Choreography 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)

Glove Garden 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)

Holiday Anesthesia 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)

Transparent Mask 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 a transparent 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)

Surgical Headdress 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)

Abdominal Retractor 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)

Gravitational Bodies 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)

Surgery Dreams 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)

Surgical Coordinator 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)

Surreal Surgery 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)

Transplant Pool 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)

Surgical Triptych 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)

Ocular Productivity 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)

Amber Light 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)

X-ray View Box 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)

Surgical Sky 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)

Surgical Shards 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)

Candel Power 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)

Gangerous Foot 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)

Tracheal Intubation 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)

Surgical Quilt 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)

Starry Lights 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)

Winter Sponges 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)

Reindeer Healer 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)

Surgical Juxtaposition 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)

Surgical Sovereignty 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)

Abdominal Sarcoma 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)

Deco Surgery 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)

Spacesuit Surgery 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)

Andy's Surgeon 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)

Portico Illumination 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)

Escher's Hands 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)

Lilliputian Surgery 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)