Book Review

In Their Hands

N Engl J Med 2002; 346:949-951March 21, 2002

Article

In Their Hands
By Javed Siddiqi. 217 pp., illustrated. New York, Thieme, 2002. $49. ISBN: 1-58890-083-5

For millions of years, the hand has helped define Homo sapiens. With its prehensile thumb, the hand first enabled humans to make and use tools. Our brains envisioned civilizations; our hands made them. So crucial are hands that they permeate language and culture. A prominent example is the ceiling of Michelangelo's Sistine Chapel, on which God's hand touches Adam's.

Hands have intervened to heal since neolithic times, as demonstrated by the fossil record. Our very word for such practice, “surgery,” derives from the classical Greek words for hand (cheir) and work (ergein). Handwork has reached a zenith in modern neurosurgery, which combines extreme dexterity and technological sophistication to heal the human brain. There is also mystery in this endeavor, in which the brain (by means of the hands) repairs the brain — a philosophical paradox.

In this context, the hands of a neurosurgeon warrant particular interest. Javed Siddiqi, a neurosurgeon in California, has created In Their Hands, a remarkable collection of photographs of the hands of about 100 neurosurgeons.

The hands are rendered in artistic black-and-white photographs, in which chiaroscuro is often used with dramatic effects (Figure 1Figure 1). The hand positions are quite varied: many are in repose, others gesture or possibly pose. Some hands pray, some open in supplication, several show fists. Only one set performs microsurgery.

To understand the meaning of the hand positions better, I showed the book to two experts in American Sign Language. They found meaning in some of the static hand positions. The most common meanings were applause, promise, marriage, prayer, and wrestling — just coincidence?

The hands display some common features. All show evidence of having worked. All seem strong and determined. Can one detect the character of the hands' owners as well? Character, including self-assurance and determination, is certainly revealed in the portrait index in the back of the book. If these photographs of hands were mixed in with those of a general population, however, I doubt that one could identify the hands of the neurosurgeons.

There is also great variety among the hands. Some are small, and others have very long fingers. Some are perfectly smooth, others quite wrinkled. A few are strikingly beautiful, and several have pudgy or stubby fingers. The color ranges from very pale to very dark. There are a few examples of arthritic knuckles. This broad spectrum recalls the photographs contained in The Family of Man (New York: Museum of Modern Art, 1996), by Steichen.

These images invite comparison with pictures of the hands of Harvey Cushing, the father of modern neurosurgery. A drawing of his elegant hand holding a scalpel was the logo for the surgical service at the Peter Bent Brigham Hospital in Boston for many years. In a collection commissioned by him, Dr. Cushing's hands were depicted in plaster casts, along with the hands of leading neurosurgeons of the 1920s and 1930s. In contrast to all these static images, the movie of Cushing's 2000th brain-tumor operation demonstrates vividly the rapid, balletic motions of his hands during surgery.

Nonetheless, photographs, motion pictures, and even eyewitness evidence of surgical hands in motion do not reveal the essence of neurosurgical skill. This essence resides in the brain of the neurosurgeon, and the hands are only its handmaidens. Against a data base of neuroanatomy, the brain uses magnetic resonance and other types of imaging to envision in three dimensions both the brain tumor and the normal surrounding tissues. Then, with use of the surgical microscope, the neurosurgeon's brain directs motor systems to act through the hands, gently separating tumor from brain.

All the hands in this book, both the beautiful and the plain, can perform neurosurgery well. Perhaps a fine hand is not essential. In fact, experience has shown that persons with moderate manual dexterity can learn adequate neurosurgical skills, but every trainee must possess extraordinary determination, for seven years of hard work are required to attain proficiency.

You cannot spot a neurosurgeon just by his or her hands, and you cannot pick out the surgical genius from his or her colleagues. The hands of Gazi Yasargil, who was recently honored by his peers as “neurosurgeon of the century,” are included in the book. He says his nose is a secret to his peerless surgery. His “nose” must be some special sensibility that downloads all his relevant anatomical knowledge and surgical experience, integrates it with tactile and visual perception, and invisibly guides his hands to extirpate the tumor, with unmatched delicacy and speed.

Dr. Siddiqi began his collection of hand photographs in homage to his three principal mentors. When he recognized that there was a more general interest in such photographs, he expanded the series to include the hands of numerous prominent neurosurgeons and others in practice. These images are primarily inspiring for neurosurgeons, but others may be interested in the aesthetic, philosophical, and sociologic aspects.

What will the future bring for neurosurgical hands? Radiosurgery and endovascular techniques have already supplanted open microsurgery for several conditions. In the operating room, the neurosurgeon is now being guided by navigation systems based on magnetic resonance imaging. Robotic systems have been introduced to steady the hand and permit ever more delicate manipulation of tissues. In the future, neurosurgeons will most likely continue to rely on intelligence, judgment, and forms of technology to extend the use of their good hands.

Robert M. Crowell, M.D.
Berkshire Associates for Neurological Diseases, Pittsfield, MA 01201