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Chest 161; Our Paddock

22 May


cHEST 161

Chest 161, Our Paddock 2017

The hills in this image are those behind our little farm, rising above them are the remnants of a chest X-ray taken from a very small, very sick newborn baby who had developed many complications arising from his prematurity including a pneumothorax (air in the chest spaces compressing the lungs). The infant is being ventilated and kept alive through the skill of the neonatologists. His hold on life is indeed tenuous, as is the hold we have upon the land we love.

Lux – Light; pel-lucidem

7 Nov
Lux pel-lucidum J

Lux – Light; Pellucidum

The middle of the human brain contains a membrane structure that separates the two halves of the cerebrum. This membrane, a septum, so fine that it allows light to pass through it, it is almost translucent; pel-lucid, named in Latin; the septum pel lucidum, i.e. the dividing wall that is translucent.

Absence of the septum pellucidum occurs in certain congenital conditions and because the septum is involved with formation of the tracts concerning vision, it is often associated with blindness, and incidentally many other neurological problems.

I have included the X-ray of a newborn baby with congenital absence of this structure as well as absence of other brain structures. The Chest X-ray itself was normal.

The image consists of two base images; a red flower, colour inverted, and a layer of rusty iron is subtracted. Light (lux in Latin) is provided by a picture of a candle overlaid to give focus to the image.


Chest 117; Silicosis

7 Nov
Chest 117 MPF 2C

Chest 117; Silicosis

After a good friend married to a mining engineer asked me to consider make a picture relating to mining diseases, I chose an X-ray of a person with severe emphysema and Progressive Massive Fibrosis of the lung due to silicosis. The name silica comes from the Latin word silex – a flint.

My upbringing from the late 1940s through to the 1970s was in a small copper-mining town, part of a series of mines known as the Copperbelt in Zambia. Almost the entire population was dependent one way or another on Copper Mine for a living, as was my father who worked underground. Underground workers spent their days breathing silica dust released during blasting. The Miners Phthisis Board figured prominently in all our lives and had the power to dictate the difference between being allowed to work or not.

Miner’s phthisis (or Potter’s Rot) is a debilitating occupational disease due to deposition of fine grains of crystalline silica dust in the lung, and the body’s immunological reaction to it. It causes fibrous scarring of the lung that restricts the ability of the tissue to absorb oxygen in exchange for carbon dioxide. It leads to emphysema with chronic shortness of breath, cough, and cyanosis (blueness of the skin). Sometimes the immune response is overwhelming and causes large lumps of fibrous tissue known as Progressive Massive Fibrosis (PMF) to form. It predisposes to infections, especially TB, and the tissue can break down causing lung cavities.

A major concern in mining and other industries, silicosis has caused such devastation that it is an important economic issue which governments cannot ignore, therefore focus was very much on the financial interests of mining. Other risks of silica were not appreciated till relatively recently. Since the 1990s there’s been re-evaluation of its role in triggering auto-immune diseases such as rheumatoid arthritis and sarcoidosis.

The ubiquity of silicosis throughout the world has given rise to an entire culture, particularly within coal-mining communities. Many ballads, poems, and works of art relate to this disease. The paradox is that the men must work to live, whilst knowing they work to die.

The opening stanza of Gabriel Gadfly’s Poem Briar Patch gives a taste of this;

Press your ear close.

Sometimes you can hear the breath
rattling in my chest like a bone shrugged
its moorings and ought to be tied back down…..

A 1940s lino-print The Cough by Noel Counihan 1947 is particularly moving and reminds me of heart-wrenching encounters with men, struggling for breath, dying of emphysema due to dust inhalation, smoking, and recurrent infections, whilst I was working in a chest hospital in a coal mining area of England.

The cough

The Cough, Noel Coulihan 1947

My picture, based around a severe case of PMF with collapse, fibrosis, and cavitation in the upper zones of the lung, includes photos of a mining rock-face and a shaft headgear such as those that were central to our life in Zambia, and which will be familiar to many mining communities. On the right side of the image a faintly perceived ghost-like figure can be seen.

Chest 120: Etched in stone

1 May
Chest 120 Stone

Chest 120; Etched in Stone

The Chest X-ray in this picture was from a man, an ex-smoker, who was losing weight, with a cough and localised wheeze in his chest. An area of density in the lung on the X-ray was obscured by blood vessels and it was determined as normal. Because the test was described as normal, clinical signs and symptoms were disregarded, no further tests were done, and the man presented months later with a large inoperable cancer. A court case followed.
A radiological diagnosis is not etched in stone. Over a long career I have been involved with many cases of physical child abuse, and for many of these been called as an expert witness in a trial of the accused abuser. It was during these trials where I discovered that medical evidence and legal evidence are two entirely different things.
Medical evidence is often fuzzy relying on statistical likelihood of a diagnosis based on imperfect criteria – sounds heard through a stethoscope, lumps palpated with the hand for example. The art of medicine is about management of uncertainty. Legal requirements on the other hand are for precisely defined points. Lawyers, and many doctors, treat a radiological image as hard, clearly defined evidence; the experience of my career tells me it is anything but!
Paradoxically, as imaging becomes more sophisticated and sensitive the importance of clinical judgement in deciding both when to order a test and to assess the clinical relevance of an abnormal finding on that test becomes more important. Real but incidental sub-clinical anatomical disorders such as normal developmental variants and degenerative changes that are not symptomatic are frequently detected. These types of changes are present in a large proportion of people with no symptoms. It is therefore important to know that a test should not be ordered unless it is likely to influence or change the treatment of a patient (although there are a few exceptions even to that rule).
Many types of errors creep into diagnosis, and it can sometimes be difficult to trust one’s own judgement. This phenomenon has been extensively studied, but the following example will serve to illustrate just one type of error in which the context determines interpretation. In the top line most people read A B C. However, exactly the same letter B when inserted into another context now reads as 13. In this type of framework the image itself can be treacherous.


Adapted from: Kahneman D. Thinking, Fast and Slow. Farrar Straus & Giroux, 201

The Belgian surrealist painter, whom I greatly admire, René Magritte’s painting of a pipe “Ceci n’est pas une pipe” whose correct name is “The treachery of images” has fascinated me since I began studying radiology. It is about the relationship of an object and a representation of that object.

The word is not the thing; the map is not the territory (Alfred Korzybski). And so, the X-ray is not the patient. It is a well-known, but poorly understood , medical aphorism; “Treat the patient, not the X-ray”. And so it should be.

Chest 113; Where the smoke goes

27 Dec
Chest 113 Where smoke goes C

Chest 113; Where the Smoke goes

I am preparing for an art installation in September 2015 and thoughts are turning about how to do this. One of my ideas, likely to be heavily modified as I realise the problems involved, is to project an animation of the development of one of my digital pictures from the source images into a piece of art.

To this end I have been experimenting with recording every phase of a picture as it is made and have come up with 30 images, starting with the source X-ray and passing through various iterations until I am satisfied with the outcome.

I’m not sure that I will use this image, however it is a start.

The X-ray was from a man, a smoker with severe emphysema and a lot of nasty changes in the lung that looks like the development of a lung cancer. My thought process revolved around air, wind, fresh air and polluted air, trees and leaves, cancerous invasion with fire and fury, and I wanted to direct the message of this image towards those ideas.

As reference images I included trees and grass from our paddock, an autumn red leaf close-up, and a strange triffid-looking plant encountered on a windy hillside in Hawaii on a previous holiday.

Colours (2)

Green colour

Flowers (3)

Triffid plant in Hawaii

Red Leaf (1)

Autumn leaf closeup

Trees (8)

Paddock, eucalyptus trees

Weeds (2)

Long grass and weeds

Here are the base pictures, with a few of the intermediate images. I used mainly the blending modes “Difference” and “Pin Light”. I left both the X-ray and triffid as “Normal” and using the “Magic Wand” tool subtracted large amounts of unwanted information, using the interesting shapes that were left to mask between different layers. Both of these layers were enhanced in “Effects” using a “Drop shadow” on one and “Bevel & Emboss” on the other. Insertion of a “Normal” layer as a mask means that the blending effects below are nullified producing a contrast with those that are not masked.  I warped the triffid in the “Transform” mode under “Edit” as part of the composition so that the point where the cancer is developing was focussed in the lower right – following the rule of thirds.  I finally colour-enhanced using the “Curves” adjustment.

The resulting image is dramatic and quite violent. It gives the impression of collapsing in flames.

Chest 112; Tummy pain

19 Dec
Chest 112 tummy pain

Chest 112; Tummy pain

The index X-ray is from a person who had a knife wound in the abdomen showing a lot of gas in the peritoneum due to perforation of the bowel. This lead to peritonitis from soiling of the peritoneum with bacteria laden bowel contents that leaked through the hole. Damage to the pancreas frequently occurs with penetrating abdominal injury with release of enzymes that make inflammation much worse. Growth of the organisms can cause infection of the bloodstream. This is a very serious situation and can lead to abscess formation, gangrene of bowel and septic shock. It is frequently lethal and must be recognised early. One of the first signs is gas in the abdomen seen on a chest X-Ray at the time of presentation.

The Chest X-ray visible in the background with the word “Erect” just visible indicating they were upright when the picture was taken. I’ve overlaid this with a picture of watery seas and a flaking door frame. The interaction of crossing lines in the right lower zone pulls the eye to the right but tension is caused because other lines within the image converge toward a point off the margin on the left, pulling the other way. A ghost reflection of the original X-ray is seen on the left.

Chest 111; Golden holes

12 Dec
Chest 111 C

Chest 111; Golden holes

Not long ago I saw a dreadful case of staphylococcal pneumonia in which a child’s lungs were very badly damaged, many cavities in the lung tissue occurred as abscesses formed. This was a so called “super-bug” – a “golden staph” called that because of its colour on a laboratory culture plate. Generally this is a harmless commensal that lives on our skin but can cause boils and wound infections. The multiresistant form tends to originate in hospitals where it has developed antibiotic resistance and mainly spreads through patient contact. Lung infection is commonest in young children and debilitated people, it starts as a short fever and goes on to severe breathing problems. Our case needed intensive care for a long time.

Stimulated by this for my picture I went to the X-ray archives and found a museum case with similar appearance as a basis. The ideas and connection with my layers was simple, taking the idea of holes in the lung tissue. The pictures were torn to pieces electronically, superimposed one on the other, and then inserted the X-ray using edge enhancement and the “find edges” tool. I used two photos of our back paddock with the golden colour of the grass contrasting with the blues of the sky above. I intended originally to give the impression of a watercolour painting but loved the granularity this technique produces. The golden colour and the tough, gritty, coarse texture is very like colonies of staphylococcal bacteria growing on a plate.

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