Deconstructing the body: medical art, medical imaging and the art of medicine, September 24, 2015

- [Donna Hirst] Welcome to the first History of Medicine Society Lecture for this current academic year. We have lectures basically once a month through the academic year, and in addition to the lectures we have a list serve where information is shared, little newsletters, miscellaneous things. So, if you would like to be on the mailing list for the History of Medicine Society, there's a signup sheet over on the ledge to the back side of the room and you just need to put your name and your email address. It's a very low traffic list, so it's not something that you're gonna get things everyday, you might get half a dozen things a month. So today I'm introducing Richard Kerber, who's gonna be talking about deconstructing the body with the focus on art. After medical school at New York University, Doctor Kerber trained in Internal Medicine and Cardiology at Bellevue and Stanford University hospitals. He spent two years in the U.S. Army, one in New Jersey and one in Vietnam, where he was awarded a Bronze Star from the United States and a declaration from the Republic of South Vietnam. Since 1971 he's been a member of the cardiology faculty at the University of Iowa hospitals. He established and still directs the Echocardiography - [Dr. Kerber] That's right You got it. - [Donna] laboratory and was interim director of the cardiology division for three years. He is still working, but is beginning to reduce his hours. His research interests are in echocardiography and cardiac resuscitation. He was very involved in the development and widespread use of automated external defibrillators and is currently exploring the potential use of ultra fast hypothermia achieved by cold liquid ventilation during CPR. Doctor Kerber has enjoyed many professional and academic successes, including at least 252 peer reviewed papers, and I suspect the number is much larger than the number I found on the web. He was the president of the American Society of Echocardiography and was chairman, twice, of the American Heart Association's National Emergency Cardiac Care Committee. Outside of work, Doctor Kerber's family is very important to him. His wife Linda is an accomplished faculty member in history and his two sons are a journalist and a rabbi. He enjoys bicycling, and playing the clarinet, so my assumption is that much of what we're gonna learn today is not about the heart particularly but about some of Doctor Kerber's broader interests. So, thank you. - [Dr. Kerber] Thank you Donna, can everybody hear me? - [Audience] Yes. - [Dr. Kerber] So the Republic of South Vietnam that was mentioned is an operation that's gone out of business and there is no forwarding address. Okay, so you've heard the title, and what I'm going to do is spend a good bit of time reviewing how artists have portrayed physicians, illness, therapy through the ages but beginning about 1500 and concentrating mostly on Western artists with occasional examples of oriental and Native American art. Then we'll briefly talk about the rise of medical imaging beginning with Roentgen and X-rays in 1899 and then I'm gonna end with examples of how contemporary artists have integrated into their art, particularly when it concerns the body and illness, how they've integrated these medical imaging techniques. So let's begin with anatomy. Now even though I said I started around 1500, this image is a little older, this is probably about maybe 10,000 B.C. and it's one of the cave paintings from Spain and it is thought that this is a bison like creature, and there's the heart. Now it takes a little imagination to believe that, but this may be the oldest depiction of the heart. Skipping forward about 10,000 years, we get to Vesalius and that's really where we should begin. So this is Vesalius' foundational tome. This is the frontispiece, and as you see Vesalius is conducting an autopsy here with hundreds of onlookers, some mythological, some real but not very identifiable. If you look at a close up you see Vesalius himself, and this is the part of the autopsy where the internal viscera of the abdomen are demonstrated. Autopsy scenes are common in Western art, and you'll see others with maybe a little more detail. This is the seal of the American College of Cardiology, which is sort of our guild in our profession. Guild in the historic sense of representing us to people who might determine our income but they have adopted as their logo this Vesalian heart, this is a heart that's drawn by Vesalius with the intercostal arteries of the chest also shown. So these are illustrations from Vesalius' anatomical tome. I don't know if we have, do we have copies of Vesalius? - [Donna] First and second edition, well we have many of his works, but certainly the tome, - [Dr. Kerber] Okay, so you see some of the originals in our library, in the Hardin Library. The custom in Vesalius' book and others, was to show the sections but in a sort of allegorical, active way, so this is the muscular system, this is bones and blood vessels and here of course we're interested mostly in bones. I just love this pose, the skeleton examining the skull of maybe a colleague. This pose is not so different from one that may look familiar to you, so this is Rembrandt, and this is Aristotle Contemplating a Bust of Homer. So this particular portrait was bought by the Metropolitan Museum of Art in New York when I was a medical student in New York, for then then unheard of price of three million dollars. In fact there was a lot of discussion about was that a wise use of museum funds to spend all that money on one painting. Of course today, a hundred million buys you, I don't know, a second line Van Gogh or some such. This is Michelangelo in the 16th century the Sistine Chapel. Paintings had become a little more lifelike then, perhaps, so this is the creation of the sun and the moon. This is God, unidentified figure, no doubt the origin of the term mooning. And this is creation of Adam, sometimes called the creation of man, mankind. God is breathing life into Adam through this connection here. We'll see this theme come back again a little later on in the talk. Let's go on and show how artists have portrayed various illnesses. I need a diagnosis from one of the physicians in the crowd. No takers, this is a disease that I fervently hope none of you will ever see in your lifetime. This patient has smallpox, okay. Eradicated from the face of the earth, except for a couple of laboratory stocks closely held in the U.S. and Russia and maybe other places that we don't know about which is a really scary thing. Anyway it's smallpox. This is the sketch of a Broad Street pump. Remember the story, cholera epidemics were common in London and other crowded cities at the time. Water was unsafe except in communal pumps which were supposed to be safe. This one turned out to be dispensing contaminated water from a latrine that was too close to the source, and the epidemiologist Snow figured out by the placement of various cases plotted against a map of London that this pump seemed to be the source of the epidemic, or one of the sources. That led to the realization that the water was contaminated. So the art is often, what's the word, humorous and not very realistic, so this is a patient who has colic and you see these little devils are sewing away at his abdomen This patient has a headache, and who could be surprised with all these guys banging away at his head. This patient has gout, happy little devil chewing away at his toe, and of course gout was understood to be associated with high living aristocrats, aristocratic practices like this well dressed upper class individual who has the leisure to practice his cello and drink a lot of wine and suffer gout. This devil here is perhaps punishing him for all of these activities. All of these are satirical demonstrations of how artists often viewed art, and this is a early twentieth century ad from France. Even then tobacco was understood to have, what's the word, unsafe consequences, and whatever this No-To_Bac was it was pedaled as a, what's the word, drug perhaps, I'm not sure what it was really but pedaled as a drug to cure the tobacco habit. The French of course are notoriously concerned with their livers, they consume a lot of red wine so they should be concerned about their livers, and this product was intended to wash all the bad things out of the liver. I just love this rather graphic description. Okay, so doctors came in for a certain amount of hitting but also a certain amount of respect. This is the firstkind of reaction. This is hydrotherapy, and this is the water cure and here you see a helpless assistant being berated by the physician for not bringing enough water or not getting it there soon enough so they could administer the cure to the patient. This is Gulliver's Travels, Hogarth. Punishment inflicted on Gulliver. It looks to me like he's getting a high colonic here, but whatever they actually are intendingto be understood by this it's clearly not a very pleasant sensation, and of course this was quackery and it's a lot of quackery in high colonics even today. Vaccination was laughed at, feared and respected by various individuals at various times. So this was a sort of vaccination party, where patients are being vaccinated. Some onlookers are horrified, some onlookers are probably drunk, but there's a lot of activity going on in this somewhat public way. Here's perhaps a more respectful demonstration. This is 1807, and here you get the sense that there's great concern about the process and about whether this is dangerous for the patient. The great, dignity given to the physician by the painter, great respect obviously. Whoops, sorry. Here we go. So physicians were used to being called out for house calls and often in emergencies, and this bust I think by Remington is a physician being brought by the fastest possible conveyance to the bedside of a very ill patient, but unfortunately sometimes the doctor arrived too late which is the theme of this painting. The patient has already expired, a grieving widow by his side. So when I decided to study medicine, I had this vision of medicine as a very contemplative profession. You would talk to the patient, you would think about the patient's problems, you would carefully examine the patient, you would spend a lot of time doing all of those activities. Sadly it doesn't usually work quite like that, and I can't remember the last time I was able to think in a leisurely way about what actually might be wrong with this patient. And sometimes, you have to, what's the word, get friendly with a patient and his family, and in this Norman Rockwell illustration this doctor is carefully examining this patient's doll before probably the patient would allow herself to be examined. Another Rockwell painting, I think Rockwell is poking fun at himself a little bit, but this was a typical sort of scene in the 1940s. Many doctors had practices in a room adjacent to their home and in some cases they saw the patient not only adjacent to the home but in the home. So you get the sense this is the doctor's study, he's got a few hunting trophies here, he's holding, you can barely see it, a stethoscope and it's not clear to me whether the patient is the baby that the mother and father are anxiously discussing with the physician, or possibly this is the patient who isn't allowed to get too close for fear of fright. This is a Victorian artist, Edward Poynter, A Visit to Aesculapius, the Greek god of medicine and healing. This is Victorian, 1880. The Victorians have this reputation for prudery, right, they were very prudish about nudity et cetera. It turns out they were really intensely interested in nudity and sex but it wasn't quite acceptable to acknowledge that. However, you could paint nude women, naked women, as long as you put some gloss on it that gave it a classic air, so hence A Visit to Aesculapius giving the artist the opportunity to paint these four naked ladies without shocking anybody because it was a classical theme. This is Winslow Homer, a scene, a sketch from the Civil War. So this is a sort of treatment on the battlefield. Here is presumably the doctor making notes, and he's using as a desk the back of a private because it's so chaotic in the battlefield. You can see horse drawn wagons bringing new casualties in. Remember, that in the Civil War abdominal wounds were always fatal from sepsis, if not hemorrhage. Head wounds were always fatal. Arm and leg wounds could be survived, providing that the limb was amputated and amputated very quickly. So they became very skilled in very rapid amputation. The anesthetic was usually several glasses of brandy poured into the patient very rapidly and hopefully that would have made the patient at least sleepy, although it all happened so fast my guess is not much of it even got absorbed. Probably, that's why this person is holding a knife here, I'm guessing that he's explaining to this wounded soldier what's about to happen to him. Things maybe improved a little bit by the Crimean War. This is Florence Nightingale in a battle scene, again more wounded soldiers being brought in and initial examination and triage, as we would understand it probably being practiced by Florence Nightingale here. This is France, an advanced dressing station in France, dressing meaning bandaging the wounds. This is very advanced because you can see there's been combat bombardment in the background, and again all kinds of chaotic medical activities are taking place in the foreground. This is a depiction from time of the Panama Canal. So the biggest, or a major problem of illness during the digging of the Panama Canal was yellow fever, and there was debate about how this disease was spread. We now understand that it was spread by mosquito, it's a mosquito borne virus. In this depiction, what's being shown after the fact is an experiment where several volunteers, enlisted men, and of course volunteer in a military setting is akin to volunteering a prison setting which is not considered acceptable anymore. But anyway, these enlisted men had volunteered and what's being shown here, is they are being bitten by mosquitoes in this tube, which is placed on exposed skin of the subject after the mosquitoes had been allowed to feed on patients who had yellow fever. And the experiment the clinical experiment, is that if it's really a mosquito borne disease, then these individuals will get ill here. In fact, what happened is they did get yellow fever and at least two of them died from yellow fever. I'm not sure which of these individuals is Walter Reed - [Audience Member] The one in white. The one in white. - [Dr. Kerber] The one in white? Thank you, this person? - [Audience Member] Yes. - [Dr. Kerber] Fanciest uniform so I should have guessed that, thank you. Walter Reed apparently was nowhere on the scene at the time, but that didn't stop the artist from painting him in. Okay, so let's transition to medical practice, and there are lots of scenes from antiquity on which display various practices. This is Ulysses having a wound treated, probably an arrow head or perhaps a broken knife is being dug out of his skin. Standing, I learned very early in medical school that you don't do anything to a patient who isn't lying down. This is pretty crude, this is an apparatus to set a fracture. Remember, little or no anesthesia, what anesthesia there is is supplied by alcohol, and you can imagine how painful this probably was. Here is a patient receiving medical aid from a friar, so this is religious based therapy. Many scenes paint that. Here's another version, this is a Native American shaman trying to cure, hopefully curing the patient who's dimly shown in the background. And this is from Asian art, what is happening here? This physician or healer is performing a diagnostic maneuver. - [Audience Member] Checking the pulse. - [Dr. Kerber] Taking the pulse, exactly. And taking the pulse was considered very important for many years in Asia and Western medicine. There are treatises, many treatises on the various diagnoses you can make from various pulses. We still teach our medical students pulses parvus and tardus, slow and delayed carotid pulse if the patient has aortic stenosis, so called warhammer or bounding carotid pulse, if the patient has aortic regurgitation. So although we have other tools today, palpation of the pulse is still carried on and was a major diagnostic tool for many years. Here's a scene from Indian art, again the pulse is being taken. And in this scene, probably 18th, maybe 19th century, probably 18th century, I'm sorry I don't know who the artist is, again the pulse is being taken. You have a feeling he just made a diagnosis from taking the pulse. In some cultures, it's considered improper for a male physician to examine a woman, but if the woman wasn't displayed, other than maybe her hand, you could at least take the pulse and make a diagnosis. And here, these are two physicians attending George Washington in his final illness. Again, I think the pulse is being taken. We've advanced scientifically to get an accurate count of the beats per minute. Okay, what diagnostic maneuver is being utilized here? - [Audience] Uroscopy. - [Dr. Kerber] Pardon? - [Audience] Uroscopy. - [Dr. Kerber] Right, this is uroscopy, examination of the urine, and the flask containing urine is being examined by a physician. Same idea here, although the surroundings are a little rougher, this looks like probably it was taking place in a neighborhood bar, and the person examining the urine is presumably conducting, consulting excuse me, a medical text to help affirm or make a diagnosis. Same thing here, again now back to a more refined setting, more aristocratic patient. And here, you have a combination of taking the pulse and presumably this is urine that the physician has been shown or will be shown to perform the uroscopy as well. This is Jan Steen, 1663. Group paintings, group portraiture, is an old staple in western and other art, so this is a military company where we see some gathering, they are wearing very fancy dress uniforms, this is no combat, but they're being portrayed with their military equipment, and the key point is that this has a documentary function. Today you would take a photograph, but they didn't have photography in the 17th century so the artist has to draw every face and make it recognizable. Let me go back here a second. So it serves its function but it's not very interesting art unless you happen to be one of the people in the group. Contrast that with what Rembrandt does. So this painting you can see, it's actually cut off a little bit at the edges, it's even bigger than this, it's an enormous painting. It's known as the Night Watch. Most probably the militia company of I think it was Captain Frans Banninck Cocq who is here, and his lieutenant is here. So again, it serves the same function, it's documentary. You can identify every individual in this painting including the few at the edges that I've cut off. There's lots of activity, it's a very interesting painting to look at. You have unexpected things like this cat racing through and this little girl racing through, maybe somebody's daughter. But it's a group painting, it's a group portrait. This is from the wars, remember Spain ruled the low countries, which are now Belgium and the Netherlands, and the Netherlands succeeded in breaking away from Spanish rule much more so than the southern countries or southern provinces I probably should say. The militia companies, especially the in Netherlands, tried to protect towns and villages against the Spanish armies that were trying to restore Spanish rule, so this is a group of very aristocratic volunteers who I doubt actually saw much combat and certainly not in these fancy costumes. But this is again an example of group art, but not yet medical art. Now here, here we are about to do an autopsy, being conducted by a group of physicians. This is Dutch, with those characteristic ruffs that they are wearing. Again, serves the function as documentary, but it's not such interesting art. Contrast again with Rembrandt. This is The Anatomy Lesson of Doctor. Tulp. So this is the Amsterdam field of physicians to which if you were well connected and fine physician you got elected, and you were expected to give a lecture and often it was in the form of conducting an autopsy. So here you see Doctor Tulp conducting an autopsy. The autopsy is, at this point, in the section of the arm. You can barely see it here but this is Vesalius' text that was being consulted, being watched by the physicians who are also watching, overseeing the section. As a painting, it's a great painting. I mean you have this wonderful triangular sort of shape, your eye goes to Doctor Tulp and then travels up to the peak of the triangle. It's worlds different from that rather flat and uninteresting kind of documentary paintings that we've seen before. Clinical Lesson at the Salpetriere, 1887, this is a class. This, the Salpetriere apparently was a place of French medical instruction. This is Charcot conducting a class. Here is a patient, Charcot of course, Charcot-Marie-Tooth disease, Charcot Joints. This is Tourette watching the discussion here. This is the patient being supported by Babinski of the reflux. Every face here is identifiable and has been identified. Every person is known, and yet it's a very interesting patient and I remember early classes that I went to as a medical student, we didn't usually have patients being walked in and being held up, but they were often on gurneys that were wheeled in and they would be inspected by the person giving the lecture. We still have so called grand rounds but they're not much in real grounds anymore, and we rarely see patients in the flesh. We hear about patients. Same idea, every face identifiable, so a combination of art and documentation. This is very famous, many of you will recognize this. This is The Gross Clinic by Thomas Eakins. It's an enormous painting, this really has no frame of reference to judge it. So this is about 1870. Here is Doctor Gross explaining to the medical students who are up in the old surgical amphitheater, very steeply banked so it could look down at the procedure that was being conducted. Doctor Gross is lecturing while his assistants are working on the patient. It's been suggested that this is the patient's mother, allowed to be there and supposedly one of these figures is actually a self portrait. It's kinda hard for me to tell of the paintings. So notice, of course, that Doctor Gross is wearing elegant street clothing. You don't see any gloves, you don't see any masks and this is a picture that portrays no knowledge of sepsis. No evidence of any antiseptic techniques. But by the time this picture was painted there was a very hot discussion going on about germ theory and whether antiseptic techniques should be part of contemporary surgery. Eakins painted this, which is the Agnew Clinic, some years later. Same idea, you have a physician lecturing while an operation is going on. Medical students watching as best as they can. Notice now they're not in street clothes, they're wearing aprons, they're wearing gloves, they're not yet wearing masks. You have a nurse in attendance as opposed to the patient's mother, and it's all much more professional and shows the influence of this idea of germ theory. It's thought that Eakins was actually painting the first one as a criticism of what was being done, and he painted this as an endorsement of the antiseptic techniques. Not everybody agrees with that interpretation of these two paintings. This is a painting, again much after the fact, of the first use of ether, which was done at Massachusetts General Hospital. They still, when you visit Mass General they take you up to the Ether Dome, which is room on top of the hospital with a big glass ceiling because they had mostly artificial light, and that's where ether was administered and that's what's happening here. It was a dental procedure. Here is the key, where every one of the participants who were known were participating can be identified. This wasa little riff on this done I believe also at Mass General, a sort of reenactment, a contemporary reenactment with various professors who are dressed in costumes who are here and a key was published so they could identify each professor. We oughta do something like that. This is a walkthrough, a walk down memory lane for me. When I arrived, well when Linda and I arrived here in Iowa City in 1971, there were still a number of these old Florence Nightingale like wards. Long rows of beds, patients lined up along the sides. Here's the single stove to warm the whole ward, the heating was a little better here in 1971 except on really cold days, and at least they had curtains. As a medical student at Bellevue Hospital in the 1960s, same kind of open wards without these curtains on rails. If you wanted to examine a patient with some privacy you dragged a portable metal device with a curtain and put it up around the bed and then you examined the patient. This is by Van Gogh, this particular painting. Okay, now let's change gears a little bit and talk about medical imaging. If you're interested in the subject I highly recommend this book, Medical Imaging in the Twentieth Century. A number of the illustrations I'm gonna show you are from Doctor Kevles' book. I got her oral permission to show the illustrations that come from the book and you'd have to do that if you wanted to show. This is fair use, we're gonna use this in lecture. This is not gonna be on our website and not on YouTube, because I don't have permission to disseminate this outside the lecture, so you have to listen hard now because you're not gonna be able to see it on the web. This is, the assassination, or the attempted assassination of President Garfield. So Garfield was shot by an anarchist when he was attending a commercial medical fair of some kind in Buffalo. He didn't die immediately, the bullet entered his abdomen, and the surgeons felt that if they knew exactly where the bullet was they would be able to probe it and get the bullet out and he would recover. But they were afraid to just indiscriminately probe, so they hired Alexander Graham Bell, who thought that by using this wand like device while an assistant listened to whatever sounds were heard they would be able to locate the bullet. And so this drawing documents that. They never were able to locate the bullet and he died a long and slow death unfortunately. - [Audience Member] The reason they couldn't locate the bullet is there were metal springs in the bed. It's thought now that would have actually worked if not for the interference of the spring mattress he was laying on. - [Dr. Kerber] Is this thing still working? Good, gets you to walk around a little bit. Okay, thank you. So this is, we're now gonna talk about Doctor Roentgen's wonderful advance. Roentgenography as it was initially known, subsequently radiography or X-rays, and this is Doctor Roentgen's wife, this is Frau Roentgen, with her ring and a nice demonstration of the bones. Every physician, once this technique became widespread, which it did very frequently, every physician in their private offices would have one of these crude fluoroscopic devices. I remember again as a medical student in the 1960s in New York and visiting some practices, we were invited to do so by some of our professors, who had evening hours, you could go to their office and they were using devices like this. The problem was most of these devices were not calibrated properly and the amount of radiation surely exceeded what would be accepted in contemporary practice. But these devices were widely sold, and here is the well known use of sex to sell products. This is by the manufacturers of the device telling that if you were a physician and bought their fluoroscope you would get at the naked truth of the bones et cetera. And of course, if the devices weren't calibrated and radiation doses were humongous, which they were, then you got various radiation injury as this early radiologist demonstrates here having lost a couple of fingers. Ultrasound became available about in the 1940s and 50s, but you had to have a medium to couple the transducer to the patient because ultrasound does not travel through air. So here, the ultrasound transducer was gonna be lowered into this tub in which the patient will be sitting and examination of the abdomen was being conducted. Same idea here, except they're looking for midline shifts, shifts of the midline brain structures which, if present, would indicate a clot, a subdural hematoma et cetera. So the patient is encased in liquid and the transducer is here and, therefore, the ultrasound can penetrate and show whether there's any midline shift or not. Here's ultrasound applied to, in this case, a heart of an animal, a cow I think that's been removed and sliced open and placed where ultrasound can traverse it and give these various echos from the muscular structures. This is the interventricular septum, this is the mitral valve, left ventricle, right ventricle et cetera. And this, if you get a recording like this and then sweep it across an oscilloscopic screen you get a pattern like this, and this was known as M-mode echocardiography, M meaning motion, and in this case this is the characteristic pattern of a beating heart and this is obtained from a patient and you see the mitral interpretation of the mitral valve opening, this is an EKG for timing up here. Closing in mid diastole, reopening with atrial contraction occurring with the P wave here, and then closing here. This technique is still in use today. Originally it was done with what was called an ice pick device. It was a single transducer, a little bigger than my finger, the technician moved it around the chest and just by looking at the screen could determine through pattern recognition what they were looking at. Now it's done with a two dimensional technique, and this kind of pattern is recorded by putting a cursor right through a two dimensional image, but we don't rely on this kind of technique very much. In fact, we rely on two and today three dimensional echocardiography. The inventor of this technique was a Swede, Doctor Edler. Doctor Edler worked in Lund, which is like the Iowa City of Sweden it's a small university town and it had a university hospital. Edler worked there and Edler had the idea that you could use ultrasound to make diagnoses noninvasively, and he learned that there was a device that was used for what was called non destructive mineral testing in Malmo, which is a seaport maybe a hundred miles from Lund. So he asked the people who owned the industrial device if he could borrow it to try on patients and they said sure, but we used it all week so you can have it on the weekends. So every Friday night he drove to Malmo, got the device, loaded it into his Volvo, drove all the way back, studied patients during Saturday and Sunday. Sunday evening he drove back to Malmo and used it. There was a wonderful symposium in Edler's honor when he retired. The symposium was held in Lund, I was one of the invited speakers which was very nice, and they had the original of this device on display at the symposium. Alright, so this is the last part of the lecture. How have contemporary artists used these techniques? I didn't have time to show you MRI imaging, magnetic resonance imaging, computed tomography, lots of techniques that we use today, nuclear techniques. Here is Rauschenberg taking various radiographic views and adding his characteristic sort of non sequitur, there's a chair here, what else have we got here? Book maybe, I'm not even sure what some of these things are. This is incorporating just straight forward medical imaging directly into the art. Here is a mammogram, as you can see here., and this is the breast, perhaps as portrayed by the artist. Now you see a skeleton, okay, which has been, painting of a skeleton really as you might see if you had an X-ray of somebody's back, somebody's spine. So this is well known, this is Frida Kahlo, the feminist icon. Frida Kahlo was involved in a terrible bus accident, as a teenager, a trolley car in Mexico City as I understand it, and she was impaled literally on a big bar that penetrated her spine. She wasn't expected to survive, she did survive, but she had back pain all her life, she suffered terribly. So this is a self portrait, Frida Kahlo, and it's a broken column, it's a Roman column, fractured, the body is being held together by these bands, and so this is, in a sense, in a sort of metaphoric sense, adapting what we know of spinal fractures, spinal injuries, into this self portrait. Okay this is kind of nasty, these next two images. This is a poster by John Hartfield, Hartfield I think it is. John Hartfield was a German artist who was so horrified by what Germany had done during World War One that he actually anglicized his name to Hartfield and continued to draw and produce art that became anti Nazi after the Nazis came to power in the 30s in Germany. So here you see a skeletal hand, except it really isn't a hand it's smoke trails from these warplanes. These are individuals who presumably have been the victim of a bombing. This looks like photographs we see today from Syria and Iraq and these bombed out cities. This is the heil that they bring you, as in heil Hitler. So this is art and if you don't like it, if you think it's the wrong message, you might say it's propaganda, so propaganda uses artistic techniques in many cases to convey the message, this is one. Adolf, the overmench, the superman. He swallows gold and speaks shit, okay. So the Nazis looted like crazy, we now understand this. So here Hitler's spine has been replaced by the gold that's been stolen from the Jews and everybody else, and just swallowed by the Nazis. If you remember the creation of man so X-rays can be manipulated and enhanced. Sisters of mercy, if any ladies in the audience are interested, they're ready for your call, if you've gotten a call. There's no, what's the word, there's no shame in American advertising. Or better yet, so anybody wearing heels here, oh you're not wearing heels, good for you. But if you wear heels, this is a good example of where all the weight is being put on the bones that nature never intended for it to be put. This is Picasso, Girl In a Mirror, right, so the point is that the mirror isn't an external reflection, as Picasso sees it maybe this is an internal reflection of what's going on within this girl's body, or not, as you like it. Here is a very kyphoscoliotic spine depicted by the artist. More spinal deformities here. And finally, these are nuclear images, just straightforward medical imaging but these digital techniques have been used by artists to enhance, improve if you will, well known paintings and I'll end with another digital type of portrait that may look familiar. This is the end of the talk and I will just tell you that when I talk to a group of sonographers, that is ecocardiographic technicians not stenographers, sonographers, I always exhort them, you know, do your best and it's not just an echo, that image it's not just an echo. It's a work of art, thank you.