In a 1932 painting called "Henry Ford Hospital," Mexican artist Frida Kahlo offers a self-portrait of herself bleeding on a hospital bed, grieving after a miscarriage.
Surrounding her image are pictures of an unborn fetus, a pelvic bone, a female abdomen and three other images that symbolize her pain, confusion and intense desire to understand why her body could not carry a baby to term.
A new study offers an explanation for at least some of Kahlo's many health woes. She may have had Asherman's syndrome -- scarring in the uterus that can cause infertility and repeated miscarriages, according to the new theory. Her fertility struggles had a profound influence on her artwork.
"A very common theme in her work was fertility, fertility, fertility," said Fernando Antelo, a surgical pathologist at the Harbor UCLA Medical Center. "In one painting, she draws pelvic bones. In another, a uterus is directly drawn. Another is showing the fetus. She's telling us what she's thinking about, but she never put her finger on what exactly was wrong."
In September of 1925, Kahlo was riding in a Mexican bus that collided with a trolley car, sending a metal handrail into her abdomen and forever changing her life. Over the following years, she suffered multiple miscarriages, extreme fatigue and chronic pain, and she endured 32 surgeries.
Instead of continuing an education in medicine after the traumatic collision, Kahlo chose to pursue art. Today, she is most well known for her colorful self-portraits.
Historians have long attributed Kahlo's infertility to the accident, Antelo said, but most explanations offer only vague references to a damaged skeleton or small ovaries. In his search for a more detailed diagnosis, Antelo began by taking a closer look at the clues embedded in her art.
Again and again, he found, Kahlo explored themes of fertility with anatomical details that she pulled from extensive readings of medical texts. In a 1943 painting called "Flower of Life," for example, she drew an upside-down plant in the form of a uterus exploding with sperm.
"What her paintings were telling me was that Frida was actively thinking about this," Antelo said. "When I was looking at her paintings, I had a lot of questions, and I think Frida had a similar spirit when physicians told her she was going to have difficulty her whole life having children but they couldn't tell her why."
In books and analyses of Kahlo's medical records, Antelo found yet more clues that helped him rule out several conditions that can cause infertility. She likely did not have polycystic ovarian syndrome, for example, because she did not have hair on her lower chin, and her doctors never described seeing cysts on her ovaries, even after a surgery that opened her abdominal wall.
In descriptions of many surgeries, there was also not a single mention of problems with coagulation of her blood, which is another common cause of repeated miscarriages.
Instead, Antelo reported at the American Association of Anatomists Meeting, Kahlo's history of trauma suggests that the trolley car's handrail damaged the lining of her uterus, leading to the development of scar tissue that made it impossible for her body to support a pregnancy.
Today, Asherman's syndrome is more often caused by a procedure used for abortions or after miscarriages.
In Kahlo's day, equipment didn't exist to diagnose the condition, so it's impossible to say for sure if she had Asherman's. And even if she did have the syndrome, something besides the trauma could have caused the scarring, said Heather Huddleston, a reproductive endocrinologist at the University of California, San Francisco.
After her first miscarriage, for example, fetal tissue leftover in the uterus could have become infected, causing the damage.
"I can't say it's impossible" that the accident caused Kahlo's problems, Huddleston said. "But when you hear that story, it's not like you think, 'That person is going to get Asherman's,'"
Kahlo explored more themes than just fertility in her work, which also delved deeply into all sorts of physical and emotional pain. And researchers have previously come up with other posthumous diagnoses for her suffering, including fibromyalgia.
Together, these analyses point out how helpful art can be for both patients and doctors.
"When we care for patients coping with such medical catastrophes, we would do well to remember what this suffering looks like -- not just a broken bone or lacerated tissue, but a human being attempting to cope with a loss of dignity and sovereignty," wrote Indiana University researcher Richard Gunderman in a 2008 study in the journal Radiology. "Only when we recognize everything that has been lost can we truly set about restoring it."