This was initially supposed to be a much shorter piece, but as with all things, the picture grows with more curiosity-driven inquiry. Franz Merke spent decades publishing works on cretinism, using iconography to observe the prevalence of goiters throughout history. Because its depictions in art span from ancient Greece to the Byzantine Empire to cultures in completely different continents, I will focus on later portrayals seen around the Renaissance Era. I won’t pretend that I understand art, let alone the complexly beautiful paintings from the era, but I do notice things and sometimes they are worth exploring. After all, the list is quite extensive!
A goiter is an enlargement of the thyroid gland in response to estrogen excess, or an iodine deficiency (the larger the thyroid gland gets, the more surface volume it has to grab iodine). The latter has been artistically depicted in nearly every civilization, with the most prevalent representations being of groups isolated in mountain ranges (Alps, Andes, Hindu Kush, etc.). Since seafood is the richest source of iodine, those living away from the coasts were likelier to develop goiters. With the advent of iodized salt, goiters became relatively rare. If the thyroid gland cannot access iodine, it simply cannot synthesize thyroxine. The lack of thyroid hormones predisposes an individual to characteristics typically associated with cretins; they are slow, unaware, deformed, unintelligent, and prone to behaviors common to the “lesser man”. The artists of Rome and Florence understood that goiters were associated with specific emotional and psychological conditions, and so during the Renaissance, executioners, torturers, and morally depraved individuals were depicted with this ailment; a soldier with a large goiter attacks a Cistercian monk (1615), a goitrous man tortures Christ in “Flagellation of Christ” (1515), an archer with a multinodular goiter ties and shoots arrows at St. Sebastian (Gothic fresco, 15th century).
A more recent example that draws the connection between psychological distress and goiters concerns the Italian painter Antonio Ligabue, who was a troubled and depressed man and was hospitalized numerous times in psychiatric wards for his “maniac-depressive” states involving self-harm and aggressiveness. In his self-portrait below, which was painted in 1951, a large goiter is visible (Accorona et al., 2018). To the right of Antonio’s portrait is a sketch of Michelangelo with his neck hyperextended, showing a protrusion on his neck. He wrote in one of his sonnets how he acquired the goiter while completing the ceiling of the Sistine Chapel. However, Michelangelo spent some time in a mountain valley in the Etruscan Apennines, where goiters are common, and may have developed it there before traveling to Rome. (Martino et al., 2004). Additionally, it took almost 500 years to notice that Michelangelo depicted God with a goiter in the “Separation of Light from Darkness”, a unique signature that incorporates himself as the embodiment of the Creator.
“A goiter it seems I got from this backward craning like the cats get there in Lombardy, or wherever bad water, they say, from lapping their fetid river. My belly, tugged under my chin is all out of whack.“
I want to make an important distinction here. From my observations, there are two “types” of goiters in terms of their depictions in art: one of iodine deficiency, which is shown as a large, protruding goiter on offenders, sinners, the poor, malnourished, etc. accompanied by other facial deformities, and one of estrogen excess, which is aesthetically smaller and usually depicted on women. Numerous paintings depict Mary holding Christ, with a clear swelling of her neck (Lazzeri et al., 2018). When women enter menarche, or their childbearing age, a slight estrogen excess can cause the thyroid gland to swell. I think Mary’s goiter is more symbolic of her entering motherhood.
I find it interesting that in many cases, the artists saw the shape of a slight goiter as an object of sensuality that complemented the healthy curvature of the female form, it being a purely aesthetic symbol.
The “Sign of Hertoghe”, or “Queen Anne’s Sign” is the thinning of the outer third of the eyebrow. The latter term is named after Queen Anne of Denmark whose portraits present her symptom. This is a classic sign of hypothyroidism and is quickly resolved with t3 supplementation. The same symptom is present in the 1434 painting of “Arnolfini Portrait”, where an Italian cloth merchant is portrayed; Hertoghe’s Sign, bilateral ptosis, melasma of the forehead, and cold intolerance (wearing warm clothes and a large hat indoors during the summer) are all present (Ashrafian, 2017). The third image is from the Ghent Altarpiece (1432), “a jewel of Gothic art”, where a hypothyroid man named Joos Vijd is depicted. He is bald, Hertoghe’s Sign is present, and there is an earlobe crease! (Lefrère et al., 2024).
“For a long time, people have been noticing the association of baldness with heart disease and also with a crease in the earlobe. Both of those have been challenged repeatedly, but there is clear evidence that they are associated.“ - Ray
I will end the article with one last observation. Neoteny is the retention of juvenile characteristics into adulthood. This type of development is almost exclusive to humans (within primates), in that the bigger brain-to-body ratio allows for more energy generation and the preservation of juvenile features into older age. This is tightly interwoven with the age of the onset of puberty; a healthy and stimulating environment facilitates the development of a larger brain over a longer developmental period, which allows for more differentiation. There are countless examples of neotenous features (globular skull, large brain, hairless face, hair on top, larger eyes, small nose, etc) in Renaissance art (and all it takes is a little effort to notice them), something that was [clearly] valued and seen as beautiful, which I think was made possible in the relatively carefree life of the aristocratic class. Preserving a culture that fosters and values these features is paramount to cultivating a healthy future.
References
Accorona, R., & Colombo, G. (2018). Self-portrait with goiter: Antonio Ligabue. Journal of Endocrinological Investigation. doi:10.1007/s40618-018-0916-y
Ashrafian, H. (2017). Hypothyroidism in the “Arnolfini Portrait” (1434) by Jan Van Eyck (1390–1441). Journal of Endocrinological Investigation, 41(1), 145–147. doi:10.1007/s40618-017-0751-6
Barale, M., & Guaraldi, F. (2014). The martyrdom of Saint Sebastian. Journal of Endocrinological Investigation, 38(3), 375–375. doi:10.1007/s40618-014-0173-7
Dionigi, G., Dionigi, R. Goiter in a fresco by i Fiammenghini, 1615 (Abbey of Santa Maria di Rovegnano, Chiaravalle, Italy). J Endocrinol Invest 45, 2023–2024 (2022). https://doi.org/10.1007/s40618-022-01763-0
Ferriss, J. B. (2008). The Many Reasons Why Goiter Is Seen in Old Paintings. Thyroid, 18(4), 387–393. doi:10.1089/thy.2007.0301
Lazzeri D, Nicoli F. The Goitrous Salting Madonnas: Iconography of Goiter in Religious Portraits. Indian J Endocrinol Metab. 2018 Mar-Apr;22(2):283-286. doi: 10.4103/ijem.IJEM_13_18.
Lefrère B, Arlet JB, Pouchot J. An iconodiagnosis for Joos Vijd, as painted by the van Eycks in the Ghent Altarpiece. Neurol Sci. 2024 Jul 3. doi: 10.1007/s10072-024-07644-z.
Martino, E., & Mariotti, S. (2004). Endocrinology and Art. Journal of Endocrinological Investigation, 27(11), 1081–1081. doi:10.1007/bf03345314
Riva, M. A., & Cambioli, L. (2021). A damned soul with goiter. “The life of Christ” (c. 1480) by Giovanni Martino Spanzotti. Journal of Endocrinological Investigation, 45(4), 905–906. https://doi.org/10.1007/s40618-021-01636-y
This was a really unique and interesting read, as always, Mr. Uncoupled.
A brilliant essay about a remarkable and fascinating phenomenon in both medicine and art history. Bravo!