Bernard Brabin
Liverpool, England

The image

By an unknown artist, the Deštná painting in the National Gallery, Prague, depicts Madonna and Infant from a fifteenth century perspective. The Madonna’s attention is directed to the child, within a space surrounded by ellipses, human figures, and two angels processing petitions. Orthogonal lines connect the gaze of these peripheral figures to the Christ Child, who looks towards the observer. To the physician’s keen eye this magnificent illusion is punctuated by the triple depiction of goiters in the Madonna, Infant, and one of the angels.

Medieval goiters

Absorbing the painting as a physician one notices suggestive clinical signs: the Madonna’s pallor, the visible goiter emphasized by her flexed neck framed by a white veil, an adolescent appearance. The infant appears goitrous, with an epicanthic fold on the right raising the possibility of Down’s syndrome and associated hypothyroidism,¹ and the right foot has a possible Babinski reflex.² The baby’s posture on the mother’s left, the preferred side in Madonna paintings, appears normal.³ In the right quadrant the angel is goitrous. This is seen in other medieval paintings and in renaissance religious scenes but depiction in a trinity of persons in one painting is possibly unique.⁵ The painting originates from Deštná, a hilly Czech region, and the type of location consistent with risk of iodine deficiency. Was there endemic iodine deficiency in this region where millet was the staple,⁶ providing a diet that affected thyroid hormone synthesis?⁷ Low iron absorption from a millet diet also could result in maternal iron deficiency, which is reported to predict pregnancy thyroid hormone concentrations.⁸

Several other painters of the period produced images showing goitrous Madonnas (Table 1), mostly from Northern Italy and Flanders, with two, including the Deštná, from the Czech region. Of paintings listed, the infant’s neck could be scrutinized in only two, which appeared normal. This geographic dispersion is controversial as Dutch artists may have embellished their paintings with goiters, being aware of their frequency in Northern Italian women and its perception as a sign of beauty.⁹ This speculation is contested, so such paintings may indicate the distribution of goiters in Europe at the time.¹⁰

The painting’s historical significance

The unknown Deštná artist could not have known that his painting predicted in medieval times the endemic disease of iodine deficiency which continues to affect women today in Europe,¹¹ including the Czech Republic¹² and the United Kingdom.¹³ Applying knowledge of visual physiology, neurophysiology, and endocrinology allows our humanistic and medical perception of reality to be integrated with an understanding of this medieval Christian image. The relation of reason to faith is expressed in a metaphorical image, with the artist’s incidental portrayal of goiter in the central figures, focusing our attention on the intermingling of realism with symbolism.

Goitres in medieval and renaissance Madonna and Child paintings

Deštná painting highlighted.

Artist’s location and reference	Artist	Madonna name	Madonna goitre size	Infant goitre size	Other physical signs	Location of painting
Constantinople1	Unknown	Mosaic	Mild diffuse	Mild  Diffuse	No	Hagia Sophia
Rome, Italy2	Unknown	Maria Lactans mosaic	Prominent neck folds	Not enlarged	Prominent neck folds in two Saints	Basilica Maria in Trastevere
Modena, Northern Italy2	Tomaso Barisini (1326-1379)	Madonna del Carmine	Moderate diffuse	Obscured	No Breast feeding	Parish of San Biagi nel Carmine
Pisa, Northern Italy3	Ugolino di Tadice (died 1277)	Madonna with Child	Not shown	Large diffuse	? infant exopthalmos	Church of San Biago
Northern Spain4	Unknown	Mare de Déu del Claustre	Broad bull shaped neck	Obscured	? maternal exophthalmos Breast feeding	Cathedral of Tarragona
Southern Italy5	Unknown	Madonna and Infant	Moderate diffuse	Large diffuse	No	Church of St Francis, Potenza
Brugge, Belgium6	Jan van Eyck (c1390-1441)	Madonna with Kanunnik Joris van der Paele	Mild diffuse	Obscured	No	Groeninge Museum, Brugge
Brugge, Belgium1	Jan van Eyck	Madonna di Lucca	Mild diffuse	Not enlarged	No Breast feeding	Städelsches Kunst Instituut, Frankfurt
Prague, Czech Republic7	Unknown	Zbraslav Madonna	Diffuse ovoid	Neck folds ?goitre	No	Parish of St James the Elder, Prague
Tournai, Flanders6	Robert Campin (1378-1444)	Virgin and Child by a fireplace (Diptych)	Bilateral (?nodular)	Obscured	Infant peri-orbital oedema	Hermitage Museum, St Petersberg
Flanders6	Follower of Robert Campin	Virgin and Child before a firescreen	Diffuse ovoid	Obscured	No	National Gallery, London
Netherlands8	Rogier van der Weyden (c1399-1464)	Durán Madonna	Diffuse	Bi-lobar	Mild exopthalmos	Museo del Prado, Madrid
Netherlands9	Rogier van der Weyden	Madonna met Anjer	Moderate	Obscured	No	Royal Museum Schone Kunsten, Ghent
Netherlands9	Rogier van der Weyden	Virgin and Child	Moderate	? enlarged	No	Toulouse Foundation, Bemberg
Netherlands9	Rogier van der Weyden	Dyptych Madonna & St Catherine of Alexandria	Moderate	Obscured	Breast feeding	Kunsthistorische Museum, Vienna
Netherlands9	Rogier van der Weyden	Virgin and Child & four Saints	Mild	Obscured	Breast feeding	Städelsches Kunst Instituut, Frankfurt
Flanders	Hans Memling (1430-1494)	Madonna col Bambino	Mild	Wide neck and skin fold	No	Museum of Fine Arts, Brussels
Deštná, South/East Bohemia7	Unknown	Deštná Assumption	Large diffuse	Moderate diffuse	Maternal pallor, Infant epicanthic fold, ? Babinski sign	Convent of Saint Agnes, Prague
Mantua, Northern Italy10	Andrea Mantegna (c1430-1506)	Madonna col Bambino Dormiente	Ovoidal neck mass	Obscured	No	Gemälde Gallerie, Berlin
Northern Italy	Follower Andrea Mantegna	Madonna with Child	Mild	Neck folds ?goitre	Exopthalmos with no lid retraction	Boston Museum of Fine Arts
Bologna, Northern Italy2	Marco Zoppi (1433-1498)	Madonna col Bambino é Ange	Mild diffuse	Obscured	Breast feeding	Louvre, Paris
Venice, Vicenza11	Cima da Conegliano (1459-c1517)	Virgin and Child	Mild diffuse	Not enlarged	No	National Gallery, London
Perugia, Italy	Giovannino Pinturicchio (c1459-1513)	Pali di Santa Maria dei Fossi	Mild diffuse	Not enlarged	No	Scala, Florence
Florence, Northern Italy111	Raphael (1483-1520)	Madonna of the Pinks	Mild diffuse	Not enlarged	No	National Gallery, London
Piedmont, Northern Italy2	Defendente Ferrari (c1480-1540)	Madonna con il Bambino	Mild diffuse	Obscured	Breast feeding	Uffizi Gallery, Florence
Italy2	Maestro del Folgliame Puntineto	Madonna del Latte	Mild diffuse	Not enlarged	Breast feeding	Private collection
Netherlands2	Jan Provost (1462/65-1529)	La Vierge col Bambino	Mild diffuse	Obscured	? exopthalmic ? thick lips, sparse hair	Museo del Prado, Madrid
Florence, Italy12	Studio of Sandro Boticelli (c1445-1510)	Madonna & Child in a Niche	Mild diffuse	Not enlarged	No	Private collection
Bamberg, Germany13	Lucas Cranach (1472-1553)	Madonna mit der Traübe	Mild diffuse	Not enlarged	No	Eltz Castle, Rhineland Palatinate
Bamberg, Germany13	Lucas Cranach	Virgin and Child under an apple tree	Mild diffuse	Not enlarged	No	Hermitage Museum, St Petersberg
Netherlands	Jon Gossart (c1478-1532)	Nossa Senora do Ampero	Mild diffuse	Obscured	No	Museum of Sacred Art, Funchai,Madeira
Northern Italy14	Caravaggio (1571-1610)	Madonna del Rosario	Large diffuse	Obscured	No	Kunsthistorische Museum, Vienna

Acknowledgements

I am grateful to Ruth Pollard for Latin translations of the motifs, to Loretta Brabin for advice on the manuscript, and the National Gallery of Prague for permission to reproduce the painting.

References

1. Sarici D, Akin1 MA, Kurtoglu S et al. Thyroid functions of neonates with Down syndrome. Italian J Pediat 2012, 38:44.
2. Massey W. Babinski’s sign in Medieval, Renaissance, and Baroque Art. Arch Neurol 1989; 46:85-88.
3. Harris LJ, Cardénas RA, Spradlin MP Jr, Almerigi JB. Adult’s preferences for side-of-hold as portrayed in paintings of the Madonna and Child. Laterality 2009; 14:590-617.
4. Martino E. Angelic hierarchies: Domination Guariento di Arpo (Padua – Notice 13338-1370). J Endocrinol Invest 2011; 34:811.
5. Ferriss JB. The many reasons why goiter is seen in old paintings. Thyroid 2008; 18:387-346.
6. Reitsema LJ, Vercellotti G. Stable isotope evidence for sex and status based variations in diet and life history in Medieval Trino, Vercellese, Italy. Am J Phys Anthropol 2012; 148:589-600.
7. Gaitan E, Lindsay RH, Reichert RD et al. Antithyroid and goitrogenic effects of millet: role of C-glycosylflavones. J Clin Endocrinol Metab. 1989; 68:707-14.
8. Pearce EN, Lazarus JH, Moreno-Reyes R, Zimmermann MB. The consequences of iodine deficiency and excess in pregnant women: an overview of current knowns and unknowns. Am J Clin Nutr 2016; 104:918S-923S.
9. Lazzeri D, Pozzilli P, Zhang YX, Persichetti P. Goiter in paintings by Rogier van der Weyden (1399-1464). Thyroid 2015; 25:559-562.
10. Riva MA, Ferretti C, Pagni F. Durán Madonna (c.1435-1438) by Rogier van der Weyden: a case of congenital goiter. Intern Emerg Med 2016; 11:1149-1150.
11. Zimmermann MB, Gizak M, Abbott K, Andersson M, Lazarus JH. Iodine deficiency in pregnant women in Europe. Lancet Diabetes Endocrinol. 2015;3:672-4
12. Bíleck R, Kaňová N, Mindžáková V et al. Iodine supply of pregnant women in the Czech Republic. Vnitř Lék 2016; 62(suppl 3):10-16.
13. Rayman MP, Bath SC. The new emergence of iodine deficiency in the UK: consequences for child neurodevelopment. Ann Clin Biochem 2015; 52:705-8.

References for table

1. Belán K. Madonna from Medieval to Modern. New York: Parkstone Press, 2001.
2. Tomasio Claudio Mineo. La Spada e il Latte, Genova: San Giorgio Editrice, 2008.
3. Martino E. Madonna with Child. J Endocrinol Invest 2011; 34:487.
4. Barral I Altet X. Les Catedrals de Catalunya. Barcelona, Edicions 12, 1994.
5. Lo Pomo F. Madonna with the Infant. J Endocrinol Invest 2001; 24:294.
6. Harbison C. Realism and Symbolism in Early Flemish Painting. The Art Bulletin 1984; 66: 588-602.
7. National Gallery Prague. http://www.ngprague.cz [accessed 1 May 2017].
8. Riva MA, Ferretti C, Pagni F. Durán Madonna (c.1435-1438) by Rogier van der Weyden: a case of congenital goiter. Intern Emerg Med 2016; 11:1149-1150.
9. Lazzeri D, Pozzilli P, Zhang YX, Persichetti P. Goiter in paintings by Rogier van der Weyden (1399-1464). Thyroid 2015; 25:559-562.
10. Traversari M, Ballestriero R, Galassi FM. A likely case of goiter in the Madonna col Bambino Dormiente (1465/1470) by Andrea Mantegna (1431-1506). J Endocrinol Invest 2017; 40:237-238.
11. Gordon D. 15^th Century Italian Paintings: National Gallery Catalogues. London: National Gallery, 2003.
12. Anonymous. A Child is Born. London: Phaidon Press, 1994.
13. Friedländer M J, Rosenberg J. The Paintings of Lucas Cranach. New York: Tabard Press, 1978.
14. Martino E. Madonna del Rosario. J Endocrinol Invest 2012;35:243