Hektoen International

A Journal of Medical Humanities

Unlocking the secrets of a bohemian painting

Bernard Brabin
Liverpool, England

The image

The Deštná painting
Oil on wood. Photograph © National Gallery in Prague, 2017. Used with permission.

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
ArtistMadonna nameMadonna goitre size  Infant goitre sizeOther physical signs Location of painting
Constantinople1UnknownMosaicMild diffuseMild  DiffuseNoHagia Sophia
Rome, Italy2UnknownMaria Lactans mosaicProminent neck foldsNot enlargedProminent neck folds in two SaintsBasilica Maria in Trastevere
Modena, Northern Italy2Tomaso Barisini
Madonna del CarmineModerate diffuseObscuredNo
Breast feeding
Parish of San Biagi nel Carmine
Pisa, Northern Italy3Ugolino di Tadice
(died 1277)
Madonna with ChildNot shownLarge diffuse? infant exopthalmosChurch of San Biago
Northern Spain4UnknownMare de Déu del ClaustreBroad bull shaped neckObscured? maternal exophthalmos
Breast feeding
Cathedral of Tarragona
Southern Italy5UnknownMadonna and InfantModerate diffuseLarge diffuseNoChurch of St Francis, Potenza
Brugge, Belgium6Jan van Eyck (c1390-1441)Madonna with Kanunnik Joris van der PaeleMild diffuseObscuredNoGroeninge Museum, Brugge
Brugge, Belgium1Jan van EyckMadonna di LuccaMild diffuseNot enlargedNo
Breast feeding
Städelsches Kunst Instituut, Frankfurt
Prague, Czech Republic7UnknownZbraslav MadonnaDiffuse ovoidNeck folds
NoParish of St James the Elder, Prague
Tournai, Flanders6Robert Campin (1378-1444)Virgin and Child by a fireplace (Diptych)Bilateral (?nodular)ObscuredInfant peri-orbital oedemaHermitage Museum, St Petersberg
Flanders6Follower of Robert CampinVirgin and Child before a firescreenDiffuse ovoidObscuredNoNational Gallery, London
Netherlands8Rogier van der Weyden
Durán MadonnaDiffuseBi-lobarMild exopthalmosMuseo del Prado, Madrid
Netherlands9Rogier van der WeydenMadonna met AnjerModerateObscuredNoRoyal Museum Schone Kunsten, Ghent
Netherlands9Rogier van der WeydenVirgin and ChildModerate? enlargedNoToulouse Foundation, Bemberg
Netherlands9Rogier van der WeydenDyptych Madonna & St Catherine of AlexandriaModerateObscuredBreast feedingKunsthistorische Museum, Vienna
Netherlands9Rogier van der WeydenVirgin and Child & four SaintsMildObscuredBreast feedingStädelsches Kunst Instituut, Frankfurt
FlandersHans Memling (1430-1494)Madonna col BambinoMildWide neck and skin foldNoMuseum of Fine Arts, Brussels
UnknownDeštná AssumptionLarge diffuseModerate diffuseMaternal pallor,
Infant epicanthic fold,
? Babinski sign
Convent of Saint Agnes, Prague
Mantua, Northern Italy10Andrea Mantegna (c1430-1506)Madonna col Bambino DormienteOvoidal neck massObscuredNoGemälde Gallerie, Berlin
Northern ItalyFollower Andrea MantegnaMadonna with ChildMildNeck folds
Exopthalmos with no lid retractionBoston Museum of Fine Arts
Bologna, Northern Italy2Marco Zoppi (1433-1498)Madonna col Bambino é AngeMild diffuseObscuredBreast feedingLouvre, Paris
Venice, Vicenza11Cima da Conegliano (1459-c1517)Virgin and ChildMild diffuseNot enlargedNoNational Gallery, London
Perugia, ItalyGiovannino Pinturicchio (c1459-1513)Pali di Santa Maria dei FossiMild diffuseNot enlargedNoScala, Florence
Florence, Northern Italy111Raphael
Madonna of the PinksMild diffuseNot enlargedNoNational Gallery, London
Piedmont, Northern Italy2Defendente Ferrari
Madonna con il BambinoMild diffuseObscuredBreast feedingUffizi Gallery, Florence
Italy2Maestro del Folgliame PuntinetoMadonna del LatteMild diffuseNot enlargedBreast feedingPrivate collection
Netherlands2Jan Provost (1462/65-1529)La Vierge col BambinoMild diffuseObscured? exopthalmic
? thick lips, sparse hair
Museo del Prado, Madrid
Florence, Italy12Studio of Sandro Boticelli (c1445-1510)Madonna & Child in a NicheMild diffuseNot enlargedNoPrivate collection
Bamberg, Germany13Lucas Cranach (1472-1553)Madonna mit der TraübeMild diffuseNot enlargedNoEltz Castle, Rhineland Palatinate
Lucas CranachVirgin and Child under an apple treeMild diffuseNot enlargedNoHermitage Museum, St Petersberg
NetherlandsJon Gossart (c1478-1532)Nossa Senora do AmperoMild diffuseObscuredNoMuseum of Sacred Art, Funchai,Madeira
Northern Italy14Caravaggio (1571-1610)Madonna del RosarioLarge diffuseObscuredNoKunsthistorische Museum, Vienna


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.


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  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
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  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. 15th 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

BERNARD BRABIN is Professor Emeritus of Tropical Paediatrics at the Liverpool School of Tropical Medicine and University of Liverpool, England, and of International Child Health at the Academic Medical Centre, University of Amsterdam, the Netherlands.

Highlighted in Frontispiece Volume 10, Issue 1 – Winter 2018 and Volume 15, Issue 4 – Fall 2023

Summer 2017




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