Unlocking the secrets of a bohemian painting

Bernard Brabin
Liverpool, England


The Deštná (Destna) painting depicting the Blessed Virgin Mary with the Infant Jesus, angels, and saints. Mary, Jesus, and one of the angels are depicted with goiters.

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

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
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
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
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
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
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
Madonna of the Pinks Mild diffuse Not enlarged No National Gallery, London
Piedmont, Northern Italy2 Defendente Ferrari
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
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



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.



  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. 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
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