“Mona Lisa looks as if she has just been sick, or is about to be.”
– Noel Coward
Leonardo da Vinci (1452–1519) was a many-talented genius of the Italian Renaissance. He was a painter, anatomist, engineer, and inventor. One of his best known paintings, a portrait of a noblewoman, is called the Mona Lisa in English and Monna Lisa in Italian, monna being the contraction of ma donna, my lady.
The painting was made between 1503–1507 and depicts Lisa di Giacondo, born Lisa Gherardini (1479–1542 or 1551).1,2 This painting has been called the “best-known, most-visited, most written about, most sung about, most-parodied artwork in the world.”3 A former director of the Louvre Museum, where the painting is on display, has said that “eighty per cent of the people [who visit the Louvre] only want to see the Mona Lisa.”4
This noblewoman’s portrait is thought to show her smiling in a mysterious, puzzling way, which has led to speculation as to a possible medical reason for her smile, as well as for her facial appearance in general.
A 1994 paper5 lists six possible diagnoses that were mentioned in eleven articles on the subject, and the authors found all the diagnoses “flawed.” Some hypotheses include Bell’s (facial nerve) palsy,6 neurosyphilis,7 bruxism,8 loss of a few front teeth,9 primary biliary cholangitis (formerly called primary biliary cirrhosis),10 or simply being bored and tired of posing for the portrait.11
A dermatologic diagnosis, frontal fibrosing alopecia,12 has been offered recently to account for part of Mona Lisa’s appearance. This entity was first described in the medical literature in 1994, and consists of a high forehead, receding frontal hairline, and absent eyebrows. The portrait shows these three features. However, scans of the painting done in 2007 showed that eyebrows were originally present.13
It should also be remembered that a high forehead was a fashionable feature during the Renaissance, and hairs were plucked out to create this appearance. There are autoimmune conditions that will produce frontal fibrosing alopecia. Post-partum hair loss (telogen effluvium) also needs to be considered.
The popular press summarized and disseminated a medical article14 from 2018, wherein the authors concluded that the lady in the painting suffered from hypothyroidism. In support of this diagnosis, they note that the “patient” has yellow skin, yellow eyes, thin hair, a slight bulge on the right side of the neck (presumably a goiter), a lump on her right hand (possibly a lipoma), and a small mass in the corner of an eye. These latter two may represent accumulations of fat, something seen in hypothyroidism.
They offer, among other possibilities, dietary iodine deficiency as a cause of the hypothyroidism, stating that the diet at that time included much cabbage, kale, and cauliflower, known goitrogens. Fish and seafood, rich in iodine, were common only in coastal areas. Another possible cause of the hypothyroidism is autoimmune thyroid disease, which was—and still is—prevalent in Italy. Autoimmune disease may develop after the delivery of an infant, and Lisa Gherardini had given birth shortly before sitting for her portrait.
The following year, an endocrinologist published a paper15 claiming that Mona Lisa had a normally functioning thyroid. An iodine-deficient diet, he wrote, would have caused a “severe and clearly demarcated goiter.” Fatty deposits, or xanthelasmata, occur only after longstanding hypothyroidism that is severe enough to impair fertility, but Lisa Gherardini had just delivered her third child and there would eventually be five children.16 Perhaps that lump on her hand was a synovial or “ganglion” cyst in a typical location. Her lack of eyebrows may have been due to plucking, and her yellow skin may be an artefact of the painting’s age. Neither of these last two possibilities support the diagnosis of hypothyroidism. If the woman in the portrait is euthyroid (having normal thyroid function), what else has been considered?
Ehlers-Danlos syndrome17 is characterized by defective collagen synthesis, producing blood vessel fragility, joint hyperextensibility, and skin fragility and hyperelasticity. There are six phenotypically different variants of Ehlers-Danlos syndrome. Hamonet and Ducret18 think that thin, stretchable skin, difficulty producing facial expressions because of abnormal proprioception, temporomandibular joint dysfunction, and bruxism may account for Mona Lisa’s appearance. They write that her gaze looks as it does because of trouble with coordination of binocular vision, another feature of the syndrome. The patients in the waiting room of their Ehlers-Danlos clinic have the same smooth skin and similar facies, which they have called the “Mona Lisa sign.”
Observers of human behavior have also had opinions about Mona Lisa’s appearance. Sigmund Freud thought that Mona Lisa’s smile was the smile of Leonardo’s mother.19 And Bob Dylan wrote, “Mona Lisa musta’ had the highways blues, you can tell by the way she smiles.”20
- Mona Lisa. Wikipedia.
- Sachi Kantha and Yuri Matsui. “Medical diagnosis on Leonardo’s ‘Mona Lisa’ portrait,” International Medical Journal, 26(6), 1994.
- Mona Lisa. Wikipedia.
- Kantha, “Medical diagnosis.”
- Claude Hamonet and Lucette Ducret. “Was Mona Lisa affected by an Ehlers-Danlos syndrome?” International Journal of Proteonomics and Bioinformatics, 4(1), 2019.
- NA. “Mona Lisa medical diagnosis,” Vsemart.com, ND.
- Primary biliary cholangitis. Wikipedia.
- Michael Yafi. “Mona Lisa is euthyroid: a modern-day diagnosis,” Hormones, 18, 2019.
- Victoria Campbell and Kevin McKenna. “The Mona Lisa: an example of frontal fibrosing alopecia masquerading as Renaissance fashion,” Clinical and Experimental Dermatology, 45(4), 2019.
- Mona Lisa. Wikipedia.
- Sandeep Mehra and Hilary Campbell. “The Mona Lisa decrypted: allure of an imperfect reality, May Clin Proc, 93(9), 2018.
- Yafi, “Euthyroid.”
- Amonet, “Ehlers-Danlos.”
- Reed Pyeritz and Thomas Provost. “Inherited connective tissue diseases,” in Thomas Provost and John Flynn, eds. Cutaneous Medicine: Cutaneous Manifestations of Systemic Disease, Hamilton, Ontario: B.C. Decker, Inc., 2001.
- Hamonet, “Ehlers-Danlos.”
- Kantha, “Medical Diagnosis.”
- Bob Dylan. “Visions of Johanna.” Blonde on Blonde. Columbia Records, 1966.
HOWARD FISCHER, M.D., was a professor of pediatrics at Wayne State University School of Medicine, Detroit, Michigan.
Highlighted in Frontispiece Volume 14, Issue 4 – Fall 2022