Mona Lisa's smile: happy or sick?

The thyroid gland is the largest endocrine gland in the human body. It controls the body's energy consumption rate, synthesizes protein, and regulates the body's sensitivity to other hormones.

Once there is a problem with the thyroid gland, such as hyperthyroidism, hypothyroidism, thyroid nodules, thyroid cancer, etc., in addition to physical pain, the patient will also experience symptoms such as anxiety and depression, and in severe cases, it may even be life-threatening.

Therefore, it is very necessary for everyone to pay attention to thyroid health and understand thyroid and related diseases. This article is the first article in the [Thyroid] popular science column. If you are interested, please follow us.

Introduction

"One day our grandchildren will be surprised that their ancestors did not understand such simple common sense."

—Seneca, Natural Problems, Book VII, 1st century

Thanks to the development of medical methods and the advancement of information technology, thyroid-related diseases are not unfamiliar to us living in modern times, because we have generally been influenced and baptized by science. But people living in ancient times were not so "lucky". Many diseases were "unknown" to them, and "unknown" meant full of "fear". Thyroid diseases have existed since ancient times. Do you know how thyroid diseases were discovered and recorded in ancient times before people knew about the thyroid gland? How did the ancients treat thyroid diseases?

Prior to the scientific enlightenment, goiters were often depicted in various styles in various types of artwork, such as Leonardo da Vinci's masterpiece, the Mona Lisa. In addition, goiters are also typical in paintings and sculptures during the Renaissance and Baroque eras.

Scientists have conducted special research on goiter in artworks and found that people of different races and regions have experienced goiter over the centuries, and the frequency is relatively high, especially in iodine-deficient areas. This also explains why the thyroid gland appears so frequently in artworks of different periods and types.

Yunmeng Yi (West Lake Omi) | Written by

Throughout the ages, works of art such as paintings and sculptures have always been a form of expression of human cognition of the world. From the descriptions of bison in the prehistoric murals of the Lascaux Caves in France to the drawings of flowers and plants by students in today's elementary school classrooms, through works of art, we can get a glimpse into the health and mental outlook of human beings.

During the Renaissance, people had little understanding of mental illness and believed that it was the ghosts in the brain that made people lose their minds, so painters recorded the scenes of skull chiseling to treat diseases. Today, we may think that these practices are both ridiculous and terrifying. In fact, such seemingly absurd records in works of art have become the historical basis for our study of diseases. Compared with the development of medical technology today, human cognition of diseases has obviously gone from ignorance to science. It is worth mentioning that many diseases that are familiar to modern people can be found in classic works of art.

Thyroid disease is a common endocrine disease in clinical practice. It is so common that it is often ignored by modern people with a fast pace of life. However, this type of disease is often seen in works of art handed down by our ancestors. So, which famous works contain this type of disease? How do these works of art show thyroid disease?

Diseases hidden in works of art, starting with Mona Lisa

The characters in many works of art are "mysterious". In addition to a variety of expression techniques, there are many things worth pondering about the characters' appearance, such as the famous painting "Mona Lisa" by the world's master painter Leonardo da Vinci.

In order to depict the human body more accurately in his paintings and sculptures, Leonardo da Vinci performed many autopsies, which led to a series of groundbreaking discoveries such as atherosclerosis. Unfortunately, most of his achievements were not made public during his lifetime, and these discoveries were not made public until later generations carefully read his manuscripts.

Image: Mona Lisa, painted by Leonardo da Vinci, 1502

Mona Lisa is one of Leonardo da Vinci's greatest works. The public is familiar with the smiling figure in the painting. However, under the veil of "smile" are various diseases. There are many different opinions about the disease Mona Lisa suffered from in history. For example, some scientists judged that Mona Lisa was a patient with familial hypercholesterolemia based on the bulge on the inner corner of her left upper eyelid and the lump at the base of her right hand.

According to the CDC website, the signs of familial hypercholesterolemia are: lumps or bumps around the knees, knuckles or elbows; swelling or pain in the Achilles tendon; yellowing areas around the eyes; and a half-moon-shaped white-gray color on the outside of the cornea. Based on the above symptoms, such as the bulge in Mona Lisa's eyelids and the swelling in the base of her hand, some scientists believe that Mona Lisa is a patient with familial hypercholesterolemia.

However, in December 2017, Mandeep R. Mehra, a researcher at Brigham and Women's Hospital in the United States, and his collaborators published a paper in Mayo Clinic Proceedings titled "The Mona Lisa Decrypted: Allure of an Imperfect Reality", stating that Mona Lisa may have suffered from hypothyroidism rather than a patient with familial high cholesterol.

Researchers pointed out that Mona Lisa's abnormal physical signs - high forehead, sparse and coarse hair, no eyebrows, xanthoma on the left inner canthus, swelling on the back of her right hand (which may be a lipoma or xanthoma), overall yellow skin, and especially the lack of corneal arcus in the thyroid area - may mean that she had an enlarged thyroid.

Mehra also believes that the prototype of Mona Lisa, Lisa del Giocondo, lived to be 63 in real life, but if she had heart disease and lipid metabolism disorders, it would be unlikely for her to live to that age based on the medical conditions at the time. Therefore, Mehra said that Giocondo was more likely to be a patient with hypothyroidism.

Thyroid swelling in art

In fact, in artworks from different styles, periods and regions, the necks of characters often appear relatively protruding and appear to be swollen.

In order to study whether this "abnormal" neck phenomenon in artworks is related to thyroid diseases, Remo Accorona, a medical doctor from the University of Brescia in Italy, and others studied 131 papers published from 1964 to May 2017 with art and thyroid as the keywords. In 2018, they published their research results in the European Thyroid Journal under the title "Thyroid Swelling: A Common Phenomenon in Art?"

The article notes that 69 of the 131 papers analyzed how thyroid goiters were depicted in art, and the authors also attempted to link different representations to specific pathological conditions.

Acorona et al. also summarized the views of the authors of artworks and anthropological researchers and put forward various hypotheses about the main causes of thyroid swelling, all of which were derived from the morphology of the characters represented in the artworks.

Endemic goiter caused by iodine deficiency

Iodine deficiency often causes large goiters (multiple nodules) in middle-aged people, which some scholars say may be a sign of poverty and low social class, though this may risk being accused of stigmatizing people.

Chronic Hashimoto's thyroiditis

In most cases, Hashimoto's thyroiditis usually affects young women and is characterized by a small thyroid gland size, but in some cases the thyroid gland may be uniformly enlarged. According to the information, some artists believe that this feature is one of the symbols of beautiful appearance in young women.

Autoimmune postpartum thyroiditis

Some researchers have speculated that postpartum thyroiditis may have been a cause of the Virgin Mary's enlarged thyroid gland, a popular topic for many artists, especially during the Renaissance.

Hyperthyroidism and Graves' disease

Hyperthyroidism is a condition that is caused by the thyroid gland itself, which is usually due to a toxic multinodular goiter, which is often associated with an overall enlargement of the thyroid gland. More rarely, hyperthyroidism is caused by Graves' disease (an autoimmune disease that does not necessarily mean the thyroid gland is enlarged). Hyperthyroidism patients often have some obvious symptoms, such as bulging eyes or restlessness, and some artists have exploited the characteristics of this condition and associated it with a special meaning in the scene (i.e. madness).

In addition to the above hypotheses, some scientists believe that the unusual enlargement of the thyroid gland of the characters in the works of art will be used to highlight the characteristics of the characters, and sometimes the thyroid gland will be exaggeratedly enlarged.

Goiter in the Renaissance and Baroque

From the above description, it is not difficult to find that a few centuries ago, goiter seemed to be a "popular" disease.

Today we know that goiter is a type of thyroid disease, which is also known as "big neck disease."

So, when did the question of whether the goiter is swollen originate? Before the physiological role of the thyroid gland was revealed, what did people, especially artists, know about goiter, and how did they portray people with abnormal thyroid glands?

This goes back to the Renaissance, a period of great cultural development that began in the middle of the 14th century and lasted until the end of the 16th century. It is worth noting that, from an anatomical point of view, the anatomy of the thyroid gland was already described during the Renaissance, even though its physiological role was not discovered until the end of the 19th century.

Historically, the first person to draw the thyroid gland was Leonardo da Vinci, who drew the first thyroid diagram in anatomical studies in 1510.

Figure: The first thyroid gland diagram in anatomy studies by Leonardo da Vinci (1510)

Subsequently, in 1543, Andreas Vesalius, the father of modern anatomy, recreated the gland in his magnum opus On the Structure of Human Organisms. After the publication of this atlas of human anatomy, the thyroid gland became known to doctors, but it was not until the second half of the 19th century that descriptions of effective surgical treatment of the gland began to appear, with the outstanding contribution of Theodor Kocher, professor of surgery at the University of Bern in Switzerland. In 1909, Kocher was awarded the Nobel Prize for his achievements in the field of thyroid surgery.

Figure: The thyroid gland as drawn by Andreas Vesalius in On the Structure of Human Organism (1543)

The researchers claim they have found at least 56 representations of goiters in artwork from the period.

Therefore, the researchers concluded that goiter was a common condition in history and that these works were often related to people's daily lives. They identified three main trends in artistic representation of the period.

Figure｜"Borghese's Descent from the Cross" and detail (B), Raffaello Sanzio

The first trend: goiter is seen in artworks as part of ideal human beauty. Take the work of Raffaello Sanzio, for example, whose art embodies the harmony and ideal beauty of the Renaissance. He believed that a swollen neck might be a normal feature of the model, and he exaggerated this feature as part of ideal beauty. For example, in the Borghese version of the Descent from the Cross, a woman on the right side of the painting is depicted with a goiter.

Image: The Apparition of Christ, by Raffaello Sanzio

In the Theophany, the lower right portion of the painting depicts a boy with an enlarged neck and signs of goiter (bulging eyes, weight loss, and agitation). A common interpretation of this artwork is that the boy is "possessed by Satan" and is waiting for a miracle. So there is a correlation between the signs of hyperthyroidism and the physical condition, and this assumption existed at the time.

Figure｜"Grotesque Head" is also known as "Scaramuzia, King of the Gypsies" (Leonardo da Vinci, 1500-1505)

The second trend: goiter is depicted as a human anatomical feature. Leonardo da Vinci was driven by a great curiosity about human anatomy and was somewhat fascinated by strange appearances, a typical example of which is his work "Grotesque Head". In Leonardo da Vinci's paintings, he often realistically expresses the more "special" physiological structure of the characters, rather than ignoring it, and the people in his paintings also have goiter.

Figure｜"The Passion of St. Andrew" by Michelangelo Merisi

The third trend: The artistic innovations of the Renaissance (perspective and the study of human anatomy) tended towards realism, and the goiter could be used as "direct evidence" of the characteristics of the characters. For example, Michelangelo Merisi wanted to create paintings with great emotional effects for the audience and avoid idealizing the characters - especially the lower class people. Every physical feature of them, including the goiter, would be accurately depicted. A representative example is "The Crucifixion of St. Andrew" (1607). In the lower left part of the painting, he depicted an old lady with a noticeable goiter, and combined with her clothes and other characteristics, she may be from a lower class group.

Goiter in other works of art

In addition to the goiter images presented in the paintings mentioned above, many sculptures and ornaments also depict goiters on people. Luigi Massimino Sena, professor emeritus at the University of Turin, Italy, has studied goiters in different works of art and created a collection called The Thyroid in Art.

Senna pointed out in the report that goiter was known to people in ancient times. There are numerous descriptions of men, women and children with goiter in coins, sculptures, paintings, simple crafts, and even in some folk tales of characters, which shows that goiter is a common and representative disease.

Let’s explore some typical and interesting cases below.

1 Pre-Colonial Sculpture

Figure｜Pre-colonial Sculpture

The person with a noticeable goiter in the sculpture belongs to the "Colorado" people, who once lived in the Guarabamba River Basin in the Ecuadorian Andes. Coincidentally, there were indeed a large number of cases of endemic goiter and endemic cretinism in this area at that time, which may be the reason why the artist made the protagonist of the sculpture a patient with goiter.

2 Human Sculpture: Adena Culture

Figure｜Human Sculptures: Adena Culture

In this work, the craftsman carved an image of a dwarf with a goiter: the head is very large, the upper torso is longer than the legs, and the legs are also bent and swollen, which is consistent with the symptoms of partial hypothyroidism.

3. Gods can also get goiters

Figure｜Gods in Ancient Greek Mythology

Artists also make great use of goiter on coins, often featuring people with goiter. One of the coins above is the familiar Athena. Can you find where she is?

From the above examples, we can see that goiter is actually very common in artworks . Studying goiter through art can further explore the epidemiological characteristics, geographical reference value, social and behavioral value of goiter.

Through these paintings, the researchers also found that the characteristics of goiter mainly belonged to the lower social classes, such as shepherds, farmers, workers, maids, and wandering singers, and only 3% of the works were personal portraits of important people.

In short, before the physiology of the thyroid gland was unveiled, an enlarged thyroid gland inevitably caused surprise or fear, which was closely related to its origin and function. For centuries, the thyroid gland has captured people's imagination, enriched works of art, and opened a window for us to understand the relationship between thyroid disease and social class. At the same time, it is also an indispensable asset for the study of thyroid disease.

➽References:

1.Stuckey HL, Nobel J. The connection between art, healing, and public health: a review of current literature. Am J Public Health. 2010 Feb;100(2):254-63. doi: 10.2105/AJPH.2008.156497. Epub 2009 Dec 17. PMID: 20019311; PMCID: PMC2804629.

2.https://en.wikipedia.org/wiki/Mona_Lisa, edited on 11 October, 2022

3.Accorona, R., Huskens, I., Meulemans, J., Cappelli, C., Nicolai, P., & Lombardi, D. (2018). Thyroid swelling: a common phenomenon in art?. European thyroid journal, 7(5), 272-278.

4.Did Mona Lisa Suffer from Hypothyroidism? https://www.sci.news/medicine/mona-lisa-hypothyroidism-06374.html, Sep 2018

5. Mandeep R. Mehra & Hilary R. Campbell. 2018. The Mona Lisa Decrypted: Allure of an Imperfect Reality. Mayo Clinic Proceedings 93 (9): 1325-1327; doi: 10.1016/j.mayocp.2017.12.029

6.Luigi Massimino Sena, The Thyroid in Art. 2011 ASCP Annual Meeting/WASPaLM XXVI World Congress, October 2011