The Remarkables

It is truly fitting that Orlo Clark, considered a father of In this unique exploration of the links between art and modern endocrine surgery and a world-renowned leader in medicine, the Clarks focus on endocrinology, the field that the field, along with Carol Clark, a writer and scholar in best explains the shaping, and misshaping, of the Perspectives in Medical Humanities How do changing notions of beauty and ugliness Carol Clark (BA, Barnard College, MA art history, have enriched our legacy with their consummate human form. In clear and concise prose, they demonstrate affect attitudes toward physical deformities? To what in English, San Francisco State University) taught high atlas The Remarkables: Endocrine Abnormalities in Art; how artists used a variety of endocrine diseases—dwarfism, extent was the birth of a dwarf, a giant or a hirsute school English at the Crystal Springs Uplands School, this work of scholarship will most certainly become a part gigantism, those with swollen goiters or ambiguous child thought to reflect the depraved imagination of the

Hillsborough, California, from 1980–2005 and was English of our unique heritage. sexuality—as points of departure. The Clarks are The Remarkables mother and classify her child as a monster or freak Dept. Chair from 1989–98. The co-author of three poetry not only meticulous in identifying the diseases but original of nature? The Remarkables: Endocrine Abnormalities anthologies, she has also edited several art catalogues for Martha A. Zeiger, MD, FACS, FACE, The Johns Hopkins in explaining the artists’ fascination with the normal The Remarkables in Art addresses these questions and others in the the Catharine Clark Gallery in San Francisco. University School of Medicine and abnormal. A “Must Read” for anyone who would understand the profound interactions of medicine context of medical, social, intellectual, and art his- and culture. Endocrine Abnormalities in Art tory from antiquity to the twentieth century in Western A visual feast with a revelatory text, The Remarkables Europe. In five chapters the authors review endocrine makes a brilliant contribution to contemporary explorations David J. Rothman, Bernard Schoenberg Professor of Social abnormalities whose physical, and sometimes mental, signs appear in European paintings and sculpture: diffuse Orlo H. Clark, MD is Professor of of science and art. The authors document artists’ Medicine and Professor of History, Columbia University and disfiguring goiter, Graves’ disease, thyroid cancer, Surgery at UCSF Medical Center. A graduate of Cornell acute powers of observation and depiction as well as the disorders of the pituitary, adrenal and parathyroid University and Cornell Medical School, Dr. Clark joined the aesthetic, spiritual, moral, and social meanings these glands, and the gonads. Each chapter includes a detailed UCSF Department of Surgery in 1973 and was Vice Chair glandular conditions connoted to their viewers. You will discussion of the medical history of the disorders: the of the department and Chief of Surgery at UCSF/ never look at a painting of a Renaissance Madonna or a etiology, epidemiology, and history of treatment followed Mt. Zion Hospital from 1990–2003. A founding member and portrait by Velasquez in the same way again. by a discussion of pertinent examples of art presented past president of the International Association of thematically to reflect the influence of geography, Endocrine Surgeons and of the American Association of Marcia Tanner, Independent Curator, Leonardo Endocrine Abnormalities in Art religion, social politics, cultural traditions, and aesthetic Endocrine Surgeons, he has also been president of the Cover theories on each artist’s representation of endocrine American Thyroid Association, the Pacific Coast Surgical Jusepe de Ribera, The Bearded Woman Breastfeeding, 1631, Toledo, disease. The book’s comparative study examines Association and the San Francisco Surgical Society. The Hospital de Tavera, Museo Fundación Duque de Lerma. the development of empirical knowledge and scientific author of over 450 peer reviewed articles, sixteen books, discovery that inspired parallel experimentation in and numerous book chapters, Dr. Clark has been the both medicine and art. With their focus on the important recipient of several teaching awards at UCSF and of the intersection of the two disciplines throughout history, the AAES Oliver Cope Meritorious Achievement Award. authors consider a variety of paintings that demonstrate the artist’s skill of observation manifested in accurate University of California illustrations of disease. Although neither artists nor Medical Humanities Consortium physicians understood the causes and manifestations of 3333 California Street endocrine disease until the late nineteenth century, Suite 485 the book’s examples document that artists were often the San Francisco, ca 94143-0850 more astute observers of the “human condition.”

University of California Press www.ucpress.edu Printed in China

Orlo H. Clark, MD Carol Z. Clark Carol Z. Clark

berkeley — los angeles — london Orlo H. Clark, MD

护封.indd 1 2011.3.3 12:03:21 PM It is truly fitting that Orlo Clark, considered a father of In this unique exploration of the links between art and modern endocrine surgery and a world-renowned leader in medicine, the Clarks focus on endocrinology, the field that the field, along with Carol Clark, a writer and scholar in best explains the shaping, and misshaping, of the Perspectives in Medical Humanities How do changing notions of beauty and ugliness Carol Clark (BA, Barnard College, MA art history, have enriched our legacy with their consummate human form. In clear and concise prose, they demonstrate affect attitudes toward physical deformities? To what in English, San Francisco State University) taught high atlas The Remarkables: Endocrine Abnormalities in Art; how artists used a variety of endocrine diseases—dwarfism, extent was the birth of a dwarf, a giant or a hirsute school English at the Crystal Springs Uplands School, this work of scholarship will most certainly become a part gigantism, those with swollen goiters or ambiguous child thought to reflect the depraved imagination of the

University of California Press www.ucpress.edu Printed in China

Orlo H. Clark, MD Carol Z. Clark Carol Z. Clark

berkeley — los angeles — london Orlo H. Clark, MD

护封.indd 1 2011.3.3 12:03:21 PM The Remarkables Endocrine Abnormalities in Art

Remarkables_7body.indd 1 9/14/11 3:40 PM Perspectives in Medical Humanities

Perspectives in Medical Humanities publishes scholarship produced or reviewed under the auspices of the University of California Medical Humanities Consortium, a multi-campus collaborative of faculty, students and trainees in the humanities, medicine, and health sciences. Our series invites scholars from the humanities and health care professions to share narratives and analysis on health, healing, and the contexts of our beliefs and practices that impact biomedical inquiry.

General Editor

Brian Dolan, PhD, Professor of Social Medicine and Medical Humanities, University of California, San Francisco (ucsf)

Forthcoming Titles

Paths to Innovation: Discovering Recombinant DNA, Oncogenes, and Prions In One Medical School, Over One Decade By Henry Bourne (Fall, 2011)

Clowns and Jokers Can Heal Us: Comedy and Medicine By Albert Howard Carter iii (Fall, 2011)

Health Citizenship: Essays in Social Medicine and Biomedical Politics By Dorothy Porter (Fall, 2011)

Darwin and the Emotions: Mind, Medicine and the Arts Edited by Angelique Richardson and Brian Dolan (Fall, 2012)

www.medicalhumanities.ucsf.edu

[email protected]

This series is made possible by the generous support of the Dean of the School of Medicine at ucsf, the Center for Humanities and Health Sciences at ucsf, and a Multi-Campus Research Program grant from the University of California Office of the President.

Remarkables_7body.indd 2 9/14/11 3:40 PM The Remarkables Endocrine Abnormalities in Art

Carol Z. Clark Orlo H. Clark, MD

Remarkables_7body.indd 3 9/14/11 3:40 PM First published in 2011

by uc Medical Humanities Consortium and distributed by UC Press.

berkeley — los angeles — london

University of California

Medical Humanities Consortium

3333 California Street, Suite 485

San Francisco, ca 94143–0850

Designed and typeset by Eduardo de Ugarte

Library of Congress Control Number: 2011930921

isbn 978-0-9834639-0-0

Printed in China

Remarkables_7body.indd 4 9/14/11 3:40 PM v

Contents

Acknowledgments 1

Introduction to The Remarkables: Endocrine Abnormalities in Art 3

Chapter 1 THE GOITER BEAUTIFUL: PURITY, SENSUALITY, FERTILITY 10

Introduction 11 History of thyroid disease and goiter, its etiology and epidemiology, the association of the full rounded neck with beauty, sensuality, fertility, and maternity 16 The goiter beautiful in art 23

Chapter 2 THE GOITER GROTESQUE: POWER, TREACHERY, OR HUMBLENESS? 62

Introduction 63 Etiology and treatment of disfiguring (surgical) goiter, Graves’ disease, and cretinism 64 The development of thyroid surgery and treatment of thyroid cancer 69 The goiter grotesque in art 72

Chapter 3 LITTLE PEOPLE: FASCINATION OR EXPLOITATION? 90

Introduction 91 Types of dwarfism; pituitary dysfunction and other etiologies 92 History of diagnosis and treatment of dwarfism 94 Little people in mythology, art, and history 97

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Chapter 4 GIANTS AND ACROMEGALICS: STIGMA OR STATURE? 124

Introduction 125 Causes of gigantism and acromegaly 126 Medical history and treatment of gigantism and acromegaly 127 Giants in mythology, art, and history 129

Chapter 5 “AN EXCESS OF SEED”: ENDOCRINE DISORDERS OF THE SEX GLANDS, 148

ADRENAL GLANDS, AND PARATHYROID GLANDS

Introduction 149 Sexual disorders controlled by the endocrine glands 150 Attitudes toward sexual ambiguity in religion, medicine, and history 152 Medical history and etiology of sexual disorders 154 Disorders of the adrenal glands and parathyroid glands 157 The gonads, adrenal glands, and parathyroid glands in art 160

List of Illustrations 176

Bibliography 184

End Notes 191

Glossary of Medical Terms 206

Index 212

Remarkables_7body.indd 6 9/14/11 3:40 PM Remarkables_7body.indd 7 9/14/11 3:40 PM viii The Remarkables

“The power of art is the power of unsettling surprise.”

— Simon Schama, The Power of Art

This book is dedicated to our children Catharine, Emilie, and Andrew and to their families, who have taught us about art in myriad and wonderful ways.

Remarkables_7body.indd 8 9/14/11 3:40 PM Carol Z. Clark & Orlo H. Clark, MD 1

to accommodate our research. We are grateful to Dept. of Surgery admin- istrative assistant Joy Oson at ucsf/ Acknowledgments Mt. Zion, Dept. of Surgery for her technical help and efficient printing of manuscripts.

We are especially grateful to Dr. Brian Dolan, Professor and Vice-Chair of

the ucsf Department of Anthropology, History & Social Medicine and Director, uc Medical Humanities We are grateful to our professional institutions, the University of Cali- Consortium for inviting us to include our book in the Consortium series. We fornia San Francisco Medical School and the Crystal Springs Uplands thank him for his careful management School, Hillsborough, CA for their generous support of sabbatical leaves of the publishing process and support of our project. We thank Doctors that enabled us to begin this project in 1997 and continue our research in Melvin Grumbach and Felix Conte of the ucsf Dept. of Pediatrics for gen- 2004. The support of Orlo’s colleagues has inspired us to pursue erously offering their expertise in the field of pediatric endocrinology. our research in the midst of busy (2006); Johns Hopkins University, We are indebted to Professor schedules: ucsf Dept. of Surgery, Dept. of Surgery, Baltimore, Sebastiano Filetti of the University of Dr. Nancy Ascher, Chair; ucsf Maryland (2007); University of British Rome, Sapienza for his encouragement Endocrine Surgery colleagues: Doctors Columbia, Vancouver, B.C., and help with accessing research Quan Yang Duh, Wen Shen, and Canada (2007); Postgraduate Course facilities and archives in Rome, and to Jessica Gosnell; and numerous col- in Endocrinology and Endocrine Dr. Menno Vriens, University of Utrecht, leagues in professional organizations: Surgery, Cesme, Turkey (2009); The Netherlands for help in securing image International Association of Endocrine Bay Area History of Medicine permissions in the Netherlands. Surgeons, American Association Club, San Francisco, California (with of Endocrine Surgeons, Pacific Coast Carol Clark) (2010); the University of We wish to acknowledge fiction writer Surgical Association, and American Utrecht, Netherlands (2010). Joel Ben Izzy and Springer/Humana Thyroid Association. Press editor Richard Lansing for Special thanks to librarians Gloria reading and commenting on our manu- We are grateful to the following Won and Gail Sorrough at the script. Thanks also to Carol’s profes- institutions and organizations for Fishbon/ucsf Mt. Zion Hospital sional colleagues at Crystal Springs arranging invited lectures on the library, to the librarians and staff at Uplands School, Helen Harper and subject of Endocrine Abnormalities the Wellcome Library, London and Steve Weislogel, for their encourage- in Art: the University of California, at the Ashmolean Museum archives, ment and suggestions for images; and San Francisco, Dept. of Surgery Oxford, and to head librarian Maria to members of Carol’s writing group (2005); University of Calgary, Calgary, Conforti at the History of Medicine Alison Draper, Liz Greenberg and Alberta, Canada (2005); the Phoenix Library, University of Rome, Sapienza, Dildar Pisani, who helped to critique Surgical Society (2006); the British Rome, Italy for their aid in locating part of our manuscript. Association of Endocrine Surgeons sources and providing pleasant spaces

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Anatomical dissection was a relatively new concept in the early seventeenth century when the great anatomy Introduction theaters of Padova, Leiden and Bologna were created. Built to resemble Greek and Roman theaters, with the dissection table at the base of several rows of tiered seating, anatomy theaters were also the center of action

in the medical sciences.2 Similar to the anatomy theater was the artist’s studio in which art students gathered The title for our book The Remarkables: Endocrine Abnormalities in Art around the “master” much as medical alludes to the intersection of scientific and aesthetic sensibilities that students gathered around the anatomist in a theatrical setting. In both began to link the seemingly unrelated disciplines of medicine and visual settings fascination with the structure and functions of the human body art in Renaissance Europe. The concept of medicine as art, the physi- led to recognition of physical abnormalities in human anatomy and cian as artist, or the artist as scientist is not as contradictory as it would physiology, among them those related seem. As artists and physicians in Renaissance Europe became more to the endocrine glands.

aware of the human body, its anatomy and functions, they began to Even with our twenty-first century’s emphasis on specialization in medicine challenge established precepts and directly or indirectly influenced each and surgery, the link between artists and medical scientists persists. A New other, often with remarkable results. York Times article dated April 17, 2006 reported that medical students at Mt. Sinai Medical School in Given the large number of Renaissance physicians, … the interests of doctors New York City were required to enroll and Baroque paintings whose human and humanists began to converge”1 in an art appreciation course in figures appear to have signs of in early Renaissance Italy, for example, order to augment the “observational endocrine disease, we can recognize and “the decades around 1400 saw abilities” needed for thorough and a developing pattern in European art a lively dialogue between students accurate examination of patients.3 that reflects artists’ accurate depic- and teachers at the studio and profes- Other schools such as Cornell, tions of anatomical detail and their sional amateur humanists outside” Stanford and Yale have instituted knowledge of human anatomy. This (Park 223). The anatomical theater similar programs (Kennedy). Recently development is not surprising when was the place where physicians and an administrator at a well known one considers the growing importance artists worked together, even sharing art museum in New York told us a of science in the fifteenth through cadavers for their research. similar story about courses for police seventeenth centuries. Historian academy students as well as medical Katharine Park argues that contrary to students. Although the general public the assumption that there was “a deep might be skeptical about the per- hostility between humanists and ceived connections between scientific

Remarkables_7body.indd 3 9/14/11 3:40 PM 4 The Remarkables

or forensic analysis and the viewing matic and aesthetic interests as well as (384–322 bce) and Galen (130–201 of art, Renaissance thinkers might a fascination with science and curiosity ce) to the present. The terms endo- have embraced such a concept quite about “the other” or those remarkable crine, endocrinology and hormone naturally. individuals marginalized by society. were not used, however, until the early twentieth century because the unusual The representation of physical abnor- Examined side by side, medical theo- nature of the ductless or endocrine malities in art actually preceded the ries and practices and artistic render- glands made the concepts those terms use of anatomical dissection theaters. ings of human subjects reflect the represent difficult to identify or under- We have discovered examples of continually evolving attempts to define stand. An endocrine gland is defined physical signs of endocrine disease in the parameters of what it means to be as an organ that secretes a hormone works dating from Greek, Etruscan human or “normal” within the context that is carried via the blood stream to and early Roman sculpture and of societal structure in a given period act at a distant site within the body. painting. Similar signs appear again of history. Both scientists and art- The term endocrine derives from the in numerous paintings dating from ists followed the practice of negative Greek adverb endon, meaning within, the early Italian Renaissance (1400’s) definition—in other words, defining and the Greek verb krino, meaning to through the Baroque period (1600’s). humanity by what it is not. Any per- separate or sift, thus leading to our These works along with medical ceived physical or mental aberration modern understanding of the remote manuscripts from the same eras docu- that fell outside of accepted param- functions of all endocrine glands. The ment a growing awareness of physical eters was relegated to the category of term hormone was first used in 1905 abnormalities while also revealing “the other” or the “abnormal.” In by Ernest Henry Starling (1866–1927) changing aesthetic, religious and social the most positive sense, such aberra- and is derived from the Greek verb attitudes. Such attitudes must have tions were thought to be fantastic or hormao, meaning to put into quick influenced the choices made by artists exotic. In the most negative sense, they motion, excite or arouse. and scientists. were considered monstrosities, terata or freaks of nature. To the religious Because of their inherent remote- Recognition and depiction of physical minded, physical or mental aberrations ness, the functions of most endocrine abnormalities in painting and sculp- were thought to be a deity’s punish- glands were misunderstood by scien- ture may have happened by chance or ment for immoral behavior, inappro- tists until the late nineteenth century may have been influenced by an art- priate thoughts or lack of faith. To when the etiology and physical ist’s interest in the use of naturalistic those in positions of political power, manifestations of endocrine disease detail. Since it was often practical for they were sometimes perceived as were gradually revealed through per- an artist to use the same model for a a threat and at other times as mere curi- sistent experimentation and observa- variety of subjects, whether religious, osities enhancing a ruler’s collection of tion of changes following removal of classical or secular, the same anatom- valuable and exotic possessions. specific endocrine glands. Accurate ical features appear frequently within scientific observation of physiological an artist’s oeuvre, thus enabling the Among the medical abnormalities that functions as well as anatomy and viewer to recognize the abnormality attracted the interest of both scientists pathology were especially important represented. The artists’ reasons for and artists are the physical and mental to the early discoveries that now representing anatomical abnormalities manifestations of endocrine disease, enable endocrinologists and endocrine such as diffuse or disfiguring goiters, the focus of a medical specialty not surgeons to make accurate diagnoses cretinism, dwarfism, gigantism and established until the twentieth century. and provide effective treatment. other rare manifestations of endocrine Such observations led to extensive Disorders such as hypothyroidism, disease were most likely diverse. Their speculation, investigation and experi- hyperthyroidism, diabetes mellitus, choices may have reflected both prag- mentation from the time of Aristotle adrenal hypo or hyper function—once

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lethal medical conditions—can now consequences of the abnormality. important, artist or anatomist.”4 Some be effectively treated. The majority of these artists’ paint- Renaissance artists actually arrived at ings depict diffuse, nodular or greatly their own theories about endocrine Like artists, medical scientists depend enlarged goiters, but there are also disease by observing human anatomy. on the discoveries enabled by a care- paintings of figures with signs of Leonardo da Vinci was one of the fully trained eye. And like artists, cretinism, the bulging eyes (exoph- first to illustrate the thyroid gland, medical scientists such as the sixteenth thalmos) and other signs of Graves’ and Michelangelo, who depicted both century Vesalius and Paracelsus have disease, dwarfism, gigantism, sexual goiter and exophthalmos in some of often risked criticism for challenging ambiguity, Addison’s disease and other the human figures in his paintings, established practices. Among the most abnormalities. These works of art pro- proposed a theory about the etiology astute scientific observers of physical vide a record of endocrine disorders in of goiter formation.5 Although the manifestations of endocrine abnormal- a time when medical scientists knew conclusions of Michelangelo and da ities were the sixteenth century French little or nothing about such diseases. Vinci were scientifically inaccurate, surgeon Ambroise Paré, the eigh- Despite a parallel trajectory in the their paintings as well as those of teenth century British surgeon John disciplines of art and medicine toward many other Renaissance artists include Hunter and the nineteenth century an increasingly sophisticated under- accurate illustrations of endocrine Swiss surgeon Theodore Kocher. These standing of the human body, for many diseases. surgeons learned about endocrine years, artists proved to be more astute disease through observation, dissec- observers than their medical and sur- The artists’ reasons for including tion and experimentation on animals gical peers. such illustrations of endocrine disease and humans. As surgical scientists, invite speculation. For example, they often challenged accepted medical Much earlier than the work of these we do not know whether artists such practices in their quest for knowl- Renaissance and Baroque artists, as Piero della Francesca, Botticelli, edge. They were unwilling to accept ancient Egyptian, Greek and Roman Artemisia Gentileschi, Caravaggio and the dogma of their medical colleagues sculptors and painters also represented others consciously chose models who were usually considered more endocrine abnormalities, sometimes with goiters or used models who coin- scholarly because of their classical in the form of votive figures, render- cidentally happened to have goiters. education in Latin and Greek and their ings of mythological characters or in Certainly the prevalence of endemic foundation in ancient medical theories realistic portraiture. Although some goiter in specific regions such as such as those of Galen. of their subjects were derived from Piedmont, Tuscany and Umbria where fantasy, the artists often rendered the Renaissance and Baroque artists Similarly, Renaissance and Baroque physical manifestations of endocrine were working may have provided artists such as Piero della Francesca, disease with anatomical accuracy. models with goiters or the features Botticelli, da Vinci, Il Sodoma, of cretinism common to those Raphael, Caravaggio, Artemisia The great Italian anatomists areas. Because the manifestations of Gentileschi, Rubens, Ribera, Velasquez and illustrators such as Andreas goiter were visible to the naked and Goya challenged the Renaissance Vesalius (1514–64) and Fabricius ab eye but the causes unknown, the value of beauty in symmetry and Acquapendente (1537–1619) were artist’s careful eye may have led the idealization of the human figure. as well known for the artistic nature him or her to make aesthetic classifica- Some of their works illustrate the of their anatomical illustrations as tions, associating smooth or more obvious anatomical manifesta- they were for their scientific accuracy. diffuse goiters with the western tions of endocrine disease undoubt- Doubt about the origin of some of notion of beauty in symmetry and the edly rendered without the artists’ Vesalius’ illustrations, for example, disfiguring goiters with ugliness in understanding of the causes or subtle raises “the question of who was more asymmetry. Moral as well as aesthetic

Remarkables_7body.indd 5 9/14/11 3:40 PM 6 The Remarkables

associations may have coupled severe people with large disfiguring goiters Representations in art of hirsutism disfigurement with negative when they were working in inland or (excessive body hair)and sexual ambi- character traits such as stupidity, mountainous regions where iodine guity in males and females were often deception or evil. deficiency caused endemic goiter, espe- used to convey a didactic or satirical cially among peasants who may not message to the viewer, frequently In the case of more dramatic and have had the opportunity to travel to associating such aberrations with easily identifiable endocrine anoma- other regions where there was suffi- moral deficiency or freakery or both. lies such as cretinism, dwarfism and cient iodine in the soil and water. In early Renaissance paintings, for gigantism, the artist’s fascination with example, the devil and his messengers “the other” is especially apparent. History tells us that those persons with are frequently represented as hirsute Painters such as Paolo Veronese, overtly large disfiguring goiters, creatures. Other endocrine disorders Orazio Gentileschi, Jusepe Ribera and especially those with accompanying such as adrenal disease (Cushing’s syn- Diego Velasquez seem to have been mental abnormalities such as drome, pheochromocytoma, Addison’s as motivated by the contrast between cretinism, were often ostracized from disease) and hyperparathyroidism the “normal” and the “abnormal” as society, whereas giants and dwarfs, were only rarely captured by the they were by representing the human who had more obvious physical mani- painter’s brush because the physical condition in myriad ways. Indeed, the festations of pituitary or other manifestations of these diseases are more physically obvious the signs of endocrine gland dysfunction, were usually much more subtle than those endocrine disease, the more such art- usually more severely marginalized of thyroid or pituitary disease. These ists seem to have been fascinated with and classified as sub-human, diseases often resulted in a profound extremes. animalistic or monstrous. Exploited illness and premature death. by those in power, they were Among the many works of art we have frequently collected and displayed in Apart from their evident powers of examined for their depiction of endo- the courts of Europe and observation, whether artists attempted crine abnormalities, the representation sometimes exhibited at freak shows. to paint realistically or actually exag- of goiter has figured most prominently. We know that artists such as Veronese gerated the details they may have Disorders of the thyroid are noticeable and Velasquez had some contact observed in their models is a ques- because the thyroid gland is super- with the court dwarfs they represented tion for debate. In his painting of The ficially located in the anterior lower in their paintings, but we know Transfiguration (see Figure 2-13, p. 83 neck whereas the other traditional little about artists’ access to actual in Chapter 2), for example, Raphael endocrine glands are more deeply situ- giants. Although examples of faithfully represented so many signs of ated: for example, the pituitary in the mythological and biblical giants probable familial Graves’ disease that head, the parathyroid in the deep neck, abound in Renaissance and Baroque we can only conclude he painted his the adrenal glands in the retro-peri- paintings, most of the portraits subjects from life. It would be unlikely toneum. The fact that it is relatively suggest an imagined rather than actual for Raphael to have imagined such easy to recognize the smooth, rounded abnormality caused by pituitary a constellation of clinical manifesta- goiter caused by thyroid enlarge- disease, in other words, a magnification tions often present in patients with ment, especially during adolescence of a “normal” human. Graves’ disease, which can include the or pregnancy in a young woman, may presence of goiter, exophthalmos, and explain why so many Renaissance gynecomastia. Similarly, some art- artists painted women with smooth ists focused on physical abnormalities diffuse goiters that artists and viewers from which they themselves suffered. probably considered a sign of beauty.6 In his paintings that included self-por- Similarly, artists may have observed traiture Piero della Francesca repre-

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sented himself with a thyroglossal duct taste dictate artists’ choices in rep- medical anatomy and treatment of cyst, and Michelangelo made a sketch resenting endocrine disease in their disease purported by Aristotle and of himself with a large goiter. Toulouse paintings? Did the gradual acceptance Galen, avoiding the opportunity for Lautrec included his own dwarfish of the artists’ use of the working class evidence-based practices? Why was the figure in several drawings. Whatever and peasants as models for paint- church so influential in the decisions the reasons for depicting such signs ings allow for greater representation made by medical doctors? Why were of endocrine abnormalities in their of endocrine diseases that may have medical theorists averse to testing their work, it remains certain that artists been more common among these often brilliant theories with experi- observed these signs in their subjects, populations? Did religious tradition mental procedures? To what extent sometimes well in advance of medical associate certain signs of endocrine were discoveries such as those of Paré scientists who tended to rely on theo- disease with damnation and therefore and Hunter dependent on bold and retical rather than empirical methods influence an artist’s rendering of those risky experimentation that even defied of diagnosis. As an interest in ana- condemned to ignominy? Did artists the civil and criminal laws of the time? tomical accuracy began to influence consciously choose male models with We know that little progress was made aesthetic choices, the faithful rendering gynecomastia and other ambiguous before the use of anatomical dissection of a multinodular goiter or an achon- secondary sex characteristics to repre- of cadavers in the sixteenth century. droplastic dwarf’s enlarged head and sent androgynous or asexual religious Until the discovery of anesthesia short limbs became more common in or mythological figures such as angels, and antisepsis in the mid nineteenth European paintings. Sometimes, too, Cupid, Adonis or Apollo? Were dwarfs century surgical science was slow to such abnormalities were useful to the and giants classified according to the advance because of the pain, suffering artists of symbolic works in which an extremity of their size? Did eighteenth and often premature death associated endocrine abnormality, often exag- century political caricaturists associate with surgery, but what other obsta- gerated, provides a metaphorical or physical disfigurement such as that cles continued to obfuscate scientific symbolic statement that has little to do caused by some endocrine diseases understanding of endocrine disease? with literal representation. with political corruption? How did seemingly primitive practices such as organotherapy that often Of particular interest in our research In our discussion of paintings we bordered on charlatanism actually have been the social, moral, religious address these questions and others contribute to effective treatment of and aesthetic implications of the concerning the delicate balance endocrine disease? artists’ choices. How did changing between an artist’s vision, the medical notions of beauty and ugliness affect knowledge available to him or her Finally, considering the powerful influ- an artist’s representation of endo- and the extent to which a knowledge ence of each historical period’s gestålt crine disease? Did artists assign moral of historicism applies to the artist’s and the intellectual cross fertilization values to some endocrine abnormali- work. We have examined the his- of the sciences and the humanities, ties, for example, associating smooth tory of medical science within social to what extent are artistic vision and goiters with purity or fertility and and art historical contexts. Why, for medical knowledge interdependent disfiguring goiters with treachery or example, were there so many centuries in the history of both disciplines? deception? Do the numerous examples of medical “dark ages” in which reli- As an artist who often incorporated of sensually appealing young female gious beliefs and superstitions rather historical references in his paintings, figures with diffuse goiters reflect an than scientific observation determined Rembrandt must have perceived a erotic association between the smooth medical diagnosis and treatment? transition concurrent with the scien- diffuse goiter and other erogenous Why were medical scientists as late tific revolution in northern Europe in zones such as the breasts? To what as the sixteenth century reluctant which “a shift in emphasis from specu- extent did changes in fashion and to advance beyond the theories of lation to experimentation” (Lyons and

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Petrocelli 427) enabled Rembrandt her study of the female imagination James Caulfield published a series and other seventeenth century art- and terata in western art, Aristotle of engravings and stories depicting ists to make use of the serious work defined monsters as “offspring” char- felons and other remarkable charac- of anatomists.7 Rembrandt’s famous acterized by “their lack of resemblance ters provoking curiosity in the public. painting of The Anatomy Lesson to their parents.”8 Even liberated Among the Remarkable Persons to (The Hague, Netherlands, Maritshuis thinkers in the Renaissance such as which the title of his four volume col- Museum) is an example of that Paré attributed the conception of a lection alludes are those he describes “shift.” In the painting the figure of monster to the imagination of the as follows: Dr. Tulp the anatomist looks toward mother. According to art historian an unidentified viewer as he displays Barry Wind, although the Roman Very different are the multitude the dissection of a cadaver’s arm for Pliny and others of the ancient world who are noticed only as instances the students and physicians who have embraced “the panoply of diversity, of the deviation of nature, such as gathered around the dissecting table. ranging from androgynes to umbrella- giants, dwarfs, strong men, personal Replace the clamp with a paint- footed tribesmen, from bearded deformity, &c. In like manner are brush, and the figure of the anatomist women to dwarfs,” the victims of such distinguished those persons who becomes that of an artist. Or imagine anomalies were still accorded less have lived to an extraordinary age; the anatomist as lead actor on the than human status in the societies in others, as empirics and quacks, stage, the operating room his theater. which they lived.9 buffoons, prize-fighters, and adven- turers, serve but to fill up the class Paintings such as Rembrandt’s reflect Thus, an artist’s use of realistic of Remarkable Characters; and if the historical importance of medical anatomical detail provokes the viewer eccentricity of manners characterizes dissection or autopsy as a public to question the artist’s motive. another description of persons, spectacle. Similar to paintings of ana- For example, by placing peasant figures that very eccentricity entitles them to tomical dissection, another popular with disfiguring thyroid nodules in a place in the present work.10 category of seventeenth century art the foreground of paintings on reli- was the subject of the artist’s studio. gious subjects, was the Italian Baroque Many of the engravings in Caulfield’s Such paintings often use a composition painter Caravaggio consciously volumes were executed by the famous analogous to that of The Anatomy mocking the church and its tendency British caricaturist Cruikshank, who Lesson with the artist/teacher demon- toward elitism? Or was he attempting also illustrated the novels of Charles strating technique for the students and to humanize the image of the religious Dickens. Although less salacious than artists gathered around him. faithful to include a wide spectrum of the material of our modern tabloids, social classes? Despite the advances Caulfield’s collection of Remarkable Despite these indications of scientific made during the scientific revolution Persons calls attention to the same advances in the understanding of seventeenth century secular paint- physical abnormalities that drew the human body for both physicians ings and later works influenced by the audiences to freak shows in the nine- and artists, superstitions still influ- Enlightenment continued to repre- teenth and twentieth centuries. In our enced the classification of individuals sent victims of endocrine disease by contemporary world, we also have with physical or mental disorders. contrasting those victims to what was myriad ways of defining, exoticizing In the various texts we have examined, considered “normal.” or denigrating the “other” in our the terms monstrosity, terata and societies, implying what is “normal” freakery have figured in discussions of Interest in the physical manifestations by defining what it is not—obesity, diseases that marginalize the afflicted of endocrine disease appeared in physical deformity, and identification in western society. As French literary the popular press of nineteenth century by certain economic, racial, ethnic, or scholar Marie-Hélène Huet reports in Britain. In 1820 the British writer social categories—to name a few.

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Our book includes numerous examples of European physicians and artists who have contributed to an understanding of endocrine disease and the remarkable characteristics of the glands that function remotely. Even before endocrine diseases were given names, they puzzled and fascinated scientists and artists throughout time. The Remarkables are those individuals whose physical and sometimes mental manifestations of endocrine disease produce ambiguous responses, depending on the time and place in which they are regarded. They are remarkable for their adaptation to “normal” society as well as for the differences that separate them from the same society. Remarkable, too, is the intricate endocrine system that explains how, for example, the pituitary or “master” gland can produce thyroid stimulating hormone and other hormones that directly lead to the symptoms of thyroid disease or other endocrine diseases. However complex and remote the relationship between endocrine cause and effect may seem, the manifestations of endocrine disorders continue to be remarkable to physicians and most certainly to those who suffer from endocrine disease. In our view the painters who represented such diseases were remarkable for their scientifically accurate and precise observations of human anatomy and pathology. They were no less remarkable than the physicians who, also by accurate observation, trial and error, eventually learned the etiology and mechanisms responsible for endocrine disorders.

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Chapter 1

The Goiter Beautiful: Purity, Sensuality, Fertility

Introduction

In the history of European portrait and narrative paintings featuring

female figures, a variety of aesthetic choices provides the viewer with

a glimpse into the ways artists perceive their subject matter. During the

early Renaissance in Italy, many artists began to use live models whose

images were rendered in formal portraits. Others created female

figures from their imaginations. Whatever the source of human images

in painting and sculpture, traditional concepts of female beauty changed Figure 1-35 according to the time and region in which the artist worked. Vittore Crivelli, St Catherine of Alexandria (1491, Oxford, Ashmolean Museum) (see p. 51)

A comparison of five female figures figure’s full rounded neck, an impor- featured in works from ancient tant attribute of the subject’s femi- Rome to Victorian England reveals nine identity. More demure and less a changing perception of female direct than the subject of the Roman beauty over a period of 1600 years. portrait, the figure of St. Catherine of For example, a second century ce Alexandria in Vittore Crivelli’s por- Roman pavement mosaic includes the trait (1494) of the saint, suggests the domestic portrait of a woman with idealization of youth and purity in a prominent eyes and youthful curls in a painting that also draws attention to frontal pose common to mosaics from the young saint’s full rounded neck. this period. What distinguishes this With contrasting boldness, the full portrait from other Roman portraits neck and voluptuous décolletage of executed in a similar style is the Rubens’s red haired Delilah in Samson and Delilah (1609) displays overt eroticism. More subtly sensual, Botticelli’s Figure 1-17, facing page Three Graces from La Primavera Sandro Botticelli, La Primavera (1481–82, (1477–78) and the subject of Rossetti’s Florence, Uffizi Galleria) (see p. 37) portrait A Daydream (1878) also

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reveal the full rounded necks of young, romanticized female figures.11

What do these women have in common as the subjects of paintings created within the larger context of Western European culture? On the surface, each painting attracts the viewer to its subject’s beauty, grace, and youth. Some of the renderings of female figures reflect notions of female purity and religious piety. Others exude confidence and power, some a subtle sensuality disguised as romantic innocence. The artist’s use of composition and color and attention to specific details of hair and clothing may reflect the culture of the time and place in which the artist worked. In the history of western civilization standards of female or male beauty are as capri- cious as modern fashion. Angular noses and high cheek bones; rounded, plump cheeks; round or almond- shaped eyes, thin or bold eyebrows; a dimpled chin—facial features that artists accentuate in pleasing combina- tions—change with the aesthetic preferences of time and region. One aspect of the figures’ female beauty remains a constant in these paintings: the full rounded neck, an early indicator of an enlarged thyroid gland or diffuse goiter frequently found in females and generally not found in males.

Figure 1-20 Dante Gabriel Rossetti, The Day Dream (1880, London, Victoria and Albert Museum) (see p. 38)

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Figure 1-1 Hans Holbein the Younger, Adam and Eve (1527, Basel, Switzerland, Kunstmuseum)

This prominent anatomical feature in or scene with an individual identity manifestations of thyroid disease. paintings of women hides the that transcends the legendary or his- Practicality demanded efficiency and if sternocleidomastoid muscles and torical figure she or he represents. the same model could be used for a Adam’s apple more visible in portraits variety of subjects, so much the better. of males. Hans Holbein the Younger’s The prevalence of the full rounded Thus the same anatomical features Adam and Eve (Figure 1-1, 1527, neck in female images from a wide in a particular model might have been Basel, Switzerland, Kunstmuseum) is spectrum of paintings in both northern repeated in numerous paintings. a good example of the difference and southern Europe and throughout When several paintings in an artist’s between male and female anatomy of history leads one to question the oeuvre feature the same model, the the neck. In the painting, the artist’s intention. Were Botticelli, Rubens, variety of poses enables the viewer to strong sternocleidomastoid muscles and the numerous other painters determine whether the figure’s neck and prominent thyroid cartilage who draw attention to the full rounded swelling is, in fact, an example of (or Adam’s apple) of Adam’s neck neck aware of the underlying thyroid thyroid disease or just a fat neck. If a create a significant contrast with the gland or other endocrine disorders that female figure in a painting is shown smooth rounded neck of Eve. such an anatomical detail indicates? to have a physical condition such as More unusual are those paintings in Most likely not. diffuse goiter, indicating possible which the artist depicts a male figure’s hypo- or hyperthyroidism, the viewer full rounded neck rather than the more The large number of Renaissance and may question the artist’s reasons for typical angular and muscular features Baroque paintings that portray representing this anatomical feature. found in many portraits of men. women, and sometimes men, with dif- In paintings with classical, religious or fuse goiters, however, suggests Considering the absence of knowledge secular themes the full rounded that artists did recognize and often of the anatomy and function of neck imbues the subject of a portrait accurately represent the physical endocrine glands in general and the

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thyroid gland in particular until the late nineteenth century, it is unlikely that artists before 1900 were conscious of displaying a subject’s goiter as such. Only a few Renaissance artists such as Leonardo da Vinci and Michelangelo revealed an awareness of the thyroid gland’s anatomy in their sketches and drawings. The large number and variety of paintings in which goiters are visible, however, indicates that many artists observed their models’ swollen necks and attempted to represent the neck’s anomalies as an anatomical feature of the human form. In many paintings, the slightly enlarged thyroid gland appears to be a sign of beauty. It is also evident that the female figures in the paintings we discuss in this chapter appear to have diffuse rather than nodular goiters with palpable thyroid nodules manifested in noticeable neck masses. Both diffuse and enlarged multinodular goiters (caused by mostly benign but sometimes malignant thyroid nodules) are examples of thyroid disorders that were particularly common to specific inland or mountainous regions of iodine deficiency in Europe where Renaissance painting flourished: Italy, Spain, the Netherlands, Flanders, and Germany.

Figure 1-5 Leonardo da Vinci, Madonna and Child (1473, Munich, Alte Pinakothek) (see p. 26)

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Did artists’ models in these countries size the sensual, even erotic, nature of coincidentally have endemic goiters the human figure with a full rounded caused by iodine deficiency and thus neck? From many examples, especially have enlarged thyroid glands? The those from the Baroque period numerous paintings by Tuscan and and later, one might question whether Umbrian artists of women with goi- a woman’s full rounded neck was Figure 1-4 ters would suggest that many of the considered part of an erogenous zone Andrea del Verocchio and assistant models had endemic goiter and artists that included the breasts. (Lorenzo di Credi), Virgin and Child were painting what they saw with a with Two Angels (1470–80, London, high degree of anatomical realism.12 National Gallery) (see p. 26) Or were the models chosen for their beauty, imagined or real, one feature of which was the fully rounded neck? Since not all painters working in the same region and time period feature the full rounded neck in their female figures, one questions whether this detail was emphasized consciously, whether the aesthetic standard varied from artist to artist, or whether the choice was made simply by chance. If an artist such as Botticelli or Caravaggio used the same model with a full rounded neck and this figure was also shown to be a beautiful woman, we might conclude that the artist, and subsequently the viewer, came to associate the full rounded neck with female beauty.

One also questions the artists’ emphasis on the full rounded neck in male figures, mostly in religious paintings of angels and saints. Is the full rounded neck in both female and male figures associated with gentle- ness and holiness as well as beauty? If the neck’s symbolism derives from multiple associations, to what extent is beauty defined as a quality of purity and innocence, martyrdom or sacrifice? If these qualities are included in the definition, how do we reconcile them with those paintings that empha-

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As late as the latter half of the nine- History of thyroid disease and goiter, Iodine deficiency is the most common teenth century through the early its etiology and epidemiology, the cause of goiter worldwide. In 1958 twentieth century, as realism gave way association of the full rounded neck the who reported approximately 7% to a more abstract rendering of subject with beauty, youth, fertility, and ma- of the world’s population, or 200 mil- matter, artists continued to represent ternity lion people, had goiters.15 In areas of the full rounded neck in paintings iodine deficiency or endemic goiter, of women. To the twenty-first century up to 85% of persons have goiters.16 viewer this prominent anatomical The normal thyroid gland is shield like Today in the United States, an iodine feature may not be as aesthetically or butterfly like in shape and rich nation because of the pres- pleasing as it might have been in the is situated in the anterior neck with ence of iodine in salt, the incidence fifteenth and sixteenth centuries. the isthmus or central connection of palpable goiter is about 4%.17 In It is possible, however, to recognize positioned just caudal to the cricoid England, Tunbridge et al reported that patterns that link the appearance of a cartilage on the trachea. The gland in citizens from Wickham, County woman’s small diffuse goiter with the normally weighs about 20 grams but is Durham goiters were present in 12.1% aesthetic, cultural, social, and moral considerably larger in individuals of women and 4.5% of men and that or religious values expressed in these from iodine deficient areas. An palpable nodules were found in 5.3% works. In this chapter we will attempt enlarged thyroid gland is a goiter, a of women and in 0.8% of men.18 to answer some of the questions term from the Latin guttur, meaning About 6% of Scandinavian women provoked by the recognition of such throat. Goiters may be diffuse and over sixty years of age have thyroid patterns as we examine the history of symmetrical, asymmetrical or nod- nodules, whereas in West Germany, an thyroid disease and the rich array ular, and functioning or non func- iodine deficient country, the incidence of examples from European paintings tioning.13 Goiters are classified by the of goiter is about 15% in young adults of women and men with evidence of World Health Organization (who) drafted for the military service.19 diffuse goiters. In Chapter 2, we will as palpable, visible, or both with the examine the contrast between artists’ following staging criteria: Stage O-A: In iodine deficient areas, certain foods representations of the full and often no goiter; Stage O-B: goiter detected such as the cassava root, which aesthetically pleasing rounded neck only by palpation and not visible even contains the goitrogen thiocyanate, and those with more dramatically dif- when the neck is fully extended; Stage and millet increase the frequency fuse or nodular enlargement to which I: goiter palpable but visible only when of goiter development.20 Certain veg- we refer as “goiter grotesque.” the neck is fully extended; Stage II: etables of the Brassica family, such as goiter visible with the neck in normal turnips, kale, cabbage, mustard position, palpation not needed for greens, and rutabaga contain gluco- diagnosis; Stage III: very large goiter sides, “which, after digestion, release that can be recognized at a consider- [the goitrogens] thiocyanate and able distance.14 Most goiters depicted isoithiocyanate.”21 Millet, a popular in Renaissance and Baroque paint- food in the Sudan, is a flavonoid ings would be classified as Stage II that has antithyroidal activity.22 or diffuse goiters. In this chapter we have included examples of Stage I and Today in many iodine sufficient or II goiters, referred to here as “goiter iodine rich countries, however, chronic beautiful.” Examples of Stage III goi- lymphocytic thyroiditis or autoim- ters, which we have termed “goiter mune Hashimoto’s thyroiditis is the grotesque,” appear in Chapter 2. most common cause of goiter. These goiters are usually small or Stage II

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goiters, and about twenty percent of the thyroid gland, and some develop neoplasms, are euthyroid or normal. individuals with Hashimoto’s into large multinodular goiters, thus In his History of Endocrine Surgery, thyroiditis develop hypothyroidism. changing from “goiter beautiful” British surgeon Richard Welbourn In the Wickham survey, anti-thyroid to “goiter grotesque.” In individuals notes that prior to the nineteenth cen- peroxidase or microsomal antibodies, consuming a normal iodine diet, tury goiters were often confused which document thyroiditis, were urinary iodine excretion should be with other abnormalities in the neck present in 10.3% of women and 2.7% more than about 100 micrograms per such as enlarged lymph nodes, of men; approximately one third gram of creatinine per day. In areas bronchial cleft cysts, neurofibromas, of the women with positive antibodies of severe iodine deficiency (excretion or tuberculous adenitis etc., and the had goiters (Tunbridge et al, 481). of less than 25 micrograms per day), term bronchiocele, meaning trachea, Autoimmune thyroiditis has been iden- goiter is often associated with clinical bronchus, and tumor in Greek, was tified at autopsy or by antibody hypothyroidism and cretinism. In used to describe these neck masses.29 testing in about 15% of women in these same areas cretinism develops in Other terms used to describe goiters the United States and Japan.23 Inborn about 10% of children with goiters. were struma, from the Latin meaning errors of metabolism, resulting Myxedematous cretinism27 is swollen gland, schilddrusen, from the in abnormal thyroid hormone bio- associated with mental retardation, German meaning shield, and oveos synthesis or dyshormonogenesis, are growth retardation, delayed bone from the Greek, also meaning shield.30 another cause of goiter formation. maturation, a large tongue, abnormali- Exposure to low dose therapeutic ties in gait and thick skin.28 Although Goiters were observed 4000 years ago radiation (6–2000 rads), especially in most individuals with goiters in China, Egypt, Greece, and other childhood, increases the risk of are euthyroid with normal thyroid countries. Even though there are much developing benign thyroid nodules, function, some are hypothyroid and earlier records of the observation of thyroiditis, and thyroid cancer.24 others may be hyperthyroid with goiter, it was not until the eighteenth Schneider et al have reported that increased thyroid hormone levels. century in Europe that scientists nodular goiter develops in about 38% discovered the association between of individuals exposed to low dose When the thyroid gland enlarges iodine deficiency and the etiology of therapeutic radiation and that about or is a goiter, it is noticeable because goiter. According to medical histo- 11% have developed thyroid cancer.25 of its relatively superficial position rian Victor Medvei in his History of After the disastrous nuclear accident in the anterior neck. Although most Endocrinology, Julius Caesar (ca. 50 near Chernobyl, Ukraine in 1986 commonly the thyroid gland can be bce) observed that one of the char- there was a marked increase in thyroid diffusely or symmetrically enlarged, acteristics of the Gauls was a big cancer in children. Thyroid cancer is the enlarged thyroid can also neck.31 Welbourn reports that goiters now the sixth most common cancer contain one or more nodules. Diffuse “were noted by non-medical Roman and the most rapidly increasing cancer or symmetrical enlargement, which authors in the first three centuries in women.26 It is also the second occurs more often in younger people, ce (Common Era) in mountainous most common cancer in women under is usually associated with benign or regions” and that both medical and forty years of age. non-cancerous thyroid conditions and non-medical writers continued to sometimes with increased or decreased observe goiters in specific endemic Endemic goiters are characteristic of thyroid function. Nodular thyroid regions (Welbourn 19–20). regions in which glaciation removed glands are often indicative of the natural iodine in the soil, leading multinodular goiter or of either benign There were numerous theories about to iodine deficiency in at least 10% or malignant thyroid tumors. the origin of goiter. For example, of the inhabitants. Most endemic Most patients with benign or malignant followers of the Greek physician goiters begin as a diffuse swelling of thyroid nodules, known as thyroid Hippocrates (460–375 bce) attributed

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the cause of goiter to the drinking of Because the origins of thyroid disease Since the function of the thyroid and melted snow (Medvei 45). The Roman were misunderstood and religious its anatomical details were unknown Caius Plinius Secundus (23–79 ce), beliefs interfered with scientific diag- or misunderstood until the late known as Pliny the Elder, recorded nosis of disease in general, effective nineteenth century, goiters were often epidemics of goiter in the Italian Alps treatment of thyroid disease was slow mistakenly thought to belong to and attributed goiter to the impurities in to develop. Medvei states that during other neck masses. According to Iason, the water, stating that “‘Only men “the period of European Monastic Hippocrates (460–377 bce) referred and swine are subject to swellings in the Medicine from the 5th to the 10th cen- to the “flesh of glands” as “different throat, which are mostly caused tury ad (ce) … zeal for preserving from that of the rest of the body, by the noxious quality of the water they the remains of ancient literature and being spongy and full of veins; they drink’” (Medvei 59). In the seventh the traditions of ancient and rational are found in the moist parts of the century ce, the Greek Paul of Aegina practice” was combined “with the body where they receive humidity … wrote about an aneurysmatic bron- newly developed cult of healing the brain is a gland as well as the chiocele. In the eleventh century Abul power of the Saints and Holy Relics” mammae’” (Iason 15). Iason also Kasim (Albucacis) of Cordoba, Spain (Medvei 90). Medieval Christians notes that the Roman Aulus Cornelius referred to an incurable “‘elephant took their ideas from the Hebrews, Celsus (25 bce–50 ce) was one of of the throat’” most frequently observed who had taken many of “their beliefs the first to distinguish differences among in women (Welbourn 20). In 1271 from ancient Mesopotamian cul- various forms of tumors of the neck the Italian explorer Marco Polo also tures, among them the conviction that (Iason 24). noted that goiters were common disease was a form of divine punish- in people from the mountainous ment and therefore a mark of sin.”33 Galen (130–200 ce) possibly described regions of Turkestan (Welbourn 20). Medvei also notes that to the medieval the normal thyroid gland, but it Renaissance painter Michelangelo mind, “[s]upernatural powers were was not until the Renaissance that (1476–1564) apparently attributed his responsible for the great epidemics its identity was generally recognized, own goiter to the drinking of toxic and heavenly aid was necessary to and the failure to differentiate substances in the water of the Apennine obtain relief from them” (Medvei 90). goiter from reactive lymph nodes Mountains in Italy. Welbourn notes Most diseases were “largely regarded caused by carious or abscessed teeth, that Michelangelo’s goiter bothered as a divine visitation,” illustrated by scrofula or other neck masses also him when he extended his neck while a legend, which “according to Hubert continued until that time. Today we he was painting the ceiling of the Sistine (Life of St. Gudula) that the Bishop of know that although most benign Chapel (Welbourn 20). Medical his- Emebert (seventh century) hurled an and malignant thyroid tumors occur torian Alfred Iason quotes an excerpt anathema at the wicked persons who sporadically, there are patients from a sonnet by Michelangelo, sup- despoiled the tomb of that saint, the with familial benign goiter, familial posedly written while he was painting curse being that their offspring should autoimmune thyroid diseases such as the ceiling: “I’ve grown a goiter by be cripples (claudicati) and the women Graves’ disease and Hashimoto’s thy- dwelling in this den/As cats from goitrous” (Iason 30). Although such roiditis, and familial thyroid cancer.34 stagnant streams in Lombardy/Or in theories may seem ridiculous in the what other land they hap to be.”32 In a twenty-first century, they are not too The sixteenth century saw more recent exhibit of Michelangelo’s draw- dissimilar to the proclamations in our advances in the understanding of the ings in Rome we saw the original poem own time of certain religious funda- thyroid’s anatomy and symptoms written on a piece of paper mentalists who even now consider of thyroid disease. Swiss physician next to a line sketch of a man’s body sexually transmitted diseases such as Paracelsus (1493–1541) taught the with a prominent goitrous swelling aids and other illnesses as the importance of the unity of medicine on the neck. consequences of sin. and surgery and rejected the ideas

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of Galen and his theory of the four Da Vinci’s drawings continue to inspire contributed many of the drawings humours.35 A pioneer of chemistry contemporary artists and scientists who based on Vesalius’ dissections even and pharmacology and the founder of value the marriage of art and science though neither he nor any other artist toxicology, like some before him, that came about in the Renaissance and was acknowledged by Vesalius in De Paracelsus attributed the presence of eventually led to a regard for anatom- Fabrica (Lyons and Petrocelli 416). “goiter to the impurities in drinking ical drawings. One of those artist/ Nonetheless, we can credit Vesalius’ water, especially sulfides of iron scientists was Andreas Vesalius (1514– writings and illustrations for revolu- (marchasita), and also postulated a 64), a Flemish professor of surgery tionizing not only human anatomy hereditary element in it. He was and anatomy at the University of Padua, but also scientific teachings in the the first to realize the connection Italy. Vesalius’ illustrations were “a Renaissance. Although he remained between cretinism, endemic goitre, and collaboration between artist and anato- a follower of Galen, he identified congenital idiocy,” stating that mist” exemplifying the strong links numerous errors in Galen’s discoveries, “‘While goitre is not a characteristic of between art and science and evincing including the limitations of “Galen’s idiots yet it is most commonly found a “degree of artistic sophistication” texts … based on dog and monkey among them’” (Medvei 98). considered “new even to artists in the anatomy.”37 Renaissance” (Lyons and Petrocelli It is to artists, however, that we can 416). In 1543 Vesalius illustrated the Working during the same period as attribute a broader dissemination of thyroid gland in his book De Humani Vesalius, the Roman Bartolomeus knowledge concerning the anatomy Corpus Fabrica. He stated that Eustachius (also known as of the thyroid gland. During the there were Bartolommeo Eustachio, 1520–74), Italian Renaissance artists demon- “who also discovered the adrenals,” strated a serious interest in human [t]wo glands, one on each side of more accurately described the anatomy that led to investigative the root of the larynx, and these thyroid as “a single ‘glandulam thyroi- drawings of organs and glands. The large and somewhat fungus and deam’ (L = shield-shaped) with most well known of artists who almost the color of flesh, but rather an isthmus connecting its lobes, but demonstrated a profound interest darker, with prominent veins…. his work was not published until in and knowledge of science was These glands be at the root of the the eighteenth century” (Welbourn Leonardo da Vinci (1452–1519). “In trachea, since they moisten its ori- 20). Eustachius was the first to about 1500 Leonardo da Vinci drew fice with a humor not indeed fluid, use “the term ‘isthmus’ for the part the thyroid as a globular, bilobate but rather viscous and thick, for the connecting the two lobes” (Medvei structure, which he regarded as two glands themselves are thicker and 109). A short time after Eustachius, glands, filling up empty spaces in denser than the rest of the gland Julius Casserius (Padua, 1545–1616) the neck that separated the trachea which secrete a humor (Iason 37). reported that the thyroid gland from the clavicle, but his drawings was “shaped like a horseshoe, and were unknown for three centuries” There has been considerable specula- regarded it as a lubricating and space- (Medvei 102). Da Vinci most likely tion about whether “the degree of filling organ, which also made the used the thyroid gland of a dog for artistic sophistication and the knowl- neck pleasing to the eye” (Welbourn his model because, in contrast to edge of techniques new even to artists 20). Fabricius ab Aquapendente humans, dogs do not have an isthmus in the Renaissance were too great for (Padua, Italy, 1537–1619) was the first in their thyroid glands. We can see a Vesalius to have been the sole person to localize the thyroid gland defini- direct application of da Vinci’s mostly responsible” (Lyons and Petrocelli tively as the anatomical seat of goiter accurate but limited knowledge in 416). Current research suggests that (Iason 33). a few of his drawings and paintings Stephan van Calcar (1499–1546/50), (Medvei 102).36 a former student of Titian, may have

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Like Vesalius, Casserius, and Fabricius noted that at the time of “puberty, in ab Aquapendente, British physician girls, often at the onset of menstrua- Thomas Wharton (1614–73) thought tion, the gland enlarges;” and in some that the function of the thyroid was to women, especially in areas of iodine lubricate the larynx. Perhaps because deficiency, “the neck becomes fuller at of the prevalence of diffuse goiters each menstruation.”39 During preg- in pubescent and pregnant women, nancy the thyroid gland may become Wharton associated the diffuse goiter goitrous and rarely “a bruit, reflecting with female attractiveness. In his the increased blood flow, may be Adenographia: Sive Glandularum present.”40 This temporary change Totius Corporis Descriptio (1656) may explain why the Roman Catullus about the thyroid and other glands (30 bce–50 ce) referred to the wom- Wharton attempts to explain the pur- an’s “honeymoon” enlargement of pose of the thyroid gland. According the neck.41 The ancient Romans often to Medvei, Wharton “did not clearly placed a thread around the neck of separate the thyroid gland from the young women to determine whether submaxillary glands, but gave it its they had lost their virginity and/or modern name, based on a wrong were pregnant (Medvei 57). The Greek deduction. He chose … (thyreos) = Soranos of Ephesus (98–138 ce) also oblong shield, because it ‘contributes noted swelling of the neck after preg- much to the rotundity and the beauty nancy during the period of lactation of the neck, filling up the vacant (Medvei 57–58). spaces around the larynx … making its protuberant parts almost to subside These theories continued to dominate and become smooth, particularly in explanations for the full and rounded females, to whom for this reason a neck until “thyroid deficiency was larger gland has been assigned, which recognized” in the nineteenth century renders their necks more even and (Welbourn 21). Subsequent remedies beautiful’” (Medvei 131). Although were followed to treat disfiguring goi- he accurately identified the form of ters or “goiter grotesque” (see Chapter the thyroid gland, Wharton misunder- 2), but in much earlier times the full stood the function. and rounded neck was apparently regarded by artists as well as scientists Wharton’s ideas were partly correct, as a sign of beauty. It was this charac- however. Since the seventeenth century teristic above all others that probably medical scientists have observed and inspired so many pictorial representa- documented that in both man and tions of the diffuse goiter. animals the thyroid attains its relative maximum size just prior to the onset of puberty (Means 2). Women have proportionately larger thyroid glands than men, and “thyroid nodules appear more frequently in mul- tiparous women.”38 Sir William Osler

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Figure 1-30 Jan Steen, The Doctor and the Patient (1670, Prague, National Gallery) (see p. 44)

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Figure 1-2 Paolo Veneziano, The Doge Dandolo and the Dogaressa Being Presented to the Virgin (1339, Venice, Frari Church)

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The Goiter Beautiful in art Torcello, Venice, Cathedral of Santa Maria Assunta), the necks of almost all of the figures, both male and Wharton’s accurate observation that female, have prominent Venus lines. women have larger thyroid glands The uniformity of detail, which is than men and his theory, echoing that similar to the stylization used in many of Casserius, that the enlarged thyroid medieval frescoes and mosaics, would “renders their necks more even and suggest that the artist is following sty- beautiful” is especially applicable to listic convention rather than accentu- portraits of the Virgin Mary in the ating an anatomical anomaly. late Middle Ages and throughout the Renaissance in Europe. The tradi- By the fourteenth century in Italy, tion of painting portraits of the Virgin however, early Renaissance paintings Mary as “objects of veneration” origi- of the Virgin Mary began to deviate nated in the early Byzantine period.42 from such consistent stylization According to art historians H. W. even though some of the features of and Anthony Janson, the accepted Byzantine iconography lingered. Christian belief of the time included Frescoes painted in Tuscany, Umbria, “the claim that Christ had appeared and the Veneto depict the Virgin Mary with the Virgin to St. Luke and per- with a more individualized expression mitted him to paint their portrait, and and a more graceful flow between that other portraits of Christ or of the the head and the body, so that the neck Virgin had miraculously appeared on no longer seems attached with its earth by divine fiat,” thus becoming characteristic bulge but rather appears “the source for the later, man-made” to grow out of the Virgin’s body as portraits (Janson 256). Early Byzantine if she is all of one piece. The Venetian portraits of the Virgin draw the viewer fourteenth century painter Paolo primarily to the face and neck, which Veneziano’s portrait of the Virgin Mary is often delineated by a prominent in The Doge Dandolo and the horizontal line at its base as if the Dogaressa Being Presented to the Virgin head and neck were painted separately (Figure 1-2, 1339, Venice, Frari and attached to a paper cutout body Church) deviates from the Byzantine covered in drapery. Such delineation of style in its portrayal of the Virgin’s the neck with a slight swelling above facial expression. Although the Virgin’s the “Venus line” (a curved crease or head and shoulders are leaning to the natural skin line) is also apparent in left, as is the convention in Byzantine Roman mosaics and in Roman paint- icons, she appears to be looking ings on Egyptian mummy covers, toward the viewer with more emotion medieval paintings, and Byzantine than is revealed in most Byzantine mosaics and frescoes. For example, portraits. The slightly lifted chin reveals in the large Byzantine mosaic of The a swelling and Venus lines in her neck. Last Judgement in the Cathedral of Despite his use of the draped cowl Santa Maria Assunta on the island of from Byzantine tradition, Veneziano’s Torcello (13th century, portrait and those by Giotto, Duccio,

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di Segna, Martini, and Piero della seems to be a positive attribute of the Francesca replace the stylized figure’s strength. As in Veneziano’s neck and Venus line with a more real- painting, the Virgin’s physical strength istic swelling that suggests the presence symbolizes her maternal role in of a diffuse goiter.43 the church.44

In two Italian Renaissance paintings that represent the Virgin Mary in the traditional pose as mother of the church, the artists portray Mary with a small diffuse goiter. Sienese painter Niccolò di Segna’s Madonna of the Misericordia (1331– 32, Siena, National Picture Gallery) features the Virgin in a frontal pose, directly facing the viewer. The viewer is drawn to the pronounced swelling in the Madonna’s lower central neck that, with her head, bisects the portrait at the apex of a triangle created by her robe and the triangular top of the painting. Symmetrically placed on both sides within the folds of the robe is a gathering of pilgrims, most of them in ecclesiastical garb, whose diminutive size in contrast to the Virgin’s emphasizes her strength, concern, and sympathy. Like di Segna’s Virgin, Piero della Francesca’s Madonna of the Misericordia (Figure 1-3, 1445, Sansepolcro, Tuscany, Museo Civico) also appears to have a diffuse goiter. It is difficult, however, to determine whether the figure’s diffuse goiter also has nodules in the lower portion of the right and left lobes of the thyroid. What appear to be nodules could be the artist’s representation of the

sternocleidomastoid muscles stretched Figure 1-3 over a diffuse goiter. In both works Piero della Francesca, Madonna of the on the subject of the older, maternal Misericordia (1445, Sansepolcro, Tuscany, Madonna the moderately goitrous Museo Civico) swelling in the center of the painting

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Less bold but with equal emphasis on the Virgin’s maternal expression are several fifteenth and early sixteenth century portraits in which a young Virgin Mary is often shown with the Christ Child and other holy figures. Typically, the mother figure is shown with eyes downcast as she contemplates her child. In Andrea del Verocchio’s Virgin and Child with Two Angels (Figure 1-4, 1470–80, London, National Gallery, see p. 15) the low neckline of the Virgin’s robe reveals a swollen neck with diffuse goiter. The triangular composition of the painting with the head and neck at the apex of the triangle accentuates the fullness of the figure’s neck. In contrast to the Virgin in the Misericordia paintings, del Verocchio’s Virgin does not look directly at the viewer and is portrayed in a state of maternal but youthful contemplation.45

A similar expression of maternal concentration appears in Leonardo da Vinci’s Madonna and Child (Figure 1-5, 1473, Munich, Alte Pinakothek, see p. 14) and in Andrea Mantegna’s The Virgin and Sleeping Child (Figure 1-6, 1465–70, Berlin, Gemaldegalerie). In both paintings the artists have portrayed the Virgin with a full rounded neck signifying a diffuse goiter. Da Vinci’s figure of the Virgin, however, Figure 1-6 reveals a slight asymmetry with a more Andrea Mantegna, The Virgin and Sleeping prominent swelling in the right neck. Child (1465–70, Berlin, Gemaldegalerie) His use of the sfumato technique46 also more finely nuances the subtleties of the model’s neck than is apparent in other paintings of the Virgin.

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Although artists such as da Vinci especially noticeable in paintings of the opposite the Angel Gabriel, creating incorrectly thought of the thyroid Annunciation that depict the Virgin symmetry in the composition that gland as two separate lobes,47 the before childbirth. Characteristically, gives equal weight to both figures. shape of the gland in his painting of the painter places the Virgin in a the Virgin is clearly one in which the modest, almost deferential, pose, head two lobes are connected by a central lowered and body leaning toward the isthmus. The contrast between theory Angel Gabriel, eyes downcast and and practice suggests that he painted arms crossed in modesty or held out the model for the Virgin the way he as if in self-defense. Melozzo da Forli’s Figure 1-7 saw her and thus accurately illustrates Annunciation (Figure 1-7, Rome, The Melozzo da Forli, Annunciation (Rome, The the anatomical description made by Pantheon) portrays the Virgin directly Pantheon) Eustachius later in the 16th century.48 Mantegna’s Virgin also has a noticeably shield-like swelling accentuated by the turning of her face “so that it brings a diagonal into the composition.”49 The enlarged thyroid gland is partly in shadow, the contrast in lighting further emphasizing the per- fectly symmetrical growth in the neck that mimics the volume and protrusion of the figure’s chin. Like that of da Vinci’s Virgin, the feminine innocence of Mantegna’s Virgin is highlighted by her delicate curls and soft downward glance. Her serious expression of contemplativeness and the strength apparent in her neck mass, however, belie the youthfulness suggested by the simple dress and the monochromatic pattern of headdress and bodice.

Da Vinci’s and Mantegna’s Virgin figures appear to be young women whose maternity may have followed quickly on the heels of pubescence, that period in which the thyroid is proportionately larger in comparison to the rest of the body. The existence of the full rounded neck in the two portraits thus seems closely associated with both fertility and young maternity.

The importance of fertility and maternity in images of the Virgin Mary is

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Figure 1-8 The Virgin figure’s diffuse goiter is humble pose. In both, the slight Botticelli, Annunciation (1489–90, Florence, noticeable in its contrast to the angel’s turning of the neck to the Virgin’s left Uffizi Gallery) thicker, more muscular neck. Both draws attention to its goitrous swelling Botticelli’s Annunciation (Figure 1-8, and distracts the viewer’s gaze from 1489–90, Florence, Uffizi Gallery) the figure of the Angel Gabriel, shifting and Fra Filippo Lippi’s Annunciation the focal point along the right (Figure 1-9, 1440’s, Rome, National diagonal to the Virgin. Both Virgins Museum of Antique Art, Palazzo also have prominent eyes (exoph- Barberini) show the Virgin in a more thalmos), suggesting that the goiter

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could be related to Graves’ disease, Figure 1-9 that is, autoimmune thyroid Fra Filippo Lippi, Annunciation (1440’s, disease.50 Botticelli’s Annunciation in Rome, National Museum of Antique Art, particular, uses the swollen neck Palazzo Barberini) as the most prominent feature of the Virgin’s figure, as if the neck mass provides physical balance for the graceful dance-like pose of the

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young woman who has just received Almost sixty years later, beauty, mod- foot on a gleaming serpent, which, such startling news from the angel. esty and a dancer’s grace are reflected according to Puglisi, alludes to a The model for this painting appears in much earthier tones in Caravaggio’s “mistranslation from the Hebrew” of to be the same as that for Botticelli’s Baroque painting of the Madonna Genesis 3 in the Vulgate Bible in Madonna with the Book (ca 1485, of the Pilgrims (Figure 1-11, 1603–4, which “God would send a second Eve Milan, Poldi Pezzoli) in which a three- Rome, Church of San Agostino), to redeem the original sin of the quarter pose places a similar emphasis also known as the Madonna of Loreto. first” (Puglisi 192). The pose therefore on the swollen neck.51 In contrast to Here the Virgin’s left-leaning head invites the observer to speculate Botticelli’s painting on the same subject, and her neck with its diffuse goiter form about Caravaggio’s intentions and the Lippi’s Annunciation shows a more the top of an arc completed by sexual as well as religious ambiguity pensive, youthful figure whose full neck her arm and that of the Christ child of his earthy Virgin. reflects her imminent womanhood she holds. The painting’s chiarascuro54 and strength. lighting and circular motion Unlike the Parmigianino Virgin, further accentuate her beautiful full Caravaggio’s Madonnas are less An unusual sixteenth century portrait neck. The sensuality of Mary in elegantly clothed and more self-effacing of the Virgin, Parmigianino’s Madonna Caravaggio’s Madonna of the Pilgrims in their downward gaze. The humble with the Long Neck (Figure 1-10, is also noticeable in his painting pose of the Virgin in The Madonna of 1534–40, Florence, Uffizi Gallery) calls of the Madonna of the Palafrenieri the Pilgrims is in keeping with the attention to the female neck in (Figure 1-12, 1605–6, Rome, Galleria presence of the humble pilgrims in the more Mannerist terms with exagger- Borghese) for which the artist right foreground of the painting. ated contours, sensual color probably used the same model.55 In Similarly, the modest dress of St. Anne tones and dramatic gestures.52 The this painting the Madonna’s diffuse in the Madonna of the Palafrenieri neck of Parmigianino’s Virgin is, goiter is equally visible, and the emphasizes the domestic simplicity of at most, indicative of a Stage I or II sensuality of her neck is heightened by the scene. Despite differences in goiter, but its rotundity seems her revealing pose. According to clothing and the contrast between pronounced in contrast to the figure’s art historian Catherine Puglisi, the pose Parmigianino’s use of a more slenderness, also emphasized by may have caused “the cardinals of formal pose and background and her long thin fingers. Her snake-like the Fabbrica di San Pietro” to reject the Caravaggio’s more natural poses and curls and the neck’s serpentine or painting as inappropriate for the settings, the Virgins in the three swan-like length and curve, echoed church because of its “indecency.”56 As paintings share a sensuality less subtle in the contours of the ribbon on Puglisi notes, the problem resides in than that in quattrocento (fifteenth her dress, accentuate the neck’s Venus “Mary’s attire: instead of her century) paintings of the Virgin. It is lines, suggesting the Virgin’s sensual customary matronly veil, mantle, and probable that Caravaggio and attractiveness and, recalling Botticelli’s robes, she wears contemporary Parmigianino have boldly incorporated Virgin in the Annunciation, the dress of a simple design and fabric, into their portraits of the Virgin the grace of a dancer.53 with skirt hitched up for the work female neck’s function as an erogenous at hand, and her stooping pose reveals zone, made all the more noticeable by rather too much breast” (Puglisi its sensual curve and swelling. 195). The dramatic chiarascuro Figure 1-10 lighting of the Madonna’s neck and Parmigianino (Girolamo Francesco Maria breasts further suggests an association Mazzola, also known as Francesco Mazzola), between neck and breasts in one Madonna with the Long Neck (1534–40, erogenous zone. The Madonna of the Florence, Uffizi Gallery) Palafreneri’s Mary stands with her

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Figure 1-11, facing page Figure 1-12 Caravaggio, Madonna of the Pilgrims, also Caravaggio, Madonna of the Palafrenieri known as the Madonna of Loreto (1603–4, (1605–6, Rome, Galleria Borghese) Rome, Church of San Agostino)

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Figure 1-13 narrative. Most likely, the artist him sleep upon her knees; and she Mariotto Albertinelli, The Creation and Fall of intended to portray the serpent of called for a man, and she caused him Man (1513–14, London, Courtauld Gallery) Genesis 3 as a female, a common to shave off the seven locks of practice in the Renaissance. The his head; and she began to afflict him, serpent’s gender is less obvious, how- and his strength went from him” If Mannerist and Baroque paintings ever, than the association it (Judges 16:19). The role of the seduc- of the Virgin Mary with a full rounded suggests between goiter and sexuality, tress in Rubens’s painting is further neck draw attention to the sensual similar to Catullus’s association adumbrated by the presence of beauty of their models, numerous of goiter with puberty and pregnancy an old woman in the background, who, works featuring biblical and classical 1600 years earlier. The phallic along with the extravagantly decorated themes go a step further in suggesting imagery of the snake’s body coiled room, is evidence of the “brothel” the erotic and seductive powers around the tree, the juxtaposition of setting.57 Delilah’s full neck, which of a woman with a diffuse goiter. An Eve’s head and that of the serpent, appears to have an asymmetrical obvious example of the connection and the serpent’s prominent goiter all thyroid nodule on the right, adds to between goiter and seduction appears convey the artist’s emphasis on the the voluptuousness of her “bulbous in Mariotto Albertinelli’s The Creation sexual potency of the scene. breasts” (Belkin 155), clearly con- and Fall of Man (Figure 1-13, necting the fleshy goiter with the paint- 1513–14, London, Courtauld Gallery). Sexual potency is evident in sixteenth ing’s atmosphere of eroticism. This In the right half of this narrative and seventeenth century works atmosphere is further suggested by the painting, a seated, naked Adam featuring biblical and mythological display of Samson’s muscular virility in accepts the fruit from Eve, who grasps themes. A diffuse goiter accentuates the the painting’s foreground. The hero’s a branch of the tree, thus encircling sensual curve of Delilah’s neck in image of strength is eclipsed, however, the human head and neck of the serpent Rubens’s Samson and Delilah (Figure by the artist’s powerful portrayal of spiraled around the tree’s trunk. A 1-14, 1609/10, London, National the beautiful and sensual seductress, prominent goiter on the serpent’s neck Gallery). In this painting of a well- who has been exhorted by the lords of appears in the V-shaped space between known Old Testament story, the the Philistines to “entice him, and see Eve’s head and arm. Eve’s gaze is pale-fleshed Delilah is shown half- wherein his great strength lieth, and focused on Adam, but the serpent’s gaze seated, half supine on a bed draped by what means we may prevail against is directed above the compliant Adam, with sumptuous fabrics and rugs, him, that we may bind him to afflict perhaps to hint at the consequences her red gown providing an ample lap him” (Judges 16:5). of seduction depicted in the continuing for Samson’s head while “she made

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Figure 1-14 The association of sexual prowess enhanced by the juxtaposition of Rubens, Samson and Delilah (1609/10, and the full rounded neck with a Circe and the lion, representing London, National Gallery) diffuse goiter is apparent in Italian Circe’s power to tame and command. Renaissance paintings that feature The painting’s use of sensual detail female mythological figures. Dosso links sorcery and eroticism with the Dossi’s Maga Circe o Melissa (Figure prominent focal point of the woman’s 1-15, ca. 1518, Rome, Galleria diffuse goiter.58 Giacinto Campana’s Borghese) portrays the Greek mytho- The Rape of Helen (Figure 1-16, logical enchantress Circe with a full 1631, Rome, Galleria Spada) shows a rounded neck and bold frontal pose, more modest female figure than

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Figure 1-15 Dosso Dossi, Maga Circe o Melissa (ca. 1518, Rome, Galleria Borghese)

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Figure 1-16 Giacinto Campana, The Rape of Helen (1631, Rome, Galleria Spada)

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Dossi’s Circe or Rubens’s Delilah. Helen’s gaze is cast toward some unknown horizon as Paris leads her to Troy. Her three-quarter pose draws attention to her weak chin and a prominent diffuse goiter, the neck and head leaning toward an indifferent Paris whose military garb portends the war that will follow. This is a sensual but seemingly obedient Helen whose full rounded neck reminds us of her youth and vulnerability as the abducted wife of Menelaus. Despite the violence suggested in the title, she is portrayed as submissive rather than rebellious.59

The paradox of female modesty and eroticism is apparent in many artists’ representations of The Three Graces, Greek goddesses who, as their name indicates, were associated with female grace and most often represented in the act of dance. Both Botticelli’s rendering of The Three Graces in La Primavera (Figure 1-17, 1481–82, Florence, Uffizi Galleria, see p. 10) and Rubens’s painting of The Three Graces Figure 1-18 Movement. Painters like Dante Gabriel (Figure 1-18, mid-1630’s, Madrid, Rubens, The Three Graces (mid-1630’s, Rossetti and Edward Burne-Jones Museo del Prado) feature women Madrid, Museo del Prado) eschewed the idealism and formality of whose diffuse goiters accent the sen- their eighteenth century predecessors, suality of their dancers’ poses, flowing practicing “a deliberately romantic, hair, and partial nudity. The blond It is not surprising that in their attempt introspective art, the aim of which, if it figure on the left of Rubens’s painting to emulate the early Italian Renaissance has one at all, is to awaken our sense exposes a full rounded neck whereas painters who preceded Raphael of beauty” (Wood 119). Rossetti’s the presence of goiter is partially and “to paint their pictures with a Monna Vanna (Figure 1-19, 1866, 61 obscured in the other two women.60 complete fidelity to nature,” the London, Tate Gallery), The Bower All of Botticelli’s Three Graces are English pre-Raphaelite painters of Meadow and Veronica Veronese all endowed with diffuse goiters, but the the nineteenth century revived the use the model Alexa Wilding whose most pronounced is in the figure on Renaissance association of the full swan like neck has a moderate sized the left. Again, the full rounded neck rounded neck with female beauty and diffuse goiter. Perhaps best known is a prominent feature that suggests an sensuality. This association is most among Rossetti’s female models was association with feminine sexuality. noticeable in works from the 1860’s Jane Morris, the wife of his friend and and later during the period of English colleague William Morris and a well painting known as the Aesthetic known figure in the pre-Raphaelite

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Equally alluring yet submissive but even more overtly sensual than the Figure 1-19 women in the Pre-Raphaelite paintings Dante Gabriel Rossetti, Monna is the female figure in a painting by the Vanna (1866, London, Tate French artist Jean August Dominique Gallery) Ingres, Angelica Saved by Ruggiero (Figure 1-21, 1819, London, National Gallery) in which a helpless naked maiden looks upward for aid while her rescuer Roger arrives on an eagle headed winged creature to slay the dragon about to devour her. A huge Figure 1-21 goiter that resembles a third breast Jean August Dominique Ingres, obstructs her neck and calls Angelica Saved by Ruggiero (1819, London, National Gallery)

circle of artists and poets; she eventually became Rossetti’s lover and was known as “the femme fatale of his life as well as his art” (Wood 98). Morris was the model for The Day Dream (Figure 1-20, 1880, London, Victoria and Albert Museum, see p. 12) as well as Astarte Syriaca, among other works. A photograph of Morris taken by Rossetti suggests that the artist was painting the model’s neck exactly as he saw it through the camera’s lens. Rossetti’s prominent exposure of Wilding’s and Morris’s diffuse goiters is gracefully integrated with familiar romantic references to sensuality conveyed by abundant hair, comple- mentary color tones, luxurious drapery and, in The Daydream, a background of voluptuous nature in full bloom. Rossetti’s numerous paintings of these and other models with long broad necks imbued with sensuous flesh tones and his signature focus on the smooth diffuse goiter undoubtedly reveal his fascination with the female neck as an erogenous zone.

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attention to her innate sensuality exposed neck, especially in paintings and the underlying eroticism of the that show only the upper third of a painting. The painting also illustrates woman’s body, draws the viewer to the idea of the full rounded neck question whether the painter intended and the breasts as one erogenous a certain eroticism in the work and zone, a notion that first appeared in whether viewers of European art Renaissance paintings. during a period of more than five hundred years naturally associated the full As we have noted in several exam- rounded neck with female sensuality. ples, paintings by Renaissance artists and their nineteenth century In addition to ambiguous notions of counterparts of classical, biblical, femininity suggested in paintings of and secular female figures with full women with full rounded necks, the rounded necks suggest a bolder or association of the diffuse goiter with more obvious sensuality than paintings a woman’s designated gender role of the Virgin Mary. Although these is apparent to the modern viewer of works may call to mind the femme Renaissance paintings. As early as fatales of the late Victorian period, the Imperial period in Roman art, the the boundaries between virgin purity marriageable woman and the newly Figure 1-22 and feminine sensuality are ambig- married woman were the subjects of Summer, detail of the full pavement on the sub- uous at best. Many genre paintings formal portraits. In many of these ject of the four seasons (4th–5th century, Rome, from the Dutch Renaissance depict portraits the full rounded neck fig- Museo Nazionale Romano, Palazzo Massimo sensual and licentious women with ures as a prominent feature and is alleTerme) large, diffuse goiters, some bordering often the focal point of the painting. on disfigurement. A typical example Whether the female figure’s present from the seventeenth century is Willem or future function as wife or mother de Mieris’s The Escaped Bird (1687, is the subject of the painting, Roman Hamburg, Kunsthalle) in which portraits of women exude an air of a pale fleshed woman with partly confidence and definition of their exposed breasts and a large, rotund presumed roles. A Roman pavement goiter looks in wonder at the fact of mosaic titled Summer (detail of the the escaped bird, “a metaphor for full pavement on the subject of the lost virginity.”62 Similarly, allegorical four seasons) features a direct frontal paintings such as Jacob de Gheyn portrait of a young woman (Figure II’s Temperantia (early 17th century, 1-22, 4th–5th century, Rome, Museo Amsterdam, Rijksmuseum) portray Nazionale Romano, Palazzo Massimo the female symbol of temperance as alleTerme). The woman looks boldly a sensual bare breasted woman with at the viewer; the large rounded neck a disfiguring goiter.63 Throughout the revealing a sizeable goiter is part of Renaissance and Baroque periods, the focal point. As a representation artists often used the same models of summer in a painting on the four for religious, secular, allegorical, and seasons, her figure would naturally be classical figures. It is understandable associated with fertility. that such a prominent feature as the

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Similarly, the Roman painting on an Egyptian mummy cover Portrait of a Young Woman with a Gilded Wreath (Figure 1-23, 120–140 ce, New York, Metropolitan Museum) reveals a full neck with prominent Venus lines, which are parallel to the line created by the young woman’s necklace. The museum’s object label notes “Venus rings on her neck call attention to her youthful plump body,”64 further evidence of the neck as focal point in a domestic portrait. More significant, however, is the symmetrical swelling in the young woman’s central neck, quite suggestive of a pubescent goiter and possibly a reflection of a pubescent diffuse goiter and imminent fertility. Art historians have long noted the connections between portraits from Roman and Egyptian antiquity and those from the Byzantine and Renaissance eras in Europe. Berenice Geoffroy–Schneiter writes about the startling almost “hypnotic gaze, as if suspended in an eternal present” characteristic of the mummy portraits, a stylistic technique that invites the viewer to engage with the artist’s subject.65 In the Portrait of a Young Woman with a Gilded Wreath, the direct frontal gaze also accentuates the prominence of the goitrous neck. Goiters were at one time endemic in the Nile Valley, a fact that may explain why there is a significant number of mummy portraits of women with full rounded necks. The contrast between those paintings with

Figure 1-23 Portrait of a Young Woman with a Gilded Wreath (120–140 ce, New York, Metropolitan Museum)

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apparent diffuse goiters and those with slender necks suggests that the artists who used realistic anatomical details to represent their subjects’ idiosyncra- sies were well aware of the difference. In both of the above Roman/Egyptian images the fertility theme is enhanced by the artists’ emphasis on the women’s youth and graceful swelling of their diffuse goiters.

By contrast, in Botticelli’s fifteenth century Portrait of a Young Woman (Figure 1-24, 1475, Florence, Pitti Palace, Palatine Gallery), a lateral view draws attention to the full rounded neck of a young woman believed to be Simonetta Vespucci. It also sepa- rates the viewer from the painting’s subject, who is looking in the distance. The side view emphasizes the sensual fluidity and curve as well as rotundity of the neck in contrast to the angular facial features of the woman.66 The band around her neck may allude to the ancient tradition of testifying to a woman’s fertility (the “honeymoon neck”) by overtly demonstrating the effect on a necklace of an enlarged thyroid gland or goiter associated with pubescence and fertility.

Figure 1-24 Botticelli, Portrait of a Young Woman (1475, Florence, Pitti Palace, Palatine Gallery)

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Among Baroque examples of the Fourment were sisters, by portraying formal portrait, Rubens painted several both women with prominently of his second wife, one of which is diffuse goiters, Rubens may have Helene Fourment (Figure 1-25, 1630– unwittingly documented the presence of 32, Munich, Alte Pinokothek). He familial thyroid disease, a phenomenon also painted a wedding portrait of his that appears in other sixteenth and wife’s sister in Portrait of Susanna seventeenth century paintings. Rubens Lunden sometimes known as The Straw made numerous paintings of his Hat (Figure 1-26, 1622–25, London, wife posing as herself or as erotic figures National Gallery).67 Both portraits depict such as the blond dancer in The upper class women/brides in engaging Three Graces (see Figure 1-18), or as frontal poses that emphasize the Venus in a Fur Wrap. Considering subjects’ femininity and status as mar- these and other examples of his con- riageable women. The plunging sistent depiction of Helene Fourment’s necklines also reveal the erogenous goiter in all his paintings of her, he zone of a full bosom and full rounded seems also to have associated the full neck associated with fertility and rounded neck with feminine, and maternity. Since Helene and Susanna possibly erotic, beauty.68 Figure 1-26 Rubens, Portrait of Susanna Lunden sometimes known as The Straw Hat (1622–25, London, National Gallery)

Figure 1-25 Rubens, Helene Fourment (1630–32, Munich, Alte Pinokothek)

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in a turgid and full neck” (Bilancioni 52–53). Similar attention to the enlarged neck of pregnant women before and after childbirth is apparent in the portrait of the lactating Virgin Mary in The Virgin and Child Before a Firescreen by a follower of Robert Campin who was known as the Master of Flémalle (Figure 1-28, 1440, London, National Gallery) and in Fra Filippo Lippi’s painting of the post-partum St. Anne in The Madonna and Child with Stories of the Life of Saint Anne (Figure 1-29, 1452, Florence, Pitti Palace, Galleria Palatina).69 In each of the three paintings the female figure has a prominent swelling in the neck, but Piero della Francesca’s Madonna del Parto best illustrates an asymmetrical goiter. Lippi and the follower of Campin portray the diffuse goiter more common to early motherhood.70

A later work by Dutch artist Jan Steen The Doctor and the Patient (Figure 1-30, 1670, Prague, National Gallery, see p. 21) reveals the goitrous neck of an older pregnant woman, presumably discussing her pregnancy with the doctor in the picture. The Figure 1-27 paintings. According to the theory, one artist’s satirical humor is suggested in Piero della Francesca, Madonna del Parto might expect to see the full rounded the darkened setting of the scene, (1460, Monterchi, Tuscany) neck in paintings of women shown as if there is an attempt to hide the during and after pregnancy. If the art- pregnancy despite the telltale signs of ists’ models lived in iodine deficient swollen neck, swollen abdomen, and Following the theory (see notes 39 regions and were also pregnant or and 40) about the enlarged size of the lactating, the presence of goiter would thyroid gland at the time of puberty have been even more likely. Several Figure 1-28, facing page and other theories about its prevalence paintings fall into this category. Follower of Robert Campin (the Master of during pregnancy and lactation, the According to Gugliemo Bilancioni, Flémalle), The Virgin and Child Before a modern viewer cannot help associating Piero della Francesca’s Madonna del Firescreen (1440, London, National Gallery) these women’s enlarged thyroids Parto (Figure 1-27, 1460, Monterchi, or full rounded necks with the marriage Tuscany) faithfully includes “the and maternity themes suggested in the languid pallor of the expectant mother

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Figure 1-29 Fra Filippo Lippi, The Madonna and Child with Stories from the Life of Saint Anne (1452, Florence, Pitti Palace, Galleria Palatina)

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the flask of urine held by the servant an enlarged goiter. The painting young woman with ragged children in the background, symbols that focuses on a female peasant figure, and the horseman, who wears shoes would have been easily recognized by presumably a wife or lover and either and rides rather than walks, raises seventeenth century viewers familiar the mother or older sister of the young a question about their relationship. Is with the popular graphic allegories of boys in the picture. She is carrying a the woman’s apparent sexuality also that period. large urn across a meadow. In the right a sign of her vulnerability in the face of foreground of the painting a horseman, masculine power? Does her noticeable The Resting Horseman, a genre who is possibly her husband but more neck mass draw more attention to painting of homely realism (Figure likely a possible lover, rests on a rock, that vulnerability to the seventeenth 1-31, 17th century, London, Victoria holding his horse’s lead. The peasant century viewer who may read a and Albert Museum) by the French woman’s full rounded neck speaks message in the narrative? artist Louis Le Nain may be less of fertility and maternity, much as the cynical than Steen’s painting but still animals in the pastoral scene suggest Figure 1-31 ambiguous in its sexual references fecundity. The puzzling contrast Louis Le Nain, The Resting Horseman (17th in a portrayal of a young woman with between the barefoot, burden-laden century, London, Victoria and Albert Museum)

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Considering the strong association between the full rounded neck and fecundity and maternity, one might expect most Renaissance and Baroque paintings of women with goiters to represent younger women at the peak of their fertility. As we have noted, many of the Virgins in the paintings already discussed and numerous others reveal a young woman who may not be more than fifteen or sixteen years old and whose goiter may be especially enlarged because she is barely post- pubescent or because she is pregnant or lactating. The Virgin Mary as a grieving (older) mother in paintings of the deposition or pietà, or as a saint after her own death, however, is an exception. Seventeenth-century Dutch painter Anthony Van Dyck features an older looking Mary in two of his paintings both of which are titled The Deposition or The Lamentation. Both works depict a grieving mother in mourning clothes, her covered head and upward gaze accentuating a thick, goitrous neck.71 Titian’s painting of the Assumption (Figure 1-32, 1518, Venice, Church of Santa Maria della Gloriosa dei Frari) also portrays a mature Virgin in the glory of her heavenly journey, her full neck reminiscent of the strength suggested in Piero della Francesca’s painting of The Virgin of the Misericordia. In Titian’s painting, Mary holds her arms out as she gazes upward almost in a state of rapture, her sumptuous red gown set off by a deep blue saint’s cloak fastened by a brooch beneath the goitrous swelling.

Figure 1-32 Titian, Assumption (1518, Venice, Church of Santa Maria della Gloriosa dei Frari)

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Figure 1-33 the grieving women who must part of Jesus after his death, and was the Il Sodoma, Life of Saint Benedict: Benedict with Benedict. In both paintings the one to whom Jesus “appeared first” leaves his father’s home to study in Rome artist has emphasized the shield-like after the resurrection (Mark 16:9). (1505, Monte Oliveto Maggiore, Tuscany) shape of the thyroid gland. Van der Weyden’s painting portrays a diminutive and modest Magdalen More youthful models with diffuse rather than a victim of evil spirits. Similarly, the mother of Saint Benedict goiters appear in paintings of female Captured in the act of reading (pre- depicted in one of the frescoes of saints and biblical heroines. Several sumably scripture), eyes cast down, Il Sodoma’s Life of Saint Benedict portraits of the Magdalen reveal she is fully covered except for her face (Figure 1-33, Benedict leaves his a young, beautiful woman with a dif- and her neck. The neck is noticeable father’s home to study in Rome, 1505, fuse goiter, among them Roger Van for its subtle swelling similar to Monte Oliveto Maggiore, Tuscany) der Weyden’s The Magdalen Reading the diffuse goiters in many paintings of looks toward her departing son with (Figure 1-34, 1438, London, National the Virgin Mary. The suggestion of motherly affection, her prominent dif- Gallery). In the New Testament youth, possibly on the cusp of puberty, fuse goiter a reminder of her maternal, parables the Magdalen was considered reveals the artist’s emphasis on the humble status and possibly of a a sinner “healed of evil spirits and fragility of this singular woman in the region of endemic goiter. Interestingly, infirmities … out of whom went seven biblical narrative. although the title refers only to the devils” (Luke 8:2). She was present “father’s home,” the painting depicts at the crucifixion, stayed by the tomb

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Figure 1-34 Roger Van der Weyden, The Magdalen Reading (1438, London, National Gallery)

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Figure 1-36 Artemisia Gentileschi, St. Cecilia (1616, Rome, Spada Gallery)

evident by the outlining of its shield like shape. As a queen, Catherine of Alexandria was tortured by the Roman Emperor Maxentius for her refusal to marry him, choosing instead to become a “bride of Christ.”72 The goitrous swelling of the saint’s neck seems to reflect the ambiguity of purity and sensuality evident in paintings of the Virgin Mary with a similar feature.

Similar to Catherine in her vow of celibacy, St. Cecilia is portrayed in a frontal pose in the Baroque painting of the saint by Artemisia Gentileschi (Figure 1-36, 1616, Rome, Spada Gallery). Luxuriously arrayed in a gold robe and holding the lute associated with her role as patroness of music, the figure of Cecilia is looking upward, chin lifted, to reveal a strong as well as full rounded neck. Unlike Catherine, Cecilia at first received a gentler fate from the suitor whom she refused to marry, and she succeeded in converting her husband to Christianity, only later to be suffocated, then beheaded for “refusing an act of idolatry.”73 Artemisia Gentileschi’s portrait of St. Cecilia suggests a strong, self-sufficient Three female saints, Saint Catherine 1491, Oxford, Ashmolean Museum, woman who knows how to control of Alexandria, Saint Cecilia, see p. 11) reflects the influence of her own destiny. and Saint Agatha, whose stories of the aesthetic idealism of the early martyrdom would have been familiar Renaissance, but anatomical realism to the Renaissance viewer, are is also apparent. Leaning to the right frequently depicted with full rounded and gazing into the distance, Crivelli’s necks indicating the presence St. Catherine is framed in gilt that con- of a diffuse goiter. The stylized pose trasts dramatically with the pale flesh and beauty of Vittore Crivelli’s St. of her face and full rounded neck. The Catherine of Alexandria (Figure 1-35, enlarged thyroid gland is made more

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Figure 1-37 saries with a bold stare as one of them themselves to the cause of religious Sebastiano del Piombo, The Martyrdom of pulls at her breast with huge pliers. conversion, and Catherine and Agatha Saint Agatha (1520, Florence, Pitti Palace, Her full rounded neck, which suggests were also victims of Roman Palatine Gallery) the presence of a diffuse goiter, and persecution of Christians. Although her bared breasts powerfully convey the portrayals of these saints as young, the artist’s emphasis on the female sexually fertile and beautiful Sebastiano del Piombo’s The strength of a saint who chose death women, attributes further emphasized Martyrdom of Saint Agatha (Figure over marriage and renunciation of by their smooth, diffuse goiters, 1-37, 1520, Florence, Pitti Palace, religious faith. suggest female vulnerability, the Palatine Gallery) portrays a strong stereotype is undercut by a powerful woman who refuses to give in to the In the stories of all three saints, the paradox. Each of the saints in these sexual advances of the Roman consul powerful appeal of celibacy is pitted portraits has a distant gaze, suggesting Quintian and the torture executed by against the threat of a forced mar- an ethereal rather than corporal the brothel-keeper to whom he sends riage or rape, or in the case of Cecilia, relationship to her fate. her (Attwater and John 28).74 Del unwanted consummation of her mar- Piombo’s Agatha confronts her adver- riage. Catherine and Cecilia devoted

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Similar moral strength and self-suffi- ciency are characteristics of a number of biblical heroines whom Renaissance painters portray with full and rounded necks: Zipporah, Susanna, and Judith. Botticelli’s The Daughters of Jethro from Scenes from the Life of Moses in the Sistine Chapel (Figure 1-38, 1481–82, Rome, Vatican) features a scene from the biblical narrative in which Moses, having “fled from the face of Pharoah, and dwelt in the land of Midian” (Exodus 2:15) aided the daughters of Jethro, the priest of Midian, in providing water for their flocks. In the painting, one of the daughters, who carries a large water urn on her head, looks plaintively toward Moses, her exposed neck revealing a large diffuse goiter, which the viewer might associate with her youth and fertility. In the story, Jethro gives his daughter Zipporah to Moses as “compensation” for his help with the flocks. Presumably the woman with the goitrous neck is a reminder of the family legacy that is to follow as Moses attempts to free the “children of Israel” from their bondage in Egypt (Exodus 2:25).

Figure 1-38 Botticelli, The Daughters of Jethro from Scenes from the Life of Moses in the Sistine Chapel (1481–82, Rome, Vatican)

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Alluding to a more dramatic scene in the biblical story from the Book of Daniel in the Apocrypha, Rubens’s Susanna and the Elders (Figure 1-39, 1607–8, Rome, Borghese Gallery) features a fully nude Susanna in the act of bathing, approached by the spying Elders who, according to the story, attempt to blackmail her into sexual submission by bearing false witness against her. Susanna’s courage in the face of difficult choices is conveyed by Rubens’s rendering of the strong gesture of her arm in which she clearly rejects the advances of the Elders as she looks up at one of them. But her sensuality, beauty, and consequent vulnerability are also openly revealed in her nudity, her long flowing hair and her neck with its full diffuse goiter.

Figure 1-39 Sir Peter Paul Rubens, Susanna and the Elders (1607–8, Rome, Borghese Gallery)

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A more familiar biblical heroine, Judith from the Book of Judith in the Apocrypha, is represented in numerous paintings that explore different interpretations of Judith’s femininity. Botticelli’s Judith’s Return to Bethulia (Figure 1-40, 1472, Florence, Uffizi Gallery) portrays a contemplative Judith after she has beheaded Holofernes in an attempt to save her people. Like Botticelli’s Virgins discussed earlier, his Judith stands with eyes cast down, her head tilting slightly to the right, revealing a full, rounded neck that seems synonymous with her sensual beauty, an attribute that Judith used in order to deceive Holofernes into thinking he would have a romantic relationship with her.75 Botticelli’s painting suggests a contrite and even melancholy expression of Judith in the final scene of the narrative from the Apocrypha after she has picked up the head of the dead Holofernes. Here her maidservant is carrying it away in a basket, presumably for Judith to show her people in Bethulia where she went “according to their custom unto prayer” (Apocrypha, Judith 12:10).

In contrast to Botticelli’s sensual but maidenly Judith, Caravaggio’s Judith

Figure 1-40 in Judith Beheading Holofernes Figure 1-41 Botticelli, Judith’s Return to Bethulia (1472, ( , 1599, Rome, Museo Florence, Uffizi Gallery) Nazionale d’Arte Antica, Palazzo Barberini) is portrayed as a strong, aggressive woman, able to exploit her femininity and commit murder at the same time. According to Puglisi, the model for Judith Beheading Holofernes was probably the same woman that Caravaggio painted in his St. Catharine of Alexandria and

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in his Conversion of Mary Magdalene artist’s faithful attention to realistic Figure 1-41 (131). In both of those works, the detail, as demonstrated in the subtle Caravaggio, Judith Beheading Holofernes model’s neck is more visibly exposed rendering of her strong, goitrous (1599, Rome, Museo Nazionale d’Arte Antica, for the viewer to see the woman’s neck. Caravaggio’s emphasis is on the Palazzo Barberini) diffuse goiter. In the painting of Judith, virtual action of murder, executed by however, the neck is partly obscured a beautiful but obviously courageous by a shadow, the light reflected instead woman. The narrative intensity of the in her distraught facial expression and painting endows his heroine with epic chest. The painting’s background of strength and aggressiveness rather rich drapery, the intense chiaroscuro than the idealized and gentler contem- lighting that links Judith with her plativeness of Botticelli’s Judith. antagonist and ultimate victim, and the shocked expression on the peasant woman’s face all dramatize the heroic narrative.76 Beautiful and ruthless at once, this Judith also exhibits the

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Figure 1-42, facing page Ambiguity of intention in the outstretched arms suggest both Caravaggio, The Supper at Emmaus numerous representations of “beau- holiness and humbleness. It is also (1481–82, London, National Gallery) tiful” or “enhancing” goiters is also possible, however, that Caravaggio apparent in paintings of male figures attempted to represent the ethereality whose goiters are more diffuse than of the resurrected Christ who was disfiguring. While some paintings reminding his disciples of their role as of the Christ Child reveal a small witnesses before he would again be diffuse goiter similar to that of the “carried up into heaven” (Luke 24:51). Virgin Mary figure in the same paint- As such, Caravaggio’s Christ figure ings, one of the few works to depict is represented with feminine grace the adult Christ with a large diffuse accentuated by a smooth diffuse goiter goiter is Caravaggio’s The Supper similar to that of a pubescent girl. at Emmaus (Figure 1-42, 1481–82, London, National Gallery). Like Caravaggio’s “pretty boys pretending to be Eros or Bacchus,”77 his figure of Christ is youthful and unencum- bered by a beard or other noticeable male characteristics such as strong sternocleidomastoid muscles. Instead, Caravaggio’s Christ figure has a diffuse goiter that rounds out and beauti- fies his neck, much as it would the neck of a Virgin Mary or baby Jesus. Caravaggio’s painting alludes to the New Testament story from the Gospel of St. Luke, in which the followers of Christ have just discovered that Christ was missing from his sepulcher (Luke 24:12) and later, unaware of the resurrection, meet him on their way to Emmaus where they dine together and where his identity is revealed when he “expounded unto them in all the scriptures the things concerning himself” (Luke 24:27). The painting is especially remarkable for its lack of hierarchical composition and the humanism evinced in the rent clothing of the disciples and in their expression of wonder and surprise. Caravaggio’s familiar use of chiaroscuro lighting illuminating the figure of Christ and the circular composition of Christ’s

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These qualities of Caravaggio’s resurrected Christ figure are similar to those conveyed in several Renaissance and Baroque paintings of angels that reveal a full rounded neck in male figures whose delicate, blonde curls, youthful faces, and luxurious robes often suggest a feminizing of male characteristics, similar to the androgynous representations of mythological figures such as Apollo and Cupid in paintings from the same period. The presence in males of diffuse goiter that enhances rather than disfigures further confuses the viewer who may associate the “goiter beautiful” with the various categories of women already discussed in this chapter. To the Renaissance painter and viewer, were angels considered asexual, androgynous or inherently effeminate, or did artists wish to accentuate their otherworldli- ness or ethereality with such feminine characteristics? Is the prominently diffuse goiter simply a sign of their heavenly role or idealized and perhaps, feminine, beauty or a suggestion of sensuality, sensitivity, and adolescence? Some of the angels depicted in Renaissance paintings appear to be young boys who are feminized in their

Figure 1-43 dress and soft facial features. Melozzo Melozzo da Forli, An Angel Playing the Viola da Forli’s An Angel Playing the Viola da Braccio from Musical Apostles and Angels da Braccio from Musical Apostles (c. 1480, Vatican State, Pinacoteca, Vatican and Angels (Figure 1-43, c. 1480, Museums) Rome, Vatican Pinacoteca) focuses on a young boy whose flaxen curls and goitrous neck suggest feminine characteristics, yet whose broad shoulders and large hands appear more male than female. Another musical angel at the base of Bartolomeo Vivarini’s Saint Mark Enthroned Surrounded by Musical Angels (detail of angels in

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central triptych) (Figure 1-44, 1474, Unaware of the function of the thyroid Venice, Santa Maria della Gloriosa dei gland or the significance of the goiter, Frari) looks like a pubescent youth, artists working in iodine deficient but beneath his delicate, almost femi- areas such as the Alps and the Tuscan nine, face a prominent goitrous lump or Umbrian hills were likely to use verges on the “goiter grotesque” like female models with full rounded necks those shown in paintings of mature because of the prevalence of endemic male figures.78 goiter in those regions. Less prevalent, but equally interesting and more Considering the range of examples noticeable to the viewer, the large, of figures with diffuse goiters in the often asymmetrical, disfiguring goiter, paintings described in this chapter, it which we term here the “goiter gro- is reasonable to conclude that the full tesque,” appears in folk art as well as rounded neck was thought to be a in the work of professional painters sign of beauty, and therefore associ- in the same regions of Italy and in ated with a variety of values impor- other parts of Europe known to have tant to the artist and viewer of the endemic goiter. In the next chapter, Renaissance and Baroque periods in we explore artists’ representations of Europe: purity, fertility, maternity, sen- Stage III goiters and other manifesta- suality, moral or heroic strength, and tions of thyroid disease, such as cre- holiness or ephemerality. The use of tinism and exophthalmos. live models that became customary in the Renaissance, and the coincidental existence of goiters in several artists’ models—especially those used multiple times by Piero della Francesca, Botticelli, Caravaggio, and Rubens— and the growing interest in anatomical realism and naturalistic detail may have contributed to the abundance of paintings that feature figures, especially women, with diffuse goiters.

Figure 1-44 Bartolomeo Vivarini, Saint Mark Enthroned Surrounded by Musical Angels, detail of angels in central triptych (1474, Venice, Santa Maria della Gloriosa dei Frari)

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Chapter 2 her Maidservant with the Head of Holofernes (Figure 2-1, 1614–20, Florence, Pitti Palace, Galleria The Goiter Grotesque: Power, Palatina) and Picasso’s Half-Length Treachery, or Humbleness? Female Nude (Figure 2-2, 1906, Chicago, Illinois, Art Institute).

Gentileschi’s painting of Judith is a particularly dramatic example of such Introduction realism. The viewer is drawn to the painting’s high focal point in which Gentileschi’s use of light accentuates As we discussed in Chapter 1, the numerous examples of a full rounded Judith’s neck. A large bulbous neck in Renaissance art, especially in paintings of women with diffuse goiter detracts from traditional notions of feminine beauty in the otherwise goiters, reveal a broad range of aesthetic choices that may have coin- elegant and aristocratically attired figure. The painting alludes to a passage cided with the presence of endemic goiter in specific regions of Europe in The Book of Judith that describes the Hebrew Judith’s use of feminine during the fourteenth through seventeenth centuries. During this period power and craftiness in her role as a and as late as the 1960s, up to 85 percent of the world’s population wealthy widow determined to save her people: She “braided the hair of her in iodine deficient areas had goiters. Whether artists working in or near head … and put on her garments of gladness,” and “she decked herself such areas revealed their models’ goiters by chance or consciously bravely “with

accentuated them for artistic reasons an idealized female beauty in figures is unknown. We have found few exam- with diffuse goiters. Although the Figure 2-2 ples, however, of women with diffuse appearance of a noticeably enlarged Pablo Picasso, Half-Length Female Nude goiters represented in a negative light. and disfiguring goiter occurs occasion- (1906, Chicago, Illinois, Art Institute) It is thought that in many rural areas, ally in paintings of women, there are large, even disfiguring, goiters were many examples of disfiguring goiters regarded with endearment. in paintings of male figures. In such cases the association between the The origin of the painter’s representa- dramatically enlarged, often multi- tion of the goiter remains aesthetically nodular, goiter and the painting’s ambiguous to the modern viewer, espe- subject more commonly reflects the cially in the repeated representation of painter’s emphasis on anatomical realism than on aesthetic idealism. Two paintings created almost three hundred Figure 2-1, facing page years apart remind us of the disfig- Artemisia Gentileschi, Judith and her uring appearance of a greatly enlarged Maidservant with the Head of Holofernes goiter in portraits of women who (1614–20, Florence, Pitti Palace, Galleria might otherwise be considered beautiful: Palatina) Artemisia Gentileschi’s Judith and

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jewels “to allure the eyes of all men signs of thyroid disease may be more Etiology and treatment of disfiguring that should see her” (Judith 10: inclined to see Gentileschi’s painting (surgical) goiter, Graves’ disease, and 3–4). Although true to the biblical as a realistic portrayal of an aggres- cretinism description of Judith’s adornment, sively vengeful but righteous heroine Gentileschi’s emphasis on the rather than that of a masculinized However flattering and/or interesting physical symbols of Judith’s courage female. The realism of Caravaggio and small diffuse goiters may have and strength eclipses the sensuality Artemisia Gentileschi among others seemed to Renaissance and Baroque in the painting suggested by the during the Baroque period in Italy and artists, modern medicine has heroine’s elaborate hairdo, gown, and northern Europe intensified the taught us that small diffuse goiters often jewels. Like a seasoned warrior, she degree of anatomical accuracy and continue to enlarge and become grips the sword’s hilt with its head of naturalistic detail in painting. multinodular with aging, eventually Medusa, an allusion to the legendary Both features reflected the growing causing cosmetic as well as physical Gorgon whose stare and serpent like interest in human anatomy and science problems for the patient with thyroid hair turned any who looked at her into during the seventeenth century.80 disease. Such goiters can also be dis- stone. The “meat basket” in which figuring if their size is disproportionate Judith has hidden the results of her The representation of enlarged to an individual’s body, and especially courageous act is barely visible in the disfiguring goiters in art such if they are asymmetrical, nodular or maidservant’s arm and looks more as Gentileschi’s portrayal of Judith substernal. In the latter situation there like a market basket than the container thus coincided with a growing is less space for the goiter to enlarge of the enemy’s head, an example of interest in the pathology of the goiter without causing symptoms such as Judith’s careful use of disguise in her but preceded an accurate under- shortness of breath or difficulty swal- departure from Holofernes’ tent. standing of thyroid disease, its causes lowing. Although most goiters occur Judith’s proud but stern gaze pre- and consequences. Although such in individuals with normal thyroid sumably directed toward the gate of features are infrequently seen in art function, some patients may have too Bethulia where she will be received after the nineteenth century, portraits little or too much thyroid hormone. as a heroine, her slightly flushed of women by modernist painters complexion and her strong goitrous such as Modigliani, Matisse and Graves’ disease is an autoimmune neck all become associated with her Picasso often focus on the female neck disease that occurs as the result unquestionable ability to accomplish as an erogenous zone. As late as of thyroid antibodies that stimulate the her quest. 1905, Picasso’s Half-Length Female function and growth of the thyroid Nude confirms the continued fascina- gland, causing the patient to become In Gentileschi’s Judith the grotesque tion with the neck and aesthetics in hyperthyroid, usually with a goiter. size of the heroine’s goiter and the portraiture. The painting’s subject is Another form of autoimmune thyroid distortion of her neck reveal the exis- shown to be more vulnerable than disease is Hashimoto’s thyroiditis, tence of thyroid pathology.79 Unlike Gentileschi’s Judith because there are which occurs when the antibodies may many of the heroic female figures with no external signs of her status such or may not lead to the development diffuse goiters in paintings that as the elegant costume and jewels in of goiter but often inhibit the function we discussed in Chapter 1, the figure of Gentileschi’s portrait. The neck of of the thyroid gland, causing the Gentileschi’s robust heroine may have Picasso’s nude and its proximity to and patient to be hypothyroid. Relatives of shocked seventeenth century viewers possible unity with the erogenous a patient with Graves’ disease or in its suggestion of brute physical zone of the breasts reminds the viewer Hashimoto’s thyroiditis are at a higher strength rather than feminine delicacy of the ambiguous effect of both risk of developing these conditions. or self-effacement. The modern beauty and distortion that a disfiguring In areas of severe iodine deficiency goi- viewer with an understanding of the goiter can create. ters are often associated with hypothyroidism, or rarely, hyperthyroidism.

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esophagus. The most common type Figures 2-11 Goiters may be diffuse and sym- of malignant goiter or thyroid cancer is Il Sodoma (Giovanni Bazzi), The Life of metrical, especially in patients with a papillary tumor, and this tumor St. Benedict: Benedict frees a peasant, shackled Graves’ disease because the follicular may metastasize to the regional lymph by the Goths (1509, Monte Oliveto Maggiore, thyroid cells are uniformly respon- nodes or, less commonly, to distant Tuscany) (see p. 80) sive to growth stimulating antibodies. sites such as the lungs or bones. Thus We have viewed such goiters in a person with thyroid cancer may When hypothyroidism occurs in the the paintings discussed in Chapter 1. have a visible mass (primary tumor) newborn or in young children, most Multinodular goiters or thyroid in the central neck and also in the commonly in areas of endemic goiter, glands with solitary nodules, however, regional lymph nodes in both the central it is associated with short stature and are usually asymmetrical and may and lateral neck. Thyroid masses mental deficiency (cretinism).81 In be either benign or malignant. Such caused by embryologic abnormalities addition to a large disfiguring goiter, goiters sometimes cause not only such as thyroglossal duct cysts occur in “mental retardation, growth retarda- cosmetic problems but also medical the central neck above the thyroid tion, delayed bone maturation, thick symptoms, such as shortness of gland. Such masses move upward when tongue, thick skin, and, frequently, breath, pain, or dysphasia reflecting the tongue is protruded forward. deafmutism,” as well as difficulty with tracheal or esophageal compression or, Some small and large goiters are only gait, are also associated with the most in the case of malignant goiter, partially or not at all observed in the common form of cretinism.82, 83 invasion of the trachea, larynx or neck because they are predominantly

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situated beneath the sternum. thyroidism or hyperthyroidism may the first to describe operations on the Persons with Graves’ disease or auto- have an altered behavior as well as human thyroid gland, but this infor- immune thyroiditis have not only an altered appearance. Symptoms of mation is speculative. The supposed thyroid related problems such as hypothyroidism or myxedema include description by Celsus of an operation goiters but also hyperthyroidism with lethargy, drowsiness, weakness, slow on goiter, presumably derived from increased basal metabolism. They may speech, memory loss, shortness of a report by a physician, more likely also have extra thyroidal manifesta- breath, low body temperature, depres- pertained to surgery on “cervical tions such as protruding eyes (exoph- sion, and rarely, confusion, mania, and cysts, dermoid cysts, atheromas” and thalmos) and potential loss of vision, paranoia. Symptoms of Graves’ hyper- to “tuberculosis of the cervical lymph and anterior subcutaneous leg swelling thyroidism include increased nervous- nodes” than to an actual goiter (Merke known as pre tibial myxedema with ness, irritability, fatigue, weakness, 94). Merke notes that in the first thickened skin usually situated over insomnia, apprehensiveness, mood century ce, one hundred years before the shins and sometimes mistaken for swings, and inability to concentrate. Galen, the Greek educated physi- insect bites.84 Men or adolescent males cian Leonides worked in Rome where with Graves’ disease commonly have Because of the large size of some he recorded medical observations. gynecomastia, that is, small female- goiters and their progressive symp- Leonides describes “the recurrent like breasts. toms such as shortness of breath, laryngeal nerves, the necessity of not medical and surgical therapies have damaging them in the operation on Other causes of neck masses not asso- been proposed from ancient times to the glands, and the impairment of the ciated with thyroid disease include the present. “The Arthora Veda, an voice that follows their injury” (Merke scrofula, lymphoma, neurofibroma- ancient Hindu collection of incanta- 86). The Greek Soranos, “who lived in tosis (multliple subcutaneous nerve tions dating from 2000 bc (bce), Rome about the same time as Galen, tumors known as “elephant man contains extensive forms of exorcisms mentioned the recurrent branches of syndrome”) reactive lymphadenop- for goiter.”85 In 340 ce, Ko Hung, the the vagus nerve but did not call them athy due to carious teeth, other head great Chinese alchemist, recommended recurrent nerves” (Merke 86). and neck infections, or other benign using seaweed for individuals with and malignant tumors. The viewer of goiter, a treatment that reappeared The often repeated story that Galen paintings of figures with large disfig- during the Middle Ages in China and operated on goiters probably arose ured necks can easily confuse such during the twelfth century in Europe from Galen’s report on “two cervical masses with goiters. (Medvei 86 and 189). Paracelsus rec- gland operations. These operations ommended treatment of goiter with were intended not only to be drastic On physical examination to the the “application of toad blood, the illustrations of the dangers of this observer’s eye the thyroid gland and stroking of a cadaver’s hand, and other surgery but also to show [Galen’s] thus the goiter move up and down therapies rather than surgery.”86 reputed ‘discovery’ of the recurrent with swallowing because the thyroid is laryngeal nerves in the proper light” attached to the trachea, whereas virtu- Since thyroid abnormalities were (Merke 85). According to Welbourn ally all other neck masses extrinsic to initially not distinguished from other and others, Galen must have been near the thyroid gland do not. Until the late neck masses, it is difficult to know the thyroid gland during his anatom- nineteenth century, however, neither when the first thyroid operation for ical dissections because he identified clinicians nor artists would have dis- goiter was performed. Some medical the recurrent laryngeal nerves and tinguished between goiters and other historians suggest that the non-medical seven of the twelve cranial nerves, neck masses. In addition to the telltale Roman writer Aulus Cornelius Celsus and he correctly suggested that in movement of the goiter during swal- (25 bce–50 ce) and the Greek physi- pigs and man the recurrent laryngeal lowing, patients with either hypo- cian Galen (129–200 ce) were among nerves were responsible for phonation

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(ability to make a sound) (Welbourn Medvei, “was more a manual of dis- of physical evidence rather than theory 21 and Garrison 115). Merke, however, section than a textbook of anatomy” in the scientific process. He attrib- disagrees, arguing that Galen “never (Medvei 93). In 1345 in France, Guy uted a probable Graves’ disease goiter gave a really accurate description of a de Chauliac considered goiter to have to an aneurysm in the neck (Medvei bronchiocele87 and still less did he ever both a “local and hereditary” etiology 72). He did so most likely because operate upon one” (Merke 86). The (Medvei 109). In his Chirurgia Magna of an associated “bruit” (noise) and Greek Paul of Aegina (625–690 ce) was (1363) he states, “the goiter consists “thrill”(vibration) caused by its rich one of the first to suggest surgery for of a ‘humour’ transformed into ‘bad blood supply. In the seventeenth and a form of bronchiocele. He cautioned matter’” (Merke 147). He recom- eighteenth centuries medical obser- against it, however, because of the mends surgical removal of the dis- vations began to include with some vascularity of the thyroid gland which eased gland (Medvei 91). These scarce degree of accuracy the association of caused considerable technical problems examples, however, are anomalies in thyroid disease with specific European in the operations (Welbourn 21). the history of medicine and surgery regions, thus suggesting the existence that remained more closely linked to of endemic goiter. Lorenz Heister It is generally accepted that the first the Dark Ages than to the enlightened (1683–1758), known as the father of thyroid operation was performed in development of knowledge in other scientific surgery in Germany, observed the latter part of the tenth century by scientific fields during the Renaissance. that “Some nations are quite free Abul Kasim or Albucasis in Baghdad Unfortunately, “[u]ntil the Renaissance from this disorder” (bronchiocele or (Merke 104). Abul Kasim was also there was neither induction nor experi- tracheocele or goiter) “while others “the first physician to supply document,” and physicians did not draw are grievously afflicted therewith,” mentary evidence of endemic goiter” conclusions based on physical evidence including “inhabitants of Spain, (Merke 107). In 1170 Roger Frugardi, (from Sir Thomas Allbut, The Thyroid Germany, Sweedland, Bavaria, France, known as Roger of Palermo, from the Gland: Medical History (quoted in Helvetia (Switzerland) and espe- Bamberg School in Salerno, Italy, also Medvei 89–90, note 20). cially inhabitants of the Tirole.”90 He recommended operations for selected observed that persons from the Tirole patients with goiter when medical Human dissection became more pop- sometimes had goiters that “extend to treatment including seaweed failed ular after 1482 when Pope Sixtus IV the navel even down to their knees” (Welbourn 21). Frugardi was prob- “issued a bull that allowed local clergy (Heister, quoted in Medvei 157). ably the first to provide “a credible to permit” it (Medvei 72). This proc- description of operations for goiter” lamation enabled artists and surgeons, There was little doubt that the envi- (Welbourn 6). who often dissected the same cadavers ronment of inland regions and of at the same time, to understand mountainous regions of Europe con- Medical progress was slow during the human anatomy more accurately. With tributed to the development of goiters Middle Ages because of the limited Vesalius’ publication of De Humani and cretinism. There were conflicting application of scientific principles in Corporis Fabrica in 1543, the knowl- theories about the origin of goiter, the practice of medicine and surgery edge of human anatomy increased however, because some people from and because of restrictions on ana- dramatically, thus leading the way to mountainous areas had goiters and tomical dissection imposed by the more accurate diagnosis and eventu- others did not. Subsequent investi- Catholic Church.88 In 1240 ce Frederic ally more effective surgery.89 gations documented that the iodine II, Emperor of the Holy Roman content of the soil in mountainous Empire, granted permission for human In the early sixteenth century the areas varied considerably because of dissection. In 1316 Mundinus of French barber surgeon Ambroise Paré glacial development of these areas Bologna, Italy published his book attempted a diagnosis of goiter, which, (Merke 18). In 1863 Rudolf Virchow titled Anathomia, which, according to though incorrect, documented his use (1821–1902), the founder of cellular

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pathology in Berlin, wrote about glands and the non traditional endo- From the sixteenth century until the goiter and cretinism, and thought “the crine glands, such as the kidneys and early nineteenth century obtaining deficiency of certain substances has heart, secrete hormones into the cadavers for human dissection was dif- been regarded as the cause of goitre” blood stream and regulate the function ficult, and therefore bodies were taken (Merke 232). The pathophysiology of of other organs. De Bordeu accu- illegally from graves. Initially, the only Graves’ disease or autoimmune thy- rately observed that more women than legal autopsies were usually performed roid disease and other types of goiter, men have goiters and recorded the on executed murderers.91 Because of however, continued to be unknown prevalence of enlarged thyroid glands these restrictions surgeons’ progress at the end of the nineteenth century. among people living in the Pyrenees; in properly identifying the anatomy of There was also no known treatment he also noted that the presence of the thyroid glands was limited. With for the various types of goiter or for goiter was sometimes associated with the Anatomy Act of 1836 the English hypothyroidism or hyperthyroidism. a “hoarse voice” (Medvei 151). The Parliament legalized the selling of Despite the growing development of latter observation suggests an associa- unclaimed bodies from workhouses theories based on observation and tion of goiter with hypothyroidism and hospitals to accredited anatomy experimentation, most medical doctors and edema of the vocal cords, or an schools, thus discouraging grave rob- and surgeons were reluctant to test invasive thyroid cancer with loss bery and making anatomical dissection their theories. of function of the recurrent laryngeal more available. nerve. Ironically, however, because One such theorist, Theophile de the vitalists thought “experiments were Despite the contributions of Vesalius, Bordeu (1722–1776), came closer than rather crude and dangerous proce- Paré, Paracelsus and others who most of his contemporaries to under- dures … because they so easily upset challenged cherished medical beliefs, it standing the mechanisms of endocrine what was known to be true on wasn’t until the experimentation glands, demonstrated in his book a priori grounds” (Medvei 154), of British surgeon John Hunter (1728– Anatomical Research on the Position de Bordeu’s theories were not generally 1793) that surgery began to emerge of the Glands and their Action accepted by other scientists in the from the depths of medieval thought. published in 1752. De Bordeu, one eighteenth century. Because learned doctors adhered to of the founders of the vitalist school the doctrines of Hippocrates, Aristotle of Montpellier, France and a physi- Partly because of the lack of experi- and Galen, primitive medical practices cian in the Court of Louis XV, favored mentation and dissection and partly impeded the development of medicine developing an “argument starting because the function of endocrine as a science. Thanks to Hunter’s from fundamental truths” (Medvei glands is more subtle than that of other anatomical studies and research, 156–157) rather than from inductive systems in the body, endocrinology and surgery was gradually regarded as a reasoning in response to experimenta- endocrine surgery lagged far behind science rather than a trade (Medvei tion. Because de Bordeu’s last book other medical and surgical special- 90). By transplanting organs from one on chronic disease published in 1775 ties. Surgical treatment of goiter was animal to another or from one site proposed the theory that “all the dangerous and slower to progress than to another in the same animal (auto organs of the body discharge their medical theories about the function transplant), both Hunter and later, secretions into the blood” (Medvei 714), and physiology of the thyroid gland, Arnold Adolf Berthold (Germany, some medical historians consider and it was equally looked upon with 1803–61), provided important infor- him to be the father of endocrinology. skepticism. The majority of physicians, mation regarding a “vital” substance His theories, such as the above therefore, persisted in using other treat- (Hunter) or a blood borne example, were generally correct: we ments besides surgery for patients suf- substance (Berthold), thus leading to know today that many organs, fering from large symptomatic goiters. the definition of an endocrine including the traditional endocrine gland as a gland that secretes a sub-

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stance that works at a distant site. The development of thyroid surgery the nineteenth century. The mid-cen- Their surprisingly successful and treatment of thyroid cancer tury discoveries of local and general transplantations demonstrated that if anesthesia followed by Joseph Lister’s one could alleviate or prevent (Glasgow/Edinburgh/London, 1827– the symptoms and clinical manifesta- In 1791 during the French Revolution, 1912) documentation in 1867 of the tions that developed after an organ Pierre-Joseph Desault (1744–1795) benefits of antisepsis and asepsis made was removed by being transplanted to of Paris recorded the first known surgical procedures more accept- another site, the organ must function published account of the successful able to the patient and surgeon, with by means of an “internal secretion removal of a goiter (Welbourn 6). a marked decrease in post-operative into the blood” (Medvei 193). During the operation to remove a 4 cm mortality. Until the mid nineteenth This “vital principle” was supposed thyroid tumor, Desault used a ver- century the mortality rate for thyroid to work independently of the tical incision and ligated the superior operations approached 50%. nervous system. and inferior arteries before removing the mass (Welbourn 22). He packed In his treatise titled “The Operative the wound, which suppurated and Story of Goiter” William Halsted healed in about one month. In 1821 (1852–1922), the famous American Johann Hedenus of Germany reported surgeon from Johns Hopkins Medical the successful removal of six “suffo- Center in Baltimore, could identify cating” goiters by ligation of all the only eight thyroid operations using arteries and the dividing of and trans- the scalpel between 1596 and 1800. fixing of the isthmus (Welbourn 23). From 1800 until 1848, however, sixty- Fortunately, these operations were suc- nine operations using the scalpel were cessful because the surgeons removed performed, thirty-one in Germany, only part of the thyroid. Their decision Austria, and Switzerland, fifteen in to leave some of the thyroid gland in France, fourteen in Great Britain, the patient, however, was not based on twelve in Italy, and five in the United knowledge of its function. They still States (Welbourn 22). Despite this did not understand the function of the progress the overall mortality rate of thyroid gland. They also did not know thyroid operations remained high, of the existence of thyroid hormone or and many leading surgeons, including of the dependence of the body on this Robert Liston (London, 1794– hormone to sustain life. 1847), Johann Dieffenbach (Berlin, 1794–1847), Theodore Billroth Although physicians such as Caleb (Zurich, 1829–94), and Samuel Gross Hillier Parry (Bath, England, 1755– (Philadelphia, 1805–1884) advised 1822), Robert Graves (Dublin, against thyroid operations (Welbourn 1796–1853), and Carl von Basedow 22). It is therefore not surprising that (Germany, 1799–1854) described the French Academy of Medicine con- patients with exophthalmic goiter and demned thyroid operations in 1850 hyperthyroidism, the pathophysiology (Welbourn 27). of Graves’ disease or autoimmune thyroid disease was still unknown in the middle of the nineteenth century. Thyroid operations were rarely performed before the second half of

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Even with pronouncements against By 1895 his operative mortality for they were treated by presumed total thyroid surgery, progress in surgery surgery on benign thyroid lesions had thyroidectomy, and both had persis- and medicine developed dramati- declined to about 1%, and by 1898 tent pyramidal lobes. “Patients of all cally in the second half of the nine- it had decreased to less than 0.2%. ages were affected, but they were most teenth century. The findings of Paul In 1883 Kocher reviewed the medical obvious in children, whom Kocher Sick (Germany, 1836–1900), Jacques literature and reported that 268 thy- again likened to cretins” (Welbourn Louis Reverdin (Geneva, 1849–1908), roid operations had been performed 32). Kocher named the condition Theodore Kocher (Switzerland, since 1877 and that the mortality for that developed after total thyroid- 1841–1917), Victor Horsley (London, benign goiters had decreased to 12%, ectomy “cachexia struma priva.”92 1857–1916), George Murray whereas it was 57% for patients with These observations documented that (Newcastle-upon-Tyne, England, malignant tumors. Sepsis and hemor- the thyroid gland was necessary for 1865–1939), and others reported that rhagic complications had dramati- normal human function and earned the behavior of patients after total cally decreased, but complications of Kocher the epithet “father of thyroid thyroidectomy changed significantly recurrent laryngeal nerve injury with surgery.” For “his work in physiology, and suggested that the thyroid gland hoarseness, tetany from removal of pathology, and surgery on the thyroid was essential for normal life. Paul Sick the parathyroid glands and myxedema gland,” in 1909 Kocher “was the first reported that an energetic and happy from removal of the thyroid gland surgeon to receive the Nobel Prize, ten-year-old boy became “quiet and were now recognized (Welbourn 31). and the only surgeon at that time ever dull” following removal of his thyroid to win it for purely clinical exploits.”93 gland by Wilhelm Hahn (Stuttgart, Kocher, Moritz Schiff (Berne, 1823– Germany, 1796–1874) and Karl 96), Sir Victor Horsley, Reverdin and Johann Mikulicz (Zurich, 1850–1905), Bockshammer (Stuttgart, Germany, others were especially instrumental an assistant to Theodore Billroth, was 1828–91). In 1882 Reverdin described in recognizing the metabolic compli- aware of the serious complications of several patients who became feeble cations that occurred after thyroid total thyroidectomy, including myx- and anemic two to three months after operations. Their observations helped edema, nerve injury with loss of voice removal of the thyroid gland. Two of surgeons determine the function not or difficulty breathing, and hypopara- these patients developed edema of the only of the thyroid gland, but also thyroidism with tetany. He therefore hands and face and looked cretinoid. of the adjacent parathyroid glands. proposed leaving the posterior portion Kocher operated upon “a spirited of the thyroid gland in the neck bilat- Theodore Kocher’s surgical results and joyous eleven year old girl Maria erally, thus decreasing the frequency of for patients with symptomatic goiters Bichsel on January 8, 1874” who the above complications. A treatment illustrate his technical expertise and became “peevish and dull and reluc- for hypothyroidism was not known the medical and surgical advances that tant to work” after her total thyroid- until 1891 when George Murray occurred during the second half of ectomy (Welbourn 32). “Kocher’s subcutaneously injected a preparation the nineteenth century. Kocher was a observations led to his evaluation of of sheep thyroid extract in a forty-six student of Theodore Billroth (Zurich, other patients who had been treated year old hypothyroid woman with 1829–94) and Bernard Langenbeck by total, and less than total, thyroidec- symptoms of myxedema. She made a (Berlin, 1810–94) in Germany. From tomy. In 1883 Kocher reported that 28 remarkable recovery from her symp- 1872 to 1882 as a surgeon in Berne, of 30 patients who had partial thyroid toms. One year later (1892) Edward Switzerland, Kocher excised 101 goi- resections were well, whereas 16 of 18 Fox (Plymouth, England, 1859–1938) ters with a mortality rate of 12.8%. patients who had total thyroidectomies reported that myxedema could be suc- He obviously learned from this experi- were dull and some looked cretinoid. cessfully treated by feeding the patient ence since his mortality rate was 2.4% Of interest is that two patients did not “half a sheep’s thyroid, lightly fried during his next 250 thyroidectomies. develop hypothyroidism even though and taken with currant jelly once a

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week.”94 These important observa- precipitated by the stress of surgery.95 tions enabled surgeons to remove the Crile was also the first surgeon to per- entire thyroid gland since the conse- form radical neck operations for head quent hypothyroidism could be treated and neck tumors, including malignant by hormone therapy. Fox’s case was tumors of the thyroid.96 Lahey did the first medical example of successful much to educate others about the sur- organotherapy. gical diseases of the thyroid gland and emphasized the value of identifying During the early part of the twentieth the recurrent laryngeal nerves and century in the United States, Charles parathyroid glands to decrease the risk H. Mayo (1865–1939) and Henry of injury.97 Because thyroid operations Plummer (1874–1936) at the Mayo were now considered relatively safe, Clinic, George Washington Crile thyroidectomy became one of the most (1864–1943) at the Cleveland Clinic, commonly performed operations. Frank H. Lahey (1880–1953) at the Lahey Clinic, and William S. Halsted In “The Operative Story of Goiter” (1852–1926) at the Johns Hopkins William Halsted states, “the extirpa- Medical Center contributed greatly to tion of the thyroid gland for goiter advances in thyroidology and thyroid typifies, perhaps better than any surgery. Because surgery on the thy- operation, the supreme triumph of roid gland was now considered to be the surgeon’s art.”98 It is an art that relatively safe, thyroidectomy became continues to be perfected as endocrine one of the most commonly performed surgeons explore new techniques and operations, even for relatively small clinical research to determine the most goiters. In 1923 Henry Plummer at the effective treatment for their patients. Mayo Clinic introduced iodine pre- During the early twentieth century thy- operatively for patients with Graves’ roidectomy was used to treat patients disease and hyperthyroidism. His doc- with hyperthyroidism even when their umentation of an increased basal met- goiters were small. At this time there abolic rate in hyperthyroid patients, were no other effective treatments. As which decreased after treatment with thyroidectomy became safer, it also iodine, established the benefits of the began to be used for cosmetic pur- preoperative treatment with iodine for poses, that is, removal of the swelling patients with hyperthyroidism. Such in the central neck (Welbourn 50). treatment made thyroid operations for patients with Graves’ disease considerably safer. George Crile had previously recommended “stealing” the toxic thyroid gland to prevent death from the initiation of “thyroid storm” (the condition of high temperature, rapid heart rate and confusion caused by increased catecholamine response to thyroid hormone during illness or surgery)

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The goiter grotesque in art Further this account tells us/That in gist Antonio Giampalmo includes an some ancient regions/People live in illustration of wooden puppets from desolate places./Everywhere in the the story of Gioppino in Bergamo, As we saw in the numerous paint- Alps, I believe, /There are women Italy, a small city in the foothills of ings of women with diffuse goiters with goiters/Of a strange and the Italian Alps, a region known for discussed in Chapter 1, the representa- curious kind:/For it hangs down to endemic goiter.102 The puppets were tion of large disfiguring goiters in art their belly … /Which is held to be probably carved in the ninth century. reflects the growing interest in realism beauty (Merke 136). All of the puppets have goiters that during the late Renaissance. The some- exaggerate their disproportionately times asymmetrical and bulbous goiter In the same period work by other large heads. Examining the traditional created a challenge for artists who encyclopedists such as Bartholomaeus view of the disfiguring goiter as a attempted to render such abnormali- Anglicus and Jacob van Maerlant mark of a fool, historian Barry Wind ties with accurate anatomical detail. includes illuminated manuscripts in notes that “Aristotle considered those Although the seventeenth century which appear primitively drawn cari- afflicted with goitres to be dull-witted” saw a flourishing marriage of science catures of men with disfiguring goiters. and that “[l]iterary descriptions … and art, the emphasis on naturalistic The goitrous figures are holding large underscored the association of goiters detail as a way of representing the clubs known as the “fool’s club”100 with fools, a perception corroborated “other,” or those outside the bound- in somewhat belligerent poses. Other in the medical literature of the period aries of society, had its origins in a manuscripts of the period feature by Paracelsus.”103 The viewer of such much earlier period. Medieval and similar curiosities that emphasize the caricatures, which seem intended to early Renaissance representations of grotesque. In Shakespeare’s Tempest shock or even frighten, cannot help disfiguring goiters appear in numerous the character of Gonzalo refers to making similar associations. Such examples of European folk art, such men afflicted with large goiters that associations imply a natural tendency as wood carvings in churches, manu- he compares to the throats of bulls, toward classification far removed from script engravings and illustrations as if they are a wonder from a world the boundaries of conventional ideas intended to instruct or entertain the of half-human, half-beast inhabit- of beauty suggested by paintings of viewer. Often such figures are carica- ants. Identifying the goitrous men as figures with diffuse goiters. tures of cretinous dwarfs with bulbous mountaineers, Shakespeare reveals the or nodular goiters.99 The dramatic correct assumption that goiters are The emphasis on naturalism during enlargement of such goiters is dis- associated with mountainous terrain, the Baroque period of the seven- proportionate to the rest of the body. the terrain of endemic goiter: teenth century is evident in two of Merke notes that the writings of the Spanish painter Jusepe de Ribera’s thirteenth century encyclopedists such Faith, sir, you need not fear. When etchings, The Small Grotesque Head as Thomas de Cantimpré in his De we were boys, /Who would believe (Figure 2-3, 1622, San Francisco, Monstruosis Hominibus include min- that there were mountaineers/Dew- California, Fine Arts Museums iatures of both men and women with lapp’d like bulls, whose throats had of San Francisco, Achenbach huge, pendulous goiters illustrating the hanging at ‘em/Wallets of flesh? Foundation for Graphic Arts) and following text: (The Tempest, III.3)101 Large Grotesque Head (Figure 2-4, 1622, San Francisco, California, Literature and folk art suggest that Fine Arts Museums of San Francisco, the physical signs of endemic goiter Mr. and Mrs. Marcus Sopher col- were commonly recognized and often lection). Both etchings “reflect his the source of humor. In an article fascination with the unusual” and the on the goiter in art, Italian patholo- influence of Leonardo da Vinci and

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possibly of Annibale Carracci (Wind 49). Completed almost one hundred years before Ribera’s drawings, the drawing by a follower of da Vinci of the Grotesque Man with Goitre (Figure 2-5, 16th century, Milan, Italy, Veneranda Biblioteca Ambrosiana) reveals bestial facial features and a large disfiguring goiter. Ribera’s Small Grotesque Head indicates a left-sided nodular mass protruding from the man’s neck, compatible with a nodular goiter, which is possibly malignant. The Large Grotesque Head also suggests a large multi-nodular goiter on the right and left sides of the neck, but other small nodules on the figure’s face. The more superficial subcutaneous position of the neck masses suggests the possibility of neurofibromatosis or Von Recklinghausen’s disease. Although Ribera’s etchings were “originally part of a series of instructional anatomical exercises for students,” Barry Wind notes that the existence of warts and hairs, along with the “bulbous nose” and the man’s Pulcinello collar, similar to “the costume of commedia dell’arte clowns” identify the figure in the etching as the “persona” of a commedia clown (Wind 53). Figure 2-3 Jusepe de Ribera, The Small Grotesque Head (1622, San Francisco, California, Fine Arts Museums of San Francisco, Achenbach Foundation for Graphic Arts)

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Figure 2-4, facing page Large Grotesque Head (1622, San Francisco, California, Fine Arts Museums of San Francisco, Mr. and Mrs. Marcus Sopher collection)

Figure 2-5 A follower of da Vinci, Grotesque Man with Goitre (16th century, Milan, Italy, Veneranda Biblioteca Ambrosiana)

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ease, it was more likely for individuals with large goiters than for those with diffuse goiters to attract the attention of physicians and artists. Even so, without an understanding of the function of the thyroid gland until the end of the nineteenth century, physicians often mistook the thyroid gland for other neck masses and made no more specific distinctions than the artists of the same time period.

Closely allied with the representation of fools and clowns with grotesque goiters are paintings that use noticeably goitrous figures to represent anti- social, negative or violent behavior. Giampalmo cites the well known example in a church in the Val Sesia (mountainous region of northern Italy) of Jean Vespin’s polychrome terracotta sculpture of a man with a huge pendulous goiter (Figure 2-6, 1600, Varallo, Italy, chapel of Salita al Calvario, Figure 2-6 The figure’s multnodular goiter Sacro Monte di Varallo Sesia). The Jean Vespin, polychrome terracotta “underscore[s] the connection to folly, figure of the man, whom Merke sculpture (1600, Varallo, Italy, chapel of Salita stupidity and the commedia. This describes as “a Negroid henchman al Calvario, Sacro Monte di Varallo Sesia) deformity had a long association with flailing away with a stick” (Merke 303), the slow-witted and with clownish is engaged in the flagellation of Christ behaviour” (Wind 53). The remarkable (Giampalmo 101). His enormous goiter physical and mental abnormalities with prominent veins and vacant stare found in many individuals with hyper- suggests the intellectual deficiency of thyroidism and hypothyroidism, cretinism. 104 The anger expressed in his such as myxedema madness, certainly eyes and in his aggressive stance with fascinated many artists. the murderous weapon further implies the demeanor of a negative persona. In a From the goiter beautiful and its fresco of the Last Supper (1400) found mostly lofty, idealized iconography the in another church in the same region the pendulum swings to exaggerated natu- figure of Judas is depicted with a large ralism and almost scientific realism goiter as well as a similar expression of in the goiter grotesque. Since disfig- antipathy (Giampalmo 101–102). Both uring goiters would have been more examples illustrate the association of noticeable to the naked eye and those disfiguring goiters with brutal or treach- afflicted by large goiters had more erous behavior. noticeable symptoms of thyroid dis-

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The grotesque goiter’s reflection of negative behavior is more ambiguous, however, in some Renaissance paintings with religious themes in which either a grotesquely large goiter or a thyroglosasal duct cyst or clinical evidence of hyperthyroidsm is visible. Giampalmo cites several examples of figures with grotesque goiters in paintings on the subject of the passion of Christ. For example, he notes that one of the sleeping soldiers in Piero della Francesco’s Resurrection (Figure 2-7, 1458, Sansepolcro, Italy, Pinacoteca Comunale) is the same model as the one who appears as a patron of the confraternity represented in Piero’s Madonna of the Misericordia in the same museum (See Figure 1-3 in Chapter 1). Giampalmo posits the theory, popularized by Vasari, that the figure might be a self-portrait of Piero (Giampalmo 100).105 In Piero’s Resurrection, therefore, the viewer may read more than was intended in the artist’s rendering of the sleeping sentry’s probable thyroglossal duct cyst, associating the disfigurement with the Figure 2-7 guard’s negative role as a persecutor of Piero della Francesco, Resurrection (1458, Christ. On the other hand, Piero’s Sansepolcro, Italy, Pinacoteca Comunale) use of a figure with such a condition may be the coincidence of a practical choice—the artist using himself as a model.

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Figure 2-8 that the painter may be illustrating the the viewer in an almost contorted Neroccio di Bartolomeo Landi, Saint Bernardino common belief of the time that there pose that reveals a hugely swollen, Performing an Exorcism, right panel (late 15th was a connection between diabolical inflamed, and elongated neck that century, Siena, Italy, Palazzo Pubblico) “possession” and a grotesque goiter. might be observed in someone with acute thyroiditis (inflammation of Representation of the disfigurement the thyroid gland). Ernst scholar A similar negative association between caused by thyroid disease is less David Hopkins identifies the figure the grotesquely enlarged goiter and common in twentieth century art, but as a “sorceress” whose “motif of her sin is apparent in paintings of women two examples serve to illustrate art- headdress or hair lifted by the wind, who are in the process of being ists’ continuing fascination with the and the positions of her arms are exorcised of the devil. Neroccio di anatomy of the enlarged diffuse goiter related to” other witch like figures in Bartolomeo Landi’s painting Saint and its symbolic value. The surre- Ernst’s work.106 Hopkins traces “the Bernardino Performing an Exorcism, alist effect of a woman’s grotesquely visual precedent for such imagery” right panel (Figure 2-8, late 15th cen- enlarged neck being “liberated” of to German woodcuts of witches and tury, Siena, Italy, Palazzo Pubblico) the devil is repeated in the symbolism to the medieval association of an illustrates the exorcism of the devil of the modern surrealist painter Max enlarged neck with diabolical pos- from the mouth of a woman who Ernst’s The Attirement of the Bride session: “we are consequently made is apparently affected by seeing the (Figure 2-9, 1940, Venice, Italy, Peggy aware that the overall composition of body of the saint (shown in the right Guggenheim Collection). Behind and La toilette de la mariée (French title quadrant of the painting). As in sev- to the right of the central “bride” who for The Attirement of the Bride) could eral Renaissance paintings featuring is robed in brilliant red feathers and be read as a scene of exorcism—the women with large necks, bulging eyes resembles a bird of prey, is another heron/stork on the left corresponding are sometimes an indication of thyroid female figure, completely nude except to one of the inquisitors whose job disease. The neck’s size and the prox- for her elaborate headdress of bird- it was to strip suspected witches imity of the neck and mouth suggest like red feathers. She looks away from and examine their bodies for ‘witch

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marks’, and the peculiar detail of the Figure 2-9 swollen red throat of the sorceress on Max Ernst, The Attirement of the Bride (1940, the right corresponding to the swell- Venice, Italy, Peggy Guggenheim Collection) ings alleged in witches’ bodies before the expulsion of demons.”107 The phallic symbolism of the stork-like figure on the left and the hermaphroditic imagery of the homunculus on the right further complicate the meaning of Ernst’s sexual symbolism in the painting.108 Is the enlarged goiter simply a reminder of old religious myths transformed by the twentieth century context of war and genocide, or does it reflect the “significance of alchemy for Ernst … in its function as an alogical sign system”?109

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Figure 2-10 Paul Klee, The Hero with the Wing (1906, San Francisco, California, Museum of Modern Art, Carl Djerassi Trust I)

German artist Paul Klee’s etching The Hero with the Wing (Figure 2-10, 1906, San Francisco, California, Museum of Modern Art, Carl Djerassi Trust I) draws the viewer’s attention to a large disfiguring goiter in the central neck of a tall heroic looking male figure whose helmet, right sided wing, and unilateral, right gynecomastia (enlarged male breast) suggest a super hero whose powers are incomplete. A comparable mass in the hero’s right neck and the mass in his central neck suggest the presence of metastatic thyroid cancer in his cervical nodes. The association of Graves’ disease with gynecomastia leads to the speculation that the hero’s goiter and enlarged breast are related. Whether Klee purposely included these examples of thyroid disease in order to emphasize the hero’s limitations is questionable. We do know, however, that Klee described his hero in his diary:

Perhaps a Don Quixote of ancient only powerless to take flight but also tion of low or humble social status times … The man born only with further encumbered by his goiter and such as that associated with manual one wing in contrast with divine neck mass, his paralysis “a bleak com- laborers or peasants. In his fresco creatures, makes incessant efforts mentary on the condition of man” series titled The Life of St. Benedict in to fly. In doing so, he breaks his (Lanchner 84). the cloister of the Benedictine mon- arm and leg but persists under the astery of Monte Oliveto Maggiore banner of his idea. The contrast But not all artists’ representations of in Tuscany, the Renaissance artist Il between his statue like solemn goiter grotesque hint at failed ideas Sodoma (Giovanni Bazzi) (Figures attitude and his already ruined state or negative associations. Some paint- 2-11 and 2-12, 1509, Monte Oliveto needs especially to be captured.110 ings with religious themes include Maggiore, Tuscany) painted a number figures whose social class as well of male peasants with large disfiguring The presence of disfiguring disease as a disfiguring goiter might dis- goiters. In the panel Benedict releases in the would-be hero’s neck further tinguish them from other figures in a peasant shackled by the Goths magnifies the “tragicomic” role and the painting. In such paintings the (Figure 2-11) (see p. 65), the figure of “absurd plight” of a man who is not disfiguring goiter is often an indica- the bound peasant is portrayed with a

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large bulbous goiter and pronounced Since it is possible that Il Sodoma used coincidence of the peasants having sternocleidomastoid muscles. His models from the mountainous area of endemic goiter is not surprising. Since upward gaze reveals a skepticism pos- southern Tuscany where the monastery monks often moved from one monas- sibly provoked by his disbelief at the is located, it is interesting to note that tery to another, the absence of goiter miracle he is about to experience. In the male figures with grotesque goiters in these figures may reflect the fact another panel Benedict completes the in these and in other panels in the that endemic goiter was less common building of twelve monasteries (Figure series all represent the peasant class in persons who moved from place to 2-12), a robust peasant with a gro- whereas the monks in the frescoes do place and were therefore less likely to tesque goiter and musculature similar not appear to have such deformities. be iodine deficient. Benedictine monks to that of the peasant in the aforemen- This distinction leads to the question were also known to have been selected tioned panel is depicted in the act of of whether the artist consciously used for their physical strength, a fact that applying mortar to the masonry super- anomalous anatomical features to might have eliminated novitiates with vised by St. Benedict. represent class difference, or possibly, swollen necks. More likely, however, in the example of the bound peasant, is the factor of geography. Since the to emphasize the difference between monastery is located in a mountainous Figure 2-12 the saint and the beneficiary of the region, Il Sodoma’s portrayal of the Il Sodoma (Giovanni Bazzi), The Life of St. miracle. One could also conjecture goiter may be merely an example of Benedict: Benedict completes the building that if Il Sodoma used local peasants faithful rendering of naturalistic detail of twelve monasteries, detail (1509, Monte as models for the peasant figures, the in local peasants. Oliveto Maggiore, Tuscany)

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Dramatic focus on an unusually The subject of Raphael’s painting is Figure 2-13, facing page large goiter distinguishes some of the the miraculous cure of the lunatic Raphael, Transfiguration (1520, Vatican State, more humble figures in a major work child, who also happens to have Italy, Pinacoteca, Vatican Museums) by Raphael that features the New physical signs of a disease associated Testament narrative of the transfigura- with behavioral manifestions such as tion from Matthew 17. In Raphael’s temporary psychological disorders. large altarpiece of the Transfiguration In the story from Matthew 17, Christ (Figure 2-13, 1520, Vatican State, “was transfigured” before disciples Italy, Pinacoteca, Vatican Museums) Peter, James, and John on a mountain. a prominent goiter draws the viewer’s After he appears to his disciples, they eye toward the central figure of a come to a large crowd of people where young adolescent boy clothed in a he encounters “a certain man, kneeling bright yellow tunic. The focal point down to him, and saying Lord, have of the painting, the boy is presum- mercy on my son: for he is lunatick ably part of a family group of mother, [sic], and sore vexed: for oftimes he father, and son in the foreground of falleth into the fire, and oft into the the painting. The boy being supported water. And I brought him to thy dis- by the father figure has a large bul- ciples, and they could not cure him” bous goiter, cross eyed gaze or squint, (Matthew 17:14–15). Jesus then asks bulging eyes (exophthalmos), and the father to bring the child to him, gynecomastia, all features of Graves’ “And Jesus rebuked the devil; and he disease. The father figure has a distinct departed out of him: and the child was stare that could be related to exoph- cured from that very hour” (Matthew thalmos, and both mother and father 17:18). Like the woman being exor- figures have smoother diffuse goiters cized in Landi’s painting (Figure 2-8), than the son. To the contemporary the child has his “lunacy” exorcized by endocrinologist familiar with genetics, a religious miracle. Both figures also the grouping of these three figures have prominent, symptomatic goiters might suggest the presence of familial that are linked to temporary mania. autoimmune thyroid disease. Although the nature of thyroid disease and the incidence of familial disease would have been unknown to Raphael, it is possible that the painter used members of an actual family group as models for the figures in the story from Matthew. As with the work of Piero della Francesco and Il Sodoma, it is possible that Raphael’s models lived in a mountainous region of central Italy with endemic goiter. Thus by coincidence Raphael might have represented the physical manifestations and the familial associations of thyroid disease.

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Without knowing the etiology or clinical pertains to the figure of the “cured” psychological behavior and a severely and psychological manifestations of boy in Raphael’s Transfiguration. enlarged goiter, or “goiter grotesque,” hyperthyroidism or Graves’ disease, Interestingly, Charcot and Richer do Raphael may have observed the Raphael might have seen physical signs not acknowledge the presence of model’s bulging eyes also associated of the disease in the model he used for the boy’s obvious goiter and other signs with such behavior and disfigure- the central figure of the boy. Raphael of Graves’ disease but instead posit ment. The fact that he repeated the renders the physical manifestations of another diagnosis of the boy’s condition: features of bulging eyes and swollen thyroid disease—bulging eyes, squint, epilepsy or hysteria. They question neck (though less disfiguring) in the large goiter, and gynecomastia—with whether Raphael intentionally exag- father figure who supports the boy and anatomical accuracy. The constellation gerated the physical manifestations that he painted the mother figure’s of a number of physical signs of of a “possessed” state of epilepsy or neck with a diffuse goiter suggests that disease might explain the prominent hysteria (Charcot and Richer 28) in Raphael may have seen examples position of the boy in the painting order to idealize the young hero of the of familial hyperthyroidism or familial and the flailing gestures of him and biblical story in a more conventional goiter in Renaissance Italy. Even others in the crowd who point toward manner than was characteristic of the though precise scientific knowledge of him or toward the transfigured Christ. artist’s usual realism.112 Although the the disease would not have been Since Raphael has compressed two diagnosis of Graves’ disease and its available to the artist, the accuracy of parts of the narrative in Matthew 17 psychological effect on behavior was anatomical details illustrates Raphael’s into one painting and has placed the described in the 1830’s, the informa- skill in rendering the pathology of boy in the center foreground, the artist tion was not widely known and was disease. Here is an example in which the may be suggesting the boy’s symbolic therefore probably not a factor in artist’s eye is more acutely observant role as a demonstration of the power of Charcot and Richer’s “diagnosis” of than that of the physicians of his time, faith, the subject of Christ’s admoni- Raphael’s figure of the boy. or even, perhaps, of physicians like tion to his disciples in Matthew 17:20. Charcot and Richer in the late nine- If one accepts this interpretation of But to a contemporary physician aware teenth century. the painting, one must conclude that the of the connection between severe viewer is therefore meant to associate Graves’ disease and temporary mental A similar example of the accuracy of the boy with the dramatic revelation of instability, a symptom that existed the artist’s eye in detecting thyroid the transfigured Christ. That the in Raphael’s time and still persists in pathology is evident in Caravaggio’s boy’s goiter verges on the grotesque undiagnosed individuals with Graves’ painting of The Crucifixion of St. and that he also looks mentally disease, a more accurate “diagnosis” is Andrew (Figure 2-14, 1607, Cleveland, disturbed further distinguishes him from available. In representing the story of Ohio, Cleveland Art Museum) in the adult figures in the painting and dra- a lunatic who was miraculously cured, which an old peasant woman in the matically singles him out as a “lunatic” Raphael may have found a model lower left corner of the painting gazes singularly blessed and cured. who, though suffering from hysteria up at the crucified saint. The woman caused or aggravated by a severe has a pronounced goiter. According to Raphael’s Transfiguration is the sub- thyroid disorder, also demonstrated Irish physician J. Barry Ferriss, “iodine ject of an essay written in 1888 by two periods of remission from the ailment. French psychiatrists, J. M. Charcot (In some uncommon cases, even the and Paul Richer, on the depiction of physical manifestations of Graves’ dis- Figure 2-14, facing page psychological illness in art.111 In ease as well as its psychological effects Caravaggio, The Crucifixion of St. Andrew the chapters titled “Le Jeune Possédé,” may spontaneously disappear.) In (1607, Cleveland, Ohio, Cleveland Art the authors include an analysis of addition to inadvertently documenting Museum) the representation of “lunacy” as it the connection between aberrant

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Figure 2-15 tion of metastatic thyroid carcinoma” teenth centuries display anatomical Jan Sanders van Hemessen, The Prodigal Son (Ferriss 518). We know that there are realism as a way of defining character (1536, Brussels, Belgium, Museés Royaux des several paintings by Caravaggio of traits in the morally didactic works Beaux-Arts de Belgique) young women with diffuse goiters as of the period. The genre paintings depict well as other paintings that seem to homely domestic narratives as well have used the same or similar elderly as bawdy tavern and brothel scenes, deficiency was common among the female peasant figure as a model. The often with implied moral symbolism or poor around Naples, where the picture grotesque goiter represented in The allegorical content. In such scenes was painted; art historians believe Crucifixion of St. Andrew is therefore physical deformities are quite common that the old woman’s goiter was used consistent with Caravaggio’s adher- and often exaggerated or accentuated to indicate her humble origins.”113 ence to naturalistic detail and practice by the artist’s use of light and compo- Ferris also notes that the old woman’s of using local peasants as models.114 sition, especially the foreshortening of “goiter is rounded rather than mul- figures in the foreground, and thus, tinodular,” and that “there are two Naturalistic details are also evident distortion of size and proportion. The discrete swellings on the right side” of in northern European paintings that setting in a genre painting also calls her neck, indicating “enlarged lymph reflect the influence of Italian Baroque attention to the physical deformities of nodes, raising the possibility that artists. Dutch and Flemish genre paint- the human figures because the figures the picture is an unwitting illustra- ings from the sixteenth and seven- are often contained within a small

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domestic space similar to a theater’s The use of caricature and realism Caravaggio is apparent in the paint- stage set. In addition to the use of set- in sixteenth century paintings to ings of Dutch artists such as Jan Steen, ting to frame the narrative, whether depict the world of the bordello and Jacob Duck, and others who studied it is the interior of a public house, a the physical abnormalities associ- in Italy or worked in Utrecht, Holland tavern or a home as an enclosure ated with it is replaced by a more where “strong Catholic traditions” for women of questionable morality, ambiguous realism in paintings by made “Caravaggio’s realism and ‘lay several paintings in this category seventeenth century Dutch artists. Christianity’” appealing (Janson 581). portray women in the act of frolicking Art historian Wayne Frantis notes the It is a realism that juxtaposes symbols with men. Frequently, the women evolution in style that reflects “wide- of prosperity with frank narratives have voluminous breasts and large spread changes in taste after 1650” of debauchery and licentiousness. diffuse, and sometimes disfiguring, when “comic themes also shifted In seventeenth century Dutch genre goiters. Both seem to be associated from their traditional focus upon the paintings, the procuresses and the with aggressive sexuality and illicit peasantry and related low-life types prostitutes are clothed in more aristo- behavior. toward persons and situations drawn cratic clothing than their counterparts from a higher social milieu” (Frantis in works of the previous century, and In the biblical painting of The Prodigal 206). The influence of Rubens and the homely, sometimes grotesque, Son (Figure 2-15, 1536, Brussels, Belgium, Museés Royaux des Beaux- Arts de Belgique), Dutch genre painter Jan Sanders van Hemessen depicts a bordello scene that alludes to the theme of debauchery in Luke 15: 11–32 in which the notorious young son, after inheriting money from his father “wasted his substance with riotous living.” In the foreground of the painting a peasant woman with coarse features and a large nodular goiter seems to be encouraging the coupling of the young woman and man on the left while in the background a younger woman, who has a large diffuse goiter and leans seduc- tively to her right, seems to be courting the man sitting next to her. The goiter is a noticeable feature of both procuress and prostitute.

Figure 2-16 Jacob Duck, The Sleeping Woman (mid 17th century, Rotterdam, Holland, Kunsthalle)

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faces of female peasants are replaced to those on the margin of society now greed and miserliness of the King and with those of more attractively includes examples from the middle Queen, and the perpetual need for groomed middle class women. Steen’s class. Duck’s painting also blurs the funds of the Prince of Wales.”117 The The Dissolute Household (1661–64, line between the association of the boldly colored print features the three London, Wellington Museum), for diffuse goiter with romantic sensuality royal figures of Queen Charlotte, the example, juxtaposes a maternal figure that we saw in some of the paintings Prince of Wales (later George IV), and “in an alcoholic stupor … while discussed in Chapter 1 and with the King George III (dressed as a woman) her husband cavorts with a busty more frank display of debauchery seated around a bowl of gold coins strumpet” (Frantis 207). The strumpet, demonstrated here. from which each ladles large quanti- elegantly clothed in velvet and furs, is ties of coins into his or her mouth. noticeable for her large, though not The use of realism and caricature All three figures have large pendulous especially disfiguring, goiter. evident in northern European genre goiters (the “craws” shaped like sacks paintings was adopted by English art- of money) hanging from their necks. Beneath the appearance of respect- ists whose work was made more acces- Those of the King and Queen hang ability, however, the painter’s satirical sible to the middle classes through with such weight that the “craws” or tools expose a cutting, ironic tone. The publication in the popular press or goiters touch the bowl of coins and large goiter, if shown at all, seems to through prints based on their paint- clearly dominate the scene. Gillray’s be associated with sensuality rather ings. In the eighteenth and nine- caricature uses the grotesquely than with a physical abnormality and teenth centuries, William Hogarth, enlarged goiter to deliver his criti- almost looks like a third breast. For Thomas Rowlandson, James Gillray, cism of the gluttony and greed of the example, Jacob Duck’s The Sleeping and George Cruikshank exploit the monarchy. Queen Charlotte’s bulging Woman (Figure 2-16, mid 17th cen- viewer’s tendency to associate med- eyes not only suggest exophthalmos, tury, Rotterdam, Holland, Kunsthalle) ical abnormalities of all kinds with which along with the enlarged goiter portrays a woman who seems to be behavior that was commonly termed may indicate a further manifestation asleep and possibly drunk. Framed “freakery.”115 Graphic distortions of of Graves’ disease, but also drama- by an erotically charged interior of conditions such as goiter, cretinism, tize the extremity of her avarice and red velvet, the woman is sitting with and dwarfism (see Chapter 3), gigan- willingness to sacrifice public funds for her head thrust back, a position that tism and acromegaly (see Chapter 4), the sake of her son.118 The Prince of accentuates her large goiter. An empty exophthalmos and gout (see Chapter Wales’s fool’s cap and “symbolically glass in her disproportionately dainty 5) are useful tools for satire. empty” craw in contrast to the King’s hand implies her drunken state and and Queen’s full craws, and the femi- the familiar relationship of drinking, Among the English caricaturists of nine dress of the King imply weakness gambling, and prostitution. The artist’s the late eighteenth century, James associated with feminine traits, thus focus on the woman’s large neck with Gillray was known for his “savage” emasculating the power of king and its pronounced nodular goiter seems political satire.116 Gillray often used heir and implying the manipulative in keeping with intimations of her low medical abnormalities as metaphors tendencies of Charlotte.119 character and drunken state, thus asso- for the disease of state, or corruption ciating the disfiguring goiter, as well, in politics. Among the most famous From anatomical realism to caricature, with her licentious behavior. In the of Gillray’s works is The Monstrous allegory and political satire, the evolution of European social history as Craws at a New Coalition Feast enlarged goiter is a prominent feature it is reflected in art, the artist’s rendi- (Figure 2-17, 1787, London, British in art that draws attention to human tion of the large or grotesque goiter Museum), a hand-colored etching with disfigurement and the singular as a reference to the lower classes, to aquatint whose subject is, according identity, vulnerability, humbleness or immoral or disrespectful behavior or to art historian Richard Godfrey, “the notoriety associated with it. A

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disfiguring goiter might identify an of a double standard between the Figure 2-17 individual as “the other,” someone who sexes in the association of physical James Gillray, The Monstrous Craws at a stands out in a crowd, whether his or beauty with feminine virtue and New Coalition Feast (1787, London, her distinction is negative or positive. disfigurement with masculine rugged- British Museum) Unlike Botticelli’s idealized, sylph-like ness. Only Gillray’s caricature female subjects with diffuse goiters places equal emphasis on the culpability that complement their graceful figures of both sexes when he depicts the and young, innocent faces, the female grotesque goiter as a symbol of greed subjects of paintings that expose in high places. disfiguring goiters are often depicted in compromising settings that suggest moral failure. Male subjects with disfiguring goiters or thyroglossal duct cysts represent a greater variety of social status and moral character. Perhaps the discrepancy is a reminder

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Chapter 3 frontal pose of the Calabazas portrait and the absence of a canine or human figure for comparison Little People: suggest an attempt to present the dwarf Fascination or Exploitation? with more dignity than one can find in Ribera’s work.

Nonetheless, as Wind and others note, an attitude of sympathy toward Introduction dwarfs did not prevail in the Spanish court of Velasquez’s time.

Renaissance and Baroque paintings of people with large disfiguring Throughout the seventeenth and goiters or the enlarged facial features and shortened limbs of cretins eighteenth centuries the noticeable contrast in size between a dwarf must have appealed to collectors who were curious about deformity or and an average European citizen set little people apart from humanity found humor in art that called attention to physical abnormalities. For as a curiosity or as a source of entertainment and a subject for derision. others such depictions of disfigurement might have served as a warning Court painters and other artists who against sin. The association of physical deformity with both the comic catered to the tastes of their patrons, especially in Spain and northern Italy, and the sinister is also apparent in paintings of little people or dwarfs represented dwarfs in both narrative and portrait paintings. Many of from the sixteenth and seventeenth centuries. The range of attitudes these paintings provide insight into attitudes among the aristocracy of toward the condition of dwarfism those regions. The use of deformity as encompasses an even greater spectrum a source of entertainment continued when one compares the implied into the early twentieth century mockery in Jusepe de Ribera’s painting when little people were displayed in of The Dwarf and a Dog (1643) freak shows and circuses on a level with a less derisive presentation of a similar to that of performing animals. dwarf in Diego de Velasquez’s portrait Although a more humane attitude of Calabazas (1638, Madrid, Prado), toward little people is apparent in late which many critics find sympathetic to nineteenth century portraits, Figure 3-9, facing page the plight of the dwarf (Wind 67).120 unfortunately the stigma of size con- Jan Molenaer, Stone-throwing Dwarf also The Ribera painting uses foreshortening tinues to marginalize little people in known as Scene with Dwarfs (1646, Eindhoven, to emphasize the comparative size contemporary society. Netherlands, Van Abbemusesum) (see p. 106) of the dwarf next to a large dog whose head is the height of the dwarf’s chest. The dog’s chain, which the dwarf holds, is a reminder of the dwarf’s status similar to that of the dog: both are someone else’s property to be kept chained and controlled. The

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Types of dwarfism; pituitary In the human fetus growth hormone Among the non-endocrine causes dysfunction and other etiologies is present in high concentrations, of dwarfism, poor maternal nutri- whereas growth hormone receptors are tion is the most important condition more limited in number. Growth hor- leading to low birth weight and length. There are more than one hundred mone is secreted by the pituitary gland Maternal height correlates better than types of dwarfs or little people, and in a pulsatile manner. It functions by paternal height with fetal size, but one dwarf is born in every 10,000 binding to the insulin-like growth eventually there is a positive correla- births.121 A dwarf or little person is factors and their binding proteins. tion between the average of the two usually less than four feet in height, Growth hormone will not increase parents’ heights and the height of the and most dwarfs are born to parents growth rate without adequate nutri- child (Styne 184). Smoking, alco- of normal size. In the United States tion and normal thyroid function. In holism, chronic illness and uterine newborn babies weighing less than cases of malnutrition growth hormone abnormalities in the pregnant mother 2,500 grams at term are considered levels increase whereas insulin-like can also result in poor fetal growth “small for gestational age,” but not all growth factor levels decrease. With (Styne 173). unusually small babies are considered advancing age, growth hormone and dwarfs.122 The causes of dwarfism are some insulin-like growth factor levels Other types of dwarfism affected by both endocrine and non-endocrine. in the blood decrease. growth hormone receptor defects but not influenced by the pituitary gland Short stature is usually marked in Other hormones such as thyroid hor- include pygmies and individuals with individuals with endocrine, primor- mone are also important for normal Laron’s dwarfism (Styne 180). Infants dial or gonadal dysfunction or from growth and development. Children with reduced or absent growth hor- an unknown or idiopathic cause. born with congenital hypothyroidism mone receptors, such as those that Growth retardation in individuals with are of normal length at birth, but if occur in Laron’s dwarfism, are small at illnesses and familial growth retarda- left untreated, they will develop cre- birth, have elevated growth hormone tion, however, are usually less severe. tinism characterized by severe mental and low serum insulin-like growth Among the endocrine causes of short retardation and delayed growth, espe- factor (igf-i) (Styne 180). The short stature, abnormalities originate from cially of the arms and legs.124 Gonadal stature of African pygmies is caused by inadequate secretions of growth hor- and adrenal steroids are also essential post-growth hormone receptor abnor- mone, thyroid hormone, and androgen for normal growth and are of major malities. Pygmies have normal growth or estrogen.123 Non-endocrine causes importance during prepubertal growth hormone levels but low insulin-like include genetic or constitutional and development of secondary sexual growth factor (igf-i) and normal origins of short stature; growth hor- features. With the augmentation of insulin-like growth factor (igf-ii) con- mone receptor dysfunction (Laron’s insulin like growth factor (igf-i) pro- centrations. They also have a normal dwarfs); post growth hormone duction, increased sex steroids result body habitus or proportions. Pituitary receptor defects in insulin-like growth in increased bone growth but also dwarfs somewhat resemble African factor known as igf, a condition cause premature epiphysial fusion pygmies in their size and skeletal profound in pygmies; inadequate and, consequently, short adult stature. portions. They differ from pygmies nutrition; illnesses or conditions such Excess glucocorticoids, whether of in their lack of truncal obesity and in as chronic renal failure; excess intake endogenous or exogenous nature, also the presence of micro phalluses and or production of corticosteroids and quickly result in growth retardation. wrinkled skin. Pygmies are unrespon- chemotherapy (Styne 180). sive to growth hormone administration, and despite low igf-i levels, they have normal serum igf-i activity.125

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Unlike the normal body habitus of the Some children with severe short however, resulted in adverse effects pygmies, an abnormal body habitus stature and high levels of growth hor- in many children such as coarsening is found in achondroplastic dwarfs, mone have growth hormone receptor of facial features, hypoglycemia, and who have normal or enlarged heads abnormalities and growth hormone minor changes in blood lipid levels and trunks but short arms and legs. insensitivity. Many of these children (Chernausek et al 905–906). Cretins, that is, dwarfs with congenital have defects in the growth hormone hypothyroidism are characterized by receptor or growth hormone response short stature and disproportionately pathway. They have a growth response short extremities, mental retardation, to treatment with insulin like growth thick tongue, deafness, protuberant factor. In the United States today, abdomen, and a broad flat nose. a significant number of short children Other causes of short stature include are being treated with recombinant mongolism, elephant man syndrome growth hormone to help make Figure 3-18 or neurofibromatosis, Turner’s syn- them grow. Bertholde, a dwarf (Engraving by A. Walker. drome or female chromosomal defects, Courtesy of the Wellcome Trust) (see p. 116) Noonan’s syndrome or male chromo- Chernausek, et al, recently reported somal defects, and other disorders.126 the long term effects of treatment of 76 small children with growth hor- Insulin-like growth factors known as mone resistance.128, 129 Thirty-nine igf’s are important for growth and are of these children had growth hormone regulated by growth hormone as well receptor defects. Twenty-three as metabolic factors other than growth had a defined molecular defect of the hormone. Insulin-like growth factor growth hormone receptor, and five binding proteins are also required for had absence of growth hormone bind- normal growth and development. A ing proteins, suggesting a defect in recent study by N.B. Sutter et al docu- the growth hormone receptor or its ments the importance of igf as a single intracellular signaling pathway. Nine allele on Chromosome 15 responsible others had neutralizing levels of for the small size of canine breeds:127 growth hormone antibodies and “A single igf-1 single-nucleotide poly- consequently were relatively growth morphism haplotype is common to all hormone deficient. Growth hormone small breeds and nearly absent from giant resistance in the children was defined as breeds, suggesting that the same causal failure to increase serum igf levels sequence variant is a major contributor after four injections of human growth to body size in all small dogs” (Sutter et hormone (0.1 mg/kg) (Levitsky 813). al 112). The igf defect in small dogs is In response to treatment with growth similar to that in pygmies. The variation hormone most short children ini- in the size of humans, however, is signifi- tially had a growth spurt during the cantly smaller in range than that of dogs first year, but subsequent growth (the latter ranging in weight from two rate only approximated the normal pounds to over 200 pounds). growth rate. Catch-up was lower than observed when growth hormone was administered to growth hormone deficient children. Such treatment,

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The variation in the life expectancy of History of diagnosis and treatment of existence of individuals with deformities little people depends on the cause of dwarfism “heightened the idea of beauty and the dwarf’s short stature. For many perfection” in those who were spared little people the life expectancy is such problems (Wind 9). His view, normal, but persons with short stature Observations of dwarfism have been shared by others in the Middle Ages, uses secondary to illness and hypopituita- recorded in writing and art since the illogical circular argument that rism have a decreased life expectancy. antiquity. These records reveal that deformity exists to provide a contrast Dasen states, “the life span of short attitudes toward little people to perfection and that perfection statured persons is generally reduced range from acceptance to curiosity, fear, therefore requires the existence of its in comparison to that of normal and rejection. Aristotle described opposite or imperfection. sized individuals because of their the Pygmies as “a race of men of small greater vulnerability to infections, stature” (Medvei 75). The emperor In the late Renaissance the negative diseases, and accidents” (Dasen 8). “Augustus, according to [the Roman religious association of dwarfs with sin Controversial recent studies docu- historian] Suetonius, despised dwarfs and the devil changed to a more secular ment that female individuals of four and other malformed creatures … view of dwarfs as curiosities designed to twenty years who have growth [believing] that the misshapen were for the entertainment of the wealthy. hormone deficiency have a short- augurs of the malign” (Wind 8). As quoted in evolutionary biologist ened lifespan.130 Males of all ages and Wind notes that the Roman Pliny and Armand Marie Leroi’s Mutants,” women over twenty years of age with the fifth century religious scholar the French scholar Isidore Geoffroy growth hormone deficiency appear to St. Augustine expressed curiosity Saint-Hilaire states, “it was necessary have a normal life span. The sexual toward little people, seeing dwarfs “and to dream up amusements of a special function of dwarfs also depends on the other terata as a manifestation of sort for the leisure of princes and it causes of short stature and is usually variety, acknowledging that deviations was to dwarfs that fell the sad privilege normal. Short stature caused by illness from the norm occurred in humanity” of serving as the toys of the world’s or hypopituitarism, however, results (Wind 8). The Hebrews considered grandees.”131 Leroi notes, however, in decreased sexual activity and, in the dwarfs to be “misfits” and denied that the tradition began in the six- latter case, small genitalia. them “access to the temple” (Medvei teenth century, possibly by “Catherine 36). During the Middle Ages when de Medici (1519–1589) … [who with] physical or mental abnormalities were the hope of breeding a race of minia- considered “creations of the devil,” ture humans … [purposely] arranged the thirteenth century “Pope Gregory a marriage between a pair of dwarfs.” IX denied higher orders to any (Leroi 170). Religious skepticism also candidate disfigured by a blemish or prevailed even among medical scien- deformity” (Wind 9). Thirteenth tists in the more enlightened ages. To century medieval scholar Albertus the French sixteenth century surgeon Magnus in De Animalibus “considered Ambrose Paré, “[m]aimed persons pygmies as imperfect and sub-human … include the … humpbacked, … [those shameless … and dishonest” and there- having] arms too short, or the nose too fore “not to be considered human” sunken” and “any other thing that is (Wind 9). Wind also notes the ironic against Nature” were “[m]onsters or view of the thirteenth century things that appear outside the course of Franciscan monk Alexander of Hales, Nature.” 132 The association of dwarfs who not only regarded deformities with humpbacked people (gobbi in such as dwarfism as the “consequence Italian) was made popular in prints and of sin” but also believed that the

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engravings of the seventeenth and eigh- Other strange theories persisted Thomas Gibson (1647–1722), a teenth century and by the commedia throughout the sixteenth and sev- physician educated at Cambridge dell’arte that featured such physically enteenth centuries. In 1543 Vesalius and Leiden, thought that the pitu- deformed characters as Pulcinello. was the first to describe the pituitary itary secreted “cerebro-spinal fluid, gland “as a separate entity” (Medvei as believed also by Sylvius and As with general attitudes toward all 65). According to Thomas Wharton, Raymond Vieussens (1641–1715) of manifestations of endocrine abnormali- Swiss professor of anatomy and Montpellier” (Medvei 140). The lat- ties, religious beliefs, mythology, and medicine Caspar Bauhin (1550–1624) ter’s book Nevrographia universalis speculation eclipsed medical knowl- also believed in Galen’s theory that was “perhaps the best illustrated work edge, which was, at best, incomplete if the pituitary served to “‘drain out of the 17th century on the configu- not inaccurate. Medical scientists did the moisture of the brain,’” and in ration of the brain, spinal cord, and not recognize the function of the pitu- Vesalius’s theory that “‘the waste nervous system” (Medvei 140). British itary gland until the end of the nine- material excreted by the brain (a physician Thomas Willis (1621–75) teenth century or the beginning of the glandular organ) passes through the thought that the pituitary was a twentieth century, therefore remaining infundibulum into the pituitary and receptive organ. According to med- unaware of a major cause of dwarfism. then into the nasopharynx’” (Medvei ical historian Hans Simmer, “When 131). This hypothesis promoted the [Willis] injected ink into a carotid Because of its significant control of use of “sneezing powders ‘to purge the artery, part of the ink appeared in the other endocrine glands, the pituitary brain’” (Medvei 131). pituitary tissue,” thus documenting gland has been referred to as the “con- the existence of uptake by the gland ductor of the orchestra” (Medvei 4). In 1660, however, physiologists and rejecting the “conception of an Early ideas about the gland’s function Conrad Victor Schneider (1614–1680) internal secretion” (Medvei 139). date from Galen (129–201 ce), of Wittenberg, Germany and Richard Because little evidence supporting the who thought that the secretions of the Lower, of Cornwall, England (1631– function of the pituitary gland was pituitary gland “discharged into the 1691) rejected the generally accepted available, until the twentieth century nasal cavities” (Medvei138). Medvei Galenic idea about the function of the the pituitary gland was “regarded quotes the French physician Theophile pituitary and the belief “that the nasal as little more than a vestigial relic” de Bordeu (1722–1776), who wrote secretions originate in the pituitary (Medvei 304). that “‘Galen honored it [the pituitary] body (1672).”133 This new informa- by calling it ‘the gland’ above all…. tion, which localized catarrh in the In 1724 Venetian anatomist Giovanni The Ancients believed that the pituitary air-passages rather than in the brain or D. Santorini (1681–1737) inaccurately existed for the retention of the animal in the pituitary gland, helped do away described the anterior pituitary, which spirits; it served, they said, as a plug to with dependence on “endless recipes he called “glandula ptui-potior,” the funnel, and without it, all the spirits for ‘purging the brain’” (Garrison note and the posterior pituitary, which contained in the ventricles would easily 2, 268). Five years later, in his Liber he named the “neuro-hypophysis, disperse’” (Medvei 151). One might primus de catarrhis (Wittenberg 1660) the pars nervosa, the infundibular wonder whether Galen’s theory about Schneider reported that although body” (Medvei 303, ref. 56). In 1888 the function of the pituitary and its role “only the macerated ethmoid bone dis- the German surgeon N. Rogowitsch in discharging brain secretions origi- plays pores,” these pores do not serve noted that the pituitary glands became nated from his observation of soldiers as a filter but are occupied by vessels enlarged and hyper plastic after he who had cerebrospinal fluid leaking and there is no “cavity or any liquid” removed thyroids from rabbits (Sawin from their noses after head injuries. in the pituitary gland (Medvei 138). 179). Rogowitsch incorrectly hypoth- esized that the pituitary took over the function of the thyroid. In 1898

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German pathologist L. Comte noted “[r]emoval of the posterior lobe only Cushing initially thought that the that the size of the pituitary gland had negative results” such as diabetes pituitary functioned like the thyroid, increased in females during pregnancy insipidus (Medvei 315). secreting one or two hormones essen- and in males after castration (Medvei tial for growth and sexual develop- 304). Unfortunately these observa- Swiss German surgeon Bernard ment. He believed the pituitary gland tions were not appreciated and had no Aschner (1883–1960) improved the was important for many functions, real impact on the scientific thinking technique of hypophysectomy including normal sexual activity and of the day (Sawin 179). Ignorance by using a “trans buccal approach” sleep. He eventually changed his mind, about the true function of the pitu- that caused less disruption to the however, because pituitary extracts itary gland persisted through the late brain; he documented “genital hypo- failed to work effectively and several nineteenth century. In 1889 and 1895 plasia” (decreased number of of his experiments initially failed to in his famous textbook of physiology cells) and, from “X-ray studies the confirm his hypotheses. Eventually, Brtish physiologist Michael Foster cessation of growth of the long Cushing became critical about the ped- (1836–1907) stated, “concerning … bones” in dogs after hypophysectomy dling of endocrine extracts and other the purposes of the organ (the pitu- (Medvei 316). His findings showed that hormonal concoctions (used for organ- itary gland) … we know absolutely partial hypophysectomy also resulted otherapy). He subsequently described nothing” (Sawin 179). in atrophy of the adrenal cortex and this practice as “endo-criminology.”134 atrophy of the thyroid, supporting the Several experiments in the late nine- concept that the pituitary is the “con- teenth and early twentieth centuries ductor” of the other endocrine glands. documented that the pituitary gland (Medvei 319 and 323, ref. 114). is necessary for life. Early experiments relating to partial removal of the In 1910 the findings of experiments pituitary gland, known as hypophy- on over 100 dogs were presented by sectomy, were difficult to interpret the American neurosurgeon Harvey because the operation itself resulted in Cushing (1869–1939) in collaboration a high mortality rate. Medvei reports with James Crowe at the American that in 1886 Sir Victor Horsley suc- Association for the Advancement cessfully removed the pituitary from of Science. Their findings confirmed two dogs (Medvei 315). Surprisingly, Paulesco’s previous observations the dogs survived. In 1907 the regarding the essential function of the Romanian physiologist Nicolas C. pituitary gland for life. In 1914–18 Paulesco (1869–1931), reported the German pathologist Morris Simmonds work of a colleague with whom he (1855–1925) described pituitary collaborated in experiments on the dwarfism resulting from anterior pituitary gland in dogs: his colleague, pituitary lobe deficiency (Garrison the surgeon Balacesco, removed the 695–696). Cushing and his associates pituitary gland from 22 dogs and 12 also observed that growth slowed or cats. All of the dogs in these experi- stopped and “sexual infantilism ments died within three days of the remained” in young dogs subjected to operation. “Separating the pituitary partial removal of their pituitary stalk produced the same result,” and glands (Medvei 316).

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Little people in mythology, art, and history

Although negative or derisive images of dwarfs were represented in antiquity as well as in the late Renaissance and Baroque periods in Europe, ancient Egyptian and Greek dwarf figures on painted pottery or in the form of small sculptures or amulets often appear in a positive light. Dasen notes that in Egypt from the period of “the New Kingdom on and probably also earlier, [dwarfs] emerge as popular deities, best known in their forms of Bes and Ptah-Pataikoi, who are invoked in a host of magical practices to protect the living and the dead” (Dasen 46). Numerous versions of the dwarf God Bes are visible in the antiquities collections of major museums, including the Metropolitan Museum of Art, the Louvre, the Vatican, and the British Museum. In the catalogue of a 2005 Metropolitan Museum exhibit titled The Art of Medicine in Egypt, five variations on the dwarf god Bes illustrate Bes’s diverse functions as protector of women (especially women in childbirth) and children;135 as musician, “perhaps because of the songs mothers have always sung to their children”; as bce–364 ce, New York, Metropolitan one. This symbolic correspondence protector against dangerous and Museum), Bes “is shown grasping seems to have passed beyond dynastic evil forces; and as protector against a serpent, demonstrating his control Egypt into the Greek world” (Dasen disease.136 Usually wearing “an animal over the inimical elements of the 53). Most of the representations of the pelt” (Allen 23) and depicted with Egyptian world, and brandishing a dwarf God Bes seem to celebrate his a “large, frontal, mask-like face” (Dasen sword, warding off danger from unseen unique appearance and body habitus. 60) sometimes representing a lion, and malevolent forces” (Allen 23). “Bes has a grotesque, malformed, and Dasen notes that such features clearly mostly naked body” that, with its distinguish Bes from the “normal Figure 3-1 disproportionately short limbs, is clearly image” of Egyptian gods (Dasen 60), Stela of the God Bes (Egypt, c. 304 bce–364 that of an achondroplastic dwarf but that the dwarf’s “physical ce, New York, Metropolitan Museum) (Dasen 60). On a plaque from the malformation was not regarded as a Ptolemaic-Early Roman Period, the Stela disquieting attribute, but as a divine of the God Bes (Figure 3-1, c. 304

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Like their Egyptian counterparts, of Hercules’ wine goblet in order “to paradox is especially apparent in Greek representations of dwarfs (in drink from it” or the feisty Lilliputians Aristotle’s comparison of dwarfs with vase paintings and friezes) “are of Gulliver’s Travels (1726), literary children and the association of dwarfs not fully naturalistic” and “may reflect and artistic representations of pygmies with satyrs in “Dionysiac scenes … folk-beliefs about dwarfs” (Dasen have traditionally emphasized their while keeping their human form. They 173), but neither do they fall into the pugilistic tendencies yet the ineffectual stand between the real and the tran- category of “traditional stock figures consequences of their attempts at war- scendental world, as privileged inter- of vase-painting and statuary” (Dasen fare.137 The stocky and fierce-looking mediaries to the deity” (Dasen 244). 166). For example, Dasen notes that pygmies in some Greek vase paintings A Roman fresco from Pompei titled the “fact that [the dwarfs’] bodies are illustrate the comparable heights of Fight between Pygmies and Animals complete” (Dasen 166) may explain the pygmy and the crane but display in a Nilotic Landscape (1st–3rd cen- why Greek artists were seemingly the superior physical strength of the tury ce, Naples, Museo Archeologico comfortable about representing the pygmy warrior.138 Other vase paint- Nazionale) illustrates the tradition of physical abnormality of short stature ings of the battle between pygmies and comparing pygmies and dwarfs to the despite their aversion toward showing cranes depict pygmies with weaker animal world. Here the artist creates a “disfigured” bodies in art. Many of the looking bodies, obviously incapable of comic atmosphere in which the help- dwarfs represented in Greek art appear fighting their enemies. Dasen suggests less pygmy flails at a huge crocodile to be achondroplastic, and “often have that the “legend of the fight between whose head is larger than the pygmy’s larger or more conspicuous genitals cranes and small men might also have body. In another scene of the same than normal-sized Athenians” (Dasen translated into a mythical language the series of frescoes, pygmies play in the 173). Among the more famous depic- fact that pygmies have hostile relation- river Nile, seemingly undaunted by the tions of dwarf figures in Greek vase ships with their tall black neighbours, large animals that reside there. In both paintings are those of pygmies battling the Nuer, Dinkas, and Chillouks, who frescoes, the artist’s rendering implies cranes. As noted earlier, pygmies are are used to stand on one leg like birds” that pygmies are childlike in behavior not true pituitary dwarfs and have (Dasen 177). Such iconography invari- as well as size. normal growth hormone levels. They ably links the pygmies with the animal owe their short stature to inadequate world or with the half-human, half- The association of dwarfs or little amounts of insulin-like growth factor animal world of satyrs (Dasen 173).139 people with the animal world also I (igf–1), yet they have normal igf-ii As Dasen notes, “[some] dwarfs are appears in Germanic and Nordic concentrations. To the artists of the equated with animals, like the puny mythologies and folktales that often classical world, however, they may pygmies who hardly resist the attacks convey a deprecating view of little have resembled undeveloped children. of the birds, or they transform into people. Dehumanizing images of As Leroi observes, such artists “were animals, like the Cercopes, who are dwarfs are common in Renaissance depicting the fabulous by appealing to changed into monkeys, or they have a paintings and sculpture, particularly the familiar” (Leroi 185). mixed appearance, like the Telchines. those that allude to the underworld Little people are also closely associated or hell. Best known among the early The mythological battle between the with childhood in the myths of pyg- Renaissance painters of the Last pygmies and the cranes appears in lit- mies and of Cercopes” (Dasen 243). Judgment and other subjects related to erature from as early as Homer’s Iliad man’s inherent depravity, the paintings (800 bce) and Pliny’s Natural History The Greek attitude toward dwarfs, of fifteenth-century Flemish painter (77–79 ce) and as late as the period of then, vacillates between acceptance Heronymous Bosch include dwarf like neo-classical English literature in the of short stature and a tendency to figures with animal limbs. early eighteenth century. Whether the marginalize the position of dwarfs fearless men who climbed up the side in society. According to Dasen, this

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Two hundred years after Bosch, David human limbs, suggests the devolution Figure 3-2 Teniers’s painting of The Rich Man of man into an animal state, further David Teniers, The Rich Man Being Led Being Led to Hell (Figure 3-2, 1647, adumbrated by the diminished stature to Hell (1647, London, England, National London, England, National Gallery of of the human figures in the painting. Gallery of Art) Art) incorporates a similar conflation Whether or not Teniers associated of human and animal characteristics. dwarfs with bestial or evil behavior, The focal point of the Teniers painting the painting strongly suggests the is the figure of an old and frightened connection between short stature and looking man, presumably the “rich sub-human status, much like that of man” in the title. To his left is a dia- the serpent in Genesis 3 condemned bolical figure with wings accompanied to slither on his belly. The painting by two dwarf-like figures, a man, and alludes indirectly to the parables in a woman with disproportionately Mark 10:17–31 and Luke 16:19–31 large human heads (suggesting achon- in which Jesus decries the evils of rich droplasia); the female figure is shown men. (In the latter parable the rich with human arms and reptilian legs. man is surprised to find himself in the The presence of other anthropomor- torments of hell after his death.) As phic creatures, including a fish with many critics have recognized, Teniers’s

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Figure 3-3 the Boboli Gardens of the Pitti Palace as the dog in the foreground (not Paolo Veronese, Feast in the House of Levi, in Florence is “the paunchy, immobile shown here), as if both are pets of detail (1573, Venice, Galleria dell’Accademia) dwarf Morgante [who] is perched on the aristocratic family gathered in the a sluggish tortoise” (Wind 34), sug- background. A black servant, pos- gesting an obvious comparison of size sibly a pygmy, is handing the dwarf painting may reflect the influence of between man and reptile.140 Possibly a bird, further connecting him with Bosch’s paintings in which half-human, reflecting the influence on the Venetian the animal world. It is worth noting half-animal creatures, some of short aristocracy of the Ottoman Empire that Veronese was admonished by stature, encounter the pains of hell. and its practice of keeping dwarfs in the church fathers for the obvious the seraglio,141 several Venetian nar- secularism of the painting that was The association of dwarfs and ani- rative paintings include court dwarfs originally titled The Last Supper mals appears in more subtle ways in and court pets in intricately detailed and destined for the refectory of the Venetian and Florentine art of the six- crowd scenes. In a detail from Paolo Venetian monastery of Saints Giovanni teenth and seventeenth centuries. Barry Veronese’s Feast in the House of Levi and Paolo.142 The alteration of the Wind notes, “dwarfs appear as deco- (Figure 3-3, 1573, Venice, Galleria title, and by implication, the subject, rative motifs on fountains or retain dell’Accademia), for example, a dwarf apparently made the display of wealth their diminutive size in small bronzes” dressed in the costume of a clown and debauchery less offensive to the (Wind 27). One of several examples in entertainer appears on the same plane church fathers since it alludes to the

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story of the publican Levi in the gospel Figure 3-4 ence to the beggar Lazarus on the right of Luke 5. In the parable Levi serves Bonifaccio de’Pitati (sometimes also called whose wounds are being licked by a great feast to Jesus, much to the Veronese) The Parable of the Rich Man and the dogs. As in Paolo Veronese’s paint- dismay of the “scribes and Pharisees Beggar Lazarus or Il Ricco Epulone (1543–45, ings, the wealthy family members also [who] murmured against his disciples, Venice, Galleria dell’Accademia) appear oblivious of the entertainment saying, Why do ye eat and drink with provided by the musicians and the publicans and sinners?” (Luke 5:30). dwarf. The painting’s theatrical display The association of dwarf servants On a smaller scale but with a similar of marble pillars and rich tapestries with excesses of wealth (represented reference to Venetian royalty who and garments draws further attention in the figures of publicans and sinners) treated dwarfs as property, Bonifaccio to the opulent household that includes and a similar theatrical composition de’Pitati’s (sometimes also called dwarf servants in its retinue, thus illus- characterizes Veronese’s The Marriage Veronese) painting The Parable of the trating the lesson of the parable. at Cana (1563, Paris, Louvre). In this Rich Man and the Beggar Lazarus or painting a dwarf and dogs are shown Il Ricco Epulone (Figure 3-4, 1543– in the foreground near the musicians 45, Venice, Galleria dell’Accademia) who entertain the wedding party. In has been characterized as a “pre- both banquet scene paintings, the text for an extraordinary description dwarf appears to be interacting with of Venetian aristocratic life” (The black servants, suggesting his servile Accademia Galleries in Venice 102). position in the household. The juxta- In the painting a pygmy appears in position of regally attired dwarfs and the center foreground as an aid to dogs in both paintings further con- the musicians entertaining the richly firms the artist’s representation of the dressed figures on the left. Alluding to common mockery of the dwarfs’ low the same parable in Luke 16 to which status in comparison to that of the Teniers refers, in The Rich Man Pitati guests at the feasts. illustrates the rich people’s indiffer-

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Figure 3-5 Anthony Van Dyck, Queen Henrietta Maria and her Dwarf Jeffrey Hudson (1633, private collection)

Anthony Van Dyck’s portrait of Queen Henrietta Maria and her Dwarf Jeffrey Hudson (Figure 3-5, 1633, private collection) includes a pyramidal hierarchy of animal/dwarf/aristocrat similar to that depicted in paintings by northern Italian artists. Van Dyck’s portrait is an example of the artist’s attempt to use little people to exaggerate the height and dignity of the aristocracy; in this case, the contrast suggests Queen Henrietta’s physical superiority. According to legend, Jeffrey Hudson was a gift to Queen Henrietta Maria (the wife of English King Charles I). Arriving at court “concealed in a cold baked pie,” he was subsequently involved in a series of royal adventures that contributed to his reputation as courageous and loyal.143 In the painting the presence of the monkey on the dwarf’s arm and other props in the scene suggest a “hint of mockery in the portrait”144 and direct the viewer to the queen’s image of authority. In addition, in the background of the painting “the lion’s head decoration may have monarchical significance …” and is “emblematic of custody, suggesting the Queen’s proprietary rights over her exotic entourage, the dwarf and the monkey. Her hand resting on the monkey confirms her dominance. Of course, the monkey picking at Hudson’s head denotes the midget’s traditional role as a fool” (Wind 102). Despite Hudson’s reputation as a significant member of the court,

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Figure 3-6 series of frescoes for the Sala frescoes depict Constantine “defeating Raphael, The Cross Appearing to Constantine of Constantine in the Vatican Palace the impious, under the inspiration of the Great Flanked by Two Popes (1520, Vatican Raphael’s painting of The Cross the cross, while displaying his gener- State, Vatican Palace, Stanze de Raffaello) Appearing to Constantine the Great osity to captured troops and to young Flanked by Two Popes (Figure 3-6, children” (Cocke 95). Almost outside 1520, Vatican State, Vatican Palace, the action of the scene, the “court Van Dyck’s painting focuses almost Stanze de Raffaello) includes a dwarf dwarf of Ippolito de Medici, Gradasso exclusively on the view of the dwarf as in the right foreground. The painting’s Berratai, comically intrudes upon an exotic possession or plaything narrative tells the story of the first the sudden revelation of the cross to of the aristocrat, clothed in regalia that Christian emperor Constantine’s vision Constantine” (Wind 23). Despite his emphasize his role as an entertainer of the cross as a sign of imminent marginal placement in the painting’s on the same level as a pet. This victory in the next day’s battle of the right foreground, the dwarf stands demeaning representation of dwarfs Milvian bridge (depicted in the fresco out as a frolicking character, playfully in paintings continued to be a adjacent to The Cross). As art histo- donning his military headdress and familiar subject for court painters in rian Richard Cocke notes, the “initial disrespectfully urinating in front of the the seventeenth century. programme [of the frescoes] reflected soldiers who flank Constantine and humanist hyperbole” to emphasize are focused on the vision of the cross. Some Italian Renaissance painters a flattering comparison between the Raphael’s purpose in distracting the feature dwarfs in both formal portraits emperor and Pope Leo, who com- viewer with the vulgarly comic dwarf and narrative paintings that emphasize missioned the frescoes.145 With the aristocratic or military power. In his implied parallels between rulers, the

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is unclear, but its inclusion adds an element of humanism to the hyperbole of the scene, suggesting that even at solemn moments for great heads of state, society’s misfits, here represented by the dwarf, may “steal the show” (Wind 23).146 Whether representing vulgar behavior or a mere curiosity, such depictions of dwarfs call attention to their marginal position in society even though, or indeed, partly because, their dress may mimic that of the aristocracy or military.

As demonstrated in the earlier work by Raphael and in paintings of Domenichino,147 Italian artists of the seventeenth century continued to convey derision in their portrayals of dwarfs in comic roles. Francesco Trevisani’s Banquet of Antony and Cleopatra (Figure 3-7, late 17th century, Rome, Italy, Spada Gallery), for example, includes a dwarf pulling a reluctant small dog in the foreground of the painting. The dog’s apparent Figure 3-7 strength in contrast to his small size Francesco Trevisani, Banquet of Antony and implies that the dwarf is physically Cleopatra (late 17th century, Rome, Italy, weaker than the weakest dog. The Spada Gallery) dwarf’s position below the table of dining aristocrats also confirms his low status. His costume and headdress suggest an exotic origin further marginalizing his position in the court. Trevisani’s painting may hark back to earlier paintings in which dwarfs were frequently included in formal paintings of the aristocracy to display the rich panoply of the court retinue. Vittore Carpaccio’s Arrival of the English Ambassadors at the Court of the King of Brittany from The Legend of St. Ursula (c. 1495, Venice, Galleria dell’Accademia), for example, includes

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an achondroplastic dwarf in the grand Figure 3-8 dwarfs in the Gonzaga family’s royal entourage of the court. The painting’s Andrea Mantegna, Ludovico Gonzaga and household. Mantegna’s placement of juxtaposition of a clown/dwarf with Family with Courtiers (1471–1474, Mantova, the dwarf in a frontal pose affirms her two dogs about half his height reminds Italy, Palazzo Ducale, Camera degli Sposi) position of dignity and pride within the the viewer of his low and, perhaps family enclave. Her head, though lower lonely, position in the Venetian court. than that of the children next to her, is on A painting by Andrea Mantegna of a higher plane than that of the dog under Ludovico Gonzaga and Family with the Duke of Mantova’s chair, perhaps Courtiers at the ducal palace in Mantova referring to her social position as less than (Figure 3-8, 1471–1474, Mantova, Italy, that of the heirs of the family but more Palazzo Ducale, Camera degli Sposi) than that of a mere pet.148 The Gonzaga suggests a slightly different interpreta- family’s “predilection for dwarfs” and tion of the role of the dwarf in the frequent appearance of dwarfs in royal households. Here a female dwarf paintings from the Veneto, Lombardia who is probably achondroplastic stands and Piemonte may reflect a long tradition close to her mistress. Her position sug- of fascination with dwarfism in northern gests a more inclusive treatment of Italy (Merke 311).149

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Figure 3-10 of the stage (Wind 29). Callot’s “series for example, a male dwarf in a hat Jan Molenaer, The Artist’s Studio (1631, Berlin, of comic ‘gobbi’—dwarfs and hunch- standing in front of two female dwarfs Germany, Gemaeldegalerie, Staatliche Museen) backs” (Wind 27) represents dwarfs appears to be throwing rocks at chil- with the caricaturist’s technique of dren who are taunting him. Although foreshortening, an emphasis on round the dwarf figure is distinguished Not all artists represented dwarfs in features and military costume, all for from the children in the scene by his formal settings. Cartoonish dwarf the entertainment of the viewer. Such adult garb, his hat and his bulbous figures appear in the form of garden prints made available to the Italian nose, the adult facial features yet sculpture and in numerous prints public have their counterparts in the child-like proportions of other figures of the period in northern Europe as well work of northern European artists in the scene suggest an ambiguity of as in Italy. Wind notes that artists such as Dutch painters Jan Molenaer normal and abnormal in which such as the French “Jacques Callot, and Jan Steen, who depict dwarfs children resemble dwarfs and dwarfs [who] worked in Florence from in compromising social scenes. In resemble children in appearance 1614–17 … had a lively interest in the Molenaer’s Stone-throwing Dwarf also and behavior.150 Ambiguously, the commedia dell’arte and the grotesque” known as Scene with Dwarfs (Figure artist may be suggesting that the (Wind 27), often recalling the image 3-9, 1646, Eindhoven, Netherlands, behavior of the dwarf is childlike and of Pulcinello and other familiar figures Van Abbemusesum) (see p. 90), harmless or that the behavior of chil-

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dren is potentially dangerous. Molenaer’s The Artist’s Studio (Figure 3-10, 1631, Berlin, Germany, Gemaeldegalerie, Staatliche Museen) also infantilizes the role of the dwarf by showing him dancing with a dog in the foreground of the painting, apparently oblivious of the adult activity in the background. The “negative response” toward dwarfs that the two paintings seem to provoke is similar to that elicited by Steen’s paintings in which dwarfs perform as entertainers in scenes of debauchery, thus reinforcing the stereotype of immoral and foolish behavior associated with dwarfs (Wind 111).151

Among the numerous seventeenth century paintings of dwarfs, those created in Spain by Spanish, Flemish and Dutch artists have contributed to a rich collection. The lost Ribera painting of The Dwarf and the Dog (discussed on the first page of this chapter) may hark back to the work of Flemish painter Anthonis Mor’s (also known as van Dashort) The Dwarf of Cardinal Granvelle (Figure 3-11, 1560, Paris, Louvre) in which the dog appears to be larger than the regally dressed dwarf who holds him. The gaze of the large-headed Figure 3-11 dog turning to look at his diminutive master dramatizes the irony Anthonis Mor (also known as van Dashort), of the dwarf/animal juxtaposition. The Dwarf of Cardinal Granvelle (1560, Paris, Louvre)

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Probably the most well known painter charged sexual significance” that may of dwarfs is the Spanish artist Diego be associated with El Primo’s Velasquez, who, as a court painter reputation as a “notorious ladies’ during the reign of Phillip IV in man” (Wind 85). Given the Madrid, executed several portraits assumption at the time that male of the royal family. Art historian dwarfs were sexually non-threat- Jonathan Brown notes that in con- ening,154 Velasquez may also be trast to Velasquez’s “official portraits challenging such notions by placing [which] provided no opportunity to the phallic pen and inkwell in the examine the inner life of the sitters,” center of the foreground. Yet despite in his “portraits of jesters and dwarfs, these symbols that might also who were on the margins of court have suggested sexual mockery and society, he was free to experiment.”152 “amusement for the court” (Wind 85), The marginal status of dwarfs thus El Primo’s serious facial expression may have contributed indirectly to with eyes cast down invites empathy the advance of psychological realism that makes Velasquez’s intention in art. Realism of expression remi- ambiguous, as if the painting is meant niscent of Caravaggio’s paintings to mock and empathize at the of peasant figures with goiters is same time. apparent in Velasquez’s portraits of dwarfs: Don Diego de Acedo or El Primo, Sebastiano de Morra, Portrait of Baltasar Carlos with Dwarf and Francisco Lezcano.

The subject of Don Diego de Acedo or El Primo (Figure 3-12, 1644, Madrid, Museo del Prado) appears to be a dwarf with normally proportioned torso and limbs. “Represented among large books, alluding to his appointment in the office of royal seals, the dwarf is captured in the paradoxical situation of an intelligent and sad buffoon and also a liber- tine….”153 The ironic juxtaposition of El Primo and the large books suggests a possible comic emphasis on the dwarf’s small stature in contrast to the weighty tomes and the serious bearing and costume of the scholar. As Wind notes, the presence of the pen in the inkwell implies “libidinous connotations,” assuming “a highly

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Figure 3-12 Diego Velasquez, Don Diego de Acedo or El Primo (1644, Madrid, Museo del Prado)

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Figure 3-13 Velasquez, Portrait of Baltasar Carlos, son of Philip IV, with a Dwarf (1631, Boston, Museum of Fine Arts)

A less sympathetic and more pronounced emphasis on the features of an achondroplastic dwarf is apparent in Velasquez’s Portrait of Baltasar Carlos, son of Philip IV, with a Dwarf (Figure 3-13, 1631, Boston, Museum of Fine Arts). Here, the contrast between the normal and the abnormal is created by the juxtaposition of the young prince’s “erect posture” (Wind 72) and the slouch of the large headed dwarf holding an apple and a rattle that resembles a royal orb. Barry Wind interprets the placement of the dwarf “on a lower physical plane” and objects held by the dwarf as indicative of a “derisive contrast” in which “Velasquez may be following an established court tradition” (Wind 77).

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Figure 3-14 Alonso Sánchez Coello, Portrait of Infanta Isabel Clara Eugenia and Magdalena Ruiz (dwarf with monkeys) (c. 1585–90, Madrid, Museo del Prado)

Wind compares the portrait of Baltasar with court painter Alonso Sánchez Coello’s Portrait of Infanta Isabel Clara Eugenia and Magdalena Ruiz (dwarf with monkeys) (Figure 3-14, c. 1585–90, Madrid, Museo del Prado), which similarly applies the “formula of contrast” (Wind 74) to illustrate the difference between royalty and the servile, physically inferior dwarfs. In this painting, the contrast in size between the Infanta and her dwarf servant Magdalena emphasizes the significant difference in status between the two women. Furthermore, the marginal placement of Magdalena next to the royal figure but partially cut off by the right border of the painting underlines that difference. Wind also notes the important placement of the Infanta’s hand on the head of the dwarf, “a gesture that implies not only protection but also dominance”; the Infanta’s dwarf “is like some court pet, and the monkeys that alight on her arms confirm the dwarf’s base nature” (Wind 74). Similar to Van Dyck’s portrait of Queen Henrietta and her dwarf, in its use of antitheses, Coello’s portrait seems intended to glorify royalty at the expense of the dwarf.

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Velasquez’s painting of Francisco Lezcano (Figure 3-15, 1636–38, Madrid, Museo del Prado) invites more speculation about the ambiguity of the artist’s intention in depicting a highly recognizable endocrine abnormality such as dwarfism. In this portrait Velasquez draws attention to the dwarf’s bulbous nose and relatively coarse features, which Jonathan Brown labels as indicative of “Down’s Syndrome,” but which, in our view more likely resemble the features of a dwarf who is also a cretin (Brown 126). It is also possible that the subject could have both Down’s Syndrome and cretinism, both of which might explain the vacuous expression on the boy’s face, suggesting decreased intellectual capacity. Wind posits that the “dark precipice” in the background of the painting “may localize the figure in the mountainous region around the Torre de la Parada” (Wind 82). The prevalence of cretinism in mountainous areas such as the Pyrenees or in the mountains near Madrid depicted in the painting supports our belief that Lezcano is a cretin whose dwarf like features resemble those of other cretins severely deprived of thyroid hormone at a young age. In this example, we agree with Jonathan Brown that the presence of derisive symbols mocks Lezcano’s low status as a fool and a plaything.155 Nonetheless, we argue that Velasquez creates a sympathetic tone in the painting, especially in the boy’s expression of pain or anxiety, as he does in the portrait of Calabazas. Figure 3-15 Diego Velasquez, Francisco Lezcano (1636–38, Madrid, Museo del Prado)

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Figure 3-16 There are numerous theories about the (Wind 89). The two dwarfs stand to Diego Velasquez, Las Meninas, detail (1656, painting’s ambiguities. One suggests the right of the infanta behind the dog Madrid, Museo del Prado) that the images of the king and queen in the foreground of the painting. reflected in the mirror to the left of the painting’s focal point reveal their María Bárbola appears to be an Velasquez’s famous court painting approval of the artist (Brown 186). achondroplastic dwarf whereas Las Meninas or The Maids of Honor, Wind speculates that the presence Nicholas Pertusato is a normally pro- detail (Figure 3-16, 1656, Madrid, of dwarfs in the painting illustrates portioned dwarf. Both are dressed in Museo del Prado) takes the concept of Velasquez’s effort to present “the tra- regal clothing, but María has a more royal portraiture to another level of ditional formula of antithesis between noticeable position in the painting’s irony and implied narrative, a compo- firm and infirm” as well as the artist’s composition. The tall maid between nent of which is the presence of two “facility in portraying all facets of her and the infanta forms the apex of different types of dwarfs in the right nature, ranging from the lower life- a triangle for which the dwarfs and foreground of the painting, María forms—the dog, María Bárbola, and dog form the right angle. Nicholas’s Bárbola and Nicholas Pertusato, both Nicholas Pertusato—to the august— figure is more obscure than María’s, members of the royal household. the infanta, and the king and queen” cut off by the right margin of the

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painting and therefore appearing less take their parts in a sort of tableau Figure 3-17 the subject of a portrait than a figure vivant, she affronts the spectator Pablo Picasso, Las Meninas, No. 1, after in action as he moves playfully toward like a blow from a muffled fist.”156 Velasquez (1957, Barcelona, Museo Picasso) the dog. By association, the viewer María’s strong frontal pose may reflect can’t help linking the dwarfs with the Velasquez’s attempt to convey in Las family pet, but at the same time, María Meninas, as he does in other paintings In the twentieth century Pablo Bárbola’s prominent position suggests of dwarfs, the “physical humiliations Picasso’s Las Meninas, No. 1, after the importance of dwarfs in the royal [which] gave them a reality which his Velasquez (Figure 3-17, 1957, household, much as does the female royal sitters lacked” (Kenneth Clark). Barcelona, Museo Picasso) is first in dwarf in Mantegna’s Gonzaga family Even the volume of Bárbola’s short but a series comprising fifty-eight oil portrait. María stares directly at the developed body and large head invites paintings. The series alludes to and viewer with an almost overt awareness a comparison with the more fragile parodies Velasquez’s painting, and presence that historian Kenneth figure of the infanta, who appears to exaggerates the static pose and Clark finds especially disturbing: be of a similar height. pumpkin shaped facies of María “While the other protagonists in the Bárbola and depicts Nicholas Meninas, out of sheer good manners, Pertusato with a simple line drawing

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that emphasizes his clownish move- a clearly defiant attitude to the viewer who achieved legendary fame in aris- ment toward the dog. In the large whom her hands, like claws, seem to tocratic circles during the Dark Ages group painting of the series, which is want to check. Her monstrous face of European history: the sixth century colored in monochromatic is covered by a veil while a menina, Bertholde of Bertagnona. According to greys, whites, and blacks, there is also in a mixture of surprise and fear, popular legends, Bertholde’s an implied comparison between watches her out of the corner of her the volume of the infanta’s wide skirt eye.”157 The entire series of Picasso’s ready wit greatly impressed Alboin, and that of Bárbola’s large head Las Meninas not only challenges per- first King of Lombardy but his (both painted white), thus reducing ceived hierarchies but also reflects the tricks made an enemy of the Queen. both figures to substantive masses complexity and political upheavals of He so annoyed her that she had within the royal portrait. In both the twentieth century in which fascist him seized and put in a sack, like a Velasquez’s and Picasso’s paintings the regimes supplanted monarchies and kitten, to await drowning the fol- eyes of María Bárbola and the the boundaries between normal and lowing day. He survived and later infanta gaze directly at the viewer abnormal are no longer clear. rose in favour so highly that Alboin whereas the other figures of the appointed him Prime Minister. painting gaze in varying directions. Although the tradition of keeping What Bertholde’s ultimate fate was dwarfs for entertainment or as com- we do not know but legend says the By singling out and linking the panions/helpers for children continued murderous queen eventually poi- infanta and the female dwarf are both to be practiced at royal European soned her husband.158 Velasquez and Picasso suggesting courts well into the eighteenth century, that this achondroplastic dwarf is an especially in Russia, the representation The frequently reproduced nineteenth- object of ironic power on a level with of dwarfs in painting is quite rare after century engraving by A. Walker, the infanta, a concept that challenges the seventeenth century. Nevertheless, Bertholde, a Dwarf (Figure 3-18) (see notions of traditional royal hierarchy? engravings and lithographs in popular p. 93) is a formal portrait of a small, Perhaps Velasquez moved from his journals abound in caricatures of wizened man standing against the earlier, more literal attempts at con- dwarfs, many of them from the world northern Italian landscape of rocks trasting dwarfs with royal children to of entertainment, especially circuses and hills. The dwarf has normally a more ambiguous questioning of the and freak shows. Frequently, the tech- proportioned limbs and torso but an meaning of power. It is possible that nique of caricature popularized by exceptionally large head and hands. both artists use the achondroplastic Jacques Callot and others is apparent His feet also appear large in the dwarf figure of María Bárbola to hint in such engravings and tends to reduce peasant style clogs he is wearing. His at the unexpected presence of power the humanity of the dwarf to his or her serious visage and mysterious finger in the “abnormal.” In his twentieth physical characteristics. There are also pointing suggest a man of determina- century interpretation of royal power, portraits of specific individuals who tion and focus, a noticeable contrast Picasso focuses more directly than gained public fame for their singular to the images of dwarf fools and gobbi Velasquez on the agony of the dwarf’s abilities related to their dwarfism. caricatured by Jacques Callot.159 position, especially that of María Among these individuals, two achieved Bárbola. One of the smaller paintings recognition not only as dwarfs but in Picasso’s series that includes only also as cultured, civic minded men who Figure 3-19, facing page Isabel de Velasco and María Bárbola made a significant contribution Philip Reinagle, Count Joseph Boruwlaski examines that relationship between to society. (1782, London, Royal College of Surgeons, the two. According to Claustre Rafar Hunterian Museum) I Planas, Picasso put “all the drama of The subject of a well-known nine- the work into the dwarf, who adopts teenth century engraving is a dwarf

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Although Bertholde’s “story has been but diminutive size in comparison a briskly adult intellect” indicate “the shown to be a folk tale” (Adelson to the chair against which he leans signatures of growth-hormone failure 46), its emphasis on a dwarf’s dis- his right arm. Dressed in aristocratic typical of pituitary dwarfs” (Leroi tinct wit and intelligence and his rise finery and carrying a sword 176). Twelve hundred years after to fame and prominence as a distin- proportioned to his size, he has the Bertholde’s dramatic story began to be guished prime minister, a position appearance of a dignified gentleman at circulated, the more authentic docu- further adumbrated by the engraving, ease in the public world. mentation of Boruwlaski’s experience reflects the growing interest during the affirms social progress in the lives of eighteenth and nineteenth centuries in Boruwlaski’s life is recorded in The dwarfs in western society. Boruwlaski’s examining the lives of dwarfs beyond Life and Love Letters of a Dwarf: story reminds us, however, that even the stereotype of court pet or curiosity. Being the Memoirs of a Celebrated in the age of Enlightenment dwarfs Dwarf, Joseph Boruwlaski, a Polish continued to be victims of social The most famous dwarf associated Gentleman. Despite the evidence marginalization. with eighteenth century European of social progress in the acceptance courts was Joseph Boruwlaski, often of Boruwlaski in aristocratic The “collecting” of dwarfs as objects referred to as “the last of the court circles, his writings reflect the humili- to whet the appetite of the curious dwarfs” (Leroi 175). Boruwlaski was ation he still felt as an object of public was not confined to European born in 1739 in Poland to poor curiosity. The memoirs express citizens. North American audiences parents who eventually allowed Boruwlaski’s pride in his considerable also found entertainment value in him to live with his mother’s “patron, accomplishments as a well-educated freak shows, circuses, Lilliputian a young local noblewoman, the man with musical talents, but they touring companies and “dime Staorina de Caorliz,” who saw to his also reveal the darker side of his life as museums” where little people and education; later he became the ward of a dwarf. For example, he writes, others with physical abnormalities the Comtesse de Humiecka, who performed (Adelson 25–27). If a per- introduced Boruwlaski to European [W]ere I upon a footing with forming company could claim exotic society (Leroi 171). Boruwlaski’s other mortals, I could, like them, origins for their performers, so much parents were of normal size, but two have supported myself by honest the better for business. Engravings of his five siblings, a sister and a industry; but my size excludes me and lithographs in popular journals brother, were dwarfs like Joseph. irrevocably from the common circle featured such exotica. In a lithograph Boruwlaski married a noblewoman, of society. There are many persons titled Two miniature people, known Isalina Borboutin, of normal size, who seem to pay no regard, nor as the Aztec Lilliputians, with their who at first rejected Joseph because of even to consider me as a man, and manager by G. Wilkinson (Figure his dwarfism (Leroi 173). The an honest man endued [sic] with 3-20 , London, Wellcome Library, no. marriage produced children of normal the most tender sensibility—how 2617i) two little people named Bartola size, and Boruwlaski lived a celebrated painful a reflection.160 and Maximo flank a normal sized man life in England where he was the who holds one of the little people in favorite of several aristocrats. In an Boruwlaski, who documented his his hand. The lettering on the litho- eighteenth century painting by growth record in his memoirs, con- graph reads as follows: Philip Reinagle (Figure 3-19, Count tinued to grow until he was thirty Joseph Boruwlaski, London, Royal years old and lived until the age of These wonderful beings were College of Surgeons, Hunterian ninety-eight, an unusual example of brought to North America in 1849, Museum), Boruwlaski is represented in longevity for the time. Leroi notes, his by Valasquez a Spaniard, who a formal portrait that calls attention to “body the size and proportions of a states that he carried them off at the dwarf’s normal proportions four-year-old’s, delayed puberty, and the hazard of his life from the

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mysterious and unknown city of Figure 3-20 Among the dwarfs to gain fame and Ixamaya, in central south America, G. Wilkinson, Two miniature people, known fortune in the United States, where this Lilliputian race has for as the Aztec Lilliputians (London, Wellcome General Tom Thumb achieved leg- many centuries been worshipped by Library, no. 2617i) endary popularity and wealth that the inhabitants as sacred objects. illustrate the paradoxical position of the little person’s fate in the public The greatly exaggerated diminution of eye. Born Charles Stratton in 1838 the little people in the lithograph sug- in Bridgeport, Connecticut, Tom gests that the dwarfs were considered Thumb was of normal birth weight mere playthings, no different from until the age of eighteen months children’s toys that might be exhibited when, according to an anonymously in a museum. In fact, however, medical authored biography published in 1863, investigation revealed that the “Nature put a veto on his further so-called Aztecs were actually twin upward progress.”162 Like Boruwlaski, children from a village in San Salvador, Tom Thumb was introduced to who “had small but long heads royalty and became the wonder of a and … an utter lack of intelligence.”161 voyeuristic society. Sponsored by The double bias against little people and people of indigenous cultures is also apparent in the lithograph’s title. According to Adelson, “J. Mason Warren, a physician renowned for his research in anesthesia who published ‘An Account of Two Remarkable Indian Dwarfs’ in 1851 accepted at face value the exhibitor’s statement” (Adelson 26). In the article summarized in Adelson’s book Warren goes on to describe the dwarfs as “resembling … intelligent individuals of the canine race” (Adelson 26). As his description illustrates and as we have seen in numerous examples of paintings from earlier centuries, the belief that little people were less than human and closely allied with animals continued even among those in the medical profession.

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Mr. P. T. Barnum (of later circus fame), Nonetheless, as the biography reports, Impressionist painter Paul Cézanne’s he was exhibited in Barnum’s descriptions of the wedding used Portrait of the Artist’s Friend, Achille traveling Museum and Menagerie and patronizing language such as “little Emperaire (1869, Paris, Musée was lauded for his ability as an lady” or “diminutive Stratton-Warren d’Orsay) is a more serious and digni- actor when he played “the role of Tom bridal pair “ (“A Chapter on Giants fied representation of a dwarf who Tit, the comic negro boy in Mrs. and Dwarfs” 5). Such language has also happened to be the artist’s friend. H. B. Stowe’s work, ‘Dred: a tale of its artistic counterpart in the engrav- Cézanne’s depiction of Emperaire’s the Dismal Swamp’” (“A Chapter ings of the wedding that appeared in thoughtful expression and elegant on Giants and Dwarfs” 3). the Sketch. The presence of wedding dress does not dwell on the man’s guests of “normal” size in the fore- dwarfism despite the accurate repre- The double irony of a marginalized ground of the picture exaggerates the sentation of Emperaire’s dispropor- “other” in the form of a dwarf playing size of the dwarf pair in the chancel tionately long fingers.164 the role of a marginalized African of the church. Like molded figures American child in a drama that atop a wedding cake, Tom Thumb and indulges racial stereotypes underlines Lavinia Warren look more like dolls Figure 3-21, facing page the limitations of social progress than human beings. Toulouse-Lautrec, Marcelle Lender Dancing the for dwarfs in the nineteenth century. Bolero in “Chilpéric” (1895, New York, private Scenes of the Bohemian world of arts collection) Although no longer kept as court pets and entertainment appear in works in a position similar to that of a valued by European artists of the impres- slave, the dwarf whose fate put him sionist and post-impressionist periods, in the public eye was still viewed as a notably those of Toulouse-Lautrec, curiosity, an aberrant product of himself a dwarf. Lautrec most likely Nature gone awry. Later, Tom Thumb suffered from bone disease resulting in settled into married life after courting frequent fractures and thus short the equally famous dwarf Lavinia stature.163 Lautrec’s Marcelle Lender Warren described in the New York Dancing the Bolero in “Chilpéric” Commerical Advertiser as “one of the (Figure 3-21, 1895, New York, private most extraordinary little ladies at collection) includes an elf-like male any time seen in this age of extraordi- dwarf dressed in black and sitting next nary beings” (“A Chapter on Giants to an animated dancer. The dwarf’s and Dwarfs” 3). The wedding of Tom wizened figure is reminiscent of Thumb and Lavinia Warren was Lautrec’s self-portrait in which the recorded in newspapers as “a grand bowler-hatted artist with large head, national event” carefully con- slim figure and short arms barely trolled by “the presiding genii, P. T. reaches the middle of his canvas on an Barnum” (“A Chapter on Giants easel. Both Lautrec figures represent and Dwarfs” 5). the dwarf as voyeuristic, perhaps in an ironic role reversal of the stereotypical position of the dwarf as a subject of interest for the voyeuristically curious.

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Finally, on the cusp of the twentieth These few but significant examples of century, we can look to Picasso more humane portraits of dwarfs for a more modern and open-minded represent a more enlightened attitude representation of a dwarf in the toward physical deformity and entertainment world of Paris. The a psychological empathy toward little female dwarf La Nana (Figure 3-22, people more characteristic of modern 1901, Barcelona, Picasso Museum) and postmodern art than was apparent stands in the foreground of the pointil- in the Renaissance. Nonetheless, list painting, seemingly in a state twentieth century history is seriously of contemplation. Her right arm is con- marred by a continued marginalization fidently bent at the elbow with of little people, most hideously exem- hand on hip as if she intends to face plified by Nazi Germany’s attempts to the world straight on. Unlike the exterminate those who fell outside the almost faceless figures of dwarf enter- definition of Aryan perfection.166 tainers in seventeenth century paintings or the derisive caricatures of later periods, La Nana confronts the world with aplomb and without irony or cynicism. In the organic composition of the flower bedecked dancer against a flowered background, Picasso accentuates her self importance by having her occupy the whole canvas without the vanishing point of perspective to suggest a larger world around her.165 The dancer appears to be an achondroplastic dwarf because of her short limbs in contrast to a normally proportioned torso.

Figure 3-22, facing page Pablo Picasso, La Nana (1901, Barcelona, Picasso Museum)

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Chapter 4

Giants and Acromegalics: Stigma or Stature?

Introduction

Among the many wonders of the Hunterian Museum collection at the

Royal College of Surgeons in London is a display of the skeletons of the

“Irish Giant” Charles Byrne and the “Sicilian Dwarf” Caroline Crachami.

The skeleton of Byrne was acquired by eighteenth century surgeon and Figure 4-1 Deanne Fitzmaurice, Gibson and Zoie anatomist John Hunter and that of Crachami by Sir Everard Home. Both

were given to the Royal College of Surgeons.167 The contrast in size as one would collect specimens of between the giant and the dwarf is impressive. Similarly, the photograph unusual creatures. Monarchs such as René of Anjou and Philip the Good of by Deanne Fitzmaurice of Gibson and Zoie (Figure 4-1), a Great Dane Burgundy (fifteenth century) collected exotic animals along with “dwarfs, and a Chihuahua, dramatizes the In our super-sized twenty-first century giants, and other human prodigies” significantly large range of sizes in culture, we are both fascinated and (Daston 101) and used them for enter- the canine species.168 Although the repelled by the concept of size. What tainment in their courts. display at the Hunterian Museum and appears outside the normal range of the photograph are similar in their adult proportions and height has, juxtaposition of contrasting sizes, the throughout history, become an object difference in size between the human of curiosity and sometimes alienation. giant and dwarf is the result of endo- Just as their short stature and, in some crine disorders whereas that between cases, disproportionately large heads the two dogs is the result of selective and short limbs have determined the breeding.169 Both examples, however, status of dwarfs or little people, aber- illustrate the effects of growth hor- rations in size have also determined mone and growth hormone receptors. the fate of giants. Children’s fairy tales abound in stories of evil giants like Jack in the Beanstalk who are out- Figure 4-9, facing page smarted by normal sized persons, even Francisco José de Goya y Lucientes, by children. Throughout European The Colossus (1810–12, Madrid, Prado) history, giants, like dwarfs, were ostra- (see p. 138) cized, exoticized, and collected, much

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Causes of gigantism and acromegaly childhood giants also develop features benign monoclonal growth hormone of acromegaly when they become secreting tumor known as an adenoma adults and their growth plates have (Melmed ref 23). Growth hormone– Most forms of gigantism and some become fixed. releasing hormone from the hypo- forms of dwarfism are manifestations thalamus induces the synthesis and of abnormal over—or under—secre- Most individuals with gigantism and secretion of growth hormone, whereas tion, respectively, of growth hormone acromegaly have pituitary tumors that the hormone somatostatin suppresses by the pituitary gland. Giants and secrete growth hormone. Pituitary the secretion of growth hormone. acromegalics are easily recogniz- tumors account for nearly 15% Another hormone, ghrelin, also influ- able because of their large size and of intracranial tumors and occur ences growth hormone secretion and prominent facial features. Like dwarfs, in four to five persons per million acts via growth hormone-releasing- giants have been featured in clas- persons.171, 172 Pituitary tumors can hormone, predominately on the hypo- sical, Renaissance, and Baroque art. secrete prolactin, growth hormone, thalamus (Melmed 2558). Growth In addition to their representation in adrenocortical stimulating hormone, hormone binds to and activates the paintings with mythological and reli- gonadotrophic stimulating hormone growth hormone receptor, which is gious themes, figures of actual living or thyroid stimulating hormone. primarily expressed in the liver and giants appear in satirical caricatures, They can also be non functional. The in cartilage.173 Growth hormone especially those by British artists in secretion of these various hormones stimulates the synthesis of peripheral the eighteenth and nineteenth centu- results in different clinical syndromes. insulin-like growth factor I (igf-i), ries. Giants have a prominent place Acromegaly and gigantism are caused which induces cell proliferation and in world mythologies, assuming both by excess secretion of growth hor- inhibits programmed cell death or heroic and anti-heroic roles, and it is mone and usually occur sporadically, apoptosis (Melmed ref 11). Fasting these mythologies that are most com- but they also occur in association increases growth hormone secretion monly represented in art. with multiple endocrine neoplasia whereas obesity and aging are associ- Type I (men-i). This inherited syn- ated with suppressed secretory bursts Similar to the source of some kinds of drome is characterized by tumors of of the hormone (Melmed 2560). Liver dwarfism—the lack of growth hor- the parathyroid and pituitary glands disease, hypothyroidism, and poorly mone or abnormalities of the growth and by the pancreas, the result of controlled diabetes mellitus inhibit hormone receptor—as we have dis- an abnormality of the menin gene the production of insulin-like growth cussed in the previous chapter, tumors on Chromosome 11. Familial gigan- factor (igf-i) and thus inhibit growth. in the pituitary gland that secrete tism or acromegaly without other growth hormone are responsible for syndromes is rare. Ectopic secretion most forms of gigantism and acro- of growth hormone may also rarely megaly. Gigantism occurs in children occur in persons with neuroendocrine when the epiphyses or growth plates of tumors of the pancreas or in patients bones are open and therefore capable with lymphoma (Melmed ref 29,30). of enlarging. The bodies of most giants maintain normal proportions. As already noted, gigantism results Acromegaly, on the other hand, has from the increased secretion of growth an adult onset when the epiphyses are hormone in children and adolescents. closed and the bones become heavier Growth hormone is secreted by the and broader rather than longer. The pituitary somatotrophic cells in a pul- condition of acromegaly creates an satile fashion. About 90% of patients appearance of disproportionately large with gigantism or acromegaly have a heads, jaws, hands, and feet.170 Many

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Medical history and treatment of A better understanding of pituitary (1728–1793), who personally and gigantism and acromegaly disease dates from 1886 when the illegally escaped with O’Brien’s body French neurologist Pierre Marie (Rolleston 84).176 (1853–1940) published his first As noted in Chapter 3, until the late observations regarding the relation of Much of our knowledge of the pitu- nineteenth century, progress in the the pituitary gland to acromegaly. In itary gland is the result of clinical understanding of the function of 1890 Marie’s student Dr. Souza-Leite observations of patients with either the pituitary gland in relation to published “A Thesis on Acromegaly” over function of the pituitary gland dwarfism was slow to develop and (known as Marie’s Malady) in which manifested as gigantism or acromegaly impeded by unproven speculation he included forty-five patients (ten or with the under function of the pitu- and erroneous theories. An under- of them his own) with acromegaly itary gland manifested as dwarfism. standing of the causes of gigantism and differentiated gigantism from was thus also lacking. Abnormally acromegaly (Medvei 306–307). Dr. Another rare cause of acromegaly or enlarged pituitary glands were noted Souza-Leite noted that the sella tursica gigantism is the excessive secretion by as early as 1679 when “Theophile (where the pituitary gland is situated the thymus or acro-trophoneurosis Bonet (1620–1669) … referred to at the base of the brain) was enlarged (Rolleston 86). In 1889 W. A. Freund enlargement of the pituitary …, as and varied in size from “a pigeon’s (1833–1917) of Berlin suggested that did Raymond Vieussens (1641–1715) egg to that of a hen’s egg or even an the appearance of acromegaly with in 1705” (Rolleston 75). In 1851 apple” (Medvei 307). (The normal kyphosis and prominent facial features the French physician Bernard Niepce human sella tursica is smaller than resembled anthropoid apes and “an (1826–1918) found enlarged pituitary a dime in size.) In 1887 shortly after atavistic reversion” in human develop- glands at autopsy in seven patients Marie and Souza-Leite’s publication, ment (Rolleston 87). German patholo- with cretinism.174 In 1864 the Italian German-Latvian physician Oskar gist Ludwig Virchow (1821–1902), Andrea Verga (1811–95) observed Minkowski (1858–1931) discussed a however, soon dismissed the idea of at autopsy that a pituitary tumor patient with acromegaly. Minkowski reversion (Rolleston 87). “had destroyed the sphenoid bone appears to have “definitely connected and pressed upon the optic chiasma” acromegaly with disease of the pitu- In 1900 German pathologist Carl (Medvei 305) of a woman with an itary” (Rolleston 86). Benda (1857–1933) documented abnormally large face. Rolleston that acromegalics have an increase in notes that “Verga’s case was the first In 1891 Scottish anatomist D. J. eosinophilic (pink staining) cells in the to connect the pituitary with acro- Cunningham wrote about enlarged lateral portions of the anterior pitu- megaly” (Rolleston 78). Symptoms in pituitary glands or pituitary tumors itary, a discovery confirmed in 1905 many patients with pituitary tumors in the Irish giant Cornelius Magrath (Rolleston 87). It was also noted that were caused by “pressure on adjacent (1742–68) and in another Irish giant compression of other pituitary cells parts” of the brain near the pituitary Charles Byrne or O’Brien.175 Because or structures adjacent to the pituitary rather than from excessive or inad- of “the large size of the pituitary gland could be responsible for the loss equate endocrine secretion from these fossae in Magrath’s skull capable of of menstruation in young women and tumors (Rolleston 76). In 1888 holding ‘half of a small tangerine the loss of strength and onset of impo- N. Rogowitsch reported that rabbit orange,’” Cunningham concluded tence in men (Rolleston 87–88). pituitary glands became hyperplastic that the two giants were also acro- and larger after thyroidectomy megalics (Rolleston 83–84). In 1782 The secondary or trophic effects of the (Sawin 179). the skeletal remains of Mr. Byrne or pituitary gland on other endocrine O’Brien were obtained at considerable glands were soon recognized by many cost by British surgeon John Hunter medical investigators. In 1908

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surgeon Julius von Hochenegg of stretch marks, a buffalo hump on the apparatus. Furthermore, injections of Vienna removed a pituitary tumor from posterior lower neck and hyperten- rat or bovine pituitary restores growth a patient with acromegaly. Five sion (Welbourn 10). Berkeley scientist and effects a partial repair of the adre- days later von Hochenegg surprisingly Brailsford Robertson “was credited nals, thyroids, and sex glands” (Sawin noted some improvement in skeletal with isolating the ‘active principle’ quoting Smith 184). deformities, as reported by of the pituitary” (Sawin, “Defining Kocher and Cushing (Rolleston 103). Thyroid Hormone” 179). Robertson In 1926 Smith reported to the Unfortunately, despite the finding found that feeding anterior pituitary American Association of Anatomists that 52% of patients with gigantism or glands to mice at first slows their that by using “the surgical parapha- acromegaly improved after removal of growth and then accelerates it (Sawin ryngeal approach to hypophysectomy pituitary tumors, at this time the 179). Although these observations in rats … he did not damage the mortality rate for such surgery was could not initially be confirmed, in hypothalamus” (the base of the brain 70% (Rolleston 103). In 1928 1921 Herbert Evans reported that the that controls the pituitary gland). It Berkeley physiologist Herbert Evans injection of “a crude pituitary extract” was a discovery that helped solve one (1882–1971) reported that the as well as pituitary growth hormone of the problems of partial hypophysec- anterior pituitary has eosinophil cells resulted in “giant rats” whereas the tomy (Sawin 184). In addition, Smith that secrete growth hormone and oral administration of the same extract reported that hypophysectomized basophil cells that secrete gonad-thy- was ineffective (Sawin 179–180). rats had a low basal metabolic rate roid-cortico-adrenal-promoting that could be corrected by the admin- hormone. In 1933 Canadian biochem- More information about the function istration of rat pituitary or thyroid ists James Collip (1892–1968), of the pituitary was provided by Philip extract (Sawin 184). Unfortunately, E. M. Anderson, and Thomson E. Smith (1884–1970), first at the although rat pituitary implants were chemically separated the pituitary cells University of California at Berkeley effective in reversing the effects of that secrete adrenotropic hormone and subsequently at Stanford and hypophysectomy, his pituitary extracts (acth) and thyrotrophic hormone (tsh). Columbia. He developed “a tech- were ineffective (Sawin184). Besides As Rolleston notes, the separa- nique of removing the pituitary gland these discoveries, other scientists tion “was obviously important as in without damaging the brain in tad- reported that hypophysectomy in dogs some of the experimental results … poles, and later in rats” (Sawin 182). caused atrophy of the adrenal cortex the atrophy of the adrenal cortex, He observed that after the removal of (Rolleston 64). following removal of the anterior the pituitary gland, “tadpoles … grew pituitary gland (hypophysectomy), more slowly, were much lighter in Today the diagnosis of acromegaly was accompanied by atrophy of the color, had small and atrophied thyroid and gigantism is usually made by thyroid and other endocrine glands” glands and did not metamorphose” measuring igf-i levels because growth (Rolleston 64). (Sawin 182). At the University of hormone secretion is pulsatile, even in Kansas Bennet M. Allen (1877–1963) hypersecreters. The failure to suppress In the early twentieth century Harvey confirmed Smith’s observations and growth below 1 ng/ml after glucose Cushing “founded the first school of noted that when he removed the administration helps confirm the diag- neurosurgery” and contributed much tadpoles’ thyroid glands, they also nosis. It is also wise to measure levels to our understanding of surgery of “failed to become frogs” (Sawin 182). of prolactin (a pituitary hormone that the pituitary gland (Welbourn 10). In Subsequent studies by Smith docu- stimulates the secretion of milk and 1932 Cushing reported that a baso- mented that removal of the pituitary can cause impotence and infertility) philic adenoma of the pituitary was gland caused “almost complete growth because pituitary tumors may co- responsible for Cushing’s disease stasis and a rapid regression in the size secrete growth hormone and prolactin. characterized by central obesity, purple of the adrenals … the thyroid, and sex Magnetic resonance imaging (mri) of

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the pituitary gland helps localize not levels while receiving this medica- Giants in mythology, art, and history only the site of the pituitary tumor but tion. Because abnormal liver function also its size and invasiveness. Selective develops in some patients receiving Similar to the representation of dwarfs, surgical removal of the pituitary tumor Pegvisomant, liver function tests are the representation of giants in art in patients with gigantism or acro- advised. Radiation therapy is recom- reveals a broad spectrum of positive megaly is successful in correcting this mended for those with incompletely and negative associations, but the endocrine disorder in about 85% of resected tumors, for non-surgical extremes of both valuations are more patients with micro adenomas (small candidates and for those who do noticeable in paintings of giants than in benign pituitary tumors) and in about not respond to surgical and medical those of dwarfs. In the vase paintings of 55% of patients with macro ade- therapy (Seaborg 20). The response to classical antiquity and in Renaissance nomas. For example, surgical resection radiation therapy may take years to and Baroque paintings that allude of growth hormone secreting pitu- lower growth hormone levels. In about to antiquity, giants are represented itary tumors normalizes igf-i levels 60% of patients with growth hor- according to narrative details in clas- in about 70 to 90% of patients with mone secreting tumors igf-i levels do sical myths from Homer, Hesiod, Ovid, micro adenomas and in less than 50% normalize within six years of radiation and others. In some examples, the art- with invasive tumors. An experienced treatment. ists use exaggeration and caricature to pituitary neurosurgeon is necessary for suggest the physical manifestations of the best results. Because about 15% of patients with specific character traits. growth hormone secreting tumors Unfortunately, patients with a persis- have persistent or recurrent disease, More often characterized as nega- tently elevated igf-i have a 1.8-fold igf-i levels should be monitored tive rather than positive, the mytho- increase in mortality compared to that postoperatively. New and improved logical Titan Saturn and the Cyclops of the normal population (Seaborg medications are being developed that Polyphemus, for example, are depicted 20). When igf-i levels return to will improve the care of patients with with monstrous proportions and normal, long-term survival rates are gigantism and acromegaly. bestial facial features and behavior comparable to those of the normal that reflect their anger and destructive population. Medical therapy includes powers. The mythological noble medications such as dopamine ago- giants such as Prometheus and Heracles nists (stimulus) including cabergo- (Hercules), however, are often line and somatostatin analogues that represented with more normal propor- inhibit growth hormone secretion, tions enhanced by highly developed and growth hormone antagonists such muscles in the torso and limbs and as Pegvisomant, which block growth a strong noble face. Paintings of giants hormone receptors. About half of the that allude to biblical stories and to patients treated with somatostatin legends about Christian saints also focus and about 20% of those treated with on the distorted features of the “bad” cabergoline develop normal igf-i giants and the noble features of levels. Better results occur with cab- the “good” giants. The biblical giant ergoline treatment in those patients Goliath is represented most often whose tumors secrete both growth as a huge angry decapitated head with hormone and prolactin. Growth hor- closed eyes and dark, bushy hair mone receptor antagonists block the and beard, a marked contrast to the growth hormone receptors. About delicate features of the boy David, his 90% of patients develop normal igf-i heroic slayer. On the other

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Figure 4-2 Black-figure oinochoe (vase), Ulysses (Odysseus) and his Companions Blinding Polyphemus (Athens, Greece, 6th to 5th century bce, Paris, Louvre)

hand, St. Christopher, whose story in The Golden Legend emphasizes the devotion and courage of a man who “sought Christ” (Attwater 84) and carried him on his shoulders across a river, is often represented as an abnormally tall man with long limbs, gentle features and humble expression. As in the paintings of dwarfs, contrast between the “normal” and “abnormal” is established by depicting the giant’s body or the giant’s head next to the bodies of ordinary mortals. In our research of The animal, reptile and insect imagery “piece of work, by god, a monster/ paintings that depict giants, we have of various classical Greek vase built like no mortal who ever supped found more artistic representations of paintings that narrate the stories of on bread,/no, like a shaggy peak, … a fictional rather than historic giants. fierce giants such as Polybotes and man-mountain/rearing head and shoul- Porphyrion suggests the association of ders over the world.”181 Polyphemus In Greek antiquity, the story of the giants with bestiality, but the propor- is easily tricked by the wily Odysseus Gigantes or Giants was especially tions of the giants in the paintings are whom Polyphemus imprisoned with popular as a subject for vase painting. similar to those of the Olympian gods, his fellow sailors in a cave. Odysseus The Giants were and there is no evidence of the serpent later brags that, having planned their like legs found in Roman sculpture and escape but making the giant drunk, he born when the blood from the mosaic scenes of the Gigantes. 178, 179 and his men mutilation of Uranus fell upon the ground; these monstrous creatures Perhaps the most famous of giants in seized our stake with its fiery tip/ are called Gegeneis, which means classical mythology is Polyphemus, and bored it round and round ‘earth-born.’ Details of the battle the son of Poseidon and the nymph in the giant’s eye/till blood came are many and varied, but it is gen- Thoosa. Polyphemus belongs to the boiling up around that smoking erally agreed that the struggle was one-eyed race of Cyclopes, “a gigantic, shaft/and the hot blast singed his fierce, ending with the imprison- insolent, and lawless race of shep- brow and eyelids round the core/ ment of the giants under the earth, herds, who lived in the south-western and the broiling eyeball burst—/its usually in volcanic regions where part of Sicily, and devoured human crackling roots blazed/and hissed … they betray their presence by the beings.”180 In Homer’s Odyssey (Odyssey 9, ii.433–9). violence of their natures.177 Polyphemus is portrayed with graphic imagery that emphasizes his size and Odysseus’ craftiness enables him strength. Homer describes him as and his men to hide under the bel- a vengeful and headstrong giant, a lies of Polyphemus’s sheep, thus freely

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Figure 4-3 Sebastiano del Piombo, Polyphemus (1512, Rome, Villa Farnesina)

A Renaissance fresco of Polyphemus by Sebastiano del Piombo (Figure 4-3, 1512, Rome, Villa Farnesina) portrays a more intimidating giant with the appearance of brute strength in his arms and legs. The large nose and protuberant chin as well as unusually large hands suggest that del Piombo’s Polyphemus may have been based on a model with acromegaly, hence the broader rather than longer bones. Although there is no other figure in the painting to invite comparison, del Piombo’s giant seems to dwarf the trees in the surrounding landscape. Like the suggestion of weakness in the vase painting of Polyphemus, his shepherd’s lute and stick hint at a gentle- ness not associated with Odysseus’ antagonist.

A similar irony associated with the paradox of the weak giant is apparent in paintings of the biblical story of David and Goliath in the book of Samuel. The first biblical reference to escaping through the cave’s opening, suggests the relative and ironic weak- giants appears in Genesis 6:4: “There from which Polyphemus has removed ness of the drunk and slow-witted were giants in the earth in those days,” a large rock that had kept the men giant in the face of cleverness. The fact who, according to the story, disap- imprisoned. An Athenian vase painting that Polyphemus was incapacitated by peared for the most part after Noah’s on a black-figure oinochoe of Ulysses a stake thrust into his one eye under- Flood with a few notable exceptions. (Odysseus) and his Companions lines the giant’s lack of peripheral or The exception made famous in the Blinding Polyphemus (Figure 4-2, 6th lateral vision perhaps caused by a story of David and Goliath in Samuel to 5th century bce, Paris, Louvre) pituitary tumor. The problem would I attracted numerous Renaissance and shows the huge Polyphemus seated in have been made worse by the existence Baroque artists.182 The giant Goliath the reclining position of the victim, his of only one eye, and slow reflexes, the is described as “a champion out of long limbs and torso almost double latter caused by his alcoholic state. the camp of the Philistines, … whose those of Odysseus and his compan- height was six cubits and a span” (I ions. In this example, the artist’s Samuel 17:4) (approximately nine feet emphasis on Polyphemus’ helplessness tall). Calling for a challenge from Saul,

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the leader of the Israelites, Goliath tage of youth, small size, and lack of announce Goliath’s death at the hands intimidates the army of the Israelites. armor, thus magnifying David’s role as of the delicate, youthful David. Eventually David, the young son of a hero. To the physician with knowl- Jesse, claims that because as a shep- edge of pituitary function, however, The face of Caravaggio’s Goliath herd he rescued his father’s sheep from David’s victory is not so surprising, in David with the Head of Goliath a lion and a bear, he can fight Goliath considering the fact of a giant’s natural (Figure 4-4, 1610, Rome, Galleria without the aid of armor: disability. In addition to the lack of Borghese) shows the giant’s downcast peripheral vision caused by a pituitary eyes as if expressing regret, a wrinkled And he took his staff in his hand tumor, other metabolic manifestations forehead accentuating the consterna- and chose him five smooth stones of gigantism and acromegaly could tion of the eyes, and an open mouth out of the brook, and put them have impeded Goliath’s ability to caught in its agonizing last breath. in a shepherd’s bag which he had, fight. For example, he might have had It is well known that in the tradition even in a scrip; and his sling symptoms of arthritis, of carpal tunnel established by Giorgione, Caravaggio was in his hand; and he drew near syndrome manifested in numbness “inserted himself into the biblical to the Philistine. And the Philistine in the hand with difficulty in tightly story” (Puglisi 363), not as David, came on and drew near unto David, holding his sword, of a weakened however, but as Goliath. Caravaggio and the man that bore the shield heart from cardiomyopathy, or of dia- created two other paintings of the went before him. And when betes mellitus possibly manifested in David and Goliath story, both of the Philistine looked about, and saw nerve pain and hyperglycemia. These them less dramatic than the Borghese David he disdained him; for he ailments, which are especially common work.183 Scholars have speculated was but a youth, and ruddy, and of in giants, could have given the giant about the dating of the Borghese a fair countenance…. And it a significant disadvantage against the painting, “most likely … subsequent to came to pass, when the Philistine agility and wit of a young, fearless boy Caravaggio’s murder of Tommasoni— arose, and came and drew nigh to whose quick movements may not have which occurred on 29 May 1606— meet David, that David hasted, and been seen clearly by Goliath. perhaps also because of the dramatic ran toward the army to meet nature of this picture” (Moreno the Philistine. And David put his Although little was known about the and Stefani 198). Further speculation hand in his bag, and took thence a causes of gigantism until the late invites the idea that the use of stone, and slang it, and smote nineteenth century, the biblical story self-portraituare reflects Caravaggio’s the Philistine in his forehead, that was a favorite among Baroque self-condemnation as a murderer. the stone sunk into his forehead; artists who made effective use of the Caravaggio scholars also subscribe to and he fell upon his face to the dramatic and visible features of the the hypothesis that “David is a earth (I Samuel 17:40–42, 49–50). abnormality. In works by Caravaggio, portrait of the painter rejuvenated, which Orazio Gentileschi, and Gian makes the painting a double self-por- After wounding the giant Goliath with Domenico Cerrini, the oversized trait” (Moreno and Stefani 198). The only a slingshot, David uses the giant’s decapitated head of the giant is juxta- painting is fraught with overt sym- sword to cut off his head and “took posed with the slight figure of bolism representing the giant’s pride in the head of the Philistine, and brought the boy David, and it is almost a third oversized dimensions.184 it to Jerusalem” (I Samuel 17:54). of the size of the young shepherd’s entire body. Goliath’s bushy hair and The details of the biblical story accen- beard also distinguish him from the Figure 4-4, facing page tuate the contrast between the giant’s boy’s innocent, beardless appearance. Michelangelo Merisi da Caravaggio, advantage of age, large size, and armor The giant’s closed eyes and evidence David with the Head of Goliath (1610, Rome, and the shepherd boy’s disadvan- of a wound on the forehead clearly Galleria Borghese)

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power” (Vicini 81). In comparison to the more effeminate youths of many paintings on this subject, Gentileschi’s David is older and stronger looking, and his hefty leg juxtaposed with Goliath’s head emphasizes the size of the giant to an even greater extent. The greenish yellow hue of the giant’s face may be intended to show post- mortem changes but could also represent the pre–mortem condition of Addison’s disease secondary to insufficient secretion of adrenal cortical stimulating hormone (acth) that stimulates adrenal cortical secretion caused by pressure from a pituitary tumor that secretes growth hormone.186

A later seventeenth century painting of the biblical story in I Samuel employs Caravaggio’s technique of exaggerated contrast between the giant’s head and the slim, almost effeminate body of David. Gian Domenico Cerrini’s David with Goliath’s Head (Figure 4-6, 1653, Rome, Galleria Spada) portrays a more youthful looking David with stunned, upward looking eyes suggesting a state of shock or perhaps fear The face of Goliath resembles the Figure 4-5 at his accomplishment. Here the giant’s face in Caravaggio’s painting Medusa Orazio Gentileschi, David with Goliath’s Head head is at least a third of the size of (1598, Florence, Uffizi) in which a (1610, Rome, Galleria Spada) David and rests precariously on the base monstrous female head with gigantic of a broken classical pillar. The giant’s proportions is also thought to be a wrinkled forehead, downcast eyes and self-portrait of the artist. Although Another Baroque work that conveys a barely visible wound suggest his recent scholars explain the self-portraiture more sympathetic view of Goliath anger and perhaps incredulousness that in the Medusa as an experiment in the and a sobered, meditative David is such a delicate, smooth-faced boy could use of realism, the artist’s fascination Orazio Gentileschi’s David with pose a threat and kill him with a single with the character of the villain, and Goliath’s Head (Figure 4-5, 1610, Rome, small blow. David’s lavish sash and specifically, the villain represented as Galleria Spada). This painting partially rent shepherd’s tunic further giant, is apparent in both paintings.185 shows “David in absorbed meditation the contrast. A serpent shaped slingshot after decapitating the giant … almost and the cast aside sword are the only as if he commiserates with Goliath evidence, apart from the wound, of the who has dared to challenge divine boy hero’s act of violence.

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Cerrini’s painting has been described as similar in style to Guido Reni’s David, Conqueror of Goliath (1638, Paris, Louvre) (Vicini 218). Reni places the boy David in a theatrical dancer’s pose, elegantly draped with furs and feathers and a red feathered cap that signify his early vocation as a hunter. Looking into the distance, Reni’s David seems oblivious to his bounty of the giant’s head, which rests on a pedestal, eyes closed, the hand of David grasping a forelock just above the wound on the giant’s forehead. As in the Caravaggio painting, the giant’s head appears to be overly large in proportion to the size of David’s body, thus drawing attention to the boy’s remarkable feat. As in Cerrini’s painting, the elegantly braided leather slingshot that comes to a triangular head mimicking that of a cobra seems inadequate, though symbolically intimidating, for the job of giant killing.

In all of these Italian Baroque paintings of David and Goliath, the contrast between a youth on the verge of manhood and the older and larger giant begs the question of the story’s credibility. How could such a boy have defeated such a “monster” with a boy’s weapon? Even though the typical loss suggest that Goliath’s loss of periph- Figure 4-6 of peripheral vision caused by a eral vision was not a factor in Gian Domenico Cerrini, David with Goliath’s pituitary tumor and other associated David’s victory. Did the story originate Head (1653, Rome, Galleria Spada) medical problems in giants could from an actual incident in which, have impeded the giant’s awareness of unbeknownst to the storyteller, the David’s presence, neither the biblical physical impediments of gigantism writer nor the painters of this led to a memorable heroic defeat by a story would have had any knowledge seemingly ill matched adversary? of the endocrine abnormalities associated with gigantism. Furthermore, the artist’s placement of the wound in the center of the forehead would

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condition of gigantism. Goya’s Saturn Devouring his Son (Figure 4-7, 1821– 23, Madrid, Museo del Prado) alludes to the classical myth in which Saturn, the father of the Olympian gods in Roman mythology (Cronus in Greek mythology), eats his children because he fears they will overtake him. Goya’s use of the myth, however, has a more complex purpose than mere representation of a familiar story. In Goya’s painting, completed before the artist went into self-imposed exile, the giant is portrayed with expressionistic detail: huge prominent eyes and long bony limbs, all in exaggerated contrast to the humanlike figure he is devouring.

Considering Goya’s anti-monarchist sympathies and the painting’s overtly expressionistic image of a deranged and violent father, the figure of the giant Saturn may represent Goya’s negative views on war. In his essay “The Mystery of Goya’s Saturn” Jay Scott Morgan questions whether the painting is the artist’s “sardonic commentary on Spain’s recent war with France,” possibly “a symbol of war itself, the culminating portrait of the horrors he chronicled in his series of etchings, The Disasters of War, in 1810–1820.”187 In an effort to dramatize the inhumanity of war and/ or political violence, Goya uses some Figure 4-7 Whereas the paintings of Polyphemus of the characteristics of the endocrine Francisco José de Goya y Lucientes, Saturn and Goliath emphasize the para- abnormality of gigantism to empha- Devouring his Son (1821–23, Madrid, Museo doxically intimidating, yet relatively size the negative power of tyranny del Prado) helpless, appearance of mythical and destruction. The familiar classical or legendary giants, two paintings myth also adds a layer of meaning in of giants by the nineteenth century its reference to the consequences of Spanish artist Goya y Lucientes sug- “fear and jealousy” (Morgan) in the gest a more symbolic rather than child of a father figure who may repre- narrative reference to the endocrine sent a more generalized form

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Figure 4-8 Sir Peter Paul Rubens, Saturn Devouring His Son (1636, Madrid, Museo del Prado)

of patriarchal power of government authorities over the masses. In his monograph on Goya, art historian Robert Hughes sees the figure of Saturn as “the combination of uncontrollable appetite and overwhelming shame that comes with addiction— Saturn goggle-eyed and gaping, tor- mented by his lust for human meat, for an unthinkable incest.”188 Saturn’s gnarled hands and startled, prominent eyes also illustrate the association of arthritis and goiter in gigantism. The disproportionately long bony limbs call attention to his size and awkward- ness. While these visual features of gigantism have scientific validity, the general effect is that of a sub-human, almost animalistic form, again suggesting the symbolic rather than realistic intent of Goya’s painting.

In a comparison between Rubens’s Saturn Devouring His Son (Figure 4-8. 1636, Madrid, Museo del Prado) and Goya’s Saturn, the Rubens painting, “which was the origin of Goya’s idea” (Hughes 383), makes clear the difference between Rubens’ Baroque naturalism and Goya’s expressionism in depicting the endocrine abnormality of gigantism. In Rubens’s more humanistic painting of the classical myth, an aging Saturn struggles in the act of devouring his child. Stooped over the struggling child, he frowns with a concentration that has none of the agony of Goya’s Saturn but expresses the dooming vengefulness of the

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Roman god. Known for his tendency gerated features of gigantism. As in tion of man and beast to emphasize to convey Ovid’s stories “simply as Goya’s Saturn, however, the use of Hercules’ size and strength. Behind stories about love and passion and contrast in size between the Colossus the three-headed dog, Hercules easily their sequels of betrayal, loss and and other human figures in the overpowers his foe while demon- vengeance” (Belkin 396), Rubens por- painting suggests the association of strating, by contrast, his superior trays the god’s determination to seek gigantism with intimidation, violence, strength and size to that of his master revenge against one of his progeny and power. As in the other paintings of Eurystheus, who hides in a pot. who have threatened to supersede “bad” giants discussed in this chapter, him. The broad limbs, dispropor- the exaggeration of size characteristic Paintings of classical themes in the tionately large hands and evidence of of this endocrine abnormality gave art- Renaissance and Baroque periods large bones suggest that the model for ists a natural image for gigantism as a exaggerate the size of Hercules to a Rubens’s giant may have been an acro- metaphor for political tyranny.189 greater degree than is seen in ancient megalic, yet giants and acromegalics art. A painting in two panels, The seldom reach old age because of car- Although artistic representations of Labors of Hercules: Hercules and the diomyopathy with cardiac failure and giants figure more prominently as Hydra (Figure 4-10, 1460, Florence, other complications. Whether or not intimidating, vengeful, and monstrous Galleria Uffizi) by Italian painter Rubens used an actual giant for his entities, stories of “good” giants or Antonio Pollaiuolo, portrays a brawny model is therefore questionable, but of superhuman men with stature Hercules pursuing his second labor, he does convey the emotion of a once of heroic and epic proportions also overcoming the Lernean Hydra. Large powerful god who has become angry abound in paintings with classical shoulders and a broad back suggest and vengeful, grasping to maintain or religious themes. The demi-god extraordinary muscular development. control. Rubens may have aimed to Hercules and the Titan Prometheus are Pollaiuolo is thought to have regarded portray the unusual muscularity and frequently portrayed with giant-like Hercules as “an expression of the pure large bone structure of an otherwise features although neither is techni- force of nature, conceived as a total normal elderly man in order to drama- cally referred to as a giant in clas- and self-sufficient reality … ready to tize his subject’s role as a jealous father sical literature. Both Hercules and fight its bestial aspects,” a metaphor- and his goal to protect himself from Prometheus were popular subjects ical, if not clinical, giant, in fact.190, 191 his children. for Greek and Roman vase paintings and for Renaissance and Baroque Similar to figures of Hercules in size More abstract than either Rubens’s or paintings that emphasize strength, and strength, the figure of Prometheus Goya’s paintings of Saturn is Goya’s size and perseverance as masculine presents a dramatic image of a Titan controversial painting The Colossus virtues that enable these god/heroes to as a giant with human proportions. (Figure 4-9, 1810–12, Madrid, Prado) overcome almost impossible obstacles. A symbol of both humanity and suf- (see p. 124). Originally titled The An Etruscan hydria (vase) (530–525 fering, Prometheus was associated Giant, the painting is dominated by bce, Paris, Louvre) depicts Hercules with his role as creator of the human the large muscular figure presented behind Cerberus, the ferocious dog race, and was to the “Athenians … in three-quarter pose with his back of Hades in the center of the narra- the benefactor of mankind and the to the viewer over a vast landscape. tive panel. Fetching Cerberus from father of all the arts and sciences” Proportionately muscular and strong Hades and taking him to Hercules’ (Larousse 95). Although few images looking, this dark-haired giant with master Eurystheus and back to Hades of Prometheus appear in classical vase closed eyes, whom Hughes compares again, Hercules thus completes the paintings, he was a popular subject to “a blind boxer” (287) has only final (twelfth) and most difficult labor in the Baroque period. In the Greek the gnarled hand of an acromegalic under the command of Eurystheus. myth, Prometheus is punished by without evincing other more exag- Here the painter uses the juxtaposi- Zeus for having stolen fire from the

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god Hephaestus and having given it to man. Zeus sends Hephaestus and others to bind Prometheus with indestructible chains to one of the crests of Mount Caucasus, There “an eagle with outstretched wings, sent by Zeus, fed upon his immortal liver; as much as the winged monster devoured during the day, that much grew again during the night.”192 Only Hercules, an equally powerful demi-god with human proportions, manages to rescue Prometheus. Both Prometheus and Hercules later achieve immortality in the Olympic pantheon.

Figure 4-10 Antonio Pollaiuolo, The Labors of Hercules: Hercules and the Hydra (1460, Florence, Galleria Uffizi)

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The painting of Prometheus Bound passed. One night he was carrying a Figure 4-11 by Rubens (and the eagle painted by child across the river when the child Sir Peter Paul Rubens (the eagle painted by Frans Snyders) (Figure 4-11, 1611–18, became so heavy that Christopher Frans Snyders), Prometheus Bound (1611–18, Philadelphia, Philadelphia Museum of could hardly get across. ‘No Philadelphia, Philadelphia Museum of Art) Art), dramatizes Prometheus’ impres- wonder!’ said the child. ‘You have sive size by “showing Prometheus in been carrying the whole world. I strong foreshortening, his massive am Jesus Christ, the king you seek’ thighs drawn up in pain” (Belkin 132), (Attwater and John 84). a technique that also draws attention to the giant’s well developed muscu- Like Prometheus and Hercules, lature. Prometheus’ protuberant jaw Christopher is depicted in art as a suggests the presence of acromegaly symbol of strength and human virtue. despite his otherwise normal proportions. Rubens’s drawings and paintings of both Hercules and Prometheus show similar strength and cunning on a gigantic scale. The painting seems to equate Prometheus’ gigantism expressed in the size, physical force and energy of the Titan with his power to challenge the fierce eagle and still endure the severe punishment Zeus exacts. Yet, despite the image of Prometheus’ superhuman powers, the painting’s use of normal human proportions creates a representation of human virtue similar to that of Hercules.

In contrast to the muscularity and strength evident in paintings of Hercules and Prometheus, the features of gigantism apparent in figures of another good giant, St. Christopher, usually reflect the saint’s height rather than his muscularity. According to legend,

Christopher was a man of gigantic stature who wished to serve the mightiest of masters. A king and Satan having both disappointed him, he sought Christ, living alone by a ford where many travelers

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Dutch and Flemish Renaissance paintings of St. Christopher portray a man whose exceptional height rather than brawn conveys the strength required to carry “the whole world” and whose facial features and a meditative expression convey a contemplative mind dwelling on his mission. Dutch painter Dieric Bouts’s panel of St. Christopher Carrying the Christ Child in the Pearl of Brabant altarpiece, right wing (Figure 4-12, 15th century, Munich, Germany, Alte Pinakothek) portrays the giant crossing the river with sturdy limbs and a facial expression of deep concentration. His considerable height is accentuated by his long, exposed thighs, and the verticality of the rocky landscape that frames the portrait. An unusually large head further amplifies the giant’s size. The pained expression on the saint’s face and broad expanse of his brow suggest that Bouts may have focused on this feature of the giant using more realistic detail than he did on the rest of the body, which appears more wooden in its conception.193

Figure 4-12 Dieric Bouts, St. Christopher Carrying the Christ Child in the Pearl of Brabant altarpiece (15th century, Munich, Germany, Alte Pinakothek)

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Figure 4-13 More detailed symbolism crowds the an enlarged thyroid gland. No other Hans Memling, The Moreel Triptych, background of the Flemish painting features of the abnormality besides the St. Christopher Carrying the Christ Child of St. Christopher Carrying the Christ giant’s height are evident, however. (1484, Bruges, Belgium, Groeninge Museum) Child by Hans Memling in the Moreel Memling’s St. Christopher is portrayed Triptych (Figure 4-13, 1484, Bruges, with the serious cerebral mien of a Belgium, Groeninge Museum) in man on a grave mission rather than which the height of the saint in con- with the brawn and physical energy of trast to the landscape is the primary the Rubens saint described below. evidence of his gigantism. The lanki- ness of Memling’s St. Christopher is emphasized by the tall staff he carries and his towering stance in the rocky landscape. Evidence of a goiter in the saint’s neck is a reminder of the medical association of gigantism with

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Like his paintings of Prometheus such as Prometheus, Hercules, and St. and Hercules, Rubens’s portrayal Christopher, some artists used images of the saint in St. Christopher and of gigantism to convey playful humor the Hermit (Figure 4-14, 1611, or satire. It should come as no surprise Cathedral, Antwerp, Belgium) depicts that the Parco di Mostri near Viterbo, Christopher as a symbol of strength Italy, built in 1552 by Pirro Ligorio for and humanistic virtue. Unlike the the Prince Orsini, includes larger than earlier northern European paintings of life sculptures of mythological and St. Christopher that represent this icon fantastic figures with gigantic pro- of religious faith as a tall, gaunt figure portions, playfully situated in a park with long limbs and questionable setting that invites visitors to compare muscular strength, Rubens’s painting themselves to the giant figures’ huge Figure 4-14 of the saint suggests that the artist dimensions, maybe even tremble at Sir Peter Paul Rubens, St. Christopher and the could have substituted Hercules for St. their monstrous features. Hermit (1611, Cathedral, Antwerp, Belgium) Christopher, so robust is his demeanor. Like his ancient forebear, Rubens’s St. Christopher seems almost encumbered by his exceptional musculature as he leans on a staff to complete his task of carrying the Christ child across a dangerous river. In this example, however, it is more likely that Rubens used an actual giant for a model or at least observed such features in an actual giant or acromegalic. The saint figure’s exceptionally large hands suggest acromegaly. He also appears to have a prominent left breast, similar to the abnormality caused by a pituitary co-secretion of both growth hormone and prolactin.

Fascination with size as an indication of grotesqueness or “otherness” was at its height in the sixteenth and seventeenth centuries when artists displayed their knowledge of human anatomy, especially in the paintings of mythological, biblical, and legendary giants. Although many of the paintings discussed here suggest derision and disdain of “bad” giants such as Polyphemus and Goliath and solemn respect for “good giants”

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By the late eighteenth century an Hunterian Museum at Lincoln’s Inn of the juxtaposition and raises the interest in anatomical anomalies Fields in London. Three thousand question of what is “normal.” took a turn toward realistic docu- of those specimens are on display for mentation, giving rise to numerous the public. The skeleton acquired Thomas Rowlandson’s satirical prints—engravings, etchings, and in Hunter’s most notorious grave rob- Drawing of Charles Byrne, The Irish lithographs of dwarfs and giants as bery was that of Charles Byrne, the Giant with an Admiring Audience well as anatomical deformities that Irish giant whose fame had made him (Figure 4-15, 1782–3, Hunterian could be reproduced in popular jour- a source of entertainment and wonder Museum, Royal College of Surgeons) nals for the public. A common type throughout the British Isles. is also displayed at the museum. of print from this period was one that As was the custom for such pictures, shows a giant and a dwarf side by Although no evidence in the form Rowlandson “compares his (Byrne’s) side. Much like the Velasquez paint- of a will has been found, newspaper size with that of normal individuals ings that use juxtaposition to draw reports at the time stressed who view him with curiosity. A youth attention to a dwarf’s short stature, Byrne’s horror at the thought of his is trying on one of the giant’s the side by side pictures of dwarfs and body falling into the hands of boots and a young lady is comparing giants emphasize their remarkable one of the many anatomists who one of her dainty feet with the differences, implying that both are were keen to acquire it. He larger version.”196 Byrne stands above “exotic” or “different,” belonging to arranged with friends to seal his the crowd of curious onlookers, that classification of “the other” that body in a lead coffin, for burial at almost haughty and patronizing as he designates them as “freaks” of nature. sea. But, while his casket was reaches his hand to touch the head Fascination with the concept of clas- buried at sea, Byrne’s body was not of one of them. Many eighteenth and sification was particularly prevalent in in it. The undertaker had been nineteenth century journals featured the eighteenth century when scientists bribed and the body was removed prints of the Irish giant and other and philosophers attempted to create from the coffin. Competition popularly known giants usually shown a modern adaptation of the medieval among anatomists to obtain the standing next to average sized people and Renaissance concepts of the Great body was widely reported in or dwarfs. Chain of Being in which each species the press, driving up the price. John and each social class has its niche in a Hunter obtained the body for linear construct.194 a sum rumoured to be over £500. To avoid detection, he hurriedly Among the eighteenth century collectors chopped the body into pieces, and of “freakery” was John Hunter, the boiled it down into the bones. British surgeon who sought specimens Only after four years did Hunter from the dead, robbing graves and admit to having the skeleton secretly assembling skeletons, aborted of Charles Byrne.195 fetuses, and organs of both humans and animals in order to study anatomy, At the Hunterian Museum today one physiology and the mechanisms can imagine the extent of Hunter’s of normality and abnormality. Almost fascination with the extremes of the 14,000 specimens from Hunter’s human form. The museum’s display collection, originally kept in the private we noted at the beginning of this museum in his house at Leicester chapter resembles that of a modern art Square, were acquired by the Royal installation in which the contrast College of Surgeons in 1799 of size between the Irish giant and the and are currently housed in the Sicilian dwarf is the artistic message

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Figure 4-15 Thomas Rowlandson, Drawing of Charles Byrne, the Irish Giant with an Admiring Audience (1782–3, Hunterian Museum, Royal College of Surgeons)

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Figure 4-16 Given the history of artistic repre- Although gigantism may cause slow Paul Serusier, Louise or The Breton Servant sentation of giants—the “bad” and movement because of its association Serusier (1890, private collection) the “good” giants immortalized in with arthritis or cardiac dysfunc- paintings of mythological and bib- tion, giants are usually of normal lical stories, the freak show figures intelligence because most giants and Although artistic representations of dehumanized in the lithographs and acromegalics reach normal brain dwarfs and giants were rare after engravings of popular journals—it development and maturity before the the eighteenth century, a late nine- is tempting to think of gigantism onset of a pituitary tumor. Some giants teenth century painting by the French represented in art as an exagger- are agile enough to play basketball in artist Paul Serusier evinces dignity ated concept of size rather than as the National Basketball Association. rather than mockery in its portrait an anatomically correct depiction of Perhaps Read and Fisher’s exag- of a woman giant or acromegalic. In an endocrine disorder of the pitu- geration is a sobering reminder of the Louise or The Breton Servant (Figure itary gland. Fascination with size temptation to generalize and classify 4-16, 1890, private collection) Serusier prevailed in political and military those whose appearance falls outside uses naturalistic detail to reveal the arenas as well as in art. As late as the what most consider “normal.” characteristics of an acromegalic eighteenth century, giants, like little woman portrayed in a frontal pose. people, were exploited for political Her prominent chin, spade like hands, power and material gain. In Berlin and enlarged thyroid are all accurate Rising, Biography of a City historians representations of the physical mani- Anthony Read and David Fischer write festations of adult onset gigantism or that the Prussian emperor Fredrich acromegaly. Serusier was one of the Wilhelm (1688–1714) “was con- founders of the French Nabis group of stantly on the lookout for taller and painters who during the last decades taller men” for his army.198 Receiving of the nineteenth century “met regu- gifts of giants from other monarchs, larly to discuss theoretical problems at “one point, he even tried breeding of art, symbolism, occult sciences, and his own giants, forcing very tall men esotericism.”197 The close up portrait to marry very tall women in the hope of the maidservant draws attention that their children would be even taller to her size, solidity, and robustness, than their parents”(Read and Fischer qualities among the Breton peasantry 37). But Frederich Wilhelm’s greed that Serusier admired (Olga’s Gallery). backfired when not only the goal of Here, the simplicity of composition his attempts at breeding failed but and use of color to define space mag- the giants “tended to be slow, simple- nify the large dimensions of the acro- minded, physically fragile, and in some megalic in a domestic setting without cases actually deformed. They were using another figure for contrast, thus useless as soldiers,” but “Friedrich inviting the viewer to regard Louise as Wilhem regarded them as far too valu- an individual rather than as a freak of able to risk in a real fight” (Read and nature. The effect is similar to that of Fischer 37). Despite the ostensibly Picasso’s representation of the dwarf deserved ironic outcome of the emper- dancer La Nana (Figure 3-22). or’s experiment, Read and Fisher’s assessment of Fredrich Wilhelm’s ineffectual giants seems exaggerated.

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Chapter 5 ambiguity. A particularly humorous example of an artist’s play on gender appears in a sculpture of Amore and “An Excess of Seed”: Endocrine Psyche in the National Museum of Disorders of the Sex Glands, Adrenal Antique Art at the Palazzo Altemps in Rome in which the male Amore or Glands, and Parathyroid Glands Cupid figure is sculpted with a female head, and the figure of the female Psyche has a male torso but female Introduction breasts. As the sculpture’s object label attests, this “baroque pastiche” of Hellenistic sculpture challenges tra- In the first four chapters we have documented that endocrine disorders, ditional notions of what is “normal” including hypo- and hyper-function of the thyroid gland and pituitary or “natural” in human sexuality, as exemplified by demigods: “The desire gland can result in abnormal metabolic activity, glandular enlargement to oppose nature quite deliberately is also seen in Psyche’s attitude toward with physical and psychological manifestations, and growth disorders. Amore, which repeats in reverse the gesture that is usually represented of Abnormal function of the testes, ovaries, adrenal glands, and Amore leaning toward Psyche.”200 parathyroid glands can also result in physical and psychological abnor- Instead of the more conventional passive stance of the female lover, the malities, changes in appearance and behavior.199 Such abnormalities can figure of Psyche takes on the aggressive male posture of leaning toward raise questions about sexual identity and sexual function and the the love partner.

psychological and social effects of Since antiquity sexual ambiguity has Similar to the way this Baroque sculp- both. It should come as no surprise been a topic of fascination in western ture teases the viewer by reversing that sexual disorders, aberrations and literature, art, and science. Classical sexual orientation in mythological variations have been of particular myths frequently suggest such ambi- figures, the Baroque fascination with interest to past as well as contempo- guity in the figures of Apollo and naturalism reveals anomalies in sexual rary endocrinologists, pediatricians, Cupid, for example. Both male figures development in the guise of sexual psychologists, urologists, and plastic are often feminized in sculpture and normalcy. A dual intention seems to and reconstructive surgeons who treat painting because of their mythological inform the revelation of the mascu- patients with such conditions. association with poetry, music, and line appearance of a hirsute woman love. Sexual ambiguity is also sug- in seventeenth century Spanish artist gested in the artistic representation Jusepe Ribera’s portrait of Magdalena Figure 5-8 of male angels whose rosy cheeks, Ventura The Bearded Woman Jusepe de Ribera, The Bearded Woman full rounded necks and feminine Breastfeeding.201 The work challenges Breastfeeding (1631, Toledo, Hospital de curls defy traditional male classifi- traditional notions of gender roles, in Tavera, Museo Fundación cation. In the figures of Greek male this case, that of the lactating mother Duque de Lerma) (see p. 166) deities or Christian angels, delicate as the epitome of femininity and calf muscles and arms, the absence of maternity. facial hair and the frequent appearance of gynecomastia hint at sexual

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Although ancient Greek art may trans sexuality, bisexualism, and Sexual disorders controlled by the have embraced sexual ambiguity and homosexuality may be common terms endocrine glands androgyny as part of a larger spectrum and concepts in our language, but of sexual identity, attitudes in ancient those who fall into such categories are Rome and throughout Europe from not always readily welcomed in the The categories of sexual disorders the Middle Ages through the nine- more conservative or traditional social controlled by the endocrine glands teenth century reflected a tendency to enclaves of the western world, even (testes, ovaries, and adrenal glands) discriminate against individuals with in the twenty first century. include the following: hermaphro- sexual differences considered to be ditism, pseudohermaphroditism, lat- outside the “normal.” Individuals who eral hermaphroditism, gynecomastia, physically manifested overt sexual hirsutism, and virilism. A hermaph- ambiguity were treated with disrespect rodite is defined as “a person whose and disdain, often ostracized, punished genital organs have the characters of or even eliminated for the aberrations both male and female in greater or less over which they had no control. degree.”203 A “true” hermaphrodite In Christian societies physical abnor- is characterized as “possessing both malities, including sexual anomalies, ovarian and testicular tissue as well were often associated with sin as external sexual features of both and punished as such. For example, sexes” (Stedman 700), whereas a false according to Judaic tradition in the or pseudohermaphrodite “is distinctly book of Leviticus 22:24, the presence of one sex (i.e. possessing either testes of an undescended testicle in a boy or ovaries) although having super- child “made a man unfit to approach ficial characteristics of both,” in the altar directly,” and “[m]en with other words, ambiguous or atypical hypospadius were not regarded fit for external genitalia (Stedman 1236). marriage … because the ejaculate Lateral hermaphroditism is “a form could not achieve conception” (Medvei of true hermaphroditism in which a 32). Mothers who gave birth to testis is present on one side and an hirsute children, especially females, ovary on the other” (Stedman 700). were thought to have had vivid Gynecomastia is the “excessive devel- imaginations, and their children were opment of male mammary glands” in thus considered tainted, even less breasts that resemble those of females than human.202 (Stedman 668). Hirsutism, which is the “abnormal presence of excessive Despite many examples of sexually tol- hair, especially in women” (Stedman erant views in today’s western society, 709), can be one of the external signs sexual ambiguity is still problematic. of virilism, which is the development Contemporary literature such as or presence of male secondary sex Jeffrey Eugenides’ novel Middlesex or characteristics in a woman. Virilism Diane Middlebrook’s biography may appear at birth or later.204 The Double Life of Billy Tipton reveals the obstacles encountered by those The origin of the word hermaphro- whose sexual differences exclude or dite derives from the ancient Greek isolate them in society. Transvestitism, Hermaphroditos, “a minor deity who had the physical characteris-

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tics of both sexes” and evolved from “a combination of the names of [Hermaphroditos’] parents, Hermes and Aphrodite, who were the embodi- ment of ideal manhood and womanhood.”205 In his Metamorphoses, a collection of myths from antiquity, the Roman poet Ovid tells of the nymph Salmacis who fell in love with the young god Hermaphrodite when he was hunting in a wooded area near Mt. Ida. When he rejected her advances, she pleaded with the gods to unite him with her. The gods answered her prayers and the two were united into “one person with the features of both sexes” (Kiefer 121). As a result “of this event the waters of the lake received the property of causing those who bathed therein to lose their virility.”206

According to historian Kathleen Long, from this conclusion it is apparent that the hermaphrodite in Ovid’s myth “expresses the fear of dissolution into the other, the fear that those boundaries created at the dawn of time may at any moment be transgressed.”207 Long explains that the

hermaphrodite’s dual nature, at once divine and monstrous in the more menacing sense of that word (from the Latin monstrare, meaning to show, but also to indict or con- demn) stemmed from long philosophical and religious traditions, already well-established by classical Figure 5-2 times. The hermaphrodite’s central Jan Gossaert, The Metamorphosis of role in early Gnostic thought, as Hermaphroditus and Salmacis (1517, Creator of the universe, is the most Rotterdam, Museum Boijmans Van Beuningen) (see p. 161)

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striking example of divine Attitudes toward sexual ambiguity in negative view of the hermaphrodite hermaphrodism. The hermaphrodite medicine, religion, and history seems to reflect the fear of loss of male as subhuman or weakened power or dominance. figure dominates Greek and Roman depictions (Long 7). According to Daston and Park, Kiefer notes “in many rabbinical Renaissance medical attitudes toward commentaries on the Old Testament Thus the range of artistic represen- hermaphrodites reveal “contrasting story of the creation of man it is held tations of hermaphroditism reflects sensibilities of wonder and repug- that Adam was a hermaphrodite and philosophies that run the gamut from nance,” such as those expressed, that the biblical story of the creation idealization to satire, and from natu- respectively, by the Italian anato- of Eve signifies separation of the two ralism to symbolism. mist Realdo Columbo (a follower of sexes” (Kiefer 121). This story sup- Vesalius) and the French anatomist ports the legend of the hermaphrodite Compared to other endocrine abnor- Jean Riolan the Younger (Daston and as the divine creator of human life. malities, examples of hermaphroditism Park 203). Traditional Judaic culture established in art are rare and most prevalent restrictions for hermaphrodites. The in works of antiquity. According to Both anatomists wrote in the purely laws of the Talmud state that a her- Kiefer, “one of the few representa- naturalistic vein of medical tradi- maphrodite “had to be circumcised tions which might have been modeled tion, … as academic anatomists, when eight days old, [that] he could from life” is the Greek bronze statue interested in the internal as well as legally marry a woman, and divorce of the “so-called Hermaphrodite of external conformation of bodily proceedings had to be carried out Mirecourt … whose genitalia show organs. But whereas Columbo saw according to the law. Marriage to a a hypospadic penis (Kiefer 121).”208 hermaphrodites as the wonder of man was, however, not permissible” Kiefer notes that “the first pictures of anatomical wonders, a male and (Medvei p 35). Caspar Bauhinus, who a hermaphrodite appeared in the text- female combined in one body, wrote about hermaphrodites in 1614, book of Realdus Columbus published Riolan, half a century later in 1614, “reviewed the Jewish laws regarding in 1559 and in the work of Ambrose described them as merely deformed hermaphrodites, namely that they Paré published in 1573” (Kiefer 121). men or (mostly) women (Daston are like men in several respects and Kiefer and others point out the “unre- and Park 203).209 are therefore unclean after a seminal alistic” nature of these illustrations, emission … like women in that they but history would argue that Paré was According to Long, Renaissance are unclean after menstrual flow and disinclined to provide examples of any views of hermaphroditism may have they may not converse with men in medical condition he did not person- stemmed from Aristotle’s work on the a private place” (Kiefer 123). From ally observe. Generation of Animals in which he these examples one can conclude that argues that an “explanation for such the marginalization of hermaphrodites deformities of excess as hermaphro- as something less than human stems dism” is “the quantity of material from the observation that they did not provided by the mother” (Long 14). belong to either sex. Following Aristotle’s logic, “if the material supplied by the maternal Early observations of external womb overcomes the male seed, then sex characteristics and sexual functions a female will be born. But if the male in humans may have provoked seed should only dominate in part, erroneous theories but nonetheless and the material maintain some power, established significant data on then a hermaphrodite will result” sexual disorders. For example, Medvei (Long 14). As in the Ovidian myth, a

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records observations by Wilhelm lished professor of medicine … over time. When Lefebre discovered what Falta in 1913 of “the effect of human the celebrated case of Marin Lemarcis, appeared to be the penis of Lemarcis, castration, known in antiquity, when the Rouen man who had been raised she naturally thought he was a man eunuchs played an important role” as a girl” (Long 78). Duval’s conclu- who disguised himself in woman’s (Medvei 8) and the effect of animal sions were based on his observations dress. Lemarcis asked Jeanne Lefebvre castration that led to questions about of Marin Lemarcis, who had grown to marry him, but Lefebvre would the way “the gonads influence the up as a girl named Marie, secured a not engage in sexual intercourse with distribution of body fat” (Medvei 8). post as a laundress in a private home Lemarcis until the proposed marriage He also notes that according to the and eventually became a prisoner was approved by her parents. When Book of Esther I:10, in Egyptian condemned to burn at the stake for Lemarcis changed his dress and name history the “castrate was described alleged sodomy in his/her relation- to those of a man and proceeded to as of soft hair, smooth skin, unable ship with Jeanne Lefebvre, a midwife the local church to declare his faith to urinate in an arc; his ‘sperm’ is who worked in the same household. and apply for a marriage license, the watery, his voice soft and feminine” Following Duval’s discovery of Marin/ two lovers were accosted and arrested (Medvei 32). Similarly “women who Marie’s male genitalia, a lengthy trial for allegedly committing sodomy since had under- or undeveloped geni- ensued at which Duval argued for the it was thought that they were two talia, lacked breast development, and defense against the prosecution, which women engaging in a homosexual rela- “had a deep voice and suffered pain was supported by Jean Riolan. Riolan tionship. After Lemarcis was impris- when attempting intercourse were claimed that Marin/Marie Lemarcis oned and initially condemned to die called ‘rams’” by the ancient Jews was not a true hermaphrodite and was for acts of sodomy, Duval’s physical (Medvei 33), a derogatory categoriza- therefore guilty of sodomy. Duval’s examination of Lemarcis’s genitalia tion connoting both masculine and insistence on physical examination of provided evidence of Lemarcis’s male bestial associations. In the sixteenth Lemarcis led to the conclusion that anatomy. The discovery of Lemarcis’s century Ambroise Paré suggested Marin/Marie was a hermaphrodite, retracted penis and testicles helped that young women who do not men- thus saving him/her from execution explain the misidentification of his/her struate become more masculine “and because he/she was not, therefore, sex as a child.212 are called masculine women or—in guilty of sodomy. Latin—viragines,210 because they are Duval’s defense not only saved the life robust, aggressive and arrogant, and In his medical legal dossier of Des of Lemarcis but also established the have a man’s voice and become hairy hermaphrodits, accouchemens des need for and value of physical exami- and develop beards” caused by reten- femmes, e traitement qui est requis nation for an accurate diagnosis and tion of blood and secretions.211 All of pour les relever en santé e bien elever for objective evidence in the court- the above examples imply a negative leurs enfants (On Hermaphrodites, room. It served to reinforce the tradi- association with aberrant sexual char- Childbirth, and the Treatment That tion of the surgeon’s preference for acteristics or functions. is required to Return Women to physical evidence rather than theory to Health and to Raise Their Children determine a medical condition. Duval’s Perhaps the most significant break- Well, Rouen 1612), Duval’s account dossier on the trial also reveals how through of seventeenth century includes depositions of both parties in religious dogma and the traditional observations and treatment of her- sixteen statements. The story begins physician’s reliance on theories of maphrodites was revealed in the dis- with the confession that Lemarcis Aristotle, Plato, Galen, etc. obstructed coveries and arguments made by the and Lefebvre met while working as scientific advancement. Duval’s stance French surgeon Jacques Duval “who domestic (female) laborers in the same on the Marin/Marie case marks a practiced at Paris and Rouen, and con- household where they were required to “significant shift being prepared in tended with Jean Riolan, a well-pub- share a bed, a common practice of the the medical profession from reliance

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on classical sources to more empirical Medical history and etiology of sexual freemartin the male calf is normal, but methods of inquiry; those treatises on disorders the sterile female calf is a hermaphro- sex, sexuality, and childbearing show dite with virilized female reproductive that these shifts are significant for the organs. In Hunter’s time the gener- early modern elaboration of sexual The observations by Paré and Duval ally accepted doctrine was that all difference and of gender roles” (Long indirectly led to further study and species were created with a fixed and 29). Along with those of Paré, the pub- experimentation regarding sexual never changing sexual state. Hunter’s lications of Duval “called into ques- abnormalities. In the second half of experiments suggested to the contrary, tion (the) conservative approaches” the seventeenth century the British “every animal and every part of every recommended by the Sorbonne that physician Thomas Willis (1621–1675) animal possessed an innate propensity “advocated Aristotelian and Thomistic documented the presence of internal to malformation.”214 Hunter thus doc- thought over any other” (Long 29).213 secretion of the male hormone testos- umented that sexual development of terone via the bloodstream. Willis’s the external genitalia can be influenced results were based on the result of by fetal “surroundings” (Kiefer 126). castration in a young man, who then became a eunuch. They confirmed Hunter also noted that removal of Aristotle’s observation that eunuchs one testis failed to alter the size of the differed from men (Medvei 139 ref seminal vesicles and that “unilateral” 69). The French vitalist Theophile de ovariectomy in a “sow did not prevent Bordeu (1722–1776) was also aware twinning” (Medvei 195). He proved of the masculinizing effects of tes- that bilateral castration, however, ticular secretions and the feminizing “prevented the re-growth of antlers effects of ovarian secretions and their in stags” (Medvei 195). In his trea- importance to secondary sex charac- tise The Natural History of Human teristics after castration (Iason 59). Teeth Hunter also documented that a spur of a hen, when transplanted to a The British surgeon John Hunter cock would grow to the size of a cock (1728–1793) took experimentation spur, whereas it would not grow when further when he published a treatise transplanted to a hen (Medvei 204). in 1782 on the freemartin known to These experiments were designed to farmers as a virilized bovine female, study the “‘vital principle’” (Medvei “the first really scientific attempt 204) independent of the nervous to explain the occurrence of her- and endocrine systems.215 Although maphroditism” (Kiefer 126). Hunter Hunter’s experiments and observations recognized that the problem of the reflected his ability as an early surgical freemartin occurs when a cow delivers scientist, unfortunately, neither Hunter twin male and female calves, a phe- nor his colleagues appeared to under- nomenon documented in his 1779 stand the importance of the experi- publication An Account of the Free- ments’ results.216 Martin in Philosophical Transactions of the Royal Society. Because of his interest in this phenomenon, Hunter dissected three such animals and was the first to report that in the case of a

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Hunter’s observations, however, led The existence of lateral hermaph- of the external genitalia. The embryo, to experiments by German physician roditism as illustrated in the above whether it is xy or xx, grows up in Arnold Berthold (1803–1861), who example has been documented as a a “sea” of estrogen, and there is no was aware of his predecessor’s work. medical interest since ancient times, evidence that estrogen per se can cause Berthold documented that autotrans- which adhered to the belief that the genital abnormalities in any indi- plantation of a cock’s testis to the back “right side is the side of heat, activity, vidual. Chromosomal errors can occur of the cock prevented the atrophy that and masculinity. The left side is the during spermatogenesis (development occurred after orchiectomy without side of coldness, passivity, and femi- of sperm) or oogenesis (development transplantation.217 Thus transplanted ninity. Normally one side or the other of eggs). testes “could produce secondary sex predominates but if the forces are characteristics” through the blood- very equally balanced a hermaph- Contemporary American pediatric stream; this information provided roditic child might result” (Kiefer endocrinologists Felix Conte and evidence supporting the function of 124). It is worth noting that certain Melvin Grumbach note that female internal secretions (Medvei 218). plants including “[m]ost angiosperms and male embryonic gonads are indis- Subsequent experiments by Berthold’s have hermaphroditic flowers having tinguishable at about forty-two days colleague Rudolf Wagner (1805–1864) both male and female organs.”218 of gestation and differentiate in either during the late nineteenth century Andromonoecy, in which plants carry direction. The gonads begin to differ- failed to confirm the findings of both pistillate and staminate or male entiate from forty-three to fifty days of Hunter and Berthold concerning trans- and female sex organs and are perfect gestation. Leydig cells can be identified plantation of testes (Medvei 218). bisexual flowers, has evolved indepen- at about sixty days with subsequent dently numerous times and is found early development of male external Among those who challenged in approximately 4,000 species in 33 genitalia by sixty-five to seventy- Berthold’s theories about the func- angiosperm families (Miller and Diggle seven days of gestation (Conte and tion of the testes were scientists who 707).219 Studies of flora and fauna Grumbach 569). Surprisingly, female studied seemingly hermaphroditic con- both contributed to and obstructed development does not require an ditions in birds with “male plumage progress in the understanding of the ovary, and normal development of the on one side of the body and female endocrinology of the sex organs. mullerian ducts and uterus will occur plumage on the other” (Medvei 219). even when “no gonad is present” Such lateral hermaphroditism must Lateral hermaphroditism is extremely (Conte and Grumbach 572). “sry have confused the eminent German rare in humans, but the presence (sex-determining region of the y chro- pathologist and anatomist Johann of dual sex characteristics has been mosome) remains the acknowledged Meckel the Younger (1781–1833), documented.220 According to contem- primary testis-determining gene—the Scottish obstetrician James Simpson porary endocrinologists, an absolute one gene that can induce testis devel- (1811–1879), and others because, distinction between men and women opment when introduced experimen- in theory, hormones should func- is not always the case, since abnormal tally into a chromosomal female. The tion bilaterally. In the case of some expression of bipotential precursors in sry protein acts as a dominant inducer birds, however, one side has masculine the embryo may result in alterations in of testis development in mammals.”221 plumage and the other feminine. sexual differentiation especially when In patients with ambiguous male geni- a female embryo is exposed to male talia, well differentiated male genital hormones as in the freemartin. Thus ducts form only when testosterone the presence of masculinizing hor- from the testes is present (Conte and mones in females may interfere with Grumbach 572). normal female sexual development and behavior. It can result in virilization

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True hermaphrodites or ovotes- levels are similar in male and female orrhea. The clinical spectrum of the ticular dsd (Disorders of Sexual fetuses. In females, however, post- feminization of the male ranges from Development) patients have both testes natal infant mammary tissue is more only mild hypospadius or undescended and ovaries. Testosterone and other pronounced and usually persists longer testes to a small penis, or to a female androgenic hormones are required for than in the male. At pubescence the appearance such as gynecomastia. the differentiation of the male external ovaries mature and estrogen secre- Hypospadius occurs in 1 in 125 new- genitalia. Although controversial, “the tion increases, resulting in breast and born males (Conte and Grumbach most likely reason for this [the free- nipple development, uterine enlarge- 601). A small number of affected martin] would seem to be that male ment, and cornification (thickening) of individuals with hypospadius have gonadal inductor substance has leaked the vulvar and vaginal epithelium. chromosomal abnormalities (Conte into the female’s circulation via the and Grumbach 601). placental anastomosis and interfered The adrenal glands are remarkably with ovarian development” (Medvei enlarged during fetal life primarily Gynecomastia is also common during 203). In humans, pituitary gonado- because of hypertrophy of the outer adolescence in the general male trophins are not required to initiate part of the adrenal gland, or the population, especially in mesomorphic prenatal testicular activity, as shown adrenal cortex. The enlargement of the males, and it occurs more frequently by the fact that anencephalic babies cortex of the adrenal glands requires in men who smoke marijuana or take without pituitary glands have normal pituitary secretion, a fact proven by other drugs, especially those con- genitalia. For the six months following autopsies on anencephalic infants who taining estrogens or those that inhibit birth, male children have higher mean lack a pituitary gland. The outermost testosterone action.223 It can also occur levels of testosterone than female area of the adrenal cortex, the zona in men with Klinefelter’s syndrome children after which testosterone glomerulosa, produces aldosterone; (individuals who have an extra x levels are similar in males and females the middle area, the zona fasciculata, chromosome = xxy) and in men with until puberty. In children of about 11 produces cortisol and androgens; estrogen secreting adrenal or testicular or 12 years of age, in response to an the inner layer that surrounds the tumors.224 increased pituitary secretion of leuti- medulla also produces cortisol and is nizing hormone, the testes mature with the primary source of adrenal andro- The most common cause of female an increase in testosterone secretion in gens. Following birth, there is rapid pseudohermaphroditism is con- the male that continues until late ado- involution of the fetal adrenal cortex, genital adrenal hyperplasia (cah) lescence. Testosterone is also required and adrenal secretion of androgen that accounts for about 50% of all for the maturation of the seminiferous precursors. The secretion of adrenal patients with ambiguous genitalia tubules (tubules that make secre- hormones causes the premature devel- (Conte and Grumbach 589). When tions that carry sperm) that lead to a opment of pubic hair before other there is an inadequate production of deepening voice, male hair pattern, signs of sexual development.222 cortisol, adrenal cortical stimulating growth of the penis, prostate, and hormone (acth) rises, and the adrenal seminal vesicles as well as an increase Unlike the androgynous presence of glands produce increased amounts of in muscle mass. both gonadal organs in true her- precursor steroids. When increased maphrodites, pseudo hermaphrodites amounts of androgens are produced, Along with the gonads, the adrenal have only testes or ovaries. A female virilizing congenital adrenal hyper- glands are also involved with hor- pseudohermadrophite has exclusively plasia (cah) results. Children with monal secretion of estrogens and ovarian gonadal structures, although cah may appear quite ill during the androgens that can influence sexual she may have masculinized external first few weeks of life and must be characteristics, hair growth and dis- characteristics such as a prominent cli- suspected of having the salt-losing type tribution. Serum estradiol (estrogen) toris and virilism in addition to amen- of adrenal hyperplasia. The presence

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of a high potassium level, a decreased Disorders of the adrenal glands and ties, a buffalo hump on the upper sodium level (hyponatremia), and the parathyroid glands back, enlarged supraclavicular fat high acidity, with low plasma corti- pads, hirsutism, acne, and purple stria sone levels confirms the diagnosis. (stretch marks) on their protuberant Immediate treatment with cortisone, Apart from sexual disorders, malfunc- abdomens, weakness, hypertension, salt and hydration is necessary to pre- tion (both hypo-and hyperfunction) diabetes mellitus and virilization.228 vent death. of the adrenal glands can be mani- Cushing’s syndrome may also be fested in other symptoms. In 1850 associated with abnormal behavior, Individuals with adrenal, testicular or British physician Thomas Addison including mania and paranoia. In ovarian hyperplasia (excess of cells) (1793-1860) was the first to document 1932, Cushing reported that pituitary or tumors can develop male or female the association of adrenal hypofunc- tumors occurred in some patients characteristics. “A common clinical tion and symptoms of weakness, salt with adrenal hyperplasia and removal manifestation of hyperandrogenism is craving, and a peculiar yellowish dis- of the pituitary tumor resulted in hirsutism. It is defined as the presence coloration of the skin, now known as a cure of the disease (Nelson 108). of excess hair growth in centrally Addison’s disease.226 Among Addison’s This syndrome is usually the result located regions, not commonly found eleven patients, five had bilateral of excess pituitary secretion of acth in women.”225 Hirsutism is most tuberculosis involving the adrenal (adrenal cortical stimulating hormone) frequently associated with polycystic glands, several had bilateral meta- that secondarily stimulates adrenal ovarian syndrome but may also be static cancer, and one had atrophy and cortical secretion (Cushing’s disease). caused by other conditions including fibrosis of the adrenal glands. In 1855 Cushing’s syndrome may also result adrenal hyperplasia or tumors, with British American physiologist Brown from excessive secretion of cortisol by increased androgen secretion, and Sequard (1817–1894) documented benign and malignant adrenal tumors it may have no known explanation that the adrenal glands were necessary or by the ectopic secretion of acth by (Rosen and Cedars 529). Excessive for life in dogs, cats, hares, and guinea neuroendocrine tumors of the bron- ovarian or adrenal secretion of andro- pigs, a fact realized when he observed chus, thymus, pancreas, thyroid or gens or the excessive conversion of that animals died at about three other glands. androgens in peripheral tissues causes days after bilateral adrenalectomy. hirsutism or virilism—increased hair Although not everyone accepted the Pituitary tumors that secrete acth growth with a male distribution and ideas concerning adrenal hypofunc- develop in about thirty percent of the development of other male char- tion or Addison’s disease, most experts patients after removal of both adrenal acteristics. The adrenal hormones agreed with Brown Sequard. In 1927 glands, as first described by American dhea, dhea sulfate, and androstene- R. L. Zwemer provided data con- endocrinologist Don Nelson and col- dione are weak androgens that are firming that the adrenal cortex, which leagues in 1951. These tumors are peripherally converted to testosterone secretes cortico steroids, was necessary among the most aggressive and rapidly and dihydrotestosterone by extra- for life.227 growing pituitary tumors. Patients gonadal tissues. present with visual field defects with In contrast to adrenal cortical hypo- loss of lateral vision, headaches, function, adrenal cortical hypersecre- extraocular muscle abnormalities, tion caused by increased production of sometimes, pituitary infarction, and cortisol from the adrenal glands results a characteristic yellowish hyperpig- in Cushing’s syndrome, named after mentation. The hyperpigmentation the neurosurgeon Harvey Cushing. that occurs in patients with Nelson’s Patients with Cushing’s syndrome syndrome and Addison’s disease is have central or centripetal obesity, thought to be caused by the binding and weight gain, with thin extremi-

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of acth to melanocyte stimulating sive amounts of catecholamines (the Sandstrom (1852–89) described the hormone cells. Treatment of Nelson’s “fright, flight, or fight” syndrome) parathyroid glands both grossly and syndrome includes surgical removal of causing hypertension, increased per- microscopically in man and animals. the pituitary tumor with post opera- spiration and headaches. Patients with He regarded them as embryonic thy- tive radiation therapy. men 2b unfortunately have the most roid tissue that served as a reserve for aggressive medullary thyroid cancers, the main thyroid gland. (Rolleston Tumors or neoplasms (new growth) and few live beyond the age of twenty- 275). Subsequently, British surgeons in the adrenal and pituitary glands one (Gardner 836). Cresswell Baber (1850–1910) and Sir usually occur sporadically but can Victor Horsley (1857–1916) inde- also develop in patients with Multiple Patients with pheochromocytomas of pendently described the parathyroid Endocrine Neoplasia Type I (men-i) the adrenal gland, whether sporadic or glands in sheep, seals, pigs, kittens, syndrome. This syndrome is associated familial in nature, may experience pigeons, and dogs (Rolleston 275). with tumors of the parathyroid, pitu- sudden death caused by cardiovascular The function of the parathyroid glands itary, pancreas, and adrenal glands. events. Some patients with familial remained unknown until the beginning Multiple fatty subcutaneous masses or medullary thyroid cancer have medullary of the twentieth century. Before that lipomas and cutaneous angiomas may thyroid cancer without other time, however, surgeons observed that also be present. Patients suspected of endocrinopathies. All patients with some patients developed tetany after having this syndrome should be tested medullary thyroid cancer should there- total or near total thyroidectomy when for hypercalcemia since primary hyper- fore be tested for the ret (rearranged the parathyroid glands were inadver- parathyroidism is the most common during transfection) oncogene on tently removed or damaged. endocrine disorder in such patients; Chromosome 10 since about 25% of they should also be tested for the pres- patients with medullary thyroid cancer The parathyroid glands became of ence of the menin gene on chromo- will have a germ line ret mutation. greater interest in 1891 after French some 11.229 About ten percent of patients with physiologist Eugene Gley (1857– men 2a who have no family member 1930) documented that removal of Another Multiple Endocrine Neoplasia with medullary thyroid cancer have all four parathyroid glands caused (men syndrome) is found in patients a new or de novo germ line mutation; tetany and was fatal (Garrison 695). with men 2a syndrome who have their children, but not their parents This observation was confirmed by medullary thyroid cancer (98%), or siblings, are therefore at increased Italian pathologists Giulio Vassale pheochromocytomas (50%) or hyper- risk for developing this syndrome (1862–1912) and Francesco Generali parathyroidism (25%). Patients may and medullary thyroid cancer. in 1896 (Garrison 695). In 1895 and also have men 2b syndrome with 1898 German histologist Alfred Kohn medullary thyroid cancer and pheo- The parathyroid glands were the last reported that the parathyroid glands chromocytomas without hyperpara- endocrine glands to be discovered. are anatomically and physiologi- thyroidism but with a marfanoid In 1850 British surgeon Sir Richard cally distinct from the thyroid gland body habitus, poor dentition, puffy Owen (1804–92) first identified a (Rolleston 276). In 1906 William lips, ectopic lenses, multiple mucosal, parathyroid gland in an Indian one Halsted (1852–1922) successfully and gastrointestinal ganglioneuromas horned rhinoceros (Welbourn 217). treated tetany by injecting parathy- and often, marked hyperextensi- German physician Robert Remak roid tissue from cattle into humans bility of the joints. Babies who carry (1815–65) also described “a small, (Garrison 695). Halsted reported that the men 2b gene are observed to cry compact, yellow, glandular body tetany would occur after the removal without tears.230 Pheochromocytomas attached to the thyroid where the of an autotransplanted parathyroid are tumors derived from the adrenal veins emerge” (Rolleston 275). In gland in animals (Garrison 695). In medullary tissue that secretes exces- 1879 Swedish histologist Viktor Ivar 1908, American pathologist George

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MacCallam (1874–1944) and chemist conditions or symptoms were diag- of these symptoms in patients with and pharmacologist Carl Voegtlin nosed.231 Primary hyperparathyroidism primary hyperparathyroidism become (1879–1960) documented that the then became a common endocrine less severe or disappear, but the precise administration of calcium successfully disorder. Osteitis fibrosa cystica is now mechanisms for clinical improvement treated tetany in man and animals. a rare presenting clinical manifesta- in neurocognitive disorders remain These observations helped make the tion in patients with primary hyper- unknown. connection between the parathy- parathyroidism, as most patients are roid glands and calcium metabolism treated before it develops and vitamin Primary hyperparathyroidism is currently (Garrison 695). Parathyroid hormone D deficiency is uncommon in chil- one of the most common endocrinopa- was the last of the non-steroidal dren. Today, most patients who are thies with about 100,000 cases occur- hormones to be identified and was diagnosed with primary hyperpara- ring in the United States each year.234 It extracted and isolated from parathyroidism are relatively asymptom- usually develops sporadically but also thyroid glands in 1925 by Canadian atic although about 25% have kidney occurs familially in association with other biochemist James Collip (1892–1965) stones and many have osteopenia or endocrine neoplasms, including patients (Garrison 695). osteoporosis and hypertension.232 with multiple endocrine neoplasia men-i syndrome and multiple endocrine neo- In 1925 primary hyperparathyroidism Currently, most patients with primary plasia men type ii a syndrome. It can also was first diagnosed and treated sur- hyperparathyroidism have mild to occur in patients with isolated familial gically by Austrian surgeon Felix moderate metabolic problems including hyperparathyroidism with or without jaw Mandl (1892–1957)in Vienna with hypertension, left ventricular hyper- tumor syndrome or as an isolated form the removal of a parathyroid tumor trophy, gout and pseudo gout, history without other endocrinopathies.235 About from a patient with hypercalcemia, of fractures, and rarely, pancreatitis 93% of patients with primary hyperpara- white urine and a crippling bone dis- and peptic ulcer disease. Probably the thyroidism have sporadic rather than ease caused by osteitis fibrosa cystica most clinically identifiable endocrine familial disease. (Medvei 486). From 1925 to 1932 all disorders associated with hyperpara- such patients diagnosed with primary thyroidism are hypertension, gout and Primary hyperparathyroidism, caused by hyperparathyroidism had bone defor- pseudo gout. The latter are conditions parathyroid tumors and both benign and mities caused by osteitis fibrosa cys- associated with increased levels of uric malignant thyroid tumors develop more tica, and about 80% of these patients acid or calcium pyrophosphate crys- often in patients who have been exposed also had kidney stones or nephrocalci- tals in the joints, respectively. Patients to low dose therapeutic radiation, a nosis with renal dysfunction. In 1932 with hyperparathyroidism appear to treatment that was formerly used to treat the first patient with primary hyper- have more somatic symptoms such children with enlarged tonsils, enlarged parathyroidism and kidney stones as musculoskeletal aches and pains thymus glands, birth marks, ring worm without osteitis fibrosa cystica was and neurocognitive disorders such and other conditions. The latency period diagnosed and successfully treated at as increased fatigue, depression, and from radiation exposure associated with Massachusetts General Hospital with weakness as well as increased thirst and the development of parathyroid tumors the removal of a parathyroid tumor. urination, nocturia and constipation is longer than for the development of The existence of kidney stones became than do control patients with benign thyroid tumors.236 Although this treat- the main clue to the underlying diag- goiters. Patients with primary hyper- ment with low dose radiation has been nosis of primary hyperparathyroidism parathyroidism are also more likely to discontinued, there is still concern about (phpt) until routine screening of blood have “painful bones, kidney stones, the increasing exposure of patients, and calcium levels became available and abdominal groans, psychic moans especially, children, to diagnostic radia- patients with primary hyperpara- and fatigue overtones.”233 Following tion such as ct scans.237 thyroidism without other metabolic successful parathyroidectomy, many

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The gonads, adrenal glands, and the ical disorder, it nevertheless echoes the association between alchemy and parathyroid glands in art erroneous theories on the subject that hermaphroditism. reveal the inaccurate medical knowledge of the sixteenth century. Paré Among the numerous examples of Drawings in early collections of writes, classical sculptures of Hermaphrodite, “monstrosities” such as those in the Greek deity who encompassed fourteenth century John Mandeville’s Now as for the cause, it is that the both sexes, the marble sculpture of Travels and Voyages and in medical woman furnished as much seed as the Sleeping Hermaphrodite in Rome books such as those by the sixteenth the man proportionately, and for (Figure 5-1, 138–192 ce, Museo century surgeon Ambroise Paré pro- this [reason] the formative virtue Nazionale Romano, Palazzo Massimo vide ample, if somewhat unrealistic or [property], which always tries to alle Terme [Antonine copy of the 2nd fanciful, illustrations of hermaphro- make its likeness—to wit, a male century, bce Hellenistic original.]) ditism that reflect the continuing fas- from the masculine matter and a illustrates the idealism of Hellenistic cination with the “other” manifested female from the feminine—oper- and early Roman periods in which in sexual abnormalities. “Among ates so that sometimes two sexes, Hermaphrodite “was seen as an the marvels [Mandeville] describes called hermaphrodites, are found in erotic figure, combining the physical are various types of monsters such the same body (Paré 26). beauties and attractions of both as dog-headed cannibals, flat faced sexes.”240 The Roman marble sculp- people without noses or mouths, The theory of “excess of seed” implies ture of Hermaphrodite, like the earlier a race of hermaphrodites, people that the error lies in the woman’s Hellenistic version in the Louvre, with ears hanging to their knees, reproductive organs, not in those of shows the deity in a seductive pose, and men whose heads grow beneath the male. lying partly on his/her side with the their shoulders.”238 In a chapter that torso exposed sufficiently to reveal a describes giants, dwarfs, and humans It is doubtful that individuals with breast, penis, and testes. The head is who resemble beasts, Mandeville hermaphroditism would have been turned away as if in ambiguous mod- includes a description of hermaphro- visible to artists or even to most esty, and the calf of the left leg bent dites observed in his travels: physicians in the sixteenth century, backwards calls attention to the femi- even though Paré claims to have ninely curvaceous lines of the figure. And they have members of genera- observed this endocrine abnormality tion of man and woman, and they in patients. Most non-medical rep- A similar figure is the centerpiece of use both when they list, once that resentations of hermaphroditism are Room V in the Galleria Villa Borghese one, and another time that other. idealized references to the mytho- in Rome where a Roman copy of And they get children, when they logical figure of Hermaphrodite, an original Greek Hermaphrodite is use the member of man and they representing a beautiful woman with turned almost in contraposto pose so bear children, when they use the both female and male sex character- that the genitalia appear on one side member of woman.239 istics. More subtle manifestations of and the right breast on the other but curiosity about androgyny, virilism, can never be seen together, as they From Mandeville’s standpoint, her- and sexual ambiguity are neverthe- can in the sculpture at the Palazzo maphrodites are to be viewed as more less noticeable in Renaissance and Massimo. The Borghese sculpture is bestial than human, as “marvels” for modern paintings. Artistic references complemented by the ceiling decora- the entertainment of their “human” to hermaphroditism and androgyny tion in Room V where the myth of observers. Although Paré’s more include a wide range of styles from Hermaphroditus and Salmacis from clinical view of hermaphroditism antique statuettes to idealized classical Ovid’s Metamorphosis is the narrative recognizes the conditions of a phys- sculptures and modernist references to feature.

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Figure 5-1 these waters impotent, / Half men, 1517, Rotterdam, Museum Boijmans Sleeping Hermaphrodite (138–192 ce, Rome, half women,’ Which his parents Van Beuningen) (see p. 151). Gossaert Museo Nazionale Romano, Palazzo Massimo heard /And gave the fountained uses the foreground of the painting to alle Terme, Antonine copy of the 2nd century, pool its weird magic.241 represent the first part of the narra- bce Hellenistic original) tive in which Salmacis embraces the The ancient sculptures of young man Hermaphroditus, who Hermaphroditus (Hermaphrodite) appears wary of her intent. The second In these examples as well as in the continue to tease the viewer who part of the narrative shows a fanciful Hellenistic version of Hermaphrodite marvels at the mythical figure’s sensual “evolving” figure, “both male and in the Louvre, the sculptors have beauty. Yet equally arresting is the female” in the left background of the embodied both feminine delicacy sculpture’s evidence of sexual duality painting.242 Confirming the result of and male virility in the nude figure that also implies sexual impotence, the union is a small human figure with whose scant drapery serves merely as if Hermaphrodite exists for the two heads, two joined torsos and only to romanticize the seemingly per- purpose of perpetually enticing and two legs. Hidden behind a garland of fect proportions and sensual appeal disappointing. It is tempting to specu- greenery, the hermphrodite’s genitalia of the hermaphrodite. In the story late too that the myth’s popularity as a are difficult to determine. of Hermaphroditus and Salmacis in subject for sculpture may derive from Ovid’s Metamorphoses there is pathos its attempt to explain sexual ambiguity Some small figures of hermaphrodites in the young boy’s discovery of his sex and androgyny, in short, the broad from Greek, Roman and Etruscan change, eventually leading to revenge: spectrum of secondary sex characteris- antiquity display the common prac- tics from effeminate males to mascu- tice of artists of the late Hellenistic When tamed Hermaphroditus line females. and early Roman periods in which the learned his fate, / Knew that his body is draped or clothed in a way bath had sent him to his doom, / The innate sensuality of the herm- that reveals the sexual organs, thus To weakened members and a girlish phrodite is apparent in one of the making clear the sexual ambiguity of voice, / He raised his hands and earliest Renaissance paintings alluding the hermaphrodite. Representations prayed, ‘Father, Mother, / Hear to Ovid’s myth, The Metamorphosis of the hermaphrodite as a victim of your poor son who carried both of Hermaphroditus and Salmacis by sexual aggression is also apparent in your names: / Make all who swim Dutch artist Jan Gossaert (Figure 5-2, some Greek and Roman sculptures.

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Some of the sculptures treat evidence of the sexual disorder with mockery. Art historian Edward Lucie-Smith notes that a Graeco-Roman sculpture “of a hermaphrodite struggling with a satyr … is especially typical of the rather gamy taste of the time—more than fifty examples are known.”243 It would seem from these examples that although a true hermaphrodite is a unification of both sexes, social practice has tended to treat people who manifest sexual ambiguity as more female than male by placing him/ her in the position of victim or passive receiver of male aggression.

Figure 5-3 Hermaphrodite (1st–3rd century ce, London, British Museum)

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Another early example of a sensual representation of a hermaphrodite is found in a small Roman bronze statuette of Hermaphrodite (Figure 5-3, 1st–3rd century ce, London, British Museum). Here the artist has covered Hermaphrodite’s upper female body and head with modest drapery, which she is lifting, almost as if in wonder at the discovery of a protruding penis. Some statuettes of hermaphrodites found in museum antiquity collections display more mesomorphic, less idealistic, proportions and place less emphasis on sensual or erotic associations with the mythical figure than those from the Hellenistic period in Greece or in Roman copies of works from that period. In other sculptures depicting hermaphrodites, the association of hermaphroditism and bestiality is apparent in the ambiguous human/animal, male/female features as if a dual sexed human is considered less than human. The treatment of hermaphroditism as a subject for exaggeration and satire is closely allied with the Renaissance attitude toward this endocrine abnormality as a sign of depravity. swollen abdomen suggest female sex Figure 5-4 characteristics. According to Paré such Ambroise Paré, Oeuvres completes d’Ambroise In his treatise On Monsters and a hermaphrodite would be one of those Paré, ed. J. –F. Malgaigne (Paris: Baillière, Marvels (originally published in 1575), described as “neither one or the other 1841) Ambroise Paré included illustrations of … those who are totally excluded from the various kinds of hermaphrodites, and void of reproduction, and their among them one that would now be sexual organs are wholly imperfect Although Paré may have observed described as a lateral hermaphrodite and are situated alongside one another such a hermaphrodite, his clinical because in addition to breasts, the and sometimes one on top and other drawings seem to be derived from his figure is shown to have a vulva in the beneath, and they can use them only to general knowledge of anatomy rather 244 right pelvic area and male genitalia eject urine” (Paré 27). Paré’s illustra- than from an actual observation of a hermaphrodite. in the left (Figure 5-4, Ambroise Paré, tion is more clinical than artistic, clearly Oeuvres completes d’Ambroise Paré, featuring the ambiguities that continued ed. J. –F. Malgaigne (Paris: Baillière, to puzzle men of science and without the 1841). Female breasts and a slightly teasing aesthetic and erotic qualities of the earlier ancient sculptures.

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Figure 5-5 In the left wing detail from The sexes in the painting.246 Here, Hieronymus Bosch, detail from The Garden of Garden of Earthly Delights (Figure according to Stalabrass, the images Earthly Delights (1470, Madrid, Museo del Prado) 5-5, 1470, Madrid, Museo del Prado), suggest that “the movements of the ‘y’ configuration “suggest[s] the moon and earth are related to sexual union of opposites necessary for activity” and that the overt references In the fifteenth century paintings of transmutation.”245 to hermaphroditism seem to reflect Hieronymus Bosch the representation the “alchemical language and of hermaphroditism is closely Just as figures of hermaphrodites imagery” of sexual identity, the sexual allied with theories of alchemy that took on symbolic value in antiquity duality or androgyny of all humans were still popular in Renaissance and continued to do so in the paint- (Stalabrass 54). Ernst’s juxtaposi- Europe. According to art historian ings of such early Renaissance artists tion of the ‘y’ configuration of legs Laurinda Dixon, as Bosch, the references to hermaph- with moon and sun seems to allude roditism that appear in two works to Bosch’s similar configuration, sug- Bosch’s exuberant youths … by modern surrealist Max Ernst also gesting that hermaphroditism reflects stand on their heads, but … also reflect the semiotics of sexual abnor- balance between male and female, spread their legs, forming human mality. In his painting Men Shall albeit in one person. ‘y’ shapes. This accords with the Know Nothing of This (Figure 5-6, doctrine of the thirteenth-century 1923, London, Tate Modern) Ernst chemist Raymond Lull, whose puzzles the viewer by placing the Figure 5-6 treatises were collected, copied focal point on the central image of Max Ernst, Men Shall Know Nothing of This and printed in the fifteenth cen- the lower half of a four-legged human (1923, London, Tate Modern) tury. Lull ascribed letters of the figure, including both male and female alphabet to various stages of the genitalia. The figure is shown below work, and reserved the letter ‘y’ a crescent moon and a sun. Familiar for the ‘hermaphrodite’, a symbol associations of the moon (Artemis or for the coming together of diverse Diana) with the female sex and the sun substances that occurred during with the male sex (Apollo) further the alchemical conjunction. ambiguous dichotomy yet fusion of the

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In his painting The Attirement of the a hairy female child next to a black Bride Max Ernst (see Figure 2-9, child, both of whom were designated p. 79) conveys a similar ambiguity as such “because of the imagination in the green figure of a hermaphro- of their parents” (Figure 5-7, Paré, ditic homunculus in the lower right Oeuvres completes d’Ambroise Paré, foreground. With four breasts, a ed. J. –F. Malgaigne (Paris: Baillière, phallus, webbed feet, and a protu- 1841). Paré’s explanation of hirsutism berant abdomen that implies the figure includes the following reference to is pregnant, the homunculus manifests antiquity: both human and animal characteristics as well as male and female sex Damascene, a serious author, attests characteristics. The large figures in the to having seen a girl as furry as a painting who appear to be female, but bear, whom the mother had bred ambiguously so, stand in opposition thus deformed and hideous, for to each other as if the robed “bride” having looked too intensely at the is the aggressor and the naked woman image of Saint John [the Baptist] with the large headdress is the pas- dressed in skins, along with his sive one playing the “female” role.247 [own] body hair and beard, which The presence of a third eye turning picture was attached to the foot of Figure 5-7 toward the naked female figure hints her bed while she was conceiving Ambroise Paré, Oeuvres completes d’Ambroise at voyeurism on the part of the more (Paré, Of Monsters and Marvels 38). Paré, ed. J. –F. Malgaigne (Paris: Baillière, aggressive sexually ambiguous robed 1841) figure.248 Turpin also notes that the This type of religious and fantastical figure of the stork serves as a “symbol explanation based on fear and super- of fertility and the broken arrow a stition about a physical abnormality inscription that appears on the right familiar phallic symbol,” which along was still prevalent in the sixteenth side of the painting and “describes with the homunculus may suggest century, even among well educated the circumstances of the commis- “merged sexual identity” (Turpin physicians such as Paré. sion, implies that it was executed to 98). Both paintings underline the record a wonder of the natural world. significance of hermaphroditism as a Fascination with sexual anoma- Magdalena Ventura was from the puzzling endocrine condition in the lies was also popular in the seven- Abruzzi, a region in the Kingdom of twentieth century, one that has taken teenth century. Probably the most Naples, and began to grow a beard on symbolic meaning in both art and famous portrait of a hirsute woman when she was thirty-seven” (Brown literature. named Magdalena Ventura is Jusepe 152). When Magdalena was fifty-two de Ribera’s The Bearded Woman years old, she gave birth to the child Along with curiosity about sexual Breastfeeding (Figure 5-8, 1631, shown in the picture. In the portrait, ambiguity in figures of hermaphro- Toledo, Hospital de Tavera, Museo Magdalena is dressed in a robe that dites, it should come as no surprise Fundación Duque de Lerma) (see p. could easily be that of a man rather that the subject of hirsutism has 148). The work was painted “[a]t than a woman. Her close fitting cap, attracted attention in the realm of the request of Alcalá,” the duke who sideburns, and dark beard all sug- freakery, a term especially popular in was one of Ribera’s “major viceregal gest a male persona, yet she is visibly Britain that encompasses a wide range patrons” (Brown 152). According to nursing a robust looking baby, and her of physical and mental abnormali- Jonathan Brown, the lengthy Latin large engorged breast appears almost ties. Paré’s book includes a picture of as a central appendage. Magdalena’s stern expression and her husband’s

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more disconcerted appearance suggest the anomalous nature of her position as an elderly nursing mother. Similar in appearance to Magdalena Ventura is the subject of an earlier painting (not shown here) by Spanish painter Juan Sánchez Cotån, La Barbuda de Peñaranda (1590, Madrid, Museo del Prado). Because Cotån’s portrait lacks the identifying evidence of female breasts, however, it is almost impossible to tell that the stern bearded face of La Barbuda is that of a woman.

Hirsutism in both men and women was a source of wonder to Renaissance royalty who “imported” them from faraway places. Historic records document that hirsute individuals were “collected” as curiosities much as dwarfs and giants were collected by European courts. Among the more famous of these “marvels of nature” was the “hairy family” of Petrus Gonsalvus. The patriarch of the family is represented by an unknown German artist in a portrait The “Hair Man” Petrus Gonsalvus (Figure 5-9 1582, Innsbruck, Austria, Schloss Ambras). The portrait depicts Gonsalvus in aristocratic robes. Because his delicate hands are the only visible parts of his body except for his head, they contrast dramatically with his hairy, almost animal-like face. Leroi notes that in 1556 “Petrus Gonsalvus arrived at the court of Henri II of France, brought there possibly as a slave from Tenerife.

Figure 5-9 An unknown German artist, The “Hair Man” Petrus Gonsalvus (1582, Innsbruck, Austria, Schloss Ambras)

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He could not have been more than entire face is covered with hair. The Figure 5-10 twelve, but already a thick pelt of juxtaposition of the men and ani- Agostino Carracci, Composition with Figures facial hair obscured his features. He mals reminds the viewer of a similar and Animals, also known as Arrigo Peloso, seems to have been treated kindly practice in paintings of dwarfs; here Pietro Matto e Amon Nano (Hairy Arrigo, there and was even given some educa- the artist seems to imply that the Insane Pietro and Dwarf Amon) (1599, Naples, tion” (Leroi 271).249 Gonsalvus’ son hairy man and the dwarf, and perhaps Museo Nazionale di Capodimonte) Arrigo Gonsalvus appears in the center even the madman Peter, are regarded of a painting by Agostino Carracci, as more beast than human.250 Barry Composition with Figures and Wind infers that Carracci is purposely Animals, also known as Arrigo Peloso, mocking the three subjects of the por- Pietro Matto e Amon Nano (Hairy trait rather than “depicting a kind of Arrigo, Insane Pietro and Dwarf ideal harmony of men and animals” Amon) (Figure 5-10, 1599, Naples, (Wind 20). Museo Nazionale di Capodimonte). The painting features a madman and a dwarf looking at Arrigo whose

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Wind’s interpretation is supported Similarly, Jan Bondeson writes of the Other endocrinopathies in art by the theories of “Cardinal Gabriele interesting history of a hirsute child Paleotti … whose treatise was pub- named Julia Pastrana who was discov- lished in 1582, [and who] distin- ered in a part of the Sierra Madres of In comparison to the more recogniz- guished between portraits that were Mexico that “was said to be ‘a region able physical manifestations of made for mockery and those of of country abounding in monkeys, hermaphroditism and hirsutism, dignified sitters” (Wind 20). All of baboons, and bears’” (Bondeson 219). artists would be less likely to capture the paintings of hirsute individuals Pastrana was eventually persuaded individuals with mild hyperparathy- discussed here raise questions about by “an American named M. Rates” roidism, adrenocortical insufficiency the ambiguous intentions of the artists, to travel “to the United States, to be (Addison’s disease) or adrenocortical similar to the ambiguity in paintings of exhibited for money” (Bondeson 219). excess (Cushing’s syndrome). dwarfs by Velasquez and others. A circus poster depicting Pastrana Patients with mild hyperparathy- emphasizes her curvaceous femininity, roidism would have had few obvious In various archives of nineteenth especially large, voluptuous breasts, a clinical manifestations such as century photographs that include tiny waist, and graceful shapely legs, all bone deformities, renal colic and gout “freaks” or “remarkables” pictured of which make the large masculine fea- or pseudo gout, and those in journals and books, the question of tures of her face, including thick hair, with Addison’s or Cushing’s ambiguous gender seems to have cre- hairy ears, mustache and beard, seem syndrome would often have been ated considerable interest in the pop- incongruous. After frequent travels quite ill because of a shortened ular press. For example, a photograph with Rates and appearances in his freak life expectancy, therefore rarely seen in Harvard University’s Houghton shows, Pastrana attracted numerous in public. Library of a married couple features a curious audiences and fans in both husband seated next to his elaborately the United States and Europe where dressed wife. The bodice of the wife’s her “dancing shows were apparently Victorian gown is covered by her regarded as a slightly obscene and scan- flowing black beard. The otherwise dalous public amusement as evidenced ordinary wedding portrait may lead by the caricature drawing of her by the one to question whether the photog- (Polish) artist Kostrzewski” (Bondeson rapher intended mere documentation 228). Interestingly, although popular of a marriage or invited satire of both culture exemplified by such posters may ambiguous gender and traditional focus on the titillating sexual appeal of marriage. the “freak” in a hirsute woman, men of science such as the New York physician Alexander Mott went a step further in degrading her as “‘one of those extraordinary beings of the present day,’ a hybrid between human and orangutan” (Bondeson 219). Mott’s narrow delineation of what it means to be human may remind us of the famous Scopes monkey trials in which Darwin’s theory of evolution made some people feel uncomfortable about their ancestry.

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Figure 5-11 In our research we have discovered Stanze di Raffaello) alludes to a scene Raphael, The Fire in the Borgo in the Stanze two possible examples of an artistic from the Trojan War recounted in dell’Incendio (1517, Vatican State, Vatican reference to Addison’s disease. The Virgil’s Aeneid. In Virgil’s epic poem Palace, Stanze di Raffaello) first is in a work by Raphael, which the hero Aeneas rescues his father may be the only one in the Borgo Anchises from a fire the Greek enemy Vecchio apartment of the Vatican has started in the royal palace of Troy executed by Raphael, rather than (Cocke 88).251 The viewer’s eye is his workshop. Richard Cocke notes especially drawn to the left foreground that the fresco uses “an inventive of the fresco depicting the ailing reworking of a widely-used late father and his strong, courageous Quattrocento formula in which fore- son. Recreating the famous scene of ground figures are set in a recogniz- filial piety and pathos in the Virgilian able architectural setting” (Cocke 88), narrative, the painting portrays the here one of the papal apartments. figure of the old man Anchises with The fresco of The Fire in the Borgo in skin of a yellow hue, possible hyper- the Stanza dell’Incendio (Figure 5-11, pigmented creases on the palms of his 1517, Vatican State, Vatican Palace, hands and darkening of the skin on

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the elbow. The apparent absence Another example of Addison’s disease Figure 5-12 of scleral icturus (yellowed eyes) found in a painting is Dante Gabriel Dante Gabriel Rossetti, The Beloved or makes Addison’s disease a more likely Rossetti’s painting The Beloved or The The Bride (1865–66, London, Tate Gallery) diagnosis than jaundice, although Bride (Figure 5-12, 1865–66, London, jaundice could be part of the differen- Tate Gallery). The pale but slightly tial diagnosis of Raphael’s Anchises. yellow hue of the bride’s complexion (Jaundice is caused by liver failure is a possible sign of tuberculosis with whereas Addison’s disease is the result consumption and Addison’s disease. It of adrenal failure. Both diseases are should be noted that the tall woman to recognizable by the yellowish pallor the bride’s right has a noticeable goiter, of the skin.) Whatever the cause of the an endocrine abnormality frequently old man’s weakness, his signs of illness documented in Rossetti’s paintings, as make him an especially sympathetic we discussed in Chapter 1. figure presented with appropriate pathos in Raphael’s fresco.

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was thought to be caused by indulgence in excess or luxury, namely a rich diet and large quantities of alcohol, the rotund gentleman with a gouty foot is a prominent image in satirical caricatures and cartoons with a political or social message. The condition was less controversial and more obvious to the public than the other endocrine disorders discussed in this chapter. William Hogarth’s famous series of engravings titled Marriage a la Mode includes The Marriage Contract (Figure 5-14, 1743, London, National Gallery) in which the viewer’s eye is drawn to the lower right quadrant of the picture where a man’s gout diseased foot rests on a stool. The picture illustrates a scene in which the marriage contract “between the daughter of a rich, miserly alderman merchant and the son of an impov- erished earl” is being negotiated (Langmuir 295). The earl points “to his family tree rooted in William the Conqueror” while

he rests his gouty foot—a sign of degeneracy—on a footstool deco- Figure 5-13 able since his voluminous costume rated with his coronet. Behind him is Bartholomeus van der Helst, Gerard Andriezs would have hidden such signs as super- a lavish building in the new classical Bicker (1670, Amsterdam, Rijksmuseum) claivicular fat pads, abdominal stria, style, unfinished for lack of money; hirsutism, or the “buffalo” hump. a creditor is thrusting bills at him. But on the table in front of him is a In our research we have discovered More often represented in paintings, pile of gold—the bride’s dowry just only one questionable example of the disease of gout, which is more handed to him by the bespectacled Cushing’s syndrome in a painting. The common than Addison’s disease and alderman, who holds the marriage portrait of Gerard Andriezs Bicker by Cushing’s syndrome, may occur contract (Langmuir 295). Bartholomeus van der Helst (Figure sporadically but more frequently 5-13, 1670, Amsterdam, Rijksmuseum) in patients with hyperparathyroidism. portrays a portly young man with In the eighteenth and nineteenth obvious centripetal obesity character- centuries, the more obvious physical istic of Cushing’s syndrome. Whether signs of gout provided an opportunity the subject of the painting had other for exaggeration and social satire indications of the disease is question- in numerous caricatures. Because gout

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Figure 5-14 Other images such as the paintings poraries such as George Cruikshank, William Hogarth, The Marriage Contract from on the wall foreshadow a pessimistic Thomas Rowlandson, and James Marriage a la Mode (1743, London, National outcome for the married couple, Gillray focused more specifically on Gallery) which the remaining paintings of the political and social satire repre- series in Marriage a la Mode expli- sented in colorful caricatures. James cate. The prominence of the earl’s Gillray’s etching/aquatint (not shown gouty foot, symbol of excess, against here) titled Visiting the Sick (1806, images of irresponsible spending and Washington, dc, Library of Congress) greed makes clear the moral message features the politician Charles James of Hogarth’s painting: irresponsible Fox with large gouty feet and limbs indulgence has its price. swaddled in bright yellow cloth and “surrounded by comforters including Although Hogarth’s intention was the Prince of Wales” and others to “cast himself as the engraver who may have benefited from their of ‘moral subjects,’”252 his contem- sycophantic attentions to Fox.253

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The artist’s focus on Fox’s condition comment that his etching interpreting gout are sometimes considered to suggests an association between the this ailment is a very apt and imagina- be the victims of a life of excess and ailment of gout and political “sick- tive illustration of the agony that gout indulgence. Such associations remind ness,” hence the title that alludes as sufferers endure.”254 On the political/ us that society is quick to judge those well to the sickness of state. A more social level, the etching seems to imply whose disfigurement or discomfort famous representation of gout is that the dangers of excess lead to self- draws attention to their ailments. Gillray’s The Gout (Figure 5-15, 1799, punishing agony represented by the London, British Museum), an etching swollen gouty foot and involve punish- of a bare gouty foot being attacked ment from the lowest orders symbol- Figure 5-15 by a rat like creature that appears to ized by the rat. James Gillray, The Gout (1799, London, be feasting on the blood swollen joint British Museum) of a grotesque foot. According to The association of disfiguring endo- his biographers, “[a]s a result of his crine diseases such as gout with moral heavy drinking Gillray suffered from depravity continued to have credence gout throughout his later life. People throughout the nineteenth century. who have shared his affliction often Even today those who suffer from

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The tendency throughout history for In our view the remarkable intricacies disease and disfigurement to be and interdependencies of the associated with sin, immoral or endocrine system are a reminder of aberrant behavior, or lack of intelli- the wonders and varieties of gence reflects the influence of human biology. Furthermore, artists’ fear and ignorance on those who visual documentation of endocrine consider good health a reward disorders has contributed a lasting for acceptable behavior and moral record of the nature of disease within righteousness. As we have noted the larger context of European throughout our discussion of history, thus verifying the relationship the relationship between endocrine between art and science throughout disorders and aesthetic, religious, time. Such a relationship can only and social history, aberrations become more significant in our age in appearance and behavior have led of fast-paced interactive technol- those in positions of power (including ogy. When medical students observe those in the medical profession) paintings in order to improve to marginalize individuals who fall their powers of observation, they are outside the accepted boundaries demonstrating the value of breaking of “normal.” The practice of catego- down arbitrary boundaries between rizing, classifying, and adhering the humanities and sciences, to a narrow definition of what is human thus helping themselves and others to also reflects a desire for control acquire new and more profound in a time when science had not yet ways of seeing and understanding the developed the tools for understand- human condition. ing the causes and effects of disease. Disease thus became a metaphor for “the other,” its implications of immorality, and even for bestiality.

Despite the advancement of medical science in the twenty-first century, the dangers of such categorization continue to undermine the more egalitarian and inclusive social environment of our times. Scientific discoveries made accessible to the general public help demystify the ramifications of disease and disfigurement, gradually promoting a more inclusive social environment for those who would otherwise be excluded from society. Although increasingly sophisticated experimentation and careful observation by medical scientists eventually led to an understanding of the endocrine system, the complex and rare nature of endocrine disorders continues to require more research and address unanswered questions.

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List of Illustrations Chapter 1 Figure 1-5. Leonardo da Vinci (1452–1519). Madonna and child Figure 1-1. Holbein, Hans the Younger (with carnation). 1473. Oil on wood, Dust Jacket (1497–1543). Adam and Eve. 62 x 47.5 cm. Inv. No. 7779. Ribera, Jusepe de (lo Spagnoletto) Photo Credit: Art Resource, ny/Kunstmuseum, Photo Credit: Bildarchiv Preussischer (c.1590–1652). The Bearded Woman Basel, Switzerland. Kulturbesitz / Art Resource, ny / Breastfeeding, 1631. Oil on canvas. Alte Pinakothek, Bayerische Hospital de Tavera, Toledo, Spain/ Peter Willi/ Figure 1-2. Veneziano, Paolo (fl.1324– Staatsgemaeldesammlungen, Munich, Germany. The Bridgeman Art Library. 1358). The Doge Dandolo and the Dogaressa Being Presented to the Figure 1-6. Mantegna, Andrea Virgin. (1431–1506). Madonna and Sleeping Photo Credit: Cameraphoto Arte, Venice / Art Child. Distemper on canvas, Resource, ny / S. Maria Gloriosa dei Frari, 43 x 32 cm. Inv. S.5. Venice, Italy. Photo: Joerg P. Anders. Photo Credit: Bildarchiv Preussischer Kulturbesitz / Art Resource, ny / Figure 1-3. Piero della Francesca Gemaeldegalerie, Staatliche Museen, Berlin, (c.1420–1492). Polyptych of the Germany. Madonna della Misericordia. Photo: George Tatge. Figure 1-7. Melozzo da Forli, Photo Credit: Alinari/Art Resource, ny/ Annunciation. Pinacoteca Comunale. Sansepolchro, Italy. Archivio Fotografico della Soprintendenza Speciale per il Patrimonio Storico, Artistico ed Figure 1-4. del Verocchio, Andrea Etnoantropologico e per il Polo Museale della (1436–1488) and assistant (Lorenzo Città di Roma. The Pantheon, Rome. di Credi, 1458–1537). The Virgin and Child with Two Angels, ca 1470–80. Figure 1-8. Botticelli, Sandro (1444– Tempera on wood, 96.5 x 70.5 cm. 1510). Annunciation. Tempera on Bought, 1857 (ng296). wood, 150 x 156 cm. Inv. 1608. © National Gallery, London / Art Resource, Photo Credit: Erich Lessing / Art Resource, ny / ny / National Gallery, London, Great Britain. Uffizi, Florence, Italy.

Figure 1-9. Fra Filippo Lippi, Annunciation. Museo Nazionale d’Arte Antica, Palazzo Barberini, Rome. Archivio Fotografico della Soprintendenza Speciale per il Patrimonio Storico, Artistico ed Etnoantropologico e per il Polo Museale della Città di Roma.

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Figure 1-10. Parmigianino (Francesco Figure 1-15. Dosso Dossi. Maga Circe. Figure 1-21. Ingres, Jean Auguste Mazzola) (1503–1540). Madonna Archivio Fotografico della Soprintendenza Dominique (1780–1867). Angelica with the long neck (post-restoration). Speciale per il Patrimonio Storico, Artistico ed saved by Ruggiero, 1819–39. Oil on 1535–40. Oil on wood. 86 1/4 x 53 Etnoantropologico e per il Polo Museale della canvas, 47.6 x 39.4 cm. Bought, 1918 1/8 in. (219 x 135 cm). Città di Roma. Galleria Borghese, Rome. (ng3292). Photo Credit: Scala/Ministero per i Beni e le © National Gallery, London / Art Resource, ny / Attività culturali / Art Resource, ny / Uffizi, Figure 1-16. Campana, Giacinto and National Gallery, London, Great Britain. Florence, Italy. Guido Reni, copy of Guido Reni, The Rape of Helen. Figure 1-22. Summer. Detail of a Figure 1-11. Caravaggio (Michelangelo Archivio Fotografico della Soprintendenza floor mosaic depicting the Four Merisi da) (1573–1610). Madonna of Speciale per il Patrimonio Storico, Artistico ed Seasons. Imperial Roman, 4th–5th the Pilgrims. Etnoantropologico e per il Polo Museale della century ce. From the area of Archivio Fotografico della Soprintendenza Città di Roma. Galleria Spada, Rome. Le Capannelle, Rome. Speciale per il Patrimonio Storico, Artistico ed Photo Credit: Vanni / Art Resource, ny / Museo Etnoantropologico e per il Polo Museale della Figure 1-17. Botticelli, Sandro Nazionale Romano (Palazzo Massimo alle Città di Roma. Church of San’Agostino, Rome. (1444–1510). La Primavera. Detail Terme), Rome, Italy. of 40-07-01/60. Tempera on wood Figure 1-12. Caravaggio (Michelangelo (1477), 203 x 314 cm. Inv. 8360. Figure 1-23. Portrait of a young Merisi da) (1573–1610). Madonna of Photo Credit: Erich Lessing / Art Resource, ny / woman with a gilded wreath. the Palafreneri. Uffizi, Florence, Italy. Egyptian. Roman Period, 120–140 ce. Archivio Fotografico della Soprintendenza Encaustic, wood, gilding. H. 36.5x W. 3 Speciale per il Patrimonio Storico, Artistico ed Figure 1-18. Rubens, Peter Paul (1577– 17.8 cm (14 ⁄8 x 7 in.). Etnoantropologico e per il Polo Museale della 1640). The Three Graces. Art Resource, ny. Rogers Fund, 1909. Città di Roma. Galleria Borghese, Rome. Photo Credit: Scala / Art Resource, ny / Museo (09.181.7.) del Prado, Madrid, Spain. The Metropolitan Museum of Art, ny. Figure 1-13. Albertinelli, Mariotto. Creation and Fall. Figure 1-19. Rossetti, Dante Gabriel Figure 1-24. Botticelli, Sandro (1444– Credit: The Samuel Courtauld Trust, The (1828–1882). Monna Vanna. Dated 1510). Portrait of a young woman Courtauld Gallery, London. 1866. Oil on canvas, 88.9 x 86.4 cm. (Simonetta Vespucci or Clarice Orsini). Photo Credit: Tate, London / Art Resource, ny / Oil on wood, 61 x 40 cm. Figure 1-14. Rubens, Peter Paul (1577– Tate Gallery, London, Great Britain. Photo Credit: Scala / Art Resource, ny / Galleria 1640). Samson and Delilah, about Palatina, Palazzo Pitti, Florence, Italy. 1609–10. Oil on wood, 185 x 205 cm. Figure 1-20. Rossetti, Dante Gabriel Bought, 1980 (ng6461). (1828–1882). The Daydream, Figure 1-25. Rubens, Peter Paul © National Gallery, London / Art Resource, ny / 1880. Oil on canvas, 158.7 x 92.7 cm. (1577–1640). Helene Fourment in her National Gallery, London, Great Britain. Inv.: cai.3. Wedding Dress. 1630. Oil on oak, Photo Credit: V&A Images, London 163.5 x 136.9 cm. Inv. 340. Art Resource, ny. Photo Credit : Bildarchiv Preussischer Victoria and Albert Museum, London, Kulturbesitz / Art Resource, ny Great Britain. Alte Pinakothek, Bayerische Staatsgemaeldesammlungen, Munich, Germany.

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Figure 1-26. Rubens, Peter Paul (1577– Figure 1-30. Steen, Jan (1626–1679). Figure 1-34. van der Weyden, Rogier 1640). Portrait of Susanna Lunden The Doctor and the Patient. (Roger) (ca.1399–1464). The (‘Le Chapeau de Paille’), ca 1622–5. Oil on canvas, ca. 1670. 49 x 46 cm. Magdalen Reading, before 1438. Oil on oak, 79 x 54.6 cm. Bought, Inv. do 4598. Oil on mahogany, transferred from 1871 (ng852). Photo: Lutz Braun. Photo Credit: Bildarchiv another panel, 62.2 x 54.4 cm. © National Gallery, London / Art Resource, ny Preussischer Kulturbesitz / Art Resource, ny / Bought, 1860 (ng654). National Gallery, London, Great Britain. National Gallery, Prague, Czech Republic. © National Gallery, London / Art Resource, ny / National Gallery, London, Great Britain. Figure 1-27. Piero della Francesca Figure 1-31. Le Nain, Louis (c.1420–1492). The Madonna del (1593–1648). Landscape with Figures Figure 1-35. Crivelli, Vittore. St. Parto (Virgin with two angels). (La Halte du Cavalier or The Resting Catherine of Alexandria. Tempera and 1 Ca. 1460. Fresco, 260 x 203 cm. Horseman). Oil on canvas, 21 ⁄2 x 26 gilding on panel, 73.7 x 41 cm. 1 Post-restoration. ⁄2 in. (54.6 x 67.3 cm). Inv.: ca.I17. Bequest of CDE Fortnum, 1899, Ashmolean Photo Credit : Scala / Art Resource, ny Photo Credit: V&A Images, London / Art Museum, Oxford, England. Cappella del Cimitero, Monterchi, Italy. Resource, ny / Victoria and Albert Museum, London, Great Britain. Figure 1-36. Gentileschi, Artemisia. Figure 1-28. Campin, Robert Santa Cecilia. (ca.1375/9–1444), follower of. The Figure 1-32. Titian (Tiziano Vecellio) Archivio Fotografico della Soprintendenza Virgin and Child before a Firescreen, (c.1488–1576). Assumption of Speciale per il Patrimonio Storico, Artistico ed about 1440. Oil with egg tempera the Virgin. Etnoantropologico e per il Polo Museale della on oak with walnut additions, 63.4 Photo Credit: Cameraphoto Arte, Venice / Art Città di Roma. Galleria Spada, Rome, Italy. x 48.5 cm. Salting Bequest, 1910 Resource, ny / S. Maria Gloriosa dei Frari, (NG2609). Venice, Italy. Figure 1-37. Sebastiano del Piombo © National Gallery, London / Art Resource, ny (1485–1547). The Martyrdom of Saint National Gallery, London, Great Britain. Figure 1-33. Sodoma (Bazzi), Giovanni Agatha. 1520. Oil on wood, Antonio. In 1497 Signorelli began 127 x 178 cm. Figure 1-29. Lippi, Fra Filippo painting the Vita of Saint Benedict da Photo Credit: Scala/Ministero per i Beni e le (1406–1469). Madonna and Child Nurcia as told by Saint Gregory. The Attività culturali / Art Resource, ny / Galleria with Stories of the Life of Saint Anne work, 36 scenes in all, was completed Palatina, Palazzo Pitti, Florence, Italy. (Tondo Bartolini). Ca. 1452. Oil on 1505–1508 by Sodoma. Saint Benedict panel, diam. 53” (135 cm). leaves his father’s house to study in Figure 1-38. Botticelli, Sandro (1444– Photo Credit: Scala/Ministero per i Beni e le Rome (in the background the town of 1510). Scenes from the Life of Moses, Attività culturali / Art Resource, ny / Galleria Nurcia). detail of woman bearing urn. (Sistine Palatina, Palazzo Pitti, Florence, Italy. Detail. Photo Credit: Erich Lessing / Art Chapel walls). Resource, ny / Abbey, Monte Oliveto Photo Credit: Scala / Art Resource, ny Maggiore, Italy. Sistine Chapel, Vatican Palace, Vatican State.

Figure 1-39. Rubens, Peter Paul (1577– 1640). Susanna and the Elders. Photo Credit: Scala / Art Resource, ny / Galleria Borghese, Rome, Italy.

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Figure 1-40. Botticelli, Sandro Chapter 2 Figure 2-6. Vespin, Jean. (Public (1444–1510). Judith with the head of Domain). Capella Salita di Calvario. Holofernes. Ca. 1472. Tempera on Figure 2-1. Gentileschi, Artemisia Sacro Monte di Varallo, Varallo Sesia, 1 1 wood. 12 ⁄4 x 9 ⁄2 in. (31 x 24 cm). (1597–c. 1651). Judith and Italy. Polychrome terracotta sculpture. Photo: NIcola Lorusso. her maidservant with the head of Photo credit: Mattana. Photo Credit: Alinari / Art Resource, ny / Uffizi, Holofernes. Ca. 1614–1620. Florence, Italy. Oil on canvas, 117 x 93 cm. Figure 2-7. Piero della Francesca Photo Credit: Scala/Ministero per i Beni e le (c.1420–1492). Resurrection. Christ Figure 1-41. Caravaggio (Michelangelo Attività culturali / Art Resource, ny / Galleria steps from the tomb while the guards Merisi da) (1573–1610). Judith and Palatina, Palazzo Pitti, Florence, Italy. sleep. Ca. 1458. Holofernes. Photo Credit: Erich Lessing / Art Resource, ny / Archivio Fotografico della Soprintendenza Figure 2-2. Picasso, Pablo (1881– Pinacoteca Comunale, Sansepolcro, Italy. Speciale per il Patrimonio Storico, Artistico ed 1973), Half-Length Female Nude Etnoantropologico e per il Polo Museale della autumn, 1906. Oil on canvas, 32 3/16 Figure 2-8. Landi, Neroccio di Città di Roma. Museo Nazionale d’Arte Antica, x 26 in. (81.8 x 66 cm). Bartolomeo (1447–1500). Saint Palazzo Barberini, Rome, Italy. Gift of Florence May Schoenborn and Samuel Bernardino of Siena Preaching (left) A. Marx, 1959.619, The Art Institute of and Saint Bernardino performing an Figure 1-42. Caravaggio (Michelangelo Chicago, Chicago, Illinois. © 2011 Artists exorcism (right). Merisi da) (1573–1610). The Supper Rights Society (ARS), New York / adagp, Paris. Photo Credit: Scala / Art Resource, ny / Palazzo at Emmaus, 1601. Oil and tempera Pubblico, Siena, Italy. on canvas, 141 x 196.2 cm. Presented Figure 2-3. de Ribera, Jusepe (1591– by the Hon. George Vernon, 1839 1652). Small Grotesque Head, ca. Figure 2-9. Ernst, Max (1891–1976). (ng172). 1622. Etching with some engraving, The Attirement of the Bride (La © National Gallery, London / Art Resource, ny / image: 217 x 143 mm. Toilette de la Mariée), 1940. Oil on National Gallery, London, Great Britain. Fine Arts Museums of San Francisco, Mr. and canvas, 129.6 x 96.3 cm. Mrs. Marcus Sopher collection, 2000.212.1. Photo Credit: Cameraphoto Arte, Venice / Art Figure 1-43. Melozzo da Forli Resource, ny / The Solomon R. Guggenheim (1438–1494). Angel playing the viola Figure 2-4. de Ribera, Jusepe (1591– Foundation, Peggy Guggenheim Collection, da braccio, c. 1480. Detached fresco, 1652). Large Grotesque Head, 1622. Venice, Italy. © 2011 Artists Rights Society 113 x 91 cm. Etching, 13.8 x 10.4 cm. (ARS), New York / ADAGP, Paris. Photo Credit: Scala / Art Resource, ny / Fine Arts Museums of San Francisco, Pinacoteca, Vatican Museums, Vatican State. Achenbach Foundation for Graphic Arts, Figure 2-10. Klee, Paul. Der Held mit 1963.30.17826. dem Flugel (The Hero with the Wing) 1 Figure 1-44. Vivarini, Bartolomeo [Invention 2], 1905, etching 10 ⁄8 in. 5 (c. 1432–c. 1499). Saint Mark Figure 2-5. Vinci, Leonardo da (1452– x 6 ⁄16 in. Enthroned surrounded by musical 1519), follower of, Grotesque man Credit: San Francisco Museum of Modern Art, angels, detail of angels. Central panel with goiter. Red chalk on white paper. Extended loan and promised gift of the Carl of triptych. 1474. Biblioteca Ambrosiana, Milan, Italy/ © Djerassi Trust I; photo: courtesy of sf moma, Photo Credit: Cameraphoto Arte, Venice / Art Veneranda Biblioteca Ambrosiana, Milano/ San Francisco, CA. Resource, ny / S. Maria Gloriosa dei Frari, De Agostini Picture Library/ The Bridgeman Venice, Italy. Art Library.

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Figure 2-11. Sodoma (Bazzi), Giovanni Figure 2-16. Duck, Jacob (c.1600–67). Chapter 3 Antonio. In 1497 Signorelli began Sleeping woman. Oil on canvas. painting the Vita of Saint Benedict da Kunsthalle, Rotterdam, Holland/ Figure 3-1. Stela of the God Bes. Nurcia as told by Saint Gregory. The Artothek/ The Bridgeman Art Library. 304 bce–364 ce. Limestone, paint, work, 36 scenes in all, was completed h. 38.7 cm, w. 17.7 cm Rogers Fund, 1505–1508 by Sodoma. Benedict frees Figure 2-17. Gillray, James. 1922 (22.2.23). a peasant, shackled by the Goths. The Monstrous Craws at a New Image copyright © The Metropolitan Museum Photo Credit: Erich Lessing / Art Resource, ny / Coalition Feast, of Art / Art Resource, ny / The Metropolitan Abbey, Monte Oliveto Maggiore, Italy. Credit © The Trustees of the British Museum. Museum of Art, New York, ny, usa.

Figure 2-12. Sodoma (Bazzi), Giovanni Figure 3-2. Teniers, David the Younger Antonio. In 1497 Signorelli began (1610–1690). The Rich Man being painting the Vita of Saint Benedict da led to Hell, about 1647. Oil on oak, Nurcia as told by Saint Gregory. The 48 x 69 cm. Bought, 1871 (ng863). work, 36 scenes in all, was completed © National Gallery, London / Art Resource, ny 1505–1508 by Sodoma. Benedict / National Gallery, London, Great Britain. completes the building of twelve monasteries. Figure 3-3. Veronese, Paolo (1528–1588). Photo Credit: Erich Lessing / Art Resource, ny / Feast in the House of Levi, detail. Abbey, Monte Oliveto Maggiore, Italy. Photo Credit: Scala / Art Resource, ny / Accademia, Venice, Italy. Figure 2-13. Raphael (Raffaello Sanzio) (1483–1520). The Transfiguration, Figure 3-4. Pitati, Bonifacio de’ (1487– 1520. Oil on wood, 410 x 279 cm. 1553). The Parable of the Rich Man Photo credit: Scala / Art Resource, ny / (Epulone) and the Beggar Lazarus. Pinacoteca, Vatican Museums, Vatican State. Photo Credit: Cameraphoto Arte, Venice / Art Resource, ny / Accademia, Venice, Italy. Figure 2-14. Caravaggio (1573–1610). The Crucifixion of Saint Andrew, Figure 3-5. van Dyck, Sir Anthony 1606–1607. Oil on canvas. 202.5 x (1599–1641). Queen Henrietta Maria 152.7 cm. and her Dwarf Sir Jeffrey Hudson, Credit: The Cleveland Museum of Art, Leonard ca.1633. C. Hanna, Jr. Fund 1976.2, Cleveland, Ohio. Private Collection/ The Bridgeman Art Library.

Figure 2-15. van Hemessen, Jan Figure 3-6. Raphael (Raffaello Sanzio) Sanders (c.1504–66). The Prodigal (1483–1520). (School of). The Cross Son, 1536. Oil on panel. Appearing to Constantine the Great, Musees Royaux des Beaux-Arts de Belgique, flanked by portraits of two popes Brussels, Belgium/ Giraudon/ The Bridgeman (Clement I on the right). Art Library. Photo Credit: Scala / Art Resource, ny / Stanze di Raffaello, Vatican Palace, Vatican State.

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Figure 3-7. Trevisani, Francisco. Figure 3-12. Velazquez, Diego Figure 3-17. Picasso, Pablo (1881– The Banquet of Mark Anthony and Rodriguez (1599–1660). The court 1973). Las Meninas, after Velazquez, Cleopatra. jester. Don Diego de Acedo “El No. 1. 1957. Archivio Fotografico della Soprintendenza Primo.” 107 x 82 cm. Photo Credit: Bridgeman-Giraudon / Art Speciale per il Patrimonio Storico, Artistico ed Photo Credit: Erich Lessing / Art Resource, ny Resource, ny / Museu Picasso, Barcelona, Etnoantropologico e per il Polo Museale della Museo del Prado, Madrid, Spain. Spain. © 2011 Artists Rights Society (ARS), Città di Roma. Galleria Spada, Rome, Italy. New York / ADAGP, Paris.

Figure 3-8. Mantegna, Andrea (1431– Figure 3-13. Velazquez, Diego Figure 3-18. Bertholde, a dwarf. 1506). Lodovico Gonzaga and family Rodriguez. Prince Baltasar Carlos Engraving by A. Walker. with courtiers. Fresco in the Camera (1629–1646), son of Philip (Felipe) Courtesy of the Wellcome Trust. degli Sposi. 1471–1474. IV, with a dwarf. 1632. Oil on canvas, 3 1 Photo Credit: Erich Lessing / Art Resource, ny / 128.0 x 101.9 cm (50 ⁄8 x 40 ⁄8 in.). Figure 3-19. Reinagle, Philip. Portrait Camera degli Sposi, Palazzo Ducale, Photo Credit: Erich Lessing / Art Resource, ny / of Joseph Borulawski, the Polish Mantua, Italy. Museum of Fine Arts, Boston, ma. dwarf, before 1793, unsigned. Credit. The Royal College of Surgeons of Figure 3-9. Molenaer, Jan Miense Figure 3-14. Sánchez Coello, Alonso England, Hunterian Museum. (1610–1668). Scene with Dwarfs, 1646, (1515–1590). Studio of. Infanta oil on canvas, 108 x1129 x 3.5 cm. Isabella Clara Eugenia (1566–1633) Figure 3-20. Two miniature people, Credit: Collection Van Abbemuseum, and Magdalena Ruiz (dwarf with known as the Aztecs. Lilliputians. Eindhoven, The Netherlands, Photograph: Peter monkeys). Canvas; 207 x 129 cm. Credit: Wellcome Library, London. Cox, Eindhoven, The Netherlands. Cat. 861. Photo Credit: Erich Lessing / Art Resource, ny / Figure 3-21. Toulouse-Lautrec, Henri Figure 3-10. Molenaer, Jan Miensz Museo del Prado, Madrid, Spain. de (1864–1901). Marcelle Lender (1610–1668). The Artist’s Studio. dancing the Bolero in ‘Chilperic,’ 1631. Oil on canvas, 96.5 x 134 cm. Figure 3-15. Velazquez, Diego 1895. Inv. 3754. Rodriguez (1599–1660). Private Collection: Mrs. John Hay Whitney, ny/ Photo: Joerg P. Anders. Photo Credit: Bildarchiv Portrait of the boy of Vallecas, The Bridgeman Art Library. Preussischer Kulturbesitz / Art Resource, ny Francisco Lezcano, 1637. Oil on Gemaeldegalerie, Staatliche Museen, Berlin, canvas, 107 x 83 cm. Figure 3-22. Picasso, Pablo (1881– Germany. Photo Credit: Scala / Art Resource, ny / Museo 1973). La Nana, 1901. Oil on card. del Prado, Madrid, Spain. Museo Picasso, Barcelona, Spain/ Giraudon/ Figure 3-11. Mor, Anthonis (1519– The Bridgeman Art Library Nationality / copy- 1576). The Dwarf of Cardinal Figure 3-16. Velazquez, Diego right status: Spanish / in copyright until 2054. Granvelle (1517–1586). Rodriguez (1599–1660). Las Meninas. © 2011 Artists Rights Society (ars), New York / Photo Credit: Erich Lessing / Art Resource, ny / Detail of central group. 1656. adagp, Paris. Louvre, Paris, France. Photo Credit: Scala / Art Resource, ny / Museo del Prado, Madrid, Spain.

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Chapter 4 Figure 4-6. Cerrini, G.D. David with Figure 4-12. Bouts, Dieric the Elder the Head of Goliath. (c.1415–1475). The Pearl of Brabant. Figure 4-1. Gibson and Zoie (Great Archivio Fotografico della Soprintendenza Right wing with Saint Christopher Dane and Chihuahua). Originally Speciale per il Patrimonio Storico, Artistico ed Carrying Christ Child. Detail. Oak appeared as cover on Science 316 Etnoantropologico e per il Polo Museale della panel, 62.6 x 28.1 cm. Inv. waf 78. (April 2007). Città di Roma. Galleria Spada, Rome. Photo Credit: Bildarchiv Preussischer Photo credit: Deanne Fitzmaurice, San Kulturbesitz / Art Resource, ny Anselmo, California Figure 4-7. Goya y Lucientes, Francisco Alte Pinakothek, Bayerische de (1746–1828). Saturn devouring Staatsgemaeldesammlungen, Munich, Germany. Figure 4-2. Theseus painter (6th–5th one of his sons, detail. From the series bce), attributed to. Ulysses and his of “Black paintings.” Oil on canvas Figure 4-13. Memling, Hans (1425/40– companions blinding Polyphemos. (1819–1823), 146 x 83 cm. Inv. 763. 1494). Saint Christopher Carrying the Small black figure oinochoe, h. 22 cm. Photo Credit: Erich Lessing / Art Resource, ny / Christ Child, flanked by Saints Maurus f342. Museo del Prado, Madrid, Spain. and Gilles. Center panel of the Moreel Photo: Chuzeville. Photo Credit: Réunion des Triptych, 1484. Musées Nationaux / Art Resource, ny / Louvre, Figure 4-8. Rubens, Peter Paul (1577– Photo Credit : Erich Lessing / Art Resource, ny Paris, France. 1640). Saturn Devouring His Son, Groeningemuseum, Bruges, Belgium. 1636. Figure 4-3. del Piombo, Sebastiano. Photo Credit: Scala / Art Resource, ny / Museo Figure 4-14. Rubens, Peter Paul (1577– (1485–1547). Polyphemus. del Prado, Madrid, Spain. 1640). Altar: Descent from Cross, 1512. Fresco. closed, left side: Saint Christopher. Photo: Alessandro Angeli, 2003. Franco Figure 4-9. Goya y Lucientes, Francisco Right: a hermit. Canvas. Cosimo Panini Editore. © Management Fratelli de (1746–1828). The Colossus. Photo Credit: Erich Lessing / Art Resource, ny Alinari. Photo Credit: Alinari / Art Resource, Canvas, 116 x 105 cm. Cat. 2785. Cathedral, Antwerp, Belgium. ny / Villa Farnesina, Rome, Italy. Photo Credit: Erich Lessing / Art Resource, ny / Museo del Prado, Madrid, Spain. Figure 4-15. Rowlandson, Thomas. Figure 4-4. Caravaggio (Michelangelo Drawing of Charles Byrne, the Irish Merisi da) (1573–1610). David with Figure 4-10. Pollaiuolo, Antonio del giant, with an admiring audience, the Head of Goliath. (1433–1498). Hercules and the Hydra, 1782–3, unsigned. Archivio Fotografico della Soprintendenza 1460. Tempera on wood, 17 x 12 cm. Credit. The Royal College of Surgeons of Speciale per il Patrimonio Storico, Artistico ed Inv. 8268. England, Hunterian Museum. Etnoantropologico e per il Polo Museale della Photo Credit : Erich Lessing / Art Resource, ny Città di Roma. Galleria Borghese, Rome, Italy. Uffizi, Florence, Italy. Figure 4-16. Serusier, Paul (1864– 1927). Louise, or The Breton Servant, Figure 4-5. Gentileschi, Orazio. David. Figure 4-11. Rubens, Peter Paul (1577– 1890 (gouache on board). Archivio Fotografico della Soprintendenza 1640). Prometheus Bound, begun ca Private Collection/ Photo. Christie’s Images/ Speciale per il Patrimonio Storico, Artistico ed 1611–12, completed by 1618 (The The Bridgeman Art Library. Etnoantropologico e per il Polo Museale della eagle was painted by Frans Snyders). 1 1 Città di Roma. Galleria Spada, Rome. Oil on canvas, 95 ⁄2 x 82 ⁄2 inches (242.6 x 209.5 cm). Purchased with the W. P. Wilstach Fund, 1950. Photo Credit: The Philadelphia Museum of Art / Art Resource, ny / Philadelphia Museum of Art, Philadelphia, pa.

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Chapter 5 Figure 5-7. Paré, Ambroise. Oeuvres Figure 5-13. van der Helst, completes d’Ambroise Paré, ed. J. –F. Bartholomeus. Gerard Andriesz Bicker Figure 5-1. Sleeping hermaphrodite. Malgaigne (Paris: Baillière, 1841). (1622–66), Heer van Engelenburg. Marble statue, Antonine copy from Image courtesy UC Regents. Drost van Muiden. 138–192 ce of a 2nd century bce Credit. Rijksmuseum, Amsterdam, The Hellenistic original. Figure 5-8. Ribera, Jusepe de (lo Netherlands. Photo Credit: Vanni / Art Resource, ny / Museo Spagnoletto) (c.1590–1652). The Nazionale Romano (Palazzo Massimo alle Bearded Woman Breastfeeding, 1631. Figure 5-14. Hogarth, William (1697– Terme), Rome, Italy. Oil on canvas, detail. 1764). Marriage A-la-Mode: 1, The Hospital de Tavera, Toledo, Spain/ Giraudon/ Marriage Settlement, about 1743. Oil Figure 5-2. Gossaert, Jan. The The Bridgeman Art Library. on canvas, 69.9 x 90.8 cm. Metamorphosis of Hermaphrodite and © National Gallery, London / Art Resource, ny Salmacis. Figure 5-9. School, German. 16th c. National Gallery, London, Great Britain. Credit: Museum Boijmans Van Beuningen, The “Hair Man,” Petrus Gonzalvus, Rotterdam, Netherlands. born 1556 on Teneriffa. Figure 5-15. Gillray, James. The Gout. Photo Credit: Erich Lessing / Art Resource, ny / Credit © The Trustees of the British Museum Figure 5-3. Hermaphrodite, Roman Schloss Ambras, Innsbruck, Austria. Imperial period. Credit © The Trustees of the British Museum. Figure 5-10. Carracci, Agostino (1557– 1609). Composition with figures and Figure 5-4. Paré, Ambroise. Oeuvres animals. completes d’Ambroise Paré, ed. J. –F. Photo Credit: Scala / Art Resource, ny / Museo Malgaigne (Paris: Baillière, 1841). Nazionale di Capodimonte, Naples, Italy. Image courtesy UC Regents. Figure 5-11. Raphael (Raffaello Sanzio) Figure 5-5. Bosch, Hieronymus. (1483–1520). Fire in the Borgo in the Garden of Delights. Left wing: Garden Stanze dell’Incendio in the Vatican of Earthly Delights, detail. Triptych Museums. with shutters Wood; Central panel Photo Credit: Alinari / Art Resource, ny / 220 x 195cm, wings 220 x 97cm. Cat. Stanze di Raffaello, Vatican Palace, 2823. Vatican State. Photo Credit: Erich Lessing / Art Resource, ny / Museo del Prado, Madrid, Spain. Figure 5-12. Rossetti, Dante Gabriel (1828–1882). The Beloved (“The Figure 5-6. Ernst, Max (1891–1976). Bride”), 1865–66. Oil on canvas, 82.5 Men Shall Know Nothing of This, x 76.2 cm. 1923. Oil on canvas, 80.3 x 63.8 cm. Photo Credit: Tate, London / Art Resource, ny / Photo Credit: Tate, London / Art Resource, ny / Tate Gallery, London, Great Britain. Tate Gallery, London, Great Britain. © 2011 Artists Rights Society (ars), New York / adagp, Paris.

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Wood, Christopher. The Pre-Raphaelites. New York: Viking Press, 1981.

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Endnotes 6. Portraits painted when low neck- Chapter 1 lines were the fashion suggest a connection between neck and breasts as 11. See Figure 22, Summer, Mosaico one erogenous zone. Pavimentale, (4th–5th century ce, Introduction Rome, Museo Nazionale Romano, 7. Horst Gerson, Rembrandt’s Massimo alle Terme); Figure 35, 1. Katharine Park, Doctors and Paintings, trans. Heinz Norden Vittore Crivelli, St. Catherine of Medicine in Early Renaissance (Amsterdam: Meulenhoff, 1968) Alexandria (1494, London, National Florence (Princeton, nj: Princeton 50. Gerson compares Rembrandt’s Gallery); Figure 14, Peter Paul Rubens, Univ. Press, 1985) 221. painting with others on the subject of Delilah in Samson and Delilah (1609, the anatomy lesson common in seven- London, National Gallery); Figure 2. The anatomy theater of Padua was teenth century Netherlands. He notes 17, Sandro Botticelli, La Primavera built in 1594, that of Leiden in 1596 that Rembrandt’s rendition of the (1477–78, Florence, Uffizi Gallery); and that of Bologna in 1637. Although familiar theme, however, “looks more Figure 20, Dante Gabriel Rossetti, A the tiered seating resembled that like a history painting than a portrait” Daydream (1878, London, Victoria of Greek and Roman theaters, the and that the “patron” (Nicholas Tulp, and Albert Museum). anatomy theater seats were arranged a well known anatomist who had in concentric circles so that the studied with a student of Vesalius) 12. We know that both Michelangelo dissection table could be viewed from “had a voice in determining what was and da Vinci made sketches of the all angles. to be painted, and how it was to be goiter, and Michelangelo wrote about done” (50). The fact of the commis- the condition. Neither, however, 3. Randy Kennedy, “At Some sion may explain the dramatic and depicted the goiter in formal paint- Medical Schools, Humanities Join somewhat public or officially docu- ings as much as some of their prede- the Curriculum,” The New York mentary nature of the painting. cessors or followers. In addition to Times (April 17, 2006), http: www. anatomical drawings of the thyroid nytimes.com/2006/04/17/arts sina. 8. Marie-Hélène Huet, Monstrous gland, da Vinci’s painting Madonna html?pagewanted=1”using art to train Imagination (Cambridge: Harvard and Child depicts a goiter. See Figure doctors&sq&st=nyt”&scp=1’ eyes. Univ. Press, 1993) 22. 1–5. Michelangelo’s fresco of The Kennedy quotes from a 2001 article Last Judgment in the Sistine Chapel in Journal of the American Medical 9. Barry Wind, ‘A Foul and Pestilent includes the head of a man with Association. Congregation’: Images of ‘Freaks’ in exophthalmos, a feature of Graves’ Baroque Art (Burlington, Vermont: disease or autoimmune thyroid 4. A. S. Lyons and R. J. Petrocelli, Ashgate, 1998) 6. disease. Medicine: An Illustrated Art History (New York: H. N. Abrams, 1987) 416. 10. “Advertisement” from James 13. Frank S. Greenspan, “Medical Caulfield, Remarkable Persons Treatment of Nodular Goiters” in 5. da Vinci’s drawing of the thyroid (London, H. R. Young, 1820, Endocrine Surgery of the Thyroid and gland was flawed, however, because iii–vii http://books.google.com/ Parathyroid Glands, ed. O.H. Clark the drawing shows the gland without books?id=n5tlAAAAMAAJ&ots=_ (St. Louis: CV Mosby Co., 1985) 35. an isthmus, probably because it was VFqtE6Cat&dq=james%20 based on the findings of animal rather caulfield%2C%20remarkable%20 14. A. Guerido et al, “Definitions than human dissection. characters&pg=PR6&output=text. of Endemic Goiter and Cretinism, Classification of Goiter Size and Severity of Endemias, and Survey Techniques in Endemic Goiter and

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Cretinism”: Continuing Threats Electron Kebebew (Philadelphia: were ‘washed from original sin,’ and to World Health, ed. J. T. Dunn Elsevier/Saunders, 2005) 19. incapable of actual sin” (286). and G. A. Medeiros—Net. # 292 (Washington, dc: paho, 1974). 22. E. Gaitan, R. H. Lindsay, 28. R. McCarrison, “Observations R. D. Reichert et al, “Antithyroid on Endemic Cretinism in the Chitral 15. F. C. Kelly and W. W. Snedden, and Gastrogenic Effects of Millet: and Gilgit Valleys,” Lancet 2 “Prevalence of Distribution of Role of C-Glycosylflavones,” Journal (1908):1275–1280. Endemic Goiter,” Bulletin WHO 18.5 of Clinical Endocrinology and (1958) 173. Metabolism 68 (1989): 707. 29. Richard Welbourn, The History of Endocrine Surgery (London: Praeger, 16. WHO/UNICEF/ICCIDD, 23. A. P. Weetman, “Autoimmune 1990) 19. “Progress Towards The Elimination Thyroid Disease,” Endocrinology, Of Iodine Deficiency Disorders 4th ed., ed. L. J. De Groot and J. L. 30. J. H. Means, The Thyroid and (Idd),” Document WHO/SHD. 99.4 Jameson (Philadelphia W.B. Saunders, its Diseases (Philadelphia: J. B. (Geneva, Switzerland: World Health 2001) 1409. Lippincott, 1948) 3. Organization, 1999). 24. Frank Greenspan, “Radiation 31. Victor Cornelius Medvei, History 17. Reported by J. E. Sokal, “The Exposure and Thyroid Cancer,” of Endocrinology (London: MTP Problem of Malignancy in Nodular Journal of the American Medical Press, Ltd., 1982) 846. Goiter: Recapitulation and a Association 237 (1977):2089. Challenge” JAMA 170 (1959): 32. Quoted in Alfred Iason, The 402–412. 25. A. B. Schneider, “Radiation- Thyroid Gland in Medical History induced Thyroid Tumors,” (New York: Frobin Press, 1946) 37 18. W. M. Tunbridge, D. H. Evered, Endocrinology and Metabolism Clinics R. Hall et al, “The Spectrum of of North America 19 (1990): 499 33. A. S. Lyons and R. J. Petrucelli, Thyroid Disease in a Community: 71. the Wickham Survey,” Clinical 26. S. Sherman and J. Phagin, “Why Endocrinology 7 (1977): 481. Thyroid Cancer?” Thyroid 15 (2005): 34. Cord Sturgeon and Orlo Clark, 303–304. “Familial Non-medullary Thyroid 19. H. Roeher and Peter Goretzki, Cancer,” Thyroid 15 (2005): 588. “Management of Goiter and Thyroid 27. Cretinism is the condition of Nodules in an Area of Endemic severe hypothyroidism in children. 35. Fielding Garrison, History of Goiter,” Surgical Clinics of North It results in abnormal body habitus, Medicine, 4th ed. (Philadelphia: W. B. America (1987): 223. short stature, swelling and intellectual Saunders, 1960) 206–207. deficiency. Myxedematous cretinism 20. E. Gaitan, ed. Environmental describes a swelling with mucus. 36. See Chapter 2 for an illustration Goitrogenesis (Boca Raton, Florida: According to Brewer’s Dictionary of and more detailed discussion of da CRC Press, 1989). Phrase and Fable, ed. Ivor H. Evans Vinci’s anatomical knowledge of the (London: Cassell, 1981), the word thyroid gland and thyroid disease. 21. P. Cheung, “Medical and Surgical cretin derives from “the Crétins of Treatment of Endemic Goiter,” the Alps” and “is a corruption of 37. Sherwin Nuland, Medicine: The Textbook of Endocrine Surgery, ed. Christian (Chrétien) because being Art of Healing (New York: Hugh Orlo H. Clark, Quan Yang Duh, baptized, and only idiots, they Lauter Levin Associates, 1992) 42. Nuland claims that with the publica-

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tion of De Fabrica and the work of 44. A similar diffuse goiter is more sense of touch that our fingers feel as Van Calcar and Vesalius, “Modern visible in the figure of the Virgin in if they had everywhere been in contact anatomy, and therefore modern Piero’s Madonna del Parto for which with [the] body,” but he also claims medical knowledge, begins on these he presumably used the same model. that Botticelli’s paintings have “a pages” (42). (See Figure 1–26). way of rendering even tactile values with almost no body, … by trans- 38. Susan Mandel and Gerard 45. Giovanni Battista Cima da lating them as faithfully … into values Burrow, “Diagnosis and Treatment of Conegliano’s Madonna of the Orange of movement” (68). The contrast Thyroid Disease During Pregnancy,” between Saints Ludovico of Tolosa between Botticelli’s emphasis on the in Endocrinology 4th ed. 2457. and Saint Jerome (early 16th century, Virgin’s movement that animates her Venice, Accademia Galleries) and sev- face and neck and Lippi’s more static 39. Sir William Osler, The Principles eral other paintings of the Virgin by emphasis on the Virgin’s face and neck and Practice of Medicine 11th ed., the same artist use a similar composi- is apparent when one views the two rev. Thomas McCrae (New York: D. tion that draws attention to the young Annunciation paintings side by side. Appleton, 1931) 889. Virgin’s diffuse goiter. 52. Mannerist painting refers to 40. Sidney Ingbar, “The Thyroid 46. Sfumato technique is defined as “Italian painting … from the period Gland” in Williams Textbook the “rendering of form by means of between the Renaissance and the of Endocrinology 7th ed., ed. subtle tonal gradations so as to elimi- Baroque period.” It “is characterized Jean Wilson and Daniel Foster nate any sharply defined contours” by a search for novelty and excitement (Philadelphia: W. B. Saunders) 706. (Thames and Hudson Dictionary of Art leading to capriciously elongated fig- and Artists, ed. Herbert Read (London: ures” (Thames and Hudson Dictionary 41. Medvei quotes Catullus’ refer- Thames and Hudson, 1994) 331. of Art and Artists 227–228). ence to the enlarged neck of a new bride as follows: “At dawn her nurse 47. See Welbourn 20. 53. Janson sees Parmigianino’s Virgin will not be able to wind/The same as an example of typical Mannerist thread round the bride’s neck/that 48. See Welbourn 20 and Medvei artifice, “elongated … embodying was there last night” [From Catullus, 107–109. an ideal of a beauty as remote from trans. James Michie (London: Panther nature as any Byzantine figure,” 485. Books, 1972), lines 376–377] quoted 49. Erich Schleier, “Italian Painting in Medvei 38. of the Thirteenth to the Eighteenth 54. Chiaroscuro refers to “the use Century,” The Gemaldegalerie, of strong contrasts of light and 42. H. W. Janson and Anthony F. Berlin: A History of the Collection shade for dramatic impact,” Thames Janson, History of Art 5th ed. (New and Selected Masterworks (London: and Hudson Dictionary of Art York: Abrams, 1997) 254. Widenfeld and Nicolson, 1990) 316. and Artists 82.

43. Although we do not show 50. See Chapter 2 for a full explana- 55. Paolo Moreno and Chiara Stefani, examples here, subtly rendered dif- tion of Graves’ disease. The Borghese Gallery (Milan: Touring fuse goiters are visible in some of the Club Italiano, 2006) 190. female figures in Giotto’s frescoes in 51. Bernard Berenson, Italian Painters the Scrovegni Chapel in Padua and in of the Renaissance (London: Phaidon, 56. Catherine Puglisi, Caravaggio some of Duccio’s and Martini’s por- 1956) goes further to suggest that (New York: Phaidon, 1998) 195. traits of the Virgin Mary in Siena. every anatomical detail in Botticelli’s paintings “appeals so vividly to the

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57. Kristin Lohse Belkin, Rubens 61. Christopher Wood, The Pre- lungho e prominente per l’ipertrofia (London: Phaidon, 1998) 155. Belkin Raphaelites (New York: Viking Press, della tiroide; ma ci piace come una suggests that all of the picture’s details 1981) 10. cosa giovane intatta, circonfusa di noted above “contribute to the atmo- un’aria limpida e vibrata” (53). (“The sphere of eroticism, which provides 62. Wayne Frantis, Dutch woman would have a neck like Niobe’s the moral of the story” 155. Seventeenth-Century Genre Paintings if it were not a bit long and prominent (New Haven: Yale Univ. Press, in its hypertrophy of a thyroid” (our 58. Paolo Moreno and Xhiara 2004) 226. translation). Comparing Botticelli’s Stefani, The Borghese Gallery note Simonetta to Niobe [a mother figure that “recent conservation work 63. In her book Shifting Priorities: who personifies maternal sorrow in has revealed … the presence of various Gender and Genre in Seventeenth- Greek mythology], Bilancioni suggests pentimenti” in the original work Century Dutch Paintings (Stanford: that the Renaissance ideal of feminine such as “a male figure toward which Stanford Univ. Press, 2004) Nanette beauty required an elongated neck the sorceress was turning her eyes,” Solomon points out that such paint- even if a frontal pose might reveal the a detail that may have called more ings were not viewed as “pejorative” diffuse swelling of the thyroid gland. attention to the subject’s sensual in their reference to alcohol (32). Thus appeal (117). the voluptuous woman representing 67. Erika Langmuir, The National temperance seems ambiguously to Gallery Companion Guide (London 59. In the original painting on the epitomize the benefits of moderation 1994) 238. same subject of which Campana’s rather than abstinence. painting was a commissioned copy, 68. It is interesting to observe that the figure of Helen has a less notice- 64. New York, Metropolitan Rubens’s series of paintings on Marie able goiter. Although Campana’s Museum, object label for Young de Medici in the Louvre also reveals copy is otherwise faithful to Reni’s Woman with a Gilded Wreath. a diffuse goiter in various represen- original in The Louvre, the choice to tations of the queen. The work was add the detail of a diffuse goiter may 65. Berenice Geoffroy-Schneiter, executed long before Rubens used reflect the artist’s familiarity with this Fayum (New York: Assouline Helene Fourment as a model. Belkin anatomical anomaly in the Emilia Publishing, 2004) 16. Geoffroy- notes that although “Juno, patroness Romana region of Italy in which he Schneiter also points out the “para- of marriage, may have been a more was painting. According to Maria doxical duality” of such realism in appropriate symbol [for Helene Lucrezia Vicini in Guide to the Spada portraits intended to be buried with Fourment], her image was a matronly Gallery (Rome: Bedart, 2002), the the dead (16). one, without the erotic connotations painting was “executed for Cardinal of Venus” (249). Bernardino Spada … and touched up 66. In his article “Le figurazioni by Reni himself” 64. Della glandola Tiroide in Leonard da 69. There are at least three women Vinci: Le prime iconografie del gozzo with diffuse goiters in the Lippi 60. Belkin notes that the model for cretinico ed esoftalmico,” Archivo di painting. Besides St. Anne, the figure this figure was most likely Rubens’s storia della scienza 4 (1923): 33–58. of the Virgin Mary also has a diffuse second wife Helene Fourment whom Coll Misc 4/34 estratto Gugliemo goiter as does the figure of the tur- he frequently painted in dramatic roles Bilancioni’s comment on this painting baned woman on the stairs at the right such as this (244). of Simonetta Vespucci further explains of the painting. the way in which the artist achieved such contrast: “La donna avrebbe un collo da Niobe se non fosse un poco

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70. Presumably, the same model aspect of the wide spectrum of the Chapter 2 with the same goiter in The Virgin human condition. and Child Before the Firescreen also 79. In their article “Goitrous appears in The Annunciation Triptych 75. Judith is described in the Apocrypha Beauty in Artemisia Gentileschi’s by Robert Campin and workshop as “of a goodly countenance, and very Judith and her Maidservant” in (New York, Metropolitan Museum of beautiful to behold” (Judith 8:7). Thyroid, 17 (2007) 1 37–38 authors Art). See From Van Eyck to Breugel: Helen Christopoulou-Aletra, Niki Early Netherlandish Painting in The 76. The peasant woman is shown Papavramidou, and Paolo Pozzilli Metropolitan Museum of Art, ed. with thyroid nodules, similar to argue that “most paintings repre- Maryan W. Ainsworth and Keith those of the peasant woman in senting female figures with goiter are Christiansen (New York: Metropolitan The Crucifixion of St. Andrew (See of either patrician women or of the Museum of Art/Abrams. 1998) 96 Figure 14 in Chapter 2). This figure sacred figure of the Virgin Mary”(37). for a discussion on the connection is another example of Caravaggio’s They note that “In Gentileschi’s between the two paintings. use of naturalistic details, in this case painting Judith is elevated both to calling attention to the humble status the status of patrician, as seen by her 71. Van Dyck appears to have used of the woman assisting the more noble attire, and to a Virgin Mary-like the same model (with the same Judith. role … chosen by God”( 37). We goitrous neck) for the grieving would argue, however, that Gentileschi Virgin Mary in The Deposition, 77. Langmuir 180. departs from the image of a humble Oxford, Ashmolean Museum and self-effacing Virgin Mary (37) and The Deposition in Munich, Alte 78. See Chapter 5 for a discussion that Gentileschi’s perspective is more Pinakothek. of androgyny and hermaphroditsm humanistic than religious. in paintings that portray men and 72. Tom Morgan, Saints: A Visual boys with both male and female 80. In a later painting of Judith by Almanac of the Virtuous, Pure, characteristics. Gentileschi (1625, Detroit, Institute Praiseworthy, and Good (San of Arts) with the same title as the Francisco, CA: Chronicle Books) 142. painting discussed above, a goiter in Judith’s neck is also visible but less 73. Donald Attwater with Catherine overtly grotesque, and the painting Rachel John, The Penguin Dictionary seems to focus more on Judith’s of Saints (London, Penguin, 1995) 80. “inner drama” than on her external role (Janson 552). Janson describes 74. In his book The Preference for this later painting as “uniquely” the Primitive: Episodes in the History Gentileschi’s rather than indicative of Western Taste and Art (New York, of the influence of Artemesia’s father Phaidon, 2002) Ernst Gombrich Orazio Gentileschi or of Caravaggio, describes Del Piombo’s work as “a an influence he sees in the earlier painting that borders on the sadistic” painting (Janson 552). Considering the (106). We would argue, however, that number of paintings in Gentileschi’s in his anatomical realism, as in that oeuvre that depict srong looking revealed in many of the paintings dis- women with noticeable goiters, cussed in our book, the artist invites however, the earlier painting seems to us to look at the brutal, the ugly, and have Artemisia Genetileschi’s indi- sadistic tendencies of humanity as one vidual stamp.

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81. F. Merke, History and 92. B. P. Colcock, “Lest We forget: 102. Antonio Giampalmo, “Il Gozzo Iconography of Endemic Goiter A Story of Five Surgeons,” Surgery 6 nell’Arte,”Medicina nel Secoli: Arte (Boston: MTP Press, 1984) 4. (December, 1968) : 1163. e Scienza, Giornale di Storia della Medicina, 8.11 (1996): 99. 82. Francis Greenspan, “Medical 93. W. F. Becker, Presidential Address: Treatment of Nodular Goiters” 37. ”Pioneers in Thyroid Surgery,” Annals 103. Wind 53. of Surgery 185 (1977): 495. 83. See Figure 2-6 for an example of 104. See Chapter 3 of our book for cretinism. 94. E. L. Fox, “Myxedema treated by more discussion of the characteristics extract of thyroid by mouth,” British of cretinism. 84. See Figure 2-13 for an example of Journal of Medicine 2 (1892): 941 exophthalmos and gynecomastia in 105. Guido Barbieri Hermitte does the male figures. 95. W. F. Becker, Presidential Address same in his book Il Gozzo. 502. 85. I. D.Vellar and Thomas Peele 106. David Hopkins, Dunhill, “The Forgotten Man of 96. G. W. Crile, “Excision of Cancer The Burlington Magazine, 133. 1057 Thyroid Surgery,” Medical History 18 of the Head and Neck,” Journal of (April, 1991): 244. (1974): 22. the American Medical Association 47 (1906): 1780. 107. Hopkins 244. Hopkins (244, 86. C. E. Sedgwick and H. S. Filtzer, note 60) also cites an account of such “Operative History of Goiter,”Major 97. W. F. Becker, Presidential sorcery, “which Ernst may well have Problems in Clinical Surgery 15 Address 502. known” in J. Michelet, La Sorciere (1974): 1–4. (1862), tr. Allinson, Satanism and 98. R. D. Harwick, “Our Legacy of Witchcraft: A Study in Medieval 87. Bronchiocele was the term used Thyroid Surgery,” American Journal Superstition, London (1965) 47. for goiter in ancient Greece and Rome. of Surgery 156 (1988): 230. 108. Alluding to Leonardo da Vinci’s 88. See Chapter 1 for the discussion 99. See Chapter 3 on the topic of painting of Leda and the Swan, on Monastic Medicine. cretinism and dwarfism. Hopkins speculates that “Ernst would surely have seen a connexion [sic] 89. See Chapter 1 for a full account of 100. See Merke 141, Figures 43 and 44. between the phallic nature of Zeus as Vesalius’ work. swan in Leonardo’s depiction 101. In an article on “The Discovery and Freud’s concern with the ‘mytho- 90. Lorenz Heister, Chiurgie, in of Thyroid Replacement Therapy, logical’ significance of the stork welcher alles, was zur Wund-Artzney Part 1: In the Beginning,” Journal of fable” 241. gehøret, nach der neusten and besten the Royal Society of Medicine 104.1 Art (Nurenberg: J. Hoffman 1718, (January 2011), Stefan Slater quotes 109. Julian Stalabrass, notes on The English translation: London, 1742) the lines from The Tempest as well as Robing of the Bride in Ian Turpin, quoted in Medvei 156–157. the comments of a character in Mark Ernst (London: Phaidon, 1979) 98. Twain in A Tramp Abroad, who after 91. Mary Roach, Stiff: The Curious traveling claims that he has seen “the 110. Paul Klee, ed. Carolyn Lanchner Lives of Human Cadavers (New York: principal features of Swiss scenery— (New York: Museum of Modern Art, Norton, 2003) 40–41. Mont Blanc and the goiter” (16). 1987) 84.

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111. J. M. Charcot and Paul Richer, multinodular goiter, almost certainly Chapter 3 “Le Jeune Possédé,” Les Démoniaques the result of iodine deficiency” 394. Dans L’Art (Paris: Editions Macula, 120. Wind argues that Ribera’s 1984) 28–31. 115. We first became aware of the painting of The Dwarf and the Dog common usage of this term in our (now lost but reproduced in Wind’s 112. In Medicine: The Art of Healing, research at the Wellcome Library in book in plate 3.7) “is not meant to contemporary surgeon and medical London where an assistant suggested elicit thoughts of charity” and that it historian Sherwin Nuland also diag- it as a key word in our investiga- reflects the “mirth-provoking formula noses the boy’s “fit” as indicative of “a tion of the library’s electronic files. practiced by court artists North and complex partial seizure,’ or epilepsy, Subsequent research has revealed that South of the Alps” (63). The portrait and in Raphael’s time “many came to “freakery” is more readily used in of Calabazas is reproduced in Wind’s believe that the devil had gotten into British historical texts than in compa- plate 4.1. patients who convulsed in an epi- rable American texts in reference to leptic fit” (38). We maintain, however, the representation of human physical 121. Veronique Dasen, Dwarfs in that the presence of so many signs of abnormalities. Ancient Egypt and Greece (Oxford: Graves’ disease makes this autoim- Clarendon Press, 1993) 7–8. mune disorder of the thyroid gland a 116. Roy Porter, Bodies Politic: more likely diagnosis. Disease, Death and Doctors in Britain, 122. Dennis Styne, “Growth,” 1650–1900 (London: Reaktion Books, Greenspan’s Basic and Clinical 113. J. Barry Ferriss, “Letter to the 2001). Endocrinology (New York, McGraw Editor on The Crucifixion of Hill, 2007), 8th ed. 171. St. Andrew by Caravaggio,” Thyroid 117. Richard Godfrey, James Gillray: 16.5: 518. Ferriss also cites The Art of Caricature (London: Tate 123. R. L. Rosenfield and L. Cutler, H. Hibbard, Caravaggio (London: Publishing, 2001) 169. “Somatic Growth and Maturation, Thames and Hudson, 1983) 221 and Endocrinology, 4th ed. 477–479. K. Christiansen, Caravaggio: The Final 118. Godfrey (169) also notes how Years (catalogue) (Napoli: Electa, “Charlotte thrusts her body for- 124. S. H. Ingbar, “The Thyroid 2005), 109 concerning the figure of ward with almost sexual avidity,” a Gland,” Williams Textbook of the old woman. reminder of the association of sexual Endocrinology, 7th ed. 782. deviancy and goiter seen in Dutch 114. Ferris, “The Many Reasons genre paintings. He points out, too, 125. Styne 195. Why Goiter is Seen in Old Paintings,” that Queen Charlotte was “the subject Thyroid 18.4: 387–394 notes a of some of Gillray’s most brutal per- 126. Robert Rosenfield and Leona contrast between the old woman in sonal caricatures”(169). Cutler, “Somatic Growth and The Crucifixion of St. Andrew and Maturation,” Endocrinology, 4th ed. another elderly woman in a now lost 119. Godfrey compares their full 477. painting by Caravaggio of Judith and craws to “massive breasts culminating Holofernes, a copy of which is in the in nipple like knots” (169), another 127. N. B. Sutter, C. D. Bustamante, Museo Pignatelli, Naples. The latter example of sexualizing endocrine K. Chase et al, “A Single igf-1 Allele painting depicts a peasant woman abnormalities. is a Major Determinatnt of Small Size standing next to Judith as they con- in Dogs,” Science 316 (2007): 115. template the head of Holofernes. As Ferris notes, “the maid has a large

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128. S. D. Chernausek, P. F. 134. Michael Bliss, “Harvey Cushing (2000): 115–134, Miles claims that Backeljauw, F. Jetel, “Long-term and ‘Endo-Criminology,’” Endocrine “mutes and dwarfs had their own Treatment with Recombinant Insulin- News (August 2007) 35. quarter in the seraglio of the 1580’s” like Growth Factor (igf-i) in Children and continued to be part of the sul- with severe igf-i Deficiency due 135. James P. Allen, The Art of tan’s household for four centuries. to Growth Insensibility,” Journal Medicine in Ancient Egypt (New York: of Clinical Endocrinology and Metropolitan Museum of Art, Yale 142. The Accademia Galleries in Metabolism 92.3 (2007): 907. University Press, 2005) 24. Venice ed. Giovanna Nephi Scare (Milan: Electa, 1998) 85. Scare writes, 129. L. L. Levitsky, Editorial: 136. Dasen also notes that dwarfs “According to the writing at the base “Defining the Role of igf-i Therapy were apparently “regarded as per- of the pillar bottom left, the work for Short Children,” Journal sons in the full legal sense, who could was completed on April 20, 1573, of Clinical Endocrinology and marry and inherit civil and religious but three months later the artist was Metabolism 92 (2007): 813. functions” (157). accused of heresy for this vast composition which contained what 130. M. H. Aguiar-Oliveira, F. T. 137. “Pygmaioi,” Theoi Greek were considered to be excessive anti- Oliveira, R. M. C. Pereira et al, Mythology: Exploring Mythology in conformist elements” (85). “Longevity in Untreated Congenital Classical Literature and Art, http:// Growth Hormone Deficiency due to a www.theoi.com/Phylos/Pygmaioi.html 143. Betty M. Adelson, The Lives of Homozygous Mutation in the ghrh Dwarfs: Their Journey from Public Receptor Gene,” Journal of Clinical 138. An example of this motif in a Curiosity toward Social Liberation Endocrinology and Metabolism 95.2 Greek vase painting is reproduced in (New Brunswick, nj: Rutgers Univ. (2010): 716. Dasen, plate 67.2 (Lekythos, Paris, Press, 2005) 15. Louvre). 131. Armand Marie Leroi, Mutants 144. Leslie Fiedler, Freaks: Myths and (New York: Viking, 2003) 169–170. 139. Dasen also suggests that the Images of the Secret Self (New York: “inelegant attribute” of “conspicuous Simon and Schuster, 1978) 56. 132. Ambroise Paré, On Monsters and genitals” could reflect the belief that Marvels, J. C. Pallister trans. (Chicago: dwarfs had “affinities with satyrs,” a 145. Richard Cocke, Raphael Univ. of Chicago Press, 1982) 3. Paré notoriously libidinous half man-half (London: Chaucer Press, 2004) 95. lists” thirteen causes of monsters,” goat species in Greek mythology (173). including heredity, God’s “glory” 146. Wind also notes seventeenth and “wrath,” “the imagination” and 140. The Pitti Palace museum to century painter Domenichino’s “debt “Demons and Devils’ (3–4). which the Boboli Gardens are attached to Raphael’s Repulse of Attila” includes other examples of dwarf and suggests a “turning also to the 133. C. V. Schneider, De catarrhis, statuary as well as Bronzino’s famous Raphaelesque Vision of Constantine” Wittenberg, 1660–1662 and R. Lower: painting of the dwarf Morgante, in Domenichino’s Meeting of St. “Dissertio de origine catarrhi in a character in a fifteenth century Nilus and Otto III (1610, Italy, qua ostenditur illum non provenire a Florentine tale by L. Pulci. Grottaferrata Abbey) (23) . We also cerebro,” in his Tractatus de corde, see parallels between Raphael’s Vision (London edition of 1680) 163–175, as 141. M. Miles, “Signing in the of the True Cross and Domenichino’s quoted in Fielding Garrison, 268. Seraglio: mutes, dwarfs and Apollo Killing Two Cyclopes (1616, jestures [sic] at the Ottoman Court London, National Gallery). In both 1500–1700,” Disability and Society 1, paintings the placement of the dwarf

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in the right foreground, as if in the 151. Wind cites Steen’s The Egg 159. See Whitehead for a discussion position of a jester on the stage set of a Dance as an example of the “dwarf on Callot’s pictures of dwarfs. theater, suggests the painter’s mockery fiddler” illustrating “Steen’s taxonomic of the dwarf’s role. depiction of intemperance” (114). 160. Joseph Boruwlaski, The Life and Love Letters of a Dwarf: 147. See note 146 above on 152. Jonathan Brown, Painting in Being the Memoirs of a Celebrated Domenichino’s two paintings that fea- Spain (New Haven, Yale University Dwarf, Joseph Boruwlaski, a Polish ture dwarfs. Press, 1998) 126. Gentleman, trans. E. Freeman, (Birmingham, England: J. Thompson, 148. Merke notes, “At that time such 153. Maurizia Tazartes, Velasquez 1792) 131. a cretinous dwarf could not have (Firenze, Italy: Giunti Gruppo been such a great rarity in Lombardy, Editoriale, 1996) 27 (our translation). 161. C. J. S. Thompson, The Mystery where goiter and cretinism were so and Lore of Monsters (London: rife”(310), but we do not see evidence 154. Adelson claims, “tradition- Williams and Norgat) 240. Adelson of cretinism in the facial features of ally, dwarfs have been portrayed as states, however, that the children the figure. asexual, and their attentions as unwel- were eventually identified as “African come” (221). She notes, however, that Americanss born in the United 149. Merke also notes that in the dwarfs in antiquity were more readily States” (26). Palazzo Ducale at Mantova the associated with libidinousness (111). 162. “A Chapter on Giants and Gonzaga family built an “‘apparta- Dwarfs,” Sketch of the Life, Personal mento dei nani’ (apartment of the 155. Wind further argues that the Appearance, Character and Manners dwarfs) the architecture and dimen- presence of cards in Lezcano’s hands of Charles S. Stratton, etc. Robert sions of which are scaled throughout is “an appropriate attribute for this Bogdan Collection, (New York: to the diminutive stature of the foolish clown” 82. Wynkoop and Hallenbeck, 1863) 1, inmates: the rooms, stairs, doors, win- http://www.disabilitymuseum.org/lib/ dows and seating accommodation are 156. Kenneth Clark, from Looking docs/693.htm all adapted to dwarfs” (311). at Pictures (http://www.artchive.com/ meninas.htm) 163. The type and cause of Lautrec’s 150. Adelson argues that in this dwarfism has been much debated. painting, “in a deviation from the 157. Claustre Rafart i Planas, According to Leroi, “Lautrec was norm, one is given a view of dwarfs Picasso’s Las Meninas, trans. Valerie diagnosed with pycnodysotosis in who act on their own behalf and are Collins (Barcelona, Editorial Meteora, 1962 by two French physicians, Pierre not merely peripheral to the lives of 2001) 88. The discussion refers spe- Maroteaux and Maurice Lamy, but others” (151–152). Wind also points cifically to Figure 45 in Las Meninas their claim has not gone unchal- out that Molenaer’s painting “has (Isabel de Velasco and María Bárbola) lenged”; pycnodysotosis “is caused defied analysis,” citing three con- dated November 8, 1957. by a deficiency in the enzyme that trasting interpretations by Sutton, osteoclasts use to dissolve the protein Haecht and Schama that see the 158. James Beswick Whitehead, matrix of bones. During adulthood painting as, respectively “not sympa- Reflections of Rigoletto, 2001, www. the activity of this enzyme is partially thetic to deformity,” or as “a comment bjornetjenesten.dk/teksterdk/Rigoletto/ repressed by hormones” (164). on immoderate behaviour” or as “a reflections_of_rigoletto.htm. Whitehead paradigm of malevolence”(110). examines the possible origins of Verdi’s notorious gobbo Rigoletto, one of which may have been Bertholde.

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164. Adelson notes, “Emperaire was Chapter 4 175. Rolleston notes that the two not a curiosity to Cézanne, but a names (Byrne and O’Brien) were used friend whose complexity Cézanne rec- 167. “Caroline Crachami,” http://sur- interchangeably. He also notes that ognized and understood and perhaps gicat.rcseng.ac.uk/%28ykl5yojgrn1wmnu the giant “Magrath when about 16 identified with” (162). She cites a sim- qcnj0prig%29/detail.aspx# years of age and 6 feet 8 and 3⁄4 inches ilar interpretation of Cézanne’s iden- in height was befriended by Bishop tification with his subject in an article 168. Fitzmaurice’s photograph origi- George Berkeley (1685–1753), … and by Michael Gibson in “Cezanne: A nally appeared on the cover of Science it was widely believed in Ireland that Tenuous Triumph” available as article 316 (April 6, 2007). Magrath’s huge frame was the result 14934 in The World and I, June 1966, of the bishop’s experiments in giant- 1. http://www.worldandi.com/archive/ 169. See N. B. Sutter et al, “A Single rearing” 84. arjune.htm (n. 86, 396). igf-i Allele is a Major Determinant of Small Size in Dogs,” Science 316 176. In Knife Man (New York: 165. In a New Left Review (April 6, 2007): 112. Broadway Books, 2005) author Wendy (November–December 1960) article Moore writes that “[a]lthough on the Tate Museum’s 1960 exhibit of 170. Medvei notes that E. Launois the true cause of Byrne’s extreme Picasso’s work, art critic Martin Baillie and P. Roy reported that gigantism height was a mystery to Hunter … he reminds us that “La Nana, the dwarf occurs “before the epiphyses are fused was certainly aware that the untreated dancer, is a clearly defined personality and acromegaly occurs after condition generally spelled an connecting with us through her aggres- fusion” (313). early death. Giants had a reputation sive attitude, and markedly different for short lives, and Byrne, as he from the figures of the blue period” of 171. Schlomo Melmed, “Acromegaly,” freely declared in his advertisements, Picasso’s early work. Martin Baillie, New England Journal of Medicine 355 was already twenty-two” when “Early Picasso” (http://newleftreview. (2006): 2558. Hunter began to follow him (207). “But org/?view=100) death itself was no longer his greatest 172. E. Seaborg, “Catching fear. The Irish giant’s worst dread 166. Adelson points out that Dr. Josef Acromegaly Early,” Endocrine News was the anatomists, and especially the Mengel’s “infamous laboratory at (March 2008): 21. best-known anatomist of them all: Auschwitz” included experimentation John Hunter” (208). on dwarfs for the study of 173. R. J. Brown, J. J. Adams, R. heredity (38). Pelekanos, et al “Model for Growth 177. Mark Morford and Robert Hormone Receptor Activation Lenardon, Classical Mythology, 4th ed Based on Subunit Rotation within a (New York: Longman, 1991) 61. Receptor Dimer,” Natural Structure of Molecular Biology 12 (2005): 814–21, 178. Poseidon and the Gigante quoted in S. Melmed, 2560. Polybotes,” Theoi Greek Mythology: Exploring Greek Mythology in 174. Clark Sawin, “Defining Thyroid Classical Literature and Art, http:// Hormone: Its Nature and Control,” www.theoi.com/Gallery/K2.6.html Endocrinology: People and Ideas, ed. S.M. McCann (Bethesda, MD; 179. For a comparison, see American Physiological Society, “Gigantes,” http://www.theoi.com/ 1988) 179. Gigante/Gigantes.html

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180. Polyphemos,” Theoi Greek 185. Puglisi speculates that “he per- 191. In a rare fresco that has been Mythology: Exploring Greek haps studied his own features in the partially cut off, Piero della Francesca’s Mythology in Classical Literature and mirror—maybe the very same convex Hercules (ca. 1467, Boston, Isabella Art, http://www.theoi.com/Gigante/ one that appears as a prop in The Gardner Museum) draws attention to GigantePolyphemos.html Conversion of Mary Magdalen,” (109) strong limbs, a slightly bowed and “he more than likely used his right leg and massive hands, the latter 181. Homer, The Odyssey, trans. own features for an intense scrutiny of suggestive of acromegaly. The Robert Fagles (New York: Penguin, extreme facial expression with bulging bone structure and size of Hercules’s 1997) 9, ll.211–14. eyes and screaming mouth” (363). head, however, do not reveal the characteristics of acromegaly. This 182. Jon Bondeson, A Cabinet of 186. See Chapter 5 for a more com- head is so similar to male heads Medical Curiosities (Ithaca: Cornell plete discussion of Addison’s disease. in other works by the painter that one Univ. Press, 1997) notes the belief might deduce that Piero simply “that the human race had steadily 187. Jay Scott Morgan, “The Mystery exaggerated the body size in order to decreased in size and that before the of Goya’s Saturn,” New England illustrate the abnormality of gigan- Flood people had been at least fifty Review (2003) http://community.mid- tism. Hillard Goldfarb in his Isabella feet tall. The church was instrumental dlebury.edu/~nereview/22-3/morgan.html Stewart Gardner Museum: A in spreading the doctrine of the antedi- Companion Guide and History (New luvian giants, which had support from 188. Robert Hughes, Goya (New Haven: Yale Univ. Press, 1995) the Old Testament,” even going so far York, Knopf, 2002) 383. suggests that the work reflects as hanging “the giants’ bones in the “Piero’s … study of classical propor- churches for the inspection of all and 189. Hughes also notes that according tions and perspective” (51); thus the sundry” (73). to art historian Nigel Glendinning exaggerated size of the giant challenges “cited in Manuela Mena Marques, traditional theories of the “golden 183. Caravaggio’s earlier paintings ‘The Colossus,’ catalog #69 in Goya mean” in human proportions. of the story include David (Madrid, and the Spirit of Enlightenment” Museo del Prado) and David with the image of the giant “illustrates a 192. New Larousse Encyclopedia of the Head of Goliath (Vienna, prophetic poem by the Basque writer Mythology, trans. R. Aldington and D. Kunsthistorisches Museum). In both Juan Bautista Arriaza, La Profecía Ames (London; Hamlyn, 1974) 95. paintings the features of the giant de los Pirineos (The Prophecy of the are less exaggerated than those in the Pyrenees), (1808), which envisions a 193. Max Friedlander in Early Borghese painting. guardian spirit rising from the moun- Netherlandish Painting: From Van tains to crush Napoleon” (287 and n. Eyck to Brueghel (New York: Phaidon 184. Puglisi notes that the markings 14, 407). In this sense, The Colossus Publishers, 1956) discusses the uneven on the sword held by David “have might serve as a more positive symbol skill with which Bouts represented lately been interpreted ingeniously, if of the will of the Spanish people to human anatomy, an observation that not conclusively, as deriving from fight back. may explain why the giant’s legs an Augustinian commentary on the seem disconnected from his body and Psalms which equates David’s triumph 190. Uffizi Florence (NewYork why the viewer’s eye is drawn to over Goliath with Christ’s over and Milan, Italy: Newsweek: the giant’s head rather than the limbs: Satan and, symbolically, with humility Great Museums of the World and “Dieric’s talent was not sufficiently over pride” (360). Mondadori Editore, 1979) 56. robust and comprehensive to create out of his own resources an outstand- ingly impressive group, to make a

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movement flow through every limb gold was the noblest and stood Chapter 5 of a body; but his devout and careful highest; lead had less “spirit” and method of working could success- more matter and so stood lower. 199. “An Excess of Seed” in our fully fashion and animate a head or a (Alchemy was based on the belief chapter title refers to Paré’s theory hand” (31). As in the Goliath paint- that lead could be changed to gold that hermaphroditism occurs ings discussed above, the head of the through an infusion of “spirit.”) when the female partner produces as giant seems the most important feature The various species of plants, much “seed” as the male partner in the work. animals, humans, and angels were (Paré 26). See p. 160 in Chapter 5 of similarly ranked from low to high our book. 194. See “The Renaissance,” http:// within their respective segments. academic.brooklyn.cuny.edu/english/ Finally, it was believed that between 200. Museum object label for Amore melani/cs6/ren.html for a full explana- the segments themselves, there was and Psyche, Palazzo Altemps, Rome. tion of the concept of the Great Chain continuity (shellfish were lowest of Being in the Renaissance, high- among animals and shaded into 201. See Figure 5-8 and the second lighted as follows: the vegetative class, for example, part of this chapter for a full discus- because without locomotion, they sion of this painting. Among the most important of most resembled plants). the continuities with the Classical 202. See Lorraine Daston and period was the concept of the Great 195. Charles Byrne, Brought to Life: Katherine Park, Wonders and the Chain of Being. Its major premise Exploring the History of Medicine, Order of Nature, 1150–1750 (New was that every existing thing in http://www.sciencemuseum.org.uk/ York: Zone Books, 2001). Daston and the universe had its “place” in a broughttolife/people/charlesbyrne.aspx Park note that among the “three kinds divinely planned hierarchical order, of monsters” were “those produced by which was pictured as a chain verti- 196. Fiona Haslam. From Hogarth the mother’s imagination (for example, cally extended. (“Hierarchical” to Rowlandson: Medicine in hairy children)” (192). refers to an order based on a series Art in Eighteenth-Century Britain of higher and lower, strictly ranked (Liverpool, England: Liverpool 203. Stedman’s Medical Dictionary gradations.) An object’s “place” University Press) 285. (Baltimore, Williams and Wilkins Co, depended on the relative propor- 1961) 700. tion of “spirit” and “matter” it 197. “Serusier,” Olga’s Gallery http:// contained—the less “spirit” and the www.abcgallery.com/S.serusier/serus- 204. Today, these conditions are gen- more “matter,” the lower down it ierbio.html erally referred to as disorders of sexual stood. At the bottom, for example, development, a term that is thought to stood various types of inanimate 198. Anthony Read and David have less disparaging associations than objects, such as metals, stones, and Fischer, Berlin Rising (New York: specific terms in earlier usage such as the four elements (earth, water, W. W. Norton and Co., 1994) 37. those listed above. In our reference to air, fire). Higher up were various art that depicts such disorders, how- members of the vegetative class, ever, we use the term hermaphroditism like trees and flowers. Then came to reflect accurately the historical con- animals; then humans; and then text of the works discussed here. angels. At the very top was God. Then within each of these large groups, there were other hierarchies. For example, among metals,

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205. J. H. Kiefer, “The 209. Daston and Park note that ably influenced by the philosophy of Hermaphrodite as Depicted in Art and Riolan “scoffed at Columbo “for mis- Aristotle” (Brewer’s Dictionary of Medical Illustration,” Trans American taking an enlarged clitoris for a penis” Phrase and Fable 1111). Association Genito-Urinary Surgeons and “castigated even more severely the 58 (1966): 121. provincial physician Jacques Duval 214. Wendy Moore 204, quoted in in Duval’s defense “of the Rouen her- Orlo H. Clark, “The Influence of 206. F. Guirand, “The Mythology maphrodite Marie/Marin le Marcis” Endocrine Surgery on General Surgery of Classical Greece,” New Larousse (203). Later in this chapter we discuss and Surgical Science,” presidential Encyclopedia of Mythology (London: Duval’s defense in more detail. address delivered at the Pacific Coast Hamlyn Publishing, 1974) 132. Surgical Association, February 14, 210. In modern usage, the word 2009 in San Francisco, Archives of 207. Kathleen Long, Hermaphrodites virago, derived from the Latin vira- Surgery 144 (2009): 802. in Renaissance Europe (Burlington, gine, refers to a “bold, impudent vt: Ashgate Press, 2006) 11. Long also woman” (oed), but in sixteenth 215. In many ways it is surprising notes the argument of Marie Delcourt century England the word had a more that Hunter’s transplantation experi- in Hermaphrodite: Mythes et rites de sexually pointed definition, referring ments were successful because in most la bisexualité dan l’antiquité clas- to a “man-like, vigorous, and heroic situations transplants from one animal sique “that in pre-historic cults, the woman”(oed). The term continues to another would be rejected without hermaphrodite was a figure of divine to have a negative connotation, sug- effective immunosuppressive therapy. power, of fertility and procreation, of gesting that qualities considered tra- the union of mother and child” (11). ditionally male are never regarded as 216. It wasn’t until 1911 that Tandler Long suggests, however, that the comic attractive in a woman. and Keller explained that freemar- representation of hermaphrodites by tins occur only when the female twin the 4th century bce Greek playwright 211. Medvei 238, n. 115. Medvei shares a common placental circulation Aristophanes is “ambiguous at best” quotes Ambroise Paré’s Les causes with her male sibling. The changes (11) and that Renaissance philoso- pourquoi le flux menstrual est retenu that occur are caused by the expo- phers such as Leone Ebreo (16th aux femmes,Vingt-troisième livre, sure of the female twin to testosterone century) combine the idea of “the spir- Chapter lx. despite the absence of a y-chromosome itual androgyne with the monstrous and anti-mullerian hormone(Medvei hermaphrodite,” 9. 212. We have summarized here depo- 200). sitions of Marin/Marie Lemarcis and 208. Kiefer’s reference to the hypo- Jeanne Lefebvre recorded in sixteen 217. Roy Porter, The Greatest Benefit spadic penis, that is, the end of the statements included in “La Storia to Mankind (New York: Norton, urethra at the base rather than at the dell’ermafrodito di Rouen: Dossier 1997) 563. end of the penis, suggests that the medico-legale del 1601” in Jacques sculptor of the Hermaphrodite of Duval, L’Ermafrodito di Rouen, una 218. A. Boualem, M. Fergang, Mirecourt most likely worked from Storia Medico-legale del XVII Secolo, R. Fernandez et al, “A Conserved direct observation because hypospa- ed. Valerio Marchetti (Venice, Marsilio Mutation in an Ethylene Biosynthesis dius is a relatively common congenital Editori, 1988) 69–103. Enzyme Leads to Andromonoecy in abnormality (121). Melons,” Science (2008) 321 (2008) 213. “Thomistic thought” refers to the 321: 836. followers of St. Thomas of Aquinas, who “drew a clear distinction between Faith and Reason and was consider-

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219. J. S. Miller and P. K. Diggle, 228. Geeta Lal and Orlo Clark, 234. J. D. Bilezikian, J. T. Potts, “Diversification of Andromonoecy “Endocrine Surgery,” Greenspan’s Basic Summary Statement from a work- in Solanum Section Lasiocarpa and Clinical Endocrinology, 8th ed. 924. shop on Asymptomatic Primary (Solanaceae): The Roles of Phenotypic Hyperparathyroidism, A Perspective Plasticity and Architecture,” American 229. D. G. Gardner, “Multiple for the 21st Century, Journal Journal of Botany (2003) 90: 707. Endocrine Neoplasia,” Greenspan’s of Clinical Endocrinology and Basic and Clinical Endocrinology, Metabolism 87.12 (2003): 5353. 220. Felix Conte and Mel Grumbach 8th ed. 835. “Disorders of Sexual Discrimination and 235. S. H. Huang, “Familial Differentiation,” Greenspan’s Basic and 230. B. M. Branckhof and O. Grim, Hyperparathyroidism,” Textbook of Clinical Endocrinology, 8th ed. 568. “Extrathyroidal Manifestations of Endocrine Surgery, 2nd ed. Multiple Endocrine Neoplasia Type 2,” 221. C. A. Quigley, “Genetic Basis Thyroid 19 (2009): 555. 236. S. M. Coleco, M. Si, E. Reiff, of Sex Determination and Sex O. H. Clark, “Hyperparathyroidism Differentiation,” Endocrinology, 231. Orlo H. Clark, “‘Asymptomatic’ after Radioactive Iodine Therapy,” 4th ed. 1931. Primary Hyperparathyroidism: Is American Journal of Surgery 194.3 Parathyroidectomy Indicated?” Surgery (2007): 326. 222. L. E. Underwood and J. J. Van 116 (1994): 943–956. Wyk, “Normal and Aberrant Growth,” 237. R. Fazel et al, “Exposure to Low Williams Textbook of Endocrinology, 232. R. Udelsman, J. Pasieka, Dose Imaging Radiation from Medical 7th ed. 155. C. Sturgeon et al, “Surgery Imaging Procedures,” New England for Asymptomatic Primary Journal of Medicine 361 (2009): 849. 223. A. G. Frantz, J. D. Wilson, and Hyperparathyroidism: Proceedings of D. W. Foster “Endocrine Disorders the Third International Workshop,” 238. “Sir John Mandeville,” of the Breast,” Williams Textbook of Journal of Clinical Endocrinology and Novelguide.com, http://www. Endocrinology, 7th ed. 415. Medicine 94.2 (Feb.2009): 368. novelguide.com/a/discover/ewb_10/ ewb_10_04161.html 224. Glen Bronstein, “Gynecomastia,” 233. A common jingle familiar to New England Journal of Medicine 357 endocrinologists and endocrine sur- 239. Sir John Mandeville, 1300–1399, (2007): 1229. geons. See the following articles for The Travels of Sir John Mandeville a more detailed discussion of the (Memphis, tn: General Books, 225. M. P. Rosen and M. I. Cedars, symptoms of hyperparathyroidism 2010) 77. “Female Reproductive Endocrinology summarized in the jingle: M. S. and Infertility,” Greenspan’s Basic and Egelberger et al, “The NIH Criteria for 240. Catherine Johns, Sex or Symbol: Clinical Endocrinology, 8th ed., 529. Parathyroidectomy in Asymptomatic Erotic Images of Greece and Primary Hyperparathyroidism: Are Rome (London: British Museum Press, 226. D. H. Nelson, “Pituitary-Adrenal they too limited?” Annals of Surgery 1989) 105. System,” Endocrinology: People and 239.2 (2004): 1–8; J. L. Pasieka and Ideas 87. L. C. Parsons, “Prospective Surgical 241. Ovid, The Metamorphoses, Book outcome study of relief of symp- IV, trans. Horace Gregory (New York, 227. R. L. Zwemer, “An Experimental toms following surgery in patients Viking, 2001) 122. Study of the Adrenal Cortex: The with primary hyperparathyroidism,” Survival Value,” American Journal of World Journal of Surgery 22 (1998): Physiology 79 (1927): 656. 513–528.

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242. Maryan W. Ainsworth with 248. See Chapter 2 for a full discus- 252. Roy Porter, Bodies Politic, 234. Lorne Campbell, “Mythological sion of this painting. The presence of Themes,” Man, Myth, and Sensual an enlarged goiter in the naked female 253. English Caricature: 1620 to the Pleasures: Jan Gossart’s Renaissance, figure further adumbrates evidence Present (London: Victoria and Albert The Complete Works, ed. Maryan of her female characteristics, whereas Museum, 1984) 89. W. Ainsworth, Stijn Alsteens, and the bright feathers suggesting male Nadine M. Orenstein, (New York: plumage and the large, almost mas- 254. Art Encyclopedia: James Gillray, Metropolitan Museum of Art and Yale culine, hand covering the pubic area Answers.com, http://www.answers.com/ University Press, 2010) 224. of the robed figure may imply that topic/james-gillray the figure is covering male genitalia. 243. Edward Lucie-Smith, Sexuality Furthermore, the presence of a mask- in Western Art (London: Thames and like face over the robed figure’s breasts Hudson, 1991) 25. suggests the features of an old man.

244. Figure 5-4 is also reproduced as 249. Leroi documents that the Paré’s Figure 19, “Picture of a her- Hapsburgs and the Farneses “could maphrodite man-and-woman” in Of not get enough of” the “hairy” Monsters and Marvels (28). Gonsalvus clan. He also notes the portrait of Arrigo’s sister Tognina, which 245. Laurinda Dixon, Bosch (London: “shows the little hairy girl dressed in Phaidon Press, 2006) 251. silvery brocades, smiling sweetly as she holds a document recounting her his- 246. J. Stalabrass refers to “Geoffrey tory aloft” (271–272). Hinton’s reading of this work in the light of Freud’s Schreber case, where 250. In his discussion of the painting, the sun stands for God and the father, Leroi also notes that Arrigo wears a the moon for the mother, where the “tamarco,” a cloak that alludes to sun’s rays are attached to the body, the “Guanches, who once inhabited and where Schreber saw himself as a Tenerife in the Canary Islands but hermaphrodite” (54). who had been briskly subjugated and largely exterminated by the Spanish 247. See note above for a discussion a hundred years before” (270–271). on gender theory and the role of the These details further suggest that the female addressed in both Ernst paint- Gonsalvus family members were kept ings (54 and 98). almost as “pets” as well as curiosities in the court.

251. Cocke notes that the implied comparison between the Pope’s Borgo apartment and the Trojan palace is used to “ennoble the Borgo” by suggesting the lineage from Aeneas, the mythical founder of Rome, to the papacy (88).

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GLOSSARY OF MEDICAL TERMS Androdiocy: A “sexual system in Cabergoline: A dopamine agonist which males co-occur with hermaph- (stimulant) that normalizes igf-i levels rodites, which have both male and in about 30% of patients with acro- Achrondroplastic dwarfism:A female function.” Science 327 (2010): megaly. It is usually used with soma- congenital disorder of bone formation 1648–1650, 2 tostatin analogue therapy for better that results in deformities of the results. (Greenspan 150) skeleton with small stature. (nwd) Androgen: male sex hormone. Cardiomyopathy: Weakness of the Acidosis: “A condition in which the Andromonoecy: A “sexual system in muscle of the heart. body’s alkali reserve is below normal, which plants produce both hermaph- because of faulty metabolism.” (nwd) roditic and female-sterile … staminate Carpal tunnel syndrome: flowers…. Andromonoecy is often Numbness and weakness of the hand Acromegaly: A growth disorder considered a form of phenotypic plas- caused by entrapment of the median characterized by progressive enlarge- ticity.” American Journal of Botany 90 nerve at the wrist. ment of the head and jaw, feet and (2003). 5 707–715 thorax due to increased levels of Catecholamines: Hormones secreted growth hormone in the adult. (s 39) Androstenedione: A precursor by the adrenal medulla, such as nor- hormone involved in the synthesis of epinephrine and dopamine, that affect ACTH (Adrenocorticotropic testosterone and secreted by the testis. blood pressure and are termed the hormone): A pituitary hormone (Williams 265) “fright, flight and fight hormones.” that stimulates cortisol secretion and growth of the adrenal cortex. Angioma: a benign vascular tumor. Chromosomal: “A rod-shaped or threadlike body of chromatin in the Addison’s disease: A disease caused Aneurysmatic: Relating to a dilated cell nucleus, which splits longitudi- by cortisol deficiency with symptoms artery. nally as the cell divides, one half going of weakness, fatigue, nausea, to the nucleus of each of the daughter hypotension (low blood pressure) and Benign: Describing the mild character cells.” (S318) classic yellowish skin pigmentation, of an illness or the non malignant and darkening of the palmar (hand) character of a neoplasm or tumor. (S200) Cortisol (hydrocortisone): “A hor- creases with hyponatremia, (low blood mone of the adrenal cortex … active in sodium), hyperkalemia, (high blood Bronchial cleft cyst: A congenital, carbohydrate metabolism.” (ahd 328) potassium) and acidosis. benign, usually cystic lateral neck mass. Cushing’s disease: Pituitary secre- Adenoma: A non cancerous or Bronchiocele: “A circumscribed tion of acth, causing increased benign growth. dilatation of a bronchus.” (S233) adrenal secretion of cortisol.

Allele: “Any of a group of possible CAH: Congenital Adrenal Hyperplasia. Cushing’s syndrome: A syndrome mutational forms of a gene.” (ahd) This condition is “responsible for most associated with increased cortisol cases of female pseudo-hermaphro- levels. The increased cortisol is the Androgyny: Existence of character- ditism and about 50% of all causes of result of one or more of the following: istics of both sexes in one person. The ambiguous genitalia. There are six a increased secretion of acth by a tendency to be “neither distinguishably major types of cah all transmitted as pituitary tumor (Cushing’s disease); b masculine nor feminine, as in dress, autosomal (a non sex chromosome) ectopic secretion of acth by neuro- appearance or behavior.” (ahd 108) recessive disorders.” (Greenspan 584) endocrine tumors (ectopic Cushing’s);

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increased cortisol secretion from Elephant man syndrome: embryonic development with the result benign or adrenal coritcol tumors. The Neurofibromatosis type 1, also called that the sex hormone of the male syndrome is characterized by Von Recklinghausen’s disease; an is conveyed in the circulation to the obesity with central fat distribution, autosomal dominant (non-sex related) female twin and influences its sexual moon and reddened facies, buffalo inherited disorder. Individuals with the development.”(s 614) hump, hirsuitism, supra clavicle syndrome have subcutaneous neu- fat pad enlargement, purple abdominal rofibromas (nerve tumors), café au Ganglioneuroma: “A benign striae, weakness, psychological lait spots, freckles in the axilla, and neoplasm composed of mature disturbances, gonadal dysfunction, adrenal medullary tumors (pheochro- ganglionic neurons, in varying and glucose intolerance. mocytomas). The abnormal gene is numbers, scattered singly or in clumps located on Chromosome 17. within a relatively abundant DSD: Disorders of sexual and dense stroma of neurofibrils and development. Endemic goiter: The presence of collagenous fibers.” (s 627) an enlarged thyroid gland prevalent Diabetes mellitus: “Clinical diabetes in certain regions and usually due Genital hypoplasia: Decreased or mellitus is a syndrome of disordered to iodine deficiency. (s 654 and arrested growth of the external glucose metabolism with inappro- Greenspan 658) genitalia. (nwd 692) priate hyperglycemia due either to an absolute deficiency of insulin secre- Epiphysis: The growth plate for the Glucocorticoids: “Any principle tion or a reduction in the biological growth of long bones. in the adrenal cortex that affects the effectiveness of insulin (or both).” metabolism of glucose.” (s 649) (Greenspan 672) Estrogen: “The generic term suggested for all substances which pro- Goiter: An enlargement of the thyroid Dopamine: “An important duce estrus whether derived from the gland, which may be diffuse, nodular neurotransmitter and a precursor of ovary or not. Estrogen also produces and hypo or hyperfunctioning. (s 654) norepinephrine (a hormone found in growth of female secondary sexual the adrenal medulla and in adrenergic characteristics….” (s 543) Goitrogen: Any substance that nerves).” (Greenspan 432). stimulates thyroid growth. (s 654) Ethymoid: “Resembling a sieve; Dopamine agonists: Agents, such cribriform [perforated with holes] … Gonadotrophic stimulating as levodopa, apomorphine, and relating to the ethymoid bone.” (s 545) hormone: Pituitary hormones bromocriptine that increase growth including luteinizing hormone (lh) hormone secretion, whereas dopamine Exophthalmos: Bilateral or unilat- and follicle-stimulating hormone antagonists such as phenothiazines eral protrusion of the eyeballs often (fsh) that stimulate the breast and inhibit growth hormone secretion. associated with Graves’ disease. gonads. (Greenspan 118) Familial: Common to a family. Gonad: A sex gland, the ovary in Dysphasia: Difficulty swallowing. (nwd 505) females and testicle in man.

Dyshormonogenesis: Abnormal Freemartin: “ A masculinized, biosynthesis of thyroid hormone. female twin calf, caused by the twin fetuses being of opposite sexes. The chorions [vascular network] become fused at a very early stage of

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Gonadotrophic hormone: Growth hormone: A pituitary hor- abdominal groans, psychic moans A hormone from the hypothalamus mone required for normal growth. and fatigue overtones” usually associ- that stimulates the gonadotrophs in Insufficient gh results in short stature. ated with hypercalcemia (excessive the pituitary gland. The gonadotrophs Excess growth hormone results in blood calcium). are pituitary cells that secrete acromegaly in adults and gigantism in luteinizing hormone and follicle-stim- children. Hyperplasia: An increased number ulating hormone that regulate gonadal of cells. function and the secretion of sex Gynecomastia: “Excessive develop- hormones. (Greenspan 122) ment of the male mammary glands, Hyperthyroidism: A condition sometimes secreting milk.” It is usually caused by inappropriately high circu- Gout: A metabolic disorder due to asymptomatic and may be unilateral lating thyroid hormone levels. deposition of sodium urate crystals in or bilateral. (S668) the joint spaces characterized by recur- Hypoglycemia: The condition of rent episodes of acute pain usually Hashimoto’s thyroiditis: An auto- having low blood sugar. in the great toe but can occur at any immune disease of the thyroid also joint. (S657) called chronic lymphocytic thyroid- Hypopituitarism: Decreased func- itis, which may result in a goiter tion of the anterior pituitary gland. Graves’ disease: An autoimmune and is the most common cause of (S744) disease associated with hyperthy- hypothyroidism in the United States. roidism and often exophthalmic goiter (Greenspan 264) Hypophysectomy: Removal of the described by the Irish physician Robert pituitary gland Graves in 1835. Hereditary: “The transmission of characteristics from parent to offspring Hypospadius: A developmental Ghrelin: Ghrelin is a gastrointestinal by means of genes in the chromo- abnormality in which the urethra peptide that is an endogenous ligand or somes.” (nwd) opens proximal to the end of the penis hormone for the gh receptor. “Ghrelin in males and in the vagina in females. increases appetite, body weight, and gh Hirsutism: “Heavy growth of hair, secretion in both animals and humans, often in abnormal distribution.” (ah) Hypothalamus: A part of the brain suggesting that it has an important that forms the floor of the third ven- role in energy homeostasis.” Low igf-i Hermaphrodite: “Androgyne; a tricle. It regulates many body func- levels are associated with increased person whose genital organs have the tions such as temperature. (nwd) gherlin levels. (A Uckum-Kitapei, characters of both male and female in A. Haqq, J. Purnell, et al, “Serum greater or less degree.” (S700) Hypoparathyroidism: A condition Ghrelin Concentrations are increased of too little parathyroid hormone, in Children With Growth Hormone Homunculus: “A little man; dwarf; resulting in low blood calcium and Insensitivity and Decrease During manikin.” (nwd) increased phosphorus levels. Long-Term Insulinlike Growth Factor-I Treatment.” Journal of Investigative Hyperglycemia: A condition of Hypothyroidism: A condition Medicine 56 (2008) 1: 26–31 elevated blood sugar. caused by inadequate amounts of thyroid hormone. Growth hormone receptor: A Hyperparathyroidism: A disorder binding site for growth hormone caused by the increased secretion of Idiopathic: Referring to a disease for which is linked to igf-i and igf-ii. parathyroid hormone by one or more which the cause is unknown parathyroid glands sometimes causing “painful bones, kidney stones,

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Infundibulum: The funnel shaped Marfan’s syndrome: A non-sexually disorder on Chromosome II. Clinical stalk of the brain (S770) related dominant abnormality of con- abnormalities in families with nective tissue caused by a mutation men-i include: hyperparathyroidism, Insulin-like growth factor 1 (IGF-1): on chromosome 15, resulting in tall pancreatic neuroendocrine tumors, A substance that belongs to a stature, long fingers, hyperextension of pituitary tumors, lipomas, angiomas family of polypeptides and stimulates joints with other vascular abnormali- and adrenal tumors. cartilage dna synthesis. “The major ties. (Greenspan 206) hormonal determinant of plasma igf-i Multiple Endocrine Neoplasia concentration is growth hormone.” Medullary thyroid cancer: Type II: men-ii is an autosomal (a (Endocrinology, 445) Malignant tumors that originate non sexual chromosome) disorder due from the parafollicular or to a ret mutation on Chromosome Intracranial: Within the skull. calcitonin producing cells (c cells) 10. Family members with men-ii-a of the thyroid gland. have medullary thyroid carcinoma, Kyphosis: An abnormal curvature of pheochromocytomas, hyperparathy- the spine with hump-back. Melanocyte stimulating hormone: roidism, and lichen planus amyloidosis A pituitary hormone mediated by (thickened skin over the scapula). Laron’s dwarfism:The condition of hypothalamic factors and inhibited by Individuals with men-ii-b have med- small persons with growth hormone melanocyte inhibiting factor. ullary thyroid cancer, pheochromo- insensitivity with elevated gh levels (Williams 518) cytomas, a marfanoid habitus with due to absent or decreased igf-i and multiple ganglioneuromas. lack of negative feedback inhibition. MENIN gene: This tumor suppressor (Greenspan 195) gene on Chromosome 11 is respon- Mullerian ducts: Ducts that develop sible for men-i syndrome “Almost 300 from mesodermal epithelium on the Leydig cells: Cells in the testes that independent mutations have been surface of urogenital folds and eventually secrete testosterone. described in men-i kindreds to date.” become the oviducts, the uterus and (Greenspan 833) the vagina. (W. Bloom and D. W. Lipids: Compounds such as fat that Fawcett, The Textbook of Histology are insoluble in water. (S869) Mesomorphic: Characterized by a (Philadelphia: Saunders, 1962) 621) muscular body habitus. Lipoma: A benign fatty tumor. Myxedematous cretinism: Millet: A small grain used for food Congenital hypothyroidism due to Lymphadenopathy: “Any disease in Europe and Asia that can be a congenital thyroid hormone deficiency process affecting a lymph node or goitrogen causing thyroid enlargement. or lack of thyroid hormone in early lymph nodes.” (S885) (nwd 902) childhood. It causes growth failure and mental retardation resulting in Luteinizing hormone: Secreted by Mongolism: “A congenital disease dwarfed idiots. (S372) the basophilic cells in the pituitary that characterized by mental deficiency, a regulate gonadal function. (Williams broad face, slanting eyes, a short fifth Nasopharynx: Also termed the 262–263) finger, etc.: the preferred term is now rhinopharynx, it is the upper Down’s syndrome.” (nwd 919) portion of the pharynx above the Malignancy: A cancer or sarcoma palate. (S1303) with uncontrollable growth and Multiple Endocrine Neoplasia dissemination. (S896) Type I: Also known as Wermer’s syndrome is an autosomal dominant

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Neoplasm: Any new growth of cells Papillary: Having small nipple like Pyramidal lobe: A midline pro- or tissues. The neoplasm can be benign projections. Papillary thyroid cancer trusion of thyroid tissue extending or malignant. is the most common type of thyroid towards the upper neck usually cancer. through the notch in the thyroid Neurofibroma:A firm tumor origi- cartilage. nating in a nerve. Parathyroid: An endocrine gland adjacent to the thyroid that is impor- Ret oncogene: Specific proto-onco- Neurofibromatosis:Also called tant for the regulation of the blood genes found on chromosome 10, von Recklinghausen disease, it is an calcium level. causing medullary thyroid cancer. inheritable disease characterized by (Greenspan 297) individuals having several to numerous Pegvisomant: A growth hormone neurofibromas. (S1023) receptor antagonist that when injected Scrofula: “Tuberculosis of the subcutaneously in patients with acro- lymphatic glands.” (nwd) Noonan’s syndrome (male megaly reduces igf-i levels to normal Turner’s syndrome): These in about 90% of patients. It is new Single-nucleotide polymorphism individuals are short with a webbed and expensive and is usually pre- haplotype (SNP): “Single-nucleotide neck, hyperteliorism and other scribed when surgery and somatostatin polymorphism (snp, pronounced deformities. Patients are genotypic and analogues have failed. (Greenspan snip) is a dna sequence variation phenotypic males and have many 150) occurring when a single nucleotide— of the clinical features of Turners’s a, t, c, or g—in the genome (or other syndrome (characterized by short Pheochromocytoma: Benign and shared sequence) differs between stature, sexual infantilism, amenorrhea, malignant tumors arising from the members of a species or paired webbed neck, ovarian dysgenesis and medullary cells of the adrenal glands chromosomes in an individual. For other abnormalities with the absence of that secrete catecholamines usually example, two sequenced dna one x chromosome). (Greenspan 525) causing hypertension and increased fragments from different individuals, perspiration. aagccta to aagctta, contain a Organotherapy: “The treatment of difference in a single nucleotide. disease with extracts of animal organs, Pre tibial myxedema: Thickening of In this case we say that there are two as of the glands of internal secretion.” the skin usually on lower anterior leg alleles: c and t. Almost all common (nwd 1002) (pre tibial), a dermopathy associated snps have only two alleles.” with Graves’ disease. (Greenspan 250) (http://en.wikipedia.org/wiki/ Oogenesis: Production of eggs Single-nucleotide_polymorphism) Pseudogout: A metabolic disorder Osteitis fibrosis cystica:High similar to gout but caused by the Somatostatin analogues: Hormones turnover bone disease associated with deposition of calcium pyrophosphate that inhibit insulin release and its syn- primary (rarely) and secondary crystals in the joint spaces. thetic analogue octreotide are used to hyperparathyroidism with skeletal treat patients with hyperinsulinism. abnormalities and brown tumors Pygmies: Small persons with low of bone. (Greenspan 302) igf-i and normal growth hormone and Somatostatin: A hypothalamic igf-ii levels. hormone that inhibits the pituitary Ovotesticular: Referring to true secretion of gh and tsh. Somatostatin hermaphrodites with both ovarian and cells are also present in the pancreas testicular tissue in one or both gonads and gastrointestinal mucosa. (Greenspan 583)

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Somatotrophic cells: These are Tumor: A swelling in the body Abbreviated References acidophilic gh-secreting cells situ- that may be benign or malignant. ated laterally in the anterior pituitary. S= Stedman’s Medical Dictionary, (Greenspan 105) Turner’s syndrome: See Noonan’s 20th ed. syndrome above. Spermatogenesis: Production of NWD = Webster’s New World sperm in males. Undescended testicle: Failure of Dictionary, 2nd ed. the testicle or gonad to descend into Sternocleidomastoid muscle: the scrotum. AMH = American Heritage A muscle in the neck that originates Dictionary, 2nd ed. by two heads from the anterior surface Virilism: “The presence of male of the manubrium (sternum) and secondary sexual characteristics: Greenspan = Greenspan’s Basic and sternal head of the clavicle and inserts hypertrichosis [excessive body hair], Clinical Endocrinology, ed. Gardner on the mastoid process and outer small breasts, broad shoulders, etc. and Shoback, 8th ed. half of the superior nuchal line of the in a woman” (s 1643) occipital bone. It functions to turn and Endocrinology = Endocrinology, ed. lower the head downward. (S982). De Groot and Jamison, 4th ed.

Struma: From the Latin meaning a Williams = Williams Textbook swollen neck caused by tuberculous of Endocrinology, ed. Wilson and adenitis or scrofula or goiter. Formerly Foster, 4th ed. any distinct swelling in the neck. (S1431)

Testosterone: male hormone.

Thiocyanate: An antithyroid compound that causes hypothyroidism and goiter. (s 1528)

Thyroid stimulating hormone: A pituitary hormone that stimulates the secretion of thyroid hormone and growth of the thyroid gland.

Thyroid storm: “An acute exacer- bation of all of the symptoms and signs of thyrotoxicosis, often presenting as a syndrome that may be of life-threatening severity.” It usually occurs in patients with Graves’ disease. (Greenspan 252–253)

Trachea: The windpipe that transmits air from mouth to lungs.

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212 The Remarkables

Index Annunciation (Lippi), 28 Calabazas (Velasquez), 91 Apollo, 7 Callot, Jacques, 116 Aristotle, 4, 7, 8, 68, 94, 98, 152–154 Campana, Giacinto A Daydream (Rossetti), 11 Generation of Animals, 152 The Rape of Helen, 35 Abul Kasim Arthora Vega, 66 Cantimpré, Thomas de First thyroid operation, 67 artist’s studio, compared to anatomy De Monstruosis Hominibus, 72 acromegaly. See gigantism theater, 3 Caravaggio, 5, 8, 15, 31, 56, 57, 59, Adam and Eve (Holbein), 13 Aschner, Bernard, 96 60, 61, 64, 84, 86, 87,132, 134 Addison, Thomas, 157 Conversion of Mary Magdalene, Assumption (Titian), 48 Addison’s disease, 5, 6, 134, 157, 169, 57 172 David with the Head of Goliath, Baber, Cresswell, 158 132 Adonis, 7 Balacesco, 96 Judith Beheading Holofernes, 56 adrenal function, 5 Banquet of Antony and Cleopatra Madonna of the Palafrenieri, 31 Albertinelli, Mariotto, 34 (Trevisani), 104 Madonna of the Pilgrims, 31 Creation and Fall, 34 Medusa, 134 Basedow, Carl von, 69 Albucasis. See Abul Kasim The Crucifixion of St. Andrew, 84 Bauhinus, Caspar, 95, 152 Allbut, Sir Thomas The Supper at Emmaus, 59 The Thyroid Gland: Medical Benda, Carl, 127 Carpaccio, Vittore History, 67 Berthold, Arnold Adolf, 68, 70, 155 Arrival of the English Allen, Bennet M., 128 Bertholde, a Dwarf (Walker), 116 Ambassadors at the Court of the King of Brittany, 104 Alexander of Hales, 94 Bes (Dwarf God), 97 Carracci, Composition with Figures Amore and Psyche, referred to,149 Billroth, Theodore, 69, 70 and Animals, 168 An Angel Playing the Viola da Braccio Bockshammer, Karl, 70 Casserius, Julius from Musical Apostles and Angels Bonet, Theophile, 127 description of thyroid, 19 (da Forli), 60 Bordeu, Theophile de, 68, 95 Caulfield, James, Remarkable Persons, Anatomical dissection, 3 Boruwlaski, Joseph (eighteenth-cen- 8 Anatomy Act of 1836 (uk), 68 tury dwarf), 118 Celsus, Aulus Cornelius, 18, 66 Anatomy theaters, 3–8 passim, 19, 66, Botticelli, 5, 89 Cerrini, Gian Domenico 67, 68 Annunciation, 28 David with Goliath’s Head, 134 Bologna, 3 Judith’s Return to Bethulia, 56 Cézanne, Paul, 121 Leiden, 3 Madonna with the Book, 31 Portrait of the Artist’s Friend, Padova, 3 Portrait of a Young Woman, 42 Achille Emperaire, 121 Anderson, E. M., 128 Scenes from the Life of Moses, 53 Charcot, J.M. and Paul Richer, essay androgyny, 161 The Daughters of Jethro, 53 The Three Graces (La Primavera), on psychological illness in art, 84 Angelica Saved by Ruggiero (Ingres), 12, 38 Charles Byrne, The Irish Giant 39 bronchiocele, 17 with an Admiring Audience Anglicus, Bartholomaeus, and carica- (Rowlandson drawing), 145 tures of goiters, 72 Brown, Jonathan, 108 Annunciation (Botticelli), 28 Burne-Jones, Edward, 38 Annunciation (da Forli), 27 Byrne, Charles, 125, 127, 144

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Carol Z. Clark & Orlo H. Clark, MD 213

Coello, Alonso Sánchez, 111 da Vinci, Leonardo, 5, 14 Don Diego de Acedo or El Primo Portrait of Infanta Isabel Clara Grotesque Man with Goitre, 73 (Velasquez), 108, 109 Eugenia and Magdalena Ruiz, 111 Madonna and Child, 14, 26 Dossi, Dosso Collip, James, 128, 159 drawings of thyroid, 19 Maga Circe or Melissa, 35, 36 Columbus, Realdus, 152 David with Goliath’s Head (Cerrini) Downs’ syndrome, 113 Figure 4-6, 134 Composition with Figures and Duck, Jacob Animals (Carracci), 165, 168 David with Goliath’s Head The Sleeping Woman, 88 (Gentileschi), 134 Conte, Felix, 155 Duval, Jacques, Des hermaphrodits, David with the Head of Goliath Conversion of Mary Magdalene accouchemens des femmes, e (Caravaggio), 132 (Caravaggio), 57 traitement qui est requis pour les David, Conqueror of Goliath (Reni), relever en santé bien elever leurs Cornell Medical School, and art 135 enfants, 153 appreciation, 3 De Fabrica dwarfism, 5 Cotån, Juan Sánchez (Vesalius), 19 and growth hormone (igf-i), 93 La Barbuda de Peñaranda, 167 de Geyn, Jacob history of diagnosis, 94 Count Joseph Borowlaski (Reinagle), Temperantia, 40 mechanisms of the pituitary 117 gland, 92 de Medici, Catherine (breeding a race Crachami, Caroline, 125 of dwarfs), 94 Creation and Fall (Albertinelli), 34 de Mieris, William endocrine disease cretinism, 4, 5, 6, 17, 19, 61, 65, 67, The Escaped Bird, 40 and morality in art, 7 68, 76, 88, 92, 113, 127 and religious explanation, 18 del Piombo, Sebastiano cretins (dwarfs with congenital hypo- The Martyrdom of Saint Agatha, “endo-criminology,” 96 thyroidism), 93, 113 52 endocrinology Crile, George Washington, 71 Polyphemus, 131 meaning of term, 4 Crivelli, Vittore del Verocchio, Andrea, 26 Ernst, Max St. Catherine of Alexandria, 11, 51 del Verocchio (workshop of) Men Shall Know Nothing of Crowe, James, 96 The Virgin and Child with Two This, 165 Cruikshank, George, 8, 88, 173 Angels, 15, 26 The Attirement of the Bride, 78 Cunningham, D.J., 212 della Francesca, Piero, 5, 6, 24 Etruscan art representing endocrine disease, 4 Cupid, 7 Resurrection, 77 Madonna del Parto, 44 Eugenides, Jeffrey, Middlesex, 150 Cushing, Harvey, 6, 96, 128, 157, Madonna della Misericordia, 25 169, 172 Eustachius, Bartolomeus de’Pitati, Bonifaccio description of thyroid, 19 Cushing’s disease, 128 The Parable of the Rich Man and Cushing’s syndrome, 6, 169 The Beggar Lazarus (Il Ricco da Forli, Melozzo, 27, 60 Epulone), 101 An Angel Playing the Viola da Desault, Pierre-Joseph, 69 Braccio, 60 di Segna, Niccolò, 24 Annunciation, 27 Madonna of the Misericordia, 14 diabetes mellitus, 4 Dieffenbach, Johann, 69

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Evans, Herbert, 128 Gillray, James, 88 Hemessen, Jan Sanders van exophthalmos (bulging eyes), 5, 6, 66 The Gout, 174 The Prodigal Son, 87 Monstrous Craws at a New Hercules, represented as giant, 138 Coalition Feast, 88 Fabricius ab Acquapendente, 5 Hermaphrodite (statuette), 162 Gley, Eugene, 158 Feast in the House of Levi (Veronese), Hermaphrodite of Mirecourt, 152 goiters, 5, 6, 13 100 hermaphroditism, 150, 155, 156 and challenges of surgical treat- Ferriss, J. Barry, 84 lateral, 150, 156 ment, 68 pseudo-, 150, 156 Fight between Pygmies and Animals and iodine deficiency, 63 Hippocrates, 68 in a Nilotic Landscape (Roman and pregnant women, 44 on goiters, 17 fresco), 98 meaning of term, 16 Fitzmaurice, Deanne staging criteria, 16 hirsutism (excessive body hair), 6, 151 Gibson and Zoie, 125 Gossaert, Jan Hogarth, William, 88 Foster, Michael, 96 The Metamorphosis of The Marriage Contract from Marriage a la Mode, 171 Fox, Edward, 70 Hermaphroditus and Salmacis, 151, 161 Holbein, Hans the Younger Francisco Lezcano (Velasquez), 113 gout, 159, 173 Adam and Eve, 13 freemartin, 154 and pseudogout, 159 Home, Sir Everard, 125 Freund, W.A., 127 Goya, Francisco, 5 Homer The Colossus, 123, 138 Iliad, 98 Galen, 4, 5, 18, 66, 68 The Disasters of War, 136 Odyssey, 130 on pituitary gland, 95 Saturn Devouring his Son, 136 Horsley, Sir Victor, 70, 96, 158 Generali, Francesco, 158 Graves, Robert, 69 Hunter, John, 5, 68, 125, 154 Gentileschi, Artemisia, 5 Greek art Hunterian Museum, London, 118, Judith and her Maidservant with representing endocrine disease, 125, 144 the Head of Holofernes, 63 4, 5 hyperparathyroidism, 6, 158, 159 St. Cecilia, 51 Gross, Samuel, 69 hyperthyroidism, 4 Gentileschi, Orazio, 6 Grotesque Man with Goitre (da hypophysectomy, 96 David with Goliath’s Head, 134 Vinci), Figure 2-5, 73 hypospadius, 150, 157 Gerard Andriezse Bicker (van der Grumbach, Melvin, 155 Helst), 171 hypothyroidism, 4 gynecomastia, 6, 66, 80, 150, 157 giants, in mythology, art and history, and iodine deficiency, 64 129 Hahn, William, 70 Gibson and Zoie (Fitzmaurice), 125 IGF (insulin-like growth factor), 125 Half-Length Female Nude (Picasso), Gibson, Thomas, 95 Il Sodoma 63 gigantism, 5, 132, 140, 143 Life of Saint Benedict, 49, 65, 81 Halsted, William, 69, 71 causes of, 126 using models from regions with The Operative Story of Goiter, 71 medical history, 127 endemic goiter, 81 therapy for, 128 Hedenus, Johann, 69 Ingres, Jean August Dominique Heister, Lorenz, 67 Angelica Saved by Ruggiero, 39 Helene Fourment (Rubens), 43 iodine deficiency and goiters, 16

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Johns Hopkins Medical Center Lister, Joseph, 69 Mantegna, Andrea and advances in thyroid surgery, Liston, Robert, 69 Ludovico Gonzaga and Family 71 with Courtiers, 105 Louise or the Breton Servant Judith and her Maidservant with the (Serusier), 146 Marcelle Lender Dancing the Bolero Head of Holofernes (Gentileschi) in “Chilpéric” (Lautrec), 121 Lower, Richard, 95 63 Marie’s Malady, 127 Ludovico Gonzaga and Family with Judith Beheading Holofernes Courtiers (Mantegna), 105 Marie, Pierre, 127 (Caravaggio), 56 lymphadenopathy, 66 Matisse, 64 Judith’s Return to Bethulia Mayo, Charles H., 71 (Botticelli), 56 MacCallum, George, 158 Meckel, Johann, 155 Madonna and Child (da Vinci), 26 medical theories of normality, 4, 5, 144 Klee, Paul in Enlightenment, 8 The Hero with the Wing, 80 Madonna del Parto (Piero della Francesca) meduallary thyroid cancer, 158 Klinefelter’s syndrome, 156 and iodine deficiency, 44 MEN (multiple endocrine neoplasia), Ko Hung (Chinese alchemist), 66 Madonna of the Misericordia (di 126 Kocher, Theodore, 5, 70 Segna), 24 Men Shall Know Nothing of This Kohn, Alfred, 158 Madonna of the Misericordia (Piero (Ernst), 165 della Francesca), 17, 24, 48, 77 menstruation, 127, 153 La Nana (Picasso), 122 Madonna of the Palafrenieri Michelangelo, 5, 7, 14 La Primavera (Botticelli), 11 (Caravaggio), 31 on goiters, 18 Lahey, Frank H., 71 Madonna of the Pilgrims Middlebrook, Diane, The Double Life Landi, Neroccio di Bartolomeo (Caravaggio), 31 of Billy Tipton, 150 Saint Bernardino Performing an Madonna with the Book (Botticelli), Mieris, Willem de, 40 Exorcism, 78 31 Mikulicz, Johann, 70 Langenbeck, Bernard, 70 Madonna with the Long Neck Minkowski, Oskar, 127 (Parmigianino), 31 Large Grotesque Head (Ribera), 72 Modigliani, 64 Maerlant, Jacob van, and caricatures Laron’s dwarfism, 92 Molenaer, Jan of goiters, 72 Las Meninas or The Maids of Honor Stone-throwing Dwarf, 106 (Velasquez), 114 Maga Circe o Melissa (Dossi), 35, 36 The Artist’s Studio, 107 Las Meninas (Picasso), 115 Maggiore, Monte Oliveto Monna Vanna (Rossetti), 38 The Life of St. Benedict (Il Le Nain, Louis Mor, Anthonis (aka van Dashort) Sodoma fresco series), 80 The Resting Horseman, 47 The Dwarf of Cardinal Granvelle, Magnus, Albertus Life of Saint Benedict (Il Sodoma), 49, 107 De Animalibus, 94 65, 81 Morris, William, 38 Magrath, Cornelius, 127 Ligorio, Pirro, Parco di Mostri, 143 Mt. Sinai Medical School, 3 Mandeville, John, Travels and Lippi, Fra Filippo, 28 Murray, George, 70 Voyages, 160 Annunciation, 28, 29 myxedema, 17 The Madonna and Child with Mandl, Felix, 159 Stories from the Life of St. Anne, 46

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Nelson’s Syndrome, 157, 158 Portrait of a Young Woman The Dwarf and the Dog, 91 Niepce, Bernard, 127 (Botticelli), 42 The Small Grotesque Head, 72 Noonan’s syndrome, 93 Portrait of a Young Woman with a Richer, Paul and J.M. Charcot, essay Gilded Wreath, 41 on psychological illness in art, 84 Norman’s Syndrome, 93 Portrait of Baltasar Carlos, son of Riolan, Jean, 153 Philip IV, with a Dwarf Robertson, Brailsford, 128 Oeuvres Complète de Ambroise Paré (Velasquez) Figure 3-13, 110 (Paré), 163, 166 Roger of Palermo (Frugardi), 67 Portrait of Infanta Isabel Clara Osler, Sir William, 20 Rogowitsch, N., 95, 127 Eugenia and Magdalena Ruiz Roman art Ovid, The Metamorphoses, 151 (dwarf with monkeys) (Coello), representing endocrine disease, 4, Owen, Sir Richard, 158 111 5, 11 Portrait of Susanna Lunden (Rubens), Rossetti, Dante Gabriel, 38 Paracelsus, 5, 18, 66 43 Astarte Syriaca, 39 Prometheus, in Greek myth, 138 Paré, Ambroise, 5, 7, 67 A Daydream, 11, 12 on dwarfism, 94 Prometheus Bound (Rubens), 140 The Beloved, 171 Oeuvres Complète, 163, 166 pygmies, 92 Monna Vanna, 39 Park, Katharine, 3 and literary representation, 98 Veronica Veronese, 39 Parry, Caleb Hillier, 69 and cranes, 98 Rowlandson, Thomas, 88 Paul of Aegina, 67 Drawing of Charles Byrne, The Irish Giant with an Admiring Paulesco, Nicolas C., 96 Queen Henrietta Maria and her Dwarf Jeffrey Hudson (Van Dyck), 102 Audience, 143 pheochromocytoma, 158 Rubens, Sir Peter Paul, 5, 11, 13, 34, Picasso, Pablo, 63, 64, 115, 116, 38, 43, 55, 61, 87, 137, 138, 140, Raphael, 5, 6, 38, 39, 82, 84, 103, 122, 147 142, 143 170, 171 Half-Length Female Nude, 63 Helene Fourment in her Wedding The Cross Appearing to La Nana, 122 Dress, 43 Constantine the Great Flanked Las Meninas, 115 paintings of subjects in iodine by Two Popes, 103 Piedmont deficient areas, 43 Transfiguration, 82 prevalence of endemic goiter, 5 polychrome terracotta sculpture, Reinagle, Philip pituitary gland and tunors, 126 76 Count Joseph Boruwlaski, 117 Portrait of Susanna Lunden, 43 Pliny the Elder Remak, Robert, 158 Prometheus Bound, 140 Natural History, 98 St. Chrisstopher and the on goiters, 18 Rembrandt, 8 The Anatomy Lesson, 8 Hermit, 143 Plummer, Henry, 71 Reni, Guido, 135 Samson and Delilah, 11, 34 Pollaiuolo, Antonio, 138 Saturn Devouring His Son, 137 Resurrection (Piero della Francesco), 77 The Labors of Hercules, 138 Susanna and the Elders, 55 polychrome terracotta sculpture of Reverdin, Jacques Louis, 70 The Three Graces, 38 henchman with club (untitled), 76 Ribera, Jusepe de, 5, 6, 91 Saint Bernardino Performing an Polyphemus (del Pombo), 131 Large Grotesque Head, 72 Exorcism (Landi), 78 The Bearded Woman Polyphemus myth, 130 Saint Cecila (Artemisia Gentileschi), 51 Breastfeeding, dust jacket, 148, 166

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Saint Mark Enthroned Surrounded by Stela of the God Bes, 97 The Labors of Hercules: Hercules and Musical Angels (Vivarini), 60 Stone-throwing Dwarf (Molenaer) the Hydra (Pollaiuolo), 138 Samson and Delilah (Rubens), 11, 34 Figure 3-9, 106 The Lamentation (Van Dyck), 48 Sandstrom, Viktor Ivar, 158 Summer (from The Four Seasons), 40 The Last Judgement in the Cathedral Santorini, Giovanni D., 95 Susanna and the Elders (Rubens), 55 of Santa Maria Assunta, 23 Saturn Devouring his Son (Goya), 136 The Life of St. Benedict (Maggiore), 80 Saturn Devouring His Son (Rubens), Temperantia (de Gheyn), 40 The Madonna and Child with Stories 137 Teniers, David, 99 of the Life of Saint Anne (Lippi) Schiff, Moritz, 70 The Rich Man Being Led to goiters and motherhood, 44, 46 Schneider, Conrad Victor, 95 Hell, 99 The Madonna of the Misericordia scrofula, 66 The Anatomy Lesson (Rembrandt), 8 (Piero della Francesca), 48 Sequard, Brown, 157 The Artist’s Studio (Molenaer) Figure The Magdalen Reading (Van der 3-10, 107 Shakespeare, The Tempest, 72 Weyden), 49 The Attirement of the Bride (Ernst), 78 Sick, Paul, 70 The Marriage at Cana (Veronese), 101 The Bearded Woman Breastfeeding Simmonds, Morris, 96 The Marriage Contract (Hogarth), 173 (Ribera), dust jacket, 148, 166 Simpson, James, 155 The Martyrdom of Saint Agatha (del The Beloved (Rossetti), 171 Sleeping Hermaphrodite, 160 Piombo), 52 The Colossus (Goya), 138 Smith, Philip E., 128 The Metamorphosis of The Cross Appearing to Constantine Soranos of Ephesus, 20 Hermaphroditus and Salmacis the Great Flanked by Two Popes (Gossaert), 151, 161 Souza-Leite, Dr. (Raphael), 103 “A Thesis on Acromegaly,” 127 The Monstrous Craws at a New The Crucifixion of St. Andrew Coalition Feast (Gillray), St. Catherine of Alexandria (Crivelli), (Caravaggio), 84 88 11, 51 The Doctor and the Patient (Steen), The Parable of the Rich Man and St. Christopher and the Hermit 21, 44 the Beggar Lazarus or Il Ricco (Rubens), 143 The Doge Dandolo and the Dogaressa Epulone (de’Pitati), 101 St. Christopher Carrying the Christ Being Presented to the Virgin The Prodigal Son (van Hemessen), 87 Child (Moreel Triptych) (Veneziano), 23 (Memling), 142 The Rape of Helen (Campana), 35 The Dwarf and a Dog (Ribera), 91 St. Christopher Carrying the Christ The Resting Horseman (Le Nain), 47 The Dwarf of Cardinal Granvelle Child (Pearl of Brabant altarpiece) The Rich Man Being Led to Hell (Mor), 107 (Bouts), 141 (Teniers), 99 The Escaped Bird (de Mieris), 40 Stanford Medical School, and art The Sleeping Woman (Duck), 88 The Fire in the Borgo in the Stanza appreciation, 3 The Small Grotesque Head (Ribera), 72 dell’Incendio (Raphael), 170 Starling, Ernest Henry, 4 The Supper at Emmaus (Caravaggio), 59 The Garden of Earthly Delights Steen, Jan, 106 (Bosch), 164 The Three Graces (Rubens), 38, 43 influence of Rubens and The Gout (Gillray), 174 The Transfiguration (Raphael), 6 Caravaggio on, 87 The Virgin and Sleeping Child The Doctor and the Patient, 44 The ‘Hair Man’ Petrus Gonsalvus, 167 (Mantegna), 26 The Dissolute Household, 88 The Hero with the Wing (Klee), 80

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thyroid disorders Velasquez, Diego de 5, 6 Wagner, Rudolf, 155 autoimmune disease (Hashimoto’s Calabazas, 91 Wharton, Thomas disease), 16, 17, 64 Don Diego de Acedo, El Primo, on function of thyroid, 20 Graves’ disease, 5, 6, 28, 64, 65, 109 Wilkinson, G. 66, 68, 69, 71, 80, 82, 84, 88 Francisco Lezcano, 113 Two miniature people, known as nodules, 16, 17 Las Meninas, 114 the Aztec Lilliputians, with their multinodular goiter, 65, 76 Portrait of Baltasar Carlos, son of manager, 118 physiological signs, 6 Philip IV, with a Dwarf, 100 Willis, Thomas, 95, 154 sixteenth-century advances in Veneziano, Paolo, 23 understanding, 18 The Doge Dandolo and the thyroid operations, 117 Dogaressa, 23 Yale Medical School, and art appreciation, 3 metabolic complications, 70 Verga, Andrea resistance to, 69 on treatment for gigantism, 127 Tom Thumb, 119, 121 Veronese, Paolo, 6 Zwemer, R. L., 157 Transfiguration (Raphael), 6, 82 Feast in the House of Levi, 100 Trevisani, Francesco Vesalius, Andreas, 5 Banquet of Antony and De Humani Corporis Fabrica, 67 Cleopatra, 104 and connections between art and Turner’s syndrome, 93 science, 19 Tuscany Vespin, Jean, 76 prevalence of endemic goiter, 5 Polychrome terracotta sculpture, 76 Two miniature people, known as the Aztec Lilliputians, with their man- Vieussens, Raymond and Sylvius, 127 ager (Wilkinson), 118 Virchow, Ludwig, 127 Virchow, Rudolf, 67 Ulysses (Odysseus) and his Virgil, Aeneid, 170 Companions Blinding Virgin and Child with Two Angels (del Polyphemus, 131 Verocchio), 26 Umbria virilism, 150 prevalence of endemic goiter, 5 vital principle medical theory of, 69 Van der Weyden, Roger, 49 Vivarini, Bartolomeo Van Dyck, Anthony, 102, 111 Saint Mark Enthroned The Deposition, 48 Surrounded by Musical Angels, 60 Queen Henrietta with her Dwarf Voegtlin, Carl, 159 Jeffrey Hudson, 102 von Hochenegg, Julius, 128 Vassale, Giulio, 158 von Recklinghausen’s disease, 73

Remarkables_7body.indd 218 9/14/11 3:46 PM It is truly fitting that Orlo Clark, considered a father of In this unique exploration of the links between art and modern endocrine surgery and a world-renowned leader in medicine, the Clarks focus on endocrinology, the field that the field, along with Carol Clark, a writer and scholar in best explains the shaping, and misshaping, of the Perspectives in Medical Humanities How do changing notions of beauty and ugliness Carol Clark (BA, Barnard College, MA art history, have enriched our legacy with their consummate human form. In clear and concise prose, they demonstrate affect attitudes toward physical deformities? To what in English, San Francisco State University) taught high atlas The Remarkables: Endocrine Abnormalities in Art; how artists used a variety of endocrine diseases—dwarfism, extent was the birth of a dwarf, a giant or a hirsute school English at the Crystal Springs Uplands School, this work of scholarship will most certainly become a part gigantism, those with swollen goiters or ambiguous child thought to reflect the depraved imagination of the

University of California Press www.ucpress.edu Printed in China

Orlo H. Clark, MD Carol Z. Clark Carol Z. Clark

berkeley — los angeles — london Orlo H. Clark, MD

University of California Press www.ucpress.edu Printed in China

Orlo H. Clark, MD Carol Z. Clark Carol Z. Clark

berkeley — los angeles — london Orlo H. Clark, MD

护封.indd 1 2011.3.3 12:03:21 PM