The Art of Endocrinology

As endocrinologists, we tend to focus on science in medicine, but there is also “art”...not just in the application of scientific knowledge, but also in being observers of what is around us all.

Since the beginning of time, artists have been portraying the people and environments they are surrounded by in order to identify ideas, people and stories they can relate to. Even depictions of gods and goddesses normally start with a basic human form, to which things are added or changed to reflect unique or even supernatural attributes. Artists often have also depicted people with severe, late-stage medical problems that, up until the modern scientific era, were left untreated and/or undiagnosed. In fact, many medical schools now teach students to hone their skills of observation and better detect physical exam findings in their patients by diagnosing people depicted in artwork.

A review of art created over time reveals that groups of people from completely different cultures and time periods who had no contact with each other often portrayed similar medical diseases. For example, up until the 20th century, iodine deficiency was very common in mountainous areas that were far away from the sea because people did not have access to seafood, which is naturally rich in iodine. Iodine is an element that is very important to thyroid function, so much so that in the 1920s, some governments around the world began adding minute amounts of iodine into table salt to prevent the devastating consequences of iodine deficiency. In babies, this condition can cause low IQ, mental retardation, stunted growth, and a distinctive posture with bent knees. In adults who were born with a normal thyroid, iodine deficiency can cause a goiter, a harmless enlargement of the thyroid gland.

Depictions of goiters (a swelling of the neck resulting from enlargement of the thyroid gland) abound in artwork. In excavations of the Ohio River Valley of the Native American Adena tribe from 800 BCE to 1 CE, many stone pipes in the shape of men have been found. These men usually have a head disproportionately larger than the body, bent knees and a swollen neck (Figure 1). These findings are consistent with someone who has a long-standing iodine deficiency. More realistic depictions of goiters are also found in the paintings of the Italian Renaissance painter Caravaggio, who chose to live among the poor and working-class citizens of inland Italy and often used his friends and neighbors as models for paintings that the Vatican and the nobility commissioned from him. As iodine deficiency was very common among the poor, many of Caravaggio’s figures also show goiters, such as in the Virgin Mary in Madonna of the Rosary (Figure 2), which was painted around 1607.

While goiters are probably the most common endocrine disease seen in artwork, they are not the only one. After Egyptian pharaoh Akhenaten ascended to power in the 14th century BCE, he completely changed Egyptian religion and shifted its focus away from the traditional depictions of numerous gods and goddesses to a single one — the sun-disk god Aten. Mirroring this development, Egyptian artwork also changed radically. Instead of the stiff, formal and stylized art of the past, Akhenaten (as the primary sponsor and tastemaker of art and architecture) preferred emphasis on a more relaxed, naturalistic style to honor the real world that was the gift of the Aten.

What is striking is the way Akhenaten himself is portrayed in artwork he commissioned and approved. In all his portraits, he is shown with a long neck, full lips, prominent breasts and curved hips. His feminine appearance in all the artwork has generated much comment and speculation. Some physicians have thought that he had a condition called aromatase excess syndrome. Aromatase is an enzyme complex that converts androgens (precursors to male hormones, such as testosterone) into estrogens. Men and women have both androgens and estrogens in differing proportions. In aromatase excess syndrome, the balance tips in favor of estrogens, which means even men end up with too much estrogen. This leads to feminizing characteristics in boys (like the ones Akhenaten had) and early breast development and puberty in girls.

Since it is dominantly inherited, Akhenaten would have passed it on to all of his children, and in a relief of Akhenaten and his family that has been found (Figure 3), this does seem to be the case. Akhenaten and his wife, Queen Nefertiti, are shown seated with one daughter standing in between them. Another daughter is standing on Nefertiti’s lap and a third sitting behind her sister. All three girls are drawn smaller than their parents to indicate they are children who haven’t reached puberty, but the one standing between her parents already has prominent breasts and hips.

As this stone slab rendering reveals, artwork often shows the unusual along with the ideal. People have had a fascination with others who exhibit various physical deformities for a long time. During the Hellenistic period between the death of Alexander the Great and the rise of the Roman Empire, “grotesque” figures of all kinds were popular. These distorted figures and shapes stand in stark contrast to the idealized human figures usually portrayed during this time. One figurine, of which only the head remains, very clearly shows acromegaly (Figure 4), a condition in which the pituitary gland starts making excessive growth hormone, which can cause an increase in soft tissue bone all over the body leading to large noses, prominent foreheads and jaws, and large tongues when it manifests in adults. All of these features can be found in this figurine.

Botanical prints also can provide historical perspective. In Figure 5, different views of a plant that was used as an old folk remedy for diabetes are shown. This plant, known under various names as goat’s rue, French lilac, Italian fitch, or professor-weed, can be toxic and has been linked to pulmonary (lung) edema, abnormally low blood pressure (hypotension), paralysis and death. But in the Middle Ages, it was used to treat diabetes. In the original form, it was too toxic for safe use, but over time, popular type 2 diabetes oral medication metformin was developed from this plant.

We tend to think of diseases, and especially endocrine diseases, in the frame of modern medicine, and there can be a tendency to forget that most of the diseases we live with now have been around for a very long time. What has changed is how we think they develop and how we treat them. In fact, since these diseases now get caught and treated early, we are fortunate that we don’t see them at the advanced and often fatal stages like we used to. As this article shows, endocrine diseases, along with many other diseases of the human body, have been described since the beginning of time, and ever since human beings have first started making art that represented the world around them.

Dr. Iram Ahmad graduated summa cum laude from The University of Arizona with a Bachelor of Science degree in Molecular and Cellular Biology and a Bachelor of Arts degree in Art History. She attended The University of Arizona College of Medicine and did her internal medicine residency at The University of Arizona Medical Center (now Banner-University Medical Center) in Tucson, AZ. Dr. Ahmad is currently a clinical fellow in the Division of Metabolism, Endocrinology, and Nutrition at the University of Washington in Seattle and does her medical research with the Division of Nephrology.