IODINE AND ENDEMIC GOITER Iconography of Goiter: Four Refined Examples in the Sacred Mountain of Varese, Italy Gianlorenzo Dionigi and Renzo Dionigi Background: Four goiter representations observed by the authors in the sculptures of the Sacred Mountain of Varese, Italy, are described here. Summary: They should be regarded as a typical and proper example of the iconography of ‘‘real goiter,’’ where the artists had the definite intention to depict persons with goiter. Conclusions: Studies of representations of individuals with goiter are not that rare, even though most of the observations reported in the literature deal with images that should be considered occasional swelling of the anterior neck, ‘‘thick neck,’’ or ‘‘pseudogoiter’’ because the artists probably did not have any intention to illustrate the pathological condition. Introduction T he iconography of endemic goiter has received more attention after the erudite work of Franz Merke, which appeared in German language in 1971 (1), and was translated into English after his death in 1984 (2). Pictorial representa- tions of goiters can be found in different expressions of visual arts: medical (3,4) and nonmedical medieval manuscripts (5,6), paintings (7–16), graphic art (17–21), sculptures (2, 22), choir stalls (2), numismatic material (22), and philately (23). In the last two decades a preeminent reputation in the study of the iconography of goiter has been attained by Enio Martino (24–27). Despite the extensive number of observations re- ported in the literature, the studies have been often based on artwork by famed and gifted artists, who probably did not have any intention to illustrate the pathological condition, and what has been identified by various observers as a goiter could have been a simple ‘‘thick neck,’’ which has been properly defined by Merke as ‘‘pseudogoiter’’ (2) or an occa- sional swelling of the anterior neck. The ‘‘real goiter’’ illustrations are mainly found when and where the artists had the definite intention to express com- miseration with the persons with goiter or to identify them as executioners or tormentors. In fact, these representations have been predominantly created in the fifteenth and sixteenth centuries in alpine and poor areas where goiter was endemic and in Europe, often in a religious Christian context of passion and martyrdoms. Goiter representations in a religious context are not the only ones, and many other examples using dif- ferent media (paintings, sculptures, etchings, engravings, ar- chitectural ornaments, anatomical drawings, tapestries) have been observed and described. Vescia and Basso have given a list of 56 goiter representations in the artwork of the Re- naissance (7). In recent years we have been interested in looking for de- pictions of goiters in an endemic area that is called Insubria, an historical–geographical region that corresponds to the area inhabited in classical antiquity by the Insubres. To find ac- curate information about the word ‘‘Insubria’’ is difficult be- cause its geographical and cultural implications have been appraised only in the last few years. The name of this region comes from the Insubres, a powerful Celtic people of Gallia Cisalpina (Cisalpine Gaul), in northern Italy. Despite their defeat at Clastidium (modern Casteggio) by Roman forces in 222 bc, they continued to be troublesome and aided the Car- thaginian general Hannibal in the Second Punic War (218–201 bc). The Insubres were finally subdued in 196 bc and gradu- ally lost their identity in the rise of municipal communities. They were granted Latin rights in 89 bc and full Roman citi- zenship 40 years later. The main town of this area was Medio- lanum (the ancient name of Milan), but also included the minor towns Como, Pavia, Novara, Lodi, and Bergamo. More recent studies are oriented to identify Insubria as the land of big lakes located north of the Milan area: Lake of Como (‘‘Lario’’), Lake of Lugano (‘‘Ceresio’’), in Canton Ticino, Switzerland, and Lake Maggiore (‘‘Verbano’’) are the major lakes. A more detailed geographical definition of Insubria that has been proposed re- cently identifies an area with the following boundaries: Adda River (east), Po River (south), Sesia River (west), Southern Canton Ticino, Switzerland (north) (28,29). In Insubria the main goiter zone is located on the diluvial gravels and morains along the border of the Alps and on the remains of local Ice Age glaciers. One of the causes of regional iodine deficiency of this and others areas has been established Division of General Surgery, Department of Surgical and Morphological Sciences, University of Insubria, Varese, Italy. THYROID Volume 23, Number 10, 2013 ª Mary Ann Liebert, Inc. DOI: 10.1089/thy.2013.0202 1301