Rossella Nassi *, autore dell’articolo                                   

La tiroide, ghiandola endocrina a forma di farfalla localizzata anteriormente e lateralmente nel collo, produce ormoni che, immessi nel sangue circolante, raggiungono i vari organi e tessuti dell’organismo, dove svolgono un ruolo insostituibile: sono infatti necessari per la crescita e lo sviluppo e per mantenere la stabilità metabolica.

Le malattie della tiroide sono relativamente comuni. Si possono distinguere in:

  • alterazioni delle dimensioni e della forma della ghiandola (si parla di gozzo quando la tiroide è aumentata di volume)
  • alterazioni della secrezione ormonale (disfunzioni).

Ciò che colpisce parlando della tiroide, anche al di fuori della cerchia degli addetti ai lavori, è l’interesse che questa ghiandola suscita, probabilmente per la multiformità e la complessità del quadro clinico che deriva dalle sue disfunzioni. Il gozzo inoltre altera inevitabilmente l’aspetto del collo, arrotondandolo nella parte anteriore e laterale, rendendolo sporgente e talvolta irregolare per la presenza di noduli più o meno grossi.

Ma, mentre oggi tali modifiche del collo vengono vissute come inestetismi, da correggere se necessario con la chirurgia, in passato la presenza di gozzo era molto più accettata, come testimoniato da dipinti e sculture che ci presentano uomini, fanciulli e donne, soprattutto donne e in particolare puerpere, con il collo grosso o arrotondato.

Addirittura Piero della Francesca ha rappresentato sé stesso con un voluminoso nodulo mediano del collo per ben due volte, nella “Resurrezione di Cristo”, dove il pittore si è ritratto tra in soldati addormentati, e nel “Polittico della Misericordia” dove compare ai piedi della Vergine.

In entrambi i dipinti il pittore appare con la testa volta in alto e indietro, come si dice “iperestesa”, che è la condizione migliore per rendere visibile la tiroide. In effetti il grosso nodulo di Piero, che non doveva evidentemente creare problemi psicologici al grande artista, è assai evidente in entrambe le opere.

Il gozzo

Nel complesso si potrebbe dire che un gozzo di modeste proporzioni era riconosciuto in passato come un carattere di bellezza muliebre e quindi abitualmente presente nelle immagini pittoriche.

Sotto un certo punto di vista dovremmo stupirci di alcune figure femminili con collo lungo e sottile come la “Dama con ermellino” di Leonardo o la “Madonna dal collo lungo” del Parmigianino, ritratte in epoche in cui quasi sempre le donne venivano rappresentate con collo ben tornito, per non dire vistosamente ingrossato.

Ne sono esempi le molteplici Madonne dipinte con queste caratteristiche, come la Maestà di Duccio, la Madonna giardiniera di Raffaello, la Madonna del garofano di Leonardo, la Madonna del Rosario di Caravaggio, le Madonne del Pontormo, la stessa Madonna del Parto di Piero.

Anche andando avanti nei secoli molti altri esempi potrebbero essere citati: addirittura “Venere che si guarda allo specchio” di Rubens, simbolo stesso della bellezza, presenta un cospicuo gozzo, come lo presentano la protagonista in “Giuditta e Oloferne” di Artemisia Gentileschi, i ritratti femminili di Dante Gabriel Rossetti o di vari impressionisti.

Basti per tutti ricordare il “Busto di donna al sole” di Renoir (foto) dove il gioco di luce e ombra disegna, sul collo della giovane donna ritratta, un’immagine simile ad una farfalla, nient’altro che una tiroide aumentata di volume, che il pittore ha fedelmente riprodotto.

Il gozzo, secondo una classificazione del 1979 del World Health Organisation (WHO), presenta vari gradi:

grado 0 assenza di gozzo, come nella “Dama con ermellino” di Leonardo
grado 1° gozzo non visibile ma palpabile e forse lo era quello della “Madonna del collo lungo” del Parmigianino
grado 1B gozzo palpabile e visibile all’iperestensione del collo, come si intravede in un bel ritratto di “Donna con bambino” di Zandomeneghi
grado 2 visibile con il collo in posizione normale, per esempio nel ritratto di “Giovane donna” di Botticelli dove il profilo del lungo collo è arrotondato anteriormente da un palese gozzo
grado 3 visibile a distanza, come quello della già citata “Giuditta e Oloferne” di Artemisia Gentileschi.

Ma possiamo anche distinguere un gozzo diffuso, in cui la ghiandola è uniformemente aumentata di volume mantenendo la sua conformazione a farfalla, come nella donna di Renoir, e il gozzo nodulare o multinodulare, molto più irregolare e esteticamente poco gradevole, che Piero non esitava a rappresentare nei suoi autoritratti.

Mentre un piccolo gozzo crea soprattutto problemi di tipo estetico, un gozzo di cospicue dimensioni, in particolare se scende dentro il torace, diventando intramediastinico, pone problemi maggiori, legati alla compressione che esercita sugli organi vicini.

Per esempio, la compressione della trachea causa dispnea, cioè difficoltà respiratoria, la compressione dell’esofago disfagia, cioè difficoltà alla deglutizione, la compressione dei nervi che vanno alle corde vocali, soprattutto la loro infiltrazione in caso di patologia neoplastica, comporta disfonia.

La presenza di questi sintomi rappresenta una chiara indicazione chirurgica.

 

“Giuditta e Oloferne” di Artemisia Gentileschi

 

Le disfunzioni tiroidee

Ipertiroidismo

I sintomi dell’ipertiroidismo si comprendono tenendo conto dell’azione degli ormoni tiroidei che

  • aumentano il consumo di ossigeno e la produzione di calore
  • stimolano l’utilizzazione dei lipidi e dei glicidi e, quando prodotti in eccesso, il catabolismo proteico
  • sono necessari per il normale accrescimento scheletrico e per lo sviluppo neurologico del feto e del bambino
  • hanno un ruolo attivante la funzione dei nostri organi, in particolare del sistema nervoso e cardiovascolare.

L’eccesso di ormoni tiroidei comporta pertanto:

  • attivazione del metabolismo basale con maggior consumo di calorie. Il calo ponderale che ne consegue non è dovuto solo alla perdita di grasso, ma anche alla riduzione del volume muscolare e del contenuto proteico e minerale dell’osso. Ciò spiega la debolezza e il maggior rischio di osteoporosi dei pazienti ipertiroidei non trattati
  • aumento del senso di fame
  • aumento della produzione di calore con intolleranza al caldo
  • attivazione delle funzioni cardiovascolari con tachicardia, cioè aumento della frequenza cardiaca con possibili aritmie, soprattutto in pazienti cardiopatici o anziani
  • ansia, irritabilità e insonnia

Nell’ipertiroidismo è tipico l’aspetto “sbarrato” degli occhi dovuto alla retrazione della palpebra superiore da ipertono neurovegetativo: è quanto sembra abbia rappresentato Albrecht Durer in un ritratto di anziana donna (“La Madre”).

In una particolare malattia causa di ipertiroidismo, il morbo di Basedow, è possibile che il coinvolgimento oculare sia più importante con esoftalmo, edema palpebrale, diplopia.

Di questa malattia, che colpisce in particolare le donne, è stato lasciato da Svevo un vivido ritratto “scritto” nel suo “La Coscienza di Zeno” nel personaggio di Ada.

Ipotiroidismo

È il contrario dell’ipertiroidismo, si manifesta cioè con:

  • riduzione del metabolismo basale con tendenza all’aumento di peso
  • maggiore sensibilità al freddo
  • bradicardia
  • sonnolenza, stanchezza, difficoltà di concentrazione. La carenza di ormoni tiroidei ha conseguenze particolarmente gravi nella vita fetale e nei primi anni di vita comportando:
  • difetti di crescita, con nanismo disarmonico
  • difetti di sviluppo del sistema nervoso con deficit intellettivi (cretinismo) e altri disturbi neurologici.

Forse era un ipotiroideo congenito il “Ragazzo di Vallices” ritratto da Velasquez e in effetti in passato questa condizione era relativamente frequente soprattutto nelle zone montane, a carenza iodica. Oggi il cretinismo è praticamente estinto in Italia e nei paesi ad elevato sviluppo socio-economico, grazie allo screening neonatale che identifica i neonati con difetti di funzionamento della tiroide e grazie all’aumento della disponibilità di iodio nell’ambiente, destinata a ridurre l’incidenza di gozzo nelle popolazioni.

Aggiungiamo inoltre che molte malattie della tiroide hanno oggi possibilità di cure del tutto assenti in un passato anche recente.

Citiamo ancora l’Ada del romanzo di Svevo, che oggi potrebbe essere curata con un farmaco che corregge l’ipertiroidismo, senza perdere la bellezza che tanto aveva colpito il protagonista del romanzo e soprattutto senza la sofferenza che tutte le disfunzioni tiroidee comportavano quando non c’erano gli efficaci trattamenti odierni.

Relazione tenuta il 27 aprile 2006

*

Endocrinologa.
Direttore U.O.C. Medicina Interna, Ospedale di San Sepolcro

 

 

 

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