Anatomy

Blood Disorders Cardiovascular System: Blood Vessels

Cardiovascular System: Blood Vessels

The David Sign

On a recent trip to Florence, Italy, I observed Michelan- gelo’s David in the Accademia Galleria and was struck by an interesting observation: the external jugular vein on the right side of David’s neck is distended well above his clavicle. Classic physical diagnosis teaching tells clini- cians to observe the height of the jugular veins to esti- mate central venous pressure (unless there is jugular ve- nous outflow obstruction). Preferably, the internal jugular vein is used for observation, but often the inter- nal jugular vein is difficult to visualize, and thus the smaller, less reliable, external jugular vein can be used, because it is more superficial and easier to see. Impor- tantly, neither jugular vein is normally persistently vis- ible above the clavicle at rest in the upright position, as it clearly is in the David (Figure). This finding on the David is a sign of elevated intracardiac pressures and possible cardiac dysfunction.

My initial response was one of fascination. The David is an awe-inspiring work with incredible attention to de- tail and accuracy in physical anatomy. With the knowledge of a cardiologist, it appeared illogical to me for the David to have jugular venous distention. I felt a chill go down my back as I realized that this observation and its implications were very possibly new and unrecognized. In addition, this message (so to speak) from Michelangelo needed an ex- planation. Immediately, my response was to document the finding with multiple photographs for study and review. I remember speaking with my girlfriend that day after we visited the Accademia Galleria and discussing that I thought I observed something very unique about the sculpture— something that appears to have been hiding in plain sight for more than 500 years.

When I returned home, I reviewed textbooks and the medical literature and discussed this with a few medi- cal and physiology colleagues. We had many very inter- esting discussions trying to understand this paradox. I also knew that I needed to know more about Michel- angelo and his work.

Michelangelo, like some of his artistic contempo- raries, had anatomical training,1,2 and in looking at the David, one can clearly see that the external jugular vein and the sternocleidomastoid muscle are anatomically correct. Michelangelo’s sculpture depicts David just be- fore his battle with Goliath. In reviewing other sculp- tures of Michelangelo, I found that he demonstrates the same finding of supraclavicular external jugular venous distention again in his sculpture of Moses at the tomb of Pope Julius the Second. Most would agree that the sit- ting Moses is thought to be in an excited state. In con- trast, the recently deceased Christ in Michelangelo’s Pietà (1499) does not demonstrate jugular venous dis- tention. Michelangelo did demonstrate the previously recognized distention of the dependent veins in the David, the Moses, and his Pietà. Dependent venous dis- tention was recognized previously and clearly present

in earlier works, such as the Colossus of Constantine (circa 325), which he would have studied. (I did also notice in photographs what could be the finding of jugular ve- nous distention in the ancient sculpture Laocoön and His Sons, but this sculpture was found in 1506, after the Da- vid was completed; Michelangelo is said to have seen this sculpture.) In my review of Michelangelo’s work, I could find no mention of anyone writing about his depiction of jugular venous distention.

To put this finding in context: at the time the David was created, in 1504, William Harvey had yet to de- scribe the true mechanics of the circulatory system. This did not occur until 1628. In addition, while Harvey pos- tulated that small vessels connected the arterial and ve- nous vessels, capillaries were not identified until 1661 (by Marcello Malpighi).3

At this point in my investigation, I realized that Mi- chelangelo must have noticed temporary jugular ve- nous distention in healthy individuals who are excited. In sculpture, one can only show a single image in time, and he must have wanted to express this observation in his work. I am amazed at his ability to recognize this find- ing and express it in his artwork at a time when there was such limited information in cardiovascular physiology. In- terestingly, even today, this phenomenon is not dis- cussed in typical cardiology textbooks.

Recognizing this message from Michelangelo also had special meaning to me. I am a physician who has spent more than 4 decades in the study and practice of medi- cine. Now nearing the end of my career, I have turned to

Figure. An Image of Michelangelo’s David, Showing Jugular Venous Distention

Photo credit: Daniel M. Gelfman, MD; image taken September 28, 2018.

FROM THE HEART

Daniel M. Gelfman, MD Division of Clinical Affairs, Marian University College of Osteopathic Medicine, Indianapolis, Indiana.

Corresponding Author: Daniel M. Gelfman, MD, Division of Clinical Affairs, Marian University College of Osteopathic Medicine, 3200 Cold Spring Rd, Indianapolis, IN 46222 (dgelfman@ marian.edu).

Opinion

124 JAMA Cardiology February 2020 Volume 5, Number 2 (Reprinted) jamacardiology.com

© 2019 American Medical Association. All rights reserved.© 2019 American Medical Association. All rights reserved.

Downloaded From: https://jamanetwork.com/ by Roger Olson on 03/04/2020

Congenital Defects of the Heart