Hektoen International

A Journal of Medical Humanities

The importance of the “The David Sign”

Daniel M. Gelfman
Thad E. Wilson
Indianapolis, Indiana, United States

Photo of the neck of Michelangelo’s David
Photo credit: Daniel M. Gelfman, MD, September 28, 2018.

A recent article in JAMA Cardiology titled “The David Sign” discussed the presence of “persistent” external jugular venous distention “hiding in plain sight” on one of the world’s most famous statues: Michelangelo’s David, completed in 15041 (Figure 1). David is shown just before his fight with the giant Goliath. Michelangelo depicts the same finding in his 1515 sculpture Moses, who is greatly disturbed by seeing his people break one of the ten commandments. The external jugular venous distention is not seen in the deceased Christ in his 1499 Pieta, although in all three sculptures Michelangelo does demonstrate dependent venous distention in the limbs. The finding of persistent internal, or the less reliable but easier-to-visualize external, jugular venous distention (JVD) above the clavicle in an upright individual has a sensitivity of 65% and a specificity of 85% for revealing an elevation in central venous pressure.2 While its presence in these sculptures would appear paradoxical, this commentary will offer a plausible physiologic explanation of what the presence of “persistent” JVD in these sculptures represents.

What was Michelangelo telling us by depicting “persistent” JVD? Artists spoke through their work and generally did not write down their thoughts.3 But we do know that Michelangelo was quite knowledgeable about normal human anatomy and most likely was aware that persistent JVD is not seen in healthy persons. We also know that the concept of JVD as a sign of disease did not exist in Michelangelo’s time. In 1504 the venous system was felt to be a means of delivering nourishment to the body, not for recirculation of blood, a concept that would not be accepted until 1628 when proposed by Harvey.4

The apparent paradoxical finding in the sculptures of persistent JVD, which is not seen in healthy individuals, must have been Michelangelo’s observation of intermittent JVD, which may be seen in people when they are excited. If one accepts the premise that the keenly observant Michelangelo did observe something that is real, we can reasonably understand his message by applying current physiology concepts. We can even see that it tells us something useful about cardiovascular physiology that is not well recognized today.

Excited persons with resultant sympathetic nervous system activation do not develop significant intermittent JVD without another process that increases right atrial pressure. Non-exercise sympathetic stimulation increases venous vascular tone and right atrial (central venous) filling and pressure in the upright position, but not above 8 mmHg,5,6 which should distend either unobstructed jugular vein above the clavicle in an upright individual.2 Logically, the additional physiologic process that is increasing right atrial pressure (central venous pressure) is recurrent partial Valsalva maneuvers. Mean peak central venous pressures have been demonstrated in exercising rowers of up to 74 mmHg due to the Valsalva maneuver.7 Elevation of the right atrial pressure above 8 mmHg through an increase in intrathoracic pressure combined with an increase in preload from sympathetic stimulation could easily occur in grunting respiration, as is likely depicted in the David or Moses, resulting in intermittent JVD. This same process can be observed in persons who are singing or speaking vigorously: simply watch the exposed necks of actors. Recurrent intermittent JVD in healthy individuals on stage is quite noticeable, as is intermittent external JVD in upright animated persons who are talking vigorously. This is a commonly occurring finding and logically could explain what Michelangelo was revealing to us in his sculptures.

So why is Michelangelo’s finding relevant today, other than demonstrating the need for careful observation and clinical reasoning? The relevance, especially in medical education, is in improving the recognition of persistent internal or external jugular vein distention, which is often neglected today8 yet essential in the evaluation of heart failure.9 Sustained JVD reliably predicts elevated right atrial pressure (central venous pressure), as it serves as a manometer of the right atrium with a direct (generally unobstructed) connection. It also has a positive predictive value of 75% for a pulmonary capillary wedge pressure (PCWP) > 22 mmHg (normal <13 mmHg). Thus, recognizing persistent internal or external JVD strongly implies an elevation in the PCWP and is the basis for treatment and estimation of overall prognosis.9,10

If practitioners regularly recognized intermittent external JVD occurring when healthy, excited individuals are talking or singing, it would follow that they could recognize pathologic JVD in their patients with heart disease. The need to emphasize this easy-to-visualize but often ignored clinical finding is highlighted by Michelangelo’s observations, especially today when the physical examination is often neglected.


  1. Gelfman DM. The David Sign. JAMA Cardiology. 2020;5(2):124-125. doi:10.1001/jamacardio.2019.4874
  2. Sinisalo J, Rapola J, Rossinen J, Kupari M. Simplifying the estimation of jugular venous pressure. Am J Cardiol. 2007;100(12):1779-1781. doi:10.1016/j.amjcard.2007.07.030
  3. Wallace WE. The genius of Michelangelo. The Great Courses. 2007.
  4. Aird WC. Discovery of the cardiovascular system: From Galen to William Harvey. Journal of Thrombosis and Haemostasis. 2011. doi:10.1111/j.1538-7836.2011.04312.x
  5. Wilson TE, Tollund C, Yoshiga CC, et al. Effects of heat and cold stress on central vascular pressure relationships during orthostasis in humans. J Physiol. 2007;585(Pt 1):279-285. doi:10.1113/jphysiol.2007.137901
  6. Pandey A, Kraus WE, Brubaker PH, Kitzman DW. Healthy Aging and Cardiovascular Function. JACC: Heart Failure. 2020;8(2):111 LP – 121. doi:10.1016/j.jchf.2019.08.020
  7. Clifford PS, Hanel B, Secher NH. Arterial blood pressure response to rowing. Med Sci Sports Exerc. 1994;26(6):715-719. DOI: 10.1249/00005768-199406000-00010
  8. Feddock CA. The lost art of clinical skills. Am J Med. 2007;120(4):374-378. doi:10.1016/j.amjmed.2007.01.023
  9. Thibodeau JT, Drazner MH. The Role of the Clinical Examination in Patients With Heart Failure. JACC: Heart Failure. 2018. doi:10.1016/j.jchf.2018.04.005
  10. Vinayak AG, Levitt J, Gehlbach B, Pohlman AS, Hall JB, Kress JP. Usefulness of the external jugular vein examination in detecting abnormal central venous pressure in critically ill patients. Archives of Internal Medicine. 2006. doi:10.1001/archinte.166.19.2132

DANIEL M. GELFMAN, MD, FACC, FACP, is a Clinical Professor Emeritus of Medicine at The Marian University College of Osteopathic Medicine. He remains active teaching clinical medicine and pursuing scholarly activities at Marian University. His research interests currently include developing effective teaching methods and combining the humanities with medicine. Recent work includes his article, “The David Sign,” published in JAMA Cardiology, revealing previously unrecognized cardiovascular physiology findings depicted in Michelangelo’s sculptures.

THAD E. WILSON, Ph.D., is a Professor in the Department of Physiology and the Saha Cardiovascular Research Center at the University of Kentucky College of Medicine. Formerly, he was a Professor of Physiology in the Division of Biomedical Sciences at Marian University College of Osteopathic Medicine. His research focuses on the autonomic control and regulation of bodily processes such as temperature, blood pressure, and blood flow. He often uses environmental perturbations to probe and quantify these autonomic reflexes in health (physiology) and disease (pathophysiology). Prof. Wilson has co-authored over 85 peer-reviewed articles and a physiology textbook (Lippincott’s Illustrated Reviews: Physiology).

Summer 2020



Leave a Reply

Your email address will not be published. Required fields are marked *

This site uses Akismet to reduce spam. Learn how your comment data is processed.