How an Indiana doctor found a medical mystery in Michelangelo's 'David'

Show Caption Hide Caption This is how a conservator repairs the peeling paint on an ancient work of art Julie Ribits, paintings conservator for the Eskenazi Museum of Art, demonstrates how she is salvaging peeling paint on a nearly 400-year-old painting.

INDIANAPOLIS – While art historians have studied Michelangelo’s "David" for centuries, it took the eye of a Marian University cardiologist to see something no one else appears to have recorded about the iconic marble sculpture.

Dr. Daniel Gelfman himself had never recognized this feature in photos he saw of the "David," but when he viewed the artwork in person during a visit to Florence, Italy, in 2018, he noticed a bulging vein on the right side of the biblical hero’s neck. If a person showed up in his exam room with such a vein, Gelfman would immediately think the patient had significant heart disease.

But the "David" is supposed to depict a healthy, vibrant person. Why would Michelangelo have bequeathed such a feature on him, wondered Gelfman, an associate professor of internal medicine at Marian University’s College of Osteopathic Medicine.

“It struck me as odd, very paradoxical. You wouldn’t expect to see that,” Gelfman said. “There are certain clues that you can pick up on physical exam that tells you that someone has heart disease and one of those clues is jugular venous distension. As a cardiologist, when I saw that, it was very dramatic to me. It really stuck out.”

This observation was so striking that Gelfman wrote an article, which appeared online last month in JAMA Cardiology. In addition to positing a theory on why Michelangelo crafted David’s jugular vein in this manner, Gelfman’s article argues for studying artworks to improve doctors’ diagnostic skills.

Although a similar condition to the one "David" displays can occur intermittently in healthy people – think of a singer belting his or her heart out – the person’s jugular vein in such cases pops out only briefly and then returns to normal. In the case of the "David," his abnormally distended vein was literally set in stone.

When Gelfman returned home, the observation haunted him. He enrolled in an online course in art history to learn more about the great Renaissance master. Eventually, he realized that Michelangelo sometimes, but not always, employed a similar technique in his depictions of historical figures.

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The more Gelfman pondered, the more he realized Michelangelo was not trying to say that his subject had heart disease. If David were ill, he would exhibit swelling elsewhere, such as in his legs or abdomen, he realized.

Instead, the sculptor had noticed the phenomenon that, when some people get excited, their jugular vein temporarily distends, just as other people flush when they’re emotional.

“What he’s noticing, which is so interesting, he’s noticing a physiological change in somebody who’s getting ready to exert,” Gelfman said. “What this shows is that it’s actually something that you can visualize on a frequent basis, given a certain set of circumstances.”

The artist may have even realized this long before medical experts did, Gelfman said.

Did Michelangelo know about jugular venous distention?

When Michelangelo began the "David" in 1501, the then-26-year-old's career was trending upward quickly. Just two years before in Rome, he had finished the heartbreakingly beautiful "Pieta," in which Jesus lays in his mother's lap after his body came down from the cross. At the turn of the century, the Vestry Board of Florence Cathedral and the Wool Guild were seeking an artist to create a giant "David." It now stands in the Accademia Gallery in Florence.

Handed to Michelangelo was an enormous block of marble, flawed enough that it had been abandoned and deemed too difficult by other artists. He decided to take a different path than previous depictions of the Bible's Old Testament hero. Instead of showing the aftermath of a victorious David, the artist depicts Israel's young warrior before he flung the stone that sunk into Goliath's forehead.

The tension and anticipation in the pose, with the sling lying in wait over David's shoulder, provide a ready reason for the bulging vein.

While scientists would not describe the circulatory system's mechanics until the 17th century, Michelangelo was known for carefully studying human anatomy, like many serious artists of his time.

Though the Catholic Church disapproved of dissection, it allowed Michelangelo and others to take apart corpses of criminals and prostitutes. The artist, who was said to have memorized all of the poet Dante as a kid, remembered the intricate muscles and bones of the human body, said William E. Wallace, an expert on Michelangelo and art history professor at Washington University in St. Louis.

But the corpses wouldn't have had jugular venous distention. Wallace said Michelangelo could have noticed the bulging vein in carvers, their apprentices and workers who were hacking marble out of quarries near where he grew up in a village in the hills overlooking Florence. The Goliath in this case was the rock itself.

"Marble carving is extremely difficult work. Working in the quarries can be very tense work and kind of dangerous," Wallace said. "People die every year up in the marble quarries, even today."

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Michelangelo might also have witnessed the bulging vein in people during harrowing events that occurred during his life.

"We call it the Renaissance, but it's an extremely violent time where he watches people who are hung and drawn and quartered, and so there could have been any other multiple times when he would've seen public executions or people under various kinds of tension," said Wallace, who recently wrote "Michelangelo, God's Architect: The Story of His Final Years and Greatest Masterpiece."

Wallace said it is likely that Michelangelo indeed recognized the effects of jugular venous distention and used it purposefully to create tense figures. But of course, scholars can't know his intent for sure.

"It's very difficult to know and very difficult to figure out what the artistic temperament really is," Wallace said. "But good ideas spawn interest, and they make us look more closely and appreciate works of art."

What Gelfman wants to do with his discovery

Gelfman doesn't want his observation of jugular venous distention to end with the JAMA Cardiology article or the international coverage his discovery has received. He hopes it spurs his students to use what they witness in diagnosis instead of depending too much on tests.

To that end, Gelfman has started to work with his colleague Jamie Higgs, an associate professor of art history at Marian University. The two met in a workshop Higgs taught after she received training in visual thinking strategies over the summer.

The method asks people what's going on in an artwork and what evidence and reasoning they have for their conclusion. Posing these questions in group discussions helps people understand ambiguity and enhances their observation skills, critical thinking, ability to listen to others and empathy for someone else's point of view, Higgs said.

Many other medical schools offer similar classes. Yale University’s School of Medicine was among the first to do so 22 years ago when a dermatologist was brainstorming ways to encourage his residents to become better observers of potential diagnostic signs.

Some of the newly trained doctors appeared to be natural diagnosticians, said Dr. Irwin Braverman, an emeritus professor of dermatology. Others needed to improve such skills, and veteran physicians such as himself at first did not know how to teach them.

Then Braverman came up with the idea of taking his students to the art museum to have them describe objectively what they saw in paintings to hone their observational skills. He realized it would be better not to wait until physicians were in postgraduate training, but to start such lessons in the first year of medical school.

Working with an art historian, Braverman first ran a pilot program to prove spending time in an art museum would help medical students’ observational skills. Since 2002, the course has been required for all Yale medical schools, and at least 100 other medical schools in the country have implemented similar courses, Braverman said.

On questionnaires, students have reported that the course taught them to look and observe before reaching a conclusion. That’s critical for doctors today, he said.

“The longer you look at something, the more you see, and in this hurried world of doctoring where you’re limited to 15 minutes per patient, it’s not a long time," Braverman said. "We might hope that this might be made more efficient by having better observational skills."

That so many other doctors have seen the "David" but not commented on the jugular venous distension shows how often people can overlook critical details in the world around them, Gelfman said.

"It’s one of those things, as a colleague of mine said to me, it takes a trained observer to recognize how abnormal this actually looks. ... This points out that there are all sorts of clues to diagnosing disease that can be readily obtained if one knows to look,” he said. “I just saw something that has been hiding in plain sight for over 500 years.”

Follow Domenica Bongiovanni on Twitter: @domenicareports.