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December 6, 2000

The Art of Physical Diagnosis

Author Affiliations

Stephen J.LurieMD, PhD, Senior EditorIndividualAuthorPhil B.FontanarosaMD, Executive Deputy EditorIndividualAuthor

JAMA. 2000;284(21):2721-2722. doi:10.1001/jama.284.21.2717

To the Editor: The artwork displayed on the cover of the August 2, 2000, issue of THE JOURNAL is unlikely to represent either a victim of the guillotine or a postmortem subject. The painting appears to represent an elderly man with his head propped up on a pillow. The laryngeal prominence appears to be intact. Because this structure begins at about the level of the fifth cervical vertebra, it is unlikely that so much tissue below it would be spared the perpendicular cut of a guillotine. The anterior cervical muscles, particularly the omohyoid, also stand out quite prominently, something that would not be expected if the muscles had been detached from their origins.

A careful examination of the painting reveals a sign that would not be expected in a corpse—jugular venous distension. Could this sign provide a clue to the cause of this man's illness? Right-sided heart failure is the most common cause of jugular venous distension. Before the advent of effective treatments for right-sided congestive heart failure, the elevated venous pressure commonly led to bowel wall edema, malabsorption, and death due to malnutrition. Perhaps it is this condition that accounts for the severe emaciation that is evident in this subject.