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On the Hippocratic Facies

Mark A. Marinella

From the Department of Internal Medicine, Division of Hematology-Oncology, Wright State University School of Medicine, Dayton, OH

Corresponding author: Mark A. Marinella, MD, 33 West Rahn Rd, #101, Dayton, OH 45429; e-mail: Mmarinella{at}pol.net

INTRODUCTION

Oncologists have many tools at their disposal to predict the prognosis of patients with cancer: computed tomography, magnetic resonance imaging, positron emission tomography, and various cytogenetic and molecular tests. Despite these, predicting when death will occur in an individual patient is often fraught with difficulty. Nonetheless, as patients with terminal malignancy approach death, various physical derangements may occur, such as hypopnea, apnea, an erratic pulse, cyanosis, cool extremities, and delirium. We as physicians are often approached by patient's family members asking us to render an opinion as to when we think their loved one will die. As an example, we recently cared for a hospitalized young man with end-stage metastatic colon cancer who died while in the hospital. One morning while making rounds in the serene quiet, I studied his sunken eyes, bitemporal muscle wasting, livid skin color, and a decreased level of consciousness. This facial expression, which all oncologists frequently encounter, serves as a useful prognostic sign as described by Hippocrates centuries ago.

PREDICTING DEATH

Certainly, clinical acumen and experience at interpreting history and physical findings, as well as radiographic and laboratory data patterns, may aid in diagnosing and assessing prognosis.¹ Assigning prognosis impacts the lives of patients and their families with regards to planning various end-of-life financial, personal, and social tasks.^2,3 Additionally, an accurate physician prognosis may help to avoid unnecessary treatments that lead to additional time spent in doctor's offices or hospitals during a patient's last weeks.³ Importantly, the typical prognostic indicators in oncology such as tumor size, grade, and stage are less relevant and predictive of prognosis in advanced malignancy.⁴ In fact, various clinical variables such as delirium, dyspnea, weight loss, asthenia, dysphagia, and performance status have been shown to correlate better with approaching death.^6-9 Additionally, laboratory derangements such as leukocytosis, lymphopenia, hypercalcemia, and hypoalbuminemia have also be shown to be associated with poor outcome and death in hospitalized patients.^2,5,10,11 However, generating prognosis based on isolated symptoms or laboratory derangements is very difficult, which has prompted the development of several prognostic indices for application to patients with advanced or terminal cancer.

Scoring systems such as the Palliative Prognostic (PaP) score,¹² the Palliative Prognostic Index,¹³ the Chuang Prognostic score,¹⁴ the Terminal Cancer Prognostic score¹⁵ and the Bruera's Prognostic Indicator¹⁶ have been devised to assist oncologists in estimating the likelihood of death in patients with advanced cancer. These predictive scoring systems are based on various symptoms, signs, and laboratory abnormalities, and yield a numerical score which can be helpful in predicting death in the short term.¹⁷ The best validated and most widely utilized prognostic scoring system is the PaP score, which was recently endorsed by the European Association for Palliative Care in their evidence-based clinical recommendations on cancer prognosis.³ The PaP score consists of the following variables: absence or presence of dyspnea, absence or presence of anorexia, Karnofsky performance status, the clinician prediction of survival in weeks, total leukocyte count, and the percentage of lymphocytes.¹² Each variable is assigned a point-score and patients are subsequently divided into three risk groups. Patients with the lowest scores (group A) have a 30-day survival probability of more than 70%, and patients with the highest scores (group C) have a 30-day survival probability of less than 30%.¹² Glare et al¹⁸ recently validated the prognostic accuracy of the PaP score in predicting the probability of 1-month survival in a population of 100 hospitalized patients with advanced cancer.

However, despite the clinical utility of prognostic scoring systems, the simple art of visual inspection may be an extremely valuable indicator of imminent death. Specifically, a term described by Hippocrates known as the facies Hippocratica, or Hippocratic facies, has empiric prognostic significance that, according to Illich, ¹⁹ indicates that the patient "had moved into the atrium of death."

HIPPOCRATIC OBSERVATION

Hippocrates, the son of the physician Herculidis, was born on the Aegean sea island of Cos in the year 460 BCE and died in 377 BCE²⁰ Considered by many to be the "Father of Medicine," Hippocrates is known for composing the oath named after him and for a collection of 72 medical dissertations known as the Corpus Hippocraticum (Hippocratic Corpus).²¹ This multivolume text stood alone as the standard reference for the entire ancient world of medicine until the Middle Ages.²² Hippocrates espoused the idea that medical therapies must depend on clinical observation and experimentation after taking into consideration the existing knowledge of medicine of the day.²³ As such, the three fundamental posits of Hippocratic medicine were observation, experience, and rationale.^23,24 Observation and experience, which are often lost today among our modern technologies and quest for productivity, formed the crux of Hippocrates’ diagnostic and prognostic approach to the patient: inspection, direct auscultation, and palpation.

Three classic physical signs are credited to Hippocrates: the Hippocratic sisis (shake) present with thoracic empyema; Hippocratic or clubbed digits often present with pyogenic or neoplastic diseases of the thorax; and the facies Hippocratica (Hippocratic facies).^21,23 In his work On Prognosis, Hippocrates pontificates on the vital importance of disease prognosis—the course a specific disease process will take in an individual patient.^21,25 He insisted that prognostic signs are intimately related to diagnostic physical signs and noted that good humor, quiet sleep, a clear mind, and mobility were signs of a favorable prognosis.²⁶ On the contrary, Hippocrates noted that lying with the mouth and eyes open with legs spread apart, insomnia, violent movements, and constant diarrhea portended an unfavorable prognosis.^26,27 Indeed, Hippocrates placed much weight into simple visual observation: "It is necessary to begin with the most important things and those most easily recognized. It is necessary to study all that one can see, feel, and hear, everything that one can recognize and use."²⁶

THE FACE OF DEATH

Perhaps the most prognostically useful eponym attributed to Hippocrates is the Hippocratic facies, a countenance often present at the verge of death.^28,29

"You should observe thus in acute diseases; first the countenance of the patient, if it be like those of persons in health, and especially if it be like its usual self, for this is best of all. But the opposite are the worst, such as these: a sharp nose, hollow eyes, sunken temples; the ears cold, contracted and their lobes turned outwards; the skin about the forehead rough, stretched and parched; the color of the face greenish or livid... be it known for certain that the end is at hand."

This morbid facial expression has been associated not only with advanced cancer,³⁰ but also trauma,³¹ heart disease, and, as noted by Sir William Osler in his classic medical text Practice of Medicine,³² peritonitis and typhoid fever.

HIPPOCRATIC WISDOM

Oncologists are all too familiar with providing care for suffering patients at the end of prolonged battles with cancer, chemotherapy, severe pain, and the discomfort of medical procedures. Even in contemporary society, some practitioners still appreciate the value that Hippocrates placed on prognostication not only in medicine as a whole, but also in oncology.³ In order to cultivate the wisdom necessary to appreciate when further treatment or chemotherapy is futile, one would do well to revisit Hippocratic prognosticators, most notably the Hippocratic facies. Indeed, Hippocrates instructed his contemporaries "not to attempt to treat those patients whose condition would seem to be terminal" and that "it is better to give no treatment in case of hidden cancer."²¹ Although millennia have passed since Hippocrates offered physicians his many aphorisms, we would do well to skillfully observe our patients’ faces—not only in life, but also in death.

AUTHOR'S DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

The author(s) indicated no potential conflicts of interest.

NOTES

Author's disclosures of potential conflicts of interest and author contributions are found at the end of this article.

REFERENCES

1. Marinella MA: Preface, in Recognizing Clinical Patterns: Clues to a Timely Diagnosis. Philadelphia, PA, Hanley and Belfus, 2002, p xi

2. Glare P: Clinical predictors of survival in advanced cancer. J Support Oncol 3:331-339, 2005[Medline]

3. Maltoni M, Caraceni A, Brunelli C, et al: Prognostic factors in advanced cancer patients: Evidence based clinical recommendations—a study by the steering committee of the European Association for Palliative Care. J Clin Oncol 23:6240-6248, 2005[Abstract/Free Full Text]

4. Mackillop WJ: The importance of prognosis in cancer medicine, in Gospodarowicz, M (ed): Prognostic Factors in Cancer (ed 2). New York, NY, Wiley-Liss, 2001, pp 3-14

5. Viganó A, Bruera E, Jhangri GS, et al: Clinical survival predictors in patients with advanced cancer. Arch Intern Med 160:861-868, 2000[Abstract/Free Full Text]

6. Llobera J, Esteva M, Rifa J, et al: Terminal cancer: Duration and prediction of survival time. Eur J Cancer 36:2036-2043, 2000[CrossRef][Medline]

7. Allard P, Dionne A, Potvin D: Factors assoiciated with length of survival among 1,081 terminally ill cancer patients. J Palliat Care 11:20-24, 1995[Medline]

8. Walsh D, Rybicki L, Nelson KA, Donnelly S: Symptoms and prognosis in advanced cancer. Support Care Cancer 10:385-388, 2002[CrossRef][Medline]

9. Caraceni A, Nanni O, Maltoni M, et al: Impact of delirium on the short term prognosis of advanced cancer patients. Cancer 89:1145-1149, 2000[CrossRef][Medline]

10. Penel N, Dewas S, Doutrelant P, et al: Cancer-associated hypercalcemia treated with intravenous diphosphonates: A survival and prognostic factor analysis. Support Care Cancer 16:387-392, 2008[CrossRef][Medline]

11. Marinella MA, Markert RJ: Admission serum albumin level and length of hospitalization in elderly patients. South Med J 91:854-858, 1998

12. Pirovano M, Maltoni M, Nanni O, et al: A new palliative prognostic score: A first step for the staging of terminally ill cancer patients—Italian Multicenter and Study Group on Palliative Care. J Pain Symptom Manage 17:231-239, 1999[CrossRef][Medline]

13. Maltoni M, Nanni O, Pirovano M, et al: Successful validation of the palliative prognostic score in terminally ill cancer patients: Italian Multicenter Study Group on Palliative Care. J Pain Symptom Manage 17:240-247, 1999[CrossRef][Medline]

14. Chuang RB, Hu WY, Chiu TY, et al: Prediction of survival in terminal patients in Taiwan: Constructing a prognostic scale. J Pain Symptom Manage 28:115-122, 2004[CrossRef][Medline]

15. Yun YH, Heo DS, Heo BY, et al: Development of terminal cancer prognostic score as an index in terminally ill cancer patients. Oncol Rep 8:795-800, 2001[Medline]

16. Bruera E, Miller MJ, Kuehn N, et al: Estimate of survival of patients admitted to a palliative care unit: A prospective study. J Pain Symptom Manage 7:82-86, 1992[CrossRef][Medline]

17. Stone RC, Lund S: Predicting prognosis in patients with advanced cancer. Ann Oncol 18:971-976, 2007[Abstract/Free Full Text]

18. Glare PA, Eychmueller S, McMahon P: Diagnostic accuracy of the Palliative Prognostic Score in hospitalized patients with advanced cancer. J Clin Oncol 22:4823-4828, 2004[Abstract/Free Full Text]

19. Illich I: Death undefeated. BMJ 311:1652-1653, 1995[Free Full Text]

20. Kanellou V: Ancient Greek medicine as the foundation of contemporary medicine. Tech Coloproctol 8:S3-S4, 2004[CrossRef][Medline]

21. Liddell K: Hippocrates of Cos (460-377 BC). Clin Exp Dermatol 25:86-88, 2000[CrossRef][Medline]

22. Orfanos CE: From Hippocrates to modern medicine. J Europ Acad Derm Venerol 21:852-858, 2007[CrossRef]

23. Falagas ME, Zarkadoulia EA, Bliziotis IA, et al: Science in Greece: From the age of Hippocrates to the age of the genome. FASEB 20:1946-1950, 2006[Free Full Text]

24. Manolidis LS: Otorhinolaryngology through the works of Hippocrates. J Otorhinolaryngol Relat Spec 64:152-156, 2002

25. Arrizabalaga J: Medical causes of death in preindustrial Europe: Some historiographical considerations. J Hist Med 54:241-260, 1999

26. Castiglioni A: The golden age of Greek medicine: Hippocratic medicine—a biologic and synthetic concept, in Krumbhaar EB (ed): A History of Medicine. New York, NY, Alfred E. Knopf, 1941, pp 148-178

27. Cheng TO: Hippocrates and cardiology. Am Heart J 141:173-183, 2001[CrossRef][Medline]

28. Singer C, Underwood EA: Ancient Greece. In: A Short History of Medicine. New York, NY, Oxford University Press, 1962, pp 16-47

29. Daikos GK: History of medicine: Our Hippocratic heritage. Int J Antimicrob Agents 29:617-620, 2007[CrossRef][Medline]

30. Rudd TN: Family doctor at the death bed: Medical classics reconsidered. Med World 85:50-52, 1956[Medline]

31. Situm M: Images: Physician in war. CMJ 43:84-85, 2002[Medline]

32. Osler W: The Principles and Practice of Medicine. New York, NY, D. Appleton and Co, 1906, pp 82, 582

Submitted December 13, 2007; accepted December 20, 2007.

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