Facial Diagnosis

I grew up with the Reader’s Digest, although I do not think that was what my parents had in mind.

I was a very early reader. I had the activity pretty much nailed by the time I was three. I could even do phonetic “sounding out” of words, as well as the obsessional “dictionary searching” that I now do on line. I also had an obsessional interest in books intended for “bigs.”

The Reader’s Digest, to which my parents had some kind of a lifetime subscription or something, was consistently to be found on top of my mother’s bedside table — which had actually been her old “hope chest.”  I would “borrow” the current copy of the Reader’s Digest in the morning when they were still asleep, and generally return it before they would wake.

I will admit I had promised them to ask about anything I did not understand, but I have no memory of ever having to do so.

Recently, my husband — the movie buff and avid reader — called my attention to a copy of RD that he saw in some waiting room.  He said it reminded him of me — since I often will comment on the condition of some movie or TV character based upon the appearance (or lack thereof) created by makeup for the dramatic effect.  I’m not really diagnosing the character, as such — merely commenting on the realism of the makeup effects.

Husband-Dear has a fondness for classic swashbuckling movies and related novels, and told me about Errol Flynn’s 1935 classic Captain Blood — one of the best pirate films ever made (he claims – and critics seem to agree).

In this story, Dr. Peter Blood is sentenced to death for treating an enemy soldier during some British rebellion .  Dr. Blood responds by diagnosing his judge with kidney failure — based upon his facial appearance — stating that the judge has already been sentenced to death by a “Higher Judge.”

The RD article in question is about facial appearance and how various conditions may be diagnosed from a visual inspection (although a good doctor will do blood tests, imaging or whatever else needed — if only to satisfy insurance companies).

I was a bit surprised, because not only is this not terribly topical, but I may have been the last of a generation to have, in the course of her medical education, been “steeped” in classical (old fashioned) clinical diagnostics.

And I mean old. Some of these go back to Hippocrates – Yes, Him of The Oath.

The function of medical education in France, when I was a student, was primarily to produce French country doctors, of which there never seemed to be enough. In our single course about the business of medicine (given by a country doctor who drove in for lectures) we were told that accounts of finances kept by hand in a bound notebook would be sufficient, and that it was advisable to use no more than a single horizontal line to cross out any errors.

We were even told not to get greedy, and not to be dishonest, as we would make a decent living and earn enough to raise our families.

We were told also to do a really good job and to be as thorough as we could with the physical examinations, and with all clinical work, as we ought not to rely excessively on “paraclinical” examinations.  It was just a pain to drive in from the country to the city to get x-rays or blood work or something fancy.  You just had to save it for when your first line did not work and you had a relationship with the patient.

“Oy,” thought I, who wanted every patient to enjoy the height of diagnostic science.

Still, there is an advantage here.

When you are acting as if you have to rely only on what you can see and feel, you have to learn an awful lot.

We had a year to learn something called “Semiology ” — the science of diagnostic signs — before learning “Therapeutics.”

“Semiology” really is an English word.  I just never heard anybody but I use it in English.

I was taught that every patient who showed up for a general physical had to be stripped, completely.

An appropriate witness was always encouraged to be present if it made that person comfortable.

Northern France being pretty cold in the winter, adequate heating in the office was a necessity.

I knew I had the most classical of medical educations imaginable. When I studied anatomy, I looked at Leonardo da Vinci’s drawings.  And Vesalius.

When I looked at diagnostic signs, I looked at Hippocrates, and subsequent greats.

So a really good doctor ought to strip folks down and look at every inch of skin, not just look at the patient’s face during a chat.

As it happens, the first symptoms in the Reader’s Digest list are indicative of dehydration.

This is one of those topics about which I am a “reluctant expert.”

I certainly have a tendency toward dehydration.

A list of surprising reasons not to get dehydrated did not surprise me.

I am writing this while sitting, albeit indoors, in a high elevation desert.

“Dry, flaky skin or lips….”

Not only are the assessment and treatment of dehydration common knowledge, but reading it off the face, and “Facial Diagnosis” more generally seem to date back to Hippocrates.

We are talking 4th century B.C. here.

The Reader’s Digest concern about excess facial hair in women is a bit naive and oversimplified.  A lot of women get a little of this after menopause.

Has nobody but me ever gone to visit an older maiden aunt and found a delicate little razor in the bathroom?

It can commonly mean just a little much male hormones (androgens) as summarized in this link (Which opens a PDF document in your browser or downloads it to your hard drive.  This requires the free Adobe Acrobat reader to access.)

Polycystic ovary includes a lot of stuff, most of which you could almost start to guess — if you look a little bit at the rest of the patient’s body.

As for the next observation — fatty deposits inside the eyelids — we know that Leonardo da Vinci at least observed them, because he painted them in the Mona Lisa (1506).

Admittedly, clinical description in a medical journal of fatty deposits around the eyelids does not seem to have appeared until sometime in the early 19th century.

These can be associated with raised lipid (fat) levels in the blood and all the possible consequences of same, but the raised blood levels seem to occur only 50% of the time.

Puffiness under the eyes?  A physician I once worked with quite closely used to call them “allergic shiners.”

I have really never needed these to tell that I have hay fever. The sneezing when pollens are in the air takes care of that one.

It has pushed me to use a fair amount of under-eye concealing cosmetics.  It may push others to facial plastic surgery, I suppose.

Facial asymmetry, although it may isolated in facial palsy — a.k.a. Bell’s Palsy — can coexist with a variety of other signs, indicate stroke.

That one is definitely call-911 or rush to the Emergency Room stuff, but at least usually it is hard to miss.

Discolored complexion is so non-specific (can mean so many different things) that I probably would not try to evaluate it without a strip-down-and look-at-all-the-skin physical — let alone a blood test.

(It is symptomatic, among other things, of poorly applied makeup)

Same problem with rashes and blotches.  I would suggest checking out the rest of the skin.

Although the rash associated with Lupus erythematosis  is memorable once you have seen one.

You may have heard of that diagnosis – frequently – as the disease to be ruled out on the medical thriller TV series House, MD.  On that show, it becomes a running joke, as it is always the first diagnosis made and is always wrong.

Our facial indicators of disease end with receding chin as a sign of sleep apnea.

Seems to me the association of outer anatomy with sleep apnea is iffy at best.  I mean, when I first learned about sleep apnea, I learned that it happened basically in males with short necks.  I have diagnosed it, and had the diagnosis confirmed with sleep testing in tall thin women with willowy necks, as well as every other anatomical type I think of.

The object here is not to put down Reader’s Digest, which seems to remain a good reference for a “general” reader in a way that few periodicals seem to be these days.

If one person has a life saved, or an improvement in quality of life, from alerting the public to “facial diagnosis,” that is fine, even great.

Me, I’m just hoping I responded appropriately to my husband’s suggestion I try to be “topical.”

One point here is that things which seem “topical” often are ancient or even iffy.

I am reminded of the (lovely) Isaac Asimov story where people who use computers and mechanical calculators “rediscover” manual calculations with a pencil and paper.

Maybe, in these days of highly sophisticated (and expensive) diagnostic tests, we need to rediscover the low cost (and even the beauty) of a really thorough physical examination by a physician.