The Roman Emperor Hadrian (Publius Aelius Hadrianus Augustus) was born in Italica-Hispanica (modern day Seville, Spain) in 76 CE and died at his villa in Baiae, an ancient Roman town on the Gulf of Naples, in 138, at the age of 62. Hadrian is regarded as one of the five “good” emperors, along with Nerva and Trajan, who preceded him, and Antoninus Pius and Marcus Aurelius, who followed him. Marriage to Trajan’s grand-niece, Vibia Sabina, solidified Hadrian’s place as heir. Hadrian is said to have spent most of his reign traveling throughout the Roman Empire visiting the provinces, overseeing administration and maintaining and reinforcing the morale of his far-flung army. He was particularly devoted to, and supportive of, the army despite the fact that his regime was marked by relative peace. He also concerned himself with all aspects of government and the administration of justice. He was a man determined to show he was in charge throughout the empire, then the largest empire in the history of the world, encompassing most of Europe, including the south of Britain, as well as north Africa and the Middle East. The historian Edward Gibbon described Hadrian’s reign as “the period in the history of the world during which the condition of the human race was most happy and prosperous …” Gibbon describes Hadrian in mixed terms: ” … an excellent prince, a ridiculous sophist, and a jealous tyrant.”

In Hadrian’s time Romans generally shaved their beards when they reached adulthood. Hadrian was the first emporer to continue to wear a beard, starting a fashion in imperial portraiture that continued until the time of Constantine in the early fourth century. Hadrian was, at least in part, influenced by his great love of Greek culture where beards traditionally signify wisdom and maturity. The marble bust of Hadrian above (Metropolitan Museum of Art, New York) is from the early part of his reign and was found in his villa at Tibur (modern Tivoli), close to Rome. Hadrian’s earlobe crease is obvious and was well recognized and recorded in other statues as well as on the coins of his time:

  

Hadrian’s policy generally was to settle disputes with peaceful discussions and negotiations, although there were notable exceptions. In 130 he visited Jerusalem, still in ruins after the First Roman-Jewish War of 66-73, well described by Flavius Josephus (37-100). Hadrian rebuilt the city according to his own designs. When he constructed a temple to Jupiter on the ruins of the Temple of Solomon (the so-called Second Temple, sacred to Jews) the people revolted under the leadership of Simon bar Kokhbar (?- 136), battling for four years (132-136 CE) with considerable losses by both Romans and Jews. By the time the rebellion was suppressed, as many as a half million Jews had been killed and 1000 villages and towns destroyed. Hadrian then banished the remaining Jews from the region, renamed Jerusalem Syria Palestina after the Philistines (traditional foes of the Jewish people) and ordered a public burning of the Torah, executed Jewish scholars and prohibited the practice of Judaism.

Hadrian’s building projects, some of which survive, are his lasting legacy. The most magnificent edifice still standing is, of course, The Pantheon at the Piazza del Rotunda in Rome, one of the best-preserved Roman buildings. Its dome is, after almost 2,000 years, still the largest unreinforced concrete dome in the world. Hadrian’s Wall (Vallum Hadrian) in north Britain is the most famous of his structures. It marks what was then the northern boundary of the Roman Empire in Britain, once stretching from coast to coast and was designed both as a defense against invaders from the north, with an accompanying defensive ditch, and also as a means to control commercial traffic.

Hadrian established cities throughout Greece, Asia Minor, Egypt and the Balkan Peninsula. He particularly loved Greece and Greek literature, visiting that country at least twice. He intended to make Athens the cultural center of Europe and ordered the construction of many ornate temples in the city. The Arch of Hadrian, in Athens, was built in his honor. He dedicated a number of sites to his young Greek lover Antinous, who drowned in the Nile when Hadrian was 54 years old, and founded the Egyptian city of Antinopolis in his honor.

For the last three of four years of his life Hadrian was ailing , apparently with congestive heart failure, and he spent periods of time in great distress. He died in 138 CE, probably from a myocardial infarction (“heart attack;” “coronary thrombosis”) which brings us to the topic of this commentary: Hadrian’s earlobe.

Diagonal earlobe creases have often, but not always, been shown to be associated with coronary artery and other vascular disease. Two thousand years after Hadrian, Dr. Sanders T. Frank, in a letter to the editor of the New England Journal of Medicine, described the earlobe crease and its association with heart disease. In an eight-month period he recognized 20 of his patients under the age of 60 with a “positive ear-lobe sign,” all but one of whom had other accepted risk factors for coronary artery disease including elevated serum cholesterol values, elevated serum triglyceride values, diabetes mellitus, hypertension, cigarette smoking, and a family history of premature cardiovascular disease; many had more than one risk factor. In recent years a few articles have referred to the diagonal earlobe crease (DELC) as the Frank sign, in recognition of the 1973 paper, although I prefer to think of it as ‘Hadrian’s earlobe.’

Other reports, including autopsy studies of patients with the ear-lobe crease, have generally confirmed Frank’s observation but it has also been shown that the earlobe crease can occur in the absence of significant coronary artery disease and the finding is not always predictive; it is suggestive but not diagnostic. In the earliest change there is only wrinkling of the skin. Later a superficial crease is seen. Many people have a deeper crease extending more than halfway across the earlobe and those with the most marked change show a deep cleft extending completely across the earlobe, as seen in artefacts depicting Hadrian.

Robert E. Lee, general of the confederate forces during the American Civil War, complained of chest pain and weakness during the last seven years of his life. An 1869 photograph of him, the year before he died, seems to show an early earlobe crease. In the recent film, Phantom Thread, it appears that the magnificent actor, Daniel Day-Lewis, may be developing Hadrian’s crease. Other famous people have had this change and it is easily recognized in the general public.

In 2015, a paper by Rodríguez-Lopez and co-workers re-emphasized the usefulness of the earlobe crease as an potential indicator of coronary artery disease. They proposed a grading system, based on the degree of crease formation, that they linked to cardiovascular disease. In their scheme a unilateral, incomplete crease is considered least severe, a unilateral complete crease as intermediate in importance and the finding of bilateral, complete crease as most severe.

In 2017 a number of papers associated the diagonal earlobe crease with deleterious cerebral vascular events (stroke) and with vascular-induced cognitive impairment (dementia). It should be born in mind that even with the most advanced earlobe change there might not be significant cardiovascular disease in a given individual. Still, the finding merits review by a physician.

We know that atherosclerotic vascular disease, including of the vessels feeding the heart and the brain, has affected humans for many millenia as shown in remains of ancient Egyptians and Peruvians. Atherosclerosis worsens with aging and occurs in association with hypertension, hypercholesterolemia, diabetes mellitus, and other factors. The morphologic correlations, macro (gross)- and microscopic, have been well studied by pathologists for more than a century.

Atherosclerosis is characterized by lipid deposition immediately under the lining (intima) of the blood vessels with subsequent reactive proliferation, scarring (fibrosis) and calcification of the various artery wall components (intima, media and adventitia). There often is also a significant inflammatory cell infiltrate.

The first description and illustration of atherosclerosis published was the aorta of Johann Jacob Wepfer (1620-1695), a physician and pathologist who had devoted his life to the study of the cerebral vessels. The usual smooth lining of the aorta is, in Wepfer’s case, distorted by fatty and fibrous plaques, as well as calcification and even ossification (bony change). There is even some widening of the lower aorta indicative of early aneurysm change. The images of Hadrian, many from when he was relatively young, suggest that he had the onset of significant atherosclerosis when he was still in his forties.

Do the arteries to the earlobe in individuals with the earlobe crease show the same changes as those of the coronary arteries, the aorta and other atherosclerotic blood vessels? Almost certainly, but it remains to be demonstrated and proven. Microscopic study of the changes to arteries feeding the earlobe in people with the Hadrian crease have not yet been performed.

More to come …

Additional readings:

Hadrian

Cooley, A. Emperor of the World. History 2016;17:26-31.
Gibbon E. The Decline and Fall of the Western Empire. Chapter 3. Of the Constitution of the Roman Empire in the Age of the Antonines. Public Domain Book 1845.
Josephus F. The Jewish War. New York, Penguin Putnam Inc, 1984.
Mark JJ. Hadrian, in Ancient History Encyclopedia. 2009. http://www.ancient.eu/hadrian/
Opper T. Hadrian: Empire & Conflict. Cambridge, Harvard University Press, 2008, pp 57-58, 220-221.

Cardiovascular implications

1973 Frank ST. Aural sign of coronary-artery disease. New England Journal of Medicine 289:327.
1980 Petrakis NL. Diagonal earlobe creases, type A behavior and the death of Emperor Hadrian. Western Journal of Medicine 132:87.
1984 Jorde LB, Williams RR, Hunt SC. Lack of association of diagonal earlobe crese with other cardiovascular risk factors. Western Journal of Medicine 140:220.
1987 Brady PM, Zive MA, Goldberg RJ, Gore JM, Dalen JE. A new wrinkle to the earlobe crease. Archives of Internal Medicine 147:65.
1987 Cumberland GD, Riddick L, Vinson R. Earlobe creases and coronary atherosclerosis. The view from forensic pathology. American Journal of Forensic Pathology 8:9.
1989 Kirkham N, Murrells, Melcher DH, Morrison EA. Diagonal earlobe creases and fatal cardiovascular disease: a necropsy study. British Heart Journal 61:361.
1990 Ishii T, Asuwa N, Masuda S et al. Earlobe crease and atherosclerosis. An autopsy study. Journal of the American Geriatric Society 38:871.
1992 Patel V, Champ C, Andrews PS et al. Diagonal earlobe creases and atheromatous disease: a postmortem study. Journal of the Royal College of Physicians London 26:274.
1992 Tranchesi Júnior B, Barbosa V, de Albuquerque CP, et al. Diagonal earlobe crease as a marker of the presence and extent of coronary atherosclerosis. American Journal of Cardiology 70:1417.
1996 Gutiu IA, Galetescu E, Gutiu LI, Raducu L. Coronary artery disease, or a mere wrinkle. Ancient Greco-Roman evidence. Roman Journal of Internal Medicine 34:271.
2004 Evengüi H, Dursonoglu D, Kaftan A et al. Bilateral diagonal earlobe crease and coronary artery disease, a significant association. Dermatology 209:271.
2006 Edston E. The earlobe crease, coronary artery disease, and sudden cardiac death” an autopsy study of 520 individuals. American Journal of Forensic Medicine and Pathology 27:129.
2014 Mark JJ, Buckley S. From the Archives – the diagonal earlobe crease: historical trivia or a useful sign of coronary artery disease? NYU Langone Online J Med http://www.clinicalcorrelations.org/?p=7953.
2014 Xu XL, Yang DY, Zhao YS, Chai WH, Jin ML. Diagonal earlobe crease and coronary artery disease in a Chinese population. BMC Cardiovascular Disorders 14:43.
2015 Rodriguez-López C, Garlito-Diaz H, Madronero-Mariscal R et al. Earlobe crease shapes and cardiovascular events. American Journal of Cardiology 15:286.
2017 Lee JS, Park S, Kim HJ et al. Diagonal earlobe crease is a visible sign for cerebral small vessel disease and Amyloid- Scientific Reports 7:13397.
2017 Nazzai S, Hijazi B, Khalila L, Blum A. Diagonal earlobe crease (Frank’s sign): a predictor of cerebral vascular events. American Journal of Medicine 30:1324.
2017 Reinhart RA. Robert E. Lee’s right ear and the relation of earlobe creased to coronary artery disease. American Journal of Cardiology 120:327.