Abstract

Objective King Philip II, the father of Alexander the Great, suffered a penetrating wound to the leg from a spear that left him severely handicapped. His skeletal remains represent the first and only case of an injury from ancient Greece that can be directly compared to its historical record. The objective of the study was to confirm the identity of the male occupant of Royal Tomb I in Vergina, Greece as Philip II of Macedonia by providing new evidence based on anatomical dissection and correlation with the historical description of the wounds. Methods Radiographs and photographs of the leg in Royal Tomb I in Vergina were examined. Anatomical dissection of a cadaver with a reconstructed wound similar to Philip's was also completed to identify associated soft-tissue injuries. Results The left leg was penetrated by an object at the knee which resulted in joint diastasis, external rotation of the tibia, knee ankylosis, and formation of a granuloma around the related object. This caused massive trauma to the joint but spared the popliteal artery. This resulted in ligamentous injury as well as injury to the peroneal nerve and probably the tibial nerve, resulting in a complete palsy of those nerves. Conclusion This evidence exactly matches the historical sources and shows conclusively that the leg and Tomb I belong to Philip II. The anatomic and archaeologic evidence also serve as independent verification of some of the historical record of that period, better enabling scholars to judge the reliability of various texts. Furthermore, it gives invaluable information about surgical practices in ancient Greece according to Hippocratic methods and their outcomes. Finally, this sheds new light on the occupants of Royal Tomb II including the fact that the armor recovered there may have belonged to Alexander the Great.

KEYWORDS:

alexander the great; joint granuloma; knee granuloma; peroneal nerve injury; philip ii

Figure 1

Views of Philip’s Leg

A: Lateral view of the knee joint with a pen demonstrating the persistent space from the wound tract and foreign body granuloma and surrounding ankylosis. B: Posterior view of the knee joint along with the persistent space from the wound and foreign body granuloma and surrounding ankylosis. C: Axial CT scan through the injured joint space oriented perpendicular to the long axis of the femur. White triangle arrowheads point to areas of post-mortem damage identified by lack of compact bone on the surface and fracture lines separating continuous channels in the cancellous bone. Orange chevron arrowheads demonstrate reactive sclerotic bone on the walls of the granuloma. Note the osteolytic nature of the lesion with some sclerotic changes around the hole typical of lesions resulting from foreign body granulomas. D: Axial CT scan through the femoral condyles oriented perpendicular to the long axis of the femur. The yellow arrow represents normal cortical bone on the surface of the femoral condyles, whose shape can be appreciated. E: Axial CT scan of the injured joint space at a level inferior to the intercondyloid fossa oriented perpendicular to the long axis of the tibia. The hole can be seen along its major axis (green arrow). The difference between the abnormal bone lining the hole (orange chevron) and the normal cortical bone along the inferior limit of the femoral condyle (yellow arrow) can easily be distinguished. F: Axial CT scan of the joint space at the level of the intercondyloid fossa oriented perpendicular to the long axis of the tibia. The yellow arrow represents normal cortical bone on the femoral condyles, whose shape can be appreciated. Note that the bone surrounding the intercondyloid fossa is evenly corticated, differentiating it from the granuloma space.

Labels - Brackets: femoral condyles, Red arrow: Tibial plateau, Green block arrow: wound tract, Blue triangle arrow: Intercondyloid fossa, A: Anterior, L: Left

Figure 2

Demonstration of the Femoral Condyles and Joint Space Granuloma

A: Posterior view of the specimen (below) with a sex and length match sample showing the condyles above it in parallel. B: En face view of the femoral condyles demonstrating the separation of the intercondyloid fossa from the wound tract. The dashed line to the left shows parallel structures. Blue line is the anterior femoral surface; note how the hole in the bone is distal to the intercondyloid fossa. C: posterior-anterior projection X-ray of the knee wound showing the inferior limit of the femoral condyles (red arrows) and wound tract granuloma space (green arrow). D: Lateral X-ray of the knee showing the inferior limit of the femoral condyles (red arrow) and the joint space granuloma (green arrow).

Labels - Red skinny arrow: inferior limit of the femoral condyles, Green block arrow: joint space granuloma from wound tract, Blue triangular arrowhead: Intercondyloid fossa. Scale = 5 cm in C and D.

Figure 3

Cadaveric Dissection Recreating Philip’s Injury

A: View of an example trajectory. Note how the spear enters medially to the long head of the biceps femoris and exits in the joint space between the femoral condyles. B: Close-up view of the dissection with anatomic structures labeled. C: Lateral oblique X-ray of cadaver specimen with a recreated injury. Note the joint diastasis similar to the knee of the specimen from Tomb I as well as the external rotation of the tibia. The penetrating foreign body can be seen as well. The red arrow represents the medial femoral condyle, the dashed bracket shows the joint space. D: Close-up view of the lateral aspect of the knee and popliteal fossa with the spear inserted. Note how the spear must either divide or radically displace the peroneal nerve to achieve this trajectory and also how this trajectory spares the large vessels of the popliteal fossa.

Labels - 1: Fibular head, 2: Peroneal nerve, 3: Popliteal artery and vein, 4: Biceps femoris, 5: Gastrocnemius.

The Leg Wound of King Philip II of Macedonia.

Abstract

KEYWORDS: