Deformity in the \"Boxing Boys\"

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Deformity in the “Boxing Boys”

Ferrence, Susan C.Bendersky, Gordon.

Perspectives in Biology and Medicine, Volume 48, Number 1,Winter 2005, pp. 105-123 (Article)

Published by The Johns Hopkins University PressDOI: 10.1353/pbm.2005.0008

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Susan Ferrence* and Gordon Bendersky†

*Department of Art History,Temple University.†Department of History, University of Pennsylvania; research accomplished at Drexel University

College of Medicine.Correspondence: Susan Ferrence, 2100 Walnut Street,Apt. 6G, Philadelphia, PA 19103.E-mail: sferrenc@temple.edu.

The authors discussed the background of the Akrotiri paintings from a medical and archaeologicalviewpoint in an earlier article (Ferrence and Bendersky 2004).We wish to thank P. P. Betancourt forhis guidance, useful comments, and encouragement during the writing of this paper; J. S.Adelman forher remarkable judgment in solving problems and formulating counter arguments; and N. Picardo forhis critiques of earlier versions of the paper.The extremely generous assistance given by the librariansof the Drexel University Hahnemann Library, the University of Pennsylvania Museum of Archaeologyand Anthropology Library, and the Bioscience Library of the University of Pennsylvania is acknowl-edged. The observations of the anonymous reviewers have also helped to significantly improve thispaper.We, however, are responsible for whatever errors remain.

Editors’ note: With deep regret, we report that Gordon Bendersky, a frequent contributor to Perspec-tives in Biology and Medicine, died October 7, 2004. He was a distinguished cardiologist, an energeticscholar, and a great friend and colleague.

ABSTRACT The late Bronze Age wall painting the Boxing Boys (c. 17th–16thcentury BCE) was excavated in the ancient town of Akrotiri on the Greek island ofThera.This article considers a medical interpretation for the spinal-pelvic anomaly inthe anatomy of one of the boys.The artist has depicted a combination of structural ana-tomical adjustments diagnostic of spondylolisthesis, a forward slippage of one of thelumbar vertebrae. The accurate portrayal of the surface appearance of this conditionsuggests that the artist painted directly from a live subject.Thus, the Boxing Boys muralmay be the earliest visual record of a sports-induced injury. Although the meaning ofthe wall paintings is unclear, the wild goats (agrimia) on the adjoining walls simulateswayback as a reflection of the boy’s torso deformity and share other features with theboxers, adding to the unifying characteristics of the room.The abnormal morphologyappears to be the earliest achievement of transforming disease into aesthetic charm ona monumental scale.

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Susan Ferrence and Gordon Bendersky

Perspectives in Biology and Medicine

. . . of those that raise their arms to box:the one to whom Apollo gives victory through enduranceand the one whom all the Achaians recognize as superior.

—Homer, Iliad 23.660–662

BEGINNING IN 1967, EXCAVATORS of the ancient town of Akrotiri,Thera, un-covered a series of late Bronze Age wall paintings (c. 17th–16th century

BCE). In 1970, the magnificently rendered Boxing Boys fresco (Figure 1) was dis-covered with adjacent wall paintings of agrimia (wild goats) in building Beta.This structure was among the town remains covered by the pumice and ash thatfell from a volcanic eruption which destroyed Akrotiri (S. Marinatos 1971b, 47).The buried frescoes are the best preserved from the Late Bronze Age Aegean.

The Boxing Boys (Figures 1 and 2) displays aesthetically formidable humanfigures that exhibit elegantly supple children’s anatomy. The general accuracy,proportions, and apparent freedom of movement excel in this life-size scale; ana-tomical criteria suggest that the boys are the earliest extant images with properchildhood proportions.1 In the 34 years since the original excavation publica-tions, the meaning of the Boxing Boys has yet to be fully comprehended.

Figure 1

The Boxing Boys fresco from Room Beta 1,Akrotiri,Thera (Doumas 1992, fig. 79).

1The boys’ prepubescent state (age 8 to 10) is correctly signified by narrow shoulders and the small

The configuration of the pelvis, low back, and abdomen of the boy on theright appears distorted. The painting reflects a rigid abnormality, probably aspinal deformity. This study attempts to explain this ungainly anomaly in theotherwise lithe boxer. Five anatomical points are discussed here: the forwardpelvic inclination, the hyperlordotic lumbar curve (low-back concavity), thelong and prominent abdomen, the forward displacement of the vertebral col-umn, and the dropped torso (Figure 3). As a corollary of this medical hypothe-sis, attention is directed to the striking resemblance of the boy’s lumbar hollowand parallel abdominal convexity with the analogous sagging back and droopingbelly in the wild goats, or agrimia, in the adjacent wall paintings.

The Hypotheses

We theorize that the boy’s torso distortion is a five-fold deformity caused byspondylolisthesis, a forward slippage of one of the lumbar vertebrae, and that theartist faithfully portrayed a deformed child.The etiology is probably a predispo-sition for the disease combined with repeated sports trauma, the underlyingpathology often occurring by the age of six (Bradford and Hu 1994, 585). Al-though there are alternative interpretations, this spinal abnormality was probablyinduced by traumatically recurrent lumbar flexion and hyperextension. Repeat-ed microtrauma causes fatigue fracture of the pars interarticularis (spondylolysis)(Figure 4), which, in turn, not uncommonly results in vertebral slippage (spon-dylolisthesis) (Figure 5) in a susceptible individual (Bradford and Hu 1994, 585–86).There are no ancient Egyptian or cuneiform texts that refer to spondylolis-

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Figure 2

Room Beta 1 showing the Boxing Boys and one pair of agrimia (N. Marinatos 1984, fig. 73).

size of the pelvises. Particularly, the size of the head in proportion to the trunk and limbs is extraor-dinarily accurate and consistent with the relevant ratios and ages found in the somatotyping of chil-dren (as discussed in the differential diagnosis below).

thesis, and no image from antiquity exhibiting this shape other than the BoxingBoys.The ancient Therans probably did not perceive the spondylolisthesis as anactual disorder; the artist may simply have interpreted the abnormality as a nat-ural variation in a child’s physical form.

We also hypothesize that the parallel of the agrimia’s swayback concavity andabdominal convexity deliberately mirrors the pugilist’s deformity.The boys andthe goats share numerous common features, but this swayback condition appearsto be a distinct deviation from the norm.The artist seems to have gone beyond

Figure 3

Figure 4

Diagram of the five external criteria for spondylolisthesis in the deformed boy on the right of the Boxing Boys fresco.

Spondylolysis: stress fracture in the pars interarticularis of L5 (after Stinson 1993, fig. 2).

the mundane physiological and artistic criteria that link the boys and agrimiaand to have stylistically added these abnormal curves to the ruminants.2 Ourhypotheses are based upon the acceptance of the conservation and reconstruc-tion of the fresco fragments.3

Archaeological and Art Historical Context

The Boxing Boys appear life-size at the height of 4�2 � (127.5 cm) and are locatedin the middle zone of the south wall in building Beta, room 1 at Akrotiri (Gural-nick 2000, 175). Altogether six agrimia are represented on the east, north, andwest walls—a pair on each of the east and west walls, with two single goats flank-ing the central window of the north wall (S. Marinatos 1971b, 47). An undula-ting expanse of red paint and heart-shaped ivy leaves unify the animals and boysby highlighting curves and prominences of their anatomy (Doumas 1992, 110).

The boxers are approximately eight to 10 years old, and they are nude exceptfor the blue cloth or leather belts worn at their waists (below the navel of theboy on the right). The boys are painted as contoured silhouettes filled with flatcolors (Immerwahr 1990, 161).They each wear only one spherical glove on theirright hands, which permits the boxer to grasp the hair or the belt of his oppo-nent with his left hand. In this manner of boxing, repeated blows could result inthe acute arching of the lumbar area when withdrawing from the punches.Theseactions may have contributed to spondylolysis, a precursor of spondylolisthesis.

Figure 5

Diagram of lateral views of slippage versus normal vertebrae.

2We have assumed the primacy of the boys in the physiognomic interrelationship with the agrimia,not the reverse (namely one boy’s form mimics that of the agrimi’s swayback), based on the ex-treme rarity of the swayback. Although swayback does occur in some ruminants, the concurrencewith spondylolisthesis in the pugilist would be statistically infinitesimal.3In the reconstruction of the fresco, the majority of the buttocks and lower limb areas of the de-formed boy were not preserved. However, archaeologists S. Marinatos (1971b) and C. Doumas(1992) claim that the reconstruction and preservation of the Thera paintings is sure, and that theThera artist tended to render nature faithfully.

Besides the exhibition of prowess and antagonism, the Boxing Boys also showsa distinctive physical contrast. Prepubertal anatomy is accurately rendered in theboy on the left, but the boy on the right is misshapen.To a modern diagnosti-cian, the contrast between the boxers provides a control for the viewer, with theboy on the left as the standard of comparison, while the opponent deviates fromthe norm.The significance of the contrast is open to interpretation.Are the box-ers juxtaposed specifically to highlight differences—bejeweled contestant withcorrect proportions opposing a boy without jewelry, who would be taller if hecould straighten his spine and pelvis—in order to identify the boy with highersocial rank as the victor and reject the other as a distorted loser? That this wasnot the artist’s intention is suggested by the fact that the deformed boy has actu-ally just delivered an aggressive blow.

Much scholarship has been devoted to the iconography and meaning of theBoxing Boys, and none more compelling than E. N. Davis’s (1986) seminal arti-cle on the significance of the boys’ shaved heads. Davis discussed various boys’and girls’ hair styles in several Theran frescoes and linked four phases of hairgrowth to different stages of youth, the transitions of which may have beenmarked by rites of passage. Davis also relates this Theran iconography to theancient Egyptian tradition of growing “Horace locks” for the boys and backlocksfor the girls. Based on this postulate, perhaps the Boxing Boys are engaging in aritual competition to mark a certain youthful transition.

The Prehistory and History of Boxing

The earliest extant images of fighters involve adults, and they were sculpted fromthe end of the 4th through the early 2nd millennium BCE in Mesopotamia(Poliakoff 1987, 69; Strommenger 1965, 12, fig. 46).4 The late Bronze Age pugil-istic scenes appearing at Alalakh, Knossos, Hagia Triada, and Tylissos are morecontemporaneous with the Boxing Boys (Evans 1902–1903, 57, fig. 35). TheBoxer Rhyton from Hagia Triada may be analogous to the Boxing Boys becausethe possible victor wears jewelry and is consistently placed on the left of thescene (N. Marinatos 1993, 214).5 At Tylissos, the miniature frescoes appear toshow males engaged in boxing games (Evans 1930, 3:35). Additionally, the

4Dating to the transition from the 4th to the 3rd millennia BCE, the fighters in the stone reliefvotive plaque from Mesopotamia may be wrestlers rather than boxers (Strommenger 1965, 26, 393,fig. 46). The Egyptian pugilists from the Beni Hasan tombs of the 12th Dynasty (c. 2000–1785BCE) appear to be primarily wrestlers or stick fighters, not boxers (Abdou 1961, 184–85); punch-ing is not involved in these contexts. Boxing is subsequently portrayed at Amarna (c. 1370–1350BCE) in the 18th Dynasty (DeVries 1960, 239).There are young boys from the Old Kingdom in-volved in sports, but they are playing games and not sparring (Schäfer 1974, 174).5For a dissenting view, see Immerwahr (1990), who suggests that the younger fighter on the rightis the aggressor because his knees are flexed (as if leaning forward) and his right arm thrusts farthercompared to his opponent.

c. 1646–1626 BCE Syrian cylinder seals from Alalakh are close to the same timeperiod as the Theran boxers, and they show adult pugilists punching or graspingat the head (Collon 2000, 287, fig. 9). Five hundred years later in Assyria, and athousand years later in Classical Greece, pugilists were illustrated again (Sjöberg1985, 9). However, because of the diverse sources for boxer images and the cul-tural interconnections in the East Mediterranean, the Classical boxing portrayalsdo not necessarily owe their origins to Thera.

A 1st millennium BCE literary source (referring to 2nd millennium BCE legends) mentions the sea goddess, Leucothea (Parke 1987, 35–37). The text describes the boxers as child goatherds who captured a swan. The boys foughtover the animal, then discovered it was Leucothea. She directed the boys to tell the townspeople that, having been pleased with their fight, she expectedthem to henceforth perform a boy’s athletic contest dedicated to her (Parke1985, 3–4).

The textual history of boys’ boxing postdates the Boxing Boys by a millenni-um. Olympic boxing events for boys began in 616 BCE. Polymnestor of Miletus,Hippomachus of Elis, and Athenaios of Ephesus, for whom a statue was erected,were well known boxing boys (Drees 1968, 69; Sweet 1987, 83;Young 1984,159). Furthermore, the 6th century BCE Greek poet Bacchylides specificallyrefers to boxing as a sport of boys (Gardiner 1930, 207). By the 5th centuryBCE, boy boxers had been painted on a vase (Kyle 1987, 184).

Other ancient texts attest to the severity of the injuries, and even death,caused by boxing (Poliakoff 1987, 87–88, 175). In fact, the Greeks correctlyviewed boxing as the most physically damaging of all athletic competition, andconsidered it a combat sport (Golden 1998, 116; Sweet 1987, 71).This inordi-nate degree of physical harm appears to play a role in the analysis of the verte-bral-fracture basis for the pathologic pelvic pentad in the Boxing Boys.

The Skeletal Disorder

Spondylolisthesis most commonly occurs as an acquired traumatic malady whenthe fifth lumbar vertebra (L5) slides anteriorly over the first sacral vertebra(Figures 3 and 6).The incidence of this condition in the general population ofchildren is 4.2% (Tachdjian 1990, 2241–42). Its precursor, spondylolysis, a stressfracture in the pars interarticularis (Figure 4), is found in 4.4% of 6-year-olds(Morrissy and Weinstein 2001, 779). In the vast majority of cases, spondylolysisarises from the combination of acute lumbar hyperextensions and rotations re-peated during strenuous sports (gymnastics, martial arts, rugby, baseball, etc.) andsometimes with minor athletic trauma (Smith 1989, 250; Wiltse, Widell, andJackson 1975, 20). Of the patients with spondylolisthesis, 93% were engaged invigorous sports at the onset of the pain of fracture (Stinson 1996, 657; Wiltse,Widell, and Jackson 1975). Spondylolysis has never been found in the newborn,indicating that it is not a congenital disorder (Hoshina 1980, 75).The peak age

at onset of spondylolysis is six, and of spondylolisthesis is nine to 10 (Epstein1976, 585–93), which fits the estimated age of the Boxing Boys.

Young athletes involved in contact sports are susceptible to physical overuseand recurrent microtrauma. They can acquire bilateral pars interarticularisdefects that, in approximately two-thirds of cases, result in spondylolisthesis(Morrissy and Weinstein 2001, 774), then pelvic tilt, hyperlordosis, forward spinaldisplacement, etc. Recurrent and strenuous twisting and lumbar hyperextensionare the mechanisms by which the repetitive microtrauma is pathogenic. Thesemechanisms occur in boxing and similar sports when defensive head and trunkwithdrawal movements are required.6 The lumbar spine may be more vulnera-ble when the opponent holds the boxer’s belt while striking the victim in thehead or below the belt, thus “jarring” him and aggravating the shear stresses(Soren and Waugh 1985).The majority of adolescent patients with spondylolis-thesis usually lack disabling symptoms, with up to 89% of patients reporting nopain (Morrissy and Weinstein 2001; Stinson 1993, 519).As a strange paradox, thisdisease can be relatively non-disabling, which may explain why the deformedboy in the fresco is able to engage in his match. In fact, the aggressive stance ofthis boy signifies his non-disability.

The one (bilateral) pars lesion, followed by vertebral slippage (the spondylo-listhesis), results in the following five maladjustments that act as exterior criteriafor diagnosing spondylolisthesis in the righthand figure in the Boxing Boys:

Figure 6

Composite of a patient with spondylolisthesis. (Drawing by G. Bendersky based on photographs of patients, each with varying degrees of L5 slippage.)

6There is a high prevalence of spondylolysis/spondylolisthesis (especially if Grade I cases are in-cluded) in various types of athletes, for example, 63% of divers and 33% of martial artists (Bulloughand Boachie-Adjei 1988, 134; Rossi 1988). Surprisingly, the disease confers no disability that wouldprevent continuing in sports, except in Grade IV spondylolisthesis.

1. Pelvic inclination in the deformed boxer is a counterclockwise rotationof the left lateral profiled pelvis, as in Figure 3 (Turek 1984, 1599–1600).This forward tilting of the pelvis emanates from the torsional forces ofthe anteriorly displaced vertebra (the spondylolisthesis) and the rest ofthe column above this dislocated vertebra.

2. Hyperlordosis, or “hollow back,” is the lumbar concavity formed by thelow back and the upper part of the buttocks. It delineates the excessiveanterior lumbar curvature resulting from the slipped vertebra.The pelvicinclination accentuates the lordosis (Bloomfield, Fricker, and Fitch 1992,11), and it becomes a conspicuous deformity characteristic, but not atruly diagnostic criterion by itself, of spondylolisthesis.This hyperlordo-sis is deeper than the normal lordotic curve, and it can be simulated bypoor posture and deliberate hyperextension of the lumbar vertebral area.Nevertheless, if a physiological hyperextension occurred in the act ofself-defense, this anterior pelvic inclination would be incongruousbecause the opposite pelvic tilt would be expected from this ordinarytorque. Furthermore, when accompanied by the pathologic forward in-clination and the prominent lower abdominal curve, this hyperlordosishighlights the deformed anatomy caused by spondylolisthesis as seen in the Boxing Boys (Figures 1, 3, and 6).

3. The abdominal convexity is probably produced by both the forwardpelvic tilting and the forward protrusion of L5, as well as by the relax-ation of the abdominis rectus musculature.The most convex part of theabdominal curve, as it connects with the pubic area, faces the parallel lordotic angle and validates this criterion.The artist’s treatment of thislong abdominal line in the Boxing Boys is appropriate for spondylolis-thesis, in that this line in the boy on the right is about 30% longer thanthe boy on the left. (Their abdominal curves are not entirely comparable,however, because the boy on the right is positioned in a three-quartersview.) Generally, the rounded belly of normal young children begins todisappear by the age of three to four. By the age of the deformed boy in the Boxing Boys, the likelihood of a bulge should be very low, and a suprapubic prominence would be extremely rare.

4. Forward displacement of the spinal column is an inherent consequenceof the slipped L5 (Figures 3 and 5). The entire alignment of the thora-co-lumbar column is forced into an anterior presentation (probably 2 to 3 cm of dislocation) of the torso.This major criterion allows for aready diagnosis of spondylolisthesis upon simple inspection of thedeformed boy: the trunk is forward relative to the pelvis (Soren andWaugh 1985, 172).

5. Under mechanical stress the trunk sags like an accordion, lowering thethorax closer to the pelvis (Soren and Waugh 1985, 172). Because thenormal angle between L5 and the vertical (plumb-line) is estimated to

be 35° to 45°, the slippage brings the spinal column down into thepelvis.The result is a shortening of the boxer’s stature caused by gravita-tional forces imposed on the vertebral line above L5 telescoping downthis 35° to 45° gradient.This sunken torso is a remarkable sign of theskeletal disorder.

It has been implied that the distortions in the Boxing Boys were caused by in-eptitude. S. Marinatos (1971b) referred to one of the boy’s forearms as not“organically related to the whole,” and Kopcke (1999) has suggested that theThera art is not as “sophisticated” as that on Crete because the “anatomy of theboys leaves something to be desired” (452).There has been no prior reference,however, to the specific misshapen morphology discussed here. However, once itbecomes apparent that the Theran artist has integrated five anomalies all result-ing from spondylolisthesis in the fresco, the artist appears much more skilful.Indeed, four orthopedic surgeons who viewed reproductions of the Boxing Boysimmediately diagnosed spondylolisthesis.7

Ancient skeletal evidence from East Mediterranean populations supports thediagnosis of the boy’s spinal-pelvic morphology.At Saqqara, Egypt, an Old King-dom (c. 2740–2250 BCE) burial reveals a case of spondylolysis (Strouhal 1995,12). In fact, paleopathologists have found examples of spondylolysis (and at leastone case of spondylolisthesis) in “all periods of antiquity” (Roberts and Man-chester 1995), including a man with spondylolisthesis found in a Middle BronzeAge (c. 1900–1700 BCE) grave at Lerna, Greece (Angel 1971, 58).8

The artist represented the deformed child’s distortion in sufficient detail toenable the diagnosis presented here and to suggest that the artist probablydirectly observed that child. Also, the placement of the loin belt on the sloped

7The orthopedic surgeons who agreed with the authors’ interpretation and immediately diagnosedthe spondylolisthesis upon seeing reproductions of the Boxing Boys included: John P. Dormans,Chief of Orthopedic Surgery at Children’s Hospital of Philadelphia and Professor of OrthopedicSurgery at the University of Pennsylvania School of Medicine; John D. Kelly IV, Co-Director ofSports Medicine and Vice Chairman of the Department of Orthopedics at Temple UniversitySchool of Medicine; Neil Kahanovitz, Director of the Spine Center and Professor of OrthopedicSurgery at Drexel University School of Medicine; and Paul A. Marchetto, Director of Sports Medi-cine and Professor of Orthopedic Surgery at Drexel University School of Medicine.These physi-cians independently identified the deformed pugilist as having an orthopedic pathology “unmis-takably” judged to be spondylolisthesis. Furthermore, two of them interpreted the ailment asspondyloptosis, the most severe degree of spondylolisthesis. Additionally, Kelly, a former amateurboxer, denied the possibility that the lordosis gesture was merely a defensive lumbar extension, andhe highlighted the multitude of diagnostic signs for spinal slippage.8There are racial differences in the incidence of spondylolysis. Burials of Eskimos who died inGreenland several hundred years ago showed that 54% had spondylolysis, compared to 5% in thegeneral population (Simper 1986).There may also be genetic predispositions to this skeletal disor-der (Turner and Bianco 1971, 1298).

pelvis of the deformed boy accentuates the severity of the pelvic tilt in contrastto that of the opponent.

It was unusual for prehistoric artists to create naturalistic, well-defined patho-logical states in their artwork. Only a few dozen examples of such conditions asmorbid obesity, muscle atrophy, supernumerary digits, Pott’s disease, and emaci-ation exist (Lyons and Petrucelli 1987; Rollefson 1983; Sigerst 1967). Boxing Boysappears to be the only extant illustration of this particular spine-pelvic deformityuntil the modern era of medical photography and schematic drawings. Perhapsit was difficult for early artists to merge the various elements of spondylolisthe-sis into a masterly depiction. This case of an orthopedic disorder at Thera fur-ther supports the contention that artistic innovation occurred at Thera, ratherthan the Near East or East Mediterranean influencing the island (Betancourt,Muhly, and Floyd 2000, 359–60;Televantou 2000, 842).

The Differential Diagnosis of the Spinal-Pelvic Deformity

The skeletal disorder in Boxing Boys might be explained in other terms. For ex-ample, what appears to be morphologically abnormal anatomy may have resultedfrom artistic stylization, such as the love of curved outlines (Televantou 2000,839). However, the probability of a deformity showing all five of the spine-pelviccriteria resulting from personal, subjective (stylized) elements, without any refer-ence to the specific spine-pelvic condition (spondylolisthesis), is extremely small.9

Bad posture and extremes of somatotype variations can exhibit a lumbar angleresembling hyperlordosis, but this is an unacceptable explanation for the boy’sdeformity, because the other four criteria are not components of bad posture.Tobe certain, we examined several thousand photographs of nude children, teen-agers, and men in profile view, many of whom were classified for somatotype(Petersen 1967; Sheldon 1954), but they were free of spinal disease. The con-torted figure of the deformed pugilist in the Boxing Boys is not among examplesof growth disorders, somatotyped photos, or more recent taxonomic investiga-

9This conclusion is based on (1) calculating the probability of one specific pattern (the externalprojection of the skeletal deformity) emerging by chance (i.e, the artist’s imagination); (2) subject-ing each of the five figural elements to combination analysis, distribution statistics, and “matchingwith reality”; and (3) integrating mutual exclusivity of arbitrary choice (Everitt 1999, 16–17; Hol-land 2002). For example, instead of the fairly sharp lordotic angle of the pathologic state, if the artisthad chosen increasingly higher degrees of concavity (thus flattening the curve) until a straight, al-most vertical edge would be obtained—each edge being successively separated by a millimeter—there would be approximately 90 possible alternative curves just for this one criterion.The aver-age of the estimated number of possible alternative configurations for the criteria is approximately40. Therefore, the results of probability computation, namely 405, are that the likelihood of theboy’s distortion being fictional rather than pathogenic is one in a hundred million.

tions of “normal” body type in children engaged in competitive sports (Carterand Heath 1990).

An athletic child defensively jerking himself backward by hyperextending hislower spine might (as discussed above) create hyperlordosis. However, the fourother pathological features are not a factor in this form of hyperextension. Closescrutiny of the fresco reveals that this defensive explanation is unlikely.The hyper-lordotic boy is thrusting forward (at least from the hips down) more aggressively,and his right hand has penetrated further than his opponent’s fist. Therefore, itappears that the lordotic angle resulted not from sudden withdrawal, but fromspondylolisthesis. Furthermore, visual analysis of videos showing professionalfighters revealed no significant abdominal protuberance, pelvic inclination, ante-rior displacement of the vertebral column, etc., during instances of pulling backfrom a punch. Finally, other illnesses, such as muscular dystrophy, hip dysplasia,tuberculosis of the hips, dislocated hips, and severe cretinism, are much less com-mon than spondylolisthesis (Brenda 1946, 41–43).All would usually prevent par-ticipation in most sports.

The Agrimia (Wild Goats)

Although the ungulates depicted in the room with the Boxing Boys were initiallycalled antelopes by the excavator, scholars recently have acknowledged that theyare a separate subspecies of wild goat designated agrimia (Bloedow 2003; Dou-mas 2004; Porter 1996).The agrimia, Capra aegagrus cretensis Lydekker, still lives inwestern Crete to this day (Nicholson and Husband 1992). Images of agrimiabegan on Crete in the Early Bronze Age (3rd millennium BCE) and became acommon subject. Of 517 relief motifs on cylinder seals, 44 (8.5%) were goats,but wild subspecies were often not identifiable (Hiller 2001). Goats also appearin wall paintings, small bronze sculptures, ivory carvings, vase painting, and stonereliefs (Grzimek 2002, 489; Hiller 2001, 293).

In the room with the Boxing Boys, there are two painted agrimia on each ofthe other three walls (Figure 2).These caprids mimic the boys, by being depictedas young males in a hostile combative stance (Bloedow 2003; Porter 1996, 309).The estimated age of the agrimia is two to three years (Porter 1996, 309), consis-tent with the eight- to 10-year-old boys. One goat in each pair resembles oneof the boys, because its foreparts are painted in a three-quarters view. Signifi-cantly, these wild goats demonstrate sagging bodies, reminiscent of the deformedboy’s hyperlordosis and long, convex abdomen. Furthermore, in the artist’s at-tempt to render depth, the boys’ limbs and heads overlap, just as one goat in eachpair overlaps the other (Televantou 1992, 151). Even though the figure is paintedin profile, each pugilist exhibits one frontal eye resembling the goats’ eyes. Also,one of the two goats in the west wall has an elevated pupil and iris, in the sameway as the boy on the right.The room is decoratively unified with an abstractred undulation above the figures. The back concavities, heads and tails of the

goats, and the contours of the boys are reflected in those curvilinear designs.Wesuggest that by crafting notable similarities between the boys and the ruminants,and distinctively linking their walls, the artist has implicitly equated the pugilistswith the wild goats.

The sport of boxing may be linked with agrimia because the Minoans (BronzeAge culture on Crete) were chiefly interested in hunting these animals. Based onobserving caprids in seals, Evans (1935) concluded that the inscribed scenes mag-ically facilitated success in the sport of hunting wild goats. Bloedow (1992) agreeswith this concept of sport involving a coveted game animal and the use of a tal-isman (depicting a javelin wounding the goat) “to bring good sport to the hunts-man” (22). Porter (1996) has indicated that the word agrimia means “game” or“animals of the chase” (299). Beta 1 cannot be declared a sports gallery (or gameroom) based on this evidence, but it does suggest a wide distribution of goat-as-sport images and a possible sports connection of the agrimia with the Boxing Boys.

Our employment of the swayback pattern in support of the human-capridrelationship is dependent upon one decisive observation. Non-pregnant agrimiado not naturally exhibit parallel sagging dorsal and convex abdominal linesexcept when diseased with actual swayback (enzootic ataxia) or occasionally inhyperextension while leaping.Veterinarians in the field of ruminant and largemammal pathology have noted that standing, normal (non-pregnant) quadru-peds exhibit back concavity and/or protuberant abdomens only very rarely(Shurter 2002). For agrimia, the ungulate swayback shape is even less common.Dozens of agrimia images have been created since the Aegean Bronze Age, andmany photographers have taken pictures of live agrimia (and other goats) (Grzi-mek 2002; Osborn and Osbornova 1998; Porter 1996).The lack of curvatures inthese images indicate that the parallel curves in the fresco are exceptional. Ofapproximately 250 goat illustrations, fewer than 1% demonstrate swayback.Theagrimia distortions at Akrotiri are indeed stylistic—possibly in evocation of theboy’s deformity—rather than caused by disease. If the Theran representation ofdeformity in the Boxing Boys is a morphosis, then the programmatic inclusion ofagrimia may be a meta-morphosis.10

Two of a Kind

Because pairs of pugilists and agrimia dominate these compositions, could twin-ning, coupling, or dualism help to explain the subject matter? Twin agrimiabirths are not unusual, and the animals are commonly paired in artwork at Knos-sos and Hagia Triada (Cameron 1978, 582). Assuming that the paired arrange-ment of the agrimia echoes the boxers, then these boys may be antecedents oflater Greek mythological pairs, such as Castor and Polydeuces, also known as the

10Morphosis means organic disease or morbid formation (Freccero 1993, 176).

Dioscuri (Hastings 1928, 12:498). These brothers protected seafarers, enjoyedreputations as divine javelin-throwers (recalling the Minoan sport of huntingwith a javelin), and, interestingly, Polydeuces became a well-known boxer (Coul-ter and Turner 2000, 116).

Following the 1970 Theran excavations, S. Marinatos (1971a) suggested thatyoung gods, heroes, brothers, or twins are commonplace in pre-Greek and Greekmythology. His emphasis was on the traditional contrast between one superiorand one other, weaker brother, a common theme in Indo-European legend.However, the creator of the Boxing Boys mural possibly demonstrates (deliber-ately or not) that disease does not necessarily confer weakness.

Ancient astronomy may also illuminate the meaning of the Akrotiri fresco.Theplanet Venus as morning and evening star was paired with the sun in the OldBabylonian Venus Tablets of Ammisaduqa (1646–1626 BCE) (Meyers 1997, 56).Egyptian hieroglyphic texts support a 20th century BCE description of Orion ashaving two prominent stars, Betelgeuxe and Rigel. Furthermore, the Egyptianschose two kids (young goats) to represent the Gemini constellation prior to theGreek twins.As a maritime trading community,Akrotiri may have utilized astro-nomical orientation in navigation.Whether or not this celestial interest translatedinto a pairing of child boxers and/or a herd of doubled agrimia is unknown.

These myths, coupled with those about Leucothea, suggest that the BoxingBoys was an early or prototypical source for the later folklore of young heroes orgods rising to their ultimate roles by means of struggle, competition, and athletictests. Alternatively, the Boxing Boys may exemplify a visual form of immortality,such as exists in constellations and mythological texts.

The images at Akrotiri of anatomically dissimilar boxers may also symbolicallyexpress the phenomena of duality. For the late Bronze Age Theran muralist, dual-ity meant contrasting torsos, the interaction of aggression, and the discipline ofoutline.

Comment

The Boxing Boys are relevant for the history of diagnostic medicine, the docu-mentation of spinal illustrations and sports trauma, and the art historical contrastwith the subsequent Classical Greeks. Also, the Boxing Boys’ spondylolisthesismay represent the earliest visual record of a sports-induced injury. The BoxingBoys is analogous to an item in the Edwin Smith Surgical Papyrus (17th centuryBCE), which strikingly describes, for the first time, the specific sequellae of thetrauma to the vertebral column (Todd 1991, 113–15). Similarly, the Boxing Boysfresco is the first monumental image of a compound spinal disorder that is diag-nostically recognizable by current medical standards.This is not inconsistent withMinoan medical skills in the decades prior to the painting of the Boxing Boys.11

11Although there are no skeletal remains from Thera, ossuaries and cemeteries in Crete have dis-

There appears to be no precedent or any precise historical framework for theBoxing Boys. The artist probably painted directly from life and was also mostlikely uninfluenced by the eastern Mediterranean cultural context. Anotherlarge, lithesome figure of a boy does not appear until the 5th century BCE nat-uralistic sculpture of the Kritios Boy and the 4th century BCE bronze youth fromthe Marathon shipwreck (Boardman 1985, fig. 135; Pedley 1993, fig. 7.19).Theillustration of boxing and vertebral naturalism, combined with the pharmaco-logical advances at Akrotiri (Ferrence and Bendersky 2004), suggest that Akrotiriwas a source of medical knowledge more that a millennium before the ClassicalGreeks. For its aesthetics and innovations,Thera was an island unto itself.

In its attention to human deformity, Bronze Age Akrotiri contrasts with thelater Classical Greek tradition. In the 5th century BCE, a prejudice against defor-mity developed, as the idealization of the human body became characteristic ofClassical Greek art (Garland 1995). Man was the measure of all things to theGreeks, and their artists strived to fashion him at his idealized best, indistin-guishable from the gods whom they conceived in man’s likeness, and who wouldnot be expected to have diseased bodies (Charbonneaux, Martin, and Villard1972, 173). But the pre-Greeks had no such imperative: human shape was accu-rately displayed and an anatomical distortion was granted full-scale display,resulting in the conspicuous show of active, athletic body control even with de-formed anatomy.The Theran artist appears to have morphologically consolidatedthe naturalism of disease with the aesthetic elegance of the rest of the pugilist’sfigure.This painting, therefore, seemingly dispels the notion of a lack of a sophis-ticated eye for medical detail in Aegean Bronze Age art.This investigation sug-gests the Boxing Boys fresco is the prototypical European medical illustration.

The ideas and metaphors employed in interpreting the Boxing Boys fresco,such as exultation of strength and agility and doubling for mystical reasons, re-main tentative. Although we offer a diagnosis to explain the one pugilist’s dis-torted figure, the agrimia and the overall meaning of the painting remain un-clear. Identifying people and events in the mid-2nd millennium BCE with latersocieties may also be problematic (Crowley 1995, 482). Additionally, retrospec-tively applying our modern notions of human behavior and artistic motivationupon a prehistoric culture creates inherent uncertainties. While the hypothesisthat the boy’s deformity is not stylized seems to be undermined by the contrast-ing postulate that the agrimia are deformed through stylization—suggestingeither that the premises are untenable or that the artist has represented conflict-

closed significant paleopathological information about the Bronze Age (McGeorge 1988). Studiesof more than 8000 human bones, including Early and Middle Minoan cave deposits (2600–1700BCE), demonstrate an orthopedic phenomenon unusual for such an ancient culture: successfullyhealed fractures at an anatomical site which is difficult to treat by manipulation. Healing of the frac-ture without appropriate reduction and prolonged immobilization would have been impossible,thus revealing the existence of outstanding medical skill.

ing traits—we believe that the artist’s traits are more aptly described as comple-mentary skills reflecting versatility. Almost certainly the artist had not observedsagging agrimia, yet he intended to more completely compare agrimia to thedeformed boy (to intensely focus on the boy’s deformity or to suggest a meta-morphosis).The artist displayed his artistic and conceptual deftness by juxtapos-ing naturalism and fictional simulation.

Drawing wide iconographic implications from isolated curves, such as theboy’s abdominal convexity and lumbar concavity, could be criticized because thecurves are minimalist designs. Leo Steinberg (1998) has demonstrated the dan-gers of drawing conclusions about similarities based solely on the viewer’s judg-ment of formal equivalences with other images. The diagnostic conclusions ofthis study, however, are justified because the five criteria are fully establishedpathological elements, the peak age of incidence and etiological athletic coinci-dence contribute to the diagnosis, and the evidence was gathered from body-type anthropological studies as well as from differential prototypes and used toexclude alternative diagnoses.All these considerations contribute to a valid med-ical connection.

Conclusion

A trained eye merely glancing at the gross pattern of figural distortion in theboxing boy on the right would immediately diagnose this condition as spondy-lolisthesis.The artist skillfully integrated the five abnormalities of the disease: thepelvic tilt, hyperlordosis, a long abdominal line associated with infraumbilicalprotuberance, a forward spinal displacement, and a sunken torso. Also, the ath-lete’s deformity closely matches the physiques of patients displaying this condi-tion. Beyond this, the age of the boxer conforms with the peak age of onset ofthe malady, and his sprightliness demonstrates that the disease does not precludephysical adeptness. Indeed, he may be portrayed as engaging in athletic activityat least in part because sports are a very common etiology of this condition.Alternative explanations for the anatomical distortions, such as chance or stylis-tic manner, are extremely unlikely.

The Beta 1 fresco probably represents contrasts (one pugilist versus the other)as well as similarities (sagging agrimia and the deformed boxer).The Boxing Boysmay represent the reenactment by humans of the actions of mythical boys, orthese pugilistic exercises may relate to ruminants based on a background of gamehunting, goddess veneration, prizes, injury, and the preoccupation in folklore oftwo-of-a-kind.

The Boxing Boys is one of the most striking scenes in all of Aegean BronzeAge art, exhibiting unsurpassed aesthetic quality, a high degree of naturalism, anda flair for the curvilinear.The artist created sparring opponents possibly to com-municate a new concept in sports: a deformed boy as neither victor nor victim,neither Adonis nor monstrous, but as a participant symbolically linked with

groups of paired agrimia.This illustrated example of spondylolisthesis is the ear-liest depiction of a human osteological abnormality in European art and the firstrepresentation of a sports trauma.

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Deformity in the \"Boxing Boys\"

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