Achilles: The Man, the Myth, the Tendon (2024)

The Man, the Myth, the Tendon

Did you ever wonder about Achilles? As orthopaedic surgeons, we frequently evoke his name while examining the foot and ankle. Most of us think he was a mythologic Greek hero (Figure 1). The truth is that there may well have been a real Thessalian warrior, later mythologized by his semi-literate people. The story goes that his mother, Thetis, made him invulnerable by dipping him in the River Styx while he was still an infant. The problem was that she held him by the heels, which were not wetted; this remained a vulnerable part of his anatomy.

Achilles became a great warrior and slew Hector of Troy in battle. Hector's father, Priam, was suffered to remove the body for cremation.¹ All of Troy mourned the death. In his final battle, at the very gates of Troy, Paris (guided by the god Apollo) launched the arrow that fatally struck Achilles in his vulnerable heel (Figure 2). Achilles was cremated and his ashes buried in the same urn as those of his friend Patroclus.² This was well, because it was said that Achilles and Patroclus shared the love that dares not speak its name.³

Is all of this just mythology? Could there be at least some minimal correspondence with actual story? Biblical archeologists and historians have talked about the epic theory of history. The story of Gilgamesh preceded our own Judeo-Christian themes and bears some striking similarities. Heinrich Schliemann excavated the mound at Hissarlik in the Dardanelles in 1873, finding convincing evidence that this was indeed the site of ancient Troy.^4,5 Schliemann also excavated a tumulus or mound that was said to contain the remains of Achilles. Finding no bones, he concluded this was really a cenotaph or memorial, rather than an actual burial place.⁶ This all still evokes interest and speculation. In all, it is easy to understand why due consideration of the subject should be of paramount importance to the practicing orthopaedic surgeon. God forbid that any one of us should be in the position of recommending surgery on the heel cord for a professor of the classics or the like! The purpose of our paper is to start your ruminations on a topic you might be called upon to discuss!

Suppose that Achilles, or a reasonable prototype, really did exist. How could an arrow shot to the heel kill anyone, mortal or immortal? On the face of it, some imagination is required. Revert then, to your days in Physical Diagnosis class and run through the categories.

1. Infectious—The tip of the arrow could have been smeared with Clostridium perfringens, Yersenia pestis, or the like. Biological warfare was known to have been practiced in the Middle Ages. Do you remember stories of pestilence victims being hurled over city walls by catapults (trebuchets)?

   Did Hippocrates, for whom we have accounts of chronic shoulder dislocations being cured with a red hot iron poker inserted into the shoulder, attempt to repair Achilles' tendon?⁷ A post-operative wound infection with subsequent gangrene and osteomyelitis may have caused Achilles' demise. Lister, for all his contributions to asepsis, had not been born yet.

   Did atelectasis set in while he was bedridden? As far as I know, the incentive spirometer had not been invented yet. Nor had antibiotics, for the ensuing pneumonia, for that matter.

   And what of his last tetanus shot?

2. Toxic—South American natives routinely hunt with darts dipped in curare.⁸ How about Botulism toxin? Bulfinch does, without attribution or further details, state that when Paris shot Achilles in the heel, it was with a poisoned arrow. Recall now Philoctetes, son of Poeas. He was bitten on the foot by a poisonous water snake. The wound putrefied and it was said that the (anaerobic) odor could be smelled miles away. Here, however, the king of Ithaca, Odysseus (Ulysses) rescued him and he was eventually cured.⁹

   The tip of the arrow may have been made with metal. Was this metal lead?

3. Metabolic—Was Achilles suffering from hyperthyroidism? In the days before Gull in the 1800's nothing was known about the thyroid. Maybe the pain caused a thyroid storm.

4. Congenital—The posterior tibial artery lies in close proximity to the Achilles tendon. Although nothing suggests it, maybe Achilles suffered form hemophilia and bled to death.

5. Immunologic—The arrow was made with a multitude of materials. Achilles may have been allergic to any one of them and succumbed to deadly anaphylaxis.

6. Traumatic—A pulmonary embolus in the post-injury time frame could be postulated. There are precedents for trauma to explain historical events of mythology. Oedipus, as a baby, was tied by the feet and left hanging from a tree till rescued by a peasant. Thereafter he was called Oedipus, or swollen foot. He obviously survived, but went on to kill his father, bed his mother, and tear his eyes out in remorse. Again, the ancients seem challenged with regard to feet.¹⁰

   Let's not forget about compartment syndrome.

7. Psychiatric—Maybe, Achilles, having proven himself such a great warrior and all of a sudden finding himself maimed, suffered a severe bout of depression and could only find peace by ending his own life.

8. Evolutionary—Was this a case of Darwinism? Having been injured, unable to move and hence, an "unfit" organism, he may just as well have been slain on the battlefield.¹¹

In conclusion, there was an ancient Troy, and also probably a mythologized prototype for Achilles. Think about it. The next time you want to get one up on a fellow orthopaedic surgeon, just casually start a conversation about poor Achilles. It is also an excellent topic to harass innocent orthopaedic residents with, as one of us (C.L.) has already learned!

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