Nicholas Summerton
Nadey Hakim
United Kingdom

Retrospective diagnosis—the practice of identifying an illness after the death of an individual using modern medical knowledge, disease classifications, and methods—is extremely difficult. Although methodological guidance has been developed in relation to retrospective diagnosis¹ and iconodiagnosis² (the medical diagnosis of human figures in artwork), the practical application of such recommendations warrants further consideration.

Thousands of Greco-Roman statues and busts still survive today, perhaps representing an untapped resource in determining the health conditions affecting our ancestors. But it can be challenging to tease out clinical data from artistic stylization, political messaging, or religious symbolism, alongside the effects of damage or restorations.^3,4 Also, most Greco-Roman carvings were painted, and this supplementary information has now been lost.⁵

The modern-day artistic aim of sculpture is to produce a convincing representation of an individual, a process that requires careful consideration of the overall facial proportions alongside any small variations and asymmetries. It is often these apparently minor deviations from an idealized or symmetrical face that contribute most strongly to the recognition of an individual. Although Greco-Roman sculptors worked within very different aesthetic and cultural contexts, they might also have sometimes attempted to faithfully reproduce individual physical characteristics. An unusual feature visible in an ancient portrait warrants consideration as a possible characteristic of the sitter rather than being dismissed immediately as artistic invention.

Two Greco-Roman sculptures may provide insights into the health of King Philip II of Macedon and the Roman Emperor Hadrian. They also highlight the importance of integrating artistic, archaeological, literary, anthropological, and medical information before applying any precise modern-day diagnosis to a sculpture.

King Philip II of Macedon

Philip II was the king of Macedon from 359 BCE until his death in 336 BCE at the age of 46. He was an extremely successful military leader and the father of Alexander the Great.

Philip was buried with the Great Tumulus at Aigai alongside three other kings of Macedon. Following a careful excavation in 1977, there is now little doubt that one vault in particular—termed Tomb II—was the final resting place for the remains of Philip II. A small ivory portrait representing Philip that had originally been affixed to a couch was discovered within this tomb, along with partially cremated human remains wrapped in purple cloth and contained within a gold larnax decorated with the starburst symbol of the Royal House of Macedon. Above the entrance door was a splendid fresco depicting a hunting scene and, according to the excavators, the glass, gold, ivory, and wooden finds were outstanding in their craftsmanship and artistry.⁶

Philip’s ivory bust exhibited abnormalities on the right side of the face; in particular, a small nick above the eye and a prominent cheek (see figure 1). Also, the eyes were not set at the same level, with the right being higher than the left. Considering the sculpture from a modern medical perspective, it has been argued that Philip sustained a traumatic injury affecting his right eye.

A review of the surviving literary sources provide additional evidence consistent with the sculptural anomalies. The contemporary author Theopompus and the later Greek statesman Demosthenes commented that Philip lost his right eye from an arrow wound at the siege of Methone in 354 BCE.⁷ The first-century Roman author Pliny the Elder wrote, “Kritoboulas achieved great renown for having extracted the arrow from the eye of King Philip, and for having treated the loss of the eyeball without causing disfigurement to the face.”⁸

Supportive information was derived from an examination of the cremated remains from Tomb II. Enough bone was still available to permit the identification of a notch at the top inner corner of the right orbit and a healed fracture of the cheek at the junction between the zygomatic and maxilla, together with a small missing piece of bone.⁶

In isolation, the features identified on Philip’s bust are difficult to interpret from a modern medical perspective with any degree of certainty. An alternative suggestion could be that the anomalies simply arose when a carpenter was attempting to fashion the small piece of ivory as an attachment for a piece of furniture. However, by considering ancient literature and paleopathology alongside the sculpture, the likelihood that the abnormalities on the portrait depicted an eye injury is significantly enhanced. This object emphasizes the importance of adopting a comprehensive and broad approach to the acquisition of evidence in any attempt to diagnose a sculpture.

Hadrian, Roman Emperor

Hadrian ruled Rome from 117–138 CE and made significant contributions to both the culture and infrastructure of the Empire. However, his later years were marred by illness, and it has been suggested that he died from heart failure linked to underlying ischemic disease.

This retrospective diagnosis is based on a combination of information provided by the Roman historian Cassius Dio—wasting and swelling—together with the discovery of diagonal earlobe creases on several sculptural representations of the emperor (Figure 2).⁹ Earlobe creases are supposedly linked with a heightened risk of coronary artery disease, an association termed “Frank’s sign.”

Although the surviving images of Hadrian are probably more life-like than had been the case for the Emperor Augustus and his immediate successors, it is still likely that every detail would have been carefully considered by the sculptor. At the time there was also a particular interest in physiognomics, a view that a person’s outward appearance could reveal their true character.¹⁰ For example, being of above average height and well-proportioned was associated with the Roman virtues of courage and a sense of duty. It is quite possible that this pseudo-science impacted the representations of emperors.

The physiognomist Polemon of Laodicea, a contemporary of Hadrian, considered that fleshy ear lobes were linked to wisdom, generosity, and longevity.¹¹ Pliny the Elder also commented that “the memory is seated in the lobe of theear.”¹² In relation to Hadrian’s images, a careful examination of surviving Greco-Roman medical and non-medical sources has not uncovered any information suggesting that earlobe creases had any medical or symbolic significance. Consequently, a sculptor probably carved exactly what he saw without any thoughts or concerns about omission or embellishment.

The association between diagonal earlobe creases and coronary heart disease was first suggested by Frank in 1973 based on a study of twenty patients with earlobe creases and affected by angina.¹³ However, a recent systematic review of thirteen studies involving 3,951 patients has cast doubt on the diagnostic accuracy of earlobe creases in the detection of active coronary disease.¹⁴ What seems more likely is that an earlobe crease is simply another independent marker for the identification of individuals at elevated cardiovascular risk alongside features such as age and gender.¹⁵ So, even if Hadrian did have an earlobe crease, its medical significance remains uncertain.

In seeking to medically interpret a feature on a sculpture, it is always important to be aware of the effects of biases arising from the contemporary context. However, as earlobe creases are not seen on other representations of Roman Emperors and there is no suggestion that, at the time, they had any symbolic or medical significance, it does not seem unreasonable to assume that it was a physical feature specific to Hadrian.

The real challenge in diagnosing Hadrian arises from the application of modern medical knowledge, as it is always necessary to apply the same standards to the interpretation of medical evidence as would be the case in an encounter with a living patient. Thus, the identification of an earlobe crease combined with second-hand information suggesting that a patient had swelling and weight loss is insufficient to generate a precise clinical diagnosis.

References

1. Summerton N. Retrospective diagnosis: process, outputs and relevance. Journal of the Royal Society of Medicine Open 2026; 17(9). doi:10.1177/20542704261483853
2. Charlier P, Perciaccante A, Kluger N, et al. Iconodiagnosis: Guidelines and recommendations. Ethics, Medicine and Public Health 2023; 31: 100951, https://doi.org/10.1016/j.jemep.2023.100951
3. Bubb K., Tabira Y, Donofrio CA, et al. Cutaneous stigmata indicative of occult spinal dysraphism in two ancient Roman statues. Child’s Nervous System 2026; 42: 168. https://doi.org/10.1007/s00381-026-07258-0
4. Engmann B. Neurologic diseases in ancient Roman sculpture busts. Neurology: Clinical Practice 2013; 3: 539–541. https://doi.org/10.1212/CPJ.0b013e3182a78f02
5. Fadda S. Neurological and Neuropsychiatric Diseases through the Lens of Roman Sculpture. Theoretical Roman Archaeology Journal 2021; 4,7: 1–25. doi: https://doi.org/10.16995/traj.4342
6. Prag J, Neave R. Making Faces. Using Forensic and Archaeological Evidence. British Museum Press, 1997.
7. Lascaratos J, Lascaratos G, Kalantzis G. The ophthalmic wound of Philip II of Macedonia. Survey of Ophthalmology 2004; 49: 256-261.
8. Jones WHS. Pliny: Natural History; Book VII, Chapter 24 (Loeb Classical Library). Harvard University Press, 1956.
9. Petrakis NL. Diagonal earlobe creases, type A behavior and the death of Emperor Hadrian. West J Med. 1980; 132: 87-91.
10. Evans EC. Physiognomics in the Roman Empire. The Classical Journal 1950; 45: 277-282.
11. Swain S. Seeing the Face, Seeing the Soul. Polemon’s Physiognomy from Classical Antiquity to Medieval Islam. Oxford University Press, 2007.
12. Jones WHS. Pliny: Natural History; Book XI (Loeb Classical Library). Harvard University Press, 1956.
13. Frank ST. Aural sign of coronary artery disease. NEJM 1973; 289: 327-328.
14. Więckowski K, Gallina T, Surdacki A, Chyrchel B. Diagonal Earlobe Crease (Frank’s Sign) for Diagnosis of Coronary Artery Disease: A Systematic Review of Diagnostic Test Accuracy Studies. J Clin Med. 2021:10; 2799. doi: 10.3390/jcm10132799.
15. Fernández Ascariz L, Rivas Mundiña B, García Mato E, et al. Frank’s Sign and Cardiovascular Risk: An Observational Descriptive Study. Am J Med. 2024; 137:47-54.