SELECTED STUDIES

Computed Tomography of

King Tut-Ankh-Amen

Mervat Shafik, MD¹, Ashraf Selim, MD¹, Isam EL Sheikh, MD¹, and Zahi Hawass, PhD²

¹ Faculty of Medicine, Cairo University
² Egyptian Council of Antiquities

Introduction:

The world’s most famous tomb of King Tutankhamun, hid his mummy and funerary regalia, gold covering his body, stunning artifacts of   jewelry, superb amulets and other objects. They were found as burial treasures, almost intact "testifying to a refined culture, to funerary rituals and practices which had to be pieced together and understood, but revealed little or nothing of   his own life and personality" and "he himself remained shrouded in mystery"(1).

The tomb was discovered by the archaeologist Howard Carter in 1922. The mummy was examined three times; the first one by H. Carter, Prof. Douglas E Derry and Dr. Saleh Bey Hamdi three years after the discovery of the tomb in 1922 AD, but the report was quite brief (2). It was examined twice by conventional X-ray (3,4,5). The X-rays provided fuel to a plethora of speculative theories on the king’s health and possible violent death presented in the lay press (6,7). In the scientific literature, the remains of Tutankhamun, and his closest royal relatives have been analyzed too (3,4,8,9,10,11).

Some reports mentioned possible disease during his life (3,12,13,14,15,16,17,18,19,20,21,22,23,24,25).

Tutankhamun’s mummy was subject to an assessment by a computed tomography examination to obtain in–depth information about pre, peri and postmortem alterations. This is the first ever CT report of an identified ancient royal mummy.

Method: -

The fragile remains of King Tutankhamun (Ca. 1365-1346 BC) were removed from his tomb in the Valley of the Kings in Luxor by an Egyptian team led by Z. Hawass. The stone sarcophagus was removed in the underground tomb. The mummy resting in the tray of sand, in which it had been placed by Carter’s team, was carried out of the tomb. The coverings were pulled back while the mummy remained in the sand tray to protect it and was then inserted into the CT machine, which was brought as close as possible to the site of the tomb.

The CT machine is housed inside a movable trailer. The machine was donated by the National Geographic Society and Siemens Ltd. to the Egyptian Supreme Council of Antiquities. It is a multislice   unit (130 KV, 124-130, m As, 0.4-3 mm slice thickness, Siemens Emotion 6, Erlanger, Germany).

A full body scan was performed. Post processing analysis included surface shaded display, maximum intensity projection and volume-rendering techniques.

Findings:

The mummy was found to be in a very critical state of preservation (fig.1). There was recent decapitation at the level of thoracic one vertebra, disarticulation of all extremities at the elbow joints, wrists and knees and a complete body separation at the level of the third lumbar vertebra. Some bones such as some phalanges, sternum, both scapulae and parts of the clavicles and pelvic bones were missing. In addition, the arms were no longer crossed over the chest. Overall the mummy appeared very slender, the skin was hard and dark, the soft tissues were shrunken and showed high density dots at multiple locations (density Ca. 1000 Hounsfield units); those are most likely embalming related artifacts. At several locations, cracks were found in the skin and soft tissues, most likely of post mortem nature.

The cranial sutures were still visible; particularly the sagittal one. The epiphyseal plates were not fused at the distal right femur, proximal humeral and femoral ends on both sides, and were united at both proximal and distal tibial ends on both sides. Three wisdom teeth had partially erupted. The above mentioned findings denote that the age estimation at death was between 18-20 years. Bearing in mind that these age assessment criteria are based on maturation charts derived from modern samples. Based on the tibial lengths (the only intact major long bone), an overall height of 170 cm was estimated. Normal anatomical variants found included bilateral lambdoid sutural bones, incomplete cleft palate and a notable dolicephalus ( ca.190 mm by 160mm, total circumference ca. 580 mm) (Fig. 2).

This seems to be a normal variant since no signs of premature suture closure were found. There was a mild prognathism and mild malalignment of three wisdom teeth while the fourth ( left lower ) was impacted and unerupted, yet the dentition in general was of excellent condition (Fig.2).There was a minimal convex to the right scoliosis with its apex at the level of the twelfth vertebra (Cobb’s angle Ca. 15^o) with no associated vertebral deformity or rotation , this reflects the way the mummy was positioned by the embalmers.

     Some of the multiple traumatic lesions were clearly caused by the embalming process such as the destruction of the nasal septum, ethmoid cells and cribriform plate due to the transnasal brain removal (Fig 2) as well as the artificial communication of the posterior cranial fossa and the oropharynx. Other changes included the almost complete destruction of both ear auricles, resulting clearly from the unwrapping and the time factor.

In addition the sternum and a large part of the front and back parts of the ribs were missing with much of the front chest wall. The ends of the missing ribs were clearly cut by a sharp instrument at different sites. This could not have been the result of trauma to the chest and actually the CT scan examination revealed that parts of the ribs, clavicles, fingers, toes and possibly also the penis were buried within the sand underneath the mummy (Fig. 4). It is evident that these chest lesions were due to the forced unwrapping by Carter's team in 1925, when the mummy artifacts had to be chiseled off from the most inner sarcophagus to which it was completely cemented by solidified resin.

Distinct from the appearances of these multiple traumatic lesions, the left femur showed at the medial epiphyseal region a fracture line involving also the lateral and medial epicondyles (Fig. 5). The fracture showed mild anterior displacement and contained irregular bone fragments with ragged edges. Along the fracture line (width ca. 2-5 mm), a clearly distinct spotted increased density of the spongiosa was visible. The left patella was intact, but was apparently already loose at the time of the unwrapping (2). It currently rests separate within the palm of the left hand. This type of femoral fracture corresponds to the clinically well-known fragmented intra-articular distal femoral fracture (type 33C3 according to AO classification) (26), to be found in individuals of still unfused epiphyses. Furthermore, within the space of the medial femoral fracture and in the subcutaneous tissues of the popliteal fossa, the infiltration of two different embalming–like materials was seen suggesting an associated open wound. We assume that the left distal femur trauma must have happened a few days or hours before death based on the absence of healing signs and the associated still open skin wound. For this speculation, the fracture itself must not have been deadly, but could have triggered lethal cascades, such as bleeding, pulmonary, or fat embolism, or infection. Yet other possibilities are that the lesion occurred post mortem especially during the embalming process, when the body was dried out, or it was caused by Carter’s team like the other fractures.

An extensive irregular defect was found in the soft tissues and adjacent bones at the left occipito cervical region, including the left posterior border of the foramen magnum and adjacent occipital bone (defect ca. 20 x 6 mms) and the posterior arch of the atlas. The soft tissue lesion extends to the left side of the neck anterior to the mandibular angle with partial destruction of the masseter muscle area. The vast majority of the surface lesion is covered by a high density substance (ca. 2000 Hu). Two free bone fragments were found within the skull cavity, one consisting of cortex and spongiosa of clasp shape (ca. 21x7x6 mms) located In the right posterior cranial fossa. These two bone fragments are clearly the detached part of the foramen magnum border and the posterior arch of the atlas respectively (fig.3). The other fragment (ca 11x3x3 mms) was in the left parietal region. These fragments were obviously loose as they are currently at different locations than what was shown by X-rays in 1968’s and 1978’s. Therefore, they are of post mortem nature and the possibility of a penetrating skull lesion that occurred premortem is now completely ruled out. In addition no associated thinning of the skull bone or calcified hematoma as possible evidences for a major premortem cranial trauma were found. Since the bony pieces were not adherent to the intracranial embalming liquids, we either believe that these fragments were remnants of a second later embalming route through the foramen magnum or were more likely caused by the modern unwrapping. A trans – foramen magnum   embalming approaches including removal of the atlas bone, was repeatedly described as being performed for the founder of Tutankhamun’s 18^th Dynasty , Pharaoh Ahmosis (ca. 1540 BC; JE 262610/CG 61056, Egyptian Museum, Cairo) (12,27). This approach in Ahmosis would have to be proven by a CT scanning too. Surprisingly, the two main approaches transnasal, versus transforamen magnum to extract the brain have been linked to different geographic origin of schools of Theban versus Memphis, respectively (28, 29). Yet, the use of a transnasal and a transforamen magnum embalming approaches in the very same individual has never been described before, but again more royal mummies would need to be CT scanned to validate this finding. Finally with regards to Tutankhamun we did not find any indication in the bones denoting severe acute, chronic or congenital disease. A more detailed account of the embalming approaches used in his remains such as e.g, the transcutaneous evisceration of the body cavity performed through a left hypochondrial approach, rather than the more frequently practiced left inguinal approaches , will be addressed elsewhere.

CONCLUSION:-

The CT examination of King Tutankhamun provides new evidence of the life and after life of this most famous ancient ruler. It rules out a penetrating skull lesion or a chest trauma to be the cause of death, but it raises a possibility of a distal femoral fracture to be of possible premortem significance. Furthermore, the numerous reports of a hurried mummification of Tutankhamun can be dismissed, based on the noted multiple and extensive use of ancient procedures of body conservation.

This study is the first ever evaluation of its kind done on an identified ancient royal mummy. Thus to our judgment, the non – invasive CT examination is ethically approvable (Holm, 2001) since it further enhances the information regarding Tutankhamun’s life and afterlife. More details can be discovered non- invasively by CT scanning of both, his separately, buried internal organs and of temporal and genetically related royal mummies.

For further readings, please refer to the four titles published
on King Tutankhamun by the distinguished Egyptologist, Dr. Zahi Hawass: