Early Osteologic Evidence of the Use of the Scalpel: Surgical Excision of a Facial Lesion in the Roman Period.

Abstract

Sir: Mentions of surgical instruments date back several millennia, but actual traces are elusive. Works of Greco-Roman medical writers (e.g., Hippocrates, Celsus, Galen, Aetius, Oribasius, and Soranus) refer to their use. Instruments themselves are preserved in personal graves and collections, such as the one from the so-named Surgeon’s House in Pompeii.1,2 The individual corpse T-127 from the late Roman Ramón y Cajal street necropolis (along one of the west entrances of Tarraco, capital of Hispania Citerior Roman province)3 was buried in an amphora. This site, part of a larger complex, consists of 220 burials dated between the third and fifth centuries ad. The highly conserved, female skeleton was oriented in the craniocaudal direction (west to east). Cranial sutures and costal articular surfaces suggest age approximately 55 ± 10 years. Pubic articular facet was a reference to valorize posthumous alterations. After femoral length (423 mm), height was estimated as 158 cm (Trotter-Gleser) or 154 cm (Pearson). The left maxilla shows an erosive lesion (Fig. 1). Its outer base pierces below the infraorbital foramen. Uneven, slim edges progressively reach the inner sheet (maximum diameter, 12 mm). The outside aspect presents periorificial destructuration with an irregular bone surface. A linear lesion along the upper third of the defect horizontally crosses at a slight angle upward-out and accurately continues from edge to edge (Fig. 2). The patina of the incised area (length, 11 mm) characterizes an old injury. The lower third presents another line at an angle of 35 degrees to the upper line (length, 12 mm). The inner face of the anterior wall of the sinus is a smooth surface. The bottom side of the sinus appears through the top face as a result of a posthumous fracture. The loss of homogeneity and the rough surface on the lower left area suggest sinusitis. The rest of the skeleton features a consolidated right rib fracture.Fig. 1.: Anterior aspect of the left maxillary bone that shows a perforating, erosive defect (after protective coating).Fig. 2.: Detail from the defect in the anterior wall of the maxillary sinus (before protective coating).Radiology shows osteoblastic reaction surrounding the edges of the incisions. The inner side of the maxilla is free of injury. The external injury may have drilled the maxilla, secondarily causing sinusitis. Primary fistulized sinusitis following erosion from the outside was ruled out. Infectious agents such as Mycobacteria (tuberculous lupus) or secondary syphilis may yield bone destruction in regular, excavated lesions. Actinomycosis is usually limited to soft tissue. In spindle cell carcinoma, basocellular carcinoma, and melanoma, bone erosion is very rare. Hemangiosarcoma and dermatofibrosarcoma are even rarer neoplasms. NK/T-cell lymphomas of the so-called nasal type may produce similar erosions. Clearly, therapeutic interventions on earlier Roman remains include the now lost modiolus described by Brothwell4 and extraction of foreign bodies (arrowheads). In this specimen, two incisions clearly follow lines of tension and seem to aim excision. The upper incision delimits the injury and accomplishes eye protection and aesthetics by following tension lines. The second incision has a concave upper mark at its bottom, completing the cut in fusiform, myrtle-leaf shape as recommended by Celsus.5 The anatomical region, Friteau’s trapezoidal area, seldom includes noble elements. Osteoblastic reaction around the incision would be indirect evidence of survival after a procedure. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. None of the authors has any potential conflict of interest. Joaquim Baxarias Tibau, M.D., Ph.D.Wenceslao M. Calonge, M.D., M.Sc.Daniele Gurrieri, M.D.Permanence Médico-Chirurgicale Vermont-Grand PréGeneva, Switzerland