302 » Wolfgang M. Pahl and W. Undeutsch 



mentioned findings cannot offer a con- 

 clusive, scientifically proven diag- 

 nosis. As in so many areas of Egyptian 

 paleopathology, a systematic researcfi 

 program is recommended fiere (see be- 

 low). Until tfien it will be difficult to 

 refute such claims as tho.se in Sand- 

 ison's paper on infectious diseases in 

 antiquity, that "macroscopic examina- 

 tion and radiographic studies are more 

 likely to give useful information than 

 histological preparations" (1972:222). 



Conclusions 



Compared with the clinical possibilities 

 of dermatological or internal medicine 

 conditions, the identification of patho- 

 logically caused soft tissue lesions in 

 mummies represents simply a minimal 

 diagnostic. In addition to absent color, 

 the typical soft tissue character of the 

 skin is lacking and the skin itself is 

 more or less destroyed by postmortem 

 decomposition, mummification sub- 

 stances, and often by long-term stor- 

 age. The normal arrangement of layers, 

 color and cell structure has often been 

 altered. In a limited number of cases 

 parasitic infection is demonstrated his- 

 tologically. Nevertheless it remains a 

 risky enterprise to diagnose soft tissue 

 involvement resulting from any disease 

 of nontraumatic and nonparasitic ori- 

 gin. 



With caution, yet supported by the 

 well-preserved and characteristic le- 

 sions, it was possible to arrive at a prob- 

 able diagnosis. In the process it became 

 increasingly clear that, except for one 

 particular disease, the other mentioned 

 conditions exhibit distinct differences 

 relative to lesions I-IV. In light of the 

 available criteria (particularly the typi- 

 cal configuration of the ulcers, their lo- 

 calization, and the exposure of skeletal 

 parts) it seems highly probable that the 

 cause of ulcerations in mummy 1565 is 

 noma. The fact that noma occurs more 

 often in children in present-day patients 

 does not contradict the diagnosis, since 

 adults are affected as well, although in 

 fewer numbers. It can be assumed that 

 noma was known in the Egypt of the 

 pharaohs when one takes the living 



conditions of the masses into account. 

 Because the harvest was dependent on 

 the degree of Nile flooding, famines 

 were common and contributed to one of 

 the predisposing factors of phagedenic 

 ulcer: malnutrition, poor hygienic con- 

 ditions, and the accompanying immune 

 deficiency. 



Attempts to identify noma in written 

 medical sources from Egypt have been 

 undertaken by Ebbell (1939), who con- 

 cluded that case 15 of the Edwin Smith 

 surgical papyrus is a description of 

 noma: 



Ca.se 15 (6.14-17). Instructions con- 

 cerning a perforation in his cheek: "If 

 thou examinest a man having a per- 

 foration in his cheek, shouldst thou 

 find there is a swelling, protruding 

 and black, [and] diseased tissue upon 

 his cheek, (conclusion in diagnosis]. 



"Thou shouldst say concerning 

 him: 'One having a perforation in his 

 cheek. An ailment which I will treat." 

 Thou shouldst bind it with [ymrwj 

 and treat afterward with grease |and] 

 honey every day until he recovers." 



From the viewpoint of modem clini- 

 cal medicine, this presentation would 

 seem to be too sparse to assign the 

 respective symptoms — consisting of 

 only three items: a hole in the cheek, a 

 kind of swelling, and a black color- 

 ing — to the family of phagedenic ul- 

 cers, much less to the disease "noma." 



James H. Breasted (1930), in his 

 translation of the Smith papyrus, states 

 that case 15 describes a traumatic per- 

 foration of the maxilla (according to 

 Breasted, "cheek" is a designation for 

 the maxillary bone, zygoma, and part 

 of the temporal bone) resulting in an 

 infection of the soft tissue wound in- 

 volving swelling and blackening of the 

 injured region. This could possibly be 

 diagnosed as a type of gangrenous or 

 necrotizing pyoderma. Due to its deter- 

 minative, the word | ^>m J Cimrw) 

 may denote a mineral substance which 

 was part of the ancient Egyptian mate- 

 ria medica, perhaps a disinfectant 

 (compare Grapow 1956:129). Thus, 

 because many pathological aspects of 

 case 15 remain ambiguous, the papyrus 



text does not confirm Ebbell's diag- 

 nosis sufficiently. 



In spite of this, it seems rather certain 

 that noma was well known in antiquity. 

 In Book VI of "de medicina," A. Cor- 

 nelius Celsus reports a disease which 

 Patrick regards as noma and not as 

 stomatitis aphthosa (Patrick 1967:243): 



But those ulcers, which the Greek 

 call aphthae, are by far the most dan- 

 gerous, that is, in children, for they 

 often kill them; in men and women 

 there is not the same danger. They 

 begin at the gums, next possess the 

 palate and the whole mouth, then de- 

 scend to the uvula and fauces. When 

 these are affected, it is not easy for 

 the child to recover (AC. Celsus, 

 book VI, translation according to 

 Greive 1756). 



Finally, we cite an epigram of the Latin 

 writer Martial, describing a disease 

 which could have been noma: 



Canace, the daughter of Aeolis, lies 

 buried in this tomb; little Canace, 

 whose seventh winter was her last. 

 Alas for the guilt and the crime of it! 

 Thou, passer-by, who art quick weep, 

 may lament here, not the shortness of 

 life, but something sadder than death, 

 the way death came. A dreadful 

 canker wasted her face and settled on 

 her tender mouth, and consumed her 

 very lips before they were surren- 

 dered to the smoky pyre. If it had to 

 come with so ill-timed a flight, fate 

 should have come by another path. 

 But death hastened to close the chan- 

 nel of her charming speech, lest her 

 tongue might have power to bend the 

 stem goddesses (Patrick 1967:243). 



General remarks 



We would first like to state that the 

 ideas and considerations expressed here 

 should not be understood as an appeal 

 for a retum to the descriptive style of 

 pathology which, especially in the area 

 of paleopathology, has fallen into dis- 

 credit in the last few years. The aver- 

 sion to it may have drawn its justifica- 

 tion from the habit, common in the area 



iCuf-reh /'(ilnipiilluilii);\ Svmp IV8S 



